Women and Birth - Articles in Press

Putting evidence into practice: A quality activity of proactive pain relief for postpartum perineal pain - Corrected Proof

J. Swain, H.G. Dahlen — 2012-05-10

Abstract: Background: Perineal pain associated with perineal trauma is often underestimated. Offering regular pain relief may be advantageous compared to waiting for women to request it. Changing clinical practice in a sustained way needs a whole of team approach.Aim: To reduce women's pain following perineal trauma in the first 48h following childbirth and to undertake this as multidisciplinary, quality activity.Methods: In November 2008 a questionnaire was distributed to 18 new mothers who had sustained perineal trauma during the birth in order to assess pain levels in the first 48h and to investigate pain management therapies used. Following this survey a multidisciplinary project team undertook a series of brainstorming sessions, reviewed the literature and undertook staff surveys to identify key factors impacting on women's perineal pain. A process of decision making led to education and support of women and staff. An evidence based guideline, which involved prescribing regular pain relief for women and offering an ice pack within 1h of giving birth was implemented, and a brochure was designed for women. A follow up questionnaire was distributed in June 2010 to 18 women and pain scores before and after the change in policy were compared.Results: Prior to the practice change in 2008 67% of the women surveyed rated their pain as ‘moderate’ to ‘a lot’ 48h following the birth. Following the change in practice and implementation of a new guideline a second survey in 2010 at 48h postpartum found 60% of women in the post intervention group rated their perineal pain as ‘a lot’ to ‘moderate’. There had been a 33% increase in women's use of pain relief options compared to the pre-intervention survey. The practice change was sustained and adopted by all the staff.Conclusion: By taking a multidisciplinary quality activity an effective practice change was facilitated that appeared to decrease women's perineal pain in the 48h following birth.

The experience of rural midwives in dual roles as nurse and midwife: “I’d prefer midwifery but I chose to live here” - Corrected Proof

Karen Yates, Jenny Kelly, David Lindsay, Kim Usher — 2012-04-19

Abstract: Objective: To explore and describe the experiences of working in the dual role as nurse and midwife in rural areas of far north Queensland, Australia.Method: The methodology was informed by Heidegger's interpretive phenomenological philosophy and data analysis was guided by van Manen's analytical approach. Data was generated by conversational interviews. Eight midwives working in a dual role as midwife and nurse were interviewed individually.Findings: Three themes were identified: Making choices between professional role and lifestyle: “Because I choose to live here”; Integration of maternity and general nursing: “All in together this fine weather” and: “That's part of working in a small place”.Conclusion: Participants recognized that in rural areas it is important to be a multi-skilled generalist; however they were concerned that midwifery skills could be eroded or even lost with the diminishing amounts of midwifery work available. Appropriate re-structuring of maternity services could provide better use of the midwifery workforce in rural centres, and reduce the current problems associated with transferring birthing mothers to larger facilities. Further research is needed to examine the extent to which the requirement to work in a dual, or multifaceted role is an impediment to the recruitment and retention of midwives to rural areas.

The commonalities and differences in health professionals’ views on home birth in Tasmania, Australia: A qualitative study - Corrected Proof

Ha Hoang, Quynh Le, Sue Kilpatrick, Madeleine Jona, Nidarshi Fernando — 2012-04-16

Abstract: Objectives: Home birth has attracted great controversy in the current context. There is a need for the public and health professionals to understand why maternity care providers have such different views on home birth, why they debate, what divides them into two opposite sides and if they have anything in common.Method: A qualitative study involving twenty maternity health providers in Tasmania was conducted. It used semi-structured interview which included closed and open-ended questions to provide opportunities for exploring emerging insights from the voices of the participants.Findings: Health practitioners who support home birth do so for three reasons. Firstly, women have the right to choose the place of birth. Secondly, home birth may be more cost effective compared to hospital birth. Thirdly, if home birth is not supported, some women might choose to have a free birth. Those who opposed home birth argue that complications could occur at childbirth and the transfer time is critical for women's and babies’ safety. These differences in opinions can be due to the differences in the training and philosophy of the maternity care providers. Despite the differing views on home births, health professionals share a common goal to protect the women and the newborns from unexpected situations during childbirth.Conclusion: This article provides some significant insights derived from the study of home birth from the maternity health professionals’ perspectives and could contribute to the enhancement of mutual understanding and collaboration of health professionals in their services to expectant mothers.

Antenatal group care in a Midwifery Group Practice—A midwife’ perspective - Corrected Proof

Belinda Jane Maier — 2012-03-30

Abstract: The following article describes a midwife's experience in the adaption of the CenteringPregnancy model into her own group practice to provide education and support to the women in her care. Using personal experience and feedback from women and midwifery students the author describes not only the process of group care in her work context but the apparent benefits to women, families’, midwifery students and herself. Antenatal group care was so successful for the author that it extended to postnatal group care and student group care, all well attended and sought after groups. This is an exciting and innovative way to provide care for women and families and the author encourages other midwives and group practices to consider how they can adapt and progress similar group care into their own practice.

The frequency and reasons for vaginal examinations in labour - Corrected Proof

Ashley Shepherd, Helen Cheyne — 2012-03-07

Summary: Objective: Vaginal examinations (VEs) in labour are a routine part of intrapartum care. Current UK guidelines recommend that VEs are offered to women at regular intervals of not less than 4h and only performed when justifiably necessary. However, justification may be interpreted differently by different midwives. This study aimed to investigate (i) the number of VEs performed in relation to length of labour and (ii) the reasons given by midwives for performing the VE.Methods: This study recruited a group of women (n=144) admitted in either spontaneous labour or for induction of labour from one NHS hospital in Scotland. The number of VEs performed, the reason provided by the midwife for its need and the length of labour were all recorded.Findings: The number of VEs carried out (mean 2.9, SD 1.5, range 1–7) increased as length of time in labour in hospital increased. Approximately half the sample (52%) had 3 or more VEs during labour. Almost 70% of women had more VEs than expected when the criteria of 4 hourly VEs was applied. The most common reason given by midwives for performing a VE was to assess labour progress and to assess the commencement of labour.Conclusions: Despite maternity care policy to limit interventions in normal labour, we found that a substantial number of women received more VEs than was consistent with adherence to guidelines. However, until further research is conducted to validate other measures of labour progress, the number of VEs undertaken during labour is unlikely to decrease.

