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(?がidalpuhιicati0πψ'the 1πtι"1rιιi0παι C0兇lhleγαιi0πψ'八lid窃liでles

Volume5, Number4,2015

ISSN 2156-52S7

O u rn al ^1・hildbirth

Intemational

Confederation

OfMidwives

Strenathening MidⅧfery clob3Ⅱy

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Internationaljournalofchildbirth

Maria Helena Bastose, MD, MSC, phD

Marje Berg, phD, MNSC, MPH, RN, RM

Susan Bewley, MA, MD, FRCOGTerese Bondas, phD, LicNSC, MNSC, RN, PHN

SheeDa Byrom, RM, MA

NgajFen cheuD島 PhD, MSC, RM, RGNHa11nah Dahlan, RN, RM, BN(Hons),McommN,phD,FACM

Frances Day、stirkMarcos Dias, MD, phD

GraceEdwards,RN,RM,ADM,cedEd,M.Ed,phD

Jenny Gamble, RM, MHlth, phDAtf Gherissi, CM, MSC, phD

Ankdelon名e, phD

Eugene Declercq, phDRaymond De vries, phD

Dedan Devane, phD, MSC, pgDip(stats),DipHE,RGN, RM, RNT

Denis walsh, phD, RM

Divisi011 qf'Mid1νiferyUhiversiり Qi'Nottiπ8h4"1

υπited Ki"gd01"

Editors・in・chief

DeputyEditor

SOO Downe, RM, MSC, phD

Scho010jHe41th

υれiversi砂 Qf'ceれhα1ιαπCashire

Uれited k'iれ宮d0111

Associate 見ditors

Iudith T. FUⅡerton, phD, CNM, FACNMVive廿e Glover, MA, phD, DSC

Mechthild Gross, RM, RN, MSC

GiⅡ Gyte, MphilEileen HU廿on, RM, RN, phD

Ken lohnson, phD

H011ypowe11Kennedy, phD, CNM, FACNM,FAAN

Patrick ιavery, MDNicky Leap, DMid, MSC, RMHeloisa Lessa, MS

AmaljLokU8amage, MBchB, BSC, MSC, MD,FRCOG

Lisa Kane low, phD, RN, CNM, FACNM

Ans luyben, RM, PGDE, PDM, phD

Mar号aretMaimbobva, phDRosemaryM抑der, MSC, phD, RGN,SCM, MTD

KerriD.schuiⅡDg, phD, CNM, NR FACNM, FAAN

C011ege qi'Health sdehιeS α11d pr0元Ssi0πalstudiesNのt11erπ Michig4" UHiversity

U"ited stat"

Frances Day-stirkPreside11t

Uπited KiπgdolH

Addtess Malata

Viιe、presideHt

Mα1α1νi

Myrte de GeusTreasurer

The Nether1α11ds

Jemima Dennis・Antwi

Gh4h4

Ia抑e MarshaⅡ, phD, MA, PGCEA, ADM,RM,RGN

Etsuko Matsuoko, phD

RobynMaude,phD,MA (Mid爾few),BN,RM,RNChris Mccourt, phD

Maria11ne Mead, RM, phD

Iudith Mercer, BSN, MS, DNS

MaryNewburn, MSC

Kerreen Reiger,入仏, phDVerenaschmidt, RM

julia seng, phD, CNM, FAAN

Theresa Ann sipe, CNM, MPH, MN, phDNick Taub, phD

jim Thornton, MD, FRCOG

Kerstin uvnas・Moberg, MD, phDSaras vedam, RN, MSN, sdD(hc)Kim watts, phD, PGCAR MSC, RM, RN

International confederation ofMidwives

Frances G抑且esChicl'Execuh'veThe Nether14nds

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RafatjanP4kistαπ

Internationaljournalofchildbirth

Volume 5, Number 4,2015

1三DITORIAI

Genderlnequality in Maternity servicesDe11is W41Sh

EXTENDED COMMENTARY

SmaⅡ Nations, Large lmpact: The caribbean RegionalMidwives AssodationDebr4h ιewis,<14rci4 R0110ck,八1αrg4ret八1αおhα11, catheガ11e C4rむ

α11d 1ιιdith FU11e光011

ARTIC工王S

Humanized childbirth and culturalHum山ty: Designing an onHneCourse for lvlaternal Health providers in 上imited・Resource settings

A1πita sreeπiν4S, SUS411πα Cohe11,ιaur4 入1484ii4・V4114dares,

411d Dilys w'41ker

Comparison ofpolicies forthe Management ofcarefor い10men andNewborns During the Third stage ofLabor Among lapanese Hospitals,Clinics, and Midwifery Birth centers

}heko Kamok4, Ka0ガ N4k4y4"14, yukaガ yaju, Hiro"1iEto,α11d shigeko Horiuchi

气Vhat Makes for Good c0Ⅱaboration and communication in Maternity care?

A scoping studyIS4be1 ν411 He1111011d,1ルπe K0おtie11S, jessiC4 MeS1114π, M4ri411πe NieU1νe11huij2e,

K1αSie11 Horst111α11, Huherh'π4 Scheepers, Marc sPαα11der111411,1Udit Keule11,4れd R4y"10πd de vries

Exploring the professiona11Ssue ofGroup B sheptococcus screenin8in presnancy

SharH4 Bicheπo a11d S4die Ger4Shty

AVAIIABIE ONIINE ONI,Y

Abstracts From the lnternational confederation ofMidwives

30th Triennial congress, prague, czech Republic,'Theme 4-八ιidlvifery: Bridging culture and pradice

178

180

188

200

210

224

E562

EDnoRIAL

Genderlnequalityin MaternityseNices

There is an overwhelmin8 evidence that women experl・

ence systematic inequality throughout most countries,

and, in some places,壮)is tips over into misogyny withmurder, rape, and various types of abuse.1t should notCome as a surprise then that gender inequality manifestsin pre名nancy and childbirth. Recently, some c0Ⅱeaguesand l 、vrote an article for 入lidirS 入lid1νif'er), Dig'est scop、in8thisissue (凡I×1alsh, christianson,&stewart,2015), and1、vant to higNightthe chaⅡenges this presents to globalmidwifery and suggestsome strategies to address it.

We highlighted in our article thatthe use ofgenderIens through which to examine midwifery policy, prac_tices,teaching, and research is noteworthybecause ofitsabsence. The wordje111加iS加 is rarely foregrounded inthese areas with the phrase ge11der i11eqU41ity only mar_gina11y more visible. Yet there is evidence in n)any con-

texts thatthe ef企Cts ofpatriarchy continues to impin8eOn midwives and women,丘Ustrating the realization oftrue agency fot childbearing women and underminingthe autonomy ofthe midwiferyprofession,

The status of the profession globaⅡy continuesto be patchy across and between countries and states,despite overwhelming evidence of the positjve impactOn childbirth of women having access to midwives.The recent ιancet series summarized d)e bene6ts of a

Strong, autonomous midwiferyprofession, contributingto a reduction in maternal and perinatal mortality.

