MIDIRS Midwifery Digest Sample

Midwifery Digest

December 2015, volume 25, number 4

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

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

413 Hot Topic Midwifery in the Sustainable Development era ......................................................................... 413 Toyin Saraki

419 Reasearch & Education Ethical aspects of current challenges to women’s choice of planned place of birth ..................... 419 Anna Maria Brown, Ann Gallagher Law and ethics: a midwifery dilemma........................................................................................ 424 Toni Martin Learning by simulation – is it a useful tool for midwifery education?......................................... 430 Fiona Coffey — Reviewed by Teresa Shalofsky “No man’s land”: an exploration of the traumatic experiences of student midwives in practice....... 432 Sarah Davies, Liz Coldridge

433 Midwifery Women’s experiences of commercial three-dimensional ultrasound scans................................... 433 Franziska Wadephul, Julie Jomeen, Lesley Glover Supporting women to make lifestyle changes using Lewin......................................................... 438 Sherrie Bearman The changing face of maternity services: the value of and challenges for the Advanced Midwifery Practitioner.............................................................................................. 444 Vicky Hamilton, Gemma Swindells, Melanie Durkin et al Midwives experiences of removal of a newborn baby in New South Wales, Australia: being in the ‘head’ and ‘heart’ space........................................................................................... 448 Louise Everitt, Jennifer Fenwick, Caroline SE Homer

449 Pregnancy Ginger is ineffective for hyperemesis gravidarum, and causes harm: an internet based survey of sufferers...................................................................................................................... 449 Caitlin R Dean, Margaret E O’Hara Association of second-trimester cervical length with prolonged pregnancy................................. 456 Emily A Donelan, William A Grobman, Emily S Miller — Reviewed by Jacqui Williams Hiccups and amniotic fluid regulation in early pregnancy.......................................................... 457 Andrew G Murchison

459 Labour & Birth The six Cs of the breech experience .......................................................................................... 459 Ruth Sanders, Kathryn Lamb Impact of prolonged dinoprostone cervical ripening on the rate of artificial induction of labor: a prospective study of 330 patients.............................................................................. 466 Christine Denoual-Ziad, Stéphanie Aicardi-Nicolas, Christian Creveuil et al The impact on midwives of their first stillbirth........................................................................... 472 Kay Jones, Liz Smythe — Reviewed by Tania McIntosh Puts the magic back into life: fathers’ experience of planned home birth.................................... 474 Siobhan Sweeney, Rhona O’Connell

475 Postnatal A systematic review of psychosocial interventions for women with postpartum stress............... 475 Ju-Eun Song, Tiffany Kim, Jeong-Ah Ahn

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Vacuum-assisted closure for episiotomy dehiscence.................................................................... 483 Emeline M Aviki, Rebecca Posthuma Batalden, Marcela G del Carmen et al Maternal and neonatal morbidity after attempted operative vaginal delivery according to fetal head station.................................................................................................................. 484 Guillaume Ducarme, Jean-François Hamel, Pierre-Emmanuel Bouet et al Effect of abortion vs. carrying to term on a woman’s relationship with the man involved in the pregnancy......................................................................................................................... 485 Jane Mauldon, Diana Greene Foster, Sarah CM Roberts

487 Infant Nutrition An exploration of the factors influencing fathers’ feelings about breastfeeding........................... 487 Michelle Tant Supporting breastfeeding: it takes a whole community............................................................... 491 Susan Way, Alison Taylor, Joyce Miller Under the spotlight: the Queen Charlotte’s Hospital Milk Bank at 75........................................ 494 Gillian Weaver Internet use by first-time mothers for infant feeding support...................................................... 499 Ruth Newby, Wendy Brodribb, Robert S Ware et al — Reviewed by Karen MacGowan

501 Neonatal & Infancy Keeping babies warm: a non-inferiority trial of a conductive thermal mattress.......................... 501 Swarna R Bhat, Nathan F Meng, Kishore Kumar et al Association of Tongue-tie Practitioners 2015 Conference: 21 September 2015, Basingstoke...... 507 Val Dickens To bathe or not to bathe: the neonatal question......................................................................... 509 Alice Colwell Neonatal Graves’ disease and cholestatic jaundice: case series and review of the literature........ 510 Osama Almadhoun, Teresa Rivera-Penera, Lauren Lipeski The effect of hat on phototherapy-induced hypocalcemia in jaundiced full-term neonates......... 510 Zahraa Ezzeldin, Yasmeen Mansi, Tamer A Abdelhamid et al

511 Worldwide Maternity Services Knowledge levels and practices of midwives in the management of severe pre-eclampsia at health centre level.................................................................................................................. 511 Beauty Siansende, Mutinta C Muleya, Margaret Siame et al Proportion of maternal near misses and associated factors in the referral hospitals of Amhara National Regional State, north-west Ethiopia: institution-based cross-sectional study.................................................................................................................. 517 Mulugeta Dile, Tatek Abate, Tewodros Seyum Community midwives’ experiences resulting from business skills training in the Sindh and Punjab provinces of Pakistan............................................................................................... 526 Shahnaz Shahid, Sadia Abbas, Rozina Sewani et al A qualitative study exploring the determinants of maternal health service uptake in post-conflict Burundi and Northern Uganda.............................................................................. 531 Primus Che Chi, Patience Bulage, Henrik Urdal et al Blood pressure changes in relation to arsenic exposure in a U.S. pregnancy cohort.................... 532 Shohreh F Farzan, Yu Chen, Fen Wu et al Informed consent in medical decision-making in commercial gestational surrogacy: a mixed methods study in New Delhi, India............................................................................... 533 Malene Tanderup, Sunita Reddy, Tulsi Patel et al

535 News & Reviews Did you miss it?......................................................................................................................... 535 Author index.............................................................................................................................. 538 Subject index.............................................................................................................................. 538

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MIDIRS Midwifery Digest 25:4 2015

From the Editor It seems such a short time since we were exchanging Season’s Greetings with each other, but once again that time has come round. Some say that as we get older time appears to go by more quickly, however many of the younger midwives I speak to also say the same. One reason for this may be the fact that midwifery is moving at such a pace that we swiftly move on with new ideas and innovations, with the purpose of continually improving the childbirth experience for all.

