Status of the midwifery workforce and childbirth services and the impact of midwife staffing on birth outcomes in China: a multicentre cross-sectional study.

OBJECTIVE: To investigate the status of the midwifery workforce and childbirth services in China and to identify the association between midwife staffing and childbirth outcomes. DESIGN: A descriptive, multicentre cross-sectional survey. SETTING: Maternity hospitals from the eastern, central and western regions of China. PARTICIPANTS: Stratified sampling of maternity hospitals between 1 July and 31 December 2021.The sample hospitals received a package of questionnaires, and the head midwives from the participating hospitals were invited to fill in the questionnaires. RESULTS: A total of 180 hospitals were selected and investigated, staffed with 4159 midwives, 412 obstetric nurses and 1007 obstetricians at the labour and delivery units. The average efficiency index of annual midwifery services was 272 deliveries per midwife. In the sample hospitals, 44.9% of women had a caesarean delivery and 21.4% had an episiotomy. Improved midwife staffing was associated with reduced rates of instrumental vaginal delivery (adjusted ß -0.032, 95% CI -0.115 to -0.012, p<0.05) and episiotomy (adjusted ß -0.171, 95% CI -0.190 to -0.056, p<0.001). CONCLUSION: The rates of childbirth interventions including the overall caesarean section in China and the episiotomy rate, especially in the central region, remain relatively high. Improved midwife staffing was associated with reduced rates of instrumental vaginal delivery and episiotomy, indicating that further investments in the midwifery workforce could produce better childbirth outcomes.

Assessing women's and health professionals' views on developing a midwifery-led mobile health app intervention in pregnancy: A descriptive qualitative study.

AIMS: To explore women's and health professionals' views on the development of a midwifery-led mHealth app intervention in antenatal care and their demands for app functionality. DESIGN: Descriptive qualitative research was utilized. METHODS: In total, 15 pregnant or postpartum women were interviewed via in-depth interviews and 10 health professionals including obstetricians, midwives and obstetric nurses were invited to participate in a focus group discussion (FGD). All interviews and the FGD were analysed using qualitative content analysis. RESULTS: Four key themes emerged from the data, including (1) limitations of current maternity care services; (2) potential benefits for mHealth app-based midwifery care; (3) possible challenges for providing midwifery care through mHealth apps and (4) suggestions and needs for developing a midwifery-led mHealth app. Participants agreed on the potential need of developing a midwifery-led mHealth app in antenatal care to increase access to midwifery care services and to meet women's diverse needs. Participants preferred to develop professional, reliable, full-featured and interactive mobile applications. The main functions of midwifery-led mHealth apps included personalized assessment and health education, self-monitoring and feedback, data sharing and interactive functions. Women mentioned that online communication and consultation with midwives could help them receive continuous support outside facilities. Health professionals expressed it would be of great convenience and timeliness to send personalized messages to women and to inform them of healthy lifestyles during pregnancy. The challenges included a shortage of human resources, medico-legal risks associated with mHealth and data security risks. CONCLUSIONS: This study explores the individual views and functional needs of target users and healthcare providers for developing a midwifery-led mHealth app in antenatal care, which will serve as a reference for future application development. IMPACT: Our study has important and practical implications for guiding the development of future midwifery-led mHealth app interventions. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.

Development and psychometric testing of a Chinese version of the postnatal care experience scale for postpartum women.