Place of birth oP廿ons are interesting to examinealongside the status of the midwifery profession. TheseOptions are much more available in countries where the

Profession of midW廿ery is strong. Home birth, birthCenters, and mid、vifery units are accessible and used inCountries such as New zealand, the Netherlands, and

the united Kingdom wha'e the midwifety professionhas a long history of autonomy and self、sovernment.Ofcourse, home birth is used in low income countriesbut genera11y 0丑en without skiⅡed birth attendantsand, consequently, is believed to contribute to matel・naland perinatal mortality By Nvay ofcontrast, home birth

//V7'ER/VA刀0/VAI_ JOU凡IVAι. OF CH/ιDB/凡TH VO/ume 5,/ssue 4,2015◎ 2015 Spriηger publishing company, LLC WWW.springerpub.com

h廿P:ガdx.doi.org/10.189ν2156-5287.5.4.178

and midW廿ay unit birth in countries with a stronmidwifery profession and pr061e are hlown t0 10werCesarean sections rates and a range ofother labor inter、

Ventions at a unit costlower than in maternityhospitals.So there are economic benefitsto be realized ifcountriesUPSMⅡ their midwifery workforce.

Gender is such an importantlens throU今h whichto viewtheseissues because self・evidendy, onlywomenbirth babies and the vast majority of midwives arefemale.凡'×1hy do countries deprioritize maternal andPerinatal health, despite the available evidence of

h0刃V to develop safe successful services?入lany femi_nists scholars Nvould view this as straightforwardgender discrimination and their arguments are begin_ning to be heard as organizations such as the 刃XlorldHealth orsanization (~×1HO) and united Na廿ons

have endorsed such an analysis. Both organizauonsare making policy statements to this end see the凡VomelゞS Health Forum of 刃XIHO (UN News centre,2015) and the HeForshe website (UN women, n.d.),among others.

叉Ve make a plea in our artide for midwiferyresearchers to invoke feminist values and feminists

methods when undertaking research into maternityCare. Feminist values in research can be summarized as:

178

1. primacy ofwomeds experience2・上istening to and valuing 、vomenls voice and womeds

Version ofevents

Establishin3 relationships ofequality and redprodtyHaving the same rights, opportunities, andPrivileges as men

5・ unmasMng ofdehumanizing and oppressivePractices against women

6. Action forempowermentand emandpation

&

Feminist research methods have developed overthe pasttlvo or three decades to be indusive and opento anymethodsthatare underpinnedorenadthevalues

34

espoused earlier. A 号ood resource to explore feministresearch further is Fe111i11ist Rese4πh iπ Theory 4πdPr4dice by Gayle l'etherby,2003.

Undergraduate and post留raduate midwiferyCourses should engage this agenda to assist students tothinkcriticaⅡyabout号enderinthepregnancyand child・birth context. currendy, atleastin the united Kingdom,this is not generaⅡy the case, and student mid、vives'Critical oudook is the poorer f01' this omission.

At a macrolevel, policymaMngregardingthe mid・W廿ay profession and childbirth more broadly shouldengage with genderinequality. Asthis remainssystemicin broader societyi such a focus can be even harderto achieve because conversations are 0丑en lvith a dis-

Proportionate numbers of men in positions of power.New zealand is an interesting case study of how thisCan be addtessed. The 6rst country to give the vote toWomen, New zealand passed a promidwifery and pro・Womeds choice legislation jn the 1990S 、vhen the NewZealand c011ege of Midwives negotiated with a femalehealth minister and later prime minister for theseVisionary changes.1t is interesting that only recentlytheir c0Ⅱege of Mid、vives applied a gender analysis to10bby for be杜er pay for midNvives.

Across mid凡Vi企ryresearch, education, practice, andPolicy,1 believe the time is right for gender equality anda 企minist consdousness to reinvigorate 壮le midwiferyProfession so that it can continue t0 丘ght 仕)e effects ofinequality 血 Womeds reproductive lives.

REFER壬NCE

Denis walsh

joint Editor・in・chief

Nottin8ham universit又 United Kingdom

〔ditoria1 179

Letherby, G.(2003). FelHi"ist research iπ theory α11d pradice.BUCMnghaln: open university press

UN News centre、(2015, February lD. UN・hosted ForU1πOpe11S iれ Ne1νγbrk, seeks to ide11tuly 4i"1S 011 W0111eπ、he41thforpost・2ω5. Retrieved from http://WWW.un.or創apps/news/story.asp?NewslD=50064#.vh6mkoxvhBd

UN wom印.(n,d.) Hcf'0心he. Re壮i0祀d from h杜Pゾ/W艸heforshe.org

Walsh, D、, christianson, M.,& stewart, M.(2015). why mid・Wives shouldbe feminists.<lidirS 八lid1νiferyDig'est,25(2),154-160

f灯fND圧DCONWIENTARY

SmaⅡNa廿ons,largelmpact: ThecaribbeanRe容ionalMidMvesAssodauon

Debr4h ιewis,入larda R0110ck,入larS4ret入14rshaル Catheri11e carむaπd/udith FU11ert0π

Thisarticlepresentsanoverviewoftheemergenceofprofessionalmidwifer inthec 'bb ,beginningwith c010nialtradition,andlinkages、vithnutsin8educationand ractice. R t t・taken to strengthen the voice ofmidwiferyas an autonomous rofession are then d 'b d,' 1 dthe vision for development ofa caribbean Re8ionalMidwives Assodation (CRMA), which antid atesrecognition as a new memberstatus by the lnternational confederation ofMidwives. CRMAbersareengagedine丘ortstobuildindividualpractitionercapacit inclinical ractice d d ,throughsharedactivitiesandresources.CRMAmembetsarealsow。rkin t。 d l・ fmidwifery core curriculum aT)d common standards for re名Ulation.

KEYWORDS: capadtybuilding;midwiferyeducation;midwifer Te ulat'。;Ⅱ b ;regionalization

侠む^"ト卓,、

INTRODUCTION

The caribbean is a re8ion ofthe world consistin ofIitera11y thousands ofislands, islets, coral reefs and caysin the Atlantic ocean dustered within the caribbeanSea, and several countries that are located in dose

Proximity to its coastline. The re8ion is located to theSoutheast ofthe North American continentandthe GUHOf Mexico, to the north of the south American conti_nent, and east of central America. Many of the ma'orCaribbean islands are independent nations; others areterritories of other countries. certain countties onthe central and south American continents also ali nthemselves with the region because of historical orCulturalidentiw. The population of the region was esti_mated in 2013 to be approximately 32,192,000 (centralInte11igence Agency lclA],2014; FiguN I).

The caribbean has been noted to have maternaland child mortality statistics that are favorable in

Comparison to the other developin8 Country regionsand to sub・saharan Africa. H0凡Vever, the region sti11ranks fourth highest for maternal mortality and eighth

fbr under・6Ve mortality among lo regions in a recentanalysis (united Nations [UN],2014a). The re今ion alsoranks third loNvest (53%) among ei8ht globalregions onthe proportion of deliveries attended by skiⅡed healthPersonnel(range of51%-100% in 2012; UN,2014b).

