The views of pregnant women in New Zealand on vaginal seeding: a mixed-methods study.

BACKGROUND: Vaginal seeding is the administration of maternal vaginal bacteria to babies following birth by caesarean section (CS), intended to mimic the microbial exposure that occurs during vaginal birth. Appropriate development of the infant gut microbiome assists early immune development and might help reduce the risk of certain health conditions later in life, such as obesity and asthma. We aimed to explore the views of pregnant women on this practice. METHODS: We conducted a sequential mixed-methods study on the views of pregnant women in New Zealand (NZ) on vaginal seeding. Phase one: brief semi-structured interviews with pregnant women participating in a clinical trial of vaginal seeding (n = 15); and phase two: online questionnaire of pregnant women throughout NZ (not in the trial) (n = 264). Reflexive thematic analysis was applied to interview and open-ended questionnaire data. Closed-ended questionnaire responses were analysed using descriptive statistics. RESULTS: Six themes were produced through analysis of the open-ended data: "seeding replicates a natural process", "microbiome is in the media", "seeding may have potential benefits", "seeking validation by a maternity caregiver", "seeding could help reduce CS guilt", and "the unknowns of seeding". The idea that vaginal seeding replicates a natural process was suggested by some as an explanation to help overcome any initial negative perceptions of it. Many considered vaginal seeding to have potential benefit for the gut microbiome, while comparatively fewer considered it to be potentially beneficial for specific conditions such as obesity. Just under 30% of questionnaire respondents (n = 78; 29.5%) had prior knowledge of vaginal seeding, while most (n = 133; 82.6%) had an initially positive or neutral reaction to it. Few respondents changed their initial views on the practice after reading provided evidence-based information (n = 60; 22.7%), but of those who did, most became more positive (n = 51; 86.4%). CONCLUSIONS: Given its apparent acceptability, and if shown to be safe and effective for the prevention of early childhood obesity, vaginal seeding could be a non-stigmatising approach to prevention of this condition among children born by CS. Our findings also highlight the importance of lead maternity carers in NZ remaining current in their knowledge of vaginal seeding research.

Women's experiences of transfer from primary maternity unit to tertiary hospital in New Zealand: part of the prospective cohort Evaluating Maternity Units study.

BACKGROUND: There is worldwide debate regarding the appropriateness and safety of different birthplaces for well women. The Evaluating Maternity Units (EMU) study's primary objective was to compare clinical outcomes for well women intending to give birth in either a tertiary level maternity hospital or a freestanding primary level maternity unit. Little is known about how women experience having to change their birthplace plans during the antenatal period or before admission to a primary unit, or transfer following admission. This paper describes and explores women's experience of these changes-a secondary aim of the EMU study. METHODS: This paper utilised the six week postpartum survey data, from the 174 women from the primary unit cohort affected by birthplace plan change or transfer (response rate 73%). Data were analysed using descriptive statistics and thematic analysis. The study was undertaken in Christchurch, New Zealand, which has an obstetric-led tertiary maternity hospital and four freestanding midwife-led primary maternity units (2010-2012). The 702 study participants were well, pregnant women booked to give birth in one of these facilities, all of whom received continuity of midwifery care, regardless of their intended or actual birthplace. RESULTS: Of the women who had to change their planned place of birth or transfer the greatest proportion of women rated themselves on a Likert scale as unbothered by the move (38.6%); 8.8% were 'very unhappy' and 7.6% 'very happy' (quantitative analysis). Four themes were identified, using thematic analysis, from the open ended survey responses of those who experienced transfer: 'not to plan', control, communication and 'my midwife'. An interplay between the themes created a cumulatively positive or negative effect on their experience. Women's experience of transfer in labour was generally positive, and none expressed stress or trauma with transfer. CONCLUSIONS: The women knew of the potential for change or transfer, although it was not wanted or planned. When they maintained a sense control, experienced effective communication with caregivers, and support and information from their midwife, the transfer did not appear to be experienced negatively. The model of continuity of midwifery care in New Zealand appeared to mitigate the negative aspects of women's experience of transfer and facilitate positive birth experiences.

Oral administration of maternal vaginal microbes at birth to restore gut microbiome development in infants born by caesarean section: A pilot randomised placebo-controlled trial.

