The challenge of defining and treating anemia and iron deficiency in pregnancy: A study of New Zealand midwives' management of iron status in pregnancy and the postpartum period.

BACKGROUND: Early recognition and management of low maternal iron status is associated with improved maternal, fetal, and neonatal outcomes. However, existing international guidelines for the testing and management of maternal iron-deficiency anemia are variable, with no national guideline for New Zealand midwives. Clinical management is complicated by normal physiological hemodilution, and complicated further by the effects of inflammation on iron metabolism, especially in populations with a high prevalence of obesity or infection. This study describes how midwives in one New Zealand area diagnose and treat anemia and iron deficiency, in the absence of established guidelines. METHODS: Data on demographics, laboratory results, and documented clinical management were retrospectively collected from midwives (n=21) and women (n=189), from September to December 2013. Analysis was predominantly descriptive. A secondary analysis of iron status and body mass index (BMI) was undertaken. RESULTS: A total of 46% of 186 women, with hemoglobin testing at booking, did not have ferritin tested; 86% (of 385) of ferritin tests were not concurrently tested with C-reactive protein. Despite midwives prescribing iron for 48.7% of second trimester women, 47.1% still had low iron status before birth. Only 22.8% of women had hemoglobin testing postpartum. There was a significant difference between third trimester median ferritin levels in women with BMI ≥25.00 (14 µg/L) and BMI <25.00 (18 µg/L) (P=.05). DISCUSSION: There was a wide range in the midwives' practice. Maternal iron status was difficult to categorize, because of inconsistent testing. This study indicates the need for an evidence-based clinical guideline for New Zealand midwives and maternity care providers.

The tensions of uncertainty: Midwives managing risk in and of their practice.

The tensions of uncertainty: midwives managing risk in and of their practice. There has been a fundamental shift in past decades in the way midwifery is enacted. The midwifery attributes of skilful practice and conscious alertness seem to have been replaced by the concept of risk with its connotations of control, surveillance and blame. How midwifery manages practice in this risk framework is of concern. Taking a critical realist approach this paper reports on a theoretically and empirically derived model of midwifery undertaken with New Zealand midwives. The model is a three legged birth stool for the midwife which describes how she makes sense of risk in practice. The seat of the stool is being with women and the legs are 'being a professional', 'working the system' and 'working with complexity'. The struts which hold the stool together are 'story telling'. Risk theory is reviewed in light of the empirical study and a theoretical gap of uncertainty and complexity are identified.

Putting intelligent structured intermittent auscultation (ISIA) into practice.

BACKGROUND: Fetal monitoring guidelines recommend intermittent auscultation for the monitoring of fetal wellbeing during labour for low-risk women. However, these guidelines are not being translated into practice and low-risk women birthing in institutional maternity units are increasingly exposed to continuous cardiotocographic monitoring, both on admission to hospital and during labour. When continuous fetal monitoring becomes routinised, midwives and obstetricians lose practical skills around intermittent auscultation. To support clinical practice and decision-making around auscultation modality, the intelligent structured intermittent auscultation (ISIA) framework was developed. AIM: The purpose of this discussion paper is to describe the application of intelligent structured intermittent auscultation in practice. DISCUSSION: The intelligent structured intermittent auscultation decision-making framework is a knowledge translation tool that supports the implementation of evidence into practice around the use of intermittent auscultation for fetal heart monitoring for low-risk women during labour. An understanding of the physiology of the materno-utero-placental unit and control of the fetal heart underpin the development of the framework. CONCLUSION: Intelligent structured intermittent auscultation provides midwives with a robust means of demonstrating their critical thinking and clinical reasoning and supports their understanding of normal physiological birth.

Midwives׳ decision making about transfers for 'slow' labour in rural New Zealand.

