"It could not have been more different." Comparing experiences of hospital-based birth and homebirth in Ireland: A mixed-methods survey.

PROBLEM: Internationally, little is known about the experiences of the minority who have birthed both in hospital and at home. This group are in a unique position to provide experiential evidence regarding perceptions of care under each approach. BACKGROUND: Obstetric care within the hospital setting is the hegemonic approach to birth in western cultures. Homebirth is at least as safe as hospital birth for those with low-risk pregnancies, yet access is strictly regulated. AIM: To explore how those who have experienced both hospital and homebirth maternity care in Ireland perceived the care received, and experienced birth in each setting. METHODS: 141 participants who birthed both in hospital and at home between 2011 and 2021 completed an online survey. FINDINGS: Participants' overall experience scores were significantly higher for homebirth (9.7/10) than hospital birth (5.5/10). In hospital, midwifery-led care scored significantly higher (6.4/10) than consultant-led care (4.9/10). Qualitative data revealed four explanatory themes: 1) Regulation of birth; 2) Continuity of care and/or carer and establishing relationships; 3) Bodily integrity and informed consent; and 4) Lived experiences of labour and birth at home and in hospital. DISCUSSION: Homebirth was perceived far more positively than hospital birth experiences across all aspects of care surveyed. Findings suggest that those who have experienced both models of care have unique perspectives and aspirations about childbirth. CONCLUSION: This study provides evidence regarding the need for genuine choices for maternity care and reveals the importance of care which is respectful and responsive to divergent ideologies about birth.

Clinicians' views of factors influencing decision-making for CS for first-time mothers-A qualitative descriptive study.

Clinicians' perspectives of the reasons for performing caesarean section (CS) are fundamental to deepening knowledge and understanding of factors influencing decision-making for CS. The aim of this study was to explore midwives' and obstetricians' views of factors influencing decision-making for CS for first-time mothers. A qualitative descriptive study with semi-structured one-to-one audio-recorded interviews was used to gather data from clinicians (15 midwives and 20 senior obstetricians). Following research ethics committee approval, clinicians, who were directly involved in the decision-making process for CS during the period of data collection, were purposively selected from three maternity units in the Republic of Ireland between June 2016 to July 2017. The interviews were transcribed verbatim and analysed thematically. Three interrelated themes with several subthemes reflective of clinicians' views and experiences emerged following data analysis. These were: 'A fear factor' describing clinicians' fear of adverse outcomes and subsequent litigation, 'Personal preferences versus a threshold-clinician driven factors emphasising the influence of clinicians' personal beliefs, and 'Standardised versus individualised care-a system perspective' explaining the effects of, or lack of, organisational policy and its direct and indirect impact on the decision-making process. Findings show that decisions to perform a CS are, on occasion, based on clinicians' personal beliefs and interpretation, similar to findings from other published literature. Consideration of broader issues related to organisational, socio-cultural and political context is essential when seeking solutions to the rising CS rates. The findings will enable clinicians to reflect on their day-to-day practice, in order to look for modifiable factors that influence their decision-making, and help women understand the multitude of factors that can lead to a decision to perform a CS. Findings will also contribute to the development of the 'next step action' and assist in devising future intervention studies to reduce any unnecessary CSs.

The effectiveness of skilled breathing and relaxation techniques during antenatal education on maternal and neonatal outcomes: a systematic review.

BACKGROUND: Several studies have investigated the relationship between antenatal education classes and pregnancy outcomes. These studies have shown positive effects on mothers, such as a lower epidural rate in the intervention groups. However, until now, the impact on outcomes for mothers and newborns of antenatal education classes that focus on breathing and relaxation techniques has not been examined. AIM: Investigate the effects of skilled breathing and relaxation techniques provided in antenatal education classes on maternal and neonatal birth outcomes. METHODS: The protocol for this study was registered with PROSPERO (ID: CRD42020192289). A systematic literature search was undertaken and completed in January 2022, using the databases MEDLINE, CINAHL, clinicalTrials.gov, Cochrane Library, Embase and MIDIRS according to a priori formulated PICO criteria: population (pregnant women), intervention (antenatal education classes with integrated breathing and relaxation techniques), comparison (antenatal education classes that do not include skilled breathing and relaxation techniques), and outcome (maternal and neonatal outcomes). The quality of the studies was assessed by two reviewers using the standardised instruments RoB 2 and ROBINS-I. RESULTS: Ten studies were included in this review, nine randomised controlled trials and one quasi-experimental study. The results indicate that skilled breathing and relaxation techniques may positively influence self-efficacy, the need for pharmacological support, specifically the use of epidural anaesthesia, and the memory of labour pain. No effects were found in relation to predefined neonatal outcomes. The quality of evidence on maternal and neonatal outcomes is inconsistent across studies, as different antenatal education classes with varying interventions, including breathing and relaxation techniques, were offered in the studies. CONCLUSIONS: Women who attended an antenatal education class with breathing and relaxation techniques appear to benefit from the intervention. This applies to the practical implementation and use of breathing and relaxation techniques during labour, increased self-confidence and self-efficacy, and a increased feeling of being in control during labour. This demonstrates the importance of information provision and a focus on breathing and relaxation techniques in antenatal education.

