MIDIRS Midwifery Digest December 2017 issue

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MIDIRS Midwifery Digest

Midwifery Digest

December 2017, volume 27, number 4

ISSN 0961-5555


December 2017, volume 27, number 4, 409-544

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Cathy Ashwin

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email: digest@midirs.org www.midirs.org Midwives Information & Resource Service Brunel House, 11 The Promenade, Clifton, Bristol, BS8 3NG, England

Editorial Board Dr Cathy Ashwin

Head of MIDIRS

Michelle Anderson

Practice Development Midwife, Buckinghamshire Healthcare Trust

Dr Rita Borg-Xuereb

Head of Midwifery Education, University of Malta

Elizabeth Duff

Freelance Journalist on Maternity and Family Care

Dr Grace Edwards

Professor of Midwifery, Aga Khan University, Uganda

Professor Edith Hillan

University of Toronto, Canada

Sophie Hinsliff

Midwife and NCT Antenatal Teacher

Karen Gallagher

Midwife, Paisley, Renfrewshire

Professor Jayne Marshall Foundation Professor of Midwifery, University of Leicester Dr Tania McIntosh

Principal Lecturer in Midwifery, University of Brighton

Dr Jenny McNeill

Lecturer in Midwifery Research, Queen’s University Belfast

Crecious M Muleya

Midwife Lecturer, University of Zambia

MIDIRS Advisory Committee Dr Cathy Ashwin

Head of MIDIRS

Dr Kuldip Bharj

Senior Lecturer in Midwifery Education, University of Leeds

Dr Tracey Cooper

Head of Midwifery, Warrington & Halton NHS Foundation Trust

Caroline Flint

NCT Trustee and Midwife

Professor Ann Thomson Professor Emerita of Midwifery, University of Manchester

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MIDIRS Midwifery Digest 27:4 2017

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Contents Housekeeping............................................................................................................................ 409 Contents.................................................................................................................................... 410 Editorial..................................................................................................................................... 412

413 Hot Topic Public and patient involvement in research: a partnership to make a difference in health research ...................................................................................................... 413 Margaret O’Hara

419 Research & Education How organisation values and engagement with service users can impact on care quality and experience .............................................................................................................. 419 Amanda Price-Davey An enquiry-based learning curriculum can help student midwives to explore the promotion of normal birth in the context of current maternity service provision ........................................ 424 Lynne Mason Premature rupture of the amniotic sac: managing the risks ....................................................... 429 Paul Stillman, Emma Herbert Site-specific onset of low bone density and correlation of bone turnover markers in exclusive breastfeeding mothers ................................................................................................ 433 Jarinthorn Teerapornpuntakit, Pharuhas Chanprapaph, Nitsara Karoonuthaisiri et al Vulnerability of pregnant women in clinical research ................................................................ 434 Indira SE van der Zande, Rieke van der Graaf, Martijn A Oudijk et al

435 Midwifery What are women’s experiences of maternity care in Ireland from a human rights perspective? .435 Leah Murphy Leadership, autonomy and the newly qualified midwife ........................................................... 441 Yvonne Nolan What factors affect the emotional well-being of newly qualified midwives in their first year of practice? ................................................................................................................. 444 Alexandra Bacchus, Amanda Firth The core of the core: what is at the heart of hospital core midwifery practice in New Zealand? 451 Andrea Gilkison, Judith McAra-Couper, Anna Fielder et al Hyperemesis in Pregnancy Study: a pilot randomised controlled trial of midwife-led outpatient care ......................................................................................................................... 452 Catherine McParlin, Debbie Carrick-Sen, Ian N Steen et al

453 Pregnancy Diagnosis and screening of gestational diabetes: conflicts of policy ........................................... 453 Judith Kennedy A healthy respect for pre-eclampsia .......................................................................................... 457 Hannah Wilson, Hannah Nathan, Andrew Shennan Supporting women with autism during pregnancy, birth and beyond ........................................ 462 Lesley Turner

467 Labour & Birth Taking the drama out of obstetric theatre: implementing change .............................................. 467 Alison Brodrick, Helen Baston Why water birth? Exploring the barriers and challenges for midwives ...................................... 472 Mary Edmondson


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479 Postnatal How effective are warm compresses and perineal massage at reducing perineal trauma? A review of the evidence ............................................................................................................ 479 Melissa Newman A review of the effect of using the non-pneumatic anti-shock garment as an emergency device to prevent postpartum haemorrhage .............................................................................. 483 Adedoyin Mulikat Adeosun, Alison Brettle The effectiveness of prescription exercises for women diagnosed with postnatal depression: a systematic review ..................................................................................................................... 488 Anna-Maria Brown, Ann Robinson, Felicity Jones et al Psychological growth after childbirth: an exploratory prospective study ................................... 496 Daisuke Nishi, Kentaro Usuda

497 Infant Nutrition Lactation following bereavement: how can midwives support women to make informed choices? .................................................................................................................... 497 Judith Kennedy, Anna Matthews, Laura Abbott et al Does the use of intrapartum medical intervention predict suboptimal breastfeeding initiation? .502 Marie Rivett A review of the safety of clozapine during pregnancy and lactation .......................................... 504 Taylor M Mehta, Ryan J Van Lieshout Nutritional aspects of commercially prepared infant foods in developed countries: a narrative review ..................................................................................................................... 512 Kate Maslin, Carina Venter

513 Neonatal & Infancy The experience of parents within neonatal units ...................................................................... 513 Caroline Thomas, Dave Clarke Piloting kangaroo mother care in the community: dyadic responses to a novel innovation facilitating skin-to-skin contact ............................................................................... 518 Roisin Bailey, Helen McIntyre, Merryl Harvey Effect of maternal obesity on birthweight and neonatal fat mass: a prospective clinical trial .... 523 Delphine Mitanchez, Sophie Jacqueminet, Jacky Nizard et al — Reviewed by Ailsa McGiveron Are babies conceived during Ramadan born smaller and sooner than babies conceived at other times of the year? A Born in Bradford Cohort Study .................................................... 525 Amanda Daley, Miranda Pallan, Sue Clifford et al Integrative review of factors and interventions that influence early father–infant bonding ........ 526 Ashley Renee Scism, Robin Lynn Cobb

527 Worldwide Maternity Services Hidden and unaccounted for: understanding maternal health needs and practices of semi-nomadic shepherd women in Maharashtra, India ............................................................. 527 Gayatri Ganesh, Nitya Ghotge Factors associated with postpartum hemorrhage maternal death in referral hospitals in Senegal and Mali: a cross-sectional epidemiological survey........................................................................... 533 Julie Tort, Patrick Rozenberg, Mamadou Traoré et al — Reviewed by Jo Gould Dual method use among postpartum HIV-infected and HIV-uninfected Malawian women: a prospective cohort study ........................................................................................................ 535 Dawn M Kopp, Jennifer H Tang, Gretchen S Stuart et al Demographic profile and pregnancy outcomes of adolescents and older mothers in Saudi Arabia: analysis from Riyadh Mother (RAHMA) and Baby cohort study ........................ 536 Amel A Fayed, Hayfaa Wahabi, Heba Mandouh et al

537 News & Reviews Did you miss it?......................................................................................................................... 537 Author index ............................................................................................................................. 539 Subject index ............................................................................................................................. 539

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From the Editor Welcome to the December edition of the Digest, heralding another busy year coming to a close. In the last editorial we were welcoming the start of a new academic year and the beginning of a new chapter in many of your lives, in particular students embarking on your careers as midwives. I have had the opportunity to meet some of you during events and visits to universities across the UK and have been swept along by the enthusiasm and passion for midwifery that you all have. It is always exciting and refreshing to think of the new ideas and innovations you will be bringing to the profession at a time when change is at the top of the agenda. For example, in the UK, the Better Births review (NHS England 2016) and The best start: a fiveyear forward plan for maternity and neonatal care in Scotland report (Scottish Government 2017) are pivotal to developing projects that improve the experiences of women and their families during pregnancy, birth and beyond. Further afield, midwifery in developed and developing countries is being given a higher priority and prominence to ensure women are supported with kindness and compassion during this unique period in their lives. Care is given based on the best available evidence with women and midwives working in partnership to enable choice and the flow of good communication. New evidence is continually emerging as a result of extensive research being undertaken. However, in the past such studies have not always considered the impact, or implications for the recipients, of such research. O’Hara (p413) explores this issue in the Hot Topic by considering the role of both public and patient participation in research, concluding that patients should be involved in the research process from the very conception of an idea. Although the word ‘patient’ is used throughout this paper it is inclusive of pregnant women who are not generally ill but can be greatly affected by the resulting recommendations from research. The women’s perspective and input is of immense value in contributing to the pieces of the research jigsaw. Price-Davey (p419) offers further insight and different perspectives into the involvement of all stakeholders; not just that of the patient but also of the staff, exploring core values, cultures and beliefs and how they can impact upon care quality and user experience. The paper intimates that the service user is still not being considered first when assessing best care and that the needs of staff often take precedence. For women to have greater choice in their care, participation is required from a wide range of stakeholders. As women with more diverse needs and backgrounds come into contact with maternity services, an ever increasing range of knowledge is required by midwives and allied health care professionals. Turner (p462) introduces the concept of supporting pregnant women with autism and explains some of the qualities associated with autism and how these can affect a woman’s experience of pregnancy, birth and parenting. The paper also discusses the reasonable adjustments that can be implemented to best support these women. However, much more research is warranted to gain a greater understanding 412

of the issues and there would be no better person to contribute than a woman affected by autism, further demonstrating the need for ‘patient’ involvement. A further thought-provoking paper can be found in Infant Nutrition, presenting the emotionally challenging concept of lactation following bereavement. For some women experiencing the loss of a baby at birth, the consequence of producing milk can be an extremely distressing process and exacerbate the loss they are feeling. This is not the same for all mothers and as Kennedy et al (p497) illustrate, some mothers do benefit emotionally from lactating and donating their milk. Midwives want to help women and protect them from the pain and anguish of the death of their baby and often advise or suggest ways to suppress lactation. However, this may not always be the appropriate course of action. We should wait and listen to what the woman feels is right for her and be guided by her wishes in situations such as these. This editorial has only touched on a few papers within the Digest and I would encourage you to explore all the other equally valuable papers in the hope that they inspire you with further ideas on how to improve the experiences of women and the midwives caring for them. Season’s greetings to you all.

References NHS England (2016). Better births. Improving outcomes of maternity services in England. A Five Year Forward View for maternity care. NHS England. The Scottish Government (2017). The best start: a five-year forward plan for maternity and neonatal care in Scotland - executive summary report. Edinburgh: Scottish Government.

Cathy Ashwin, Head of MIDIRS. © MIDIRS 2017.

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Hot Topic

Public and patient involvement in research: a partnership to make a difference in health research Margaret O’Hara ORIGINAL Researchers in health and social care should involve patients in all stages of their research from design and conduct through to interpretation, dissemination and implementation. The National Institute of Health Research (NIHR) drives and supports Patient and Public Involvement in Research (PPIR) and is regarded as a leader in the field. The NIHR funded INVOLVE unit (http://www.invo. org.uk/) was set up with a mission to provide leadership and develop resources for the use of the research community. INVOLVE defines public involvement in research as ‘research being carried out “with” or “by” members of the public rather than “to”, “about” or “for” them’ (INVOLVE 2017). Research involving patients and the public is more likely to be relevant, more effective and more cost-effective (Staley 2009). Although PPIR is not a new concept, its implementation has been patchy across the research sector and there are concerns that it is being implemented in a tokenistic way. This paper will set out the principles underpinning PPIR, illustrate ways in which it adds value to research and signpost practitioners to sources of information. days of acquired immune deficiency syndrome (AIDS) research. David Adams, Dean of the Medical School at the University of Birmingham, describes how, as a young scientist in the USA, he would walk past groups of activists with placards outside the research institute begging the scientists to find a cure.

© Dreamstime.com

PPIR is a concept which has already spent several decades going through a protracted birthing and growing up period. The origins of the movement are in human immunodeficiency virus (HIV) research where gay activists put pressure on scientists to direct their research towards patients’ priorities in the early

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Hot Topic

The idea of involving patients has since been taken up enthusiastically by, especially, mental health networks and crosses over into service delivery, rather than simply research. The NHS Constitution for England (Department of Health (DH) 2015) states that: ‘The patient will be at the heart of everything the NHS does’ and the government white paper, Equity and excellence (DH 2010) says that patients will be at the heart of decision-making in the NHS. There are moves throughout the NHS, some more successful than others, to bring patients into the design of service delivery and reconfiguration. It is perhaps easier to see why patients should be involved in the design of services which are for them, but research is often seen as a step removed from patients. Academic researchers can often find it difficult to see why they should be speaking to patients and may feel that they are too far removed from service delivery for it to be relevant for them. Often the first point at which an academic researcher sees a patient is when they are recruiting them for a study, and, even then, they may be regarded as a source of data, rather than a person with an opinion. At the root of PPIR there is a very basic idea: listen to the patients. This seems simple but for numerous reasons it does not always happen effectively. Just because a researcher has sat in a room where patients were speaking, this does not mean that effective listening has happened. Researchers must listen with their minds open to the possibility that how they had planned do to their research study may not be the best approach and could perhaps be changed. Where researchers have not done PPIR before, this can seem like a somewhat alien concept. Researchers are, by definition, experts in their field and they may not at first understand how untrained people can usefully contribute to research projects. PPIR is not about who is right or wrong, or who knows the most. Rather it is about developing partnerships between researchers and patients so that they can, collaboratively, come to a better understanding of the disease. Without either partner, knowledge of the disease is incomplete. ‘It’s a difference perspective. It is not better. It is not inferior. We need the doctor. We need the scientist. We need the neurologist. We need the PPI. We need a team. And it’s a team effort that will eventually yield the results’ (Crocker et al 2017:522).

The research cycle The point at which much patient involvement happens at the moment is in the review of patient information leaflets. This is an obvious benefit of 414

PPIR — if you want patients to understand the patient information then it makes sense to have these reviewed beforehand. For many studies, this is as far as it goes, but patients can have valuable input in all stages of the research cycle (Figure 1).

Figure 1: The research cycle. Patients can be involved at all stages of the research cycle (https://www.nihr.ac.uk/patients-and-public/how-to-join-in/the-research-cycle/).

The INVOLVE report Exploring impact (Staley 2009) gives numerous examples of where patient involvement has improved research projects at all of these stages. In this paper I will explore in more detail some of the ways in which PPIR can add value to research.

Who’s at the table? At the heart of PPIR there exists the ideal of flattening the hierarchy so that those who traditionally sit at the top of the medical research tree — clinicians with strings of letters after their names — sit as equal partners at the table with everyone else. This includes not just patients, but all of the other professions which feed into service delivery and medical research: nurses, doctors and midwives of all grades; the allied health professionals; other non-clinical frontline staff such as receptionists and porters. To really gain a fuller understanding of the impact of disease and its treatment it is necessary to examine the entirety of the patient experience in the round and this may involve speaking to everyone who impinges on that patient’s journey. Academics often work with clinicians, usually doctors, to develop research studies and believe that the clinician will tell them all they need to know about the disease and the patient experience. My message is that, no, they will not. It is impossible for even the most empathetic clinician to fully understand the experience of disease — they see the patient for a short time, they do not go home with them and observe the 99% of their time spent outside of hospital. In short, if a researcher wants to know how things are for the patient, they will have to ask the patient. MIDIRS Midwifery Digest 27:4 2017

Hot Topic

A lack of diversity in decision making in health care is part of what drives health inequality. This has been described as the ‘inverse care law’ (Shimmin et al 2017) where those with the greatest health needs are also those who have the least access to health care. This is a problem in consultations about service delivery as well as in research. To gain a fully comprehensive understanding of the disease, the patient sample group must represent the diversity of people who have that disease in the general population. If you are an Asian woman and your doctor is recommending you take a drug which has only been tested on white men, then you can legitimately say that there is no evidence that the drug will work for you. The same principle works in PPIR. A researcher will not gain full insight into a disease if their PPIR group comprises only white, middle-class, educated people. This is not to denigrate the efforts and insights of middle-class, white people who do invaluable involvement work in research. It is to say that we must not stop there but continue to seek the voices of all sectors of the community. This is not simply a moral imperative, but a scientific one as well. If you do not derive information from all sources your information base is incomplete and you run the risk of your research being biased, and therefore, not widely applicable.

Whose priorities? An important aspect of PPIR is that it can help to inform research priorities. There is often a mismatch between priorities for research as viewed by patients and the research which is actually conducted. This has been highlighted by others working in PPIR (Crowe et al 2015) and is especially a problem in commercially funded research where PPIR remains a rarity. The James Lind Alliance (JLA) is a charity which exists for the sole purpose of addressing this problem. It oversees Priority Setting Partnerships (PSPs), a defined process whereby clinicians, patients, carers and any other stakeholders come together to develop a list of research priorities in a given disease area. These lists are then published on their website (http://www.jla.nihr.ac.uk/) and are available for use by the rest of the research community. I recommend that anyone doing health research checks the JLA website to see if their disease area is listed. They can then assess whether or not their research idea addresses any of these priorities. If so, they can be confident that their research idea is relevant to patients. If not, they can consider refocusing their research such that it does address one of those priorities. PSPs are often initiated by patients themselves, primarily through patient support charities. The JLA PSPs which have already been conducted in women’s health include: womb cancer, miscarriage, preterm birth, stillbirth, contraception and pessary use for prolapse. Developing a PSP could also be a piece of research in its own right. If there has been no PSP in your area of interest, then you could develop a project to create one. MIDIRS Midwifery Digest 27:4 2017

Whose ideas?

Research is often seen as a rarified activity only to be indulged in by the highly educated and not for the ‘unwashed masses’. I would love to move away from this mindset because anyone can have a research idea or have an insight into the disease process. I am keen to encourage patients and staff who do not normally do research to consider themselves as valuable partners in the process of generating research ideas. Frontline staff often have a feel for what is happening with patients and which things are changing. They are well placed to spot trends and emerging problems which may need to be researched systematically in order to understand their scale and features. Often these concerns are dismissed by professional researchers as inconsequential, but then we are back to the issue of whose opinion counts and who should decide which research questions are answered. My bottom line is: if it’s important to the patients, it’s worthy of research. I would also encourage all health care professionals to think about actually doing research themselves. My fellow trustee of Pregnancy Sickness Support (PSS), Caitlin Dean, and I have done a number of selfinitiated research studies in hyperemesis gravidarum (HG). While I do have a research degree, I am a physicist, not a clinician and I have no medical training. Caitlin is a nurse by profession and had no research degree when she started doing research. Our work is survey-based and explores the experiences of women with HG. It seeks to answer the questions that women ask PSS but for which there are no answers in the medical literature. We highlight issues which come up repeatedly on our helpline or on our online forum but to which the medical research community seems entirely oblivious. An example of this is the phenomenon of the recommended use of ginger to treat HG. To outsiders this may seem like a trivial issue but to the women we support it is a major problem. We demonstrated why the recommendation of ginger to women with HG is not only deeply irritating but also demoralising, potentially harmful and may cause damage to the patient-health care professional relationship (Dean & O’Hara 2015). This work is greatly appreciated by women with HG but would have been highly unlikely to have originated outside of the patient support community.

What are you measuring and how?

A crucial area for patient insight is in determining what should be measured and how. Researchers set out to answer a question, eg ‘is drug A better than drug B?’ Then they must decide which outcomes to measure to answer that question. Some may relate directly to the patient’s physiology, eg blood tests or scans, and some may be operational, such as reduced treatment costs or inpatient stays. For some patients, these outcomes may be far less important to them than those which relate to how they are feeling or 415

Hot Topic

how they can live their lives. Quality of life (QoL) measurements have often been considered to be secondary outcomes if they have even been measured at all. This is partly because patients have not had a voice in the research, but also because it is more difficult to measure a patient’s pain than their biochemistry. Scientists need measurements to be objective, and have shied away from measures which, by definition, must be reported by the patient, eg pain and nausea, seeing these as too subjective. It is hard to believe but early studies into epidurals did not actually measure pain. Rather they measured cortisol in the blood as this was believed to be a good surrogate measure for pain. It may seem obvious that there are major confounding factors here — cortisol is increased by stress and yes, pain does cause stress, but there are a number of other factors around childbirth which are also somewhat stressful! This research then does not answer the woman’s primary question, which is, ‘will this stop the pain?’ You have to wonder whether anyone in the research team had ever even been in a room where someone was giving birth, never mind given birth themselves. It is true that some measures are subjective and this makes them difficult to study, but the response should be to develop better measurement methods, not simply to ignore them. There is now a large body of literature into patient reported outcome measures (PROMs) and QoL measures by organisations such as the International Society for Quality of Life Research (ISOQOL) (http://www.isoqol.org) and the Centre for Patient Reported Outcome Research (CPROR) (http://www.birmingham.ac.uk/research/activity/mds/ centres/cpror/index.aspx). A large number of validated QoLs and PROMs are now available to allow researchers to measure and compare patients’ experiences. If we are asking the question ‘which drug or treatment or intervention is better?’ but we are not asking the patient what does ‘better’ look like?, then we have to ask ourselves what really is the point of the research. And who is it for? Whenever I see a study which has measured the number and length of hospital inpatient stays, I always wonder for whose benefit the research was done — the patients or the hospital managers? There are situations where a reduction in hospital stays is beneficial for the patient, but not necessarily. For most patients the burning question is not ‘will this treatment reduce hospital stays?’, but ‘will this treatment make me feel better faster?’. The only way to find out what is important to the patient is to ask patients, and if the study does not measure outcomes which are important to patients then it will never be able to answer their questions. Another benefit of involving patients in the design of the study is that they will be able to advise on the feasibility of your methodology. If you are asking study participants to do something which is too onerous, patients will be able to flag this up and 416

suggest how you could amend it to make it more suitable, or perhaps drop it altogether and rethink the design. This will have a huge benefit for your recruitment when you come to do the study.

‘And I said… “I don’t think this study is going to work, this food study… Because a dementia person will not sit down at mealtimes, at lunchtime, and eat a full meal.” […] And they must have listened because like I said they did take it off, they didn’t bother with it’ (Crocker et al 2017:523).

Whose conclusions? Patients can do more than just proofread your manuscript. They may be able to spot confounding factors or give a view on incidental findings that you may find surprising. Perhaps you have found an unexpected association between a treatment and an outcome, but it is simply because of a side effect which is well known to patients but not particularly well known in the research literature. You would be surprised by what is common knowledge in the hive-mind of patient communities but which is virtually absent in the established literature. An example of this is the number of women who have terminations of pregnancy as a direct result of HG. I have had numerous conversations with senior obstetricians and midwives who had no idea that this happens at all, yet it is common knowledge and discussed widely in patient communities (PSS & British Pregnancy Advisory Service 2015).

Communities The internet has enabled the creation of a vast array of patient support groups. Patients with uncommon conditions who would rarely, if ever, meet someone else with the same complaint now have access to thousands of other sufferers. There is a hunger within these groups to understand how one’s own experience compares with others. A great deal of comfort can be derived simply from knowing that it is not just you who is suffering. Another great value of these groups is the sharing of information and grassroots intelligence about medical treatments. Patients will let others know where and from whom they have received good-quality treatment and what worked for them. Conversely, they will let each other know who and what to avoid. This can make health care professionals uncomfortable. There is an understandable fear that they may end up on some kind of blacklist if they don’t do what patients want. From the patient’s point of view though, this information sharing can circumvent the dispiriting process of going through multiple consultations with practitioners who don’t truly understand the condition and who are not aware of the latest guidelines before MIDIRS Midwifery Digest 27:4 2017

Hot Topic

chancing upon one who is knowledgeable. This makes it all the more important for health care professionals to engage with patients. These online forums are extremely powerful arenas for education. Where patients are empowered and properly informed they themselves become educators of their peers. Pregnancy and maternal health, seemingly more so than other areas of health, are replete with myths and misunderstandings. Women can encourage their peers to follow evidence-based guidance and reassure them that these treatments work and are safe. It is one thing to read a guidance document which says that the use of antiemetics in early pregnancy is safe for your baby, it is quite another to hear first-hand accounts from other women that they have taken these antiemetics and their babies were fine. For many women this is the extra reassurance they require to give them confidence in the treatment that is most beneficial for them. These communities can also be a source of patients who would be willing to be involved in research and also for the generation of research ideas. The kinds of discussions which begin with ‘Is it just me or…’ can bring to light other factors which are associated with the condition which can be a useful starting point for prospective research. Just as there are communities of sufferers online, there are communities of PPIR professionals, patients and researchers. I have always found the online PPIR community to be a friendly place, full of people who live and breathe the principles of openness, equality of voices and sharing of information. Some recommendations to follow on twitter are @ NIHRINVOLVE; @KristianStaley2; @sally_crowe; @SDenegri; @ePatientDave; @DavidGilbert43.

Closing the loop It has been estimated that it takes an average of 17 years for a new research finding to make it into routine practice (Morris et al 2011). This is clearly too long and represents a waste of time and money. We must become better at closing the loop between research findings and changes in clinical practice. Where a research group has good engagement with patients, where the study itself is of value to them and their input has ensured that it is of good quality, the patients will take those findings and help to disseminate them. They will tell other patients on their support forums as well as taking the findings to their health care practitioners. Again, there may be a wariness amongst health care professionals of patients bringing them information. In many ways, the internet is the ‘Wild West’ for health information and many a health care professional’s eyes must have rolled at the words ‘I found this on the internet’. But equally, nowadays, the internet is also where you find Royal College practice guidelines, Cochrane reviews, NHS choices and numerous other robust, reliable MIDIRS Midwifery Digest 27:4 2017

sources. Where patients bring information from a credible, scientific source this can be a valuable way for busy, overloaded health care professionals to find out about new developments, as it is impossible in practice to keep up with every new scientific finding. Professionals must try to keep abreast of an entire area of medicine, whereas patients will be able to focus only on those conditions which affect them and their family. This is potentially the beginnings of a partnership combining medical training and a breadth of knowledge, with detailed focus and in-depth knowledge in one area. I have a clinical colleague who sees himself as one part of a suite of information sources which his patients use to manage their condition. Not all patients are equipped, nor want to do this but where they do, it is an opportunity for health care professionals to work in a different way that ultimately will be more effective for both of them. Dave deBronkart (2017) describes powerfully how a combination of information gleaned from patient forums coupled with state-of-the-art medical treatment saved his life when he was diagnosed with an advanced cancer with a very poor prognosis. He explains how in the absence of either of these he would almost certainly be dead (deBronkart 2017).

Training Most patients will need some kind of training to help them better understand the research process. There is no ‘one size fits all’ answer, as not all patients are beginning from the same place. Members of the public come from different backgrounds, while some of them are professionals and are used to sitting around a table discussing documents, others have never attended a formal meeting in their lives. Researchers may have to think of inventive ways to fully engage with different sectors of the public and will probably also need training in how to work with patients. The types of conversations a public involvement group will have are not necessarily what researchers are used to. Researchers have chosen to study this medical condition, patients have not. Most patients wish they had never heard of the condition and could live their lives in blissful ignorance of it, but they are giving up their time and exposing themselves emotionally for the benefit of others. They may become distressed when describing their experiences, it is difficult to dispassionately explain how your life has been devastated by your illness without becoming upset. This will probably put most researchers well out of their comfort zone and they may need some guidance on how to navigate this situation. There will be ethical issues that need to be considered and also the care of the patients in your involvement group. INVOLVE has guidance on developing training and factors to consider when setting up a group. For background reading I like Testing treatments 417

Hot Topic

interactive (http://www.testingtreatments.org). This website is aimed at the public and has a mission to encourage critical thinking about health research. Their downloadable e-book clearly and engagingly describes how research should and shouldn’t be done and can be read in short chapters rather than all at once. I would recommend it not just for patients who want to learn more about how research works but also to health care professionals as a primer on how to do good research.

their treatment choices. Ultimately this costs not just money but the burden of unnecessary illness. Successful medical research, as well as adding to the sum of human knowledge, makes a difference to the life of an individual patient. Partnering with our patients brings us all closer to this goal.

Embarking on meaningful involvement

A note on terminology: the word ‘patient’ has been used in this article for simplicity, but in the context of PPIR, this may also include carers and parents. You may come across different acronyms for PPIR, including PPI and PI. In this example ‘R’ for research is included to make it clear that this refers to involvement in research rather than service delivery.

INVOLVE provides a large number of freely available resources for PPIR which are all accessible from their website (http://www.invo.org.uk/resource-centre/ resource-for-researchers/). They cover everything from basic principles, practical advice on costing, tips on how to make contact with patients, training, use of social media, ethical considerations and much more. You may be reading this having already started a research project without having done any PPIR but this doesn’t mean that it is too late. As I hope I have explained, patients can be involved at any stage of the research cycle. If you are in clinical practice, you can recruit for an involvement group directly from your own patients. If there is a relevant charity, they may be able to put you in touch with their networks to reach a wider patient population. Above all, doing meaningful PPIR is about developing a long-term relationship and this does not happen overnight. Even if patients are coming late to your current study, the discussions you have with them will feed into and shape the next study that you do. It may even shape your own clinical practice. If it does, then it will have assisted in the great Holy Grail of health and medical research; this is how we can make a difference. PPIR has been around for a long time, yet in some ways it still seems like a fringe idea. The growing insistence of funding bodies to see PPIR in grant applications will help to drive it forward, but we must be careful that it does not become a tick box exercise. INVOLVE talks about ‘meaningful’ involvement as opposed to tokenistic. Hywel Williams, chair of the Health Technology Assessment programme (https:// www.nihr.ac.uk) says: ‘We see two types of PPI in our applications — genuine PPI where it is clear how researchers have worked with patients to plan better research for the NHS, and token PPI where a patient has been drafted in to agree with the team’s preconceived ideas. Try to be the former’ The upshot of poorly conducted and designed research is that patients and professionals are left without adequate information upon which to base 418

Dr Margaret O’Hara is Patient and Public Involvement and Engagement in Research Lead at University Hospital Birmingham. She is also vice-chair of trustees of the charity Pregnancy Sickness Support. She tweets at @Know_HG

References Crocker JC, Boylan A-M, Bostock J (2017). Is it worth it? Patient and public views on the impact of their involvement in health research and its assessment: a UK-based qualitative interview study. Health Expectations 20(3):519-28. Crowe S, Fenton M, Hall M et al (2015). Patients’, clinicians’ and the research communities’ priorities for treatment research: there is an important mismatch. Research Involvement and Engagement 1:2. Dean CR, O’Hara ME (2015). Ginger is ineffective for hyperemesis gravidarum, and causes harm: an internet based survey of sufferers. MIDIRS Midwifery Digest 25(4):449-55. deBronkart D (2017). The paradigm of patient must evolve: why a false sense of limited capacity can subvert all attempts at patient involvement. Patient Experience Journal 4(2):4-8. Department of Health (2010). Equity and excellence: liberating the NHS executive summary. London: DH. https://www.gov.uk/ government/publications/equity-and-excellence-liberating-the-nhsexecutive-summary. [Accessed 5 October 2017]. Department of Health (2015). The NHS Constitution for England. London: DH. https://www.gov.uk/government/publications/the-nhsconstitution-for-england/the-nhs-constitution-for-england#patientsand-the-public-your-rights-and-the-nhs-pledges-to-you. [Accessed 5 October 2017]. INVOLVE (2017). Jargon buster: public involvement. http:// www.invo.org.uk/resource-centre/jargon-buster/page/3/?letter=P [Accessed 5 October 2017] Morris ZS, Wooding S, Grant J (2011). The answer is 17 years, what is the question: understanding time lags in translational research. Journal of the Royal Society of Medicine 104(12):510-20. Pregnancy Sickness Support, British Pregnancy Advisory Service (2015). I could not survive another day. Improving treatment and tackling stigma: lessons from women’s experience of abortion for severe pregnancy sickness. London: PSS. Shimmin C, Wittmeier KDM, Lavoie JG et al (2017). Moving towards a more inclusive patient and public involvement in health research paradigm: the incorporation of trauma-informed intersectional analysis. BMC Health Services Research 17(1):539. Staley K (2009). Exploring impact: public involvement in NHS, public health and social care research. Eastleigh: INVOLVE. http:// www.invo.org.uk/wp-content/uploads/2011/11/Involve_Exploring_ Impactfinal28.10.09.pdf. [Accessed 5 October 2017].

O’Hara M. MIDIRS Midwifery Digest, vol 27, no 4, December 2017, pp 413-418. Original article. © MIDIRS 2017.

MIDIRS Midwifery Digest 27:4 2017

Research & Education

How organisation values and engagement with service users can impact on care quality and experience Amanda Price-Davey


legislation maternity services communication innovation principles

© MIDIRS 2017

policy making culture values

strategy decision stakeholders making culture principles legislation communities health care providers service reflection strategy user social media experience staff engagement code of practice commissioning services Introduction The Kirkup Report (Kirkup 2015), commissioned by the Department of Health (DH) to investigate maternity and neonatal services at University Hospitals of Morecambe Bay NHS Foundation Trust, was a watershed moment for maternity services across the country and led to a complete change in how the midwifery profession is regulated. Failures in robust reporting and investigation of serious incidents, along with an ‘us and them’ culture between different professions working within the NHS and a misguided value set of ‘natural childbirth’ at any cost, are all cited as either directly or indirectly leading to the preventable deaths of one mother and 11 babies (Kirkup 2015). Just two years later, the health secretary has requested an investigation into a number of deaths of babies at an NHS Trust in the Midlands, after seven have been deemed avoidable. The purpose of this paper is to look at organisational values and culture, in relation to active stakeholder engagement, and reflect on how these things can impact on care quality and user experience. It is imperative to know how we can ensure incidences, such as those at Morecambe Bay, do not ever happen again. To do this, we will need to look closely at stakeholder engagement: what it is, and how it can be achieved, along with its relevance in the commissioning and monitoring of maternity services. How values affect decisions made, at both individual and organisational level, will need to be explored, so we can analyse how organisational values also impact on care quality and user experience. Analysis Core values are the fundamental beliefs of a person (or organisation). They drive our behaviours and the way we interact with others in life. Our values reflect what is important to us and what we care about (Pattison & Pill 2004). Values are generally instilled in MIDIRS Midwifery Digest 27:4 2017

us in our childhood, such as understanding right from wrong, and are often role-modelled by our parents or significant people in our lives. They can change however, through our life experiences, exploring other cultures and by interacting with a diverse population in the wider world as we grow and learn (Taylor 2012). 419

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Values drive the way we influence and interact with each other and they determine how we work together to achieve results. An organisational value is a belief that a specific mode of conduct is preferable to an opposite or contrary mode of conduct (Rokeach 1973). Understanding what generates value within us is vital when looking at organisational values and why they play a key role in improving care quality and user experience. Most organisations will have a set of written values that are published for all stakeholders to see, so they know what to expect when they are dealing with the organisation, for example: ‘The NHS is founded on a common set of principles and values that bind together the communities and people it serves — patients and public — and the staff who work for it’ (DH 2015). Each individual NHS Trust has its own set of values, based around the common values set out in the NHS constitution, but differentiated to reflect the culture of its own organisation, the diversity of people within it and of the people that it serves. However, in some cases, the written statement of values is simply not reflected in the culture of the organisation. This is when systems and processes can break down. Staff may see the statement as something which the organisation and its leaders merely pay lip service to. They may see behaviours, generally known as ‘politics’, which will give the perception of unfairness and that leaders themselves are not living by the values (Great Place to Work 2014). This perceived hypocrisy can generate resentment and employees in values-driven organisations can become disenchanted by insufficient alignment between the values and organisational structures and policies (Walton 1980). In order for the values to change the culture of an organisation, they must be ‘lived’ and reflected in every aspect of that organisation — in its strategic plan, commissioning of services, policy making, decisions taken and recruitment strategy, as well as point of care delivery. This is a hugely complex subject; one of the difficulties in achieving this is ensuring everyone within the organisation is adhering to the same set of values. The alignment of personal values with that of the organisation is not an easy process. The NHS is a diverse workplace, employing in excess of 1.7 million people from varying backgrounds, cultures and faiths. In midwifery, around 43,000 midwives are currently registered to practise in the UK (Nursing Midwifery Council (NMC) 2016). It would seem an impossible task to employ this many staff with aligning values. You could argue that midwives are in their chosen profession due to their personal values and the desire to care for women. In fact, The Code: professional standards of practice that all nurses and midwives agree to follow, stipulates quite clearly the values and behaviours expected of those working within the profession (NMC 2015). Obstetricians working within the maternity service also have a similar code of practice, published by the General Medical Council (GMC). With professionals having their own value set, it could seem that organisation values are unnecessary. 420

There are, however, many other employees that work within the NHS and maternity services that do not have a specific code of conduct to work within. Administrators, support workers, domestic service staff, portering services, technicians and many other staff all work to a standard with a specific goal, so it could be argued that organisational values are much more inclusive and not just directed at those who belong to a professional body. A clearly written and accessible set of values will act as a standard for stakeholders to access, so service users can be assured of the same treatment and care from everyone within the organisation, not just specific professionals. A further argument against values alignment could be related to innovation. Innovation and improvement features regularly in Trusts’ individual values statements, but, for organisations to innovate, there needs to be a culture of challenging the status quo (Dohmen 2016). Mavericks within an organisation are those individuals who are innovative, independently minded and goal-focused, but are less team-focused and more radical in terms of how they think and how they prioritise work tasks. These personality types can be very perseverant, often pursuing goals at all costs (Morse 2006). The pursuit of natural childbirth at all costs was something that the midwives at Morecambe Bay were heavily criticised for (Kirkup 2015). These mavericks, however, are often working at the leading edge of practice. They will question existing practice and explore new methods of working and identify areas for action. Consequently, in health care we need people like this in order to change, evolve and improve. Values are not about everyone doing the same thing in the same way; they are more about affording people the same opportunities to reach a shared goal and doing it in ways that will make sure those using the service are safe and happy with their experience and the care they receive. At Morecambe Bay, the mavericks were leading with a command and control culture and regulation was ineffective. The fail-safe, local supervising authority, did not work as it should and dangerous practices went unchecked. This has ultimately led to a complete revision of statutory supervision of midwifery and since April 2017, changes to legislation have come into force (DH 2016). It has been shown that values drive culture and decision making and decisions must be appropriately regulated in order to maintain safety. It could be argued that the most effective way of doing this is by engaging with multiple stakeholders. Stakeholder engagement is a process by which the organisation consults with people affected by the decisions it makes, whether that be service users, staff or commissioners of services, all of whom will have the ability to influence decision making. Engagement can transform the experience of the NHS for all stakeholders, staff and patients (The King’s Fund 2012). Engagement can empower people; by involving, listening to and working with patients and staff alike, it can influence and improve care. MIDIRS Midwifery Digest 27:4 2017

Research & Education

Alongside evidence showing that involving service users in the development of their health service can have a positive impact on their self-esteem, studies have also shown that medical staff who were more engaged were less likely to make mistakes. Other studies, involving over 8000 nursing staff and other allied professionals, have shown that better engagement was linked to improved safety (West & Dawson 2012). With so many different people being consulted on their ideas and thoughts in relation to service development and care giving, there are bound to be many opposing ideas on how improvements can best be achieved. In a study undertaken in north-west London, Renedo & Marston (2015) explored factors influencing quality improvement and patient-centered care. The study demonstrated that patients initially tried to influence by discussing actions dependent on collective agreement (ie by themselves and health care professionals). However, many then expressed more neoliberal ideas about individual responsibility, moving away from government and health care providers and being held accountable for upholding patients’ rights to quality care, and towards an idea of selfimprovement (Renedo & Marston 2015). When taking into consideration the patients’ voice in terms of measuring quality, government and NHS organisations must be mindful of how neoliberal rationalities, currently driving some policies and services, may discourage service users from claiming their rights to quality care, as some may be unwilling to challenge the status quo in service provision. Rather than using this research as an excuse not to engage, however, understanding this background should make it more relevant — and not only relevant but essential, since it also emphasises the need to engage with a wide variety of people in a diverse population. Moreover, Leviton & Melichar (2016) believe understanding the varying cultures and backgrounds of those with whom engagement will take place, requires commitment to the process and a high level of skill and experience from a representative work force. Using multiple platforms and tactics to engage with ‘harder to reach’ communities is essential. Social media platforms, community groups and stands at supermarkets, are just a few of the different communication approaches to reaching a wide range of people in the community. In terms of staff engagement, some respond to surveys, others do not, some prefer face-to-face open meetings or one-to-one drop in sessions. It is not one size fits all. One thing that is irrefutable, is that staff engagement is the best predictor of outcomes. It can predict care quality (based on CQC ratings), patient mortality and the quality of service user experience (based on friends and family surveys) (West 2013). Analysing patient experience could be viewed as a relatively straightforward task. Data can be collected through simple surveys, and the results analysed in order to improve care and services for the future. Nonetheless, Leviton & Melichar (2016) contest that service user needs may often conflict and this can have serious implications on the usefulness and quality of evaluations. MIDIRS Midwifery Digest 27:4 2017

Patients’ experience is an important quality performance indicator, so making sure conflicting views are analysed robustly is essential if care quality is to be improved. Leviton & Melichar (2016) believe that engaging more widely with stakeholders is the key, whereas Greenwood (2007) argues that that view belies the true complexity of the relationship between engagement and responsibility. This endeavor requires responsible leaders and leadership practices. This leads back to values and values-based leadership. Priorities assigned to values will change dependent on individual motives; for instance, point of care teams are often driven by moral values to provide care and comfort to the people they serve. There is, however, a perception that leaders in organisations are driven primarily by institutional considerations and finding cost savings in service delivery and this can often lead to conflict. Furthermore, Nath (2015) considers one casualty of this conflict can be quality of patient care. When leaders are anxious or fearful they will exhibit dysfunctional behaviours such as command and control, manipulation and blame. Leaders who engage in caring and trusting behaviours experience increased engagement and outcomes massively improve (Barrett 2013). Fundamentally, values-based leadership is leading a team or organisation and analysing performance based on a set of positive values, rather than specific targets or milestones — or indeed institutional arrangements and cost considerations. Gleeson (2017) opines that it is clear that leaders will remain responsible for making sure work gets done, that budgetary limits are not exceeded and that team members are all accountable for their own success. However, Gleeson (2017) determines values-based evaluations must be at the forefront of ‘how things are done’ in an organisation if there is to be improvement. For health care organisations, this means improvement in care quality and user experience. Positive user experience can be defined as: receiving good treatment in a caring and safe environment, delivered in a kind and compassionate manner; the ability to make informed choices; feeling confident and in control; being listened to as an equal; treated with honesty, respect and dignity (DH 2012). Assessment of user experience as a means to guide and monitor care quality is becoming increasingly popular. Satisfaction rates are published and many use these when making their choice of health care provider (Anhang Price et al 2014). Patient experience is not just about receiving great care; it is about receiving the right care for you. What one patient may perceive as a genuinely positive experience another may not. This is apparent when considering the shift to single rooms from open bay wards. This shift was initially driven by a desire to reduce infection rates and was celebrated as a great success when introduced in a local consultant-led maternity unit. Women saw the increased privacy the single rooms afforded as a positive factor. Five years on, many women now report feeling isolated and when asked if 421

Research & Education

they were happy with the amount of social contact they experienced, satisfaction rates have fallen. The isolation also meant they did not see nurses, midwives or support workers as regularly as they expected and some, who were not confident to call for assistance, opted to ‘soldier on’ rather than being a nuisance and calling for help. However, Janssen et al (2000), argue that a study carried out at B.C. Women’s Hospital, revealed that maternity care carried out in singleroomed units was associated with significant improvement in user satisfaction. This emphasises that one size does not fit all. The challenge of meeting the needs of all is far greater than just responding to ‘friends and family’ questionnaires. For maternity care, this means providing women with greater choice, so they can choose which care model is most appropriate to their needs and requirements. Offering greater choice has been identified as one of the key objectives in the DH’s strategy for improving maternity services (Blunt 2014). Patient involvement in their care is not a new concept, but health care providers are still not consistently putting patients first, with health care services still being designed around the needs of staff in some areas. Experienced-based design, where services are specifically designed around user experience, is an innovative way of placing the service user at the heart of their care. Furthermore, Bate & Robert (2006), argue that a good design of services should result in a good service user experience. It has been recognised that leadership within maternity services is not always supportive of initiatives to improve user experience and satisfaction. This is clearly shown where policy makers are seen to be reactive rather than proactive, specifically to bad outcomes, with a lack of strategic thinking identified as a common theme in this area (Blunt 2014). When responding to a poor outcome, when something has gone wrong, it is essential that health professionals and leaders are open and honest. There is a professional duty of candour (GMC & NMC 2015). Being listened to and talked to honestly goes a long way to increasing user satisfaction, even when things have gone awry. An acknowledgement that things could have been done differently and that lessons will be learned for the future is sometimes all that is required. There needs to be trust on both sides. Staff have a duty to report incidences and need to feel confident that they will be treated fairly in a blame-free culture. Errors can have lasting effects on service users and their families, but they can also have a similar emotional toll for the caregiver (Bell et al 2010). Disclosing errors is increasingly regarded as an essential skill for health care providers to learn, both in reporting and investigating and also for service user satisfaction, if lessons are to be learned and care quality improved. The Francis Report (2013) should act as a powerful reminder that there needs to be a renewed focus on listening to and understanding what service users are saying. 422

Conclusion The potential impact of both organisational values and stakeholder engagement on care quality and service user experience seems well proven — the challenge is to ensure that the impact of both is as positive as possible. Organisational values must be inclusive, encompassing all staff and procedures, if they are to be fully effective, but they must also be flexible enough to avoid stifling innovation and the questioning and challenging of existing practice. A key danger here is the potential dominance of a command and control culture (such as Morecambe Bay), so effective regulation and supervision is also crucial. Successful stakeholder engagement is key to increased understanding of both the concerns and the quality of experience for service users and staff. This needs to be carried out through multiple platforms to encourage full participation from the wide range of cultures and backgrounds involved. Two key points emerge: effective staff engagement is the best predictor of organisational outcomes and service user experience and satisfaction levels are best improved by providing women with greater choice. Not surprisingly, offering greater choice has been identified as one of the key objectives in the DH’s strategy for improving maternity services. Amanda Price-Davey, Lead Operational and Maternity Transformation Midwife, Maidstone and Tunbridge Wells NHS Trust.

References Anhang Price R, Elliott MN, Zaslavsky AM et al (2014). Examining the role of patient experience surveys in measuring health care quality. Medical Care Research and Review 71(5):522-54. Barrett R (2013). The values-driven organization. London: Routledge. Bate P, Robert G (2006). Experience-based design: from redesigning the system around the patient to co-designing services with the patient. Quality and Safety in Healthcare 15(5):307-10. Bell SK, Moorman DW, Delbanco T (2010). Improving the patient, family, and clinician experience after harmful events: the ‘when things go wrong’ curriculum. Academic Medicine 85(6):1010-17. Blunt L (2014). Improving service user experience in maternity services. A report prepared by The Patient Experience Network for NHS England. http://patientexperiencenetwork.org/Resource/ ImprovingPatientExperienceinMaternityServicesfinal.pdf [Accessed 23 April 2017]. Department of Health (2012). NHS Patient Experience Framework. London: DH. https://www.gov.uk/government/publications/ nhs-patient-experience-framework [Accessed 18 April 2017]. Department of Health (2015). NHS Constitution for England. London: DH. https://www.gov.uk/government/publications/ the-nhs-constitution-for-england [Accessed 18 April 2017]. Department of Health (2016). Proposals for changing the system of midwifery supervision in the UK. London: DH. https://www.gov.uk/ government/publications/changes-to-midwife-supervision-in-the-uk/ proposals-for-changing-the-system-of-midwifery-supervision-in-theuk [Accessed 21 August 2017]. Dohmen D (2016). Five success factors for healthcare innovation: are you applying them? [Blog] Focuscura, 5 February. https://www. focuscura.com/en/knowledge-development/blog/five-success-factorshealthcare-innovation-are-you-applying-them [Accessed 18 April 2017]. Francis R (2013). Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. London: DH. https://www.gov.uk/government/ publications/report-of-the-mid-staffordshire-nhs-foundation-trustpublic-inquiry [Accessed 18 April 2017].

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Research & Education General Medical Council, Nursing and Midwifery Council (2015). Openness and honesty when things go wrong: the professional duty of candour. London: NMC. http://www.gmc-uk.org/DoC_ guidance_englsih.pdf_61618688.pdf [Accessed 21 April 2017]. Gleeson B (2017). How values-based leadership transforms organizational cultures. Forbes, 10 March. https://www.forbes.com/ sites/brentgleeson/2017/03/10/how-values-based-leadershiptransforms-organizational-cultures/#18d5da2b1fbd [Accessed 21 April 2017]. Great Place to Work (2014). Organisational values. Are they worth the bother? How values can transform your business from good to great. London: Great Place to Work Institute UK. http://www. greatplacetowork.co.uk/storage/documents/organisational%20 values%20are%20they%20worth%20the%20bother%20 final2%20web%20031114.pdf [Accessed 21 April 2017]. Greenwood M (2007). Stakeholder engagement: beyond the myth of corporate responsibility. Journal of Business Ethics 74(4):315-27. Janssen PA, Klein MC, Harris SJ et al (2000). Single room maternity care and client satisfaction. Birth 27(4):235-43. Kirkup B (2015). The report of the Morecambe Bay Investigation. Morecambe Bay Investigation. Leviton LC, Melichar L (2016). Balancing stakeholder needs in the evaluation of healthcare quality improvement. BMJ Quality & Safety 25(10):803-7. Morse G (2006). Connecting maverick minds. Harvard Business Review. https://hbr.org/2006/03/connecting-maverick-minds. [Accessed 21 April 2017]. Nath V (2015). A return to values-driven leadership or more of the same? London: The Kings Fund. https://www.kingsfund.org.uk/ blog/2015/06/return-values-driven-leadership-or-more-same [Accessed 23 April 2017]. Nursing and Midwifery Council (2015). The Code: professional standards of practice and behaviour for nurses and midwives. London: NMC. Nursing and Midwifery Council (2016). Annual Report and Accounts 2015-2016 and Strategic Plan 2016-2017. London:

NMC. https://www.nmc.org.uk/globalassets/sitedocuments/annual_ reports_and_accounts/annual-report-and-account-2015-2016.pdf [Accessed 2 April 2017]. Pattison S, Pill R (2004). Values in professional practice: lessons for health, social care and other professionals. London: Routledge. Renedo A, Marston C (2015). Developing patient-centred care: an ethnographic study of patient perceptions and influence on quality improvement. BMC Health Services Research 15(122). Rokeach M (1973). The nature of human values. New York: The Free Press. Taylor J (2012). Personal growth: your values, your life. https:// www.psychologytoday.com/blog/the-power-prime/201205/ personal-growth-your-values-your-life [Accessed 5 April 2017]. The King’s Fund (2012). Leadership and engagement for improvement in the NHS: together we can. London: The King’s Fund. https://www.kingsfund.org.uk/sites/files/kf/field/field_ publication_file/leadership-for-engagement-improvement-nhs-finalreview2012.pdf [Accessed 2 April 2017]. Walton RE (1980). Establishing and maintaining high commitment work systems. Boston: Harvard University. West M, Dawson JF (2012). Employee engagement and NHS performance. https://www.kingsfund.org.uk/sites/default/files/ employee-engagement-nhs-performance-west-dawson-leadershipreview2012-paper.pdf [Accessed 20 April 2017]. West M (2013). Cultures of engagement. [Blog] NHS Employers, 25 June. http://www.nhsemployers.org/blog/2013/06/cultures-ofengagement%20 [Accessed 17 April 2017].

Price-Davey A. MIDIRS Midwifery Digest, vol 27, no 4, December 2017, pp 419-423. Original article. © MIDIRS 2017.

Student Midwife Global Health Conference 2018 Birmingham City University, Edgbaston, 10th January 2018



– of interest to student midwives considering an elective placement


Details of attendance, presentation and poster abstract requirements at: www.bcu.ac.uk. Accepted presentation abstracts and posters will be published on www.midirs.org following the conference.

MIDIRS Midwifery Digest 27:4 2017

For further details email Helen.McIntyre@bcu.ac.uk or call 0121 331 7116 423

Research & Education

An enquiry-based learning curriculum can help student midwives to explore the promotion of normal birth in the context of current maternity service provision Lynne Mason ORIGINAL Background The Nursing and Midwifery Council’s (NMC) standards for pre-registration midwifery education (NMC 2015) require students to demonstrate knowledge of, and competence in, facilitating the normal physiology of childbirth. They acknowledge an international definition of a midwife’s scope of practice as including the promotion of normality (International Confederation of Midwives (ICM) 2017), and adherence to the moral principle of respect for the health and well-being of women and newborns (ICM 2014). Yet normal birth (NB) is a socially constructed phenomenon with a fluid meaning influenced by the values, beliefs and experiences of individuals and communities (Rothman 1977), that lacks consensual definition, and delineation within the maternity service (Downe & McCourt 2008). This was particularly evident in a recent media debate about the Royal College of Midwives’ (RCM) position on normal birth (RCM 2017, Smyth 2017). The theory-practice gap, which educators seek to bridge for students training in the health professions, may, therefore, be wide for student midwives in relation to NB (Anderson 2015). This paper considers the concept of normality, understanding of NB from a range of perspectives; and enquiry-based learning (EBL) as a valuable pedagogic approach to exploration of a complex topic. It concludes that, because EBL encourages students to generate ideas and identify connections, it has the potential to foster the deep learning (Kahn & O’Rourke 2005) necessary if midwifery students are to be equipped, at the point of registration, to promote NB effectively. Midwifery support for normal birth Midwives are the lead carers for low-risk women experiencing a normal labour and birth but also need the knowledge and skills to recognise deviations from normal and refer to the multiprofessional team. The making of a referral shifts a midwife’s professional responsibilities from those of an autonomous practitioner to those of a co-ordinator of care planning and implementation (NMC 2015). Gould (2000) identifies the need for midwives to understand the meaning of normal labour in order to fulfil their statutory duty. Gould (2000) argues that the failure of midwives to define normality on their own terms contributes to the dominance of a medicalised, technologically-driven, interventionist birthing culture. Evidence indicates that physiological birth is supportive of the health and well-being of mother and child (Carolan-Olah et al 2015) for example, promoting mother-baby bonding and successful initiation and continuation of breastfeeding (Moore et al 2016). The Epigenetic Impact of Childbirth (EPIIC) hypothesis theorises that physiological birth has evolved to remodel 424

the fetal epigenetic profile for optimal health, and that the use of synthetic oxytocin and antibiotics in labour, and birth by caesarean section, affect that remodelling process, impacting negatively on the health of mother and baby (Dahlen et al 2013). In the long term neonates experiencing impaired remodelling may be at risk of problems of metabolism such as type 1 diabetes and obesity (Taylor 2015). The latter health issue alone is estimated to cost the National Health Service (NHS) £6.1 billion annually (Public Health England 2017). Midwifery support for normal birth would seem, therefore, to have considerable potential for supporting the health of current and future generations thereby relieving financial pressure on the NHS. The National Institute for Health and Care Excellence (NICE) (2014) states that nine out of ten women in England and Wales in 2013 gave birth in hospital ‘under the ultimate supervision of obstetricians’. Keating & Fleming (2009) explored midwives’ perceptions of facilitating NB in an obstetric-led unit and identified that they found facilitation difficult because their understanding of childbirth was considered inferior to MIDIRS Midwifery Digest 27:4 2017

Research & Education

that of obstetricians, in a hierarchical system that supported medicalised care. Scientific knowledge based on technological output, such as continuous monitoring of the fetal heart rate (FHR), was privileged over body knowledge and intuition and the midwife-mother relationship was interrupted by a task-driven labour ward culture. Miller et al (2015) found that factors associated with having a NB were: not having continuous monitoring of the FHR, being mobile in labour, birthing in a non-supine position, and doing that outside of ‘business’ hours. The position of junior midwives trying to promote normality was distinguished as particularly difficult because of a hierarchical midwifery management structure in which they had the least authority (Keating & Fleming 2009). All of the ten midwives interviewed drew strength and inspiration from colleagues modelling the facilitation of physiological birthing. Keating & Fleming (2009) concluded that midwifery education has a significant role to play in supporting normality in an obstetric-led unit because students can be helped to become skilful in NB practice. Midwives working in obstetric-led units, when asked for their response to uncertainty in low-risk labour, were less tolerant of it than their counterparts in midwife-led care settings (Page & Mander 2014). How a midwife responds to an uncertainty in a low-risk labour, such as the presence of meconium in late second stage, becomes a defining characteristic of that labour, in terms of normality. Page & Mander (2014:31) describe a ‘normality boundary’ that is shaped by a midwife’s clinical decision making, which is, in turn, informed by the professional values and experience that she brings to low-risk birthing. This research, and that of Keating & Fleming (2009), signal a need for midwifery educators to ensure that student midwives fully explore normality; that they think about normality as a concept, as well as in terms of the midwifery philosophy, values and skills that underpin the promotion and facilitation of it. Page & Mander (2014) identify that the placing of the normality boundary is dependent on a midwife’s confidence in, and response to, a woman’s birthing body, the coherence of the relationship with that woman, the culture prevalent in the birth setting, and the quality of peer support. It shows in addition, therefore, that identifying deviation from normal is not a simple response to a cut and dried event as regulatory standards suggest (NMC 2015).

Normal birth perspective Student midwives, when asked for their understanding of NB, identified a woman working to birth her baby without pharmacological pain relief or intervention as representing an ideal of NB (Gilkison et al 2005). Furthermore, Anderson (2015) found that students regarded NB as the unfolding of a physiological process without disturbance. These students did not experience this in practice as often as they had expected from their MIDIRS Midwifery Digest 27:4 2017

theoretical work but, because they saw themselves as potential agents for change they considered it to be important that educators shared with them an ideal of NB. They identified hospital policies as a barrier to NB because they were valued over autonomous practice in the birthing culture. However, the key determinants of NB were the midwives themselves, with an individual’s beliefs, knowledge and skills in relation to NB having a significant influence on the course of a woman’s labour. Students in both studies (Gilkison et al 2005, Anderson 2015) concluded that you could classify normal as what happened regularly which, in an obstetric-led unit, could involve a number of interventions in the birthing process. Some of the students who talked to Gilkison et al (2005) felt very strongly that normality could, in fact, only be defined by the birthing woman. One gave the example of a woman whose birth met the Maternity Care Working Party’s inclusion criteria for normal birth (MCWP 2007) but, because she was induced and birthed in hospital rather than at home as planned, for her the labour was not normal. The students distinguished birth that unfolds undisturbed as physiological, and NB as a product of each woman’s understanding and expectations of birthing. One student said: ‘Normal in some ways trivialises the whole experience for the woman, it is astronomically abnormal for her... giving birth is a major, don’t call her normal.’ (Gilkison et al 2005:13) This view is echoed by one of the women sharing their perspectives on normal birth: ‘Relative to marriage or first time sex, I would put my birth experiences way beyond these... they strike at the very heart and soul of you...’ (Beech & Phipps 2008:68) Beech & Phipps (2008) acknowledge that the views of these women, as members of the National Childbirth Trust (NCT) and the Association for Improvements in the Maternity Services (AIMS), are not generalisable. However, it is reasonable to infer that for some women giving birth is a profound experience which, for those who felt in control of the process, engendered a sense of health and well-being that benefitted their parenting. Conversely, women who felt that they had not experienced NB, and this was related to interventions during labour and mode of birth, suffered physical, mental and emotional morbidity that compromised their transition to parenthood. Hunter (2010) found, by contrast, that positive birth experiences enjoyed by women she talked to were not dependent on mode of birth, setting for birth, or model of care experienced. Positivity was dependent on mutually trusting relationships with health professionals and a strong sense of labour and birth as an embodied experience that they controlled. It can be seen, therefore, that the journey for student midwives to qualification as practitioners who are confident and skilful in the 425

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promotion and facilitation of normal birth is complex. Indeed, a student midwife who does not recognise that the topic of NB raises questions around epistemological understanding, ethical practice, advocacy and mutually respectful multiprofessional working, may lack competence as an autonomous practitioner. A midwife needs to recognise and guard normality because, as a specialist, she knows that undisturbed, physiological birthing supports safety and satisfaction for mother and baby. The parameters of NB are the boundaries of midwifery autonomy, and change the direction of a woman’s care in labour but an agreed definition across the multidisciplinary team remains elusive. Perhaps this is because NB, as a social construct, built by individuals and communities from ideas, values, interests, experience and cultural influences, is a chimera. Different definitions of NB are informing models of care that are in competition with one another for status and resources, and there may be tensions for midwives attempting to reconcile conflicting values systems in order to meet the individual needs of labouring women. Educators, therefore, need to identify ways of facilitating learning that encourage depth and breadth of exploration so that the gap between theory and practice around NB can be bridged.

Why enquiry-based learning? Long et al (1999) proposed that EBL or problembased learning (PBL), using real-life scenarios as a means of arousing students’ interest, can foster the development of skills such as critical thinking and problem solving needed for efficient application of theory to practice. EBL, sometimes also called inquiry-based learning in the literature, and PBL overlap in terms of pedagogical philosophy and educational method (Savery 2006). Kahn & O’Rourke (2005) state the EBL approach encourages students to become partners in the learning process because they have to identify their own learning needs and assume responsibility for disseminating the evidence that is identified. Schmidt et al (2011) emphasise, however, that it is the combination of self-direction and group-working that gives PBL its potency as a means of learning. In addition, the quality of facilitation can have a significant impact for good or ill upon learning (Van Berkel & Dolmans 2006). Facilitators are not characterised as fonts of knowledge but as guides to learning (Hmelo-Silver 2004). Schmidt & Moust (1995) and Chng et al (2011) have identified that facilitators with good interpersonal skills help to shape a stimulating and safe learning environment that supports open debate. Fry et al (2008:21) cite Lave and Wenger’s 1991 theory of situated learning that proposes that students learn more, individually and collectively, within a community of practice, that is, as part of a group with a shared profession. A multifaceted topic like NB has to be unpacked and, therefore, needs students to feel that they share in the midwifery discourse and can contribute to it by full and frank discussion. 426

Hmelo-Silver (2004) and Schmidt et al (2011) say that the PBL process encourages students to develop higher-order thinking skills such as analysis and evaluation because they are looking for meaning and so identify patterns and connections at micro and macro levels. Figure 1 (below) describes the EBL process that first year midwifery students follow at the University of Worcester. Figure 1: EBL process: February, cohort year one midwifery students, University of Worcester. Introduction of enquiry trigger by tutor. Cohort directs group ‘explosion’ of trigger recorded on whiteboard by nominated scribe: what is known; what is unknown. (Cohort has tutor learning outcomes. Tutor present as facilitator)

Cohort breaks into designated EBL groups for initial identification of focus of interest. (Tutor present as facilitator). Group nominates chairperson and scribe. Group identifies a key question or a learning outcome. Cohort decides whether sufficient and appropriate learning will be generated by key questions/learning outcomes identified.

Time allocated for self-directed learning and group work.

Small group tutorials timetabled.

Time allocated for self-directed learning and group work.

Tutor available to facilitate for EBL groups.

Each EBL group feeds back its findings to the cohort. (All students participate). Verbal feedback from tutor.

Written feedback from tutor to each group regarding identification of chosen topic, quality of evidence identified, style of presentation.

