Marina Weckend

Background: Physiological plateaus (slowing, stalling, pausing) during normal labor and birth have been reported for decades, but have received limited attention in research and clinical practice. To date, heterogeneous conceptualizations and terminology have impeded effective communication and research in this area, raising concern as to whether some physiological plateaus might be misinterpreted as dystocia. To address this issue, we provide a point of orientation, mapping contemporary concepts, and terminologies of physiological plateaus during normal labor and birth.

Methods: We conducted a scoping review, considering published and unpublished reports of physiological plateaus, reported in any language, between 1990 and 2021. Database searches of CINAHL, EMBASE, Emcare, MIDIRS, MEDLINE, Scopus, and Open Grey yielded 1,953 records, with an additional 35 reports identified by hand searching. In total, 43 reports from eleven countries were included in this scoping review.

Results: Conceptualizations of physiological plateaus are heterogeneous and can be allocated to six conceptual groups: cervical reversal or recoil, plateaus, lulls during transition, "rest and be thankful" stage, deceleration phase, and latent phases. Across included material, we identified over 60 different terms referring to physiological plateaus. Overall, physiological plateaus are reported across the entire continuum of normal labor and birth.

Conclusions: Physiological plateaus may be an essential mechanism of self-regulation of the mother-infant dyad, facilitating feto-maternal adaptation and preventing maternal and fetal distress during labor and birth.

Objective: In this scoping review, contemporary concepts and definitions of phenomena during normal labor and birth, wherein the process appears to plateau (slow, stall, or pause) but remains within physiological limits, will be mapped.

Introduction: During labor and birth, it is frequently perceived as pathological if contractions, cervical dilation, or fetal descent plateau. However, there is evidence to suggest that some plateaus during labor may be physiological, and a variety of concepts and terms refer to this phenomenon. Where a physiological plateau is perceived as pathological arrest, this may contribute to undue interventions, such as augmentation of labor. Therefore, it is important to advance understanding of physiological labor patterns, including potentially physiological labor plateaus.

Inclusion criteria: Publications mentioning any plateaus of the processes of normal human labor and birth will be considered. This may also include phenomena where labor is perceived to “reverse,” for example, a closing cervix or a rise of the presenting fetal part. Publications where plateaus are defined as pathological will be excluded.

Methods: All types of evidence, published and unpublished, will be considered. The search strategy will be applied to the databases MEDLINE, Embase, MIDIRS, Emcare, CINAHL, and Scopus, and will be limited to the past 30 years. Gray literature will be searched via Open Grey, reference list screening, and contacting authors. Data extraction will comprise information on concept boundaries, terminology, precedents, consequences, concept origin, and types of evidence that report this phenomenon. Results will be presented in tabular, diagrammatical, and narrative manner.

In this article, I explore norms around what is considered "normal" during healthy childbirth, and how these norms affect our everyday practice. 

Background: Currently, maternity care in Germany is experiencing a major structural transition. A continuous rise of liability insurance fees as well as an increasing centralisation and privatisation of maternity care have triggered a shortage of health service coverage in many places. At the same time, an individualization of care in terms of family-centredness has been protracted.

Aims: This study aims to identify a) the most prominent shortcomings that women describe in their care experience and b) the areas of care where a daily commitment shows a particularly positive effect.

Methods: The study is a part of the Babies Born Better (B3) User Survey. It is a mixed-method online-survey based on convenience sampling. Currently, the survey is available in 23 languages and is represented through country coordinators in 31 countries. The German language version of the survey was launched on 1st March 2014 and since then continuously collects data. German data from the first six months was analysed using descriptive statistics, bivariable associations and geo-mapping.

Results: The German language sample counted 3,050 responses in the first six months of data collection. Respondents particularly valued the availability of their midwife and the time that the midwife spent with them (40.6%, n=1,002) as well as the extent of personal autonomy, which they were able to maintain (36.3%, n=897). Furthermore, the overall care experience was positively influenced by the provision of antenatal care through midwives (5.4%, n=133) and by the involvement of an independent midwife for birth (6.5%, n=160). Exclusively positive accounts of care were associated with multiparity (χ²=25.70, df=4, p<0.001), uncomplicated pregnancy (χ²=12.37, df=1, p<0.001) and out-of-hospital birth (χ²=85.968, df=4, p<0.001). Major critique was voiced with respect to a lack of midwives, particularly in community services (7.1%, n=175) and an inadequate inter-professional collaboration (7.7%, n=191).

Relevance: Due to the convenience sample the generalizability of findings is limited. The sample significantly over-represents the views of women who gave birth in an out-of-hospital setting. With this in mind, the B3 User Survey in Germany reflects the current crisis in health and maternity services with a continuously declining availability of community care. The themes, which women highlighted as being important for a positive care experience are well described in the literature and centre in the provision of a safe and calm atmosphere. However, this is rarely achieved due to staff shortages, insufficient continuity of care in hospital settings and radical cuts in community care. Already, some regions face a significant shortage or a complete lack of maternity services. Through this situation the freedom of choice of the place and the circumstances of birth is severely violated.

