Out-of-Hospital Birth.

Since the 1970s, most births in the United States have been planned to occur in a hospital. However, a small percentage of Americans choose to give birth outside of a hospital. The number of out-of-hospital births has increased, with one in every 61 U.S. births (1.64%) occurring out of the hospital in 2018. Out-of-hospital (or community) birth can be planned or unplanned. Of those that are planned, most occur at home and are assisted by midwives. Patients who choose a planned community birth do so for multiple reasons. International observational studies that demonstrate comparable outcomes between planned out-of-hospital and planned hospital birth may not be generalizable to the United States. Most U.S. studies have found statistically significant increases in perinatal mortality and neonatal morbidity for home birth compared with hospital birth. Conversely, planned community birth is associated with decreased odds of obstetric interventions, including cesarean delivery. Perinatal outcomes for community birth may be improved with appropriate selection of low-risk, vertex, singleton, term pregnancies in patients who have not had a previous cesarean delivery. A qualified, licensed maternal and newborn health professional who is integrated into a maternity health care system should attend all planned community births. Family physicians are uniquely poised to provide counseling to patients and their families about the risks and benefits associated with community birth, and they may be the first physicians to evaluate and treat newborns delivered outside of a hospital.

Midwifery continuity of care versus standard maternity care for women at increased risk of preterm birth: A hybrid implementation-effectiveness, randomised controlled pilot trial in the UK.

BACKGROUND: Midwifery continuity of care is the only health system intervention shown to reduce preterm birth (PTB) and improve perinatal survival, but no trial evidence exists for women with identified risk factors for PTB. We aimed to assess feasibility, fidelity, and clinical outcomes of a model of midwifery continuity of care linked with a specialist obstetric clinic for women considered at increased risk for PTB. METHODS AND FINDINGS: We conducted a hybrid implementation-effectiveness, randomised, controlled, unblinded, parallel-group pilot trial at an inner-city maternity service in London (UK), in which pregnant women identified at increased risk of PTB were randomly assigned (1:1) to either midwifery continuity of antenatal, intrapartum, and postnatal care (Pilot study Of midwifery Practice in Preterm birth Including women's Experiences [POPPIE] group) or standard care group (maternity care by different midwives working in designated clinical areas). Pregnant women attending for antenatal care at less than 24 weeks' gestation were eligible if they fulfilled one or more of the following criteria: previous cervical surgery, cerclage, premature rupture of membranes, PTB, or late miscarriage; previous short cervix or short cervix this pregnancy; or uterine abnormality and/or current smoker of tobacco. Feasibility outcomes included eligibility, recruitment and attrition rates, and fidelity of the model. The primary outcome was a composite of appropriate and timely interventions for the prevention and/or management of preterm labour and birth. We analysed by intention to treat. Between 9 May 2017 and 30 September 2018, 334 women were recruited; 169 women were allocated to the POPPIE group and 165 to the standard group. Mean maternal age was 31 years; 32% of the women were from Black, Asian, and ethnic minority groups; 70% were in employment; and 46% had a university degree. Nearly 70% of women lived in areas of social deprivation. More than a quarter of women had at least one pre-existing medical condition and multiple risk factors for PTB. More than 75% of antenatal and postnatal visits were provided by a named/partner midwife, and a midwife from the POPPIE team was present at 80% of births. The incidence of the primary composite outcome showed no statistically significant difference between groups (POPPIE group 83.3% versus standard group 84.7%; risk ratio 0.98 [95% confidence interval (CI) 0.90 to 1.08]; p = 0.742). Infants in the POPPIE group were significantly more likely to have skin-to-skin contact after birth, to have it for a longer time, and to breastfeed immediately after birth and at hospital discharge. There were no differences in other secondary outcomes. The number of serious adverse events was similar in both groups and unrelated to the intervention (POPPIE group 6 versus standard group 5). Limitations of this study included the limited power and the nonmasking of group allocation; however, study assignment was masked to the statistician and researchers who analysed the data. CONCLUSIONS: In this study, we found that it is feasible to set up and achieve fidelity of a model of midwifery continuity of care linked with specialist obstetric care for women at increased risk of PTB in an inner-city maternity service in London (UK), but there is no impact on most outcomes for this population group. Larger appropriately powered trials are needed, including in other settings, to evaluate the impact of relational continuity and hypothesised mechanisms of effect based on increased trust and engagement, improved care coordination, and earlier referral on disadvantaged communities, including women with complex social factors and social vulnerability. TRIAL REGISTRATION: We prospectively registered the pilot trial on the UK Clinical Research Network Portfolio Database (ID number: 31951, 24 April 2017). We registered the trial on the International Standard Randomised Controlled Trial Number (ISRCTN) (Number: 37733900, 21 August 2017) and before trial recruitment was completed (30 September 2018) when informed that prospective registration for a pilot trial was also required in a primary clinical trial registry recognised by WHO and the International Committee of Medical Journal Editors (ICMJE). The protocol as registered and published has remained unchanged, and the analysis conforms to the original plan.