The rate of progress toward meeting 入liⅡenni山nDevelopment Goals has been Very uneven across coun-

trieS 血 the region (castelazo・Morales,2013; Mitra &

Rodri8Uez・Fernandez,2010; oestergaard et al,2011; shah& say,2007; wodd Hea1壮10rganization [WH01, unitedNationschildNdsFund luNICE羽,unitedNatjonspopu_IationFund [UNFPA], The、vorldBank,&unitedNations

Population Division,2012). The maternal mortality ratiofbr 15 C0山ltries in 廿le caribbean re8ions is cited at 150(uncertah)tyinterva1110.1-206.フ; Kassebaum etal.,2014).Progress toward reductions il)仕le under、ave 6ndudinginf会nt) mortality rate has ra11ged from 12.8% t0 25.1%Of2015 target goals acrosS 17 re号ional countries a11d ter_ritories (UN,2010; UN,2014a). A dedine in the neonat凪mortality rate (NMR) has not been demonstrated in over

a decade (Alial)za,2015). Newborn mortality accounts血r 60% ofinfant deaths and,in Lat加 American 肌d the

180/NTER/VAT/0/VAι. JOU月/VAι OF CH/ιDB/RTH VO/ume 5,/ssue 4,2015

⑥ 2015 Springer publishing company, LLC WWW.springerpub.comh廿P:ノ/dx.doi.org/10.189ν2156-5287.5.4.180

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The caribbean Regional Mid、vlves Association ιewis et a/.181

0

ン・、

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I Angudla2ADtigua and Barbuda3 BaTbados

4 Dominica

5 Grenada

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6 G口adeloupe

7 MaTtinque8 Monteseττat

9 NetheT】andAntⅡles

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FIGURE I Map ofthe carribean region. The caribbean RegionalMidwivesAssodation membershゆ also indudestheSouthAlnerican countries ofGuyana and suriname.

Caribbea11, the stⅡlbir廿l rate approximates the neonatalmortali智(save the children,2014a).

These less favorable indicators exist despite thefad that access to care in these nations is genera11y今ood and referra11evelinstitutions are generaⅡy we11eqUゆPed and offer subspedalized care. Table l depictsthe variation in maternal,infant, and neonatalstatisticsin countries of interest.

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12 Saintvincent and the Grerladines

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IHf HISTORYANDADVANCEMENT OFTHE

MID、NIFERY PROF重SSION IN IHE CARIBBEAN

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The tegion has great diversity itlitS 3eopolitical evolution・awhistory. However,せ)e broadhistoryofmidwi企ryi11杜le

d

re8ionis quiteS血Ⅱ笹. Earlymid爾feryhistoryi11Corporates杜)e assimilation of traditionS 飢d pradices accumulated杜lrough decades ofearlyc010nizationby仕leBritish, Dutch,French, a11dA111erica11S, accompa11iedbypopulationmigra・tion across the isla11ds. The trai11hlg a11d re8istrauon of註)dividuals as midwivesis fourld i111iterature 丘'om 壮le early180OS (~V辿血S・cook,1975). Modern midM企W itltheEnglish・speaMng caribbea11is, however, historica11y ljl)kedt0 せle Btitish system (Burke,197フ; Gard11er,1993) a11dStrongly 血丑Uenced by a11 embeddi11g Mth血 the nursi11gPr0企Ssion (HoweⅡ, Ra任erty & snai血,2011; Mi11er,1992;~vei11Steil),197&~vright, cloona11,王e0血ardy,& wright,2005). Fur吐ler education itl midwi企ry was largely viewedas a path、vay to senior or superⅥSory positions in nurshlgadmhlistration. Midwi企ry as a contelnporary a11d autono・mous pr0企Ssion is odyrecentlyemerg血g (LeMS,20ID.

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182 The car山bean Re8ional Mid、vives Assodation ιewis et a/

TABI、E I Maternal,Neonatal,andlnf飢tMortalitystatisticsandMothet'slndexRanMngforcountrieswhoHaveExpressed anlnterest hlMembership in the caribbea11RegionalMidwivesAssodation

MATfRNALMORTAUTY RAτ10 NfoNATAI. INFANT

COUNTRY [UNCERTAINIY INTERVAU MORTAUTY RAτモ MORTAU丁Y RATE

Anti呂山andBarbuda 42.0 【279-62.3】0

No rank

Aruba

Bahamas

Barbados

Belize

No matemal death5 reported2006-2010f

603 B83-91.2 10

37 124-55]h

49.9 B43-70.フ]0

52 B3-83]h

55.5 B7.6-78.9].

45 BO-681h

36'1 [232-52.71.Donlinica

Crenada

Cuyana

Haiti

42

jamaica

56.フ[41.0-76.9]0

23 Π 4-371h

118.1 {75.8-179.410

250 Π 60-380lh

333 [219.1-480.1】、

380 [220-680lh

44.7 129.フ-66.0]0

80157-110lh

20 Π 3-321hPuerto Rico

5.7b

5 'OC

No datab,0

1 1.ob41'0128.0-58'8}'、 80

34121-54】h 9.0'

Saint K11ts and Nevis 3 (1ealhs rel)orled betvveen 2006 10.ob No rank

and 2010k No datが

Sainlvlncent 引ld the フ.9b60.1 143.フ-80.81. 86

45 129-0]hCrenadines 12.00

Suriname 12.ob652 [442-91.3]0 99

BO [87-190]h 12.00

TrinidadandTobag0 49.7 B6.4-65.6]. 23.ob 65

84153-140】h 15.00

Note. Maternalmort田ity tatio is the number ofmaternaldeaths in a given time period per loo,ooo live births durin the same time eriod(VVHO,UNICEE UNFPA,TheworldBank,UNFPA,2014).

NeoDatalmortality rate is the number ofdeaths in the 6rst 28 days oflife per l,00O Hve births (The wotld Bank,2013).

Infant mortalityrate isthe number ofinfant deaths youn名erthan age 1 γear per l,ooo live births (centers for Disease control and prevention,2014).

Mother's lndex measures the status ofmothers vis一会一vis several health and sodo-economic indicatoTS,such as accessto health care, use ofc0刀trace tionand familyplannin名,1iteracy, and participation in government progTams (save the chⅡdren,2014b).

'Kassebaum et al.(2014).

boester8aard et al.(2011).

气Vorld Bank (2013).

dcentr田 lntelHgence Ageng (2014).

'save the chi]dren (2014b)

fpanknerican Health 0弔anization (2013a)

glnfoplease (n.d.)

hwHO, UNICEE UNFPA, Theworld Bank,andthe united Nations population Division (2014).'1nd如nundi(D.d.)

」1nde血Undi(2012)

kpan knerican Hea】th organization (20Bb)

Saint Lucia

1 12

168

5.7b

フ.0'

6.4b

8.00

8.1b

8.0'

フ.4b

8'00

フ.6b

6.0'

21.ob

20.00

27.ob

25.OC

12.4b

10.0'

フ.9 (2012).

91

13.2d

162g

11.7d

13.8g

12.5d

23.1g

109d

122g

20.3d

23.og

11.6d

13.伊

10.5d

132g

33.5'1

29.6g

49.4'1

59,7g

13,フ'

15.2H

フ7d

フ.91

1 1.フ'1

13,4'

8.9d

13.9h

13.1'1

15.N

27.od

18.8g

24.8d

29.9'

MOTHER'SINDEX RANKINC

(OF 178 COUNTR1郎)0

No rank

No rank

70

49

No rank

86

The w'HO, the lnternational Federation of

Gynaec0108y and obstetrics, and the lnternationalConfederation of MidwiveS σCM) developed a jointStatement(2004) aboutthe contribuuon ofskiⅡed birthattendants to the reducuon of maternal and neonatal

mortality, which brought renewed a廿ention to therole of midwives as a health human resource (~×1HO,

Department of Reproductive Health and Research,2004). The lcM then developed the essential compe・tendes for basic midwifery practice (2010a), aTld theGlobalstandards for Midwjfery Education (2010b) andregulation (2011a), and began 、vorldwide disseminatione丘OTts. The wHO (2013) complemented these e丘ortsby development of basic competencies for midwiferyeducators and conducted similar 810bal advocacy forthejr adopuon.

