Sally Baddock

Planned Place of Birth in New Zealand: Does it Affect Mode of Birth and Intervention Rates Among Low‐Risk Women?

BACKGROUND Midwives providing care as lead maternity caregivers in New Zealand provide continuity of care to women who may give birth in a variety of settings, including home, primary units, and secondary and tertiary level hospitals. The purpose of this study was to compare mode of birth and intrapartum intervention rates for low-risk women planning to give birth in these settings under the care of midwives. METHODS Data for a cohort of low-risk women giving birth in 2006 and 2007 were extracted from the Midwifery Maternity Provider Organisation database. Mode of birth, intrapartum interventions, and neonatal outcomes were compared with results adjusted for age, parity, ethnicity, and smoking. RESULTS Women planning to give birth in secondary and tertiary hospitals had a higher risk of cesarean section, assisted modes of birth, and intrapartum interventions than similar women planning to give birth at home and in primary units. The risk of emergency cesarean section for women planning to give birth in a tertiary unit was 4.62 (95% CI: 3.66-5.84) times that of a woman planning to give birth in a primary unit. Newborns of women planning to give birth in secondary and tertiary hospitals also had a higher risk of admission to a neonatal intensive care unit (RR: 1.40, 95% CI: 1.05-1.87; RR: 1.78, 95% CI: 1.31-2.42) than women planning to give birth in a primary unit. CONCLUSIONS Planned place of birth has a significant influence on mode of birth and rates of intrapartum intervention in childbirth.

Bed-sharing and the infant’s thermal environment in the home setting

Aims: To study bed-sharing and cot-sleeping infants in the natural setting of their own home in order to identify differences in the thermal characteristics of the two sleep situations and their potential hazards. Methods: Forty routine bed-sharing infants and 40 routine cot-sleeping infants aged 5–27 weeks were individually matched between groups for age and season. Overnight video and physiological data of bed-share infants and cot-sleeping infants were recorded in the infants’ own homes including rectal, shin, and ambient temperature. Results: The mean rectal temperature two hours after sleep onset for bed-share infants was 36.79°C and for cot-sleeping infants, 36.75°C (difference 0.05°C, 95% CI −0.03 to 0.14). The rate of change thereafter was higher in the bed-share group than in the cot group (0.04°C v 0.03°C/h, difference 0.01, 0.00 to 0.02). Bed-share infants had a higher shin temperature at two hours (35.43 v 34.60°C, difference 0.83, 0.18 to 1.49) and a higher rate of change (0.04 v −0.10°C/h, difference 0.13, 0.08 to 0.19). Bed-sharing infants had more bedding. Face covering events were more common and bed-share infants woke and fed more frequently than cot infants (mean wake times/night: 4.6 v 2.5). Conclusions: Bed-share infants experience warmer thermal conditions than those of cot-sleeping infants, but are able to maintain adequate thermoregulation to maintain a normal core temperature.

Risk of severe postpartum hemorrhage in low-risk childbearing women in new zealand: exploring the effect of place of birth and comparing third stage management of labor.

BACKGROUND Primary postpartum hemorrhage is a leading cause of maternal mortality and morbidity internationally. Research comparing physiological (expectant) and active management of the third stage of labor favors active management, although studies to date have focused on childbirth within hospital settings, and the skill levels of birth attendants in facilitating physiological third stage of labor have been questioned. The aim of this study was to investigate the effect of place of birth on the risk of postpartum hemorrhage and the effect of mode of management of the third stage of labor on severe postpartum hemorrhage. METHODS Data for 16,210 low-risk women giving birth in 2006 and 2007 were extracted from the New Zealand College of Midwives research database. Modes of third stage management and volume of blood lost were compared with results adjusted for age, parity, ethnicity, smoking, length of labor, mode of birth, episiotomy, perineal trauma, and newborn birthweight greater than 4,000 g. RESULTS In total, 1.32 percent of this low-risk cohort experienced an estimated blood loss greater than 1,000 mL. Place of birth was not found to be associated with risk of blood loss greater than 1,000 mL. More women experienced blood loss greater than 1,000 mL in the active management of labor group for all planned birth places. In this low-risk cohort, those women receiving active management of third stage of labor had a twofold risk (RR: 2.12, 95% CI: 1.39-3.22) of losing more than 1,000 mL blood compared with those expelling their placenta physiologically. CONCLUSIONS Planned place of birth does not influence the risk of blood loss greater than 1,000 mL. In this low-risk group active management of labor was associated with a twofold increase in blood loss greater than 1,000 mL compared with physiological management. (BIRTH 39:2 June 2012).

