This week the Journal of Asian Midwives published our short article ‘Out-of-hospital births: A small but growing phenomenon in high income countries: A viewpoint‘ [1]. OOHBs (out-of-hospital births), is also referred to as freebirth (or freebirthing), unassisted childbirth and/or unassisted pregnancy [2]. OOHB does not refer to giving birth at home before the midwife arrives at a home birth or the birth taking place in an ambulance or along the side of the road on the way to a maternity unit, this is called ‘born before arrival’. OOHB suggests an element of planning of planning a birth without a midwife (or other maternity-care professional).
The paper in the Journal of Asian Midwives highlights that during the COVID-19 pandemic, OOHBs were a way to avoid Public Health regulations and lock-down constraints, and to guarantee the presence of a partner at the birth. The authors argue, however, that the pandemic is not at the origin of the trend, but more of a catalyst. Advocacy groups, maternity-service users’ groups, the media, and midwifery organisations in several high-income countries have in recent years underlined the growing criticism of existing maternity care and midwifery services and a long-term shortage of midwives. This is in addition to a longstanding trend in the United Kingdom of closing community-based hospitals, including small, free-standing midwife-led units.
Prof. Edwin van Teijlingen
Centre for Midwifery & Women’s Health
Reference:
Miani, C, Batram-Zantvoort, S, Pitchforth, E, Treadgold, B, Johnston, K, Rozée, V, MacDougall, C, Schantz, C, van Teijlingen, E. (2023) Out-of-hospital births: A small but growing phenomenon in high income countries: A viewpoint. Journal of Asian Midwives 10(2):77–78.
Rosie Harper and Malika Felton write for The Conversation about the physical changes that take place during pregnancy and childbirth and share advice on recovery.
After all the physical changes during pregnancy and following childbirth, many women are left wondering how to get active again and where to begin. Of course, activity after childbirth is an individual journey with multiple things to consider – and one of the first considerations may not be what you expect: your pelvic floor.
Your pelvic floor muscles sit at the base of the pelvis. The muscles form a hammock-like structure that supports the bladder, womb and bottom. As many as one in three women experience unwanted bladder leaks or vaginal prolapse in their lifetime and many of these symptoms can start during pregnancy or following childbirth. This is because this small muscle group takes the weight of the baby for nine months and may be stretched during vaginal delivery.
Your pelvic floor supports the bladder and vaginal tissues, helping bladder and bowel control and vaginal position. Recovery of these muscles prevents unwanted leaks, improves internal comfort and allows women to confidently increase activity.
This article is part of Women’s Health Matters, a series about the health and wellbeing of women and girls around the world. From menopause to miscarriage, pleasure to pain the articles in this series will delve into the full spectrum of women’s health issues to provide valuable information, insights and resources for women of all ages.
So focusing on your pelvic floor around pregnancy and postnatally can help you to recover more easily after childbirth and will allow you to get ready to be more active when you feel up to it.
If you’ve just given birth (or are about to) and you’re wondering where to start, here’s what you need to know:
1. Keep your poo soft
Straining on the toilet can overstretch the pelvic floor muscles which makes it harder for them to work properly. To avoid this you can keep your poo soft by drinking lots of water and increasing the fibre in your diet, such as high-fibre cereals, brown pasta and nuts.
Also, consider your position on the toilet. The use of a stool underneath your feet can make it easier to poo without straining as it helps to straighten the end of the bowel.
2. Get your pelvic floor moving
Squeezing and relaxing the pelvic floor muscles daily can improve blood flow to the area and speed up recovery following childbirth. This is because pelvic floor activity can improve the strength and function of the muscles to help bladder control and vaginal support.
The evidence shows that it usually takes a good three months of regular pelvic floor use to change symptoms – and every squeeze can make a difference. After a vaginal delivery and even after a c-section, the recovery time for the pelvic floor continues for up to one year.
One of the biggest problems with pelvic floor training is that women aren’t sure they are doing the exercises correctly and regularly forget to do the exercises.
To engage your pelvic floor muscles imagine you are holding in wind and trying to close the vaginal opening at the same time. You may feel a lifting and tightening inside of you. Try to breathe normally and relax other muscles like your tummy and buttocks.
