What bereaved parents want health care providers to know when their babies are stillborn: a community-based participatory study.

BACKGROUND: Bereaved parents experience higher rates of depressive and post-traumatic stress symptoms after the stillbirth of a baby than after live-birth. Yet, these effects remain underreported in the literature and, consequently, insufficiently addressed in health provider education and practice. We conducted a participatory based study to explore the experiences of grieving parents during their interaction with health care providers during and after the stillbirth of a baby. METHODS: This community-based participatory study utilized four focus groups comprised of twenty-seven bereaved parents (44% fathers). Bereaved parents conceptualized the study, participating at all stages of research, analyses, and drafting. Data were reduced into a main theme and subthemes, then broad-based member checked to ensure fidelity and nuances within themes. RESULTS: The major theme that emerged centered on provider acknowledgement of the baby as an irreplaceable individual. Subthemes reflected 1) acknowledgement of parenthood and grief, 2) recognition of the traumatic nature of stillbirth, and 3) acknowledgement of enduring grief coupled with access to support. It was important that providers realized how grief was experienced within health care and social support systems, concretized by their desire for long-term, specialized support. CONCLUSIONS: Both mothers and fathers feel that acknowledgement of their baby as an individual, their parenthood, and their enduring traumatic grief by healthcare providers are key elements required in the process of initiating immediate and ongoing care after the stillbirth of a baby.

Evaluation of a Patient Education Pamphlet for Women Considering Vaginal Birth After Cesarean.

We evaluated a patient education pamphlet on vaginal birth after cesarean (VBAC). Focus groups with 17 women in 4 communities involved a 5-item knowledge pretest and question on intention to plan VBAC, reading the pamphlet, a knowledge posttest, and a moderated discussion. Forming a preference for birth after cesarean was characterized by (a) consolidating information from social sources, (b) seeking certainty in your next birth, and (c) questioning your ability to have a vaginal birth. Participants preferred vaginal birth, but all feared the uncertainty of labor. Knowledge scores increased for all participants, but intentions to plan a VBAC did not change. Our findings may encourage the development of interventions to reduce women's fear of vaginal birth.

The Canadian birth place study: examining maternity care provider attitudes and interprofessional conflict around planned home birth.

BACKGROUND: Available birth settings have diversified in Canada since the integration of regulated midwifery. Midwives are required to offer eligible women choice of birth place; and 25-30% of midwifery clients plan home births. Canadian provincial health ministries have instituted reimbursement schema and regulatory guidelines to ensure access to midwives in all settings. Evidence from well-designed Canadian cohort studies demonstrate the safety and efficacy of midwife-attended home birth. However, national rates of planned home birth remain low, and many maternity providers do not support choice of birth place. METHODS: In this national, mixed-methods study, our team administered a cross-sectional survey, and developed a 17 item Provider Attitudes to Planned Home Birth Scale (PAPHB-m) to assess attitudes towards home birth among maternity providers. We entered care provider type into a linear regression model, with the PAPHB-m score as the outcome variable. Using Students' t tests and ANOVA for categorical variables and correlational analysis (Pearson's r) for continuous variables, we conducted provider-specific bivariate analyses of all socio-demographic, education, and practice variables (n=90) that were in both the midwife and physician surveys. RESULTS: Median favourability scores on the PAPHB-m scale were very low among obstetricians (33.0), moderately low for family physicians (38.0) and very high for midwives (80.0), and 84% of the variance in attitudes could be accounted for by care provider type. Amount of exposure to planned home birth during midwifery or medical education and practice was significantly associated with favourability scores. Concerns about perinatal loss and lawsuits, discomfort with inter-professional consultations, and preference for the familiarity of the hospital correlated with less favourable attitudes to home birth. Among all providers, favourability scores were linked to beliefs about the evidence on safety of home birth, and confidence in their own ability to manage obstetric emergencies at a home birth. CONCLUSIONS: Increasing the knowledge base among all maternity providers about planned home birth may increase favourability. Key learning competencies include criteria for birth site selection, management of obstetric emergencies at planned home births, critical appraisal of literature on safety of home birth, and inter-professional communication and collaboration when women are transferred from home to hospital.

How birth doulas help clients adapt to changes in circumstances, clinical care, and client preferences during labor.

This study examined how doulas adapt to challenges in client's labors. There were 104 Canadian and 92 American doulas who responded to a survey distributed at a doula conference. We report results from open-ended questions in which doulas describe how they manage changes deviating from the mother's birth plan and how they navigate differences of opinion between themselves and providers. Four themes emerged: giving nonjudgmental support, assisting informed decision making, acting as a facilitator, and issues with advocacy. Although 30% of doulas said that advocacy and information giving could result in conflict with providers, doulas reported working within their scope of practice and striving to be part of the team. Issues in doula responsibility and patient advocacy remain, and ongoing role clarification is needed.