Recommendations: To halt the continuing incapacitation of women and their families, the maintenance of community health services and the improvement of inter-professional collaboration are mandatory. Furthermore, health professionals of all occupational groups are encouraged to foster a secure and calm atmosphere of care. This can only succeed, if health care systems recognize the individuality of women and families.

This study explored the mechanisms behind the formation of a positive care experience for women who accessed maternity care. The non-probability sample comprised 2921 women, aged 18-52, who had given birth in the past five years. Participants self-administered a mixed-method online-questionnaire and returned demographic data and free text comments about positive and negative attributes of their care encounters. Data analysis comprised descriptive statistics, bivariate exploration of relationships, geo-mapping for Germany and
Austria and thematic framework analysis of qualitative data. In addition, a post hoc rating was performed to identify exclusively positive care encounters. 23% (n=581) of respondents described their care in exclusively positive terms. The overall care experience of respondents was most prominently affected by the availability (40.6%, n=1002) and empathy (11.1%, n=275) of the care professional and the personal degree of autonomy (36.3%, n=897). A high satisfaction with care was associated with multiparity (χ²=25.706, df=4, p<0.001), uncomplicated pregnancy (χ²=12.369, df=1, p<0.001) and birth in a birth centre (χ²=85.968, df=4, p<0.001). Individual aspects of a positive care encounter were interrelated and cumulated in the essential feelings of safety and calm. To increase the care satisfaction and long term health of women and families it is recommended to foster family-centred care, facilitate midwifery in community settings and orientate legislation and policy on salutogenic principle.

Aim: This paper explores the concept of migrant women as used in European healthcare literature in context of pregnancy to provide a clearer understanding of the concept for use in research and service delivery.

Methods: Walker and Avant's method of concept analysis.

Results: The literature demonstrates ambiguity around the concept; most papers do not provide an explicit or detailed definition of the concept. They include the basic idea that women have moved from an identifiable region/country to the country in which the research is undertaken but fail to acknowledge adequately the heterogeneity of migrant women. The paper provides a definition of the concept as a descriptive theory and argues that research must include a clear definition of the migrant specific demographics of the women. This should include country/region of origin and host, status within the legal system of host country, type of migration experience, and length of residence.

Conclusion: There is a need for a more systematic conceptualization of the idea of migrant women within European literature related to pregnancy experiences and outcomes to reflect the heterogeneity of this concept. To this end, the schema suggested in this paper should be adopted in future research.

[German language article]

Obgleich es keine verlässlichen Zahlen darüber gibt, wie viele Frauen während ihrer Flucht schwanger sind, schätzen Mitarbeiter der Organisation Ärzte ohne Grenzen ihren Anteil entlang europäischer Eintrittsrouten auf bis zu 30%. Dieser Beitrag beleuchtet, welche Besonderheiten bei der Gesundheitsversorgung von Frauen auftreten, die im Verlauf ihrer Flucht schwanger sind oder ein Kind zur Welt bringen.

[German language article]

Weltweit befinden sich gegenwärtig rund 15 Millionen Menschen auf der Flucht. Rund die Hälfte davon sind Frauen und Mädchen; ungefähr 41% sind Kinder. Dieser Beitrag beleuchtet einige Herausforderungen, die involvierten Berufsgruppen bei der Betreuung von geflüchteten Frauen und ihren Familien begegnen können. Es soll insbesondere aufgezeigt werden, welche Strukturen und Maßnahmen einen positiven Einfluss auf die Gesundheit von Familien mit Fluchthintergrund haben können.

In response to the Syrian war and other conflicts, a large number of refugees arrived in Germany in summer 2015. Unprepared for the arrivals, many communities had to set up emergency accommodation to bridge the time between their arrival and the allocation of permanent housing. In a remote camp with up to 1,700 residents, Marina Weckend set up a midwifery service to reach out directly to women and their families. The service was facilitated by the German Asylum Seekers' Benefit Act, which states that all maternity care, including referrals and prescriptions have to be accessible and free of charge for asylum seekers. In this article, Marina recounts the stories of three families whose experiences highlight the meaning and importance of health care access, acceptability and equity, particularly for women and families with a background of displacement.

Background: Cultural immersion as a learning activity provides students with the opportunity to experience diversity and develop cultural safety. Both, ‘Study Abroad Programs’ and ‘Internationalisation at Home’ (IaH) aim to provide a cultural immersion experience for students. However, explicit learning objectives are essential for quality pedagogy and for students to develop cultural safety from their learning experience.

Objective: To identify the learning objectives of study abroad and Internationalisation at Home (IaH) programs in higher education health profession programs.