To check you are doing it correctly, you can use a mirror to look at the area between your front and back passage. This area (the perineum) will move slightly up and inwards with a correct contraction. After each contraction, let your pelvic floor muscles fully relax. Pelvic health physiotherapists recommend squeezing your pelvic floor for ten seconds before relaxing for ten repetitions, followed by ten short squeezes. And to do this three times a day.
3. Let things settle and go gently
The pelvis and abdominal muscles also need time to recover from carrying a baby. Many women have a normal stretch and separation of their tummy muscles, which in a lot of cases improves around eight weeks after delivery, for others it can take six months. The tummy helps to support the pelvis so rushing back to activity too quickly can put unnecessary strain on these areas.
Opt instead for a gentle increase in activity to help the muscles and joints settle such as walking, yoga or pilates rather than starting higher impact activity, like running, too early.
4. Check your mental health
The pressures on women postnatally can feel overwhelming and combined with sleep deprivation things can take a toll mentally. The National Perinatal Mental Health Project Report focuses on improving mental health support for women after they have given birth by providing more support services. These services can be accessed by speaking to your GP, midwife, health visitor or pelvic health physiotherapist.
Although a good level of activity can improve mental health, over-training can have a negative effect on the body, so take it steady and keep checking in with yourself to make sure you’re functioning at a pace that feels comfortable and that you’re not overdoing it. Listen to your body and avoid comparison as everybody and every pregnancy is different.
Above all else, remember to be kind to yourself, your body has just gone through a massive change. Looking after your mental health and concentrating on your pelvic floor are good starting points. Getting more active with the muscles around your pelvis, including your tummy, can all help during the natural recovery time frame. But listen to your body and take things at your own pace.
A few weeks ago I was invited as Associate Editor for BMC Pregnancy & Childbirth to draft a few paragraphs about how my research links to the Sustainable Development Goals (SDGs). BMC Pregnancy & Childbirth is an international scientific journal published by Springer. The edited version of my draft was put online earlier today, click herefor access.
Prof. Edwin van Teijlingen
CMMPH (Centre for Midwifery, Maternal & Perinatal Health)
Congratulations to FHSS PhD students Aniebiet Ekong and Nurudeen Adesina on the acceptance of their paper by MIDIRS Midwifery Digest [1]. This methodological paper reflects on their data collection approaches as part of their PhD involving African pregnant women in the UK.
This paper provides a snapshot of some of the challenges encountered during the recruitment of pregnant Black African women living in the UK for their research. Though there are several strategies documented to access/invite/recruit these ‘hard-to-reach population’ these recruitment strategies however were found to be unsuitable to properly engage members of this community. Furthermore, ethical guidelines around informed consent and gatekeeping seem to impede the successful engagement of the members of this community. It is believed that an insight into the experience and perceptions of ethnic minorities researchers will enhance pragmatic strategies that will increase future participation and retention of Black African women across different areas of health and social care research. This paper is co-authored with their BU PhD supervisors: Dr Jaqui-Hewitt Taylor, Dr Juliet Wood, Dr Pramod Regmi and Dr Fotini Tsofliou.
Well done !
Pramod Regmi
Ekong, A., Adesina, N., Regmi, P., Tsofliou, F., Wood, J. and Taylor, J., 2022. Barriers and Facilitators to the recruitment of Black African women for research in the UK: Hard to engage and not hard to reach. MIDIRS Midwifery Digest (accepted).
The scientific journal Nepal Journal of Epidemiology published its fourth and final issue of 2021 on December 31. This issue included our systematic review ‘Epidemiologic characteristics, clinical management and Public Health Implications of Coronavirus Disease 2019 (COVID-19) in Pregnancy: A Systematic Review and meta-analysis’. This review covered the published literature on the epidemiology, clinical management and public health prevention aspects of pregnancy and childbirth and coronavirus (COVID-19) up until December 2020. We worked hard and fast to submit the paper as soon as possible after the end of 2020 to be able to publish up-to-date findings. We managed this and submitted the paper on March 5th, the peer-review took some months and so did the making of the revisions. As a result we resubmitted the manuscript of 29 September and we got the acceptance email within a week. We made it into the next issue of the Nepal Journal of Epidemiology which published exactly one year after the data collection period had ended for our systematic review.
