Women's reasons and perceptions around planning a homebirth with a registered midwife in Western Australia.

BACKGROUND: Qualitative evidence has provided rich descriptions around reasons for planning a homebirth with a midwife. Reasons and the importance, confidence and support around this option have not been examined by parity with a larger cohort. AIM: Examine women's characteristics, reasons and perceptions of the importance, confidence and support around choosing homebirth based upon parity. METHODS: A mixed method approach was undertaken within a prospective cohort study in Western Australia where women planning a homebirth have the option of a publicly funded model or care from privately practising midwives. At recruitment a questionnaire collected demographic data, perceived importance, confidence and support plus reasons for choosing homebirth. A qualitative component included an open ended question that encouraged sharing of opinions providing textual data explored by content analysis. FINDINGS: Reasons noted by 211 pregnant women for choosing homebirth were: avoidance of unnecessary intervention (58.8%), comfort and familiarity of home (34.1%), freedom of making own choices (25.6%), and having more continuity of care (24.2%). Reasons for planning homebirth were similar by parity, except for comfort of home being more important (44.0% vs 28.7%, p=0.025) and continuity of care (13.3% vs 30.1%, p=0.006) being less important to primigravid women. Themes revealed common beliefs around childbirth, appreciation for access to homebirth and a desire for greater awareness and less negativity around homebirth. CONCLUSION: Regardless of parity, homebirth was believed to be safe and supported by partners. Reasons identified from qualitative research to avoid intervention, the comfort of home, choice and continuity of care were supported.

Under scrutiny: Midwives' experience of intrapartum transfer from home to hospital within the context of a planned homebirth in Western Australia.

BACKGROUND: Women's experience of homebirth has been a focus of research, with limited international research and no Australian evidence of the experiences of midwives in relation to their experience of intrapartum transfers within the context of a planned homebirth. OBJECTIVE: To explore the experience of Western Australian midwives involved in an intrapartum transfer from home to hospital. METHODS: A descriptive phenomenological study was conducted. Women who elect to have a homebirth in Western Australia have the choice of care from privately practising midwives or a publicly funded program. Midwives who were currently practising or had practised within the past three years and experienced an intrapartum transfer were invited to participate. In-depth interviews were conducted with 13 midwives and data analysed using the Stevick-Colaizzi-Keen method. RESULTS: Analysis revealed an overarching theme "under scrutiny" which captured four themes: "decision to transfer: getting the timing right"; "reception at the hospital: welcoming or not"; "maintaining continuity of carer" and "reflections: coming to terms with the experience". CONCLUSION: The decision to transfer to hospital represents a profound shift in expectations for the woman and midwife that is often not recognised by hospital staff. Intrapartum transfer is a challenging clinical decision for all parties; midwives, women, partners and health services. Increased effort by maternity health professionals to improve communication and collaboration must be a priority to better support women and their partners who make an informed decision to have a planned homebirth.

Benefits of Bifidobacterium breve M-16V Supplementation in Preterm Neonates - A Retrospective Cohort Study.

