Jennifer McNeill

A systematic review of systematic reviews of interventions to improve maternal mental health and well-being

OBJECTIVE to identify non-invasive interventions in the perinatal period that could enable midwives to offer effective support to women within the area of maternal mental health and well-being. METHODS a total of 9 databases were searched: MEDLINE, PubMed, EBSCO (CINAHL/British Nursing Index), MIDIRS Online Database, Web of Science, The Cochrane library, CRD (NHS EED/DARE/HTA), Joanne Briggs Institute and EconLit. A systematic search strategy was formulated using key MeSH terms and related text words for midwifery, study aim, study design and mental health. Inclusion criteria were articles published from 1999 onwards, English language publications and articles originating from economically developed countries, indicated by membership of the Organisation for Economic Co-operation and Development (OECD). Data were independently extracted using a data collection form, which recorded data on the number of papers reviewed, time frame of the review, objectives, key findings and recommendations. Summary data tables were set up outlining key data for each study and findings were organised into related groups. The methodological quality of the reviews was assessed based on predefined quality assessment criteria for reviews. FINDINGS 32 reviews were identified as examining interventions that could be used or co-ordinated by midwives in relation to some aspect of maternal mental health and well-being from the antenatal to the postnatal period and met the inclusion criteria. The review highlighted that based on current systematic review evidence it would be premature to consider introducing any of the identified interventions into midwifery training or practice. However there were a number of examples of possible interventions worthy of further research including midwifery led models of care in the prevention of postpartum depression, psychological and psychosocial interventions for treating postpartum depression and facilitation/co-ordination of parent-training programmes. No reviews were identified that supported a specific midwifery role in maternal mental health and well-being in pregnancy, and yet, this is the point of most intensive contact. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE This systematic review of systematic reviews provides a valuable overview of the current strengths and gaps in relation to maternal mental health interventions in the perinatal period. While there was little evidence identified to inform the current role of midwives in maternal mental health, the review provides the opportunity to reflect on what is achievable by midwives now and in the future and the need for high quality randomised controlled trials to inform a strategic approach to promoting maternal mental health in midwifery.

Exploring the perspective of midwives involved in offering serum screening for Down's syndrome in Northern Ireland

AIMS To explore the perspective of midwives offering serum screening for Downs syndrome. BACKGROUND Previous literature has indicated that the offer and discussion of prenatal serum screening tests with women is complex, and health professionals may influence womens decisions to accept or decline screening. Midwives are usually the key professional to offer serum screening for Downs syndrome in the UK but their perspective is relatively neglected in the literature. DESIGN An explorative qualitative interview study with 15 midwives employed in a maternity unit in Northern Ireland involved in offering prenatal screening to pregnant women. Data were collected from 1 July 2005-31 October 2005. METHODS A focused ethnographic approach was used to explore the perspective of midwives. RESULTS Midwives reported difficulty in explaining the test to women and felt unable to provide the necessary information to adequately inform women within their appointment time. The test offered (the triple test) and potential pathway of subsequent care, were identified as sources of professional and personal conflict by midwives. The expectation that midwives would provide a universal offer of Downs syndrome serum screening but be unable to support women regarding termination of pregnancy also created dissonance. CONCLUSIONS The feasibility of proceeding with a universal serum screening programme for Downs syndrome is questionable in countries which legally or culturally oppose termination of pregnancy. Professionals practising within environments such as this experience conflict in their role, which affects communication with women when discussing screening tests. RELEVANCE TO CLINICAL PRACTICE As midwives are often, the primary health professional providing information to women, it is important that midwives are key participants in ongoing planning and discussions about screening policy to ensure programmes are implemented successfully.

Rethinking Prenatal Care Within a Social Model of Health: An Exploratory Study in Northern Ireland

Implementation of maternity reform agendas remains limited by the dominance of a medical rather than social model of health. This article considers group prenatal care as a complex health intervention and explores its potential in the socially divided, postconflict communities of Northern Ireland. Using qualitative inquiry strategies, we sought key informants’ views on existing prenatal care provision and on an innovative group care model (CenteringPregnancy®) as a social health initiative. We argue that taking account of the locally specific context is critical to introducing maternity care interventions to improve the health of women and their families and to contribute to community development.