Childbirth care in Egypt: a repeat cross-sectional analysis using Demographic and Health Surveys between 1995 and 2014 examining use of care, provider mix and immediate postpartum care content.

BACKGROUND: Egypt has achieved important reductions in maternal and neonatal mortality and experienced increases in the proportion of births attended by skilled professionals. However, substandard care has been highlighted as one of the avoidable causes behind persisting maternal deaths. This paper describes changes over time in the use of childbirth care in Egypt, focusing on location and sector of provision (public versus private) and the content of immediate postpartum care. METHODS: We used five Demographic and Health Surveys conducted in Egypt between 1995 and 2014 to explore national and regional trends in childbirth care. To assess content of care in 2014, we calculated the caesarean section rate and the percentage of women delivering in a facility who reported receiving four components of immediate postpartum care for themselves and their newborn. RESULTS: Between 1995 and 2014, the percentage of women delivering in health facilities increased from 35 to 87% and women delivering with a skilled birth attendant from 49 to 92%. The percentage of women delivering in a private facility nearly quadrupled from 16 to 63%. In 2010-2014, fewer than 2% of women delivering in public or private facilities received all four immediate postpartum care components measured. CONCLUSIONS: Egypt achieved large increases in the percentage of women delivering in facilities and with skilled birth attendants. However, most women and newborns did not receive essential elements of high quality immediate postpartum care. The large shift to private facilities may highlight failures of public providers to meet women's expectations. Additionally, the content (quality) of childbirth care needs to improve in both sectors. Immediate action is required to understand and address the drivers of poor quality, including insufficient resources, perverse incentives, poor compliance and enforcement of existing standards, and providers' behaviours moving between private and public sectors. Otherwise, Egypt risks undermining the benefits of high coverage because of substandard quality childbirth care.

Advancement of global health: Recommendations from the Global Advisory Panel on the Future of Nursing & Midwifery (GAPFON®).

AIMS: To discuss nurses' contributions to global health through their participation in GAPFON®. DESIGN: Discussion paper that reviews literature related to global health, global nursing and midwifery based on the contributions of the GAPFON® report. DATA SOURCES: A literature search of electronic databases was conducted for published articles during 2014-2018 in English focusing on the main themes of the GAPFON® report. Manual searches of relevant journals and internet sites were also undertaken. RESULTS: Recommendations and strategies were discussed that could have an impact on the advancement of the nursing profession's contribution to global health based on the GAPFON® report outcomes. IMPLICATIONS FOR NURSING: GAPFON® provides a framework to synergize and converge our activities to address professional issues around the globe, through implementation of the suggested strategies identified in the GAPFON® report. GAPFON® has engaged with nursing and midwifery leaders around the globe to determine both the most pressing health issues and professional issues in regions and the report is a synthesis of all the data, reflecting regional and global challenges. This article explores ways of how the report can be used as a basis for engagement with decision makers in global health. CONCLUSION: Advances in the professional areas embedded in the GAPFON® Model are expected to lead to capacity building, evidence-based practice and ultimately improved quality of global health care. The strategies for implementation identified by regional stakeholders can have an impact on the global health agenda by focusing on nurses and midwives as the drivers of this change.

[Academisation of the Midwifery Profession (Part 2): Risks - and How they can Be Avoided as Best as Possible in the Degree Programs]. / Akademisierung des Hebammenberufs (Teil 2): Risiken ­ und wie sie in den Studiengängen bestmöglich vermieden werden können.

The full academisation of midwifery training, which thus far has been given in technical colleges, is now beginning in Germany and poses a great challenge for both the German federal states and the universities. Against this background, the aim of this article is to identify possible risks arising from the full academisation of training and the revision of the Midwifery Act and to show possible solution strategies to promote the implementation of study programmes.

