Exploring the process of implementing a smoking cessation intervention in pregnancy training program for midwives

The question of how to implement evidence effectively reveals a deficiency in our knowledge and understanding of the compound factors involved in such a process (Kitson, Rycroft-Malone et al. 2008). Although there is some awareness of the complexities of the process, there has been little exploration of the effectiveness of implementing evidence-based programs in health care. Despite public awareness of the dangers of smoking in pregnancy, and widespread public health measures to prevent smoking-related disease, women still continue to smoke in pregnancy (Ananth, Savitz et al. 1997; Laws and Hilder 2008). Evaluation of public health measures concludes that smoking cessation interventions during pregnancy increase quit rates among pregnant women (Melvin, Dolan-Mullen et al. 2000; Albrecht, Maloni et al. 2004; Lumley, Oliver et al. 2007). Notwithstanding the potential for improvement in health outcomes for pregnant women and their unborn babies, smoking interventions are often conducted poorly or not at all. Although midwives understand why women smoke in pregnancy and parenthood and are aware of the risks of smoking to both the pregnancy and the unborn child, they require specific knowledge and skills in the provision of support and advice on smoking for pregnant women (Bull and Whitehead 2006) . Organisational-change research demonstrates the complexity of the process of planned change in professionalised institutions such as health care (Greenhalgh, Robert et al. 2005). Some innovations and interventions are never accepted, and others are poorly supported (Greenhalgh, Robert et al. 2004). Comprehension of the change process around health promotion is crucial to the implementation of new health promotion interventions within health care (Riley, Taylor et al. 2003). This study utilised a case study approach to explore the process of implementing a smoking cessation training program for midwives in Queensland metropolitan and regional clinical areas, who attended a ‘Train-the-Trainer program’. The study draws on the organisational change work of Greenhalgh et al (2004) as the theoretical framework through which situational and structural factors are explored and examined as they inform the implementation of smoking cessation programs. The research data constituted staged interviews with midwives who instituted training programs for midwives, as well as organisational and policy documentation. Analysis of the data identified some areas that were not fully addressed in the theoretical model; these formed the basis of the Discussion and Implications for Future Research.

Screening for alcohol and drug use in pregnancy

Objective - this study examined the clinical utility and precision of routine screening for alcohol and other drug use among women attending a public antenatal service. Study design - a survey of clients and audit of clinical charts. Participants and setting - clients attending an antenatal clinic of a large tertiary hospital in Queensland, Australia, from October to December 2009. Measurements and findings - data were collected from two sources. First, 32 women who reported use of alcohol or other drugs during pregnancy at initial screening were then asked to complete a full substance use survey. Second, data were collected from charts of 349 new clients who attended the antenatal clinic during the study period. Both sensitivity (86%, 67%) and positive predictive value (100%, 92%) for alcohol and other drug use respectively, were high. Only 15% of surveyed women were uncomfortable about being screened for substance use in pregnancy, yet the chart audit revealed poor staff compliance. During the study period, 25% of clients were either not screened adequately or not at all. Key conclusions and implications for practise - despite recommended universal screening in pregnancy and the apparent acceptance by our participants, alcohol and other drug (A&OD) screening in the antenatal setting remains problematic. Investigation into the reasons behind, and ways to overcome, the low screening rate could improve health outcomes for mothers and children in this at-risk group. Targeted education and training for midwives may form part of the solution as these clinicians have a key role in implementing prevention and early intervention strategies.