BACKGROUND: Birth by caesarean section (CS) is associated with aberrant gut microbiome development and greater disease susceptibility later in life. We investigated whether oral administration of maternal vaginal microbiota to infants born by CS could restore their gut microbiome development in a pilot single-blinded, randomised placebo-controlled trial (Australian New Zealand Clinical Trials Registry, ACTRN12618000339257). METHODS: Pregnant women scheduled for a CS underwent comprehensive antenatal pathogen screening. At birth, healthy neonates were randomised to receive a 3 ml solution of either maternal vaginal microbes (CS-seeded, n = 12) or sterile water (CS-placebo, n = 13). Vaginally-born neonates were used as the reference control (VB, n = 22). Clinical assessments occurred within the first 2 h of birth, and at 1 month and 3 months of age. Infant stool samples and maternal vaginal extracts from CS women underwent shotgun metagenomic sequencing. The primary outcome was gut microbiome composition at 1 month of age. Secondary outcomes included maternal strain engraftment, functional potential of the gut microbiome, anthropometry, body composition, and adverse events. FINDINGS: Despite the presence of viable microbial cells within transplant solutions, there were no observed differences in gut microbiome composition or functional potential between CS-seeded and CS-placebo infants at 1 month or 3 months of age. Both CS groups displayed the characteristic signature of low Bacteroides abundance, which contributed to a number of biosynthesis pathways being underrepresented when compared with VB microbiomes. Maternal vaginal strain engraftment was rare. Vaginal seeding had no observed effects on anthropometry or body composition. There were no serious adverse events associated with treatment. INTERPRETATION: Our pilot findings question the value of vaginal seeding given that oral administration of maternal vaginal microbiota did not alter early gut microbiome development in CS-born infants. The limited colonisation of maternal vaginal strains suggest that other maternal sources, such as the perianal area, may play a larger role in seeding the neonatal gut microbiome. FUNDING: Health Research Council of New Zealand, A Better Start - National Science Challenge.

Maternal bacteria to correct abnormal gut microbiota in babies born by C-section.

INTRODUCTION: There is evidence that caesarean section (CS) is associated with increased risk of childhood obesity, asthma, and coeliac disease. The gut microbiota of CS-born babies differs to those born vaginally, possibly due to reduced exposure to maternal vaginal bacteria during birth. Vaginal seeding is a currently unproven practice intended to reduce such differences, so that the gut microbiota of CS-born babies is similar to that of babies born vaginally. Our pilot study, which uses oral administration as a novel form of vaginal seeding, will assess the degree of maternal strain transfer and overall efficacy of the procedure for establishing normal gut microbiota development. METHODS AND ANALYSIS: Protocol for a single-blinded, randomized, placebo-controlled pilot study of a previously untested method of vaginal seeding (oral administration) in 30 CS-born babies. A sample of maternal vaginal bacteria is obtained prior to CS, and mixed with 5 ml sterile water to obtain a supernatant. Healthy babies are randomized at 1:1 to receive active treatment (3 ml supernatant) or placebo (3 ml sterile water). A reference group of 15 non-randomized vaginal-born babies are also being recruited. Babies' stool samples will undergo whole metagenomic shotgun sequencing to identify potential differences in community structure between CS babies receiving active treatment compared to those receiving placebo at age 1 month (primary outcome). Secondary outcomes include differences in overall gut community between CS groups (24 hours, 3 months); similarity of CS-seeded and placebo gut profiles to vaginally-born babies (24 hours, 1 and 3 months); degree of maternal vaginal strain transfer in CS-born babies (24 hours, 1 and 3 months); anthropometry (1 and 3 months) and body composition (3 months). ETHICS AND DISSEMINATION: Ethics approval by the Northern A Health and Disability Ethics Committee (18/NTA/49). Results will be published in peer-reviewed journals and presented at international conferences. REGISTRATION: Australian New Zealand Clinical Trials Registry (ACTRN12618000339257).

Mapping midwifery and obstetric units in England.

OBJECTIVE: to describe the configuration of midwifery units, both alongside&free-standing, and obstetric units in England. DESIGN: national survey amongst Heads of Midwifery in English Maternity Services SETTING: National Health Service (NHS) in England PARTICIPANTS: English Maternity Services Measurements descriptive statistics of Alongside Midwifery Units and Free-standing Midwifery Units and Obstetric Units and their annual births/year in English Maternity Services FINDINGS: alongside midwifery units have nearly doubled since 2010 (n = 53-97); free-standing midwifery units have increased slightly (n = 58-61). There has been a significant reduction in maternity services without either an alongside or free-standing midwifery unit (75-32). The percentage of all births in midwifery units has trebled, now representing 14% of all births in England. This masks significant differences in percentage of all births in midwifery units between different maternity services with a spread of 4% to 31%. KEY CONCLUSIONS: In some areas of England, women have no access to a local midwifery unit, despite the National Institute for Health&Clinical Excellence (NICE) recommending them as an important place of birth option for low risk women. The numbers of midwifery units have increased significantly in England since 2010 but this growth is almost exclusively in alongside midwifery units. The percentage of women giving birth in midwifery units varies significantly between maternity services suggesting that many midwifery units are underutilised. IMPLICATIONS FOR PRACTICE: Both the availability and utilisation of midwifery units in England could be improved.