BACKGROUND: Systematic reviews of randomised controlled trials report that probiotics reduce the risk of necrotising enterocolitis (NEC) in preterm neonates. AIM: To determine whether routine probiotic supplementation (RPS) to preterm neonates would reduce the incidence of NEC. METHODS: The incidence of NEC ≥ Stage II and all-cause mortality was compared for an equal period of 24 months 'before' (Epoch 1) and 'after' (Epoch 2) RPS with Bifidobacterium breve M-16V in neonates <34 weeks. Multivariate logistic regression analysis was conducted to adjust for relevant confounders. RESULTS: A total of 1755 neonates (Epoch I vs. II: 835 vs. 920) with comparable gestation and birth weights were admitted. There was a significant reduction in NEC ≥ Stage II: 3% vs. 1%, adjusted odds ratio (aOR) = 0.43 (95%CI: 0.21-0.87); 'NEC ≥ Stage II or all-cause mortality': 9% vs. 5%, aOR = 0.53 (95%CI: 0.32-0.88); but not all-cause mortality alone: 7% vs. 4%, aOR = 0.58 (95% CI: 0.31-1.06) in Epoch II. The benefits in neonates <28 weeks did not reach statistical significance: NEC ≥ Stage II: 6% vs. 3%, aOR 0.51 (95%CI: 0.20-1.27), 'NEC ≥ Stage II or all-cause mortality', 21% vs. 14%, aOR = 0.59 (95%CI: 0.29-1.18); all-cause mortality: 17% vs. 11%, aOR = 0.63 (95%CI: 0.28-1.41). There was no probiotic sepsis. CONCLUSION: RPS with Bifidobacterium breve M-16V was associated with decreased NEC≥ Stage II and 'NEC≥ Stage II or all-cause mortality' in neonates <34 weeks. Large sample size is required to assess the potential benefits of RPS in neonates <28 weeks.

Levels of innate immune factors in preterm and term mothers' breast milk during the 1st month postpartum.

There is a paucity of data on the effect of preterm birth on the immunological composition of breast milk throughout the different stages of lactation. We aimed to characterise the effects of preterm birth on the levels of immune factors in milk during the 1st month postpartum, to determine whether preterm milk is deficient in antimicrobial factors. Colostrum (days 2-5 postpartum), transitional milk (days 8-12) and mature milk (days 26-30) were collected from mothers of extremely preterm (<28 weeks of gestation, n 15), very preterm (28-<32 weeks of gestation, n 15), moderately preterm (32-<37 weeks of gestation, n 15) and term infants (37-41 weeks of gestation, n 15). Total protein, lactoferrin, secretory IgA, soluble CD14 receptor (sCD14), transforming growth factor-ß2 (TGF-ß2), α defensin 5 (HD5), ß defensins 1 (HBD1) and 2, IL-6, IL-10, IL-13, interferon-γ, TNF-α and lysozyme (LZ) were quantified in milk. We examined the effects of lactation stage, gestational age, volume of milk expressed, mode of delivery, parity and maternal infection on milk immune factor concentrations using repeated-measures regression analysis. The concentrations of all factors except LZ and HD5 decreased over the 1st month postpartum. Extremely preterm mothers had significantly higher concentrations of HBD1 and TGF-ß2 in colostrum than term mothers did. After controlling for other variables in regression analyses, preterm birth was associated with higher concentrations of HBD1, LZ and sCD14 in milk samples. In conclusion, preterm breast milk contains significantly higher concentrations of some immune proteins than term breast milk.

Leukocyte Populations in Human Preterm and Term Breast Milk Identified by Multicolour Flow Cytometry.

BACKGROUND: Extremely preterm infants are highly susceptible to bacterial infections but breast milk provides some protection. It is unknown if leukocyte numbers and subsets in milk differ between term and preterm breast milk. This study serially characterised leukocyte populations in breast milk of mothers of preterm and term infants using multicolour flow cytometry methods for extended differential leukocyte counts in blood. METHODS: Sixty mothers of extremely preterm (<28 weeks gestational age), very preterm (28-31 wk), and moderately preterm (32-36 wk), as well as term (37-41 wk) infants were recruited. Colostrum (d2-5), transitional (d8-12) and mature milk (d26-30) samples were collected, cells isolated, and leukocyte subsets analysed using flow cytometry. RESULTS: The major CD45+ leukocyte populations circulating in blood were also detectable in breast milk but at different frequencies. Progression of lactation was associated with decreasing CD45+ leukocyte concentration, as well as increases in the relative frequencies of neutrophils and immature granulocytes, and decreases in the relative frequencies of eosinophils, myeloid and B cell precursors, and CD16- monocytes. No differences were observed between preterm and term breast milk in leukocyte concentration, though minor differences between preterm groups in some leukocyte frequencies were observed. CONCLUSIONS: Flow cytometry is a useful tool to identify and quantify leukocyte subsets in breast milk. The stage of lactation is associated with major changes in milk leukocyte composition in this population. Fresh preterm breast milk is not deficient in leukocytes, but shorter gestation may be associated with minor differences in leukocyte subset frequencies in preterm compared to term breast milk.