Hypoxic and Hypercapnic Events in Young Infants During Bed-sharing

OBJECTIVES: To identify desaturation events (arterial oxygen saturation [Sao2] <90%) and rebreathing events (inspired carbon dioxide (CO2) >3%), in bed-sharing (BS) versus cot-sleeping (CS) infants. METHODS: Forty healthy, term infants, aged 0 to 6 months who regularly bed-shared with at least 1 parent >5 hours per night and 40 age-matched CS infants were recruited. Overnight parent and infant behavior (via infrared video), Sao2, inspired CO2 around the infant’s face, and body temperature were recorded during sleep at home. RESULTS: Desaturation events were more common in BS infants (risk ratio = 2.17 [95% confidence interval: 1.75 to 2.69]), associated partly with the warmer microenvironment during BS. More than 70% of desaturations in both groups were preceded by central apnea of 5 to 10 seconds with no accompanying bradycardia, usually in active sleep. Apnea >15 seconds was rare (BS infants: 3 events; CS infants: 6 events), as was desaturation <80% (BS infants: 3 events; CS infants: 4 events). Eighty episodes of rebreathing were identified from 22 BS infants and 1 CS infant, almost all preceded by head covering. During rebreathing, Sao2 was maintained at the baseline of 97.6%. CONCLUSIONS: BS infants experienced more oxygen desaturations preceded by central apnea, partly related to the warmer microenvironment. Rebreathing occurred mainly during bed-sharing. Infants were at low risk of sudden infant death syndrome and maintained normal oxygenation. The effect of repeated exposure to oxygen desaturation in vulnerable infants is unknown as is the ability of vulnerable infants to respond effectively to rebreathing caused by head covering.

Wahakura Versus Bassinet for Safe Infant Sleep: A Randomized Trial

OBJECTIVES: To compare an indigenous sleep device (wahakura) for infants at high risk for sudden unexpected death with a bassinet, for measures of infant sleep position, head covering, breastfeeding, bed-sharing, and maternal sleep and fatigue. METHODS: A total of 200 mainly Māori pregnant women were recruited from deprived areas of New Zealand. They were randomized to receive a bassinet or wahakura and asked to sleep the infant in this device from birth. Questionnaires at 1, 3, and 6 months and an overnight infrared video in the home at 1 month were completed. RESULTS: An intention-to-treat and an “as-used” analysis of questionnaires showed no group differences at 1, 3, and 6 months in infant-adult direct bed-sharing (7% vs 12%, P = .24 at 1 month), and at the 6-month interview, the wahakura group reported twice the level of full breastfeeding (22.5% vs 10.7%, P = .04). Maternal sleep and fatigue were not significantly different between groups. Video identified no increase in head covering, prone/side sleep position, or bed-sharing in the wahakura group, either from intention-to-treat analysis, or when analyzed for actual sleep location. CONCLUSION There were no significant differences in infant risk behaviors in wahakura compared with bassinets and there were other advantages, including an increase in sustained breastfeeding. This suggests wahakura are relatively safe and can be promoted as an alternative to infant-adult bed-sharing. Policies that encourage utilization are likely to be helpful in high-risk populations.

The Pēpi-Pod study: Overnight video, oximetry and thermal environment while using an in-bed sleep device for sudden unexpected death in infancy prevention: The Pēpi-Pod study

The aim of this study was to identify the potential risks and benefits of sleeping infants in a Pēpi‐Pod distributed to families with high risk of sudden unexpected death in infancy compared to a bassinet.

Becoming a midwife: A survey study of midwifery alumni

BACKGROUND Becoming a competent midwife is a complex process. The aim of midwifery education is to support the development of competence in midwifery skills, knowledge and to prepare graduates to meet the responsibilities inherent in the midwifery role. AIM To explore the experiences of our alumni midwives, ask how well they perceived their midwifery programme had prepared them for beginning midwifery practice and to identify any curriculum changes, or postgraduate study topics, that would support the transition to midwifery practice. METHODS An online survey was conducted with alumni of a Bachelor of Midwifery programme (New Zealand) who graduated between 2011 and 2014. The quantitative data were analysed using descriptive statistics, and a general inductive approach was used to develop themes from the qualitative data in the comment boxes. FINDINGS Forty-two alumni viewed becoming a midwife as a blend/combination of: (1) gaining the knowledge and practical skills required for the profession; (2) management skills in areas of running a business, working with other people, navigating local procedures and processes effectively, and balancing work with personal life; (3) gaining confidence in ones competence, and (4) having support along the way. DISCUSSION Competence in current evidence-based midwifery knowledge and practice is important in educating midwifery students. However, to transition to practice, a supportive environment is needed to assist midwives to develop self-management, business skills, and the confidence to negotiate and collaborate with colleagues and other health professionals. CONCLUSIONS Not only did midwifery knowledge and practice skills matter for alumni, but also the acquisition of management skills, strategies for building confidence, and ongoing support. Content that facilitates these requirements should be included in midwifery programmes to support the transition from student to practitioner.

