Luc Budé

Antenatal interventions to reduce maternal distress: A systematic review and meta-analysis of randomised trials

Maternal distress can have adverse health outcomes for mothers and their children. Antenatal interventions may reduce maternal distress.

Preferred place of birth: Characteristics and motives of low-risk nulliparous women in the Netherlands

OBJECTIVE to explores preferences, characteristics and motives regarding place of birth of low-risk nulliparous women in the Netherlands. DESIGN a prospective cohort study of low-risk nulliparous women and their partners starting their pregnancy in midwifery-led care or in obstetric-led care. Data were collected using a self-administered questionnaire, including questions on demographic, psychosocial and pregnancy factors and statements about motives with regard to place of birth. Depression, worry and self-esteem were explored using the Edinburgh Depression Scale (EDS), the Cambridge Worry Scale (CWS) and the Rosenberg Self Esteem Scale (RSE). SETTING participants were recruited in 100 independent midwifery practices and 14 hospitals from 2007 to 2011. PARTICIPANTS 550 low-risk nulliparous women; 231 women preferred a home birth, 170 women a hospital birth in midwifery-led care and 149 women a birth in obstetric-led care. FINDINGS Significant differences in characteristics were found in the group who preferred a birth in obstetric-led care compared to the two groups who preferred midwifery-led care. Those women were older (F (2,551)=16.14, p<0.001), had a higher family income (χ(2) (6)=18.87, p=0.004), were more frequently pregnant after assisted reproduction (χ(2)(2)=35.90, p<0.001) and had a higher rate of previous miscarriage (χ(2)(2)=25.96, p<0.001). They also differed significantly on a few emotional aspects: more women in obstetric-led care had symptoms of a major depressive disorder (χ(2)(2)=6.54, p=0.038) and were worried about health issues (F (2,410)=8.90, p<0.001). Womens choice for a home birth is driven by a desire for greater personal autonomy, whereas womens choice for a hospital birth is driven by a desire to feel safe and control risks. KEY CONCLUSIONS the characteristics of women who prefer a hospital birth are different than the characteristics of women who prefer a home birth. It appears that for women preferring a hospital birth, the assumed safety of the hospital is more important than type of care provider. This brings up the question whether women are fully aware of the possibilities of maternity care services. Women might need concrete information about the availability and the characteristics of the services within the maternity care system and the risks and benefits associated with either setting, in order to make an informed choice where to give birth.

Influence on birthing positions affects women's sense of control in second stage of labour

OBJECTIVE to explore whether choices in birthing positions contributes to womens sense of control during birth. DESIGN survey using a self-report questionnaire. Multiple regression analyses were used to investigate which factors associated with choices in birthing positions affected womens sense of control. SETTING midwifery practices in the Netherlands. PARTICIPANTS 1030 women with a physiological pregnancy and birth from 54 midwifery practices. FINDINGS in the total group of women (n=1030) significant predictors for sense of control were: influence on birthing positions (self or self together with others), attendance of antenatal classes, feelings towards birth in pregnancy and pain in second stage of labour. For women who preferred other than supine birthing positions (n=204) significant predictors were: influence on birthing positions (self or self together with others), feelings towards birth in pregnancy, pain in second stage of labour and having a home birth. For these women, influence on birthing positions in combination with others had a greater effect on their sense of control than having an influence on their birthing positions just by themselves. KEY CONCLUSIONS women felt more in control during birth if they experienced an influence on birthing positions. For women preferring other than supine positions, home birth and shared decision-making had added value. IMPLICATIONS FOR PRACTICE midwives can play an important role in supporting women in their use of different birthing positions and help them find the positions they feel most comfortable in. Thus, contributing to womens positive experience of birth.

Weight gain in healthy pregnant women in relation to pre-pregnancy BMI, diet and physical activity

