Five studies on my reading pile… (Autumn 2014)

medium_376900808I’ve been having such a lovely time getting out and about and meeting midwives and birthworkers at workshops over the past week or two that I’ve got a bit behind on my reading!  As a result, I’ve got a bumper pile of interesting articles that I’ve glanced at and want to read properly, so I thought I would share a few of those that are on my list in case they were of interest to anyone else as well…


The first one was published in the September 2014 issue of Birth:

Ye J, Betran AP, Vela MG et al (2014). Searching for the optimal rate of medically necessary cesarean delivery. Birth 41(3): 237-244.

BACKGROUND: Over the past three decades, the World Health Organization expert panel proposed cesarean delivery rate of 10-15 percent was used as a doctrine for an optimal rate of cesarean delivery despite the lack of concrete evidence. We set out to compile cesarean delivery rates, socioeconomic indicators, and health outcomes by countries in the last three decades to explore the optimal rates for medically necessary cesarean delivery.
METHODS: We selected 19 countries which have readily accessible cesarean delivery and low maternal and infant mortality, including countries in North and West Europe, North America, Australia, New Zealand, and Japan. Information on cesarean delivery rate, human development index (HDI), gross domestic products (GDP), maternal, neonatal, and infant mortality rates of each country in the past 30 years was collected from published reports. A two-level fractional polynomial model was used to model the association between cesarean rate and mortality rates.
RESULTS: Most of the countries have experienced sharp increases in cesarean delivery rates. Once cesarean delivery rate reached 10 percent, with adjustment for HDI and GDP, further increase in cesarean delivery rate had no impact on maternal, neonatal, and infant mortality rates.
CONCLUSIONS: Our findings corroborate the statement that a population-level cesarean section rate above 10-15 percent is hardly justified from the medical perspective.

That sounds right up my street, and as a stats nerd I’m looking forward to the maths and hoping that there are good graphs 😉  This is a vital piece of research, though.  As a newly qualified midwife, I worked in a practice where we looked after all but the most ‘high risk’ women, and our caesarean section rate was just over 4%.  This is partly what has underpinned my conviction that intervention begets intervention.  Similar figures have emerged from studies of birth centres in both the UK and the USA, so if anything I think the 10% figure is generous…


While we’re on mode of birth, I spotted this freely available article on BioMed Central:

Knape N, Mayer H, Schnepp W et al (2014). The association between attendance of midwives and workload of midwives with the mode of birth: secondary analyses in the German healthcare system. BMC Pregnancy and Childbirth 14(300), 2 September 2014.

medium_6994463172Background: The continuous rise in caesarean rates across most European countries raises multiple concerns. One factor in this development might be the type of care women receive during childbirth. ‘Supportive care during labour’ by midwives could be an important factor for reducing fear, tension and pain and decreasing caesarean rates. The presence and availability of midwives to support a woman in line with her needs are central aspects for ‘supportive care during labour’. To date, there is no existing research on the influence of effective ‘supportive care’ by German midwives on the mode of birth. This study examines the association between the attendance and workload of midwives with the mode of birth outcomes in a population of low-risk women in a German multicentre sample.
Methods: The data are based on a prospective controlled multicentre trial (n = 1,238) in which the intervention ‘midwife-led care’ was introduced. Four German hospitals participated between 2007 and 2009. Secondary analyses included a convenience sample of 999 low-risk women from the primary analyses who met the selection criterion ‘low-risk status’. Participation was voluntary. The association between the mode of birth and the key variables ‘attendance of midwives’ and ‘workload of midwives’ was assessed using backward logistic regression models.
Results: The overall rate of spontaneous delivery was 80.7% (n = 763). The ‘attendance of midwives’ and the ‘workload of midwives’ did not exhibit a significant association with the mode of birth. However, women who were not satisfied with the presence of midwives (OR: 2.45, 95% CI 1.54-3.95) or who did not receive supportive procedures by midwives (OR: 3.01, 95% CI 1.50-6.05) were significantly more likely to experience operative delivery or a caesarean. Further explanatory variables include the type of hospital, participation in childbirth preparation class, length of stay from admission to birth, oxytocin usage and parity.
Conclusion: Satisfaction with the presence of and supportive procedures by midwives are associated with the mode of birth. The presence and behaviour of midwives should suit the woman’s expectations and fulfil her needs. For reasons of causality, we would recommend experimental or quasi-experimental research that would exceed the explorative character of this study.

