Developing a woman-centered, inclusive definition of positive childbirth experiences: A discussion paper.

INTRODUCTION: A positive childbirth experience promotes women's health, both during and beyond the perinatal period. Understanding what constitutes a positive childbirth experience is thus critical to providing high-quality maternity care. Currently, there is no clear, inclusive, woman-centered definition of a positive childbirth experience to guide practice, education, and research. AIM: To formulate an inclusive woman-centered definition of a positive childbirth experience. METHODS: A six-step process was undertaken: (a) Key concepts associated with a positive childbirth were derived from a rapid literature review; (b) The key concepts were used by interdisciplinary experts in the author group to create a draft definition; (c) The draft definition was presented to clinicians and researchers during a European research meeting on perinatal mental health; (d) The authors integrated the expert feedback to refine the working definition; (e) A revised definition was shared with women from consumer groups in six countries to confirm its face validity; and (f) A final definition was formulated based on the women's feedback (n = 42). RESULTS: The following definition was formulated: "A positive childbirth experience refers to a woman's experience of interactions and events directly related to childbirth that made her feel supported, in control, safe, and respected; a positive childbirth can make women feel joy, confident, and/or accomplished and may have short and/or long-term positive impacts on a woman's psychosocial well-being." CONCLUSIONS: This inclusive, woman-centered definition highlights the importance of provider interactions for facilitating a positive childbirth experience. Feeling supported and having a sense of control, safety, and respect are central tenets. This definition could help to identify and validate positive childbirth experience(s), and to inform practice, education, research, advocacy, and policy-making.

Developing a woman-centered, inclusive definition of traumatic childbirth experiences: A discussion paper.

INTRODUCTION: Many women experience giving birth as traumatic. Although women's subjective experiences of trauma are considered the most important, currently there is no clear inclusive definition of a traumatic birth to help guide practice, education, and research. AIM: To formulate a woman-centered, inclusive definition of a traumatic childbirth experience. METHODS: After a rapid literature review, a five-step process was undertaken. First, a draft definition was created based on interdisciplinary experts' views. The definition was then discussed and reformulated with input from over 60 multidisciplinary clinicians and researchers during a perinatal mental health and birth trauma research meeting in Europe. A revised definition was then shared with consumer groups in eight countries to confirm its face validity and adjusted based on their feedback. RESULTS: The stepwise process confirmed that a woman-centered and inclusive definition was important. The final definition was: "A traumatic childbirth experience refers to a woman's experience of interactions and/or events directly related to childbirth that caused overwhelming distressing emotions and reactions; leading to short and/ or long-term negative impacts on a woman's health and wellbeing." CONCLUSIONS: This definition of a traumatic childbirth experience was developed through consultations with experts and consumer groups. The definition acknowledges that low-quality provider interactions and obstetric violence can traumatize individuals during childbirth. The women-centered and inclusive focus could help women to identify and validate their experiences of traumatic birth, offering benefits for practice, education, and research, as well as for policymaking and activism in the fields of perinatal mental health and respectful maternity care.

Effectiveness of a guided ACT-based self-help resilience training for depressive symptoms during pregnancy: Study protocol of a randomized controlled trial embedded in a prospective cohort.

BACKGROUND: During pregnancy, about 10 to 20% of women experience depressive symptoms. Subclinical depression increases the risk of peripartum depression, maternal neuro-endocrine dysregulations, and adverse birth and infant outcomes. Current treatments often comprise face-to-face psychological or pharmacological treatments that may be too intensive for women with subclinical depression leading to drop-out and moderate effectiveness. Therefore, easily accessible, resilience enhancing and less stigmatizing interventions are needed to prevent the development of clinical depression. This paper describes the protocol of a prospective cohort study with an embedded randomized controlled trial (RCT) that aims to improve mental resilience in a sample of pregnant women through a self-help program based on the principles of Acceptance and Commitment Therapy (ACT). Maternal and offspring correlates of the trajectories of peripartum depressive symptoms will also be studied. METHODS: Pregnant women (≥ 18 years) receiving care in Dutch midwifery practices will participate in a prospective cohort study (n ~ 3500). Between 12 and 18 weeks of pregnancy, all women will be screened for depression with the Edinburgh Postnatal Depression Scale (EPDS). Women with an EPDS score ≥ 11 will be evaluated with a structured clinical interview. Participants with subclinical depression (n = 290) will be randomized to a 9-week guided self-help ACT-training or to care as usual (CAU). Primary outcomes (depressive symptoms and resilience) and secondary outcomes (e.g. anxiety and PTSD, bonding, infant development) will be collected via online questionnaires at four prospective assessments around 20 weeks and 30 weeks gestation and at 6 weeks and 4 months postpartum. Maternal hair cortisol concentrations will be assessed in a subsample of women with a range of depressive symptoms (n = 300). The intervention's feasibility will be assessed through qualitative interviews in a subsample of participants (n = 20). DISCUSSION: This is the first study to assess the effectiveness of an easy to administer intervention strategy to prevent adverse mental health effects through enhancing resilience in pregnant women with antepartum depressive symptomatology. This longitudinal study will provide insights into trajectories of peripartum depressive symptoms in relation to resilience, maternal cortisol, psychological outcomes, and infant developmental milestones. TRIAL REGISTRATION: Netherlands Trial Register (NTR), NL7499 . Registered 5 February 2019.