Antenatal breast expression: Exploration and extent of teaching practices amongst International Board Certified Lactation Consultant midwives across Australia - Corrected Proof

Tegan Chapman, Jan Pincombe, Mary Harris, Jennifer Fereday — 2012-02-17

Summary: Background: Antenatal breast expression (ABE) has been taught in the past as breast preparation. Now some authorities are advising ABE and storage of colostrum for the feeding the newborn in the treatment and/or prevention of hypoglycaemia in the immediate postnatal period (thus avoiding the need for formula supplementation).The actual incidence of ABE teaching amongst International Board Certified Lactation Consultant (IBCLC) Midwives is unknown. Results of this study will provide valuable baseline data for future randomised controlled trials into this practice.Research question: What are the teaching practices surrounding ABE and the incidence of this type of teaching by IBCLC Midwives across Australia?Method: A descriptive cross-sectional Internet survey containing both quantitative and qualitative questions was sent to Australian IBCLC Midwives. Simple descriptive statistics was used to analyse quantitative data. Content analysis examined qualitative textual data of open-ended questions.Findings: Response rate was 27% (n=347/1269). 93% (n=322) of those responding to the survey had heard of ABE. 60% (n=134) actively teach the practice. Descriptive statistics and content analysis revealed marked differences in teaching practices amongst this specialised group of midwives.Conclusion: This study suggested a large proportion of lactation qualified midwife respondents were aware of ABE and some currently teach the skill. However, advice given to women during pregnancy varied substantially.

Evidence based workplace interventions to promote breastfeeding practices among Pakistani working mothers - Corrected Proof

Shela Akbar Ali Hirani, Rozina Karmaliani — 2012-02-06

Summary: Background and aim: Breastfeeding is an essential source of nutrition for young babies; however, it is challenging for employed mothers to continue breastfeeding with employment, especially if workplace support is minimal or missing. In Pakistan, from 1983 to 2008, the prevalence of breastfeeding at 6 months has decreased from 96% to 31%. In this region, workplace barriers have been reported as one of the reasons that result in early cessation of breastfeeding among working mothers. This paper aims at reviewing global literature to explore workplace interventions that can promote the breastfeeding practices among working mothers in Pakistan.Methods: A literature search of peer reviewed databases, including CINHAL (1980–2009), MEDLINE (1980–2009), Pub Med (1980–2009), Springer Link (1980–2008), and Cochrane Database of Systematic Reviews (3rd quarter, 2008), was undertaken. Considering the pre-set inclusion and exclusion criteria, out of more than 500 literature sources, 50 were shortlisted and reviewed.Results: A review of global literature revealed that in order to promote breastfeeding practices among employed mothers, the most powerful workplace interventions include: educating working mothers about management of breastfeeding with employment; enhancing employers’ awareness about benefits of breastfeeding accommodation at workplace; arranging physical facilities for lactating mothers (including privacy, childcare facilities, breast pumps, and breast milk storage facilities); providing job-flexibility to working mothers; and initiating mother friendly policies at workplace that support breastfeeding.Conclusion: In Pakistani workplace settings, where little attention is paid to sustain breastfeeding practices among working mothers, there is a need to initiate lactation support programmes. These programmes can be made effective by implementing composite interventions at the level of breastfeeding working mothers, employers, and workplace.

Pain relief for childbirth: The preferences of pregnant women, midwives and obstetricians - Corrected Proof

2012-01-27

Abstract: Objective: To compare the personal preferences of pregnant women, midwives and obstetricians regarding a range of physical, psychosocial and pharmacological methods of pain relief for childbirth.Method: Self-completed questionnaires were posted to a consecutive sample of 400 pregnant women booked-in to a large tertiary referral centre for maternity care in South Australia. A similar questionnaire was distributed to a national sample of 500 obstetricians as well as 425 midwives at: (1) the same hospital as the pregnant women, (2) an outer-metropolitan teaching hospital and (3) a district hospital. Eligible response rates were: pregnant women 31% (n=123), obstetricians 50% (n=242) and midwives 49% (n=210).Findings: Overall, midwives had a greater personal preference for most of the physical pain relief methods and obstetricians a greater personal preference for pharmacological methods than the other groups. Pregnant women's preferences were generally located between the two care provider groups, though somewhat closer to the midwives. All groups had the greatest preference for having a support person for labour with more than 90% of all participants wanting such support. The least preferred method for pregnant women was pethidine/morphine (14%).Conclusion: There are differences in the personal preferences of pregnant women, midwives and obstetricians regarding pain relief for childbirth. It is important that the pain relief methods available in maternity care settings reflect the informed preferences of pregnant women.

Cross sectional study of Australian midwives knowledge and use of sterile water injections for pain relief in labour - Corrected Proof

Nigel Lee, Lena B. Martensson, Sue Kildea — 2012-01-06

Abstract: Background: The effectiveness of sterile water injections (SWI) to relieve back pain in labour is supported by a number of randomised controlled trials. Although the procedure is available in a number of Australian maternity units, there is no information regarding the use of SWI by midwives, in terms of knowledge and availability, clinical application or technique used. Neither is there any data on midwives who do not use SWI nor the specific challengers and barriers encountered by midwives introducing SWI.Method: An invitation to participate in an online survey was emailed to 4700 members of the Australian College of Midwives (ACM) and 484 members of CRANAplus (Remote Health Organisation). Nine hundred and seventy midwives completed the survey (19%).Results: Four hundred and seven (42.5%) midwives currently used SWI in their practice and five hundred and fifty-one (57.5%) indicated they did not. Eighty-six percent (n=478/548) indicated they would consider using SWI and 90% (n=500/547) were interested in obtaining further information about SWI. The main reasons cited for not using SWI was the lack of a policy or guideline (n=271, 57.5%) and being unable to access workshops or resource material (n=68, 14.4%).Conclusion: This study indicates that SWI is not being used by the majority of midwives participating in the study, although there is a strong desire by midwives to learn about and explore its use. Greater access to information and workshops on SWI is highlighted. In response to the findings of this survey the authors are currently developing an online resource and training to support units to introduce SWI.