Improved outcomes for elderly patients who received care on a transitional care unit.

OBJECTIVE: To determine whether providing elderly alternate level of care (ALC) patients with interdisciplinary care on a transitional care unit (TCU) achieves better clinical outcomes and lowers costs compared with providing them with standard hospital care. DESIGN: Before-and-after structured retrospective chart audit. SETTING: St Joseph's Hospital in Comox, BC. PARTICIPANTS: One hundred thirty-five consecutively admitted patients aged 70 years and older with ALC designation during 5-month periods before (n = 49) and after (n = 86) the opening of an on-site TCU. MAIN OUTCOME MEASURES: Length of stay, discharge disposition, complications of the acute and ALC portions of the patients' hospital stays, activities of daily living (mobility, transfers, and urinary continence), psychotropic medications and vitamin D prescriptions, and ALC patient care costs, as well as annual hospital savings, were examined. RESULTS: Among the 86 ALC patients receiving care during the postintervention period, 57 (66%) were admitted to the TCU; 29 of the 86 (34%) patients in the postintervention group received standard care (SC). All 86 ALC patients in the postintervention group were compared with the 49 preintervention ALC patients who received SC. Length of stay reduction occurred among the postintervention group during the acute portion of the hospital stay (14.0 days postintervention group vs 22.5 days preintervention group; P < .01). Discharge home or to an assisted-living facility increased among the postintervention group (30% postintervention group vs 12% preintervention group; P < .01). Patients' ability to transfer improved among the postintervention group (55% postintervention group vs 14% preintervention group; P < .01). At discharge, 48% of ALC patients in the postintervention group were able to transfer independently compared with 17% of ALC patients in the preintervention group. Hospital-acquired infections among the postintervention group decreased during the acute phase (14% postintervention group vs 33% preintervention group; P < .01) and in the ALC phase of hospital stay (16% postintervention group vs 31% preintervention group; P = .011). Antipsychotic prescriptions decreased among the postintervention group (45% postintervention group vs 66% preintervention group; P = .026). Despite greater use of rehabilitation services, TCU costs per patient were lower ($155/d postintervention period vs $273/d preintervention period). CONCLUSION: Elderly ALC patients experienced improvements in health and function at reduced cost after the creation of an interdisciplinary TCU, to which most of the nonpalliative ALC patients were transferred. Although all the postintervention ALC patients (those admitted to the TCU and those who received SC) were analyzed together, it is very likely that the greatest gains were made in the ALC patients who received care in the TCU.

The modified medical office assistant role in rural diabetes care.

INTRODUCTION: Diabetes care in Canada is usually provided in family practice offices, which may not have nurses to provide planned, proactive care as recommended by guidelines. The use of medical office assistants (MOAs) to do key tasks in diabetes care may improve the effectiveness of care and reduce costs. We sought to determine whether an expanded MOA role in a rural practice was beneficial to patients and the practice. METHODS: We systematically evaluated the provision of diabetes care as measured by key indicators, patient and provider satisfaction, and use of health care services. RESULTS: Involvement by MOAs improved adherence to selected aspects of guideline-based care, and patient and provider satisfaction was high. The actual outcomes of the surrogate markers measured in care and downstream use of acute care services appeared to be unchanged during this study. CONCLUSION: Use of MOAs to help provide team-based diabetes care in family practice resulted in improved performance of key indicators for diabetes care.

INTRODUCTION: Les soins aux personnes atteintes de diabète au Canada sont habituellement fournis par des pratiques de médecine familiale qui ne disposent pas nécessairement d'infirmières pour dispenser les soins proactifs planifiés recommandés par les lignes directrices. Le recours aux adjointes de bureau médical (ABM) pour effectuer des tâches clés en soin du diabète peut améliorer l'efficacité des soins et réduire les coûts. Nous avons cherché à déterminer si un rôle élargi pour les ABM dans une pratique rurale était bénéfique pour les patients et la pratique. MÉTHODES: Nous avons évalué systématiquement la prestation de soins aux personnes atteintes de diabète telle que mesurée par des indicateurs clés, par la satisfaction des patients et des fournisseurs et par l'utilisation des services de santé. RÉSULTATS: L'intervention des ABM a amélioré l'observation de certains aspects des soins basés sur les lignes directrices, et la satisfaction des patients et des fournisseurs était élevée. Les résultats concrets au niveau des marqueurs substituts mesurés pour les soins et l'utilisation en aval des services de soins actifs n'ont pas semblé changer au cours de l'étude. CONCLUSION: Le recours aux ABM pour aider à fournir les soins du diabète en équipe dans une pratique de médecine familiale a amélioré le rendement d'indicateurs clés en soin du diabète.

The University of British Columbia.