The characteristics and effectiveness of pregnancy yoga interventions: a systematic review and meta-analysis.

BACKGROUND: Yoga is a popular mind-body medicine frequently recommended to pregnant women. Gaps remain in our understanding of the core components of effective pregnancy yoga programmes. This systematic review and meta-analysis examined the characteristics and effectiveness of pregnancy yoga interventions, incorporating the FITT (frequency, intensity, time/duration and type) principle of exercise prescription. METHODS: Nine electronic databases were searched: MEDLINE, PsycINFO, EMBASE, CINAHL, WHOLiS, AMED, ScieLo, ASSIA and Web of Science. Randomised control trials and quasi-experimental studies examining pregnancy yoga interventions were eligible. Covidence was used to screen titles, abstracts, and full-text articles. Outcomes of interest were stress, anxiety, depression, quality of life, labour duration, pain management in labour and mode of birth. The Cochrane Collaboration's Risk of Bias Assessment tool was used to assess methodological quality of studies and GRADE criteria (GRADEpro) evaluated quality of the evidence. Meta-analysis was performed using RevMan 5.3. RESULTS: Of 862 citations retrieved, 31 studies met inclusion criteria. Twenty-nine studies with 2217 pregnant women were included for meta-analysis. Pregnancy yoga interventions reduced anxiety (SMD: -0.91; 95% CI: - 1.49 to - 0.33; p = 0.002), depression (SMD: -0.47; 95% CI: - 0.9 to - 0.04, P = 0.03) and perceived stress (SMD: -1.03; 95% CI: - 1.55 to - 0.52; p < 0.001). Yoga interventions also reduced duration of labour (MD = - 117.75; 95% CI - 153.80 to - 81.71, p < 0.001) and, increased odds of normal vaginal birth (OR 2.58; 95% CI 1.46-4.56, p < 0.001) and tolerance for pain. The quality of evidence (GRADE criteria) was low to very low for all outcomes. Twelve or more yoga sessions delivered weekly/bi-weekly had a statistically significant impact on mode of birth, while 12 or more yoga sessions of long duration (> 60 min) had a statistically significant impact on perceived stress. CONCLUSION: The evidence highlights positive effects of pregnancy yoga on anxiety, depression, perceived stress, mode of birth and duration of labour. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42019119916. Registered on 11th January 2019.

Learning about midwifery in another country from a distance: Evaluation of a virtual classroom learning session.

BACKGROUND: Studying abroad promotes cultural awareness and understanding of different healthcare settings and practices but family or financial constraints prevent some students from taking advantage of these opportunities. We developed a virtual classroom learning session to give Danish and Irish midwifery students an opportunity to explore midwifery and maternity care in another country. OBJECTIVES: To evaluate the content of midwifery students' chat room discussions about the differences in maternity and midwifery care during an international online learning session, and their opinions of the session. PARTICIPANTS: 27 Danish and 37 Irish undergraduate direct entry midwifery students. METHODS: Content analysis of students' chat room discussions and post-session survey. FINDINGS: Students engaged enthusiastically in the chat room discussions throughout the session. Almost all of the interactivity was between students themselves, and questions raised by students from one country were answered by students in the other country. Discussions centred on the lecture content, rates of interventions and birth outcomes, but developed into broader issues relating to one-to-one midwifery care during labour, factors that facilitate normal birth, national data availability, staffing levels, and financial and cultural aspects of having children at earlier or later ages. In the survey, students described the session as awakening curiosity and a fun way to learn. They found it 'cool' to talk with real students from another country, a memorable way of discussing differences between the two maternity care systems and expanding knowledge. Negative comments related to technological problems. CONCLUSION: An international virtual classroom learning session can give midwifery students insights into midwifery elsewhere, stimulate curiosity and be an engaging way to learn. Our students' experiences show that it can offer a real, engaging and positive learning experience and enrich students' knowledge of cultural differences.