Detection and management of mood disorders in the maternity setting: The Australian Clinical Practice Guidelines - Corrected Proof

Marie-Paule V. Austin, Philippa Middleton, Nicole M. Reilly, Nicole J. Highet — 2012-01-04

Abstract: Background: Mood disorders arising in the perinatal period (conception to the first postnatal year), occur in up to 13% of women. The adverse impact of mood disorders on mother, infant and family with potential long-term consequences are well documented. There is a need for clear, evidence-based, guidelines for midwives and other maternity care providers.Aim: To describe the process undertaken to develop the Australian Clinical Practice Guidelines for Depression and Related Disorders in the Perinatal Period and to highlight the key recommendations and their implications for the maternity sector.Method: Using NHMRC criteria, a rigorous systematic literature review was undertaken synthesising the evidence used to formulate graded guideline recommendations. Where there was insufficient evidence for recommendations, Good Practice Points were formulated. These are based on lower quality evidence and/or expert consensus.Findings: The quality of the evidence was good in regards to the use of the Edinburgh Postnatal Depression Scale and psychological interventions, but limited as regards medication use and safety perinatally. Recommendations were made for staff training in psychosocial assessment; universal screening for depression across the perinatal period; and the use of evidence based psychological interventions for mild to moderate depression postnatally. Good Practice Points addressed the use of comprehensive psychosocial assessment – including risk to mother and infant, and consideration of the mother–infant interaction – and gave advice around the use and safety of psychotropic medications in pregnancy and breastfeeding. In contrast to their international counterparts, the Australian guidelines emphasize a more holistic, woman and family centred approach to the management of mental health and mood disorders in the perinatal setting.Conclusion: The development of these Guidelines is a first step in translating evidence into practice and providing Australian midwives and other maternity care providers with clear guidance on the psychosocial management of women and families.

Midwifery group practice and mode of birth - Corrected Proof

Michael Beckmann, Sue Kildea, Kristen Gibbons — 2011-12-14

Summary: Background: Midwifery-led models of care, specifically Midwifery Group Practices (MGPs), have been promoted as one way to address the increasing caesarean rate. Whilst women report a high level of satisfaction, and experience lower rates of induction and epidural analgesia, a Cochrane review reported no differences in mode of birth.Method: A retrospective cohort study was performed using routinely collected de-identified data of all term births between 2006 and 2010. Outcomes for 1545 women under MGP model were compared with 13,880 women cared for in all other models. Primary outcome measure was unassisted vaginal birth. Predictors investigated were model of care, induction and epidural analgesia. Both bivariate analysis and multivariate logistic regression analysis was undertaken (controlling for important confounders) with adjusted odds ratios (aOR) and 95% confidence intervals (CI) presented.Findings: Significant differences were demonstrated in the demographic and clinical characteristics of the groups. Compared with those in other models of care, women in MGP care had similar rates of induction but significantly fewer received epidural analgesia (28.4% vs 33.5%; p<0.001). There was no difference in the mode of birth. When adjusted for confounders, women in MGP care were no more or less likely to have an unassisted vaginal birth (aOR 1.07; 95% CI 0.92–1.24; p=0.397), birth assisted by instrument (aOR 1.02; 95% CI 0.86–1.21; p=0.852) or emergency caesarean section (aOR 0.89; 95% CI 0.74–1.06; p=0.193). However, in the subgroup of women who did not receive epidural analgesia, women in MGP care had an increased likelihood of an unassisted vaginal birth (aOR 1.29; 95% CI 1.06–1.58; p=0.013).Conclusion: Women in MGP care are no more or less likely to have an unassisted vaginal birth.

Perceptions of teen motherhood in Australian adolescent females: Life-line or lifederailment - Corrected Proof

Jennifer L. Smith, S. Rachel Skinner, Jennifer Fenwick — 2011-12-05

Abstract: Purpose: The findings presented in this paper describe the beliefs and attitudes of three different groups of adolescent females about teen motherhood. These were elicited from a larger analysis that explored and theorized contraceptive pathways in a sample of young Australian women.Methods: A purposive sample of females aged 14 to 19years was recruited from three distinct populations in the city of Perth, Western Australia: (1) never-pregnant; (2) pregnant-terminated; and (3) pregnant-continued. Grounded theory principles were used to analyze data generated from 69 semi-structured interviews conducted over a 21month period (2006–2008).Results: Two categories that described teenagers’ attitudes to pregnancy and motherhood were elicited from the analysis. These explained the level of priority that teenagers placed on using contraception and postponing the transition to parenthood. The category labeled ‘life derailment’ represented how those who had never had a pregnancy or had terminated a pregnancy constructed teen motherhood as potentially restricting their personal, career and social transition to adulthood. The alternative category, ‘life-line’, reflected how those who continued with their pregnancy perceived teen motherhood as a positive and transformative experience that fostered personal growth.Conclusions: The findings from this study contribute further insight into the complex nature of adolescent contraceptive use and pregnancy risk. The analysis has strengthened evidence of the critical role of self-perceptions of pregnancy and childbearing on teenagers’ fertility outcomes. It has also emphasized the broader life circumstances that shape these attitudes, intentions and related behavior. Strategies directed toward academic support and vocational skill development may broaden teenage girls’ perceived future options and achievement capacity, thus influencing key reproductive health outcomes.

Health belief dualism in the postnatal practices of rural Swazi women: An ethnographic account - Corrected Proof

Siphiwe B.P. Thwala, Eleanor Holroyd, Linda K. Jones — 2011-11-24

Abstract: Objective: This study explores and describes the values, beliefs, and practices of rural Swazi women regarding childbearing in the postpartum period.Method: A retrospective ethnographic research design was used. A snowballing sampling method was used to recruit fifteen participants. Face-to-face unstructured audio-taped interviews and field notes were utilised to gather data.Findings: Results showed that rural Swazi women held a dual health belief system of modern and traditional medicinal use; practiced lengthy periods of postpartum confinement; customarily gave regular enemas and traditional medicines to their babies; undertook the specific cultural practice of taking the baby to enyonini [a tree struck by lightening] to perform specific rituals; used self-prescribed pharmacy medicines; used both traditional and modern contraception; as well as practiced breastfeeding.Conclusion: Rural Swazi women observe modern health practices alongside traditional customary practices that are inherent to their health belief and value systems in the postnatal period. These customary beliefs and values underpin their birth practices postpartum. Recommendations include the need to consider including formal knowledge on cultural aspects of childbirth and postpartum care into midwifery education; a review of maternal care practices and policies to incorporate widely practised traditional elements including redressing the use of self-prescribed pharmacy medicines to ensure a higher level of safety.