Traumatic childbirth experiences: practice-based implications for maternity care professionals from the woman's perspective.

OBJECTIVE: To explore women's traumatic childbirth experiences in order to make maternity care professionals more aware of women's intrapartum care needs. METHOD: A qualitative exploratory study with a constant comparison/grounded theory design was performed. Thirty-six interviews were conducted with women who had given birth in a Dutch birth setting. FINDINGS: Three themes, playing a profound role in the occurrence of traumatic birth experiences, emerged: (i) lack of information and consent - maternity care professionals' unilateral decision making during intrapartum care, lacking informed-consent. (ii) feeling excluded - women's mal-adaptive response to the healthcare professionals's one-sided decision making, leaving women feeling distant and estranged from the childbirth event and the experience. (iii) discrepancies - inconsistency between women's expectations and the reality of labour and birth - on an intrapersonal level. CONCLUSION: Women's intrapartum care needs cohere with the concept of woman-centred care, including personalised care and reflecting humanising values. Care should include informed consent and shared decision-making. Maternity care professionals need to continuously evaluate whether the woman is consistently part of her own childbearing process. Maternity care professionals should maintain an ongoing dialogue with the woman, including women's internalised ideas of birth.

The effect of Wazzup Mama?! An antenatal intervention to prevent or reduce maternal distress in pregnancy.

We evaluated the effect of the intervention WazzUp Mama?! on antenatal maternal distress in a non-randomized pre-post study including healthy women in 17 Dutch midwifery practices. The control group (n = 215) received antenatal care-as-usual. The experimental group (n = 218) received the intervention. Data were collected at the first and third trimester of pregnancy. Maternal distress (MD) was measured with the Edinburgh Depression Scale (EDS), State-Trait Anxiety Inventory (STAI), and Pregnancy-Related Anxiety Questionnaire (PRAQ). We used multivariate repeated-measure analysis to examine the across time changes and ANCOVA was used to examine the differences between the two groups. In the control group, mean EDS, STAI, and MD scores significantly increased from first to third trimester of pregnancy, mean PRAQ scores increased, but not significantly, the proportion of scores above cut-off level of EDS, STAI, and PRAQ significantly increased from first to third trimester, and the proportion of MD scores above cut-off level increased, but not significantly. Within the experimental group, the mean STAI, PRAQ, and MD scores significantly decreased from first to third trimester, the EDS mean scores decreased but not significantly, proportions of scores above cut-off level for PRAQ and MD significantly decreased from first to third trimester of pregnancy, the proportions of EDS and STAI scores above cut-off level decreased but not significantly. There was a moderate significant positive effect of WazzUP Mama?! on the MD scores (F(1.43) = 27.05, p < 0.001, d = 0.5). The results provide support for the effectiveness of the intervention WazzUp Mama?!

Reducing maternal anxiety and stress in pregnancy: what is the best approach?

PURPOSE OF REVIEW: To briefly review results of the latest research on approaching antenatal maternal anxiety and stress as distinct constructs within a broad spectrum of maternal antenatal distress and the preventive strategic role of the maternal healthcare practitioner. RECENT FINDINGS: Maternal antenatal anxiety and stress are predominant contributors to short and long-term ill health and reduction of these psychological constructs is evident. Anxiety and stress belong to a broad spectrum of different psychological constructs. Various psychometric instruments are available to measure different individual constructs of antenatal maternal emotional health. Using multiple measures within antenatal care would imply a one-dimensional approach of individual constructs, resulting in inadequate management of care and inefficient use of knowledge and skills of maternity healthcare practitioners. A case-finding approach with slight emphasis on antenatal anxiety with subsequent selection of at-risk women and women suffering from maternal distress are shown to be effective preventive strategies and are consistent with the update of the National Institute for Health and Care Excellence guideline 'Antenatal and postnatal mental health'. Educational aspects of this approach are related to screening and assessment. SUMMARY: A shift in perception and attitude towards a broad theoretical and practical approach of antenatal maternal mental health and well-being is required. Case finding with subsequent selective and indicated preventive strategies during pregnancy would conform to this approach and are evidence based.

