Factors influencing the clinical decision-making of midwives: a qualitative study.

BACKGROUND: Although midwives make clinical decisions that have an impact on the health and well-being of mothers and babies, little is known about how they make those decisions. Wide variation in intrapartum decisions to refer women to obstetrician-led care suggests that midwives' decisions are based on more than the evidence based medicine (EBM) model - i.e. clinical evidence, midwife's expertise, and woman's values - alone. With this study we aimed to explore the factors that influence clinical decision-making of midwives who work independently. METHODS: We used a qualitative approach, conducting in-depth interviews with a purposive sample of 11 Dutch primary care midwives. Data collection took place between May and September 2015. The interviews were semi-structured, using written vignettes to solicit midwives' clinical decision-making processes (Think Aloud method). We performed thematic analysis on the transcripts. RESULTS: We identified five themes that influenced clinical decision-making: the pregnant woman as a whole person, sources of knowledge, the midwife as a whole person, the collaboration between maternity care professionals, and the organisation of care. Regarding the midwife, her decisions were shaped not only by her experience, intuition, and personal circumstances, but also by her attitudes about physiology, woman-centredness, shared decision-making, and collaboration with other professionals. The nature of the local collaboration between maternity care professionals and locally-developed protocols dominated midwives' clinical decision-making. When midwives and obstetricians had different philosophies of care and different practice styles, their collaborative efforts were challenged. CONCLUSION: Midwives' clinical decision-making is a more varied and complex process than the EBM framework suggests. If midwives are to succeed in their role as promoters and protectors of physiological pregnancy and birth, they need to understand how clinical decisions in a multidisciplinary context are actually made.

MATERNAL INTERACTION QUALITY MODERATES EFFECTS OF PRENATAL MATERNAL EMOTIONAL SYMPTOMS ON GIRLS' INTERNALIZING PROBLEMS.

The role of mother-infant interaction quality is studied in the relation between prenatal maternal emotional symptoms and child behavioral problems. Healthy pregnant, Dutch women (N = 96, M = 31.6, SD = 3.3) were allocated to the "exposed group" (n = 46), consisting of mothers with high levels of prenatal feelings of anxiety and depression, or the "low-exposed group" (n = 50), consisting of mothers with normal levels of depressive or anxious symptoms during pregnancy. When the children (49 girls, 47 boys) were 23 to 60 months of age (M = 39.0, SD = 9.6), parents completed the Child Behavior Checklist (T.M. Achenbach & L.A. Rescorla, ), and mother-child interaction quality during a home visit was rated using the Emotional Availability Scales. There were no differences in mother-child interaction quality between the prenatally exposed and low-exposed groups. Girls exposed to high prenatal emotional symptoms showed more internalizing problems, if maternal interaction quality was less optimal. No significant effects were found for boys.

Maternal thyroid hormone trajectories during pregnancy and child behavioral problems.

There is ample evidence demonstrating the importance of maternal thyroid hormones, assessed at single trimesters in pregnancy, for child cognition. Less is known, however, about the course of maternal thyroid hormone concentrations during pregnancy in relation to child behavioral development. Child sex might be an important moderator, because there are sex differences in externalizing and internalizing behavioral problems. The current study examined the associations between maternal thyroid hormone trajectories versus thyroid assessments at separate trimesters of pregnancy and child behavioral problems, as well as sex differences in these associations. In 442 pregnant mothers, serum levels of TSH and free T4 (fT4) were measured at 12, 24, and 36weeks gestation. Both mothers and fathers reported on their children's behavioral problems, between 23 and 60months of age. Latent growth mixture modeling was used to determine the number of different thyroid hormone trajectories. Three trajectory groups were discerned: 1) highest and non-increasing TSH with lowest fT4 that decreased least of the three trajectories; 2) increasing TSH and decreasing fT4 at intermediate levels; 3) lowest and increasing TSH with highest and decreasing fT4. Children of mothers with the most flattened thyroid hormone trajectories (trajectory 1) showed the most anxiety/depression symptoms. The following trimester-specific associations were found: 1) lower first-trimester fT4 was associated with more child anxiety/depression, 2) higher first-trimester TSH levels were related to more attention problems in boys only. A flattened course of maternal thyroid hormone concentrations during pregnancy was a better predictor of child anxiety/depression than first-trimester fT4 levels.

