Catastrophic thinking: Is it the legacy of traumatic births? Midwives' experiences of shoulder dystocia complicated births.

BACKGROUND: Shoulder dystocia (SD) is considered one of the most traumatic birth experiences not only for women, but for clinicians involved as well. Adverse effects of birth trauma on the emotions and psyche of midwives have been well established. AIM: To explore the impact of SD, as a birth trauma, on midwives' orientation towards normal births and on their clinical practice and the factors which may deteriorate or improve the experience of SD. METHODS: In a qualitative descriptive study design, 25 in-depth interviews were undertaken with Australian midwives who had experienced at least one case of SD. Data were analysed thematically. FINDINGS: A total of four themes emerged: 1) an unforgettable birth; a wake-up call, 2) from passion to caution, 3) factors worsening the experience, and 4) factors soothing the experience. Fear, anxiety and doubt about their professional competence were the most common feelings experienced by midwives after SD. For many, the first exposure to SD left them contemplating their previous attitude towards normal birth. Disturbed orientation of normal birth shifted midwives towards hypervigilance in practice. Not having effective relationships with women and receiving poor support from colleagues were perceived to worsen the traumatic experience, whereas working in a midwifery continuity of care model and the sense of being appreciated improved midwives' experience after the trauma. CONCLUSION: Shoulder dystocia is a birth emergency that midwives will inevitably experience. Involvement in such births can potentially direct midwives towards a 'worst case scenario' mentality and affect the way they provide care for women in future.

Aromatherapy intervention on anxiety and pain during first stage labour in nulliparous women: a systematic review and meta-analysis.

This systematic review and meta-analysis aimed to critically evaluate and summarise all available evidence derived from randomised clinical trials (RCTs) regarding aromatherapy's effects on labour pain and anxiety relief. Literature search was performed in MEDLINE/PubMed, Cochrane library, Cochrane Central Register of Controlled Trials (CENTRAL) and Scopus since their respective inception to January 2019. Additionally, Google Scholar was also searched to explore citations of eligible final studies which were subsequently included in the systematic review. The search strategy used was: (pregnancy or pregnant or prenatal or antenatal or perinatal or maternal) AND (aromatherapy or essential oils or aroma therapy). Per inclusion and exclusion criteria established by the current study, nine RCTs were included in the systematic review. Results from the current study suggested that aromatherapy significantly decreased pain and anxiety in the first stage of labour.IMPACT STATEMENTWhat is already known on this subject? Several studies have shown aromatherapy's effectiveness in relieving pain and anxiety for hospitalised patients and on relieving nausea and vomiting for women during pregnancy. Some results have further indicated that aromatherapy was effective in facilitating episiotomy healing and in reducing pain, fatigue and distress. Aromatherapy was also found to play a role in improving maternal moods; reducing post-caesarean pain; and preventing or mitigating stress, anxiety and depression after childbirth. Though most non-pharmaceutical pain management options were considered non-invasive and presumably safe for mothers and their foetuses, their exact efficacies remained unclear due to a lack of high quality evidence.What the results of this study add? This systematic review and meta-analysis summarises all evidence derived from RCTs wherein aromatherapy was performed as a supportive analgesic method during labour. Results of this meta-analysis identified more credible evidence validating that aromatherapy could significantly decrease labour pain both in early active and late active phases.What the implications are of these findings for clinical practice and/or further research? Availability of credible evidence supporting aromatherapy's effectiveness on reducing physiological and psychological stress during pregnancy and childbirth would be useful, both theoretically and practically, for all stakeholders concerned, such as pregnant women, medicine and midwifery students, midwives, nurses, gynaecologists and health policymakers.

Key indicators influencing management of prolonged second stage labour by midwives in freestanding birth centres: Results from an ethnographic interview study.

