Associations of intrapartum antibiotics and growth, atopy, gastrointestinal and sleep outcomes at one year of age.

BACKGROUND: Studies investigating neonatal outcomes following intrapartum antibiotic exposure show conflicting results. METHODS: Data were collected prospectively in pregnancy to 1-year-of-age, from 212 mother-infant pairs. Adjusted multivariable regression models estimated relationships following exposure to intrapartum antibiotics among vaginally-born, full-term infants and outcomes related to growth, atopic disease, gastrointestinal symptoms, and sleep at 1-year. RESULTS: Intrapartum antibiotic exposure (n = 40) was not associated with mass, ponderal index, BMI z-score (1- year), lean mass index (5-months) or height. Antibiotic exposure in labour ≥4-h was associated with increase in fat mass index at 5-months (ß 0.42 [95% CI: 0.03, 0.80], p = 0.03). Intrapartum antibiotic was associated with atopy in the first year (OR: 2.93 [95% CI: 1.34, 6.43], p = 0.007). Antibiotic exposure during intrapartum or day 1-7 was associated with newborn fungal infection requiring antifungal therapy (OR 3.04 [95% CI: 1.14, 8.10], p = 0.026), and number of fungal infections (IRR: 2.90 [95% CI: 1.02, 8.27], p = 0.046). CONCLUSION: Intrapartum and early life exposure to antibiotics were independently associated with measures of growth, atopy, and fungal infections suggesting that intrapartum and early neonatal antibiotics be used prudently following careful risk-benefit analysis. IMPACT: This prospective study: Shows a shift in fat mass index at 5 months associated with antibiotic administration ≥4 h in labour; an earlier age than previously reported; Shows atopy reported less frequently among those not exposed to intrapartum antibiotics; Supports earlier research of increased likelihood of fungal infection following exposure to intrapartum or early-life antibiotics; Adds to growing evidence that antibiotics used intrapartum and in early neonatal periods influence longer-term outcomes for infants. Suggests that use of intrapartum and early neonatal antibiotics should be used prudently after careful consideration of risk and benefit.

Mediating expectations and experiences that influence birth experiences in Canada's first Alongside Midwifery Unit.

BACKGROUND: Globally, midwifery-led birthing units are associated with excellent maternal and neonatal outcomes, and positive childbirth experiences. However, little is known about what aspects of midwife-led units contribute to favorable experiences and overall satisfaction. Our aim was to explore and describe midwifery service user experiences at Canada's first Alongside Midwifery Unit (AMU). METHODS: We used a qualitative, grounded theory approach using semi-structured interviews with recipients of midwifery care at the AMU. FINDINGS: Data were collected from twenty-eight participants between September 2018 and March 2020. Our generated theory explains how birth experiences and satisfaction were influenced by how well the AMU aligned with expectations or desired experiences related to the following four themes: (1) maintaining the midwifery model of care, (2) emphasizing control and choice, (3) facilitating interprofessional relationships, and (4) appreciating the unique AMU birthing environment. CONCLUSION: Canada's first AMU met or exceeded service-user expectations, resulting in high levels of satisfaction with their birth experience. Maintaining core elements of the midwifery model of care, promoting high levels of autonomy, and facilitating positive interprofessional interactions are crucial elements contributing to childbirth satisfaction in the AMU environment.

Growth and body composition trajectories in infants meeting the WHO growth standards study requirements.

