Midwife-Led Continuity of Antenatal Care and Breastfeeding Duration Beyond Postpartum Hospital Discharge: A Systematic Review.

BACKGROUND: The World Health Organization recommends that infants should be exclusively breastfed for the first 6 months of life and that breastfeeding should continue for 2 years and beyond. Most women initiate breastfeeding, but many do not continue for the recommended duration. While midwife-led continuity of antenatal care is linked to improved mother and infant outcomes, the influence on breastfeeding duration has not been previously reviewed. RESEARCH AIM: To critically analyze the literature that compared midwife-led continuity of antenatal care with other models of care where researchers have measured breastfeeding duration beyond postpartum hospital discharge. METHODS: A systematic literature review with critical analysis was used to answer the research aim. We systematically searched and screened five databases for quantitative studies where researchers had reported breastfeeding duration beyond postpartum hospital discharge after midwife-led continuity of antenatal care, compared with another model of antenatal care. Methodological quality was assessed using tools from the Cochrane Collaboration (RoB2 and ROBINS-I). In total, nine studies met the inclusion criteria. RESULTS: Clear conclusions about the association between midwife-led continuity of antenatal care and breastfeeding duration were not found. The risk of bias within non-randomized studies ranged from serious to critical, and a judgement of "some concerns" of risk of bias in the one randomized study. CONCLUSION: To date, the question of whether midwife-led continuity of antenatal care improves breastfeeding duration has not been established. There has been a lack of consistency in definitions of breastfeeding and descriptions of models of care, which has weakened the evidence-based of literature reviewed.Our review protocol was registered with PROSPERO; although due to COVID-19, this registration was not checked for eligibility by the PROSPERO team (CRD42020151276). https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020151276.

Implementation barriers and enablers of midwifery group practice for vulnerable women: a qualitative study in a tertiary urban Australian health service.

BACKGROUND: Maternity services have limited formalised guidance on planning new services such as midwifery group practice for vulnerable women, for example women with a history of substance abuse (alcohol, tobacco and other drugs), mental health challenges, complex social issues or other vulnerability. Continuity of care through midwifery group practice is mostly restricted to women with low-risk pregnancies and is not universally available to vulnerable women, despite evidence supporting benefits of this model of care for all women. The perception that midwifery group practice for vulnerable women is a high-risk model of care lacking in evidence may have in the past, thwarted implementation planning studies that seek to improve care for these women. We therefore aimed to identify the barriers and enablers that might impact the implementation of a midwifery group practice for vulnerable women. METHODS: A qualitative context analysis using the Consolidated Framework for Implementation Research was conducted at a single-site tertiary health facility in Queensland, Australia. An interdisciplinary group of stakeholders from a purposeful sample of 31 people participated in semi-structured interviews. Data were analysed using manual and then Leximancer computer assisted methods. Themes were compared and mapped to the Framework. RESULTS: Themes identified were the woman's experience, midwifery workforce capabilities, identifying "gold standard care", the interdisciplinary team and costs. Potential enablers of implementation included perceptions that the model facilitates a relationship of trust with vulnerable women, that clinical benefit outweighs cost and universal stakeholder acceptance. Potential barriers were: potential isolation of the interdisciplinary team, costs and the potential for vicarious trauma for midwives. CONCLUSION: There was recognition that the proposed model of care is supported by research and a view that clinical benefits will outweigh costs, however supervision and support is required for midwives to manage and limit vicarious trauma. An interdisciplinary team structure is also an essential component of the service design. Attention to these key themes, barriers and enablers will assist with identification of strategies to aid successful implementation. Australian maternity services can use our results to compare how the perceptions of local stakeholders might be similar or different to the results presented in this paper.

Experiences of women, hospital clinicians and general practitioners with gestational diabetes mellitus postnatal follow-up: A mixed methods approach.

PROBLEM: Postnatal screening rates to detect type two diabetes following gestational diabetes are low. The quality of communication is an important element to consider in developing targeted strategies that support women in completing recommended follow-up care. AIMS: To explore the communication perspectives, practices and preferences of women, hospital clinicians and general practitioners, to determine strategies that may promote completion of recommended postnatal GDM follow-up, in Queensland Australia. METHOD: We used an exploratory, three-phase, mixed-methods approach, interpreted through intergroup communication theory. Phase one: convergent interviews explored perspectives of the communication experience in GDM care among new mothers (n = 13), hospital clinicians (n = 13) and general practitioners (n = 16). Phase two: a retrospective chart audit assessed current practice in postnatal discharge summaries of women (n = 86). Phase three: an online survey identified the preferences of general practitioners and hospital clinicians who provide maternity care in Queensland. Triangulation of the findings from the interviews, audit and surveys was used to clarify results and increase the robustness of the findings. RESULTS: Three themes: Seeking information, Written hospital discharge summary (discharge summary) and Clarity of follow-up requirements, provide direction for pragmatic strategies to promote follow-up. Practical recommendations include continued discussion about care with women from the point of GDM diagnosis into the postnatal period; discharge summaries that give primacy to diagnosis and ongoing treatment; and provision of explicit directions for recommended testing and timing. IMPLICATIONS: This research informs seven practical recommendations to help promote completion of recommended postnatal GDM follow-up.

