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Risk of childhood asthma
increases in babies given antibiotics, scientists warn
Source:
Daily Mail, Date: 14/03/2006
Emily Cook, health reporter in the Daily Mail, reports that
scientists have warned that babies given antibiotics appear to
have a much higher risk of developing childhood asthma. The
suggestions come from a study undertaken at the University of
British Columbia, and published in Chest, in which eight
previous studies were analysed where babies given antibiotics
were compared with those who were not. It was found that infants
aged under one treated with antibiotic were twice as likely to
develop asthma than those children who were untreated. Children
who received a multiple course of antibiotics were at an
increased risk, with each additional course during the first
year equating to a 16% rise in risk. Dr Lyn Smurthwaite of
Asthma UK said that the study "...highlights that antibiotics
should always be prescribed and taken responsibly."
Chest. 2006
Mar;129(3):610-8.
Does antibiotic exposure during infancy lead to development of
asthma?: a systematic review and metaanalysis.
Marra F, Lynd
L, Coombes M, Richardson K, Legal M, Fitzgerald JM, Marra CA.
Health Economics Program, Centre for Clinical Epidemiology and
Evaluation, Vancouver Coastal Health Research Institute, Faculty
of Pharmaceutical Sciences, University of BC, 828 W Tenth
Avenue, Vancouver, BC, V5Z 1L8 Canada.
OBJECTIVES: To
determine the association between antibiotic exposure in the
first year of life and the development of childhood asthma.
DESIGN: Metaanalysis of observational studies retrieved through
systematic search of all available electronic data sources.
Studies included in the metaanalyses were those with populations
exposed to one or more courses of antibiotics during the first
year of life, and asthma diagnosis was defined as diagnosis by a
physician between the age of 1 to 18 years.
SETTING:
Retrospective and prospective studies published in the
English-language literature from 1966 to present.
RESULTS: Eight
studies (four prospective and four retrospective) examined the
association between exposure to at least one course of
antibiotics and development of childhood asthma. The total
number of subjects for the analysis comparing exposure to at
least one antibiotic to no exposure in the first year of life
was 12,082 children and 1,817 asthma cases. In the dose-response
analysis, we included data from a total of 27,167 children and
3,392 asthma cases. The pooled odds ratio (OR) for the eight
studies was 2.05 (95% confidence interval [CI], 1.41 to 2.99).
The association was significantly stronger in the retrospective
studies (OR, 2.82; 95% CI, 2.07 to 3.85) than the prospective
studies (OR, 1.12; 95% CI, 0.88 to 1.42). Five of the eight
studies examined whether the association was related to the
number of courses of antibiotics taken in the first year of
life. The overall OR for the dose-response analysis was 1.16
(95% CI, 1.05 to 1.28) for each additional course of
antibiotics; however, this association was not significantly
stronger in the retrospective studies (OR, 1.37; 95% CI, 1.18 to
1.60) relative to the prospective studies (OR, 1.07; 95% CI,
0.95 to 1.20).
CONCLUSIONS:
Exposure to at least one course of antibiotics in the first year
of life appears to be a risk factor for the development of
childhood asthma. Because of the limitations of the studies
conducted to date, additional large-scale, prospective studies
are needed to confirm this potential association.
Int J Occup Med
Environ Health. 2006;19(1):70-6.
The prenatal use of antibiotics and the development of allergic
disease in one year old infants. A preliminary study.
Jedrychowski
W, Galas A, Whyatt R, Perera F.
Chair of Epidemiology and Preventive Medicine, Jagiellonian
University Medical College, Krakow, Poland.
myjedryc@cyf-kr.edu.pl
OBJECTIVES:
Recent research has suggested that the protective effect of
natural infections may be due to their influence on the
development of the immune system in early life. The purpose of
the study was to determine whether maternal use of antibiotics
during pregnancy is a risk factor for wheezing and allergy in
early infancy.
MATERIALS AND
METHODS: Nonsmoking women, aged 18-35 years, were enrolled in
2000/2001 from prenatal clinics during the second or third
trimester of pregnancy. After delivery, newborns were
followed-up every three months over one year and trained
interviewers conducted a standardized interview with mothers on
infants' health at each visit held every three-month. In total,
102 infants were followed over a one-year period and
questionnaires on the use of various medications during
pregnancy and potential risk factors for allergy and asthma were
completed. Relative risk for persistent wheezing (9+ days over
the follow-up) adjusted for potential confounders was
significantly associated with the duration of antibiotic
therapy, however, it was significant only if the antibiotic
treatment took place in the second and the third trimester.
Results: The adjusted relative risk was increasing by 14% with
each day of using antibiotics compared with the reference group
(RR = 1.14; 95% CI: 1.01-1.27). When usage of antibiotics was
regarded as a dichotomous variable in the logistic model
(cut-off point at 5 days), the estimated adjusted risk for
persistent wheezing was 4.42 (95% CI: 1.05-18.8). The risk for
hay fever due to exposure to antibiotics was 2.65 (95% CI:
1.03-6.81) and a corresponding estimate for eczema was 2.30 (95%
CI: 0.91-5.80).