The experiential knowledge of migrant women about vulnerability during pregnancy: A woman-centred mixed-methods study.

PROBLEM: Within maternity care policies and practice, pregnant migrant women are regarded as a vulnerable population. BACKGROUND: Women's experiential knowledge is a key element of woman-centred care but is insufficiently addressed in midwifery practice and research that involves migrant women. AIM: To examine if pregnant migrant women's experiential knowledge of vulnerability corresponds with sets of criteria of vulnerability, and to explore how migrant women make sense of vulnerability during pregnancy. METHODS: A sequential two-phased mixed-methods study, conducted in the Netherlands, integrating survey data of 89 pregnant migrant women and focus group data obtained from 25 migrant mothers - living in deprived areas according to the Dutch socio-economic index. RESULTS: Criteria associated with vulnerability were reported by 65.2% of the participants and 62.9% of the participants reported adverse childhood experiences. On a Visual Analogue Scale, ranging from 0 (not vulnerable) to 10 (very vulnerable), participants self-reported sense of vulnerability showed a mean score of 4.2 (±2.56). Women's experiential knowledge of vulnerability significantly correlated with the mean sum score of clinical criteria of vulnerability (r .46, p .002) and with the mean sum score of adverse childhood experiences (r .48, p<.001). Five themes emerged from the focus group discussions: "Look beyond who you think I am and see and treat me for who I really am", "Ownership of truth and knowledge", "Don't punish me for being honest", "Projection of fear" and "Coping with labelling". CONCLUSION: Pregnant migrant women's experiential knowledge of vulnerability is congruent with the criteria. Calling upon experiential knowledge is an attribute of the humane woman-midwife relationship.

Proactive behaviour in midwifery practice: A qualitative overview based on midwives' perspectives.

BACKGROUND: Midwifery practice is in the process of continuing developments and contemporary working conditions asking for proactive behaviour, which could increase work-efficiency, job satisfaction, commitment and coping attitudes towards stress resistance. This study aims to provide an in depth exploration of midwives' perceptions of facilitators and/or barriers of proactive behaviour in midwifery practice. METHODS: A qualitative descriptive study, using individual semi-structured interviews, was undertaken within a sample of 102 Flemish and Dutch midwives who were interviewed from September to December 2017 using a four-item topic-list. RESULTS: Six influencing factors emerged from the data consisted of the causal, contextual and conditional factors faced by the midwives in order to show proactive behaviour in midwifery practice. Midwives elaborated the need for team consultations, a safe organizational culture, an appreciative midwifery leader and an attitude of lifelong learning. Furthermore, midwives are looking for a way to deal with both challenges in healthcare and the competitive societal system. CONCLUSION: This inductive study confirmed, supported and expanded previous deductive research and provided additional insights of proactive behaviour in midwifery. Providing midwives with knowledge of the influencing factors, required to successfully effecting proactive behaviour in midwifery, this study has subsequently merit for future research in the transfer of recommendation in daily midwifery practice, education and policymaking.

Dutch midwives' views on and experiences with woman-centred care - A Q-methodology study.

BACKGROUND: Woman-centred care is a philosophy for midwifery care management of the childbearing woman. There is no mutually recognised internalised way in midwifery to provide woman-centred care. OBJECTIVE: To reveal midwives' distinct perspectives about woman-centred care. METHODS: A Q-methodology study amongst 48 Dutch community-based midwives who rank-ordered 39 statements on woman-centred care, followed by semi-structured interviews to motivate their ranking. By-person factor analysis was used to derive latent views, representing midwives (factors) with similar attitudes towards woman-centred care. The qualitative data was used to aid interpretation of the factors. RESULTS: Four distinct factors emerged: (1) the humane midwife, containing two twinning factors: (1+) The philosophical midwife, who is the woman's companion during childbearing in being an authentic individual human being; (1-) the human-rights midwife, who is the woman's advocate for achieving autonomy and self-determination regarding care during the childbearing period. (2) The quality-of-care midwife, who regards good perinatal health outcomes, responsive care and positive maternal experiences as benchmarks for the quality of woman-centred care. (3) The job-crafting midwife, who focuses on self-organisation while seeking balance between the childbearing woman, herself as a professional and an individual and as a colleague. CONCLUSION/IMPLICATIONS: Each factor represented specific perspectives feeding into woman-centred practice. Although the humane midwife seems to represent the dominant and preferable perspective of woman-centred care, awareness and exploration of and reflection on the thoughts patterns represented by the four different perspectives, should be considered in education and professional development of (student)midwives of be(com)ing a woman-centred midwife.