BACKGROUND: While the World Health Organization (WHO) developed postnatal growth standards for infants, corresponding body composition data remains scarce. This study explores growth and body composition trajectories in infants meeting the WHO Multicentre Growth Reference Study (MGRS) eligibility criteria. STUDY DESIGN: Infants enrolled in this longitudinal cohort underwent anthropometric and body composition measurement by air displacement plethysmography (ADP) at 6 weeks, 12 weeks, and 5 months postnatally. Age and sex-specific growth and body composition percentiles were generated using GAMLSS, with extrapolated data at 5 months for those exceeding ADP weight limits. We evaluated which anthropometric measure (body mass index (BMI), weight for length or mid upper arm circumference) was most closely related to adiposity. RESULTS: Of the 225 infants with body composition measures, 187 met the WHO MGRS criteria. Their length and weight curves were comparable with WHO growth curves. Trajectory curves for fat and fat-free mass were developed. Of the anthropometric measures, BMI z score was most closely related to fat mass index z score at all timepoints. CONCLUSION: This study presents body composition trajectories for infants meeting the WHO growth standard criteria. BMI z score is the best anthropometric metric to estimate adiposity in infants. IMPACT: While postnatal growth standards derived from the WHO Multicentre Growth Reference Study (MGRS) exist for the routine clinical assessment of infant growth, this study fills the previous gap in the availability of corresponding body composition data for term-born, healthy, breastfed infants meeting the MGRS criteria. Extrapolation was used to obtain body composition values for infants exceeding the weight limit of the ADP device, to avoid construction of biased body composition curves. Sex-specific growth curves for fat mass, fat-free mass, fat mass index, and fat-free mass index are presented for a population meeting the World Health Organization growth standard criteria.

How Do Health Schemas Inform Healthy Behaviours During Pregnancy? Qualitative Findings from the Be Healthy in Pregnancy (BHIP) Study.

OBJECTIVE: Excess gestational weight gain (GWG) is associated with adverse long and short-term outcomes for both woman and child, yet evidence demonstrates pregnant women are frequently not engaging in healthy behaviours linked to appropriate weight gain. The purpose of the current study was to explore women's values and beliefs related to weight, nutrition and physical activity during pregnancy and to describe how these beliefs influence their behaviours. METHODS: As part of a larger randomized controlled trial, we conducted 20 focus groups with 66 pregnant women between 16 and 24-weeks gestation using a semi-structured interview guide. Focus groups were recorded and transcribed verbatim and analyzed using a grounded theory approach. RESULTS: Three personal health schemas emerged from the findings which illustrated women's diverging beliefs about their health behaviours in pregnancy. 'Interconnected health' described beliefs regarding the impact their health had on that of their growing baby and awareness of risks associated with inappropriate weight gain. 'Gestational weight gain as an indicator of health' illustrated perceptions regarding how GWG impacted health and the utility of guidelines. Finally, 'Control in pregnancy' described the sense of agency over one's body and health. CONCLUSIONS FOR PRACTICE: Our results showed that health-related behaviours in pregnancy are driven by personal health schemas which are often discordant with clinical evidence. Interventions and health care provider advice aimed at behaviour modification would benefit from first understanding and addressing these schemas. Tackling the conflict between beliefs and behaviour may improve health outcomes associated with appropriate weight gain in pregnancy.

Be Healthy in Pregnancy: Exploring factors that impact pregnant women's nutrition and exercise behaviours.

Excess gestational weight gain is associated with short- and long-term pregnancy complications. Although a healthy diet and physical activity during pregnancy are recommended and shown to reduce the risk of complications and improve outcomes, adherence to these recommendations is low. The aims of this study were to explore women's view of nutrition and physical activity during pregnancy and to describe barriers and facilitators experienced in implementing physical activity and nutrition recommendations. In a substudy of the Be Healthy in Pregnancy randomized trial, 20 semistructured focus groups were conducted with 66 women randomized to the control group when they were between 16 and 24 weeks gestation. Focus groups were recorded, transcribed verbatim, coded and thematically analysed. The results indicate that women felt motivated to be healthy for their baby, but competing priorities may take precedence. Participants described limited knowledge and access to information on safe physical activity in pregnancy and lacked the skills needed to operationalize both physical activity and dietary recommendations. Women's behaviours regarding diet and physical activity in pregnancy were highly influenced by their own and their peers' beliefs and values regarding how weight gain impacted their health during pregnancy. Pregnancy symptoms beyond women's control such as fatigue and nausea made physical activity and healthy eating more challenging. Counselling from care providers about nutrition and physical activity was perceived as minimal and ineffective. Future interventions should address improving counselling strategies and address individual's beliefs around nutrition and activity in pregnancy.

Resident Attitudes Towards Caesarean Delivery in Canadian Obstetrics and Gynaecology Residency Programs.