CONCLUSIONS:
The study suggests that maternal use of antibiotics during
pregnancy may prove to be a risk factor for persistent wheezing
and development of allergy in early infancy.
Ultrasounds could affect brain growth
WASHINGTON — Expo-sure to ultrasound can affect
fetal
brain development, a new study suggests. But researchers say the
findings, in mice, should not discourage pregnant women from
having ultrasound scans for medical reasons. When pregnant mice
were exposed to ultrasound, a small number of nerve cells in the
developing brains of their fetuses failed to extend correctly in
the cerebral cortex. “Our
study
in mice does not mean that use of ultrasound on human fetuses
for appropriate diagnostic and medical purposes should be
abandoned,” said lead researcher Pasko Rakic, chairman of the
neurobiology department at Yale University School of Medicine.
However, he added in a telephone interview, women should avoid
unnecessary ultrasound scans until more research has been done.
Ultrasound
affects mouse brains: study
By Maggie Fox, Health and Science Correspondent Mon Aug 7, 5:05
PM ET
WASHINGTON
(Reuters) - Ultrasound disrupts the brain development of unborn
mice, U.S. researchers said in a study published on Monday that
adds to growing evidence that too many ultrasound scans could
also affect human fetuses.
Prolonged
ultrasound scans of the brains of fetal mice interfered with a
process known as neuronal migration in which neurons move from
one place to another, the team at Yale University in Connecticut
reported.
"Proper
migration of neurons during development is essential for normal
development of the cerebral cortex and its function," Dr. Pasko
Rakic, chair of the Department of Neurobiology at Yale, said in
a statement.
"We have
observed that a small but significant number of neurons in the
mouse embryonic brain do not migrate to their proper positions
in the cerebral cortex following prolonged and frequent exposure
to ultrasound."
Writing in
the Proceedings of the
National
Academy of Sciences, Rakic's team
said the findings do not necessarily mean that ultrasound of
human fetuses is dangerous but they said doctors and pregnant
mothers should probably keep the scans to a minimum.
Ultrasound
scans are one of the delights of pregnancy, giving the parents a
peek at the unborn child and doctors a chance to see if there
are any serious defects that might be corrected before or right
at birth.
But several
studies have suggested that ultrasound may affect the developing
brain, not necessarily adversely.
For
instance, a 1993 study published in the Lancet medical journal
found that babies given ultrasounds before they were born were
more likely to be left-handed. A separate study found a possible
decrease in weight in newborns who were scanned, while a third
found delayed speech.
But another
study showed that children who had received ultrasound exams
before birth actually did better on language tests when they
were older, said Dr. Verne Caviness of Massachusetts General
Hospital.
More study
is clearly needed, Rakic said in a statement.
"We do not
have any evidence ourselves that ultrasound waves cause
behavioral effects in mice or have any effect on the developing
human brain," he said.
"Therefore I
want to emphasize that our study in mice does not mean that use
of ultrasound on human fetuses for appropriate diagnostic and
medical purposes should be abandoned. On the contrary:
ultrasound has been shown to be very beneficial in the medical
context," Rakic added.
He said the
study suggests that pregnant women should not get multiple
ultrasound scans for fun or out of curiosity. The American
College of Radiology and the U.S.
Food and
Drug Administration currently
recommend that women only get ultrasounds when medically needed.
For their
study, Rakic and colleagues did scans of pregnant mice on the
16th day of gestation. This is the last week of gestation and a
time when, in mice, the brain cells known as neurons move to a
new position in the brain.
After
prolonged, multiple scans, some of these cells went to the wrong
place, they found.
"Does this
study indicate that we should be concerned about human fetal
ultrasound?" Caviness asked in a commentary published in the
same journal.
He said the
implications were not known and noted a human fetus has a much
larger and denser brain, and that scans usually just pass over
the brain for a few seconds.
"The
corresponding neurons in the human brain would probably be
formed in the 16th week and continue to migrate for at least 1-2
weeks," Caviness wrote.
No one knows
how sound waves might disturb a developing fetus or embryo, both
Caviness and Rakic said.
Voluntary
C-Sections Result in More Baby Deaths
LARGE
STUDY shows significant evidence
Article published in the New York Times
By NICHOLAS BAKALAR
Published: September 5, 2006
A recent
study of nearly six million births has found that the risk
of death to newborns delivered by voluntary Caesarean
section is much higher than previously believed.
Researchers have found that the
neonatal mortality rate for
Caesarean delivery among low-risk women is 1.77 deaths per
1,000 live births, while the
rate for vaginal
delivery is 0.62 deaths per 1,000. Their
findings were published in this month's issue of Birth:
Issues in Perinatal Care.