The use of midwife-led primary antenatal care by obese women in The Netherlands: An explorative cohort study.

OBJECTIVE: to study the effect of body mass index (BMI) on the use of antenatal care by women in midwife-led care. DESIGN: an explorative cohort study. SETTING: 11 Dutch midwife-led practices. PARTICIPANTS: a cohort of 4421 women, registered in the Midwifery Case Registration System (VeCaS), who received antenatal care in midwife-led practices in the Netherlands and gave birth between October 2012 and October 2014. FINDINGS: the mean start of initiation of care was at 9.3 (SD 4.6) weeks of pregnancy. Multiple linear regression showed that with an increasing BMI initiation of care was significantly earlier but BMI only predicted 0.2% (R2) of the variance in initiation of care. The mean number of face-to- face antenatal visits in midwife-led care was 11.8 (SD 3.8) and linear regression showed that with increasing BMI the number of antenatal visits increased. BMI predicted 0.1% of the variance in number of antenatal visits. The mean number of antenatal contacts by phone was 2.2 (SD 2.6). Multiple linear regression showed an increased number of contacts by phone for BMI categories 'underweight' and 'obese class I'. BMI categories predicted 1% of the variance in number of contacts by phone. KEY CONCLUSIONS: BMI was not a relevant predictor of variance in initiation of care and number of antenatal visits. Obese pregnant women in midwife-led practices do not delay or avoid antenatal care. IMPLICATIONS FOR PRACTICE: Taking care of pregnant women with a high BMI does not significantly add to the workload of primary care midwives. Further research is needed to more fully understand the primary maternal health services given to obese women.

The effect of gestational weight gain on likelihood of referral to obstetric care for women eligible for primary, midwife-led care after antenatal booking.

OBJECTIVE: to examine the effect of gestational weight gain (GWG) on likelihood of referral from midwife-led to obstetrician-led care during pregnancy and childbirth for women in primary care at the outset of their pregnancy. DESIGN: secondary analysis of data from a prospective cohort study. SETTING: Dutch midwife-led practices. PARTICIPANTS: a cohort of 1288 women of Northern European descent, with uncomplicated, singleton pregnancy at antenatal booking who consequently were eligible for primary, midwife-led care. MEASUREMENTS: because of the absence of an established GWG guideline in the Netherlands, we compared the effect of inadequate and excessive GWG according to two GWG guidelines: the criterion traditionally used, which is based on knowledge of the physiological components of GWG, advising 10-15kg as a normal GWG irrespective of a woman׳s BMI category, and the 2009 Institute of Medicine recommendations (IOMr) on GWG, which provide BMI related advice. Outcome measures were: number of women referred from midwife-led to obstetrician-led care during pregnancy and during childbirth; indications of referral and birth outcomes. FINDINGS: GWG above traditional criteria (Tc; >15kg between 12 and 36 weeks) was associated with increased odds for referral during childbirth (adjusted odds ratio (aOR) 1.88; 95% confidence interval (CI) 1.22-2.90), but had no effect on referral during pregnancy (aOR .86; 95% CI .57-1.30). No associations were established between GWG below Tc (<10kg) and referral during pregnancy (aOR 1.08; 95% CI .78-1.50) or childbirth (aOR 1.08; 95% CI .74-1.56). No associations were found between GWG below and above the IOMr and referral during pregnancy (below IOMr: aOR 1.01; 95% CI .71-1.45; above IOMr: aOR .89; 95% CI .61-1.28) or childbirth (below IOMr: aOR .85; 95% CI .57-1.25; above IOMr: aOR 1.09; 95% CI .73-1.63). With regard to the effect of GWG according to both recommendations on indications for referral and birth outcomes, GWG above Tc was associated with higher rates of referral for hypertensive disorders (aOR 1.91; 95% CI 1.04-3.50) and for meconium stained liquor (aOR 2.22; CI 1.33-3.71) after adjusting for BMI and parity. CONCLUSIONS: GWG above Tc - irrespective of BMI category - was associated with doubled odds of referral to specialist care during childbirth. GWG below or above IOMR and GWG below TC were not associated with adverse obstetric outcomes in women who were eligible for primary care at the outset of their pregnancy. IMPLICATIONS FOR PRACTICE: weight gain <15kg between 12 and 36 weeks is advised for women in all BMI categories in this population. It is important to validate GWG guidelines in a target population before implementing them.