Antimicrobial protein and Peptide concentrations and activity in human breast milk consumed by preterm infants at risk of late-onset neonatal sepsis.

OBJECTIVE: We investigated the levels and antimicrobial activity of antimicrobial proteins and peptides (AMPs) in breast milk consumed by preterm infants, and whether deficiencies of these factors were associated with late-onset neonatal sepsis (LOS), a bacterial infection that frequently occurs in preterm infants in the neonatal period. STUDY DESIGN: Breast milk from mothers of preterm infants (≤ 32 weeks gestation) was collected on days 7 (n = 88) and 21 (n = 77) postpartum. Concentrations of lactoferrin, LL-37, beta-defensins 1 and 2, and alpha-defensin 5 were measured by enzyme-linked immunosorbent assay. The antimicrobial activity of breast milk samples against Staphylococcus epidermidis, Staphylococcus aureus, Escherichia coli, and Streptococcus agalactiae was compared to the activity of infant formula, alone or supplemented with physiological levels of AMPs. Samples of breast milk fed to infants with and without subsequent LOS were compared for levels of AMPs and inhibition of bacterial growth. RESULTS: Levels of most AMPs and antibacterial activity in preterm breast milk were higher at day 7 than at day 21. Lactoferrin was the only AMP that limited pathogen growth >50% when added to formula at a concentration equivalent to that present in breast milk. Levels of AMPs were similar in the breast milk fed to infants with and without LOS, however, infants who developed LOS consumed significantly less breast milk and lower doses of milk AMPs than those who were free from LOS. CONCLUSIONS: The concentrations of lactoferrin and defensins in preterm breast milk have antimicrobial activity against common neonatal pathogens.

Attitudes and barriers to the introduction of umbilical cord blood gas and lactate analysis at birth.

BACKGROUND: Despite a growing body of evidence demonstrating the value of universal umbilical cord blood gas analysis (UCBGA), there remains reluctance in some maternity units to adopt universal testing. AIMS: Identify perceived barriers and benefits of universal UCBGA. METHODS: Medical and midwifery staff involved in intrapartum care at four level two maternity units (one metropolitan and three regional) completed questionnaires evaluating attitudes to UCBGA. Questionnaires included 13 statements with responses ranging from strongly agree to strongly disagree and background demographic data. RESULTS: Most respondents considered UCBGA beneficial to perinatal care (n = 72; 67.3%), with only nine individuals (8.4%) believing UCBGA had no place in perinatal care. The majority of respondents considered benefits of UCBGA to include being an effective and objective marker of neonatal status (n = 64; 59.8%), as well as playing a role in medicolegal issues (n = 74; 69.2%) and audit and teaching (n = 64; 59.8%). Respondents considered that barriers to universal UCBGA introduction included insufficient time following delivery, increased workload and encroachment of technology into birth. CONCLUSIONS: The majority of respondents indicated support for UCBGA. Information derived from this study may be useful in identifying and resolving concerns prior to the introduction of UCBGA. Further, it could be useful in the preparation of education and implementation packages necessary for introduction of UCBGA.

The effects of fish oil supplementation in pregnancy on breast milk fatty acid composition over the course of lactation: a randomized controlled trial.