[The Shift to Academic Degree Level of the Midwifery Profession (Part 1): Opportunities - and how they can be used in the Best Possible Way In The Study Programmes]. / Akademisierung des Hebammenberufs (Teil 1): Chancen ­ und wie sie in den Studiengängen bestmöglich genutzt werden können.

The reform of the midwifery profession law was long overdue. The WHO has been demanding an academic primary qualification for midwives for years, the EU changed its corresponding directive in 2013, so that within the EU all countries had to change midwifery training accordingly, if they had not already done so. Nevertheless, the reform was controversially discussed in Germany. Especially on the part of medical representatives, numerous concerns were expressed. The need for reform in midwifery training in Germany is enormous, as the last change took place in 1985. The WHO points out that over 50 outcomes in obstetrics will be improved if the quality of midwifery training is increased. There is therefore enormous potential in the reform of legislation. Special provisions of the new midwifery law are novelties and can be exemplary for other studies for health care professions, such as the financing of practical study parts and the student salary.

Leadership in nursing and midwifery: Activities and associated competencies of advanced practice nurses and midwives.

AIM: To explore the practice profile and competencies of advanced practice nurses (APNs) and midwives (AMPs), and factors associated with task non-execution. BACKGROUND: Advanced practitioner roles are increasingly implemented internationally. Unofficial role introduction led to confusion regarding task performance. Studies examining associations between APNs'/AMPs' task performance and competency levels, and factors associated with task non-execution are lacking. METHOD: A cross-sectional study among APNs/AMPs in Flanders (Belgium) explored tasks and competencies in seven domains: clinical/professional leadership, change management/innovation, research, clinical expertise/guidance/coaching, consultation/consultancy, multidisciplinary cooperation/care coordination and ethical decision-making. Task performance and competency level frequencies were calculated. Regression analysis identified factors associated with task non-execution on domain/item level. RESULTS: Participants (n = 63) executed tasks in all domains. Task non-execution related to research and clinical expertise was associated with work setting; task non-execution regarding care coordination and ethical decision-making was associated with competency perception. Several tasks were performed by few APNs/AMPs despite many feeling competent. Five of ten tasks performed by fewest participants belonged to the leadership domain. CONCLUSION AND IMPLICATIONS FOR NURSING AND MIDWIFERY MANAGEMENT: Supervisors could play an important part in APNs'/AMPs' role development, especially regarding leadership and tasks executed by few participants. Future studies should provide in-depth knowledge on task non-execution.

Enablers and challenges to advanced nursing and midwifery practice roles.

AIM: To describe the enablers and challenges to the development and implementation of advanced nursing and midwifery practice roles in Ireland. BACKGROUND: Leadership strategies need to be put in place to enhance the development and implementation of advanced nursing and midwifery practice roles. METHOD: A descriptive qualitative approach using semi-structured interviews with key stakeholders (n = 15) was undertaken with nurses and midwives working in specialist and advanced practice roles and participants from other areas such as legislative, regulatory, policy, pharmacy, medicine and education. RESULTS: Participant's perspectives on the enablers and challenges to enacting specialist and advanced practice roles resulted in the generation of three themes: organisational factors; collegial, interprofessional and interpersonal support; and role clarity, economic and regulatory contexts. CONCLUSION: Addressing organisational factors, encouraging collegial and interprofessional support and establishing role clarity contribute to the effective development and implementation of the role of advanced practitioners. IMPLICATIONS FOR NURSING AND MIDWIFERY MANAGEMENT: Managers of nursing services need to provide leadership in developing strategies to enhance the enablers and overcome the challenges to advanced practice role development in their own organisation.

Nursing Now: nurses at the heart of the challenge to improve global health.

Elizabeth Rosser, Acting Executive Dean, Bournemouth University, discusses two initiatives to promote nursing around the world and make improvements in global health.

Characteristics of patients receiving midwife-led prenatal care in Canada: results from the Maternity Experiences Survey (MES).