International organizations and regional andCountry minjstries of healtb and education werePrompted to take another look at the situation ofmidwifery in the various caribbean island nations.These e丘orts were built on the foundation ofthe 、vork

Ofthe caribbean community and common Market(CARICOM), established in 1963, which had been

、vorking to standardize health professional educationfor many years.

Governments, nongovernmental organizations,and both public and pTivate development a号enciesOffered assistance to increase the capadty of the mid・、V迂eryworkforce, worMng in individualcountries oftheregion. For example, countlessinternationalhumanitat・ian aid or容anizations mobilized to provide assistanceto the country of Hai廿, f0110win号 the 2010 earth・quake、 Midwifery faculty from MCMaster universityPtovided multiple years offaculty exchange, buildin80fa resource library induding teachjng models, and pro・Viding technical assistance to Haitfs national midwiferyProgram.

Numerous a3endes provided workshops in vari・Ous countries to teach or to enhance evidence-based

Practice in various maternal or newborn manage・mentsM11S. The united states Agency for lnternationalDevelopment(USAID) andthe uNFPAhaveprioritizedtraining master midwifery trainers in key clinical areas.The American Academy of pediatrics (201の HeφiπgB4hiesBre4the workshop conducted in Trinidad in 2012is a single example. These agencies also provided 丘nan・dal support for the translation of key documents formidwifery dinicians and faculw.

However,凡Vhile valuin号 these contributions toCapadty building at the individual country level, itWas recognized that a broader, re今ional, perspective

The carlbbean Regional Midwives Assodation ιewis et a/.183

Would be advantageous for the 、vider region. severalre今ionale丘orts were implemented, focusing on assoda・tion buildin3 and strengthenin8 Professional educationand re8Ulation

Countries in both the Latin American and

Caribbean regions were assisted through the uNFPA/ICM lnvesting in MidMves program (2008-2013). ThisProgram focused on the professional development ofindividualmidwi企ry leaders and enhancement ofmid・Wifery education in selected countries.

UNFPA,1CM, and the pan American Health

Organization, in c0Ⅱaboration with Family care lnter・national, supported a regional meetin留 in 2011 enu・ded pr01πotiH8'ハ4idwifery iπι4h'π A1πeriC4 απd theC4n'hbe4π: str4tegic P1411πiπ8jorAchievi11gハ1DG5. Thisregional forum provided opportunity to disseminatethe lcM global competencies for midwifery practiceand standards for education and regulation and for a11Countriesto discuss howthese documents couldbe used

across the caribbean countries.

USAID, worNn8 血rough 血e }hpie今0-1ed Mater・nal and child Health lntegrated program, and succes-Sor Nlaternal and child sutvival program, conductedmany activities focused on association buildin8 andthe preparation of mid、vi企ry educators. This indudedSponsorshゆ of several workshops in 2011,2012, and2013 to teach midwifery educators how to frame theireducational pracuces in accord with the prindples ofCompetency・based teaching.1t also induded support ofan lcM regionalmeetingto beheld in surinamein 2015.

The mid刃Vives of the caribbean were partners in thee丘orts to raise the pt0飢e of midwifery in the regionand to take owne郡hゆ oftheir identity (in accord withthe lcM de6nition [1CM,2011bD and their pradice.Re今ional history documents the emergence of mid・Ivifery professional assodauons over half a centuryago. The lamaican Midwives Assodation was started in1960; other midwifery assodations have been inaugu・rated in the recent few years. Table 20丘ers an abbrevi・ated example of this diversity. History also documentsthe unsuccesS6、11 e丘orts to establish a midwifery 3roupWithin the caribbean Nurses organization (CNO),Which itself has an almost 50・year history The cNO,the professional assodation for nurses in the region,has been hesitant to separate the professions ofnursin号and midlvifery but has recently 0丘ered support fot the

THモモMERCENCE OF A CARIBBEAN MID、VIFERY

C01.kABORATIVE

184 The caribbean Regional Mid、vlves Assoclatlon ιewis et a/

TAB王E2 MidW廿eryAssodationsinthecaribbean:A11Exemplat

COUNTRY

Ba1ねmas

Cuyanajamaica

Salnt Kitts and Nevis

Saintvincent 引ld 小e

Crenadines

DATf MID、、/1FERYASSOCIATION

OR INTEREST CROUPSTART[D

Saint Lucia

Suriname

丁rinidad and Tobago

October 2005

2009

june 1960

Developin8 Constitution phaseNo midwifery a5Sociation.

A11 nurses and nurse・mid~vives

Use the nurses association

May 2011june 1969

September 1995

inausuration of cRMA (D.1,ewis, personal communi、Cation, odober 27,2014).

The 丘rst discussions about establishing aCaribbean network occurred during a MidwiferyTodayConference in jamaica in 1999. There was early tecogni、tion of the value of a uni丘ed voice, and this led to the

establishment of the caribbean AⅡia11Ce of Midwives,

induding an initial membership of both traditionaland professional midwives representing 丘Ve countries/territories in 2001.

A larger c0Ⅱaborative^the caribbean lvlidlviferyInitiative^Was formed in AprⅡ 2012. partidpantsinduded midwifery delegationS 丘om B of the 18Caribbean countries that had been invited to a廿end.

This proportion of representation 、vas itself remark、

able, given the fad that, although island nations maybe geographicaⅡy dose to each other, the cost oftrans、Portation bet、veen nations is very high, and there isgreat lan今Uage diversity Despite these cha11enges, therepresentatives agreed to work toward establishment ofa regionalnetwork ofmidwives.

The outcome of that meeung was the formalestablishment ofcRNIA, whichwaslegaⅡyincorporatedin january2014. The mission ofthe cRMA isto provideand promote hi8h qualiw standards of midwifery careto meet the needs of women and their families in the

Caribbean through education, research, pradice, andIeadership. Table 3 depicts cRMAs action agenda, setfbrth atthe inauguralmeeting ofthe assodation.

CRMA members recognized the power of num・bersasacomponent ofautonomyand advocacy Towardthat end, CRMA applied for and holds a伍liate status

Withthe cARICOM RegionalNutsingBody(RNB). TheRNB had previously achlowledged and been supportiveOfa distinction between the t、vo cadres. Nevertheless,the

RNB spoke on behalf ofboth mjdwives, and the much

NUMBEROF

MID、VIV略 IN

COUNTRY

300

755

450

125

NUMBER OF MID、VIVES

INASSOCIA110NAS % OF

MID、VIVES IN COUNTRY

200

85

1,600

20%

75%

6ヲ1,

NA

Iarger number of nurses, with a single voice. Thjs ne、Vaff11iate statusis astep forward, providing avoice forpro、fessionalmidwi企ry, distinct from the voice ofnursing.