The percentage of Caesarean births in the United States
increased to 29.1 percent in 2004 from 20.7 percent in 1996,
according to background information in the report.
Mortality in Caesarean deliveries has consistently been
about 1½ times that of vaginal delivery, but it had
been assumed that the difference was due to the higher risk
profile of mothers who undergo the operation.
This study, according to the authors, is the first to
examine the risk of Caesarean delivery among low-risk
mothers who have no known medical reason for the operation.
Congenital malformations were the leading cause of neonatal
death regardless of the type of delivery. But the risk in
first Caesarean deliveries persisted even when deaths from
congenital malformation were excluded from the calculation.
Intrauterine hypoxia — lack of oxygen — can be both a reason
for performing a Caesarean section and a cause of death, but
even eliminating those deaths left a neonatal mortality rate
for Caesarean deliveries in the cases studied at more than
twice that for vaginal births.
"Neonatal deaths are rare for low-risk women — on the order
of about one death per 1,000 live births — but even after we
adjusted for socioeconomic and medical risk factors, the
difference persisted," said Marian F. MacDorman, a
statistician with the Centers for Disease Control and
Prevention and the lead author of the study.
"This is nothing to get people really alarmed, but it is of
concern given that we're seeing a rapid increase in
Caesarean births to women with no risks," Dr. MacDorman
said.
Part of the reason for the increased mortality may be that
labor, unpleasant as it sometimes is for the mother, is
beneficial to the baby in releasing hormones that promote
healthy lung function. The physical compression of the baby
during labor is also useful in removing fluid from the lungs
and helping the baby prepare to breathe air.
The researchers suggest that other risks of Caesarean
delivery, like possible cuts to the baby during the
operation or delayed establishment of breast-feeding, may
also contribute to the increased death rate.
The study included 5,762,037 live births and 11,897 infant
deaths in the United States from 1998 through 2001, a sample
large enough to draw statistically significant conclusions
even though neonatal death is a rare event.
There were 311,927 Caesarean deliveries among low-risk women
in the analysis.
The authors acknowledge that the study has certain
limitations, including concerns about the accuracy of
medical information reported on birth certificates.
That data is highly reliable for information like method of
delivery and birth weight, but may underreport individual
medical risk factors.
It is possible, though unlikely, that the Caesarean birth
group was inherently at higher risk, the authors said.
Dr. Michael H. Malloy, a co-author of the article and a
professor of pediatrics at the University of Texas Medical
Branch at Galveston, said that doctors might want to
consider these findings in advising their patients.
"Despite attempts to control for a number of factors that
might have accounted for a greater risk in mortality
associated with C-sections, we continued to observe enough
risk to prompt concern," he said.
"When obstetricians review this information, perhaps it will
promote greater discussion within the obstetrical community
about the pros and cons of offering C-sections for
convenience and promote more research into understanding why
this increased risk persists."
Ultrasounds could affect brain
growth
WASHINGTON —
Expo-sure to ultrasound can affect fetal brain development, a new
study suggests. But research-ers say the findings, in mice, should
not discourage pregnant women from having ultrasound scans for
medical reasons.
When pregnant mice were exposed to ultrasound, a small number of
nerve cells in the developing brains of their fetuses failed to
extend cor-rectly in the cerebral cortex.
“Our study in mice does not mean that use of ultrasound on human
fetuses for appropriate diagnostic and medical pur-poses should be
abandoned,” said lead researcher Pasko Rakic, chairman of the
neurobiology department at Yale Uni-versity School of Medicine.
However, he
added in a telephone interview, women should avoid unnecessary
ultrasound scans until more research has been done.
Ultrasound affects
mouse brains: study
By Maggie Fox, Health and Science Correspondent Mon Aug 7, 5:05 PM
ET
WASHINGTON
(Reuters) - Ultrasound disrupts the brain development of unborn
mice, U.S. researchers said in a study published on Monday that adds
to growing evidence that too many ultrasound scans could also affect
human fetuses.
Prolonged
ultrasound scans of the brains of fetal mice interfered with a
process known as neuronal migration in which neurons move from one
place to another, the team at Yale University in Connecticut
reported.
"Proper
migration of neurons during development is essential for normal
development of the cerebral cortex and its function," Dr. Pasko
Rakic, chair of the Department of Neurobiology at Yale, said in a
statement.
"We have
observed that a small but significant number of neurons in the mouse
embryonic brain do not migrate to their proper positions in the
cerebral cortex following prolonged and frequent exposure to
ultrasound."
Writing in the
Proceedings of the
National
Academy of Sciences, Rakic's team said
the findings do not necessarily mean that ultrasound of human
fetuses is dangerous but they said doctors and pregnant mothers
should probably keep the scans to a minimum.
Ultrasound scans
are one of the delights of pregnancy, giving the parents a peek at
the unborn child and doctors a chance to see if there are any
serious defects that might be corrected before or right at birth.
But several
studies have suggested that ultrasound may affect the developing
brain, not necessarily adversely.
