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Using critical discourse analysis and the concept of food security to understand pregnant women’s nutrition in Aotearoa/New Zealand

By Raven, B., Stewart-Withers, R.
on Sunday, 01 Dec 2019 in New Zealand College of Midwives Journal - Volume: 55

Background: Increasingly, pregnant women in Aotearoa/New Zealand (Aotearoa) are unable to achieve the dietary intakes recommended by the Ministry of Health (MOH). While health professionals express frustration at “being the ambulance at the bottom of the cliff”, the continued government response to this public health concern is to “educate women”, as per the current mantra of personal responsibility and choice-based rhetoric. Aim: Using critical discourse analysis (CDA), this study examined the discourses regarding nutrition in pregnant women in Aotearoa. Pregnant women’s nutrition is further considered within the contexts of food security and empowerment. Method: In July 2017, using 30 documents from three different platforms – media, government and academia – with a focus on Aotearoa, the first author undertook a CDA. Findings: Three key messages were identified: firstly, pregnant women, in not being viewed holistically or relationally, are isolated as being solely responsible for nutrition; secondly, women are positioned as naïve recipients, and achieving a healthy pregnancy requires women to be educated and to adhere to complex food guidelines; and lastly, there is an authoritarian use of fear and monitoring to motivate adherence to guidelines. Thus, women are personally responsible for achieving complex, unrealistic and often unaffordable nutritional targets. Conclusion: The most dominant discourse is one whereby malnutrition is seen as deficit behaviour and thinking by women, and one of self-responsibility, regardless of context. This is very much in keeping with the modus operandi of public health and neo-liberal discourse. We argue, however, this renders silent the fact that malnutrition for some women results more from food insecurity and disempowerment. Midwives need to make audible other less dominant narratives, alongside advocating for woman-centred, policy-based approaches towards nutrition, whereby the underlying drivers of poverty are actively addressed.

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Rethinking engagement: Exploring women’s technology use during the perinatal period through a Kaupapa Māori consistent approach

By Gasteiger, N., Anderson, A., Day, K.
on Sunday, 01 Dec 2019 in New Zealand College of Midwives - Volume: 55

Background: Barriers to accessing perinatal health services in New Zealand remain a significant problem, especially for Māori and rural populations. Information technologies and telehealth can facilitate the distribution of health-related information and promote provider engagement during the perinatal period. Aim: This study explored the perceptions and use of technologies by women and their partners who were pregnant or new mothers/caregivers and who utilised Kaupapa Māori perinatal health services. Method: A Kaupapa Māori consistent methodology was applied. An equal explanatory sampling approach was used for recruitment. Conversational interviews were conducted with a total of nine Northland-residing participants of an antenatal programme. Data were analysed thematically. Findings: Four overarching themes emerged from the interview narratives: communication, information, facilitators and barriers. Participants used a range of online tools to access diverse health-related topics and executed autonomous control over the information gained. The credibility and reputability of sources as well as knowledge sharing were valued. Similar technologies were used to communicate with perinatal healthcare providers, including lead maternity carers, and to make in-person appointments. Barriers were related to the technology itself or the experience of using it, whilst ease of access and emotional elements facilitated engagement. Participants were generally satisfied with the technologies. Conclusion: Technology can play an important role in health literacy and minimising barriers to perinatal healthcare, by facilitating the distribution of information and promoting provider engagement. As the research indicated that online tools and services available in Northland are generally adequate for the population served, perinatal healthcare providers should leverage these to further promote engagement with service users. It is crucial that Māori health values such as whānau (extended family structures) and kanohi ki te kanohi (face-to-face interactions) are incorporated for successful perinatal healthcare delivery via telehealth.

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Low-cost, self-paced, educational programmes increase birth satisfaction in first-time mothers

By Howarth, A.M., Swain, N.R.
on Sunday, 01 Dec 2019 in New Zealand College of Midwives Journal - Volume: 55

Introduction: Birth satisfaction is an important aspect of giving birth. It is a subjective way to quantify how the experience went for new mothers. Aim: This research aimed to assess whether either of two self-directed educational programmes could improve birth satisfaction in New Zealand first-time mothers. Method: One hundred and eighty-two women were recruited and randomly assigned to a skills preparation group, a birth stories booklet group, or a treatment as usual (TAU) group. Findings: One hundred and thirty-seven women completed the three questionnaires relevant for this report (a 75% retention rate). Birth satisfaction was measured soon after birth. It was found that women who received either of the birth preparation programmes (skills or birth stories booklet) had significantly higher birth satisfaction scores. A post-hoc analysis found that, irrespective of programme, having either an induction or a caesarean birth had a negative effect on birth satisfaction, while having birth expectations met had a positive impact on birth satisfaction. Conclusions: Increased preparation for childbirth may be important for birth satisfaction; both induction and caesarean section reduce satisfaction; and expectations around birth might be managed to improve satisfaction. This study found evidence that simple low-cost programmes can improve birth satisfaction.

