Chapter 6. Pregnancy and birth
Health and wellbeing for the woman and family
Cheryl Benn1
Learning outcomes
Reading this chapter will help you to:
» describe the maternity care systems in Australia and New Zealand
» identify at least four evidence-based practices for maintaining optimal health of the woman and her baby during pregnancy
» define the concept ‘health literacy’ and apply the concept to antenatal preparation of parents
» define attachment and describe the ways that attachment can be promoted in the early postnatal period
» describe the key factors that can influence breastfeeding in the early postnatal period, and
» discuss the impact on parents of giving birth to a preterm or sick baby.
Introduction
The decision to have a child or the discovery of pregnancy can be an exciting time for most women. It may also be challenging, depending on personal and social circumstances. It initiates a complex set of changes and transitions, which impact on the individuals in a family in dramatic and sometimes unrecognised ways. A healthy pregnancy and good preparation for the important parenting transitions and family adjustments ahead are critical to ensure the best health and wellbeing of the woman, her child, her partner and other family. The challenges are biophysical, emotional and psychosocial, woven in complex webs in a woman’s life.
In this chapter, women’s health in pregnancy, maternity services, options for antenatal care and birth, as well as parenting preparation, are discussed. In addition, attention is given to preterm birth, an experience that creates unique and significant stressors and vulnerabilities for the health and wellbeing of childbearing women and their families.
Setting the scene: a clinical scenario
This scenario introduces us to a woman early in her third pregnancy. It shows some of the challenges pregnant women and their families encounter, and the numerous, and at times, unplanned, pathways they follow towards the birth of a child.
Kay, aged 37, and her partner Richard, aged 40, live in Auckland. They are expecting a baby. Kay has two children from a previous relationship—Scotty, aged 8, and Oliver, aged 6, both born at term, in hospital. Early in this pregnancy Kay and Richard chose a midwife as their lead maternity carer. They are hoping that they may be able to have a homebirth.
All progressed well until at 33 weeks Kay’s waters broke and she went into spontaneous labour. She was admitted to the maternity unit. Her baby was born vaginally, weighing 1875 grams, and was transferred to the neonatal special care nursery.
The context of maternity care in Australia and New Zealand
Kay and Richard had health provider options available to support Kay’s pregnancy and were in a position to make a choice. Service organisations in New Zealand and Australia are quite distinct.
In New Zealand, the maternity system requires a woman to choose a health professional to be her Lead Maternity Carer (LMC), and in some areas this person may be a midwife, a general practitioner or an obstetrician. Rural areas and some provincial towns do not have all these types of practitioners available to provide LMC, so the choice is limited for those women. However, currently over 80% of women choose a midwife as their LMC (Guilliland 2006).
The important principles underpinning maternity services in New Zealand include, first, a commitment to primary healthcare, provided in the home or hospital, and, second, continuity of care by a known/named caregiver through pregnancy, childbirth and the postnatal period to 4–6 weeks postpartum, supported by secondary and tertiary services (Ministry of Health New Zealand 2000, MidCentral Health District Health Board 2005). Further, maternity services are underpinned by the key principles of informed decision making and informed consent.
In Australia, private and public maternity health service options are available. Women may attend for antenatal care with their general practitioner or at a health service such as a local hospital or clinic. Many health services offer midwifery-led care, but this varies from service to service and state to state. Women may choose to contract a midwife working in private practice for their maternity care, but at a cost to themselves.
While options for midwifery-led care have expanded, equitable access to one-to-one maternity care is not available for all women, a situation that has led to a number of political actions. For example, Maternity Coalition has developed a National maternity action plan for the introduction of services in rural and regional Australia (www.maternitycoalition.org.au/), and, more recently, a review of birthing services in Queensland has highlighted the need for maternity care reform in Australia (Hirst 2005). There is research evidence that this one-to-one kind of service by a known health professional provides clear benefits for women during pregnancy and childbirth, an issue which is discussed further later in this chapter (Hodnett 2000, Hildingsson et al. 2002).
Hospital or home: an issue of safety?
