Helen Stapleton

Caseload midwifery care versus standard maternity care for women of any risk: M@NGO, a randomised controlled trial

BACKGROUND Women at low risk of pregnancy complications benefit from continuity of midwifery care, but no trial evidence exists for women with identified risk factors. We aimed to assess the clinical and cost outcomes of caseload midwifery care for women irrespective of risk factors. METHODS In this unblinded, randomised, controlled, parallel-group trial, pregnant women at two metropolitan teaching hospitals in Australia were randomly assigned to either caseload midwifery care or standard maternity care by a telephone-based computer randomisation service. Women aged 18 years and older were eligible if they were less than 24 weeks pregnant at the first booking visit. Those who booked with another care provider, had a multiple pregnancy, or planned to have an elective caesarean section were excluded. Women allocated to caseload care received antenatal, intrapartum, and postnatal care from a named caseload midwife (or back-up caseload midwife). Controls received standard care with rostered midwives in discrete wards or clinics. The participant and the clinician were not masked to assignment. The main primary outcome was the proportion of women who had a caesarean section. The other primary maternal outcomes were the proportions who had an instrumental or unassisted vaginal birth, and the proportion who had epidural analgesia during labour. Primary neonatal outcomes were Apgar scores, preterm birth, and admission to neonatal intensive care. We analysed all outcomes by intention to treat. The trial is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12609000349246. FINDINGS Publicly insured women were screened at the participating hospitals between Dec 8, 2008, and May 31, 2011. 1748 pregnant women were randomly assigned, 871 to caseload and 877 to standard care. The proportion of caesarean sections did not differ between the groups (183 [21%] in the caseload group vs 204 [23%] in the standard care group; odds ratio [OR] 0·88, 95% CI 0·70-1·10; p=0·26). The proportion of women who had elective caesarean sections (before onset of labour) differed significantly between caseload and standard care (69 [8%] vs 94 [11%]; OR 0·72, 95% CI 0·52-0·99; p=0·05). Proportions of instrumental birth were similar (172 [20%] vs 171 [19%]; p=0·90), as were the proportions of unassisted vaginal births (487 [56%] vs 454 [52%]; p=0·08) and epidural use (314 [36%] vs 304 [35%]; p=0·54). Neonatal outcomes did not differ between the groups. Total cost of care per woman was AUS

Bonny babies? Motherhood and nurturing in the age of obesity

566·74 (95% 106·17-1027·30; p=0·02) less for caseload midwifery than for standard maternity care. INTERPRETATION Our results show that for women of any risk, caseload midwifery is safe and cost effective. FUNDING National Health and Medical Research Council (Australia).

Does the way maternity care is provided affect maternal and neonatal outcomes for young women? A review of the research literature

The ‘bonny’ baby is traditionally the prized emblem of good health, yet there has been speculation that within the context of rising levels of obesity and diabetes within childbearing populations that this may change. Within epidemiological understandings, obesity and diabetes in pregnancy are strongly implicated in the increasing numbers of very large babies. Given the power of biomedical risk discourses to shape womens experiences of pregnancy, motherhood and infant feeding, lay understandings of infant size/health and the ‘bonny’ baby are perhaps subject to revision. This paper, draws upon critical obesity studies and contemporary commentaries regarding ‘parental causality’ to discuss the medicalisation (through BMI) and moralisation of large bodies in pregnancy as ‘obese’ and (by implication) the creation of subjects ‘at risk’ to themselves and their foetus/infant. Through an analysis of longitudinal interview data from large-bodied women in their transitions to motherhood, this paper explores how this powerful biomedical discourse plays out in womens reported interactions with maternity professionals in pregnancy, birth and the months that follow. The paper concludes by discussing the implications of such findings for contemporary parenting, policy and professional practice.

The Murri clinic: a comparative retrospective study of an antenatal clinic developed for Aboriginal and Torres Strait Islander women

BACKGROUND Young pregnant women who continue a pregnancy are primarily from a socioeconomically deprived background. The risk factors associated with low socio-economic status may independently affect perinatal and neonatal morbidity to a greater extent than the young age of the woman. Young pregnant women are frequently sceptical about health care providers who they can perceive to be judgemental. This may lead to late booking for pregnancy care, attending few appointments, or not attending the health service for any antenatal care. QUESTION Does the way maternity care is provided affect maternal and neonatal outcomes for young women? METHOD A systematic search of the major health databases. RESULTS Nine research articles met the eligibility criteria: one randomised controlled trial, three prospective cohort studies, two comparative studies with concurrent controls, two comparative studies with historical controls, and one case series. DISCUSSION Providing young women with a non-standard model of maternity care has some beneficial and no known detrimental effects on childbirth outcomes. While there is a dearth of evidence on the effectiveness of a Midwifery Group Practice model of care for young women, there is strong evidence to suggest that a Group Antenatal Care model increases antenatal visit attendance and breastfeeding initiation, and decreases the risk of preterm birth. There is research to indicate that a Young Womens Clinic model may also increase antenatal visit attendance and decrease the incidence of preterm birth. CONCLUSION More well-designed and resourced midwifery models of care for young women should be implemented and rigorously researched.