Respectful and disrespectful care in the Czech Republic: an online survey.

BACKGROUND: Respectful maternity care includes treating women with dignity, consulting them about preferences, gaining consent for treatment, respecting their wishes, and giving care based on evidence, not routines. In the absence of any documented evidence, this study aimed to ascertain maternity care-givers' perceptions of respectful care provided for childbearing women in Czech Republic. METHODS: Following ethical approval, an online quantitative survey with qualitative comments was completed by 52 respondents recruited from workshops on promoting normal birth, followed by snowball sampling. The majority were midwives (50%) or doulas (46%) working in one of 51 hospitals, or with homebirths. Chi-square analysis was used for comparisons. RESULTS: Non-evidenced-based interventions, described as 'always' or 'frequently' used in hospitals, included application of electronic fetal monitoring in normal labour (n = 40, 91%), shaving the perineum (n = 10, 29%), and closed-glottal pushing (n = 32, 94%). Positions stated as most often used for spontaneous vaginal births were semi-recumbent (n = 31, 65%) or lying flat (n = 15, 31%) in hospital, and upright at home (n = 27, 100%). Average episiotomy and induction of labour rates were estimated at 40 and 26%, respectively, higher than accepted norms. Eighteen respondents (46%) said reasons for performing vaginal examinations were not explained to women in hospitals, and 21 (51%) said consent was 'never' sought. At home, 25 (89%) said reasons were explained, and permission 'always' sought (n = 22, 81%). Thirteen (32%) said hospital clinicians explained why artificial rupture of membranes was necessary, but only ten (25%) said they 'always' sought permission. The majority said that hospital clinicians 'never'/'almost never' explained reasons for performing an episiotomy (13 = 34%), gained permission (n = 20, 54%) or gave local anaesthetic (n = 19, 51%). Contrastingly, 17 (100%) said midwives at home explained the reasons for episiotomy and asked permission. When clinicians disagreed with women's decisions, 13 (35%) respondents said women might be told to 'face the consequences', six (16%) stated that the 'psychological pressure' experienced caused women to 'give up and give their permission', and four (11%) said the intervention would be performed 'against her will.' CONCLUSIONS: Findings reveal considerable levels of disrespectful, non-evidenced-based, non-consensual and abusive practices that may leave women with life-long trauma.

Factors influencing decision-making for caesarean section in Sweden - a qualitative study.

BACKGROUND: Rising rates of caesarean section (CS) are a concern in many countries, yet Sweden has managed to maintain low CS rates. Exploring the multifactorial and complex reasons behind the rising trend in CS has become an important goal for health professionals. The aim of the study was to explore Swedish obstetricians' and midwives' perceptions of the factors influencing decision-making for CS in nulliparous women in Sweden. METHODS: A qualitative design was chosen to gain in-depth understanding of the factors influencing the decision-making process for CS. Purposive sampling was used to select the participants. Four audio-recorded focus group interviews (FGIs), using an interview guide with open ended questions, were conducted with eleven midwives and five obstetricians from two selected Swedish maternity hospitals after obtaining written consent from each participant. Data were managed using NVivo© and thematically analysed. Ethical approval was granted by Trinity College Dublin. RESULTS: The thematic analysis resulted in three main themes; 'Belief in normal birth - a cultural perspective'; 'Clarity and consistency - a system perspective' and 'Obstetrician makes the final decision, but...', and each theme contained a number of subthemes. However, 'Belief in normal birth' emerged as the core central theme, overarching the other two themes. CONCLUSION: Findings suggest that believing that normal birth offers women and babies the best possible outcome contributes to having and maintaining a low CS rate. Both midwives and obstetricians agreed that having a shared belief (in normal birth), a common goal (of achieving normal birth) and providing mainly midwife-led care within a 'team approach' helped them achieve their goal and keep their CS rate low.

Clinicians' views of factors influencing decision-making for caesarean section: A systematic review and metasynthesis of qualitative, quantitative and mixed methods studies.