UNLABELLED: Midwives who provided Lead Maternity Care (LMC) to women in rural areas were invited to share their experiences of decision making around transfer in labour. Ethics approval was obtained from the NZ National Ethics Committee. OBJECTIVE: to explore midwives׳ decision making processes when making transfer decisions for slow labour progress from rural areas to specialist care. DESIGN: individual and group interviews were conducted with a purposive sample of rural midwives. The recalled decision processes of the midwives were subjected to a content and thematic analysis to expose experiences in common and to highlight aspects of probabilistic (normative), heuristic (behavioural), and group decision making theory within the rural context. SETTING: New Zealand. PARTICIPANTS: 15 midwives who provided LMC services to women in their rural areas. FINDINGS: 'making the mind shift', 'sitting on the boundary', 'timing the transfer' and 'the community interest' emerged as key themes. The decision processes were also influenced by the woman׳s preferences and the distance and time involved in the transfer. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: the findings contribute insights into the challenge of making transfer decisions in rural units; particularly for otherwise well women who were experiencing slow labour progress. Knowledge of the fallibility of our heuristic decision making strategies may encourage the practitioner to step back and take a more deliberative, probabilistic view of the situation. In addition to the clinical picture, this process should include the relational and aspirational aspects for the woman, and any logistical challenges of the particular rural context.

Intelligent Structured Intermittent Auscultation (ISIA): evaluation of a decision-making framework for fetal heart monitoring of low-risk women.

BACKGROUND: Research-informed fetal monitoring guidelines recommend intermittent auscultation (IA) for fetal heart monitoring for low-risk women. However, the use of cardiotocography (CTG) continues to dominate many institutional maternity settings. METHODS: A mixed methods intervention study with before and after measurement was undertaken in one secondary level health service to facilitate the implementation of an initiative to encourage the use of IA. The intervention initiative was a decision-making framework called Intelligent Structured Intermittent Auscultation (ISIA) introduced through an education session. RESULTS: Following the intervention, medical records review revealed an increase in the use of IA during labour represented by a relative change of 12%, with improved documentation of clinical findings from assessments, and a significant reduction in the risk of receiving an admission CTG (RR 0.75, 95% CI, 0.60-0.95, p = 0.016). CONCLUSION: The ISIA informed decision-making framework transformed the practice of IA and provided a mechanism for knowledge translation that enabled midwives to implement evidence-based fetal heart monitoring for low risk women.

The emotional journey of labour-women's perspectives of the experience of labour moving towards birth.

BACKGROUND: there has been minimal exploration of women's emotional flow during labour and towards birth. This research aimed to capture woman's remembered experiences of this process. METHOD: a critical feminist standpoint methodology guided this research which used in depth interviews to explore the perspectives of 18 women who had experienced a spontaneous labour and birth. These women all had continuity of care from a known midwife FINDINGS: women described labour and birth in terms of their emotions. These emotions flowed from excitement at the beginning, to calm as they waited for the labour to strengthen. This waiting time was variable in length and the women were often able to continue with many aspects of normal life. As the labour intensified women described moving into a 'zone' of timelessness and spacelessness; a time of letting go of control. The external world was shut out. Some women described feeling overwhelmed as the birth approached, others felt intensely tired. During the birth the women returned to a state of alertness. Some described shock or disbelief. They were surprised at how effectively their body had worked and taken them through labour. CONCLUSION AND IMPLICATION FOR PRACTICE: women described labour as defined by their emotions. The feelings described were linear and consistent and may be an indication of normal labour and birth physiology. These descriptions may be helpful when supporting women during labour and birth.

Women's perspectives of the stages and phases of labour.

BACKGROUND: within childbirth there is a common and widely known explanation of labour and birth which describes and defines the birth process as stages and phases. The aim of this research was to determine whether the discourse of labour as stages and phases resonated with women who had experienced spontaneous labour and birth. METHOD: a critical feminist standpoint methodology was used to explore the perspectives of 18 New Zealand women through in-depth, one to one, interviews. FINDINGS: the participants did not talk about their labour as occurring in stages or phases and often considered this description to be an abstract concept. The current descriptions of labour onset and progression did not appear to resonate with these women or provide sufficient clarity for them to understand how far they had progressed in their labour. For women who had previously laboured there was the ability to make comparisons with their previous experiences and therefore experiential knowledge was privileged over other forms of knowledge. Despite this the discourse of measurement of cervical dilatation was dominant and considered as an authoritative means of determining labour and labour progress. CONCLUSION AND IMPLICATION FOR PRACTICE: women considered labour to be a continuous process. If women are to be able to make sense of their experience of labour, the maternity sector needs to explore and determine descriptions of labour which resonate more fully with the woman's experience of labour and birth.

