Cheryl Benn

Planned Place of Birth in New Zealand: Does it Affect Mode of Birth and Intervention Rates Among Low‐Risk Women?

BACKGROUND Midwives providing care as lead maternity caregivers in New Zealand provide continuity of care to women who may give birth in a variety of settings, including home, primary units, and secondary and tertiary level hospitals. The purpose of this study was to compare mode of birth and intrapartum intervention rates for low-risk women planning to give birth in these settings under the care of midwives. METHODS Data for a cohort of low-risk women giving birth in 2006 and 2007 were extracted from the Midwifery Maternity Provider Organisation database. Mode of birth, intrapartum interventions, and neonatal outcomes were compared with results adjusted for age, parity, ethnicity, and smoking. RESULTS Women planning to give birth in secondary and tertiary hospitals had a higher risk of cesarean section, assisted modes of birth, and intrapartum interventions than similar women planning to give birth at home and in primary units. The risk of emergency cesarean section for women planning to give birth in a tertiary unit was 4.62 (95% CI: 3.66-5.84) times that of a woman planning to give birth in a primary unit. Newborns of women planning to give birth in secondary and tertiary hospitals also had a higher risk of admission to a neonatal intensive care unit (RR: 1.40, 95% CI: 1.05-1.87; RR: 1.78, 95% CI: 1.31-2.42) than women planning to give birth in a primary unit. CONCLUSIONS Planned place of birth has a significant influence on mode of birth and rates of intrapartum intervention in childbirth.

The midwife's role in facilitating smoking behaviour change during pregnancy

OBJECTIVE To explore the midwifes role in providing education and support for changes in smoking behaviour during usual primary maternity care. DESIGN A qualitative study using a thematic approach to analysis of data collected in face-to-face interviews. SETTING AND PARTICIPANTS Eleven women who had participated in the intervention groups of the MEWS Study, a cluster randomised trial of education and support for women who smoke, and 16 midwives from the intervention and control arms of the trial. The trial was set in the lower North Island of New Zealand in 2000. FINDINGS Midwives acknowledged that asking women about smoking was part of their role as maternity care providers. However, many found it difficult to know how to ask women about their smoking, how to identify the women who would be receptive to advice and how to support them to make changes to their smoking. Midwives were also concerned about making women feel guiltier than they already did about their smoking, and about the impact of providing smoking cessation on their relationship with women. In contrast, women expected their midwife to ask them about their smoking. When women wanted to quit their midwife was an extremely valuable source of information and support. Midwives were also in a position to help women who did not want to quit to make other changes to their smoking behaviour. Even women who did not want to quit were prepared to be asked about their smoking. Problems arose when the way the midwife asked and the frequency of her enquiries were not appropriate for the stage of the change cycle the woman was in. IMPLICATIONS FOR PRACTICE Midwives can effectively provide education and support for smoking change during pregnancy if they match the womans readiness to make changes with the type of advice and support they provide.

Can support and education for smoking cessation and reduction be provided effectively by midwives within primary maternity care

OBJECTIVE To test the hypothesis that appropriate interventions delivered by midwives within usual primary maternity care, can assist women to stop or reduce the amount they smoke and facilitate longer duration of breast feeding. DESIGN, SETTING AND PARTICIPANTS In a cluster randomised trial of smoking education and breast-feeding interventions in the lower North Island, New Zealand, midwives were stratified by locality and randomly allocated into a control group and three intervention groups. The control group provided usual care. Midwives in the intervention groups delivered either a programme of education and support for smoking cessation or reduction, a programme of education and support for breast feeding or both programmes. Sixty-one midwives recruited a total of 297 women. INTERVENTIONS Structured programmes provided by midwives. FINDINGS Women receiving only the smoking cessation or reduction programme were significantly more likely to have reduced, stopped smoking or maintained smoking changes than women in the control group, at 28 weeks and 36 weeks gestation. Women receiving both the smoking cessation and breast-feeding education and support programmes were significantly more likely than women in the control group to have changed their smoking behaviour at 36 weeks gestation. There was no difference in rates of cessation or reduction between the groups in the postnatal period. There was no difference in rates of full breast feeding between the control and intervention groups for women who planned to breast feed. KEY CONCLUSIONS Education and support by midwives, as part of primary midwifery, can facilitate smoking cessation and reduction during pregnancy.

