Irish and New Zealand Midwives' expertise at preserving the perineum intact (the MEPPI study): Perspectives on preparations for birth.

OBJECTIVES: perineal trauma during birth can result in short or long term morbidity for women. Internationally, rates of episiotomy and severe perineal tears vary considerably. In New Zealand, in 2011, and in a trial of midwife-led care in Ireland, episiotomy rates were found to be considerably lower than those in many other countries. A qualitative exploratory study was undertaken to ascertain how midwives achieve these low rates, in these countries and settings. DESIGN AND PARTICIPANTS: a qualitative exploratory study was conducted. Midwives expert in preserving the perineum intact (PPI) from two maternity units in the Republic of Ireland and from varied birth settings in New Zealand, were eligible to participate. Twenty-one consenting midwives took part, seven from Ireland and 14 from New Zealand. METHODS: university ethical approval was granted. Face-to-face, semi-structured interviews were used to collect the data. Interviews were recorded and transcribed verbatim. The data were analysed using Ethnograph software and were organised into prominent themes. FINDINGS: four themes were identified; 'Sources of knowledge for PPI', 'Associated factors', 'Decision-making on episiotomy', and 'Preparations for PPI'. Participants drew heavily on multiple sources of knowledge in building their own expertise for PPI. Physical characteristics of the perineum featured prominently as factors leading to PPI. Episiotomy was, in the main, only performed when there were signs of fetal distress. Antenatal perineal massage was supported. CONCLUSION: this study provides valuable insight into the views and skills of midwives, with expertise in PPI at birth, adding to the body of evidence on this topic.

Midwifery empowerment: National surveys of midwives from Australia, New Zealand and Sweden.

BACKGROUND: the predicted midwifery workforce shortages in several countries have serious implications for the care of women during pregnancy, birth and post partum. There are a number of factors known to contribute to midwifery shortages and work attrition. However, midwives assessment of their own professional identity and role (sense of empowerment) are perhaps among the most important. There are few international workforce comparisons. AIM: to compare midwives' sense of empowerment across Australia, New Zealand and Sweden using the Perceptions of Empowerment in Midwifery Scale-R (PEMS-Revised). METHOD: a self-administered survey package was distributed to midwives through professional colleges and networks in each country. The surveys asked about personal, professional and employment details and included the Perceptions of Empowerment in Midwifery Scale-R (PEMS-Revised). Descriptive statistics for the sample and PEMS were generated separately for the three countries. A series of analysis of variance with posthoc tests (Tukey's HSD) were conducted to compare scale scores across countries. Effect size statistics (partial eta squared) were also calculated. RESULTS: completed surveys were received from 2585 midwives (Australia 1037; New Zealand 1073 and Sweden 475). Respondents were predominantly female (98%), aged 50-59 years and had significant work experience as a midwife (+20 years). Statistically significant differences were recorded comparing scores on all four PEMS subscales across countries. Moderate effects were found on Professional Recognition, Skills and Resources and Autonomy/Empowerment comparisons. All pairwise comparisons between countries reached statistical significance (p<.001) except between Australia and New Zealand on the Manager Support subscale. Sweden recorded the highest score on three subscales except Skills and Resources which was the lowest score of the three countries. New Zealand midwives scored significantly better than both their Swedish and Australian counterparts in terms of these essential criteria. DISCUSSION/CONCLUSIONS: midwives in New Zealand and Sweden had a strong professional identity or sense of empowerment compared to their Australian counterparts. This is likely the result of working in more autonomous ways within a health system that is primary health care focused and a culture that constructs childbirth as a normal but significant life event. If midwifery is to reach its full potential globally then developing midwives sense of autonomy and subsequently their empowerment must be seen as a critical element to recruitment and retention that requires attention and strengthening.

Changing trends in pregnancy registration for New Zealand women.