Design: A scoping review was undertaken according to recommendations by the Joanna Briggs Institute (Peters et al., 2020) and PRISMA guidelines.

Data sources: The electronic databases CINAHL, MEDLINE, PsychINFO and PubMed and were searched in November 2019 and updated September 2020. The search was limited to qualitative studies, text and opinion pieces, English language, published between 2015 and 2019.

Review methods: Inclusion criteria using the participants, concept, and context (PCC framework) was utilised and search terms such as study abroad and Internationalisation at Home were combined with learning objectives to identify articles. The articles were screened for eligibility by title, abstract, and full text review by two independent reviewers. A data extraction tool was utilised to extract and synthesise data into categories that represent the core learning objectives of cultural immersion programs reviewed.

Results: Fourteen of the 66 initially identified studies were included in this scoping review. Qualitative synthesis yielded five broad categories of learning objectives used in cultural immersion programs: cultural competence, internationalisation, pedagogy, collegiality, and personal growth.

Conclusion: A minimum set of essential learning outcomes was derived from this review that will be of interest to developers and implementers of cultural immersion programs.

Around the world, midwives support women and families during an exciting and vulnerable time of their life. Although there are general aspects of midwifery, such as the support during labour and birth, the scope of practice differs greatly between countries and regions around the globe. The education of midwives also varies, with the aim to prepare aspiring midwives successfully for their work environment. Despite this, there might be a little (or larger) gap between what students are taught and what they will be confronted with as junior midwives. This chapter presents insights into midwifery practice and training in Germany and illustrates how junior midwives in Germany master the transition from student to midwife. The chapter will commence with some background information about Germany to provide the context to midwifery. It will then present the scope of maternity services and the variety of educational pathways which lead to registration as a midwife in Germany. At the end, one midwife illustrates her own transition process as a newly qualified midwife.

Background: Worldwide, 14.9 million infants (11%) are born preterm each year. Up to 40% of preterm births (PTBs) are associated with genital tract infections. The vaginal pH can reflect changes in the vaginal milieu and, if elevated, indicates an abnormal flora or infection.

Objective: The aim of the study was to investigate whether an increased antenatal vaginal pH >4.5 in pre-labour pregnant women is associated with an increased PTB rate <37 completed weeks gestation.

Search strategy: Key databases included SCOPUS, EMBASE, MEDLINE, PsycInfo and the Cochrane Central Register of Controlled Trials, complemented by hand search, up to January 2017.

Selection criteria: Primary research reporting vaginal pH assessment in pre-labour pregnant women and PTB rate.

Data collection and analysis: Data extraction and appraisal were carried out in a pre-defined standardised manner, applying the Newcastle-Ottawa scale (NOS) and Cochrane risk of bias tool. Analysis included calculation of risk difference (RD) and narrative synthesis. It was decided to abstain from pooling of the studies due to missing information in important moderators.

Main results: Of 986 identified records, 30 were included in the systematic review. The risk of bias was considered mostly high (40%) or moderate (37%). Fifteen studies permitted a calculation of RD. Of these, 14 (93%) indicated a positive association between increased antenatal vaginal pH and PTB (RD range: 0.02–0.75).

Conclusion: An increased antenatal vaginal pH >4.5 may be associated with a higher risk for PTB. It is recommended to conduct a randomised controlled trial (RCT) to investigate the effectiveness of antenatal pH screening to prevent PTB.

Objective: Worldwide, 14.9 million infants (11%) are born preterm (PTB) each year. Up to 40% of PTB are associated with genital tract infections. The vaginal pH can reflect changes in the vaginal milieu and, if elevated, indicates an abnormal flora or infection. The aim of this study is to investigate, whether an increased antenatal vaginal pH > 4.5 in pre-labour pregnant women is associated with an increased preterm birth rate < 37 completed weeks gestation.

Methods: Databases included SCOPUS, EMBASE, MEDLINE, PsycInfo and the Cochrane Central Register of Controlled Trials, complemented by hand search, up to January 2017. Selection criteria were primary research reporting vaginal pH assessment in pre-labour pregnant women and preterm birth rate. Data extraction and appraisal were carried out in a pre-defined standardised manner, applying the Newcastle-Ottawa Scale and Cochrane Risk of Bias tool. Analysis included calculation of risk difference (RD) and narrative synthesis. It was decided to abstain from pooling of the studies due to missing information in important moderators.

Results: Of 986 identified records, 30 were included in the systematic review. Risk of bias was considered mostly high (40%) or moderate (37%). Fifteen studies permitted a calculation of RD. Of these, fourteen (93%) indicated a positive association between increased antenatal vaginal pH and PTB (RD range: 0.02 – 0.75).

Conclusions: An increased antenatal vaginal pH > 4.5 may be associated with a higher risk for preterm birth. It is recommended to conduct an RCT to investigate the effectiveness of antenatal pH to prevent PTB.

No abstract available (protocol publication).