BACKGROUND: Postnatal period is a critical transitional phase in the lives of mothers and newborn babies. In recent years the importance on promoting a positive experience of care following childbirth is increasingly emphasized. Yet published evidence of the methodological and psychometric quality of instruments to evaluate women's experience of comprehensive postnatal care is still lacking. OBJECTIVE: This study aimed to develop and validate a unique scale (the Chinese version of the Postnatal Care Experience Scale, PCES) to measure women's overall experience of care during postnatal periods. METHODS: The PCES instrument was developed and validated over three phases, including item development, scale development, and scale evaluation. The item pool of the PCES was generated through existing literature and in-depth semi-structured interviews, followed by assessment of content validity and rating of importance and feasibility of items through two-round Delphi surveys. Psychometric properties were examined in a convenience sample of 736 postpartum women. Both exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were conducted to assess the construct validity of the developed PCES. The relationship between the total PCES score and the global item construct was estimated using Pearson product-moment coefficient. Reliability was assessed using Cronbach's alpha and Spearman Brown coefficients. RESULTS: The content validity index of the Chinese version PCES was 0.867. Following item reduction analysis, this instrument consisted of 30 five-point Likert items. The Kaiser-Meyer-Olkin statistic was 0.964 and the chi-square value of the Bartlett spherical test was 11665.399 (P < .001). The scale explained 75.797% of the total variance and consisted of three subscales, including self-management, social support, and facility- and community-based care. The Pearson correlation coefficient between the total PCES score and the global item construct was 0.909. The CFA showed that the 3-factor model had suitable fitness for the data. Cronbach's alpha value and Spearman-Brown Split-half reliability for the total scale were 0.979 and 0.941, respectively. CONCLUSIONS: The newly developed 30-item PCES is a psychometrically reliable and valid instrument that assesses women's overall experience of postnatal care. Future research should aim to use the PCES in various populations to obtain further evidence for its validity and reliability.

The effects of a midwife-led weight management program for pregnant women: A randomized controlled trial.

BACKGROUND: Inappropriate weight gain during pregnancy may present risks for maternal and newborn health. Pregnancy is considered the optimal time to intervene on women's health behaviors such as eating habits and physical activity. However, current clinical practice guidelines for weight management during pregnancy were not fully based on randomized trials, thus lacking specific "active intervention ingredients" that are proven effective in achieving appropriate gestational weight gain. Therefore it is essential to develop and implement an evidence-based weight management program for pregnant women. OBJECTIVE: To examine the effects of a midwife-led weight management program on improving appropriate gestational weight gain, health literacy, experience of antenatal care, and maternal and neonatal outcomes among Chinese pregnant women. DESIGN: A two-group randomized controlled trial. SETTINGS AND PARTICIPANTS: A total of 426 pregnant women were recruited from a tertiary women's hospital in eastern China. METHODS: Participants were randomly allocated to either intervention group (n = 213) or control group (n = 213). Women in the intervention group participated in a midwife-led weight management program during pregnancy, while women in the control group received the conventional obstetrician-led antenatal care. We assessed women at the first antenatal contact, 35-36 weeks gestation and 2-3 days postpartum. Data on gestational weight gain, health literacy, experience of antenatal care, and maternal and neonatal outcomes were compared between the two groups. Dummy variable analysis was conducted to reveal the effect of weight management program on gestational weight gain. RESULTS: The overall gestational weight gain between the two groups was not statistically different (t = -1.377, P = 0.170). Compared with women in the control group, the odds of having inappropriate gestational weight gain was lower in the intervention group (OR = 0.270, 95%CI 0.169, 0.431). Further subgroup analyses showed that women in the intervention group had lower risk of inadequate gestational weight gain (OR = 0.305, 95%CI 0.180, 0.515) and excessive gestational weight gain (OR = 0.236, 95%CI 0.138, 0.404) than those in the control group. The score of experience of antenatal care was significantly higher in the midwife-led weight management group than that in the control group (193.70 ±â€¯18.51 versus 165.70 ±â€¯28.23, P < 0.001). Women's health literacy score was higher in the intervention group than control group [74.41 (69.57, 81.77) versus 71.88 (66.23, 77.18), P = 0.004]. CONCLUSION: Compared with the conventional antenatal care, the midwife-led weight management program could facilitate appropriate gestational weight gain, enhance health literacy, and promote positive experience of antenatal care for Chinese pregnant women.

Breastfeeding Supportive Services in Baby-Friendly Hospitals Positively Influenced Exclusive Breastfeeding Practice at Hospitalization Discharge and Six Months Postpartum.