OBJECTIVE: This study aimed to explore the attitudes of obstetrics and gynaecology residents in Canada towards interventions that influence caesarean section rates. The study looked at residents' attitudes towards four guidelines that support vaginal and assisted delivery (vaginal birth after caesarean section, induction of labour, operative vaginal birth, and fetal health surveillance in labour) and towards Society of Obstetricians and Gynaecologists of Canada (SOGC) guidelines in general. The study also sought to investigate whether these attitudes vary by residency training location. METHODS: An online survey of obstetrics and gynaecology residents across Canada was conducted. Residents responded to statements derived from guidelines using a five-point attitudinal scale and to an optional long-answer question about how residency has prepared them to make decisions around interventions. Descriptive summary statistics are used to present the findings (Canadian Task Force Classification III). RESULTS: A total of 27% of residents completed the survey. The majority demonstrated attitudes congruent with guidelines and favourable towards SOGC guidelines in general. Residents attitudes were least favourable towards electronic fetal monitoring, with 67.4% of responses congruent with the guideline. Attitudes were most aligned with the operative vaginal birth guideline, with 87.9% of responses congruent with the guideline. This sample was underpowered to detect statistically significant differences among residency programs, although there was some variation in attitudes across programs, with the most congruent scoring program at 81.8% congruent responses and the lowest at 66.7%. CONCLUSION: Obstetrics and gynaecology residents in Canada have favourable attitudes towards interventions that support vaginal and assisted delivery. There was variability in observed attitudes across programs, although this was not statistically significant.

Understanding the conditions that influence the roles of midwives in Ontario, Canada's health system: an embedded single-case study.

BACKGROUND: Despite the significant variability in the role and integration of midwifery across provincial and territorial health systems, there has been limited scholarly inquiry into whether, how and under what conditions midwifery has been assigned roles and integrated into Canada's health systems. METHODS: We use Yin's (2014) embedded single-case study design, which allows for an in-depth exploration to qualitatively assess how, since the regulation of midwives in 1994, the Ontario health system has assigned roles to and integrated midwives as a service delivery option. Kingdon's agenda setting and 3i + E theoretical frameworks are used to analyze two recent key policy directions (decision to fund freestanding midwifery-led birth centres and the Patients First primary care reform) that presented opportunities for the integration of midwives into the health system. Data were collected from key informant interviews and documents. RESULTS: Nineteen key informant interviews were conducted, and 50 documents were reviewed in addition to field notes taken during the interviews. Our findings suggest that while midwifery was created as a self-regulated profession in 1994, health-system transformation initiatives have restricted the profession's integration into Ontario's health system. The policy legacies of how past decisions influence the decisions possible today have the most explanatory power to understand why midwives have had limited integration into interprofessional maternity care. The most important policy legacies to emerge from the analyses were related to payment mechanisms. In the medical model, payment mechanisms privilege physician-provided and hospital-based services, while payment mechanisms in the midwifery model have imposed unintended restrictions on the profession's ability to practice in interprofessional environments. CONCLUSIONS: This is the first study to explain why midwives have not been fully integrated into the Ontario health system, as well as the limitations placed on their roles and scope of practice. The study also builds a theoretical understanding of the integration process of healthcare professions within health systems and how policy legacies shape service delivery options.

A critical interpretive synthesis of the roles of midwives in health systems.

BACKGROUND: Midwives' roles in sexual and reproductive health and rights continues to evolve. Understanding the profession's role and how midwives can be integrated into health systems is essential in creating evidence-informed policies. Our objective was to develop a theoretical framework of how political system factors and health systems arrangements influence the roles of midwives within the health system. METHODS: A critical interpretive synthesis was used to develop the theoretical framework. A range of electronic bibliographic databases (CINAHL, EMBASE, Global Health database, HealthSTAR, Health Systems Evidence, MEDLINE and Web of Science) was searched through to 14 May 2020 as were policy and health systems-related and midwifery organisation websites. A coding structure was created to guide the data extraction. RESULTS: A total of 4533 unique documents were retrieved through electronic searches, of which 4132 were excluded using explicit criteria, leaving 401 potentially relevant records, in addition to the 29 records that were purposively sampled through grey literature. A total of 100 documents were included in the critical interpretive synthesis. The resulting theoretical framework identified the range of political and health system components that can work together to facilitate the integration of midwifery into health systems or act as barriers that restrict the roles of the profession. CONCLUSIONS: Any changes to the roles of midwives in health systems need to take into account the political system where decisions about their integration will be made as well as the nature of the health system in which they are being integrated. The theoretical framework, which can be thought of as a heuristic, identifies the core contextual factors that governments can use to best leverage their position when working to improve sexual and reproductive health and rights.