Publicly-funded homebirth models in Australia - Corrected Proof

Christine Catling-Paull, Maralyn J. Foureur, Caroline S.E. Homer — 2011-11-21

Abstract: Background: Publicly-funded homebirth programs in Australia have been developed in the past decade mostly in isolation from each other and with limited published evaluations. There is also distinct lack of publicly available information about the development and characteristics of these programs. We instigated the National Publicly-funded Homebirth Consortium and conducted a preliminary survey of publicly-funded homebirth providers.Aim: To outline the development of publicly-funded homebirth models in Australia.Methods: Providers of publicly-funded homebirth programs in Australia were surveyed using an on-line survey in December 2010. Questions were about their development, use of policy and general operational issues. A descriptive analysis of the quantitative data and content analysis of the qualitative data was undertaken.Findings: In total, 12 programs were identified and 10 contributed data to this paper. The service providers reported extensive multidisciplinary consultation and careful planning during development. There was a lack of consistency in data collection throughout the publicly-funded homebirth programs due to different databases, definitions and the use of different guidelines.Discussion: Publicly-funded homebirth services followed different routes during their development, but essentially had safety and collaboration with stakeholders, including women and obstetricians, as central to their process.Conclusion: The National Publicly-funded Homebirth Consortium has facilitated a sharing of resources, processes of development and a linkage of homebirth services around the country. This analysis has provided information to assist future planning and developments in models of midwifery care. It is important that births of women booked to these programs are clearly identified when their data is incorporated into existing perinatal datasets.

Adolescent clients’ perceptions of maternity care in KwaZulu-Natal, South Africa - Corrected Proof

Ravani Duggan, Oluyinka Adejumo — 2011-11-21

Abstract: Background: Adolescent pregnancy continues to pose a challenge in both the developed and developing countries across the globe. Adolescent maternity clients (AMCs) have special needs and it is imperative to ensure that maternity services are able to respond appropriately to their needs.Objective or question: The purpose of this study was to explore adolescent maternity clients’ perceptions of maternity care and to identify important characteristics of an adolescent-friendly maternity service.Method: A qualitative approach was used and a total of 18 adolescent maternity clients, between 15 and 19 years of age, were purposively recruited from antenatal and postnatal services. Data were collected through individual and group interviews.Findings or discussion: Findings fell into 3 categories: AMC-health care provider (HCP) interaction; health care system; and health education. Participants wanted HCPs to be caring and supportive. Additionally HCPs should use appropriate interaction and body language to make adolescent clients feel respected and comfortable within the health care setting. Participants expected clinic waiting times to be decreased and measures to make the waiting rooms comfortable be put in place. AMCs also expressed the importance of having extra support during labour and birth. Health education was perceived as essential to their preparation for childbirth and parenting, with them having a role in peer education.Conclusion: The relationship between the HCP and AMC is essential to ensuring an optimal outcome for mother and baby. Careful consideration needs to be given to how the health care facility and system are set up in order to ensure that the AMC is comfortable within this context.

Choosing homebirth – The women's perspective - Corrected Proof

Maija-Riitta Jouhki — 2011-11-16

Summary: Objective: To describe the decision-making process and birth experience of ten women in Finland who had planned to have a home birth.Method: The data were collected by means of in-depth interviews in 2008 and were analyzed using qualitative content analysis.Results: Several reasons led to a decision to give birth at home. The main reasons were: previous birth experience, considering birth to be a natural process, increased autonomy, the home environment, intuition, the desire to choose the birth attendant, mistrust of the medical establishment and the opportunity to have the baby's siblings present at the birth. There were inhibiting and facilitating factors which influenced the women's decisions, and before making their decisions women sought out information about home birth. Home birth was an extremely positive experience and women highlighted their desire for the development of parent education to empower women in their preparations for birth. Full autonomy, the participation of family members, trust in one's ability to give birth and the absence of pharmacological pain relief were major contributors to the positive birth experience. The need for empowerment through parent education was highlighted in the interviews.Conclusion: To the women of this study home birth was very positive experience in which the autonomy was the important factor. According to this study maternity care services do not respond to women's individual wishes and services should be offer more alternatives and should be more empowering.

Influences on Australian breastfeeding practice - Corrected Proof

Virginia Thorley — 2011-10-26

The article by Thompson, Kildea, Barclay and Kruske raised a number of interesting points, one of which is the value of mother-to-mother support for breastfeeding women, especially after hospital discharge. For many women, contact with an experienced mother with a positive approach and the right support at the right time is all that is needed. Like the authors, I deplore the change from one lot of rigorous rules to another, such as the teaching of the cross-cradle hold as the one correct position for breastfeeding. The authors attribute much of the ‘medicalisation’ of breastfeeding to the International Board Certified Lactation Consultant (IBCLC) profession, yet the trend to exhort mothers to override their ‘instincts’ and follow prescriptive regimens involving timing and measurement preceded the advent of the new profession in 1985. Some of those at the forefront in advocating for a biologically appropriate approach to mammalian breastfeeding behaviours are, in fact, IBCLCs, for instance, Mobbs and Genna.

A review of midwifery education curriculum documents in Jordan - Corrected Proof

Insaf Shaban, Nicky Leap — 2011-09-28

Summary: Background: There is worldwide recognition that midwives are specialists in normal pregnancy, labour and birth and the postnatal period and that they should be educated to be primary providers of maternity care. In Jordan midwives currently have limited opportunities to fulfil this role. Since the mid-1980s, two public community colleges have offered three-year diploma midwifery education programmes in two major cities in Jordan. In 2002 the first and only four-year bachelor of midwifery education programme was established in one public university.Aim: A review to describe the design and content of midwifery education programmes in Jordan and address the question: Does the design of midwifery education programmes in Jordan encourage confidence that graduates will be competent to practise to the full capacity of the internationally defined role and scope of practice of the midwife and undertake the role of primary maternity care providers for women with low-risk pregnancies?Design: A review of Jordanian midwifery education curriculum documents was undertaken using information and documents provided by midwifery programme coordinators.Participants: Programme coordinators in all institutions in Jordan providing midwifery education programmes.Findings: The curriculum documents reflected a medical model, with an emphasis on illness and intervention rather than preparation for the internationally defined full role and scope of practice of the midwife.Implications for practice: This study provides a profile of midwifery education curriculum documents in Jordan with recommendations for changes that would position midwives as potential primary maternity care providers for women in Jordan who have uncomplicated pregnancies.