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Singleton breech presentation at term: Review of the evidence and international guidelines for application to the New Zealand context

By Dixon, L, Gray, E, MacDonald, C, Gullam, J, Powell, R
on Saturday, 01 Dec 2018 in New Zealand College of Midwives Journal - Volume: 54

Background: Over the last few decades the management of a breech baby at term has been immersed in controversy. It is important that New Zealand midwives and doctors have sufficient understanding of the evidence to be able to effectively counsel women to make an informed decision when a baby presents in a breech position at term. Aims: To review the evidence and international guidance related to mode of birth for singleton breech presentation at term, identify the current evidence and gaps in knowledge and highlight how the evidence can be used to support women within the New Zealand context of maternity care. Method: We searched Scopus, PubMed and the Cochrane Database of Systematic Reviews for peer reviewed publications about term breech presentation. The search terms used were "breech presentation" and "term". Limiters were set for the time period between 2000 and 2015, English language, human pregnancies, and peer reviewed journals. Findings: We found 456 published papers covering breech presentation related to clinical outcomes, professional commentaries, professional guidelines and the woman’s perspectives. We identified and retrieved 37 papers as relevant to our search criteria. We report specifically on the papers that provided professional commentary (detailed critique of the evidence), clinical studies, systematic reviews, meta-analyses and professional guidelines. Following the publication of the Term Breech Trial there was a change in practice to that of recommending planned caesarean section for term breech presentation. Subsequent critiques and reviews have identified concerns with the study which undermine its reliability. Further retrospective/prospective studies, a systematic review and a meta-analysis have demonstrated equivocal results and suggest that perinatal mortality during vaginal breech births can be reduced when strict criteria are applied and an experienced clinician is involved. Many professional guidelines now advise that offering women the option of a vaginal breech birth is reasonable. Conclusion: New Zealand midwives and doctors need to be in a position to inform women with breech presenting babies about factors that support the safety of vaginal breech birth, as well as about the benefits and potential harms of both caesarean section and vaginal breech birth, to support their decision making.

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Pasifika women’s choice of birthplace

By McAra-Couper, J, Farry, A, Marsters, N, Otukolo, D, Clemons, J, Smythe, L
on Saturday, 01 Dec 2018 in New Zealand College of Midwives Journal - Volume: 54

Background: Birth is a socially constructed experience for Pasifika living in New Zealand that is shaped by their community and maternity provider’s influences. Pasifika women in the Counties Manukau region predominantly choose to birth in a tertiary facility despite there being primary facilities available. Aim: This study asked Pasifika women about their choices for place of birth within the Counties Manukau District Health Board region. Method: Six healthy, low risk Pasifika women, who had given birth in the Counties Manukau District Health Board region, participated in this study. All women were interviewed individually and conversations were analysed using thematic analysis, followed by a hermeneutic interpretation. Findings: The women shared a culture of “we birth at Middlemore [Hospital] and that is where you have babies”. Their data surprised us as researchers. Those who had been transferred postnatally to primary units tended to still prefer Middlemore. We use the word “prejudice” in recognising that we thought (backed by research evidence) that they would be more likely to have a normal birth in a primary unit, and would prefer that experience. They told us that Middlemore Hospital was close to home; it was a place they knew; and it was where they preferred to give birth. The Pasifika women’s understanding of choice of birthplace was influenced by their community and, perhaps, by their midwife. While they seemed to have minimal understanding of why they would choose to birth at a primary birthing unit, there was a sense that even if they had this knowledge, they would not have changed their minds. They had a trust of, and familiarity with, Middlemore Hospital that held firm. They had their prejudice; we had ours. Recognising these different views offers a different space for conversation. Conclusion: It is important that any new or re-designed birthing unit be planned in collaboration with Pasifika women if it is intended for their use. Further, it is important that midwives take the time to listen to Pasifika women, and those from other cultures, to understand their point of view.