PROBLEMS: Complications for newborns and postpartum clients in the hospital are more frequent after a prolonged second stage of labour. Midwives in community settings have little research to guide management in their settings. AIM: We explored how US birth centre midwives identify onset of second stage of labour and determine when to transfer clients to the hospital for prolonged second stage. METHODS: Ethnographic interviews of midwives with at least 2 years' experience in birth centres and participant observation of birth centre care. FINDINGS: We interviewed 21 midwives (18 CNMs, 3 CPMs/equivalent) from 18 birth centres in 11 US states, 45% with hospital practice privileges. Midwives relied on and engaged in embodied practice in evaluating each labour and making decisions concerning management of labour. Midwives considered time a useful but limited measure as a guiding factor in management. Though ideas of time and progress do play an important role in the decision-making process of midwives, their usefulness is limited due to the continual, multifactorial, and multisensory nature of the assessment. Relationship with the transfer hospital structured midwives' decision-making about transfers. DISCUSSION & CONCLUSION: These findings can inform future robust multivariate evaluation of factors, including but not limited to time, in guidelines for management of second stage of labour. Optimal management may require formal consideration of more than just time and parity. Our findings also suggest the need for evaluation of how structural issues involving hospital privileges for midwives and relationships between birth centre and hospital staff affect the well-being of childbearing families.

"I lost my happiness, I felt half dead and half alive" - a qualitative study of the long-term aftermath of obstetric near-miss in the urban district of Zanzibar, Tanzania.

BACKGROUND: This study aims to explore the stories of three women from Zanzibar, Tanzania, who survived life-threatening obstetric complications. Their narratives will increase understanding of the individual and community-level burden masked behind the statistics of maternal morbidity and mortality in Tanzania. In line with a recent systematic review of women-centred, qualitative maternal morbidity research, this study will contribute to guidance of local and global maternal health agendas. METHODS: This two-phased qualitative study was conducted in July-August 2017 and July-August 2018, and involved three key informants, who were recruited from a maternal near-miss cohort in May 2017 in Mnazi Mmoja Hospital, Zanzibar. The used methods were participant observation, interviews (informal, unstructured and semi-structured), participatory methods and focus group discussions. Data analysis relied primarily on grounded theory, leading to a theoretical model, which was validated repeatedly by the informants and within the study team. The findings were then positioned in the existing literature. Approval was granted by Zanzibar's Medical Ethical Research Committee (reference number: ZAMREC/0002/JUN/17). RESULTS: The impact of severe maternal morbidity was found to be multi-dimensional and to extend beyond hospital discharge and thus institutionalized care. Four key areas impacted by maternal morbidities emerged, namely (1) social, (2) sexual and reproductive, (3) psychological, and (4) economic well-being. CONCLUSIONS: This study showed how three women's lives and livelihoods were profoundly impacted by the severe obstetric complications they had survived, even up to 16 months later. These impacts took a toll on their physical, social, economic, sexual and psychological well-being, and affected family and community members alike. These findings advocate for a holistic, dignified, patient value-based approach to the necessary improvement of maternal health care in low-income settings. Furthermore, it emphasizes the need for strategies to be directed not only towards quality of care during pregnancy and delivery, but also towards support after obstetric complications.

The Effectiveness of Aromatherapy in the Management of Labor Pain and Anxiety: A Systematic Review.

BACKGROUND: Aromatherapy as an alternative and complementary medicine is a well-known method for reducing the symptoms of various physiological processes such as labor experience. The aim of this study was to systematically review the currently available evidences evaluating the use of aromatherapy for management of labor pain and anxiety. METHODS: In a systematic review, 5 databases (PubMed, SCOPUS, Web of Science, Google Scholar and Scientific Information Database [SID]) were searched, from database inception up to December 2019. Keywords used included (aromatherapy OR ""essential oil" OR "aroma*") AND (pain OR anxiety) AND (labor OR delivery). Using the Cochrane Collaboration's 'Risk of bias' method; the risk of bias in the included studies was evaluated. RESULTS: A total of 33 studies were verified to meet our inclusion criteria. Most of the included studies were conducted in Iran. Aromatherapy was applied using inhalation, massage, footbath, birthing pool, acupressure, and compress. The most popularly used essential oil in the studies was lavender (13 studies), either as a single essential oil or in a combination with other essential oils. Most of included studies confirmed the positive effect of aromatherapy in reducing labor pain and anxiety. CONCLUSION: The evidences from this study suggest that aromatherapy, as a complementary and alternative modality, can help in relieving maternal anxiety and pain during labor.

Integrated mental health screening for obstetric fistula patients in Mali: From evidence to policy.