OBJECTIVE to explore gestational weight gain in healthy women in relation to pre-pregnancy Body Mass Index, diet and physical activity. DESIGN a cross-sectional survey was conducted among 455 healthy pregnant women of all gestational ages receiving antenatal care from an independent midwife in the Netherlands. Weight gain was assessed using the Institute of Medicine (IOM) guidelines and classified as below, within, or above the guidelines. A multinomial regression analysis was performed with weight gain classifications as the dependent variable (within IOM-guidelines as reference). Independent variables were pre-pregnancy Body Mass Index, diet (broken down into consumption of vegetables, fruit and fish) and physical activity (motivation to engage in physical activity, pre-pregnancy physical activity and decline in physical activity during pregnancy). Covariates were age, gestational age, parity, ethnicity, family income, education, perceived sleep deprivation, satisfaction with pre-pregnancy weight, estimated prepregnancy body mass index, smoking, having a weight gain goal and having received weight gain advice from the midwife. FINDINGS forty-two per cent of the women surveyed gained weight within the guidelines. Fourteen per cent of the women gained weight below the guidelines and 44 per cent gained weight above the guidelines. Weight gain within the guidelines, compared to both above and below the guidelines, was not associated with pre-pregnancy Body Mass Index nor with diet. A decline in physical activity was associated with weight gain above the guidelines (OR 0.54, 95 per cent CI 0.33-0.89). Weight gain below the guidelines was seen more often in women who perceived a greater sleep deprivation (OR 1.20, 95 per cent CI 1.02-1.41). Weight gain above the guidelines was seen less often in Caucasian women in comparison to non-Caucasian women (OR 0.22, 95 per cent CI 0.08-0.56) and with women who did not stop smoking during pregnancy (OR 0.49, 95 per cent CI 0.25-0.95). KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE a decline in physical activity was the only modifiable factor in our population associated with weight gain above the gain recommended by the guidelines. Prevention of reduced physical activity during pregnancy seems a promising approach to promoting healthy weight gain. Interventions to promote healthy weight gain should focus on all women, regardless of pre-pregnancy body mass index.

Patterns of gestational weight gain in healthy, low-risk pregnant women without co-morbidities

BACKGROUND little is known of the impact of gestational weight gain (GWG) in relation to Body Mass Index (BMI) classification on perinatal outcomes in healthy pregnant women without co-morbidities. As a first step, the prevalence of obesity and the distribution of GWG in relation to the Institute of Medicine (IOM) 2009 guidelines for GWG were examined. METHODS data from a prospective cohort study of - a priori - low risk, pregnant women from five midwife-led practices (n=1449) were analysed. Weight was measured at 12, 24 and 36 weeks. FINDINGS at 12 weeks, 1.4% of the women were underweight, 53.8% had a normal weight, 29.6% were overweight, and 15.1% were obese according to the WHO classification of BMI. In our study population, 60% of the women did not meet the IOM recommendations: 33.4% had insufficient GWG and 26.7% gained too much weight. Although BMI was negatively correlated to total GWG (p<.001), overweight and obese women class I had a significant higher risk of exceeding the IOM guidelines. Normal weight women had a significantly higher risk of gaining less weight than recommended. Obese women classes II and III were at risk in both over- and undergaining. CONCLUSIONS our data showed that the majority of women were unable to stay within recommended GWG ranges without additional interventions. The effects on pregnancy and health outcomes of falling out the IOM guidelines remain unclear for - a priori - low risk women. Since interventions to control GWG would have considerable impact on women and caregivers, harms and benefits should be well-considered before implementation.

Factors influencing maternal distress among Dutch women with a healthy pregnancy

BACKGROUND Maternal distress is a public health concern. Assessment of emotional wellbeing is not integrated in Dutch antenatal care. Midwives need to understand the influencing factors in order to identify women who are more vulnerable to experience maternal distress. OBJECTIVE To examine levels of maternal distress during pregnancy and to determine the relationship between maternal distress and aetiological factors. METHODS A cross-sectional study including 458 Dutch-speaking women with uncomplicated pregnancies during all trimesters of pregnancy. Data were collected with questionnaires between 10 September and 6 November 2012. Demographic characteristics and personal details were obtained. Maternal distress was measured with the Edinburgh Depression Scale (EDS), State-Trait Anxiety Inventory (STAI), and Pregnancy-Related Anxiety Questionnaire (PRAQ). Behaviour was measured with Coping Operations Preference Enquiry-Easy (COPE-Easy). Descriptive statistics and multiple linear regression analysis were used. RESULTS Just over 20 percent of the women in our sample (21.8%) had a heightened score on one or more of the EDS, STAI or PRAQ. History of psychological problems (B=1.071; p=.001), having young children (B=2.998; p=.001), daily stressors (B=1.304; p=<.001), avoidant coping (B=1.047, p=<.001), somatisation (B=.484; p=.004), and negative feelings towards the forthcoming birth (B=.636; p=<.001) showed a significant positive relationship with maternal distress. Self-disclosure (B=-.863; p=.004) and acceptance of the situation (B=-.542; p=.008) showed a significant negative relationship with maternal distress. CONCLUSION Maternal distress occurs among women with a healthy pregnancy and is significantly influenced by a variety of factors. Midwives need to recognise the factors that make women more vulnerable to develop and experience maternal distress in order to give adequate advice about how to best cope with this condition.

