Holly Powell Kennedy

Midwifery and quality care: findings from a new evidence-informed framework for maternal and newborn care

In this first paper in a series of four papers on midwifery, we aimed to examine, comprehensively and systematically, the contribution midwifery can make to the quality of care of women and infants globally, and the role of midwives and others in providing midwifery care. Drawing on international definitions and current practice, we mapped the scope of midwifery. We then developed a framework for quality maternal and newborn care using a mixed-methods approach including synthesis of findings from systematic reviews of womens views and experiences, effective practices, and maternal and newborn care providers. The framework differentiates between what care is provided and how and by whom it is provided, and describes the care and services that childbearing women and newborn infants need in all settings. We identified more than 50 short-term, medium-term, and long-term outcomes that could be improved by care within the scope of midwifery; reduced maternal and neonatal mortality and morbidity, reduced stillbirth and preterm birth, decreased number of unnecessary interventions, and improved psychosocial and public health outcomes. Midwifery was associated with more efficient use of resources and improved outcomes when provided by midwives who were educated, trained, licensed, and regulated. Our findings support a system-level shift from maternal and newborn care focused on identification and treatment of pathology for the minority to skilled care for all. This change includes preventive and supportive care that works to strengthen womens capabilities in the context of respectful relationships, is tailored to their needs, focuses on promotion of normal reproductive processes, and in which first-line management of complications and accessible emergency treatment are provided when needed. Midwifery is pivotal to this approach, which requires effective interdisciplinary teamwork and integration across facility and community settings. Future planning for maternal and newborn care systems can benefit from using the quality framework in planning workforce development and resource allocation.

Improvement of maternal and newborn health through midwifery

In the concluding paper of this Series about midwifery, we look at the policy implications from the framework for quality maternal and newborn care, the potential effect of life-saving interventions that fall within the scope of practice of midwives, and the historic sequence of health system changes that made a reduction in maternal mortality possible in countries that have expanded their midwifery workforce. Achievement of better health outcomes for women and newborn infants is possible, but needs improvements in the quality of reproductive, maternal, and newborn care, alongside necessary increases in universal coverage. In this report, we propose three priority research areas and outline how national investment in midwives and in their work environment, education, regulation, and management can improve quality of care. Midwifery and midwives are crucial to the achievement of national and international goals and targets in reproductive, maternal, newborn, and child health; now and beyond 2015.

The Effects of Mindfulness-Based Yoga During Pregnancy on Maternal Psychological and Physical Distress

OBJECTIVE To examine the feasibility and level of acceptability of a mindful yoga intervention provided during pregnancy and to gather preliminary data on the efficacy of the intervention in reducing distress. DESIGN Baseline and post-treatment measures examined state and trait anxiety, perceived stress, pain, and morning salivary cortisol in a single treatment group. Postintervention data also included participant evaluation of the intervention. SETTING The 7 weeks mindfulness-based yoga group intervention combined elements of Iyengar yoga and mindfulness-based stress reduction. PARTICIPANTS Sixteen healthy pregnant nulliparous women with singleton pregnancies between 12 and 32 weeks gestation at the time of enrollment. METHODS Outcomes were evaluated from pre- to postintervention and between second and third trimesters with repeated measures analysis of variance and post hoc nonparametric tests. RESULTS Women practicing mindful yoga in their second trimester reported significant reductions in physical pain from baseline to postintervention compared with women in the third trimester whose pain increased. Women in their third trimester showed greater reductions in perceived stress and trait anxiety. CONCLUSIONS Preliminary evidence supports yogas potential efficacy in these areas, particularly if started early in the pregnancy.

Keeping Birth Normal: Research Findings on Midwifery Care During Childbirth

OBJECTIVE This study describes processes and outcomes of midwifery care through narratives told by exemplary midwives. DESIGN Narrative analysis. SETTING Midwifery practices in hospital, birth center, and home settings. PARTICIPANTS Purposive sample of 14 midwives drawn from a large national Delphi panel on exemplary midwifery practice. DATA ANALYSIS Systematic analysis of interview data was conducted until interpretive consensus was achieved across all text and codes. Results were compared with two prior qualitative studies conducted by the first author on midwifery practice for congruence and emergence of new findings. RESULTS The support of normalcy was identified as a significant process of midwifery care during labor and birth. CONCLUSIONS The midwives believed that birth is normal, and many of their actions were specifically aimed toward the support of it as a physiologic, rather than pathologic, process. Through their words, we see subtle care processes focused on meeting a womans individual needs and tapping into her personal strength. Implications for practice and further research to link their approach to caring for women with perinatal outcomes are reviewed.

Negotiating sleep: a qualitative study of new mothers.

Objective The purpose of this qualitative study was to learn from 20 mothers about their experience of sleep during pregnancy and the immediate months of becoming a new mother. The study was part of a larger randomized clinical trial on an intervention to improve sleep and well-being among new mothers. Methods Semistructured, audiotaped interviews were conducted in which women were asked to describe the continuum of the sleep experience across the pregnancy and early postpartum and to describe strategies they found helpful as they established sleep patterns with their infant. Narrative analysis was used to interpret their stories, and data were managed with Atlas.ti qualitative software. Results and Conclusions Sleep disturbances were common to all of the mothers, and sleep became a negotiated behavior as they adjusted to the mothering role. All of the mothers were surprised at the level of disturbance and exhaustion they experienced. Strategies included enlistment of partners to facilitate naps, development of a “sleep consciousness,” and bed-sharing. Mercers stages of becoming a mother are used to describe the process of incorporating sleep changes into their lives.