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Effects of cervical excisional procedures for cervical intraepithelial neoplasia on pregnancy and birth: A literature review

By Hay, R, Patterson, J
on Saturday, 01 Dec 2018 in New Zealand College of Midwives Journal - Volume: 54

ABSTRACT Background: Anecdotal evidence suggests midwives recognise that pregnancy and birth may be affected by cervical scarring caused by excisional procedures in the treatment of cervical intraepithelial neoplasia (CIN2 and 3). Affected women seeking information about the effect on their pregnancy and labour must rely on the knowledge of maternity care providers or take guidance from consumer publications. A literature review was undertaken with the objective of exploring pregnancy and birth outcomes following cervical excisional procedures. Method: CINAHL, ProQuest, Pubmed, Google Scholar and Cochrane databases were searched for full text, peer-reviewed articles discussing either original research or systematic reviews, published from 2001-2016. Inclusion criteria were applied and comparative analysis was used to identify and compare outcomes. Findings: Seventeen articles were included for review. Fifteen articles discuss the relationship of cervical excisional procedures to an increased incidence of preterm birth. Other outcomes include the increased incidence of preterm, pre-labour rupture of membranes, or consideration of associated low birthweight related to the method or depth of excision. No articles were found which considered the provision of intrapartum care to women with a history of cervical excision procedures. Conclusion: Current research regarding the effect of cervical excision procedure history on pregnancy and birth is largely limited to quantifying the incidence of preterm birth and preterm, pre-labour rupture of membranes, or in discussing the impact of the method and depth of excision. Research to identify, describe, or best clinically manage the experience of birthing at term with cervical scarring appears to be absent. Further research is needed to extend midwifery knowledge regarding the provision of care during pregnancy and labour to affected women at term.

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Health policy and its unintended consequences for midwife-woman partnerships: Is normal pregnancy at risk when the BMI measure is used?

By Knox, S, Crowther, S, McAra-Couper, J, Gilkison, A
on Saturday, 01 Dec 2018 in New Zealand College of Midwives Journal - Volume: 54

Background: Little attention has been paid to understanding the unintended consequences of health policy for midwife-woman partnerships. The measure of Body Mass Index (BMI) is one such policy example which has become established in contemporary midwifery practice as a tool for assessing pregnancy risk. The universal acceptance of BMI creates an unsettling paradox for midwives concerned with promoting woman-centred practice. The increasing focus on BMI is challenging for midwives as they navigate ethical tensions when directed to undertake practices which have potential unwonted consequences for the midwife-woman partnership. Aim: The aim of the study was to explore the use of an indicator, using BMI as an example, to provide an international perspective on obesity prevention policy and maternity care provision. Method: A comparative case study approach was taken, using descriptive cross-national comparative analysis of obesity prevention policy, weight management guidelines and midwifery models of care in New Zealand and Scotland. Discussion: Despite promoting healthy weight gain in pregnancy, New Zealand and Scottish health policies may be missing health promotion opportunities. Focusing on BMI in maternity, per se, should not prohibit other assessment of lifestyle issues or delivery of services based on individual needs, capacities, histories and sociological characteristics. Relying solely on pre-pregnancy BMI as a marker of health in all women has remained relatively unchallenged and, as such, constitutes a policy problem because it occludes the factoring in of other lifestyle issues that may significantly alter individual risk status. Further, such an assessment of risk status is ideally arrived at within a partnership model of maternity care, rather than reliance on an a priori medical test. Conclusion: Decontextualised policies are challenging for midwives where medical and midwifery values are in conflict. Policy which fails to consider the multiple and complex contexts of women’s lives is confronting for midwives as they attempt to re-articulate the meaning of woman-centred practice. Furthermore, BMI as a tool may be ineffectual. The current focus on BMI in policy and practice requires re-consideration.

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Pasifika student experience in a Bachelor of Midwifery programme

By Beatson, D, Seiuli, A, Patterson, J, Griffiths, C, Wilson, K
on Saturday, 01 Dec 2018 in New Zealand College of Midwives Journal - Volume: 54