For Kay and Richard, the place of birth for their baby was important. After two uncomplicated hospital births, Kay and Richard planned a birth at home with a midwife as LMC provider. However, the early labour required a change of plan.
Looking back to the early 1900s, most women in New Zealand and other parts of the world gave birth at home (Banks 2000, Tew 1990). The rise of public health initiatives and health surveillance led to, first, antenatal clinics and lying-in wards and, finally, the normalisation of hospital as the safe place to give birth. The notion of the hospital as a safe birthing place has been critiqued (Tew 1990). In the 1990s, a number of studies examined the relative safety of birth settings (Bateman et al. 1994, Berghs et al. 1995, Truffert et al. 1998, Waldenstrom & Nilsson 1997). A recent systematic review regarding home/homelike versus hospital or conventional institutional settings for birth concluded that homelike settings were associated with reduced medical interventions and increased maternal satisfaction. They did warn however that ‘caregivers and clients should be vigilant for signs of complications’ (Hodnett et al. 2005 p. 1).
The important points from the Hodnett et al. (2005) review indicate that women labour better and are more satisfied with the outcomes and the care received when in homelike settings. Homelike settings were described as relaxed, where there were no routine interventions, dress code or expectations. Women were able to move around freely and adopt any position they wished. Continuity of carer is also important in this setting, with no time constraints such as those imposed by institutions with strict protocols.
One of the advantages of homebirth settings over homelike settings is that the woman is in her own home and the professional is a guest, who decides when she needs to hand over or transfer care. The midwife also attends when the woman decides she wants her to do so. This kind of environment means there are fewer interventions and the woman is not constrained to ‘perform’ according to a specified timeline. Debate continues on this issue and looks set to do so for some time yet. To explore further the issue of continuity, see Box 6.1.
Box 6.1
The terms ’continuity of care‘ and ’continuity of caregiver‘ have been differentiated by some practitioners as being equally acceptable or meaning the same thing. However, an examination of the extant literature reveals some subtle differences. Continuity of care would be the care provided by different caregivers, but with a good overview of the woman’s history and pregnancy to date through the use of clinical records (Medical Records Institute 2006), while continuity of caregiver is defined as care provided by one person or a small group of caregivers through the maternity or illness experience (Haggerty et al. 2003).
Other terms used to describe this relationship were found by Haggerty et al. who were commissioned by the Canadian health services and policy research bodies to develop a common understanding of the concept of continuity. The additional terms include ‘longitudinality’, ‘relational’ or ‘personal continuity’ (p. 1219). Buetow (2004) borrowed the terms ‘informational continuity’ and ‘relational or interpersonal continuity’ from Haggerty et al. (2003), but challenged the fact that continuity of caregiver is focused on the one carer who is usually a health professional rather than on all those involved in care, such as family members, who will ask questions on behalf of, listen to information provided and provide ongoing supportive care in the absence of the health professional.
There is good evidence (Hodnett 2000, Hildingsson et al. 2002) that continuity of caregiver does make a positive difference to women’s attendance of antenatal classes, their use of analgesia in labour and the resuscitation required by their newborns. However, Hodnett (2000) does indicate that it is not clear from the two major studies that were included in the systematic review undertaken whether the differences were due to continuity of caregiver or the fact that the caregiver was a midwife. Hildingsson et al. (2002) in their survey of Swedish women attending for antenatal care found that the 91% of women who responded (N = 3061) appreciated the system of continuity of midwife carer during pregnancy.
Critical question: barriers and restraints
1. As continuity of carer is considered to have positive impacts on the health and wellbeing of women and their families, what are the barriers and constraints to implementing such care in mainstream maternity services?
Health promotion during pregnancy
Promoting a woman’s health in pregnancy influences perinatal outcomes and antenatal care has become a central focus of professional support for pregnant women and their families. However, antenatal care is a twentieth century phenomenon, which was first introduced by means of pro-maternity hospitals set up by Dr JW Ballantyne for women who were ill and tired in pregnancy, but primarily for doctors to learn more about the mother and fetus during pregnancy (Tew 1990).