In terms of NB students may, for example, identify factors that facilitate it, and those that restrain it, leading to consideration of labour ward culture, evidence-based practice, defensive practice, professional identity, the medicalisation of birth as a feminist issue, and so on. An evaluation of EBL, introduced into a midwifery degree programme to support students in understanding psychological theory and applying it to practice, identified that the process facilitated in-depth exploration and increased student confidence (Fisher & Moore 2005). Hollins et al (2008) found that midwives MIDIRS Midwifery Digest 27:4 2017

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were likely to obey a senior colleague and conform to that person’s viewpoint, to the detriment of individual women making safe requests that were deemed inappropriate by an authority figure. If students qualify feeling confident in their ability to question and analyse usual practice around NB then they will be the autonomous, evidence-based practitioners constituted by statutory regulation. Enquiry-based learning can be transformative learning as described by Mezirow (2006) cited by Illeris (2014:148-9). Transformative learning is the radical alteration of a learner’s cognition; a redefining by the individual of how he or she acquires knowledge and understanding so that habits of mind are formed that support cognitive development. Illeris (2014) has extended this cognitive transformation to encompass the emotional and social aspects of learning by proposing a concept of identity as a term suggestive of the totality of an individual. He says that by adulthood individuals have reasonably stable and established identities so that motivation that connects to a person’s experience, understanding and relationships, is needed if learning is to effect transformation. The EBL process, underpinned by student-led learning and utilisation of diverse experience, encourages students to locate their individual motivations through self-direction, group discussion, team working and tutor contact (Kirwan & Adams 2009). This is particularly important when students are exploring NB because, as discussed earlier in this paper, its promotion and facilitation is strongly influenced by the motivations and values of individual midwives. Nairn et al (2012) assert that nurse education often fails to support students to achieve deep reflection that is transformative because it pays too little attention to the influence on reflection of individual and communal values systems. They suggest combining Mezirow’s concept of reflexivity (1998 cited by Nairn et al 2012) and Bourdieu’s concept of ‘habitus’ (1993 cited by Nairn et al 2012) to create a means whereby nurses can critically examine their own values systems and those which drive the settings where they work. Mezirow (1998 cited by Nairn et al 2012:196) called individual values systems, ‘meaning schemes’ and asserted that a comprehensive interrogation of these was essential if reflection was to be transformative. Bourdieu (1993 cited by Nairn et al 2012:191) identified an internalisation by the individual of the values systems of particular milieux that he called habitus. Hobbs (2012), researching seven newly qualified midwives, questioned whether they internalised the labour ward habitus or were able to restructure it to more closely resemble their ideal of midwifery practice. Furthermore, Hobbs (2012) attributed their ability to resist conforming to established practice that compromised normality to their exposure as undergraduates to higher-order thinking, such as that involved in reflexivity. Enquirybased learning, because it is rooted in real life scenarios, fosters the use of narrative discourse in the MIDIRS Midwifery Digest 27:4 2017

classroom to break down experience into its component parts and remake it for improved future service. It is essential for midwives that they appreciate the impact of their own values on NB, and those of the organisation within which they are working, in order to reconcile tensions between woman-centred care giving and task-driven practice that may do labouring women a disservice. Fisher & Moore (2005) found that EBL was particularly valuable in supporting students in the acquisition of the key transferable skills that graduate professionals are expected to have, such as welldeveloped cognitive, communication and interpersonal skills. Barry et al (2014) identified stages that newly graduated midwives move through during their first six months in practice before arriving at a more comfortable place where they can put women first and practice autonomously. The new midwives displayed considerable resilience, and made sophisticated use of communication and relationships to promote the primacy of their midwifery values in caring for women. Russell (2007) found that midwives working in obstetric units where the culture was hierarchical, task-driven and interventionist used tactics, such as underestimating cervical dilatation, to protect normal labour from disturbance. Midwives determined to practise the art of midwifery were labelled mad and ‘bolshie’ but this colouration, though it risked social isolation, helped to protect them from interference by other staff. These midwives had been qualified for between two and more than 15 years but were being strategic to support NB rather than acting as agents to change labour ward culture. It may be that university-educated midwives (Hobbs 2012, Barry et al 2014, Anderson 2015), and particularly those who have acquired their professional identity through EBL, have the confidence and the cognitive and interpersonal skills to unpick the workplace culture and remake it in favour of supporting NB.

Summary This paper demonstrates that NB is a nebulous concept that has different meanings for childbearing women, midwives, obstetricians, health regulators and funders of maternity services. Midwives need to recognise it because they have a professional duty to promote and facilitate it and it marks the boundary of their specialist area of autonomous practice. Women need it because physiological birthing protects the health and well-being of mothers and babies. This is recognised by organisations concerned with health, both in the United Kingdom and internationally, as society struggles to meet the cost of medical intervention in birth, and a rising caesarean section rate. The values systems of birth workplaces and of individual midwives have a significant impact upon NB. Educators of midwifery students are also midwives with the same responsibility for guardianship of normality as is incumbent upon their 427

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clinical colleagues. Midwife tutors have a duty to ensure that, at the point of registration students can promote and facilitate NB, and so need to identify pedagogical approaches that inspire deep learning capable of transfer from theory to practice. Enquirybased learning is both an educational philosophy, and a teaching method that can be effective in helping students to become self-directed and reflexive with effective cognitive skills and a strong sense of professional identity. Newly qualified midwives need these attributes if they are to be agents of change for the promotion of woman-centred NB and have the potential to become consultant midwives who can inspire others and lead service development that offers the best possible experience to birthing women. Lynne Mason, Senior Lecturer/Admissions Tutor, Midwifery, Worcester University.

References Anderson G (2015). An evaluation of direct-entry student midwives’ perceptions of normal birth. Evidence Based Midwifery 13(2):66-70. Barry MJ, Hauck YL, O’ Donoghue T et al (2014). Newly-graduated midwives transcending barriers: mechanisms for putting plans into actions. Midwifery 30(8):962-7. Beech BL, Phipps B (2008). Normal birth: women’s stories. In: Downe S ed. Normal childbirth: evidence and debate. 2nd ed. Edinburgh: Churchill Livingstone: 67-80. Carolan-Olah M, Kruger G, Garvey-Graham A et al (2015). Midwives’ experiences of the factors that facilitate normal birth among low risk women at a public hospital in Australia. Midwifery 31(1):112-21. Chng E, Yew EHJ, Schmidt HG (2011). Effects of tutor-related behaviours on the process of problem-based learning. Advances in Health Sciences Education 16(4):491-503. Dahlen HG, Kennedy HP, Anderson CM et al (2013). The EPIIC hypothesis: intrapartum effects on the neonatal epigenome and consequent health outcomes. Medical Hypotheses 80(5):656-62. Downe S, McCourt C (2008). From being to becoming: reconstructing childbirth knowledges. In: Downe S ed. Normal childbirth: evidence and debate. 2nd ed. Edinburgh: Churchill Livingstone: 3-28. Fisher M, Moore S (2005). Enquiry-based learning links psychology theory to practice. British Journal of Midwifery 13(3):148-52. Fry H, Ketteridge S, Marshall S (2009). Understanding student learning. In: Fry H, Ketteridge S, Marshall S eds. A handbook for teaching and learning in higher education. 3rd ed. Abingdon: Routledge: 8-26. Gilkison A, Holland D, Berman S et al (2005). Defining normal birth: a student perspective. New Zealand College of Midwives Journal 32:11-23. Gould D (2000). Normal labour: a concept analysis. Journal of Advanced Nursing 31(2):418-27. Hmelo-Silver CE (2004). Problem-based learning: what and how do students learn? Educational Psychology Review 16(3):235-66. Hobbs JA (2012). Newly qualified midwives’ transition to qualified status and role: assimilating the ‘habitus’ or reshaping it? Midwifery 28(3):391-9. Hollins Martin CJ, Bull P (2008). Obedience and conformity in clinical practice. British Journal of Midwifery 16(8):504-9. Hunter B (2010). Implementing a national policy initiative to support normal birth: lessons from the All Wales Clinical Pathway for Normal Labour. Journal of Midwifery and Women’s Health 55(3):226-33. Illeris K (2014). Transformative learning and identity. Journal of Transformative Education 12(2):148-63. International Confederation of Midwives (2014). International code of ethics for midwives. http://internationalmidwives.org/ knowledge-area/icm-publications/icm-core-documents.html [Accessed 2 September 2017]. International Confederation of Midwives (2017). International definition of the midwife. http://internationalmidwives.org/


knowledge-area/icm-publications/icm-core-documents.html [Accessed 2 September 2017]. Kahn P, O’Rourke K (2005). Understanding enquiry-based learning. In: Barrett T, Mac Labhrainn I, Fallon H eds. Handbook of enquiry and problem based learning: Irish case studies and international perspectives. Galway: CELT:1-12. http://www.aishe.org/readings/2005-2/chapter1.pdf [Accessed 2 September 2017]. Keating A, Fleming VEM (2009). Midwives’ experiences of facilitating normal birth in an obstetric-led unit: a feminist perspective. Midwifery 25(5):518-27. Kirwan A, Adams J (2009). Students’ views of enquiry-based learning in a continuing professional development module. Nurse Education Today 29(4):448-55. Long G, Grandis S, Glasper EA (1999). Investing in practice: enquiry- and problem-based learning. British Journal of Nursing 8(17):1171-4. Maternity Care Working Party (2007). Making normal birth a reality. Consensus statement from the Maternity Care Working Party: our shared views about the need to recognise, facilitate and audit normal birth. London: NCT/RCM/RCOG. Miller YD, Prosser SJ, Thompson R (2015). Back to normal: a retrospective, cross-sectional study of the multi-factorial determinants of normal birth in Queensland, Australia. Midwifery 31(8):818-27. Moore ER, Bergman N, Anderson GC et al (2016). Early skin-toskin contact for mothers and their healthy newborn infants. The Cochrane Database of Systematic Reviews, Issue 11. Nairn S, Chambers D, Thompson S et al (2012). Reflexivity and habitus: opportunities and constraints on transformative learning. Nursing Philosophy 13(3):189-201. National Institute for Health and Care Excellence (2014). NICE confirms midwife-led care during labour is safest for women with straightforward pregnancies. [Press release]. 3 December. London: NICE. https://www.nice.org.uk/news/press-and-media/midwife-care-during-labour-safest-women-straightforward-pregnancies [Accessed 2 September 2017]. Nursing and Midwifery Council (2015). Standards for competence for registered midwives. London: NMC. Page M, Mander R (2014). Intrapartum uncertainty: a feature of normal birth, as experienced by midwives in Scotland. Midwifery 30(1):28-35. Public Health England (2017). Health Matters: obesity and the food environment. 31 March. https://www.gov.uk/government/publications/ health-matters-obesity-and-the-food-environment/health-matters-obesity-and-the-food-environment--2 [Accessed 2 September 2017]. Rothman BK (1977). The social construction of birth. Journal of Midwifery & Women’s Health 22(2):9-13. Royal College of Midwives (2017). Statement on RCM’s Better Births Initiative. https://www.rcm.org.uk/news-views-and-analysis/ news/statement-on-rcm’s-better-births-initiative [Accessed 2 September 2017]. Russell KE (2007). Mad, bad or different? Midwives and normal birth in obstetric led units. British Journal of Midwifery 15(3):128-31. Savery JR (2006). Overview of problem-based learning: definitions and distinctions. Interdisciplinary Journal of Problem-Based Learning 1(1):9-20. Schmidt HG, Moust JH (1995). What makes a tutor effective? A structural-equations modeling approach to learning in problem-based curricula. Academic Medicine 70(8):708-14. Schmidt HG, Rotgans JI, Yew EHJ (2011). The process of problem-based learning: what works and why. Medical Education 45(8):792-806. Smyth C (2017). Midwives back down on natural childbirth. The Times, 12 August, https://www.thetimes.co.uk/article/midwives-backdown-on-natural-childbirth-2f78d65ng [Accessed 2 September 2017]. Taylor PD (2015). Bugs and stress ‘on top of genetics’: can the way we are born affect our health? Midwifery 31(3):341-4. Van Berkel HJ, Dolmans DH (2006). The influence of tutoring competencies on problems, group functioning and student achievement in problem-based learning. Medical Education 40(8):730-6.

Mason L. MIDIRS Midwifery Digest, vol 27, no 4, December 2017, pp 424-428. Original article. © MIDIRS 2017.

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Premature rupture of the amniotic sac: managing the risks Paul Stillman, Emma Herbert ORIGINAL Introduction Vaginal wetness is common during pregnancy. Every year, the Office for National Statistics (2017) records around 696,000 live births in England and Wales, and about a third of these women will experience some sort of vaginal leakage. Furthermore, the Hygeia Foundation and Institute for Perinatal Loss (Odunsi et al 2017) state that approximately 20% of pregnant women present at hospital or birth units reporting wetness. In most cases, it is harmless, resulting from urinary incontinence or changes to the vaginal secretions. The Chartered Society of Physiotherapy (2014) and the Royal College of Midwives (2012) confirm that one in three women (34%) experience urinary incontinence during pregnancy. It is also not unusual for hormonal changes during pregnancy to increase the amount of mucous and moisture in the vagina, which might be mistaken for something more serious. Mild infections, such as thrush or bacterial vaginosis may also mimic amniotic rupture. Although dampness may indicate a rupture of the membranes, it is important to promptly rule out other causes. When women experience vaginal wetness during pregnancy, it can cause embarrassment, confusion and/or fear of the consequences. Others may dismiss it, assuming it to be a normal part of pregnancy, possibly only mentioning it in passing. This presents midwives with a tough challenge as without invasive intervention, it can be difficult to tell whether it is urine, vaginal discharge or leaking amniotic fluid. If it is leaking amniotic fluid, there is an urgent need for attention and action. Finding the right balance for the best outcomes for mother and child can be problematic. Health care professionals in primary and community settings have often felt they have little choice but to refer women to the hospital for further tests. The amniotic sac The amniotic sac is a double membrane, filled with fluid, which begins forming within days of conception, and provides protection and support throughout the pregnancy — usually until the membranes rupture, heralding the beginning of the baby’s birth. At its peak capacity, which is around week 34 to 36, the amniotic sac will hold around two pints of clear, slightly yellow fluid, but having too much, or too little, can lead to complications because the amniotic fluid and sac play a number of important roles. This protective cocoon provides a buffer from bumps and injury, ensuring the umbilical cord is not compressed, which would reduce the developing baby’s oxygen supply. It also maintains a constant temperature within the womb. As the fetus grows, it ‘breathes in’, swallows and excretes amniotic fluid which aids the development of a healthy respiratory and digestive system. Amniotic fluid provides the space and support for the baby to move around, which is important for developing muscles and bones (NHS Choices 2015a). MIDIRS Midwifery Digest 27:4 2017

Cells from the fetus accumulate in the fluid, so a small sample of amniotic fluid can be used to check for signs of any chromosomal or genetic abnormalities. This is carried out between weeks 11 and 14, while amniocentesis is usually carried out between weeks 15 and 20 of the pregnancy. Both carry a small risk of complications, including premature rupture of the amniotic sac and miscarriage. Insufficient amniotic fluid, known as oligohydramnios, occurs in around 4% of pregnancies with dehydration, diabetes, placental problems and damage to the amniotic sac all leading to insufficient fluid. Excess fluid or polyhydramnios, is thought to occur in around 1% of pregnancies, and one in five cases is associated with a congenital abnormality, women with diabetes, or carrying more than one baby who are more likely to have excess amniotic fluid (American Pregnancy Association 2017).

Rupture of the amniotic sac Although estimates vary, as many as one in ten pregnancies is complicated by premature rupture of 429

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membranes (PROM); however Bornstein et al (2006) argue that estimation of the number of pregnancies affected by PROM is complicated by differing definitions of PROM (Table 1) in the United Kingdom (UK) and the United States of America (USA). Moreover, the National Institute for Health and Care Excellence (NICE) (2017) state that three out of five women go into labour within 24 hours. Table 1. Definitions of the premature rupture of membranes in the UK. The terminology used to describe rupture of the amniotic sac in the UK can vary: •

PROM – Premature rupture of membranes occurs in around ten per cent of pregnancies. This is a rupture before 37 weeks which is followed by spontaneous labour. These women need to be identified to ensure those who do not go into labour receive appropriate treatment. Women who have experienced PROM during a previous pregnancy are at increased risk of it happening again. Women who have undergone cervical surgery or those born with a shorter cervix are also at increased risk (Mulhair et al 2009). P-PROM – preterm premature rupture of membranes. This occurs in one in 50 pregnancies. In cases of P-PROM, the membranes rupture before 37 weeks but the mother does not go into labour within 18 to 24 hours. P-PROM is associated with 40% of preterm deliveries and can lead to significant morbidity and mortality. The challenge for doctors is that this is, by definition, often a diagnosis that can only be made retrospectively. It is crucial to identify women who may not go into labour and become P-PROM because a third of women (36%) who experience a confirmed P-PROM have an infection inside the womb. In some cases, there may be warning signs, such as raised temperature or an unpleasant vaginal discharge. In most cases the infection is subclinical, which means there are no obvious symptoms until amniotic fluid begins to leak out, or the waters break completely (NHS Choices 2015a).

It is crucial to identify the women who may not go into labour and become P-PROM because a third (36%) of those confirmed P-PROM have a uterine infection. In some cases, there may be warning signs, such as raised temperature or an unpleasant vaginal discharge, although for others the infection is subclinical, which means there are no obvious symptoms until amniotic fluid begins to leak out, or the waters break completely (Jolley & Wing 2008). Factors that increase the risk of PROM and P-PROM: •

Having too much amniotic fluid, or carrying more than one baby, can overstretch the amniotic sac and cause an early rupture.

Women who have experienced PROM during a previous pregnancy (O’Connor et al 1999).

Women who have undergone cervical surgery — such as a cone biopsy or laser treatment following an abnormal smear test — or those who just happen to have been born with a shorter cervix, are also at increased risk (Committee on Understanding Premature Birth and Assuring Healthy Outcomes et al 2006). Around 31,800 cases of in situ cervical carcinoma are picked up every year in the UK (Cancer Research UK 2017a), and two out of five of these women will undergo surgical resection as part of their treatment (Cancer Research UK 2017b).

Some placental problems can lead to a rupture and tests such as amniocentesis and chorionic villus sampling also carry a small risk.

Diabetes carries a higher risk because it can lead to excess amniotic fluid and overstretching of the membranes. NICE (2015) estimates that one in 20 women (5%) who gives birth in England and Wales has diabetes, and almost nine out of ten of these (87.5%) are diagnosed during their pregnancy.

Being overweight increases the risk too. Moreover, Cnattingius et al (2013), when examining birth records for more than 1.5 million women, found the chances of going into early labour with problems such as a PROM, rose in line with increases in the mother’s body mass index (BMI). A BMI of between 25 and 30 was associated with a 21% increase in PROM; a BMI of 30 to under 35 elevated the risk by 27%; 35 to less than 40 raised the threat by 35% and a BMI of more than 40% increased the risk by 52%.

Zhang et al (2009) state that poor nutrition and low haemoglobin levels caused by iron deficiency have been linked to PROM. This is worrying as low iron intake is common among women in the UK. The latest National Diet and Nutrition Survey confirms that more than a quarter of women aged 19 to 64 (27%) and almost half of girls aged 11 to 18 (48%) are failing to meet the minimum intake of iron needed for good health (Public Health England 2016). While iron

SROM – Rupture after 37 weeks is described as spontaneous rupture of membranes (SROM), when the waters break naturally sometime after week 37 and the woman goes into labour.

PROM and P-PROM are factors in two out of five cases of babies being born too early and it can be fatal on three counts: prematurity, sepsis, and pulmonary hypoplasia, where the lungs have not fully formed and babies cannot breathe without assistance (Porter 2017). Moreover, the Royal College of Obstetricians and Gynaecologists (RCOG) states that for women, there is the risk of infection and other potentially 430

serious problems, including retained placenta and postpartum haemorrhage (Carroll 2006).

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Research & Education

supplements are often prescribed during pregnancy, they are poorly absorbed and side effects are common. Woods et al (2001) argue that having low levels of vitamins C and E also increases the risk of PROM. •

Smoking, particularly earlier in the pregnancy. A large Canadian study, which analysed data from 17,961 births, found that smoking more than ten cigarettes a day significantly increased the danger of a woman’s waters breaking too soon (Woods et al 2001).

Endometriosis, a gynaecological condition characterised by heavy periods and endometrial cells growing outside the womb, has also been shown to increase the risk of PROM (Harada et al 2016).

Asherman Syndrome, which is characterised by adhesions and scarring of the womb lining, is associated with an increased risk of PROM. It is not clear how many women may be affected by Asherman’s, but having a previous miscarriage or dilation and curettage (D&C) also increases the risk (Harada et al 2016).

Identification and treatment Membranes can rupture at any stage of a woman’s pregnancy. The treatment options and outcomes depend on the baby’s development, the extent and position of the tear and — most importantly — how quickly the mother receives medical care or goes into labour. Many risk factors and variables will influence outcomes, but one thing is constant: if a leak of amniotic fluid is suspected, it must be investigated at once because both the mother and child may need immediate and expert attention. Guidance from NICE (2013) is unequivocal in stating that maternal and neonatal morbidity can be reduced by the early detection of amniotic fluid leakage and appropriate management. Unless there is an obvious rupture, using a sterile speculum and actually seeing amniotic fluid draining from the cervix and pooling in the vagina after the woman has been lying down for 30 minutes has traditionally been the most commonly-used diagnostic method. Testing for insulin-like growth factor binding protein-1 or placental alpha-microglobulin-1 may aid diagnosis but results should not be considered in isolation. Nitrazine testing is no longer recommended as urine, semen and other contaminants may give a false-positive test result. Ultrasound may be useful to check for gestation and liquor volume, alongside temperature monitoring, fetal monitoring, a high vaginal swab and, if infection is suspected, tests checking a full blood count for white cell count, c-reactive protein, blood cultures and a midstream specimen of urine. Antibiotic treatment can be started if tests, along with clinical signs, confirm intrauterine infection (NICE 2013, 2015). However, a speculum examination and watching for pooling may not always detect non continuous small MIDIRS Midwifery Digest 27:4 2017

ruptures and hind leaks. This type of testing can also be time consuming, uncomfortable for the patient and may even increase risk of infection. A new evidencebased test in the form of a two-staged diagnostic polymer strip located inside a panty liner has been proven to be as accurate as hospital-based examinations, such as the Ferning test, sterile speculum examination and pH (measure of alkalinity or acidity) test (Bornstein et al 2006, 2009, NICE 2013). The diagnostic test, AmnioSense, has been approved by NICE (2013) and unlike a speculum examination, allows for constant monitoring. AmnioSense looks like an ordinary panty liner; however, the AmnioSense test differs in that it includes a strip which turns blue-green when it comes into contact with moisture with a pH of more than 6.5. Amniotic fluid has a pH of 6.7 or more, while normal vaginal secretions range from 3.5 to 4.5. The pH of urine can vary from 4.0 to 8, but it also contains ammonia. As a result, AmnioSense includes reagents that react differently to ammonia which aids the elimination of any false positives caused by incontinence. If the liner changes colour due to urine, it will then fade within ten minutes. The test area will remain a blue-green colour for at least two hours when the reaction has been triggered by amniotic fluid. Several studies have confirmed the accuracy, sensitivity and ease-of-use of this latest diagnostic tool (Bornstein et al 2006, 2009) which often eliminates the need for a speculum procedure. NICE (2013) has concluded that 42% of these examinations would be unnecessary if this new test were used as a simple prenatal triage measure to rule out leaks caused by vaginal mucus or urine. AmnioSense also avoids the discomfort and intrusion of a physical examination. NICE (2013) illustrated that a single visit to an antenatal unit costs £147. However, by using the new polymer strip test, 38% of women did not have to attend an antenatal unit as they were able to use the at-home test to confirm leaks were harmless. Confirmation of a harmless vaginal leak also provided women with great reassurance. Where an amniotic leak is diagnosed, the outcomes for mother and child are improved. Before 24 weeks, the odds of the baby surviving a major rupture are heartbreakingly low, although sometimes a small hole, high in the sac, will heal over. However, as long as the membranes are largely intact, with bed rest and expert care clinicians may be able to delay labour, retaining stability until the baby has a chance of surviving outside the womb. The chances of a preterm baby surviving improve with every additional week and if the waters break at 34 weeks or later, the RCOG advises induction of labour in the absence of spontaneous contractions (Carroll 2006). 431

Research & Education

Before 34 weeks, treatment for PROM will focus on trying to prevent infection. In a third of cases (36%) infection is already present and may well have pre-empted the rupture. The risk of infection escalates rapidly once there is any form of rupture in the sac, no matter how small. Antibiotics are prescribed as soon as a leak is detected as the infection may be caused by group B streptococcus — carried by one in four women (NHS Choices 2015b). This usually harmless bacteria not only increases the risk of a rupture, but is also likely to invade the amniotic sac and infect the baby if there is a leak. This can lead to a number of problems for the baby, including heart and breathing issues, pneumonia, meningitis and stillbirth. The RCOG confirm that giving prophylactic antibiotics almost halves the risk of infection and significantly reduces the risk of infants being born within the following 48 hours (Carroll 2006).

Conclusion Identifying an amniotic rupture quickly is the key to achieving the best outcomes so that effective treatment can be put into place. Timely adoption of simple, clinically proven diagnostic tests using the very latest technology, such as AmnioSense, helps provide reassurance and clear benefits for both maternity and midwifery health care professionals and for women with suspected SROM, PROM and P-PROM. Dr Paul Stillman, General Practitioner, Emma Herbert, Community Midwife.

References American Pregnancy Association (2017). Low amniotic fluid levels: oligohydramnios. http://americanpregnancy.org/pregnancycomplications/oligohydramnios [Accessed 2 September 2017]. Bornstein J, Geva A, Solt I et al (2006). Nonintrusive diagnosis of premature ruptured amniotic membranes using a novel polymer. American Journal of Perinatology 23(6):351-4. Bornstein J, Ohel G, Sorokin Y et al (2009). Effectiveness of a novel home-based testing device for the detection of rupture of membranes. American Journal of Perinatology 26(1):45-50. Cancer Research UK (2017a). Cervical cancer diagnosis and treatment statistics. http://www.cancerresearchuk.org/healthprofessional/cancer-statistics/statistics-by-cancer-type/cervicalcancer/diagnosis-and-treatment. [Accessed 2 September 2017]. Cancer Research UK (2017b). Pregnancy and abnormal cervical cells. http://www.cancerresearchuk.org/about-cancer/cervicalcancer/treatment-for-abnormal-cervical-cells/pregnancy [Accessed 2 September 2017]. Carroll SGM (2006). Preterm prelabour rupture of membranes. London: Royal College of Obstetricians and Gynaecologists.

Committee on Understanding Premature Birth and Assuring Healthy Outcomes, National Academy of Sciences, Board on Health Sciences Policy et al (2006). Preterm birth: causes, consequences, and prevention. Washington DC: National Academies Press. Harada T, Taniguchi F, Onishi K et al (2016). Obstetrical complications in women with endometriosis: a cohort study in Japan. PLoS One 11(12):e0168476. http://journals.plos.org/ plosone/article?id=10.1371/journal.pone.0168476 [Accessed 2 September 2017]. Jolley JA, Wing DA (2008). Pregnancy management after cervical surgery. Current Opinion in Obstetrics & Gynecology 20(6):528-33. Mulhair L, Carter J, Poston L et al (2009). Prospective cohort study investigating the reliability of the AmnioSense method for detection of spontaneous rupture of membranes. BJOG: An International Journal of Obstetrics and Gynaecology 116:313-18. National Institute for Health and Care Excellence (2013). Vision amniotic leak detector to assess unexplained vaginal wetness in pregnancy. London: NICE. National Institute for Health and Care Excellence (2015). Diabetes in pregnancy: management of diabetes and its complications from preconception to the postnatal period. London: NICE. National Institute for Health and Care Excellence (2017). Intrapartum care for healthy women and babies. London: NICE. NHS Choices (2015a). What is the amniotic sac? http://www.nhs.uk/ chq/Pages/2310.aspx?CategoryID=54 [Accessed 9 September 2017]. NHS Choices (2015b). Streptococcal infections. http://www.nhs.uk/ conditions/streptococcal-infections/pages/introduction.aspx [Accessed 9 September 2017]. O’Connor S, Kuller JA, McMahon MJ (1999). Management of cervical cerclage after preterm premature rupture of membranes. Obstetrical & Gynecological Survey 54(6):391-4 Odunsi K, Rinaudo P, Yale-New Haven Hospital (2017). Summary: premature rupture of the fetal membranes. Hygeia Foundation and Institute for Perinatal Loss: 2:4. Office for National Statistics (2017). Births in England and Wales: 2016. https://www.ons.gov.uk/peoplepopulationandcommunity/ birthsdeathsandmarriages/livebirths/bulletins/ birthsummarytablesenglandandwales/2016 [Accessed 9 September 2017]. Porter H (2017). Pulmonary hypoplasia. BMJ Journals: Archives of Disease and Childhood Fetal & Neonatal Edition 81(2). http:// fn.bmj.com/content/81/2/F81.full [Accessed 9 September 2017]. Public Health England (2016). National Diet and Nutrition Survey: Results from Years 5 and 6 (combined) of the Rolling Programme (2012/2013-2013/2014). https://www.gov.uk/government/uploads/ system/uploads/attachment_data/file/551352/NDNS_Y5_6_UK_ Main_Text.pdf [Accessed 9 September 2017]. Royal College of Midwives (2012). Evidence based guidelines for midwifery-led care in labour. London: RCM. Woods JR, Plessinger MA, Miller RK (2001). Vitamins C and E: missing links in preventing preterm premature rupture of membranes? American Journal of Obstetrics and Gynecology 185(2):5-10. Zhang Q, Ananth CV, Li Z et al (2009). Maternal anaemia and preterm birth: a prospective cohort study. International Journal of Epidemiology 38(5):1380-9.

Chartered Society of Physiotherapy (2014). Pregnancy-related incontinence. http://www.csp.org.uk/your-health/conditions/ pregnancy-related-incontinence [Accessed 2 September 2017].

Stillman P, Herbert E. MIDIRS Midwifery Digest, vol 27, no 4, December 2017, pp 429-432.

Cnattingius S, Villamor E, Johansson S et al (2013). Maternal obesity and risk of preterm delivery. JAMA 309(22):2362-70.

Original article. © MIDIRS 2017.


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Site-specific onset of low bone density and correlation of bone turnover markers in exclusive breastfeeding mothers Jarinthorn Teerapornpuntakit, Pharuhas Chanprapaph, Nitsara Karoonuthaisiri, Narattaphol Charoenphandhu Purpose: Lactation often affects calcium metabolism and induces bone loss. Calcium supplementation and a high calcium diet are recommended to prevent bone loss, especially during inadequate calcium intake. Our study aimed at determining bone loss in breastfeeding mothers, and if it occurred, whether it was site specific and there were correlations between serum bone turnover markers. Materials and methods: Since the 6-month exclusive breastfeeding is usually recommended in several countries, our study examined bone mineral density (BMD) in early (1–2 month), mid (3–4 month)-, and late (5–6 month) lactation compared with nonpregnant, nonlactating control women. Site-specific bone loss was monitored in lumbar vertebrae and femora. Bone turnover markers, that is, C-terminal telopeptide of type 1 collagen and N-terminal propeptide of type 1 collagen (P1NP), were determined by electrochemiluminescence immunoassays. Results: The onset of bone loss in exclusive breastfeeding mothers was site specific, for example, in the lumbar bone at mid-lactation and in the femoral bone in late lactation. Serum ionized calcium levels in late lactation were lower than the normal levels. In addition, a correlation was found between bone turnover marker, P1NP, and femoral BMD. Conclusions: The onset of bone loss in exclusive breastfeeding mothers was site specific, and the lumbar bone was a vulnerable and perhaps better representative site for bone loss detection. It was suggested that the optimal starting time for calcium supplementation should be before the mid-lactation when the bone loss was observed. In addition, the biochemical marker that best predicted the onset of bone loss in lactating women was P1NP. Teerapornpuntakit J, Chanprapaph P, Karoonuthaisiri N et al. Breastfeeding Medicine, vol 12, no 6, July 2017, pp 331–337.

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Author abstract. © Mary Ann Liebert, Inc. publishers All rights reserved, USA and worldwide 2012.

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Research & Education

Vulnerability of pregnant women in clinical research Indira SE van der Zande, Rieke van der Graaf, Martijn A Oudijk, Johannes JM van Delden Background: Notwithstanding the need to produce evidence-based knowledge on medications for pregnant women, they remain underrepresented in clinical research. Sometimes they are excluded because of their supposed vulnerability, but there are no universally accepted criteria for considering pregnant women as vulnerable. Our aim was to explore whether and if so to what extent pregnant women are vulnerable as research subjects. Method: We performed a conceptual and empirical analysis of vulnerability applied to pregnant women. Analysis: A conceptual analysis supports Hurst’s definition of vulnerability. Consequently, we argue that pregnant women are vulnerable if they encounter an identifiably increased likelihood of incurring additional or greater wrong. According to the literature, this increased likelihood could exist of four alleged features for pregnant women’s vulnerability: (i) informed consent, (ii) susceptibility to coercion, (iii) higher exposure to risk due to lack of knowledge, (iv) vulnerability of the fetus. Discussion: Testing the features against Hurst’s definition demonstrates that they all concern the same issue: pregnant women are only vulnerable because a higher exposure to risk due to lack of scientific knowledge comprises an increased wrong. Research Ethics Committees have a responsibility to protect the vulnerable, but a higher exposure to risk due to lack of scientific knowledge is a much broader issue and also needs to be addressed by other stakeholders. Conclusions: The only reason why pregnant women are potentially vulnerable is to the extent that they are increasingly exposed to higher risks due to a lack of scientific knowledge. Accordingly, the discussion can advance to the development of practical strategies to promote fair inclusion of pregnant women in clinical research. van der Zande ISE, van der Graaf R, Oudijk MA et al. Journal of Medical Ethics, 17 July 2017. Online first. doi: 10.1136/medethics-2016-103955. [Epub ahead of print]

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Author abstract. © BMJ Publishing Group Ltd & Institute of Medical Ethics. All rights reserved 2017.


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What are women’s experiences of maternity care in Ireland from a human rights perspective? Leah Murphy ORIGINAL Background: There are many international organisations dedicated to improving childbirth-related outcomes; however, it is important to focus beyond maternal and fetal mortality rates as the importance of human rights is becoming more evident in the literature. Many human rights issues are faced by women internationally, with women experiencing disrespect and abuse in maternity care on a global scale. Aims and objectives: The aim of this study was to investigate women’s experiences of maternity care in Ireland, and was specifically focused on identifying issues related to human rights. Objectives included gaining an understanding of the lived experiences of women and identifying whether or not disrespect and abuse presented as an issue in maternity care in Ireland. Research method: The chosen research method for this study was a quantitative descriptive design, using a survey as the instrument for data collection. Facebook, the social media platform, was the chosen method of survey distribution, as the researcher recognised the benefits of utilising online resources not only to distribute the data but also to analyse the results in an effective manner. Data analysis: A plethora of information was received from the respondents to the survey, allowing the researcher to analyse quantitative data from 205 participants. Comments and additional information were also provided by respondents, allowing the researcher to gain a deeper understanding of the experiences of the participants.

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Results: This study helped to identify issues relating to consent, respect and privacy in maternity care in Ireland and the findings also indicated to the researcher that each woman’s experience was individual. Further research should be conducted into human rights and maternity care in Ireland, and that more research will need to be conducted in order to successfully close the gap in the literature.

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Following a review of the literature (Murphy 2017) it became apparent that there is a dearth of literature surrounding women’s experiences of maternity care, particularly in Ireland. As a consequence the author undertook a research study to explore the phenomenon in greater depth. Initially, a qualitative descriptive design was proposed to answer the research question, using individual indepth interviews; however, as there is limited information regarding human rights in maternity care in Ireland, it was decided that collecting a broad array of information would be more insightful. Therefore, a quantitative descriptive research design was chosen, using a survey to gather relevant information. As specified by Mouton (1996), a survey can be used to collect original data from a population that is too large to observe directly.

The validity of an instrument is its ability to effectively measure what it is designed to measure (Polit & Hungler 1999). As the survey questions were developed using the categories of disrespect and abuse devised by Bowser & Hill (2010), the researcher ensured content validity (Murphy 2017). As the survey was completed voluntarily by Facebook members of the AIMSI group, it is acknowledged that the findings may not be as generalisable as if they had been chosen from a randomised sample.

Aims • To gain an understanding of women’s lived experiences of their care in the Irish maternity care system. • To assess issues, if any, that women have with their care. • To develop knowledge of human rights in maternity care in Ireland and add to the existing bodies of knowledge. • To identify experiences of disrespect and abuse (Bowser & Hill 2010), if any, in Ireland.

Inclusion criteria The following inclusion criteria applied to the participants of this study. They should: • have had at least one child in Ireland • be the person in direct association with the maternity care providers • be over 18 years of age. The researcher is aware that due to the method of distribution (via social media) there was no precise means of examining whether all respondents matched the above criteria, other than to trust that the participants were relevant for the study.

Data collection A survey was constructed online using the Survey Monkey website, which respondents accessed via Facebook. The social media platform Facebook through the Association for Improvements in the Maternity Services in Ireland (AIMSI) was used as the data collecting instrument; respondents had access to the survey for a period of five days. As the research was predominantly concerned with collecting generalisable data, collecting a large quantity of responses was of particular concern. Although there are many advantages to online surveys, there are also disadvantages: respondents may not answer the questions accurately and valuable information may be lost due to answers being short. Furthermore, as the survey was conducted in English, women who had a poor understanding of the language may have been excluded. 436

Ethical considerations As this was a voluntary survey, the participants were immediately given an opportunity to opt into the research or to opt out if they so desired, respecting their autonomy. The anonymity of the participants was also maintained, as there was no requirement for participants to provide personal information which may have led to their identification. An option was provided for the participants to provide their email if they wished, in order to be contacted by the researcher regarding further research into human rights and maternity care. As specified by Ellis (2010) participants of a study have a right to expect that their confidentiality will be maintained throughout the research process, and for this research the participants were identified by number. Data were analysed through Survey Monkey, represented in graphs and tables, with the open-ended questions assessed via quantitative content analysis.

Results Demographic data The survey results are represented in the following tables: Table 1. Demographics

Aged between

Ethnicity Caucasian Mixed ethnicity Relationship Married Single/cohabiting Single/never married Civil union/domestic partnership Separated Divorced/widowed No. of children 1 2 3 4 5+ Declined to respond

242 responses – 84.7% 18–24 25–34 35–44 45–54 over 54

Complete (n=205)

202 3

98.5% 1.5%

151 26 16 9

73.7% 12.7% 7.8% 4.4%

3 0

1.5% 0%

72 78 11.8 33.4 5 2

34.5% 37.5% 16.7% 5.9% 2.5% 1%

4.9% 39.5% 49.3% 6.3% 0%

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Table 2. Highest level of education achieved Answer choices Some secondary school but no leaving certificate/ equivalent Completed leaving certificate/ equivalent Some college but no degree Diploma Bachelor degree Graduate degree Other (please specify) Total

Responses 0.98%






17.07% 23.90% 27.32% 10.73%

35 49 56 22



There appeared to be some confusion in the answer choices as some participants selected the ‘Other’ option only to identify themselves as having achieved Masters and PhDs. These participants would have been better included in the ‘Graduate’ category and taking this into consideration it would have altered the data in the ‘Other’ category to include only four respondents (1.3% of the respondents). This also would have increased the number who held a Graduate degree to 74 respondents, equating to a representation of 36.0%.

Table 3. Year of infant’s birth, type of care/birth Year women gave birth to at least one infant 1981–1990 1991–2000 January 2001–August 2016 Type of care Public consultant led Public midwife led Total Private/semi-private consultant-led care Private via self employed community midwife Type of birth Non-assisted vaginal birth Lower segment caesarean section Ventouse Forceps Vaginal birth after caesarean Other (type not stated) Comments Episiotomies Ectopic Twin birth Epidural Emergency Home births

1 12 192 39.6% 25.6% 65.2% 33.3% 1.9%

41.3% 24.8% 15.5% 11.5% 3.9% 8 3 1 1 1 1 2

Survey responses In order to examine human rights in maternity the survey also included categories of disrespect and abuse (Bowser & Hill 2010). MIDIRS Midwifery Digest 27:4 2017

Table 4. Were there any procedures performed on you or your baby which made you feel uncomfortable? Answer choices Responses Yes 38.54% 79 No 61.46% 126 Total 100% 205

In addition to the data there were 22 comments left by respondents. Figure 1. Do you feel like you were given enough information to make choices about your care?

Yes No

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

The tables represent the quantitative survey answers. There were also over 200 additional comments received (N=211) which were examined and categorised as specified by Bowser & Hill (2010). The categories of disrespect and abuse identified by their landscape analysis interlink, with issues presented on a spectrum rather than being individual, evolving as the data were collected.

Qualitative responses Physical abuse Through analysis of the comments and additional information provided by respondents no evidence to the extent described by Bowser & Hill (2010) could be found. The White Ribbon Alliance (WRA) (2011) has identified that physical abuse impinges on the human right to freedom from harm and ill treatment. In this study, the data did indicate that numerous respondents were unhappy with procedures performed on them, namely episiotomies. Four women reported having episiotomies, with all of them also reporting that minimal information was received prior to the intervention and that consent was not sought prior to the procedure being performed. Unnecessary episiotomies can be considered a manifestation of physical abuse, or an example of obstetric violence. The respondents described experiences of episiotomies and although the procedures may not be classified as physical abuse other issues were identified relating to informed choice and consent as illustrated in the following quotes. One woman requested not to have an episiotomy, asking if it was necessary: ‘the ob/gyn SpR told me to hush and did it’ [sic] (Respondent #173). Consent was sought in a very intimidating way: ‘I’m going to make a small cut is that ok?’ (Respondent #145). The procedure was presented as something that must happen, rather than as an option. 437


Table 5. Was consent sought? Physical examinations Procedures during pregnancy Procedures during labour and birth Procedures postnatally/ after birth Procedures relating to your baby

Never 6.37% 13 5.42% 11 9.85% 20 8.37% 17 8.46% 17

Rarely 6.37% 13 3.94% 8 5.91% 12 5.91% 12 4.98% 10

Sometimes 14.22% 29 13.79% 28 23.65% 48 15.27% 31 10.45% 21

Often 8.33% 17 12.81% 26 10.84% 22 13.79% 28 18.41% 37

Always sought 62.75% 128 56.16% 114 47.78% 97 53.20% 108 54.23% 109

N/A 1.96% 4 7.88% 16 1.97% 4 3.45% 7 3.48% 7


Weighted average











Table 6. How would you rate your privacy during your care? Not good 19.51% 40

Fair 20.98% 43

Good 17.56% 36

Very good 23.90% 49

Excellent 18.05% 37

N/A 0.00% 0


Weighted average



Table 7. At any point in your care did you feel discriminated against due to: Age

Race/ethnicity Traditional/religious beliefs Education Occupation Pre-existing medical issues Total Weighted average















Table 8. Do you agree or disagree with the following statements.

I felt physically safe during my care (pregnancy, birth and postnatally) I felt emotionally safe during my care (pregnancy, birth and postnatally) I felt comfortable speaking to my care providers My choices were respected and my wishes listened to I received enough information to make decisions about my care I am happy with my experience I am happy with the care I received I would change my experience(s) of pregnancy, birth and postnatal care if I could I feel empowered by my experience I feel like my human rights were respected

Strongly Disagree Neither disagree Agree disagree or agree 11.22% 13.17% 8.78% 40.98%

Strongly agree Total Weighted average





















16 12.68%

46 17.56%

27 14.15%

77 38.54%

26 14.71%

36 18.63%

29 12.25%



20.10% 41 16.10%

25.85% 205




39 17.07%



79 35.78%

35 18.63%












30 16.10%

25 10.73%

65 34.15%

43 22.93%



33 16.10%

33 16.10%

22 11.22%

70 27.32%

47 29.27%















35 12.87%

43 12.87%

47 15.35%

55 38.61%

25 20.30%










Table 9. Overall, how would you describe your experience. Not good 22.93% 47 438

Fair 16.10% 33

Good 18.05% 37

Very good 20.00% 41

Excellent 22.93% 47

N/A 0.00% 0


Weighted average


3.04 MIDIRS Midwifery Digest 27:4 2017


Non-consented care There were many reports of non-consented care that emerged from analysis of the comments and responses. In relation to procedures performed during pregnancy, one respondent reported that: ‘[…] a sweep was performed against my will’. The largest number of comments received was in relation to procedures performed during labour and birth, with a respondent reporting that coercive methods were used in order to gain consent: ‘Consent procured by denial of pain relief until consent given’ (Respondent #80). Other respondents indicated that they were told about procedures prior to their occurrence with no consultation: ‘I was only allowed to push a few times on my first before suction was used. I was not consulted, but rather told. Same then for the episiotomy’ (Respondent #161). The trend in answers continued into postnatal care experiences. However there were a smaller number of comments for the researcher to evaluate. One comment stood out in particular relating to an unconsented hormone injection given post birth to stimulate the third stage of labour. The most worrying comment, however, appeared in relation to consent sought prior to procedures performed on the infants of participants: ‘[…] baby taken off for a blood test without explanation’ (Respondent #93). ‘2 xrays performed that I was only informed of at discharge’ (Respondent #80). Other comments relating to consent were scattered throughout the survey responses, with some issues discussed further by respondents. The respondents were expressive in their comments, with the responses more in-depth than in the comments previously mentioned. The largest recurring theme was that of dismissiveness on the part of, and coercion by, health care professionals. ‘[…] Midwives were most supportive but one male doctor struggled with respecting our wishes and tried to pressurise me to intervention without explaining the situation well’ (Respondent #151). ‘I was lied to and forced into an unnecessary induction which resulted in an emergency c-section... so my consultant could go on holidays’ (Respondent #110). ‘My first birth was horrific. I knew enough second time round to insist on certain things that made the experience a good one. I was induced both times against my express wishes but was told I had no choice in the matter as I was overdue’ (Respondent #99). These findings are consistent with literature concerning the area, such as previous research conducted by AIMSI (2007). There is an international awareness of the fact that women face issues regarding consent in maternity care, acknowledged by the World Health Organization (WHO) (2015) and WRA (2011). MIDIRS Midwifery Digest 27:4 2017

Non-confidential care Internationally, non-confidential care can be witnessed through the disclosure of personal information or the performance of procedures or interventions. There were a limited number of comments indicating that respondents had experienced non-confidential care compared to the statistical evidence. These responses ranged from having personal information discussed publicaly in hallways (Respondent #87), to one respondent reporting that building works were ongoing at the window to her birthing room, with construction workers able to see into the room (Respondent #7). The reports of participants experiencing nonconfidential care, while present, do not reach the extent documented by Abuya et al (2015) and Okafor et al (2015) in their respective studies of disrespect and abuse in Kenya and Nigeria. However, as discussed previously, 19.5% of participants rated their experience of privacy in maternity care as ‘Not good’, with a further 21% indicating their experience of privacy as ‘Fair’. Further research is necessary to completely understand women’s experiences of nonconfidential care, as these experiences limit the human right to privacy and confidentiality. Non-dignified care ‘Every woman has the right to be treated with dignity and respect’ (WRA 2011:4) Participants were questioned on their experiences of respect in maternity care, resulting in 33 associated comments with the statistics demonstrating both physical and emotional disrespect, as well as non-dignified care. The reports of disrespect varied; however, three respondents reported experiencing disrespect during postnatal care, disrespect that specifically related to infant feeding. ‘My wish was to breastfeed, I was offered to give my baby top up of formula every night. My baby developed slight jaundice. They told me if I didn’t give my baby formula for one night she might be in a chance if having brain damage (which is ridiculous) and when I refused to give her formula the doctor then threatened me with bringing my baby to nursery where she would be hooked up to a drip and I would not be allowed in to see her. Despite the fact that leaflets in the hospital it states breastfeeding flushes out the jaundice quick they insisted on formula. Complete bully tactics [sic]’ (Respondent #57). ‘My struggle with breastfeeding & weight loss in baby on my first was not supported. I was genuinely devastated to have failed my baby so badly & it had a negative impact on my health & confidence as a mother. My wish to breastfeed exclusively was not supported & I was made to feel irresponsible for resisting formula top ups. I asked about cup/syringe feeding & was told those options were not available to me. I have never felt so alone in all my life’ (Respondent #145). ‘Felt pressured into giving formula when baby didn’t wet enough nappies, no one suggested weighing 439


nappies or trying to support breastfeeding in any other way first other than one kind midwife. This happened with both babies’ (Respondent #192). There was also one account of disrespectful care having long lasting psychological impacts. Respondent #131 discussed such an experience: ‘I suffered PTSD and vowed to never have a baby in Ireland again, and never did, parted from the father of my baby partly because of it and now romantic relationships are hard.’ Women’s traumatic experiences of childbearing can stay with them, contributing to a perceived climate of fear around childbearing. As the above quote confirms, women can indeed suffer long-term emotionally as a consequence of their care.

Discrimination based on specific patient attributes Discrimination can manifest in many ways, including in terms of race or ethnicity. Interestingly, there were no reports of this type of discrimination in the results of this survey. The largest number of respondents felt discriminated against due to age (n=28), followed by previous medical conditions (n=14), with four respondents citing traditional or religious discrimination. Two experienced discrimination due to their education, and two more based on their employment. Unfortunately there were no comments provided for this question to clarify the responses. Two respondents made comments elsewhere in the survey pertaining to experiences of discrimination in relation to relationship status and religious views. The following are only two of the examples taken from 50 respondents reporting that they had experienced discrimination: ‘[…] I was treated like a piece of meat without the capacity to make decisions, and my partner was ignored by the midwife as we weren't married. They even refused to take his details as “if you're not married it doesn't matter”. This was in 2009, not 1909’ (Respondent #99). ‘[…] also the nurse admitting me gave me a huge grilling about being atheist. She was a young nurse and was downright rude that I didn't believe in God. Very condescending’ (Respondent #175).

Conclusion The largest issues relating to human rights identified within this paper are in relation to consent, respect and privacy. There was insufficient evidence to assess the experiences of women in relation to detention in facilities and abandonment of care. The use of disrespect and abuses identified by Bowser & Hill (2010) proved successful in identifying literature relevant to the topic area and again in examining the experiences of women. Overall 12.9% of respondents strongly disagreed with the statement: ‘I feel like my human rights were respected’. 440

Previous studies (Murphy 2017) identified that improving maternal health involves recognising the basic human rights of women. The findings in this paper are significant, highlighting that all experiences are individual to the service user, with no two respondents experiencing the same care. It is acknowledged that this study is small, with a total of 205 respondents to the survey; nonetheless there were a broad range of findings and an overwhelming number of comments and additional information provided. This paper has exposed the many human rights issues that women have experienced in Irish maternity care. It is hoped that this research will contribute positively to the existing body of limited knowledge in Ireland, in order to improve the maternity care experiences of future service users. ‘Every woman has the right to the highest attainable standard of health, which includes the right to dignified, respectful health care’ (WHO 2015:1). Leah Murphy holds a BSc in Midwifery and an MA in International Relations, and is currently working in the area of sexual health and reproductive rights in Ireland.

References Abuya T, Ndwiga C, Ritter J et al (2015). The effect of a multicomponent intervention on disrespect and abuse during childbirth in Kenya. BMC Pregnancy and Childbirth 15(224). https://doi. org/10.1186/s12884-015-0645-6 [Accessed 10 August 2016]. Association for Improvements in the Maternity Services in Ireland (2007). ‘What matters to you?’ http://aimsireland.ie/wp-content/ uploads/2014/04/AIMS-Ireland-What-Matters-To-You-2007.pdf [Accessed 10 August 2016]. Association for Improvements in the Maternity Services in Ireland (2015). ‘What matters to YOU?’ 2014 report on consent in the Irish maternity system. http://aimsireland.ie/what-matters-to-yousurvey-2015/womens-experiences-of-consent-in-the-irish-maternityservices/ [Accessed 12 August 2016]. Bowser D, Hill K (2010). Exploring evidence for disrespect and abuse in facility-based childbirth: report of a landscape analysis. Boston: Harvard School of Public Health. Ellis P (2010). Understanding research for nursing students. 1st ed. London: SAGE Publications Ltd. Mouton J (1996). Understanding social research. Hatfield: Van Schaik Publishers. Murphy L (2017). An investigation into women’s experiences of maternity care in Ireland from a human rights perspective: a review of the literature. MIDIRS Midwifery Digest 27(3):291-8. Okafor II, Ugwu EO, Obi SN (2015). Disrespect and abuse during facility-based childbirth in a low-income country. International Journal of Gynecology & Obstetrics 128(2):110-13. Polit DF, Hungler BP (1999). Nursing research: principles and methods. 6th ed. Philadelphia: Lippincott Williams & Wilkins. White Ribbon Alliance (2011). Respectful maternity care: the universal rights of childbearing women. Washington: WRA. http:// whiteribbonalliance.org/wp-content/uploads/2013/10/Final_RMC_ Charter.pdf World Health Organization (2015). The prevention and elimination of disrespect and abuse during facility-based childbirth. Geneva: WHO. http://apps.who.int/iris/bitstream/10665/134588/1/ WHO_RHR_14.23_eng.pdf?ua=1&ua=1

Murphy L. MIDIRS Midwifery Digest, vol 27, no 4, December 2017, pp 435-440. Original article. © MIDIRS 2017.

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Leadership, autonomy and the newly qualified midwife Yvonne Nolan ORIGINAL Introduction The transition from student midwife to autonomous practitioner within an institution such as the National Health Service (NHS) can be a turbulent period, which requires the collaboration and commitment of the universities and NHS Trusts to adequately support and nurture this essential professional phase (Kitson-Reynolds et al 2015). Lecturers frequently remind student midwives of their impending autonomous status, yet failures exist to adequately and accurately reflect the ‘concept and realities’ of autonomy in professional practice (Baird 2007). The universities and hospitals alike appear to regard autonomy as a panacea for the next generation of midwives. The attributes of independence, self-governance and self-determination (Pairman et al 2015), are no doubt attractive definitions to add to any ‘person specification’ when seeking to employ staff who appear to have the skill set to address the failings that perpetually persist within the maternity setting. The NHS remains a hierarchal, antiquated institution and is arguably completely incompatible with the rhetoric of autonomy. The NHS was prophetically described in 1997 by Nigel Lawson, a Tory Chancellor of the Exchequer, as ‘the closest thing to a religion in England’ (The Economist 2000). Similar to religion it is frequently inflexible and interpreted to suit the needs of misguided individuals, often holding positions of power they are no longer suitable to hold in the 21st century. Autonomy So where does autonomy fit for the newly qualified practitioner entering an institution respected by some, yet confusingly greatly vilified by others; misused and abused by the masses, whether intentionally or unintentionally. Recent years have witnessed the publication of several damning reports and inquiries into the NHS (NHS Borders 2013). It is widely recognised that the NHS has undergone one of the most turbulent times in its history (Royal College of Anaesthetists 2013). Autonomy, for the newly qualified, evokes notions of ‘coming of age’, self-sufficiency, self-governance and independence; however, is it now time to dispense of this overpromoted, questionable ‘aspiration’ and focus on genuine dependable cooperative team working that supports and nurtures the newly qualified midwife during this period of substantial attrition? There have been numerous public inquiries conducted into the NHS since its inception; these have frequently followed a catastrophic failing in patient care and/or safety which provoked a public outcry. Each successive published report, to one extent or another, finds the same common themes emerge: ‘professional isolation, disempowerment of staff, poor communication, ineffective systems and inadequate leadership’ (Halligan 2010), clearly all words and statements at odds with any definition of autonomy unless the numerous uses of the prefix MIDIRS Midwifery Digest 27:4 2017

‘self’ when defining autonomy truly reflects the reality of autonomy in the NHS — of being ‘on your own’ — with autonomous actions merely highlighting an effective way to identify a person to blame. Is it misguided naivety to expect an institution that has been described as being built on fear and bullying (Kline 2013) to ever have the capacity for change, and the real commitment required, to develop effective team working? The maternity ‘bullying’ culture, although frequently denied, is well documented (Durant 2015, Royal College of Midwives (RCM) 2016); yet wisely it has been suggested ‘those that fail to acknowledge its existence are often complicit in its continuation’ (Black 2017).

Policy makers The government as policy makers are perhaps culpable in the creation of the NHS we see today. A parallel can be drawn between leadership and management in the NHS and the government in power. Turmoil ensues when there is discourse at the top. Politically this is a turbulent time, with conflicting priorities and vast differences in the vision of society presenting many challenges. Margaret Thatcher ominously stated ‘there’s no such thing as society’ (Keay 1987); perhaps herein lies one explanation of what appears to be the demise of the NHS, the demise of society, the rise of the ‘self’ society — primarily the self-centred, self-interested, selfish society. 441


Leadership Once again, similar to the current chaotic political situation, for an organisation to flourish it must have strong leadership and management with clear objectives that are both achievable and manageable (NHS Leadership Academy 2014). This simplistic notion is notoriously difficult to achieve. It is difficult to find a definitive definition of what is a leader. It cannot be encapsulated in a standardised statement. Adair (1998) considered it to be a ‘journey word’ meaning the travelling to a common destination. This ‘destination’ has clearly caused some to become ‘lost’ in understanding what is expected from them. It is suggested ‘Followers are more important to leaders than leaders are to followers’ (Kellerman 2007), something Theresa May (current UK Prime Minister) has come to realise. The NHS needs unity on the future leadership approach. Wong et al (2010) found that transformational leadership, leading by example, results in greater satisfaction amongst staff, which correlates directly with fewer adverse outcomes for patients. It is not inconceivable to consider that having leaders and management who operate in isolation from the workforce results in a more disengaged and disempowered workforce. This hierarchal, aloof approach consequently impacts upon team work and halts communication. Perhaps the modern day leaders have become less discriminate in their ability to accurately critique the latest buzz words in the NHS, resulting in a failure to recognise the potential dangers of autonomy, especially for the newly qualified practitioner charged with a role of immense responsibility, yet powerless within the hierarchal structure of the NHS.

Quality care There remains conflicting opinions as to whether the NHS is a business in its truest sense. Bruce Keogh considered that the NHS should be run as a business, whereby no guaranteed funding instils a hunger to seek evermore innovative and efficient work practices (Cooper 2013). However, National Advisory Group (2013) opposes this view, his emphasis clearly centred on life-long learning. Perhaps it is time to accept the NHS may be a business of sorts but that it is not comparable to a business with shareholders. Successful businesses target their market, selecting the clientele they wish to attract to elicit the most profit for the shareholder; this is perhaps the most salient factor when trying to run the NHS as a shareholder business — it does not have the luxury of selecting its clientele (The Kings Fund 2011). The over use of market research tools adapted from the commercial sector to gauge performance should be viewed with caution as there remains a lack of understanding in how to utilise market research tools to best effect to illicit an accurate assessment of service users’ true experience (Spiby & Munro 2010). Auditing appears to have become a pointless burden. 442

The practice of quantifying has been cautioned National Advisory Group (2013) yet Keogh (2013) recommended the friends and family test be extended; however this tool could be regarded as flawed as a ‘better the devil you know’ that when audited would incorrectly appear as a favourable endorsement. It is saddening that historically certain NHS boards were so inhumane they believed mortality rates to be the crucial measurement of quality care; it would be tragic if survival rates were the definition of good care. Quality care cannot be quantified in to a time and motion study. The therapeutic benefits of companionship, empathy and sympathy cannot be measured in minutes. The quality of emotional care must correlate to the physical care (Department of Health & Hunt 2012).

Communication It is widely accepted the NHS cannot be sustained in its current format; therefore we all have an ‘autonomous’ duty towards this national institution. Is it now time to accept all means everyone? The National Advisory Group (2013) spoke of the need for patients to become co producers in their care and to build relationships, recognising that a relationship cannot exist without mutual involvement. Perhaps we need to encourage a level of ‘autonomy’ and self-care where appropriate. The paternalistic attitudes of old and fear of blame have impeded and prevented real empowerment of individuals and families. There remains a culture of fear and a reluctance to whistle blow; only the exceptionally brave are equipped for this David and Goliath battle. The fear of reprisals and the effects on future career prospects unsurprisingly clearly silences some staff (Keogh 2013, Mid Staffordshire NHS Foundation Trust Public Inquiry 2013, National Advisory Group 2013). Therefore the task of calling the NHS and the rogue individuals holding positions of power to account frequently falls to families or ex-staff with ‘nothing left to lose’. The National Advisory Group (2013) was unambiguous in the need to abandon a culture of blame and trust the goodwill and intentions of the staff. A father, whose son died from sepsis, spoke of the lack of teamwork and communication as the overriding factors in the death of his son (Titcombe 2008). It was reported that there was no cohesion, collaborative working was only demonstrated unethically by the deceitful attempts of individuals to cover up the actual care, perhaps evidence of the fear of becoming the scapegoat that existed amongst the staff at this time. Failure to communicate is one of the greatest causes of poor team work (Bach & Ellis 2011).

Finally… The midwives and nurses of the future will all be degree educated, yet poor pay, difficult working conditions, unreasonable shift patterns and a largely negative media representation do little to enhance MIDIRS Midwifery Digest 27:4 2017


the contentment and retention of the workforce. There appears an unspoken disapproval of extrinsic motivation as opposed to the desirable intrinsic motivation associated with ‘caring professions’. Describing midwifery as a ‘calling’, whilst noble, appears an altruistic view not entirely plausible or sustainable in the 21st century. The working hours of a student midwife with no extrinsic motivator may push future students to the point of breaking upon qualification, both financially and emotionally. Perhaps it is time within the university syllabus to address the issue of emotional burnout upon registration? Glasby (2014) recognised if we continue to deplete our emotional bank account the mistakes of the past will continue to be repeated. The definition of autonomy being ‘independent and self-governing’ has, for some, negative connotations of isolation and being alone. Perhaps it is now time to abandon the notion of autonomy within midwifery in the NHS. Yvonne Nolan is a Midwife, currently working as a Health Visitor for London’s North West Healthcare in Harrow.

Keogh B (2013). Review into the quality of care and treatment provided by 14 hospital trusts in England: overview report. London: NHS. http://www.nhs.uk/NHSEngland/bruce-keoghreview/Documents/outcomes/keogh-review-final-report.pdf [Accessed 20 June 2017]. Kitson-Reynolds E, Ferns P, Trenerry A (2015). Transition to midwifery: collaborative working between university and maternity services. British Journal of Midwifery 23(7):330-5. https://eprints. soton.ac.uk/382949/1/Kitson%2520Reynolds-2015Transition%2520to%2520midwifery.pdf [Accessed 19 June 2017]. Kline R (2013). Bullying: the silent epidemic in the NHS. Public World, 15th May. http://www.publicworld.org/blog/bullying_the_ silent_epidemic_in_the_nhs [Accessed 20 June 2017]. Mid Staffordshire NHS Foundation Trust Public Inquiry (2013). Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry: executive summary [the Francis Inquiry]. London: The Stationery Office. National Advisory Group on the Safety of Patients in England (2013). A promise to learn – a commitment to act. Improving the safety of patients in England. National Advisory Group on the Safety of Patients in England. London: DH. NHS Borders (2013). Review of the Francis, Keogh and Berwick reports – considerations for NHS Borders. http://www.nhsborders. scot.nhs.uk/media/194992/Review-of-the-Francis-Keogh-andBerwick-Reports.pdf [Accessed 20 June 2017].


NHS Leadership Academy (2014). About the Academy. http://www. leadershipacademy.nhs.uk/about/?repeat=w3tc [Accessed 20 June 2017].

Adair J (1998). Leadership skills: management shapers. London: Chartered Institute of Personnel and Development.

Pairman S, Pincombe J, Thorogood C et al (2015). Midwifery: preparation for practice. 3rd ed. Chatswood: Churchill Livingstone.

Bach S, Ellis P (2011). Leadership, management and team working in nursing. Exeter: Learning Matters.

Royal College of Anaesthetists (2013). NHS Change Day – 13th March 2013. https://www.rcoa.ac.uk/news-and-bulletin/rcoa-newsand-statements/nhs-change-day-13-march-2013 [Accessed 20 June 2017].