Access to midwifery care for people of low socio-economic status: a qualitative descriptive study.

BACKGROUND: Despite public funding of midwifery care, people of low-socioeconomic status are less likely to access midwifery care in Ontario, Canada, but little is known about barriers that they experience in accessing midwifery care. The purpose of this study was to examine the barriers and facilitators to accessing midwifery care experienced by people of low-socioeconomic status. METHODS: A qualitative descriptive study design was used. Semi-structured interviews were conducted with 30 pregnant and post-partum people of low-socioeconomic status in Hamilton, Ontario from January to May 2018. Transcribed interviews were coded using open coding techniques and thematically analyzed. RESULTS: We interviewed 13 midwifery care recipients and 17 participants who had never received care from midwives. Four themes arose from the interviews: "I had no idea…", "Babies are born in hospitals", "Physicians as gateways into prenatal care", and "Why change a good thing?". Participants who had not experienced midwifery care had minimal knowledge of midwifery and often had misconceptions about midwives' scope of practice and education. Prevailing beliefs about pregnancy and birth, particularly concerns about safety, drove participants to seek care from a physician. Physicians are the entry point into the health care system for many, yet few participants received information about midwifery care from physicians. Participants who had experienced midwifery care found it to be an appropriate match for the needs of people of low socioeconomic status. Word of mouth was a primary source of information about midwifery and the most common reason for people unfamiliar with midwifery to seek midwifery care. CONCLUSIONS: Access to midwifery care is constrained for people of low-socioeconomic status because lack of awareness about midwifery limits the approachability of these services, and because information about midwifery care is often not provided by physicians when pregnant people first contact the health care system. For people of low-socioeconomic status, inequitable access to midwifery care may be exacerbated by lack of knowledge about midwifery within social networks and a tendency to move passively through the health care system which traditionally favours physician care. Targeted efforts to address this issue are necessary to reduce disparities in access to midwifery care.

Experiences regarding nutrition and exercise among women during early postpartum: a qualitative grounded theory study.

BACKGROUND: Excess gestational weight gain has long- and short-term implications for women and children, and postpartum weight retention is associated with an increased risk of long-term obesity. Despite the existence of dietary and exercise guidelines, many women struggle to return to pre-pregnancy weight. Experiences of women in tackling postpartum weight loss are poorly understood. We undertook this study to explore experiences related to nutrition, exercise and weight in the postpartum in women in Ontario, Canada. METHODS: This was a nested qualitative study within The Be Healthy in Pregnancy Study, a randomized controlled trial. Women randomized to the control group were invited to participate. Semi-structured focus groups were conducted at 4-6 months postpartum. Focus groups were audio recorded, transcribed verbatim, coded and analyzed thematically using a constructivist grounded theory approach. RESULTS: Women experienced a complex relationship with their body image, due to unrealistic expectations related to their postpartum body. Participants identified barriers and enablers to healthy habits during pregnancy and postpartum. Gestational weight gain guidelines were regarded as unhelpful and unrealistic. A lack of guidance and information about weight management, healthy eating, and exercise in the postpartum period was highlighted. CONCLUSION: Strategies for weight management that target the unique characteristics of the postpartum period have been neglected in research and in patient counselling. Postpartum women may begin preparing for their next pregnancy and support during this period could improve their health for subsequent pregnancies. TRIAL REGISTRATION: NCT01689961 registered September 21, 2012.

Birth Outcomes for Midwifery Clients Who Begin Postdates Induction of Labour Under Midwifery Care Compared With Those Who Are Transferred to Obstetrical Care.

