Kathleen Fahy

Factors that positively influence breastfeeding duration to 6 months: A literature review

QUESTION What modifiable factors positively influence breastfeeding duration to 6 months postpartum? AIM This question was posed in order to be able to develop a midwifery intervention aimed at prolonging breastfeeding. METHOD An online literature search was conducted in Medline, CINAHL, Maternity and Infant Care, and Cochrane Database of systematic reviews. The search strategy included the following keywords: breastfeeding, duration, initiation, cessation, factors, intervention, education, partner, intention, confidence, self-efficacy and support. Additional studies were located and extracted from online publications of New South Wales Department of Health, Australia. Bio-psycho-social factors that are positively associated with breastfeeding duration were identified. RESULTS Modifiable factors that influence womens breastfeeding decisions are: breastfeeding intention, breastfeeding self-efficacy and social support. Existing midwifery breastfeeding promotion strategies often include social support but do not adequately address attempts to modify breastfeeding intention and self-efficacy. CONCLUSION The modifiable factors that are positively associated with breastfeeding duration are the womans breastfeeding intention, her breastfeeding self-efficacy and her social support. Intervention studies to date have focussed on modifying these factors individually with variable results. No interventional studies have been conducted with the aim of positively modifying all three factors simultaneously.

REFLECTING ON PRACTICE TO THEORISE EMPOWERMENT FOR WOMEN: USING FOUCAULT'S CONCEPTS

The aim of this research is to understand how power operates in the medical encounter with the childbearing woman and to theorize ways in which midwives can empower women to experience control over what happens to them. Thirty-three Australian pregnant young women and the researcher participated in this study. A post-modern, feminist praxis approach was the research method used. Data was collected using participant observation, in-depth interviewing and reflective journaling. Data was analysed using Michel Foucaults theoretical concepts concerning disciplinary power/knowledge. Key theoretical findings are: knowing how power operates allows midwives to predict what will happen if the woman is intending to resist standardised medical birthing practices. When disciplinary medical power is used the purpose is to coerce patients to do what the doctor wants. Power and knowledge are inseparable, as each strengthens the other, thus Foucault writes of a single concept--Power/Knowledge. Medical power operates most effectively with the co-operation of the midwife and the submission of the childbearing woman. Medical power is normally invisible; it only becomes visible when resistance is encountered, whereupon rewards, threats and punishments are used in an attempt to gain submission. Women can be more empowered if the midwife shares knowledge, not just about pregnancy, labour and birth, but also about the womans legal rights and what might happen if she decides to refuse standardised medical care. In this way womens empowerment can be facilitated so that they are more likely to experience the type of childbirth they desire.

Trusting enough to be out of control: a pilot study of women's sense of self during childbirth

The findings of a pilot study undertaken to determine what features of childbirth have a positive effect on womens sense of self are presented in this paper. This research contrasted the midwifery and medical models of maternity care using feminist constructivism, personal narrative and a thematic analysis. Using theory that is strongly grounded in empirical data, this paper outlines the influence of features inherent in the womans experience of childbirth that have been theoretically linked to how women feel about themselves. Primary focus was given to the internal characteristics that enable the woman to feel positive about herself during labour, birth and afterwards. The importance of the woman releasing mind control and allowing herself to move into an altered conscious state during labour is discussed in terms of womens subsequent enhanced sense of self. Results illustrate how women are more likely to trust enough to let go of mind control and release control of their bodies when supported within a midwifery model rather than when cared for in the medical model.

Decision-making theories and their usefulness to the midwifery profession both in terms of midwifery practice and the education of midwives.

What are the strengths and limitations of existing Decision-Making Theories as a basis for guiding best practice clinical decision-making within a framework of midwifery philosophy? Each theory is compared in relation with how well they provide a teachable framework for midwifery clinical reasoning that is consistent with midwifery philosophy. Hypothetico-Deductive Theory, from which medical clinical reasoning is based; intuitive decision-making; Dual Processing Theory; The International Confederation of Midwives Clinical Decision-Making Framework; Australian Nursing and Midwifery Council Midwifery Practice Decisions Flowchart and Midwifery Practice. Best practice midwifery clinical Decision-Making Theory needs to give guidance about: (i) effective use of cognitive reasoning processes; (ii) how to include contextual and emotional factors; (iii) how to include the interests of the baby as an integral part of the woman; (iv) decision-making in partnership with woman; and (v) how to recognize/respond to clinical situations outside the midwifes legal/personal scope of practice. No existing Decision-Making Theory meets the needs of midwifery. Medical clinical reasoning has a good contribution to make in terms of cognitive reasoning processes. Two limitations of medical clinical reasoning are its reductionistic focus and privileging of reason to the exclusion of emotional and contextual factors. Hypothetico-deductive clinical reasoning is a necessary but insufficient condition for best practice clinical decision-making in midwifery.