Are first-time mothers who plan home birth more likely to receive evidence-based care? A comparative study of home and hospital care provided by the same midwives.

BACKGROUND: "Place of birth" studies have consistently shown reduced rates of obstetric intervention in low-technology birth settings, but the extent to which the place of birth per se has influenced the outcomes remains unclear. The objective of this study was to compare birth outcomes for nulliparous women giving birth at home or in hospital, within the practice of the same midwives. METHODS: An innovative survey was generated following a focus group discussion that compared midwifery practice in different settings. Two groups of matched, low-risk first-time mothers, one group who planned to give birth at home and the other in hospital, were compared with respect to birth outcomes and midwifery care, and in relation to evidenced-based care guidelines for low-risk women. RESULTS: Survey data (response rate: 72%) revealed that women in the planned hospital birth group (n = 116) used more pharmacological pain management techniques, experienced more obstetric interventions, had a greater rate of postpartum hemorrhage, and achieved spontaneous vaginal birth less often than those in the planned home birth group (n = 109). All results were significant (p < 0.05). CONCLUSIONS: Despite care by the same midwives, first-time mothers who chose to give birth at home were not only more likely to give birth with no intervention but were also more likely to receive evidence-based care. (BIRTH 39:2 June 2012).

Consultation, referral, and collaboration between midwives and obstetricians: lessons from New Zealand.

There has been substantial growth in the provision of midwifery-led models of care, yet little is known about the obstetric consultation and referral practices of these midwives or the quality of the collaboration between midwives and obstetricians. This study aimed to describe these processes as they are practised in New Zealand, where midwifery-led maternity care is the dominant model. A total population postal survey was conducted that included 649 New Zealand midwives who provided midwifery-led care in 2001. There was a 56.5% response rate, describing care for 4251 women. Within this cohort, there was a 35% consultation rate and 43% of these women had their lead carer role transferred to an obstetrician. However, the midwives continued to provide care in collaboration with obstetricians for 74% of transferred women. Seventy-two percent of midwives felt that they were well supported by the obstetricians to continue care. Midwifery-led care is reasonable for the general population of childbearing women, and a 35% consultation rate can be seen as a benchmark for this population. Midwives can, when well supported, provide continuity of care for women who experience complexity during pregnancy and/or birth. Collaboration with obstetricians is possible, but there needs to be further work to describe what successful collaboration is and how it might be fostered.

Design and evaluation of a community participatory, birth preparedness project in Cambodia.

OBJECTIVE: to evaluate a pilot project, which used a community participatory approach to introduce birth preparedness in rural Cambodia. DESIGN: a feasibility and outcome evaluation. This included observation, interview, document analysis and costing. SETTING: the project was undertaken in 15 villages linked to five health centres in Kampong Chhnang, Cambodia. PARTICIPANTS: key management personnel, local midwives, village leaders, village volunteers and village members who had participated in the programme. FINDINGS: community engagement was not only feasible but was also a successful and cost-effective way to introduce birth preparedness. A high degree of satisfaction was reported by the health staff and the community. Over the year in which the project was undertaken, there was a 22% increase in antenatal care, a 32% increase in the number of women delivered by a midwife, and a 281% increase in referrals to hospital. IMPLICATIONS FOR PRACTICE: discussion about birth preparedness should occur not only with pregnant women but also with the communities that support them. Communities that are poor and isolated are responsive to the health needs of their women as they give birth, and articulate their needs when given the opportunity. Interacting with health staff in a way in which there is shared information can lead to greater utilisation of the health services that they provide.