This study is one of a series of recent publications that attempt to sort out the impact of mode of birth on maternal and newborn outcome. The focus on elective cesarean section compared to planned vaginal birth beginning in spontaneous labor is an improved methodology over the earlier comparisons that failed to be able to separate planned from unplanned cesarean section or vaginal birth. The retrospective case control methodology based on birth record data that is employed in this research is similar to others, though with more respectable numbers. Most suffer from the problem of ascertainment difficulties, failure to stratify by parity, and of course, the unavailability of randomization, which some consider the ideal methodology.

Factors associated with differences in Canadian perinatal nurses' attitudes toward birth practices.

OBJECTIVE: To test whether demographic characteristics predict registered nurses' attitudes toward birth practices. DESIGN: A secondary analysis of a cross-sectional survey, the National Maternity Care Attitudes Survey. SETTING: A national survey conducted with health care providers providing maternity care in Canada. PARTICIPANTS: A convenience sample of 545 registered nurses. METHODS: Hierarchical regression analysis was used to examine three hypotheses about nurses' demographic differences in relationship to their attitudes toward birth practices. Attitude scales included acceptability of doulas, effects of routine electronic fetal monitoring, factors decreasing cesarean birth rates, the importance of vaginal birth for women, safety of birth, episiotomy, and epidural analgesia. RESULTS: Tertiary hospital-level of employment was associated with more positive attitudes toward epidural analgesia and less positive attitudes toward the importance of vaginal birth. Nurses working at a tertiary hospital were more likely to select an obstetrician for their own maternity care. Those who worked at a community hospital were more likely to select a family physician. Nurses' selection of an obstetrician was associated with less positive attitudes toward the safety of birth and importance of vaginal birth and more positive attitudes toward electronic fetal monitoring, episiotomy, and epidural analgesia. CONCLUSION: Nurses' attitudes may be influenced by exposure in their workplaces to predominant care providers' birth practices. Research examining the relationships between nurses' workplace exposures, attitudes, and practice behaviors is needed to develop understanding about how nurses contribute to rates of intervention in maternity care.

The Canadian Birth Place Study: describing maternity practice and providers' exposure to home birth.

OBJECTIVES: (1) to describe educational, practice, and personal experiences related to home birth practice among Canadian obstetricians, family physicians, and registered midwives; (2) to identify barriers to provision of planned home birth services, and (3) to examine inter-professional differences in attitudes towards planned home birth. DESIGN: the first phase of a mixed-methods study, a quantitative survey, comprised of 38 items eliciting demographic, education and practice data, and 48 items about attitudes towards planned home birth, was distributed electronically to all registered midwives (N=759) and obstetricians who provide maternity care (N=800), and a random sample of family physicians (n=3,000). SETTING: Canada. This national investigation was funded by the Canadian Institutes for Health Research. PARTICIPANTS: Canadian registered midwives (n=451), obstetricians (n=245), and family physicians (n=139). FINDINGS: almost all registered midwives had extensive educational and practice experiences with planned home birth, and most obstetricians and family physicians had minimal exposure. Attitudes among midwives and physicians towards home birth safety and advisability were significantly different. Physicians believed that home births are less safe than hospital births, while midwives did not agree. Both groups believed that their views were evidence-based. Midwives were the most comfortable with including planned home birth as an option when discussing choice of birth place with pregnant women. Both midwives and physicians expressed discomfort with inter-professional consultation related to planned home births. In addition, both family physicians and obstetricians reported discomfort with discussing home birth with their patients. A significant proportion of family physicians and obstetricians would have liked to attend a home birth as part of their education. CONCLUSIONS: the amount and type of education and exposure to planned home birth practice among maternity care providers were associated with attitudes towards home birth, comfort with discussing birth place options with women, and beliefs about safety. Barriers to home birth practice across professions were both logistical and philosophical. IMPLICATIONS FOR PRACTICE: formal mechanisms for midwifery and medical education programs to increase exposure to the theory and practice of planned home birth may facilitate evidence based informed choice of birth place, and increase comfort with integration of care across birth settings. An increased focus among learners and clinicians on reliable methods for assessing the quality of the evidence about birth place and maternal-newborn outcomes may be beneficial.

The tyranny of meta-analysis and the misuse of randomized controlled trials in maternity care.

Recent meta-analyses of key areas in maternity care have covered home birth and epidural analgesia. In each of these cases serious issues have arisen from the use of subjective inclusion and exclusion criteria, heterogeneity of included studies, and inclusion of studies that were conducted in settings that were not representative of usual maternity care. This latter flaw is especially notable for early epidural analgesia, where study environments with very low cesarean section rates are included. Such study settings lack external validity and have raised concerns about the political uses of meta-analysis. For a meta-analysis to be useful, the included studies must be broadly representative of the way that maternity care is carried out in usual birth environments.