In this edition the Hot Topic, written by Her Excellency Toyin Saraki, demonstrates how we are making changes to the health of childbearing women and their families through campaigning and determination. The topic under discussion is the culmination of fulfilling the targets of the Millennium Goals by the end of this year and the introduction of the Sustainable Development Goals (SDGs) to continue this valuable work. Toyin firmly believes that midwives are an important part of this ongoing pathway in being the constant presence and support for woman. As Goodwill Ambassador for the International Confederation of Midwives, Toyin clearly illustrates her passion and belief in supporting the profession of midwifery and midwifery-led care to continue throughout the world. The ultimate goal for all is to reduce maternal and infant mortality by being able to give the highest quality of care, reaching out to the most remote and deprived areas of the world. As midwives together we can all contribute to achieving these goals wherever we practise.

Another area for discussion that has raised concerns over the last few months is the question of midwifery supervision. Within their paper, Brown & Gallagher (p 419) comment on this topic, exploring autonomy and examining the ethical aspects of the challenges in place of birth. This paper encourages us to think deeply about how we make our decisions and where support may be found.

The decision to remove statutory supervision from the jurisdiction of the Nursing and Midwifery Council (NMC) will change the way midwives have been supported since the inception of the 1902 Midwives Act. However, this may be the time to change, because regulation has always been this way, does it have to continue the same? We all claim to be autonomous practitioners and, as such, is supervision as we know it appropriate for our needs, or does it provide the safe environment for us to practise autonomously?

Midwifery supervision is something that has always been around us like an invisible blanket, take the blanket away and we may feel vulnerable and afraid, MIDIRS Midwifery Digest 25:4 2015

take away our rules and regulations will we rebel and embrace the freedom or will we creep into our shells and stay very quiet? Next year may be quite a time of change and as autonomous practitioners we should be clear and vocal on how we want our profession to move into the future, to safeguard all we believe in and work for. We need choice, control and clarity to give the same to the women we support.

We shall be keeping you up to date with all the latest news and topics of interest on our website, so I would encourage you to take the time to take a look when you have a free moment and to join the blog with any comments or ideas you may wish to share with a wider audience. Also on the website we feature the Student Midwifery Societies to again share thoughts and innovations among the midwifery community.

If your society is not yet featured on our website — do get in touch. This is not restricted to the UK; we would be keen to hear from any Student Midwifery Societies from around the world and to be able to put you in touch with each other. This could provide good links and ideas for those of you considering an elective placement during your training.

I do hope this has been a fulfilling year for you all and that you are beginning to think about what you would like to achieve in 2016. This is the ideal time to put together your aims and ambitions as well as reviewing your achievements over the past year. We should all now be thinking about the NMC revalidation process which will come into force next year in order to renew our registration. Considering your achievements, aims and ambitions will set you on the path to preparing for your revalidation which will now be required every three years.

With all the demands upon our lives I hope that you will be able to find time for some rest and relaxation during the festive season and be able to recharge for the year ahead.

Best wishes to you all.

Cathy Ashwin, principal editor. © MIDIRS 2015.

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Hot Topic

Midwifery in the sustainable development era Toyin Saraki

ORIGINAL

© ICM/WBFA 2015.

Midwives have played an invaluable role in women’s health for over 2000 years, with references to midwives even included in the Bible. As support for the profession grew, and training became formalised over time, the medical skills of midwives have grown significantly. Skilled midwives now have the training, knowledge and potential to provide expert advice to pregnant women about their health and the health of their child — both during and after pregnancy. This year is one of great importance for the international community as we make the transition from the Millennium Development Goals (MDGs) to the Sustainable Development Goals (SDGs). This pivotal year for international development is also crucial for the direction of midwifery, as I firmly believe that midwives will play a key role in the achievement of SDG 3 — to ensure healthy lives and promote well-being for all at all ages.

Her Excellency Toyin Saraki at the 30th ICM Triennial Congress

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MIDIRS Midwifery Digest 25:4 2015

Hot Topic

As the Global Goodwill Ambassador for the International Confederation of Midwives (ICM), the journey of the midwifery profession and midwives around the world is exceptionally important to me. As ICM Global Goodwill Ambassador, I seek to ensure that the voice of midwives is heard on international stages, such as the United Nations General Assembly (UNGA). This September at the 70th UNGA in New York, I amplified the voice of midwives globally, speaking of the incomparable impact that midwives can have in overcoming social determinants of health, protecting pregnant migrants and refugees, and providing antenatal care that can transform health habits for generations. In this role, I seek to expand the visibility of midwives by shining a spotlight on the excellent work of local midwives through my global tour of national midwifery associations, which has already seen me visit Suriname, Lesotho, the United States of America and many other countries, for regional ICM conferences. I also seek to further the vision of the ICM, its member associations, and individual midwives, of a world where every childbearing woman has access to a midwife’s care for herself and her newborn. This role is one that I am passionate about because I know that by expanding the voice, visibility, and vision of midwives, we can make a drastic impact on the health of mothers, newborns, and children around the world in this new era of sustainable development. No mother, anywhere in the world, should have to risk her life and that of her baby by going through childbirth without expert care. Complications that kill hundreds of thousands of women and babies in developing countries are managed effectively in richer countries by a midwife or health worker with the right skills, the right equipment and the support of a health system.

Since 2000, when eight MDGs came into effect, the international development community has focused its efforts on fulfilling the targets by the end of 2015.

On 1st January 2016, 17 SDGs will come into effect.

The SDGs seek to set the world on the road to human dignity by 2030, encompassing far-reaching goals that include peaceful, inclusive societies, climate change, the reduction of inequality, and the strengthening of global partnerships.