NUMBEROF

SCHO0[SIN

COUNTRY

40ヲ1,

100

40'%,

ι0OKINCTOYVARDIHEFUIURE

1 (4 Campuses)

CRMA dele留ates have accepted the chaⅡenge to worktoward regionali2ation of midwifery education and

TAB亘,E3 CaribbeanRe名ionalMidwivesAssodatiolfsActionAgenda

Re名Ulatlon goal: Movement of midwives within the

Caribbean to pradice free1γ and autonomouS1γDevelop a re8ionaHicensure examination for midwlferyHarmonize 小e mid゛/ifery re8Ulationyla~VS 、Nithin the ceribbean

elforce continuln8 education requirements for midwiferyreⅡCensure

Education goal: standardize educational preparation for a11mid、ん,ives in t11e caribbean re810n

Develop a competency・ba5ed curriculum for midwiferyeducation in 小e caribbean using lhe lntemationalConfedera(ion of Midwive5 (1CM) competencies, standards,and 8Uidelines

0仟er midwlfery pr08rams p.tthe baccalaureate degree levelUse rec08nized accredi捻tion bodies for nlidwiferyeducaⅡon programs ln 小e car山bean

Improve and maintain 小e art and 5Ci印Ce of mldwiferythrough evidence・based pradice and re記arch

Assodatlon goal: ESねb11Sh a carlbbean Regional MidM/ivesAssoclation

Eacl] country to establish a national mi(1Wifery associationMandate membership in 小e national aS50dation for licensure

F0訂η a1Ⅱances with 0小er relevant national, regional, andinternaⅡonal associati01鴨 and organizations

A(1Vocate au〔onomoU5 midwives as the most al〕proprialeCaregivel's for d]ildbearing 、vomen and lheir families

1 3

ーー

ーー 2

regulation to fadlitate the visibility and growth of theProfession; a perspective shared with other aggre3ates ofmidwiferyprofessionalassodations (Gherissi & Brown,2014). Regionalization is perceived as a critical stepin facilitating the mobility of midwives throU号houtthe caribbearl nations,、vhich in itself is a pathwayt0凡Vard addressing the critical issue of out・migration(AIU廿is, BisbaN & Ftank,2014; Anderson & 1Ssacs,

2007; salmon, Yan, Hewitt,& Gusinger,2007).1Ssuesto be addressed indude such things as a common cur・riculum of studies, indudin3 Competency・based edu・Cational approaches; common licensure examinations,With a今reed pass/fail cut scores; and a common scopeand standards ofclinicalpracuce. CRMA embraces themutual advocacy that、viⅡ Underpin the pursuit ofedu・Cation and practice policy chan3es that 、vi11 need to benegotiated lvith nursing and governmentrepresentativesacross the many countries.

The association has already made great stridestoward achievement ofthese goals. Three examples areOffered as a modelfor other countries, which might alsoConsider regional aggregauon, to advance these sameeducational and practice goals.

A 丘rst example is the commitment by educatorsin the region to acquirin旦 individualsMⅡS in the theoryand practice of competency・based education (CBE).A series of workshops, and subsequent atrain・the・trainer" r0ⅡOut, has resulted in wide dissemination of

this approach to curriculum development and dass・room and clinicalteaching in the re今ion. Twelve mid・Wifery faculty from across the region have achievedmaster status, and four have achieved cBE trainer sta・

tus, or are completin8 requirements for this credential.A second eX鯨Iple is the e丘ort made by re名ional

faculty to acquire or to enhance skiⅡS in the use ofContemporary techn010gies to support teaching. Theseindude online・ and smartphone・based plaぜorms (suchas Qstream) and both online and ofaine capacity・building courses (such aS 入10dcAL) to enhance their0、vn abilities to teach both preservice, and continuingeducation sessions.

Faculty who are networked through this techn01、Ogy also use it to advance their learning in coundessadditional domains of their practice. For example, fac・111ty share information about new teachin3 techniques,the availability of resource materials, and advances inevidence・based practice. some members have used theirneW 叉/X7eb・based learning competendes to enl'011inOnline courses, to advance their own education, even in

SettingS刃Vhere continuedprofessionaldevelopmentis notPresently requiTed for continued licensure.

The caribbean Reglonal Midwives Assoclation ιewis et a/.185

CRMAmembershaverecognizedthattheseteach・ing and learning approaches and resources wi11inevita・bly be used in the sttate号y to develop and disseminatea regionalized cul'riculum of mid、vifery studies. At theSame time, CRMA members recognize that these newe・1earning techn0108ies 、viⅡ require some time t0 丘lteracross a11 Countries in the region.

A third example is offered in BO× 1. This narrativeexempli負es how the enthusiasm of cRMA members

for shared learning opportunities ignited a similarenthusiasm in another,to the beneat ofmany

Most important, CRMA members are commit、

ted to promotin号 the highest standards of quaⅡty ofClinical services 0丘ered by aⅡ those who are identi丘edas midwives in the caribbean region (Bohren, et al.,2014). strategies to achieve those goals indude, a1110n8Others,(a) building leadetship capadty within cRMA;(b) promotin今 the development ofmidwiferyeducators,in accord with internauonalstandards; and (C) creatingIinkages 、vith existing regional assodations for strategicinput and regional development. This approach hasattracted the a廿ention ofthe donor community whichrec08nizes the value of 0丘ering assistance to net、vorksOfmidwives which offers opportunjty for broaderreachand 、vider impad.

CRMA has already successfU11y promoted its vis、ibility as a re号ional membership consortium, throughits advocacy with lcM, resulting in observer status forCRMA at the 2014 triennial meeting. Re号ional mem、bersh中 Status is presently under consideration as amodification oflcM membership cateσories. A regionalassociation is envisioned as a c0Ⅱective of midNvives'

assodations, which may indude botb members andnonmembers of lcM.1denti丘Cation as a tegional c01、Iective wi11 Pr0Ⅵde an opportunity for partidpation jnICM activities by countries such as those that have toofew mid、vives to support establishment of a countryassodation, or country assodauons whose membershゆ

BO×1 A11ExampleoftheBene6tofNetworMng

A neonatal specialist and educator from the country ofBarbados a5ked to parⅡCipate as an observer at a recentmeeting of cRMA delegates to learn about competency、based educational methods and curriculum development.She wa5 able to iclentify the seamless Yvays in 、vhich sheCould integrate her expertlse in neonatalintensive clinicalCare and neonatalresuscl[aⅡon me小ods into the midwiferyCurriculum.丁h15 netvvorking opportunlty resulted ln th isqualified teacher 0仟ering train・小e・trainer continuing eduCι1、Iion to faculty in countries that did not 11ave qualified teach、ing personne11n her topics of expertise.

186 The car山bean Reglonal Midwives Associatlon ιeレVis et a/

is too sma11to support global partidpation using theirindividual country resources. The regional memberassodation is antidpated to have a vote independent ofthe votin8 Status that would be retained as a privilegeOf individua11CM・member countries within the con、

Sortium, which would conunue to speak on their o、vnbehalf cRMA seesthisstatus asthe opportunityto pro、mote the unity ofthe caribbean region and strengthenits globalvisibility and voice.

CONCI.USION

A model consortium of midwifery professional asso、Ciauons has been established. This type of regionalC0Ⅱective has been proposedbythelcM as a newmem、bership category The cRMA regional association isWeⅡ Positioned to advocate for promotion ofmidwiferyacTossits geogtaphic locale and in internationalforums.The voice of professional midwifery in the caribbeanhas been strengthened through unity and c0Ⅱaboration,to the benefit ofmembers ofthe ptofession and the cli、ents that they serve.

Burke, G. A.(197フ). Nurse・midwifery in the caribbean.BU11eh'れ qf the P4π A1πeriC411 Health org411izati011,11(4),332-337.

Castelazo・Motales, E.(2013). why are mothers sti11 dyinσ inLatinAmericaandthe caribbean? 1πter11aガ011α1/ourπα1

ψGyπaec0108y ""d 0みStetn'CS,122(3),183-184.