BACKGROUND: Caesarean section rates are increasing worldwide and are a growing concern with limited explanation of the factors that influence the rising trend. Understanding obstetricians' and midwives' views can give insight to the problem. This systematic review aimed to offer insight and understanding, through aggregation, summary, synthesis and interpretation of findings from studies that report obstetricians' and midwives' views on the factors that influence the decision to perform caesarean section. METHODS: The electronic databases of PubMed (1958-2016), CINAHL (1988-2016), Maternity and Infant Care (1971-2016), PsycINFO (1980-2016) and Web of Science (1991-2016) were searched in September 2016. All quantitative, qualitative and mixed methods studies, published in English, whose aim was to explore obstetricians' and/or midwives' views of factors influencing decision-making for caesarean section were included. Papers were independently reviewed by two authors for selection by title, abstract and full text. Thomas et al's 12 assessment criteria checklist (2003) was used to assess methodological quality of the included studies. RESULT: The review included 34 studies: 19 quantitative, 14 qualitative, and one using mixed methods, involving 7785 obstetricians and 1197 midwives from 20 countries. Three main themes, each with several subthemes, emerged. Theme 1: "clinicians' personal beliefs"-('Professional philosophies'; 'beliefs in relation to women's request for CS'; 'ambiguous versus clear clinical reasons'); Theme 2: "health care systems"-('litigation'; 'resources'; 'private versus public/insurance/payments'; 'guidelines and management policy'). Theme 3: "clinicians' characteristics" ('personal convenience'; 'clinicians' demographics'; 'confidence and skills'). CONCLUSION: This systematic review and metasynthesis identified clinicians' personal beliefs as a major factor that influenced the decision to perform caesarean section, further contributed by the influence of factors related to the health care system and clinicians' characteristics. Obstetricians and midwives are directly involved in the decision to perform a caesarean section, hence their perspectives are vital in understanding various factors that have influence on decision-making for caesarean section. These results can help clinicians identify and acknowledge their role as crucial members in the decision-making process for caesarean section within their organisation, and to develop intervention studies to reduce caesarean section rates in future.

Process evaluation for OptiBIRTH, a randomised controlled trial of a complex intervention designed to increase rates of vaginal birth after caesarean section.

BACKGROUND: Complex interventions encompassing several interconnecting and interacting components can be challenging to evaluate. Examining the underlying trial processes while an intervention is being tested can assist in explaining why an intervention was effective (or not). This paper describes a process evaluation of a pan-European cluster randomised controlled trial, OptiBIRTH (undertaken in Ireland, Italy and Germany), that successfully used both quantitative and qualitative methods to enhance understanding of the underlying trial mechanisms and their effect on the trial outcome. METHODS: We carried out a mixed methods process evaluation. Quantitative and qualitative data were collected from observation of the implementation of the intervention in practice to determine whether it was delivered according to the original protocol. Data were examined to assess the delivery of the various components of the intervention and the receipt of the intervention by key stakeholders (pregnant women, midwives, obstetricians). Using ethnography, an exploration of perceived experiences from a range of recipients was conducted to understand the perspective of both those delivering and those receiving the intervention. RESULTS: Engagement by stakeholders with the different components of the intervention varied from minimal intensity of women's engagement with antenatal classes, to moderate intensity of engagement with online resources, to high intensity of clinicians' exposure to the education sessions provided. The ethnography determined that, although the overall culture in the intervention site did not change, smaller, more individual cultural changes were observed. The fidelity of the delivery of the intervention scored average quality marks of 80% and above on repeat assessments. CONCLUSION: Nesting a process evaluation within the trial enabled the observation of the mode of action of the intervention in its practice context and ensured that the intervention was delivered with a good level of consistency. Implementation problems were identified as they arose and were addressed accordingly. When dealing with a complex intervention, collecting and analysing both quantitative and qualitative data, as we did, can greatly enhance the process evaluation. TRIAL REGISTRATION: Current Controlled Trials Register, ISRCTN10612254 . Registered on 3 April 2013.

Alumina nanoparticles enhance growth of Lemna minor.

The industrial use of nanoparticles is rapidly increasing, and this has given rise to concerns about potential biological impacts of engineered particles released into the environment. So far, relatively little is known about uptake, accumulation and responses to engineered nanoparticles by plants. In this study, the effects of alumina nanoparticles on growth, morphology and photosynthesis of Lemna minor were quantified. It was found that alumina nanoparticles substantially increase biomass accumulation of L. minor. Such a stimulatory effect of alumina nanoparticles on growth has not been reported previously. Enhanced biomass accumulation was paralleled by morphological adjustments such as increased root length and number of fronds per colony, and by increased photosynthetic efficiency. Metal nanoparticles have previously been shown to enhance the energy transfer efficiency of isolated reaction centres; therefore it is proposed that the mechanism underlying the alumina mediated enhancement of biomass accumulation in L. minor is associated with increased efficiencies in the light reactions of photosynthesis.