The first outpatient clinic for pregnant women was established in 1911 in the United States, followed by similar clinics in Britain in 1915 and later in other parts of the world. Antenatal care from the 1960s onwards was seen as a means of reducing and preventing fetal death and handicap, rather than reducing maternal mortality.
The World Health Organization (2005) recommends that effective and appropriate antenatal care be offered to all women; however, it questions some of the practices and interventions included. Some interventions offered to women with a low-risk pregnancy are not effective, while many others have not been evaluated, such as the timing and type of antenatal visits that may be most effective (Enkin et al. 2000).
Antenatal care has been cited as ritualistic rather than rational (Enkin et al. 2000). One systematic review of literature concerning antenatal visiting patterns suggests that while a smaller number of visits may be more effective than the number traditionally suggested, women are less satisfied with less rather than more (Villar et al. 2001, Villar & Khan-Neelofur 2001). In Box 6.2, selected evidence-based practices are described.
Box 6.2
• Attend for antenatal care regularly. However, the schedule of appointments should be individualised and have a specific focus rather than just following a routine schedule (National Collaborating Centre for Women’s and Children’s Health 2003).
• Women-held antenatal records improves clinical safety, wellbeing and women’s sense of control (Brown & Smith 2004, Elbourne et al. 1987, Homer et al. 1999).
• Women should be informed of the symptoms of advanced pre-eclampsia, such as any visual disturbances, epigastric pain, vomiting and increasing oedema, and the need to report them early to their care provider (National Collaborating Centre for Women’s and Children’s Health 2003).
• Screen for risk factors for pre-eclampsia at the first antenatal visit and schedule visits according to identified risks (National Collaborating Centre for Women’s and Children’s Health 2003).
• Women should be encouraged to report decreased movements to their healthcare provider. However, there is no evidence that routine monitoring of fetal movements prevents late fetal deaths (National Collaborating Centre for Women’s and Children’s Health 2003). A systematic review is currently being undertaken by Mangesi and Hofmeyr (2004 p. 2)‘to assess the outcome of pregnancy when fetal movement is done routinely, selectively, or not at all and using various methods’.
• Symphysis–fundal height should be measured and plotted at each antenatal appointment (National Collaborating Centre for Women’s and Children’s Health 2003). This is a recommended method of assessing fetal growth, as opposed to the formerly used method of routine weighing of pregnant women.
Preconception and pregnancy health
Ideally, women and their partners will consider their health and lifestyle prior to pregnancy. The aim of preconception health and care is to identify and if possible modify biomedical, behavioural and social risks to a woman’s health and prospective pregnancy (Centers for Disease Control 2006). The focus of preconception care is to screen for risks, engage in health promotion and education, and intervene when risks are identified (Centers for Disease Control 2006).
The key areas of concern during the preconception period include:
» management of existing disorders (e.g. diabetes)
» screening and vaccination, if necessary, against rubella
» folic acid supplementation to reduce the risk of neural tube defects
» smoking cessation counselling, to reduce the risk of low birth weight and other adverse perinatal outcomes
» recommending abstinence from alcohol to prevent fetal alcohol syndrome and other alcohol-related birth defects
» review of medication use, and
» sexually transmitted disorders screening to reduce risks to mother and fetus (Centers for Disease Control 2006).
Preconception care helps ensure that the woman entering pregnancy is in good health with as few risk factors as possible, which will optimise maternal and perinatal outcomes (Moos 2003). However, the majority of women receive fragmented care throughout the childbearing period and often will only attend for care when there are signs of a pregnancy. Moos (2003) suggests a continuum model of integrated care for women, where health providers build on what is learned about a woman’s health and integrate health promotion opportunistically, prior to pregnancy. In this model, all women who are of reproductive age benefit from care and information that will influence their health at the time of a pregnancy. Cullum (2003) suggests that preconception refers to that time when a woman is fertile, but not pregnant, widening the potential for healthcare and health promotion among women prior to pregnancy.