Evaluating Maternity Units: a prospective cohort study of freestanding midwife-led primary maternity units in New Zealand-clinical outcomes.

OBJECTIVE: To compare maternal and neonatal birth outcomes and morbidities associated with the intention to give birth in a freestanding primary level midwife-led maternity unit (PMU) or tertiary level obstetric-led maternity hospital (TMH) in Canterbury, Aotearoa/New Zealand. DESIGN: Prospective cohort study. PARTICIPANTS: 407 women who intended to give birth in a PMU and 285 women who intended to give birth at the TMH in 2010-2011. All of the women planning a TMH birth were 'low risk', and 29 of the PMU cohort had identified risk factors. PRIMARY OUTCOMES: Mode of birth, Apgar score of less than 7 at 5 min and neonatal unit admission. SECONDARY OUTCOMES: labour onset, analgesia, blood loss, third stage of labour management, perineal trauma, non-pharmacological pain relief, neonatal resuscitation, breastfeeding, gestational age at birth, birth weight, severe morbidity and mortality. RESULTS: Women who planned a PMU birth were significantly more likely to have a spontaneous vaginal birth (77.9%vs62.3%, adjusted OR (AOR) 1.61, 95% CI 1.08 to 2.39), and significantly less likely to have an instrumental assisted vaginal birth (10.3%vs20.4%, AOR 0.59, 95% CI 0.37 to 0.93). The emergency and elective caesarean section rates were not significantly different (emergency: PMU 11.6% vs TMH 17.5%, AOR 0.88, 95% CI 0.55 to 1.40; elective: PMU 0.7% vs TMH 2.1%, AOR 0.34, 95% CI 0.08 to 1.41). There were no significant differences between the cohorts in rates of 5 min Apgar score of <7 (2.0%vs2.1%, AOR 0.82, 95% CI 0.27 to 2.52) and neonatal unit admission (5.9%vs4.9%, AOR 1.44, 95% CI 0.70 to 2.96). Planning to give birth in a primary unit was associated with similar or reduced odds of intrapartum interventions and similar odds of all measured neonatal well-being indicators. CONCLUSIONS: The results of this study support freestanding midwife-led primary-level maternity units as physically safe places for well women to plan to give birth, with these women having higher rates of spontaneous vaginal births and lower rates of interventions and their associated morbidities than those who planned a tertiary hospital birth, with no differences in neonatal outcomes.

Freestanding midwifery units: Maternal and neonatal outcomes following transfer.

BACKGROUND: the viability of freestanding midwifery units in Australia is restricted, due to concerns over their safety, particularly for women and babies who, require transfer. AIM: to compare the maternal and neonatal birth outcomes of women who planned, to give birth at freestanding midwifery units and subsequently, transferred to a tertiary maternity unit to the maternal and neonatal, outcomes of a low-risk cohort of women who planned to give birth in, tertiary maternity unit. METHODS: a descriptive study compared two groups of women with low-risk singleton, pregnancies who were less than 28 weeks pregnant at booking: women who, planned to give birth at a freestanding midwifery unit (n=494) who, transferred to a tertiary maternity unit during the antenatal, intrapartum or postnatal periods (n=260) and women who planned to give, birth at a tertiary maternity unit (n=3157). Primary outcomes were mode, of birth, Apgar score of less than 7 at 5minutes and admission to, special care nursery or neonatal intensive care. KEY FINDINGS: the proportion of women who experienced a caesarean section was lower, among the freestanding midwifery unit women who transferred during the, intrapartum/postnatal period compared to women in the tertiary maternity, unit group (16.1% versus 24.8% respectively). Other outcomes were, comparable between the cohorts. Rates of primary outcomes in relation to, stage of transfer varied when stratified by parity. DISCUSSION: these descriptive results support the provision of care in freestanding, midwifery units as an alternative to tertiary maternity units for women, with low risk pregnancies at the time of booking. A larger study, powered, to determine statistical significance of any differences in outcomes, is, required.

Transfer from primary maternity unit to tertiary hospital in New Zealand - timing, frequency, reasons, urgency and outcomes: Part of the Evaluating Maternity Units study.