Baird E (2007). Exploring autonomy in education: preparing student midwives. British Journal of Midwifery 15(7):400-5. Black V (2017). Conversation with Yvonne Nolan, 29th May. Cooper C (2013). Run the NHS like PC World, says Britain’s leading doctor Sir Bruce Keogh. Independent, 28th July. http://www. independent.co.uk/news/uk/politics/run-the-nhs-like-pc-world-saysbritains-leading-doctor-sir-bruce-keogh-8735618.html [Accessed 20 June 2017]. Department of Health, Hunt J (2012). 28 November 2012, Jeremy Hunt, Kings Fund – Quality of Care. https://www.gov.uk/ government/speeches/28-november-2012-jeremy-hunt-kings-fundquality-of-care [Accessed 20 June 2017]. Durant E (2015). Bullying in midwifery: one small but mighty technique. Midwife Diaries, 12th May. https://midwifediaries.com/ bullying-in-midwifery/ [Accessed 19 June 2017]. Glasby J (2014). NHS staff do a fantastic job, it’s time we gave them more credit. The Conversation, 17th January. http:// theconversation.com/nhs-staff-do-a-fantastic-job-its-time-we-gavethem-more-credit-20804 [Accessed 19 June 2017].

Royal College of Midwives (2016). Why midwives leave – revisited. London: RCM. https://www.rcm.org.uk/sites/default/files/Why%20 Midwives%20Leave%20Revisted%20-%20October%202016.pdf [Accessed 19 June 2017]. Spiby H, Munro J (2010). Evidence based midwifery: applications in context. Chichester: Wiley-Blackwell. The Economist (2000). The English patient. The Economist, 27th July. http://www.economist.com/node/341220. [Accessed 19 June 2017]. The King’s Fund (2011). The future of leadership and management in the NHS – no more heroes. London: The King’s Fund. https:// www.kingsfund.org.uk/sites/default/files/future-of-leadership-andmanagement-nhs-may-2011-kings-fund.pdf [Accessed 20 June 2017]. Titcombe J (2008). In loving memory of Joshua Titcombe 2008– 2008. 15th December. http://www.gonetoosoon.org/memorials/ joshua.titcombe.2008 [Accessed 19 June 2017].

Halligan A (2010). The need for an NHS Staff College. Journal of the Royal Society of Medicine 103(10):387-91. http://www.ncbi. nlm.nih.gov/pmc/articles/PMC2951166/ [Accessed 20 June 2017].

Wong CA, Spence Laschinger HK, Cummings GG (2010). Authentic leadership and nurses’ voice behaviour and perceptions of care quality. Journal of Nursing Management 18(8):889-900.

Keay D (1987). Margaret Thatcher. Interview for Woman’s Own (‘no such thing as society’). 23rd September. Margaret Thatcher Foundation. http://www.margaretthatcher.org/document/106689 [Accessed 20 June 2017].

Nolan Y. MIDIRS Midwifery Digest, vol 27, no 4, December 2017, pp 441-443.

Kellerman B (2007). What every leader needs to know about followers. Havard Business Review 85(12):84-91.

MIDIRS Midwifery Digest 27:4 2017

Original article. © MIDIRS 2017.



What factors affect the emotional well-being of newly qualified midwives in their first year of practice? Alexandra Bacchus, Amanda Firth ORIGINAL The Royal College of Midwives (RCM) reports that between 5–10% of newly qualified midwives (NQM) leave the profession in the UK within a year of registration, with similar losses reported internationally (RCM 2010). NQMs are in a position of vulnerability and are highly susceptible to workplace adversity that subsequently may affect their emotional well-being. This literature review explores the experiences of NQMs surrounding their emotional well-being within the first 12 months of transition. Following a thorough search and appraisal of the literature, four papers were reviewed. Two key themes were identified consisting of factors that challenge NQMs’ resilience causing negative emotional well-being, and factors that enhance resilience, promoting positive emotional well-being. The findings of this review demonstrate that there is a need for the consistent implementation of protective mechanisms such as structured preceptorship and supportive mentorship. Such interventions may improve physical and emotional well-being, increase retention and better prepare NQMs for the journey ahead; ultimately also improving quality of care for women and patient safety. Keywords: Newly qualified midwife, confidence, experiences, resilience, well-being, transition. Introduction Midwives are currently placed under pressure due to the rising birth rate (Royal College of Midwives (RCM) 2016), increasing numbers of women presenting in pregnancy with complex social and physical care needs (Hunter & Warren 2014, RCM 2017) and a national shortage of midwives (Warwick 2012, RCM 2017) subsequently leading to stress and burnout in the midwifery profession (Yoshida & Sandall 2013). The RCM reports that between 5–10% of new midwives leave the profession in the UK within a year of qualifying (RCM 2010), with similar losses reported internationally (Fenwick et al 2012). Newly qualified midwives (NQMs) are in a vulnerable position and are therefore highly susceptible to workplace adversity (Hunter & Warren 2014). Resilience is defined by Rutter (1999) as a relative resistance to adversity. Working cross sector in a new unfamiliar environment can adversely affect the adaptability of NQMs due to uncertainties of their role (Hunter 2004, Hughes & Fraser 2011, Avis et al 2013). A recognised strategy to ensure retention of midwives and NQMs within the profession, is to empower them with the tools to protect their own emotional well-being by creating resilience (Deery 2005, Kirkham et al 2006). Emotional well-being is difficult to define and multifactorial. Dixon et al (2017) define emotional well-being as ‘psychological well-being’. The Mental Health Foundation (https://www.mentalhealth.org. uk/) defines it as good mental health and a positive 444

sense of well-being. Murthy (2016) describes it as an inner resource allowing resilience and strength in the face of adversity. For the purpose of this literature review ‘emotional well-being’ is defined as the experience of a meaningful life, being able to work productively and coping with daily stresses (Coyle et al 2014). The level of safety and quality of care that women receive is directly correlated to a midwife’s well-being (Pezaro 2016), demonstrating that this review topic is both relevant and important. Distressed midwives often have impaired cognitive function affecting compassion and decision making (Beaumont et al 2016). Reviewing studies of NQMs’ experiences in their first 12 months can identify factors affecting their well-being which could be utilised to create support interventions. Priorities should be given to enhance well-being and build resilience, readying NQMs for their professional journey.

Background There is a plethora of literature addressing newly qualified nurses’ (NQNs) transition into the workforce and their emotional well-being (Chana et al 2015, Smith & Yang 2017). Less literature exists for the same experiences of NQMs; therefore nursing literature which is transferrable to midwifery, is also explored within this appraisal of the current working environment. Historic seminal work by Kramer (1974) describes NQNs experiencing a ‘reality shock’ when adjusting to the workplace, arguing that their MIDIRS Midwifery Digest 27:4 2017


Newly qualified practitioners report a ‘theorypractice gap’, describing the dichotomy between theory learnt at university and the reality of practice (Newton & McKenna 2007). Midwives describe a dissonance between learning about woman-centred care at university and the reality of clinical practice constraints and expectations (Seibold 2005, Licqurish & Seibold 2008). Frustration and inability to practise in the way they wish is a key reason for midwives leaving the profession (RCM 2015). Midwife shortages and inadequate, unsustainable working conditions with chronic understaffing cause midwives to become stressed and burnt out (Warwick 2012, Hunter & Warren 2013, Byrom 2016). This is a difficult working environment for NQMs to be entering into. The midwifery culture of giving 100% or more to prove their worth is a positive attribute in the midwifery workforce but can be used negatively to persuade compliance to institutional needs. Midwives work long shifts with little or no breaks due to heavy workloads, which has been termed ‘service and sacrifice’ (Kirkham 1999).

Data sources CINAHL Maternity and Infant Care Medline PsycINFO

NQMs in transition period (within 12 months) working in the UK, Ireland, Australia and New Zealand NQMs' working environment Not considered necessary NQM well-being Primary qualitative research studies of NQMs’ experiences in transition in both hospital and community settings

Intervention Comparison Outcome Studies

A literature-scoping exercise was undertaken to identify relevant keywords and associated synonyms, including global variations in terms (Brunton et al 2017). Literature scoping demonstrated that the term ‘newly qualified midwife’ was interchangeable with ‘new graduate midwife’ in Australia and New Zealand; therefore this was added as a keyword. Boolean operators and Medical Subject Headings (MeSH) were searched in addition to keywords. Hand searches were undertaken on reference lists of relevant journal articles (Aveyard 2014). Figure 1 displays that after the removal of duplicates a total of 178 papers were screened by title and abstract. Figure 1. PRISMA flow diagram. Records identified through database searching (n=186)

Additional records identified through other sources (n=2)



Records after duplicates removed (n=178)


MIDIRS Midwifery Digest 27:4 2017

ScienceDirect Cochrane Database of Systematic Reviews


There is little research concerning the experiences of NQMs during the first year of practice following registration; therefore this literature review aims to answer the question, What factors affect the emotional well-being of NQMs in their first year of practice? A systematic search strategy was undertaken enabling identification of relevant published material (Aveyard 2014). An electronic search was also undertaken through both university and external databases to increase the range of literature retrieved (Gomersall & Cooper 2010). Table 1 shows databases searched between December 2016 and January 2017. The PICOS framework (Population, Intervention, Comparator, Outcome and Studies) was used to help the researcher define the individual elements of the research question (Table 2).

External databases searched Google Scholar TRIP

Table 2. Factors affecting NQMs (PICOS framework).


The Francis report (Mid Staffordshire NHS Foundation Trust Public Inquiry 2013) describes a culture of bullying within the National Health Service (NHS) hierarchies. Bullying is not only detrimental to the individual and the institution but also has a negative impact on the care of service users. NQMs may struggle and feel overwhelmed by their lack of confidence to practise autonomously (Avis et al 2013). Access to support from colleagues is essential for creating confidence and sustaining resilience for NQMs (Hunter & Warren 2014). NQMs require investment to enable focused, supported learning and nurturing by experienced midwives promoting role modelling (Hart et al 2007, McDonald et al 2012).

Table 1. Data sources.


pre-registration nursing education had given them unrealistic expectations. This theme of reality shock persists today and is the key reason why NQNs leave (Al-Hussami et al 2014).

Records screened (n=178)

Records excluded by title and abstract (n=172)

Full text articles assessed for eligibility (n=6)

Full text articles excluded, with reasons (n=2)

Studies included in qualitative synthesis (n=4)

Database search results flowchart using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).

Studies included in quantitative synthesis (n=0)



Table 3. Inclusion/exclusion criteria.

Study focus

Inclusion criteria NQMs (in first 12 months of qualifying) NQMs working within the NHS in the UK and in Australia/ New Zealand Experiences of NQMs in practice

Type of study Language Publication date

Published qualitative research studies Only English language 2007–2017


One hundred and seventy-two articles were excluded and the remaining six papers were mapped against the inclusion/exclusion criteria (Table 3). The two papers excluded by review of full text (Hughes & Fraser 2011, Avis et al 2013) did not meet the criteria set by the reviewer but were used for

Exclusion criteria Student midwives Midwives practising for more than 12 months Not focusing on emotional well-being Not preceptorship Not primary research Any other language Before 2007

discussion elsewhere in the review. An overview of the final studies is shown in Table 4. The internationally recognised Critical Appraisal Skills Programme (CASP) checklist for qualitative studies was used to appraise the quality of the four papers (CASP 2017). Thematic synthesis of the qualitative studies was undertaken identifying two overarching themes.

Table 4. Overview of final studies. Paper 1

Reynolds EK, Cluett E, Le-May A (2014). Fairy tale midwifery – fact or fiction: the lived experiences of newly qualified midwives. British Journal of Midwifery 22(9):660-8.


Qualitative interpretive phenomenology in van Manen’s perspective.


Three semi-structured face-to-face interviews, first one held at university, then at four and 12 months, digitally recorded and transcribed verbatim.


Purposive sampling of 12 NQMs, aged 18–45 and from different ethnic, social and cultural backgrounds in UK


Reality shock – Felt shocked and disappointed once the reality of midwifery failed to measure up to their ideals and self-made expectations. Heavy workloads. Anxiety of ‘being on own’. Felt unprepared for real world of clinical practice. False promises – Idealistic perception of the midwife role and false expectations of midwifery relating to the work they would be expected to do and the relationships that they would have with others. Lack of staff and/or support, preceptorships not being what they thought. Being part of the club – To survive meant being accepted by the team. Felt they had to impress and prove themselves. Self-doubt – Confidence was knocked when having to cover shifts in unfamiliar areas. Expected within the first few weeks of qualifying to be the only qualified midwife in a busy high-risk ward. Assuming responsibility. Felt under-valued. Struggling – Suffered from anxiety and lack of self-belief. Negative and positive feelings of the role. Beyond competence – Responsibility remained the participant’s biggest cause of anxiety. Struggled with feeling devoid of autonomy, advocacy and decision making.

Paper 2

Hobbs JA (2012). Newly qualified midwives’ transition to qualified status and role: assimilating the ‘habitus’ or reshaping it? Midwifery 28(3):391-9.


Qualitative ethnographic study with a reflexivity approach.


Observant participation and semi-structured interviews in the field over three phases. Researcher kept a field diary to take into account her own perceptions and interactions with participants.


Non-probability sampling method of seven NQMs in the UK.


Hanging on in – Participants felt unprepared, in at the deep end and a reality shock of the role of the midwife not being what they expected. Fitting in to the midwifery culture – Conflict and competition (dog eat dog) and then starting to fit in by ‘playing the game’. Service and sacrifice – to gain respect by staying after your shift or going without or having short breaks, considered a way to fit in. Determining what type of midwife they wanted to be – Being with the woman and challenging the old-school midwives with entrenched viewpoints.


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Paper 3

van der Putten D (2008). The lived experience of newly qualified midwives: a qualitative study. British Journal of Midwifery 16(6):348-58.


Qualitative approach using Heiderggerian phenomenology.


An initial in-depth 1-1 interview with interview guides, and tape recorded. Then once the data analysis was in final stages, the researcher returned to participants for a final interview to validate the findings.


Purposive sample of six NQMs who had all qualified within the previous six months in Ireland.


Reality shock – NQMs felt insecure and fear in fulfilling their new role. Felt overwhelmed and vulnerable. Feeling prepared – They unanimously felt well prepared theoretically but felt unprepared for the real world of clinical practice. Living up to expectations – NQMs were aware of increased expectations of women and their families as being stressful. Theory-practice gap – Conflicting ideologies. Lack of confidence to speak up as an advocate for the women. Clinical support and mentorship – Identified the importance of good clinical support for NQMs and the need for preceptorship as important. Continuous professional education – Their level of responsibility stimulated an awareness of the importance of continuing professional development in order to provide safe care for women.

Paper 4

Fenwick J, Hammond A, Raymond J et al (2012). Surviving, not thriving: a qualitative study of newly qualified midwives’ experience of their transition to practice. Journal of Clinical Nursing 21(13-14):2054-63.


Qualitative descriptive approach.


Tape recorded in-depth 1-1 interviews and as analysis progressed other questions were added. Transcribed verbatim.


A convenience sample of 16 NQMs from two preregistration educational programmes from same university but over two years (eight from direct entry degree and eight were already nurses who had completed 18 month course) in Australia.


The pond – Midwifery culture with a hierarchical system and hectic chaotic understaffed environment with unmanageable workloads. Poor or lacking support. Institution vs womancentred care. Told to ‘get on with it’ and ‘toughen up’. Life-raft – Some relationships with inclusive midwifery colleagues who willingly shared their knowledge and were positive had a powerful effect on either facilitating or hindering confidence levels. Negative or inhibitory midwifery behaviours. Swimming – Gaining confidence and competence from positive relationships with colleagues and a supportive environment. Sinking – Poor relationships with midwives and a difficult working environment.

Findings Two main themes emerged containing several further subthemes. Theme 1: Factors which challenge resilience and cause negative emotional well-being: working conditions and environment. All papers identified heavy workloads, a busy environment and staff shortages as key issues. Covering shifts due to staff sickness and rotation caused NQMs pressure and anxiety. NQMs described a perceived lack of support making them feel pressured, out of control and panicked (Fenwick et al 2012). Working 14 and a half-hour shifts with a ten minute break due to heavy workloads MIDIRS Midwifery Digest 27:4 2017

is described by one NQM as causing stress (Hobbs 2012). Staffing issues exacerbated an already busy environment in which NQMs struggled to give quality care to women causing feelings of guilt and frustration (van der Putten 2008). NQMs felt exhausted, frustrated and stressed due to working long shifts (Reynolds et al 2014). Reality shock/theory-practice gap In all papers NQMs described experiencing a reality shock on entering the workplace, experiencing negative feelings of frustration and disappointment and some feeling unprepared on entry to clinical practice (van der Putten 2008, Reynolds et al 2014). NQMs experienced the conflicting ideology of 447


being taught woman-centred care at university and the reality of working autonomously within an environment where the medical model of care dominates. Subsequently, NQMs felt guilt and emotional distress at not being able to give womancentred care (van der Putten 2008, Fenwick et al 2012, Hobbs 2012). Frustration was also felt at women being perceived as commodities (Fenwick et al 2012). Further to this, guilt and emotional distress was caused by NQMs’ lack of confidence to speak up and be the woman’s advocate (van der Putten 2008, Fenwick et al 2012). All studies described NQMs feeling confused and struggling with senior midwives’ attitudes towards intervening with women’s labours. They were frustrated by their lack of autonomy and its effect on the women in their care, when taught at university to empower women to make their own decisions. Responsibilities of the role Two studies identified how new-found responsibility caused NQMs to feel stressed, frightened and anxious (van der Putten 2008, Reynolds et al 2014). One paper described physical manifestations of stress such as abdominal pain (Fenwick et al 2012). Other midwives’ negative attitudes and expectance for NQMs to cope with responsibility made NQMs feel anxious and alone (Fenwick et al 2012, Reynolds et al 2014). However, some NQMs adapted and the new-found responsibility provided them with a learning curve that forced them to use their autonomy (Reynolds et al 2014). NQMs also described fear of disappointing women in their care and worrying about not being able to facilitate perfect births or live up to women’s expectations of a midwife (van der Putten 2008). Midwifery culture and identity NQMs were acutely aware of being at the bottom of a midwifery hierarchy which made them feel worthless and undervalued by some mentors and preceptors (Fenwick et al 2012, Hobbs 2012). They describe being ill but still going into work, not taking a break or taking a short break and feeling a need to belong by proving their worth and commitment (Hobbs 2012). NQMs described the need for acceptance into the team by going above and beyond to prove themselves (Reynolds et al 2014). Feeling unsupported Lack of support from other midwives, which was seen as a detrimental factor to their emotional wellbeing during transition, was featured in three studies (Fenwick et al 2012, Hobbs 2012, Reynolds et al 2014). NQMs described knowing who to ask for help and who to avoid, with intimidation linked to senior midwives (Hobbs 2012, Reynolds et al 2014). 448

Perceived bullying is described by one NQM as having a finger pointed in her face by another midwife (Fenwick et al 2012). Other NQMs describe humiliation and passive aggressive behaviour expressed to them when they required support causing them feel guilt, excluded and to lose confidence (Fenwick et al 2012). Hobbs (2012) describes NQMs having to learn to adapt to certain senior midwives’ attitudes making them question if they were in the right career. Theme 2: Factors which build resilience and sustain positive emotional well-being: positive relationships with midwives and women. All studies feature positive relationships with mentors, other midwives and women as being a critical factor in their transition in the first twelve months. Positive support by a mentor provided NQMs with reassurance and safety giving them confidence, promoting better performance and competence and making them feel valued at having a positive learning experience (van der Putten 2008, Fenwick et al 2012). In comparison the NQMs in the study by Reynolds et al (2014) did not fully understand or value the supernumerary aspect of preceptorship periods which were offered to smooth their transition. Building a great rapport with women and being able to be ‘with woman’ and support her throughout labour made NQMs feel that they had made a positive difference to her experience that produced feelings of satisfaction (Hobbs 2012). Positive role models and practising women-centred care Three studies describe NQMs having positive feelings when working with midwives who are midwifery focused, and even though working within a medicalised environment are still providing womancentred care (van der Putten 2008, Fenwick et al 2012, Hobbs 2012). This positive role modelling of midwives created satisfaction and a positive identity in the NQMs (Hobbs 2012).

Discussion Reality shock experienced by NQMs in transition was apparent in all papers and is supported in previous nursing and midwifery literature (Kramer 1974, Duchscher 2009, Hughes & Fraser 2011, Al-Hussami et al 2014). This demonstrates that reality shock is not a new phenomenon, even though the NHS is perceived to be working under greater constraints than ever before. It could be argued that reality shock is a normal part of the transition process and that the intervention required is to support this process. Crow & Hartman (2005) argue that newly qualified practitioners can become disillusioned with their new role if unsupported in their transition to practice, making them more likely to leave. Evidence proves the effectiveness of preceptorship packages in midwifery (Whitehead et al 2016) but unfortunately MIDIRS Midwifery Digest 27:4 2017


provision and quality of preceptorship is variable due to the lack of statutory requirement and emphasis on employers to manage the transition. NQMs require investment to enable focused, supported learning and to be nurtured by experienced midwives promoting role modelling (Hart et al 2007, McDonald et al 2012, Avis et al 2013, Hunter & Warren 2014). Avis et al (2013) suggest it is crucial for midwifery managers to provide tailored support for NQMs by allocating ‘around the clock’ clinical support to their first rotation. The scheduling of experienced midwives ready and willing to be supportive and work side-byside with NQMs is crucial. Two review papers found that role responsibilities caused NQMs to feel stressed and anxious which is reiterated in other literature (Hobbs & Green 2003, Avis et al 2013). This could be addressed by working in collaboration with the Nursing and Midwifery Council (NMC) and pre-registration educators to develop an undergraduate curriculum that facilitates students to gain more complex care and leadership skills required for practice in addition to ‘with woman’ midwifery skills (Skirton et al 2012, Schytt & Waldenström 2013). All papers described the theory-practice gap resulting in frustration, disappointment and stress. Midwives and NQMs who learn to overcome adversity and adapt become more resilient which then becomes protective (Lyons et al 2009, Hunter & Warren 2014). Experiences of being over-ruled by senior midwives in the care they gave to women appeared in all four review papers but this issue is not unique to NQMs. Both Leap (2010) and Walsh & Downe (2010) have written about hierarchies, power and attitudes in midwifery. Hunter & Warren (2014) found that positive relationships with women and midwives are essential for creating resilience, supporting the findings of this review where NQMs have described the positive effect of good relationships in the workplace. The themes emerging from this review concur with findings from historically-published literature, demonstrating that the same issues persist and although decades have passed, no effective solutions have been implemented. All papers described environmental and working conditions as factors which affect emotional well-being, supporting the issues raised previously by authors (Sandall 1997, Hunter 2004, Kirkham et al 2006). Pressure and stress felt by NQMs on rotation and covering shifts due to sickness was also evident in all papers. Avis et al (2013) challenge that this is negative as NQMs who experience a lack of familiarity on rotation to different areas are forced to take the initiative in developing autonomy which in turn builds confidence. Negative workplace issues and the effect on wellbeing for all staff is acknowledged by the RCM in their ‘Caring for you’ campaign, aiming to improve MIDIRS Midwifery Digest 27:4 2017

midwives’ health, safety and well-being in the work environment (RCM 2016). It will be interesting to see if the impact of this campaign is effective in helping NQMs who describe distinct issues unique to the NQM transition period.

Conclusion and recommendations This literature review demonstrates that there are both positive and negative factors that affect emotional well-being during the first year of qualified midwifery practice. Negative factors were predominant in the experiences reviewed but contrasting this evidence with previously published literature shows that factors such as reality shock, theory-practice gap and issues with working conditions are historic in nature. It is argued by the reviewer that some issues, particularly reality shock, may be both a natural and reasonable response to the transition from student to autonomous midwifery practitioner. Theory-practice gaps have potential to be narrowed if universities, the NMC and the NHS are able to work collaboratively in supporting both students and newly qualified practitioners to be competent and confident to work in today’s NHS environment. The review suggests that comprehensive and consistently delivered preceptorship packages may improve the emotional well-being of NQMs, demonstrating that NQMs value positive relationships and support from more experienced midwives. This review is based on the final stage project of a sole undergraduate midwifery student which is acknowledged as a limitation and a factor affecting the reliability and validity of the review findings. Further research is required in this topic area with a larger funded midwifery research team. More research is needed in this area to investigate why some NQMs cope well, and some do not, in their experience of transition to practice in the first year after qualification. Alexandra Bacchus, newly qualified midwife. Amanda Firth, Lecturer in Midwifery.

References Al-Hussami M, Darawad M, Saleh A et al (2014). Predicting nurses’ turnover intentions by demographic characteristics, perception of health, quality of work attitudes. International Journal of Nursing Practice 20(1):79-88. Aveyard H (2014). Doing a literature review in health and social care: a practical guide. 3rd ed. Maidenhead: Open University Press. Avis M, Mallik M, Fraser DM (2013). ‘Practising under your own pin’ – a description of the transition experiences of newly qualified midwives. Journal of Nursing Management 21(8):1061-71. Beaumont E, Durkin M, Hollins Martin CJ et al (2016). Compassion for others, self-compassion, quality of life and mental well-being measures and their association with compassion fatigue and burnout in student midwives: a quantitative survey. Midwifery 34:239-44. Brunton G, Stansfield C, Caird J et al (2017). Finding relevant studies. In: Gough D, Oliver S, Thomas J eds. An introduction to systematic reviews. London: SAGE: 93-122.


Midwifery Byrom S (2016). When midwives are broken – what can we do? Sheena Byrom [Blog], 1st May. http://www.sheenabyrom.com/blog/ when-midwives-are-broken [Accessed 23 March 2017]. CASP (2017). CASP checklists. http://www.casp-uk.net/casp-toolschecklists [Accessed 1 December 2016]. Chana N, Kennedy P, Chessell ZJ (2015). Nursing staffs’ emotional well-being and caring behaviours. Journal of Clinical Nursing 24(19-20):2835-48. Coyle D, Thieme A, Linehan C et al (2014). Emotional well-being. International Journal Human-Computer Studies 72(8-9):627-8. Crow SM, Hartman SJ (2005). Nurse attrition as a process. Health Care Management 24(3):276-83. Deery R (2005). An action-research study exploring midwives’ support needs and the effect of group clinical supervision. Midwifery 21(2):161-76. Dixon L, Guilliland K, Paliant J et al (2017). The emotional wellbeing of New Zealand midwives: comparing responses for midwives in caseloading and shift work settings. New Zealand College of Midwives Journal 53:5-15. Duchscher JE (2009). Transition shock: the initial stage of role adaptation for newly graduated registered nurses. Journal of Advanced Nursing 65(5):1103-13. Fenwick J, Hammond A, Raymond J et al (2012). Surviving, not thriving: a qualitative study of newly qualified midwives’ experience of their transition to practice. Journal of Clinical Nursing 21(13-14):2054-63. Gomersall A, Cooper C (2010). Database selection bias and its affect on systematic reviews: a United Kingdom perspective. Keystone: Joint Cochrane and Campbell Colloquium. Hart A, Blincow D, Thomas H (2007). Resilient therapy: working with children and families. London: Routledge. Hobbs J, Green S (2003). Development of a preceptorship programme. British Journal of Midwifery 11(6):372-5. Hobbs JA (2012). Newly qualified midwives transition to qualified status and role: assimilating the ‘habitus’ or reshaping it? Midwifery 28(3):391-9. Hughes AJ, Fraser DM (2011). ‘SINK or SWIM’: the experience of newly qualified midwives in England. Midwifery 27(3):382-6. Hunter B (2004). Conflicting ideologies as a source of emotion work in midwifery. Midwifery 20(3):261-72. Hunter B, Warren L (2013). Investigating resilience in midwifery: final report. Cardiff: Cardiff University. Hunter B, Warren L (2014). Midwives’ experiences of workplace resilience. Midwifery 30(8):926-34. Kirkham M (1999). The culture of midwifery in the National Health Service in England. Journal of Advanced Nursing 30(3):732-9. Kirkham M, Morgan RK, Davies C (2006). Why do midwives stay. London: RCM. Kramer M (1974). Reality shock: why nurses leave nursing. St Louis: C.V. Mosby Company. Leap N (2010). The less we do the more we give. In: Kirkham M ed. The midwife-mother relationship. 2nd ed. London: Palgrave Macmillan: 17-36. Licqurish S, Seibold C (2008). Bachelor of Midwifery students’ experiences of achieving competencies: the role of the midwife preceptor. Midwifery 24(4):480-9. Lyons DM, Parker KJ, Katz M et al (2009). Developmental cascades linking stress inoculation, arousal regulation, and resilience. Frontiers in Behavioural Neuroscience 3(32). McDonald G, Jackson D, Wilkes L et al (2012). A work-based educational intervention to support the development of personal resilience in nurses and midwives. Nurse Education Today 32(4):378-84.


Mid Staffordshire NHS Foundation Trust Public Inquiry (2013). Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry: executive summary [the Francis Inquiry]. London: The Stationery Office. Murthy V (2016). Facing addiction in America. The Surgeon General’s report on alcohol, drugs, and health. Washington DC: U.S. Department of Health & Human Services. Newton JM, McKenna L (2007). The transitional journey through the graduate year: a focus group study. International Journal of Nursing Studies 44(7):1231-7. Pezaro S (2016). The case for developing an online intervention to support midwives in work-related psychological distress. British Journal of Midwifery 24(11):799-805. Reynolds EK, Cluett E, Le-May A (2014). Fairy tale midwifery – fact or fiction: the lived experiences of newly qualified midwives. British Journal of Midwifery 22(9):660-8. Royal College of Midwives (2010). Midwifery 2020 programme. Workforce and workload workstream. Final report. London: RCM. Royal College of Midwives (2015). State of maternity services report 2015. London: RCM. Royal College of Midwives (2016). Caring for You campaign. London: RCM. Royal College of Midwives (2017). The gathering storm: England’s midwifery workforce challenges. London: RCM. Rutter M (1999). Resilience concepts and findings: implications for family therapy. Journal of Family Therapy 21(2):119-44. Sandall J (1997). Midwives’ burnout and continuity of care. British Journal of Midwifery 5(2):106-11. Schytt E, Waldenström U (2013). How well does midwifery education prepare for clinical practice? Exploring the views of Swedish students, midwives and obstetricians. Midwifery 29(2):102-9. Seibold C (2005). The experiences of a first cohort of Bachelor of Midwifery students, Victoria, Australia. Australian Midwifery News 18(3):9-16. Skirton H, Stephen N, Doris F et al (2012). Preparedness of newly qualified midwives to deliver clinical care: an evaluation of pre-registration midwifery education through an analysis of key events. Midwifery 28(5):e660. Smith GD, Yang F (2017). Stress, resilience and psychological well-being in Chinese undergraduate nursing students. Nurse Education Today 49:90-5. van der Putten D (2008). The lived experience of newly qualified midwives: a qualitative study. British Journal of Midwifery 16(6):348-58. Walsh D, Downe S (2010). Essential midwifery practice: intrapartum care. Oxford: Wiley-Blackwell. Warwick C (2012). “Campaigning vital to ensure promises are kept” says Cathy Warwick. RCM Protect Maternity Services, 16 May. Whitehead B, Owen P, Henshaw L et al (2016). Supporting newly qualified nurse transition; a case study in a UK hospital. Nurse Education Today 36:58-63. Yoshida Y, Sandall J (2013). Occupational burnout and work factors in community and hospital midwives: a survey analysis. Midwifery 29(8):921-6.

Bacchus A, Firth A. MIDIRS Midwifery Digest, vol 27, no 4, December 2017, pp 444-450. Original article. © MIDIRS 2017.

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The core of the core: what is at the heart of hospital core midwifery practice in New Zealand? Andrea Gilkison, Judith McAra-Couper, Anna Fielder, Marion Hunter, Diana Austin Background: New Zealand midwives who are employed by District Health Boards and are based in hospitals and maternity units are known as core midwives. Half of New Zealand midwives are employed as core midwives, performing a variety of key roles and, as such, are central to the functioning of maternity services. The sustainability of core midwifery is therefore highly significant for the future of maternity services in New Zealand. Research on sustainable midwifery practice operates as a constructive counterpoint to the growing literature on burnout and stress amongst midwives. Aim: The question this study asked is: What sustains midwives who have been in hospital practice in New Zealand for more than eight years? The findings will inform workforce planners, managers and the midwifery profession about what may well contribute to the retention of midwives who are essential to the maternity services provided in hospital settings. Methods: A qualitative descriptive study was conducted in New Zealand, recruiting and interviewing 22 core midwives with between eight and 40-plus years’ experience. Interviews were transcribed and thematic analysis was undertaken by the research team. Analysis was done as a group in a reciprocal fashion between the individual interviews and the data as a whole. Themes were clustered into groups and excerpts from the data used to illustrate the agreed themes. Ethical approval was obtained from Auckland University of Technology Ethics Committee. Findings: This study found that core midwives sustain themselves in practice through developing significant core midwifery skills. Core midwives quickly build a partnership with women; and they are prepared to deal with everything, including unexpected and critical incidents. Core midwives often take on a managerial role in a unit and, as such, create the culture of the unit while supporting students and new graduates, as well as Lead Maternity Carers. Conclusion: Core midwives highlight the importance of effective relationships with women, whãnau, colleagues and managers. Our sample displayed unique and specific skills: connecting quickly with women, anticipating ahead to keep women safe, managing complexity, being prepared for everything, managing a unit and displaying flexibility and adaptability in their work. However, these core midwives feel invisible and undervalued at times, a finding that may well shine much needed light on what threatens sustainability of the core midwifery service nationwide. Gilkison A, McAra-Couper J, Fielder A et al. New Zealand College of Midwives Journal, Issue 53, 2017. Author abstract. © New Zealand College of Midwives Journal 2017. This article is freely available at: https://www.midwife.org.nz/pdf/Journal/Jnl%2053%20article%204.pdf

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Hyperemesis in Pregnancy Study: a pilot randomised controlled trial of midwife-led outpatient care Catherine McParlin, Debbie Carrick-Sen, Ian N Steen, Stephen C Robson Objective: To assess the feasibility of implementing a complex intervention involving rapid intravenous rehydration and ongoing midwifery support as compared to routine in-patient care for women suffering from severe nausea and vomiting in pregnancy, (NVP)/ hyperemesis gravidarum (HG). Study design: 53 pregnant women attending the Maternity Assessment Unit (MAU), Newcastle upon Tyne NHS Foundation Trust, Newcastle, UK with moderate-severe NVP, (as determined by a Pregnancy Unique Quantification of Emesis and Vomiting [PUQE] score ≥nine), consented to participate in this pilot randomised controlled trial (RCT). Subsequently 27 were randomised to the intervention group, 26 to the control group. Women in the intervention group received rapid rehydration (three litres Hartman’s solution over 6h) and symptom relief on the MAU followed by ongoing midwifery telephone support. The control group were admitted to the antenatal ward for routine in-patient care. Quality of life (QoL) determined by SF36.V2 score and PUQE score were measured seven days following randomisation. Completion rates, readmission rate, length of hospital stay and pregnancy outcomes data were collected. Results: Groups were comparable at baseline. Questionnaire two return rate was disappointing, only 18 women in the control group (69%) and 13 women in the intervention groups (44%). Nonetheless there were no differences between groups on Day seven in terms of QoL, mean PUQE score, satisfaction with care, obstetric and neonatal outcomes or readmission rates. However, total combined admission time was higher in the control group (94h versus 27h, p=0.001). Conclusions: This study suggests that day-case management plus ongoing midwifery support may be an effective alternative for treating women with severe NVP/HG. A larger trial is needed to determine if this intervention affects women’s QoL. McParlin C, Carrick-Sen D, Steen IN et al. European Journal of Obstetrics & Gynecology and Reproductive Biology, vol 200, May 2016, pp 6–10.

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Author abstract. © Elsevier Ireland Ltd. All rights reserved 2016.


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Diagnosis and screening of gestational diabetes: conflicts of policy Judith Kennedy ORIGINAL Introduction

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Although the midwife’s role has its foundations in the support of normality, the ability to identify complex physical needs and provide appropriate care is key to modern midwifery. The Midwifery 2020 report (Chief Nursing Officers of England, Northern Ireland, Scotland and Wales 2010) acknowledges that rapid changes in the demographics of the childbearing population is resulting in an increasing number of pregnant women with complex needs. Midwives have a professional responsibility to coordinate high-quality individualised care with the aim of optimising birth experiences (Chief Nursing Officers of England, Northern Ireland, Scotland and Wales 2010, Nursing and Midwifery Council (NMC) 2015). It is therefore necessary for midwives to be able to recognise altered health states in the childbearing woman, understand their impact on pregnancy and provide evidence-based care. To demonstrate the importance of midwives recognising complex medical and obstetric conditions and providing high-quality support and information, the screening and diagnosis of gestational diabetes mellitus (GDM) at 24–28 week’s gestation will be discussed.

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Screening for GDM

GDM is defined as glucose intolerance resulting in hyperglycaemia that has its onset, or is first diagnosed, in pregnancy (Buchanan & Xiang 2010). The intolerance can vary in severity, and includes hyperglycaemia below the diagnostic threshold for overt diabetes mellitus (DM) (Erjavec et al 2016). GDM is thought to affect 3.5% of pregnancies in England and Wales; although it is acknowledged that incidence depends on the population studied, due to prevalence of risk factors and the diagnostic criteria used (National Institute of Health and Care Excellence (NICE) 2015). Common to all pregnancies as they advance is higher insulin resistance due to increased maternal adiposity and the effects of placental hormones desensitising insulin (Buchanan & Xiang 2010). GDM occurs because of insufficient insulin production from the islet beta cells of the pancreas to compensate for this increased tissue resistance, resulting in maternal hyperglycaemia (Ben-Haroush et al 2004). Chronic hyperglycaemia has been demonstrated to negatively impact normal physiology, inducing microvascular complications such as retinopathy, neuropathy, and nephropathy alongside increased susceptibility to infection due to reduced immune function (Kawahito et al 2009). Maternal hyperglycaemia also increases placental transfer of glucose to the fetus, with resultant fetal hyperinsulinaemia (Benhalima et al 2015). The impact of these maternal and fetal physiological changes can profoundly affect maternal and fetal well-being.

Despite widespread consensus of the importance of screening women for GDM, screening practices remain inconsistent between health institutions. Based on the findings of the HAPO Study Cooperative Research Group (2008) study, the International Association of Diabetes and Pregnancy Study Group (IADPSG) published recommendations on GDM screening and diagnosis, aiming to globally unite health institutions to enhance quality of care (IADPSG Consensus Panel 2010). However, as Agarwal et al (2015) note, there continues to be division amongst health institutions on a local, national, and global scale about the optimal method of GDM screening and diagnosis. The contentious areas of GDM screening are listed by Benhalima et al (2015), and include the use of universal or selective screening and the diagnostic thresholds used.

The Hyperglycaemia and Adverse Pregnancy Outcomes (HAPO) study (HAPO Study Cooperative Research Group 2008) is frequently referenced as a landmark study which investigated the impact of hyperglycaemia on outcomes of over 23,000 pregnancies. This described several maternal and fetal adverse outcomes associated with GDM. Macrosomia resulting in birthweight above the 90th centile, clinical neonatal hypoglycaemia, premature delivery, shoulder dystocia, hyperbilirubinaemia, pre-eclampsia and caesarean section were all demonstrated to have a correlation with GDM (HAPO Study Cooperative Research Group 2008). The impact of GDM is not limited to pregnancy and the perinatal period, however; 15–50% of women who develop GDM are diagnosed with Type 2 DM later in life, and offspring of women with GDM are at increased risk of obesity and Type 2 DM (Wu et al 2016). Public Health England (PHE) (2014) explain the prevalence of obesity and Type 2 DM is increasing, and highlight that prevention of these is a key public health agenda for health professionals due to their impact on morbidity and mortality. As antenatal management of blood glucose levels to maintain normoglycaemia improves clinical outcomes (Ferrara 2007, Wilmot & Mansell 2014), accurate screening and diagnosis of GDM is a vital component of maternity care. 454

The use of selective screening, where women with a single risk factor associated with GDM are offered a two hour 75G oral glucose tolerance test (OGTT) at 24–28 week’s gestation, is advocated by NICE (2015). Sukumaran et al (2014) found this selective screening occurs in 90% of NHS Trusts in England. Recognised risk factors include: women with a body mass index (BMI) greater than 30 kg/m²; women diagnosed with GDM in previous pregnancies; women who have previously birthed a macrosomic baby; women with familial history of diabetes in a first degree relative; and women of non-caucasian ethnicity (NICE 2015). The midwife’s role in correctly identifying women with these risk factors plays a significant part in the success of selective screening for GDM. A study by Murphy (2010) discovered that health professionals failed to correctly identify 38% of women with risk factors for GDM. Acknowledging the health implications of poorly managed GDM, Murphy (2010) highlights the role midwives play in screening and diagnosis, and the importance of midwives having the knowledge and training to correctly identify risk factors. Furthermore, as women without risk factors may present antenatally with symptoms of hyperglycaemia, such as polydipsia, polyuria and glucosuria, midwives should have knowledge of the clinical presentation of GDM and the care pathway this initiates (Hunt et al 2014). In recognition of the risks associated with adverse health outcomes, Knight et al (2016) highlight the importance of midwives acting appropriately to identify women in an altered health state to improve morbidity and mortality rates. The use of selective screening contrasts with the IADPSG Consensus Panel’s (2010) recommendation of universal screening, where all pregnant women not already known to be diabetic are offered diagnostic testing at 24–28 week’s gestation. Cundy et al (2014) note universal screening is advantageous as women with GDM are commonly asymptomatic, and may not possess associated risk factors. A further advantage of MIDIRS Midwifery Digest 27:4 2017


universal screening is its high rate of GDM detection; Benhalima et al (2015) state universal screening has the highest detection rate, whilst selective screening may miss up to one third of women with GDM. However, increased detection rates due to universal screening do not necessarily translate into therapeutic justification (Buckley et al 2012). Whilst Griffin et al (2000) concluded that universal screening significantly reduced adverse pregnancy outcomes when compared to selective screening, this research had limitations with the universal screening cohort being screened 4–6 weeks earlier than the selective screening cohort. Buckley et al (2012) propose this could have offered the universal screening cohort a therapeutic advantage in reducing adverse outcomes. Furthermore, a recent Cochrane review concluded that although increasing the number of women tested for GDM, there was insufficient evidence that universal screening significantly improved maternal and fetal outcomes (Tieu et al 2017). Based on this evidence, universal screening is not currently considered to offer a sufficient advantage over selective screening to warrant the additional economic output it would require (NICE 2015).

The impact of GDM screening for women Beyond suggested diagnostic advantages of universal GDM screening, the impacts of GDM screening on women should be a key consideration. NICE (2015) suggests universal screening subjects a significant number of women to a diagnostic test that is ultimately unnecessary and increases the number of false-positive results. The two hour, 75g OGTT is recognised as the ‘gold standard’ test (Stewart & Murphy 2014), but can be unpleasant for women to undertake. The test requires women to fast for 8–12 hours before their appointment and undergo two episodes of venepuncture; the first a fasted sample, and the second taken two hours after the woman has ingested a 75g oral glucose drink (Kirsopp & Earp 2010). Buckley et al (2012) identify that some women experience anxiety and stress prior to GDM screening, and often feel nauseous due to the initial 8–12 hour fast and later the taste of the glucose drink; it is suggested that these experiences negatively impact the compliance of women on GDM screening. Furthermore, Verhoef et al (2016) recommend the financial cost to women is considered (transport expenditure, loss of earnings and time), and the effect this has on women’s compliance. Similarly, Cullinan et al (2012) found women’s compliance for GDM screening decreased as the travelling distance increased, emphasising the impact GDM screening has on women’s day-to-day life. Buckley et al (2012) question the value of universal screening given these negative impacts on women, most of whom will not be diagnosed with GDM. Despite this, Görig et al (2015) suggest women are generally accepting of universal screening for GDM when well-supported by their health care professional, as women ultimately MIDIRS Midwifery Digest 27:4 2017

feel it diminishes the risk of undiagnosed GDM. These contrasting views emphasise that midwives should aim to reduce women’s anxieties and increase compliance through sensitive conversations to demonstrate the importance of GDM diagnosis. Despite NICE (2015) and the IADPSG Consensus Panel (2010) both advocating the two-hour 75g OGTT for GDM diagnosis at 24–28 week’s gestation, they propose different diagnostic criteria for its interpretation. Gestational diabetes is diagnosed by identification of impaired fasting glucose (where the fasting plasma glucose is elevated) or impaired glucose tolerance (where plasma glucose is elevated two hours postprandially) (Bartoli et al 2011). NICE (2015) state that GDM is diagnosed if fasting plasma glucose is greater or equal to 5.6mmol/L, or two-hour plasma glucose is greater or equal to 7.8mmol/L. In comparison, the IADPSG Consensus Panel (2010) recommendations have reduced the fasting plasma glucose diagnostic threshold to 5.1mmol/L. This reduction increases the population of women who would be diagnosed with GDM to include those who would be considered normoglycaemic by NICE (2015) recommendations. Meek et al (2015) retrospectively compared the number of women diagnosed with GDM following NICE (2015) and the IADPSG Consensus Panel (2010) diagnostic criteria; they discovered over the course of five years 126 more women would have been diagnosed and treated for GDM using the lower threshold. Furthermore, women within the diagnostic gap caused by the different thresholds have been shown to have a slightly increased risk of adverse perinatal outcomes compared with women with lower fasting plasma glucose levels (Meek et al 2015, Djelmis et al 2016). Whilst the cost of implementation of the lower threshold was considered unacceptably high by NICE (2015), Meek et al (2015) argue that failure to adopt the lower threshold increases women’s risk of adverse perinatal outcomes. Although the reduced diagnostic threshold identifies women with a slightly increased pregnancy risk, consideration should be given to the value of this compared to a woman’s well-being. The GDM care pathway results in several pregnancy interventions, including more frequent antenatal appointments, daily blood glucose checks, changes in eating and exercise habits, and early induction of labour (Abayomi et al 2013). In the case of women with mild hyperglycaemia who fall within the diagnostic gap, these interventions have been suggested to negatively affect women’s pregnancy journeys whilst offering few measurable health benefits (Agarwal et al 2015). The differing diagnostic thresholds are described as frustrating to women who discover, whilst researching GDM, their diagnosis would change based on different recommendations (Draffin et al 2016). Women who fall within the diagnostic gap, may feel conflicted about their 455


care; awareness of the differing diagnostic thresholds and current evidence for their implementation would enable midwives to support women through these concerns.

The role of the midwife GDM diagnosis precipitates a care pathway involving a multidisciplinary team to support women in managing GDM effectively, in order to limit adverse outcomes, but this may negatively impact women’s perceptions of their pregnancy journey (Draffin et al 2016). Women have described feelings of guilt over GDM diagnosis alongside anxiety, a feeling of stigmatisation, and fear of the potential adverse outcomes GDM poses to their pregnancy (Draffin et al 2016). Van Ryswyk et al (2015) add that women may no longer identify themselves with ‘healthy normality’ and feel a sense of shame at their diagnosis. It is therefore important that midwives recognise the potential emotional impact of GDM diagnosis and provide information and counselling to prepare and support women through this. Support such as this can improve women’s well-being; Wu et al (2016) demonstrated women’s anxiety following GDM diagnosis reduced when high-quality support through the care pathway was provided. Abayomi et al (2013) draw attention to the midwife’s unique position within the multidisciplinary team as the ‘keeper of normality’, ensuring women receive consistent, evidence-based information to allow them to maintain control of their pregnancy despite their altered health state. This demonstrates how effective communication between the multidisciplinary team and the woman is key to the successful implementation of GDM screening and diagnosis as part of the GDM care pathway (Renfrew et al 2014).

Summary GDM is a key altered health state midwives may encounter when caring for childbearing women and being able to competently identify those at risk of the condition is therefore an important aspect of midwifery care. While the importance of effective diagnosis of GDM is widely accepted in view of the associated adverse pregnancy outcomes and the risk to public health, the optimal screening method and diagnostic criteria remain controversial. Universally adopted recommendations would offer women greater stability and reassurance; these should be based not only on proven outcomes but also on the impact they may have on women’s well-being. The potential impact of screening on women highlights the important role midwives play in the multidisciplinary team, supporting women through the screening and diagnosis of GDM. The ability of midwives to identify risk factors associated with adverse outcomes and support them in maintaining normality not only fulfils their professional responsibility, but ultimately contributes to the well-being of women. Judith Kennedy, Student Midwife, University of Hertfordshire. 456

References Abayomi J, Wood L, Spelman S et al (2013). The multidisciplinary management of type 2 and gestational diabetes in pregnancy. British Journal of Midwifery 21(4):236-42. Agarwal MM, Dhatt GS, Othman Y (2015). Gestational diabetes: differences between the current international diagnostic criteria and implications of switching to IADPSG. Journal of Diabetes and its Complications 29(4):544-9. Bartoli E, Fra GP, Carnevale Schianca GP (2011). The oral glucose tolerance test (OGTT) revisited. European Journal of Internal Medicine 22(1):8-12. Benhalima K, Devlieger R, Van Assche A (2015). Screening and management of gestational diabetes. Best Practice and Research: Clinical Obstetrics and Gynaecology 29(3):339-49. Ben-Haroush A, Yogev Y, Hod M (2004). Epidemiology of gestational diabetes mellitus and its association with Type 2 diabetes. Diabetic Medicine 21(2):103-13. Buchanan TA, Xiang AH (2010). What causes gestational diabetes? In: Kim C, Ferrara A eds. Gestational diabetes during and after pregnancy. London: Springer-Verllag: 113-24. Buckley BS, Harreiter J, Damm P et al (2012). Gestational diabetes mellitus in Europe: prevalence, current screening practice and barriers to screening. A review. Diabetic Medicine 29(7):844-54. Chief Nursing Officers of England, Northern Ireland, Scotland and Wales (2010). Midwifery 2020: delivering expectations. Edinburgh: Midwifery 2020 Programme. https://www.gov.uk/government/ publications/midwifery-2020-delivering-expectations. [Accessed 1 February 2017]. Cullinan J, Gillespie P, Owens L et al (2012). Accessibility and screening uptake rates for gestational diabetes mellitus in Ireland. Health and Place 18(2):339-48. Cundy T, Ackermann E, Ryan EA (2014). Gestational diabetes: new criteria may triple the prevalence but effect on outcomes is unclear. BMJ 348(g1567):1-5. Djelmis J, Pavić M, Kotori VM et al (2016). Prevalence of gestational diabetes mellitus according to IADPSG and NICE criteria. International Journal of Gynecology and Obstetrics 135(3):250-4. Draffin CR, Alderdice FA, McCance DR et al (2016). Exploring the needs, concerns and knowledge of women diagnosed with gestational diabetes: a qualitative study. Midwifery 40:141-7. Erjavec K, Poljičanin T, Matijević R (2016). Impact of implementation of new WHO diagnostic criteria for gestational diabetes mellitus on prevalence and perinatal outcomes: a population-based study. Journal of Pregnancy https://www.hindawi. com/journals/jp/2016/2670912/ [Accessed 1 February 2017]. Ferrara A (2007). Increasing prevalence of gestational diabetes mellitus: a public health perspective. Diabetes Care 30(2):S141-6. Görig T, Schneider S, Bock C et al (2015). Screening for gestational diabetes in Germany: a qualitative study on pregnant women’s attitudes, experiences, and suggestions. Midwifery 31(11):1026-31. Griffin ME, Coffey M, Johnson H et al (2000). Universal vs. risk factor-based screening for gestational diabetes mellitus: detection rates, gestation at diagnosis and outcome. Diabetic Medicine 17(1):26-32. HAPO Study Cooperative Research Group (2008). Hyperglycemia and adverse pregnancy outcomes. New England Journal of Medicine 358(19):1991-2002. Hunt KF, Whitelaw BC, Gayle C (2014). Gestational diabetes. Obstetrics, Gynaecology and Reproductive Medicine 24(8):238-44. International Association of Diabetes and Pregnancy Study Groups Consensus Panel (2010). International Association of Diabetes and Pregnancy Study Groups recommendations on the diagnosis and classification of hyperglycemia in pregnancy. Diabetes Care 33(3):676-82. Kawahito S, Kitahata H, Oshita S (2009). Problems associated with glucose toxicity: role of hyperglycaemia-induced oxidative stress. World Journal of Gastroenterology 15(33):4137-42. Kirsopp R, Earp R (2010). Glucose tolerance test. NHS East and North Hertfordshire Trust: Department of Obstetrics. http://www. enherts-tr.nhs.uk/patient-information/files/downloads/2011/04/ glucose_tolerance_test_diabetes_maternity.pdf [Accessed 1 February 2017].

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Pregnancy Knight M, Nair M, Tuffnell D et al on behalf of MBRRACE-UK (2016). Saving lives, improving mothers’ care - surveillance of maternal deaths in the UK 2012-14 and lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009-14. Oxford: National Perinatal Epidemiology Unit, University of Oxford. https://www. npeu.ox.ac.uk/mbrrace-uk/reports [Accessed 1 February 2017]. Meek CL, Lewis HB, Patient C et al (2015). Diagnosis of gestational diabetes mellitus: falling through the net. Diabetologia 58(9):2003-12. Murphy HR (2010). Gestational diabetes: what’s new? Medicine 38(12):676-78. National Institute for Health and Care Excellence (2015). Diabetes in pregnancy: management of diabetes and its complications from preconception to the postnatal period. London: NICE. Nursing & Midwifery Council (2015). The Code: professional standards of practice and behaviour for nurses and midwives. London: NMC. Public Health England (2014). From evidence into action: opportunities to protect and improve the nation’s health. https://www.gov.uk/ government/publications/from-evidence-into-action-opportunitiesto-protect-and-improve-the-nations-health [Accessed 1 February 2017].

Sukumaran S, Madhuvrata P, Bustani R et al (2014). Screening, diagnosis and management of gestational diabetes mellitus: a national survey. Obstetric Medicine 7(3):111-5. Tieu J, McPhee AJ, Crowther CA et al (2017). Screening for gestational diabetes mellitus based on different risk profiles and settings for improving maternal and infant health. Cochrane Database of Systematic Reviews, Issue 8. Van Ryswyk E, Middleton P, Shute E et al (2015). Women’s views and knowledge regarding healthcare seeking for gestational diabetes in the postpartum period: a systematic review of qualitative/survey studies. Diabetes Research and Clinical Practice 110(2):109-22. Verhoef TI, Daley R, Vallejo-Torres L et al (2016). Time and travel costs incurred by women attending antenatal tests: a costing study. Midwifery 40:148-52. Wilmot EG, Mansell P (2014). Diabetes and pregnancy. Clinical Medicine 14(6):677-80. Wu E-T, Nien F-J, Kuo C-H et al (2016). Diagnosis of more gestational diabetes lead to better pregnancy outcomes: comparing the International Association of the Diabetes and Pregnancy Study Group criteria, and the Carpenter and Coustan criteria. Journal of Diabetes Investigation 7(1):121-6.

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Stewart ZA, Murphy HR (2014). Gestational diabetes. Medicine 43(1):44-7.

Original article. © MIDIRS 2017.

A healthy respect for pre-eclampsia Hannah Wilson, Hannah Nathan, Andrew Shennan ORIGINAL Pregnancy in the UK has never been safer. In December 2016, MBRRACE, producers of the UK and Ireland’s Confidential Enquiries into Maternal Deaths and Morbidity report stated that less than one in 10,000 women now die in or around pregnancy, the lowest rate since records began in 1952 (Knight et al 2016). Moreover, fewer than one woman in every million now dies from pre-eclampsia or hypertensive related diseases, a significant decrease since the previous report. This is in stark contrast to the daily global death toll from pre-eclampsia (World Health Organization (WHO) 2015). Historic death rates have been frequently linked to poor care. Changing practice to follow the National Institute for Health and Care Excellence (NICE) guidelines introduced in 2010 may well explain the latest low figures. This positive news means clinicians in the UK have less exposure to the danger and unpredictability of pre-eclampsia and, consequently, less experience of the necessary management should they encounter it. It is critical for us to be vigilant against complacency. Midwives are essential to further improvement efforts in the continued reduction in mortality and morbidity arising from pre-eclampsia, as well as enhancing the experience of women and families who encounter this disease. This article considers what is in a midwife’s armory against pre-eclampsia, as well as reviewing ongoing research into the condition. ‘Pregnancy in the UK has never been safer for the mother’ (Shennan et al 2017:582). The UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity published their most recent report in December 2016 (examining deaths between 2012– 2014), highlighting that fewer than one in 10,000 women now die in or around pregnancy, the lowest rate recorded since records began in 1952 (Knight et al 2016). It is startling to consider that in the UK today, the maternal mortality rate is lower than agematched male death rates (Office for National Statistics 2017), ie: ‘a man is more likely to die while his partner is pregnant than she is’ (Shennan et al 2017:582). MIDIRS Midwifery Digest 27:4 2017

The majority of women who die in or around the time of pregnancy die from medical or mental health-related conditions (Knight et al 2016). Remarkably, fewer than one in every million women who gives birth now dies from pre-eclampsia or hypertensive-related diseases (Knight et al 2016). Although deaths from pre-eclampsia have been falling for some time (Knight et al 2016), this is a significant decrease, both clinically and statistically, from the previous report, which examined deaths from 2009–2012 (Knight et al 2014). Pre-eclampsia has historically been the leading direct cause of death in pregnancy in the UK. Yet today, it is the least common cause. When deaths do occur from pre-eclampsia, it is most commonly as a 457


result of intracranial haemorrhage, followed closely by hepatic complications (Knight et al 2016). Poor care has often been associated with deaths from hypertensive disorders, suggesting that many are avoidable (Shennan et al 2012), and there have been repeated calls to action to reduce these deaths. It has been suggested that the ongoing fall in death rates from pre-eclampsia can largely be attributed to improvements in care. The largest fall in mortality occurred between the 1950s (200 deaths) and 1970s (fewer than 40 deaths) and is thought to be related to improved surveillance, diagnosis and timing of delivery (Shennan et al 2017). The introduction of guidelines on fluid management in the 1980s meant deaths from pulmonary oedema disappeared from maternal causes of death in 2002 (Lewis 2004), and the ongoing benefits of this change in management is reinforced in the latest report where no women died as a result of poor fluid management, and thus pulmonary oedema and renal failure (Knight et al 2016). In 2010, evidence-based guidelines were introduced outlining an integrated package of care for pregnant women with hypertensive disorders, including pre-eclampsia, incorporating the use of aspirin for women with risk factors for pre-eclampsia, the importance of fluid restriction, controlling systolic hypertension to reduce the risk of intracranial hemorrhage and guidance around the optimal timing of delivery for mother and baby (NICE 2010). Changing practice to follow these guidelines may well explain the latest low figures. A UK midwife today would rarely witness a mother dying and might never experience a woman having an eclamptic fit, yet in many hospitals around the world this is a daily occurrence. We must not forget that left untreated, pre-eclampsia can be deadly. Globally, 40,000 women die each year from pre-eclampsia; this equates to around five women every hour (WHO 2015). Pre-eclampsia is only safe for the mother if diagnosed promptly and appropriate management is instigated (Shennan et al 2017). It is legitimate to be concerned about complacency regarding the ongoing importance of evidence-based management of women who have or are at risk of hypertensive disorders in pregnancy. Furthermore, there is a genuine need to continue to improve aspects of care (Knight et al 2016). Even in the UK, the death rate is not the whole story; the near misses, the almost tragedies, and the trauma suffered by women and families continue (Action on Pre-eclampsia (APEC) 2016). For example, a study from one region of the UK reported that one in 20 (5%) women with severe pre-eclampsia or eclampsia was admitted to intensive care (NICE 2010). Creanga et al (2014) highlight that although maternal mortality is comparatively rare, morbidity is not. Figures from the United States (US) show that for every woman who dies there are approximately 75 more that experience near fatal emergencies such as myocardial infarction, renal failure or haemorrhage. 458

The latest MBRRACE report states that a woman born outside of the UK has no greater risk of dying than her UK-born equivalent, even if the mother was born in a low-income setting (Shennan et al 2017), suggesting that it is universal care provision, rather than ‘who we are’ that influences the reduction of maternal mortality rates (Knight et al 2016). Comparing UK rates to those of the US seems to reinforce the importance of universal antenatal care (Shennan et al 2017). The proportion of maternal deaths from hypertensive disorders is 1.5% in the UK (Knight et al 2016) compared to 7.4% in the US (Centers for Disease Control and Prevention 2016) and 14% globally (WHO 2015). In California, where one in eight American births takes place, the total maternal mortality rate has decreased from 17 in 2006 to six deaths per 100,000 in 2010 by implementing new ways of managing haemorrhage and pre-eclampsia. The Economist (Anon 2015) believes the most compelling explanation for the higher US mortality rate is that more American women are in poorer health when they become pregnant and are failing to receive proper care. Chronic health conditions, such as obesity, hypertension, diabetes and heart disease, are increasingly common among pregnant women. African-American women are nearly four times more likely to die from pregnancy-related complications than white women (Creanga et al 2014). Any recent progress made may well backslide to some degree with the potential dismantlement of the 2010 Affordable Care Act (Popovich et al 2017). Globally, the issue is compounded by lack of accessibility and availability of basic care. In 2015, only 40% of all pregnant women in low-income countries had the recommended number of antenatal care visits (WHO 2016). Midwives are critical in ensuring that women have a safe and emotionally satisfying experience during their pregnancy, childbirth and postnatal period (Chief Nursing Officers of England, Northern Ireland, Scotland and Wales 2010). This is supported by robust evidence from both the UK and overseas (Birthplace in England Collaborative Group 2011). The principle that all women need a midwife and some need a doctor too is widely accepted (Royal College of Midwives 2014). The WHO states that implementing quality midwifery care could prevent around two-thirds of maternal and newborn deaths globally (WHO 2014). The midwife on the frontline is central to high-quality maternity care and consequently key in maintaining quality preeclampsia management. Previous substandard care related to poor recognition of the deterioration of pregnant women has been attributed to health professionals including midwives. If over one-third of women who develop pre-eclampsia have no risk factors whatsoever (Duckett & Harrington 2005) our safeguard for diagnosing the condition is universal routine antenatal care. As the disease becomes ‘safer’ with good care, we must guard against forgetting the MIDIRS Midwifery Digest 27:4 2017


lessons of the past. Regular checking of blood pressure and proteinuria, awareness of symptoms (headache, epigastric pain, nausea, vomiting and vision disturbance) and prompt referral remain central to safety. As midwives, we are ideally placed to both maintain current low rates of death and improve the care offered to women with preeclampsia. Our role, encompassing both the support and promotion of normal birth, as well as detecting complications and preventing escalation in mother and child (International Confederation of Midwives 2005) is crucial in managing the ongoing challenge of preeclampsia.