BACKGROUND: Obstetric fistula significantly impacts women's mental health and well-being. Routine screening for mental health in fistula repair programs can be a gateway to link patients to services, and can produce routine data to inform programmatic investments. This study observed the integration of a mental health screening program into an obstetric fistula repair program in Mali, with two specific objectives: 1) to describe the social and mental health well-being of women presenting with obstetric fistulas in Mali, and 2) to document the impact of the mental health screening pilot on policy change in Mali. METHODS: Seven fistula repair campaigns were conducted between June 2016 and May 2017. All individuals presenting for fistula repair completed a mental health assessment at intake, including a depression screener (PHQ-9) and an assessment of psycho-social impacts of fistula. The depression screener was repeated three months following inpatient discharge. Findings were shared with stakeholders in Mali and impacts on policy were documented. RESULTS: Of 207 women who presented for fistula repair, 167 patients completed the mental health assessment at surgical intake, and 130 patients repeated the screener at 3-month follow-up. At intake, 36.5% of women had moderate or severe depression, decreasing to 16.9% at follow-up. The mean depression score differed significantly by timepoint (9.14 vs. 6.72, p <0.001). Results were shared in a report with stakeholders, and consultations with the Mali Ministry of Health. As a result of advocacy, mental health was a key component of Mali's National Fistula Prevention and Treatment Strategy (2018-2022). CONCLUSION: The high prevalence of depression in Malian fistula patients underscores a need for more robust mental health support for patients after surgery. Data on mental health from routine screening informs community reintegration strategies for individual patients, elevates the overall quality of care of fistula repair programs by addressing patients' holistic health needs, and contributes to evidence-informed decision-making and data-driven policy change within the larger health system.

Influence of non-pharmacological obstetric interventions on adverse outcomes of childbirth under regional analgesia.

Background We examined the influence of companionship and the use of complementary therapies on adverse outcomes in parturients under regional analgesia. Methods This study is a single-center retrospective cohort of 986 term pregnant women, and it was based on data from medical records (hospitalization period: November 2012-November 2018). The women were in the active phase of labor under regional analgesia. A statistical program was used to search for an association between companionship and the use of complementary therapies with sample data. Bi- and multivariate logistic regressions based on significant associations were used to analyze the potential intervening variables in the adverse outcomes. Results Models were constructed for each of the maternal adverse outcomes. Childbirth complications were significantly associated with complementary therapies [adjusted odds ratio (AOR) = 0.42; 95% confidence interval (CI) = 0.28-0.63; P < 0.001] and companionship (AOR = 0.36; 95% CI = 0.22-0.57; P < 0.001). Prolonged maternal hospitalization was significantly associated with companionship (AOR = 0.57; 95% CI = 0.36-0.92; P < 0.05). Unplanned cesarean section showed a significant association with complementary therapies (AOR = 0.05; 95% CI = 0.01-0.47; P < 0.01). Conclusion The likelihood of childbirth complications and prolonged maternal hospitalization is reduced by companionship, whereas the likelihood of childbirth complications and cesarean section rates is reduced by the use of complementary therapies.

Effectiveness of midwife-led brief counseling intervention on post-traumatic stress disorder, depression, and anxiety symptoms of women experiencing a traumatic childbirth: a randomized controlled trial.

BACKGROUND: This study investigated the effectiveness of brief midwife-led counseling based on Gamble and colleagues' approach in decreasing post-traumatic stress disorder, depression, and anxiety symptoms among a group of women who had experienced a traumatic childbirth. METHODS: From among 270 pregnant women screened to participate in the study, 90 women experienced a traumatic childbirth. They were randomly assigned into two groups: intervention (n = 45) and control group (n = 45). We did a face-to-face counseling session within 72 h after giving birth and a telephone counseling session four to 6 weeks after giving birth for the intervention group. The control group only received the postnatal routine care. The outcome measures were post-traumatic stress disorder, depression, and anxiety symptoms. RESULTS: At the three-month follow-up, the intervention group showed significantly higher improvement on post-traumatic stress disorder, depression, and anxiety symptoms compared to the control group. CONCLUSIONS: Gamble and colleagues' midwife-led brief counseling could be an effective approach to reduce psychological distress of women who have experienced a traumatic childbirth. TRIAL REGISTRATION NUMBER: IRCT201608285417N2, Date of Registration: 2/21/2017.

STRAWB2 (Stress and Wellbeing After Childbirth): a randomised controlled trial of targeted self-help materials to prevent post-traumatic stress disorder following childbirth.