Anxiety and fear of childbirth as predictors of postnatal depression in nulliparous women - Corrected Proof

Zahra Alipour, Minoor Lamyian, Ebrahim Hajizadeh — 2011-09-28

Abstract: Background and purpose: Perinatal mental health problems have been studied in more than 90% of high income countries but this information is available only for 10% of low and middle income countries. A study on the relationship between anxiety during pregnancy and postpartum depression has not been performed in Iran. This prospective study aimed to investigate whether anxiety and fear of childbirth during pregnancy is an independent predictor of postpartum depressive symptoms.Methods: In this prospective longitudinal study participants were 160 women with a gestational age of 28–30 weeks from 10 prenatal care clinics in Qom, Iran. Subjects were interviewed and the State-Trait Anxiety Inventory (STAI) and Childbirth Attitudes Questionnaire (CAQ) were completed at 28 and 38 weeks of gestation. They were followed up 45 days and 3 months after childbirth. Postpartum depression was defined as a score≥13 on the Edinburgh Postpartum Depression Scale (EPDS).Results: Antenatal state anxiety (odds ratio [OR]=3.2; P=0.002 and OR=2.91; P=0.007 at 28 and 38 weeks of gestation, respectively) and trait anxiety (OR=3.33; P=0.001 and OR=3.30; P=0.003 at 28 and 38 weeks of gestation, respectively) increased the risk of postpartum depression 45 days after birth (P<0.05). Likewise, the presence of antenatal state and trait anxiety at 28 and 38 weeks of gestation significantly increased the risk of postpartum depression during the first three months after childbirth (P<0.05). On the contrary, prenatal fear of childbirth was not a significant predictor of postpartum depression symptoms (P>0.05).Conclusions: The findings from this study suggest that antenatal state and trait anxiety, assessed by interview, is an important predictor of postpartum depression. Therefore, it should be routinely screened in order to develop specific preventive interventions.

Managing women with acute physiological deterioration: Student midwives performance in a simulated setting - Corrected Proof

2011-09-23

Abstract: Objective: Midwives’ ability to manage maternal deterioration and ‘failure to rescue’ are of concern with questions over knowledge, clinical skills and the implications for maternal morbidity and, mortality rates. In a simulated setting our objective was to assess student midwives’ ability to assess, and manage maternal deterioration using measures of knowledge, situation awareness and skill, performance.Methods: An exploratory quantitative analysis of student performance based upon performance, ratings derived from knowledge tests and observational ratings. During 2010 thirty-five student, midwives attended a simulation laboratory completing a knowledge questionnaire and two video, recorded simulated scenarios. Patient actresses wearing a ‘birthing suit’ simulated deteriorating, women with post-partum and ante-partum haemorrhage (PPH and APH). Situation awareness was, measured at the end of each scenario. Applicable descriptive and inferential statistical tests were, applied to the data.Findings: The mean total knowledge score was 75% (range 46–91%) with low skill performance, means for both scenarios 54% (range 39–70%). There was no difference in performance between the scenarios, however performance of key observations decreased as the women deteriorated; with significant reductions in key vital signs such as blood pressure and blood loss measurements. Situation, awareness scores were also low (54%) with awareness decreasing significantly (t(32)=2.247, p=0.032), in the second and more difficult APH scenario.Conclusion: Whilst knowledge levels were generally good, skills were generally poor and decreased as the women deteriorated. Such failures to apply knowledge in emergency stressful situations may be resolved by repetitive high stakes and high fidelity simulation.

A review of midwifery in Mongolia utilising the ‘Strengthening Midwifery Toolkit’ - Corrected Proof

Sue Kildea, Margareta Larsson, Salik Govind — 2011-09-19

Summary: Objective: The World Health Organization (WHO) developed the ‘Strengthening Midwifery Toolkit’ in response to an international emphasis on increasing midwifery's role in providing maternal newborn health services. It was used to assist a review of midwifery in Mongolia.Method: A rapid situational assessment included site visits to eight health facilities and four educational institutions resulting in 30 key informant interviews and six focus group discussions (67 midwives and students). A desk review of pertinent documents (n=19) was undertaken. Data collected included assessments of: midwife competency (n=96), scope of practice (n=2), health facilities (n=8), educational institutions (n=4), legislation and regulation (n=1), and midwifery (n=4) Feldsher-Nurse (n=4) and Bachelor-Nurse (n=1) curricula.Findings: Stakeholders in Mongolia are committed to strengthening midwifery across the country to better align with international standards. This requires: a long-term investment in reorientating the health workforce and educational institutions, regulatory changes, educational investment, job description changes which will impact on other maternal newborn health service providers. Additional support and incentives for providers in rural and remote areas is needed and investment in health facilities to enable appropriate infection control; and adequate provision of essential equipment and drugs, are important strategies needed to protect staff. Maternity emergency training is required across the country.Conclusion: The Midwifery Toolkit was adapted to suit the local context and provided an excellent framework for this review.

Addressing obesity in pregnancy: The design and feasibility of an innovative intervention in NSW, Australia - Corrected Proof

2011-09-19

Abstract: Objective: Obesity amongst women of child bearing age is increasing at an unprecedented, rate throughout the Western world. This paper describes the design of an innovative, collaborative, antenatal intervention that aims to assist women to manage their weight during pregnancy and, presents aspects of the programme evaluation.Data sources/study setting: The programme was introduced at two sites, one in South East Sydney and, the other on the Central North Coast of NSW. Data were drawn from both sites and pooled for analysis.Study design: This evaluation used mixed methods drawing on qualitative and quantitative data.Data collection methods: Focus groups were held with staff in the antenatal clinic, who were, responsible for recruiting to the new service. Members of staff were also asked to record BMI for all women offered the service and using a simple questionnaire, record the reasons women gave for declining the new service.Principle findings: The recruitment rate to the new service was 35% though this result should be treated with caution. Those women with a BMI of >35 were twice as likely to elect to participate in the new service as women with a BMI of less than 35. Focus groups with midwives in the antenatal clinic responsible for recruitment identified three themes impacting on recruitment to the service; ‘finding the words’, ‘acknowledging challenges’ and ‘midwives’ knowledge’.Conclusions: Antenatal clinic midwives were unprepared for talking to women about their weight. Increasing the confidence and skills of staff in offering service innovations to eligible women is a major challenge to be met if new models of care are to be successful in addressing overweight and obesity in pregnancy.