I established the Wellbeing Foundation Africa (WBFA) in 2004 to accelerate progress on the MDGs in Nigeria and sub-Saharan Africa, with a particular emphasis on MDG 4, which sought to reduce child mortality, MDG 5, which is dedicated to improving maternal health and MDG 6, which sought to combat HIV, AIDS, malaria and other diseases like polio.

The progress that has been made on the MDGs globally has been outstanding, with a 53% decrease in preventable deaths of children under the age of five between 1990 and 2013 (BBC News 2015) and a 45% reduction in global maternal mortality rates between 1990 and 2013 (World Health Organization (WHO) 2014a). And just over ten years after WBFA MIDIRS Midwifery Digest 25:4 2015

began its work in sub-Saharan Africa, child mortality has fallen by 48% in the region (Gladstone & Sengupta 2014). However, despite these achievements, maternal and infant mortality rates remain high in developing countries, with Nigeria having the second highest rate of maternal and child mortality across the world (Oyedele 2014, WHO et al 2014).

During the MDG process, it became abundantly clear to those of us working to improve reproductive, maternal, newborn, child and adolescent health (RMNCAH), that access to a skilled midwife can often be the difference between life and death for a mother and her newborn in the fragile 24 hours during and after birth. In fact, the WHO (2014a) identified skilled midwifery care as one of the most powerful weapons in our fight to prevent maternal and newborn mortality, and a recent Lancet Series report on Midwifery found that by increasing access to midwives by just 25%, we could halve maternal mortality rates (Renfrew et al 2014). This cemented my belief that midwives are the linchpins of an effective health care system and if given the right education, regulation, and support of midwifery associations, midwives will enable us to achieve SDG 3 targets to reduce the global maternal mortality ratio to less than 70 per 100,000 live births and end preventable deaths of newborns and children aged under five.

Following this year’s UNGA in September, I believe that for midwives to be able to immediately implement and accelerate progress on SDG 3, a global midwifery services framework (MSF) in line with the ICM’s recommendations should be adopted in all countries (ICM 2015). A global MSF will be crucial to scaling up, improving, and incorporating sexual, reproductive, maternal, and newborn health services by midwives within national health systems. This will offer a systematic approach and support for a midwife-led model of care, which provides effective and desirable services for women and their families.

This will strengthen midwifery services by offering a step-by-step guide to improving quality of care, education, regulation, and effective management of health care professionals. By adopting this framework, nations can ensure an integrated and sustainable approach to health and well-being, which are key to achieving SDG 3 and its targets.

Midwives are uniquely placed to be able to provide integrated care that can detect, prevent, and treat illnesses or health challenges that can affect maternal and newborn survival. Starting from the onset of pregnancy, skilled midwives offer vital antenatal care that can ensure both mother and baby remain healthy by providing an invaluable health education, as well as screening tests that can identify risks to pregnancy or preventable illnesses. Identifying these risks or illnesses early helps women make informed choices about their pregnancy and enables midwives to rapidly treat the

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© ICM/WBFA 2015.

Hot Topic

Her Excellency Toyin Saraki visits the offices of the Lesotho Prime Minister with the President and CEO of the ICM and representatives of the Lesotho midwives association.

illness before birth. Moreover, antenatal care enables women to work with their midwife to develop a birth plan that prepares mothers and ensures that their wishes are adhered to during childbirth, setting the course for respectful maternity care.

During childbirth, midwives provide crucial support at one of the most vulnerable junctures of a woman’s life, and are viewed as an integral part of a labour and delivery team due to this relationship. This relationship is maintained in the weeks following birth, with midwives providing insight on bonding with your baby, postnatal depression, family planning, and birth spacing. A midwife working at the heart of the community and within a functioning health service is able to visit women to give care, advice and support.

The relationship between a midwife and a newborn is also invaluable. The first 24 hours following birth are the most critical for a newborn, with one million babies dying on their first and only day of life, each year (Wright et al 2014). The frustration is greater when considering how attainable the solutions are: they sit not with complicated technological advances but with good quality care provided during pregnancy, labour and the first 24 hours after birth. Without immediate skilled medical attention from a midwife, the life of a newborn could hang in the balance. Many countries have now invested in bicycles or motorbikes for midwives, enabling them to travel to remote communities more easily and to provide more frequent visits and support.

Following birth, a skilled midwife is also well positioned to deliver advice on nutrition.

Undernutrition is a serious condition that accounts for 45% of all deaths of children aged five and under (Black et al 2013) and contributes to stunting — a serious condition that affects a child’s life well into adulthood. Stunting can trap children into a lifelong cycle of poor nutrition, illness, impaired learning

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skills and lower earning abilities. Breastfeeding can safeguard against this and prevent 800,000 child deaths from malnutrition each year (UNICEF 2013).

From the first hour of a baby’s life to age two, breastfeeding offers protection against infection, malnutrition, and stunting. Midwives can inform mothers about the benefits of breastfeeding and offer guidance, especially in line with timing the critical first feed. They provide counsel and comfort on any health issues that may arise, such as: the need for better nutrition in the pre-pregnancy and pregnancy phases; diminished milk supply or pain in the postdelivery phase; and helping mothers track their breastfeeding progress.

However, in order to provide effective integrated care and accelerate progress on SDG 3, midwives need the tools and resources that can track patient data and provide a continuum of care. Midwives in sub-Saharan Africa often point to a paucity of data as a major challenge in treating pregnant women effectively and providing integrated RMNCAH care.

The African continent suffers from a lack of accurate record keeping and data collection, with only four out of 54 countries on the continent capturing 75% or more of their births and deaths (Oti 2015). For midwives, a lack of accurate record keeping means that they cannot effectively track patient progress or identify health risks in pregnancy. For patients, a lack of accurate records means that they cannot track their own progress during pregnancy, leaving them without vital life-saving information. Learning from this situation, WBFA introduced the client-held, integrated Maternal, Newborn, and Child Personal Health Record (PHR). The PHR has been designed to be in the custody of mothers so that they can bring them to health centres during their pregnancy and labour, and up until their child attains the age of five years.