OBJECTIVE: This study sought to compare clinical outcomes of midwifery clients who had postdates induction of labour with oxytocin under midwifery care with those transferred to obstetrical care. METHODS: This was a retrospective cohort study using 2006-2009 Ontario Midwifery Program data. All low-risk Ontario midwifery clients who had postdates oxytocin induction were included. Groups were established according to the planned care provider at onset of induction. The primary outcome was Cesarean section (CS). The secondary outcome was a composite of stillbirth, neonatal death, or serious morbidity. Other outcomes included assisted vaginal delivery, pharmaceutical pain relief, and use of episiotomy. We stratified by parity and used logistic regression to conduct analyses controlling for maternal age (Canadian Task Force Classification II-2). RESULTS: For nulliparas, postdates induction with oxytocin under midwifery care decreased the odds of interventions including assisted vaginal delivery (OR 0.68; 95% CI 0.48-0.97), episiotomy (OR 0.49; 95% CI 0.34-0.70), and pharmaceutical pain relief (OR 0.57; 95% CI 0.36-0.90), with no difference in odds of neonatal morbidity or mortality (OR 0.71; 95% CI 0.25-2.04) when compared with induction under obstetrical care. For multiparas, the use of pharmaceutical pain relief was significantly lower in the midwifery group (OR 0.65; 95% CI 0.44-0.96). CONCLUSION: For low-risk midwifery clients at 41 weeks or more gestation, the odds of Caesarean section and neonatal morbidity and mortality are similar when induction of labour with oxytocin under the care of a midwife is compared with induction of labour under obstetrical care, and rates of intervention are decreased.

Continuous glucose monitoring in pregnant women with type 1 diabetes (CONCEPTT): a multicentre international randomised controlled trial.

BACKGROUND: Pregnant women with type 1 diabetes are a high-risk population who are recommended to strive for optimal glucose control, but neonatal outcomes attributed to maternal hyperglycaemia remain suboptimal. Our aim was to examine the effectiveness of continuous glucose monitoring (CGM) on maternal glucose control and obstetric and neonatal health outcomes. METHODS: In this multicentre, open-label, randomised controlled trial, we recruited women aged 18-40 years with type 1 diabetes for a minimum of 12 months who were receiving intensive insulin therapy. Participants were pregnant (≤13 weeks and 6 days' gestation) or planning pregnancy from 31 hospitals in Canada, England, Scotland, Spain, Italy, Ireland, and the USA. We ran two trials in parallel for pregnant participants and for participants planning pregnancy. In both trials, participants were randomly assigned to either CGM in addition to capillary glucose monitoring or capillary glucose monitoring alone. Randomisation was stratified by insulin delivery (pump or injections) and baseline glycated haemoglobin (HbA1c). The primary outcome was change in HbA1c from randomisation to 34 weeks' gestation in pregnant women and to 24 weeks or conception in women planning pregnancy, and was assessed in all randomised participants with baseline assessments. Secondary outcomes included obstetric and neonatal health outcomes, assessed with all available data without imputation. This trial is registered with ClinicalTrials.gov, number NCT01788527. FINDINGS: Between March 25, 2013, and March 22, 2016, we randomly assigned 325 women (215 pregnant, 110 planning pregnancy) to capillary glucose monitoring with CGM (108 pregnant and 53 planning pregnancy) or without (107 pregnant and 57 planning pregnancy). We found a small difference in HbA1c in pregnant women using CGM (mean difference -0·19%; 95% CI -0·34 to -0·03; p=0·0207). Pregnant CGM users spent more time in target (68% vs 61%; p=0·0034) and less time hyperglycaemic (27% vs 32%; p=0·0279) than did pregnant control participants, with comparable severe hypoglycaemia episodes (18 CGM and 21 control) and time spent hypoglycaemic (3% vs 4%; p=0·10). Neonatal health outcomes were significantly improved, with lower incidence of large for gestational age (odds ratio 0·51, 95% CI 0·28 to 0·90; p=0·0210), fewer neonatal intensive care admissions lasting more than 24 h (0·48; 0·26 to 0·86; p=0·0157), fewer incidences of neonatal hypoglycaemia (0·45; 0·22 to 0·89; p=0·0250), and 1-day shorter length of hospital stay (p=0·0091). We found no apparent benefit of CGM in women planning pregnancy. Adverse events occurred in 51 (48%) of CGM participants and 43 (40%) of control participants in the pregnancy trial, and in 12 (27%) of CGM participants and 21 (37%) of control participants in the planning pregnancy trial. Serious adverse events occurred in 13 (6%) participants in the pregnancy trial (eight [7%] CGM, five [5%] control) and in three (3%) participants in the planning pregnancy trial (two [4%] CGM and one [2%] control). The most common adverse events were skin reactions occurring in 49 (48%) of 103 CGM participants and eight (8%) of 104 control participants during pregnancy and in 23 (44%) of 52 CGM participants and five (9%) of 57 control participants in the planning pregnancy trial. The most common serious adverse events were gastrointestinal (nausea and vomiting in four participants during pregnancy and three participants planning pregnancy). INTERPRETATION: Use of CGM during pregnancy in patients with type 1 diabetes is associated with improved neonatal outcomes, which are likely to be attributed to reduced exposure to maternal hyperglycaemia. CGM should be offered to all pregnant women with type 1 diabetes using intensive insulin therapy. This study is the first to indicate potential for improvements in non-glycaemic health outcomes from CGM use. FUNDING: Juvenile Diabetes Research Foundation, Canadian Clinical Trials Network, and National Institute for Health Research.