A new concept of maternity blues: Is there a subgroup of women with rapid cycling mood symptoms?

BACKGROUND: Rapid cycling mood symptoms during the first postpartum week are an important aspect of maternity blues. The aim of this study is to identify women with these rapid cycling mood symptoms in the general population and to investigate possible risk factors of these symptoms. METHODS: The Maternity Blues Scale (MBS) was validated in The Netherlands in 949 women at one week postpartum. Personal and family history of mood disorders and obstetric demographics were collected and the Edinburgh Postnatal Depression Scale (EPDS) was completed. A 16-item three-factor MBS solution was found: depression, negative and positive affect. The latter two were used to define a rapid cycling mood symptoms group. RESULTS: Using the 75th percentile cut-off, 20 (2%) women reported high negative/high positive affect (rapid cycling mood group) and 65 (7%) women were depressed (EPDS≥11). A previous episode of depression, major life events and instrumental delivery were independently related to depression (OR 3.5, 2.5 and 2.3, respectively) while only a history of depression in first-degree relatives was independently related to rapid cycling mood (OR 3.4, 95% CI 1.2-9.8). Limitations First, no syndromal diagnoses were obtained for depression and rapid cycling mood disorder. Second, history of depression was self-reported (not based on structural psychiatric interviews). Third, our study was not designed to study the longitudinal follow-up of women with rapid cycling mood symptoms. Conclusion the 16-item MBS could be useful in screening programs in detecting postpartum women at risk for (severe) mood disorders. Postpartum women with 'rapid cycling mood symptoms' can be identified with a possible more familiar form of mood disorder.

The HAPPY study (Holistic Approach to Pregnancy and the first Postpartum Year): design of a large prospective cohort study.

BACKGROUND: The HAPPY study is a large prospective longitudinal cohort study in which pregnant women (N ≈ 2,500) are followed during the entire pregnancy and the whole first year postpartum. The study collects a substantial amount of psychological and physiological data investigating all kinds of determinants that might interfere with general well-being during pregnancy and postpartum, with special attention to the effect of maternal mood, pregnancy-related somatic symptoms (including nausea and vomiting (NVP) and carpal tunnel syndrome (CTS) symptoms), thyroid function, and human chorionic gonadotropin (HCG) on pregnancy outcome of mother and foetus. METHODS/DESIGN: During pregnancy, participants receive questionnaires at 12, 22 and 32 weeks of gestation. Apart from a previous obstetric history, demographic features, distress symptoms, and pregnancy-related somatic symptoms are assessed. Furthermore, obstetrical data of the obstetric record form and ultrasound data are collected during pregnancy. At 12 and 30 weeks, thyroid function is assessed by blood analysis of thyroid stimulating hormone (TSH), free thyroxine (FT4) and thyroid peroxidase antibodies (TPO-Ab), as well as HCG. Also, depression is assessed with special focus on the two key symptoms: depressed mood and anhedonia. After childbirth, cord blood, neonatal heel screening results and all obstetrical data with regard to start of labour, mode of delivery and complications are collected. Moreover, mothers receive questionnaires at one week, six weeks, four, eight, and twelve months postpartum, to investigate recovery after pregnancy and delivery, including postpartum mood changes, emotional distress, feeding and development of the newborn. DISCUSSION: The key strength of this large prospective cohort study is the holistic (multifactorial) approach on perinatal well-being combined with a longitudinal design with measurements during all trimesters of pregnancy and the whole first year postpartum, taking into account two physiological possible markers of complaints and symptoms throughout gestation: thyroid function and HCG. The HAPPY study is among the first to investigate within one design physiological and psychological aspects of NVP and CTS symptoms during pregnancy. Finally, the concept of anhedonia and depressed mood as two distinct aspects of depression and its possible relation on obstetric outcome, breastfeeding, and postpartum well-being will be studied.