OBJECTIVES: To test whether providing psychological self-help materials would significantly lower the incidence of post-traumatic stress disorder (PTSD) at 6-12 weeks postnatally. DESIGN: Open-label randomised controlled trial, with blinded outcome assessment. SETTING: Community midwifery services in two National Health Service (NHS) trusts in the North West. SAMPLE: A cohort of 2419 women receiving normal NHS postnatal care. METHODS: Midwives screened women for traumatic birth experience; 678 women who screened positively (28.1%) were randomly allocated to self-help with usual care (n = 336) or to usual care alone (n = 342). The self-help materials were a leaflet and online film designed to prevent the development of PTSD after trauma exposure through explaining how to manage early psychological responses. MAIN OUTCOME MEASURE: The primary outcome was a composite of diagnostic and subdiagnostic PTSD at 6-12 weeks postnatally using the gold-standard Clinician-Administered PTSD Scale (CAPS-5) interview. RESULTS: Of the 678 women correctly randomised plus the nine women randomised in error, 478 (70.5%) were followed up. Diagnostic or subdiagnostic PTSD rates at follow-up did not differ between groups who received self-help (26.7%, 65/243) or usual care alone (26.2%, 64/244) (intention-to-treat analysis: RR 1.02, 95% CI 0.68-1.53). Findings remained consistent in the per-protocol analysis (RR 1.04, 95% CI 0.85-1.27). Women viewed the materials very positively. There were no adverse effects. Health economic micro-costing indicated implementation would be very low cost. CONCLUSIONS: Many women experience a traumatic birth and risk developing PTSD, but self-help strategies without professional support are insufficient and should not be routinely introduced. TWEETABLE ABSTRACT: Self-help information alone does not reduce the number of women developing PTSD after a traumatic childbirth.

Left alone with the emotional surge - A qualitative study of midwives' and obstetricians' experiences of severe events on the labour ward.

BACKGROUND: Working on the labour ward entails being responsible for severe events during which a mother or baby may be injured or may die. Such events might affect decision-making, team-working, capacity for empathy, and patient safety. AIM: To explore midwives' and obstetricians' experiences, reactions and interpretations of being part of a severe event on the labour ward. DESIGN: A qualitative study using content analysis of in-depth interviews. PARTICIPANTS: Fourteen Swedish healthcare providers: seven midwives, and seven obstetricians. METHODS: Qualitative content analysis was used to describe and interpret the manifest and latent meaning of the interview text, while remaining close to participants' lived experiences. RESULTS: The overarching theme "Left alone with the emotional surge" was developed around three subthemes, supported by categories and subcategories. Professionals identified factors that had contributed to the course of events that made them perceive that they had been "acting within an illusory system of control and safety". When the severity of the situation became clear, "cognitive and emotional discordance was experienced", and, in the aftermath, the professionals described a "search for internal and external redemption" related to strong emotions of being left alone. CONCLUSIONS: Facing severe obstetric events entails exposure to emotionally demanding situations and hence joint vulnerability. Midwives and obstetricians described a sense of loneliness and perceptions of insecurity regarding the organisational system, managers and colleagues, following a complex, severe event with a woman or her baby during childbirth.

Secondary sphincter repair for anal incontinence following obstetric sphincter injury: functional outcome and quality of life at 18 years of follow-up.

AIM: Secondary sphincter repair has been the conventional management of anal incontinence (AI) when a structural defect in the sphincter is recognized. However, disappointing long-term results have contributed to a tendency towards an increasing use of alternative treatment methods. This study aimed to assess the long-term functional outcomes following a secondary sphincter repair in women with AI after obstetric sphincter injury. METHOD: This is a questionnaire study of women who underwent a secondary sphincter repair in Denmark between January 1990 and December 2005. Patients were identified through the Danish National Patient Registry. Functional outcomes were assessed by a self-administered questionnaire in 2010 and 2018. Primary outcomes were Wexner and St. Mark's scores. Impact on quality of life was assessed using the Fecal Incontinence Quality of Life Scale. RESULTS: Functional outcome was assessed in 370 women in 2010 and 255 women in 2018. At 18.3 [interquartile range (IQR 15.0-22.0)] years of follow-up, the mean ± SD Wexner score was 8.8 ± 4.8 and the mean St. Mark's score was 11.7 ± 5.0. Flatus incontinence was the most frequent symptom, reported by 97%. Incontinence for liquid and solid stools was reported by 75% and 54%, respectively. There were no significant changes in incontinence frequencies over time. Women with a Wexner score of ≥ 9 had a significantly lower quality of life score in all domains than did women with a Wexner score of < 9 (P < 0.001). CONCLUSION: At long-term follow-up, few patients are fully continent following a secondary sphincter repair. However, it appears that the functional results remain stable at very long-term follow-up.