For instance, a
1993 study published in the Lancet medical journal found that babies
given ultrasounds before they were born were more likely to be
left-handed. A separate study found a possible decrease in weight in
newborns who were scanned, while a third found delayed speech.
But another
study showed that children who had received ultrasound exams before
birth actually did better on language tests when they were older,
said Dr. Verne Caviness of Massachusetts General Hospital.
More study is
clearly needed, Rakic said in a statement.
"We do not have
any evidence ourselves that ultrasound waves cause behavioral
effects in mice or have any effect on the developing human brain,"
he said.
"Therefore I
want to emphasize that our study in mice does not mean that use of
ultrasound on human fetuses for appropriate diagnostic and medical
purposes should be abandoned. On the contrary: ultrasound has been
shown to be very beneficial in the medical context," Rakic added.
He said the
study suggests that pregnant women should not get multiple
ultrasound scans for fun or out of curiosity. The American College
of Radiology and the U.S.
Food and Drug
Administration currently recommend that
women only get ultrasounds when medically needed.
For their study,
Rakic and colleagues did scans of pregnant mice on the 16th day of
gestation. This is the last week of gestation and a time when, in
mice, the brain cells known as neurons move to a new position in the
brain.
After prolonged,
multiple scans, some of these cells went to the wrong place, they
found.
"Does this study
indicate that we should be concerned about human fetal ultrasound?"
Caviness asked in a commentary published in the same journal.
He said the
implications were not known and noted a human fetus has a much
larger and denser brain, and that scans usually just pass over the
brain for a few seconds.
"The
corresponding neurons in the human brain would probably be formed in
the 16th week and continue to migrate for at least 1-2 weeks,"
Caviness wrote.
No one knows how
sound waves might disturb a developing fetus or embryo, both
Caviness and Rakic said.
Vaginal Birth after Caesarean
Section: Seeing the bigger picture
By Judy Slome Cohain
July 2006 - British Journal of Midwifery
CLICK TO VIEW
Risk of Uterine Rupture with a Trial of Labor in Women with
Multiple and Single Prior Caesarean Delivery
©
American College of Obstetricians and Gynecologists
July 2006
CLICK TO VIEW
INTERNATIONAL
CONFERENCE OF MIDWIVES
THE MIDWIFE IS THE FIRST-CHOICE HEALTH
PROFESSIONAL
FOR CHILDBEARING WOMEN
BACKGROUND
In the context of widespread discussion about the global
consensus on skilled attendants at childbirth, ICM has recognised a
need to identify the midwife specifically as the most appropriate
health care professional for women during pregnancy, childbirth and
the postnatal period.
STATEMENT OF BELIEF
The ICM believes that midwives and midwifery skills are
essential resources in achieving safer childbirth and that all women
should have access to a midwife. The ICM believes that appropriate
collaboration with others will improve the health and social
outcomes for mothers and their newborns.
POSITION
The ICM recognises midwives as the professional of choice for
childbearing women in all areas of the world. This universal
standard is based on initial and ongoing midwifery education that is
competency based. The ICM promotes the midwifery model of care based
on respect for human dignity, compassion and the promotion of human
rights for all persons.
Given that there are insufficient midwives throughout the world to
meet the needs of all childbearing women, the ICM recognises the
vital role that other health professionals play in saving the lives
of both mothers and babies, especially in low-resource countries.
Midwives will work with all levels of health workers to make
childbearing safe for all women and newborns, while at the same time
aspiring to achieve universal care by midwives for all women.
In all collaborative work, the ICM will promote and endorse midwives
and midwifery skills as defined by the Definition of the Midwife (ICM,
2005) and the ICM Essential Competencies for Basic Midwifery
Practice (ICM, 2002), as vital to the health and wellbeing of women
and the newborn. This belief will underpin all ICM collaborative
efforts. Where the ICM’s position is compromised, in global
negotiations, in order to move forward, they will continue to issue
a parallel statement endorsing the value of midwifery care in
achieving the above.
GUIDANCE TO MEMBER ASSOCIATIONS
All member associations will promote and endorse midwives and
midwifery skills, as defined by the ICM core documents and position
statements, as vital to the health and wellbeing of women and the
newborn.
Member associations are encouraged to use this position statement,
as needed, as a guide for expanding education programmes and
regulatory frameworks, which will lead to an increased number of
competent midwives in their country practising the full scope of
midwifery, in order better to serve childbearing women and their
families.
RELATED ICM DOCUMENTS
• Making pregnancy safer: the critical role of the skilled
attendant, a joint statement by WHO, ICM and FIGO. Geneva,
Switzerland: WHO/RHR, 2004.
• ICM. Definition of the Midwife. ICM, 2005.
• ICM. Essential Competencies for Basic Midwifery Practice. ICM,
2002.
• ICM. Council resolution on redirecting activities. ICM, 2005.