Home birth integration into the health care systems of eleven international jurisdictions.

BACKGROUND: The purpose of this study was to develop assessment criteria that could be used to examine the level of integration of home birth within larger health care systems in developed countries across 11 international jurisdictions. METHODS: An expert panel developed criteria and a definition to assess home birth integration within health care systems. We selected jurisdictions based on the publications that were eligible for inclusion in our systematic review and meta-analysis on planned place of birth. We sent the authors of the included publications a questionnaire about home birth practitioners and practices in their respective health care system at the time of their studies. We searched published peer-reviewed, non-peer-reviewed, and gray literature, and the websites of professional bodies to document information about home birth integration in each jurisdiction based on our criteria. Where information was lacking, we contacted experts in the field from the relevant jurisdiction. RESULTS: Home birth is well integrated into the health care system in British Columbia (Canada), England, Iceland, the Netherlands, New Zealand, Ontario (Canada), and Washington State (USA). Home birth is less well integrated into the health care system in Australia, Japan, Norway, and Sweden. CONCLUSIONS: This paper is the first to propose criteria for the evaluation of home birth integration within larger maternity care systems. Application of these criteria across 11 international jurisdictions indicates differences in the recognition and training of home birth practitioners, in access to hospital facilities, and in the supplies and equipment available at home births, which give rise to variation in the level of integration across different settings. Standardized criteria for the evaluation of systems integration are essential for interpreting planned home birth outcomes that emerge from contextual differences.

Midwifery and obstetrics: Factors influencing mothers' satisfaction with the birth experience.

BACKGROUND: Satisfaction is a key component of the care experience and part of the health system "triple aim," along with improving population health and reducing per capita health care costs, the other two parts of the "triple aim." The objectives of the study were to examine birth-experience satisfaction among women in Ontario, Canada, who received care from midwives, family physicians, and obstetricians. METHODS: We used Statistics Canada's 2006 national Maternity Experiences Survey. The sample includes 1900 Ontario women and is, with appropriate weighting, representative of an estimated population of 29 700 women who gave birth in Ontario to a singleton baby during the study period. Information was collected on respondents' satisfaction with their health care providers, demographic characteristics, and a range of pregnancy, labor, birth, and postpartum experiences. We used logistic regression analysis to assess differences in patient/client satisfaction by type of health care provider. RESULTS: Women cared for by midwives were three times more likely to be satisfied with their care (OR 3.32 [95% CI 2.26-4.86]) when compared with obstetrician-led care. Depression symptoms, having to travel outside the respondents' community to give birth, and being born in an East Asian country were associated with lower levels of satisfaction. CONCLUSION: Given recent health system reforms emphasizing the importance of shifting from expensive acute hospital-based care to community-based care, our findings support empirically the importance of supporting women's access to midwifery services within their communities. Findings of ethnocultural differences in satisfaction with care can inform policy makers as health systems move to provide culturally appropriate care to increasingly diverse populations.