The impact of obesity on outcomes of midwife-led pregnancy and childbirth in a primary care population: a prospective cohort study

To assess the impact of obesity on the likelihood of remaining in midwife‐led care throughout pregnancy and childbirth.

Dutch Midwives' Behavior and Determinants in Promoting Healthy Gestational Weight Gain, Phase 1: A Qualitative Approach

BACKGROUND: A significant contributor to the global threat of obesity is excessive gestational weight gain (GWG). The aim of this article is to explore Dutch primary care midwives’ behaviors in promoting healthy GWG. METHODS: We used the attitude–social influence–self-efficacy (ASE) model to guide interviews with a purposive sample of 6 midwives working in primary care. RESULTS: Midwives reported activities in 3 areas related to GWG: GWG monitoring (weighing and discussing GWG), diet education, and to a lesser degree physical activity education. The determinants from the ASE model were confirmed and other relevant determinants, including midwives’ perception of their role in health promotion, were added. PRACTICE IMPLICATIONS: The identified determinants can be used for quantitative research. Quantitative research is necessary to identify the magnitude of the determinants associated with midwives’ behavior in promoting healthy GWG.

Factors affecting perceived change in physical activity in pregnancy

OBJECTIVE reduction of physical activity (PA) during pregnancy is common but undesirable, as it is associated with negative outcomes, including excessive gestational weight gain. Our objective was to explore changes in five types of activity that occurred during pregnancy and the behavioural determinants of the reported changes in PA. DESIGN we performed a secondary analysis of a cross sectional survey that was constructed using the ASE-Model - an approach to identifying the factors that drive behaviour change that focuses on Attitude, Social influence, and self-Efficacy. PARTICIPANTS 455 healthy pregnant women of all gestational ages, receiving prenatal care from midwifery practices in the Netherlands. FINDINGS more than half of our respondents reported a reduction in their PA during pregnancy. The largest reduction occurred in sports and brief rigorous activities, but other types of PA were reduced as well. Reduction of PA was more likely in women who considered themselves as active before pregnancy, women who experienced pregnancy-related barriers, women who were advised to reduce their PA, and multiparous women. Fewer than 5% increased their PA. Motivation to engage in PA was positively associated with enjoying PA. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE all pregnant women should be informed about the positive effects of staying active and should be encouraged to engage in, or to continue, moderately intensive activities like walking, biking or swimming. Our findings concerning the predictors of PA reduction can be used to develop an evidence-based intervention aimed at encouraging healthy PA during pregnancy.

Effect of the use of a national information brochure about foetal movements on patient delay

BACKGROUND Perinatal audits in the Netherlands showed that stillbirth was nearly always preceded by a period of reduced fetal movements. Patient or caregiver delay was identified as a substandard care factor. AIM To determine whether the use of a new information brochure for pregnant women on fetal movements results in less patient delay in contacting their maternity caregiver. METHODS A pre- and post-survey cohort study in the Netherlands, including 140 women in maternity care with a singleton pregnancy, expecting their first child. All participating women filled out a baseline questionnaire, Cambridge Worry Scale and pre-test questionnaire at the gestational age of 22-24 weeks. Subsequently, the intervention group received a newly developed information brochure on fetal movements. At a gestational age of 28 weeks, all women received the post-test questionnaire. Multiple regression analyses were used. FINDINGS Per-protocol analysis showed less patient delay in the intervention group compared to the control group (Odds Ratio 0.43; 95% Confidence Interval 0.17-0.86, p=0.02). A significant linear relation was observed between reading the information brochure and an increase of knowledge about fetal movements (B=1.2, 95% Confidence Interval 1.0-1.4, p<0.001). Maternal concerns did not affect patient delay to report reduced fetal movements. CONCLUSION Use of an information brochure regarding fetal movements has the potential to reduce patient delay and increase knowledge about reduced fetal movements. A national survey to determine the effect of an information brochure about reduced fetal movements on patient delay and stillbirth rates is needed.