Writing for publication: The basics

PROBLEM Most midwives and nurses do not write for publication. Previous authors on this topic have focussed on the processes of writing and getting published. Although definitive English usage style guides exist, they are infrequently consulted by new midwifery authors. PURPOSE To enable new writers to confidently apply the basic skills of scientific writing when preparing a paper for publication. OVERVIEW The basic skills needed for scientific writing are the focus of this paper. The importance of careful word choices is discussed first. Next, the skills of writing sentences are presented. Finally, the skills of writing paragraphs are discussed. Examples of poor and better writing are given in relation to each of these basic elements.

What do midwives need to understand/know about smoking in pregnancy?

AIM This paper seeks to help midwives more fully understand smoking in pregnancy, particularly from a midwifery partnership perspective. METHOD Using the midwifery philosophy of partnership as a framework for reviewing literature on smoking in pregnancy, we explored the literature on nicotine metabolism and addiction in general, and the changes that occur in pregnancy. Quit smoking interventions commonly used were examined to see if knowledge about addiction and the physiological adaptations of pregnancy are incorporated into anti-smoking efforts aimed at pregnant women. RESULTS Quitting is harder for the pregnant woman because the physiological adaptations of pregnancy increase the clearance of nicotine thus lowering nicotine levels and increasing the desire to smoke. Women who continue to smoke generally have fewer external sources of pleasure and satisfaction in their lives, which, when combined with the physiological and emotional challenges of pregnancy, means that they are less likely to quit smoking and remain abstinent. These factors do not appear to be taken into account for pregnant smokers. The concept of partnership between women and midwives during anti-smoking interactions is lacking. CONCLUSION Midwives are in a position to support women and their families in all health related issues, including smoking cessation. We recommend that midwives ask permission before making enquires about sensitive issues such as smoking. When discussing smoking with pregnant women, midwives work within the philosophy of midwifery, with the emphasis on building trust and maintaining relationships. Great sensitivity is required and as much as possible the conversation should be a dialogue, not a monologue.

Effects of skin-to-skin contact and breastfeeding at birth on the incidence of PPH: A physiologically based theory

BACKGROUND The importance of optimising maternal/baby psychophysiology has been integrated into contemporary midwifery theories but not in the detail required to really understand the underpinning biological basis. METHOD The functioning of the autonomic nervous system, as it relates to the uterus is reviewed. The physiology of myometrial cell contraction and relaxation is outlined. The main focus is on the factors that affect the availability and uptake of oxytocin and adrenaline/noradrenaline in the myometrial cells. These are the two key neuro-hormones, active in the 3rd and 4th stages of labour, that affect uterine contraction and retraction and therefore determine whether the woman will have an atonic PPH or not. DISCUSSION The discussion explains and predicts the physiological functioning of the uterus during the 3rd and 4th stages of labour when skin-to-skin contact and breastfeeding occurs and when it does not. CONCLUSION This biologically based theory hypothesises that to achieve and maintain eutony and eulochia, midwives and birthing women should ensure early, prolonged and undisturbed skin-to-skin contact for mother and baby at birth including easy access for spontaneous breastfeeding.

Reducing length of stay for women who present as outpatients to delivery suite: A clinical practice improvement project

PROBLEM Access block is an increasing problem in delivery suites due to the rising birth rates. As well as more labouring women, more women are presenting to delivery suite with pregnancy concerns (at 18 weeks gestation and over). Waiting times for women with pregnancy concerns were prolonged because, prior to the implementation of the present project, these women were required to be assessed by a midwife and then a medical officer. AIM The aim of this project was to safely and effectively reduce the length of stay of pregnant women presenting with pregnancy concerns who were managed as outpatients in the delivery suite. PROJECT SETTING: The project was undertaken in the Delivery Suite of a major tertiary referral hospital, NSW, Australia. METHODS The project team used clinical practice improvement methodology (clinical audit, outpatient flow mapping, flowcharting, cause and effect diagrams, brainstorming, multi-voting and Pareto charting) to investigate and propose recommendations to improve the clinical process for this group of women. SUBJECTS Five hundred thirty two pregnant women who were not in labour. INTERVENTION The interventions involved developing the new clinical midwifery pathways and standing orders for the categories of cases where the midwives were able to assess, order tests and make independent clinical decisions; selecting, training and accrediting the advanced practice midwives; implementing the new clinical pathways; and evaluating the effectiveness, cost and stakeholder satisfaction levels with the changes. FINDINGS The average length of stay was reduced from 178.4 to 91.5min (49%) p<0.001. Approximately 8h a week of midwifery specialist time (AU

The effectiveness of medical interventions aimed at preventing preterm birth: a literature review.

33.75 per hour) was estimated to have been saved each week during the project at a cost saving of about AU

Quality and significance of Australian midwifery research

270.00 per week. The yearly projected saving would be AU