So what do we have in our armory? Pre-conception care • As midwives, we should be encouraging all women and their partners to enter into pregnancy as fit and as healthy as possible; this includes diet, how much they exercise, and whether they smoke or drink alcohol (Korenbrot et al 2002). Increased body mass index (BMI) is a major risk factor for pre-eclampsia (Duckett & Harrington 2005). • Women with pre-existing medical conditions such as diabetes and chronic hypertension may require therapeutic alterations prior to pregnancy. • Those with risk factors should be counselled about the risk of pre-eclampsia. These are numerous and include family history, previous pre-eclampsia, as well as diseases such as diabetes and anti-phospholipid syndrome. Association of pre-eclampsia to assisted conception technologies, including multiple pregnancies and donor eggs should be discussed with the relevant women (Bartsch et al 2016). Antenatal care • Identifying women with risk factors for preeclampsia as early as possible and ensuring early contact with the obstetric team. Pregnant women who have a higher risk of developing pre-eclampsia should be offered a prescription of aspirin (unless unsuitable) to take every day from 12 weeks of pregnancy (until delivery) (NICE 2010). • All women should be educated about the signs and symptoms of pre-eclampsia, and the importance and details of referral for further investigation should they have concerns. Carter et al (2017) found widespread lack of knowledge and understanding of the signs and symptoms of pre-eclampsia amongst women and their families. ‘White coat hypertension’ should not be dismissed (Nathan et al 2015). • Ensure that blood pressure and urine checks are carried out at every antenatal contact, with increased frequency for those women at high risk or where there are concerns. This remains a MIDIRS Midwifery Digest 27:4 2017

key conclusion for MBRRACE in their 2016 report. Automated blood pressure devices limit user error but are known to systematically underestimate both systolic and diastolic blood pressure, particularly in pre-eclampsia (Nathan et al 2015). There are only a handful of automated devices which have been validated for use in pregnancy. Appropriate cuff size is also critical to accuracy. If in doubt over-cuffing (using a cuff that is too large for the arm circumference) is better than undercuffing (using a cuff that is too small for the arm circumference) (Nathan et al 2015). • Consider the wider definition of pre-eclampsia when assessing a woman. The International Society for the Study of Hypertension (ISSHP) (Tranquilli et al 2014) recommend the use of a broader definition of pre-eclampsia; at times not depending on the presence of proteinuria. There is a growing understanding that pre-eclampsia may have several sub-types, the result of abnormal placental function or abnormal placentation. Tranquilli et al (2014) recommend that asymptomatic women with less than severe hypertension (140–159/90–109) and no dipstick proteinuria should have the appropriate investigations done to exclude end-organ dysfunction, ie: proteinuria, renal, hepatic, neurological, hematological or fetal growth restriction. Additional investigations need to be carried out in order to truly exclude pre-eclampsia. Gestational hypertension may progress to pre-eclampsia in about 25% of cases, particularly if detected early (less than 30 weeks’ gestation). Tranquilli et al (2014) consider that pre-eclampsia may be present without overt hypertension, but at present recommend maintaining new onset hypertension in the diagnosis. For example, it is possible that women with gestational proteinuria have an early and mild form of pre-eclampsia. Monitoring these women more frequently than usual is therefore recommended for the remainder of their pregnancy. NICE (2016) have recently recommended using angiogenic markers to rule out pre-eclampsia in suspected cases. These new tests are likely to revolutionise the detection of the disease. Management • Support our obstetric colleagues in the management of hypertension. The Control of Hypertension in Pregnancy Study (CHIPS) (Magee et al 2015) found that tighter control of blood pressure in women with pre-existing hypertension resulted in significantly less severe hypertension with no adverse effects for the baby. • Ensure timely management of women with severe hypertension within the appropriate 459


critical care setting. Managing systolic blood pressure is critical in preventing intracerebral haemorrhage. Evidence supports the administration of magnesium sulphate in women with severe pre-eclampsia or imminent eclampsia (The Magpie Trial Collaborative Group 2002). • Ensure steroids have been prescribed and administered if appropriate (<34 weeks). • Advise women with a pre-eclampsia diagnosis that inpatient management is best practice due to the unpredictability of the condition (NICE 2010). Diagnosing a woman’s condition as ‘mild pre-eclampsia’ is unhelpful due to the variation in how the disease progresses in different women, and is only a diagnosis in retrospect (Preeclampsia Foundation 2013). Early onset disease frequently becomes severe. • Ensure appropriate timing of delivery. In 2010, there was a change in guidelines indicating delivery from 37 weeks in women with a diagnosis of pre-eclampsia was optimal (NICE 2010). Women had better outcomes and were less likely to have a caesarean section with this intervention (Koopmans et al 2009). As midwives, it is important for us to consider that intervening in disease states may result in a more normal experience of birth. Postnatal care • Adequate monitoring of blood pressure in hospital and within the community setting. We need to be consistently mindful of the potential danger of the postnatal period. Counsel women and remain alert to symptoms of pre-eclampsia, as it is possible that it may show itself for the first time after delivery (APEC 2013). Data from the Nationwide Inpatient Sample demonstrated that between 1994–1995 and 2006–2007 the rate of postpartum hospitalisations for stroke increased from 0.12 to 0.22 per 1000 deliveries (August & Malha 2015). The highest blood pressure readings can often occur in the postnatal period. • Ensure evaluation of the need for and/or type of anti-hypertensive medication required postdelivery. • Ensure adequate follow-up in terms of birth debrief and medical review as women may have had complicated pregnancy and birth experiences. • Counsel women regarding the risk of preeclampsia in future pregnancies, to other females in their family and to their long-term health. A first degree relative (mother or sister), particularly with early onset disease (<34 weeks) is a risk factor for pre-eclampsia (English et al 2015). Overall, one in six women who have 460

had pre-eclampsia will get it again in a future pregnancy. Of those women who have ‘severe pre-eclampsia’ or eclampsia: one in two women will get pre-eclampsia in a future pregnancy, if their baby needed to be born before 28 weeks of pregnancy, and one in four women if their baby needed to be born before 34 weeks of pregnancy (Royal College of Obstetricians and Gynaecologists (RCOG) 2012). Hypertensive disorders are considered to significantly contribute to the 2.6 million stillbirths globally (Lancet 2016). Moreover, there is no cure for preeclampsia other than delivery of the baby. Once a woman has pre-eclampsia, we cannot tell who will deteriorate and when. Research into the new angiogenic markers may change this. A woman with pre-eclampsia will not improve while she remains pregnant, and is likely to get worse. Balancing the risk to the mother versus that of the baby remains a feature of the condition. Iatrogenic prematurity and its consequences for those same neonates will continue to be a challenge.

Research in progress Prevention Other than aspirin, no medication has yet been found to conclusively make a positive difference to the incidence of pre-eclampsia. Giving aspirin to women considered to be high risk has been beneficial (CLASP Collaborative Group 1994). New research is evaluating if early blood tests (such as PlGF) can be used to diagnose those at risk. Higher doses of aspirin (150mg) are also being investigated. Calcium supplementation may well have some potential, especially in populations with deficient diets, but more work needs to be done to demonstrate this conclusively (Hofmeyr et al 2014). Screening and diagnosis The diagnosis of pre-eclampsia remains a clinical challenge. The deaths that still occur often relate to poor diagnosis and detection of deterioration. The presentation is varied and signs and symptoms may progress over some weeks before diagnosis is confirmed or deterioration occurs suddenly. Even with severe disease, women can often be asymptomatic. Severe adverse events have seemingly occurred in the absence of any clinical signs. For example, a national survey of eclampsia cases from the UK reported that hypertension and proteinuria were absent in 38% of women who presented with an eclamptic fit (Douglas & Redman 1994). However, this may be due to doctors and midwives failing to recognise hypertension and proteinuria. There is also the challenge for women not being able to distinguish signs and symptoms from ‘normal’ pregnancy changes (Carter et al 2017). Investigations for pre-eclampsia MIDIRS Midwifery Digest 27:4 2017


currently identify symptoms (hypertension and proteinuria) that arise late in the disease course. New angiogenic markers have found to be good at ruling out the disease (ie: if they are normal it is highly unlikely a significant disease process exists). Ongoing work is establishing if risk is related to the degree of abnormality in established pre-eclampsia. There is currently no test with sufficient sensitivity, specificity, and convenience for the diagnosis or prediction of pre-eclampsia. Management Although timely delivery is beneficial for the mother, the baby is still prone to the effects of iatrogenic prematurity. New research is evaluating interventions, such as statins, Viagra and alpha-one-globulin that may allow the pregnancy to continue further, safely, with established disease. When a diagnosis of preeclampsia is made at or beyond 37 weeks of gestation, it is currently recommended that delivery be induced, since maternal and fetal risks can be significantly reduced without any apparent additional risk associated with the intervention (Koopmans et al 2009). In pregnancies complicated with pre-eclampsia at less than 34 weeks’ gestation, management depends on the severity of the condition and the risk to the mother and the baby compared to the risk of pre-term birth. When pre-eclampsia occurs between 34 and 37 weeks of gestation, the optimal timing of delivery, without increasing problems related to infant immaturity or complications, remains unclear. Current research is evaluating if women should be routinely delivered at these gestations. Future pregnancies and long-term health There is evidence to suggest an association between having pre-eclampsia and long-term effects on mortality and morbidity. Understanding this association may tip the balance of timing of delivery when a woman is diagnosed with pre-eclampsia before 37 weeks. Current research is evaluating if timing of delivery is related to subsequent cardiovascular risk in the mother. Those involved in delivering maternity care in the UK should be pleased with the latest low rate of death from pre-eclampsia. Evidently, the care we give is improving outcomes for women. Nevertheless, it is vital for us to maintain our respect for the dangers of pre-eclampsia, not only in its potential to kill, but also to cause irreparable harm to women, babies and their families. We need to uphold our focus on the highquality maintenance of these life-saving interventions, and work to provide more answers and solutions for women to this complicated and unpredictable condition. Not to mention transferring our most effective interventions to low-resource settings where death and serious adverse outcomes from preeclampsia are still common. MIDIRS Midwifery Digest 27:4 2017

Hannah Wilson, Research Midwife, Women’s Health Academic Centre, King’s College, London; Hannah Nathan, Research Fellow, Women’s Health Academic Centre, King’s College, London; Andrew Shennan, Professor of Obstetrics, Women’s Health Academic Centre, King’s College, London.

References Action on Pre-eclampsia (2013). Postnatal recovery from pre-eclampsia. Leicester: APEC http://action-on-pre-eclampsia.org.uk/wp-content/ uploads/2012/07/Postnatal_leaflet.pdf [Accessed 12 March 2017]. Action on Pre-eclampsia (2016). One in a Million - UK death rate from pre-eclampsia falls to all time low. 7th December. http://action-onpre-eclampsia.org.uk/one-million-uk-death-rate-pre-eclampsia-falls-timelow/#sthash.IaUSYauV.dpuf [Accessed 2 February 2017]. Anon (2015). Exceptionally deadly. The Economist, 16th July. http:// www.economist.com/news/united-states/21657819-deathchildbirth-unusually-common-america-exceptionally-deadly [Accessed 2 February 2017]. August P, Malha L (2015). Postpartum hypertension: ‘It ain’t over ‘til it’s over’. Circulation 132(18):1690-2. Bartsch E, Medcalf KE, Park AL et al (2016). Clinical risk factors for pre-eclampsia determined in early pregnancy: systematic review and meta-analysis of large cohort studies. BMJ 353:i1753. http:// www.bmj.com/content/353/bmj.i1753 [Accessed 8 September 2017]. Birthplace in England Collaborative Group (2011). Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study. BMJ 343:7400. http://www.bmj.com/ content/343/bmj.d7400 [Accessed 8 September 2017]. Carter W, Bick D, Mackintosh N et al (2017). A narrative synthesis of factors that affect women speaking up about early warning signs and symptoms of pre-eclampsia and responses of healthcare staff. BMC Pregnancy and Childbirth 17:63. Centers for Disease Control and Prevention (2016). Pregnancyrelated deaths. Atlanta, GA: CDC: https://www.cdc.gov/ reproductivehealth/maternalinfanthealth/pregnancyrelatedmortality.htm [Accessed 2 February 2017]. Chief Nursing Officers of England, Northern Ireland, Scotland and Wales (2010). Midwifery 2020: delivering expectations. Edinburgh: Midwifery 2020 Programme. https://www.gov.uk/government/ uploads/system/uploads/attachment_data/file/216029/dh_119470. pdf [Accessed 2 February 2017]. CLASP (Collaborative Low-dose Aspirin Study in Pregnancy) Collaborative Group (1994). CLASP: a randomised trial of low-dose aspirin for the prevention and treatment of pre-eclampsia among 9364 pregnant women. Lancet 343(8898):619-29. Creanga AA, Berg CJ, Ko JY et al (2014).Maternal mortality and morbidity in the United States: where are we now? Journal of Women’s Health 23(1):3-9. Douglas KA, Redman CWG (1994). Eclampsia in the United Kingdom. BMJ 309(6966):1395-400. Duckitt K, Harrington D (2005). Risk factors for pre-eclampsia at antenatal booking: systematic review of controlled studies. BMJ 330(7491):565-7 http://www.bmj.com/content/bmj/330/7491/565. full.pdf [Accessed 2 February 2017]. English FA, Kenny LC, McCarthy FP (2015). Risk factors and effective management of preeclampsia. Integrated Blood Pressure Control 8:7-12. Hofmeyr GJ, Belizan JM, von Dadelszen P et al (2014). Low-dose calcium supplementation for preventing pre-eclampsia: a systematic review and commentary. BJOG: An International Journal of Obstetrics and Gynaecology 121(8):951-7. International Confederation of Midwives (2005). Definition of the midwife. The Hague: ICM. https://tinyurl.com/ycygqvn2 [Accessed 2 February 2017]. Knight M, Kenyon S, Brocklehurst P et al on behalf of MBRRACE UK (2014). Saving lives, improving mothers’ care. Lessons learned to inform future maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity


Pregnancy 2009-2012. Oxford: National Perinatal Epidemiology Unit, University of Oxford. Knight M, Nair M, Tuffnell D et al on behalf of MBRRACE-UK (2016). Saving lives, improving mothers’ care - surveillance of maternal deaths in the UK 2012-14 and lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009-14. Oxford: National Perinatal Epidemiology Unit, University of Oxford. https://www. npeu.ox.ac.uk/mbrrace-uk/reports [Accessed 2 February 2017]. Koopmans CM, Bijlenga D, Groen H et al (2009). Induction of labour versus expectant monitoring for gestational hypertension or mild pre-eclampsia after 36 weeks’ gestation (HYPITAT): a multicentre, open-label randomised controlled trial. The Lancet 374(9694):979-88. Korenbrot CC, Steinberg A, Bender C et al (2002). Preconception care: a systematic review. Maternal and Child Health Journal 6(2):75-88. Lewis G ed (2004). Why mothers die 2000-2002: the sixth report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. London: RCOG press. Magee LA, von Dadelszen P, Rey E et al (2015). Less-tight versus tight control of hypertension in pregnancy. New England Journal of Medicine 372(5):407-17.

December. https://www.preeclampsia.org/the-news/1-latest-news/299new-guidelines-in-preeclampsia-diagnosis-and-care-include-reviseddefinition-of-preeclampsia [Accessed 2 February 2017]. Royal College of Midwives (2014). High quality midwifery care. London: RCM. https://www.rcm.org.uk/sites/default/files/High%20 Quality%20Midwifery%20Care%20Final.pdf [Accessed 2 February 2017]. Royal College of Obstetricians and Gynaecologists (2012). Information for you: pre-eclampsia. https://www.rcog.org.uk/ globalassets/documents/patients/patient-information-leaflets/ pregnancy/pre-eclampsia.pdf [Accessed 18 April 2017]. Shennan AH, Green M, Chappell LC (2017). Maternal deaths in the UK: pre-eclampsia deaths are avoidable. The Lancet 389(100569):582-4. Shennan AH, Redman C, Cooper M et al (2012). Are most maternal deaths from pre-eclampsia avoidable? The Lancet 379(9827):1686-7. The Lancet (2016). Ending preventable stillbirths. An executive summary for The Lancet’s Series http://www.thelancet.com/pb/ assets/raw/Lancet/stories/series/stillbirths2016-exec-summ.pdf [Accessed 2 February 2017].

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National Institute for Health and Care Excellence (2016). PIGF-based testing to help diagnose suspected pre-eclampsia (Triage PIGF test, Elecsys immunoassay sFlt-1/PIGF ratio, DELFIA Xpress PIGF 1-2-3 test, and BRAHMS sFlt-1 Kryptor/ BRAHMS PIGF plus Kryptor PE ratio). London: NICE. https:// www.nice.org.uk/guidance/dg23 [Accessed 31 January 2017].

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Wilson H, Nathan H, Shennan A. MIDIRS Midwifery Digest, vol 27, no 4, December 2017, pp 457-462. Original article. © MIDIRS 2017.

Supporting women with autism during pregnancy, birth and beyond Lesley Turner ORIGINAL Women with a diagnosis of autism are accessing maternity care and practitioners have often received little education or training in this area. This paper explains some of the qualities associated with autism and how these can affect a woman’s experience of pregnancy, birth and parenting. The areas of communication, sensory perception, emotional regulation and cognition are explored. Reasonable adjustments are suggested based on the published evidence. Further research is needed to inform evidence-based practice. We must invest in the training of maternity staff so that women with autism are not disadvantaged due to their condition and the care they receive. Keywords: Autism, sensory processing, communication, reasonable adjustments 462

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Approximately 1.1% of UK adults have autism, with rates of diagnosis higher in men than women (NHS Information Centre 2012). There is thought to be a hidden pool of undiagnosed women with autism (Hill 2016) as services have concentrated on the diagnosis of children, especially boys. Autism in women may present as anxiety, isolation and depression (Maloret & Sumner 2014) resulting from the social struggle of living with autism. Children who were diagnosed in the last few decades are now of childbearing age and will be recognised in the maternity system. As autism is a lifelong developmental condition, pregnant women will still have differences that need to be accommodated.

Barriers and outcomes There is evidence that adults with autism experience barriers that prevent them from accessing health care and there are disparities in the services provided to them (Nicolaidis et al 2013, Warfield et al 2015, Dern & Sappok 2016). They may be reluctant to see health professionals as they find the environment frightening and communication difficult (Maloret & Sumner 2014). Ultimately these barriers could influence health outcomes as there could be missed opportunities to access preventative care or receive prompt and appropriate treatment. A large retrospective cohort study in the United States found that women with intellectual or developmental disability (such as autism) had worse pregnancy outcomes in terms of preterm birth, perinatal mortality, low Apgar score, low birth weight and an increased caesarean section rate (Mitra et al 2015).

Aim of this paper The aim of this paper is to help health professionals understand the characteristics of autism and how they may affect a mothers’ experience of maternity care. By working closely with individuals and understanding their needs, maternity staff can plan care that is sensitive and reasonable adjustments can be made so users can access services fully. This is a requirement of the Equality Act (Government Equalities Office 2010) as autism is recognised as a disability and public bodies have an obligation to make the necessary adjustments to ensure that individuals are not disadvantaged. MIDIRS Midwifery Digest 27:4 2017

© Lesley Turner.

Autism is described as a ‘lifelong, developmental disability that affects how a person communicates with and relates to other people, and how they experience the world around them’ (National Autistic Society 2017a). It is a spectrum condition meaning that it can have many and varied effects on an individual. Autism is a relatively new condition, being described for the first time by Leo Kanner in the 1940s (Wallang et al 2016). Autism is a hidden disability as it is not always initially obvious. Emerging strategies for people with learning disabilities may not be applicable as most people with autism do not have impaired intelligence (Williams et al 2008).

The UK National Autism Strategy (HM Government 2014) states that autism awareness training should be made available to all mainstream health care professionals. Recent research has shown that 39% of UK general practitioners had received no previous training on autism (Unigwe et al 2017) and some relied on tacit knowledge of autistic family members, friends or colleagues. The Royal College of General Practitioners have now created an educational toolbox for primary care staff (RCGP 2017). This includes a guide for receptionist staff and clinicians, and a checklist for autism-friendly environments. Education on autism has yet to become common practice in maternity care with very few study days and professional papers on this topic.

Features of autism Autism Spectrum Disorder is the umbrella term that encompasses many other previous diagnoses such as Asperger’s disorder, autistic disorder and pervasive developmental disorders (American Psychiatric Association 2013). The defining characteristics of autism are differences in social communication, problems recognising social cues and non-verbal gestures, processing and organising of information, heightened or dulled sensory experiences and difficulty in being flexible and adaptable to change (Shankar et al 2013, Lum et al 2014, Nicolaidis et al 2015). Some individuals will have a reduced IQ and others may engage in repetitive behaviour (such as hand flapping) which can be a calming mechanism to filter out unwanted sensory information. Mental health and self-esteem are often affected as individuals try to ‘fit in’ to the social world around them (Maloret & Sumner 2014). The diagnosis of autism may have come later in life as autism is often ‘masked’ or hidden in girls (Lum et al 2014, Rogers et 463


al 2017). Self-esteem may have been affected by bullying or difficulties understanding social situations and making social mistakes. This can contribute to a history of anxiety, depression and isolation in some individuals (Trembath et al 2012). The following sections of this paper will highlight some of the adjustments that could be offered to women with autism to help them participate in their maternity care. It is not suggested that these adaptations would be necessary for all women as an individual approach should be taken by maternity staff.

Considerations in pregnancy Many women with autism can feel anxious in busy waiting rooms (Lum et al 2014) and not feel comfortable making ‘small talk’ with other mothers or members of staff. This could be discussed at booking when the patterns of antenatal checks are discussed. In cases of extreme anxiety, mothers could receive antenatal care at home or be scheduled to have the first appointment of the day. The sensory stimulation in a waiting room can add to a mother’s distress as the noises, crowding and lack of familiarity can heighten anxiety (Bloch et al 2012). In hospital, a quieter waiting area could be offered if available. Clear instructions of what to expect would be of great benefit, especially if this can be reinforced in writing. Some individuals have difficulty extracting the most important information from a conversation (Aylott 2010) and may have a slower processing time before being able to answer a question. This should be considered when giving information about antenatal screening and enabling women to make choices. Instructions and information should be very explicit rather than relying on hints, gestures or facial expressions (Wallang et al 2016). Some information may be taken literally and colloquial phrases may be misunderstood eg ‘just hop up onto the couch’. Preparation for labour is particularly important as familiarity with the labour process and environment can help reduce anxiety. Social storiesTM are a strategy used to prepare people with autism for unfamiliar events (Timmins 2017), such as travelling on a plane or going to the theatre. This strategy involves taking photos and writing down the process in the form of a story which can be accessed at home. This helps with sequencing of events and answers the questions: where, when, who, what, how and why? Web pages for maternity units could be expanded to include this feature. A physical tour of the maternity unit would be beneficial in allaying fears. A useful resource for childbirth education is From here to maternity (Grant 2015). This book has been written by a mother with autism and outlines her experience and learning from her six pregnancies. Difficulty adapting to change is often experienced by individuals with autism (Gillott & Standen 2007). This could be reduced by ensuring continuity of carer 464

during maternity care as much as possible. Place of birth is significant, with home birth offering benefits in terms of having a familiar environment with reduced sensory and information overload. Pregnancy is known to be unpredictable and mothers may need help with adapting to changes such as alterations in estimated due dates, or if plans for increased antenatal monitoring or induction of labour are recommended. Cognitive processes have been described as ‘black and white thinking’ meaning that some individuals have problems accepting uncertainty and being flexible with plans (Bloch et al 2012). Sensory differences may make pregnancy experiences such as nausea and fetal movements feel more extreme (Rogers et al 2017). A known problem for many with autism is a difficulty in translating emotions and physical symptoms into speech (known as alexithymia and interoception) as described by Shah et al (2016). This can lead to a sense that something is wrong although it cannot be easily described (Lum et al 2014, Nicolaidis et al 2015). Maternity staff may need to allocate extra time and use visual charts to help mothers to express their symptoms so they receive appropriate care.

Implications for labour care Altered sensory processing may mean that some women dislike the physical sensations of being touched which may affect their experience of abdominal palpation, vaginal examination or massage in labour. This information could be included in the birth plan so that all staff are aware and are sensitive to this. One case study participant noted how helpful it was when the midwife explained what she would be doing and what it would feel like in advance (Rogers et al 2017). The physical environment can produce many sources of anxiety for individuals with autism (Trembath et al 2012). The combination of auditory stimuli, pain signals, touch receptors, light, warmth, information processing and perceived demands may become overwhelming in labour (Bloch et al 2012). This may result in a ‘meltdown’ or ‘shutdown’ as the stress builds up. Meltdowns are periods of psychological distress which can include crying, pacing and volatile behaviour. Shutdowns are when a person retreats and withdraws, stops communicating and may adopt a fetal position. The woman or her birth partner may recognise early signs of this and could alert staff before the stress has become overwhelming (Bloch et al 2012). Removal of stimuli and time alone is often enough to help the person recover from this intense period. It is usually not helpful to try to engage in conversation, but to wait until the period has passed and the person feels more in control again. It has been suggested that tolerance for sensory overload is lowered in individuals who are already anxious (Rogers et al 2017) which means a meltdown or shutdown can be triggered more easily. The birth MIDIRS Midwifery Digest 27:4 2017


environment should be prepared so it is less stimulating as it can be more difficult to filter out external distractions and regulate emotions. Fear and anxiety are known to have a negative effect on labour due to the production of adrenaline and inhibition of oxytocin (Gaskin 2003). Perception of pain is noted to be altered in many people with autism (Soraya 2010, Shankar et al 2013). This may mean that they do not recognise the deep pain of labour (hyposensitive) while simultaneously having increased sensitivity in superficial structures like the skin (hypersensitive). This has implications in terms of recognising labour and the risk of unattended birth. In contrast, some women may feel the pain of labour more intensely (Taylor 2014). It is important that staff are aware of the woman’s own perception of her pain threshold. In one study, women with autism reported greater challenges in communicating their pain and needs during childbirth (Lum et al 2014). The National Autistic Society has devised a hospital passport which is endorsed by the Department of Health (National Autistic Society 2017b). This is an excellent resource that mothers can complete to list their communication needs and preferences, how they experience pain, things that cause distress and measures that can help. Cognitive differences may mean that individuals may struggle to interpret other people’s thoughts, motivations and intentions and may not appreciate a sense of urgency (Lum et al 2014, Wallang et al 2016). This may be particularly relevant in obstetric emergencies where consent and fast intervention are needed, often involving unanticipated touch and a change in management (Bloch et al 2012). A useful account of midwifery care in early labour is documented by Taylor (2014). Adjustments are described such as providing a low stimulating environment and only asking questions that are necessary. The author expresses surprise about the lack of guidelines for caring for women with autism in labour.

Postnatal challenges In the immediate postnatal period, a woman with autism may value time alone to process the event and cope with overstimulation (Bloch et al 2012). Moving onto a busy postnatal ward may cause additional stress due to the number of staff, other mothers and their babies and visitors, noise, light, and the pressure to make social conversation with other families (Grant 2015). A single room may be requested for these reasons. Giving birth at home or a birth centre would reduce these environmental triggers. Adapting to change and the transition to motherhood may be challenging. The use of structure and clear guidance can help a new mother feel more secure. Unless there is significant learning disability or mental health problems then there is no reason why a mother MIDIRS Midwifery Digest 27:4 2017

cannot care for her baby independently. The postnatal team will need to be aware if there are sensory difficulties related to breastfeeding. In everyday life, people with autism can develop anxiety if their routine is changed and they are more prone to sleep difficulties (Wallang et al 2016). These issues will be magnified with the arrival of a newborn and as the woman manages her transition to becoming a mother. There will be an increased risk of postnatal depression and stress if these are already present in the antenatal period (Leigh & Milgrom 2008). Postnatal staff should be advised to monitor a mother’s mood carefully and provide screening tools and support in this vulnerable period. Due to social communication difficulties, mothers with autism may need encouragement to stimulate their baby and work out the cues to interpret what the baby needs (Bloch et al 2012). Organising social play dates may seem less attractive if they cause anxiety or make the mother feel inadequate or different. There is a risk of isolation from lack of peer support, although the internet is now a good source of information and friendship for new mothers. Maternity staff need to be aware of some of the differences in a mother’s communication skills, sensory regulation, emotional tolerance and cognitive functioning when planning her care and understanding her responses. In a UK online survey, mothers with autism reported greater difficulties in areas of parenting such as multitasking, coping with domestic responsibilities, and creating social opportunities for their child. Motherhood was found to be more isolating and mothers with autism expressed worry about others judging their parenting (Pohl et al 2016). Hill (2016) expresses a concern that autistic traits may be misinterpreted by health and social care staff. The woman with autism in the case study by Rogers et al (2017) felt that she had been stereotyped by midwives as having poor parenting behaviour which resulted in ‘watchfulness’ over her and her baby. A mother’s confidence and skills should be promoted at every opportunity with effective two-way communication so that she can share her concerns. Improvements are needed as 80% of women with autism felt that they did not receive adequate support to meet their needs as a parent (Pohl et al 2016). One woman writing in the British press said she was terrified that social services would take away her children because of her autism (Hill 2017).

Next steps More research is needed on women’s experience of maternity care and how their autism affects this. Evidence-based guidelines can then be developed and shared as they are distinctly lacking at present. Many of the measures recommended in this article such as continuity of carer, a calm birth environment and preparation for birth are already embedded within 465


maternity services. Our understanding of autism highlights that these measures are particularly important to help avoid distress and achieve a positive experience. Health care interactions are altered for women with autism due to differences in communication, sensory perception and thinking styles (Nicolaides et al 2015). Training and resources are needed within maternity services so that staff can improve their skills, knowledge, attitudes and confidence to meet the needs of women with autism. NHS Education for Scotland (2017) has produced an excellent learning resource to address this in primary care. Autism needs to be put on the agenda for maternity services so that women with this condition are not overlooked or misunderstood. Lesley Turner, Lecturer in Health and Social Care, Southampton Solent University.

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Hill A (2017). Mothers with autism: ‘I mothered my children in a very different way’ The Guardian, 15 April. https://www. theguardian.com/lifeandstyle/2017/apr/15/women-autistic-mothersundiagnosed-children [Accessed 12 June 2017]. HM Government (2014). Think autism. Fulfilling and rewarding lives, the strategy for adults with autism in England: an update. https://www.gov.uk/government/uploads/system/uploads/attachment_ data/file/299866/Autism_Strategy.pdf [Accessed 7 June 2017]. Leigh B, Milgrom J (2008). Risk factors for antenatal depression, postnatal depression and parenting stress. BMC Psychiatry http:// bmcpsychiatry.biomedcentral.com/articles/10.1186/1471244X-8-24 [Accessed 7 June 2017]. Lum M, Garnett M, O’Connor E (2014). Health communication: a pilot study comparing perceptions of women with and without high functioning autism spectrum disorder. Research in Autism Spectrum Disorders 8(12):1713-21. Maloret P, Sumner K (2014). Understanding autism spectrum conditions. Learning Disability Practice 17(6):23-6. Mitra M, Parish SL, Clements KM et al (2015). Pregnancy outcomes among women with intellectual and developmental disabilities. American Journal of Preventive Medicine 48(3):300-8.


Trembath D, Germano C, Johanson G et al (2012). The experience of anxiety in young adults with autism spectrum disorders. Focus on Autism and Other Developmental Disabilities 27(4):213-24. Unigwe S, Buckley C, Crane L et al (2017). GPs’ confidence in caring for their patients on the autism spectrum: an online self-report study. British Journal of General Practice 67(659):e445-52. Wallang P, Elmer D, Woodage J (2016). Autistic spectrum conditions: the essentials for healthcare assistants and assistant practitioners. British Journal of Healthcare Assistants 10(2):62-6. Warfield ME, Crossman MK, Delahaye J et al (2015). Physician perspectives on providing primary medical care to adults with autism spectrum disorders (ASD). Journal of Autism and Developmental Disorders 45(7):2209-17. Williams E, Thomas K, Sidebotham H et al (2008). Prevalence and characteristics of autistic spectrum disorders in the ALSPAC cohort. Developmental Medicine and Child Neurology 50(9):672-7.

Turner L. MIDIRS Midwifery Digest, vol 27, no 4, December 2017, pp 462-466. Original article. © MIDIRS 2017. MIDIRS Midwifery Digest 27:4 2017

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Taking the drama out of obstetric theatre: implementing change Alison Brodrick, Helen Baston ORIGINAL The value of skin-to-skin contact (SSC) is universally acknowledged as being of benefit to both mother and baby (Brimdyr et al 2012, UNICEF UK Baby Friendly Initiative 2012). Whether women experience SSC can sometimes be affected by the need for emergency care. It is also evident that culture and individual practice can play a role (Gouchon et al 2010, Hung & Berg 2011). This article describes an innovative service programme aimed at improving the experiences of women in obstetric theatre and optimising the opportunity for SSC. It explores the use of forum theatre as a medium for knowledge transformation and for mobilising action in the practice setting. Introduction

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The art and science of midwifery is grounded firmly in evidence-based practice, debated nationally and internationally. This continuing expansion of our knowledge and understanding is vital in improving the care to women and their families. Yet knowing what midwifery practice is and how to undertake it is just one element. Evidence-based guidelines do not by their existence alone translate automatically into practice change (Kitson et al 2008). Each practice

setting is a unique blend of established practices, routines and culture, all of which influence how care is delivered and how new knowledge is operationalised (Fervers et al 2006). Each mother and her partner have a set of expectations around giving birth and meeting their new baby, hence, there may be a dichotomy between what they expect (holding their baby immediately, having uninterrupted skin-to-skin contact (SSC) and personalised care and what they experience (separation from each other and their baby, unexpected procedures, environments and fear).

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Implementation science

Impact of separation for the mother and baby

It is globally acknowledged that health care research is not uniformly adopted into practice (Grimshaw et al 2012, van Lieshout et al 2012) and there is a growing body of evidence concerning the implementation phase of research and how it informs the best way to ensure sustainability in practice. Implementation science is the scientific study of the methods used to promote research uptake at all levels, from clinician to policy maker (Grimshaw et al 2012).

Women who have a caesarean birth are less likely to experience SSC immediately after birth (Berg & Hung 2011). They are also less likely to initiate breastfeeding (Dashti et al 2010), less likely to exclusively breastfeed (Thu et al 2012) and more likely to experience delayed lactation (Scott et al 2007). Women who return to theatre for perineal repair or removal of retained placenta are more likely to have SSC interrupted than women who have had a vaginal birth without such complications.

This project is the result of a successful funding bid to the National Institute for Health Research Collaboration for leadership in Applied Health Research and Care (NIHR CLAHRC) under the ‘Translating Knowledge into Action’ (TK2A) theme. The ‘Getting Research into Practice’ (GRiP) funding stream provides successful applicants with funds to support clinicians to mobilise knowledge and evidence and make real changes to local practice.

Background — the experience of childbirth The psychological elements which help to make a mother feel safe during childbirth are just as important as the physical elements of safety (Green et al 2005). ‘Intelligent guardianship’ is a conceptual model describing staff behaviours that enable women to have an enduring positive experience of emergency caesarean birth (Baston et al 2010). It comprises ‘engagement’, ‘perceived competence’ and ‘demeanour’ and all three are required to meet the woman’s clinical, emotional and social needs. Childbirth is about more than the safe arrival of the baby — the journey is important too. Whilst women who give birth by emergency caesarean are more likely to look back on their birth negatively (Baston et al 2010, Chalmers et al 2010), how they give birth only forms one part of a woman’s appraisal of her birth experience. An experience which enables the woman to feel totally connected, valued and supported will transcend the type of birth and birth environment (Waldenström et al 2004). Also important to a woman’s appraisal of the experience is having a sense of control throughout labour and childbirth (Green & Baston 2003) and the attitude of caregivers (Grekin & O’Hara 2014). These elements of psychological safety can be difficult to replicate in obstetric theatre (Spear 2006) as theatres tend to be technology-focused rather than woman-centred and it is not uncommon for the mother and baby to experience spatial, visual, and auditory separation from one another (Spear 2006). Locally, we found that 24.5% of women will undergo unplanned procedures in obstetric theatre during or after birth. Feedback from women via the ‘Birth afterthoughts’ service and an audit of infant feeding practices also reveals that women’s psychological adaption to motherhood can be impaired by theatre practice. 468

SSC is physiologically important for a range of reasons. It increases the release of maternal oxytocin (Matthiesen et al 2001) which is particularly valuable as women who have a caesarean section have less circulating oxytocin than women who have a vaginal birth (Nissen et al 1996). Oxytocin aids the bonding process (Feldman et al 2007), supports the development of a close and loving relationship (Entwistle 2013) and initiates the milk ejection reflex by causing the myoepithelial cells surrounding the alveoli to contract (Cadwell 2007). SSC is also important for the baby, helping to maintain its temperature (Nolan & Lawrence 2009) and blood glucose levels (Moore et al 2016). When a baby is in SSC it progresses through nine behavioural phases, culminating in sucking and sleeping. If this process is interrupted, subsequent breastfeeding may be compromised (Brimdyr et al 2012). Bergman (2014:e1) powerfully asserts that: ‘There are harmful effects of dysregulation and subsequent epigenetic changes caused by separation… Zero Separation of mother and newborn should thus be maintained at all costs within health services’. Therefore, we know that early separation can influence an infant’s emotional and cognitive development long term (Flacking et al 2012), hence the importance of aiming to achieve the UNICEF Baby Friendly Initiative accreditation standard: ‘Support all mothers and babies to initiate a close relationship and feeding soon after birth’ (UNICEF UK Baby Friendly Initiative 2012:14). There is emerging evidence that with carefully managed processes, significant differences can be made to theatre practice to support the maintenance of the motherinfant dyad in close proximity (Stevens et al 2014). With this weight of evidence, we aim to make this a reality for all women who have a baby in Sheffield.

Framework for introducing behaviour change We decided to use the COM-B framework (Michie et al 2011) to support the implementation of our service change. This valuable practice-orientated model (Figure 1) enables the user to ensure that essential drivers for behaviour change are covered when contemplating introducing a new way of working. All three aspects must be addressed otherwise the MIDIRS Midwifery Digest 27:4 2017

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innovation may be counter productive. For example, if a lot of attention is paid to increasing motivation but not on providing staff with the capability or opportunity, then the result could be demotivation and apathy.

Figure 1. The COM-B model of behaviour change (Michie et al 2011)

We therefore needed to ensure that we covered the following issues: Capability – Do staff have the knowledge and understanding to facilitate SSC in theatre? Are they clear about the benefits of keeping mothers and babies together at all times? Are they able to challenge practice with their colleagues? Motivation – Why should I do this? How will it make a difference to women and their babies? What is in it for me? Will it increase my workload? What if the baby gets cold? What if it’s not my role? Opportunity – Is it supported by colleagues? Is this how we do things here? Do we have the resources? Does the environment support this change in practice? Are there processes in place to keep things running smoothly in theatre?

Getting engagement An experienced senior midwife was appointed to the role of project lead and supported by consultant midwives and a multiprofessional team/steering group. The project employed key concepts of implementation, theory fostering, engagement collaboration and mutual goal sharing. Forum theatre was used as a means of supporting these values, bringing staff together from a range of disciplines and experience to identify what and how changes could be made. Essential to the team membership was representation from the key practitioners who deliver care to women and their families. Throughout the process it was essential to be flexible and take account of everyone’s views and find common ground to ensure that all members remained engaged. Smith et al (2008) noted that the biggest challenge to changing the environment of obstetric theatre is the reluctance of staff to change MIDIRS Midwifery Digest 27:4 2017

roles and give up rituals. Berg & Hung (2011) who looked specifically at initiating SSC in theatre noted that whilst staff were initially resistant to change, they became more positive after education. Adopting a change management model to include staff involvement and staff education, and implementing evidenced-based best practice to the theatre environment, has the potential to offer considerable benefits not only to the mother-infant relationship but to wider public health initiatives. It is important to use such frameworks flexibly to ensure intelligent application of their attributes (Ilott et al 2013). We used the ‘Plan, do, study, act’ model (Langley et al 2009) that has been shown to be effective in a similar project (Brady et al 2014). The COM-B framework for introducing behaviour change (Michie et al 2011) was used to ensure that staff were fully supported and resourced. A series of outcomes, indicators and measures were identified and agreed over regular steering group meetings.

‘Plan, do, study, act’ model Plan: We identified shared agendas: relationship building takes time, so it was important that regular meetings were scheduled to build trust and keep pace with the shifting clinical context. Membership of the project team was constantly reviewed and additional key personnel were invited as the need arose. We gathered intelligence by collecting personal stories and experiences from women, which provided invaluable insight into how aspects of care impacted on their lived experience. These initial findings provided the parameters for interviews with women and a baseline audit to enable the project team to focus the forward plan. Do: Included spreading awareness of the project to the multidisciplinary team through a range of media, thus stimulating discussion and debate. Education sessions using forum theatre were key and involved the use of actors to depict scenes of good and not-sogood practice, based on real scenarios. Such compelling communications were invaluable and were videoed to enhance spread and reduce cost. GRiP funds were also used, enabling staff to be released from clinical duties. The project lead provided mentorship and role modelling in the obstetric theatre, using a solution-focused approach. The challenges and successes were fed back to the steering group, to ensure that the project was on target, and further informed the spread strategy. The baseline audit tool was refined and implemented. Study: The results of the interviews with women and audit of theatre practice were analysed and discussed with the steering group. Learning was summarised and the project plan appraised to inform future changes. Act: To ensure sustainability of the changes achieved, innovative means of continuing the enhancements were further explored, including ongoing staff 469

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training. Activities during this stage were informed by previous audit. Consideration was given to making permanent changes to documentation, mandatory training, and appraisals to embed and maintain practice change. Spread strategy: Central to the success of the project was an integrated spread strategy. An identity logo for the project was developed (Figure 2). It was targeted to the different professions involved by a variety of media, eg posters, postcards, email, T-shirts and feedback pads, as well as face-to-face meetings. The strategy included elements of the social ‘norms’ approach to engage the audience with key concepts.

Figure 2. Project logo

Seeing is believing — challenging social ‘norms’ Discussion with staff and at the stakeholder meetings highlighted that there were a range of theatre practices. An obstetric anaesthetist undertook an audit of 21 elective caesarean sections during a one-week period, to observe what happened when the baby was born with regard to separation. To obtain a true reflection, other theatre staff were blind to the data collection. The results showed that many well babies were being taken to the resuscitaire immediately after birth. Indeed, 76% of babies were separated from their mothers to go to the resuscitaire for a median time of 9.5 minutes: • Fifty-two per cent of partners left the mother to go to the resuscitaire • Only 19% of mothers experienced SSC in theatre. The project lead undertook face-to-face interviews with women 1–2 days after their caesarean birth using a structured questionnaire to elicit what happened and how they subsequently evaluated their experiences. All the women interviewed had experienced a caesarean birth, 85% of which were unplanned. Most could remember the name of the midwife, but none could recall the name of the surgeon or anaesthetist, although they all said they were introduced to staff and felt welcome. They all knew why they had needed a caesarean and 70% felt they knew what to expect, either because they had previously been to theatre or they had watched videos on social media. 470

Key findings: • No partners were present during the spinal insertion • Only 10% of women experienced SSC contact with their baby in theatre • Only 60% could see their baby at all times whilst in theatre • Fifteen per cent of women felt left alone at a time that worried them whilst in theatre. These findings coupled with narratives collected from the local ‘Birth afterthoughts’ service, were used as the basis for the drama workshops which were central to the co-production of solutions. It was clear that a range of issues were influencing current obstetric theatre practice, not just for women having a caesarean section, but for all women experiencing theatre. Many of the most poignant narratives were from women who needed theatre post-vaginal birth. This included a woman requesting a caesarean section next time to avoid the risk of being separated again to undergo a manual removal of the placenta. This has been accepted, unchallenged practice in most maternity units. On discussion with staff it became evident that an alternative just hadn’t been considered. These accepted practices and their impact on women needed to be reflected back to staff in a non-judgemental way, to highlight and explore challenges in real practice and to work together democratically for change.

Curtains up! Using forum theatre to enable change Used correctly, drama is an engaging and dynamic tool with the ability to draw out the complexities of real life practice settings, engaging the imagination and fostering compassion (Kontos & Naglie 2006). More specifically forum theatre, founded by the Brazilian theatre director Augustus Boal, enables interaction with the audience and allows them to challenge and shape solutions to real practice scenarios (Boal 2002). Actors with experience of the maternity setting were commissioned to work with consultant midwives to develop and deliver two interactive workshops addressing issues that included: • how midwives feel in theatre • how midwives juggle tasks in theatre • how the woman feels in theatre • how the partner feels being left out of theatre • how SSC can be facilitated in theatre • multiprofessional staff tensions. Scripts were written and songs created that reflected an understanding of a range of perspectives. Emotions of sadness and frustration were combined with MIDIRS Midwifery Digest 27:4 2017

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optimism and the sense of a real opportunity to engage a range of staff in scenarios that were both fun, and often poignant, showed both actors and members of the project team baring their souls. One of the most poignant portrayals was delivered by a midwife actor as a monologue to the audience, based on real narratives from partners left alone ‘holding the baby’ and imagining the worst. The central part of the workshop was a theatre scenario depicting what currently happens with a woman journeying from active labour in the midwifery-led unit to emergency caesarean section in the obstetric theatre. The difference with forum theatre is that the audience are then invited to ‘clap’ and stop whenever they saw a practice they wanted to comment on or change. They would then be invited to come into the scene and depict for themselves how it could be run differently. This meant that the audience were coming up with their own solutions to this complex and challenging situation, discussing and challenging each other with ways in which the situation could be better for all, including the midwife. This interactive approach to realising change enabled clinicians to trial behaviours and actions in a safe environment. The workshops ran for two hours and included all members of the multidisciplinary team including support workers and midwifery students. Reflecting on practices in obstetric theatres and their impact on women proved to be a positive experience for attendees:

Figure 3. Tear off and share pad

Conclusion This project has provided a valuable opportunity to move practice forward. It has generated many valuable spin-off developments and generated an enhanced zest for ensuring new families stay together and that zero separation becomes the norm. Thanks to the focus this funding facilitated, momentum has been gained in changing ingrained practices as staff understand and value the significance, emotionally and physiologically, of close maternal and infant contact in the hours after birth. To make real changes to practice, it is not enough to understand the evidence: the science of implementation and engagement of the hearts and minds of clinicians is vital in achieving sustainable change and improving the experiences of women and their families through childbirth and beyond.

‘I now have better ideas on how to achieve skin-toskin and bonding in theatre.’

Alison Brodrick is a Consultant Midwife and Clinical Lead for the labour ward at Sheffield Teaching Hospitals’ NHS Foundation Trust.

‘I’m not going to take a well baby out of theatre again!’

Helen Baston is a Consultant Midwife in Public Health at Sheffield Teaching Hospitals’ NHS Foundation Trust.

Maintaining momentum


Central to the project identity was the logo ‘No drama in our theatre’ developed earlier in the process. This was used as a way to remind staff of the importance of getting it right for women experiencing obstetric theatre, and it continues to promote the work. The project lead worked with staff to challenge ritualistic practice, build relationships across the professions and to demonstrate how changes in practice could be made through small incremental steps. This role and her expertise and determination were key to the progress this project made. Groups of staff are now beginning to expect mothers and babies to stay together in theatre. Some anaesthetists are requesting it and questioning it if it is not implemented. Staff are also encouraged to ‘tear off and share’ successes and challenges on specifically designed feedback pads. MIDIRS Midwifery Digest 27:4 2017

Baston H, Green J, Renfrew M (2010). Intelligent guardianship. A conceptual model for intrapartum care. Normal labour and birth 5th International Conference, Vancouver, Canada, 21-23 July. Berg O, Hung KJ (2011). Early skin-to-skin to improve breastfeeding after cesarean section. JOGNN: Journal of Obstetric, Gynaecologic & Neonatal Nursing 40(Suppl):S18-19. Bergman NJ (2014). The neuroscience of birth - and the case for zero separation. Curationis 37(2):e1-4. Boal A (2002). Games for actors and non-actors. London: Routledge. Brady K, Bulpitt D, Chiarelli C (2014). An interprofessional quality improvement project to implement maternal/infant skin-to-skin contact during cesarean delivery. JOGNN: Journal of Obstetric, Gynecologic & Neonatal Nursing 43(4):488-96. Brimdyr K, Widstrom AM, Cadwell K et al (2012). A realistic evaluation of two training programs on implementing skin-to-skin as a standard of care. Journal of Perinatal Education 21(3):149-57. Cadwell K (2007). Latching-on and suckling of the healthy term neonate: breastfeeding assessment. Journal of Midwifery & Women’s Health 52(6):638-42. Chalmers B, Kaczorowski J, Darling E et al (2010). Cesarean and vaginal birth in Canadian women: a comparison of experiences. Birth 37(1):44-9.


Labour & Birth Dashti M, Scott JA, Edwards CA et al (2010). Determinants of breastfeeding initiation among mothers in Kuwait. International Breastfeeding Journal 5(7). Entwistle FM (2013). The evidence and rationale for the UNICEF UK Baby Friendly Initiative standards. London: UNICEF UK. Feldman R, Weller A, Zagoory-Sharon O et al (2007). Evidence for a neuroendocrinological foundation of human affiliation: plasma oxytocin levels across pregnancy and the postpartum period predict mother-infant bonding. Psychological Science 18(11):965-70. Fervers B, Burgers JS, Haugh MC et al (2006). Adaptation of clinical guidelines: literature review and proposition for a framework and procedure. International Journal for Quality in Health Care 18(3):167-76. Flacking R, Lehtonen L, Thomson G et al (2012). Closeness and separation in neonatal intensive care. Acta Pædiatrica 101(10):1032–7. Gouchon S, Gregori D, Picotto A et al (2010). Skin-to-skin contact after cesarean delivery: an experimental study. Nursing Research 59(2):78-84. Green JM, Baston HA (2003). Feeling in control during labor: concepts, correlates, and consequences. Birth 30(4):235-47. Green JM, Coupland V, Kitzinger J (2005). Expectations and experiences of childbirth, 1987. UK Data Archive. Grekin R, O’Hara MW (2014). Prevalence and risk factors of postpartum posttraumatic stress disorder: a meta-analysis. Clinical Psychology Review 34(5):389-401. Grimshaw JM, Eccles MP, Lavis JN et al (2012). Knowledge translation of research findings. Implementation Science 7(50). Hung KJ, Berg O (2011). Early skin-to-skin after cesarean to improve breastfeeding. MCN - American Journal of Maternal Child Nursing 36(5):318-26. Ilott I, Gerrish K, Laker S et al (2013) Naming and framing the problem: using theories, models and conceptual frameworks. National Institute for Health Research https://docs.google.com/ file/d/0B7Zq0J4mkDqecGRfMVJrSk43eEU/edit?pli=1 [Accessed 7 September 2017]. Kitson AL, Rycroft-Malone J, Harvey G et al (2008). Evaluating the successful implementation of evidence into practice using the PARiHS framework: theoretical and practical challenges. Implementation Science 3(1). 
 Kontos PC, Naglie G (2006). Expressions of personhood in Alzheimer’s: moving from ethnographic text to performing ethnography. Qualitative Research 6(3):301-17. Langley GJ, Moen R, Nolan KM et al (2009). The improvement guide: a practical approach to enhancing organizational performance. 2nd ed. San Francisco: Jossey Bass.

Matthiesen AS, Ransjö-Arvidson AB, Nissen E et al (2001). Postpartum maternal oxytocin release by newborns: effects of infant hand massage and sucking. Birth 28(1):13-19. Michie S, van Stralen MM, West R (2011). The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implementation Science 6(42). Moore ER, Bergman N, Anderson GC et al (2016). Early skin-toskin contact for mothers and their healthy newborn infants. The Cochrane Database of Systematic Reviews, Issue 11. Nissen E, Uvnäs-Moberg K, Svensson K et al (1996). Different patterns of oxytocin, prolactin but not cortisol release during breastfeeding in women delivered by caesarean section or by the vaginal route. Early Human Development 45(1-2):103-18. Nolan A, Lawrence C (2009). A pilot study of a nursing intervention protocol to minimize maternal-infant separation after cesarean birth. JOGNN: Journal of Obstetric, Gynecologic & Neonatal Nursing 38(4):430-42. Scott JA, Binns CW, Oddy WH (2007). Predictors of delayed onset of lactation. Maternal & Child Nutrition 3(3):186-93. Smith J, Plaat F, Fisk NM (2008). The natural caesarean: a woman-centred technique. BJOG: An International Journal of Obstetrics and Gynaecology 115(8):1037-42. Spear HJ (2006). Policies and practices for maternal support options during childbirth and breastfeeding initiation after cesarean in southeastern hospitals. JOGNN: Journal of Obstetric, Gynecologic & Neonatal Nursing 35(5):634-43. Stevens J, Schmied V, Burns E et al (2014). Immediate or early skin-to-skin contact after a caesarean section: a review of the literature. Maternal & Child Nutrition 10(4):456-73. Thu HN, Eriksson B, Khanh TT et al (2012). Breastfeeding practices in urban and rural Vietnam. BMC Public Health 12(964). UNICEF UK Baby Friendly Initiative (2012). Guide to Baby Friendly Initiative standards. London: UNICEF UK. van Lieshout J, Grol R, Campbell S et al (2012). Cardiovascular risk management in patients with coronary heart disease in primary care: variation across countries and practices. An observational study based on quality indicators. BMC Family Practice 13(96). Waldenström U, Hildingsson I, Rubertsson C et al (2004). A negative birth experience: prevalence and risk factors in a national sample. Birth 31(1):17-27.

Brodrick A, Baston H. MIDIRS Midwifery Digest, vol 27, no 4, December 2017, pp 467-472. Original article. © MIDIRS 2017.

Why water birth? Exploring the barriers and challenges for midwives Mary Edmondson ORIGINAL Introduction Promoting normal physiological birth, reducing unnecessary interventions and offering water birth is recommended by the National Institute for Health and Care Excellence (NICE) (2014) guidance, and has been advocated by Odent (2007), Walsh (2007, 2011), Downe (2008), Buckley (2009, 2015), Kennedy et al (2010), Uvnäs-Moberg (2011) and Sprague (2011). Notwithstanding, Kennedy et al (2010), exploring the concept of normalising birth in UK obstetric units, identified that it was not always easy to promote normal birth in obstetric units. This notion was put forward in the belief that midwives had become so accustomed to the medical paradigm that following the medicalised approach was considered the safer option (Kennedy et al 2010). 472

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Lack of universal guidelines on safe practice in facilitating water births has been cited as a concern and a barrier for midwives, impeding the promotion and support of water birth for women (Edmondson 2017). As a consequence, the author (Edmondson 2017) undertook an extensive systematic review of water birth to aid the development of universal guidelines. The risk factors and problems relating to water birth will be explored and need to be taken into account when developing guidelines and policies to enable midwives to provide informed choice, competent and confident care for women who labour and/or birth in water. Background The philosophy for promoting normal physiological birth and reducing interventions is based on the concept of promoting the physiology of spontaneous labour by enhancing the effect of oxytocin. Understanding the effect of the catecholamines, adrenaline and the noradrenalin response is crucial because as the stress hormones increase, oxytocin, the hormone of labour, is reduced (Odent 2007, Buckley 2009). Tjarkovsky was one of the first pioneers who wanted to create an ‘aquatic environment’ (Balaskas & Gordon 1992:19). Tjarkovsky asserted land based animals also have a fear of water, thus linking back to when sea creatures left the water to live on land (Sidenbladh 1983). He argued that because babies develop in water, why could they not be delivered in water, thereby eliminating a fear of water (Sidenbladh 1983). Moreover, Tjarkovsky’s work centred on reducing pain and shock, stating: ‘Why can’t we deliver babies in water in order to spare them the painful transition from a state of near weightlessness to the full effect of gravity’s force?’ (Sidenbladh 1983:54). Leboyer (1975) considered that tenderness towards the neonate is awe-inspiring. Furthermore, Leboyer (1975) promoted a caring and respectful attitude towards the mother and baby by promoting the concept of returning the baby to water after birth, to ensure the baby did not forget the comfort of the womb having since emerged into a world of terror (Leboyer 1975). He did not promote birthing in water, but the healing effects of its gentleness after the birth. Conversely, Odent (1983) was interested in reducing women’s pain, and discovered that women often wanted to get out of the water for the birth, but when they stayed in the water, the baby birthed without any harm done. It was noticed by all the early researchers that women moved about more in the pool (Odent 1983). Odent wanted to link the ‘instincts with reason’ (Balaskas & Gordon 1992:20) to facilitate a smoother transition for the baby from the womb (Odent 1983, Balaskas & Gordon 1992). Odent (1983) found that the presence of and/or immersion in water encouraged progress in labour.

The safety of water birth The safety of water birth is dependent on the provision of safe antenatal care (NICE 2008) and intrapartum care (NICE 2014) so that medical risks such as diabetes and infections, blood group rhesus MIDIRS Midwifery Digest 27:4 2017

status and haematological abnormalities can be identified and excluded. The safe installation of birthing pools and adherence to the recommended temperatures of pool water and maternal temperature (Deans & Steer 1995, Johnson 1995) and cleanliness (Thoeni et al 2005, Garland 2010) all underpin the safety of water immersion. The NHS Outcomes Framework emphasises its fifth domain to ‘treat and care for people in a safe environment and protect them from avoidable harm’. (Department of Health 2013:3). There is renewed concern over the stillbirth rate and the care bundle for saving babies lives and clinical guidance states the following to reduce stillbirths: ‘reduce smoking, risk assessment and surveillance for fetal growth, raising awareness of reduced fetal movement and effective fetal monitoring during labour’ (O’Connor 2016:12). However, fetal cardiotocograph monitoring in low-risk labour is not indicated (Devane et al 2017) but intelligent auscultation of the fetal heart is (Gibb & Arulkuraman 2007, Harding 2014, NICE 2014). It has been highlighted in the latest MBRRACE report (Knight et al 2016) that communication remains a concern and improving communication skills is of paramount importance (Silverman et al 2013), particularly relating to water birth, to gain trust and partnership. Furthermore, errors have been made in observing women; therefore using the obstetric early warning score ensures that early signs of illness are detected (Carle et al 2013, Knight et al 2016, Singh et al 2016).

Environmental considerations Water quality is a priority of the World Health Organization (WHO) and it provides global guidelines on water quality safety (UNICEF & WHO 2015). It is important to note that there have been reported cases of babies becoming infected by legionnaires’ disease during water birth (Public Health England 2014). Furthermore, Cohain (2010) has highlighted the importance of considering water birth for mothers with group B Streptococcus.

Birth setting The wider provision of birth centres and midwiferyled units has been a priority promoted by the work of the architect Lepori (1994) who designed spaces for mobility, and Fahy and Parratt (2006) who proposed the concept of birth territory. Fahy and Parratt (2006) 473

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promoted the concept of the woman being at the centre of her birth, with midwives recognising their own power to protect the birth territory (Hastie & Fahy 2011). However, Hodnett et al (2012) found that the physical environment did not influence outcomes but the provision of care that promoted normal labour did. Sandall et al (2016) confirmed in a recent study that midwifery care in low-risk settings produces positive outcomes. Therefore, a combination of improved skills and a conducive environment will impact on the care of birthing women.

Risk-averse culture Risk has been defined in a number of ways, but is often seen as the likelihood that an individual will experience the effect of danger (Clark & Short 1993). Midwives have a duty to preserve safety for women (Nursing & Midwifery Council 2015); therefore hospital guidelines and policies should aim to reduce harm by detailing care pathways (Brouwers et al (2016) and providing high-level evidence to support guidance (Centre for Evidence Based Intervention 2016). NICE (2014) advocates the use of risk assessment to reduce harm, for such concerns as neonatal aspiration, low Apgar score, neonatal gasping, perineal trauma, and that the level of midwives’ knowledge and confidence should be considered. Oltedal et al (2004) state that midwives have their own perception of risk with regard to water birth and practise accordingly. However, anecdotal evidence identified by the author through informal discussion with midwives suggests that there is fear and uncertainty about the safety of water birth, leading to poor outcomes and litigation, which has led to a culture of perceived fear of water birth, as confirmed by Healy et al (2016). Further compounding factors, such as the hierarchical power of obstetricians and some senior midwifery staff, have perpetuated this risk paradigm by challenging normal birth practice, and doubting the expertise of midwives not so well known to them (Page & Mander 2014). It seems that midwives’ skills and knowledge are constantly undermined, yet conversely most midwives understand the importance of professional accountability and are naturally concerned if there is an adverse outcome (Scamell & Alaszewski 2012). Moreover, Scamell & Alaszewski (2012) found that midwives’ confidence, ability and decision making were affected when they were involved in incident investigations, and were further undermined because they were aware that the attitude of those investigating an adverse outcome ‘would start from the premise that errors had been made’ (Scamell & Alaszewski 2012:11). With the rise of investigations by NHS trusts, advocated by Kirkup (2015), it is not surprising that Scamell & Alaszewski’s (2012:219) self-fulfilling prophecy prevails: 474

‘Midwifery activity functions not to preserve normality, but to introduce a pathologisation process where birth can never be imagined to be normal until it is over’. This prophecy is further perpetuated by the use and promotion of medical interventions. Page & Mander (2014) and Newnham et al (2015) both assert that taking the risk-averse approach appears to be the norm. Furthermore, Newnham et al (2015) raised the profile of risk perception regarding promoting epidurals or water birth, comparing two very different pain relief options. Midwives regularly face the dilemma of complying with guidance that may increase risk to women such as having an epidural anaesthetic (Newnham et al 2015) rather than promoting alternative pain relief options. Indeed, Byrom & Downe (2015) go further and claim that the technocratic environments that midwives work in along with the risk culture are ‘suffocating midwives’.

Midwives’ competency in normal birth and water birth Problems observed and identified in clinical practice concern the facilitation of water birth and the training and competency of midwives, resulting in women not being offered water birth on a regular basis (Young & Kruske 2013). However, Russell et al (2014) suggest a lack of opportunity for midwives to become water birth competent is due in part to those midwives who are competent in water birth not being able to share, teach, clarify and articulate its benefits and barriers. This has a limiting effect, by perpetuating the confidence issues of other midwives who want to learn and acquire the skills of water birth, but who are already fearful because of a clinical culture. In addition, Russell et al (2014) and Edmondson (2017) suggest that fear can also be obstructive and as such has a detrimental effect on the provision of water birth.

Reports from government and regulatory bodies The Better Births review (NHS England 2016) has raised national concern over the quality of care childbearing women receive in relation to the increase in caesarean section rates and complex health issues affecting women. The report advocates improving the quality of care for women, which if not addressed could culminate in affecting the long-term health of the whole population (NHS England 2016). Knight et al (2016) regularly report on what lessons need to be learnt from poor maternal outcomes, and it is often the basic observations that have been missed or not acted upon. The psychological well-being of women is of growing importance, as highlighted in guidance by MBBRACE (Knight et al 2016) and NICE (2014). The effect of intervention and instrumental delivery has been raised by Rowlands and Redshaw’s (2012) secondary MIDIRS Midwifery Digest 27:4 2017

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analysis, as a cause of psychological distress with symptoms lasting for three months. If midwives can learn to promote normal birth safely and appropriately, theoretically there will be less psychological distress for women as a result of their birthing experience (NICE 2014, Knight et al 2016). Kirkup (2015) and Francis (Mid Staffordshire NHS Foundation Trust Public Inquiry 2013) both uncovered serious concerns over clinical management strategies in two UK hospitals. Inabilities to address poor practice were uncovered, patients were not always put first and standards were not adhered to (Mid Staffordshire NHS Foundation Trust Public Inquiry 2013, Titcombe 2015) which ultimately led to deaths in both hospitals. The Better Births review (NHS England 2016) has asserted that high-quality care is vital to the safety of women and their families. Further to this Kirkup (2015) identified that there have been risk assessment issues identified with facilitating normal birth in low-risk units.

Neonatal outcomes Carpenter & Weston (2012), comparing water birth to land birth, examined the x-rays and outcomes of those babies who had transient tachypnoea of the newborn and those who had water aspiration. They reported that the water birth babies had more severe symptoms than those babies who had transient tachypnoea of the newborn. The babies took longer to establish feeding and were acidotic for longer. However, Burns et al (2012) argue that less than 1% of babies had respiratory distress in England. Whereas, Menakaya et al (2013) demonstrated a statistically significant result through their study that indicated that more babies were admitted to the neonatal unit with respiratory problems. It appears that the characteristics are comparable with other low-risk settings and included mothers who had group B Streptococcus and had antibiotic cover where 1.8% of babies were admitted to the neonatal unit. Both New Zealand and Australia have shown increased severity results, which could be indicative of honest reporting and perhaps dishonest reporting in the UK or insufficient data which Burns et al (2012) highlighted. It could mean that pool practice is more closely monitored in the UK regarding thermoregulation (Johnson 1995). Johnson (1995) deduces that delayed breathing at birth may be due to the lack of stimuli at water birth, resulting in slower breathing and gaseous exchange, though this is not yet fully understood.