OTHER RELEVANT DOCUMENTS
• The World Health Report 2005. Make every mother and child
count. Geneva, Switzerland: WHO, 2005.
Adopted at Brisbane Council meeting, 2005
Due for next review 2011
Finally ready for delivery:
midwives through Medicare
By Mark Metherell
and Jacqueline Maley
August 16, 2005
The Federal Government
will for the first time consider extending Medicare to midwives
- the bridesmaids of maternity care.
The Minister for Health, Tony Abbott, has told advocates
of midwifery he will consider paying midwives Medicare benefits
if their patients have been referred by doctors.
Midwives described Mr Abbott's gesture as a breakthrough.
They have battled resistance from doctors and officials for
federal recognition for many years.
"For someone like Tony Abbott to use the words midwife
and Medicare in the same sentence is an important new
development," the executive officer of the Australian College of
Midwives, Barbara Vernon, said yesterday.
Dr Vernon said countries where midwives played a bigger
role in managing pregnancy and childbirth had lower costs and
fewer interventions by doctors, including caesarean deliveries.
She said a greater role for midwives, particularly in
country areas, would reduce the need for expectant patients to
travel to bigger towns for childbirth - a situation blamed for
several recent emergency births en route.
The lack of Medicare payments, and difficulties securing
medical indemnity cover, has largely prevented independent
private practice by midwives and means most of Australia's
12,500 midwives are employed by hospitals.
Mr Abbott's spokeswoman said he would examine the
midwives' proposals "but has made no commitment".
The leader of the Australian Democrats, Lyn Allison, who
initiated a meeting last week with Dr Vernon and Mr Abbott, said
Mr Abbott had acknowledged the merit in plans for a national
maternity services policy and promised to ask his department to
explore greater use of midwives.
"This is a major breakthrough and I congratulate the
Government on finally listening to women and giving them a
choice," Senator Allison said.
Shea Caplice has been a midwife for more than 20 years
and estimates she has caught more than a thousand babies. But
like other midwives she is not covered by Medicare, and since
2002 has not got medical indemnity insurance as a private
practitioner.
"It's been a long time coming," Ms Caplice said of the
mooted changes. "Even podiatrists get access to Medicare, but
not women having babies wanting a midwife."
Without a Medicare provider number it is difficult to
schedule even the most basic diagnostic tests, she said. "I love
working with doctors but it seems to be a competition. It's not
a competition; it's just basic health care."
Ms Caplice has been appointed to co-ordinate a new
home-birthing service at St George Hospital. She says it is
proof of the continuing demand for midwifery.
"Certainly Medicare numbers will streamline the service I
provide and make it much more accessible for women, and that
really is their right."
The Australian Medical Association's spokesman on
obstetrics and gynaecology, Andrew Pesce, said despite past
resistance many doctors would accept a greater role for
midwives, if doctors could still decide whether to keep riskier
cases in their care.
But Dr Kenneth Clark, an obstetrician from the Royal
Australian and New Zealand College of Obstetricians and
Gynaecologists, highlighted a "critical need" for debate within
the profession and with the public before funding midwifery
through Medicare.
Government funding of midwives in New Zealand had limited
women's choices, not expanded them, he said.
The secretary of the NSW Midwives Association, Hannah
Dahlen, said evidence increasingly pointed to midwives as the
most appropriate carers for women during low-risk childbirths.
Studies had shown midwife-led births had much lower rates
of intervention, such as forceps delivery. Women reported higher
satisfaction with the experience, and were more likely to
breast-feed successfully for longer, she said.
Australian College of Midwives
GPO Box 666
CANBERRA 2601
Ph: 02 6230 7333
acmi@acmi.org.au
www.acmi.org.au
ABN 49 289 821 863
MIDWIVES – WORKFORCE ISSUES – 26
October 2005
Workforce
shortages in maternity services
-
There are
currently estimated shortages in the maternity workforce of
midwives, GPs and specialist obstetricians. The College of
Midwives’ submission to the Productivity Commission
workforce Inquiry argues that these shortages can be all
resolved through changing the skill mix for the delivery of
services.
-
The obstetric
workforce (mostly GP in rural areas and specialist in urban
areas), should be reserved for the care of a minority of
women (<20%) with identified need of medical care, and the
healthy majority of pregnant women receive primary care from
midwives. At present the vast majority of women are
channeled into medical maternity services and fewer than 5%
of women have access to continuity of care by a midwife.
-
As specialists
in normal pregnancy and birth, midwives can provide high
quality care to women, with referral to medical services as
needed in line with evidence-based referral guidelines.
International experience indicates that 70-80% of women
can receive primary midwifery care, with the remainder
receiving collaborative care from obstetricians, while
retaining low maternal and perinatal mortality rates.