ISeeYou - Evaluation of a woman-centred care pilot project in Bachelor midwifery education and research.

AIM: to evaluate the ISeeYou project that aims to equip first year Bachelor midwifery students to support them in their learning of providing woman-centred care. METHODS: the project has an ethnographic design. First year midwifery students buddied up to one woman throughout her continuum of the childbirth process and accompanied her during her antenatal and postnatal care encounters. Participant-observation was utilised by the students to support their learning. The Client Centred Care Questionnaire (CCCQ) was administered to collect data about women's care experiences. The project was evaluated using the SWOT model. MAIN FINDINGS: 54 first year students completed the project and observed and evaluated on average eight prenatal visits and two postnatal visits. Students gained insight into women's lived experiences during the childbirth process and of received care throughout this period. Students reported that this was meaningful and supported and enhanced their comprehension of women-centred care. Logistic issues (lectures, travel, time) and being conscious of their role as an 'outsider' sometimes constrained, but never hindered, the students in meeting the requirements of the project. Overall, the project provided students with opportunities to expand competencies and to broaden their outlook on midwifery care. CONCLUSION: the project offers students unique and in-depth experiences supporting and augmenting their professional competencies and their personal, professional and academic development.

Woman-centered care 2.0: Bringing the concept into focus.

INTRODUCTION: Woman-centered care has become a midwifery concept with implied meaning. In this paper we aim to provide a clear conceptual foundation of woman-centered care for midwifery science and practice. METHODS: An advanced concept analysis was undertaken. At the outset, a systematic search of the literature was conducted in PubMed, OVID and EBSCO. This was followed by an assessment of maturity of the retrieved data. Principle-based evaluation was done to reveal epistemological, pragmatic, linguistic and logic principles, that attribute to the concept. Summative conclusions of each respective component and a detailed analysis of conceptual components (antecedents, attributes, outcomes, boundaries) resulted in a definition of woman-centered care. RESULTS: Eight studies were selected for analyses. In midwifery, woman-centered care has both a philosophical and a pragmatic meaning. There is strong emphasis on the woman-midwife relationship during the childbearing period. The concept demonstrates a dual and equal focus on physical parameters of pregnancy and birth, and on humanistic dimensions in an interpersonal context. The concept is epistemological, dynamic and multidimensional. The results reveal the concept's boundaries and fluctuations regarding equity and control. The role of the unborn child is not incorporated in the concept. CONCLUSION: An in-depth understanding and a broad conceptual foundation of womancentered care has evolved. Now, the concept is ready for research and educational purposes as well as for practical utility.

Reports of work-related traumatic events: A mixedmethods study.

INTRODUCTION: There is limited evidence of the effect and impact on midwives of being involved or witnessing traumatic work-related events. We categorised midwives' selfreported traumatic work-related events and responses to an event and explored the impact on the midwives' professional and personal life. METHODS: A sequential explanatory mixed-methods study, consisting of a questionnaire and semi-structured interviews for midwives who practised or who had practised in the Netherlands or Flanders. RESULTS: In total, 106 questionnaires were completed. We categorised various workrelated traumatic events: witnessing birth trauma/complications (34%), death (28.3%), (mis)management of care (19.8%), events related to the perceived social norm of maternity services' practitioners (9.5%), events related to environmental and contextual issues (5.6%) and to (mis)communication (2.8%). Sharing the experience with colleagues, family and friends, a supervisor or the woman involved in the event, was the most common response. In all, 74.5% of the participants still experienced the influence of work-related events in day-to-day practice and 37.5% still experienced the effects in their personal life. The scores of three participants (3.2%) indicated the likelihood of post-traumatic stress. Twenty-four interviews were conducted. Four themes emerged from the content analysis: 1) Timeline, 2) Drawing up the balance of relations with others, 3) Fretting and worrying, and 4) Lessons learned. CONCLUSIONS: Various work-related traumatic events can impact on midwives' professional and/or personal life. Although not all midwives reported experiencing (lasting) effects of the events, the impact was sometimes far-reaching. Therefore, midwives' experiences and impact of work-related traumatic events cannot be ignored in midwifery practice, education and in supervision or mentoring.

Responding to maternal distress: from needs assessment to effective intervention.