Effects of mindful yoga on sleep in pregnant women: a pilot study.

Purpose: The purpose of this experimental pilot study was to measure the effects of a mindfulness-based yoga intervention on sleep in pregnant women. Methods: Fifteen healthy, nulliparous women in their second or third trimesters with singleton pregnancies attended weekly mindfulness meditation and prenatal Hatha yoga classes in the community for 7 weeks. Sleep variables, as estimated by 72 hr of continuous wrist actigraphy and the General Sleep Disturbance Scale (GSDS), were recorded at baseline (Time 1) and postintervention (Time 2). Control data were obtained by evaluating sleep in the third-trimester group at Time 1. Due to small sample size, data were analyzed using parametric and nonparametric statistics. Results: Women who began the intervention in the second trimester had significantly fewer awakenings, less wake time during the night, and less perceived sleep disturbance at Time 2 than at baseline. Those who began during the third trimester had poorer sleep over time in spite of the intervention. Women who began the intervention in their second trimester had less awake time at Time 2 compared to third-trimester controls at Time 1. Conclusions: Mindful yoga shows promise for women in their second trimester of pregnancy to diminish total number of awakenings at night and improve sleep efficiency and merits further exploration. Results from this pilot study provide the data to estimate sample size and design and implement powered and more controlled studies in the future.

A Randomized Clinical Trial of Group Prenatal Care in Two Military Settings

A 3-year randomized clinical trial was conducted to test for differences in perinatal health behaviors, perinatal and infant health outcomes, and family health outcomes for women receiving group prenatal care (GPC) when compared to those receiving individual prenatal care. Women in GPC were almost 6 times more likely to receive adequate prenatal care than women in individual prenatal care and significantly more satisfied with their care. No differences were found by group for missed days of work, perceived stress, or social support. No differences in prenatal or postnatal depression symptoms were found in either group; however, women in GPC were significantly less likely to report feelings of guilt or shame. The findings suggest that women in GPC have more adequate care and no untoward effects were found with the model. Further study is important to evaluate long-term outcomes of GPC.

Women’s Experience of Group Prenatal Care

Group prenatal care (GPNC) is an innovative alternative to individual prenatal care. In this longitudinal study we used ethnographic methods to explore African American and Hispanic women’s experiences of receiving GPNC in two urban clinics. Methods included individual, in-depth, semistructured interviews of women and group leaders in GPNC, participant observation of GPNC sessions, and medical record review. GPNC offered positive experiences and met many of women’s expressed preferences regarding prenatal care. Six themes were identified, which represented separate aspects of women’s experiences: investment, collaborative venture, a social gathering, relationships with boundaries, learning in the group, and changing self. Taken together, the themes conveyed the overall experience of GPNC. Women were especially enthusiastic about learning in groups, about their relationships with group leaders, and about having their pregnancy-related changes and fears normalized; however, there were also important boundaries on relationships between participants, and some women wished for greater privacy during physical examinations.

Tensions and Teamwork in Nursing and Midwifery Relationships

OBJECTIVE To explore the practice of midwifery within a busy urban tertiary hospital birth setting and to present findings on the relationships between nurses and midwives in providing maternity care. DESIGN/METHOD A focused ethnography on midwifery practice conducted over 2 years (2004-2006) in a teaching hospital serving a primarily Medicaid-eligible population in Northern California. Data were collected through participant observations and in-depth interviews with midwives (N=11) and nurses (N=14). Practices and relationships among the midwives and nurses were examined in an ethnographic framework through thematic analysis. FINDINGS Two themes described the nature of nursing-midwifery relationships: tension and teamwork. Tension existed in philosophic approaches to care, definitions of safe practice, communication, and respect. Teamwork existed when the midwives and nurses worked in partnership with the woman to develop a plan of care. Changes were brought about to improve the midwife-nurse relationship during the conduct of the study. CONCLUSIONS Midwives and nurses experienced day-to-day challenges in providing optimal care for childbearing women. The power of effective teamwork was profound, as was the tension when communication broke down. Failure to include nurses resulted in impaired translation of evidence into practice. All stakeholders in birth practices and policy development must be involved in future research in order to develop effective maternity care models.

A LIGHT IN THE FOG: CARING FOR WOMEN WITH POSTPARTUM DEPRESSION

It is estimated that at least 1 in 10 women will experience postpartum depression, yet systematic screening for it in clinical practice is too often neglected. The foggy unreality of this affective disorder leads women to believe they are losing their minds, and their efforts to find help can be elusive. Women with postpartum depression who go undetected and untreated are at risk for immediate harm and potential lifelong sequelae for themselves and their families, and especially for their children. This article provides 1) an understanding of the womans experience of postpartum depression, 2) a review of two instruments, developed through a focused program of research to screen for the disorder, 3) triage in clinical practice, and 4) an overview of the three dimensions of treatment: psychopharmacology, psychotherapy, and psychosocial care. Practical guidance and client information are provided to assist midwives and primary care providers to incorporate systematic screening into clinical practice, to identify effective interdisciplinary treatment teams, and to muster family and community resources to help with this commonly hidden childbearing crisis.