How changing the
skill mix would solve the workforce problems
-
The College of
Obstetricians estimated in 1996 to the AMWAC (1998) that
there is a need for 1 obstetrician per 12,500 women aged
15-49 in the population. At that time there were 2 to 3
times more obstetricians than this ratio indicates is
necessary. This is still the case today despite a
contraction in the obstetric workforce (there are 1240
obstetricians working today when the ratio would suggest
only 370-380 are needed). There is only a shortage if the
current reliance on specialist obstetricians over-servicing
healthy women continues.
-
Expanding the role of midwives
would also solve the shortage of midwives. Research has
shown that midwives are leaving the profession due largely
to stress and frustration caused by the dominance of
medicalised systems of maternity care in Australia. Standard
maternity services currently
give midwives limited
opportunities of caring for women across the full scope of
midwifery practice as defined by the World Health
Organisation (WHO) and practiced in other OECD countries.
- The
impact of a shortage of GPs in rural areas could also be
lessened with an expanded reliance on midwifery. GP
obstetricians may be more willing to practice where midwives
carry the bulk of the load of caring for healthy women, and
only call on the GP when their expertise is genuinely
needed.
Commonwealth
Government reforms needed to enhance the use of the midwifery
workforce
-
Leadership in
moves to change the skill mix in maternity services to make
full use of the expertise of midwifery and appropriate use
of medical expertise
-
Support for
midwives to access skills and refresher courses since the
majority of midwives in Australia at present are not
accustomed to practicing across the full scope of midwifery
due to a lack of opportunity to do so. Most midwives have
no access to paid leave for CPD (contrast with supports for
CPD for doctors).
-
Equitable access
for midwives to Medicare rebates for relevant services
provided
-
Support for
national consistency in midwifery education and regulation
standards
-
Support for
midwives’ ongoing professional development and
accountability through a program of professional peer
review, and
-
Leadership in
encouraging the necessary state government reforms
Reforms needed by
State governments
-
Legislative
amendments to:
-
authorize
midwives to order and interpret routine diagnostic
tests, as recommended by the NHMRC in its 1998 report (Review
of
Services Offered by Midwives)
-
grant
midwives prescribing rights for relevant drugs (e.g.
syntocinon for post=partum haemorrhage)
-
facilitate
midwives gaining visiting access to hospitals
-
provide for
midwifery regulation and registration separately from
nursing (this has now happened in 3 states and is being
considered in several others)
HOMEBIRTHS IN AUSTRALIA:
THE MIDWIFE'S PERSPECTIVE
MIDWIFERY IS
SAFE AND ACCESS A RIGHT
Obstetricians and midwives
modus vivendi
for current times
O
Obstetric services need to be women-centred and based on mutual
respect and collaboration
By
2020, it can only be hoped that an Australian National Maternity
Policy will be in place.
EDITORIALS
The Medical
Journal of Australia ISSN: 0025-729X 2 May 2005 182 9 436-437
©The Medical
Journal of Australia 2005
www.mja.com.au Editorials
Obstetricians and midwives have complementary roles
in the care of pregnant women, and each group would find survival
without the other difficult. Nor would women necessarily receive the
best care if access to one or other of these professions were
restricted. Having complementary roles, though, has not prevented
hostility or “turf” wars between the two groups, with midwives
claiming that maternity services are over-medicalised,1 and
obstetricians counterclaiming that there is no demand for
midwife-led care.2 So what is the current
modus vivendi
for obstetricians and midwives, and to where
feasibly could it evolve by 2020?
Maternity
services in Australia in 2005 provide much choice for women,
including private or public care by obstetricians, general
practitioners and midwives. These services can take place in
traditional hospital obstetric units, birthing centres and, now less
frequently, at home.
Australia
has not followed the New Zealand model of care in allowing women to
choose a midwife as a “lead maternity carer” as a mainstream option
in the public health system. However, in some Australian states,
this may soon change.3 If this were to eventuate, Australia would
do well to look at the lessons learned from the experience in New
Zealand. Across the Tasman many positive changes have resulted from
maternity services reform, such as significant improvement for many
women in continuity of maternity caregiver, and greater availability
of non-medically based models of care for those women wanting them.
But negative changes have also occurred, such as the effective loss
of the option for women to have a GP involved in their maternity
care, and an initial exodus of experienced midwives out of the
public hospital
system. In
particular, the sheer pain of major change, for both women and care
providers, could have been minimised by thorough and consultative
planning.