OBJECTIVES: to examine the transfers from primary maternity units to a tertiary hospital in New Zealand by describing the frequency, timing, reasons and outcomes of those who had antenatal or pre-admission birthplace plan changes, and transfers in labour or postnatally. DESIGN: mixed methods prospective (concurrent) cohort study, which analysed transfer and clinical outcome data (407 primary unit cohort, 285 tertiary hospital cohort), and data from the six week postpartum survey (571 respondents). PARTICIPANTS AND SETTING: well, pregnant women booked to give birth in a tertiary maternity hospital or primary maternity unit in one region in New Zealand (2010-2012). All women received midwifery continuity of care, regardless of their intended or actual birthplace. RESULTS: fewer than half of the women who planned a primary unit birth gave birth there (191 or 46.9%). A change of plan may have been made either antenatally or before admission in labour; and transfers were made after admission to the primary unit in labour or during the postnatal stay (about 48 hours). Of the 117 (28.5%) planning a primary unit birth who changed their planned birthplace type antenatally 73 (62.4%) were due to a clinical indication. Earthquakes accounted for 28.1% of birthplace change (during the research period major earthquakes occurred in the study region). Most (73.8%) labour changes occurred before admission in labour to the primary unit. For the 76 women who changed plan at this stage the most common reasons to do so were a rapid labour (25.0%) or prolonged rupture of membranes (23.7%). Transfers in labour from primary unit to tertiary hospital occurred for 27 women (12.6%) of whom 26 (96.3%) were having their first baby. "Slow progress" of labour accounted for 21 (77.8%) of these and 17 (62.9%) were classified as 'non-emergency'. The average transfer time for 'emergency' transfers was 58 minutes. The average time for all labour transfers from specialist consultation to birth was 4.5 hours. Nine postnatal transfers (maternal or neonatal) from a primary unit occurred (4.7%), making a total post-admission transfer rate of 17.3% for the primary unit cohort. KEY CONCLUSIONS: birthplace changes were not uncommon, with many women changing their birthplace plan antenatally or prior to admission in labour and some transferring between facilities during or soon after birth. Most changes were due to the development of complications or 'risk factors'. Most transfers were not urgent and took approximately one hour from the decision to arrival at the tertiary hospital. Despite the transfers the neonatal clinical outcomes were comparable between both primary and tertiary cohorts, and there was higher maternal morbidity in the tertiary cohort. IMPLICATIONS FOR PRACTICE: although the study size is relatively small, its comprehensive documentation of transfers has the potential to inform future research and the birthplace decision-making of childbearing women and midwives.

Women׳s birthplace decision-making, the role of confidence: Part of the Evaluating Maternity Units study, New Zealand.

OBJECTIVE: to explore women׳s birthplace decision-making and identify the factors which enable women to plan to give birth in a freestanding midwifery-led primary level maternity unit rather than in an obstetric-led tertiary level maternity hospital in New Zealand. DESIGN: a mixed methods prospective cohort design. METHODS: data from eight focus groups (37 women) and a six week postpartum survey (571 women, 82%) were analysed using thematic analysis and descriptive statistics. The qualitative data from the focus groups and survey were the primary data sources and were integrated at the analysis stage; and the secondary qualitative and quantitative data were integrated at the interpretation stage. SETTING: Christchurch, New Zealand, with one tertiary maternity hospital and four primary level maternity units (2010-2012). PARTICIPANTS: well (at 'low risk' of developing complications), pregnant women booked to give birth in one of the primary units or the tertiary hospital. All women received midwifery continuity of care, regardless of their intended or actual birthplace. FINDINGS: five core themes were identified: the birth process, women׳s self-belief in their ability to give birth, midwives, the health system and birth place. 'Confidence' was identified as the overarching concept influencing the themes. Women who chose to give birth in a primary maternity unit appeared to differ markedly in their beliefs regarding their optimal birthplace compared to women who chose to give birth in a tertiary maternity hospital. The women who planned a primary maternity unit birth expressed confidence in the birth process, their ability to give birth, their midwife, the maternity system and/or the primary unit itself. The women planning to give birth in a tertiary hospital did not express confidence in the birth process, their ability to give birth, the system for transfers and/or the primary unit as a birthplace, although they did express confidence in their midwife. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: birthplace is a profoundly important aspect of women׳s experience of childbirth. Birthplace decision-making is complex, in common with many other aspects of childbirth. A multiplicity of factors needs converge in order for all those involved to gain the confidence required to plan what, in this context, might be considered a 'countercultural' decision to give birth at a midwife-led primary maternity unit.

New Zealand's unique maternity system.

This discussion paper describes New Zealand's maternity system. It includes a brief background of the country and its history, key aspects of the legislative and funding contexts and the framework for the woman centred and midwife-led maternity system itself.