Background: In New Zealand the Pasifika population comprises 6.9%. Rapid growth in the Pasifika population is anticipated and, with only 2.2% of registered midwives identifying as Pasifika, most Pasifika women are currently, and could increasingly be, unable to access a midwife from their culture. To help address this need Otago Polytechnic has identified Pasifika midwifery student success as a priority area. Aim: The objective of the research was to hear how Pasifika students experience studying midwifery, and to seek their contribution to the ongoing development of the learning environment and School processes, with the aim of increasing their enjoyment, success and retention rate in the programme. Method: Possible methodologies were considered, with the aim of developing a culturally appropriate relationship between the researcher and the participant. The Talanoa and the Kakala research approaches informed how the students were approached and the interviews conducted. To help frame the research, a flexible participatory model, “Spacifichology”, was chosen which recognises four categories of Pasifika learners. Following ethical approval, individual interviews were undertaken by the Pasifika researcher with the participants. The recordings were transcribed and analysed for themes. Findings: Two broad areas were uncovered. Firstly, “the experience of being Pasifika” with subthemes: trying to fit in; it’s not easy to ask for help; determination to succeed; and the desire to work with Pasifika women. And, secondly, “the student experience in the programme” with subthemes: the value of ākonga (local tutorial groups); the costs of the programme; assignment writing; preferring face-to-face; making connections: a place to belong; and collectivism (it is about us). Conclusion: Pasifika students are challenged by competing demands from family, social responsibilities, financial issues and unfamiliarity in the tertiary education environment. Fostering a “learning village” will help students to feel like they fit in. As educators, it is crucial for us to understand that it is always about “us” for Pasifika students; not about them as individuals. Finally, these Pasifika students are determined to succeed.

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Recognising and responding to acutely deteriorating women in New Zealand maternity wards: A literature and environmental scan

By Dann, L, Hill, J
on Saturday, 01 Dec 2018 in New Zealand College of Midwives Journal - Volume: 54

Background: A significant body of evidence now demonstrates that early warning, recognition and response systems can help to prevent harm associated with in-hospital clinical deterioration. Systems for early recognition of, and response to, pregnant or recently pregnant (<42 days) women whose conditions are acutely deteriorating in hospital maternity settings have been recommended in other countries as a useful way of supporting rapid intervention and treatment, but it was not known what systems were in place in New Zealand (NZ) hospitals. The Maternal Morbidity Working Group (MMWG), within the Perinatal and Maternal Mortality Review Committee, has recommended the development of a national approach to detecting and responding to acute deterioration in inpatient pregnant women to align with the national patient deterioration programme currently in implementation. Aim: The aim of this project was to investigate current practice nationally and internationally, by identifying the evidence related to early warning systems and tools, and investigating current models in place at NZ district health boards (DHBs) that support the early identification and treatment of an inpatient pregnant woman’s deteriorating condition. Method: We performed a literature search and environmental scan. The search strategy incorporated both academic and grey literature databases using the same search terms. The environmental scan involved contact with all NZ DHB midwifery leaders to request information on early warning systems and tools currently in use. Findings: Sixteen papers met the inclusion criteria for the literature scan. The majority of evidence about the role of maternal early warning systems in preventing morbidity comes from retrospective case reviews, retrospective cohort studies, cross-sectional surveys, and validation studies, with some prospective evidence where early warning systems were evaluated after implementation. There were some indications that early warning systems can contribute to earlier identification of deterioration and cost-effectively reduce harm, although there is wide variation in the parameters used. The environmental scan found that 15 of the 17 DHB maternity services who responded (from 20 total services) have introduced, or are in the process of introducing, modified obstetric early warning systems. There is wide variation in the designs, parameters and thresholds of these scores, as well as the recognition and response systems in use. Conclusion: A substantial proportion of DHBs are developing and implementing tools and early warning systems for maternity care. There is significant variation in the tools and approaches in current use. The MMWG and the Health Quality & Safety Commission have recommended development of a nationally standardised recognition and response system for use in NZ hospitals for pregnant or recently pregnant (<42 days) women to align with the national patient deterioration programme.

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Developing confidence in competence: My experience of the Midwifery First Year of Practice programme

By Chapman, A.
on Saturday, 01 Dec 2018 in New Zealand College of Midwives Journal - Volume: 54

Background: Confidence and competence do not always co-exist in the context of a new graduate midwife. Being competent does not always mean being confident and vice versa. In New Zealand, the Midwifery First Year of Practice (MFYP) programme supports new graduate midwives through their first year of practice. Aim: This paper examines the concepts of competence and confidence in the context of my experiences as a new graduate midwife in New Zealand, participating in the MFYP programme. The four aspects of the MYFP programme are identified as they relate to my experience. These are: clinical practice, one-to-one mentoring, funded education/professional development and quality assurance, with the focus being on the mentoring aspect of the programme. Discussion: Using published research about transition programmes alongside my experience of the MFYP programme, I identify my individual challenges during my transition year and how the individualised support available to me through the MFYP programme helped me to meet those challenges. Conclusion: Whilst there is no clear demarcation point between being a graduate and becoming a confident midwife, my experience suggests that building confidence in the first year of practice is a very individual journey. I believe the MFYP programme successfully supports a graduate’s transition from a competent to a confident midwife.

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