Centers for Disease control and prevention.(2014). Dcf1πi、h'0π qf'mjhπt 抗ortali砂 r4te. Retrieved from h杜P://WWWCdc,名OV/reprodudivehealth/maternalinfanthealth/infantmoTtaliw.htm

Cent毅11nt0Ⅱigence Ag■0'y.(2014). Wωldfadhook 2014 esti、抗4tes. Retrieved from http://WWW.cia.gov

Gardner, R a993). The develop"1e11t qf'11Ursi11g eduC4tioH iHthe 三π宮lish・speakiπg C4riみbe4H IS1411ds (Doctoral Dis、

Sertation). Retrieved from h杜PS://repositories.tdl.otg/ttu・ir/bitstream/handle/2346noo05/31295007673790

Pdf?sequence=1

Gh6tissi, A.,& Bro、vn }. M.,(2014). A situational analysisOf the status of midwifery in North Afrjca and theMiddle East. hlter114tio"41 10ur11al qf' childbirth,4(2),69-76.

RffERENCES

Alianza.(2015). Let's get there! Reduce newborn mortal、ity by 2015 ルatin Ametica and caribbean New、

born Health A11iance]. Retrieved from h廿P://WWWhealthynewbornnetwork.or8/partner/alianza、de、

Salud・neonatal・para・am%C3%A9rica・1atina、y、el、Caribelatin・alnerica・and・caribbean、newborn

AIU杜is, C. E, BishaN T.,& Frank, M. W.(2014). The work、

force for health in a globalized context-Global short、ages and international m培ration. Gloh41Health Acti011,フ. http://dx.doi.orgn03402/号ha.V723611

American Academy of pediatrics.(201の. HゆiHg b4みieshル4the. Thegoldeπ 111iπUte. Retrieved from ht中:/ノエUWW.helpingbabiesbreathe.org/

Anderson, B. A.,& 1Saacs, A. A.(2007). simply not there.The impact of 加ternational migration of nurses and

midwives-perspectives from Guyana./ourπ41 ql'Midwif町y 6 W0沈πき Henlth,52(4),392-397.

Bohren, M., Hunter, E., Munthe・Kaas, H. M., souza,1. P.,Vogel,1. R,& G田mezoglu, A. M.(2014). Fadlita、

tors and barriers to fadlity・based delivery in low、and middle・income countries: A qualita廿Ve evidenceSynthesis. Reprodιιdive He41th,11,71. ht中://dx.doiOr今/10.1186n742-4755-11-71

Howe11,}., Ra丘ertyi A. M.,& snaith, A.(2011).(Author)ityabroad: The life wrjting ofc010nial nurses.111terHati01141jourπ41qf'NursiπgS畝dies,48(9), H52-H62.

Indexmundi.(2012).111j411t 柳ortalitγ 1'4te: pueπO Rico

RetTieved from http://WWW.血dexmundi.comノ号/g.aspx?C=rq&V=29

Indexmundi.(n.d.). Mater11411110rt41ity r4te: COUHtry co"1Pのi、S011S. Retrieved from h杜P://WWW.1ndexmundi.com/g/r.aspx?V=2233

Infoplease.(n.d.).1πjhπt 1110rt41it), rates qf'C01ιπtries. Retrievedfrom http://IVWW.infoplease.com/ipa/A0934744.html

International confederation of Midwives.(2010a). Esse11tiα1

C0111Pete11Ciesjbr b4SI'C IHid1νiferypradice;α111eHded2013.

Retrieved from h杜P://WWW.internationalmidwives.org

InternationalconfederationofMidwives.(2010b).1CMGlohα1

St4れdards jor "1idwif'ery educati011; 4"1eHded 2013.

Retrieved from http://WWW.internationalmidwives.org

International confederation of Mid、vives.(2011a). Globα1

Stα11dards jor "1idWザery re8U14ti011. Retrieved from

hせP://WWW.internationalmidwives.or8

International confederation of Midwives.(20ub). Dcf、i"iti011 の゛ the 111idwife. Retrieved from h杜P://WWW.internationalmidwife.org

Kassebaum, N.1,, Bertozzi・vi11a, A., coggeshaⅡ, M. S.,Shackelford, K. A., steiner, C., Heuton, K. R....1'02ano,

R.(2014). Global, re8ional, and nationa11evels and

Causes ofmaternal mortality during 1990-2013: A sys、tematic analysis fotthe GlobalBurden ofDisease studyι4πCet,384(9947),980-1004

LOW玲, D.(20ID. Midwifay 血 the caribbean. The state げthe world太ハ1id1νifery 2011. Uπited N4ti0πS POPU14ti0πFU11d. Retrieved from http://WWW.unfpa.or呂ノSowmy/reporvhome.html

MiⅡer, S. a992). Nurse・midwifery in st. vincent and theGrenadines./our1141qf'Nurse Midwifery,37(1),53-60.

Mitra,A.K.,&Rodriguez・Fernandez,G.(201の.LatinAmericaand the caribbean: Assessment ofthe advances in pub・Iichealth forthe achievement ofthe MiⅡennium Devel・

Opment Goals.111ter11αh011α1 /'ourHal qf'Eπνir011"1eπtα1Research 411d public He41th,フ(5),2238-2855.

Oestergaard, M. Z.,1noue, M., Yoshida, S., Mahanani, W R.,Mathers, C. D.(20IDGore, E M., cousens, S.,

Neonatalmortalitylevels for 193 Countries in 2009 、vithtrends since 1990. A systematic analysis of progress,Projedions, and priorities. PιOS 1πediciπe,8. h杜P://dx.doi.org/10.B7νjournalpmed.1001080

Pan American Health 0弔anization.(20Ba). Atuba. He41thiπ the A"1eriC4S. Retrieved from ht中://WWW.paho.org/Saludenlasamericas

Pan American Health organization.(2013b). st. Kjtts &Nevis. He41th iπ the A111ericas. Retrieved from http://Wwwpaho.org/saludenlasamericas

Salmon,M'E.,Yan,j.,He、vi壮,H.,&Gusinger,V.(2007).ManagedMi8ration: The caribbeatlapproach to addressing nurs・加gservicescapadw.He41thservicesResearch,42(3,pt.2).http://dx.doi.org/10.1H vj.1475-6773.2007.00708.X

Save the children.(2014a). Reduciπ8 πe0παt41 抗のtality411d 1110rhidity i"ιαtiπ A111eriCααπd the caribbeαπRetrieved from h廿Pゾ/resourcecentre.savethechildren.se/sites/defaulV61es/doC山nents/2729Pdf

S.V. the childルn.(2014b). st4te ψthe worldち抗otheお 2ω4.Retrieved from h廿P://WWW.savethechildren.net/sowm

Shah,1. H.,& say, L.(2007). Maternalmortalityand maternityCare from 1990 t02005: uneven but important gainsReprodudive Health M4tters,15(3の,17-27

United Nations.(201の. Mi11eππiU111 DeveloplHeπt Goals2ωo jad sheet. Retrieved from h杜P://WWW.cepal.org/MDG/notidas/pa部nas/6/40006/MDG4_CHILD_

MORTALITY_FACT_SHEET.pdf

United Nations,(2014a). The Mi11eπiU抗 DeveloP1πeπt G041SルPの't 2014. Retrieved from http:ノノWWW.un.org/mⅡlenniumgoals/2014%20MDG%20reporvMDG%202014%20En81ish%20web.pdf

United Nations.(2014b). Mi11eππiU柳 Develop"1eπt G0αIS(MDGS)ルd sheet. Retrieved from h杜P://WWW.who.invmediacentre/factsheets/fS290/en/

Weinstein, R.(1978). A projed report: F0110W・up of trainednurse・midwives. jourπ41qf'Nurse・Midwif'ery,23,36-39.