Perineal outcomes Many of the included studies have highlighted that perineal trauma will occur following childbirth; however the significance of severe perineal trauma in water birth remains unclear as the results are not significant (Dahlen et al 2013, Henderson et al 2014, MIDIRS Midwifery Digest 27:4 2017

Bovbjerg et al 2016, Edqvist et al 2016). This does not mean to say that severe perineal trauma does not occur as Cortes et al (2011) discovered, and Dahlen et al (2013) identified that there was no difference in water birth compared to dry land birth, despite midwives being unable to view the perineum. Edqvist et al (2016) found similar results when women adopted different positions. Dahlen et al (2013) recommend solutions to the problem such as developing communication and coaching skills for midwives to help women as they give birth. This recommendation is also supported by the Royal College of Midwives (2012), Basu et al (2016), Cooper (2016) and Aasheim et al (2017).

Midwifery outcomes Russell et al (2014), Bedwell et al (2015), Nicholls et al (2016) and Pezaro et al (2016) all highlight the issues of confidence when midwives provide intrapartum care, and the anxiety midwives experience when engaging in new practices. As many midwives have worked in medicalised models of care (Byrom & Downe 2015) when they are introduced to new challenges, some may find it difficult to work within a normal midwifery model (Kennedy et al 2010). Furthermore, Bedwell et al (2015) and Skogheim & Hanssen (2015), agree that facilitating changing practices, and ensuring peer and leader support are therefore essential to promote midwives’ confidence.

Conclusion This paper has highlighted some of the issues and evidence surrounding the controversy of water birth which may impact on midwives’ beliefs around this topic. The risk of a baby having a low Apgar score as a result of water birth cannot be proved. There are occasions when babies of both the water birth group and the dry land birth group have had low Apgar scores, and been admitted to the neonatal unit. Therefore, reasons for this need to be better understood. Dahlen et al (2015) discuss the problem of perineal trauma, indicating that it remains a problem for all birthing women which is on the increase (Laine et al 2012, Gurol-Urganci et al 2013). Further studies need to be identified to gain a better understanding of the causes of perineal trauma. In conclusion, the facilitation of water birth draws upon many facets that must be considered from issues of safety, government policy and recommendations, to midwives’ confidence and competency levels. To enable women to have the choice of labouring and birthing in water, midwives must be trained and supported to achieve this goal. In addition, the provision of evidence-based universal water birth guidelines will also contribute to this aim. This paper has exposed a plethora of evidence that can be continually reviewed and evaluated. It is with 475

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this constant investigatory approach that clinicallybased midwives will be empowered to restore their midwifery philosophy (Russell et al 2014, Nicholls et al 2016).

Recommendations for practice • The facilitation of promoting learning, sharing and support between midwives, that will promote further learning and enquiry, should be implemented. • The education of leaders in relation to promoting water birth is of prime importance. • Mandatory training on water birth for midwives should be developed and anonymised case histories discussed. • Further research – one of the main concerns about water birth is the lack of randomised controlled trials to provide concrete evidence. Carrying out research by identifying the effect of water birth on babies and women, in a controlled environment, would be unethical due to the risk of harm to both mother and baby. In order to satisfy both practitioners and birthing mothers that water birth is constantly being reviewed, clinical care should be audited, and outcome studies should continue. • Physiological birth should be promoted by ensuring midwives understand the concept (Odent 2007, Buckley 2009, Uvnäs-Moberg 2011) and are supported in the facilitation of midwifery skills in practice (Bedwell et al 2015). • Study findings should be shared to reinforce to midwives the positive aspects of water birth, increase their confidence (Nicholls et al 2016) and encourage resilience (Hunter & Warren 2014). Mary Edmondson, Practising Midwife.

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Edmondson M. MIDIRS Midwifery Digest, vol 27, no 4, December 2017, pp 472-477. Original article. © MIDIRS 2017.


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How effective are warm compresses and perineal massage at reducing perineal trauma? A review of the evidence Melissa Newman ORIGINAL Introduction

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The second stage of labour is defined as full cervical dilation until delivery of the baby, but in reality it is so much more than this. The woman is encompassed in a paradox of physical strength but emotional vulnerability, as with each push she journeys closer to the life-changing rite of passage that is motherhood. For many years pregnancy internet forums have been littered with questions concerning the emotive topic of how to prevent tears, and it continues to be a frequently asked question at antenatal appointments. Researchers are forever seeking the elusive answer. Midwives utilise a variety of hand techniques that they believe help to reduce genital trauma rates. Such techniques include the use of warm compresses and perineal massage in labour with the aim of potentially reducing trauma due to the effects of vasodilation and increased blood supply, muscle relaxion, altered pain perception and improving stretching and extensibility of the tissues. Part of the midwife’s role is to stay up to date with research in order to provide gold standard evidence-based care. However, midwives often feel uncertain about what can be done to reduce the chance of tearing and many women therefore accept it as a given that they will tear. Due to the lack of knowledge of both midwives and women regarding prevention techniques, the ‘caring for your stitches’ leaflet is handed out all too often.

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Review of the literature Kettle & Frolich (2011) state that 85% of women giving birth vaginally sustain perineal injury, which can result in severe long-term physical problems such as dyspareunia, flatus and urinary and faecal incontinence. However, effects can also be psychological, such as a feeling of failure or post-traumatic stress disorder, particularly if the woman has had a straightforward labour without pain relief and then requires transfer to theatre for a spinal anaesthetic and complex suturing. Women may also feel too emotionally insecure and embarrassed to resume sexual relations because they are afraid of what their partner might think, which can negatively impact on self-esteem and confidence. In 2017, Aasheim et al undertook a Cochrane review examining various techniques that claim to reduce perineal trauma during the second stage of labour. Research studies were identified using a search strategy followed by three review authors independently evaluating them. Eight randomised control trials (involving 11,651 women from six countries) were selected and systematically reviewed, with the aim of assessing whether perineal massage or a warm compress applied to the perineum in the second stage of labour reduces perineal trauma. For the women to meet the selection criteria they had to be over 18 years old with no medical complications and planning to have a singleton cephalic vaginal birth after a gestation of 36 weeks. Using a computer software programme to reduce selection bias, participants were assigned perineal massage, a warm compress or no technique. It was revealed that the incidence of third and fourthdegree tears was significantly reduced in the women who received a warm compress or perineal massage, compared to women who had neither. Aasheim et al’s (2017) research is current, meaning midwives can use it to inform practice and enable them to provide evidence-based care. However, the methodological quality of the studies reviewed by Aasheim et al (2017) varied due to extraneous variables, for example, not being able to measure the pressure applied by the midwife holding the warm compress or massaging the perineum, the temperature of the warm compress and how far into the vagina the midwife went when massaging. The studies examined used different lubricants to carry out the massage and it could be argued that the lubricant plays a more important role in preventing tears than the massage action itself. Therefore, further investigation is necessary to investigate which lubricants are the most effective at reducing perineal trauma. It was also impossible to ensure that all groups were treated equally, as many different midwives were used to deliver the interventions. These midwives had their own thoughts and opinions, which could impact on the results if they carried out the technique incorrectly or half-heartedly because they did not believe it would work. A further weakness of this Cochrane review is that ethnicity of the participants was not controlled and because Dahlen et al (2013a) found that Asian 480

women are more likely to sustain perineal injury than non-Asian women; the results of the study could be impacted if there were a large number of Asian participants. Dahlen (2013a) also found that nulliparous women are at higher risk of tearing than multiparous women. The women in this Cochrane review were both nulliparous and multiparous, with no differentiation between the two in the results. Therefore it remains unknown whether massage or a compress is more or less effective for primigravid women or those who have had a previous vaginal birth. However, the research has high validity because all studies successfully measured what they were designed to and the data collection tool was accurate and consistent, thus increasing reliability. Furthermore, the large sample size was a huge strength as the results were more representative of the general population and the influence of extreme cases was limited. The findings are generalisable, although are potentially not relevant to populations where women do not routinely give birth in hospital settings or where there is no midwife present, for example in rural regions of Africa. This is because all the participants delivered in hospital and it was always the midwife who carried out the massage or applied the warm compress, meaning outcomes may be different if women or their partners do it. Nonetheless, if carried out exactly as in the studies, the results are transferable to other populations. The effect of perineal massage in labour was also explored in Geranmayeh et al’s (2012) study. Ninety women between 38–42 weeks’ gestation were randomly assigned to either a control or intervention group. In the latter, the midwife used sterile Vaseline to perform perineal massage during the second stage of labour. When the women were examined after delivery, the massage group were found to have a significantly higher number of intact perineums than the control group and it was also noted that they has shorter second stages. It was concluded that massaging the perineum increases integrity, therefore reducing perineal trauma. In this study all participants were primiparous, which is a strength because parity is known to affect perineal outcome. It was also advantageous that the participants were all similar in characteristics such as demographic area, weight gain in pregnancy, fetal weight and abortion history. Notwithstanding, too many variables being controlled can lead to the results being less generalisable to other populations. The methodological quality of this research is debateable due to not being able to control the length of time each participant’s perineum was massaged for. They were simply massaged for the length of their second stage — which may have been five minutes in some women or hours for others. Furthermore it was not stated whether the women were massaged immediately upon discovery of full dilation or once they commenced active pushing. Assessing perineal trauma can be subjective and Geranmayeh et al (2012) do not establish whether an ‘intact perineum’ MIDIRS Midwifery Digest 27:4 2017


means that no suturing was required (therefore is inclusive of minor first-degree tears), or whether the woman sustained no damage at all. Compared to the other studies reviewed in this paper, the sample size of 90 is quite small, meaning the link between intervention and outcome may not be significant enough to inform practice. At 36 weeks’ gestation, Stamp et al (2001) recruited and randomised 1340 women who were expecting a normal singleton birth. The aim was to determine whether perineal massage in labour has an effect on prevention of tears. For the intervention group, midwives used a water-soluble lubricant to massage the perineum of women during each contraction in the second stage. No substantial difference in first and second-degree tear rates between the two groups was found (122 first-degree tears and 190 second-degree tears in the massage group in comparison with 106 first-degree tears and 164 second-degree tears in the control group). However, there was a strong link between perineal massage and an almost 50% reduction in third-degree tears, which is clinically very significant. Therefore, further investigation is required in order to establish whether there is a definite relationship between perineal massage and reduction in severe perineal trauma. A criticism of this study is that 43 women in the massage group and 39 in the control group had practised antenatal perineal massage. A Cochrane review by Beckmann & Stock (2013) found that antenatal perineal massage reduces the incidence of trauma by 9%, meaning the women in Stamp et al’s (2001) study who had practised perineal massage antenatally may have had reduced perineal trauma due to the antenatal perineal massage rather than perineal massage in labour. A further weakness is that 24 of the women in the massage group and 23 from the control group had emergency caesareans and were recorded as having intact perineums in the overall results even though they did not have a vaginal birth, swaying the results to appear as though perineal massage is more effective than it really is. In addition, Dahlen et al (2013b) found that perineal outcome is affected by different birth positions, for example, delivering on a birth stool leads to a higher rate of perineal trauma than water birth. However, in the Stamp et al (2001) study the birth position variable was not controlled, meaning that birth position may have played a bigger part in perineal outcome than massage. Another variable that was not controlled was whether the midwife assisting delivery practised hands-off or hands-on technique. For example, Aasheim et al (2017) found that hands-off technique significantly reduces incidence of episiotomy. One of the studies informing the National Institute for Health and Care Excellence (NICE) (2017) intrapartum guidance is by Albers et al (2005). The Fleiss method was used to determine that a sample size of 1200 women was necessary to detect change MIDIRS Midwifery Digest 27:4 2017

with 80% power and 5% statistical significance. To meet eligibility criteria women had to be aged over 18, medically uncomplicated and have a single vertex presentation at term. 1211 women were randomised to one of three groups: the warm compress, perineal massage or control group, with the objective being to establish whether there is a relationship between techniques to reduce perineal trauma and severity of perineal trauma. What is meant by an intact perineum is clearly defined as: absence of any tissue separation. Albers et al (2005) discovered that neither compresses nor massage has any impact upon reducing genital tract damage. Across all three groups the number of women who suffered first, second, third and fourth-degree tears was very similar, as was the number of women who sustained no trauma. Location of trauma was also consistent between each of the groups. Furthermore, Albers et al (2005) declared that in a quarter of births, there was a second midwife present to give a second opinion on the degree of trauma. In 16% of these deliveries the midwives disagreed on the degree of trauma, creating discrepancy over the findings. However, it is not detailed what happened in these cases. The study was carried out by the same 12 midwives in the same location over a period of four years. Having such a small number of midwives deliver the interventions is a major strength of this study as it means the techniques would have been carried out consistently for each woman. The midwives all had a high level of clinical experience and skill in minimising perineal injury, so reduction in trauma may have been a result of the midwives advising the best positions and breathing techniques, as opposed to the control variables. It was reported that the women were verbally encouraged, praised and coached but this is subjective and individual to the midwife assisting delivery. It is also dependant on how much of a rapport the midwife has built with the woman and how much the woman trusts and listens to her midwife, which may be affected by different forms of pain relief. There is no mention of the types of analgesia used by the women in the study. However, Albers et al (2005) clearly state the way in which the warm compresses were used for each woman: they were continuously applied against the mother’s perineum and external genitalia during and between pushes, regardless of position. They were changed as necessary to maintain hygiene and temperature, although specific temperature is not stated. Perineal massage technique was also controlled, with each midwife using a water-soluble lubricant to gently and slowly move two gloved fingers from side to side just inside the vagina. This was alternated with applying mild, downward pressure with steady, lateral strokes lasting one second in each direction. This was performed both during and between pushes, again regardless of position. It was the woman who dictated how much pressure to apply when massaging, meaning for some women the pressure may have been too gentle to impact the results; yet they were still counted as taking part. Interestingly, 13.4% of women in the massage group asked the midwife to 481


cease the technique, suggesting that some women find the intimate act unacceptable or unbearable. All women were included in the results regardless of whether they actually participated in the study or if they actually had a vaginal delivery. However, a strength of this research is the similarity in characteristics of the participants. For example all women were alike in age, body mass index, parity, ethnicity and weight gain in pregnancy. Position was another variable that was well controlled, as 80% of the participants delivered sitting. The control over these confounding factors increases the internal and external validity of the study. Prolonged length of second stage has been proven to impact on degree of perineal trauma, increasing the likelihood of third- and fourth-degree tears, as demonstrated by Laughon et al (2014). However, none of the studies discussed in this paper provide details on length of second stage. The risk of perineal injury significantly increases where assisted delivery is necessary; however, the studies here do not provide statistics regarding the number of women who had an instrumental birth and women were also still included in the results even if they had a caesarean section.

Discussion Despite reviewing a range of different sources, the evidence is inconclusive. Some research has found applying a warm compress to the perineum reduces damage whilst other studies have branded it ineffective. As there is conflicting evidence regarding the effectiveness of massage and compresses in labour, midwives should carry out their normal practice and offer women the option of a warm compress in the second stage of labour, advising them that this may reduce the likelihood of sustaining a perineal tear. Whatever a midwife’s personal opinion on the use of compresses in labour, it is the woman’s prerogative to choose and withholding would be unethical. Although not routine, the Royal College of Midwives (2012) advocates offering a warm compress to every woman. It is cheap, non-invasive, has no side effects and is acceptable to most women; additionally it may help reduce perineal damage. On the other hand, NICE (2017) recommends against offering perineal massage as women from some cultures or backgrounds may deem it unacceptable and a breach of their privacy and dignity. Midwives and women should work in partnership with the sole aim of achieving optimal outcome for mother and baby. In order to assist women to make informed decisions, it is requisite that health care professionals provide them with unbiased, evidencebased information and the time to think about all options. Midwives need to be adaptable and midwifery care tailored to the needs of the individual, enabling the woman to have a positive experience of birth.

Conclusion The research discussed in this paper is reductionist as the phenomenon of childbirth is reduced to simple statistics with no expression of emotion. Some of 482

the research may find that warm compresses reduce perineal damage, but women’s thoughts and feelings were not considered. The psychological impact from having this intervention may be greater for them than if they had sustained physical damage. It must also be noted that compresses and massage require the constant bedside presence of the midwife, which women often appreciate at such a pivotal point in their lives. Therefore it may be the greater support and bond between the midwife and woman that positively impacts on her birth experience, more so than the technique used in aiming to reduce perineal trauma. A limitation of the research is that it only considers warm compresses and perineal massage as strategies to prevent trauma, rather than looking at the whole picture and considering factors such as position, hands on or off and ways to control the speed of delivery of the head. The answer to the question ‘how do we prevent perineal trauma?’ is a complex multifactorial issue that requires examination of many more factors than a simple compress or massage. Melissa Newman, Community Midwife, Royal Berkshire Hospital.

References Aasheim V, Nilsen ABV, Reinar LM et al (2017). Perineal techniques during the second stage of labour for reducing perineal trauma. The Cochrane Database of Systematic Reviews, Issue 3. Albers LL, Sedler KD, Bedrick EJ et al (2005). Midwifery care measures in the second stage of labour and reduction of genital tract trauma at birth. Journal of Midwifery and Women’s Health 50(5):365-72. Beckmann MM, Stock OM (2013). Antenatal perineal massage for reducing perineal trauma. The Cochrane Database of Systematic Reviews, Issue 4. Dahlen H, Priddis H, Schmied V et al (2013a). Trends and risk factors for severe perineal trauma during childbirth in New South Wales between 2000 and 2008: a population-based data study. BMJ Open, 3:e002824. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3657654/ pdf/bmjopen-2013-002824.pdf [Accessed 15 July 2017]. Dahlen HG, Dowling H, Tracy M et al (2013b). Maternal and perinatal outcomes amongst low risk women giving birth in water compared to six birth positions on land. A descriptive cross sectional study in a birth centre over 12 years. Midwifery 29(7):759-64. Geranmayeh M, Habibabadi ZR, Fallahkish B (2012). Reducing perineal trauma through perineal massage with vaseline in second stage of labour. Archives of Gynecology and Obstetrics 285(1):77-81. Kettle C, Frohlich J (2011). Perineal care. BMJ Clinical Evidence. 11th April. https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC3275301/ [Accessed 15 July 2017]. Laughon SK, Berghella V, Reddy UM et al (2014). Neonatal and maternal outcomes with prolonged second stage of labor. Obstetrics and Gynecology 124(1):57-67. National Institute for Health and Clinical Excellence (2017). Intrapartum care for healthy women and babies. London: NICE. Royal College of Midwives (2012). Evidence based guidelines for midwifery-led care in labour. London: RCM. https://www.rcm. org.uk/sites/default/files/Care%20of%20the%20Perineum.pdf [Accessed 15 July 2017]. Stamp G, Kruzins G, Crowther C (2001). Perineal massage in labour and prevention of perineal trauma: randomised controlled trial. British Medical Journal 322(7297):1277-80.

Newman M. MIDIRS Midwifery Digest, vol 27, no 4, December 2017, pp 479-482. Original article. © MIDIRS 2017.

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A review of the effect of using the non-pneumatic anti-shock garment as an emergency device to prevent postpartum haemorrhage Adedoyin Mulikat Adeosun, Alison Brettle ORIGINAL Introduction: Postpartum haemorrhage (PPH) is the major cause of maternal mortality globally. Lack of resources and delays in accessing a comprehensive health care facility are the major contributors; therefore the use of the non-pneumatic anti-shock garment (NASG) as an emergency device can contribute significantly to the reduction of maternal deaths and the achievement of part of the objectives developed for a low-resource economy. The aim of this review was to assess the effect of the use of NASG as an emergency device for PPH. Method: Literature was searched using the databases CINAHL, PubMed, Cochrane and Medline. Search criteria included the use of NASG as a tool for the emergency management of PPH, along with the standard protocol in any setting located in a low-resource economy. Data was synthesised using a narrative approach. Result: There were a total of 19 studies included: three qualitative and 16 quantitative. The qualitative studies indicated a positive attitude amongst health care providers towards the introduction of the NSAG into practice while the quantitative research shows a reduction in the amount of blood loss, the rate of maternal mortality and the rate of utilisation of emergency hysterectomy during the intervention phase of the study. Conclusion: The use of the NSAG along with the standard protocol of each setting, with availability of resources for further intervention after the emergency care, is vital for the reduction of maternal mortality. Keywords: Postpartum haemorrhage, maternal mortality, non-pneumatic anti-shock garment

Introduction Globally, maternal mortality resulting from postpartum haemorrhage PPH is the leading cause of maternal deaths (Miller et al 2007). Furthermore, a UNICEF (2016) report states that more than a quarter of maternal mortality (27%) is attributed to haemorrhage. While the global rate of maternal mortality decreased slightly between 1990 and 2015 from 532,000 to 303,000, there has been no significant change in low-resource countries where there is the highest rate of maternal mortality (World Health Organization (WHO) 2016). Hence, there is a need to identify effective interventions to reduce maternal mortality, especially in low-resource settings. This review investigated the use of NASG as a form of technology, aimed at reducing maternal mortality. PPH is defined as blood loss of approximately 500 to 1000mls (Devine 2009) within the first day following childbirth (Mousa et al 2014), and can be categorised as primary or secondary PPH. Primary PPH is the loss MIDIRS Midwifery Digest 27:4 2017

of any amount of blood above 500mls (WHO 2012), while secondary PPH is the excessive loss of blood within one day and up to three months following childbirth (Alexander et al 2008). Primary PPH can be categorised as minor or major PPH, with minor PPH described as the loss of 500 to 1000mls of blood, while major PPH is the loss of over 1000mls of blood which can be further divided into either moderate or severe blood loss. Moderate PPH is classified as a loss of about 1000 to 2000mls of blood, while severe PPH is described as a blood loss of over 2000mls (Royal College of Obstetricians and Gynaecologists (RCOG) 2016). NASG was developed from the pneumatic antishock garment in the United States in 1971 by Dr Ralph Pelligra (Miller et al 2007). It was specifically developed for use in low-resource settings with a high rate of maternal mortality (Miller et al 2009). NASG does not require complex training before use, compared to the pneumatic anti-shock garment which consists of manometers, foot pump and tubing that needs a level of understanding and training before 483


use (Miller et al 2007). However, it is not so much a treatment for PPH (Geller et al 2007), but rather an emergency device used to preserve the life of women (Miller et al 2009). Therefore, the NSAG can be utilised in low-resource settings for the management of PPH, where a delay in accessing health care is a major cause of maternal death (Miller et al 2007). However, lack of support from governments and other stakeholders in low-resource settings may continue to affect the availability of the garment for use (Downing et al 2015).

bleeding is managed, but lack of a good measuring device affects the quantification of the amount of blood loss, potentially rendering the estimated value incorrect (Gabel & Weeber 2012). In all the studies included in this review, the onset of bleeding began either at home, before transfer, or within the (health care) facility (Turan et al 2011). However, it was noted that blood loss prior to study-entry was only estimated, based on the presenting signs, urine output and vital signs, with further loss measured using a well calibrated drape for accuracy (Kausar et al 2012).

Aims of this review

Fourteen studies used the amount of blood loss as a tool to assess the impact of the NASG, including two studies demonstrating no significant difference in the amount of blood loss (Hensleigh 2002, Miller et al 2013). Five studies did not use blood loss for assessment (Oshinowo et al 2007, Berdichevsky et al 2010, Turan et al 2011, El Ayadi et al 2013a, Jordan et al 2016).

This review aimed to explore the effects of NASG as an emergency device for improving maternal health outcomes in low-resource settings.



A total of 19 studies were included in this review. The search criteria is shown in Figure 1.

Records identified through database searching (n=53)

Additional records identified through other sources (n=2)



Records after duplicates removed (n=38)

Records screened (n=38)

Full text articles assessed for eligibility (n=28)

Records excluded (n=10)

Full text articles excluded, with reasons (n=9)


Studies included in synthesis (Qualitative studies n=3)

Studies included in synthesis (Quantitative studies n=16)

Figure 1. Search criteria

There were four main categories arising from the review into the effects of NSAG: blood loss, maternal mortality, emergency hysterectomy and delay.

Blood loss The measurement of blood loss starts immediately after childbirth, and continues till the cause of the 484

Four studies claimed a 50% reduction in the amount of blood loss (Miller et al 2006, Mourad-Youssif et al 2010, Kausar et al 2012, El Ayadi et al 2013b), whereas four claimed less than a 50% reduction (Miller et al 2010a, Fathalla et al 2011, Morris et al 2011, Turan et al 2011) and four showed more than a 50% reduction in the amount of blood loss, after the use of NASG (Miller et al 2009, Ojengbede et al 2011, Magwali et al 2012, Ojengbede et al 2014). A reduction in the amount of blood loss at any rate demonstrates that the use of the NSAG is a promising device that can be used to save lives and prevent further complications; however it is not a complete treatment for the management of PPH because it has to be used along with the standard hospital protocol (WHO 2012). It was noted that the unit of measurement across the selected studies varied, with two studies estimating the median amount of blood loss (Miller et al 2006, Kausar et al 2012) and six studies measuring the estimated value using the mean amount of blood loss (Miller et al 2009, Miller et al 2010a, Miller et al 2010b, Mourad-Youssif et al 2010, Fathalla et al 2011, Ojengbede et al 2011). Only one study used both mean and median to estimate the amount of blood loss (Ojengbede et al 2011), while four studies did not indicate the method used in the calculation of the estimated amount of blood loss (Morris et al 2011, Magwali et al 2012, El Ayadi et al 2013b, Miller et al 2013). In conclusion, the results of the review show on average a 50% reduction in the amount of blood loss using NSAG.

Maternal mortality Maternal mortality is a global health challenge, affecting women during the antenatal, intrapartum and postnatal periods (Paxton & Wardlow 2011, Montgomery et al 2014). MIDIRS Midwifery Digest 27:4 2017


Fourteen studies measured the impact of NSAG on maternal mortality rates: six studies demonstrated more than a 50% reduction in the maternal mortality rate (Miller et al 2009, Mourad-Youssif et al 2010, Morris et al 2011, Ojengbede et al 2011, Kausar et al 2012, Ojengbede et al 2014), while two studies show less than a 50% reduction (Miller et al 2010a, El Ayadi et al 2013a). Five studies did not measure the rate (Oshinowo et al 2007, Berdichevsky et al 2010, Turan et al 2011, El Ayadi et al 2013b, Jordan et al 2016). Six studies showed no significant difference in the rate of maternal mortality between the preintervention and intervention group (Hensleigh 2002, Miller et al 2006, Miller et al 2010b, Fathalla et al 2011, Magwali et al 2012, Miller et al 2013); this may be the consequence of early initiation of emergency management of obstetric haemorrhage with or without the use of the NSAG. The time of arrival at the hospital can determine the survival of a woman with PPH and is usually pre-determined by the geographical location of the woman’s home, which may be where the haemorrhage starts (Høj et al 2002). The woman’s arrival can be further complicated by the weather, especially during the rainy season, when road conditions can be destroyed due to the lack of a good drainage system (Pirkle et al 2011).

Emergency hysterectomy There are various issues which can affect women’s health following childbirth (Beck 2005). One such issue is PPH (Beck & Watson 2010). The consequence can sometimes be life threatening, leading to the need to save the life of both the mother and child or one of the two dependant on the situation, by performing an emergency or non-emergency hysterectomy (OmoleOhonsi & Ashimi 2009). The rate of non-emergency hysterectomy is increasing (Gaym 2002), especially in developed nations where it may be due to women with career aspirations or in choosing to have a small family (Omole-Ohonsi & Ashimi 2009). However, in selected developing nations like Nigeria, culture and the importance of childbearing women affects the rate of emergency hysterectomy (Ezenwafor & Jimoh 2007). In addition, obtaining informed consent for hysterectomy is a difficult task, except when there is a life-threatening situation (Lindberg & Nolan 2001), but both an emergency and non-emergency hysterectomy can affect the woman’s health and lifestyle (Teplin et al 2007), along with the initial experience of motherhood (Elmir et al 2012). Five of the studies show a reduction in the rate of emergency hysterectomy after the application of the NASG (Miller et al 2010a, Miller et al 2010b, Mourad-Youssif et al 2010, Morris et al 2011, Kausar et al 2012). However, the remaining 14 studies did MIDIRS Midwifery Digest 27:4 2017

not measure the rate of emergency hysterectomy (Hensleigh 2002, Miller et al 2006, Oshinowo et al 2007, Miller et al 2009, Berdichevsky et al 2010, Fathalla et al 2011, Ojengbede et al 2011, Turan et al 2011, Magwali et al 2012, El Ayadi et al 2013a, El Ayadi et al 2013b, Miller et al 2013, El Ayadi et al 2014, Ojengbede et al 2014).

Delay The delay in accessing health care services contributes to the rate of maternal mortality (Kausar et al 2012). This varies from a delay within the community due to lack of transport and a delay at the comprehensive health care facility due to lack of resources and hospital protocol (Miller & Belizán 2015). Only two out of the nineteen studies assessed the impact of the delay on the outcome of the NASG (Oshinowo et al 2007, Turan et al 2011); while one study negates the effect of the delay, the other study suggested that the effect of the delay can be prevented. The result of this review shows the impact of the amount of blood loss, rate of maternal mortality, delay and emergency hysterectomy. However, there are some key underlying findings which affect the results of this review. They include the time of onset of bleeding, which is not necessarily at the hospital for all study participants: some women began bleeding at home and were later selected to participate in the study due to their presenting signs and symptoms on arrival at the (health care) facility. However, blood loss before hospital arrival cannot be accurately measured. Consequently, the total estimation of the amount of blood loss for the selected studies is an approximate value of the calculation of blood loss after hospital arrival. This therefore affected the result of the study because the effectiveness of the use of NASG is based on the rate of control of the amount of blood loss.

Discussion This review shows the effectiveness of the use of the NASG as an emergency device for the management of obstetric haemorrhage following any underlying cause. The studies in the review provide further information on the use of the NASG in treating PPH with additional underlying conditions. All the clinicians participating in the studies were trained in the use of the NASG and the administration of uterotonics during the third stage of labour. Information from the training was implemented to inform change to practice during the study, and it was later included as part of the standard protocol for the management of PPH (WHO 2012). However, not all the studies provided information about how samples were selected and the actual location of where the research was conducted (Morris et al 2011); therefore the selected samples may not be a true representation of the population, thus affecting the application of 485


the study result because of the level of bias involved in study selection (Suresh et al 2011). The studies included in the review were predominantly quantitative and mostly comparative. They show that the use of the NSAG led to a reduction in the amount of blood loss, the rate of maternal mortality and the rate of utilisation of emergency hysterectomy. There were, however, other effects on various factors contributing to maternal mortality, including prevention of hypovolemic shock and restoration of vital signs within minutes of application (dependent upon the time of application of the garment) (Kausar et al 2012). The intervention, which involves the use of the NSAG, shows a reduction in the rate of maternal mortality, with four studies indicating more than a 50% reduction (Miller et al 2009, Mourad-Yousiff et al 2010, Ojengbede et al 2011, Magwali et al 2012). The result of the review thus supports the theoretical use of the NSAG, which is prevention of further complications by preserving the life of the woman until there is availability of resources for advanced management. Furthermore, the evidence intimates that the NASG is useful in low-resource settings. Most importantly, people can be trained on the use of the NSAG within a short period and can implement it into practice, without the presence of medical personnel. However, it must always be removed by a skilled person (Miller et al 2013). There are numerous challenges associated with the implementation of the NSAG; inadequate staffing and skilled birth attendants affect the utilisation of the NSAG, thereby limiting its use on women with PPH (Ojengbede et al 2014). Lack of motivation due to poor salaries can mean health workers in low-resource settings often change jobs, relocating from a rural to an urban area in search of higher paid work, thus the relocation of NASGtrained clinicians reduces the number of health care workers knowledgeable in its use (Geller et al 2007). Finally, there is the need for more information about the referral system to ensure the availability of the NSAG in all facilities within a low-resource economy (Ojengbede et al 2014).

Limitations of the review It is acknowledged that although there are other methods of emergency management of PPH, this review only included studies involving NSAG. Also, there is lack of homogeneity in the cause of PPH across all the study participants; however the presenting signs and symptoms were the same for all the selected review samples, which may have been due to the inclusion criteria of the author. Additionally, there was limited information about the effectiveness of the NSAG on maternal mortality. This


is due to the difficulty in measurement and lack of accurate statistical data, but most of the results used the amount of blood loss as a tool for measuring the effectiveness of the garment as is evident from the results which show that only four out of 19 studies did not assess the effect of the NSAG on blood loss (Oshinowo et al 2007, Turan et al 2011, El Ayadi et al 2013a, Jordan et al 2016). Only one of the studies found no significant reduction in blood loss (Hensleigh 2002). Furthermore, studies included in the review were all conducted in a low-resource setting with a high maternal mortality rate; therefore it may be of benefit to assess the effectiveness of the NSAG in developed countries.

Implications for practice • Facilities located in communities with a high rate of maternal mortality resulting from PPH should utilise NSAG as an emergency approach to saving lives (Miller et al 2013). • The findings of this review imply that the unmet Millennium Development Goals can be achieved with further education and training on the use of the NSAG (El Ayadi et al 2014) and death resulting from PPH can be prevented through the utilisation of the NSAG (Miller et al 2010b).

Implications for future research • Future research studies should focus on assessing the effectiveness of the NSAG after several uses, in order to determine the effect of multiple usage on the outcome of the health of the patient. • Lack of accurate statistical data has an impact on the measurement of the maternal mortality rate in developing countries, thereby affecting implementation of the research findings in health care practice (Ahmed & Hill 2011). Therefore there should be further research into the method of reporting and recording the rate of maternal mortality, especially in developing countries (Hill et al 2001).

Conclusions The use of the NSAG, along with the standard protocol of each setting, with availability of resources for further intervention after emergency care is vital for the reduction of maternal mortality. Further research and training is recommended to increase the scope for consideration of the NSAG for use in other settings where emergency treatment of PPH may reduce maternal morbidity and mortality. Adedoyin Mulikat Adeosun, PhD student, University of Salford, Professor Alison Brettle, University of Salford.

References Ahmed S, Hill K (2011). Maternal mortality estimation at the subnational level: a modelbased method with an application to Bangladesh. Bulletin of the World Health Organization 89(1):12-21.

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Postnatal Alexander J, Thomas P, Sanghera J (2008). Treatments for secondary postpartum haemorrhage. The Cochrane Database of Systematic Reviews, Issue 2. Beck CT (2005). Benefits of participating in internet interviews: women helping women. Qualitative Health Research 15(3):411-22. Beck CT, Watson S (2010). Subsequent childbirth after a previous traumatic birth. Nursing Research 59(4):241-9. Berdichevsky K, Tucker C, Martinez A et al (2010). Acceptance of a new technology for management of obstetric hemorrhage: a qualitative study from rural Mexico. Health Care for Women International 31(5):444-57. Devine PC (2009). Obstetric hemorrhage. Seminars in Perinatology 33(2):76-81. Downing J, El Ayadi A, Miller S et al (2015). Cost-effectiveness of the non-pneumatic anti-shock garment (NASG): evidence from a cluster randomized controlled trial in Zambia and Zimbabwe. BMC Health Services Research 15(37). El Ayadi AM, Butrick E, Geissler J et al (2013a). Combined analysis of the non-pneumatic anti-shock garment on mortality from hypovolemic shock secondary to obstetric hemorrhage. BMC Pregnancy and Childbirth 13(208). El Ayadi A, Raifman S, Jega F et al (2013b). Comorbidities and lack of blood transfusion may negatively affect maternal outcomes of women with obstetric hemorrhage treated with NASG. PLoS One 8(8):e70446. El Ayadi A, Gibbons L, Bergel E et al (2014). Per-protocol effect of earlier non-pneumatic anti-shock garment application for obstetric hemorrhage. International Journal of Gynaecology and Obstetrics 126(1):95-6. Elmir R, Schmeid V, Wilkes L et al (2012). Separation, failure and temporary relinquishment: women’s experiences of early mothering in the context of emergency hysterectomy. Journal of Clinical Nursing 21(7-8):1119-27. Ezenwafor G, Jimoh G (2007). Abdominal hysterectomy at the university of Ilorin teaching hospital – a 5-year review. Nigeria Hospital Practice 1(2):45-9. Fathalla MM, Youssif MM, Meyer C et al (2011). Nonatonic obstetric haemorrhage: effectiveness of the nonpneumatic antishock garment in Egypt. ISRN Obstetrics and Gynecology 10th August. https://www.hindawi.com/journals/isrn/2011/179349/ [Accessed 8 September 2017]. Gabel KT, Weeber TA (2012). Measuring and communicating blood loss during obstetric hemorrhage. JOGNN: Journal of Obstetric, Gynecologic and Neonatal Nursing 41(4):551-8. Gaym A (2002). Elective hysterectomy at Tikur Anbessa Teaching Hospital, Addis Ababa. Ethiopian Medical Journal 40(3):217-26. Geller SE, Adams MG, Miller S (2007). A continuum of care model for postpartum hemorrhage. International Journal of Fertility and Women’s Medicine 52(2-3):97-105. Hensleigh PA (2002). Anti-shock garment provides resuscitation and haemostasis for obstetric haemorrhage. BJOG: An International Journal of Obstetrics and Gynaecology 109(12):1377-84. Hill K, AbouZhar C, Wardlaw T (2001). Estimates of maternal mortality for 1995. Bulletin of the World Health Organization 79(3):182-93. Høj L, da-Silva D, Hedegaard K et al (2002). Factors associated with maternal mortality in rural Guinea-Bissau: a longitudinal population-based study. BJOG: An International Journal of Obstetrics and Gynaecology 109(7):792-9. Jordan K, Butrick E, Yamey G et al (2016). Barriers and facilitators to scaling up the non-pneumatic anti-shock garment for treating obstetric hemorrhage: a qualitative study. PLoS One 11(3):e0150739. Kausar F, Morris JL, Fathalla M et al (2012). Nurses in low resource settings save mothers’ lives with non-pneumatic anti-shock garment. MCN: The American Journal of Maternal Child Nursing 37(5):308-16. Lindberg CE, Nolan LB (2001). Women’s decision making regarding hysterectomy. JOGNN: Journal of Obstetric, Gynecologic and Neonatal Nursing 30(6):607-16. Magwali TL, Butrick E, Mambo V et al (2012). Non-pneumatic anti-shock garment (NASG) for obstetric hemorrhage: Harare, Zimbabwe. International Journal of Gynaecology and Obstetrics 119:S410.

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Miller S, Hamza S, Bray EH et al (2006). First aid for obstetric haemorrhage: the pilot study of the non-pneumatic anti-shock garment in Egypt. BJOG: An International Journal of Obstetrics and Gynaecology 113(4):424-9. Miller S, Ojengbede A, Turan J et al (2007). Anti-shock garments for obstetric hemorrhage. Current Women’s Health Reviews 3(1):3-11. https://www.cmqcc.org/resource/775/download [Accessed 8 September 2017]. Miller S, Ojengbede O, Turan JM et al (2009). A comparative study of the non-pneumatic anti-shock garment for the treatment of obstetric hemorrhage in Nigeria. International Journal of Gynaecology and Obstetrics 107(2):121-5. Miller S, Fathalla MM, Youssif MM et al (2010a). A comparative study of the non-pneumatic anti-shock garment (NASG) for the treatment of obstetric haemorrhage in Egypt. International Journal of Gynaecology & Obstetrics 109(1):20-4. Miller S, Fathalla MF, Ogengbede OA et al (2010b). Obstetric hemorrhage and shock management: using the low technology Non-pneumatic Anti-Shock Garment in Nigerian and Egyptian tertiary care facilities. BMC Pregnancy and Childbirth 10(64). Miller S, Butrick E, Giesssler K (2013). A unique first-aid device for obstetric hemorrhage and hypovolemic shock: policy implications for implementing the non-pneumatic anti-shock garment. NASG Policy Brief. https://www.mhtf.org document/a-unique-first-aid-devicefor-obstetric-hemorrhage-and-hypovolemic-shock-policyimplications-for-implementing-the-non-pneumatic-anti-shockgarment/ [Accessed 8 September 2017]. Miller S, Belizán JM (2015). A promising device to save maternal lives associated with obstetric hemorrhage: the non-pneumatic anti-shock garment (NASG). Reproductive Health 12(26). Montgomery AL, Ram U, Kumar R et al (2014). Maternal mortality in India: causes and healthcare service use based on a nationally representative survey. PLoS One https://doi.org/10.1371/ journal.pone.0083331 [Accessed 8 September 2017]. Morris JL, Meyer C, Fathalla MMF et al (2011). Treating uterine atony with the non-pneumatic anti-shock garment in Egypt. African Journal of Midwifery and Women’s Health 5(1):37-42. Mourad-Youssif M, Ojengbede OA, Meyer CD et al (2010). Can the Non-pneumatic Anti-Shock Garment (NASG) reduce adverse maternal outcomes from postpartum hemorrhage? Evidence from Egypt and Nigeria. Reproductive Health 7(24). https:// reproductive-health-journal.biomedcentral.com/ articles/10.1186/1742-4755-7-24 [Accessed 8 September 2017]. Mousa HA, Blum J, Abou El Senoun G et al (2014). Treatment for primary postpartum haemorrhage. The Cochrane Database of Systematic Reviews, Issue 2. Ojengbede O, Galadanci H, Morhason-Bello IO et al (2011). The non-pneumatic anti-shock garment for postpartum haemorrhage in Nigeria. African Journal of Midwifery and Women’s Health 5(3):135-9. Ojengbede O, Butrick E, Galandanci H et al (2014). The nonpneumatic anti-shock garment in Nigeria: the tension between research and implementation. In: White RC. Global case studies in maternal and child health. Burlington: Jones & Bartlett Learning: 303-15. http://www.safemotherhood.ucsf.edu/wp-content/ uploads/2015/05/Global-Case-Studeis-Chapter.pdf [Accessed 8 September 2017]. Omole-Ohonsi A, Ashimi OA (2009). Non-emergency hysterectomy: why the aversion? Archives of Gynecology and Obstetrics 280(6):953-9. Oshinowo A, Miller S, Hensleigh P (2007). Preliminary progress report. Overcoming delays in childbirth due to hemorrhage: a qualitative study of the non-pneumatic anti-shock garment (NASG) in Nigeria. Stanford Medical Student Research & Population Health Symposium, 16 May. Paxton A, Wardlaw T (2011). Are we making progress in maternal mortality? New England Journal of Medicine 364(21):1990-3. Pirkle CM, Fournier P, Tourigny C et al (2011). Emergency obstetrical complications in a rural African setting (Kayes, Mali): the link between travel time and in-hospital maternal mortality. Maternal and Child Health Journal 15(7):1081-7. Royal College of Obstetricians and Gynaecologists (2016). Prevention and management of postpartum haemorrhage. London: RCOG. https://www.rcog.org.uk/en/guidelines-research-services/ guidelines/gtg52/ [Accessed 14 August 2017].


Postnatal Suresh K, Thomas SV, Suresh G (2011). Design, data analysis and sampling techniques for clinical research. Annals of Indian Academy of Neurology 14(4):287-90. Teplin V, Vittighoff E, Fen-Lin MS et al (2007). Oophorectomy in premenopausal women: health-related quality of life and sexual functioning. Obstetrics and Gynecology 109(2 pt 1):347-54. Turan J, Ojengbede O, Fathalla M et al (2011). Positive effects of the non-pneumatic anti-shock garment on delays in accessing care for postpartum and postabortion hemorrhage in Egypt and Nigeria. Journal of Women’s Health 20(1):91-8. UNICEF (2016). UNICEF Annual Report 2015. https://www.unicef. org/publications/index_92018.html [Accessed 8 September 2017].

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Adeosun AM, Brettle A. MIDIRS Midwifery Digest, vol 27, no 4, December 2017, pp 483-488. Original article. Š MIDIRS 2017.

The effectiveness of prescription exercises for women diagnosed with postnatal depression: a systematic review Anna-Maria Brown, Ann Robinson, Felicity Jones, Alison Smith, Peter Williams, Jane Hanley ORIGINAL Aim: To evaluate the effectiveness of prescribed postnatal exercise on postnatal depression. Prescribed exercise was defined as any physical activity that was carried out in the postnatal period with the objective of reducing postnatal depression, as determined by identified scales. Background: Research has identified that regular physical exercise interventions are beneficial to mental health conditions such as depression and anxiety. Design: A systematic review and narrative analysis of randomised controlled trials (RCTs) reporting on the effectiveness of prescription postnatal exercise on postnatal depression. Data sources: Selection criteria included full text, academic articles written in English comparing exercise retrieved from MEDLINE, CINAHL, PsycINFO, EMBASE and SPORTDiscus. Research focusing on postnatal or postpartum exercise or physical activity; depression or mood swings, published between 2008 and 2016 was included. The search was refined to include females aged eighteen years or more. Review methods: Forty-seven articles were initially identified and full text analysis was performed by two members of the research team. Twelve articles were identified as meeting the inclusion criteria and were distributed for scrutiny and assessment amongst the five members of the research team. Methodological quality was assessed using a Quality Assessment Tool for Quantitative Studies published by the Effective Public Health Practice Project (EPHPP) (1998). Finally the articles were redistributed amongst the team for a second assessment and verification. Discrepancy of ratings for a paper between the reviewers was resolved by a third reviewer through reassessment of the paper and further discussion. Results: Eight studies were included in the final systematic review carried out using the EPHPP assessment tool; the review identified six quality RCTs meeting the inclusion criteria. Conclusions: The findings indicate that a tailored exercise intervention can effectively alleviate postnatal depressive symptoms, benefiting women both physically and psychologically. Social support experienced by participants in relation to the exercise intervention was seen to have a positive impact. Keywords: postnatal, depression, exercise, physical activity, systematic review, nursing/midwifery. 488

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Summary statement: Why is this review needed? • The nature of depressive illness experienced by women during pregnancy and in the postnatal period does not differ from depression experienced by the general population (National Institute for Health and Care Excellence (NICE) 2014). The impact of a depressive illness post-birth has far-reaching implications for mother, child and surrounding family members. • Research has identified that regular physical exercise interventions are beneficial to mental health conditions such as depression and anxiety. • Previous systematic analysis of exercise effectiveness for postnatal depression has identified that, despite the heterogeneity of exercise programmes offered for this participant group, exercise has some benefit for women with postnatal depression. What are the key findings? • The findings indicate that a tailored exercise intervention can effectively alleviate postnatal depressive symptoms, benefiting women both physically and psychologically. • Social support experienced by participants in relation to the exercise intervention was seen to have a positive impact.

Background It has been evident for some time that physical exercise can be beneficial for the general population, particularly in terms of promoting well-being and emotional health (Stathopoulou et al 2006). Exercise on ‘prescription’ for physical health conditions, such as Type 2 diabetes and obesity, is well established with beneficial outcomes reported (Cooney et al 2013). As a result of such positive indicators, exercise has been increasingly offered in the United Kingdom (UK) for additional client groups, such as those experiencing mental health conditions in addition to physical health concerns (Stanton et al 2015). Studies have established the impact of regular physical exercise interventions on specific mental health conditions, such as depression and anxiety, and in substance misuse programmes (Stathopoulou et al 2006, Alexandratos et al 2012, Josefsson et al 2014). Exercise interventions for depression have been a key focus in mental health care (Josefsson et al 2014, Rosenbaum et al 2016), this is primarily due to the substantial economic and health burden that depression, anxiety and comorbid physical conditions carry worldwide (Lopez et al 2006, World Health Organization (WHO) 2015). Exercise groups that have been tailor-made for individuals with MIDIRS Midwifery Digest 27:4 2017

• Combining exercise with parenting education was seen as an innovative and effective mechanism for reducing depressive symptoms, significant long-term improvement can be seen by integrating exercise with education and support. How should the findings be used to influence policy, practice, research/education? • Implications for practice focus on the type of activity, duration, support provided and the tailoring of activities to patient circumstance, eg a tailored intervention, increased over time can be beneficial, particularly for women with more than one child. • Exercise location was important in relation to duration, with greater success seen in home exercise programmes within the first few months rather than later on, perhaps an indication of the need for increased/improved social support. • Enhanced social support and encouragement experienced in relation to an exercise intervention will have a positive impact on women across the world, even those with thoughts of self-harming and those with high Edinburgh Postnatal Depression Scale (EPDS) scores.

depression have made a significant impact in reducing symptoms such as anxiety and anhedonia (Rethorst & Trivedi 2013, Josefsson et al 2014). Notable mood improvement has also been noted when exercise has been prescribed for severe mental health problems where depression is seen as a primary debilitating component (Alexandratos et al 2012). It has been noted that the nature of depressive illness experienced by women during pregnancy and in the postnatal period does not differ from depression experienced by the general population (NICE 2014). However, the impact of such a depressive illness can have far-reaching implications for mother, child and surrounding family (Wilkinson & Mulcahy 2010). The WHO (2015) has recognised that maternal mental health problems are a major public health issue. Prevalence rates of postnatal depression vary between 10 and 20%, but on average it is reported that 13% of women who have recently given birth will experience a mental health disorder (WHO 2015). Postnatal depression is known to impact on maternal health and have negative consequences on marital relationships, causing relationship distress and disharmony (Speier 2015). Postnatal depression also has implications for the relationship between the mother and child, as 489


symptoms of depression can impact on maternal interactions and attachment styles (Wilkinson & Mulcahy 2010). This, in turn, can lead to child development issues, including cognitive and language development, and in addition to behavioural concerns (Hunt 2006). Evidence also indicates that there may be an association between postnatal depression and adverse psychological outcomes in adolescence (Sanger et al 2015). Postnatal depression also has wider economic repercussions: it is estimated that perinatal mental health conditions cost UK society approximately £8.1 billion for every birth cohort year with three-quarters of this cost being related to the adverse impact on the child (Bauer et al 2014). Pathways for the support and treatment of women with postnatal depression indicate the use of pharmacological, psychological and psychosocial treatment strategies (NICE 2014). Current evidence indicates that, as with the general population, structured exercise programmes that have been tailored to individual needs have moderate outcomes in reducing the symptoms of postnatal depression (Blamey et al 2012). It has been highlighted that women prefer psychological and social management of the condition rather than medication in the postnatal stages. Previous analysis of exercise effectiveness for postnatal depression has identified that, despite the heterogeneity of exercise programmes offered for this participant group, exercise is beneficial for women with postnatal depression (Daley et al 2009). A randomised controlled trial which explored the outcomes of an exercise-based intervention found increased maternal well-being and reduced risk indicators for depression in the intervention group (Norman et al 2010). Bearing in mind the differences in study interventions it is important to note that evidence suggests that increased and specific exercise is beneficial for this group (Ko et al 2013, Lewis et al 2014, Gong et al 2015). In addition, exercise has the potential to be an inexpensive intervention easily accessed by the women concerned (Songøygard et al 2012). Given the heterogeneous nature of the current literature available, it is timely to undertake a systematic review of the literature exploring the outcomes of exercise interventions, focusing on the structured and prescribed nature of the programmes available.

The review The systematic review was registered on the PROSPERO database and followed a procedure which was suitable to the focus of the study (Boland et al 2013). Aim The aim of this study was to determine the effectiveness of prescribed postnatal exercise on 490

postnatal depression. Prescribed exercise was defined as any physical activity that was carried out in the postnatal period with the aim of reducing postnatal depression as determined by identified scales. For physical activities this was assessed through moderate to vigorous physical activity (MVPA) in one study. Those for depression included the Hamilton Depression Rating Scale (HDRS) (abbreviated HAM-D) (Hamilton 1960); the EPDS study (Cox et al (1987); Patient Health Questionnaire (PHQ-9) (Kroenke et al 2001); Structured Clinical Interview for the DSM-IV Axis I Disorders (SCID-I) (First et al 2002); Pain Attitudes and Beliefs Scale (PABS) (Houben et al 2005). Design The systematic review only included experimental studies which were carried out through RCTs and included the following terms: ‘postnatal’ or ‘postpartum’, ‘exercise’ or ‘physical activity’, ‘depression’ or ‘mood swings’. A similar focus of study carried out a systematic review up to 2007, on the effects of exercise on postnatal depression and concluded that further research was suggested, as findings indicated that although there is some support to suggest that exercise can reduce postnatal depression, the five trials reviewed and analysed demonstrated non-significance despite heterogeneity of studies (Daley et al 2009). Therefore, this systematic review only included studies published from 2008 to 2017. The search was refined to include females aged eighteen years or more. Search methods and outcomes Full text, academic articles written in English were retrieved and a MeSH search on MEDLINE, CINAHL, PsycINFO, EMBASE and SPORTDiscus was carried out which resulted in the numbers of articles identified in Table 1. Forty-seven articles were initially identified and were reviewed by two members of the research team. Full text analysis was performed on these identified articles to confirm that the inclusion criteria had been fulfilled. Several articles were discarded, including those that were not RCTs, those that explored the effect of antenatal interventions and exercise and those that were duplicated. Twelve articles were identified as meeting the inclusion criteria and were distributed for scrutiny and assessment amongst the five members of the research team. Methodological quality was assessed using a Quality Assessment Tool for Quantitative Studies published by the EPHPP (1998). After an initial analysis, the articles were redistributed amongst the team for a second assessment and verification. Any discrepancy of ratings for a paper between the reviewers was resolved by a third reviewer through reassessment of the paper and further discussion; six articles were approved after systematic scrutiny (Table 1). MIDIRS Midwifery Digest 27:4 2017


Table 1. Search results from different databases. Databases – Keywords and process EBSCHost CINAHL





Postnatal or postpartum – 2420 Exercise or physical activity – 10257 Depression or mood swings – 11763 1 and 2 – 86 1 and 3 – 685 4 and 5 – 19 Inclusion and exclusion criteria


Postnatal or postpartum – 6007 Exercise or physical activity –22977 Depression or mood swings – 26862 1 and 2 – 201 1 and 3 – 1135 4 and 5 – 33 Inclusion and exclusion criteria


Postnatal or postpartum – 2719 Exercise or physical activity – 12943 Depression or mood swings – 33555 1 and 2 – 114 1 and 3 – 1334 4 and 5 – 41 Inclusion and exclusion criteria


Postnatal or postpartum – 3456 Exercise or physical activity – 8679 Depression or mood swings – 852 1 and 2 – 6175 1 and 3 – 615 4 and 5 – 62 Inclusion and exclusion criteria


SPORTDiscus Postnatal or postpartum – 0 Exercise or physical activity – 1 Depression or mood swings – 0 1 and 2 – 1 1 and 3 – 0 4 and 5 – 0


Full text only (21+11+9+5+1) CINAHL & MEDLINE & PsycINFO & EMBASE & SPORTDiscus


Duplications Reviewed by team removed


Review and assessment


Papers with weak outcomes identified through assessment tool and removed

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Data abstraction Initially, details of selected RCTs were collectively entered and recorded, detailing author names, date of publication and inclusion criteria of participants in the study. Age, population, social classification, and method of participant recruitment were recorded. The pre-intervention postnatal depression assessment scales for each study were identified, and details of the intervention and its duration were noted. Details of the control groups and comparison measurement tools after intervention were also identified. Shortand long-term outcomes (if any) were also included in the evaluation, with assessment and results of statistical analysis of the study findings noted. Other information identified was attrition of participants, to evaluate the robustness of participant numbers, and any limitations of the published studies. Six RCTs finally met the inclusion criteria and were selected; Table 2 presents the findings from the six studies exploring the effectiveness of physical activity in reducing postnatal depression.


Double assessment of each paper through EPHPP assessment tool

Quality appraisal Many reliable and validated quality assessment tools are suitable for both quantitative and qualitative studies. Literature was reviewed to ascertain the most appropriate tool for this systematic review (National Collaborating Centre for Methods and Tools 2008). Olivio et al (2008) suggest that a well-designed validated tool is required to ensure that the quality of the RCTs is robust and is essential in drawing conclusions about existing evidence. After an intensive search, the EPHPP (1998) quality assessment tool was identified as suitable for this systematic review. It can be applied to any public health topic area, including promotion of family and public health, to generate knowledge synthesis. The seven steps for using this tool, as described by Thomas et al (2004), were followed prior to data identification of the selected studies.


Data synthesis Although the included studies are valid in relation to postnatal depression, the statistical findings are insufficient to be used in meta-analysis; a narrative synthesis of data was therefore deemed to be appropriate and is discussed in the sections below (Boland et al 2013) (Table 2).

Results A total of six recorded articles were identified through the five databases searched, as identified in Table 1. Records that did not fulfil the inclusion criteria, and were irrelevant to the review, were excluded. Duplications were also removed. Forty-seven papers were selected based on title and abstract and full texts reviewed. On further scrutiny and analysis of the full texts, a further 35 articles were excluded for methodological quality, ie not RCTs, inclusion of interventions other than physical activity and 491


Table 2. Selected articles meeting inclusion criteria. Study

Type Intervention

Albright et RCT al 2014

Daley et al RCT 2015

Tailored telephone counselling + website of PA versus website of PA only Facilitated exercise intervention + usual care versus usual care only

Da Costa et al 2009


12-week homebased exercise versus usual care

Heh et al 2008


Exercise support versus usual care

Lewis et al RCT 2014

Theory-based PA intervention via telephone versus wellness support contact via telephone Mother & Baby programme with personalised exercise and education versus educational material only

Norman et RCT al 2010


Control Assessment Outcome group tool Yes MVPA A tailored exercise intervention effectively increased MVPA

Summary of findings 95% CI; p= 0.275 (two children), p=0.016 (one child)

An internet randomisation service with blinded randomisation 50:50 split Stratified randomisation assigned on a baseline of mild, moderate and severe HAM-D scoring An allocation of women alternately to the two groups without taking blinding measures Block randomisation with varying block sizes



Exercise intervention and social support may be effective treatment for PND

MD -2.04, 95% CI; -4.11 to 0.03, p=0.05 Adjusted MD -2.26, 95% CI;4.36 to -0.16 p=0.03



Home-based exercise may alleviate postnatal depressive symptoms

MD 4.06, 95% CI; 1.51-6.61, p=<0.001 MD 1.83, 95% CI; 0.24-3.41, p= 0.02



An exercise support programme can benefit postnatal women psychologically

MD 2.6, 95% CI; 5.377.09, p=0.01



No significant Physical activity differences found related to fewer depressive symptoms between groups in postnatal women

A computergenerated random numbers list and randomly stratified groups


PABS: 8–12 wks

Exercise with parenting education demonstrated significant improvements in scores for postnatal depression

Blinded stratified randomisation

EPDS: 8–12 wks

MD 11.82, 95% CI; 11.24-12.37, p=0.007 MD 11.93, 95% CI; 11.38-12.45, p=0.580 MD 5.47, 95% CI; 4.19-6.92, p=<0.001 MD 4.73; 95% CI; 3.49-6.23, p= 0.194

Intervention abbreviations: Physical Activity: PA Assessment tool abbreviations: Activity: Moderate to Vigorous Physical Activity (MVPA). Depression: Edinburgh Postnatal Depression Scale (EPDS); Pain Attitudes and Beliefs Scale (PABS); The Hamilton Depression Rating Scale (HDRS) (abbreviated HAM-D); Structured Clinical Interview for the DSM-IV Axis I Disorders (SCID-I); Patient Health Questionnaire (PHQ-9)

interventions carried out in the antenatal period. Eight studies were included in the final assessment carried out using the EPHPP assessment tool, this identified six quality RCTs meeting our inclusion criteria. Participants A total of 916 postnatal women aged 18 and upwards were the participants across the six studies reviewed. The smallest group of participants were those in the Heh et al study (2008) and the largest group of 311 women were in the Albright et al (2014) study. It is difficult to identify if the demographic characteristics of the women were similar across the studies. However they were all postnatal women with depression scores above normal ranges before the intervention of a physical exercise tool. Only two studies (Norman et al 2010, Albright et al 2014) identified the age range of the participants; all the 492

studies reported the recruitment period for participation. The settings of the studies included: Taiwan (Heh et al 2008); United States of America (USA) (Da Costa et al 2009; Australia (Norman et al 2010); Hawaii (Albright et al 2014) and the UK (Lewis et al 2014, Daley et al 2015). Randomisation strategies Randomisation strategies varied across the six papers reviewed. Albright et al (2014) implemented blinded stratified randomisation, whilst Daley et al (2015) used an internet randomisation service with blinded randomisation of a 50:50 split. Stratified randomisation was used in the Da Costa et al (2009) study, assigned on a baseline of mild, moderate and severe HAM-D scoring. Blinding for personal bias regarding the allocation of women to the two groups with blocks of 4–6 was carried out. This was similar MIDIRS Midwifery Digest 27:4 2017


to Lewis et al (2014) who also randomly assigned in a 1:1 ratio, women were divided into two groups whilst the research assistants were blinded to the treatment assigned to the participants. In addition Lewis et al (2014) permuted block randomisation with varying block sizes. Heh et al (2008) simply allocated women alternately to the two groups without taking blinding measures during the participant allocation. Norman et al (2010) used a computer-generated random numbers list and randomly stratified groups, according to whether they were primiparous or multiparous women, in blocks of 16 participants. Interventions Varied physical activities were reported in the studies including: tailored community-based physical exercises through a website for mothers with telephone support (Albright et al 2014); a facilitated exercise intervention and social support (Daley et al 2015); a 12-week home-based exercise programme and emotional support (Da Costa et al 2009); one hour per week of exercise at a hospital and two sessions at home for three months (Heh et al 2008); home-based physical activity intervention plus 11 telephone contacts during a six-month period (Lewis et al 2014) and eight weeks’ intervention specialist exercises in addition to parenting education (Norman et al 2010). All the interventions were facilitated alongside control groups who accessed routine postnatal care. Outcomes This systematic review aimed to examine the impact of physical exercise on postnatal depression as the main outcome of interest. As discussed, several scales were used across the studies reviewed to identify changes in depressive state after the exercise intervention. A self-reporting MVPA and accelerometers were used in the Albright et al (2014) study pre- and post- intervention. Their tailored intervention effectively increased over a 12-month period with a resultant greater significant difference in mothers with two children as compared to those with one child. Daley et al (2015) recruited women who scored on the ICD-10 for major depression in the first six months post-birth. Symptoms of depression were measured using the EPDS at six and 12 months after the birth of their infant. The authors concluded that an intervention that encouraged exercise and social support resulted in a significant difference in EPDS scores between the intervention group and the control group. The HAM-D and EPDS scales were used in the study by Da Costa et al (2009) to determine the effects of a 12-week home-based exercise programme on women experiencing postnatal depressive moods. Both scores from the above scales indicated significant differences between the intervention and control groups immediately post-treatment and at three months on the EPDS scores but no differences noted at six months post-intervention. The HAM-D scores were significantly lower posttreatment but were non-significant at three months. MIDIRS Midwifery Digest 27:4 2017

Similarly women with EPDS scores of above ten at six weeks post-birth in the Heh et al (2008) study were allocated to an intervention receiving exercise support as compared to the control group. The exercise consisted of one hour of exercise per week at the hospital and two sessions at home for three months. Their EPDS scores at five months post-birth had lower depression scores as compared to the control group. The difference between groups was significant. The study by Lewis et al (2014) recruited two groups of women less than eight weeks post-birth and assigned one group to a telephone intervention over six months for home-based physical activity and the other to a wellness/support group as the control. Eight per cent of each group met the assessment criteria for the SCID-I. Assessment post-intervention at six months was carried out through the PHQ-9 and the EPDS scores. In addition, the Perceived Stress Scale and the Pittsburgh Sleep Quality Index, were used to measure the effect of exercise on sleep. The Seven Day Physical Activity Recall Interview and MVPA were also administered at six months. The results indicated that there were no significant differences between the groups on the depression scales but the authors identified that the control group had exercised more than anticipated and therefore skewed the results. Finally in Norman et al’s (2010) study, 161 postnatal women were allocated randomly to two groups, the experimental group receiving an eight-week intervention of specialist exercises plus parenting education and information as compared to the control group who received parenting education only. The Positive Affect Scale and EPDS scores were measured at baseline, after eight weeks post-intervention and then four weeks later. There were significant improvements in the intervention group as compared to the control group and this effect was maintained four weeks after completion of the intervention.