Canadian care providers' and pregnant women's approaches to managing birth: minimizing risk while maximizing integrity.

We employed grounded theory to explain how Canadian pregnant women and care providers manage birth. The sample comprised 9 pregnant women and 56 intrapartum care providers (family doctors, midwives, nurses, obstetricians, and doulas [individuals providing labor support]). We collected data from 2008 to 2009, using focus groups that included care providers and pregnant women. Using concurrent data collection and analysis, we generated the core category: minimizing risk while maximizing integrity. Women and providers used strategies to minimize risk and maximize integrity, which included accepting or resisting recommendations for surveillance and recommendations for interventions, and plotting courses vs. letting events unfold. Strategies were influenced by evidence, relationships, and local health cultures, and led to feelings of weakness or strength, confidence or uncertainty, and differing power- and responsibility-sharing arrangements. The findings highlight difficulties resisting surveillance and interventions in a risk-adverse culture, and the need for attention to processes of giving birth.

Cesarean section on maternal request: a societal and professional failure and symptom of a much larger problem.

The scientific literature was silent about a relationship of pelvic floor, urinary, and fecal incontinence and sexual issues with mode of birth until 1993, when Sultan et al's impressive rectal ultrasound studies were published. They showed that perirectal fibers were damaged in many vaginal births, but not as a result of a cesarean section. These findings helped to pioneer a new area of research, ultimately leading to increasing support among health professionals and the public that maternal choice of cesarean delivery could be justified-even that maternal choice and autonomous decision-making trump other considerations, including evidence. A growing number of birth practitioners are choosing cesarean section for themselves-usually on the basis of concerns over pelvic floor, urinary incontinence, and sexual issues. Behind this choice is a training experience that focuses on the abnormal, interprets the literature through a pathological lens, and lacks sufficient opportunity to see normal childbirth. Cesarean section on maternal request is a complex issue based on fear and misinformation that is a symptom of a system needing reform, that is, a major change in community and professional education, governmental policy making, and creation of environments emphasizing the normal. Systemic change will require the training of obstetricians mainly as consultants and the education of a much larger cadre of midwives and family physicians who will provide care for most pregnant women in settings designed to facilitate the normal. Tinkering with the system will not work-it requires a complete refit.

Birth technology and maternal roles in birth: knowledge and attitudes of canadian women approaching childbirth for the first time.

OBJECTIVE: To describe Canadian nulliparous women's attitudes to birth technology and their roles in childbirth. METHODS: A large convenience sample of low-risk women expecting their first birth was recruited by posters in laboratories, at the offices of obstetricians, family physicians, and midwives, at prenatal classes, and through web-based advertising and invited to complete a paper or web-based questionnaire. RESULTS: Of the 1318 women completing the questionnaire, 95% did so via the web-based method; 13.2% of respondents were in the first trimester, 39.8% were in the second trimester, and 47.0% in the third. Overall, 42.6% were under the care of an obstetrician, 29.3% a family physician, and 28.1% a registered midwife. The sample included mainly well-educated, middle-class women. The planned place of giving birth ranged from home to hospital, and from rural centres to large city hospitals. Eighteen percent planned to engage a doula. Women attending obstetricians reported attitudes more favourable to the use of birth technology and less supportive of women's roles in their own delivery, regardless of the trimester in which the survey was completed. Those women attending midwives reported attitudes less favourable to the use of technology at delivery and more supportive of women's roles. Family practice patients' opinions fell between the other two groups. For eight of the questions, "I don't know" (IDK) responses exceeded 15%. These IDK responses were most frequent for questions regarding risks and benefits of epidural analgesia, Caesarean section, and episiotomy. Women in the care of midwives consistently used IDK options less frequently than those cared for by physicians. CONCLUSIONS: Regardless of the type of care provider they attended, many women reported uncertainty about the benefits and risks of common procedures used at childbirth. When grouped by the type of care provider, in all trimesters, women held different views across a range of childbirth issues, suggesting that the three groups of providers were caring for different populations with different attitudes and expectations.

A pilot for improving depression care on college campuses: results of the College Breakthrough Series-Depression (CBS-D) project.

OBJECTIVE: To implement a pilot quality improvement project for depression identification and treatment in college health. PARTICIPANTS: Eight college health center teams composed primarily of primary care and counseling service directors and clinicians. METHODS: Chronic (Collaborative) Care Model (CCM) used with standardized screening to identify, treat, and track depressed students for 12 weeks to monitor predetermined process and clinical outcomes. RESULTS: Of all students receiving primary medical care services between January 2007 and May 2008, 69% (n = 71,908) were screened for depression. A total of 801 depressed students were treated and tracked; most predetermined treatment process and clinical outcome targets were achieved. CONCLUSION: The CCM for depression shows promise for improving depression identification and care for college students.