WiⅡiams・cook, E.(1975). The evolution of the Trinidad

midwife. The NUお加g coUπCil qf' Triπ1'dad 6 robα80,

丁he caribbean Reglonal Mid、vlves Associatlon ιeレVis et a/.187

25th Aππiveお4ry.1950-1975 (P.32). port of spain,Trinidad: Key caribbean.

The ~vorld Bank.(2013). Mortali砂 r4te,πe0παtα1 φer l,000Iive births). Retrieved from: h壮P://data.worldbank.org/indicator/SH.DYN

World Health 0弔on丘ation.(2013). MidWびのy ed"mtの卯reC0111Pete11des. Retrieved from http://WWW.who.invhrh/nursing__midwifery/educator_competendes/en/

World Health organi2ation, Department of ReproducuveHealth and Research.(2004). M4k加g pre8Hα11Cy sqf'er:The critical role qf the ski11ed 4tteπdαれt. Retrieved fromhttp:ノ/WWW.who.invreproductivehealthゆUblications/maternal_perinatal_health/9241591692/en/

~vorld Health 0弔anization, united Nations childNtゞS Fund,United Nations population Fund,& The world Bank.(2012).乃eπds iπ柳αter11α1 "10rtα1どy 1990 t0 2ω0.WHO, UNICEE UNFPA απd The レVorldB4πkesh1π4tes'

Retrieved from http://who.invreproductivehealth/Publications/monitoring/9789241503631/en/

~vorld Health organization, united Nations childrents Fund,United Nations population Fund, The world Bank,&United Nations population Division.(2014).乃eπdsiπ 1114ter11α11110rtality:1990 t0 2013. Rettieved from:h杜P://WWW.who.invreproductivehealthゆUblications/monitoring/maternal・mortality・20B/en/

~vright, S., cloonan, R, Leonhardy, K.,& wright, G.(2005).An internationalprogrammein nursing andmidwifery:Building capadtyforthe new mj11ennium.1"ter11αti01141NursiπgReview,52(1),18-23

Debrah Lewis, MSC, CNM, Mamatoto Resource & Birth

Centre, Belmont, Trinidad, westlndies.

Marcia R0110ck, MEd,上M, Trinidad & Tobago Assodation ofMidwives, couva, Trinidad.

Margaret MarshaⅡ, EdD, CNM, FACNM,1nternationalcon・Sultant, Arlington, virginia, USA.

Catherine carr, DrpH, CNM, FACNM, senior Technical

Advisor, jhpie80, Baltimore, Maryland, USA

}udith FU11etton, phD, CNM, FACNM,1nternationalconsul、

tant, san Diego, california, USA

Ackn01νledg机e11ts. The authors acknowled号e the 丘nandalandtechnicalcontributionsmadebytheunitedstates Agencyfor lnternational Development and to lhpiego corporation,through its Matetnal child Health lntegrated program andMaternaland cbild survivalprogram,to the development ofmidwifery and midwivesin the caribbean region.

Correspondence regarding this article should be directed toIudith T. FU11erton, pbD, CNM,フ717 Canyon point ιane, sanDiego, CA 92126. E・mail:j.fUⅡerton@hotmail.com

ARnC任S

Humanizedchildbirth and cU1加ralHumⅡity:Designh1号 an onlhle coursefor MaternalHea1血

ProviderS 血王imited・Resource se廿ingsA111it4 Sreeπiν侃S, susa11114 Cohe11,ι4Ur4 入14g4iia、V4114d4res, a11dD記戸 Walker

This artide reviews the implications of disresped and abuse in maternal health services, tbe ro、vinmovementto humani2e chi]dbirth and promote culturalhumility, and one strategyto build an onlineCourse to addressthisissue among maternalhealth workers in Mexico. Reports ofdisres ed and abusehave been wide1γ reported bywomen seeMn合 health services,indudin3 maternity care, acrossthe lobe.Evidence indicates 0丘enders are 0丑en health care professionals who do not consider their behaviorinappropriate and believe they are acting in the interests ofboth mother and baby、 These same provid_ers are 0丑en overworked, underpaid, and have few role models who humani2e childbirth and dem、

Onstrate cultural humility. strate名ies which aim to foster competendesin humanized childbirth andCultural humility among health providers are lacking in current health professionaltraining pro rams.Using the case ofMexico,the authors describe the template and justi6Cation for an online course fornovice to expert hea1出 Professionalsto build competendesin h山nanized childbirth and culturalhumility Recommendations for future work are discussed.

KEYWORDS: humanized childbirth; culturalhumility; disrespect and abuse; web、based learnin ;Self、reaection; values dari丘Cation

健1

INTRODUCTION

<laternal mortality is estimated to be 15 times higher in10W・ versus hi8h・resource countries and remainsslowto

deCⅡne (united Nations[UN],2006). Toreduceprevent、able maternal deaths, signiflcant resources have beenaⅡOcated toward interventions to help lvomen accessmaternalhealth services (UN,2006). Yet, disresped andabuse 0丑en deters families from seeNn8 fadlity、basedCare even when theyhlow a woman requires assistance,Care is accessible, and resources ate available to payfor care (Bowser & H辺,2010; Rahangdale et al.,2010;叉Varren et al.,2013). Furthermore, women who seek

fadlity・based care are atrisk ofpoor clinicaloutcomes as

a result ofpoor qualityhealth care services compoundedby disresped6.11 and abusive care (Bowser & HiⅡ,2010).To achieve global health objectives to reduce maternal

mortality world刃Vide,1eaders must address disrespectand abuse in their polides and intervenuons. Themovementto humanize childbirth and promote culturalhumility has been proposed as a way to decrease disre、Spect and abuse in maternalhealth care.

In a landmark document published by the unitedStates Agency for lnternauonalDevelopment(USAID),authors report disrespect6.11 and abusive maternity careis a globalissue (Bowser & HiⅡ,201の. The authors

Contend there is a lack ofconsensus re8arding the medi、Cal need for resped6、11 Care during childbirth (B0刃Vser& HiⅡ,2010). HO、vever,in a more recent statement bythe 凡I×70rld Health organization (~×1HO), internationalhealth organizations have joined together in a caⅡ、to、actionto ensure "everywoman hastherightto the hi号h、esta杜ainable standard ofhealth,、vhichindudestherightto di8ni6ed, respectful health card'(WHO,2014, P、D.

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Evidence indicates offending health care providers donot consider their behavior inappropriate, or do notrealize their actions cause harm (Bowser & Hi11,2010).

Many believe they are acting in the interests of bothmother and baby and their practices are the best optionin the context of critica1 丘nandal, human, and infra・

Strudural resource shortages (Bowser & HiⅡ,201の.Importantly,thesesameproviders are 0丘en overworked,Underpaid, and havefew role models who humanjzethebirthin号 experience and demorlstrate cultural humilityin clinical practice.