BACKGROUND: Studies have shown that implementing the Ten Steps to Successful Breastfeeding of the Baby-Friendly Hospital Initiative can protect, promote, and support breastfeeding. However, few studies have valuated the quality of breastfeeding supportive services provided by Baby-Friendly Hospitals from the perspective of service users. METHODS: This was a hospital-based prospective study, conducted at eight Baby-Friendly Hospitals with a total of 707 pregnant women in Shanghai, China between October 2016 and September 2021. Breastfeeding supportive services during hospitalization were assessed at childbirth discharge using a 12-question questionnaire based on the Chinese "Baby-Friendly Hospital Evaluation Standards". Women were followed up on six months postpartum. The impact of breastfeeding supportive services during hospitalization on the exclusive breastfeeding at discharge and six months postpartum were assessed. RESULTS: Of the 707 mothers who completed the survey at discharge, 526 were followed up on six months after delivery. The overall exclusive breastfeeding rate among participants was 34.4% at discharge and 52.1% at six months postpartum. Mothers who received better breastfeeding supportive services during hospitalization were more likely to practice exclusive breastfeeding at hospitalization discharge compared with mothers who received poorer services (aOR: 3.00; 95% CI: 2.08, 4.35; p < 0.001). Furthermore, they were also more likely to exclusively breastfeed at six months postpartum (aOR: 1.50; 95% CI: 1.03, 2.22; p = 0.033). CONCLUSION: Better breastfeeding supportive services during hospitalization were significantly associated with higher rate of exclusive breastfeeding at discharge and six months postpartum. More effective measures should be adopted to improve the implementation of the breastfeeding supportive services in Baby-Friendly Hospitals to promote exclusive breastfeeding and better maternal and child health.

Developing a midwifery service task list for Chinese midwives in the task-shifting context: a Delphi study.

OBJECTIVE: To develop and validate a midwifery-led task list in the task-shifting context. DESIGN: An extensive literature review followed by a two-iterative Delphi survey. SETTING: Twenty university hospitals, three non-university hospitals and four university colleges from nine provincial regions of China. PARTICIPANTS: Purposive non-probability sampling of a national panel of experts in maternal healthcare, obstetrics, nursing and midwifery. Experts in the panel were asked to rate each midwifery service item regarding importance, feasibility and advancement on a 5-point scale, in order to determine those best suited for midwifery-led practice in China. RESULTS: Two rounds of Delphi surveys were completed before consensus was achieved, with effective response rate ranging from 96.4% (27/28) to 100% (27/27), indicating a high positive coefficient of the experts. The authority coefficient of experts was 0.882, indicating the high reliability of this study. The Kendall harmony coefficient (W) in the two rounds of consultations was 0.196 (p<0.001) and 0.324 (p<0.001), respectively. A detailed, three-level midwifery-led task list was developed, including 3 domains of midwifery practice (first-level indicators), 13 types of task (second-level indicators) and 58 midwifery service items (third-level indicators). The 3 domains of midwifery practice involved the appropriate scope of practice for Chinese midwives, including antenatal care, intrapartum care and postnatal care. The 58 service items embraced core components of caring task in the Chinese midwifery profession. CONCLUSION: This study outlines the first midwifery-led task list that defines clearly the Chinese midwives' scope of practice. It will provide a foundational framework for future midwifery practice in China and abroad, and can be used to inform the design of midwifery-led task shifting interventions in various maternity settings.

Pregnant women's clinical characteristics, intrapartum interventions, and duration of labour in urban China: a multi-center cross-sectional study.