‘Selling it as a holistic health provision and not just about condoms …’ Sexual health services in school settings: current models and their relationship with sex and relationships education policy and provision

BackgroundIndigenous Australians are a small, widely dispersed population. Regarding childbearing women and infants, inequities in service delivery and culturally unsafe services contribute to significantly poorer outcomes, with a lack of high-level research to guide service redesign. This paper reports on an Evaluation of a specialist (Murri) antenatal clinic for Australian Aboriginal and Torres Strait Islander women.MethodsA triangulated mixed method approach generated and analysed data from a range of sources: individual and focus group interviews; surveys; mother and infant audit data; and routinely collected data. A retrospective analysis compared clinical outcomes of women who attended the Murri clinic (n=367) with Indigenous women attending standard care (n=414) provided by the same hospital over the same period. Both services see women of all risk status.ResultsThe majority of women attending the Murri clinic reported high levels of satisfaction, specifically with continuity of carer antenatally. However, disappointment with the lack of continuity during labour/birth and postnatally left some women feeling abandoned and uncared for. Compared to Indigenous women attending standard care, those attending the Murri clinic were statistically less likely to be primiparous or partnered, to experience perineal trauma, to have an epidural and to have a baby admitted to the Neonatal Intensive Care Unit, and were more likely to have a non-instrumental vaginal birth. Multivariate analysis found higher normal birth (spontaneous onset of labour, no epidural, non-instrumental vaginal birth without episiotomy) rates amongst women attending the Murri clinic.ConclusionsSignificant benefits were associated with attending the Murri clinic. Recommendations for improvement included ongoing cultural competency training for all hospital staff, reducing duplication of services, improving co-ordination and communication between community and tertiary services, and working in partnership with community-based providers. Combining multi-agency resources to increase continuity of carer, culturally responsive care, and capacity building, including creating opportunities for Indigenous employment, education, and training is desirable, but challenging. Empirical evidence from our Evaluation provided the leverage for a multi-agency agreement to progress this goal within our catchment area.

QF2011: a protocol to study the effects of the Queensland flood on pregnant women, their pregnancies, and their children's early development

In this article we discuss the findings from a recent study of UK policy and practice in relation to sexual health services for young people, based in – or closely linked with – schools. This study formed part of a larger project, completed in 2009, which also included a systematic review of international research. The findings discussed in this paper are based on analyses of interviews with 51 service managers and questionnaire returns from 205 school nurses. Four themes are discussed. First, we found three main service permutations, in a context of very diverse and uneven implementation. Second, we identified factors within the school context that shaped and often constrained service provision; some of these also have implications for sex and relationships education (SRE). Third, we found contrasting approaches to the relationship between SRE input and sexual health provision. Fourth, we identified some specific barriers that need to be addressed in order to develop ‘young people friendly’ services in the school context. The relative autonomy available to school head teachers and governors can represent an obstacle to service provision – and inter-professional collaboration – in a climate where, in many schools, there is still considerable ambivalence about discussing ‘sex’ openly. In conclusion, we identify areas worthy of further research and development, in order to address some obstacles to sexual health service and SRE provision in schools.

Women from refugee backgrounds and their experiences of attending a specialist antenatal clinic. Narratives from an Australian setting

BackgroundRetrospective studies suggest that maternal exposure to a severe stressor during pregnancy increases the fetus’ risk for a variety of disorders in adulthood. Animal studies testing the fetal programming hypothesis find that maternal glucocorticoids pass through the placenta and alter fetal brain development, particularly the hypothalamic-pituitary-adrenal axis. However, there are no prospective studies of pregnant women exposed to a sudden-onset independent stressor that elucidate the biopsychosocial mechanisms responsible for the wide variety of consequences of prenatal stress seen in human offspring. The aim of the QF2011 Queensland Flood Study is to fill this gap, and to test the buffering effects of Midwifery Group Practice, a form of continuity of maternity care.Methods/designIn January 2011 Queensland, Australia had its worst flooding in 30 years. Simultaneously, researchers in Brisbane were collecting psychosocial data on pregnant women for a randomized control trial (the M@NGO Trial) comparing Midwifery Group Practice to standard care. We invited these and other pregnant women to participate in a prospective, longitudinal study of the effects of prenatal maternal stress from the floods on maternal, perinatal and early childhood outcomes. Data collection included assessment of objective hardship and subjective distress from the floods at recruitment and again 12 months post-flood. Biological samples included maternal bloods at 36 weeks pregnancy, umbilical cord, cord blood, and placental tissues at birth. Questionnaires assessing maternal and child outcomes were sent to women at 6 weeks and 6 months postpartum. The protocol includes assessments at 16 months, 2½ and 4 years. Outcomes include maternal psychopathology, and the child’s cognitive, behavioral, motor and physical development. Additional biological samples include maternal and child DNA, as well as child testosterone, diurnal and reactive cortisol.DiscussionThis prenatal stress study is the first of its kind, and will fill important gaps in the literature. Analyses will determine the extent to which flood exposure influences the maternal biological stress response which may then affect the maternal-placental-fetal axis at the biological, biochemical, and molecular levels, altering fetal development and influencing outcomes in the offspring. The role of Midwifery Group Practice in moderating effects of maternal stress will be tested.