Women's knowledge of options for birth after Caesarean Section - Corrected Proof

Meiman M. Chen, Heather Hancock — 2011-09-07

Abstract: Objective: In Australia, the Caesarean Section rate has risen from 21.8% to 31.1% (2010) in a decade; in South Australia the rate was 32.2% in 2009. Caesarean Section is a life saving intervention in certain circumstances, but also a major surgical procedure with potential adverse effects on both mother and baby. The aim of this study was to ascertain the determinants of knowledge regarding options for subsequent birth in women who have experienced a previous Caesarean Section with a live baby.Method: A sample of 33 women in South Australia who had a previous Caesarean Section were surveyed to assess their awareness of birth options and their advantages versus disadvantages as well as the possible factors influencing their information gathering and decision-making on birth options for their subsequent pregnancy.Findings: Most women perceived Caesarean Section to be major surgery but 69.6% were not aware that babies might have problems with breastfeeding, 60.6% did not know the rarity of uterine rupture during labour and/or birth and 48.5% were not aware that a caesarean may involve any complications for the baby at or after birth.Conclusion: Women's knowledge deficits relating to risks and benefits of birth options after previous caesarean can constrain them as most women chose caesarean rather than normal birth in their subsequent pregnancy.

“Bouncing back”: How Australia's leading women's magazines portray the postpartum ‘body’ - Corrected Proof

Heike Roth, Caroline Homer, Jennifer Fenwick — 2011-09-07

Summary: Purpose: To examine how the Australian media portrays the childbearing body through the use of celebrity stories in women's magazines. The study aimed to provide insight into socially constructed factors that might influence women's body image and expectations during pregnancy and the early postnatal period.Method: Media content analysis was used to analyse 25 celebrity stories about the childbearing postnatal body (images and texts) collected from Australia's three leading women's magazines between January and June 2009 (n=58).Findings: A variety of persuasive textual and visual messages were elicited. The major theme representing how the postnatal body was constructed was labelled ‘Bouncing back’; the focus of this paper. The social messages inherent in the magazine stories were that women need to strive towards regaining a pre-pregnant body shape with the same effort one would employ when recovering from an illness. Three specific sub-themes that promoted weight loss were identified. These were labelled ‘Racing to bounce back’, ‘Breastfeeding to bounce back’ and ‘Pretending to bounce back’. A fourth sub-theme, ‘Refusing to bounce back: Celebrating my new body’, grouped together stories about celebrities who appeared to embrace their changed, but healthy, postnatal body.Conclusions: The study highlighted the expectations of the postpartum body in relation to speedy return to the pre-pregnant state. Understanding how these portrayals may contribute to women's own body image and expectations in the early postpartum period may better assist maternity health care providers to engage with women in meaningful discussions about this important time in their lives and challenge notions of ideal body types. Assisting women to accept and nurture themselves and have confidence in their ability as a new parent is a crucial element of quality maternity service provision.

Women's perceptions of their healthcare experience when they choose not to breastfeed - Corrected Proof

Lisa A. Wirihana, Alan Barnard — 2011-09-07

Abstract: Research question: How do women who choose not to breastfeed perceive their healthcare experience?Method: This qualitative research study used a phenomenographic approach to explore the healthcare experience of women who do not breastfeed. Seven women were interviewed about their healthcare experience relating to their choice of feeding, approximately 4weeks after giving birth. Six conceptions were identified and an outcome space was developed to demonstrate the relationships and meaning of the conceptions in a visual format.Findings: There were five unmet needs identified by the participants during this study. These needs included equity, self sufficiency, support, education and the need not to feel pressured.Conclusion: Women in this study who chose not to breastfeed identified important areas where they felt that their needs were not met. In keeping with the Code of Ethics for Nurses and Midwives, the identified needs of women who do not breastfeed must be addressed in a caring, compassionate and just manner. The care and education of women who formula feed should be of the highest standard possible, even if the choice not to breastfeed is not the preferred choice of healthcare professionals.

Reviewing and reflecting on practice: The midwives experiences of credentialling - Corrected Proof

Rachel Smith, Patricia Brodie, Caroline S.E. Homer — 2011-09-07

Abstract: Research question: What are the experiences of midwives working in midwifery-led models of care in NSW who undertake the credentialling process?Background: In 2005, the NSW Health Department issued a directive requiring midwives who worked in midwifery-led models of care to undergo a process known as credentialling. Credentialling involved a four-step process: self-assessment, face-to-face panel review of midwifery practice, assessment of emergency management skills and discussion of a case study from practice.Method: A descriptive exploratory study examined the experiences of the midwives who undertook the credentialling process in NSW. Data were collected through in-depth, semi-structured interviews with 12 midwives who had experienced credentialling and analysed using descriptive and thematic analysis.Findings: The themes were preparing for credentialling; doing credentialling; achieving credentialling; valuing credentialling; and, improving credentialling. Initially, the midwives were self-focused in their understanding and impressions of the value of credentialling. There were a number of contentions including seeing credentialling as another ‘hoop to jump through’ or a need to ‘tick the box’ and not as a framework for practice. Some viewed it as a necessary move to increase professionalism and facilitate practice review. Others felt they were being unfairly targeted as not all midwives were expected to undertake it. The midwives were cognisant of the need for a process that encouraged responsibility for ongoing professional development and continuing competence and believed the process would be useful in promoting deeper reflection on practice.Implications for practice: Credentialling was recognised as being valuable for all midwives to undertake as it encourages both a review of, and reflection on, practice. The process has further developed into Midwifery Practice Review (MPR) and is administered by the national professional association for midwifery.

Factors that may influence midwives work-related stress and burnout - Corrected Proof

Lyndall Mollart, Virginia M. Skinner, Carol Newing, Maralyn Foureur — 2011-09-02

Abstract: Research question: To determine the incidence and level of work-related stress and burnout in midwives and contributing and protective demographic factors that may influence those levels.Participants and method: All registered midwives (152) working in two public hospital maternity units within the same health service district in NSW completed the Maslach Burnout Inventory Human Services Survey and a demographic survey including care model, shift work, lifestyle data and exercise level.Findings: There was a response rate of 36.8% with 56 (56/152) midwives completing the surveys. Almost two thirds (60.7%) of midwives in this sample experienced moderate to high levels of emotional exhaustion, a third (30.3%) scoring low personal accomplishment and a third (30.3%) experiencing depersonalization related to burnout. Significant differences were found among groups of midwives according to years in the profession, shifts worked, how many women with multiple psychosocial issues were included in the midwife's workload and the midwife's uptake of physical exercise. Those midwives who had spent longer in the profession and exercised scored low burnout levels.Conclusion: The impact of years in the profession, shifts worked, how many women with multiple psychosocial issues were included in their workload and the midwife's level of exercise significantly affected how these midwives dealt with burnout and provided care for women. As the response rate was low, and the study cannot be generalised to the entire midwifery workforce but provides important insights for further research. Understanding factors related to burnout can benefit health care institutions financially and in terms of human costs, especially in view of consistent international shortages of midwives.