BACKGROUND: There is an increasing global trend towards the widespread over-medicalisation of labour and childbirth. The present study aimed to investigate pregnant women's clinical characteristics, intrapartum interventions, duration of labour and its associated factors; and to compare the differences of these variables between nulliparas and multiparas in China. METHODS: A multi-center cross-sectional study was carried out in three tertiary hospitals of Fudan University in Shanghai, China. A total of 1523 participants were approched and assessed for eligibility. Data on women's sociodemographic characteristics, intrapartum interventions, and duration of labour were measured and collected. Kaplan-Meier survival analysis was performed to present the curves of total duration of labour by parity. After z-transformation of labour duration, multivariable linear regression was used to control for confounding and to identify independent associations between potential associated factors and the primary outcome of labour duration. RESULTS: Overall, 1209 eligible women agreed to participate and were investigated. Rates of different intrapartum interventions were 27.4% in use of amniotomy, 37.9% in use of oxytocin, 53.0% in continuous electronic fetal monitoring, and 52.9% in epidural use, respectively. The curve of total duration of labour was significantly different between nulliparas and multiparas (P < .001). Of the 1209 participants, 983 (81.3%) women eventually achieved successful vaginal birth while 226 (18.7%) women ended in intrapartum caesarean section. The median duration of total stage of labour was significantly longer in the nulliparous group [9.38 (6.33,14.10) hours] than that in the multiparous group [5.08 (3.00,7.83) hours] (P < .001). The following factors were independently associated with longer duration of total stage of labour: epidural analgesia (P < .001), primiparity (P < .001), continuous electronic fetal monitoring (P = .035), and increased birth weight (P = .005). CONCLUSIONS: Intrapartum medical interventions become common obstetric practices in urban China. Multifactorial variables independently associated with longer duration of labour were identified, including epidural analgesia, primiparity, continuous electronic fetal monitoring, and increased birth weight. Further research is required to validate these variables and to determine the modifiable factors for labour management. And models of care with lower intervention rates such as midwife-led models of care should be developed and implemented in China.

Correction to: Pregnant women's clinical characteristics, intrapartum interventions, and duration of labour in urban China: a multi-center cross-sectional study.

An amendment to this paper has been published and can be accessed via the original article.

China's child policy shift and its impact on Shanghai and Hangzhou women's decision-making.

OBJECTIVES: The Chinese government launched the two-child policy in 2015 to counteract the demographic changes, skewed sex ratio, and decreasing number of labor force. The policy shift has a significant impact on all levels of society and economy. This study aimed to describe how Mainland Chinese women face this new decision-making on their reproduction and family planning and captures factors contributing to the judgment and decision-making. METHOD: The present qualitative study included a sample of 37 women, with an average age of 29.51 years, and well educated with bachelor degrees from urban areas of Shanghai and Hangzhou cities. The women were interviewed by social science students, using a 26-item interview targeting the women's decision-making, expectations, and wishes with regard to the two-child policy. RESULTS: The contributors include the status of women, career, benefits, and challenges of two children, one-child generation, governmental support, and restrictions of reproductive freedom. These factors contribute to the women's prolonged decision-making on whether to have a second child. These factors highlight the impact of the policy on perinatal health, societal, and economic changes. The study illustrates the need to continue understanding the impact of the child policy shift for families and the society of the China on multiple levels. CONCLUSION: With the outcomes of research on the families' judgment and decision-making with regard to a second child, support can be targeted where it is needed the most. The acquired knowledge may serve as a prognosis for the child policy's future development and used to target perinatal care and education of health care specialists, essential to governmental planning and resource allocation.

Factors associated with Chinese nulliparous women's choices of mode of delivery: A longitudinal study.

BACKGROUND: Caesarean section rates have risen beyond the WHO recommended level in many countries worldwide. An emerging epidemic in caesareans has appeared in China over the past two decades, mainly driven by non-medical factors. China's one-child policy was previously seen as a potential factor for contributing to women's high caesarean section rates. The Chinese government has officially announced a two-child policy in recent years, causing numerous families to reshape their fertility intentions and birth preferences. There have been few studies focusing on women's expected and actual delivery mode and the associated factors affecting their choices of mode of delivery. OBJECTIVE: To investigate nulliparous women's expected and actual mode of delivery, and the related factors associated with delivery mode in the context of China's two-child policy. DESIGN, SETTINGS, AND PARTICIPANTS: This longitudinal study approached 1368 pregnant women who attended the antenatal clinic regularly at a tertiary specialized women's hospital in Shanghai, China. Among the 1368 women, 1211 agreed to participate and were investigated at admission of this study. METHODS: Data were collected via questionnaires using Birth Attitude Questionnaire (BAQ), Subjective Norm Questionnaire (SNQ), and Childbirth Self-Efficacy Scale (CSES). Descriptive statistics and logistic regression analyses were used. RESULTS: Of 1211 participants, the number of women expecting a vaginal delivery at three pregnancy stages accounted for 74%, 78%, and 83%, respectively. Finally 48% (520/1084) ended up having a caesarean delivery. Caesarean section for lack of medical indications accounted for 57% (297/520). Among women who met the requirements of two-child policy, 39% planned to have a second child. In logistic regression analyses, participants with stronger expectations of caesarean deliveries during late pregnancy (aOR, 35.18; 95% CI, 12.66-97.74), having higher scores of birth attitude toward CS (aOR, 1.13; 95% CI, 1.06-1.20), and with lower scores of intrapartum childbirth self-efficacy (aOR, 0.85; 95% CI, 0.77-0.92) had significantly higher odds of having an actual caesarean delivery. CONCLUSIONS: During the initial period of China's two-child policy, the majority of women value vaginal delivery whereas high caesarean section rate still becomes a great concern in current China. Individual preferences, birth attitude, and childbirth self-efficacy are altogether associated with women's different choices of mode of delivery.