Lost in Translation: Staff and Interpreters’ Experiences of the Edinburgh Postnatal Depression Scale with Women from Refugee Backgrounds

PROBLEM In response to an identified need, a specialist antenatal clinic for women from refugee backgrounds was introduced in 2008, with an evaluation planned and completed in 2010. QUESTION Can maternity care experiences for women from refugee backgrounds, attending a specialist antenatal clinic in a tertiary Australian public hospital, be improved? METHODS The evaluation employed mixed methods, generating qualitative and quantitative data from two hospital databases, a chart audit, surveys and interviews with service users, providers and stakeholders. Contributions were received from 202 participants. FINDINGS The clinic was highly regarded by all participants. Continuity of care throughout the antenatal period was particularly valued by newly arrived women as it afforded them security and support to negotiate an unfamiliar Western maternity system. Positive experiences decreased however; as women transitioned from the clinic to labour and postnatal wards where they reported that their traditional birthing and recuperative practices were often interrupted by the imposition of Western biomedical notions of appropriate care. The centrally located clinic was problematic, frequently requiring complex travel arrangements. Appointment schedules often impacted negatively on traditional spousal and family obligations. CONCLUSIONS Providing comprehensive and culturally responsive maternity care for women from refugee backgrounds is achievable, however it is also resource intensive. The production of translated information which is high quality in terms of production and content, whilst also taking account of languages which are only rarely encountered, is problematic. Cultural competency programmes for staff, ideally online, require regular updating in light of new knowledge and changing political sensitivities.

Maternal overweight and obesity: a survey of clinicians’ characteristics and attitudes, and their responses to their pregnant clients

This paper explores the cross-cultural application of the Edinburgh Postnatal Depression Scale (EPDS) and the difficulties associated with administration to women from refugee backgrounds. Assessing womens comprehension of individual scale items identified problems associated with “Western” terminology and concepts. Re-interpretation of discrete items on the scale was often necessary, raising doubts about the objectivity and reliability of scores. Our findings call for a closer examination of the ethnocentric assumptions underpinning the EPDS items, and the need to incorporate a more diverse range of cross-cultural understandings into future iterations.

Overweight and obesity in pregnancy: the evidence-practice gap in staff knowledge, attitudes and practices

BackgroundStatewide (Queensland) Clinical Guidelines reflecting current best practice have recently become available for the management of pregnancy-related obesity. Our aim was to assess staff knowledge about, adherence to, and characteristics that influence delivery of care according to these Guidelines.MethodsAn online survey, available over a three week period (May-June 2011), was disseminated to obstetric, midwifery and allied health staff working in a tertiary maternity hospital. Outcomes included knowledge of guideline content, advice given, knowledge of obesity pregnancy-related complications, previous training, referral patterns, and staff characteristics, including lifestyle habits, body satisfaction, and Body Mass Index (BMI).ResultsSeventy-three staff completed surveys (59.6% response rate). Mean self-reported BMI was 24.2 ± 4.1 kg/m2 (17.9-36.4); 28.5% of staff were overweight (19%) or obese (9.5%), and 27.4% were underweight. However, 28.6%, 2.4%, and 1.2% ‘self-classified’ themselves as overweight, obese, and underweight, respectively. Almost 40% were dissatisfied/extremely dissatisfied with their weight. While the majority reported overweight/obesity (ow/ob) as an important/very important general obstetric issue and most correctly identified associated perinatal complications, only 32.1% were aware of existing guidelines, with only half correctly identifying BMI categories for ow/ob. A quarter indicated they did not provide women with gestational weight gain (GWG) advice relative to BMI category. Staff identified they would like more training in the area of supporting women to achieve and understand the need for healthy GWG. Staff role was significantly associated with guideline adherence (p=0.03) and association with BMI category approached significance (p=0.07). An association was observed between staff’s BMI and their belief in the influence of their advice on women’s GWG (p=0.013) and weight satisfaction and belief in women having the resources to make the changes they recommend (p=0.003).ConclusionsWhilst lack of guideline knowledge provides a barrier to best-practice care, our findings suggest an interplay between staff confidence and personal characteristics in delivering such care which deserves recognition in staff education and training, and service development programs and future research.