Discussion This systematic review focused on RCTs between 2008 and 2016, the primary outcome being to determine the effectiveness of prescribed postnatal exercise on postnatal depression. A rigorous approach to data collection and analysis revealed a total of six published RCTs; these were assessed using a validated assessment tool published by the EPHPP (1998). This was a strength of the review: a well-designed validated tool tends to ensure that the RCTs included have been undertaken with attention paid to rigour, validity and reliability. A total of 916 postnatal women aged 18 and over participated across the six studies reviewed. Participant groups and ages varied, making direct comparisons difficult. Although this may be viewed as a limitation, all participants were postnatal women with a depression score above normal prior to physical exercise taking place. 493


Implications for practice and research This systematic review examined the impact of physical exercise on postnatal depression as the main outcome of the study. Varied physical activities were reported in the studies ranging from tailored community-based physical exercises to home-based exercises. All the interventions were facilitated alongside control groups where participants accessed routine postnatal care.

Prescribed exercise was classified as being any physical activity that was carried out in the postnatal period with the aim of reducing postnatal depression. In one study however, physical activity was assessed by MVPA, altering the assessed activity. Tools used to assess the scale of depression amongst participants in the various studies also varied, leading to a lack of transparency. Depression scales included the EPDS; PABS; HDRS (abbreviated HAM-D); SCID-I; PHQ-9.

The findings indicate that a tailored exercise intervention can effectively alleviate postnatal depressive symptoms, benefitting women both physically and psychologically. Social support experienced by participants in relation to the exercise intervention was also seen to have a positive impact on women (Daley et al 2015). In relation to location, although social support was an important factor in reducing symptoms, home-based exercise was also seen to alleviate postnatal depressive symptoms. In addition, exercise with parenting education demonstrated significant improvements in scores for postnatal depression.

Although the included studies were valid in relation to postnatal depression and the use of prescribed exercise, the statistical findings are insufficient to be used in meta-analysis. Because the papers presented different primary outcomes and statistical analysis procedures were also different, constructing forest plots or similar representations was not possible. Therefore a narrative synthesis of data was deemed to be appropriate.

Implications for practice focus on the type of activity, duration, support provided and the tailoring of activities to patient circumstance, eg a tailored intervention increased over time can be beneficial, particularly for women with more than one child (Albright et al 2014). Exercise location was important in relation to duration, with greater success seen from home exercise programmes within the first few months rather than later on, perhaps an indicator of the need for social support. EPDS scores were seen to reduce both in relation to being part of an exercise programme and in relation to location (Heh et al 2008), emphasising less postnatal isolation when women participate in group activities. Combining exercise with parenting education was seen as an innovative and effective mechanism for reducing depressive symptoms (Norman et al 2010) where significant long-term improvement can be seen by integrating exercise with education and support. Limitations Randomisation strategies varied, some were blinded and some not. Measures included stratified internet and alternated randomisation making the assessment of validity complex due to a lack of transparency and comparability. Although a total of 916 postnatal women aged in excess of 18 years had participated in the six RCTs reviewed, it was difficult to identify whether the demographic characteristics of the women were similar across the studies, since detail provided by the researchers varied. Although generalisable in relation to inclusion criteria, the settings for the studies varied, eg Australia, USA and Taiwan, making generalisability less certain due to demographic differences and patient experiences. 494

Conclusion Depressive illness experienced by women during the childbearing continuum does not differ from depression experienced in general (NICE 2014). This systematic review has identified that regular physical exercise interventions are beneficial to mental health conditions such as depression and anxiety. For the purpose of this systematic review and narrative analysis, prescribed exercise was defined as any physical activity that was carried out in the postnatal period with the objective of reducing postnatal depression as determined by identified scales. Having undertaken a rigorous analysis of published evidence, six studies were included in the final systematic review carried out using the assessment tool EPHPP (1998). This systematic review examined the impact of physical exercise on postnatal depression as the main outcome of the study. Varied physical activities were reported in the studies, ranging from tailored community-based physical exercises to home-based exercises. All the interventions were facilitated alongside control groups where participants accessed routine postnatal care. The findings indicate that a tailored exercise intervention can effectively alleviate postnatal depressive symptoms, benefitting women both physically and psychologically. Social support and encouragement experienced by participants in relation to an exercise intervention was seen to have a positive impact on women across the world, even those with thoughts of self-harming and those with high EPDS scores. Under the new care model outlined in the NHS Five Year Forward View (NHS England et al 2014) practitioners need to work in collaboration to support patients. For women experiencing mental health problems following childbirth, mental health specialists and practitioners in primary and acute care services will benefit from focusing on contemporary research evidence to individualise care, in this instance, in relation to the benefits of exercise and social contact during and following pregnancy. MIDIRS Midwifery Digest 27:4 2017


Dr Anna Maria Brown, Midwifery Teaching Fellow, Faculty of Health & Medical Sciences, University of Surrey; Dr Ann Robinson, Midwifery Teaching Fellow, Faculty of Health & Medical Sciences, University of Surrey; Felicity Jones, Teaching Fellow Integrated Care, Faculty of Health & Medical Sciences, University of Surrey; Alison Smith, Mental Health Teaching Fellow, Faculty of Health & Medical Sciences, University of Surrey.

Contributors Peter Williams, Statistical Consultant, Dept of Maths, University of Surrey; Dr Jane Hanley, Honorary Senior Lecturer, College of Human & Health Sciences, University of Swansea.

References Albright CL, Steffen AD, Wilkens LR et al (2014). Effectiveness of a 12-month randomized clinical trial to increase physical activity in multiethnic postpartum women: results from Hawaii’s Nā Mikimiki Project. Preventative Medicine 69:214-23. Alexandratos K, Barnett F, Thomas Y (2012). The impact of exercise on the mental health and quality of life of people with severe mental illness: a critical review. British Journal of Occupational Therapy 75(2):48-60. Bauer A, Parsonage M, Knapp M et al (2014). The costs of perinatal mental health problems. London: Centre for Mental Health. http://eprints.lse.ac.uk/59885/ [Accessed 19 July 2016]. Blamey RV, Daley AJ, Jolly K (2012). Exercise for postnatal psychological outcomes: a systematic review and meta-analysis. The Lancet 380(S25) Boland A, Cherry G, Dickson R (2013). Doing a systematic review: a student’s guide. London: SAGE. Cooney GM, Dwan K, Greig CA et al (2013). Exercise for depression. The Cochrane Database of Systematic Reviews 2013, Issue 9. Cox JL, Holden JM, Sagovsky R (1987). Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry 150:782-6. Da Costa D, Lowensteyn I, Abrahamowicz M et al (2009). A randomized clinical trial of exercise to alleviate postpartum depressed mood. Journal of Psychosomatic Obstetrics and Gynaecology 30(3):191-200. Daley A, Jolly K, MacArthur C (2009). The effectiveness of exercise in the management of post-natal depression: systematic review and meta-analysis. Family Practice 26(2):154-62. Daley AJ, Blamey RV, Jolly K et al (2015). A pragmatic randomized controlled trial to evaluate the effectiveness of a facilitated exercise intervention as a treatment for postnatal depression: the PAM-PeRS trial. Psychological Medicine 45(11):2413-25. Effective Public Health Practice Project (1998). Quality assessment tool for quantitative studies. Hamilton, ON: McMaster University. http://www.ephpp.ca/tools.html [Accessed May 2016]. First M, Spitzer RL, Gibbon ML et al (2002). Structured clinical interview for DSM-IV-TR Axis I disorders, research version, non-patient edition. New York: New York State Psychiatric Institute. Gong H, Ni C, Shen X et al (2015). Yoga for prenatal depression: a systematic review and meta-analysis. BMC Psychiatry 15(14). Hamilton M (1960). A rating scale for depression. Journal of Neurology, Neurosurgery, and Psychiatry 23:56-62. Heh SS, Huang LH, Ho SM et al (2008). Effectiveness of an exercise support program in reducing the severity of postnatal depression in Taiwanese women. Birth 35(1):60-5. Houben RM, Ostelo RW, Vlaeyen JW et al (2005). Pain Attitudes and Beliefs Scale (PABS). European Journal of Pain 9:173-83. Hunt C (2006). When baby brings the blues: family therapy and postnatal depression. Australian and New Zealand Journal of Family Therapy 27(4):214-20. Josefsson T, Lindwall M, Archer T (2014). Physical exercise

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intervention in depressive disorders: meta-analysis and systematic review. Scandinavian Journal of Medicine and Science in Sports 24(2):259-72. Ko YL, Yang CL, Fang CL et al (2013). Community-based postpartum exercise program. Journal of Clinical Nursing 22(15-16):2122-31. Kroenke K, Spitzer RL, Williams JB (2001). The PHQ-9: validity of a brief depression severity measure. Journal of General Internal Medicine 16(9):606-13. Lewis BA, Gjerdingen DK, Avery MD et al (2014). A randomized trial examining a physical activity intervention for the prevention of postpartum depression: The Healthy Mom Trial. Mental Health and Physical Activity 7(1):42-9. Lopez AD, Mathers CD, Ezzati M et al (2006). Global and regional burden of disease and risk factors, 2001: systematic analysis of population health data. The Lancet 367(9524):1747-57. National Collaborating Centre for Methods and Tools (2008). Quality assessment tool for quantitative studies. Hamilton, ON: McMaster University. http://www.nccmt.ca/knowledge-repositories/ search/14 [Accessed 28 September 2017]. National Institute for Health and Care Excellence (2014). Antenatal and postnatal mental health: clinical management and service guidance. London: NICE. NHS England, Public Health England, Monitor et al (2014). Five Year Forward View. London: NHS England. Norman E, Sherburn M, Osborne RH et al (2010). An exercise and education program improves well-being of new mothers: a randomized controlled trial. Physical Therapy 90(3):348-55. Olivio SA, Macedo LG, Gadotti IC et al (2008). Scales to assess the quality of randomized controlled trials: a systematic review. Physical Therapy 88(2):156-75. Rethorst CD, Trivedi MH (2013). Evidence-based recommendations for the prescription of exercise for major depressive disorder. Journal of Psychiatric Practice 19(3):204-12. Rosenbaum S, Tiedemann A, Stanton R et al (2016). Implementing evidence-based physical activity interventions for people with mental illness: an Australian perspective. Australasian Psychiatry 24(1):49-54. Sanger C, Iles JE, Andrew CS et al (2015). Associations between postnatal maternal depression and psychological outcomes in adolescent offspring: a systematic review. Archives of Women’s Mental Health 18(2):147-62. Songøygard KM, Stafne SN, Evensen KA et al (2012). Does exercise during pregnancy prevent postnatal depression? A randomized controlled trial. Acta Obstetricia et Gynecologica Scandinavica 91(1):62-7. Speier DS (2015). Strengthening couple relationships to reduce the risk of perinatal mood and anxiety disorders for parents. Journal of Health Visiting 3(3):160-5. Stanton S, Rosenbaum S, Kalucy M et al (2015). A call to action: exercise as treatment for patients with mental illness. Australian Journal of Primary Health 21(2):120-5. Stathopoulou G, Powers MB, Berry AC et al (2006). Exercise interventions for mental health: a quantitative and qualitative review. Clinical Psychology: Science and Practice 13(2):179-93. Thomas BH, Ciliska D, Dobbins M et al (2004). A process for systematically reviewing the literature: providing the research evidence for public health nursing interventions. World Views on Evidence-Based Nursing 1(3):176-84. Wilkinson RB, Mulcahy R (2010). Attachment and interpersonal relationships in postnatal depression. Journal of Reproductive and Infant Psychology 28(3):252-65. World Health Organization (2015). Maternal mental health. Geneva: WHO.

Brown AM, Robinson A, Jones F et al. MIDIRS Midwifery Digest, vol 27, no 4, December 2017, pp 488-495. Original article. © MIDIRS 2017.



Psychological growth after childbirth: an exploratory prospective study Daisuke Nishi, Kentaro Usuda Introduction: It is important to elucidate the psychologically positive aspects of childbirth for mothers, and not only the negative aspects such as perinatal depression. This study aimed to examine psychological growth after childbirth and its related variables by focussing on five factors of posttraumatic growth: relating to others, new possibilities, personal strength, spiritual change and appreciation of life. Methods: Pregnant women during mid-pregnancy were consecutively recruited at a women’s hospital in Japan and followed up one month after childbirth. Psychological growth was assessed by the Posttraumatic Growth Inventory. Results: Among 177 participants, 117 (66.1%) completed follow-up assessments one month after childbirth. Multivariable regression analysis revealed that primipara, higher resilience and less fear at childbirth were associated with posttraumatic growth factors of relating to others and new possibilities. High resilience and less fear at childbirth were also associated with personal strength. On the other hand, being primiparous and high depressive symptoms were associated with greater appreciation of life. No variables were associated with spiritual change. Discussion: These findings suggest that giving birth for the first time could be a highly challenging life event as well as an opportunity which leads to posttraumatic growth, and that giving birth with low fear might lead to mothers’ psychological growth. On the other hand, appreciation of life might need attention as it might signify some sorts of coping response. These findings contribute to our understanding of the psychological changes experienced by mothers. Nishi D, Usuda K. Journal of Psychosomatic Obstetrics & Gynecology, vol 38, no 2, 2017, pp 87–93.

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Author abstract. © Taylor & Francis 2017.


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Lactation following bereavement: how can midwives support women to make informed choices? Judith Kennedy, Anna Matthews, Laura Abbott, Jacqueline Dent, Gillian Weaver, Natalie Shenker ORIGINAL Introduction Perinatal loss, defined as the death of a baby within the neonatal period, stillbirth or late miscarriage (determined for the purpose of this paper as 20 weeks’ gestation), has been identified by multiple agencies and organisations as a focus for increased parental support. However, the lactation needs of mothers are broadly overlooked, which can lead to engorgement, mastitis and psychological harm. The most commonly offered option of pharmacological suppression is controversial due to a lack of efficacy, and concerns about physiological effects (Cole 2012). Women may already have stored frozen expressed breast milk (EBM) within the neonatal intensive care unit (NICU), or be discharged home before their milk comes in several days later. In our experience, information and guidance for bereaved mothers about lactation and EBM are often lacking. human milk is used (Maffei & Schanler 2017). While mother’s-own-milk (MOM) is the optimal form of human milk, the use of donor human milk can act as a bridge whilst a mother establishes her milk production, or in instances where MOM cannot be used. Milk banking has been carried out in the United Kingdom (UK) for over 80 years, based on the voluntary

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For preterm neonates, the use of human milk for nutrition has been demonstrated to have significant health benefits compared to artificial formula (Quigley & McGuire 2014). Incidence of infectionrelated events, such as urinary tract infections, necrotising enterocolitis and sepsis can be reduced, and lengths of stay in the NICU are shortened when

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donation of milk from women screened according to national guidelines (NICE 2010). Current research describes a diverse population of milk donors in the UK, for whom key motivators to donate were the encouragement of health professionals alongside the sense of altruism gained from the experience (Thomaz et al 2008). For bereaved parents, with appropriate support, milk donation may aid the grieving process, but previously the evidence had not been examined in a systematic manner. Expressed milk belongs to the mother and its fate after infant loss is her decision. However, bereaved mothers are often overlooked as potential milk donors (Carroll et al 2014). This study aimed to search the literature and examine local practice in order to explore the experience of bereaved mothers; in particular regarding the subject of milk donation following perinatal loss, in order to guide training and inform recommendations for future practice.

Literature review in relation to milk donation and bereavement The first phase of research involved an examination of available anecdotal evidence via internet searches, using keywords such as ‘milk donation’, ‘lactation’ and ‘bereavement’. To avoid bias, searches did not include words suggesting a positive or negative association. Results from this search included blogs, charity websites, online news articles and milk bank websites. It was considered that personal accounts published by milk banks were likely to demonstrate bias, so these accounts were excluded from the review. Following a review of anecdotal evidence, a literature review was conducted examining evidence regarding lactation options following perinatal loss, including milk donation. There was a wealth of anecdotal evidence, yet only a limited number of published articles were found. Seventeen articles were reviewed alongside National Institute for Health and Care Excellence (NICE) and Royal College of Obstetricians and Gynaecologists (RCOG) clinical guidelines. National Health Service (NHS) Trust bereavement care policies from hospitals local to the authors were examined, and professionals contacted to identify current practice. Finally, bereavement charities, often an important source of information for parents, were contacted to discuss what information they provided to bereaved parents regarding lactation and milk donation. Key themes were identified using a systematic approach, including benefits and drawbacks, individualised care and choice, and education and training.

Benefits: ‘expression brought an unexpected release’ The experiences of women who chose to donate following perinatal loss appeared mainly positive; several statements described milk donation as an experience which aided grieving: ‘expression brought an unexpected release… gave me purpose… my milk 498

could benefit others while giving my baby’s existence meaning’ (Anderson 2016); ‘donating has helped us to heal’ (Cruz-Chan 2016) and ‘people said I was generous to donate EBM from weaning my lactation, but I was the one who benefitted (Carroll 2013). This is mirrored in the published literature, where there is widespread consensus that milk donation provides bereaved mothers with catharsis and may aid the grieving process (NICE 2010, Britz & Henry 2013, Carroll et al 2014). Welborn (2012) expands on the theme, finding that women experience the period during which they express their milk transitional, allowing them time to accept their grief whilst having a tangible link with their baby. Moreover, perinatal mourning includes mourning for what may have been, including the aspirations parents held for their child (Leon 1990). The sense of legacy that parents report milk donation creates may therefore bring comfort (Welborn 2012). Consideration should be given to the physical benefits that gradual weaning, rather than immediate suppression, provides regardless of donation intention. The physical challenges women face as a result of their milk coming in can exacerbate the grief they experience. McGuinness et al (2014a) highlight the impact of physical pain, stating that women felt unable to be embraced and comforted due to painful breast engorgement. Woo & Spatz (2007) state that expressing milk in order to achieve involution, thereby suppressing lactation, helps reduce the risk of engorgement, mastitis and physical pain. While this paper does not address the long-term benefits associated with periods of breastfeeding, the effects of breastfeeding on women’s health, such as reducing the risk of breast and ovarian cancer (Victora et al 2016) and reducing the development of postnatal depression (Hartmann 2017) are undeniable. Despite this, currently RCOG guidelines (Siassakos et al 2010) do not recognise expression to wean as an option for bereaved women and favour pharmacological suppression, such as carbergoline over other nonpharmacological means, such as ice packs and well-fitting brassieres. However, one woman, when advised to suppress through pharmacological means, stated: ‘Suppression of lactation at doctor’s orders brought physical and emotional suffering’ (Anderson 2016). While further research would clarify the optimal suppression method, women should be offered comprehensive advice on all lactation options.

Drawbacks: ‘a second bereavement’ Although the process of milk donation may offer catharsis, Carroll et al (2014) reminds readers that grief is individual and every woman’s experience of lactation following bereavement will be different. While the emotive accounts mentioned above suggest the benefits associated with milk donation, not all women may find the process beneficial. Lactation, to some, can be a physical symbol of what they have lost MIDIRS Midwifery Digest 27:4 2017

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(Welborn 2012). This is demonstrated by women describing wanting to suppress lactation as quickly as possible: ‘I didn’t want to have my supply reminding me of what I couldn’t bring home’ (Anonymous 2016). One woman who had donated her breast milk following bereavement reported that although the experience aided her grieving, when she ceased donating she experienced ‘a second bereavement’ (Cruz-Chan 2016). This highlights the critical importance of ongoing care and emotional support to ensure the well-being of donors (Cole 2012).

Choice and individualised care: ‘I wish I had been given the option of a milk bank’ Modern midwifery practice is based on the provision of individualised care; the Nursing and Midwifery Council (NMC) professional standards assert that midwives must treat people as individuals, recognise diversity and choice, and uphold dignity (NMC 2015). A theme of milk donation as an overlooked option became apparent, illustrated by: ‘I wish I had been given the option of a milk bank… it would have helped knowing a baby was getting what my baby no longer could’ (Anonymous 2016). The literature highlights the importance of choice for women suffering perinatal loss; Carroll et al (2014) indicate that such choice can be empowering for women, especially at a time of utter devastation. However, women can only make informed choices regarding lactation when they are aware of all options available to them (Kobler 2012, Welborn 2012). Carroll et al (2014) identified the possible options available to women as follows: • Suppression of lactation, by pharmacological or non-pharmacological means • Donation of stored EBM • Donation of EBM through expression as a method to wean their milk supply • Establishment or continuation of lactation. The last option, establishing lactation following perinatal loss, either for milk donation or to maintain a connection to the lost child, is the most divisive. If a mother choses to continue to express and donate milk, Hartmann (2017) emphasises that it is the responsibility of milk banks to ensure the act of donation causes no harm. He also points out that continued lactation may compromise well-being, by deferring an individual from resuming required medications. Carroll et al (2014) add that milk banks should consider the impact of sustained lactation on relationships and family planning due to lactational amenorrhea. The support offered to parents when considering their lactation options and the ongoing support provided if women choose to donate their breast milk is critical in ensuring the well-being of women and their families, and is an area for future research within the field of milk banking in the UK and internationally. MIDIRS Midwifery Digest 27:4 2017

Cultural appropriateness The health professional’s role involves tailoring the information and support they provide as appropriate to the individual mother (McGuinness et al 2014b). Alongside personal choice, Chen et al (2015) suggest cultural differences may determine the way a woman chooses to suppress her milk; this should be taken into consideration. Islamic law and ‘Mahramiat’ dictate that women may only donate to recipients that they know. Some Asian cultures would not acknowledge the birth of a stillborn child, and therefore the lactation issues suffered by a mother would not be addressed (Chen et al 2015). Gribble (2013) cites potential objections of some mothers to the inherent anonymity of the process of milk donation to milk banks, as in this situation they would not have information about the recipient of their milk. In such cases, mothers would prefer informal milk sharing. In an increasingly multicultural landscape, knowledge and awareness of society’s diversity is required for health professionals to support all women in their care.

Education and training Bereaved mothers are often overlooked as possible milk donors, despite NICE (2010) clinical guidelines recommending that this choice is offered. Carroll et al (2014) suggest that professional reluctance to discuss lactation options is a factor in overlooking this population of donors. Hughes & Goodall (2013) recommend that more knowledgeable professionals within the midwifery department or NICU support women and their families in making informed choices; staff members with experience in bereavement care are more likely to provide information in a compassionate and sensitive manner. McGuinness et al (2014b) acknowledge that grief affects a mother’s ability to fully understand information given by health professionals. Therefore, when discussions are taking place, written information should be provided to supplement and support the advice provided, especially when in-depth discussions may be unlikely (Stapleton et al 2001). One immediate outcome from this work is to enhance and disseminate currently available information from the UK Association for Milk Banking (UKAMB) (2017) that would be available in hospital and community health care settings for easy dissemination to bereaved mothers. The way in which a mother manages her grief can often be affected by the care she receives from health care professionals (Kohner & Henley 2001). The anecdotal evidence demonstrates that many women feel unprepared for lactation following bereavement; one women reports: ‘having to lead myself blindly due to inexperience in the realm of lactation after perinatal loss’ (Anderson 2016), while another states: ‘when I left hospital, my breasts started leaking… I didn’t know what to do’ (Cruz-Chan 2016). Studies have demonstrated that health professionals are the 499

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main motivators in milk donation, therefore training is key (Thomaz et al 2008). However, the concept of milk donation following bereavement appears mainly to be driven by the women themselves, rather than being an option provided by health care professionals: ‘I knew there was a high demand for breastmilk so my husband and I decided to donate’ (Cruz-Chan 2016). Welborn (2012) states that health care providers are key to educating mothers but often lack the tools to address lactation. This is demonstrated through the current lack of training in lactation options and milk donation following bereavement in the UK. A review of bereavement training available from the Royal College of Midwives (RCM 2015), Sands – the stillbirth and neonatal death charity (Schott et al 2007) and local policy (Local Trust A 2016) identified a paucity of information and guidance on lactation care and options after perinatal loss. In consideration for the future generation of midwives and neonatal nurses this lack of training should be addressed; Hollins Martin et al (2016) explored students’ experiences of caring for bereaved women and highlighted that greater training is needed in all bereavement care, not only lactation options. Researchers agree that robust national guidance and protocols should be adopted regarding lactation and donation after perinatal loss (Carroll et al 2014, Sereshti et al 2016). Given national guidance often dictates local policy (Sheldon et al 2004), an implication of this would be greater education and increased visibility of milk banks.

Individuality and choice are vital for woman-centred care; women should be aware of and supported in making informed choices regarding their lactation options. The option of milk donation may offer catharsis and aid the grieving process, and should be a visible option to women following perinatal loss. However, cultural differences alongside other potential drawbacks require a sensitive approach that needs further investigation to determine the best way to raise lactation issues and the option of milk donation. To empower health professionals to discuss all lactation options sensitively and confidently, further high-quality bereavement training is required, with a focus on the ethos of providing women with choice.



One limitation within the review included the possibility of bias within the published studies; therefore, the authors excluded evidence available from milk banks alongside the recorded experience of milk bank staff. A further limitation of the study is that existing studies only include women who choose to donate their milk, and the opinions of those women who do not are not documented in current research.

Anderson A (2016). Breastmilk donation after stillbirth. Evolutionary parenting with Tracy Cassels PhD, 28 March. http:// evolutionaryparenting.com/guest-post-breastmilk-donation-afterstillbirth/ [Accessed 8 July 2017]. Anonymous (2016). Lactation after loss – dealing with a breastmilk supply. BellyBelly, 8 November. https://www.bellybelly.com.au/ breastfeeding/lactation-after-loss-dealing-with-breastmilk-supplyafter-loss/ [Accessed 8 July 2017]. Britz SP, Henry L (2013). Supporting the lactation needs of mothers facing perinatal and neonatal loss. JOGNN: Journal of Obstetric, Gynecologic & Neonatal Nursing 42(Suppl 1):S105-6. Carroll K (2013). Donating breastmilk helps bereaved mothers deal with loss. The Conversation, 7 November. http://theconversation. com/donating-breast-milk-helps-bereaved-mothers-deal-withloss-17426 [Accessed 8 July 2017]. Carroll KE, Lenne BS, McEgan K et al (2014). National Stakeholder meeting on breast milk donation after neonatal death in Australia: a report. International Breastfeeding Journal 9(23). Chen FH, Chen SL, Hu WY (2015). Taiwanese women’s experiences of lactation suppression after stillbirth. JOGNN: Journal of Obstetric, Gynecologic & Neonatal Nursing 44(4):510-17. Cole M (2012). Lactation after perinatal, neonatal or infant loss. Clinical Lactation 3(3):94-100. http://lunalactation.com/final_ clinical_lactation.pdf [Accessed 8 July 2017]. Cruz-Chan W (2016). I donated 2,000 oz of breastmilk when my baby died and it helped me find purpose again. BBC iPlayer, 26 October. http://www.bbc.co.uk/bbcthree/item/10d0f106-042d-403eb651-9ab6ddccc06e [Accessed 8 July 2017]. Gribble KD (2013). Peer-to-peer milk donors’ and recipients’ experiences and perceptions of donor milk banks. JOGNN: Journal of Obstetric, Gynecologic & Neonatal Nursing 42(4):451-61. Hartmann BT (2017). Ensuring safety in donor milk banking in neonatal intensive care. Clinics in Perinatology 44(1):131-49.

Conclusion This review highlights the fact that lactation following bereavement is an overlooked issue. Although anecdotal evidence comprising women’s individual stories is a valuable resource supporting midwifery’s woman-centred philosophy, fundamental to practice is a formal evidence base. Given the current limited volume of research in this field, further studies are needed to examine the lactation needs of women following perinatal loss, to increase the visibility of milk banks, and ultimately broaden the evidence base. It should be emphasised that the authors do not intend for the rigorous recruitment of bereaved women at a vulnerable time to milk donation, but rather the option of milk donation to be offered in a compassionate and informed manner once a range of information has been discussed and a relationship of trust established with the family. 500

Acknowledgements The authors would like to acknowledge the members of charities, support organisations and NHS Trusts who responded to our enquiries in such a timely and supportive manner. Judith Kennedy, third year Student Midwife, University of Hertfordshire; Anna Matthews, third year Student Midwife, University of Hertfordshire; Laura Abbott, Senior Lecturer in Midwifery, University of Hertfordshire; Jacqueline Dent, Senior Lecturer in Midwifery, University of Hertfordshire; Gillian Weaver, Human Milk Banking Consultant, Co-founder and Director, Hearts Milk Bank: www.heartsmilkbank. org; Dr Natalie Shenker, Director, Hearts Milk Bank and Honorary Research Associate, Imperial College, London. JK and AM contributed equally to the literature review and preparation of the manuscript.

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Infant Nutrition Hollins Martin CJ, Robb Y, Forrest E (2016). An exploratory qualitative analysis of student midwives views of teaching methods that could build their confidence to deliver perinatal bereavement care. Nurse Education Today 39:99-103. Hughes KH, Goodall UA (2013). Perinatal bereavement care: are we meeting families’ needs? British Journal of Midwifery 21(4):248-53. Kobler K (2012). NICU bereavement breast milk donation. Journal of Pain and Symptom Management 43(2):453-4. Kohner N, Henley A (2001). When a baby dies – the experience of late miscarriage, stillbirth and neonatal death. London: Routledge. Leon IG (1990). When a baby dies: psychotherapy for pregnancy and newborn loss. New Haven: Yale University Press. Local Trust A (2016). Pregnancy loss. [Guidelines]. Maffei D, Schanler RJ (2017). Human milk is the feeding strategy to prevent necrotizing enterocolitis! Seminars in Perinatology 41(1):36-40. McGuinness D, Coghlan B, Butler M (2014a). An exploration of the experiences of mothers as they suppress lactation following late miscarriage, stillbirth or neonatal death. Evidence Based Midwifery 12(2):65-70. McGuinness D, Coughlan B, Power S (2014b). Empty arms: supporting bereaved mothers during the immediate postnatal period. British Journal of Midwifery 22(4):246-52. National Institute for Health and Care Excellence (2010). Donor milk banks: service operation. London: NICE. Nursing and Midwifery Council (2015). The Code: professional standards of practice and behaviour for nurses and midwives. London: NMC. Quigley M, McGuire W (2014). Formula versus donor breast milk for feeding preterm or low birth weight infants. The Cochrane Database of Systematic Reviews, Issue 4. Royal College of Midwives (2015). One chance to get it right: bereavement care. RCM i-learn. London: RCM. http://www.ilearn. rcm.org.uk/course/info.php?id=124 [Accessed 7 July 2017]. Schott J, Henley A, Kohner N (2007). Pregnancy loss and the death of a baby: guidelines for professionals. 3rd ed. London: Sands.

Midwifery Leadership Opportunities making our vision a reality! At National Women’s Health, we’re on the lookout for Midwives who are excited by the prospect of ‘doing your life’s best work.’ We have a clear vision, new leadership and a range of exciting service initiatives that will take our service to the next level. This is your chance to either step up to a leadership role, or to use your existing leadership skills to help build something very special. “Contact me and I’ll be happy to talk with you about how joining us to make our vision a reality is the best professional development opportunity you will make for your midwifery career!” - Melissa Brown, Midwifery Director. The leadership positions we have available are: • Service Clinical Director Primary Maternity • Midwifery Unit Manager • Charge Midwife • Clinical Charge Midwife What are we looking for in new team members? • Desire to support and develop our people to reach their full potential

MIDIRS Midwifery Digest 27:4 2017

Sereshti M, Nahidi F, Simbar M et al (2016). An exploration of the maternal experiences of breast engorgement and milk leakage after perinatal loss. Global Journal of Health Science 8(9):234-44. Sheldon TA, Cullum N, Dawson D et al (2004). What’s the evidence that NICE guidance has been implemented? Results from a national evaluation using time series analysis, audit of patient’s notes, and interviews. British Medical Journal 329(7473):999. Siassakos D, Fox R, Draycott T et al (2010). Late intrauterine fetal death and stillbirth. London: RCOG. Stapleton H, Kirkham M, Thomas G (2001). Qualitative study of evidence based leaflets in maternity care. British Medical Journal 324:1-6. Thomaz ACP, Loureiro LVM, da Silva Oliveira T et al (2008). The human milk donation experience: motives, influencing factors and regular donation. Journal of Human Lactation 24(1):69-76. UK Association for Milk Banking (2017). When a baby dies: advice for breastfeeding mothers. http://www.londonneonatalnetwork.org. uk/wp-content/uploads/2015/09/When_a_baby_dies_SM2.pdf [Accessed 3 August 2017]. Victora CG, Bahl R, Barros AJD et al (2016). Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. The Lancet 387(10017):475-90. Welborn JM (2012). The experience of expressing and donating breast milk following a perinatal loss. Journal of Human Lactation 28(4):506-10. Woo K, Spatz D (2007). Human milk donation: what do you know about it? MCN - American Journal of Maternal/Child Nursing 32(3):150-57.

Kennedy J, Matthews A, Abbott L et al. MIDIRS Midwifery Digest, vol 27, no 4, December 2017, pp 497-501. Original article. © MIDIRS 2017.

• Genuine leadership skills, or the potential to grow into great leaders • A mindset of collaboration, knowledge sharing and being multidisciplinary • Excellent clinical skills Everything we do is about delivering the best health outcomes for our women and families. We’re working hard to build a workforce of people that reflect the population we serve. Whatever your background, if you share our values of diversity, inclusivity and empathy and if your motivation is to make a difference and strive for excellence, apply now and ‘do your life’s best work’ at Auckland DHB. To find out more, contact Melissa directly on +64 21 720 874, email MelissaBro@adhb.govt.nz, or email Eileen at EDreyer@adhb.govt.nz for a copy of a position description. To apply, visit www.careers.adhb.govt.nz using reference CEN04369. PS. If you’re interested in what we have to offer, but not quite ready to make a change, then we’d still love to chat. Employing and developing the Midwifery leaders of tomorrow is something we are really enthusiastic about. Closing date Sunday, 17th December 2017.


Infant Nutrition

Does the use of intrapartum medical intervention predict suboptimal breastfeeding initiation? Marie Rivett ORIGINAL Background Despite recommendations from international bodies, few mothers achieve the target of breastfeeding their infant exclusively for six months (Herzhaft-Le Roy et al 2017). Interventions often focus on maternal motivation to breastfeed because the assumption is made that the neonate’s ability to breastfeed is physiological and automatic. However, there is some evidence to suggest that intrapartum care practices may impede innate breastfeeding reflexes and reduce early mother-infant contact (Bai et al 2013). Therefore, it can be suggested that practitioners must also focus on the ability of the infant to breastfeed at birth. Generally, women and their families have faith in medical clinicians and for that reason it is important that they are fully informed about the immediate and long-term effects of complex interventions before labour commences (Beauchamp & Childress 2001). Factors that may affect breastfeeding initiation During labour Complications that may arise during labour often increase the need for medication, in particular, epidural anaesthesia (EA) and it is believed that the association between regional anaesthesia and assisted vaginal delivery (AVD) can indirectly affect breastfeeding initiation (Jordan et al 2005). AVD is useful because it decreases the rate of caesarean section and can therefore preserve the maternal and paediatric benefits of a vaginal delivery (Bailey et al 2017). However, it is suggested that AVD often causes neonatal cranial and facial asymmetry due to compression of the parietal bones. Findings also indicate that mechanical deliveries often precipitate neonatal nerve damage and jaw deviation that can impair suckling ability (Tappero & Honeyfield 1993, Smith 2007, Stellwagen et al 2008). Therefore, cranial trauma and nerve disability may enhance our understanding as to why some infants appear unwilling to attach to the breast, despite their innate ability to exhibit organised breastfeeding behaviours. For example, according to Varendi & Porter (2001), maternal breast odour helps to guide the infant towards the breast, however, if the trigeminal nerves have been damaged, then the infant may not be able to implement olfactory learning and sense the presence of the breast. It would, therefore, be interesting to evaluate the provision of osteopathic treatments on the labour ward to help correct cranial dysfunction and thus inhibit the helplessness that professionals often feel when biomechanical difficulties persist, despite their breastfeeding support and advice. Maternal and neonatal fluid overload Intravenous clear fluids are generally used in conjunction with regional anaesthesia, as a 502

background infusion to help prevent maternal supine hypotension (Watson et al 2012). According to Mizuno et al (2008), intravenous fluid administration presents a risk of maternal fluid overload that may cause severe breast, nipple and areola oedema. Nevertheless, results suggest that fluid overload presents a challenge to the onset of lactogenesis II, because breast oedema will inhibit the deep attachment at the breast that is associated with effective milk transfer. There would, therefore, seem to be a definite need for access to professional breastfeeding support to be facilitated at this time to demonstrate techniques such as reverse pressure softening (RPS) to release interstitial fluid and help mothers to overcome breast oedema, inhibit milk stasis and promote the effective establishment of lactogenesis III. Evidence indicates that unit policies should address the challenges that practitioners face in relation to: suboptimal midwife/patient staffing ratios; clinician’s level of expertise in supporting complex breastfeeding issues; and the difficulties that can be experienced when trying to balance the provision of breastfeeding support with nursing care. According to Chantry et al (2011), neonatal fluid overload can also contribute to poor breastfeeding establishment because of the exaggerated weight loss as the neonate diureses. Findings identified that neonates are three times more likely to lose more than 10% of their birth weight if their mothers have a positive fluid balance of more than 200ml per hour during labour and delivery. Therefore, it is reasonable to suggest that maternity care providers should give consideration to appropriate intrapartum fluid management that may help to inhibit iatrogenically imposed neonatal weight loss and a cascade of breastfeeding problems. For example, aggressive supplementation is often advocated following MIDIRS Midwifery Digest 27:4 2017

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significant weight loss, because newborn weight loss is always a driver for further intervention. Furthermore, evidence suggests that it would be sensible to evaluate the safety of antenatal breast milk expression in order that maternity providers extend the recommendation of antenatal expression to include non-diabetic mothers, to protect the availability of colostrum in the postpartum period. Oxytocin Exogenous oxytocin is an intervention that is commonly used to induce and augment labour when prolonging the pregnancy poses maternal or fetal risk and is, therefore, an integral part of intrapartum care (Ekelin et al 2015). Surprisingly, it has been identified that exposure to synthetic oxytocin may have a positive influence on breastfeeding establishment, because its use is associated with higher maternal prolactin levels (Jonas et al 2009). However, findings indicate that synthetic oxytocin has an inhibitory effect on the normal pulsatile pattern of oxytocin release and, furthermore, the more exogenous oxytocin that women receive, the lower their endogenous oxytocin levels can become (Rahm et al 2002). It is, therefore, almost certain that synthetic oxytocin infusion will compromise the endogenous oxytocin levels required for milk synthesis and release during breastfeeding and, if essential maternal oxytocin instincts are compromised by endogenous oxytocin deficiency, then healthy mothering behaviour and lactation may be undermined. Interestingly, unintended breastfeeding cessation often causes maternal symptoms of anxiety and depression (Ystrom 2012). However, if consideration is given to the hypothesis that suboptimal breastfeeding initiation and continuance can be a risk factor of labour intervention, then mothers may be less vulnerable to the feelings of dejection that they often experience when breastfeeding is particularly challenging. Furthermore, practitioners may feel less incompetent when their efforts to promote and support early breastfeeding are unsuccessful.

Summary In summary, it must be acknowledged that routine childbirth intervention can significantly reduce maternal and neonatal mortality; however, emerging research indicates that medical intervention may undermine the mutuality of breastfeeding due to the effect it can have on maternal condition and neonatal behaviour. For this reason, evidence suggests that the use of intervention in modern birth should be more judicious. Great emphasis is placed on the importance of evidence-based practice. However, consideration is lacking in relation to the theory that suboptimal breastfeeding initiation may be an additional harmful effect of labour intervention and an indication for hospital providers to target women who are at risk of not initiating breastfeeding. Furthermore, as the ubiquitous use of pharmacological and mechanical MIDIRS Midwifery Digest 27:4 2017

intervention continues and women are more likely to experience multiple interventions, future research must examine the effects of cumulative intrapartum interventions on breastfeeding duration and exclusivity. Marie Rivett has a degree in breastfeeding and previously worked for the NHS as a breastfeeding support worker. She is currently based at the University of Worcester as a second-year midwifery student.

References Bai DL, Wu KM, Tarrant M (2013). Association between intrapartum interventions and breastfeeding duration. Journal of Midwifery and Women’s Health 58(1):25-32. Bailey PE, van Roosmalen J, Mola G et al (2017). Assisted vaginal delivery in low and middle income countries: an overview. BJOG: An International Journal of Obstetrics and Gynaecology 124(9):1335-44. Beauchamp TL, Childress JF (2001). Principles of biomedical ethics. 5th ed. New York: Oxford University Press. Chantry CJ, Nommsen-Rivers LA, Peerson JM et al (2011). Excess weight loss in first-born breastfed newborns relates to maternal intrapartum fluid balance. Pediatrics 127(1):e171-9. Ekelin M, Svensson J, Evehammar S et al (2015). Sense and sensibility: Swedish midwives’ ambiguity to the use of synthetic oxytocin for labour augmentation. Midwifery 31(3):e36-42. Herzhaft-Le Roy J, Xhignesse M, Gaboury I (2017). Efficacy of an osteopathic treatment coupled with lactation consultations for infants’ biomechanical sucking difficulties: a randomized controlled trial. Journal of Human Lactation 33(1):165-72. Jonas W, Johansson LM, Nissen E et al (2009). Effects of intrapartum oxytocin administration and epidural analgesia on the concentration of plasma oxytocin and prolactin, in response to suckling during the second day postpartum. Breastfeeding Medicine 4(2):71-82. Jordan S, Emery S, Bradshaw C et al (2005). The impact of intrapartum analgesia on infant feeding. BJOG: An International Journal of Obstetrics and Gynaecology 112(7):927-34. Mizuno K, Nishida Y, Mizuno N et al (2008). The important role of deep attachment in the uniform drainage of breast milk from mammary lobe. Acta Paediatrica 97(9):1200-4. Rahm VA, Hallgren A, Hogberg H et al (2002). Plasma oxytocin levels in women during labor with or without epidural analgesia: a prospective study. Acta Obstetricia et Gynecologica Scandinavica 81(11):1033-9. Ramsay DT, Kent JC, Hartmann RA et al (2005). Anatomy of the lactating human breast redefined with ultrasound imaging. Journal of Anatomy 206(6):525-34. Smith LJ (2007). Impact of birthing practices on the breastfeeding dyad. Journal of Midwifery & Women’s Health 52(6):621-30. Stellwagen L, Hubbard E, Chambers C et al (2008). Torticollis, facial asymmetry and plagiocephaly in normal newborns. Archives of Disease in Childhood 93(10):827-31. Tappero EP, Honeyfield ME eds (1993). Physical assessment of the newborn: a comprehensive approach to the art of physical examination. 1st ed. New York: Springer Publishing Company. Varendi H, Porter RH (2001). Breast odour as the only maternal stimulus elicits crawling towards the odour source. Acta Paediatrica 90(4):372-5. Watson J, Hodnett E, Armson BA et al (2012). A randomized controlled trial of the effect of intrapartum intravenous fluid management on breastfed newborn weight loss. JOGNN: Journal of Obstetric, Gynecologic & Neonatal Nursing 41(1):24-32. Ystrom E (2012). Breastfeeding cessation and symptoms of anxiety and depression: a longitudinal cohort study. BMC Pregnancy and Childbirth 12(36).

Rivett M. MIDIRS Midwifery Digest, vol 27, no 4, December 2017, pp 502-503. Original article. © MIDIRS 2017.


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A review of the safety of clozapine during pregnancy and lactation Taylor M Mehta, Ryan J Van Lieshout REPRINT Clozapine is an antipsychotic used in the management of treatment-resistant schizophrenia. However, little is known about clozapine use during pregnancy and lactation, or its impact on the mother, foetus, and infant. This review aims to summarize the available literature on the safety of clozapine use during the perinatal period. EMBASE, PsycINFO, and MEDLINE were searched from their inceptions through June 2016. The review encompasses 21 studies that have examined clozapine use during pregnancy and lactation. The limited available data do not support an increased risk of congenital malformations in foetuses exposed to clozapine during pregnancy, though rates of gestational diabetes are twice as high in pregnant women using clozapine. Clozapine accumulation in foetal serum possibly contributes to increased rates of floppy infant syndrome at delivery, decreased foetal heart rate variability, and seizures in infancy. Clozapine crosses the placenta and also accumulates in breast milk, which may increase the risk of agranulocytosis in infants and may necessitate infant testing. The majority of these data come from case reports and case series, making it unclear if the published risks associated with clozapine are due to mental illness, lifestyle factors, or co-treatment with other psychotropic medications. While the available literature on clozapine use during the perinatal period is very limited, the risks of clozapine use during pregnancy and the postpartum period should be discussed with women and weighed against those associated with other treatments and partially or untreated schizophrenia. Keywords: Pregnancy, postpartum period, clozapine, schizophrenia, treatment-resistant. Introduction Schizophrenia is a neuropsychiatric disorder characterized by delusions, hallucinations, disorganized speech and behaviour, and social or occupational dysfunction (American Psychiatric Association 2013). As the mean age of onset of schizophrenia in women is around 25 years, a significant number with the disorder are of childbearing age. Indeed, up to 60% of women with schizophrenia will become pregnant (Robinson 2012), and this population poses unique challenges as these women must balance their mental health treatment and their prenatal and postpartum care. The presence of schizophrenia during pregnancy and the postpartum period poses significant challenges to both the mother and her offspring. Foetal exposure to untreated schizophrenia is associated with an increased risk of stillbirth, preterm birth, congenital malformations, low birth weight, and elevated rates of infant death (Lin et al 2010, Nilsson et al 2002). Additionally, these women are more likely to develop placental abnormalities during pregnancy and are at increased risk for antepartum haemorrhage (Jablensky et al 2005). The cornerstone of schizophrenia management is antipsychotic medication (Canadian Psychiatric Association 2005). However, this is also associated with an increased risk of complications including 504

preterm birth, congenital malformations, and abnormal foetal growth (BodĂŠn et al 2012a). Additionally, when antipsychotic medications are stopped, patients are at high risk of relapse. This risk is even greater when medications are stopped abruptly, which is often the case during pregnancy (Robinson 2012). As both untreated and treated schizophrenia pose risks to the mother and the infant, it is essential that the benefits and risks of antipsychotic use during pregnancy and lactation are understood by women and their healthcare providers. A subset of women with schizophrenia who may be at particularly high risk for complications during pregnancy and lactation are those who have not responded to multiple courses of antipsychotic medication and have been labelled as treatmentresistant. One potential treatment option for these women is the antipsychotic clozapine. However, despite its clinical utility in treating treatmentresistant psychotic disorders, very little is known about its effects on women, foetuses, and infants. Clozapine is an antipsychotic that acts as a serotonin 5HT2A and dopamine D2 antagonist (Stahl 2013). It is indicated for the management of schizophrenia and has a relatively low risk of tardive dyskinesia and hyperprolactinemia (Stahl 2013). Clozapine may be more efficacious than other antipsychotics, MIDIRS Midwifery Digest 27:4 2017

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particularly in those with treatment-resistant illness, and has been shown to reduce the risk of suicide in those with schizophrenia (Hennen & Baldessarini 2005). Despite its promising clinical profile, clozapine is associated with an increased risk of serious side effects in patients including agranulocytosis, myocarditis, and seizures (Rajagopal 2005, Kilian et al 1999, Wong & Delva 2007), as well as weight gain, hypersalivation, and excess sedation (Miller 2000). The provision of evidence-based care to women with treatment-resistant schizophrenia and other mental disorders relies on a knowledge of the benefits and drawbacks of clozapine use during pregnancy and lactation. While evidence from non-human animal studies during pregnancy has not indicated an increased risk to the foetus, human data on perinatal clozapine use is currently limited (Armstrong 2008). This literature consists mainly of case studies and case series, with no recent reviews outlining its use during pregnancy and lactation. This review seeks to compile and summarize the available literature on clozapine use during pregnancy and lactation, providing a summary of its benefits, risks, and recommendations for use.

Methods To examine the effects of clozapine use during pregnancy and lactation, EMBASE, PsycINFO, and MEDLINE searches were conducted. The search terms (((pregnancy OR pregnan*) AND clozapine) OR ((lactation OR breastfeeding) AND clozapine)) were used. Searches were further limited to human studies and English language articles. This initial search resulted in 387 EMBASE articles, 22 PsycINFO articles, and 41 MEDLINE articles. The titles and abstracts of these articles were screened for relevance. Articles were excluded at this stage unless the abstract specifically addressed outcomes associated with clozapine use during pregnancy and/or lactation. Based on this screening, the full-text of 42 articles was read. The references of these articles were also screened for potential inclusion. A total of 21 articles were eligible for use in this review. HLS Therapeutics, Novartis, and Sandoz were contacted to locate additional information. HSL Therapeutics provided a brief literature search on clozapine use during the pregnancy and postpartum period; however, all of these articles had been previously located through our searches.

Results The risks of clozapine use during pregnancy and lactation are summarized below. Of the 21 eligible articles located in the searches, there were four case-control or cohort studies containing 61 cases, one summary paper with 102 cases, and 16 case studies and case series with 18 cases. Additionally, the Novartis database contains information on 523 cases. The results of these studies are summarized in Table 1. MIDIRS Midwifery Digest 27:4 2017

Clozapine use during pregnancy Risks to mother With respect to the risks posed to mothers, data suggest that women taking clozapine are more than twice as likely to have gestational diabetes mellitus compared to mothers not taking any antipsychotics (OR = 2.44 [95% CI 1.14–4.24]; Bodén et al 2012b). Additionally, cases of reduced haemoglobin, pregnancy-induced hypertension, and excess weight gain in pregnant women taking clozapine have been reported (Vavrusova & Konikova 1998, Gupta & Grover 2004, Barnas et al 1994). However, given that women with treatment-resistant schizophrenia may also be at increased risk for physical health problems, in the absence of control participants, it is unclear whether these risks are due to clozapine, the experience of serious psychotic illness, previous treatment, or a combination of these. Risks to foetus Research to date suggests that clozapine crosses the placental barrier, and so may pose a risk to the foetus during gestation (Bolén et al 2012b). In one case study, Barnas et al (1994) found that clozapine entered both the foetal plasma and the amniotic fluid. Additionally, there have been cases of foetuses exposed to clozapine who have demonstrated decreased heart rate variability (Guyon et al 2015, Yogev et al 2002). Heart rate variability is the variation in the time interval between heartbeats, and low heart rate variability may be predictive of an increased risk of cardiovascular disease and death in adults (Dekker et al 2000). Congenital malformations Data suggest that congenital malformations do occur in infants born to mothers taking clozapine. However, Novartis has reported only 22 congenital malformations in 523 cases (4.2%) of clozapine exposure during pregnancy (McKenna et al 2005). Additionally, Dev & Krupp (1995) described five cases of malformations among 61 babies (8.2%) exposed to clozapine. Bodén et al (2012b)) reported that infants born to mothers taking either clozapine or olanzapine are at increased risk for macrocephaly (OR = 3.02 [95% CI, 1.60– 5.71]) Shoulder dystocia has also been observed in multiple cases (Waldman & Safferman 1993, Dickson & Hogg 1998). Other observed malformations do not seem to follow any particular pattern but do include hyperpigmentation folds, a coccygeal dimple, a recessed mandible, hernia of the linea alba, a missing left testicle, craniosynostosis, hypospadias, hypertolism, gastroschisis, and horseshoe kidney (Stoner et al 1997, Karakula et al 2004, Kulkarni et al 2014). As some of the mothers of these infants took other medications during pregnancy, it is unknown if the genesis of these malformations is due to clozapine or the other medications. These studies could also not rule out that the malformations could 505

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Table 1. Summary of 20 eligible studies Study Review paper Dev & Krupp 1995a

Case-control studies Shao et al 2015

McKenna et al 2005

Number of cases 102



Case information

Pregnancy, delivery, Foetus and infant outcomes and maternal outcomes N/A - 8 non-elective - 5 malformations in 61 babies abortions in 102 cases - Agranulocytosis reported in 1 out of 4 babies who breastfed - Excessive sleepiness reported in 1 out of 4 babies who breastfed - Higher Apgar score at 1 minute - Cases: women taking clozapine (n = 33) - No significant differences for Apgar score at 5 minutes - Controls: women taking risperidone, - No significant differences for weight and olanzapine, or height at birth quetiapine (n = 30) - Lower mean adaptive-behaviour scores of Bayley-III at 2 and 6 months - No significant differences in meanadaptive-behaviour scores of Bayley-III at 12 months - Cases: women taking - No significant - No significant difference in cognitive, clozapine (n = 6), differences for language, motor, and social-emotional olanzapine (n = 60), spontaneous scored of Bayley-III at 2, 6 and 12 months risperidone (n = 49), abortions and labour - Higher rates of disturbed sleep at 2 and quetiapine (n = 36) complications months - Controls: women not taking antipsychotics (n = 105)

Cohort studies Kulkarni et al 2014



BodĂŠn et al 2012b


- Group 1: women taking clozapine (n = 11) or olanzapine (n = 159) - Group 2: women taking other antipsychotics (n = 338) - Group 3: women taking no antipsychotics (n = 357696)

- Higher rates of gestational diabetes in group 1 vs group 3)

Case series Duran et al 2008


Case 1: - 200 mg/day of clozapine - Case 2: - 200 mg/day of clozapine

Case 1: - Two uneventful pregnancies and deliveries Case 2: - Uneventful pregnancy and delivery of twins

Stoner et al 1997


Case 1: - 30 years old - 300 mg/day of clozapine but was noncompliant for 2 weeks before administration to a psychiatric unit at 23 weeks gestation - Unknown doses of lithium taken before hospitalization

Case 1: - Delivery at 39 weeks gestation Case 2: - Delivery at 40 weeks gestation


- No significant differences for mean gestational age, mean birth weight, major malformations, neonatal complications - One baby with craniosynostosis, hypospadias, and hypertolism - One baby with gastroschisis and horseshoe kidney - Increased risk of having a large head circumference in group 1 vs group 3 - Increased risk of being small for gestational age in group 1 vs group 3

Case 1: - Abnormal findings at birth: cephalhematoma, hyperpigmentation folds, and coccygeal dimple - All resolved at two days after delivery - Experienced seizure 8 days after delivery - Diagnosed with gastroenteritis and possible mild gastroesophageal reflux - No physical problems at 2-years - Postpartum low-grade fever that was resolved before discharge

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Table 1 continued Study

Number of cases

Case information - At least one dose of lorazepam, haloperidol, acetaminophen, guaifenesin, magaldrate, aluminium/ magnesium hydroxide, cephalexin, metronidazole, acetaminophen with codeine, multivitamin with folate, and clozapine at 350mg/ day given during hospitalization Case 2: - 32 years old - 600-625 mg/day of clozapine - Lithium taken prior to knowledge of pregnancy - 37 years old - 125 mg/day of clozapine - 25ug/day of levothyroxine - 27 years old - Clozapine was discontinued in first trimester - Switched to valproate, promethazine, risperidone, and fluoxetine

Case studies Guyon et al 2015


Klys et al 2007


Doherty et al 2006


- 33 years old

Mendhekar 2006


Gupta & Grover 2004


- 30 years old - 100 mg/day of clozapine - 25 years old Pregnancy 1: - 200 mg/day of clozapine - 1500 mg/day of methyldopate hydrochloride administered at 30 weeks

Karakula et al 2004


- 29 years old - 200 mg/day of clozapine

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Pregnancy, delivery, Foetus and infant outcomes and maternal outcomes

- Mild gestational diabetes at 26 weeks gestation that was managed with diet

- Foetal heart rate at 32 weeks gestation showed low variability with a normal baseline and accelerations - Normalized at 38 weeks gestation

- Delivery at 39 weeks gestation - Admitted to emergency at 39 weeks gestation - Found in bed have seizures and vomiting - Four empty boxes of clozapine with 50 tablets of 100 mg per box were found - Caesarean section performed under general anaesthesia - Uneventful delivery at 9 months and 2 days gestation

- Died 20 minutes after birth

- Late foetal heart rate decelerations - Breastfed until 1 year old - Delayed speech development until 5 years of age Pregnancy 1: - Normal developmental growth (measured until age 20 months) Pregnancy 2: - Normal development growth (measures until age 6 months)

Pregnancy 1: - Delivery at 39 weeks - Pregnancy-induced hypertension at 38 weeks gestation Pregnancy 2: - Caesarean section occurred at 39 weeks - Pregnancy-induced hypertension at 30 weeks gestation - Delivery by Caesarean - Medical indications at birth: arrhythmia section in foetus and threat of asphyxiation - 14 hours after birth: clonic-tonic convulsions, opisthotonus, lock-jaw, apnoea - Chest x-ray showed abnormal heart shape 507

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Table 1 continued Study

Number of cases

Case information -

Mendhekar et al 2003


Yogev et al 2002


Dickson & Hogg 1998


TĂŠnyi & Trixler 1998


Vavrusova & Konikova 1998



Pregnancy, delivery, Foetus and infant outcomes and maternal outcomes - Diagnoses at Intensive Unit for Newborns: convulsions, myocarditis suspected, organic heart disease suspected, malformations of CNS susp. - Diagnoses at Neonatal Pathology Ward: encephalopathy as a side effect of medical with convulsions and coma, respiratory insufficiency - Diagnoses at 10th day in hospital: mandibular recessed, decreased muscle tone, periodic convulsions in upper extremities, flaccid chest, dyspnoea, hernia of linea alba, left testicle not palpable, chord of connect tissue only - Diagnoses at 15th day in hospital: floppy infant syndrome, status post seizures, CNS under observation, missing left testicle - Delayed development at 7 months - Labour at 9 months - No reported foetal movements and 9 days - Delivered a macerated stillborn male baby

- 22 years old - 75 mg/day of clozapine; dose was reduced to 50 mg during first trimester and 62.5 mg in second trimester, but relapse quickly occurred both times - 31 years old - Two previous uncomplicated pregnancies - Labour at 37 weeks gestation - Hyperglycaemia - 28 years old before pregnancy - 450 mg/day of - Insulin prescribed to clozapine reduced manage diabetes to 200–250 mg/ day during second - Labour induced at 38 trimester, and 150 mg/ weeks day during final two - Delivery complicated months with shoulder dystocia - Metformin taken until pregnancy was confirmed - Insulin taken during pregnancy First pregnancy: - Early to mid-20s - Caesarean section at First pregnancy: 40 weeks - 100 mg/day of clozapine decreased to Second pregnancy: 50 mg/day at 12 weeks - Caesarean section at gestation 40 weeks Second pregnancy: Third pregnancy: - 25 mg/day of - Caesarean section clozapine Third pregnancy: - 25 mg/day of clozapine - 32 years old - 100 mg/day of clozapine

- Sight decrease of haemoglobin - Leukocytosis

- Decreased foetal heart rate variability with accelerations and no decelerations

First pregnancy: - Uneventful psychomotor development at age 6 Second pregnancy: - Uneventful psychomotor development at age 3.5 Third pregnancy: - Uneventful psychomotor development at age 1.5

- Atrial septal defect requiring surgery - Systolic murmur at 5 days

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Table 1 continued Study Di Michele et al 1996

Number of cases 1

Barnas et al 1994


Waldman & Safferman 1993


Case information - 37 years old - 200 mg/day of clozapine was increased to 300 mg/ day three times during pregnancy - 2.5 mg 3–5x daily of lorazepam - 31 years old - 100 mg/day of clozapine, reduced to 50 mg/day during at 9 weeks, returned to 100 mg/day three days after delivery - 30 years old

Pregnancy, delivery, Foetus and infant outcomes and maternal outcomes - Caesarean section at - Benign tachypnoea and mild floppy 37 weeks gestation infant syndrome - Hypotonia resolved 5 days later

- Weight gain of 25 kg - Delivery at 41 weeks gestation

- Physician only noticed pregnancy at 6 months - Development of gestational diabetes in second trimester - Labour induced at 38 weeks - Complicated with shoulder dystocia

Novartis registry 523 N/A - 22 infants with congenital malformations Novartis Registry a This review paper described risks of clozapine use during pregnancy and lactation; however, original citations were not provided.

be a result of schizophrenia and/or its associated life style changes. Miscarriage The few studies that examined the miscarriage rates of women taking clozapine have not supported an increased risk relative to the general population (Dev & Krupp 1995). However, there is one case report of foetal death in a treatment-resistant woman with schizophrenia who was taking 75 mg of clozapine a day (Mendhekar et al 2003). Complications at birth The accumulation of clozapine in foetal serum may put the offspring at risk for a variety of complications at delivery. One such problem is floppy infant syndrome, characterized by reduced muscle tone and decreased resistance to passive movements of joints (Igarashi 2004). This syndrome is associated with motor developmental delay, abnormal postures, and hyperextensibility of joints (Igarashi 2004), and has been reported in multiple case reports of women taking clozapine (Di Michele et al 1996, Karakula et al 2004). Additionally, neonatal seizures have been reported in a number of infants exposed to clozapine during pregnancy (Stoner et al 1997, Karakula et al 2004). Long-term outcomes of clozapine use during pregnancy Unfortunately, no data exist on the long-term outcomes of infants exposed to clozapine during pregnancy and lactation. The longest reported followMIDIRS Midwifery Digest 27:4 2017

up period of an infant exposed to clozapine appears to be 6 years, with typical psychomotor development reported at this age (Tényi & Trixler 1998).

Lactation Presence in breast milk Many women who take clozapine during pregnancy may wish to attempt to breast feed after delivery. The American Academy of Pediatrics (2001) has deemed clozapine a drug “for which the effect on nursing infants is unknown but may be of concern.” While few case reports exist, clozapine has been detected in breast milk. Barnas et al (1994) reported breast milk concentrations of clozapine for a woman taking 100 mg/day of clozapine who was switched to 50 mg/day in the last nine weeks of pregnancy. One week after delivery, the concentration of clozapine in breast milk was found to be 115.6 ng/mL (Barnas et al 1994). Additionally, the relative infant dose of clozapine has been calculated to be 1.33–1.4% of adult dosages (Hale 2012). Agranulocytosis is a major side effect of clozapine use in adults. Dev & Krupp (1995) examined the effects of four women on clozapine who breastfed their child and found that one of these infants developed agranulocytosis. Since clozapine crosses the placenta, it is also possible that exposure during gestation could produce agranulocytosis in infants postnatally. Increased sedation has also been noted in breastfeeding infants of mothers prescribed clozapine (Dev & Krupp 1995). 509

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Furthermore, a case study reported irregular speech development in a child who was breastfed for one year by a mother taking clozapine (Mendhekar 2006). Infant complications Shao et al (2015) studied infants whose mothers took clozapine during pregnancy and/or breastfeeding and compared them to other commonly used antipsychotics. Adaptive behaviour scores on the Bayley Scales of Infant and Toddler Development were significantly lower in the clozapine group at 2 months (89.1 vs 96.3) and 6 months (94.8 vs 100.5), although these differences disappeared at 12 months (Shao et al 2015). No significant differences were found on the other Bayley subscales, including the cognitive, social-emotional, language, and motor components (Shao et al 2015). Additionally, the 1-min Apgar scores of infants were similar in those whose mothers took clozapine versus other atypical antipsychotics (8.6 vs 8.3; Shao et al 2015). Furthermore, of the 33 clozapine-exposed infants tested in the study by Shao et al (2015), 75.8% also had disturbed sleep.