Post - effects of obstetric fistula in Uganda; a case study of fistula survivors in KITOVU mission hospital (MASAKA), Uganda.

BACKGROUND: Obstetrical fistula (OF) is a public health challenge that is among the previously neglected components of maternal health in the developing world. The condition, which in the recent past has increasingly drawn more attention from the public, has a devastating impact on the health and wellbeing of both women and girls worldwide. The most common cause of obstetric fistula in developing countries is prolonged obstructed labor affecting approximately 2 million women and girls across Africa and Asia. The objective of this study was to examine the post-effects of fistula and reintegration strategies of fistula survivors in Uganda. METHODS: A descriptive case study design was used to collect data from women aged 15-49 years who had experienced OF and been successfully treated/repaired. Data collection was aided by in-depth interview guides designed for collecting qualitative data which was analyzed using thematic and content analysis. RESULTS: The study results showed that 45.6% were aged 18-24 years, 43% had only primary level education and 55.7% of the women were married. Fistula survivors continue to suffer from shame, rejection, isolation and stigma, trauma and disgrace among other effects even after successful repair/surgery. Some of the reintegration strategies for fistula survivors include; seeking for successful repair, remarriage and relocation from their parent communities to new environments. CONCLUSION: In addition to capacity building, changing attitudes and strengthening the health system, a comprehensive and holistic fistula care approach is required to facilitate the reintegration process and restoration of women dignity.

Effects of music intervention during caesarean delivery on anxiety and stress of the mother a controlled, randomised study.

BACKGROUND: Stress and anxiety during pregnancy and childbirth have negative consequences for both mother and child. There are indications that music has a positive effect in this situation. The present study investigates the influence of music during the caesarean on anxiety and stress of the expectant mother. METHODS: The SAMBA study is a single-centre, controlled, randomized study including 304 patients. Women in the intervention group heard music via loudspeakers from one of four self-selected genres. The control group had standard treatment without music. The caesarean was performed in regional Anesthesia. At admission, at skin incision, during skin suture and two hours after completion of surgery, different subjective (State-Trait Anxiety Inventory, visual analogue scale for anxiety) and objective parameters (salivary cortisol/amylase, heart rate, blood pressure) were collected. Mixed-factorial Analysis of variances as well as independent sample t-tests were applied for data analysis. RESULTS: At skin suture, significantly lower anxiety levels were reported in the intervention group regarding State anxiety (31.56 vs. 34.41; p = .004) and visual analogue scale for anxiety (1.27 vs. 1.76; p = .018). Two hours after surgery, the measured visual analogue scale for anxiety score in the intervention group was still significantly lower (0.69 vs. 1.04; p = .018). The objective parameters showed significant differences between the groups in salivary cortisol increase from admission to skin suture (12.29 vs. 16.61 nmol/L; p = .043), as well as systolic blood pressure (130.11 vs. 136.19 mmHg; p = .002) and heart rate (88.40 vs. 92.57/min; p = .049) at skin incision. CONCLUSIONS: Music during caesarean is an easy implementable and effective way of reducing stress and anxiety of the expectant mother. TRIAL REGISTRATION: German registry for clinical trials ( DRKS00007840 ). Registered 16/06/2015. Retrospectively registered.

The experiences of midwives and women during intrapartum transfer from one-to-one midwife-led birth environments to obstetric-led units.

OBJECTIVE: To explore the transition from midwifery one-to-one support in labour within a midwife-led birth environment to an obstetric-led unit from the perspectives of midwives and women. DESIGN: Ethnographic study. Data was collected from eleven transfers to an obstetric-led unit. The transfer process was observed for four women. Semi-structured interviews were completed following the births with eleven women and eleven midwives. Nine maternity records were also analysed. SETTING: An alongside midwife-led unit, freestanding midwife-led unit, women's homes in England. FINDINGS: Territorial behaviour was the main theme experienced by midwives when transferring women to obstetric-led units. Territorial behaviour manifested itself as a feeling of 'us versus them' behaviours, 'feeling under scrutiny' and being aware of 'conflicting ideologies'. For women there were four themes that had an impact on their experiences of transfer obstetric-led units including: (1) their midwife continuing the care on the labour ward, (2) having time to adjust to their new situation, (3) all staff introducing themselves and (4) not being separated from their baby for long periods of time. CONCLUSION AND IMPLICATIONS FOR PRACTICE: Transfer from a midwife-led birth environment to an obstetric-led unit is a stressful situation for midwives and women. This paper highlights how territorial behaviours impacted negatively for midwives during transfer to an obstetric-led unit. More research is required to understand territorial behaviours within the maternity services and how more respectful compassionate working relationships can be created. Additionally, from the perspective of women this paper highlights four aspects of care that positively impacted on the experiences of women and even helped them to build resilience to cope with the change of location, situation, medical interventions and new carers when transferring to an obstetric-led unit.