Development of the Childbirth Perception Scale (CPS): perception of delivery and the first postpartum week.

Some caregivers suggest a more positive experience of childbirth when giving birth at home. Since properly developed instruments that assess women's perception of delivery and the early postpartum are missing, the aim of the current study is to develop a Childbirth Perception Scale (CPS). Three focus groups with caregivers, pregnant women, and women who recently gave birth were conducted. Psychometric properties of 23 candidate items derived from the interviews were tested with explorative factor analysis (EFA) (N = 495). Confirmatory factor analysis (CFA) was performed in another sample of women (N = 483) and confirmed a 12-item CPS. The EFA in sample I suggested a two-component solution: a subscale 'perception of delivery' (six items) and a subscale 'perception of the first postpartum week' (six items). The CFA in sample II confirmed an adequate model fit and a good internal consistency (α = .82). Multivariate linear regression showed a positive effect of home delivery on perception of delivery in multiparous but not in primiparous women. The 12-item CPS with two dimensions (perception of delivery and perception of first postpartum week) has adequate psychometric properties. In multiparous women, home delivery showed to be independently related to more positive perception of delivery.

Maternal thyroid parameters, body mass index and subsequent weight gain during pregnancy in healthy euthyroid women.

CONTEXT: Obesity and too much weight gain during gestation have a negative effect on obstetric and neonatal outcomes. OBJECTIVE: To determine the relationship between thyroid hormone parameters, body mass index (BMI) and weight gain during gestation. DESIGN: Prospective follow-up study of thyroid parameters and gestational weight gain. SETTING: Healthy pregnant women, included at first antenatal consultation. PATIENTS: Thyroid function (TSH, FT4 and TPO-Ab) was assessed at 12, 24 and 36 weeks' gestation in 1035 Dutch Caucasian women who delivered at ≥37 weeks. BMI (WHO criteria) was assessed at eight weeks, and weight gain throughout gestation was also assessed using the US Institute of Medicine (IOM) criteria. PRIMARY OUTCOME MEASURE: a possible relationship between maternal thyroid parameters and BMI at the first trimester. SECONDARY OUTCOME MEASURE: the relationship between thyroid parameters and weight gain throughout gestation. RESULTS: At 12 weeks' gestation, BMI correlated with FT4 (r = -0·14, P < 0·001), but not with TSH (r = 0·04, P = 0·89). 415 (40%) of the women met the IOM criteria for appropriate weight gain, 326 (32%) showed less weight gain and 294 (28%) gained too much weight. At all trimesters, the latter group of women showed higher median TSH and lower median FT4 compared with those with normal weight gain. FT4 at 24 weeks' gestation (OR: 0·84, 95% CI: 0·77-0·91), younger age (OR: 0·97, 95% CI: 0·95-0·99) and primiparity (OR: 0·51, 95% CI: 0·38-0·68) were independently related to too much weight gain. CONCLUSIONS: Maternal thyroid parameters are related to both prepregnancy BMI and weight gain throughout gestation.

The current state of midwifery and development of midwifery research in four European countries.