Keeping all of this information in this MIDIRS Midwifery Digest 25:4 2015

© ICM/WBFA 2015.

Hot Topic

Frances Ganges, Her Excellency Toyin Saraki and Frances Day-Stirk

client-held PHR is an effective way of ensuring that mothers and children receive the right care throughout the periods of pregnancy, labour/delivery, and early childhood development, even leading up to adolescence. Through partnering with the Midwives Service Scheme, WBFA’s PHRs were adopted into the very frontline of the Nigerian health system.

The PHR is groundbreaking for integrated care provided by midwives in the post-2015 sustainable development era because it is far more than a data collection tool — it is an information delivery platform. It empowers women to track their health and the health of their child, including their nutrition, immunisation, and more. It provides health care professionals like midwives, with an early warning signal, in case of any risks during pregnancy and in the early stages of childhood, and enables them to provide timely care and advice to mothers and their families. And as a vital audit tool, it can identify gaps in practice and improve quality of care. A recently released report, (World Bank Group et al 2015) highlighted how personal health records, like WBFA’s PHR, were a critical component of effective measurement and accountability systems. This will be a crucial aspect of not just meeting the SDGs but measuring progress and accountability of national health systems.

Midwives will play a major role in achieving SDG 3 in the post-2015 development agenda but in order to get to that point, we must first urgently address the challenge of midwife recruitment and retention.

Despite a tradition of midwifery in Nigeria, access to skilled birth attendants like midwives remains limited, and only 40% of Nigerian women give birth with

MIDIRS Midwifery Digest 25:4 2015

a skilled birth attendant present (National Population Commission (NPC) [Nigeria] and ICF International 2014). An already precarious situation for many Nigerian women is predicted to become even harder over the next 15 years. With an estimated population increase of over 60% in Nigeria by 2030, its already stretched maternal and newborn frontline health services may struggle to respond to 12.8 million pregnancies per year (United Nations Population Fund et al 2014).

This is not a problem unique to Nigeria as globally, the world’s population is expected to rapidly rise to 8.3 billion by 2030 (Population Institute 2015). We must act now to scale up the sustainable recruitment and training of more midwives across the world, in order to meet the growing demand from a rapidly growing population (WHO 2014b).

Shortages in skilled birth attendants are triggered by a number of factors, including a lack of institutional and practical training, and varying standards in midwifery education. Service quality is compromised by inadequate absorption into the workforce and ineffective regulation. Retaining midwives is made difficult by poor working conditions, low remuneration, and limited support and supervision. This is a problem that affects countries across the world as even in 2014, legislation was introduced to the US House of Representatives to address a maternity care provider shortage. The Improving Access to Maternity Care Act incentivised health care professionals to work in the communities that need them most in urban and rural areas (American College of Nurse-Midwives 2015). The loss of skilled midwives from the profession does not need to be a fait accompli — with increased advocacy, increased co-working and amplification of the impact of midwives to millions of lives globally, we will be 7

Hot Topic

able to see policy changes that support the midwives.

In line with these initiatives, WBFA and I have worked with the ICM to encourage governments to implement robust recruitment and retention policies for midwives.

Through the adoption of the ICM’s global MSF, I believe national governments can easily strengthen their recruitment and retention programmes of midwives.

Overcoming the challenge of midwife retention in the post-2015 development era must consider how health services, including access to midwifery care, is funded in developing countries. When we began our work in 2004, WBFA’s frontline health programmes in Kwara State, western Nigeria, included the Positive Lifeline Programme, Twins and Multiple Births Programme and the Indigent Medical Fund, which helped thousands of lives. Through these initiatives, WBFA and I would intervene to help with costs of medical bills and specialist care for patients in need. However, we have found that this model, whilst successful, is ultimately unsustainable. We realised that transforming how we approach primary health care would require a more comprehensive and innovative financing mechanism.

Therefore, we introduced the Alaafia Universal Health Coverage Fund (AUHCF).

Through the AUHCF — a global best practices model — we fund the insurance premiums for 5000 Nigerians each year. The programme enables patients to access affordable primary health care, rather than relying primarily on expensive emergency care. This will in turn have a positive impact on overall health habits and encourage healthier home practices. Most importantly, innovative financing for universal health coverage through schemes like AUHCF guarantees payment for health care professionals for their services.

The guarantee of payment through a robust financing system will result in more motivated health care workers, thus improving quality of care and ensuring that skilled birth attendants like midwives are retained within the profession. The AUHCF model can be scaled up and replicated in various contexts and settings to help both health care professionals and patients. The implementation of similar schemes across sub-Saharan Africa and other developing regions will help ease the financial pressures and concerns facing midwives regarding payment. In the Sustainable Development era, it is time we moved away from the financial insecurity that plagues the lives of so many midwives across the African continent. The expertise of midwives should be fairly compensated and covered as part of a comprehensive universal health coverage scheme in every country. Without this, developing countries will struggle to make sufficient progress on SDG 3.

After my time in New York during the UNGA summit in September representing WBFA and the ICM as their

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Global Goodwill Ambassador, I am more confident than ever of the role that midwives can play in RMNCAH and the achievement of SDG 3. However, with the post2015 development agenda confirmed, it is crucial that we keep sight of the human lives, dignity, and stories that the SDGs seek to serve. It can be easy to get lost behind the goals and targets but it is important that we keep our focus on the people we seek to serve and the people on the frontlines of changing lives — the mothers and the midwives. We will be encouraging this through our #MaternalMonday campaign. Maternal Monday is a digital campaign that has been created by WBFA to educate people and drive a global conversation about maternal health. Building on the success of this campaign, every Monday, WBFA will be encouraging mothers, fathers, daughters, sons — and midwives — to share their stories using the #MaternalMonday.

In honour of SDG 3, we invite all midwives across the world to share their #MaternalMonday stories via Instagram, Twitter, and Facebook and nominate others to put a human face on global development.

Simply upload a photo of you, your mother, your baby, or even your midwife colleagues using the hashtag #MaternalMonday to amplify the voice, visibility, and vision of midwives across the world in this new stage for the midwifery profession.