This study evaluated the longitudinal effect of fish oil in pregnancy on breast milk fatty acid composition and infant outcomes. In a randomized, controlled trial, 98 women received 2.2 g docosahexaenoic acid (DHA) and 1.1 g eicosapentaenoic acid (EPA) or olive oil from 20 wk of gestation until delivery. Fatty acid composition in breast milk (at 3 d, 6 wk, and 6 mo) and infant erythrocyte membranes (at 1 y) were determined by gas liquid chromatography. Breast milk fatty acids were examined in relationship to growth and development. Compared with control group, breast milk from women who received fish oil had proportionally higher DHA and EPA levels at 3 d and 6 wk after delivery, but this difference was no longer apparent by 6 mo. Infant DHA status at 1 y of age was directly related to DHA levels at 3 d, 6 wk, and 6 mo postpartum (but not to antenatal supplementation). Both EPA and DHA in breast milk were positively correlated with Griffith's developmental scores including hand and eye coordination. Thus, supplementation in pregnancy was associated with increased n-3 long-chain polyunsaturated fatty acids (LCPUFAs) in breast milk, particularly in early lactation, and this was positively associated with infant DHA status at 1 y.

Patent ductus arteriosus in extremely preterm infants receiving phototherapy: does shielding the chest make a difference? A randomized, controlled trial.

BACKGROUND: Patent ductus arteriosus (PDA), a common complication in extremely preterm infants, is associated with increased mortality and morbidity. Phototherapy has been associated with PDA, and one randomized, control trial has shown that shielding of the chest may decrease the risk of PDA. AIM: To examine if chest shielding reduces the incidence and severity of PDA in extremely preterm infants. STUDY DESIGN: Randomized clinical trial of infants < 29 wk gestation (stratified into two groups: < 27 wk gestation and 27-28 wk gestation). METHODS: Following written parental consent, eligible infants were randomized to receive phototherapy, with or without a chest shield. Ductal parameters were assessed by Doppler echocardiogram in all infants prior to starting phototherapy and at 48 h after initiation, or earlier if phototherapy was discontinued. RESULTS: 54 infants were enrolled in the study. The incidence of PDA (shield 19/27 vs no shield 21/27), ductal size (1.4 vs 1.0 mm) and left atrial/aortic root (LA/Ao) ratio (1.2 vs 1.3) were similar in the two groups pre-phototherapy. There was no difference between the groups post-phototherapy in incidence (shield 12/27 vs no shield 13/27), ductal size (1.4 vs 1.5 mm) or LA/Ao ratio (1.1 vs 1.3). CONCLUSION: Chest shielding did not alter the incidence or severity of PDA in our population of extremely preterm infants.

Postnatal home visiting for illicit drug-using mothers and their infants: a randomised controlled trial.

BACKGROUND: Postnatal home-visiting programs for illicit drug-using mothers have reported some success in reducing harms in some areas but there is a lack of data on their impact on breastfeeding and immunisation rates. AIMS: To investigate the effect on breastfeeding, immunisation and parental drug use. The hypothesis was that the outcomes of the home-visiting group (HVG) would be superior to the control group (CG). METHOD: One hundred and fifty-two illicit drug-using women were recruited at 35-40 weeks gestation from King Edward Memorial Hospital, Perth, Western Australia and randomised after delivery to the HVG or the CG. The HVG had eight home visits; the CG had telephone contact at two months and a home visit at six months. The HVG received education and support for parenting, breastfeeding and child development. This was not provided by the research midwives for the CG. RESULTS: The main drugs were heroin, amphetamines, cannabis and benzodiazepines. Immunisation rates were similar for each group. Median duration of breastfeeding for the HVG was eight weeks (95% CI, 3.8-12.2); for the CG ten weeks (95% CI, 7.3-12.7). Drug use was reduced during pregnancy but increased by six months post-partum in both groups. The retention rates were: HVG 93%; CG 86%. CONCLUSION: The hypothesis for this study was not supported. Long-term studies are urgently required to assess the effects of parental drug use on infant and child development.

Does magnesium sulfate reduce the short- and long-term requirements for pain relief after caesarean delivery? A double-blind placebo-controlled trial.