The introduction to this article notes that, while there is known to be a relationship between the concept of continuous support and the likelihood of more spontaneous labour, most of the studies in this area have been carried out in a different cultural context to that in which the (German) authors of the current research are working.  One of the key differences noted by the authors is that most of the studies in the Cochrane review have included outcomes for women attended by doulas or other relatively unskilled birth attendants, which (the authors note) is uncommon in Germany.  This is also uncommon in the UK, but we have an emerging doula movement and I have recently facilitated a couple of workshops in which midwives, doulas and other birthworkers have come together.  These experiences have further convinced me that we need to focus on questions about what women need and will benefit from and how we can work together to bring that about, so I’m very interested in studies that will illuminate such questions.


The next study on my pile highlights an area needing change, at least in the Stockholm hospitals where it was undertaken, although I imagine that midwives in other areas will relate to its findings.  It is sad to see research studies which evidence elements of good practice that aren’t (for whatever reason) being implemented, but at least they confirm where we need to put our energies.  In this case, there would appear to be a need for more information on this for both parents and professionals, and for strategies that would enable midwives to spend time helping mothers to initiate and sustain skin-to-skin contact.

Zwedberg S, Blomquist J and Sigerstad E (2014).  Midwives׳ experiences with mother–infant skin-to-skin contact after a caesarean section: ‘Fighting an uphill battle’.  Midwifery, in press.

Objective: to explore midwives׳ experiences and perceptions of skin-to-skin contact between mothers and their healthy full-term infants immediately and during the first day after caesarean section.
Design: qualitative interviews with semi-structured questions.
Setting and participants: eight midwives at three different hospitals in Stockholm participated in the study. All participants provided care for mothers and their newborn infants after caesarean birth.
Analysis: transcribed material was analysed and interpreted using qualitative content analysis. The analysis yielded the theme ‘fighting an uphill battle’.
Findings: skin-to-skin contact was considered to be important, and something that midwives strove to implement as a natural element of postnatal care. However, in daily practice, midwives experienced many obstacles to such care, such as lack of knowledge among parents and other professionals about the benefits of skin-to-skin contact, the mother׳s condition after the caesarean section, and other organisational difficulties (e.g. collaboration with other professionals, lack of time). Introducing more skin-to-skin care was a challenge for the midwives, who sometimes felt both dismissed and disappointed when they tried to communicate the benefits of this type of care.
Conclusion: skin-to-skin contact is not prioritised because many health care practitioners are unaware of its positive effects, and their care reflects this lack of knowledge. There is a need for education among all health care practitioners involved in caesarean procedures. Another difficulty is that many parents are unaware of the benefits of skin-to-skin contact. Maternity outpatient clinics need to inform parents about the benefits of such care, so mothers will understand the importance of skin-to-skin contact.


One of the studies is in my pile because it contains a phrase that intrigues me…

Kajeepeta S, Sanchez SE, Gelaye B et al (2014).  Sleep duration, vital exhaustion and odds of spontaneous preterm birth: a case-control study.  BMC Pregnancy and Childbirth 2014, 14:337  doi:10.1186/1471-2393-14-337.