There are two lessons here, first even when submitting to an online journal one will experience a delay in publishing. Secondly, the 36 papers we had appraised and included were published in 2020, meaning these scientific papers were submitted in mid-2020 at the latest in order to make it through the peer-review process, get accepted and formatted for online publication.
In the resubmitted version we had to add as a weakness of this review that: “It is worth noting that this extensive systematic review only cover papers published in 2020, and hence studies conducted in or before 2020. This was before the emergence of variants of COVID-19, especially the delta and omicron variants.”
Prof. Edwin van Teijlingen
CMMPH (Centre for Midwifery, Maternal & Perinatal Health).
Congratulations to FHSS authors on the publication of their paper “A Priori and a Posteriori Dietary Patterns in Women of Childbearing Age in the UK” which has been published in the scientific journal Nutrients[1]. The authors highlight that a poor diet quality is a major cause of maternal obesity. They investigated investigate a priori and a-posteriori derived dietary patterns in childbearing-aged women in the United Kingdom. An online survey assessed food intake, physical activity (PA), anthropometry and socio-demographics. A poor diet quality was found among childbearing-aged women; notably in the younger age category, those of white ethnicity, that were more physically inactive and with a lower socioeconomic background.
The article is Open Access and freely available (click here!).
Reference:
Khaled, K.; Hundley, V.; Almilaji, O.; Koeppen, M.; Tsofliou, F. (2020) A Priori and a Posteriori Dietary Patterns in Women of Childbearing Age in the UK. Nutrients2020, 12, 2921.
Huge numbers of pregnant women and new mothers are taking their own lives in Nepal as they deal with extreme poverty, natural disasters, domestic violence and oppression. Research shows suicide represents 16% of all deaths in women of reproductive age. The rate is higher than previously recorded and there has been a considerable increase over the past few years. But a new project which trained midwives about mental health issues might hold the key to turning this around.
Suicide is primarily associated with unwanted pregnancy or the feeling of being trapped in poverty or situations of sexual and physical abuse. A study of 202 pregnant women (carried out between September and December 2014) found that 91% of them experienced some kind of physical, emotional or sexual abuse – mostly at the hands of their husbands and/or mother-in-laws.
The sad fact is that almost 40% of suicides in the world occur in South-East Asia. And one in three pregnant woman and new mothers are taking their own lives in low-income countries. In Nepal, 21% of the suicides among women aged 15-49 were in girls under 18 due to violence and being powerless in their families and communities.
Pregnancy is a known trigger for mental health problems. But gender discrimination and domestic violence are making matters worse. In addition to these issues, natural disasters are also a huge contributing factor to the spiralling mental health problems of young mothers.
A woman on a collapsed building in Kathmandu after the earthquake in May, 2015. Shutterstock/Somjin Klong-ugkara
Lack of control
In Nepal, making decisions about seeking maternity care is not in the hands of the pregnant woman but usually lies with her mother-in-law or husband. When young women marry they move in with their husbands’ family and their lives are ruled by their in-laws. These women often have little say in seeking health care during pregnancy, childbirth and the postnatal period.
In many poor families, husbands migrate for work leaving their young wives with family. Nepal has a real migrant workers economy with close to 50% of Nepalis relying on financial help from relatives abroad. Mental health problems can worsen for women who have been taken away from their own families. In other cases, young women face domestic violence due to their husbands’ drinking leading to mental health issues and suicide.
There is also a lack of understanding of pregnancy and childbirth-related mental health issues and husbands and mothers-in-law often fail to support these vulnerable young women. They in turn are reluctant to seek help due to the stigma associated with mental illness.
Cultural and social norms
Cultural practices and social norms, like gender inequalities and early marriage, hinder women who have a lack of choice when it comes to their role as mothers. There is also a preference for sons rather than daughters, who are seen as an “economic burden” in many families. If a woman is expecting a daughter, especially for the second or third time, this can also trigger mental health issues.