A qualitative study of nulliparous women's decision making on mode of delivery under China's two-child policy.

OBJECTIVE: To explore nulliparous women's perceptions of decision making regarding mode of delivery under China's two-child policy. DESIGN: Qualitative descriptive design with in-depth semi-structured interviews. SETTING: Postnatal wards at a tertiary specialized women's hospital in Shanghai, China. PARTICIPANTS: 21 nulliparous women 2-3 days postpartum were purposively sampled until data saturation. METHODS: In-depth semi-structured interviews were conducted between October 8th, 2015 and January 31st, 2016. RESULTS: Two overarching descriptive categories were identified: (1) women's decision-making process: stability versus variability, and (2) factors affecting decision making: variety versus interactivity. Four key themes emerged from each category: (1) initial decision making with certainty: anticipated trial of labour, failed trial of labour, 'shy away' and compromise, anticipated caesarean delivery; (2) initial decision making with uncertainty: anticipated trial of labour, failed trial of labour, 'shy away' and compromise; (3) internal factors affecting decision making: knowledge and attitude, and childbirth self-efficacy; and (4) external factors affecting decision making: social support, and the situational environment. CONCLUSION AND IMPLICATIONS FOR PRACTICE: At the initial period of China's two-child policy, nulliparous women have perceived their decision-making process regarding mode of delivery as one with complexity and uncertainty, influenced by both internal and external factors. This may have implications for the obstetric setting to develop a well-designed decision support system for pregnant women during the entire pregnancy periods. And it is recommended that care providers should assess women's preferences for mode of delivery from early pregnancy and provide adequate perinatal support and continuity of care for them.

Pelvic floor muscle training for the prevention of urinary incontinence in antenatal and postnatal women: a best practice implementation project.

BACKGROUND: Pregnancy and vaginal delivery may cause urinary incontinence (UI) in some women, which can impact on their quality of life. Pelvic floor muscles training (PFMT) is a safe and effective intervention for preventing UI associated with pregnancy. OBJECTIVES: The aim of this evidence-implementation project was to promote PFMT to prevent UI among antenatal and postnatal women in an obstetric and gynecological hospital in China. METHODS: A clinical audit was undertaken using the Joanna Briggs Institute Practical Application of Clinical Evidence System tool. Six audit criteria that represent best practice recommendations for PFMT were used. A baseline audit was conducted followed by the implementation of multiple strategies and finalized with a follow-up audit to determine change in practice. RESULTS: Results from pre- and post-implementation audits indicated that compliance rates for Criterion 1 (nurse education), Criterion 2 (information providing), Criterion 3 (needs and precautions identifying), Criterion 4 (assessment of pelvic floor function and referral suggestion) reached 100% in the follow-up audit. The compliance rate for Criteria 5 (women education) and Criteria 6 (follow-up providing) attained 90 and 63%, respectively, in the follow-up audit. CONCLUSION: The project was successful in improving women's knowledge and skills around UI and PFMT. A variety of strategies, such as an effective education program, simple and clear instruments, multiple educational materials can facilitate implementation of evidence in clinical practice. Future plans for continuous improvements in practice and outcomes should be discussed. Further audits will need to be carried out to monitor practice and effect change as required.

The effectiveness of a Chinese midwives' antenatal clinic service on childbirth outcomes for primipare: a randomised controlled trial.