BACKGROUND: The aim of this study was to determine the characteristics of women in Canada who received care from a midwife during their prenatal period. METHODS: The findings of this study were drawn from the Maternity Experiences Survey (MES), which was a cross-sectional survey that assessed the experiences of women who gave birth between November 2005 and May 2006. The main outcome variable for this study was the prenatal care provider (i.e. midwife versus other healthcare providers). Demographic, socioeconomic, as well as health and pregnancy factors were evaluated using bivariate and multivariate models of logistic regression. RESULTS: A total of 6421 participants were included in this analysis representing a weighted total of 76,508 women. The prevalence of midwife-led prenatal care was 6.1%. The highest prevalence of midwife-led prenatal care was in British Columbia (9.8%), while the lowest prevalence of midwife-led prenatal care was 0.3% representing the cumulative prevalence in Nova Scotia, Prince Edward Island, Newfoundland and Labrador, New Brunswick, Saskatchewan, and Yukon. Factors showing significant association with midwife-led prenatal care were: Aboriginal status (OR = 2.26, 95% CI: 1.41-3.64), higher education with bachelor and graduate degree attainment having higher ORs when compared to high-school or less (OR = 2.71, 95% CI: 1.71-4.31 and OR = 3.17, 95% CI: 1.81-5.55, respectively), and alcohol use (OR = 1.63, 95% CI: 1.17-2.26). Age, marital status, immigrant status, work during pregnancy, household income, previous pregnancies, perceived health, maternal Body Mass Index (BMI), and smoking during the last 3 months of pregnancy were not significantly associated with midwife care. CONCLUSIONS: In general, women who were more educated, have aboriginal status, and/or are alcohol drinkers were more likely to receive care from midwives. Since MES is the most recent resource that includes information about national midwifery utilization, future studies can provide more up-to-date information about this important area. Moreover, future research can aim at understanding the reasons that lead women to opt for midwife-led prenatal care.

Trends in newborn umbilical cord care practices in Sokoto and Bauchi States of Nigeria: the where, who, how, what and the ubiquitous role of traditional birth attendants: a lot quality assurance sampling survey.

BACKGROUND: Neonatal infections caused by unsafe umbilical cord practices account for the majority of neonatal deaths in Nigeria. We examined the trends in umbilical cord care practices between 2012 and 2015 that coincided with the introduction of chlorhexidine digluconate 7.1% gel in Bauchi and Sokoto States. METHODS: We obtained data from three rounds of lot quality assurance samples (LQAS) surveys conducted in 2012, 2013 and 2015. Households were randomly sampled in each round that totaled 1140 and 1311 households in Bauchi and Sokoto States respectively. Mothers responded to questions on cord care practices in the last delivery. Coverage estimates of practice indicators were obtained for each survey period. Local Government Area (LGA) estimates for each indicator were obtained with α ≤ 5%, and ß ≤20% statistical errors and aggregated to State-level estimates with finite sample correction relative to the LGA population. RESULTS: Over 75 and 80% of deliveries in Bauchi and Sokoto States respectively took place at home. The proportion of deliveries in public facilities reported by mothers ranged from 19% in 2012 to 22.4% in 2015 in Bauchi State and from 12.9 to 13.2% in 2015 in Sokoto State. Approximately 50% of deliveries in Bauchi and more than 80% in Sokoto States were assisted by traditional birth attendants (TBAs) or relatives and friends, with little change in the survey periods. In Bauchi and in Sokoto States, over 75% and over 80% of newborn cords were cut with razor blades underscoring the pervasive role of the TBAs in the immediate postpartum period. Use of chlorhexidine digluconate 7.1% gel for cord dressing significantly increased to the highest level in 2015 in both States. Health workers who attended deliveries in health facilities switched from methylated spirit to chlorhexidine. There were no observable changes in cord care practices among the TBAs. CONCLUSION: Unsafe umbilical cord care practices remained prevalent in Bauchi and Sokoto States of Nigeria, although a recent introduction of chlorhexidine digluconate 7.1% gel positively changed the cord care practices toward safer practices among public health providers. TBAs, friends and relatives played the strongest immediate postpartum roles and mostly retained the unsafe cord care practices such as use of ash, cow dung and hot compress. We recommend that existing TBAs are retrained and refocused to forge stronger links between communities and the primary health centers to increase mothers' access to skilled birth attendants.

How history shaped the modern day midwife.