Discussion Very limited data have addressed the use of clozapine during pregnancy and lactation. Based on the available evidence, it appears that clozapine is associated with an increased risk of gestational diabetes mellitus in mothers, compared to the general population. For foetuses exposed to clozapine, congenital malformations have been reported, although the risk does not appear to exceed that of the general population. Clozapine does, however, accumulate in foetal serum, which may be due to the high concentration of albumin in foetal serum or ion trapping in the foetal compartment resulting in a pH gradient in the foetus (Barnas et al 1994). This may contribute to the increased rates of floppy infant syndrome, decreased heart rate variability, and seizures in foetuses. Finally, clozapine use during pregnancy or lactation may be associated with an increased risk of agranulocytosis and other complications in offspring. These clinical challenges have led some to suggest that clozapine should not be used during pregnancy (Larsen et al 2015, Uguz 2016), although it is important that its risks be weighed against the potential harm of untreated or sub-optimally treated schizophrenia during the perinatal period. While the relative infant dose associated with breastfeeding while taking clozapine appears low, it is associated with a number of potential complications. Clozapine accumulation in breast milk is most likely attributable to the lipophilic properties of clozapine and the high lipid concentration of breast milk (Ernst & Goldberg 2002). In the postpartum period, Barnas et al (1994) recommend keeping the clozapine dose as low as possible on the days immediately following delivery. Others have suggested that clozapine is not recommended for use during lactation because of the risk of bone marrow suppression and agranulocytosis 510

(Parikh et al 2014). Because of this risk, Kulkarni et al (2015) have suggested that if clozapine is used during pregnancy and lactation, newborns should have white blood cell monitoring once a week for 6 months. This is an important consideration when physicians and patients are discussing the benefits and drawbacks of clozapine use during pregnancy and the postpartum period. Indeed, more data are urgently needed to help inform women who wish to breastfeed while taking clozapine. Of course, whether clozapine should be used during pregnancy and lactation is a personal decision for women that should be discussed and assessed on a case-by-case basis. This should include not only a discussion of the risks associated with clozapine in particular and antipsychotics in general, but also the drawbacks of partially or untreated schizophrenia, as the risks of untreated schizophrenia can be significant for both women and their offspring. If a woman is treated with clozapine, it often implies that other treatments may have been less effective or even ineffective, or produced intolerable side effects. These issues need to be seriously considered before a woman taking clozapine during pregnancy switches to another medication or discontinues clozapine use. Unfortunately, evidence regarding the risks posed to women and foetuses by clozapine exposure in pregnancy is very limited. By their nature, studies lacking a control group prevent us from being able to determine the risks associated with untreated illness or even illness treated with other antipsychotics. Moreover, extant studies do not permit a determination of the contribution of psychiatric comorbidity, physical health problems, lifestyle factors, and polypharmacy to these risks. Furthermore, very few of the studies adjusted for factors that might confound associations between clozapine exposure and maternal and foetal outcomes. As a result, causal links cannot be inferred at this time and more research is sorely needed. Nonetheless, it is important that patients and clinicians be aware of the data that do exist.

Conclusion Howard et al (2001) suggest that as many as 63% of women with psychotic disorders are mothers. Therefore, evidence informing the risks and benefits of antipsychotic treatment during pregnancy and lactation is of critical importance. Clozapine is a potential treatment option for women with schizophrenia, particularly those who are treatment-resistant. Clozapine may be chosen after a full discussion of the benefits and drawbacks of treatment versus treatment with another agent versus no treatment. The evidence regarding the safety and efficacy of clozapine use during pregnancy and in postpartum is still very limited, and further research should be conducted to help women and their healthcare providers make better informed decisions about treatment. MIDIRS Midwifery Digest 27:4 2017

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Taylor M Mehta1 mehtatm@mcmaster.ca Ryan J Van Lieshout1,2 vanlierj@mcmaster.ca Department of Psychiatry and Behavioural Neurosciences, McMaster University, 1280 Main Street West, Hamilton, ON L8S 4K1, Canada 2 Women’s Health Concerns Clinic, St. Joseph’s Hospital, 100 West 5th Street, Hamilton, ON L8N 3K7, Canada 1

Acknowledgments The authors thank Dr Duncan Maccrimmon, Mr John Krzeczkowski, and Ms Eliza Pope for their helpful comments on an earlier version of this manuscript. Dr Van Lieshout is supported by the Albert Einstein/Irving Zucker Chair in Neuroscience.

References American Academy of Pediatrics. Committee on Drugs (2001). The trans­fer of drugs and other chemicals into human milk. Pediatrics 108(3):776-89. American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub. Armstrong C (2008). ACOG guidelines on psychiatric medication use during pregnancy and lactation. Obstet Gynecol 111(4):1001-20. Barnas C, Bergant A, Hummer M, Saria A, Fleischhacker WW (1994). Clozapine concentrations in maternal and fetal plasma, amniotic fluid, and breast milk. Am J Psychiatry 151(6):945.­­ Bodén R, Lundgren M, Brandt L, Reutfors J, Andersen M, Kieler H (2012a). Risks of adverse pregnancy and birth outcomes in women treated or not treated with mood stabilisers for bipolar disorder: population based cohort study. BMJ 345(6):e7085-e7085. Bodén R, Lundgren M, Brandt L, Reutfors J, Kieler H (2012b). Antipsychotics during pregnancy: relation to fetal and maternal met­abolic effects. Arch Gen Psychiat 69(7):715-21. Canadian Psychiatric Association (2005). Clinical practice guidelines: treatment of schizophrenia. Can J Psychiatr 50(13):7S. Dekker JM, Crow RS, Folsom AR, Hannan PJ, Liao D, Swenne CA, Schouten EG (2000). Low heart rate variability in a 2-minute rhythm strip predicts risk of coronary heart disease and mortality from sev­eral causes: the ARIC study. Circulation 102(11):1239-44. Dev V, Krupp P (1995). The side effects and safety of clozapine. Rev Contemp Pharmacother 6:197-208. Di Michele V, Ramenghi LA, Sabatino C (1996). Clozapine and loraze­pam administration in pregnancy. Eur Psychiat 11(4):214. Dickson RA, Hogg L (1998). Pregnancy of a patient treated with cloza­pine. Psychiatr Serv 49(8):1081-83. Doherty J, Bell PF, King DJ (2006). Implications for anaesthesia in a patient established on clozapine treatment. Int J Obstet Anesth 15(1):59-62. Duran A, Ugur MM, Turan S, Emul M (2008). Case report: clozapine use in two women with schizophrenia during pregnancy. J Psychopharmacol 22(1):111-13. Ernst CL, Goldberg JF (2002). The reproductive safety profile of mood stabilizers, atypical antipsychotics, and broad-spectrum psychotro­pics. J Clin Psychiat 63(Suppl 4):42-55. Gupta N, Grover S (2004). Safety of clozapine in 2 successive pregnan­cies. Can J Psychiatry 49(12):863. Guyon L, Auffret M, Coussemacq M, Béné J, Deruelle P, Gautier S (2015). Alteration of the fetal heart rate pattern induced by the use of clozapine during pregnancy. Therapie 70(3):301-03. Hale T (2012). Medications and mothers’ milk. Hale Publishing, Amarilla. Hennen J, Baldessarini RJ (2005). Suicidal risk during treatment with clozapine: a meta-analysis. Schizophr Res 73(2):139-45. Howard LM, Kumar R, Thornicroft G (2001). Psychosocial characteris­tics and needs of mothers with psychotic disorders. Brit J Psychiat 178(5):427-32. Igarashi M (2004). Floppy infant syndrome. J Clin Neuromuscul Dis 6(2):69-90. Jablensky AV, Morgan V, Zubrick SR, Bower C, Yellachich LA (2005). Pregnancy, delivery, and neonatal complications in a

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population cohort of women with schizophrenia and major affective disorders. Am J Psychiat 162(1):79-91. Karakula H, Szajer K, Rpila B, Grzywa A, Chuchra M (2004). Clozapine and pregnancy–a case history. Pharmacopsychiatry 37(6):303-304. Kilian JG, Kerr K, Lawrence C, Celermajer DS (1999). Myocarditis and cardiomyopathy associated with clozapine. Lancet 354(9193):1841-45. Klys M, Rojek S, Rzepecka-Woźniak E (2007). Neonatal death following clozapine self-poisoning in late pregnancy: an unusual case report. Forensic Sci Int 171(1):e5-e10. Kulkarni J, Worsley J, Gilbert H, Gavrilidis E, Van Rheenen TE, Wang W, McCauley K, Fitzgerald P (2014). A prospective co­hort study of antipsychotic medications in pregnancy: the first 147 pregnancies and 100 one year old babies. PLoS One 9(5):e94788. Kulkarni J, Storch A, Baraniuk A, Gilbert H, Gavrilidis E, Worsley R (2015). Antipsychotic use in pregnancy. Expert Opin Pharmacotherapy 16(9):1335-45. Larsen ER, Damkier P, Pedersen LH, Fenger-Gron J, Mikkelsen RL, Nielsen RE et al (2015). Use of psychotropic drugs during pregnancy and breast-feeding. Acta Psychiatr Scand 132(S445):1-28. Lin HC, Chen IJ, Chen YH, Lee HC, Wu FJ (2010). Maternal schizophre­nia and pregnancy outcome: does the use of antipsychotics make a difference. Schizophr Res 116(1):55-60. McKenna K, Koren G, Tetelbaum M, Wilton L, Shakir S, DiavCitrin O, Levinson A, Zipursky R, Einarson A (2005). Pregnancy outcome of women using atypical antipsychotic drugs: a prospective compara­tive study. J Clin Psychiat 66(4):444-49. Mendhekar DN (2006). Possible delayed speech acquisition with cloza­pine therapy during pregnancy and lactation. J Neuropsych Clin C 19(2):196-97. Mendhekar DN, Sharma JB, War L (2003). Clozapine and pregnancy. J Clin Psychiat 64(7):1-478. Miller DD (2000). Review and management of clozapine side effects. J Clin Psychiat 61(suppl 8):14-17. Nilsson E, Lichtenstein P, Cnattingius S, Murray RM, Hultman CM (2002). Women with schizophrenia: pregnancy outcome and infant death among their offspring. Schizophr Res 58(2):221-29. Parikh T, Goyal D, Scarff JR, Lippmann S (2014). Antipsychotic drugs and safety concerns for breast-feeding infants. South Med J 107(11):686-88. Rajagopal S (2005). Clozapine, agranulocytosis, and benign ethnic neu­tropenia. Postgrad Med J 81(959):545-546. Robinson GE (2012). Treatment of schizophrenia in pregnancy and post­partum. J Popul Ther Clin Pharmacol 19(3):e380-e386. Shao P, Ou J, Peng M, Zhao J, Chen J, Wu R (2015). Effects of clozapine and other atypical antipsychotics on infants development who were exposed to as fetus: a post-hoc analysis. PloS One 10(4):e0123373. Stahl SM (2013). Stahl’s essential psychopharmacology: neuroscientific basis and practical applications. Cambridge University Press, Cambridge. Stoner SC, Sommi RW, Marken PA, Anya I, Vaughn J (1997). Clozapine use in two full-term pregnancies. J Clin Psychiat 58(8):1-478. Tényi T, Trixler M (1998). Clozapine in the treatment of pregnant schizophrenic women. Psychiatr Danub 10:15-18. Uguz F (2016). Second-generation antipsychotics during the lactation period: a comparative systematic review on infant safety. J Clin Psychopharm 36(3):244-52. Vavrusova L, Konikova M (1998). Clozapine administration during preg­nancy. Ceska Slov Psychiatr 94:282-85. Waldman MD, Safferman AZ (1993). Pregnancy and clozapine. Am J Psychiat. Wong J, Delva N (2007). Clozapine-induced seizures: recognition and treatment. Can J Psychiat 52(7):457-63. Yogev Y, Ben-Haroush A, Kaplan B (2002). Maternal clozapine treatment and decreased fetal heart rate variability. Int J Gynecol Obstet 79(3):259-60.

Mehta TM, Van Lieshout RJ. Archives of Women’s Mental Health, vol 20, no 1, February 2017, pp 1–9. Reprinted with permission. © Springer-Verlag Wien 2016.


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Nutritional aspects of commercially prepared infant foods in developed countries: a narrative review Kate Maslin, Carina Venter Nutritional intake during infancy is a critical aspect of child development and health that is of significant public health concern. Although there is extensive research on breastfeeding and timing of solid food introduction, there is less evidence on types of solid foods fed to infants, specifically commercially prepared infant foods. The consumption of commercially prepared infant foods is very prevalent in many developed countries, exceeding the consumption of homemade foods in some situations. Although these food products may have practical advantages, there are concerns about their nutritional composition, sweet taste, bioavailability of micronutrients, diversity of ingredients and long-term health effects. The extent that the manufacturing, fortification and promotion of these products are regulated by legislation varies between countries and regions. The aim of the present narrative review is to investigate, appraise and summarise these aspects. Overall there are very few studies directly comparing homemade and commercial infant foods and a lack of longitudinal studies to draw firm conclusions on whether commercial infant foods are mostly beneficial or unfavourable to infant health. Maslin K, Venter C. Nutrition Research Reviews, vol 30, no 1, June 2017, pp 138–148.

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Author abstract. Š The Authors 2017.


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The experience of parents within neonatal units Caroline Thomas, Dave Clarke ORIGINAL This article will explore the experiences of parents in neonatal services and the challenges the multidisciplinary team face in supporting parents during this time of anxiety, grief and distress. Key points: • Neonatal services are finding it difficult to meet the demands placed upon them for a variety of reasons, including the increasing United Kingdom (UK) birth rate and the improved outcomes for babies in neonatal units. • Parents of premature and low birth weight babies admitted to neonatal services undergo a period of anxiety, grief and stress. • Specific strategies should be implemented to help parents come to terms with their baby’s health and their experience within neonatal services. Keywords: Parental care, neonatal services, family-centred care. Introduction

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The expectation of parenthood is that of cuddling, feeding and changing the newborn infant, essentially continuing the attachment and bonding process begun during pregnancy. However, parents of premature

and low birth weight infants may often feel that they are unable to provide the care and attention for their child in the way that they had expected. Parents may become distraught, experiencing feelings of inadequacy over their dependence upon nursing and

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medical staff to do what they had anticipated doing for their child (World Health Organization 2016). Moreover, NHS England (2013) suggests that the introduction of their new addition to family and friends is a natural expectation for parents and a chance to ‘show off’ their infant. However, when the infant requires treatment on the neonatal intensive care unit (NICU) this may not be possible. Within the UK there has been a rise in births over the last ten years. Figures for the period between 2002 to 2012 indicate an increase in births by 17%, and an increase in the birth of infants born prematurely (below 37 weeks’ gestation) by 7–8%. Additionally, Bliss (2016) reported an increase in the number of low birth weight infants of less than 2.500 gms by 7.1%. An increasing number of premature, low birth weight and term infants being born in the UK has put added pressure on neonatal services, which in turn may place pressure on nursing and medical staff. This paper will review the current state of neonatal services in the UK and the experience of parents in the NICU, as well as making recommendations for improving the quality of parental care within the NICU.

Neonatal services: standards and challenges Neonatal care has been severely underfunded and understaffed for many years, with recommendations to improve services, which included an initial investment of ten million pounds and an increase in staff, not being addressed in the UK (National Audit Office 2007). Mader et al (2010) purport that this issue is relevant to the whole of the UK and that subsequently quality of service will not be increased. The absence of substantial funding has now become a major cause for concern as the care of infants may be compromised by understaffing and under-resourcing. Bliss (2016) has specifically addressed and highlighted the fact that the shortfall in neonatal nurses could have a direct impact upon the health and well-being of newborn infants and their families and that although most neonatal unit staff provide excellent care, they do so in difficult circumstances. The Tucker & UK Neonatal Staffing Study Group (2002) found that nursing and medical understaffing is associated with higher rates of infant mortality, an increase in bacterial infections and higher levels of stress in staff. Moreover, Mader et al (2010) argue that not only will the care of infants in neonatal units be affected, but also care of the parents.

Parents in neonatal services Being the parent of a baby admitted to neonatal services is challenging and stressful. It is not unusual for parents to feel as though the infant is no longer theirs, that they are being prevented from caring for their infant by the nursing and medical staff, and hindered by the incubator and NICU environment (Heermann et al 2005). Traditionally the promotion 514

of family-centred care in the NICU would focus upon helping the family and child as a whole. However, often parents feel isolated and uninformed and it is therefore vital that they are kept up to date with the condition of their child. Any admission into the NICU must focus on both the care of the child and the parents. The unexpected preterm birth or birth of a sick child is a shocking and traumatic experience for parents, and nursing care must address the needs of the whole family, while ensuring that the health and well-being of the child is a priority. Jambulingam (2012) states that it has been well documented that parents, and in particular mothers, of infants admitted to the NICU are subject to high levels of stress and anxiety. The care and treatment of a premature/low birth weight or sick baby is in itself enough to instil parents with feelings of uneasiness and alarm, and the initial appearance of their infant often shocks and reduces parents to tears (Sweet & Mannix 2012). Additionally, parents having to communicate with nursing and medical staff and feeling afraid that the worst may happen to their child, often leads to anxiety, stress and depression. Indeed, Carter et al (2005) intimate parents may feel ill-equipped to deal with walking into the NICU to see their newborn child for the first time.

Parental emotional labour The number and variety of emotional reactions of parents noted within NICUs has been extensively researched and includes a mixture of feelings such as joy, loss, a sense of failure, grief, fear, anger, and loss of self-esteem (Affleck & Tennen 1991, Miles et al 1992, Miles et al 1993, Miles & HolditchDavis 1997, Singer et al 1999, Jackson et al 2003). Furthermore, Hall (2005) states that there may be the added anguish as to whether their infant will survive. Merenstein & Gardner (2006) expand on this notion suggesting feelings of bereavement are not unusual and parents may exhibit signs such as shock, denial, anger, depression, withdrawal and also acceptance of the infant’s condition. Heermann et al (2005) expostulate that mothers specifically may feel that they are outsiders and unable, or indeed not needed, to participate in the care of their infant. Several studies have examined the experiences of parents during the admission of their child to a NICU, and have evaluated their outcomes in relation to increased levels of stress within this environment. Some studies have made comparisons between parents of full-term infants and those parents whose infants have been admitted to a NICU (Miles & Holditch-Davis 1997, Carter et al 2005, Franck et al 2005). In comparison to parents of well, full-term infants, Singer et al (1999) purport it is generally regarded that parents of infants requiring care in a NICU may develop increased levels of stress, anxiety MIDIRS Midwifery Digest 27:4 2017

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and depression. Additionally, Doering et al (1999) determined mothers reporting higher stress levels than fathers in such circumstances. Busse et al (2013), when using the Parental Stress Survey NICU scale, found that parental stress increased, leading to sleep deprivation, increased anxiety and depression. The survey was self-reported, which could influence some factors within its reliability and validity, although two studies (Reid & Bramwell 2003, Franck et al 2005) concur with these findings. Reid & Bramwell (2003) and Franck et al (2005) elaborate further, highlighting areas of possible stresses within the neonatal environment, eg unfamiliar sights and sounds, the appearance of their infant possibly supported by equipment alien to the new parents, such as ventilators, monitors and medication pumps, and communication concerns with staff over such issues as receiving conflicting information.

Parental coping There are several factors which may determine an individual’s ability to cope with the birth of a preterm or sick infant. Lancaster et al (2010) noted that mothers who have suffered from stress during their pregnancy often go on to develop depression after delivery and beyond. In addition, this was often found to be associated with the absence of partner support, so it is vital that single mothers are provided with support and encouragement within the NICU to help them cope with their new infant (Lancaster et al 2010). Often parents feel too upset to visit, or they visit infrequently. They may not wish to hold or even touch their infant, and may feel unable to bond with their infant, apprehensive in case they potentially have to deal with a consequential loss (Aargaard & Hall 2008). Whilst some parents may have an excellent family and friendship support system and therefore feel more able to deal with such a situation, others could find themselves alone with no support other than nursing and medical staff who are unknown to the parent. It is therefore essential that nursing care incorporates the parents’ involvement to ensure that they are part of the decision-making process, provided with up to date information, feel welcome within the unit and that their wishes are respected. Reid et al (2007) maintain that introducing or supporting these factors may therefore ensure anxiety and distress is kept to a minimum.

Providing family-centred care Providing family-centred care for parents within the neonatal setting is challenging for the nursing and medical team. However, for parents who are trying to come to terms with their new parental role and the difficulties this may entail in having a child who is sick or preterm, family-centred care is essential (Nethercott 1993, Bliss 2010, Picker Institute Europe MIDIRS Midwifery Digest 27:4 2017

2011). Furthermore, Ramezani et al (2014) agree that holistic care of the child and family is an essential aspect of care. Nonetheless, Pinch & Spielman (1989) noted that care within neonatal units in practice does often defer to patriarchal methods of care whereby the medical and nursing staff control much of what parents can, or are allowed, to do. However, Bliss (2016) signifies that engaging parents in the care of their infant can help to reduce stress and anxiety and may in turn reduce pressure on neonatal staff. Daley & Willis (1989) consider that parents may want to defer their infant’s care to staff who they feel are more able to deal with the complexities of care required, until they feel able to provide care themselves. Today’s hospital environment should openly welcome the participation of families in the care of their infant, and provide a welcoming and non-judgmental attitude within the neonatal setting. This can be accomplished if they are provided with open access to visit their infant whenever they wish, instead of feeling that they are merely visitors. This can be facilitated by the nurse who should always introduce her or himself to parents and visitors. Moreover, Bliss (2016) recommends care should also be negotiated between the nurse and the parents to ensure that parents have plenty of opportunities to provide care for their infant.

Promoting family support Mader et al (2010) are of the belief that promoting family support and involvement is one area of neonatal care which is currently not encouraged as often as it should. The ‘Parents of Premature babies Project’ steering group (POPPY) (2009) highlighted that family-centred care within the UK is sadly lacking in neonatal units. They recommend that many improvements in family involvement can and should be made. POPPY (2009) also identified several interventions that nursing and medical teams could carry out that would help in the promotion of parenting, and also assist in reducing parental stress. These include: • ensuring that the parents are involved in and recognised as the most important aspect of the child’s psychosocial and developmental care • providing parents with the necessary education to help them care for their infant and any specific health needs • ensuring that any given communication and information provides an understanding of the infants’ developmental care needs and assistance with breastfeeding. It has also been suggested that care of the family is promoted during and following discharge. Once home, parents may often feel bewildered; both POPPY (2009) and the Picker Institute Europe (2011) have emphasised the importance of the neonatal outreach service which can help families to adjust. 515

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Reid et al (2007) suggest providing effective communication is one of the most important aspects of care within the NICU and can help reduce the stress and anxiety felt by parents when visiting such a highly technological environment. Fenwick et al (2000) argue that giving orders and instructing families as to what to do can be viewed as obstructive, rude and uncaring, whereas chatting to parents, asking what they feel would be best and instead offering help and reassurance, makes them feel that they are being talked to as friends, and that their role as parents is respected. In addition, Taylor (2008) concludes that infants are often cared for within the neonatal environment for long periods. A prolonged stay will mean that the relationship between parents, staff and infant will become more involved and can therefore change during this time, and it is crucial that a good relationship between nurse and parent is developed. Moreover, Spence (2000) states that the nurse should enhance the parent’s ability to engage in the decision-making process regarding the care of their child. However, Stein-Parbury (2000) intimates false reassurance is sometimes given by a nurse who makes a dismissive comment in an effort to provide reassurance and is unsure what to say; this can often confuse and upset parents who are trying to come to terms with their infant’s condition and need accurate information, assistance and support. On the other hand, Sheeran et al (2013) consider at times mothers feel that their opinion is not required, or that they are not allowed to participate in decision making regarding the ongoing care of their child. Additionally, mothers may feel that their opinions are not valued or that some nursing staff are better able to explain treatments or problems than others, which could cause upset, confusion and conflict between staff and families. Some mothers also feel that nursing staff exerted power over them by restricting access to their infants. Picker Institute Europe (2011) confirmed that although steps are being carried out to improve family care within neonatal units, there still remain areas of great concern. The survey concluded that 65% of parents could not speak to a doctor at a time that was convenient to them, 34% were not provided with any written information regarding their child’s condition or treatment, and that when an admission was known to be a possibility before delivery, 43% of parents were not given any support regarding any possible difficulties their infant may experience. In point of fact, Howell & Graham (2011) also suggest parents were not given an opportunity to visit the neonatal environment. The multidisciplinary team need to make themselves aware of the potential impact upon parents who are feeling anxious and stressed. Providing relevant information and support to parents consistently is essential as it can help to reduce the likelihood of parents feeling detached from their infant, and therefore unable to bond (Coyne et al 2011). 516

The British Association for Perinatal Medicine (BAPM) (2010) advises that parents should be able to access psychological help and support as soon as possible following admission of their infant to the unit. A mother’s ability to cope with giving birth to a sick or premature infant may depend upon the level and amount of emotional and psychological support she has received (Howland 2007). Providing emotional support to parents within the neonatal environment has been shown to help in reducing stress, anxiety and depression (National Collaborating Centre for Mental Health (UK) 2005, Poppy 2009). Parker (2011) considered it was clearly felt by all mothers that counselling was an essential aspect of parental well-being within the neonatal unit. It was further suggested that counsellors should be drawn from neonatal nursing staff, as parents felt that only someone who was in such an environment would understand their feelings and needs. However, neonatal staff are already stretched and both BAPM (2010) and Bliss (2016) advocate extensive psychological support, which should include bereavement support, counsellors, psychological advice and access to a social worker.

Conclusion It is clear that neonatal services are increasingly placed under pressure and that they may not be able to always meet the professional standards laid out by organisations such as BAPM (2010) in the context of staffing shortages and an increasing rate of admission. It is also clear that the care of babies admitted to neonatal services has to be the first concern of the multidisciplinary team. However, ensuring that parents are offered both emotional and psychological support, and that they are informed and involved in their baby’s care and feel welcome to be with their baby, will assist with parental bonding and the longterm relationship parents have with their child after discharge from neonatal services. Specific recommendations neonatal services should consider are: • Ensuring national standards for nursing staff levels are met, although it is acknowledged that this is increasingly difficult in the current recruitment climate. • Providing psychological support to parents and ensuring that the needs of fathers are not overlooked. • Promotion and expansion of community outreach services to offer continued support to families. Caroline Thomas, Staff Nurse, Neonatal Unit, Royal Glamorgan Hospital. Dave Clarke, Professor of Nursing, College of Medicine, Psychology and Biological Sciences, University of Leicester. MIDIRS Midwifery Digest 27:4 2017

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References Aagaard H, Hall EO (2008). Mothers’ experiences of having a preterm infant in the neonatal care unit: a meta-synthesis. Journal of Pediatric Nursing 23(3):e26-36. Affleck G, Tennen H (1991). The effect of newborn intensive care on parents’ psychological well-being. Children’s Health Care 20(1):6-14. Bliss (2008). BLISS baby report 2008: neonatal care in Scotland. London: Bliss. Bliss (2010). The chance of a lifetime? Bliss baby report 2010. London: Bliss. Bliss (2016). BLISS baby report 2016: time for change: Wales. London: Bliss. British Association for Perinatal Medicine (2010). Service standards for hospitals providing neonatal care. 3rd ed. London: BAPM. https://www.bapm.org/resources/service-standards-hospitalsproviding-neonatal-care-3rd-edition-2010 [Accessed 15 June 2013]. Busse M, Stromgren K, Thorngate L et al (2013). Parents’ responses to stress in the neonatal intensive care unit. Critical Care Nurse 33(4):52-9. Carter JD, Mulder RT, Bartram AF et al (2005). Infants in a neonatal intensive care unit: parental response. Archives of Disease in Childhood - Fetal and Neonatal Edition 90(2):F109-13. Coyne I, O’Neill C, Murphy M et al (2011). What does familycentred care mean to nurses and how do they think it could be enhanced in practice. Journal of Advanced Nursing 67(12):2561-73. Daley J, Willis E (1989). Technological innovation and the labour process in health care. Social Science & Medicine 28(11):1149-57. Doering LV, Dracup K, Moser D (1999). Comparison of psychosocial adjustment of mothers and fathers of high-risk infants in the neonatal intensive care unit. Journal of Perinatology 19(2):132-7. Fenwick J, Barclay L, Schmied V (2000). Interactions in neonatal nurseries: women’s perceptions of nurses and nursing. Journal of Neonatal Nursing 6(6):197-203.

Miles MS, Holditch-Davis D (1997). Parenting the prematurely born child: pathways of influence. Seminars in Perinatology 21(3):254-66. National Audit Office (2007). Caring for vulnerable babies: the reorganisation of neonatal services in England. London: Stationery Office. National Collaborating Centre for Mental Health (UK) (2005). Depression in children and young people: identification and management in primary, community and secondary care. Leicester: British Psychological Society. Nethercott S (1993). A concept for all the family. Family centred care: a concept analysis. Professional Nurse 8(12):794-7. NHS England (2013). High quality care for all, now and for future generations: transforming urgent and emergency care services in England. The evidence base from the Urgent and Emergency Care Review. https://www.england.nhs.uk/wp-content/uploads/2013/06/ urg-emerg-care-ev-bse.pdf. [Accessed 3 March 2013]. Parents of Premature babies Project (2009). Family-centred care in neonatal units: A summary of research results and recommendations from the POPPY project. London: NCT. http://www.nna.org.uk/ html/POPPY_Family%20centered%20care.pdf [Accessed 15 March 2013]. Parker L (2011). Mothers’ experience of receiving counselling/ psychotherapy on a neonatal intensive care unit (NICU). Journal of Neonatal Nursing 17(5):182-9. Picker Institute Europe (2011). Picker Institute - making patients’ views count. Guideline Ref ID PICKER2011. Pinch WJ, Speilman ML (1989). Parental voices in the sea of neonatal ethical dilemmas. Issues in Comprehensive Pediatric Nursing 12(6):423-35. Ramezani T, Hadian Shirazi Z, Sabet Sarvestani R et al (2014). Family-centred care in neonatal intensive care unit: a concept analysis. International Journal of Community Based Nursing and Midwifery 2(4):268-78.

Franck LS, Cox S, Allen A et al (2005). Measuring neonatal intensive care unit-related parental stress. Journal of Advanced Nursing 49(6):608-15.

Reid T, Bramwell R (2003). Using the Parental Stressor Scale: NICU with a British sample of mothers of moderate risk preterm infants. Journal of Reproductive and Infant Psychology 21(4):279-91.

Hall EOC (2005). Being in an alien world: Danish parents’ lived experiences when a newborn or small child is critically ill. Scandinavian Journal of Caring Sciences 19(3):179-85.

Reid T, Bramwell R, Booth N et al (2007). Perceptions of parentstaff communication in neonatal intensive care: the findings from a rating scale. Journal of Neonatal Nursing 13(2):64-74.

Heermann JA, Wilson ME, Wilhelm PA (2005). Mothers in the NICU: outsider to partner. Pediatric Nursing 31(3):176-81.

Sheeran N, Jones L, Rowe J (2013). The relationship between maternal age, communication and supportive relationships in the neonatal nursery for mothers of preterm infants. Journal of Neonatal Nursing 19(6):327-36.

Howell E, Graham C (2011). Parents’ experiences of neonatal care: a report on the findings from a national survey. Oxford: Picker Institute Europe. http://www.picker.org/wp-content/ uploads/2014/10/Parents-experiences-of-neonatal-care....pdf [Accessed 15 March 2013]. Howland LC (2007). Preterm birth: implications for family stress and coping. Newborn and Infant Nursing Reviews 7(1):14-19. Jackson K, Thernestedt BM, Scollin J (2003). From alienation to familiarity: experiences of mothers and fathers of preterm infants. Journal of Advanced Nursing 43(2):120-9.

Singer LT, Salvator A, Guo S et al (1999). Maternal psychological distress and parenting stress after the birth of a very low-birthweight infant. JAMA 281(9):799-805. Spence K (2000). The best interest principle as a standard for decision making in the care of neonates. Journal of Advanced Nursing 31(6):1286-92. Stein-Parbury J (2000). Patient and person: interpersonal skills in nursing. 2nd ed. Sydney: Churchill Livingstone.

Jambulingam M (2012). Anxiety in mothers with preterm infants in the neonatal intensive care unit. JOGNN: Journal of Obstetric, Gynecologic & Neonatal Nursing 41(Suppl 1):S152.

Sweet L, Mannix T (2012). Identification of parental stressors in an Australian neonatal intensive care unit. Neonatal, Paediatric and Child Health Nursing 15(2):8-16.

Lancaster CA, Gold KJ, Flynn HA et al (2010). Risk factors for depressive symptoms during pregnancy: a systematic review. American Journal of Obstetrics and Gynecology 202(1):5-14.

Taylor LS (2008). A Rites of Passage analysis of the families’ experience of premature birth. Journal of Neonatal Nursing 14(2):56-60.

Mader S, Merialdi M, Keller M (2010). EU Benchmarking Report 2009/2010: Too little, too late? Why Europe should do more for preterm infants. European Foundation for the Care of Newborn Infants. http://www.efcni.org/fileadmin/Daten/Web/Brochures_ Reports_Factsheets_Position_Papers/benchmarking_report/ EFCNI_report_light_copyright.pdf [Accessed 15 March 2013].

Tucker J, UK Neonatal Staffing Study Group (2002). Patient volume, staffing and workload in relation to risk-adjusted outcomes in a random stratified sample of UK neonatal intensive care units: a prospective evaluation. The Lancet 359(9301):99-107.

Merenstein BG, Gardner SL (2006). Handbook of neonatal intensive care. 6th ed. St. Louis, MO: Mosby Elsevier.

World Health Organization (2016). Preterm birth: fact sheet. www. who.int/mediacentre/factsheets/fs363/en [Accessed 15 March 2013].

Miles MS, Funk SG, Kasper MA (1992). The stress response of mothers and fathers of preterm infants. Research in Nursing & Health 15(4):261-9.

Thomas C, Clarke D. MIDIRS Midwifery Digest, vol 27, no 4. December 2017, pp 513-517.

Miles MS, Funk SG, Carlson J (1993). Parental stressor scale: neonatal intensive care unit. Nursing Research 42(3):148-52.

Original article. © MIDIRS 2017.

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Piloting kangaroo mother care in the community: dyadic responses to a novel innovation facilitating skin-to-skin contact Roisin Bailey, Helen McIntyre, Merryl Harvey ORIGINAL Introduction Skin-to-skin contact between a mother and her baby may first occur straight, or soon after birth, where the naked baby is dried and placed prone on the mother’s bare chest. The maternal chest is regarded as the ideal evolutionary habitat for the fulfilment of the baby’s immediate and long-term biological needs through its own neurodevelopment, such as the establishment of feeding (Moore et al 2016). Kangaroo mother care (KMC) was developed in Bogotá, Colombia in 1979 (Rey & Martínez 1983). It consists of a care package that incorporates early, continuous, or prolonged mother-baby skin-toskin contact, ideally with exclusive breastfeeding, and early discharge from the hospital unit, with appropriate neonatal follow-up (World Health Organization 2003). This care package was designed in response to inadequate incubator facilities for low birth weight babies which, once stable, required support only to feed and grow (World Health Organization 2003). A systematic review of trials using KMC demonstrated a reduction in neonatal morbidity and mortality rates in low birth weight and premature babies when compared to babies receiving incubator care (Conde-Agudelo & Díaz-Rossello 2016). Meta-analysis of neonatal outcomes for preterm and full-term babies being cared for in KMC demonstrated a reduction in the incidence of neonatal sepsis, hypothermia and hyperthermia, hypoglycaemia, and hospital readmission — concluding that implementation strategies were necessary to facilitate KMC across the neonatal population (Boundy et al 2016). Breastfeeding behaviour also differs between babies receiving KMC and those receiving swaddling or cot care. Mother-baby skin-to-skin contact following birth results in increased effectiveness of the first breastfeed (Moore et al 2016), and is associated with an increase in breastfeeding exclusivity up to six months postpartum (Vaidya et al 2005). Despite rigorous data on safety and neonatal health benefits, implementation of KMC within highincome settings has remained low (Engmann et al 2013). UNICEF’s Baby Friendly Initiative standards advocate maintaining close proximity between the mother and baby, and skin-to-skin contact from birth, and throughout the postnatal period (UNICEF UK Baby Friendly Initiative 2012). However, routine separation of mothers and babies immediately following birth has occurred widely in industrialised nations since the 20th century, with babies being dressed and wrapped, and cared for in a crib or nursery (Moore et al 2016). Further separation of the mother-baby dyad may result from obstetric or neonatal medical interventions, such as maternal caesarean section, or admission to a neonatal special care unit. Specific to the UK, extremely low breastfeeding rates, coupled with discouragement of motherbaby bed-sharing, based on the association between co-sleeping and sudden infant death syndrome (National Institute for Health and Care Excellence (NICE) 2006, The Lullaby Trust 2017), may also contribute to the separation of the baby from the evolutionary habitat of the maternal chest. A novel innovation A novel health innovation has been designed to facilitate dyad-led KMC in the context of a population of healthy mothers, and their healthy, term babies. This aims to counteract the routine separation of the dyad on a non-medical basis both in acute 518

settings, and within the community. It constitutes a specially-designed soft, cotton top with an in-built pouch to support the baby against the mother’s chest. This can be used at home or within the hospital or birth centre, and as frequently, or for as long as, the mother wishes. MIDIRS Midwifery Digest 27:4 2017

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The garment was commissioned by Dr Helen McIntyre, Senior Midwifery Lecturer at Birmingham City University, and has been developed as part of a joint enterprise between the midwifery and fashion departments. The garment is currently pending patenting, prior to further production. This pilot study is part of a larger PhD research project, and opens a growing research focus with Birmingham City University, investigating the effects of a facilitation strategy of KMC on maternal and neonatal health and well-being.

Ethics The research proposal was presented to both the Health, Education and Life Sciences Faculty Academic Ethics Committee at Birmingham City University, and the Health Research Authority. Favourable ethical opinion was gained from both committees.

Aims The research project aims to explore what impact the facilitation of skin-to-skin contact may have on skin-to-skin contact uptake and duration, infant feeding practices, maternal-infant interaction and bonding, and maternal experience of using the innovation as part of motherhood. A pilot study was designed to trial the garment with a minimum of ten healthy mother-infant dyads, receiving routine postnatal and neonatal care in the community. The pilot study aimed to investigate the garment’s effect on neonatal thermoregulation, maternal-infant feeding and responsiveness, and the maternal perception of wearing and using the garment. This constituted a preliminary safety and efficacy evaluation of the garment to guide subsequent design and methodology changes necessary for a larger trial.

Methodology Recruitment The mixed method design of the pilot study gathered quantitative and qualitative data on safety, efficacy and experience of using the garment to facilitate kangaroo care. Direct observation of the motherinfant dyads using the garment at home was used to collect data on the dyad’s behaviour whilst having skin-to-skin contact. This direct observation occurred on a single occasion, lasting between forty minutes to two hours, as led by the maternal participant. A table was completed by the maternal participants, documenting neonatal axilla temperature readings and a multiple-choice neonatal behavioural state ranking, recorded before and thirty minutes into the skin-to-skin episode. In addition to participant-led data collection, verbatim comments elicited spontaneously, or through direct questions related to the design, fit, and appearance of the garment, were transcribed, and researcher field notes documenting maternal vocal tone and body language, and signs of MIDIRS Midwifery Digest 27:4 2017

mother-infant reciprocal bonding and feeding were recorded contemporaneously. A checklist was used as an audit tool to assess the safe positioning and fit of the garment, completion of the data collection sheet, and adherence to the study documentation detailing safe usage and correct thermometer use. The checklist was completed by the researcher at the end of the home visit. The methodology was designed to be woman-centred, with the data collection taking place at the mother’s home, and the mother instigating and discontinuing the data collection episode, as well as assessing and recording her baby’s temperature and behaviour.

Setting Pregnant and postnatal women were recruited across three months in the inpatient and outpatient settings of an NHS trust in England facilitating around 6000 births per year. Participants were recruited from antenatal and postnatal wards, parent craft classes, and antenatal and community clinics. Data collection visits took place in the participants’ homes across the locality. Several visits took place during unusually high seasonal temperatures, averaging 20–30 degrees Celsius.

Sample recruitment The sample of women all met inclusion criteria of a singleton pregnancy, with spontaneous or induced labour on or after 37 weeks’ gestation, resulting in a vaginal birth. Maternal participants had booked their pregnancy at a specific NHS trust in England, and had basic spoken English as a first or additional language. Participants were recruited antenatally, irrespective of pregnancy-risk status that did not affect the exclusion criteria. Maternal exclusion criteria were: aged less than 16 years old, multiple pregnancy, a caesarean birth, current high-dependency care, and significant child protection concerns. Maternal participants were diverse in ethnicity, nationality, age and parity. Nine of the 11 participants’ postcodes generated an Index of Multiple Deprivation score (National Perinatal Epidemiology Unit 2017); the remaining two postcodes produced no results. Eight of the nine scores were within the 5th centile of most deprived, and one was in the 3rd centile. The sample of infants all met inclusion criteria of a birth weight >/2500g, born at or after 37 completed gestational weeks, aged from newborn to six weeks old. Infants requiring transitional, special or intensive care at the time of data collection were excluded from the study. Inclusion and exclusion criteria were applied antenatally following an expression of interest in the study, and repeated postnatally following birth, prior to consenting to participate. Demographic, medical, obstetric, and neonatal details were reviewed from the participant’s maternity notes to ensure eligibility criteria were met, with prior consent. 519

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Participants had a minimum of two weeks to consider participation after receiving a participant information sheet. Of the 18 women who expressed interest antenatally, and remained eligible for participation, 11 chose to participate in the study.

Instruments and equipment Neonatal axilla temperatures were monitored using Omron EcoBasic axilla thermometers, issued by the researcher to each participating dyad. Garments were issued to each participating dyad based on maternal pre-pregnancy clothing size. Garments were returned to the researcher immediately following data collection until preliminary pilot data analysis and quality control testing demonstrated no issues with quality or design. Following this, participants that remained in the six week postnatal period could opt to have the garment back. No cost was incurred by the participants for study equipment or participation.

Outcome measures Axilla temperatures were recorded to one decimal place as displayed on the thermometers. Temperatures within the range of 36.5–37.5 degrees Celsius were regarded as normal (Wyllie et al 2015). The same researcher recorded field notes with each dyad, including on infant feeding. This constituted whether the infant had a breast or bottle feed, infant feeding cues and maternal responsiveness, and the infant’s positioning for the feed, recorded as longitudinal, oblique, or transverse in relation to the maternal spine (Colson 2005). Infant feeding cues and maternal responsiveness were assessed using Cadwell’s breastfeeding assessment (2007) and themes from the Responsiveness to Child Feeding Cues Scale (Hodges et al 2013), which applied to neonates. An 11 point checklist was completed by the researcher to audit compliance to safe usage instructions, completion of the data collection sheets, and axilla temperatures within normal parameters (Wyllie et al 2015). Checklists scoring 11/11 were the outcome measure for safe usage of the garment and appropriate documentation.

Recruitment and retention The target for recruitment was met and exceeded, with one additional participating dyad. Recruitment took place over three months, with one third of the thirty-three women recruited antenatally proceeding to study enrolment. A fifty per cent attrition rate was forecast, which was exceeded, with a recruitment to enrolment attrition rate of 66%.

Results Safety checklist All audit checklists scored a maximum of 11/11, demonstrating participant adherence to the study design and safety information. Neonatal temperature and behaviour changes with the garment The eleven participating dyads collected data on the neonate’s behaviour and temperature before, and during, skin-to-skin contact. The second range of temperatures were taken 30 minutes after the commencement of skin-to-skin contact, apart from dyads 1 and 7, where the second temperature was taken at 15 minutes, prior to maternal-led discontinuation of the skin-to-skin episode. Neonatal axilla temperature The mean temperature difference of the neonates before and during skin-to-skin contact was 0.0 degrees Celsius, with the mode average of temperature differences -0.1 degrees Celsius. These temperature fluctuations lack clinical or statistical significance in this study. There were no incidences of hypothermia or hyperthermia during participation; the garment maintained normothermic temperatures in all 11 neonates. Neonatal behaviour The most commonly identified neonatal behaviour prior to commencing skin-to-skin contact was ‘hungry’ (6/11 neonates). Of these six, all went on to breastfeed in skin-to-skin contact.

Table 1. Dyad demographic details. Dyad subject Maternal age (years) 1 29 2 26 3 39 4 23 5 26 6 35 7 30 8 30 9 24 10 27 11 32

Parity 3 2 1 2 1 3 2 1 1 2 2

Ethnicity and nationality 5 5 1 6 4 7 2 6 2 5 1

Gestation at birth (week+day) 42+2 39+6 39+4 42+2 40+4 38+3 38+4 41+6 40+5 37+5 41+0


Neonatal age (days) 20 9 5 12 4 6 14 7 10 11 9

Neonatal birth weight (grams) 3050 3240 3320 3840 3300 2900 4000 3160 3320 2500 4300

Ethnicity key: 1 White British, 2 White European, 3 Irish Traveller/Roma, 4 Black British, 5 Black African/Caribbean, 6 British Asian – Indian subcontinent, 7 Asian – Indian subcontinent, 8 Asian – other, 9 Mixed ethnicity. Birth type key: SVB Spontaneous vaginal birth, NBF Neville Barnes forceps assisted birth, VEN Ventouse assisted birth.


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Table 2. Neonatal temperature and behaviour during garment facilitated skin-to-skin contact (SSC). Neonate Feeding practice 1 BF 2 BF 3 FF 4 MF 5 BF 6 BF 7 MF 8 FF 9 MF 10 BF 11 FF

Temperature before SSC (°C) 36.7 37.1 36.5 36.7 37.0 36.9 36.9 36.8 36.9 36.6 36.6

Temperature during SSC (°C) 36.8 37.0 36.6 36.9 36.9 36.8 36.8 36.7 36.7 36.6 36.8

Temperature difference (°C) +0.1 -0.1 +0.1 +0.2 -0.1 -0.1 -0.1 -0.1 -0.1 0 +0.2

Behaviour before SSC 3 3 2 3 3 3 3 4 4 1 4

Behaviour after SSC 4 2 4 4 2, 4 4 2 2 4 4 4

Duration of SSC (minutes) 15 40 60 45 40 40 15 37 43 30 40

Feeding key: BF Breastfeeding exclusively, or with the addition of expressed breast milk supplementation, MF Mixed feeding including breastfeeding and formula feeding, with or without expressed breast milk supplementation, FF Formula feeding exclusively. Neonatal behaviour key: 1 Unsettled, 2 Settled, 3 Hungry, 4 Asleep.

Maternal reactions to their perception of a hungry baby were similar across all six dyads, with breastfeeding initiated by all of the dyads within the first 30 minutes of skin-to-skin contact. None of the mothers identified that skin-to-skin contact had led to their baby being unsettled. Two mothers, who had moved from breastfeeding to formula feeding, voiced their concern prior to skinto-skin contact that having skin-to-skin contact may unsettle the baby by encouraging rooting at the breast. However, both reported the behaviour as settled or asleep during skin-to-skin contact, with one of the mothers giving a formula feed part way through. Infant feeding cues and maternal responsiveness Feeding cues were observed in eight of 11 dyads. These were increased activity (n=5), head bobbing (n=8), rooting (n=3), and fussing (n=2). Although six babies were described by their mothers as ‘hungry’ prior to skin-to-skin contact, eight went on to exhibit feeding cues when in skin-to-skin contact. Of the eight exhibiting feeding cues, all eight mothers responded by instigating or facilitating a feed, in seven instances, a breastfeed, and in one instance, a formula feed. Of the two neonates who displayed feeding cues and were mixed feeding, both were breastfed rather than formula fed during the skin-to-skin contact.

baby ‘really liked it’, and one mother asked her baby ‘What’re you thinking about? Are you happy?’ All 11 mothers increased verbalisations to their babies on commencement of skin-to-skin contact, including use of rhetorical questions, and infant-directed speech.

Maternal experience using the garment Maternal participants remarked positively on the design, fit, and appearance of the garment. Simple word repetition identified ‘safe’, ‘secure’, and ‘comfortable’ as the most frequently used descriptors of the garment. None of the participants reported a negative experience; however, one participant discontinued skin-to-skin contact as she felt too hot.

Discussion In the 11 episodes of trialling the innovation, no adverse outcomes occurred; there was no deterioration perceived in neonatal behaviour, no clinically significant fluctuations in neonatal temperature, and no unsafe positioning of the infant in the garment pouch. Pilot findings suggest the design maintains neonatal temperatures in a thermo-neutral range, with no clinically significant fluctuations in temperature.

Maternal responses to feeding cues included verbal cooing and smiling (n=4), stroking of the baby’s back and head (n=2), and facilitating the move to the nipple (n=7). Other maternal behaviour noted following feeding cues were: facilitating a change of the baby’s position (n=5), reclining their position (n=4), gazing or reciprocal eye contact (n=4), and laughter (n=1).

Further research is required with an adequately powered sample size to compare neonatal temperature fluctuation in the garment to that in conventionally facilitated skinto-skin contact. A mixed method, randomised, controlled trial is planned, involving the recruitment of a larger sample of mother-infant dyads meeting the same inclusion and exclusion criteria. Recruitment for the randomised controlled trial will take place at the same NHS trust in England, targeting an ethnically diverse and socioeconomically disadvantaged urban population.

Dyadic interaction was heightened following commencement of skin-to-skin contact. Four of the 11 mothers expressed their perception of how the baby was feeling. Two mothers spontaneously reported that their baby ‘loved it’, one mother reported that her

The unanticipated use of the garment to support a breastfeed in skin-to-skin contact has emerged from the pilot observations, as mothers used and adapted the garment to support their preferred positioning for breastfeeding. Further research is

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needed to understand the garment’s potential role in breastfeeding uptake, continuation, and exclusivity, in order to guide breastfeeding support practices. Positive maternal experiences conveyed in this pilot study warrant further exploration of the mother’s voice in providing KMC. Experiences of using skinto-skin contact at home in the postnatal period will be explored in small focus groups, providing womancentred data to guide facilitation strategies to support ongoing skin-to-skin contact. This pilot study supports further exploration into the potential effect skin-to-skin facilitation may have on neonatal thermoregulation, breastfeeding, dyadic bonding, and the mother’s experience of caring for her baby through the postnatal period. Roisin Bailey, Registered Midwife, PhD student, and Assistant Lecturer in Midwifery, Birmingham City University. Dr Helen McIntyre, DHSci, Registered Midwife, Senior Lecturer in Midwifery, Birmingham City University. Dr Merryl Harvey, PhD, Professor of Nursing and Family Health, Birmingham City University.

References Boundy EO, Dastjerdi R, Spiegelman D et al (2016). Kangaroo mother care and neonatal outcomes: a meta-analysis. Pediatrics 137(1). Cadwell K (2007). Latching-on and suckling of the healthy term neonate: breastfeeding assessment. Journal of Midwifery and Women’s Health 52(6):638-42.

Colson S (2005). Maternal breastfeeding positions: have we got it right? (2). Practising Midwife 8(11):29-32. Conde-Agudelo A, Díaz-Rossello JL (2016). Kangaroo mother care to reduce morbidity and mortality in low birthweight infants. The Cochrane Database of Systematic Reviews, Issue 8. Engmann C, Wall S, Darmstadt G et al (2013). Consensus on kangaroo mother care acceleration. Lancet 382(9907):e26-7. Hodges EA, Johnson SL, Hughes SO et al (2013). Development of the responsiveness to child feeding cues scale. Appetite 65:210-19. Moore ER, Bergman N, Anderson GC et al (2016). Early skin-toskin contact for mothers and their healthy newborn infants. The Cochrane Database of Systematic Reviews, Issue 11. National Institute for Health and Care Excellence (2006). Postnatal care up to 8 weeks after birth. London: NICE. National Perinatal Epidemiology Unit (2017). IMD tool. University of Oxford. https://tools.npeu.ox.ac.uk/imd/ [Accessed 23 August 2017]. Rey E, Martínez H (1983). Manejo racional del niño prematuro. Bogotá: Curso de Medicina Fetal, Universidad Nacional. The Lullaby Trust (2017). Co-sleeping with your baby. https://www. lullabytrust.org.uk/safer-sleep-advice/co-sleeping/ [Accessed 18 August 2017]. UNICEF UK Baby Friendly Initiative (2012). Guide to the Baby Friendly Initiative standards. London: UNICEF UK. Vaidya K, Sharma A, Dhungel S (2005). Effect of early mother-baby close contact over the duration of exclusive breastfeeding. Nepal Medical College Journal 7(2):138-40. World Health Organization (2003). Kangaroo mother care: a practical guide. Geneva: WHO. Wyllie J, Bruinenberg J, Roehr et al (2015). European Resuscitation Council Guidelines for Resuscitation 2015: Section 7. Resuscitation and support of transition of babies at birth. Resuscitation 95:249-63.

Bailey R, McIntyre H, Harvey M. MIDIRS Midwifery Digest, vol 27, no 4, December 2017, pp 518-522. Original article. © MIDIRS 2017.

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Effect of maternal obesity on birthweight and neonatal fat mass: a prospective clinical trial Delphine Mitanchez, Sophie Jacqueminet, Jacky Nizard, Marie-Laure Tanguy, Cécile Ciangura, Jean-Marc Lacorte, Céline De Carne, Laurence Foix L’Hélias, Pascale Chavatte-Palmer, Marie-Aline Charles, Marc Dommergues Objective: To discriminate the effect of maternal obesity and gestational diabetes on birth weight and adipose tissue of the newborn. Methods: Normal BMI women (group N, n = 243; 18.5≤ BMI<25 kg/m2) and obese women (group Ob, n = 253; BMI≥30 kg/m2) were recruited in a prospective study between 15 and 18 weeks of gestation. All women were submitted to a 75g oral glucose tolerance test in the second and third trimester. First trimester fasting blood glucose was also obtained from Ob women. All women with one measurement above normal values were considered positive for gestational diabetes and first treated by dietary intervention. When dietary measures were not efficient, they were treated by insulin. Neonatal anthropometrics, sum of skinfolds and cord serum hormones were measured. Results: 222 N and 226 Ob mothers and their newborns were included in the analysis. Diabetes was diagnosed in 20% and 45.2% of N and Ob women, respectively. Birth weight was not statistically different between groups (boys: 3456g±433 and 3392g±463; girls: 3316g±402 and 3391g±408 for N and Ob, respectively). Multivariate analysis demonstrated that skinfold thickness and serum leptin concentrations were significantly increased in girls born to women with obesity (18.0mm±0.6 versus 19.7mm±0.5, p = 0.004 and 11.3ng/ mL±1.0 versus 15.3ng/mL±1.0, p = 0.02), but not in boys (18.4mm±0.6 versus 18.5mm±0.5, p = 0.9 and 9.3ng/mL±1.0 versus 9.0ng/mL±1.0, p = 0.9). Based on data from 136 N and 124 Ob women, maternal insulin resistance at 37 weeks was also positively related to skinfold in girls, only, with a 1-point increase in HOMA-IR corresponding to a 0.33mm±0.08 increase in skinfold (p<0.0001). Conclusions: Regardless of gestational diabetes, maternal obesity and insulin resistance were associated with increased adiposity in girls only. Persistence of this sexual dimorphism remains to be explored during infancy. Mitanchez D, Jacqueminet S, Nizard J et al. PLoS One, vol 12, no 7, 27 July 2017. e0181307. Author abstract. © Mitanchez et al 2017. This article is freely available at: https://doi.org/10.1371/journal.pone.0181307

Reviewed by Ailsa McGiveron Obesity is one of the greatest public health challenges of the 21st century. Modern living ensures every generation is heavier than the last – a trend known as ‘Passive Obesity’ (Foresight 2012). The people of Britain are becoming heavier simply by living in the ‘obesogenic’ environment of today with its energy dense foods, motorised transport and sedentary lifestyles. As the number of obese women increases, so does the number of women who are obese at the start

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of their pregnancies and this has, and will continue to have, implications for both the mother and her infant. This paper seeks to examine the correlation between the effect of maternal obesity and gestational diabetes on birth weight and adipose tissue of the newborn. This is an extremely well-timed paper in view of the increase in the numbers of both women who are obese in pregnancy and those who are developing gestational diabetes. The article can be viewed as an open access paper

with the underlying data being available upon request due to ethical restrictions imposed. The authors, all based in France, declared that there were no conflict of interests. The study was supported by a research grant from the French Ministry of Health and funded by the Département de la Recherche Clinique et du Développement, Assistance Publique-Hôpitaux de Paris. It was also stated that all participants gave their written, informed consent for inclusion in the study.


Neonatal & Infancy

The researchers designed a prospective exposure-matched cohort study comparing neonates born to women with normal pregestational body mass index (BMI) (18.5≤BMI<25kg/m²) and neonates born to obese women with a pregestational (BMI ≥30kg/ m²). Screening and subsequent treatment for gestational diabetes were enhanced in order to minimise the potential effect of maternal hyperglycaemia on neonatal anthropometrics. The participants were recruited from two Parisian hospitals before 18 weeks’ gestation. The inclusion criteria were clear: the stated BMI range, aged over 18 and less than 41 years and a singleton pregnancy. The exclusion criteria being: initiation of antenatal care after 18 weeks’ gestation, known type 1 or 2 diabetes, obesity due to a genetic disorder or secondary to intracranial tumor or radiotherapy, bariatric surgery, chronic illnesses other than obesity and non-fluency in French. The sample size was lower than expected with only 496 women included at the end of the study. The participants received care and timing for delivery based on local standards of care with the exception being glycaemic status. It was noted that all participants received the general dietary recommendations and weight gain targets were explained but no specific weight management intervention was proposed. The women received the usual screening for gestational diabetes with an additional oral glucose tolerance test (OGTT) at 32 weeks’ gestation. The usual blood glucose thresholds and diagnostic levels were utilised. If diagnosed as a gestational diabetic (GDM), the women saw one of the two diabetologists involved in the study with the first line treatment being dietary intervention. Patients unable to achieve the blood glucose goals by diet alone after two failed weeks, were prescribed insulin therapy.


The neonates involved received routine care and were weighed at birth (minus their nappy). The skinfold thickness was measured (in neonates >37 weeks gestation) with a skinfold caliper at four sites: triceps, biceps, suprailiac and subscapular. Placentas were also weighed. Bloods were taken on admission to delivery suite for HbA1c and hormone assays. Of the 496 pregnant women recruited, 243 had a normal BMI and 253 were classed as obese. Preterm (<37 weeks) were excluded from the analysis as were fetal losses. The final number of live births included were, 222 women in the normal BMI group and 226 women in the obese group. GDM was diagnosed in 20% in the normal BMI group and 45.2% of the obese group. Findings revealed that regardless of GDM, maternal obesity was not associated with increased birthweight, numbers of large for gestational age or small for gestational age babies. It was nevertheless associated with higher fat mass and leptin in girls but not boys. Fetal leptin levels are believed to have a correlation with fetal fat mass independently to maternal and placental contributions. A strong association between maternal insulin resistance and fat mass in girls was also found. The authors acknowledge that the high number of women in the obese group who developed GDM, could have been due to the high ethnic diversity of the group that could influence the frequency of diabetes. Insulin resistance in normal weight women increases throughout pregnancy and is highest in the third trimester, in contrast to obese women who already have higher insulin resistance in early pregnancy, (most of the women in the obese group were diagnosed as GDM in the first trimester). Interestingly, placental weights in girls born to women in the obese group were found to be

significantly higher than girls born to women in the normal BMI group but there was no difference in placental weight for boys. Limitations of the study recognised that in 40% of the neonates, hormone levels were not available, and that placental weights were not available in 37% of mothers. In addition, despite paediatricians undertaking training for the skinfold measurements, these measurements were significantly different in the two hospital centres. The authors also acknowledge that some women may have had hyperglycaemia prior to pregnancy, and that some may have changed their lifestyles, particularly their diet, because of enrolment on the study; both these factors could also have affected the results. Fascinating reading, presented in a logical, well-written, academic manner. For readers who are not completely au fait with in-depth numerical data, the paper may prove very overwhelming! It is perhaps of greater interest to readers with a quantitative mind. It is useful in establishing the extent to which maternal obesity and GDM affect the birth weight and adipose tissue of the new-born, but further studies are required to better understand this correlation. A thought-provoking paper when you consider the increase in obesity and the effect this could have on female newborns and the ensuing lifecycle.

References Foresight (2012). Tackling obesities: future choices – project report. 2nd ed. London: Government Office for Science.

Ailsa McGiveron, specialist midwife for diabetes and obesity, United Lincolnshire NHS Trust. © MIDIRS 2017.

MIDIRS Midwifery Digest 27:4 2017

Neonatal & Infancy

Are babies conceived during Ramadan born smaller and sooner than babies conceived at other times of the year? A Born in Bradford Cohort Study Amanda Daley, Miranda Pallan, Sue Clifford, Kate Jolly, Maria Bryant, Peymane Adab, KK Cheng, Andrea Roalfe Background: It is not known whether infants exposed to intermittent maternal fasting at conception are born smaller or have a higher risk of premature birth than those who are not. Doctors are therefore unsure about what advice to give women about the safety of Ramadan fasting. This cohort study aimed to investigate these questions in Muslim mother–infant pairs to inform prenatal care. Methods: Routinely collected data accessed from maternity records were the source for information. Mothers were considered exposed if they were Muslim and Ramadan overlapped with their infant conception date, estimated to be 14 days after the last menstrual period. Infants were included as exposed if their estimated conception date was in the first 21 days of Ramadan or seven days prior to Ramadan. Results: After adjusting for gestational age, maternal age, infant gender, maternal body mass index at booking, smoking status, gestational diabetes, parity and year of birth, there was no significant difference in birth weight between infants born to Muslim mothers who were conceived during Ramadan (n=479) and those who were not (n=4677) (adjusted mean difference =24.3 g, 95% CI −16.4 to 64.9). There was no difference in rates of premature births in exposed and unexposed women (5.2% vs 4.9%; OR=1.08, 95% CI 0.71 to 1.65). Conclusions: Healthy Muslim women considering becoming pregnant prior to, or during Ramadan, can be advised that fasting does not seem to have a detrimental effect on the size (weight) of their baby and it appears not to increase the likelihood of giving birth prematurely. Daley A, Pallan M, Clifford S et al. Journal of Epidemiology & Community Health, vol 71, no 7, July 2017, pp 722–728.

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Author abstract. © BMJ Publishing Group Ltd. All rights reserved 2017.

MIDIRS Midwifery Digest 27:4 2017


Neonatal & Infancy

Integrative review of factors and interventions that influence early father–infant bonding Ashley Renee Scism, Robin Lynn Cobb Objective: To report on the current state of research analyzing early father–infant bonding, including influential factors and interventions, to identify gaps in the literature. Data sources: CINAHL, MEDLINE, PubMed, and PsychInfo computerized databases were searched using the keywords bonding, paternal, father, infant, relationship, engrossment, and postpartum. Study selection: Twenty-eight articles were compiled on the basis of key inclusion criteria. Quality measures were undertaken using specific components of SQUIRE 2.0 to ensure quality of methodology and data. Data extraction and synthesis: Each study was carefully dissected and initially arranged in a generic annotated bibliography. This process resulted in pattern recognition and identification of three major themes. The findings of every article were compared for commonalities and differences and were synthesized into an integrated review of father– infant bonding. Results: The synthesis revealed three themes: Father’s Adjustment and Transition, Variables That Influence Father–Infant Bonding, and Interventions That Promote Father–Infant Bonding. Conclusion: There is an immediate need to perform studies on specific interventions aimed at the promotion of early father–infant bonding in the United States. More research is needed to better understand the timing of early father–infant bonding and how this bonding influences a provider’s role, attitude, and priority for establishing successful bonding interventions for fathers. Scism AR, Cobb RL. JOGNN: Journal of Obstetric, Gynecologic and Neonatal Nursing, vol 46, no 2, March-April 2017, pp 163–170.