The evolution of the MDGs to the SDGs is an important moment for not just the international development community but for the midwives of today and tomorrow. Midwifery is going to play an invaluable role in the post-2015 development agenda and the SDGs will have an impact on the direction of the profession across the world. Recruiting, training and retaining more midwives is vital to saving lives, as is ensuring that existing midwives are in the right places within countries, more importantly, ensuring that midwives are reaching the poorest, most vulnerable and most remote women and children, and not just those that are easiest to reach. As the countdown begins to 2030, reducing the global maternal mortality ratio and ending preventable deaths of newborns and children under five is going to be hard work. The road to 2030 is long and it is daunting — yet, with skilled midwives on the side of mothers, newborns, and children, I know that we can reach this goal together. There is an African proverb that says, ‘If you want to go fast, go alone. If you want to go far, go together.’ As we enter the Sustainable Development era, let us go far and go together, for every woman and every child.

Her Excellency Toyin Saraki, Goodwill Ambassador for the International Confederation of Midwives (ICM). Founder and President of the ‘Well-Being Foundation Africa’, International Campaigner for Maternal, Newborn and Child Health, Healthcare Philanthropist and former First Lady of Kwara State, Nigeria.

MIDIRS Midwifery Digest 25:4 2015

© Nancy Durrell McKenna/SafeHands for Mothers.

Hot Topic

References American College of Nurse-Midwives (2015). Leading midwifery organization applauds bill to address maternity care shortage.

4 March. http://www.midwife.org/Maternity-Care-Shortage-NewsRelease [Accessed 7 October 2015].

BBC News (2015). Child mortality falls by 50% since 1990 - report.

9 September. http://www.bbc.co.uk/news/world-34194704 [Accessed 7 October 2015].

Black RE, Victora CG, Walker SP et al (2013). Maternal and child undernutrition and overweight in low-income and middle-income countries. The Lancet 382(9890):427-51.

Gladstone R, Sengupta S (2014). Despite declines, child mortality and hunger persist in developing nations, U.N. reports. New York Times 16 September. http://www.nytimes.com/2014/09/17/health/childmortality-falling-un-says-but-not-fast-enough.html?_r=0 [Accessed 7 October 2015].

International Confederation of Midwives (2015). Midwifery Services Framework Guidelines for developing SRMNAH services by midwives. Field-test version. 17 March 2015. http://www. internationalmidwives.org/assets/uploads/documents/Manuals%20 and%20Guidelines/MSF%20for%20field-testing,%2017Mar15.pdf [Accessed 7 October 2015].

National Population Commission (NPC) [Nigeria] and ICF International (2014). Nigeria Demographic and Health Survey 2013.

Rockville, Maryland, USA: ICF International. https://dhsprogram.com/ pubs/pdf/FR293/FR293.pdf [Accessed 7 October 2015].

Oti S (2015). Counting every birth and death could make a difference to health inequities in Africa. Times Live. 4 October. http://www. timeslive.co.za/africa/2015/10/04/Counting-every-birth-and-deathcould-make-a-difference-to-health-inequities-in-Africa [Accessed 7 October 2015].

Oyedele D (2014). Nigeria accounts for 13% global maternal mortality rates. This Day Live. 12 July. http://www.thisdaylive. com/articles/nigeria-accounts-for-13-global-maternal-mortalityrates/183394/ [Accessed 7 October 2015].

Population Institute (2015). 2030: The ‘Perfect Storm’ Scenario. https://www.populationinstitute.org/external/files/reports/The_Perfect_ Storm_Scenario_for_2030.pdf [Accessed 7 October 2015].

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Renfrew MJ, McFadden A, Bastos MH et al (2014). Midwifery and quality care: findings from a new evidence-informed framework for maternal and newborn care. The Lancet 383(9948):1129-45.

UNICEF (2013). Breastfeeding on the worldwide agenda: findings from a landscape analysis on political commitment for programmes to protect, promote and support breastfeeding. New York: UNICEF. http://www.unicef.org/eapro/breastfeeding_on_worldwide_agenda.pdf [Accessed 13 October 2015].

United Nations Population Fund, International Confederation of Midwives, World Health Organization (2014). The State of the World’s Midwifery 2014.A universal pathway. A woman’s right to health. http://unfpa.org/public/home/publications/pid/17601 [Accessed 7 October 2015].

World Bank Group, United States Agency for International Development, World Health Organization (2015). The Roadmap for Health Measurement and Accountability. http://ma4health.hsaccess. org/docs/support-documents/the-roadmap-for-health-measurementand-accountability.pdf?sfvrsn=0 [Accessed 20 October 2015].

World Health Organization (2014a). Maternal mortality. London: WHO. http://www.who.int/mediacentre/factsheets/fs348/en/ [Accessed 7 October 2015].

World Health Organization (2014b). State Of The World’s Midwifery 2014 Report. http://www.who.int/maternal_child_adolescent/news_ events/events/2014/midwifery_infographic.pdf [Accessed 7 October 2015].

World Health Organization, UNICEF, World Bank Group et al (2014).

New data show child mortality rates falling faster than ever. Geneva: WHO. http://www.who.int/mediacentre/news/releases/2014/child_ mortality_estimates/en/ [Accessed 7 October 2015].

Wright S, Mathieson K, Brearley L et al (2014). Ending newborn deaths: ensuring every baby survives. Save the Children. http://www.savethechildren.org/site/c.8rKLIXMGIpI4E/b.8989373/k.

E376/Ending_Newborn_Deaths_Ensuring_Every_Baby_Survives.htm [Accessed 7 October 2015].

Saraki T. MIDIRS Midwifery Digest, vol 25, no 4, December 2015, pp 413–418.

Original article. © MIDIRS 2015.