Exercise in obese pregnant women: The role of social factors, lifestyle and pregnancy symptoms

Background Physical activity may reduce the risk of adverse maternal outcomes, yet there are very few studies that have examined the correlates of exercise amongst obese women during pregnancy. We examined which relevant sociodemographic, obstetric, and health behaviour variables and pregnancy symptoms were associated with exercise in a small sample of obese pregnant women. Methods This was a secondary analysis using data from an exercise intervention for the prevention of gestational diabetes in obese pregnant women. Using the Pregnancy Physical Activity Questionnaire (PPAQ), 50 obese pregnant women were classified as "Exercisers" if they achieved ≥900 kcal/wk of exercise and "Non-Exercisers" if they did not meet this criterion. Analyses examined which relevant variables were associated with exercise status at 12, 20, 28 and 36 weeks gestation. Results Obese pregnant women with a history of miscarriage; who had children living at home; who had a lower pre-pregnancy weight; reported no nausea and vomiting; and who had no lower back pain, were those women who were most likely to have exercised in early pregnancy. Exercise in late pregnancy was most common among tertiary educated women. Conclusions Offering greater support to women from disadvantaged backgrounds and closely monitoring women who report persistent nausea and vomiting or lower back pain in early pregnancy may be important. The findings may be particularly useful for other interventions aimed at reducing or controlling weight gain in obese pregnant women.

Who carries the can? Alcohol and pregnancy

This paper examines legal aspects related to the damage of the foetus in utero and discusses who might have some responsibility for ensuring a healthy outcome. In 2008 the legal ramifications of damage to a foetus were investigated and Australian National Guidelines on alcohol consumption were passed recommending abstention during pregnancy.

Women, alcohol and pregnancy

This paper examines a history of knowledge from Greek times regarding the possible teratogenic effect of alcohol. Literature on the topic up to the early 1980s is included and some recommendations are suggested.

Pregnancy losses in young Australian women : findings from the Australian Longitudinal Study on Women's Health

INTRODUCTION: Little research has examined recognized pregnancy losses in a general population. Data from an Australian cohort study provide an opportunity to quantify this aspect of fecundity at a population level. METHOD: Participants in the Australian Longitudinal Study on Women's Health who were aged 28-33 years in 2006 (n = 9,145) completed up to 4 mailed surveys over 10 years. Participants were categorized according to the recognized outcome of their pregnancies, including live birth, miscarriage/stillbirth, termination/ectopic, or no pregnancy. RESULTS: At age 18-23, more women reported terminations (7%) than miscarriages (4%). By 28-33 years, the cumulative frequency of miscarriage (15%) was as common as termination (16%). For women aged 28-33 years who had ever been pregnant (n = 5,343), pregnancy outcomes were as follows: birth only (50%); loss only (18%); and birth and loss (32%), of which half (16%) were birth and miscarriage. A comparison between first miscarriage and first birth (no miscarriage) showed that most first miscarriages occurred in women aged 18-23 years who also reported a first birth at the same survey (15%). Half (51%) of all first births and first miscarriages in women aged 18-19 ended in miscarriage. Early childbearers (<28 years) often had miscarriages around the same time period as their first live birth, suggesting proactive family formation. Delayed childbearers (32-33 years) had more first births than first miscarriages. CONCLUSION: Recognized pregnancy losses are an important measure of fecundity in the general population because they indicate successful conception and maintenance of pregnancy to varying reproductive endpoints.

Challenges for researchers investigating contraceptive use and pregnancy intentions of young women living in urban and rural Australia : face-to-face discussions to increase participation in a web-based survey

Background: It is imperative to understand how to engage young women in research about issues that are important to them. There is limited reliable data on how young women access contraception in Australia especially in rural areas where services may be less available. Objective: This paper identifies the challenges involved in engaging young Australian women aged 18-23 years to participate in a web-based survey on contraception and pregnancy and ensure their ongoing commitment to follow-up web-based surveys. Methods: A group of young women, aged 18-23 years and living in urban and rural New South Wales, Australia, were recruited to participate in face-to-face discussions using several methods of recruitment: direct contact (face-to-face, telephone or email)and snowball sampling by potential participants inviting their friends. All discussions were transcribed verbatim and analyzed using thematic analysis. Results: Twenty young women participated (urban, n=10: mean age 21.6 years; rural, n=10: 20.0 years) and all used computers or smart phones to access the internet on a daily basis. All participants were concerned about the cost of internet access and utilized free access to social media on their mobile phones. Their willingness to participate in a web-based survey was dependent on incentives with a preference for small financial rewards. Most participants were concerned about their personal details and survey responses remaining confidential and secure. The most appropriate survey would take up to 15 minutes to complete, be a mix of short and long questions and eye-catching with bright colours. Questions on the sensitive topics of sexual activity, contraception and pregnancy were acceptable if they could respond with “I prefer not to answer”. Conclusions: There are demographic, participation and survey design challenges in engaging young women in a web-based survey. Based on our findings, future research efforts are needed to understand the full extent of the role social media and incentives play in the decision of young women to participate in web-based research.