OBJECTIVE: The purpose of this study was to determine whether magnesium sulfate decreases postoperative pain and analgesic consumption. STUDY DESIGN: Women who underwent elective cesarean delivery were randomized into groups according to high-dose magnesium sulfate (50 mg/kg load and 2 g/h), low-dose magnesium sulfate (25 mg/kg load and 1 g/h), or placebo. Before the delivery, the dose of patient-controlled opioid that was used and the visual analogs of pain during the first 48 hours after delivery and at 6 weeks were assessed. RESULTS: Forty-two women were assigned randomly to the high-dose arm; 38 women were assigned to the low-dose magnesium arms, and 40 women were assigned to the control arm. The cumulative opioid use (P = .636); pain scores at 6, 12, 24, and 48 hours at rest (P = .786) and with movement (P = .179); the use of analgesics after hospital discharge (P = .711); and wound pain with movement (P = .429) or pressure (P = .144) after 6 weeks were similar. CONCLUSION: Magnesium sulfate does not reduce the severity of short-term or long-term (6 weeks) pain after cesarean delivery.

Sex differences in survival in non-small cell lung cancer patients 1974-1998.

This study comprised a total of 7,553 patients with non-small cell lung cancer (2,660 women and 4,893 men) treated at a comprehensive cancer centre between 1974 and 1998. Significant differences in tumour histology were associated with gender (p < 0.001); adenocarcinoma was the most common diagnosis in both men (50.0%) and women (41.7%); squamous cell carcinoma was the second most prevalent diagnosis (21% and 31% in women and men, respectively); and bronchioalveolar tumours were more prevalent in men (3% compared with 7% in women). Frequency distributions with local, regional or distant disease at registration were similar between men and women (p = 0.906). In a multivariable Cox regression analysis the indications were that gender is an important risk factor for survival. Adjusting for age, stage, treatment received and ability to pay for care, a statistically significant interaction between gender and tumour histology (p = 0.043) was found, where, in relation to female sex and histologies other than squamous carcinoma, women who presented with squamous carcinoma had an increased risk of death (HR = 1.09, 95% CI 1.02-1.18) while men had an increased risk of death for all histologies (HR = 1.29, 95% CI 1.21-1.40, and HR = 1.15, 95% CI 1.07-1.24 for squamous and other histologies, respectively). This study confirms previous reports of strong gender-dependent differences in survival in patients with non-small cell lung cancer, including a histology-specific effect in women.

Infant intake of fatty acids from human milk over the first year of lactation.

Despite the importance of human milk fatty acids for infant growth and development, there are few reports describing infant intakes of individual fatty acids. We have measured volume, fat content and fatty acid composition of milk from each breast at each feed over a 24 h period to determine the mean daily amounts of each fatty acid delivered to the infant from breast milk at 1, 2, 4, 6, 9 and 12 months of lactation in five women. Daily (24 h) milk production was 336.60 (SEM 26.21) and 414.49 (SEM 28.39) ml and milk fat content was 36.06 (SEM 1.37) and 34.97 (SEM 1.50) g/l for left and right breasts respectively over the course of the first year of lactation. Fatty acid composition varied over the course of the day (mean CV 14.3 (SD 7.7) %), but did not follow a circadian rhythm. The proportions (g/100 g total fatty acids) of fatty acids differed significantly between mothers (P<0.05) and over the first year of lactation (P<0.05). However, amounts (g) of most fatty acids delivered to the infant over 24 h did not differ during the first year of lactation and only the amounts of 18:3n-3, 22:5n-3 and 22:6n-3 delivered differed between mothers (P<0.05). Mean amounts of 18:2n-6, 18:3n-3, 20:4n-6 and 22:6n-3 delivered to the infant per 24 h over the first year of lactation were 2.380 (SD 0.980), 0.194 (SD 0.074), 0.093 (SD 0.031) and 0.049 (SD 0.021) g respectively. These results suggest that variation in proportions of fatty acids may not translate to variation in the amount delivered and that milk production and fat content need to be considered.