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Research & Education extract

Ethical aspects of current challenges to women’s choice of planned place of birth Anna Maria Brown, Ann Gallagher ORIGINAL Women have to face a myriad of choices on which to make informed decisions during the childbearing continuum. Planned place of birth is of particular importance to them and their families in providing a positive birthing experience. This experience will influence future planned pregnancies and have an impact on their beliefs in the normality of labour and birth and enhance outcomes in terms of breastfeeding uptake and continuity (Sandall 2008). A challenge to ethical practice is the proposed threat to midwifery supervision, an activity that safeguards women and midwives. This paper examines the ethical implications, such as autonomy, of choosing place of birth from available choices, specifically midwifery-led care, and how these decisions can impact women’s birth experience. The discussion draws on the four principles of biomedical ethics (Beauchamp & Childress 2013) and the new Nursing and Midwifery Council Code (NMC 2015).

Background Supervision of midwives has to date been lodged in statute ensuring good midwifery practice through clinical supervision, mentorship and preceptorship support (Baird et al 2015). The NMC has recently accepted recommendations that statutory supervision should no longer be part of its legal framework. In the future the role of the Local Supervisory Authority will be abolished and the Department of Health will now have to consider how best to ensure ongoing supervision and support for midwives. As a result of the Parliamentary and Health Service Ombudsman’s investigation (Parliamentary and Health Service Ombudsman 2013) it is suggested that combining professional regulation and supervision presents

a conflict of interest to the public. Consequently, contextual factors and statutory changes in the supervisory aspects of midwifery will have an impact on midwives’ autonomy as they must consider the consequences of their decisions without support of the supervisory process (Baird et al 2015). This places midwives in what is perceived to be a vulnerable position (MacLellan 2014) and therefore they must seek alternative approaches to the care they provide.

One useful approach would be the value of relational autonomy, which is discussed in the next section.

A number of studies indicate that women’s perception of midwifery-led care provides a better childbirth experience (Coyle et al 2001, Walsh & Downe 2004, Morano et al 2007, Begley et al 2011). In addition, in contrast to previous studies, Rogers et al (2011) found that 87% of women perceived that birth in a stand-alone birth centre provided a safe alternative to either home birth or a hospital birth. This is one aspect of maternity service provision both in the UK and in other parts of the world.

© Monkey Business, Fotolia.com

Hatem et al (2008:2) points out that: ‘The underpinning philosophy of midwife-led care is normality, continuity of care and being cared for by a known and trusted midwife during labour.

There is an emphasis on the natural ability of women to experience birth with minimum intervention’.

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MIDIRS Midwifery Digest 25:4 2015

Midwifery extract

Women’s experiences of commercial three-dimensional ultrasound scans Franziska Wadephul, Julie Jomeen, Lesley Glover ORIGINAL Ultrasound has become a routine part of UK maternity care and has a range of diagnostic and screening purposes. The last two decades have seen the development of three-dimensional (3D) scans, which use computer software to produce a seemingly 3D image of the fetus (Rankin et al 1993). Four-dimensional (4D) scans include the dimension of time, ie moving images of the fetus. This technology does currently have limited diagnostic use (Campbell 2002, Kurjak et al 2007) though it can be helpful in screening for facial anomalies. supported by research into the psychological impact of 3D and 4D scans, which suggests that while these scans may enhance parental recognition of the fetus, they do not increase ‘bonding’ or reassurance compared to conventional two-dimensional (2D) scans (Righetti et al 2005, Rustico et al 2005, Leung et al 2006, Sedgmen et al 2006, Lapaire et al 2007, de Jong-Pleij et al 2013).

© Olesia Bilkei, Fotolia.com

Over the last two decades 3D and 4D scans have become available to expectant parents (Roberts 2012) through commercial screening companies. They are generally marketed as ‘bonding scans’ or ‘reassurance scans’ (Wadephul 2013), in line with claims that the more ‘baby-like’ images enhance the parental relationship with the fetus and provide reassurance to expectant parents (Campbell 2002). This is not

MIDIRS Midwifery Digest 25:4 2015

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Pregnancy extract

Ginger is ineffective for hyperemesis gravidarum, and causes harm: an internet based survey of sufferers Caitlin R Dean, Margaret E O’Hara ORIGINAL Objective: Ginger is commonly suggested to women experiencing nausea and vomiting of pregnancy (NVP). Evidence for the efficacy of ginger for hyperemesis gravidarum (HG) is lacking despite its well-known status. The aim of this study was to assess the efficacy of ginger for controlling symptoms of HG and to investigate possible negative side effects.

Design: A self-selected internet-based survey.

Setting: Participants were recruited principally through social media and were predominantly UK-based.

Sample: 512 women who had been hospitalised for HG within the past five years.

Methods: Internet survey platform Survey Monkey.

Main outcome measures: Questions were mostly asked using Likert-Type scales with the option for additional free text responses.

Results: Women reported that ginger is often suggested for HG and 87% of respondents have tried it. Eighty-eight per cent of those report that it is completely ineffective. Fifty-one per cent of respondents who tried ginger reported that it actually exacerbated symptoms.

Eighty-two per cent of women reported that suggestions of ginger caused a worsening of their mood, inducing feelings of anger, lack of validation, isolation, guilt and exacerbating the feeling that they are misunderstood. Seventy-nine per cent of women who had ginger suggested by a health care professional (HCP) reported that it eroded their trust and confidence in the HCP. Conclusions: HCPs should stop suggesting ginger to women with hyperemesis. Not only is it ineffective, but it can cause harm to the sufferer and damages the patient-HCP relationship.

Keywords: Ginger, hyperemesis gravidarum, nausea, vomiting, pregnancy, health care professional.

Introduction HG is a severe form of pregnancy sickness.

Although no agreed definition of the condition exists, clinical manifestations include weight loss of 5% or more of pre-pregnancy weight, ketosis and/or a urine output of <500ml in 24 hours. Electrolyte imbalance and further complications can occur without adequate treatment (Dean 2014). Its prevalence varies depending on how HG is defined, but a recent meta-analysis of international studies

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gives a prevalence of 1.1% (Einarson et al 2013).

