A pre-post implementation study of a care bundle to reduce perineal trauma in unassisted births conducted by midwives.

PROBLEM: The perineal-bundle is a complex intervention widely implemented in Australian maternity care facilities. BACKGROUND: Most bundle components have limited or conflicting evidence and the implementation required many midwives to change their usual practice for preventing perineal trauma. AIM: To measure the effect of perineal bundle implementation on perineal injury for women having unassisted births with midwives. METHODS: A retrospective pre-post implementation study design to determine rates of second degree, severe perineal trauma, and episiotomy. Women who had an unassisted, singleton, cephalic vaginal birth at term between two time periods: January 2011 - November 2017 and August 2018 - August 2020 with a midwife or midwifery student accoucheur. We conducted logistic regression on the primary outcomes to control for confounding variables. FINDINGS: data from 20,155 births (pre-implementation) and 6273 (post-implementation) were analysed. After implementation, no significant difference in likelihood of severe perineal trauma was demonstrated (aOR 0.86, 95% CI 0.71-1.04, p = 0.124). Nulliparous women were more likely to receive an episiotomy (aOR 1.49 95% CI 1.31-1.70 p < 0.001) and multiparous women to suffer a second degree tear (aOR 1.18 95% CI 1.09-1.27 p < 0.001). DISCUSSION: This study adds to the growing body of literature which suggests a number of bundle components are ineffective, and some potentially harmful. Why, and how, the bundle was introduced at scale without a research framework to test efficacy and safety is a key concern. CONCLUSION: Suitably designed trials should be undertaken on all proposed individual or grouped perineal protection strategies prior to broad adoption.

Women's unmet needs in early labour: Qualitative analysis of free-text survey responses in the M@NGO trial of caseload midwifery.

OBJECTIVE: to analyse women's experiences of early labour care in caseload midwifery in Australia. DESIGN: this study sits within a multi-site randomised controlled trial of caseload midwifery versus standard care. Participant surveys were conducted at 6-weeks and 6-months after birth. Free-text responses about experiences of care were subject to critical thematic analysis in NVivo 11 software. SETTING: two urban Australian hospitals in different states. PARTICIPANTS: women 18 years and over, with a singleton pregnancy, less than 24 weeks' pregnant, not planning a caesarean section or already booked with a care provider; were eligible to participate in the trial. INTERVENTIONS: participants were randomised to caseload midwifery or standard care for antenatal, labour and birth and postpartum care. MEASUREMENTS AND FINDINGS: The 6-week survey response rate was 58% (n = 1,019). The survey included five open questions about women's experiences of pregnancy, labour and birth, and postnatal care. Nine-hundred and one respondents (88%) provided free text comments which were coded to generate 10 categories. The category of early labour contained data from 84 individual participants (caseload care n = 44; standard care n = 40). Descriptive themes were: (1) needing permission; (2) doing the 'wrong' thing; and (3) being dismissed. Analytic themes were: (1) Seeking: women wanting to be "close to those who know what's going on"; and (2) Shielding: midwives defending resources and normal birth. KEY CONCLUSIONS: Regardless of model of care, early labour care was primarily described in negative terms. This could be attributed to reporting bias, because women who were neutral about early labour care may not comment. Nevertheless, the findings demonstrate a gap in knowledge about early labour care in caseload midwifery models. IMPLICATIONS FOR PRACTICE: Maternity services that offer caseload midwifery are ideally placed to evaluate how early labour home visiting impacts women's experiences of early labour.

Is the Birthing Unit Design Spatial Evaluation Tool valid for diverse groups?

BACKGROUND: Awareness of the impact of the built environment on health care outcomes and experiences has led to efforts to redesign birthing environments. The Birth Unit Design Spatial Evaluation Tool was developed to inform such improvements, but it has only been validated with caseload midwives and women birthing in caseload models of care. AIM: To assess the content validity of the tool with four new participant groups: Birth unit midwives, Aboriginal or Torres Strait Islander women; women who had anticipated a vaginal birth after a caesarean; and women from refugee or culturally and linguistically diverse backgrounds. METHODS: Participants completed a Likert-scale survey to rate the relevance of The Birth Unit Design Spatial Evaluation Tool's 69 items. Item-level content validity and Survey-level validity indices were calculated, with the achievement of validity set at >0.78 and >0.9 respectively. RESULTS: Item-level content validity was achieved on 37 items for birth unit midwives (n=10); 35 items for Aboriginal or Torres Strait Islander women (n=6); 33 items for women who had anticipated a vaginal birth after a caesarean (n=6); and 28 items for women from refugee or culturally and linguistically diverse backgrounds (n=20). Survey-level content validity was not demonstrated in any group. CONCLUSION: Birth environment design remains significant to women and midwives, but the Birth Unit Design Spatial Evaluation Tool was not validated for these participant groups. Further research is needed, using innovative methodologies to address the subconscious level on which environment may influence experience and to disentangle the influence of confounding factors.