BACKGROUND: Antenatal care is an important component of maternity care. In many parts of the world, midwives are the primary caregivers for childbearing women, providing a high level of continuity of care during a normal pregnancy. While in China, obstetricians are the primary providers of antenatal care for all childbearing women; and midwives only provide intrapartum care to labouring women. Today midwifery as a profession in China has been marginalised. Pregnant women usually lack individualised continuity of care from midwives during the perinatal period. There have been few randomised controlled trials of midwifery care practice in mainland China. OBJECTIVE: (1) To develop and implement a model of Chinese midwives' antenatal clinic service and (2) to explore its effect on childbirth outcomes, psychological state and satisfaction, for primiparae. DESIGN AND METHODS: Two-group randomised controlled trial. One hundred and ten pregnant women were assessed for eligibility and invited to participate in either the intervention group (midwives' antenatal clinic service) or the control group (routine antenatal care) in the Obstetrics and Gynaecology Hospital of Fudan University from September 2011 to December 2011. Baseline data were collected, and then women were randomised to individual midwives' antenatal clinic care (intervention group) or regular antenatal clinic service by obstetricians and obstetric nurse (control group). The research hypothesis was that compared with regular obstetrician-led antenatal care, the midwives' antenatal clinic service would decrease the caesarean section rate, produce more favourable birth outcomes and women's greater satisfaction with care. Data were collected by retrospective review of case records and self-report questionnaires. The sample size of 110 was calculated to identify a decrease in caesarean birth from 70% to 40%. Birth outcomes, satisfaction and anxiety score in the two groups were compared. SETTING: The midwives' antenatal clinic in the Obstetrics and Gynaecology Hospital of Fudan University, Shanghai, China. PARTICIPANTS: 55 women, attending the midwives' antenatal clinic (the intervention group) and 55 women, entering the control group. RESULTS: Women in the intervention group were more likely than women in the control group to have a vaginal birth (35 [66.04%] versus 23 [43.40%]; 95% CI for difference 3.69-41.60). Women in the intervention group had a higher perinatal satisfaction but lower anxiety score than those in the control group. No differences were seen in neonatal Apgar score and in the amount of bleeding 2h post partum. CONCLUSION AND IMPLICATIONS FOR PRACTICE: The midwives' antenatal clinic can decrease the rate of caesarean section and enhance women's satisfaction with midwifery care. Further research needs to be conducted to implement this model of care more widely. We will attempt to make midwifery care a true choice for Chinese women.

Chinese midwives' experience of providing continuity of care to labouring women.

OBJECTIVE: to explore and describe Chinese midwives' experience of providing one-to-one continuity of care to labouring women. DESIGN: a qualitative study using a phenomenological approach. Data were collected using open-ended, tape-recorded interviews. The analysis of the transcribed texts included searching for themes sorted into clusters for a final expression of the essential structure of the phenomenon. SETTING: Obstetrics and gynaecology hospital of Fudan University, Shanghai, China. PARTICIPANTS: 12 midwives, providing one-to-one continuity of care to labouring women. FINDINGS: two main categories were identified: (1) midwives' feelings on providing continuity of care, and (2) impact of on-call system on midwives providing continuity of care. Key themes emerged from each main category: (1) 'playing important roles in labour care', 'gaining a sense of self-achievement', 'falling into exhaustion and frustration' and 'coping with caring work'; and (2) 'on-call syndrome', 'affecting personal lives' and 'managing on-call shift'. The midwives experienced mixed feelings of being with women and expressed their adaptation to being on-call, which was the essence of this study. They played important roles in caring for women, gained a sense of self-achievement and developed suitable coping strategies. However, they also indicated the impact of the on-call system upon them in the process of providing continuity of care. CONCLUSION AND IMPLICATIONS FOR PRACTICE: midwives have gained both positive and negative experiences when providing continuity of care to labouring women. The positive aspects may facilitate other professional midwives working in a similar role, whereas the negative aspects may inform them of learning to live with this situation, and may also have implications for managers to develop new approaches to the organisation and provision of continuity of care to support midwives' practice, and to fully utilise 'flexibility' under an on-call system.