HCPs can be reluctant to prescribe pharmaceuticals for HG (Gadsby 2004, Gadsby et al 2011) and both HCPs and women over estimate the teratogenicity of medication (Koren & Levichek 2002). The only drug licensed worldwide for NVP is doxylamine succinate and pyridoxine hydrochloride 10mg/10mg, known as Diclectin in Canada and Diclegis in the USA. Ginger is often recommended to women as a ‘natural’ remedy for NVP, regardless of severity of symptoms.

MIDIRS Midwifery Digest 25:4 2015

Labour & Birth extract

The six Cs of the breech experience Ruth Sanders, Kathryn Lamb ORIGINAL The North of England Breech Conference, held in late 2014, offered the unique opportunity for practitioners to unite for practical training in facilitating breech birth and a discussion about a much needed shift in care philosophies for breech birth. The conference also engaged with the wide reaching psychological impact, for the woman and her family, of carrying a breech baby. At a time already fraught with emotions and vulnerability, the diagnosis of a breech baby exposes women to additional stress, anxiety and life-altering options and decisions, especially as breech birth remains a contentious and challenging issue for obstetricians and midwives (Waites 2003, Guittier et al 2011, Homer et al 2015). Upon opening the conference, OBE Sheena Byrom, an independent midwifery advisor and best-selling author, powerfully advocated situating breech birth in relation to the core nursing principles of the 6 Cs: care, commitment, communication, compassion, competence and courage.

This affords midwives and obstetricians the opportunity to appreciate the holistic diversities and complexities of breech from a woman-centred perspective, empowering women and their families to make truly informed choices about their care.

Š Monkey Business, Fotolia.com

Keywords: 6 Cs, breech birth, maternal psychology, informed consent, woman-centred facilitation.

MIDIRS Midwifery Digest 25:4 2015

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Postnatal extract

A systematic review of psychosocial interventions for women with postpartum stress Ju-Eun Song, Tiffany Kim, Jeong-Ah Ahn REPRINT Objective: To analyze the effects of psychosocial interventions with the aim of reducing the intensity of stress in mothers during the postpartum period as compared with usual care.

Data sources: Eligible studies were identified by searching MEDLINE, EMBASE, CINAHL, and ProQuest dissertations and theses.

Study selection: Randomized controlled trials (RCTs) treating stress in postpartum mothers older than age 19 years were included. The suitability of the quality of articles was evaluated using Joanna Briggs Institute’s Critical Appraisal Checklist for Experimental Studies. Fourteen articles met the inclusion criteria for data analysis.

Data extraction: Authors, country, sample, setting, methods, time period, major content of the intervention, outcome measures, and salient findings were extracted and summarized in a data extraction form for further analysis and synthesis.

Data synthesis: Standardized mean differences with 95% confidence intervals were calculated for 13 suitable articles using Cochrane Review Manager.

Results: Of 1,871 publications, 14 RCTs, conducted between 1994 and 2012, were evaluated in the systematic review and 13 studies were included in the meta-analysis.

Studies were categorized into three major types by interventional methods. We found that psychosocial interventions in general (standard mean difference −1.66, 95% confidence interval [−2.74, −0.57], p = .003), and supportive stress management programs in particular (standard mean difference −0.59, 95% confidence interval [−0.94, −0.23], p = .001), were effective for women dealing with postpartum stress.

Conclusions: This review indicated that psychosocial interventions including supportive stress management programs are effective for reducing postpartum stress in women, so those interventions should become an essential part of maternity care.

Keywords: Mothers, postpartum period, stress, intervention studies, review.

The postpartum period represents one of the most important transitional times in a woman’s life.

It is a time of biological, psychological, and social change that can contribute to personal enrichment, maturity, and happiness; at the same time it may also predispose a woman to psychological distress (Bener, Gerber, Sheikh 2012). After childbirth, women may experience a number of physical and psychological stressors. Physical stressors include perineal pain, backaches, urinary incontinence, hemorrhoids/

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constipation, fatigue/physical exhaustion, sleep difficulties, and breast problems. Psychological stressors include the pressure to return to prepregnancy weight, sexual changes, concerns about the maternal role, feeding the newborn, growth and development of the newborn, unpredictable behaviors or sudden sickness of the newborn, relationships with partner and family, and the lack of social resources and support (Beck, Gable, Sakala, Declercq 2011, Cheng & Li 2008, Hung, Lin, Stocker, Yu 2011).

MIDIRS Midwifery Digest 25:4 2015

Infant Nutrition extract

An exploration of the factors influencing fathers’ feelings about breastfeeding Michelle Tant ORIGINAL Introduction Although the health benefits of breastfeeding for mother and baby are endlessly debated in contemporary health care practice, the influence of fathers on decisions and practice around infant feeding is rarely discussed. This article explores the literature around fathers’ attitudes to breastfeeding and unpicks both the positive and negative impact of this on breastfeeding success.

Indeed, Mannion et al (2013) also support the evidence recognising the significant effect fathers have on women’s experience and success in initiating and sustaining breastfeeding. exclusively breastfeeding at the recommended six months (McAndrew et al 2012). Eighty per cent of the women who discontinued breastfeeding did not wish to stop, citing lack of information and support (Trickey & Newburn 2013), highlighting a clear discrepancy between need and provision.

An increasingly recognised contributory factor of success in breastfeeding is the influence the father has.

© tuelekza, Fotolia.com

It is well-established that breastfeeding is the optimal method of infant feeding which brings with it many benefits to both the mother and baby (WHO & Unicef 2003). However, breastfeeding rates in the United Kingdom are among the lowest in Europe (OECD 2009). Despite numerous strategies to support breastfeeding mothers and facilitate breastfeeding and high initiation rates, the figures rapidly decline, leading to less than 2% of women

MIDIRS Midwifery Digest 25:4 2015

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Neonatal & Infancy extract

Keeping babies warm: a non-inferiority trial of a conductive thermal mattress Swarna R Bhat, Nathan F Meng, Kishore Kumar, Karthik N Nagesh, Ashwini Kawale, Vinod K Bhutani

REPRINT Background: External thermal support is critical for preterm or ill infants due to altered thermoregulation. Incubators are the gold standard for long-term support and have been adopted successfully in many countries. Alternatives such as radiant warmers, blankets and others are often used as standard of care (SoC) in resource-limited settings when infants are otherwise not in Kangaroo Mother Care (KMC).