Is Asian ethnicity an independent risk factor for severe perineal trauma in childbirth? A systematic review of the literature - Corrected Proof

Janet Wheeler, Deborah Davis, Margaret Fry, Pat Brodie, Caroline S.E. Homer — 2011-08-31

Abstract: Objective: To undertake a systematic review of the literature to determine whether Asian ethnicity is an independent risk factor for severe perineal trauma in childbirth.Method: Ovid Medline, CINAHL, and Cochrane databases published in English were used to identify appropriate research articles from 2000 to 2010, using relevant terms in a variety of combinations. All articles included in this systematic review were assessed using the Critical Appraisal Skills Programme (CASP) ‘making sense of evidence’ tools.Findings: Asian ethnicity does not appear to be a risk factor for severe perineal trauma for women living in Asia. In contrast, studies conducted in some Western countries have identified Asian ethnicity as a risk factor for severe perineal trauma. It is unknown why (in some situations) Asian women are more vulnerable to this birth complication. The lack of an international standard definition for the term Asian further undermines clarification of this issue. Nevertheless, there is an urgent need to explore why Asian women are reported to be significantly at risk for severe perineal trauma in some Western countries.Conclusion: Current research on this topic is confusing and conflicting. Further research is urgently required to explore why Asian women are at risk for severe perineal trauma in some birth settings.

Developing a Core Competency Model and Educational Framework for Primary Maternity Services: A national consensus approach - Corrected Proof

2011-08-19

Abstract: Background: An appropriately educated and competent workforce is crucial to an effective health care system. The National Health Workforce Taskforce (now Health Workforce Australia) and the Maternity Services Inter-Jurisdictional Committee funded a project to develop Core Competencies and Educational Framework for Primary Maternity Services in Australia. These competencies recognise the interdisciplinary nature of maternity care in Australia where care is provided by general practitioners, obstetricians and midwives as well as other professionals.Participants: Key stakeholders from professional organisations and providers of services related to maternity care and consumers of services.Methods: A national consensus approach was undertaken using consultation processes with a Steering Committee, a wider Reference Group and public consultation.Findings: A national Core Competencies and Educational Framework for Primary Maternity Services in Australia was developed through an iterative process with a range of key stakeholders. There are a number of strategies that may assist in the integration of these into primary maternity service provider professional groups’ education and practice.Conclusions: The Core Competencies and Educational Framework are based on an interprofessional approach to learning and primary maternity service practice. They have sought to value professional expertise and stimulate awareness and respect for the roles of all primary maternity service providers. The competencies and framework described in this paper are now a critical component of Australian maternity services as they are included in actions in the newly released National Maternity Services Plan and thus have relevance for all providers of Australian maternity services.

A provoking choice—Swedish women's experiences of reactions to their plans to give birth at home - Corrected Proof

Ingela Sjöblom, Ewa Idvall, Ingela Rådestad, Helena Lindgren — 2011-08-10

Summary: Objective: The home birth rate in Sweden is less than 1 in 1000, and home birth is not included within the health care system. This study describes women's experiences concerning reactions to their decision to give birth at home.Design and setting: A nationwide survey (SHE – Swedish Homebirth Experience) in Sweden was conducted between 1992 and 2005 whereas 735 women had given birth to 1038 children. Of 1038 questionnaires 1025 were returned.Measurements: In the questionnaires an open-ended question asked women to report their experience of reactions to their decision to give birth at home The question was answered by 594 women, and data were analysed using content analysis.Findings: The analysis yielded one overarching theme; “To be faced with fear for life and death” including being exposed to reactions about risks. This describes attitudes of professionals and family towards life and death and suggests perceptions of risk and fear of unexpected events. Four main categories were identified; Seen as an irresponsible person, Met with emotional arguments, Exposed to persuasion and Alienation.Conclusion: Women who plan for a home birth were confronted with negative attitudes and persuasion to make them change their mind. This made them feel alienated, and they searched for support among like-minded. Negative attitudes from health care professionals may erode their confidence in conventional health services and turn them towards other options.Implication for practice: Women who want to give birth at home should be given evidence-based information about risks and benefits. Enhanced knowledge among public and professionals about home births would improve the options for respectful encounters.

Self reported fear of childbirth and its association with women's birth experience and mode of delivery: A longitudinal population-based study - Corrected Proof

Christina Nilsson, Ingela Lundgren, Annika Karlström, Ingegerd Hildingsson — 2011-07-18

Abstract: Objective: To explore fear of childbirth (FOC) during pregnancy and one year after birth and its association to birth experience and mode of delivery.Design: A longitudinal population-based study.Population: Pregnant women who were listed for a routine ultrasound at three hospitals in the middle-north part of Sweden.Method: Differences between women who reported FOC and who did not were calculated using risk ratios with a 95% confidence interval. In order to explain which factors were most strongly associated to suffer from FOC during pregnancy and one year after childbirth, multivariate logistic regression analyses were used.Results: FOC during pregnancy in multiparous women was associated with a previous negative birth experience (RR 5.1, CI 2.5–10.4) and a previous emergency caesarean section (RR 2.5, CI 1.2–5.4). Associated factors for FOC one year after childbirth were: a negative birth experience (RR 10.3, CI 5.1–20.7), fear of childbirth during pregnancy (RR 7.1, CI 4.4–11.7), emergency caesarean section (RR 2.4, CI 1.2–4.5) and primiparity (RR 1.9, CI 1.2–3.1).Conclusion: FOC was associated with negative birth experiences. Women still perceived the birth experience as negative a year after the event. Women's perception of the overall birth experience as negative seems to be more important for explaining subsequent FOC than mode of delivery. Maternity care should focus on women's experiences of childbirth. Staff at antenatal clinics should ask multiparous women about their previous experience of childbirth. So that FOC is minimized, research on factors that create a positive birth experience for women is required.