The midwifery profession can be traced back over thousands of years. Globally, midwives have expressed noticeable changes to their role over the years, and the impact on childbearing women (Larsson et al 2009; Mavalankar and Vora 2008; Dickerson et al 2014). During this time the midwifery profession has battled continuously against external pressures and this, in turn, has shaped the role of the midwife and the midwifery profession as a whole. This article will provide an insight into the history of midwifery; the challenges both midwives and the midwifery profession have faced; how these challenges have changed; and how this has assisted the development of the 'modern day midwife'. Of course this could not be discussed without acknowledging the continuing impact on childbearing women in the United Kingdom and globally.

The new Irish maternity strategy 2016-2026.

Report review runs alongside Guideline commentary and the other evidence series articles, examining local, national and international reports that have implications directly or indirectly for midwives. It helps readers to understand what reports mean for midwifery practice and to place report recommendations into context. As with all our evidence series articles, report reviews support you to critique recommendations and implications for your own practice. In 2016, Ireland launched its first ever maternity strategy (Department of Health (IDH) 2016). This followed many high-profile controversies, including maternal and neonatal deaths due to medical misadventure. This article reviews Ireland's history of maternity services, the new strategy and current perinatal mental health services.

Nursing priorities in Wales over the next five years.

The strategic goal for nursing and midwifery in Wales is to realise the full potential of the nursing and midwifery professions to meet, in partnership with others, the changing health and well-being needs of the people living in Wales.

Interprofessional Collaboration in Perinatal Care: The Future of Midwifery.

Healthcare delivered by teams is becoming more common, and an estimated 50% of obstetricians in the United States (US) work with or employ nurse practitioners or nurse-midwives. The number of midwife-attended births in the United States is also growing. Interprofessional collaboration between midwives and physicians can increase access to safe, quality maternity care for women in the United States. A review of the literature indicates that successful collaborative practice includes effective communication, trust, and respect between providers. A review of concepts and theoretical frameworks offers a foundation for scholarly inquiry, suggests a research agenda for future study, and provides suggestions for organizational leaders to translate current knowledge into the clinical setting. Midwifery, through increasing collaborative practices, has the potential to change care delivery in the years to come.

[Changes in the situation in out-of-hospital birth and the role of midwives in Hungary]. / Az intézeten kívüli szülés helyzetének és a szülésznok szerepének alakulása hazánkban.

The rate of homebirth decreased significantly by the 20th century, however, the practice has never disappeared. The Hungarian government issued a regulation of out-of-hospital birth in 2011, then allowed midwives to provide prenatal care for low-risk mothers in 2014. These were great steps toward the midwifery model of care. In this study the authors gathered the statistics of three licensed Hungarian out-of-hospital service providers. Despite the low number of cases, the data confirm that the rate of hospital transports in Hungary is quite similar to those found in other countries. The authors present five different studies to demonstrate that home births are just as safe as hospital births. Finally, the authors summarize a study in which hospital transports based on several criteria were analyzed. The authors conclude that in these events, fear and prejudice influences the participants on either side, harming interprofessional relationships. To improve the care given, mutually respectful communication and education of families about the option of hospital transport are key issues.

Continuity of midwifery care for rural women through caseload group practice: Delivering for almost 20 years.

OBJECTIVE: To describe the clinical outcomes and sustainability factors of a long-standing midwifery led caseload model of rural maternity care. DESIGN: Retrospective clinical audit from 1998 to 2011 and autoethnographic narrative of the midwifery program told by the longest serving midwives under three key themes relating to sustainable practice. SETTING: Regional Health Service with annual birth rate of 500. Maternity care is provided by either public antenatal clinic/GP shared care or midwife-led care. PARTICIPANTS: Women attending a rural caseload midwifery group practice between the period 1998-2011 and midwives working in the same group practice during that period. MAIN OUTCOME MEASURES: Antenatal attendance, maternal mortality, infant morbidity and mortality, mode of birth, known midwife at birth, initiation of breastfeeding. RESULTS: There were 1674 births between 1998 and 2011. Clinical outcomes for women and infants closely reflected national maternity indicator data. The group practice midwives attribute sustainability of the program to the enjoyment of flexibility in their working environment, to establishing trust amongst themselves, the women they care for, and with the obstetricians, GPs and health service executives. The rigorous application of midwifery principles including robust clinical governance have been hallmarks of success. CONCLUSION: This caseload midwifery group practice is a safe, satisfying and sustainable model of maternity care in a rural setting. Clinical outcomes are similar to standard care. Success can be attributed to strong leadership across all levels of policy, health service management and, most importantly, the rural midwives providing the service.