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Author abstract. © Elsevier Inc. All rights reserved 2017.


MIDIRS Midwifery Digest 27:4 2017

Worldwide Maternity Services

Hidden and unaccounted for: understanding maternal health needs and practices of seminomadic shepherd women in Maharashtra, India Gayatri Ganesh, Nitya Ghotge ORIGINAL Introduction This paper looks at the so far undocumented maternal health needs and practices among women of semi-nomadic shepherd pastoral communities called Dhangars that migrate across the western Indian state of Maharashtra. The constant migration of these communities through remote areas where health services are scarce, poses particular challenges for women during pregnancy and childbirth. Semi-nomadic pastoral populations travel with their livestock in search of grazing pastures and their livelihood is derived from the sale, or exchange of, livestock for cash or other commodities. Exclusive pastoralists grow no crops of their own and depend on the exchange of livestock for food and grains or offer fertilisation of the farmer’s fields with manure in exchange for food and essential household items (Hatfield & Davies 2006). While practitioners of pastoralism are often viewed as being socially, economically and politically marginalised, they have also been known to make significant contributions to national economies and to the maintenance of ecosystems, especially those which are unsuitable for agricultural production. The profession of pastoralism involves the whole family and is usually hereditary; therefore herding is strongly rooted to their ethnic and cultural identity.

Š Gayatri Ganesh 2017.

An estimated 20 to 100 million people worldwide make their living as pastoralists (Blench 2000, Downie 2011). No official figures exist for the population of pastoral communities in India but they are estimated to make up 7–11% of the population (8.7 to 13 million people). Almost all the small ruminant meat consumed in India and a large part of the milk consumed originates from pastoral sources. Although hidden from public discourse with no official figures, their contribution to the Indian economy is considered to be substantial (Sharma et al 2003).

MIDIRS Midwifery Digest 27:4 2017


Worldwide Maternity Services

Maternal health in Maharashtra India accounts for 20% of the world’s maternal death burden (Goldie et al 2010), but there are large interstate variations well-documented within the country. Maternal deaths in India tend to occur during the intrapartum and postpartum period with obstetric haemorrhage being the leading medical cause of death (Montgomery et al 2014). The western Indian state of Maharashtra is one of only five Indian states that have already achieved Millennium Development Goal (MDG) 4 — reduce child mortality (by two-thirds) and MDG 5 — improve maternal health (by reducing maternal mortality by three-quarters and improving universal access to reproductive health care by 2015) (United Nations 2014). Maharashtra experienced a sharp decline in maternal mortality rate (MMR) which is currently 37 per 100,000 births, well below the national average of 167 (Ministry of Health and Family Welfare 2017). According to the National Family Health Survey - 4 2015-2016 (Ministry of Health and Family Welfare 2017), 69.4% of rural women in Maharashtra received four antenatal checkups, 86.7% delivered at a health facility, and 3.6% delivered at home, assisted by a skilled birth attendant. While Maharashtra has created an extensive health infrastructure and trained personnel that has brought down the MMR and infant mortality rate, inter-district variations mean that some districts are comparable to the worst in the country. These districts have a high number of scheduled tribe and scheduled caste populations — constitutionally protected tribal and lower caste populations that have suffered generations of marginalisation — that live in rural areas, and have inequitable access to education, economic opportunities and maternal and child health (MCH) services. The size and plight of these communities is well-documented and efforts to mitigate the inequities faced by them are a priority for civil society groups and state governments (Sanneving et al 2013).

Limited data on semi-nomadic communities However, the Dhangar shepherds are not officially classified as a scheduled tribe or scheduled caste — vulnerable populations that enumerators focus on due to known inequalities in health, education and economic status — but as denotified tribes, for which there is very little data. Due to the shepherds’ differences in lifestyle and traditions, it would be a mistake to attribute the same beliefs, practices and challenges of the tribal populations to the seminomadic Dhangars, despite both being vulnerable populations. Very little is known about the Dhangars’ social and gender relations or how much access they have to health care and education. The little research and knowledge that exists about pastoralists has been driven by ecologists and veterinarians investigating the health of livestock, animal husbandry, their migratory patterns, genetic variation, and access to water (Dhas 2006). There is little anthropological, developmental 528

or interdisciplinary studies on pastoralists in India. One of the first attempts to profile these varied communities was by the Ministry of Social Justice and Empowerment (2008) who undertook a survey (among 122 communities in 16 states) and found that 70% of nomadic communities lived in temporary tents with no toilets, electricity or running water; only six per cent of nomadic communities reported access to Below the Poverty Line ration cards (to access government food subsidies); 50% did not possess caste certificates or voter identity cards; more than 50% did not have access to medical facilities and nine per cent of children from nomadic communities were working instead of attending school. An absence of information and documentation affects the Dhangars’ ability to access constitutional benefits as well as the benefits of development programmes, many of which focus on MCH issues and institutional deliveries. Their report concludes that these communities are the most neglected and oppressed in India, pushed to the fringes of society. A major debate in India today is about expanding the scope of a national digital identity card called Aadhar that the current government wants to make mandatory for all citizens to access welfare, banking, telecommunications, utilities and other public services and benefits. The Dhangars’ constant migration means they lack the ‘proof of address’ document that is vital to registering for the Aadhar card, immediately excluding them from essential services. The issues facing the Dhangars intersect on multiple dimensions: economically, environmentally, politically, culturally and socially.

Working with the Dhangars Anthra is an organisation working in the field of rural livestock development and sustainable use of resources (www.anthra.org). The organisation was started by a team of women veterinarians in 1992, several of whom are also on the board. Anthra mainly works with poor livestock holders, including small dairy farmers, women raising backyard poultry and pastoralists. We have been working with the Dhangar pastoralists for over a decade. The Dhangars are semi-nomadic shepherds who migrate seasonally across the semi-arid Deccan Plateau for six to nine months of the year in search of grazing pastures and fodder. They travel in small groups of three to five individuals with 50 to 200 sheep and goats, three to five horses, chickens and dogs. It was in discussions with the Dhangars that Anthra discovered one of the women in the community had died in childbirth. Anthra began to understand that other women and children had also faced difficulties and sometimes death in childbirth. We came to realise that the health of the livestock was closely linked to the health of the people looking after them and that we could not ignore the role of women and the challenges they face, particularly due to their constant migration. Jolted by the death of a Dhangar woman in childbirth, Anthra set out to understand how Dhangar women MIDIRS Midwifery Digest 27:4 2017

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deal with pregnancy, maternal health and giving birth while migrating for eight months of the year. It is part of a larger programme aimed at addressing some of the problems faced by pastoralists including access to fodder and grazing lands, better health care for their animals and ensuring a heightened sensitivity towards these communities and their problems by policy makers and development workers. The authors were unable to find any research on the health, particularly maternal health, of pastoral communities in India, although a rigorous body of work from Africa, the Middle East and Central Asia (Thaddeus & Maine 1994, Münch 2007 cited in Randall 2010, Schelling et al 2008) informed our discussions with the Dhangars.

The role of women in Dhangar communities Dhangars travel in groups as small as one man, his wife, children and mother, to as large as ten families with some elders. They can have as few as 100 goats to about 800 sheep and goats. They migrate to find grazing land for their animals and usually follow the path of the south west monsoon. They criss-cross the arid, rocky Deccan Plateau traveling a distance of about 800 kms over the eight- to nine-month period. They live in temporary makeshift tents and carry few possessions including blankets made of coarse sheep’s wool and utensils for cooking. The Dhangar women are responsible for looking after children, chickens, horses and young lambs, cooking, collecting water and firewood and dried cow dung for fuel. The men are responsible for herding and finding grazing pastures. The women are also responsible for packing up belongings, loading the horses with packs for migrating, and setting up camp (tents, pens for animals, utensils for cooking, starting fires, collecting fuel and water) when the herd stops. Women play a vital role in maintaining the Dhangar livelihood. But similar to most communities in India and the developing world, women have a lower position in (Dhangar) society which can affect their health. Research in many developing parts of the world, including Tanzania (Evjen-Olsen et al 2008), Nepal (Gittlesohn 1991) and Maharashtra (Ganatra et al 1998) has shown that the literacy level of the decision maker of the household, usually a male, seems to have a bearing on the woman’s access to health care and risk of maternal death. The decisionmaking powers of gatekeepers like mothers-in-law or husbands are an indication of the low status of women in the household and their lack of autonomy to make decisions. A woman’s educational, cultural, economic, legal and political position in a given society generally shapes her access to health services, and there are specific ways in which it directly affects and can delay the decision to seek care. Women needing to seek permission from men and to be accompanied by a man to a health facility are common requirements among pastoral societies. MIDIRS Midwifery Digest 27:4 2017

Research objectives and methods The objective of the research was to understand Dhangar women’s views and practices in relation to MCH. This was an inductive and iterative approach where we began the research with a blank slate asking broad questions about demographic information and MCH practices, including number of pregnancies and children (alive and dead), pregnancy and childbirthing experiences (eg traditional practices: use of herbs, foods; sources of information; visiting health facility — frequency, access, experience, cost; procedures at health facility — reports, results, advice, medications; experience of childbirth — when, where and who they were with, what they did; postnatal period — breastfeeding, immunisation, birth registration, hospital visits). Through the interviews, we hoped to understand their practices and motivations, meanings, priorities and assumptions by constructing their views and actions in relation to MCH and determining where these sit in the larger social structure. The constructivist approach to grounded theory acknowledges that many social realities exist, and that all reality is a construction or interpretation by both researcher and participant. Data were collected through in-depth interviews, analysing data in situ and using categories, insights and concepts from one interview to inform not only questions asked in the next interview but also to direct who was interviewed. This is a key concept of grounded theory, known as theoretical sampling. For example, the decision to interview women who had birthed in the last five years was informed by a pilot study among women of different ages, which showed that older women had all birthed in the field rather than a hospital and had received no checkups at a health facility. This pattern coupled with the known reduction in maternal and infant mortality in Maharashtra in the last decade and health infrastructure improvements, led to interviewing Dhangar women who had birthed in the last five years, for a more current representation. The decision to interview mothers-in-law and husbands, arose out of insights in interviews with Dhangar women that highlighted the consideration of concepts such as ‘gatekeepers’ and ‘enablers’ of maternal health. Concepts and categories then move to a higher level of hypothesis with the aim of theory building, which is a journey still in progress. This paper reports on the pilot phase of the research and some of the challenges and results. Due to space constraints verbatim comments have not been included. Between February and April 2015, the authors interviewed six Dhangar women who had had a child in the last five years, and three mothers-in-law. Between them they had 14 pregnancy and birthing experiences with one neonatal death a few hours after childbirth. The team travelled over 800 kms from the base in Pune to interview Dhangar women migrating around more populated areas including Pen, Chakan, 529

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Wai and Narayangaon. Families who migrate across the vast and sparsely populated Deccan Plateau may have different experiences of pregnancy and childbirth and are still to be interviewed. Anthra is in contact with about 350 migrating families via mobile phones. Some of the challenges of conducting the research include travelling great distances to locate Dhangar families in interior areas on dirt tracks and on foot where vehicles cannot reach. The mobile phone has made a considerable difference to staying in contact with Dhangars; however, often their mobile phones are not working, not charged, out of cellular range, or they have changed their telephone numbers. Conducting interviews in the open during the summer heat and monsoon rains without sheltered areas to speak to the women also proved challenging. Women are extremely busy and they had to be interviewed while they were looking after the lambs, cooking food or bathing the children. In their daily lives, Dhangar women are rarely asked for their opinion on any matter. Sometimes a second visit encouraged them to open up about their experiences, sensing our genuine interest in their views. While the repeat visits were beneficial to the research, the team also had to consider the time and cost involved.

Early findings Presented here is a snapshot of the initial findings for this ongoing project. Description of maternal health-seeking behaviour Dhangar women appeared to prioritise, using a health facility in the antenatal period rather than during the birth. Their main concern was the health of the fetus during pregnancy rather than the potential risks involved during and after birth. The researchers explored why women believed that a doctor or medical professional was not required during delivery. Initial discussions revealed that their proximity to living with animals and being constant witness to the birth of lambs, chickens, and puppies, made them more familiar with the birthing process and they did not believe it to be a potentially life-threatening situation. Two women had heard of a Dhangar woman dying in childbirth. Despite their concern about the early phases of pregnancy, a number of factors prevented Dhangar women from accessing a health care clinic which had diagnostic facilities such as blood tests and sonography. Women described the great deal of planning that had to take place in order for a woman to go for a check-up during her pregnancy, especially for those travelling in small groups; both husband and wife could not leave the sheep, children and other animals unattended. Animal predators (wolves, foxes, dogs) and hostile villagers are a security risk. Women are not allowed to travel without male accompaniment. Women expressed difficulties in 530

arranging for a male relative or friend from another Dhangar group to accompany them or look after the sheep while their husband took them for a checkup. Nonetheless, with the advent of mobile phones, getting in touch with people is easier. Making the journey from a campsite to a main road, village or town is arduous, with the pregnant woman sitting on the back of a bicycle travelling on unpaved, rocky dirt tracks. Most Dhangars do not have access to motorbikes or cars. As they migrate between villages and towns, women visited different doctors during the antenatal period. Medical records were not always preserved, and women said that doctors disapproved of their migratory lifestyle. They are unable to follow through with the advice of the doctor in terms of fulfilling prescriptions and not exerting themselves during pregnancy. Being on constant migration they do not have access to pharmacies which are located in large hamlets or towns. Their outdoor lifestyle herding sheep and trekking across vast landscapes makes curtailing physical activity improbable. The women perceived less stigma when visiting a private practitioner, and some had in-house diagnostic facilities but the fees were higher. The women said that government facilities were less developed, waiting times were longer and staff often unfriendly but fees were considerably less. Due to their lack of education, the Dhangar women we spoke to were unaware of mandatory clinical and diagnostic procedures during the different stages of the antenatal period. Their perception of a good doctor’s visit was if he/she performed an ultrasound. They were also unaware of the importance of their own weight, diet and blood test results and the impact of their health on the baby’s well-being. None of the women interviewed could read or write and no one had explained to them what their test results meant. They were aware of their due date but they did not have calendars. Some men used the calendars on their mobile phone but often lost track of the days and weeks. Most women had at least one antenatal check-up during her pregnancy either within the first three months or in the seventh or eighth month of pregnancy. They expressed a desire to go every month for a check-up but they had no decision-making powers and they acknowledged a number of limitations such as constant travel and having livelihood responsibilities, eg looking after sheep and children. Women also faced challenges that other studies have documented among semi-nomadic pastoral groups in the Middle East and Africa such as lack of accessibility and acceptability of hospital care and staff practices. Women did not experience the same amount of concern during the antenatal period as they did during the time of childbirth. Women were less worried about having to birth in the fields without medical aid, possibly because it is a common practice among women from this community. Furthermore, the unacceptability of MIDIRS Midwifery Digest 27:4 2017

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hospital practices (including being forced in to a supine position and the way the placenta is disposed of), lack of transport, distance and cost were dissuading factors. In fact, husbands and mothers-in-law made no arrangements to be near a large town or to have transport available as the due date approached. A hospital birth was sought out only when labour was prolonged and the woman was in extreme pain. The decision to take the woman to a hospital was made by the mother-in-law (if present) or the husband/any other male present. Moreover, arrangements to get her to a hospital were made at the last minute. We asked women to describe their experience of giving birth in the field. Not all women had the company of a mother-in-law or a woman who had gone through labour herself. When the woman began to experience painful contractions, she was taken to a tree or a tent and a sari or long cloth was used to make a screen for privacy. The woman was made to walk and pace right up to the point of birth. The woman birthed in the squatting position with a sheep’s wool blanket placed underneath her. One woman interviewed was alone during the time of birth as her husband and sister-in-law had taken the sheep for grazing. She recalls how she cut the umbilical cord herself, with a ‘chaku’ (all-purpose knife), buried it and then walked down to a stream where she bathed herself and the baby. One woman we interviewed went in to labour while on migration, walking across the barren Deccan Plateau. There were no trees for privacy. She recalled that she kept walking until the final moment. Some Dhangar groups that travel with ten or more families and herd thousands of sheep may have a ‘dai’ or traditional birth attendant with them. We met one group with a ‘dai’ but at the time of the visit she had been called away to attend to a woman in labour in a nearby traveling Dhangar group. One woman recalled having experienced an infant death. She had birthed alone in the field and believes that she fainted after giving birth. She recalls that the baby was a boy and that she placed the baby down next to her. When she regained consciousness, she says the baby was not breathing. Most women believed that the umbilical cord had spiritual significance. It is buried along with a lime, flowers and some coconut, if available. As is common in south Asia, due to a lack of education, Dhangar women believe the colostrum to be dirty. It is thrown out and the baby is given pre-lacteal feeds in some cases for up to three days before feeding breast milk. None of the babies or children on this occasion had received full immunisation. Some had received one oral polio dose. Men were unaware of the importance of vaccination for infants, although all their sheep had received vaccinations.

Discussion The key challenge for women to receive MCH is balancing their livelihood responsibilities that are MIDIRS Midwifery Digest 27:4 2017

dependent on a migratory lifestyle with health services and infrastructure that are targeted to sedentary immobile populations. Despite these challenges, the Dhangar women in this study sought care in the antenatal period. Their motivation is to find out the health of the fetus. However, they seek out care at times suitable to their lifestyle, when someone is able to accompany them and take on their responsibilities of looking after sheep and homestead, rather than at a medically appropriate period in their pregnancy. Similar to challenges faced by many Indian women, Dhangar women lack education and decision-making powers. They are unable to read the doctor’s notes or due date or ask relevant questions due to their lack of literacy. The low status of women coupled with their migratory lifestyle means that they are stuck in a disempowering web where they are dependent on men to accompany them to a health care facility. Distances from habitations, the lack of a secure homestead to leave children and animals, and the lack of family support due to small households, magnifies their challenge. Dhangar women are highly aware of the crucial role they play in pastoral livelihoods. Few studies have evaluated delivery of primary health care services to nomadic populations (Swift et al 1990). An intervention in Ethiopia’s Afar region showed that mobile health services reaching nomadic camps were avidly used by nomadic pastoralists but it was not a cost-effective strategy (Green 1979, Schelling et al 2012). A World Bank funded initiative found that mobile health clinics were especially popular for women and children’s illnesses in some Indian states but required public-private partnerships and civil society intervention to sustain operations (The World Bank 2012). Mobility makes it difficult to deliver services. Migration in general has been seen as deviant behaviour that has to be normalised by making these groups sedentary. However, ecologically and economically, pastoralism can only survive with mobility and in grassland landscapes pastoralism is one of the best land-use options. The current health infrastructure is unable to successfully deliver services to vulnerable village-based populations. Delivering services to migratory populations will require a significant shift in how we perceive the health care needs of different populations.

Conclusion The maternal health needs and practices of semi-nomadic pastoral communities in India are largely hidden from view and unaccounted for. The lack of enumeration of these economically and ecologically significant populations means that the scale of the MCH issues and the problems they face cannot be quantified. Without knowing the magnitude of the problem their inequities and disadvantages remain hidden to policy makers. These populations make a significant contribution to the state and country’s economy and women are an integral part of maintaining the occupation. 531

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Anthra continues to examine these issues and explore a ‘One Health’ approach that recognises that humans, animals and ecosystems are all inter-connected. We believe there is an artificial separation of livestock care and human medical care. Communities do not necessarily view these as two separate streams. To integrate the two, ten women will participate in learning programmes through an improvisation on the One Health model. They will simultaneously learn and share experiences on livestock health care and MCH. This would also be an attractive model to get men involved in to contribute to the health of their women, building on their knowledge of animal health. Gayatri Ganesh has a Master of Arts in Sociology and is a Research Consultant for Anthra. Dr Nitya Ghotge has a Masters in Veterinary Science with a specialisation in surgery and is currently the Director of Anthra. This study is funded by Misereor, the German Catholic Bishops’ Organisation for Development Cooperation, based in Germany. The views expressed are those of the researchers.

Sanneving L, Trygg N, Saxena D et al (2013). Inequity in India: the case of maternal and reproductive health. Global Health Action 6:1-31. Schelling E, Wiebel D, Bonfoh B (2008). Learning from the delivery of social services to pastoralists: elements of good practice. Basel: Swiss Tropical Institute. https://cmsdata.iucn.org/downloads/social_ services_to_pastoralists__english__2.pdf [Accessed 15 September]. Schelling E, Bechir M, Daugla MD et al (2012). Health research among highly mobile pastoralist communities of Chad. Society, Biology & Human Affairs 75(2):95-116. http://www.biosocsoc.org/ sbha/sbha_journal/SBHA-2010-75_2.pdf [Accessed 15 September]. Sharma VP, Köhler-Rollefson I, Morton J (2003). Pastoralism in India: a scoping study. London: Natural Resources Institute, University of Greenwich. https://assets.publishing.service.gov.uk/ media/57a08ce2e5274a31e00014fa/ZC0181b.pdf [Accessed 15 September]. Swift J, Toulmin C, Chatting S (1990). Providing services for nomadic people: a review of the literature and annotated bibliography. UNICEF Staff Working Paper 8. New York: UNICEF. Thaddeus S, Maine D (1994). Too far to walk: maternal mortality in context. Social Science & Medicine 38(8):1091-110. The World Bank (2012). Improving health services for tribal populations. http://www.worldbank.org/en/news/ feature/2012/02/28/improving-health-services-for-tribal-populations [Accessed 15 September 2017]. United Nations (2014). The Millennium Development Goals Report 2014. New York: United Nations.

References Blench R (2000). Extensive pastoral livestock systems: issues and options for the future. http://dlc.dlib.indiana.edu/dlc/bitstream/ handle/10535/5313/Blench.pdf?sequence=1 [Accessed 15 September]. Dhas M (2006). How the migrant sheep and goat rearers of Maharashtra manage the water requirement of their herds. Annual Partners Meet of IWMI-Tata Water Policy Programme. Anand, 8-10 March. http://publications.iwmi.org/pdf/H043617.pdf [Accessed 15 September].

Ganesh G, Ghotge N. MIDIRS Midwifery Digest, vol 27, no 4, December 2017, pp 527-532. Original article © MIDIRS 2017.

Downie K (2011). A review of good practice and lessons learned in programming for ASAL populations in the Horn of Africa. UNICEF ESARO. https://goo.gl/E5RxdF [Accessed 15 September]. Evjen-Olsen B, Hinderaker SG, Lie RT et al (2008). Risk factors for maternal death in the highlands of rural northern Tanzania: a case-control study. BMC Public Health 8(52). http://www. biomedcentral.com/1471-2458/8/52 [Accessed 15 September]. Ganatra BR, Coyaji KJ, Rao VN (1998). Too far, too little, too late: a community-based case-control study of maternal mortality in rural west Maharashtra, India. Bulletin of the World Health Organization 76(6):591-8. Gittlesohn J (1991). Opening the box: intrahousehold food allocation in rural Nepal. Social Science and Medicine 33(10):1141-54. Green PF (1979). Taking western medicine to a nomadic people. Transactions of the Royal Society of Tropical Medicine and Hygiene 73(4):361-4. Hatfield R, Davies J (2006). Global review of the economics of pastoralism. World Initiative for Sustainable Pastoralism. http:// cmsdata.iucn.org/downloads/global_review_ofthe_economicsof_ pastoralism_en.pdf [Accessed 15 September]. Ministry of Health and Family Welfare (2017). National Family Health Survey – 4 2015-2016. India fact sheet. Mumbai: International Institute of Population Sciences. http://rchiips.org/ nfhs/pdf/NFHS4/India.pdf [Accessed 15 September]. Ministry of Social Justice and Empowerment (2008). National commission for denotified, nomadic and semi-nomadic tribes. https://www.india.gov.in/national-commission-denotified-nomadicand-semi-nomadic-tribes-ncdnsnt [Accessed 15 September]. Montgomery AL, Ram U, Kumar R et al (2014). Maternal mortality in India: causes and healthcare service use based on a nationally representative survey. PLoS One 9(1):e83331. Randall S (2010). Nomads, refugees and repatriates: histories of mobility and health outcomes in Northern Mali. Society, Biology & Human Affairs 75(2):1-26. http://www.biosocsoc.org/sbha/sbha_ journal/SBHA-2010-75_2.pdf [Accessed 15 September].


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MIDIRS Midwifery Digest 27:4 2017

Worldwide Maternity Services

Factors associated with postpartum hemorrhage maternal death in referral hospitals in Senegal and Mali: a crosssectional epidemiological survey Julie Tort, Patrick Rozenberg, Mamadou Traoré, Pierre Fournier, Alexandre Dumont Background: Postpartum hemorrhage (PPH) is the leading cause of maternal mortality in Sub-Saharan-Africa (SSA). Although clinical guidelines treating PPH are available, their implementation remains a great challenge in resource poor settings. A better understanding of the factors associated with PPH maternal mortality is critical for preventing risk of hospitalbased maternal death. The purpose of this study was thus to assess which factors contribute to maternal death occurring during PPH. The factors were as follows: women’s characteristics, aspects of pregnancy and delivery; components of PPH management; and organizational characteristics of the referral hospitals in Senegal and Mali. Methods: A cross-sectional survey nested in a cluster randomized trial (QUARITE trial) was carried out in 46 referral hospitals during the pre-intervention period from October 2007 to September 2008 in Senegal and Mali. Individual and hospital characteristics data were collected through standardized questionnaires. A multivariable logistic mixed model was used to identify the factors that were significantly associated with PPH maternal death. Results: Among the 3278 women who experienced PPH, 178 (5.4%) of them died before hospital discharge. The factors that were significantly associated with PPH maternal mortality were: age over 35 years (adjusted OR = 2.16 [1.26–3.72]), living in Mali (adjusted OR = 1.84 [1.13–3.00]), residing outside the region location of the hospital (adjusted OR = 2.43 [1.29–4.56]), pre-existing chronic disease before pregnancy (adjusted OR = 7.54 [2.54– 22.44]), prepartum severe anemia (adjusted OR = 6.65 [3.77–11.74]), forceps or vacuum delivery (adjusted OR = 2.63 [1.19–5.81]), birth weight greater than 4000 grs (adjusted OR = 2.54 [1.26–5.10]), transfusion (adjusted OR = 2.17 [1.53–3.09]), transfer to another hospital (adjusted OR = 13.35 [6.20–28.76]). There was a smaller risk of PPH maternal death in hospitals with gynecologist-obstetrician (adjusted OR = 0.55 [0.35–0.89]) than those with only a general practitioner trained in emergency obstetric care (EmOC). Conclusions: Our findings may have direct implications for preventing PPH maternal death in resource poor settings. In particular, we suggest anemia should be diagnosed and treated before delivery and inter-hospital transfer of women should be improved, as well as the management of blood banks for a quicker access to transfusion. Finally, an extent training of general practitioners in EmOC would contribute to the decrease of PPH maternal mortality. Tort J, Rozenberg P, Traoré M et al. BMC Pregnancy and Childbirth, vol 15, no 235, 30 September 2015. Author abstract. © Tort et al 2015.

Reviewed by Jo Gould It is a sobering process, to review a paper on maternal death associated with postpartum haemorrhage (PPH) in sub-Saharan Africa. Here, a woman’s lifetime risk of dying during pregnancy and birth is 1:36, with deaths from haemorrhage the single largest

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contributor (McDougall et al 2016). The World Health Organization’s (WHO) Safe Motherhood Initiative was launched in 1987, with the aim of reducing deaths in pregnancy and childbirth (estimated at 500,000 annually) by 50% by the year 2000. Despite a significant reduction, this target was not met. The

WHO Millennium Development Goal 5a subsequently identified a maternal mortality target of 70 per 100,000 live births by 2030 (WHO 2015). The current rate is 216/100,000, indicating there is still some way to go. This paper is the first attempt by a team of researchers to look in detail at the factors that


Worldwide Maternity Services

contribute to maternal death from PPH in a sub-Saharan setting. Studies such as this provide greater insight into the causes of maternal mortality and contribute to the ongoing drive to improve global maternal health outcomes. The stated aim of the study is clear; better understanding of the factors contributing to PPH mortality is critical to reducing risk of occurrence. A crosssectional survey was undertaken in 46 referral hospitals in Senegal and Mali over a 12-month period. Individual and organisational characteristics data were collected using a standardised questionnaire. The data were subject to statistical analysis to identify factors significantly associated with PPH maternal death. A total of 3278 cases of PPH were identified and 178 maternal deaths were recorded (5.4% mortality). A detailed breakdown of individual characteristics and risk of death is given in Table 1; these include maternal age over 35 years, residence in Mali, preexisting chronic disease, postpartum severe anaemia, instrumental delivery and birthweight greater than 4.0 kilogrammes. Components of management of PPH associated with increased risk of mortality included transfusion, hysterectomy and transfer to another institution. Organisational factors associated with increased mortality included having a general practitioner, rather than obstetrician in attendance. The authors make a number of recommendations as a result of their findings, identifying the need for the following: better diagnosis and treatment of antenatal anaemia, better management of transfer between hospitals, wider access to, and management of transfusion/transfusion services and improved training and education of attending doctors. The strengths of the study are clear. Data were collected from 90% of referral


hospitals in Mali and Senegal; the findings are therefore representative and could be generalised to similar health systems. The sample size was large enough to perform a number of analyses with high statistical power, contributing to the reliability of the findings. There were a number of weaknesses identified by the authors; the first and arguably most critical, was the manner in which PPH was diagnosed. In Mali, PPH was recorded following a visual estimate of blood loss, together with patient status; in Senegal on visual estimate alone. This has implications for the reliability of the findings of the study and may account for the fact that mortality for women in Mali was apparently much higher than for women in Senegal. The Mali definition was more likely to result in the diagnosis of severe PPH cases. The difficulties encountered with visual estimation of blood loss and recording of PPH in the study highlight the complexity in diagnosis. There is no single, satisfactory definition of PPH, which contributes to the underestimation and poor management of the condition globally (Rath 2011). In line with this, the study authors state that the rate of PPH was 3.9%, possibly due to under recording. This rate is much lower than has been found in other studies in African health facilities and raises questions regarding the reliability of the data. In addition, management of the third stage of labour was not recorded, which is a missed opportunity. Not only is it possible that this may have contributed to the differences seen between Senegal and Mali, it may have been a significant contributory factor to risk of PPH and maternal outcome. Data collection was performed up to the point of discharge from hospital, which was typically day two postpartum. Follow-up may have revealed additional maternal mortality post-discharge, which again casts

doubt on the reliability of some of the mortality figures quoted in the study. Finally, the data collection for the study was carried out in referral hospitals, which account for only 10% of births in Mali and Senegal. As 90% of births occur out of hospital, this study does not provide information about maternal mortality in the general population. The results can therefore only help to inform measures to reduce maternal mortality in hospital settings. The WHO (2015) has identified that global maternal mortality is an issue of equality and human rights. The overwhelming majority of women in developing countries die because they are unable to access skilled routine and emergency care. It is imperative that there is continued focus on targeting resources in these settings. Research such as this provides a valuable perspective on some of the factors implicated in maternal mortality from PPH and is key to identifying which resources improve health outcomes. Further research focused on antenatal care, management of the third stage of labour and PPH in the out-of-hospital births would provide a more complete picture and add to the findings of the study.

References McDougall L, Campbell O, Graham W (2016). Maternal health. An executive summary for The Lancet’s series. http:// www.thelancet.com/pb/assets/raw/Lancet/ stories/series/maternal-health-2016/ mathealth2016-exec-summ.pdf [Accessed 21 September 2017]. Rath WH (2011). Postpartum hemorrhage - update on problems of definitions and diagnosis. Acta Obstetricia et Gynecologica Scandinavica 90(5):421-8. World Health Organization (2015). Millennium Development Goal 5: improve maternal health. Geneva: WHO. http://www.who.int/topics/millennium_ development_goals/maternal_health/en [Accessed 21 September 2017].

Jo Gould, Midwifery Lecturer, University of Brighton. Š MIDIRS 2017.

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Worldwide Maternity Services

Dual method use among postpartum HIVinfected and HIV-uninfected Malawian women: a prospective cohort study Dawn M Kopp, Jennifer H Tang, Gretchen S Stuart, William C Miller, Michele S O’Shea, Mina C Hosseinipour, Phylos Bonongwe, Mwawi Mwale, Nora E Rosenberg Dual method use, use of condoms plus another effective contraceptive method, is important in settings with high rates of unintended pregnancy and HIV infection. We evaluated the association of HIV status with dual method use in a cohort of postpartum women. Women completed baseline surveys in the postpartum ward and telephone surveys about contraceptive use three, six, and 12 months later. Nonpregnant women who completed at least one follow-up survey were eligible for this secondary analysis. Prevalence ratios were calculated using generalized estimating equations. Of the 511 sexually active women who completed a follow-up survey, condom use increased from 17.6% to 27.7% and nonbarrier contraceptive use increased from 73.8% to 87.6% from three to 12 months after delivery. Dual method use increased from 1.0% to 18.9% at three to 12 months after delivery. Dual method use was negligible and comparable between HIV-infected and HIV-uninfected women at 3 months but significantly higher among HIVinfected women at six months (APR = 3.9, 95% CI 2.2, 7.1) and 12 months (APR = 2.7, 95% CI 1.7, 4.3). Dual method use was low but largely driven by condom use among HIV-infected women at six and 12 months after delivery. Kopp DM, Tang JH, Stuart GS et al. Infectious Diseases in Obstetrics and Gynecology, vol 2017, 18 July 2017, 9 pages. Author abstract. © Dawn M Kopp et al 2017.

© Fotolia.com

This article is freely available online: https://www.hindawi.com/journals/idog/2017/1475813/

MIDIRS Midwifery Digest 27:4 2017


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Demographic profile and pregnancy outcomes of adolescents and older mothers in Saudi Arabia: analysis from Riyadh Mother (RAHMA) and Baby cohort study Amel A Fayed, Hayfaa Wahabi, Heba Mandouh, Reham Kotb, Samia Esmaeil Objectives: To investigate the impact of maternal age on pregnancy outcomes with special emphasis on adolescents and older mothers and to investigate the differences in demographic profile between adolescents and older mothers. Methods: This study is a secondary analysis of pregnancy outcomes of women in Riyadh Mother and Baby cohort study according to maternal age. The study population was grouped according to maternal age into five subgroups; <20, 20–29, 30–34, 35–39 and 40+years. The age group 20–29 years was considered as a reference group. Investigation of maternal age impact on maternal and neonatal outcomes was conducted with adjustment of confounders using regression models. Results: All mothers were married when conceived with the index pregnancy. Young mothers were less likely to be illiterate, more likely to achieve higher education and be employed compared with mothers ≥40 years. Compared with the reference group, adolescents were more likely to have vaginal delivery (and least likely to deliver by caesarean section (CS)); OR=0.6, 95% CI 0.4 to 0.9, while women ≥40 years, were more likely to deliver by CS; OR 2.9, 95% CI 2.3 to 3.7. Maternal age was a risk factor for gestational diabetes in women ≥40 years; OR 1.7, 95% CI 1.3 to 2.1. Adolescents had increased risk of preterm delivery; OR 1.5, 95% CI 1.1 to 2.1 and women ≥40 years had similar risk; OR, 1.3, 95% CI 1.1 to 1.6. Conclusion: Adverse pregnancy outcomes show a continuum with the advancement of maternal age. Adolescent mothers are more likely to have vaginal delivery; however, they are at increased risk of preterm delivery. Advanced maternal age is associated with increased risk of preterm delivery, gestational diabetes and CS. Fayed AA, Wahabi H, Mamdouh H et al. BMJ Open, vol 7, no 9, September 2017, e016501. Author abstract. © BMJ Publishing Group Ltd. All rights reserved 2017.

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This article is freely available at: http://doi:10.1136/bmjopen-2017-016501


MIDIRS Midwifery Digest 27:4 2017

News & Reviews

Did you miss it? Normal Labour & Birth Conference, 2017

Bereaved father praises midwifery training scheme

Speaking after the event, Chris said: ‘Many bereaved parents love the opportunity to get involved in improving care in the future, and this innovative and effective idea is making a huge difference to how well-prepared the Salford midwifery students are to care for bereaved parents in the future’. The technique has received such positive feedback from students and health service colleagues that the university has begun working with some NHS hospital trusts to use these sessions to provide additional training for their own staff. Anne Leyland said: ‘This is the most devastating news that any expecting parent can receive, and I devised a technique using simulation to immerse students in a realistic setting and enable them to play it out and think very deeply about the right things to say and do in that situation. ‘Receiving some positive feedback from Chris was very important to us and we hope that his input will help us prepare our student midwives for having to give somebody the worst news.’

A father whose child was stillborn has praised an innovative scheme to train midwifery students to care for bereaved parents. Chris Binnie became involved in the Our Angels charity following the tragic death of his son Henry in 2014. He was the first bereaved parent to get involved in the University of Salford’s simulation sessions training midwives to provide effective support in these situations. The sessions were devised by Anne Leyland, Lecturer in Midwifery at the University of Salford; she believes traditional teaching methods may not effectively prepare students to communicate sensitively and empathically with parents whose baby has died. In the simulation scenario a group of midwifery students are assigned to support and care for the bereaved parents — played by another group of students — and respond to their concerns and anxieties. The scenario takes place in an area of the university’s state-of-the-art simulation suite designed to look like a birthing centre. It is then streamed live, and recorded, so larger groups of students can watch, before a debrief is carried out by lecturers to help the students learn from and reflect upon the experience.

Following a successful event held at Windsor, UK on 5th–6th October, it was announced that the International Colloquium on Hyperemesis Gravidarum (ICHG) 2019 will be hosted by Rebecca Painter and colleagues in Amsterdam. The depth and breadth of research and clinical practice covered at ICHG 2017 was incredible; it was the biggest and best event exclusively on hyperemesis gravidarum that the world has ever seen. However, this really is just the beginning. ICHG 2017 built on foundations laid two years ago at the No Hype HG Conference in Norway. Collaborations which then were mere seedlings have now grown into tender young stems and it is hoped that by 2019 such international alliances will be beginning to bloom (in a way hyperemesis gravidarum women never get the chance to!). Further details available at: https://www. hgconference.org/ichg-2019/ or contact Caitlin Dean, Chairperson Pregnancy Sickness Support, email: caitlin@pregnancysicknesssupport.org.uk

The 12th International Normal Labour and Birth Research Conference took place on 2nd–4th October this year at Grange-over-Sands, Cumbria, UK. The conference was stimulating and fruitful in equal measure. Health professionals from all corners of the world attended, contributing to the international reputation for which the conference is known. All the keynote speakers spoke with true passion about their beliefs, hopes and dreams for safe, kind and compassionate care for all women, supporting them to have access to high-quality care and to have the best experience of childbirth possible. The presentations covered a whole spectrum of emotions with each telling a story encompassing truth, humour, anger, sadness and hope. Delegates went back to their respective workplaces filled with energy and optimism for the future. Information about next year’s conference can be found at: nursing.umich.edu/research/birthconf2018

MIDIRS Midwifery Digest 27:4 2017

International Colloquium on Hyperemesis Gravidarum, 2017


News & Reviews

Spirituality and childbirth, meaning and care at the start of life Susan Crowther, Jenny Hall eds. Routledge, 2018. 204 pages. £29.99 (pbk). ISBN: 978–1138229419 positive event enabling spiritual growth whereas a perceived medicalised birth is often placed at the opposite end of the spectrum. Thomson (p142) acknowledges that women may suffer post– traumatic stress disorder but also that such events can encourage positive psychological growth or post-traumatic growth (PTG). Fear of childbirth is an increasing concern for women and midwives and we should consider how spirituality can support greater PTG in such circumstances.

The world we live in today revolves so fast that it often feels as if there is no time to reflect and consider our innermost feelings. Time is precious but so is the quality of our lives and of the women who fleetingly cross paths with us as midwives. This book is a welcome addition to midwifery literature as we seek to provide high quality care to women and their families at such a lifechanging and life-affirming event. The contributors to this book cover a broad range of topics moving from pregnancy, childbirth, loss and sick newborns through to spirituality in parenthood. Some midwives may initially wonder how this fits within their daily lives in often medicalised obstetric units: Chapter 9 specifically draws attention to such concerns, putting spirituality into context in this environment. Chapter 10, building upon alternative concepts, discusses how a ‘normal’ birth is seen as a


Childbirth uniquely changes the whole family dynamic, from announcing the pregnancy through birth and beyond. It moves every member’s position within the family, just as the birth of each royal child alters the succession to the throne, and causes life trajectories to follow a different path. Chapter 6, which explores the concept of loss, considers how devastating it can be for families when all their dreams and aspirations for the unborn child are cruelly taken away. Lalor (p85) suggests more work is needed to understand the role of spirituality in coming to terms with such news. The experience of birth is a profound event for all concerned: this book reminds midwives of the importance of enabling women to immerse themselves in their spirituality, and find time for quiet and calm in the birthing environment. Some of the most enriching events in my life have been the privilege of sharing birthing experiences and I feel honoured to have been part of them. However, this book has made me consider if there have

been times when I have not fully considered the spirituality of the woman and partner during this time, I do hope not! The extract from Cheyney (2011:40) encapsulates all this review is expressing: ‘As the structure and content of ritual carries participants into new representational spaces, the physical body is transformed along with the participant’s social status and sense of self. The performance of birth at home enables women to map their own individual experiences onto a collective, mythic, world – in this case, the mythic world of “natural”, “alternative”, “empowered” or “womancentred” childbirth. Emotionally charged symbols (birth tubs, home and reinterpreted technologies like the Doppler) allow social worlds to be manipulated, and it is this manipulation that facilitates a corresponding transformation of the mother’s embodied, birthing experience.’ Some midwives may consider that this book is not for them— but I would urge you to dip into it, if not to read it in its entirety, as spirituality affects us all and we would not be midwives if we were not emotionally and spiritually moved by the miracle of childbirth.

Cathy Ashwin, Principal Editor, MIDIRS © MIDIRS 2017.

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News & Reviews

CUMULATED AUTHOR INDEX FOR vol 27, 2017 Abakoba Ssengabadda P…………223, 359 Abbott L…………...43, 217, 497 Adeosun AM ......... 483 Allotey J ................ 163 Ashwin C……….4, 134, 140, 267, 538 Atsali EN ............... 119 Austin K ................ 23 Avery A et al ......... 80 Bacchus A ............ 444 Bacchus LJ et al ... 125 Bailey R ................ 518 Baraz L ................. 105 Baston H ............... 467 Bélanger-Lévesque M-N et al ............ 68 Bell S .................... 322 Berens P et al ....... 102 Borrelli S et al ....... 391 Brettle A ................ 483 Britt S .................... 318 Brodrick A ............. 467 Brown AM ............. 488 Brubaker K et al .... 264 Carter AG et al ...... 308 Case-Stevens J .... 105 Cattaneo A ............ 391 Cawley S et al ....... 190 Cheelo C et al ....... 124 Church S et al ....... 267 Clarke D ................ 513 Clayton J ............... 94 Coombe J et al ..... 322 Cooper M .............. 53 Crowther S….128, 538 Daley A et al ......... 525 Dean C………..11, 177 Deas J……….197, 339 Debevec AD et al .. 102

Herbert E ............... 429 Demerath EW et al..................... 235 Hilde G et al .......... 51 Demirci JR et al ..... 103 Hinsliff S ................ 374 Dent J .................... 497 Hunter B ................ 270 Dickens V .............. 93 Hunter M et al ....... 32 Dietz HP et al ........ 52 Ikonen R et al ........ 101 Dingens AS et al.... 249 Inayat S ................. 398 Dolo O et al ........... 127 Institute of Health Visiting ............... 288 Durrell McKenna N ......................... 134 Islam MJ et al ........ 234 Eadie IJ et al.......... 205 Javed Z ................. 398 Edmondson M ....... 325, John R ................... 251 472 Johnson AM et al .. 232 Edwards G............. 119 Joly T .................... 36 Faller S .................. 268 Jones F ................. 488 Fallon V et al ......... 99 Kawwass JF et al .. 189 Fayed AA et al ....... 536 Kennedy J…...453, 497 Firth A .................... 444 Ko YL et al ............ 332 Fleet JA et al ......... 374 Kokanovic R .......... 69 Furber C ................ 277 Kopp DM et al ....... 535 Gallagher K ........... 49 Krawczak EM Ganesh G…...251, 527 et al .................... 92 Gelhorn S .............. 133 Krishnamurti T Ghotge N ............... 527 et al .................... 324 Gilkison A et al ...... 451 Kristinsdottir T Glasgow C ............. 115 et al .................... 389 Golden P ............... 147 Kroll-Desrosiers Gould J………201, 533 AR et al .............. 215 Gowers D .............. 132 Lawrence S ........... 406 Grace N ................. 270 Leap N .................. 270 Guerra-Reyes L Leazer R et al ........ 390 et al..................... 216 Malis FR et al ........ 176 Gundacker C Marsden J…….11, 177 et al..................... 402 Marshall JE….161, 277 Hall J ..................... 538 Martiniuk A et al .... 250 Hampel D et al....... 377 Maslin K et al ........ 512 Hanley J ................ 488 Mason L ................ 424 Hart C .................... 97 Matthews A ........... 497 Harvey M ............... 518 Maxwell C ............. 191 Hawamdeh S……..268, McAllister S et al ... 175 304 McCutcheon H ...... 53 Healy M et al ......... 26 McGiveron A..187, 523

McIntosh T….133, 141, 286, 405 McIntyre H….369, 518 McParlin C et al .... 452 Meddings FS......... 281 Mehta TM et al ...... 504 Mercuri M .............. 110 Michaelides S ....... 237 Minson H............... 251 Mitanchez DM et al ............. 523 Mullan J ................ 345 Murphy L…….291, 435 Myhre J et al ......... 263 Nathan H............... 457 Neiterman E et al .................... 349 Nesbitt R ............... 281 Nespoli A .............. 391 Nevin G ................. 20 Newburn M ........... 5 Newman M ............ 479 Nishi D et al .......... 496 Nolan Y ................. 441 O’Hara ME….309, 413 Olander RK et al ... 187 Ozgoli G et al ........ 201 Powell-Jackson T et al .................... 126 Price-Davey A ....... 419 Recalcati R ........... 391 Reynolds J ............ 43 Riley S .................. 20 Rivett M……..229, 366, 502 Robinson A ........... 488 Rousseau PV et al .................... 379 Safa H et al ........... 203 Scism AR et al ...... 526 Scott T .................. 217 Shane AL et al ...... 388

Shenker N ............. 497 Shennan A ............. 457 Singh PM ............... 251 Smith A .................. 488 Smoker A ............... 132 Sonmezer E ........... 299 Spendlove Z .......... 20 Spiby H et al .......... 22 Sprawson E ........... 191 Stillman P .............. 429 Stone M ................. 69 Subramanian A ...... 86 Symon A et al ........ 49 Taniguchi F et al .... 162 Taylor M ................ 20 Teerapornpuntakit J et al .................. 433 Thomas C .............. 513 Todhunter F ........... 20 Tort J et al ............. 533 Trevisanuto D et al ..................... 244 Turkstra E et al ...... 167 Turner L ................. 462 van der Zande ISE et al .............. 434 Warland J .............. 53 Waterman K .......... 59 Weaver G .............. 497 Wells R .................. 232 Williams B et al ...... 152 Williams P .............. 488 Wilson H ................ 457 WOMAN Trial Collaborators ...... 338 Wood S .................. 33 Wouk K et al .......... 358 Xeuatvongsa A et al ..................... 254 Yalcin SS et al ....... 97 Young F et al ......... 100

CUMULATED SUBJECT INDEX FOR vol 27, 2017 A acupressure............................. 201

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adolescents social factors affecting

pregnancy and birth ...........43 pregnancy outcome ...............536


News & Reviews

advanced midwifery practice ... 127 A-EQUIP (midwifery supervision model) .................................. 299 Africa exclusive breastfeeding rates .................................. 97 history of upright birth ........... 119 age, maternal .......................... 536 alcohol drinking ....................... 49 anaesthesia, regional .............. 366 antenatal care adolescents .......................... 43 autistic women ...................... 462 folic acid supplementation .... 190 antenatal education, mindfulness programmes ..... 176 anxiety, postnatal .................... 215 apps……………………………...324 Australia contraceptive use and unintended pregnancy ....... 322 counselling for fear of childbirth ............................ 167 autism……………………………462 autonomy................................. 441

effect of intrapartum intervention ........................ 502 effect of pain relief……..366, 374 effect of skin-to-skin care ...... 518 effect on maternal bone density ............................... 433 exclusive……223, 234, 359, 433 grandmothers’ influence........ 100 impact of postnatal depression ......................... 358 insufficient milk...................... 103 maternal well-being ............... 229 milk banks…………………..93, 497 micronutrient analysis ........ 377 pain……. ............................... 102 postnatal depression ............. 229 professional support.............. 232 student midwives’ experiences of supporting women ............................ 359 support .................................. 102 UNICEF UK Baby Friendly Initiative accreditation ........ 369 while in prison ....................... 217 women’s experiences…101, 102

B Baby Friendly Initiative annual conference 2016................... 94 bacterial vaginosis ................... 249 Bangladesh, exclusive breastfeeding........................ 234 bereavement ........................... 497 birth trauma ............................. 345 body change (maternal) .......... 349 body composition (premature infants) .................................. 235 body mass index, impact on IVF outcomes ....................... 189 bonding………………………….526 bottle feeding ........................... 99 breastfeeding see also infant feeding; lactation Africa…………………………..97 Baby Friendly Initiative annual conference 2016................ 94 clozapine .............................. 504


C caesarean section elective .................................. 167 impact of antenatal sleep quality on ........................... 332 maternal and infant outcomes ........................... 203 subsequent birth ................... 59 cardiomyopathy........................ 197 caseload midwifery .................. 32 child abuse, influence on breastfeeding ........................ 234 childbirth adolescents ........................... 43 natural ................................... 52 positive birth .......................... 406 risk………………………...23, 141 spirituality………………...68, 538 support .................................. 270 childhood sexual abuse ........... 339

choice……………………….23, 299 clinical placements .................. 391 clozapine ................................. 504 communication (infantparent) .................................. 379 complementary therapies………….103, 201, 175 continuity of care ..................... 237 continuous positive airway pressure ............................... 263 contraception……………..322, 535 Coombs test ............................ 389 counselling, for fear of childbirth ............................... 167 critical thinking skills ................ 308 cytomegalovirus ...................... 33

D dementia .................................. 318 demographic factors ................ 536 depression, impact of cash transfers on .......................... 126 developing countries advanced midwifery practice .............................. 127 exclusive breastfeeding ........ 234 India……………………………251 Kenya……………………263, 264 labour positions .................... 119 Lao People’s Democratic Republic ............................ 254 mental health policy initiatives ............................ 126 Pakistan ................................ 398 postnatal contraception ........ 535 postpartum haemorrhage…………483, 533 SafeHands for Mothers ........ 134 semi-nomadic women’s health................................. 527 traditional birth attendants .... 124 developmental delay (infant) ... 110 diabetes, gestational ............... 453 direct antiglobulin test .............. 389 discharge from hospital, neonatal................................ 237 domestic violence

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News & Reviews

abuse………………………….288 influence on breastfeeding ... 234 screening .............................. 125 Donnison, Jean ....................... 163 doulas……………………………22 drama, use in practice change.................................. 467

E education see also midwifery education……………….127, 152 emotions, newly-qualified midwives ............................... 444 enquiry-based learning ............ 424 epidural pain relief ................... 366 Erasmus exchange programme ........................... 161 ethnic groups……………..232, 288 evidence-based practice….26, 325 exercise in pregnancy, effect on placental weight ................. 51 postnatal ............................... 488 expectant management (for PPROM) ............................... 191

F family-centred mental health care…………………………….318 fasting……………………………525 fathers…………………………...526 fear of childbirth ....................... 167 fentanyl…………………………..374 folic acid .................................. 190

G geophagy................................. 402 gestational diabetes ................ 453 grandparents, influence on infant feeding choice ............ 100 guidelines development of ..................... 26 parental adherence to .......... 250

H health visiting ........................... 288

MIDIRS Midwifery Digest 27:4 2017

heart disease, maternal ........... 197 hepatitis B vaccination ............. 254 herbs…………………………….103 high dependency care ............. 205 history childbirth ............................... 141 midwifery ............................... 163 perceptions of pregnancy…………….286, 405 HIV……………………………….535 home visiting, domestic violence screening ................ 125 human rights……………...291, 435 hyperemesis gravidarum…...11, 177, 309, 452 hypnosis ................................... 175

I India health needs of semi-nomadic women ........ 527 maternal depression ............. 126 uterine rupture ...................... 251 induction of labour ................... 191 infant, epidemiology of meningitis .............................. 390 infant feeding see also breastfeeding; lactation commercial infant foods ........ 512 grandmothers’ role in choice of method ........................... 100 women’s experiences…..99, 101 infant, newborn Coombs test .......................... 389 effect of maternal fasting on size………………………….525 effect of maternal obesity on……………………………523 hepatitis B vaccination .......... 254 jaundice ................................ 237 Moro reflex ............................ 379 mortality ................................ 115 outcome following caesarean section .............. 203 plagiocephaly ........................ 250 resuscitation…………….105, 244 sepsis ................................... 388 sudden infant death

syndrome........................... 250 infant, premature body composition and growth................................ 235 respiratory distress ............... 263 women’s experiences of expressing milk .................. 101 information seeking, postnatal ............................... 216 informed choice lactation following bereavement ..................... 497 informed consent…………..52, 299 Ireland, women’s experiences of maternity care……….291, 435 international midwifery Australia ............................... 167 childbirth practices ................ 267 Liberia .................................. 127 New Zealand ........................ 32 interventions, obstetric ............ 52 interviews ................................ 132 intimate partner violence, influence on breastfeeding ... 234 intrapartum care, effect on postnatal depression ............ 86 IVF, impact of maternal weight .................................. 189

J jaundice .................................. 237 job applications ........................ 132

K kangaroo care ......................... 518 Kenya men’s role in maternal health................................. 264 respiratory distress in premature infants .............. 263 kernicterus ............................... 237

L labour acupressure for pain relief .... 201 effect of yoga on ................... 36 effect on breastfeeding ......... 502


News & Reviews

hypnosis ............................... 175 impact of antenatal stress and sleep quality on .......... 332 induced ................................. 191 perineal massage ................. 479 positions for second stage .... 119 positive birth ......................... 406 regional anaesthesia ............ 366 support ................................. 270 water birth............................. 53 lactation, following bereavement ........................ 497 leadership ................................ 441 lead exposure .......................... 402 learning during clinical placements .... 391 methods………………...381, 424 resources.............................. 20 legal issues………………...52, 147 Liberia, advanced midwifery practice ................................. 127

M Mali, postpartum haemorrhage ........................ 533 massage, perineal ................... 479 maternal health, men’s role ............................. 264 maternal morbidity and mortality ................................ 134 postpartum haemorrhage ..... 533 pre-eclampsia ....................... 457 maternity services India…………………………...527 international childbirth practices ............................ 267 Ireland …………………..291, 435 user involvement .................. 5 values .................................. 419 Maternity Services Liaison Committees (MSLCs) ........... 5 McKenna, Nancy Durrell ......... 134 medicalisation of childbirth ...... 23 meditation ................................ 103 meningitis ................................ 390 mental health midwifery care ...................... 133


midwifery education .............. 318 policy initiatives ..................... 126 midwife-led care developing guidelines for admission ........................... 26 impact on VBAC success rates ................................... 59 premature pre-labour membranes ........................ 191 midwifery care adolescents ........................... 43 childhood sexual abuse ........ 339 midwife-woman relationship ........................ 304 perinatal mental health ......... 133 philosophy ............................. 268 risk management .................. 23 rural areas ............................. 128 supporting women……..270, 497 water birth………………325, 472 midwifery education advanced obstetrics .............. 127 breastfeeding support ........... 359 care of women with obesity... 187 clinical placements ................ 391 critical thinking skills.............. 308 dementia awareness ............. 318 enquiry-based learning ......... 424 Erasmus exchange programme......................... 161 high dependency care .......... 205 higher education as midwifery career choice ..... 277 infant feeding curriculum ....... 369 job applications and interviews ........................... 132 online resources.................... 20 problem-based learning ........ 281 professionalism ..................... 20 midwifery profession autonomy .............................. 441 career choices....................... 277 caseload practice .................. 32 counselling intervention for fear of childbirth ................. 167 emotional well-being ............. 444 history ................................... 163 job applications and

interviews .......................... 132 legal issues ........................... 147 migrant workers .................... 167 New Zealand ........................ 451 supervision ........................... 299 midwives’ experiences high dependency care .......... 205 neonatal death...................... 115 midwives’ role care of childhood sexual abuse survivors ................. 339 neonatal resuscitation .......... 105 prevention and management of pre-eclampsia ................ 457 screening and diagnosis of gestational diabetes .......... 453 migration .................................. 267 milk banks…………………………...93 human (micronutrient analysis) ............................ 377 mindfulness ............................. 176 mobile technology for seeking health information......................... 216 use in infant vaccination management ..................... 254 use in pregnancy .................. 324 Moro reflex .............................. 379 motherhood ............................. 349

N natural childbirth ...................... 52 nausea and vomiting……...11, 177, 309, 452 neonatal intensive care, parents’ experiences ............ 513 neural tube defects .................. 190 New Zealand caseload midwifery ............... 32 rural midwifery ...................... 128 newly qualified midwives………………..441, 444 non-pneumatic anti-shock garment (NASG) ................... 483 normal childbirth ...................... 424 Northern Ireland, midwife-led

MIDIRS Midwifery Digest 27:4 2017

News & Reviews

units…………………………...26 Nursing and Midwifery Council (NMC) ...................... 147 nursing education .................... 20

O obesity……………………..187, 523 operating theatre, promotion of skin-to-skin care ............... 467 opioids, effect on breastfeeding…………...366, 374 oral glucose tolerance test ...... 453 organisational values ............... 419 ovarian endometriomas ........... 162 oxytocin, effect on postnatal mental health ........................ 215

P pain, breastfeeding .................. 102 pain relief acupressure.......................... 201 effect on breastfeeding…………366, 374 effect on postnatal depression ......................... 86 Pakistan ................................... 398 parents experiences of neonatal intensive care .................... 513 father-infant bonding ............ 526 patient and public involvement in research (PPIR) ................ 413 peer-assisted learning ............. 152 perineal massage .................... 479 pethidine .................................. 374 philosophy of health care............................ 304 midwifery care ...................... 268 place of birth………………..26, 299 placental weight, effect of exercise during pregnancy ... 51 plagiocephaly .......................... 250 positions for birth ..................... 119 positive birth ............................ 406 post-traumatic stress disorder ................................ 345 postnatal care

MIDIRS Midwifery Digest 27:4 2017

adolescents ........................... 43 autistic women ...................... 462 following birth trauma ............ 345 postnatal depression breastfeeding cessation ........ 229 effect of exercise ................... 488 effect of intrapartum care ...... 86 effect of peripartum oxytocin .............................. 215 effect of sleep and biological rhythm on ........................... 92 effect on breastfeeding………...234, 358 women’s experiences ........... 69 postnatal health maternal heart disease ......... 197 weight management.............. 80 women’s informationseeking behaviour .............. 216 postnatal period body change ......................... 349 contraception ........................ 535 effect of antenatal mindfulness programmes... 176 psychological growth............. 496 puerperal psychosis .............. 339 postnatal visits, hepatitis B vaccination ............................ 254 postpartum haemorrhage……..203, 338, 483, 533 preconception care, folic acid supplementation..... 190 pre-eclampsia midwives’ role in prevention and management ............... 457 pregnancy adolescents ........................... 43 after ovarian surgery ............. 162 alcohol drinking ..................... 49 autistic women ...................... 462 body change ......................... 349 clozapine ............................... 504 complications cytomegalovirus ................. 33 gestational diabetes ........... 453 hyperemesis gravidarum….11 177, 309, 452

obesity………………...187, 523 pre-eclampsia .................... 457 premature rupture of membranes .................... 429 effect of exercise on placental weight ................. 51 geophagy.............................. 402 historical perceptions….286, 405 outcomes according to age .. 536 participation in research ....... 434 positive birth ......................... 406 smartphone apps .................. 324 stress .................................... 332 unintended ............................ 322 weight gain ........................... 80 yoga...................................... 36 premature birth, prevention ..... 324 premature pre-labour rupture of membranes………….191, 429 prison, breastfeeding in ........... 217 problem-based learning ........... 281 professionalism ....................... 20 psychological growth ............... 496 psychosocial factors, influence on breastfeeding ................... 234 puerperal psychosis ................ 339

Q quality of health care…….398, 419

R regulation ................................. 147 religious beliefs ........................ 525 research patient and public involvement ....................... 413 vulnerability of participants ........................ 434 respiratory distress .................. 263 resuscitation, neonatal…..105, 244 risk………………….……….23, 141 rural health services……..251, 527 rural midwifery ......................... 128

S safeguarding ............................ 288 SafeHands for Mothers ........... 134


News & Reviews

Saudi Arabia ............................ 536 schizophrenia .......................... 504 screening, domestic violence .. 125 Senegal, postpartum haemorrhage ........................ 533 sepsis, neonatal ...................... 388 sexual abuse ........................... 339 skin-to-skin care………….467, 518 slavery, domestic ..................... 288 sleep effect on postnatal depression ......................... 92 in pregnancy ......................... 332 social support breastfeeding…………..223, 232 in labour................................ 270 socioeconomic factors, effect on information-seeking behaviour ........................... 216 spirituality……………..68, 268, 538 stillbirth, lactation following ...... 497 stress, in pregnancy ................ 332 student midwives breastfeeding support ........... 359 clinical placements ............... 391 critical thinking skills ............. 308 dementia awareness ............ 318 professionalism .................... 20 promoting normal birth ......... 424 sudden infant death syndrome.............................. 250 supervision of midwives…147, 299


support breastfeeding ........................ 102 doulas ................................... 22

T teaching methods, peerassisted learning ................... 152 teenagers see adolescents time perception, in health care professionals ......................... 244 tokophobia ............................... 167 traditional birth attendants ....... 124 tranexamic acid ........................ 338

U UNICEF UK Baby Friendly Initiative…………………...94, 369 unintended pregnancy ............. 322 United States, perinatal home visits…………………………...125 uterine rupture.......................... 251

V vaccination, hepatitis B ............ 254 vaginal birth after caesarean section .................................. 59 values, organisational .............. 419 vitamin supplements, effect on breast milk composition ... 377 volunteers (doulas) .................. 22

W water birth…………….53, 325, 472 weaning………………………….512 weight management, postnatal ............................... 80 woman-centred care................ 304 women’s experiences accessing health care ........... 527 body change in pregnancy ... 349 breastfeeding…………...102, 232 expressing milk ..................... 101 feeding with infant formula ... 99 hyperemesis gravidarum ...... 309 information-seeking .............. 216 Irish maternity services……………….291, 435 mindfulness .......................... 176 postnatal depression ............ 69 research participation ........... 434 women’s knowledge, folic acid supplementation ................... 190

Y yoga……………………………….36

Z Zambia, traditional birth attendants............................. 124

MIDIRS Midwifery Digest 27:4 2017

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MIDIRS Midwifery Digest

Midwifery Digest

December 2017, volume 27, number 4

ISSN 0961-5555


December 2017, volume 27, number 4, 409-544

Brunel House, 11 The Promenade, Clifton, Bristol BS8 3NG Customer services: 0800 581009 (freephone) tel: 0117 370 6799 (+44 117 370 6799 overseas) email: digest@midirs.org www.midirs.org

research & education midwifery pregnancy labour & birth postnatal infant nutrition neonatal & infancy worldwide maternity services news & reviews


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