Iron supplementation has minor effects on gut microbiota composition in overweight and obese women in early pregnancy.

Fe is an essential nutrient for many bacteria, and Fe supplementation has been reported to affect the composition of the gut microbiota in both Fe-deficient and Fe-replete individuals outside pregnancy. This study examined whether the dose of Fe in pregnancy multivitamin supplements affects the overall composition of the gut microbiota in overweight and obese pregnant women in early pregnancy. Women participating in the SPRING study with a faecal sample obtained at 16 weeks' gestation were included in this substudy. For each subject, the brand of multivitamin used was recorded. Faecal microbiome composition was assessed by 16S rRNA sequencing and analysed with the QIIME software suite. Dietary intake of Fe was assessed using a FFQ at 16 weeks' gestation. Women were grouped as receiving low (<60 mg/d, n 94) or high (≥60 mg/d; n 65) Fe supplementation. The median supplementary Fe intake in the low group was 10 (interquartile range (IQR) 5-10) v. 60 (IQR 60-60) mg/d in the high group (P<0·001). Dietary Fe intake did not differ between the groups (10·0 (IQR 7·4-13·3) v. 9·8 (IQR 8·2-13·2) mg/d). Fe supplementation did not significantly affect the composition of the faecal microbiome at any taxonomic level. Network analysis showed that the gut microbiota in the low Fe supplementation group had a higher predominance of SCFA producers. Pregnancy multivitamin Fe content has a minor effect on the overall composition of the gut microbiota of overweight and obese pregnant women at 16 weeks' gestation.

Women's use of herbal and alternative medicines for preconception care.

BACKGROUND: Use of complementary and alternative medicine (CAM), particularly herbal and alternative medicine supplements, for preconception care and fertility management is becoming increasingly common. AIMS: To determine the factors associated with the use of CAMs by women for preconception care. MATERIALS AND METHODS: 412 women who had visited an antenatal 'first visit' clinic situated at a Brisbane obstetric hospital or had visited a private ultrasound clinic in the same city for the purposes of a routinely indicated ultrasound scan in the first trimester were recruited into the study. Data were collected via a cross-sectional questionnaire. RESULTS: Complementary and alternative medicines (not including multivitamins) were used during preconception by 8.3% of women attending for obstetric care. Approximately half (55.8%) of women taking herbal and alternative medicines ceased these medications on discovery of their pregnancy, though fewer (17.4%) ceased taking multivitamin supplements. Baseline characteristics (age, education and income) are not significantly different between CAM users and those who did not take CAMs preconception. The results of statistical analyses showed that only visiting a practitioner to check for health (OR = 2.00; 95% CI: 1.33, 3.00) and trying to lose weight prior to pregnancy (OR = 1.53; 95% CI: 1.00, 2.36) were the key predictors for women using CAM during preconception. CONCLUSIONS: Women do consume CAMs to enhance preconception care to a certain extent, though CAM users remain in the minority. CAM users also tend to cease use once pregnant.

Probiotics and pregnancy.

Complications of pregnancy are associated with adverse outcomes for mother and baby in the short and long term. The gut microbiome has been identified as a key factor for maintaining health outside of pregnancy and could contribute to pregnancy complications. In addition, the vaginal and the recently revealed placental microbiome are altered in pregnancy and may play a role in pregnancy complications. Probiotic supplementation could help to regulate the unbalanced microflora composition observed in obesity and diabetes. Here, the impact of probiotic supplementation during pregnancy and infancy is reviewed. There are indications for a protective role in preeclampsia, gestational diabetes mellitus, vaginal infections, maternal and infant weight gain and allergic diseases. Large, well-designed randomised controlled clinical trials along with metagenomic analysis are needed to establish the role of probiotics in adverse pregnancy and infancy outcomes.

Barriers to addressing overweight and obesity before conception.

OBJECTIVE: To investigate the issues that confront women when addressing overweight and obesity before conception. DESIGN: Questionnaire-based study of 412 unselected women in early pregnancy. SETTING AND PARTICIPANTS: 255 women who attended a public, antenatal "first visit" clinic at a major urban obstetric hospital in Brisbane and 157 women who presented to a private obstetrician in Brisbane for a routine ultrasound scan during a 6-week period in 2006 were surveyed. MAIN OUTCOME MEASURES: Preconception health activities, prepregnancy body mass index (BMI), self-reported weight category, attempts to lose weight before pregnancy, and weight loss advice received before pregnancy. RESULTS: Folic acid supplementation was reported by 56% of participants, and 53% attended a preconception health check. Of women who provided details of height and prepregnancy weight, 30% were overweight or obese before pregnancy. However, 23 of 65 women with a BMI in the overweight range categorised themselves as normal weight (36%), and only 8 of 50 women with a BMI in the obese range categorised themselves as obese (16%). As BMI increased, more women reported trying to lose weight (P < 0.001) and reported receiving advice regarding weight loss (P < 0.001). Prepregnancy weight loss was reported by 52 of 115 overweight and obese women (45%). CONCLUSIONS: Potential barriers to addressing overweight and obesity before pregnancy include poor uptake of routine prepregnancy health activities, inaccurate self-categorisation of weight, unsuccessful weight loss attempts and inadequate advice regarding prepregnancy weight loss.