Labour Outcomes After Successful External Cephalic Version Compared With Spontaneous Cephalic Version.

OBJECTIVE: This study sought to compare obstetrical outcomes for women with a cephalic presentation at birth resulting from successful external cephalic version (ECV) compared to those resulting from spontaneous cephalic version (SCV). METHODS: Secondary analysis was performed on Early External Cephalic Version Trial data. A total of 931 study participants had breech presentations between 34 and 36 weeks' gestation and cephalic presentations at birth. The incidence of intrapartum interventions was compared between patients with successful ECV (557) and those with SCV (374). A generalized linear mixed model was used to determine ORs for our primary outcomes. Parity, maternal BMI, previous CS, and enrolment centre were controlled for in the analysis. RESULTS: No differences were found after ECV compared with SCV in the incidence of CS (96 of 557 and 76 of 374, respectively; adjusted OR [aOR] 0.89; 95% CI 0.63-1.26), instrumental birth (68 of 557 and 29 of 373, respectively; aOR 1.55; 95% CI 0.96-2.50), or normal vaginal birth (393 of 557 and 268 of 373, respectively; aOR 0.92; 95% CI 0.68-1.24). Multiparous women with successful ECV were half as likely to require a CS compared with those with SCV and no ECV (28 of 313 and 42 of 258, respectively; aOR 0.45; 95% CI 0.26-0.80). CONCLUSION: This is the first study to compare birth outcomes of breech pregnancies that convert to cephalic presentation by means of SCV with birth outcomes of breech pregnancies that have ECV. Women with a cephalic-presenting fetus at birth as a result of successful ECV are not at greater risk of obstetrical interventions at birth when compared with women with fetuses who spontaneously turn to a cephalic presentation in the third trimester.

Predictors of success of external cephalic version and cephalic presentation at birth among 1253 women with non-cephalic presentation using logistic regression and classification tree analyses.

INTRODUCTION: Among women with a fetus with a non-cephalic presentation, external cephalic version (ECV) has been shown to reduce the rate of breech presentation at birth and cesarean birth. Compared with ECV at term, beginning ECV prior to 37 weeks' gestation decreases the number of infants in a non-cephalic presentation at birth. The purpose of this secondary analysis was to investigate factors associated with a successful ECV procedure and to present this in a clinically useful format. MATERIAL AND METHODS: Data were collected as part of the Early ECV Pilot and Early ECV2 Trials, which randomized 1776 women with a fetus in breech presentation to either early ECV (34-36 weeks' gestation) or delayed ECV (at or after 37 weeks). The outcome of interest was successful ECV, defined as the fetus being in a cephalic presentation immediately following the procedure, as well as at the time of birth. The importance of several factors in predicting successful ECV was investigated using two statistical methods: logistic regression and classification and regression tree (CART) analyses. RESULTS: Among nulliparas, non-engagement of the presenting part and an easily palpable fetal head were independently associated with success. Among multiparas, non-engagement of the presenting part, gestation less than 37 weeks and an easily palpable fetal head were found to be independent predictors of success. These findings were consistent with results of the CART analyses. CONCLUSIONS: Regardless of parity, descent of the presenting part was the most discriminating factor in predicting successful ECV and cephalic presentation at birth.

Association of external cephalic version before term with late preterm birth.