OBJECTIVE: to describe the current state of midwifery and explore the development of midwifery research during the last two decades in four non-English speaking European countries in order to understand what factors influenced the course of establishing research as a professional activity. DESIGN: qualitative collective case study. SETTING: Germany, Austria, Switzerland and the Netherlands. FINDINGS: with the ICM Workshop in Germany in 1989 as a central starting point for midwifery research in all four countries, different courses, in timing as well as content, characterised its development in the individual countries. Major factors contributing to this development during the last decades involved the history and character of midwifery, initiatives of individual midwifery researchers, alliances with other professions and the transition of midwifery programmes into higher education. Whereas midwifery research is currently established as a professional role in all countries, future challenges involve the creation of its own profile and identity, while building up its own academic workforce and strengthening the role of midwifery in multidisciplinary alliances. KEY CONCLUSIONS AND IMPLICATIONS: although a common vision was shared between the four countries in 1989, midwifery research developed as a context-specific phenomenon related to the character of midwifery and education in each country. These factors have to be taken into account in the further development of midwifery as an academic discipline at a national as well as at an international level.

Patterns of gestational weight gain in healthy, low-risk pregnant women without co-morbidities.

BACKGROUND: little is known of the impact of gestational weight gain (GWG) in relation to Body Mass Index (BMI) classification on perinatal outcomes in healthy pregnant women without co-morbidities. As a first step, the prevalence of obesity and the distribution of GWG in relation to the Institute of Medicine (IOM) 2009 guidelines for GWG were examined. METHODS: data from a prospective cohort study of - a priori - low risk, pregnant women from five midwife-led practices (n=1449) were analysed. Weight was measured at 12, 24 and 36 weeks. FINDINGS: at 12 weeks, 1.4% of the women were underweight, 53.8% had a normal weight, 29.6% were overweight, and 15.1% were obese according to the WHO classification of BMI. In our study population, 60% of the women did not meet the IOM recommendations: 33.4% had insufficient GWG and 26.7% gained too much weight. Although BMI was negatively correlated to total GWG (p<.001), overweight and obese women class I had a significant higher risk of exceeding the IOM guidelines. Normal weight women had a significantly higher risk of gaining less weight than recommended. Obese women classes II and III were at risk in both over- and undergaining. CONCLUSIONS: our data showed that the majority of women were unable to stay within recommended GWG ranges without additional interventions. The effects on pregnancy and health outcomes of falling out the IOM guidelines remain unclear for - a priori - low risk women. Since interventions to control GWG would have considerable impact on women and caregivers, harms and benefits should be well-considered before implementation.

Development of the Tilburg Pregnancy Distress Scale: the TPDS.

BACKGROUND: Pregnant women with high levels of stress, depression and/or anxiety are at increased risk for adverse perinatal outcomes and impaired neurologic and emotional development of the offspring. Pregnancy specific instruments to measure psychological functioning during gestation are scarce and do not define items based on in-depth interviews of pregnant and recently delivered women. The current study developed a pregnancy specific scale that measures psychological functioning using in-depth interviews. METHODS: Three focus groups were formed to discuss issues most relevant to pregnancy distress; 22 candidate items were derived for pilot testing (study I, n = 419) its psychometric properties by means of explorative factor analyses (EFA). This resulted in a 17-item TPDS which was further explored by confirmatory factor analyses (CFA) and concurrent and construct validity assessment (study II, n = 454). RESULTS: EFA in study I suggested a two component solution (negative affect (NA) and partner involvement (PI)). CFA in study II resulted in a higher order model of the NA subscale into three more subscales: NA regarding confinement, delivery and general health. TPDS, EPDS and GAD-7 were all significantly correlated. CONCLUSIONS: The TPDS constitutes a valid and user friendly instrument to assess pregnancy distress. In addition to its proven ability to pick up pregnancy specific negative affect it also includes an important sub-scale measuring perceived partner involvement.

Maternal thyroid hormone concentration during late gestation is associated with foetal position at birth.