Background: Preterm birth is a leading cause of perinatal morbidity and mortality worldwide, resulting in a pressing need to identify risk factors leading to effective interventions. Limited evidence suggests potential relationships between maternal sleep or vital exhaustion and preterm birth, yet the literature is generally inconclusive.
Methods: We examined the relationship between maternal sleep duration and vital exhaustion in the first six months of pregnancy and spontaneous (non-medically indicated) preterm birth among 479 Peruvian women who delivered a preterm singleton infant (<37 weeks gestation) and 480 term controls who delivered a singleton infant at term (>=37 weeks gestation). Maternal nightly sleep and reports of vital exhaustion were ascertained through in-person interviews. Spontaneous preterm birth cases were further categorized as those following either spontaneous preterm labor or preterm premature rupture of membranes. In addition, cases were categorized as very (<32 weeks), moderate (32-33 weeks), and late (34- <37 weeks) preterm birth for additional analyses. Logistic regression was used to estimate adjusted odds ratios (aORs) and 95% confidence intervals (CIs).
Results: After adjusting for confounders, we found that short sleep duration (<=6 hours) was significantly associated with preterm birth (aOR = 1.56; 95% CI 1.11-2.19) compared to 7-8 hours of sleep. Vital exhaustion was also associated with increased odds of preterm birth (aOR = 2.41; 95% CI 1.79-3.23) compared to no exhaustion (Ptrend <0.001). These associations remained significant for spontaneous preterm labor and preterm premature rupture of membranes. We also found evidence of joint effects of sleep duration and vital exhaustion on the odds of spontaneous preterm birth.
medium_8025692978Conclusions: The results of this case-control study suggest maternal sleep duration, particularly short sleep duration, and vital exhaustion may be risk factors for spontaneous preterm birth. These findings call for increased clinical attention to maternal sleep and the study of potential intervention strategies to improve sleep in early pregnancy with the aim of decreasing risk of preterm birth.

I’ve been talking a lot about the ‘activities of daily living’ recently, with sleep being a key one of these, and whether or not a lack of sleep is linked with preterm birth, I am intrigued by the notion of vital exhaustion and the impact that this might have on women and their babies. I feel that we need to keep reminding ourselves – particularly in this era of constant technical and often fear-based information – of the importance of focusing on the basics…


Finally, another subject that I’ve been talking about a lot recently, because of my concern with the increasing volume of evidence showing that a good part of the alleged increase in risk experienced by women of size is because of health care providers’ perceptions that being of size is risky.  This study of New Zealand women was published earlier this year and showed that there were discrepancies between women’s size and weight as recorded on laboratory forms and as measured by staff when the women arrived for an ultrasound test:

Jeffs E, Sharp B, Gullam J et al (2014). Weight and height measurement: potential impact in obstetric care. New Zealand Medical Journal 127: 1392.

Aim: To assess the accuracy of reported weight and height in a pregnant population.
Method: Participants were recruited when attending their nuchal translucency scan if they attended with an ‘antenatal screening for Down syndrome and other conditions’ laboratory form (used for the maternal serum screening in the first trimester (MSS1) blood test) that had weight and/or height recorded. Participants’ weight and height were measured by trained recruitment centre staff and body mass index (BMI) was calculated. Differences in reported (MSS1) and measured weight, height and BMI were analysed using Bland-Altman plots.
Results: 248 women participated. Only 23% (n=56) of participants had a weight recorded on the MSS1 laboratory form that was within ± 0.5 kg of measured weight: 62% (n=155) had an under-reported weight, and 15% (n=37) an over-reported weight. 30% (n=74) of participants had a correctly reported height: 26% (n=63) an under-reported height, and 44% (n=107) an over-reported height. 6% (n=14) of participants had a correctly reported BMI: 69% (n=166) had an under-reported BMI, and 25% (n=60) an over-reported BMI. 17% of participants (n=40) were incorrectly classified by BMI category based on MSS1 data.
Conclusion: Our study suggests that there are considerable inaccuracies in the recording of weight and height during pregnancy in New Zealand. This results in a false reduction in BMI in many women which can affect clinical care.

Even on just reading the abstract, this looked to me like a prime candidate for a research critiquing workshop!  That abstract raises so many questions.  When were the forms filled out, and by whom?  Is accurate recording of weight and height on an ultrasound form deemed important by those people who were filling it out?  Doesn’t weight fluctuate by more than half a kilo on a daily basis?  Does the study report contain adequate appreciation / discussion of the realities of the context in which these forms are filled out and/or in which the related information is recorded?  Is there any relationship between these discrepancies and the restrictions that are sometimes placed on women’s decision-making if they fall outside of the current ‘normal limits’?

Always more questions than answers, and I welcome your thoughts on any of the above…


Articles by jepoirrier, birth room by JasonUnbound, exhaustion by jazbeck via photopin cc cc and cc

1 comment for “Five studies on my reading pile… (Autumn 2014)

  1. katharina
    October 6, 2014 at 7:03 am

    dear sara,
    looking forward to your ideas about the german paper – i read it and it left me with more than mixed feelings… there is more than one problematic issue in it.. so very much interested in your input!

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