The Antenatal Risk Questionnaire (ANRQ): Acceptability and use for psychosocial risk assessment in the maternity setting - Corrected Proof

2011-07-18

Summary: Objectives: To assess the value of the Antenatal Risk Questionnaire (ANRQ) as a predictor of postnatal depression, to evaluate its acceptability to pregnant women and midwives, and to consider its use as part of a model for integrated psychosocial risk assessment in the antenatal setting.Method: This paper further analysed published data from the Pregnancy Risk Questionnaire in a sample of 1196 women. We extracted 12 items from the original 23 item Pregnancy Risk Questionnaire to assess how the shorter ANRQ would perform, and undertook the analysis in the subset who were administered the Composite International Diagnostic Interview (CIDI) at 2 or 4 months postpartum to assess for major depression (N=276). We also sampled a subset of pregnant participants (N=378) and midwives (N=44) to assess the tool's acceptability to these groups respectively.Findings: ROC curve analysis for the ANRQ yielded an acceptable area under the curve of 0.69. The most ‘clinically’ useful cut off on the ANRQ was a score of 23 or more, yielding a sensitivity of 0.62 and specificity of 0.64 with positive predictive value of 0.3. The odds that a woman scoring 23 or more on the ANRQ is also a case was 6.3 times greater than for a woman scoring less than 23. Acceptability of the ANRQ was high among both women and midwives.Conclusion: The ANRQ is a highly acceptable self-report psychosocial assessment tool which aids in the prediction of women who go on to develop postnatal depression. In combination with a symptom based screening measure (e.g., the Edinburgh Postnatal Depression Scale) and routine questions relating to drug and alcohol use and domestic violence, the ANRQ becomes most useful as a key element of a “screening intervention” aimed at the early identification of mental health risk and morbidity across the perinatal period. Evaluation of this model in terms of clinical outcomes remains to be undertaken.

The self reported confidence of newly graduated midwives before and after their first year of practice in Sydney, Australia - Corrected Proof

2011-06-20

Abstract: Background: Graduates from a new, 3-year Bachelor of Midwifery program joined those educated through the 1 year, postgraduate route (for those already qualified as nurses) for the first time in New South Wales (NSW) Australia in 2007. Many hospitals offer transition support programs for new graduates during their first year of practice though there is little evidence available to inform these programs.Objectives: To establish the new midwife's confidence in working to the 14 “National Competency Standards for the Midwife” and the International Confederation of Midwives (ICM) Definition of a Midwife and to explore whether the new midwife's confidence changed over the new graduate year. In particular the study set out to determine whether there were any differences in the confidence of new graduates from undergraduate or postgraduate programs.Design: Pre and post survey with comparisons longitudinally and within undergraduate and postgraduate cohorts.Settings: Three Area Health Services in Sydney and surrounding areas, Australia.Participants: A convenience sample of all new graduate midwives employed in the three Area Health Services in the early months of 2008.Methods: New graduate midwives rated their level of confidence (1–10) in working to the 14 National Competency Standards for the Midwife and the ICM Definition of a Midwife during their first weeks of employment and after the completion of their first year of practice.Results: Midwives prepared through the undergraduate and postgraduate routes commenced their first year of practice with similar levels of confidence. The confidence of these midwives increased modestly over the first year of practice. Those from postgraduate programs were significantly more confident than those from undergraduate programs on four competencies after the first year of practice. Participant's self reported confidence in working to the ICM Definition of a Midwife was low.Conclusions: Our profession and community need strong, confident midwives and it is in all our interests to look to ways we can best achieve this. While the findings of this study should be treated with caution, this study suggests that there is room for improvement in the way we support newly graduated midwives to build their confidence over their first year of practice. Further research is needed to identify the needs of newly graduated midwives and how best we can support them to develop as strong and confident practitioners through their first year of practice.

Complementary and alternative medicine for induction of labour - Corrected Proof

Helen G. Hall, Lisa G. McKenna, Debra L. Griffiths — 2011-06-20

Summary: Background: Induction of labour is a common obstetric procedure. Some women are likely to turn to complementary and alternative medicine in order to avoid medical intervention.Aim: The aim of this paper is to examine the scientific evidence for the use of complementary and alternative medicine to stimulate labour.Method: An initial search for relevant literature published from 2000 was undertaken using a range of databases. Articles were also identified by examining bibliographies.Results: Most complementary and alternative medicines used for induction of labour are recommended on the basis of traditional knowledge, rather than scientific research. Currently, the clinical evidence is sparse and it is not possible to make firm conclusions regarding the effectiveness of these therapies. There is however some data to support the use of breast stimulation for induction of labour. Acupuncture and raspberry leaf may also be beneficial. Castor oil and evening primrose oil might not be effective and possibly increase the incidence of complications. There is no evidence from clinical trails to support homeopathy however, some women have found these remedies helpful. Blue cohosh may be harmful during pregnancy and should not be recommended for induction. Other complementary and alternative medicine (CAM) therapies may be useful but further investigation is needed.Conclusions: More research is needed to establish the safety and efficacy of CAM modalities. Midwives should develop a good understanding of these therapies, including both the benefits and risks, so they can assist women to make appropriate decisions.

What are the facilitators, inhibitors, and implications of birth positioning? A review of the literature - Corrected Proof

Holly Priddis, Hannah Dahlen, Virginia Schmied — 2011-06-20

Abstract: Background: From the historical literature it is apparent that birthing in an upright position was once common practice while today it appears that the majority of women within Western cultures give birth in a semi-recumbent position.Aim: To undertake a review of the literature reporting the impact of birth positions on maternal and perinatal wellbeing, and the factors that facilitate or inhibit women adopting various birth positions throughout the first and second stages of labour.Methods: A search strategy was designed to identify the relevant literature, and the following databases were searched: CINAHL, CIAP, the Cochrane Database of Systematic Reviews, Medline, Biomed Central, OVID and Google Scholar. The search was limited to the last 15 years as current literature was sought. Over 40 papers were identified as relevant and included in this literature review.Results: The literature reports both the physical and psychological benefits for women when they are able to adopt physiological positions in labour, and birth in an upright position of their choice. Women who utilise upright positions during labour, have a shorter duration of the first and second stage of labour, experience less intervention, and report less severe pain and increased satisfaction with their childbirth experience than women in a semi recumbent or supine/lithotomy position. Increased blood loss during third stage is the only disadvantage identified but this may be due to increased perineal oedema associated with upright positions. There is a lack of research into factors and/or practices within the current health system that facilitate or inhibit women to adopt various positions during labour and birth. Upright birth positioning appears to occur more often within certain models of care, and birth settings, compared to others. The preferences for positions, and the philosophies of health professionals, are also reported to impact upon the position that women adopt during birth.Conclusion: Understanding the facilitators and inhibitors of physiological birth positioning, the impact of birth settings and how midwives and women perceive physiological birth positions, and how beliefs are translated into practice needs to be researched.