INTRODUCTION: Early pregnancy registration is recommended and provides an opportunity for screening, risk assessment and health promotion. AIM: To determine the gestation at pregnancy registration for a cohort of pregnant New Zealand women who received maternity care from a midwife Lead Maternity Carer (LMC) and to determine if women are registering earlier in pregnancy. METHODS: The gestation of pregnancy at registration was reviewed for the 81,821 women who registered with a midwife LMC between 2008 and 2010 and had data recorded in the New Zealand College of Midwives Clinical Outcomes Research Database (COMCORD). RESULTS: Over the three-year period, there was a trend towards earlier registration with 22.0% of women registering before 10 weeks' gestation in 2008 increasing to 29.9% in 2010. Women of New Zealand European ethnicity were more likely to register before 10 weeks' gestation compared to women who identified as Maori or Pacific ethnicity. Women under 20 or over 40 years of age were more likely to register in the second or third trimester than other age groups. DISCUSSION: Groups that were slower to register with a midwife LMC were women under 20 years or over 40 years of age and women of Maori or Pacific ethnicity. These groups have higher perinatal mortality rates, higher rates of smoking and lower uptake of antenatal Down syndrome screening. Further research is required to explore the barriers to earlier registration for these groups.

Outcomes of physiological and active third stage labour care amongst women in New Zealand.

BACKGROUND: during the third stage of labour there are two approaches for care provision - active management or physiological (expectant) care. The aim of this research was to describe, analyse and compare the midwifery care pathway and outcomes provided to a selected cohort of New Zealand women during the third stage of labour between the years 2004 and 2008. These women received continuity of care from a midwife Lead Maternity Carer and gave birth in a variety of birth settings (home, primary, secondary and tertiary maternity units). METHODS: retrospective aggregated clinical information was extracted from the New Zealand College of Midwives research database. Factors such as type of third stage labour care provided; estimated blood loss; rate of treatment (separate to prophylaxis) with a uterotonic; and placental condition were compared amongst women who had a spontaneous onset of labour and no further assistance during the labour and birth. The results were adjusted for age, ethnicity, parity, place of birth, length of labour and weight of the baby. FINDINGS: the rates of physiological third stage care (expectant) and active management within the cohort were similar (48.1% vs. 51.9%). Women who had active management had a higher risk of a blood loss of more than 500mL, the risk was 2.761 when a woman was actively managed (95% CI: 2.441-3.122) when compared to physiological management. Women giving birth at home and in a primary unit were more likely to have physiological management. A longer labour and higher parity increased the odds of having active management. Manual removal of the placenta was more likely with active management (0.7% active management - 0.2% physiological p<0.0001). For women who were given a uterotonic drug as a treatment rather than prophylaxis a postpartum haemorrhage of more than 500mL was twice as likely in the actively managed group compared to the physiological managed group (6.9% vs. 3.7%, RR 0.54, CI: 0.5, 0.6). CONCLUSIONS: the use of physiological care during the third stage of labour should be considered and supported for women who are healthy and have had a spontaneous labour and birth regardless of birth place setting. Further research should determine whether the use of a uterotonic as a treatment in the first instance may be more effective than as a treatment following initial exposure prophylactically.

Irish and New Zealand midwives' expertise in expectant management of the third stage of labour: the 'MEET' study.

OBJECTIVE: to explore the views of expert midwives in Ireland and New Zealand of the skills they employ in expectant management of the third stage of labour (EMTSL). DESIGN: university ethical approval was granted for a qualitative descriptive study in 2010. Recorded, semi-structured interviews were undertaken. Constant comparative analysis was used. SETTING: community birth settings in Ireland and New Zealand. PARTICIPANTS: 27 consenting midwives who used EMTSL in at least 30% of births, with PPH rates less than 4%. FINDINGS: the majority of respondents believed the third stage was a special time of parent-baby discovery and 'watchful waiting', with no intervention necessary. Great importance was placed on women's feelings, behaviour and a calm environment. Skin-to-skin contact, breast feeding, not clamping the cord, upright positions and maternal effort, sometimes assisted by gentle cord-traction were also used. KEY CONCLUSIONS: some components of EMTSL identified by these expert midwives are not recorded in text-books, but are based on experience and expertise. These elements of EMTSL add to midwifery knowledge and provide a basis for further discussion on how normal physiology can be supported during the third stage. IMPLICATIONS FOR PRACTICE: use of these elements is recommended for women who request EMTSL, and for those in countries without ready access to uterotonics.