Drugs in pregnancy and labour

27. Drugs in pregnancy and labour 27.1 Introduction 27.2 Common complaints in pregnancy and labour and their treatments 27.2.1 Pre-eclampsia and eclampsia. 27.2.2 Suppression of early labour 27.2.3 Neonatal respiratory distress syndrome 27.2.4 Postpartum haemorrhage 27.2.5 Prolactin excess 27.2.6 Nausea

A prospective study of pregnancy weight gain in Australian women

Background: While weight gain during pregnancy is regarded as important, there has not been a prospective study of measured weight gain in pregnancy in Australia. This study aimed to prospectively evaluate pregnancy-related weight gain against the Institute of Medicine (IOM) recommendations in women receiving antenatal care in a setting where ongoing weight monitoring is not part of routine clinical practice, to describe women's knowledge of weight gain recommendations and to describe the health professional advice received relating to gestational weight gain (GWG). Methods: Pregnant women were recruited ≤20 weeks of gestation (n = 664) from a tertiary obstetric hospital between August 2010 to July 2011 for this prospective observational study. Outcome measures were weight gain from pre-pregnancy to 36 weeks of gestation, weight gain knowledge and health professional advice received. Results: Thirty-six percent of women gained weight according to guidelines. Twenty-six percent gained inadequate weight, and 38% gained excess weight. Fifty-six percent of overweight women gained weight in excess of the IOM guidelines compared with 30% of those who started with a healthy weight (P < 0.001). At 16 weeks, 47% of participants were unsure of the weight gain recommendations for them. Sixty-two percent of women reported that the health professionals caring for them during this pregnancy ‘never’ or ‘rarely’ offered advice about how much weight to gain. Conclusions: The prevalence of inappropriate gestational weight gain in this study was high. The majority of women do not know their recommended weight gain. The advice women received from health professionals relating to healthy weight gain in pregnancy could be improved.

Improving health behaviours during pregnancy: A new direction for the pregnancy handheld record

Obstetric documentation processes may influence the clinical, behavioural, and psychological outcomes of pregnancy, although recent alterations to integrate obstetric documentation with pregnancy handheld records have been unsuccessful. Woman-held records as a companion to usual obstetric documentation have the potential to improve pregnancy-related health behaviours with a demonstrated association with maternal and infant health outcomes, and recommendations for their format and content are provided.

Pregnancy as public property: The experience of couples following diagnosis of a foetal anomaly

Background: Pregnant women find themselves subject to comments and questions from people in public areas. Normally, becoming ‘public property’ is considered friendly and is relatively easy for pregnant women to deal with. However, following diagnosis of a fetal anomaly, the experience of being public property can exacerbate the emotional turmoil experienced by couples. Original research question: What is the experience of couples who continue pregnancy following the diagnosis of a fetal anomaly? Method: The study used an interpretive design informed by Merleau-Ponty and this paper reports on a subset of findings. Thirty-one interviews with pregnant women and their partners were undertaken following the diagnosis of a serious or lethal fetal anomaly. Women were between 25 and 38 weeks gestation at the time of their first interview. The non-directive interviews were audiotaped, transcribed verbatim and the transcripts were thematically analysed. Findings: A prominent theme that emerged during data analysis was that pregnancy is embodied therefore physically evident and ‘public’. Women found it difficult to deal with being public property when the fetus had a serious or lethal anomaly. Some women avoided social situations; others did not disclose the fetal condition but gave minimal or avoidant answers to minimise distress to themselves and others. The male participants were not visibly pregnant and they could continue life in public without being subject to the public’s gaze, but they were very aware and concerned about its impact on their partner. Conclusion: The public tend to assume that pregnancy is normal and will produce a healthy baby. This becomes problematic for women who have a fetus with an anomaly. Women use strategies to help them cope with becoming public property during pregnancy. Midwives can play an important role in reducing the negative consequences of a woman becoming public property following the diagnosis of a fetal anomaly.