INTRODUCTION: While evidence suggests that beginning an external cephalic version (ECV) before term (340/7 to 366/7 weeks) compared with after term may be associated with an increase in late preterm birth (340/7 to 366/7 weeks), it remains unknown what might account for this risk. The objective of the present study is to further investigate the association between ECV before term and late preterm birth. MATERIAL AND METHODS: Secondary analysis of data collected from the international, multicenter Early ECV trials. We evaluated the relation between ECV exposure and late preterm birth (340/7 to 366/7 weeks), as well as whether additional risk factors for preterm birth (such as maternal age, height, body mass index, parity, placental location, and perinatal mortality rate) moderated this relation. Generalized linear mixed methods were used to account for center effect and adjust for covariates. RESULT: Among 1765 women with breech pregnancies and without a prior preterm birth, 749 (42.4%) received at least one ECV before term. Exposure to an ECV before term was not associated significantly independently with odds of preterm birth. However, placenta location moderated the association between early ECV exposure and late preterm birth. The odds of preterm birth in women who were exposed to an ECV before term and who also had an anterior placenta were doubled (OR 2.05; 95% CI 1.12-3.71; p = 0.02). CONCLUSION: In a large cohort of women without known risks for preterm birth, those with an anterior placenta who undergo an ECV before term constitute a subgroup at particular risk for late preterm birth.

Student midwives' perceptions on the organisation of maternity care and alternative maternity care models in the Netherlands - a qualitative study.

BACKGROUND: A major change in the organisation of maternity care in the Netherlands is under consideration, going from an echelon system where midwives provide primary care in the community and refer to obstetricians for secondary and tertiary care, to a more integrated maternity care system involving midwives and obstetricians at all care levels. Student midwives are the future maternity care providers and they may be entering into a changing maternity care system, so inclusion of their views in the discussion is relevant. This study aimed to explore student midwives' perceptions on the current organisation of maternity care and alternative maternity care models, including integrated care. METHODS: This qualitative study was based on the interpretivist/constructivist paradigm, using a grounded theory design. Interviews and focus groups with 18 female final year student midwives of the Midwifery Academy Amsterdam Groningen (AVAG) were held on the basis of a topic list, then later transcribed, coded and analysed. RESULTS: Students felt that inevitably there will be a change in the organisation of maternity care, and they were open to change. Participants indicated that good collaboration between professions, including a shared system of maternity notes and guidelines, and mutual trust and respect were important aspects of any alternative model. The students indicated that client-centered care and the safeguarding of the physiological, normalcy approach to pregnancy and birth should be maintained in any alternative model. Students expressed worries that the role of midwives in intrapartum care could become redundant, and thus they are motivated to take on new roles and competencies, so they can ensure their own role in intrapartum care. CONCLUSIONS: Final year student midwives recognise that change in the organisation of maternity care is inevitable and have an open attitude towards changes if they include good collaboration, client-centred care and safeguards for normal physiological birth. The graduating midwives are motivated to undertake an expanded intrapartum skill set. It can be important to involve students' views in the discussion, because they are the future maternity care providers.

Client-Related Factors Associated with a "Less than Good" Experience of Midwifery Care during Childbirth in the Netherlands.

BACKGROUND: A "less than good" experience during childbirth can affect a mother's early interaction with her child and may significantly influence a woman's emotional well-being. In this study, we focus on clients who experienced midwifery care provided during childbirth as "less than good" care. The aim of this study was to understand the relationship between client-related factors and the experience of midwifery care during childbirth to improve this care. METHODS: This study was part of the "DELIVER study" where mothers report on the care they received. We used generalized estimation equations to control for correlations within midwife practices. Forward multivariate logistic regression analyses were conducted to model the client-related factors associated with the experienced midwifery care during childbirth. RESULTS: We included the responses of 2,377 women. In the multivariable logistic regression model, odds of reporting "less than good care" were significantly higher for women who experienced an unplanned cesarean birth (OR 2.21 [CI 1.19-4.09]), an instrumental birth (OR 1.55 [CI 1.08-2.23]), and less control during the dilation phase (OR 0.98 [CI 0.97-0.99]) and pushing phase (OR 0.98 [CI 0.97-0.99]). DISCUSSION: Birth-related factors were more likely than maternal characteristics to be associated with the experience of midwifery care during childbirth. We conclude that there is room for midwives to improve their care for women during childbirth particularly in improving the patient centeredness of the care provider, using strategies to enhance sense of control, and focusing on the particular needs of those who experience instrumental vaginal or unplanned cesarean births.