Risk of severe postpartum hemorrhage in low-risk childbearing women in new zealand: exploring the effect of place of birth and comparing third stage management of labor.

BACKGROUND Primary postpartum hemorrhage is a leading cause of maternal mortality and morbidity internationally. Research comparing physiological (expectant) and active management of the third stage of labor favors active management, although studies to date have focused on childbirth within hospital settings, and the skill levels of birth attendants in facilitating physiological third stage of labor have been questioned. The aim of this study was to investigate the effect of place of birth on the risk of postpartum hemorrhage and the effect of mode of management of the third stage of labor on severe postpartum hemorrhage. METHODS Data for 16,210 low-risk women giving birth in 2006 and 2007 were extracted from the New Zealand College of Midwives research database. Modes of third stage management and volume of blood lost were compared with results adjusted for age, parity, ethnicity, smoking, length of labor, mode of birth, episiotomy, perineal trauma, and newborn birthweight greater than 4,000 g. RESULTS In total, 1.32 percent of this low-risk cohort experienced an estimated blood loss greater than 1,000 mL. Place of birth was not found to be associated with risk of blood loss greater than 1,000 mL. More women experienced blood loss greater than 1,000 mL in the active management of labor group for all planned birth places. In this low-risk cohort, those women receiving active management of third stage of labor had a twofold risk (RR: 2.12, 95% CI: 1.39-3.22) of losing more than 1,000 mL blood compared with those expelling their placenta physiologically. CONCLUSIONS Planned place of birth does not influence the risk of blood loss greater than 1,000 mL. In this low-risk group active management of labor was associated with a twofold increase in blood loss greater than 1,000 mL compared with physiological management. (BIRTH 39:2 June 2012).

Reasons for Stopping Exclusive Breastfeeding Between Three and Six Months: A Qualitative Study

Purpose: Scant published qualitative literature exists focusing on why exclusive breastfeeding rates decline between three and six months. This study aims to develop an understanding of why exclusive breastfeeding tails off so dramatically between three and six months after birth in New Zealand. Design and Methods: A generic qualitative methodology was employed in this study and social constructionism selected as the main epistemological framework underpinning the research. This study was carried out between September 2013 and July 2014, involving face‐to‐face interviews with 30 women who were characterised as highly motivated to complete six months exclusive breastfeeding prior to the birth of their child. In order to gain an in‐depth understanding of the research material, thematic analysis of the interview transcripts was completed using manual coding techniques. Results: After thematic analysis of the data four key themes were identified: 1) The good employee/good mother dilemma. 2) Breastfeeding is lovely, but six months exclusively is demanding. 3) Exclusive breastfeeding recommendations should be individualised. 4) Introducing solids early as a cultural practice. Conclusions: Most studies have linked barriers to six months exclusive breastfeeding to difficulties within the mother‐infant dyad, as well as negative maternal socioeconomic and socio‐demographic characteristics. However, this study has shown that the maintenance of six months exclusive breastfeeding is also challenging for this group of mothers who were socially advantaged, well‐educated and highly motivated to breastfeed their babies exclusively for six months. HIGHLIGHTSConsideration of the mother‐infant dyad as the main target for promoting six months exclusive breastfeeding has failed to address the low rate of this behaviour particularly between three and six months postpartum. The drop off in breastfeeding after three months suggests that infant feeding behaviour is not limited to the mother‐infant dyad; the sociocultural contexts of this behaviour need to be taken into account.The maintenance of six months exclusive breastfeeding behaviour is challenging and demanding even for mothers who are socially advantaged, well‐educated and highly motivated to breastfeed their babies exclusively for six months.Returning to work and maintaining exclusive breastfeeding is very difficult for mothers. Therefore, this study recommends the development of a Baby Friendly Workplace Initiative (BFWI) which provides education to both employees and employers about the legislation, their obligations and responsibilities as well as the importance of breastfeeding for the long term health of mothers and babies, staff retention, reduced sick leave and increased productivity of female employees.