Why health and wellbeing in, before and during pregnancy is important
At the heart of preconception and pregnancy care is the proposition that optimising the health of mother and fetus will influence not only perinatal outcomes, but also the infant’s health in adult life. Important to this understanding is the influence of social as well as physical health during the reproductive years. The practice highlight in Box 6.3 describes two selected health issues for women to consider before and during pregnancy.
Box 6.3
Substance use in pregnancy
The use of substances such as alcohol, nicotine via cigarette smoking or nicotine patch or gum use, or other toxins via marijuana smoking or the use of other illegal or prescribed drugs, is considered potentially harmful to the developing baby. The fetus is also particularly vulnerable during the first 3–8 weeks of pregnancy, and may be at risk of being born preterm or of low birth weight. These babies may also suffer from drug withdrawal and conditions known as fetal alcohol syndrome (FAS) or to a lesser extent a range of effects grouped under the term fetal alcohol spectrum disorder (FASD) and/or fetal tobacco syndrome, which will affect their long-term cognitive abilities and behaviours. Substance use and abuse often leads to poor nutrition in pregnancy (Parackal 2003). In the case of alcohol abuse, this may be because of the energy derived from the alcohol or because of economic or lifestyle constraints related to a high alcohol intake.
Folate in pregnancy and breastfeeding
Folate is a generic term applied to dietary sources of related compounds involved in the metabolism of nucleic and amino acids. They are expressed as Dietary Folate Equivalents (DFE), which includes folate from food and folic acid which is a synthetic form of folate (Ministry of Health New Zealand 2006). Folates are especially important during pregnancy and breastfeeding when nucleotide synthesis and cell division are occurring, and have been associated with a decrease in the incidence of neural tube defects, the most common congenital abnormality (Boddie et al. 2000).
Critical questions: smoking cessation
1. Review the literature related to smoking cessation in pregnancy.
2. Which strategies have been successful and which have not been so successful?
The way in which social and physical health are interrelated is highlighted through an understanding of the fetal origins hypothesis. Proposed by Barker in 1998, this hypothesis suggests that infants born following fetal growth retardation and, therefore, of low birth weight, are at increased risk for developing cardiovascular and diabetic disease later in life (Barker 2003). In addition to biophysical factors, there are many social determinants of low birth weight, and thus the importance of health promoting activities focused on healthy pregnancy are made clear.
Spencer (2000 p. 194) suggests:
‘… the birth weight of an infant reflects quality of the fetal environment and the length of gestation, which are influenced by intergenerational, genetic, constitutional, dietary and lifestyle factors. It is a pivotal point in the life-course continuum reflecting maternal health and predicting future health in childhood and adulthood.’
Such interconnected factors influence the fetal and early childhood environment and may provide protection or place the child at risk.
Pregnancy is a time when opportunities for health promotion present themselves, not only for the woman and family in this pregnancy and birth, but also for long-term health. One strategy used to frame this health promotion has been antenatal education.
Antenatal education
Nolan (1997) suggests that antenatal education is not new—women previously and still do learn about pregnancy and birth from their female relatives and friends. Nolan (1997) suggests that antenatal education is an artificial construct aiming to replace the knowledge and insights traditionally transmitted among women. This replacement has, however, not been entirely successful.
Antenatal classes have traditionally focused on preparing the couple or woman for labour and birth, but new parents are increasingly voicing their concerns about the lack of preparation for actual parenting—the most important and long-term role that results from a pregnancy (Ho & Holroyd 2002). While antenatal education is constantly evaluated and changing, much of the class time is spent covering topics such as pain management and obstetric interventions.
In addition, the needs of young teenage mothers and sometimes their partners may not be addressed through mainstream antenatal classes, as they are often aimed at older women in partnered relationships. The classes, and the teachers, need to be innovative and flexible so as to be able to address the needs of individuals and couples as they arise over the course of the classes. However, despite many decades of development in the field of antenatal education, the effects of general antenatal education for childbirth and/or parenthood remain unknown (Gagnon 2000, World Health Organization 2005).
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