OBJECTIVES: To perform a needs assessment of maternal distress to plan the development of an intervention for the prevention and reduction of antenatal maternal distress. METHODS: We searched PubMed, OVID and EBSCO and applied the PRECEDE logic model to select the data. Experts in the field validated the findings. RESULTS: We identified 45 studies. Maternal distress was associated with diminished maternal and child's quality of life. Aetiological factors of maternal distress included past and present circumstances related to obstetric factors and to a woman's context of living, coping behaviour, and support mechanisms. Lacking knowledge of coping with (maternal) distress was identified as a predisposing factor. Reinforcing factors were relaxation, partner support, counselling experiences and positive interaction with the midwife. Enabling factors were the availability of a support network. CONCLUSIONS: When planning the development of an antenatal intervention for maternal distress, it is advisable to focus on assessment of antenatal emotional wellbeing, the context of the woman's past and present circumstances, her coping behaviour and her environment. The identified predisposing factors, enabling and reinforcing factors should also be taken into consideration.

Factors influencing maternal distress among Dutch women with a healthy pregnancy.

BACKGROUND: Maternal distress is a public health concern. Assessment of emotional wellbeing is not integrated in Dutch antenatal care. Midwives need to understand the influencing factors in order to identify women who are more vulnerable to experience maternal distress. OBJECTIVE: To examine levels of maternal distress during pregnancy and to determine the relationship between maternal distress and aetiological factors. METHODS: A cross-sectional study including 458 Dutch-speaking women with uncomplicated pregnancies during all trimesters of pregnancy. Data were collected with questionnaires between 10 September and 6 November 2012. Demographic characteristics and personal details were obtained. Maternal distress was measured with the Edinburgh Depression Scale (EDS), State-Trait Anxiety Inventory (STAI), and Pregnancy-Related Anxiety Questionnaire (PRAQ). Behaviour was measured with Coping Operations Preference Enquiry-Easy (COPE-Easy). Descriptive statistics and multiple linear regression analysis were used. RESULTS: Just over 20 percent of the women in our sample (21.8%) had a heightened score on one or more of the EDS, STAI or PRAQ. History of psychological problems (B=1.071; p=.001), having young children (B=2.998; p=.001), daily stressors (B=1.304; p=<.001), avoidant coping (B=1.047, p=<.001), somatisation (B=.484; p=.004), and negative feelings towards the forthcoming birth (B=.636; p=<.001) showed a significant positive relationship with maternal distress. Self-disclosure (B=-.863; p=.004) and acceptance of the situation (B=-.542; p=.008) showed a significant negative relationship with maternal distress. CONCLUSION: Maternal distress occurs among women with a healthy pregnancy and is significantly influenced by a variety of factors. Midwives need to recognise the factors that make women more vulnerable to develop and experience maternal distress in order to give adequate advice about how to best cope with this condition.

Dutch midwives' behavioural intentions of antenatal management of maternal distress and factors influencing these intentions: an exploratory survey.

OBJECTIVE: to explore midwives' behavioural intentions and the determinants of these intentions with regard to the management of antenatal care of women with maternal distress. DESIGN: an exploratory survey using a questionnaire. Descriptive statistics calculated expanded TPB constructs, demographic information, personal characteristics and work related details. Multiple linear regression analyses were used to examine which factors influence midwives' intention to provide antenatal care of maternal distress. SETTING: midwives working in Dutch primary care. PARTICIPANTS: 112 midwives completed the survey. RESULTS: midwives did not report a clear intention to screen for maternal distress (3.46 ± 1.8). On average, midwives expressed a positive intention to support women with maternal distress (4.63 ± 1.57) and to collaborate with other health-care professionals (4.63 ± 1.57). Finding maternal distress an interesting topic was a positive predictor for the intention to screen (B=0.383; p=0.005), to support (B=0.637; p=<0.000) and to collaborate (B=0.455; p=0.002). Other positive predictors for the intention to screen for maternal distress were years of work experience (B=0.035; p=0.028), attitude about the value of screening (B=0.326; p=0.002), and self-efficacy (B=0.248; p=0.004). A positive attitude toward support for women with maternal distress (B=0.523; p=0.017) predicted the intention to support these women. Number of years of work experience (B=0.042; p=0.017) was a positive predictor for the intention to collaborate with other health-care professionals. KEY CONCLUSIONS: the intention to screen for maternal distress was less evident than the intention to support women with maternal distress and the intention to collaborate with other health-care professionals. Important factors predicting the midwife's intention to screen, support and collaborate were finding maternal distress an interesting topic, years of work experience, attitude about the value of screening and support and self-efficacy about screening. IMPLICATIONS FOR PRACTICE: to provide care involving all three components of antenatal management of maternal distress implies efforts to influence the factors that predict the intention to screen, to support women with maternal distress and the intention to collaborate with other health-care professionals.