Primary Maternity Units in rural and remote Australia: Results of a national survey.

BACKGROUND: Primary Maternity Units (PMUs) offer less expensive and potentially more sustainable maternity care, with comparable or better perinatal outcomes for normal pregnancy and birth than higherlevel units. However, little is known about how these maternity services operate in rural and remote Australia, in regards to location, models of care, service structure, support mechanisms or sustainability. This study aimed to confirm and describe how they operate. DESIGN: a descriptive, cross-sectional study was undertaken, utilising a 35-item survey to explore current provision of maternity care in rural and remote PMUs across Australia. Data were subjected to simple descriptive statistics and thematic analysis for free text answers. SETTING AND PARTICIPANTS: Only 17 PMUs were identified in rural and remote areas of Australia. All 17 completed the survey. RESULTS: the PMUs were, on average, 56km or 49minutes from their referral service and provided care to an average of 59 birthing women per year. Periodic closures or downgrading of services was common. Low-risk eligibility criteria were universally used, but with some variability. Medically-led care was the most widely available model of care. In most PMUs midwives worked shift work involving both nursing and midwifery duties, with minimal uptake of recent midwifery workforce innovations. Perceived enablers of, and threats to, sustainability were reported. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: a small number of PMUs operate in rural Australia, and none in remote areas. Continuing overreliance on local medical support, and under-utilisation of the midwifery workforce constrain the restoration of maternity services to rural and remote Australia.

Women's, midwives' and obstetricians' experiences of a structured process to document refusal of recommended maternity care.

PROBLEM/BACKGROUND: Ethical and professional guidance for midwives and obstetricians emphasises informed consent and respect for patient autonomy; the right to refuse care is well established. However, the existing literature is largely silent on the appropriate clinical responses when pregnant women refuse recommended care, and accounts of disrespectful interactions and conflict are numerous. Policies and processes to support women and maternity care providers are rare and unstudied. AIM: To document the perspectives of women, midwives and obstetricians following the introduction of a structured process (Maternity Care Plan; MCP) to document refusal of recommended maternity care in a large tertiary maternity unit. METHODS: A qualitative, interpretive study involved thematic analysis of in-depth semi-structured interviews with women (n=9), midwives (n=12) and obstetricians (n=9). FINDINGS: Four major themes were identified including: 'Reassuring and supporting clinicians'; 'Keeping the door open'; 'Varied awareness, criteria and use of the MCP process' and 'No guarantees'. CONCLUSION: Clinicians felt protected and reassured by the structured documentation and communication process and valued keeping women engaged in hospital care. This, in turn, protected women's access to maternity care. However, the process could not guarantee favourable responses from other clinicians subsequently involved in the woman's care. Ongoing discussions of risk, perceived by women and some midwives to be pressure to consent to recommended care, were still evident. These limitations may have been attributable to the absence of agreed criteria for initiating the MCP process and fragmented care. Varying awareness and use of the process also diminished women's access to it.

Maternity care providers' perceptions of women's autonomy and the law.

BACKGROUND: Like all health care consumers, pregnant women have the right to make autonomous decisions about their medical care. However, this right has created confusion for a number of maternity care stakeholders, particularly in situations when a woman's decision may lead to increased risk of harm to the fetus. Little is known about care providers' perceptions of this situation, or of their legal accountability for outcomes experienced in pregnancy and birth. This paper examined maternity care providers' attitudes and beliefs towards women's right to make autonomous decisions during pregnancy and birth, and the legal responsibility of professionals for maternal and fetal outcomes. METHODS: Attitudes and beliefs around women's autonomy and health professionals' legal accountability were measured in a sample of 336 midwives and doctors from both public and private health sectors in Queensland, Australia, using a questionnaire available online and in paper format. Student's t-test was used to compare midwives' and doctors' responses. RESULTS: Both maternity care professionals demonstrated a poor understanding of their own legal accountability, and the rights of the woman and her fetus. Midwives and doctors believed the final decision should rest with the woman; however, each also believed that the needs of the woman may be overridden for the safety of the fetus. Doctors believed themselves to be ultimately legally accountable for outcomes experienced in pregnancy and birth, despite the legal position that all health care professionals are responsible only for adverse outcomes caused by their own negligent actions. Interprofessional differences were evident, with midwives and doctors significantly differing in their responses on five of the six items. CONCLUSIONS: Maternity care professionals inconsistently supported women's right to autonomous decision making during pregnancy and birth. This finding is further complicated by care providers' poor understanding of legal accountability for outcomes experienced in pregnancy and birth. The findings of this study support the need for guidelines on decision making in pregnancy and birth for maternity care professionals, and for recognition of interprofessional differences in beliefs around the rights of the woman, her fetus and health professionals in order to facilitate collaborative practice.