Given all
this choice, why should there be hostility between obstetricians and
midwives? The main criticisms from midwives stem from a perception
that obstetric care in Australia is too medicalised and that
obstetric intervention rates are too
high.4 Because better continuity of care from a known
midwife may lead to fewer obstetric interventions5 and greater
certainty for women, there has been a strong push by midwives and
consumer groups, such as the Maternity Coalition, for funded
midwife-led care.6 On the other hand, obstetricians point to an
established system of care, with low rates of maternal and perinatal
morbidity as well as generally high levels of community
satisfaction.2
Provision
of maternity services in Australia has also been made more difficult
by workforce issues. The average age of
obstetricians in Australia is 51 years7 and of
midwives 41 years.8 The workforce survey carried out by the Royal
Australian
and New
Zealand College of Obstetricians and Gynaecologists (RANZCOG) in
2003 revealed that a quarter of Australian
Fellows were now aged 60 or more.7 The same workforce
survey also highlighted the possibility of a major shortage of
obstetricians in the next 10 years, due to retirements, new RANZCOG
Fellows not wishing to practise obstetrics, increased feminisation
of the obstetric workforce, and problems associated with safe
working hours.7 There has also been a major decrease in GPs
practising obstetrics, especially in rural areas, for lifestyle
reasons and because of the cost of medical indemnity.9
The shortage of midwives is also a problem. The
Australian Health Workforce Advisory Committee estimates a current
national shortage of 1850 midwives, and this is expected to increase
over the remainder of the decade.8 Problems with recruiting and
retaining midwives seem to be related to midwives’ perceptions of a
lack of professional recognition, stress and workload issues, as
well as limited opportunities for midwives to practise as primary
carers and provide continuity of care to women.10
To
facilitate discussion between maternity care providers, the RANZCOG
re-established the Joint Committee for Maternity Services in 2002.
This has representatives from the RANZCOG, the Australian College of
Midwives, the Royal Australian College of General Practitioners, and
the Australian College of Remote and Rural Medicine, as well as
consumer representation. Each representative feeds back to his or
her governing body, with the committee proving useful in airing
problems and encouraging a collaborative approach to maternity care
provision. The committee has made some progress in reviewing
international clinical guidelines for possible use in Australia, but
has been hampered by lack of funding, obstetricians suspicious of
change, and midwives frustrated by lack of change. Difficulties have
arisen in reconciling differences between obstetricians, GPs and
midwives in how to provide safe evidence-based care that will not
diminish current levels of safety.
By 2020,
it can only be hoped that an Australian National Maternity Policy
will be in place. At present, there is none. If this is to occur,
obstetricians, GPs and midwives must work to develop collaborative
policies that are women-centred, not provider-centred, and which
will ensure individualised care to meet the particular needs of each
pregnant woman. The development of adequate continuing professional
development programs (CPD) for all maternity care providers should
be mandatory, and the development of some joint CPD programs
crossing profession groups would be useful. There should be
development of systems of care that allow for continuity of care for
women during pregnancy, labour and postnatally, but which protect
against burnout of care providers.
There are
already good examples of effective services in various places across
Australia, ranging from large metropolitan
units, such as the Adelaide Women’s and Children’s
Hospital Community Midwifery Program, to rural services, such as
those provided at Wangaratta Hospital in Victoria, that are women-centred
and based on mutual respect and collabo-ration
between obstetricians and midwives. The challenge is to make this
the norm for the benefit of mothers and babies as well as their
care providers.
EDITORIALS
Edward
W Weaver
Chairman,
Joint Committee for Maternity Services, RANZCOG
dreweaver@bigpond.com
Kenneth
F Clark
President, RANZCOG, Melbourne, VIC
Barbara
A Vernon
Chief
Executive Officer, Australian College of Midwives, Turner, ACT
1
Johanson R, Newburn M, Macfarlane A. Has the medicalisation of
childbirth gone too far?
BMJ
2002; 324: 892-895.
2 Lumley
J, editor. Having a baby in Victoria. Melbourne: Health Department
Victoria, 1990.
3 Future
directions for Victoria’s maternity services. Melbourne: Department
of Human Services, Victoria, 2002.
4 Roberts
C, Tracy S, Peat B. Rates for obstetric intervention among private
and public patients in Australia: population based descriptive
study.
BMJ
2000; 321: 137-141.
5 Homer
CS, Davis GK, Brodie PM, et al. Collaboration in maternity care: a
randomised controlled trial comparing community based continuity
of care with standard hospital care.
BJOG
2001; 108: 16-22.
6
Maternity Coalition, AIMS (Australia), Australian Society of
Independent Midwives, Community Midwifery WA Inc. The National
Maternity Action Plan for the Introduction of Community Midwifery
Services in Urban and Regional Australia. September 2002. Available
at: http://www.maternitycoalition.org.au/THE%20FINAL%20NMAP
%20Sepember%2024th%202002.pdf (accessed Mar 2005).
7 Bell R. The 2003 RANZCOG Workforce Survey.
O&G
2003; 5: 174-178.
Available
at: http://www.ranzcog.edu.au/publications/o-g_pdfs/O&G-2000-2003/OG-Sept-2003.pdf
(accessed Mar 2005).
8
Australian Health Workforce Advisory Committee. The midwifery
workforce in Australia 2002-2012. AHWAC Report 2002.1. North Sydney:
NSW Health. Available at: http://www.health.nsw.gov.au/amwac/pdf/midwifery_20022.pdf
(accessed Mar 2005).
9 Mohen DP. Future of obstetric practice in
provincial Australia.