United but divided? The need to consider the potential consequences of devolved UK government on midwifery education and practice

The health policy setting in which midwives practice is rapidly changing as the philosophy, structure and funding of the NHS across the four countries of the UK becomes increasingly diverse. Recent headlines have predicted the break-up of the National Health Service (NHS) in England ( [Lancet, 2011] and [Pollock, 2011]), and have highlighted that the devolution of the United Kingdom (UK) government is having an impact on the NHS far beyond what was anticipated at its introduction in 1999 ( [16], [3] and [28]). Within the UK, all relevant stakeholders including clinicians, educators, policy, service commissioning and service user representatives should be aware of the changing political landscape and the effect this may have on the provision of high quality maternity care across the UK. In this commentary we highlight some of the similarities and differences in the NHS across the four UK countries and reflect on some of the possible impacts on midwifery education and practice.

Impact of Enquiry Based Learning (EBL) on Student Midwife Praxis

Midwifery training in Ireland moved to Higher Education in 2006. This shift established a physical and educational separation of theory and practice. The adoption of Enquiry Based Learning (EBL) by one Irish midwifery education institution attempted to address this division. Enquiry Based Learning (EBL) has the potential to develop student reflexivity and evidence assimilation across the career-span and may therefore enhance student praxis. EBL has been championed as an example of an educational model that supports praxis, helping to create competent practitioners through the use of authentic learning scenarios that address the theory practice divide. The current research study represents the first formal evaluation of EBL in undergraduate midwifery education in the South of Ireland. The study was a mixed-methods design that utilised focus groups, interviews and survey to ascertain the opinions of first exposure to EBL amongst a cohort of first year student midwives. Findings demonstrate the value of EBL in enhancing student midwife praxis.

Maternal nutrition and fetal macrosomia in uncomplicated pregnancies: a prospective cohort study

Fetal macrosomia or delivery of a large for gestational age (LGA) infant (birthweight > 4000 g) in uncomplicated pregnancies is increasing in many Western countries which may have serious implications for maternal and neonatal morbidity (1) . While fetal macrosomia has an established link with maternal diabetes the majority of macrosomic infants are born to non-diabetic mothers (2) , with maternal obesity now considered an established risk factor for delivering a macrosomic baby (3) . Evidence relating to maternal nutrition and macrosomia is inconclusive with the majority of studies to date investigating associations between maternal nutrition and birthweight rather than macrosomia specifically. The aim of this study was to investigate maternal nutrition as a potential modifiable risk factor for fetal macrosomia. Low risk pregnant women predicted to deliver LGA infants (study group) and women predicted to deliver appropriate for gestational age (AGA) infants (control group) were recruited from antenatal clinics. Participants maintained a four day food diary in the third trimester of pregnancy. Demographic and obstetric data were collected from maternity records. Completed food diaries were imported into a food analysis database (WISPg). Total energy intake (TEI) and nutrient intakes were calculated. Data were analysed by recruitment groups (study and control group) and by delivery birthweight groups: predicted to and delivered a LGA infant (LGA:LGA); predicted to deliver a LGA infant but delivered an AGA infant (LGA:AGA); and, predicted to and delivered an AGA infant (AGA:AGA). Of the 114 women who participated in the study, 100 women completed the food diary at 32 (2.6) weeks gestation. Intake of PUFA n-3 was significantly higher in the study group (women predicted to deliver LGA infants) when compared to the control group, after adjustment for known variables associated with birthweight (p = 0.047). Further analyses by delivery birthweight demonstrated that intake of PUFA n-3 remained significantly different between delivery groups (p = 0.015), and post hoc analyses revealed that women in the LGA:AGA group consumed significantly higher PUFA n-3 than women in the LGA:LGA group (p = 0.044). Furthermore, LGA:AGA women had significantly higher TEI (p = 0.038), significantly higher intake of total fats (p = 0.029) and PUFA n-6 (p = 0.034) and significantly lower intake of carbohydrates (p = 0.032) after adjustment for variables associated with birthweight. Results suggest that an increased intake of PUFAs, combined with a decreased carbohydrate intake in the third trimester may have had a modifying effect on subsequent birthweight, in women predicted to have macrosomic babies. Further research is required to determine if adopting a diet high in PUFAs and low in carbohydrate can reduce the risk of macrosomia in low risk pregnancies.