Methods: In this pilot study, we evaluate the feasibility of a conductive thermal mattress (CTM) using phase change materials as a low-cost warmer. We conducted a prospective multicentre open-label randomised controlled trial to determine non-inferiority of this CTM to SoC warming practices in low birthweight infants. The primary outcome was maintenance of axillary temperature.

Results: We equally randomised 160 infants to CTM or SoC. The latter cohort continued to receive warmth by radiant warmers (n=48), blankets (n=18), warmed cradles (n=7) or KMC (n=7) before, during and subsequent to the study. CTM was deemed non-inferior since warmed babies had higher axillary temperature compared with SoC (mean increase 0.11±0.03°C SEM; p<0.001). Post hoc comparison to radiant warmers alone showed that CTM led to a higher axillary temperature (mean increase by 0.14±0.03°C SEM; p<0.001).

Conclusions: Short-term use of CTM compared with radiant warmers and other modes of warming is non-inferior to SoC and efficacious in maintaining body temperature.

No adverse effects were reported. An extended multinational trial, preferably one that demonstrates longer-term thermoregulation, is warranted.

© PHOTO NO 18: © famfeldman, Fotolia.com

Trial registration number: Clinical Trials Registry of India (CTRI/2010/091/002916 and CTRI/2011/04/ 001696).

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MIDIRS Midwifery Digest 25:4 2015

Worldwide Maternity Services extract

Knowledge levels and practices of midwives in the management of severe pre-eclampsia at health centre level Beauty Siansende, Mutinta C Muleya, Margaret Siame, Lilian Mbewe, Dorothy Bwalya

ORIGINAL Background: Severe pre-eclampsia (PE) is an obstetric emergency that causes serious pregnancy complications. Zambia has one of the highest maternal and neonatal mortality rates in the sub-Saharan region, with a maternal mortality rate of 398 per 100,000 live births, with 17% due to hypertensive disorders. Midwives, who are the first contact for these pregnant women, should be knowledgeable and competent in the assessment and diagnosis of pregnant women who are at risk of developing severe PE, and be able to manage them.

Objective: The aim of this study was to explore knowledge levels and practices of midwives in the management of severe PE at health centre level.

Method and materials: The study used a descriptive design and a structured interview schedule to determine the knowledge levels and practices of midwives from health centres in two districts (Lusaka and Luanshya) of Zambia. A total of 196 respondents were interviewed.

Results: The results revealed that knowledge among the midwives of management of severe PE was generally medium (81%). The majority of the respondents had good levels of practice (76%) on management of severe PE. However, lack of in-service training in emergency management of obstetric complications, poor staffing levels, and lack of supervision were some of the challenges that compromised the management of clients with severe PE. Conclusion: Results from this study have highlighted some gaps in the management of severe PE. Although midwives have some knowledge in the management of severe PE, lack of in-service training and inadequate human and material resources compromise management. Therefore, the government needs to strengthen support for midwives especially those in the health centres where there are no obstetricians.

Š Nancy Durrell McKenna SafeHands for Mothers

Key words: knowledge, practice, severe PE, management, midwife.

MIDIRS Midwifery Digest 25:4 2015

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News & Reviews extract

Did you miss it?

Baby-Friendly Certificate awarded to Kingston and St Georges Kingston University and St Georges, University of London has been awarded a Certificate of Commitment in its first step towards gaining international recognition from the Unicef UK Baby Friendly Initiative for the high levels of training in breastfeeding provided to students on its midwifery/ health visiting course.

The Certificate was presented to staff and students by the Dean of the Faculty, Professor Andy Kent on 15th October 2015 at the St Georges campus.

Dr Jayne Marshall, Head of School of Midwifery and Lead Midwife for Education at Kingston and St Georges said: ‘We decided to work with the Baby Friendly Initiative to ensure a high standard of training in breastfeeding for all student midwives graduating from our midwifery programmes.’

Lansinoh breast pumps You may have noticed in the last few issues that Lansinoh have been advertising in the journal. From experience in practice I have always seen good results using their nipple cream for women with sore or cracked nipples. However, I had not used the breast pumps and so was not in a position to recommend them until now with the recent arrival of a grandson!

Three pumps were trialled with excellent results.

The twin electric pump proved useful in stimulating the milk production in the early days, for a first time mum a little self-conscious, consideration to privacy was taken into account to allow the let-down reflex to respond and the milk to flow. This pump would be particularly helpful if the baby was unable to suck from the breast due to illness or prematurity or with more than one baby to feed. Again the single electric pump lived up to expectations, simple to use, painless and effective. Once again consideration was given to when and where the pump would be used, very useful if breasts are engorged to relieve and soften the breasts to enable the baby to latch

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Professor Andy Kent presenting the Certificate of Commitment award to Dr Jayne Marshall on behalf of Kingston and St Georges

on easily, particularly with a smaller/preterm baby.

The favourite pump for all round use was perhaps surprisingly the manual hand pump. Reasons for this were in the fact it could be taken out and used away from the home more discretely than the electric models and felt more personal to use. Particularly useful if a mother has to return to work while continuing to breastfeed. Overall, all three pumps evaluated well and could be utilised for different situations dependent upon need, particularly when the baby is unable to suckle straight from the breast.

For more information go to: http://www.lansinoh. co.uk/professional

Erratum In the September edition of the Digest we published a paper by Shawn Walker entitled, ‘Turning breech upside down: upright breech birth’ in which we incorrectly named James Paget University Hospitals NHS Foundation Trust as permission holder for all included photos. The correct permission holder is in fact the author Shawn Walker. Please accept our apologies for this.

MIDIRS Midwifery Digest 25:4 2015

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