O&G
2004; 6:
10-11. Available at: http://www.ranzcog.edu.au/publications/og_pdfs/O&G-March-2004/OG-March-2004.pdf
(accessed Mar 2005).
10 Brodie
P. Addressing the barriers to midwifery: Australian midwives
speaking out.
Aust J Midwifery
2002; 15: 5-14.
MJA
�
Volume
182 Number 9
�
2 May 2005
437
Antenatal screening for
Group B Streptococcus:
A diagnostic cohort study
Janet E Hiller , Helen M McDonald , Philip Darbyshire and Caroline A
Crowther
BMC Pregnancy and Childbirth 2005, 5:12 doi:10.1186/1471-2393-5-12
Published 22 July 2005
Abstract (provisional)
Background
A range of strategies have been adopted to prevent early onset Group
B Streptococcal (EOGBS) sepsis, as a consequence of Group B
Streptococcal (GBS) vertically acquired infection. This study was
designed to provide a scientific basis for optimum timing and method
of GBS screening in an Australian setting, to determine whether
screening for GBS infection at 35-37 weeks gestation has better
predictive values for colonisation at birth than screening at 31-33
weeks, to examine the test characteristics of a risk factor strategy
and to determine the test characteristics of low vaginal swabs alone
compared with a combination of perianal plus low vaginal swabs per
colonisation during labour.
Methods
Consented women received vaginal and perianal swabs at 31-33 weeks
gestation, 35-38 weeks gestation and during labour. Swabs were
cultured on layered horse blood agar and inoculated into selective
broth prior to analysis. Test characteristics were calculated with
exact confidence intervals for a high risk strategy and for
antenatal screening at 31-33 and 35-37 weeks gestation for vaginal
cultures alone, perianal cultures alone and combined low vaginal and
perianal cultures.
Results
The high risk strategy was not informative in predicting GBS status
during labour. There is an unequivocal benefit for the
identification of women colonised with GBS during labour associated
with delaying screening until 36 weeks however the results for
method of screening were less definitive with no clear advantage in
using a combined low vaginal and perianal swabbing regimen over the
use of a low vaginal swab alone.
Conclusions
This study can contribute to the development of prevention
strategies in that it provides clear evidence for optimal timing of
swabs. The addition of a perianal swab does not confer clear
benefit. The quantification of advantages and disadvantages provided
in this study will facilitate communication with clinicians and
pregnant women alike.
15 August 2005
Research update: Duration of breastfeeding linked to reduced obesity risk
A study among 2087 Australian children has concluded that babies breastfed for at least a year are leaner than those weaned earlier. Babies never breastfed were the most likely to be overweight. (1)
A meta-analysis of the existing studies on duration of breastfeeding and risk of overweight strongly supports a dose-dependent association between longer duration of breastfeeding and decrease in risk of overweight. (2)
Seventeen studies were included which reported the odds ratio and 95% confidence interval of overweight associated with breastfeeding and the duration of breastfeeding.
The duration of breastfeeding was inversely associated with the risk of overweight (regression coefficient = 0.94, 95% confidence interval (CI): 0.89, 0.98).
Categorical analysis confirmed this dose-response association (<1 month of breastfeeding: odds ratio (OR) = 1.0, 95% CI: 0.65, 1.55; 1-3 months: OR = 0.81, 95% CI: 0.74, 0.88; 4-6 months: OR = 0.76, 95% CI: 0.67, 0.86; 7-9 months: OR = 0.67, 95% CI: 0.55, 0.82; >9 months: OR = 0.68, 95% CI: 0.50,
0.91).
1. Burke V et al (2005). Breastfeeding and Overweight: Longitudinal Analysis in an Australian Birth Cohort. J Ped 147: 56-61.
[Abstract]
2. Harder T et al (2005). Duration of Breastfeeding and Risk of Overweight: A Meta-Analysis. Am. J. Epidemiol, available online in advance of publication.
[Abstract]
This is a research update from the UNICEF UK Baby Friendly Initiative.
16-08-2005
Midwife Medicare considered
From: AAP
THE Federal Government will consider extending the Medicare scheme to include midwives, as part of a national maternity services policy.
Health Minister Tony Abbott said he would consider paying midwives Medicare benefits if their patients had been referred by doctors, newspapers reported today.
While he said he would consider the proposal, he had made no "commitment".
Midwifery advocates described the gesture as a "breakthrough".
"For someone like Tony Abbott to use the words midwife and Medicare in the same sentence is an important new development," said Barbara Vernon, executive officer of the Australian College of Midwives.
Ms Vernon said it would allow independent private midwives to practice in rural and regional areas, reducing the need for expectant mothers to travel to bigger towns for childbirth.
The NSW Midwives Association said studies showed midwife-led births had much lower rates of intervention, such as forceps delivery, had higher rates of patient satisfaction, and led to longer breastfeeding.
However, the Royal Australian and New Zealand College of Obstetricians and Gynaecologists said there was a critical need for public and professional debate before any such changes were made.