[Traumatic Birth: Recognition and Prevention]. / Traumatische Geburtsverläufe: Erkennen und Vermeiden.

A history of sexual as well as physical or emotional abuse may represent a high-risk factor for difficult pregnancies and birth processes, potentially yielding the development of postpartum posttraumatic stress disorder as well as impaired mother-child attachment. However, birth itself may also be experienced as primarily traumatic, i. e., without having had prior trauma experiences. Difficult and traumatic births may affect midwives and obstetricians, too. This article provides an overview of the prevalence and risk factors of traumatic childbirth as well as the course, consequences, and intervention possibilities.

A meta-ethnographic synthesis of midwives' and nurses' experiences of adverse labour and birth events.

INTRODUCTION: Health professionals are frequently exposed to traumatic events due to the nature of their work. While traumatic and adverse labour and birth events experienced by women are well researched, less attention has been given to midwives' and nurses' experiences of these events and the impact it has on their lives. AIMS AND OBJECTIVES: To undertake a meta-ethnographic study of midwives' and nurses' experiences of adverse labour and birth events. METHODS: Scopus, CINHAL PLUS, MEDLINE and PUBMED databases were searched using subject headings and keywords. The search was limited to papers published in peer-reviewed journals from 2004-October 2016. Quality appraisal was undertaken using the Critical Appraisal Skills Programme tool. INCLUSION CRITERIA: Papers had to be qualitative or have a substantial qualitative component. Studies were included if they primarily focused on midwives' or nurses' perspectives or experiences of complicated, traumatic or adverse labour and birth events. ANALYTIC STRATEGY: A meta-ethnographic approach was used incorporating methods of reciprocal translation guided by the work of Noblit and Hare (1988, Meta-Ethnography: Synthesizing qualitative studies (Vol. 11). Newbury Park: Sage publications). FINDINGS: Eleven qualitative studies were included in the final sample. Four major themes were (i) feeling the chaos; (ii) powerless, responsible and a failure; (iii) "It adds another scar to my soul"; and (iv) finding a way to deal with it. CONCLUSION: Midwives and nurses feel relatively unprepared when faced with a real-life labour and birth emergency event. While many of the midwives and nurses were traumatised by the experience, some were able to view their encounter as an opportunity to develop their emergency response skills. RELEVANCE TO CLINICAL PRACTICE: Witnessing and being involved in a complicated or adverse labour and birth event can be traumatic for nurses and midwives. Organisational and collegial support needs to be available to enable these health professionals to talk about their feelings and concerns.

Responses to birth trauma and prevalence of posttraumatic stress among Australian midwives.

BACKGROUND: Midwives frequently witness traumatic birth events. Little is known about responses to birth trauma and prevalence of posttraumatic stress among Australian midwives. AIM: To assess exposure to different types of birth trauma, peritraumatic reactions and prevalence of posttraumatic stress. METHODS: Members of the Australian College of Midwives completed an online survey. A standardised measure assessed posttraumatic stress symptoms. FINDINGS: More than two-thirds of midwives (67.2%) reported having witnessed a traumatic birth event that included interpersonal care-related trauma features. Midwives recalled strong emotions during or shortly after witnessing the traumatic birth event, such as feelings of horror (74.8%) and guilt (65.3%) about what happened to the woman. Midwives who witnessed birth trauma that included care-related features were significantly more likely to recall peritraumatic distress including feelings of horror (OR=3.89, 95% CI [2.71, 5.59]) and guilt (OR=1.90, 95% CI [1.36, 2.65]) than midwives who witnessed non-interpersonal birth trauma. 17% of midwives met criteria for probable posttraumatic stress disorder (95% CI [14.2, 20.0]). Witnessing abusive care was associated with more severe posttraumatic stress than other types of trauma. DISCUSSION: Witnessing care-related birth trauma was common. Midwives experience strong emotional reactions in response to witnessing birth trauma, in particular, care-related birth trauma. Almost one-fifth of midwives met criteria for probable posttraumatic stress disorder. CONCLUSION: Midwives carry a high psychological burden related to witnessing birth trauma. Posttraumatic stress should be acknowledged as an occupational stress for midwives. The incidence of traumatic birth events experienced by women and witnessed by midwives needs to be reduced.