Depression and anxiety are common and affect ten to 15 out of every 100 pregnant women in the country. Postnatal depression is often reported, but less attention is given to more common and less obvious mental health issues.
Natural disasters and midwives
Recurrent earthquakes and floods exacerbate issues of depression and helplessness as women are forced to live in temporary shelters and have the burden of increased poverty.
For many rural Nepali women, the most qualified birth attendant they can expect to look after them is the Nepali Auxiliary Nurse Midwives (ANMs). But a study found that they received little or no formal training on perinatal mental health issues. Although there have been gradual improvements in health care for women during pregnancy, mental health support is leaving many women feeling that suicide is their only option.
As part of a Tropical Health and Education Trust project, funded by DFID, around 80 ANMs were trained on perinatal mental health issues. The project used UK-based volunteers in Nepal over two years.
The training helped raise awareness of mental health well-being and improved access to mental health care for pregnant women and new mothers. This is a vital first step towards improving community-based services for pregnant women in rural Nepal. But to offer hope to more young women there needs to be a significant increase in this type of training and awareness raising.
We are preparing a lively debate on the motion: “Advising pregnant women to avoid drinking alcohol during pregnancy is symptom of the Nanny State and another step towards the medicalisation of childbirth”. The venue for this event is the Executive Business School on 89, Holdenhurst Road. Members of the public, staff and students are invited to come along on Tuesday 28th June 13.30-14.30!
The UK Government state there is no known safe level for drinking alcohol in pregnancy. Therefore, it recently changed the official recommendation to pregnant women avoid drinking any alcohol as a precaution. In doing so the UK follows countries like Canada, where a similar recommendation has been in place for over a decade. At the same time one can ask whether such approach undermines a woman’s right to make an informed choice regarding the health of her unborn child. Some would argue that is represents yet another step towards the medicalisation of childbirth.
Faculty of Health & Social Sciences’ staff Liz Norton and Edwin van Teijlingen affiliated with the Centre for Midwifery, Maternal & Perinatal Health and will argue in favour of the motion. Donna Wixted, Joint Bournemouth University (BU)-Portsmouth Hospitals NHS Trust, doctoral student and Greta Westwood of Portsmouth Hospitals NHS Trust & the University of Southampton will argue against the motion.
The audience will be asked to vote for or against the motion, both before and after the debate, to see if the debate has helped anybody in making up their mind. Our debate will be chaired by Prof. Vanora Hundley from the Faculty of Health & Social Sciences. In previous Festival of Learning events she has been involved in various debates around childbirth, such as The media is responsible for creating fear in childbirth and the year before that on Caesarean Section on demand under the title Intervention in childbirth: What’s wrong with letting women choose?
The debate is part of BU’s annual Festival of Learning which this year for the first time has satellite events in China and Malaysia.
If you are interested to come along please book your free ticket here! The Executive Business School is easy to find on 89, Holdenhurst Road near Bournemouth Railway Station.
Donna Wixted, Liz Norton, Greta Westwood, Vanora Hundley & Edwin van Teijlingen
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The paper in the Journal of Asian Midwives highlights that during the COVID-19 pandemic, OOHBs were a way to avoid Public Health regulations and lock-down constraints, and to guarantee the presence of a partner at the birth. The authors argue, however, that the pandemic is not at the origin of the trend, but more of a catalyst. Advocacy groups, maternity-service users’ groups, the media, and midwifery organisations in several high-income countries have in recent years underlined the growing criticism of existing maternity care and midwifery services and a long-term shortage of midwives. This is in addition to a longstanding trend in the United Kingdom of closing community-based hospitals, including small, free-standing midwife-led units.
This review covered the published literature on the epidemiology, clinical management and public health prevention aspects of pregnancy and childbirth and coronavirus (COVID-19) up until December 2020. We worked hard and fast to submit the paper as soon as possible after the end of 2020 to be able to publish up-to-date findings. We managed this and submitted the paper on March 5th, the peer-review took some months and so did the making of the revisions. As a result we resubmitted the manuscript of 29 September and we got the acceptance email within a week. We made it into the next issue of the Nepal Journal of Epidemiology which published exactly one year after the data collection period had ended for our systematic review.
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