OBJECTIVE: To evaluate whether there is an association between maternal thyroid hormone and foetal cephalic head position at term gestation. CONTEXT: Rotation and flexion of the head enables the foetus to negotiate the birth canal. Low-normal range thyroid hormone concentrations in euthyroid pregnant women constitute a risk of infant motor abnormality. We hypothesized that low normal maternal thyroid hormone levels are associated with increased risk of abnormal foetal position at delivery. DESIGN: In 960 healthy Dutch women with term gestation and cephalic foetal presentation, thyroid parameters [foetal T4 (FT4), TSH and thyroid peroxidase antibody] were assessed at 36 weeks of gestation, and related to foetal head position (anterior cephalic vs. abnormal cephalic) and delivery mode (spontaneous vs. assisted delivery). RESULTS: Women presenting in anterior position (n = 891) had significantly higher FT4 levels at 36 weeks of gestation than those with abnormal cephalic presentation (n = 69). There were no between-group differences for TSH. Regression analyses indicated that the risk of abnormal head position decreased as a function of increasing FT4 [single odds ratio (OR) = 0.87, 95% confidence intervals (CI) 0.77-0.98; multivariate OR = 0.88, 95% CI 0.72-0.99)]. A similar inverse relationship between maternal FT4 and risk of assisted delivery was obtained (OR = 0.86, 95% CI 0.79-0.95; OR = 0.91, 95% CI 0.84-0.98). CONCLUSION: The lower the maternal FT4 concentration at 36 weeks of gestation, the higher the risk of abnormal cephalic foetal presentation and assisted delivery.

The relation between gestational thyroid parameters and depression: a reflection of the downregulation of the immune system during pregnancy?

OBJECTIVE: To assess the relation between thyroid parameters and an episode of major depression at different trimesters during pregnancy, taking into account possible confounders. DESIGN: Prospective follow-up of 1017 pregnant women from the general population with assessment of thyroid parameters and depression using syndromal diagnosis interviews at 12, 24, and 36 weeks' gestation. MAIN OUTCOME: The prevalence of major depression decreased from 5.3% to 2.9%, and that of elevated concentrations of thyroid peroxidase antibody (TPOAb) titers from 8.4% to 6.5% toward the end of term. Subclinical hyperthyroidism not related to TPO-Ab (odds ration [OR] 3.6; 95% confidence interval [CI]: 1.2-0.2) and TPO-Ab (OR 2.1; 95% CI: 1.1-5.8) at 12 weeks' gestation, and TPO-Ab (OR 2.8; 95% CI 1.9-7.1) at 24 weeks' gestation were independently related to major depression. Anxiety and the occurrence of stressful life events were related to depression at all trimesters. CONCLUSIONS: The occurrence of major depression and high titers of TPO-Ab show a similar pattern of decline throughout pregnancy. During early gestation, thyroid autoimmunity seems to be related to depression while at the end of term-when there is maximal downregulation of the immune system-autoimmunity does not seem to play an important role with regard to the occurrence of depression.

Peritraumatic dissociation and emotions as predictors of PTSD symptoms following childbirth.

UNLABELLED: The current study investigated the contributive role of perinatal dissociative and perinatal emotional responses to the development of PTSD symptoms following childbirth. METHOD: Using a prospective, longitudinal design, 140 women were studied who were followed from the first week after delivery to three months postpartum. RESULTS: Three women (2.1%) met criteria for PTSD and 21.4% reported a traumatic childbirth experience. Both perinatal negative emotional reactions and perinatal dissociative reactions were the predictors of PTSD symptoms at three months postpartum. The effect of perinatal dissociation, however, was partially mediated by perinatal emotional reactions. CONCLUSION: Posttraumatic stress disorder can be a consequence of the experience of childbirth. Women who reported high levels of negative emotions during and shortly after childbirth were more likely to develop PTSD symptoms than women who did not. Women who experienced an instrumental delivery and also reported higher levels of psychoform perinatal dissociation, were at higher risk than women who reported higher levels of perinatal dissociation during a spontaneous delivery. These findings add to the growing body of literature regarding traumatic childbirth and indicate that perinatal dissociative and emotional phenomena are associated with posttraumatic stress.