Predictors of breastfeeding duration in a predominantly Māori population in New Zealand

BackgroundAlthough breastfeeding duration in New Zealand’s indigenous Māori is shorter than in non-Māori, we know little about barriers or motivators of breastfeeding in this community. The aim of this analysis was to identify predictors for extended duration of breastfeeding amongst participants drawn from predominantly Māori communities in regional Hawke’s Bay.MethodsMother/baby dyads were recruited from two midwifery practices serving predominantly Māori women in mostly deprived areas, for a randomised controlled trial comparing the risks and benefits of an indigenous sleeping device (wahakura) and a bassinet. Questionnaires were administered at baseline (pregnancy) and at one, three and six months postnatal. Several questions relating to breastfeeding and factors associated with breastfeeding were included. The data from both groups were pooled to examine predictors of breastfeeding duration.ResultsMāori comprised 70.5% of the 197 participants recruited. The median time infants were fully breastfed was eight weeks and Māori women were more likely to breastfeed for a shorter duration than New Zealand European women with an odds-ratio (OR) of 0.45 (95% CI 0.24, 0.85). The key predictors for extended duration of breastfeeding were the strong support of the mother’s partner (OR = 3.64, 95% CI 1.76, 7.55) or her mother for breastfeeding (OR = 2.47, 95% CI 1.27, 4.82), longer intended duration of maternal breastfeeding (OR = 1.02, 95% CI 1.00, 1.03) and being an older mother (OR = 1.07, 95% CI 1.02, 1.12). The key predictors for shorter duration of breastfeeding were pacifier use (OR = 0.28, 95% CI 0.17, 0.46), daily cigarette smoking (OR = 0.51, 95% CI 0.37, 0.69), alcohol use (OR = 0.54, 95% CI 0.31, 0.93) and living in a more deprived area (OR 0.40, 95% CI 0.22, 0.72).ConclusionsBreastfeeding duration in this group of mainly Māori women was shorter than the national average. Increasing the duration of breastfeeding by these mothers could be further facilitated by ante and postnatal education involving their own mothers and their partners in the support of breastfeeding and by addressing pacifier use, smoking and alcohol use.

Physiological stability in an indigenous sleep device: a randomised controlled trial

Objective To compare overnight oxygen saturation, heart rate and the thermal environment of infants sleeping in an indigenous sleep device (wahakura) or bassinet to identify potential risks and benefits. Design Randomised controlled trial. Setting Family homes in low socio-economic areas in New Zealand. Patients 200 mainly Māori mothers and their infants. Interventions Participants received a wahakura or bassinet from birth. Main outcome measures Overnight oximetry, heart rate and temperature at 1 month. Results Intention-to-treat analysis for 83 bassinet and 84 wahakura infants showed no significant differences between groups for the mean time oxygen saturation (SpO2) was less than 94% (0.54 min, 95% CI -1.36 to 2.45) or less than 90% (0.22 min, 95% CI -0.56 to 1.00), the mean number of SpO2 dips per hour >5% (-0.19, 95% CI -3.07 to 2.69) or >10% (-0.41, 95% CI -1.63 to 0.81), mean heart rate (1.99 beats/min, 95% CI -1.02 to 4.99), or time shin temperature >36°C (risk ratio (RR): 0.63, 95% CI 0.13 to 2.99) or <34°C (RR: 0.89, 95% CI 0.61 to 1.30). A per-protocol analysis of 45 bassinet and 26 wahakura infants and an as-used analysis of 104 infants in a bassinet and 48 in a wahakura found no significant differences between groups for all outcome measures. Conclusions This indigenous sleep device is at least as safe as the currently recommended bassinet, which supports its use as a sleep environment that offers an alternative way of bed-sharing. Trial registration number Australian New Zealand Clinical Trials Registry: ACTRN12610000993099.

Predictors of supplementation for breastfed babies in a Baby-Friendly hospital

PROBLEM Supplementation of breastfed babies is common during the hospital stay. BACKGROUND The Baby Friendly Hospital Initiative (BFHI) optimises practices to support exclusive breastfeeding, yet supplementation is still prevalent. OBJECTIVE To determine predictors for supplementation in a cohort of breastfed babies in a Baby-Friendly hospital. METHODS Electronic hospital records of 1530 healthy term or near term singleton infants and their mothers were examined retrospectively and analysed to identify factors associated with in-hospital supplementation using Poisson regression (unadjusted and adjusted). FINDINGS Fifteen percent of breastfed infants were supplemented during their hospital stay. Analysis by multivariable Poisson regression found that supplementation was independently associated with overweight (reference normal weight) (aRR [adjusted relative risk]=1.46; 95% CI: 1.11-1.93); primiparity (aRR=1.40; 95% CI: 1.09-1.80); early term gestation (37-376 weeks, aRR=2.79; 95% CI: 1.88-4.15; 38-386 weeks, aRR=2.03, 95%CI: 1.46-2.82); birthweight less than 2500 grams (reference 3000-3499 grams) (aRR=3.60; 95% CI: 2.32-5.60) and use of postpartum uterotonic (aRR=2.47; 95% CI: 1.09-5.55). Greater than 65 minutes of skin-to-skin contact at birth reduced the risk of supplementation (aRR=0.66; 95% CI; 0.48-0.92). CONCLUSION These identified predictors for supplementation, can inform the development of interventions for mother-infant pairs antenatally or in the early postpartum period around increased breastfeeding education and support to reduce supplementation. It may also be possible to reduce supplementation through judicious use of postpartum uterotonics and facilitation of mother-infant skin-to-skin contact at birth for greater than one hour duration.