Postpartum diet quality in Australian women following a gestational diabetes pregnancy

BACKGROUND/OBJECTIVES: To describe the diet quality of a national sample of Australian women with a recent history of gestational diabetes mellitus (GDM) and determine factors associated with adherence to national dietary recommendations. SUBJECTS/METHODS: A postpartum lifestyle survey with 1499 Australian women diagnosed with GDM p3 years previously. Diet quality was measured using the Australian recommended food score (ARFS) and weighted by demographic and diabetes management characteristics. Multinominal logistic regression analysis was used to determine the association between diet quality and demographic characteristics, health seeking behaviours and diabetes-related risk factors. RESULTS: Mean (±s.d.) ARFS was 30.9±8.1 from a possible maximum score of 74. Subscale component scores demonstrated that the nuts/legumes, grains and fruits were the most poorly scored. Factors associated with being in the highest compared with the lowest ARFS quintile included age (odds ratio (OR) 5-year increase=1.40; 95% (confidence interval) CI:1.16–1.68), tertiary education (OR=2.19; 95% CI:1.52–3.17), speaking only English (OR=1.92; 95% CI:1.19–3.08), being sufficiently physically active (OR=2.11; 95% CI:1.46–3.05), returning for postpartum blood glucose testing (OR=1.75; 95% CI:1.23–2.50) and receiving riskreduction advice from a health professional (OR=1.80; 95% CI:1.24–2.60). CONCLUSIONS: Despite an increased risk of type 2 diabetes, women in this study had an overall poor diet quality as measured by the ARFS. Women with GDM should be targeted for interventions aimed at achieving a postpartum diet consistent with the guidelines for chronic disease prevention. Encouraging women to return for follow-up and providing risk reduction advice may be positive initial steps to improve diet quality, but additional strategies need to be identified.

The role of Ureaplasma urealyticum in adverse pregnancy outcome

We investigated Ureaplasma urealyticum genital tract colonisation rates in an Australian population to determine whether colonisation was associated with adverse pregnancy outcome. Women attending an antenatal clinic were evaluated for lower genital tract colonisation at their first antenatal visit (162 women) and at 28 weeks gestation (120 women). Placentas from 92 women were cultured. U. urealyticum was the predominant isolate from the lower (57.4%) and upper (17.4%) genital tract in this population of pregnant women. U. urealyticum was a persistent coloniser during mid-trimester of pregnancy (in 88% of women colonised) whereas M. hominis, G. vaginalis, and Group B streptococcus were present as transient flora of the lower genital tract. Lower genital tract colonisation during pregnancy was not directly associated with adverse pregnancy outcome. However preterm delivery in afebrile, asymptomatic women, could possibly be associated with chorioamnionitis (four of 16 preterm births). Screening of women with a history of preterm birth may prevent upper genital tract infections and preterm delivery.

Estimating vulnerable windows of exposure to air pollution during pregnancy

Exposure to air pollution during pregnancy is a potential cause of adverse birth outcomes such as preterm birth and stillbirth. The risk of exposure may be greater during vulnerable windows of the pregnancy which might only be weeks long. We demonstrate a method to find these windows based on smoothing the risk of weekly exposure using conditional autoregression. We use incidence density sampling to match cases with adverse birth outcomes to controls whose gestation lasted at least as long as the case. This matching means that cases and controls are have equal length exposure periods, rather than comparing, for example, cases with short gestations to controls with longer gestations. We demonstrate the ability of the method to find vulnerable windows using two simulation studies. We illustrate the method by examining the association between particulate matter air pollution and stillbirth in Brisbane, Australia.