'I've Changed My Mind', Mindfulness-Based Childbirth and Parenting (MBCP) for pregnant women with a high level of fear of childbirth and their partners: study protocol of the quasi-experimental controlled trial.

BACKGROUND: Approximately 25 % of pregnant women suffer from a high level of Fear of Childbirth (FoC), as assessed by the Wijma Delivery Expectancy Questionnaire (W-DEQ-A, score ≥66). FoC negatively affects pregnant women's mental health and adaptation to the perinatal period. Mindfulness-Based Childbirth and Parenting (MBCP) seems to be potentially effective in decreasing pregnancy-related anxiety and stress. We propose a theoretical model of Avoidance and Participation in Pregnancy, Birth and the Postpartum Period in order to explore FoC and to evaluate the underlying mechanisms of change of MBCP. METHODS/DESIGN: The 'I've Changed My Mind' study is a quasi-experimental controlled trial among 128 pregnant women (week 16-26) with a high level of FoC, and their partners. Women will be allocated to MBCP (intervention group) or to Fear of Childbirth Consultation (FoCC; comparison group). Primary outcomes are FoC, labour pain, and willingness to accept obstetrical interventions. Secondary outcomes are anxiety, depression, general stress, parental stress, quality of life, sleep quality, fatigue, satisfaction with childbirth, birth outcome, breastfeeding self-efficacy and cost-effectiveness. The total study duration for women is six months with four assessment waves: pre- and post-intervention, following the birth and closing the maternity leave period. DISCUSSION: Given the high prevalence and severe negative impact of FoC this study can be of major importance if statistically and clinically meaningful benefits are found. Among the strengths of this study are the clinical-based experimental design, the extensive cognitive-emotional and behavioural measurements in pregnant women and their partners during the entire perinatal period, and the representativeness of study sample as well as generalizability of the study's results. The complex and innovative measurements of FoC in this study are an important strength in clinical research on FoC not only in pregnant women but also in their partners. TRIAL REGISTRATION: Dutch Trial Register (NTR): NTR4302 , registration date the 3rd of December 2013.

Factors determining choice of delivery place among women of child bearing age in Dega Damot District, North West of Ethiopia: a community based cross- sectional study.

BACKGROUND: In the latest report of Ethiopia Demography and Health Survey (EDHS) 2011, the Maternal Mortality Ratio was estimated at 676/100,000 live births. Most of these deaths are preventable. Increasing the proportion of women who deliver in a health facility can be an important means in reducing maternal mortality in low-income settings including Ethiopia. We aimed to identify factors determining choice of delivery place among child bearing age women. METHOD: A community based cross sectional survey was conducted in Dega Damot District from April- May, 2014. Mixed methods were employed in the study. Multistage sampling method was used. The primary outcome variable for this study was women who delivered their most recent baby in a health facility. RESULT: Three hundred sixty one women who gave birth in the past 1 year were included in the study. The mean age of the respondents was 30.9 [SD ±6.006]. One hundred seven (29.6 %) of the respondents were in the age range of 25-29 years. In our study, the proportion of women assisted by skilled health workers during institutional delivery was 89.1 % followed by Health extension workers (8.0 %). Most women (87.4 %) who did not deliver in health facilities were assisted by families, friends or neighbors followed by Health extension workers (7.2 %), and traditional birth attendants (5.4 %), respectively. The qualitative data has described and gave an insight of the contributing factors that influence the women using the health institutions for delivery. These included: ANC attendance, Positive attitude of Health workers and complications during labor and delivery. The preference for a health facility delivery was largely due to the understanding that if complications occurred either during labor or delivery, this was the only place where they could be managed. CONCLUSION: The study revealed that women's institutional delivery service utilization in the study area is low. Based on these findings, improving the utilization of health facility for delivery through educating women and health promotion have been recommended. This would help reduce the complications and dangers that often characterized home-based, unsupervised delivery.