In Mexico, for example, there is documentedWidespread mistreatment in maternal health servicesindudin8 Verbal, psycbosodal and physical abuse,Unnecessary medicalintervention, and a disregard forinformed consent (castro & Erviti,2003; 1nstituto

Nacional de salud P仙lka [1NSP],2013; KendaⅡ,2009;

Ma廿hias, Maria,& M6nica,2013).1n a governmente丘ortto prevent disrespect and abuse in maternity careby health professionals, the lNsp in Mexico (NationalInstitute ofpublic Health) has partneredwith pRONTOInternational(pr08r41114 de ResC4te obstどhico y Ne0114・t41: Tr4t4111ieπto opti1110 y op0光記π0 111ter114h0114b, todevelop an online course on humanized childbirth careand cultul'al humility.

PRONTo lnternationalis a nonpr0丘t organiza・tion which c0Ⅱaborated with lNsp in the development,implementation, andevaluationofatrainingcurriculumWhich deliverslow・tech, hi3hly・realisuc,simulation, andteam・training for improving the management ofobstet・ric and neonatalemer牙endes (PRONTO,2013;~valkeret al.,2012). Building on the succesS丑.11implementationOfthe pRONTo course,1Nsp and pRONTo lnterna・

Uonal continued to c0Ⅱaborate to develop an onlineCourse on emergency obstetric and neonatal manage・ment which is 0丘ered to health care professionals priorto theirin・person partidpation in the pRONTo course(PRONTO,2013). This article presentsthe developmentOf an adjund online training to foster competendesin humanized chⅡdbirth and cultural humiⅡty amongmaternal health providers. subjed to funding, thisCourse would be disseminated to maternal health pro・Viders throughoutthe public sedor.

Humanized childbirth and cultural Humility sreenivas et a/.189

he41th C4re) refers to being awoman・centered,nature・centered,[and having an] appropriate techn01・Ogy approach to childbirtH'(Bowser & H辺,2010中.39)as weⅡ as a woman 企eⅡng "safe and satiS丘ed"(Misa80et al.,2001, P S69) with her birthing experience. MoreformaⅡy, Misago, umenai, onuM, Haneda, andwa今nera999) de負ne h1ι111411ized 111ater111'ty care as:

Care that:is fU1負Ⅱing and elTlpowering bot11

to 、vomen and to their care providers; promotes

the active partidpation and dedsion making

Of 、vomen in aⅡ aspects of their own care;is

Provided by physidans and non・physidans

Working together as equals;is evidence based,

induding techn010名γ; is in a decentralized sys・tem of birth attendants and institutions 、vit11

high priority to comnlunity・based prin〕m'y

Care; and is 、vith cost・benefit analysis for 丘nan・dal feasibili1γ.(PP. B91-B92)

Disre叩ect and Abuse in childbirth

DisrespeCぜUl and abusive care is lar3ely founded uponand reinforced by systems of gender inequity, infra・Struduraltolerance, and po、ver differenuals which pre・Vent women from having a voice (Bowser & HiⅡ,201の.BO、vser and Hi11(201の Characterize disrespectful andabusive treatment in seven categories:(a) nondi今ni6edCare,(b) abandonment or denial of care,(C) physicalabuse,(d) noncon6denual care,(e) nonconsented care,

(f) discrimination based on sped6C a杜rjbutes, and(8)inappTopriatedemandsforpayment(e.g.,detainment,bribery, etc.).

Honoring cultural pteferences 、vhen safeto do so for mother and baby is an integral part ofredudng disrespectful and abusive maternity care.1nSettin3S where women have sU丘ered from sti号ma anddiscrimination because of personal traditions andCultural beliefs, e丘orts to promote cultural humil・ity 80 hand・in・hand with humanizjng childbirth(Bowser & Hi11,2010; Fahey et al.,2013). practidngCultural humiHty in maternal health is having theawareness every woman wiⅡ Process and expresstheir cultural context differently as weⅡ as 、vorking toremove culturalbarriers between health care sta丘and

Women 凡Vith deeply rooted culturaltraditions regard・ing childbirth and motherhood (Bowser & HiⅡ,2010;Fahey et al.,2013).

THEORETICAk BASIS FOR COURsf coNIENI

Humanized childbirth and cU1加ral HumiⅡty

The concept "humanized childbirtH'(also krlown ashU111απized 柳αterπity Cα↑'e and hU1π4πized 1114ter1141

190 Humanized childbirth and cultural HumiⅡty sreenivas et a/

There are manyimPⅡCations ofongoingdisrespedandabuse inhealth caresystemswhere offenders are notat risk ofbeing held accountable (Bowser & HiⅡ,2010;Rahan合dale et al.,2010; warren et al.,2013). Research、ers have found women who are fearfi110fmistreatment

Or have been mistreated by health providers in the pastare less likely to seek necessary fadlity・based care, plac、ing them at greater risk during obstetric emergendes(Bowser & Hi11,2010; Njuki et al.,2013; Rahan今daleet al.,2010; warren et al.,2013).1n addition to deterringWomen from seeMng fadlity・based care, disresped andabuse can have a deleterjous e仔ed on clinicaloutcomes

for the mother-baby dyad, either directly or caused bySigni丘Cant stress and fear (Blackburn,2013; Bowser &

HiⅡ,2010; Field, Hernandez・Reif, Taylor, Quintino,&Burman,1997; Matsubara, Mika, Kikkawa,& SUZUM,

2012; Matsuo, shiM, YamasaM,&shimoya,2009; Merhi& Awongua,2005; simMn, Boldin昌 Kepple二 Durham,& whaⅡey,2侃0; sleutel,2002; verheijen, Raven,&Hofmeyr,2009;).

(Blackburn,2013; Held et al.,1997; Ha11 et al.,2012;

John, Nischintha,& Ghose,2014; 0'Mahony, Hofmeyr,& Menon,2010; prior et al.,2012; simNn et al.,2010;

Sleutel,2002; smai11 & GriveⅡ,2014).

Physical trauma, as a tesult of jnappropriateOr nonevidence based "care, can also impact thehealth of the mother, fetus, and newborn (Matsubara

et al.,2012; Matsuo et al.,2009; Merhi & Awongua,2005; verheijen et al.,2009). Anecdotal evidenceand expert opinion indicate physical mistreatment,induding routine manualfundalpressure, can lead tomajor maternal-newborn complications such as uter、ine rupture, severe perinea11aceration, bone fracture,

and neonatal brain damage, aⅡ of which undermineCurrent e丘orts to ilnprove conditjons in maternal-nelvborn care across the globe (1Ylatsubara et al.,2012;Matsuo et al.,2009; Merhi&Awongua,2005; verheijenet al.,2009).

Medlcanmplications of Disresped and Abuse

凡Vomen who are a丘ected by stress and fear are moreIikely to experience asuffering" during childbirth-theinability to cope with labor and birth (Blackburn,2013;Field et al.,1997; Ha11, st011, Hutton,& Brown,2012;

SimNn,2011; simkin, Boldin号, Keppler & Durham,2010; sleutel,2002)."suffering ... has its source in chal、Ienges that threaten the intadness of the person as aComplex sodal and psych010gical entity"(cassel,1982,P.639). Thus, unnecessary and inappropriate medicalintervention compounded by stress and fear generatedfrom disresped611 and abusive care can affed clini、

Cal outcomes (Bowser & Hi11,2010; Rahangdale et al.,2010; warren, et al.,2013). psych0108icaltesponses andSequelae ofstress, fear, and sufferin3 may indude ni名ht、mares, aashbacks, fears of recutrence, panic attacks,avoidance of people or location 、vhere the originaltrauma occurred, and poS廿raumatic stress disorder(Ha11 et al.,2012; simkin,20ID. physical responsesindude pr010nged labor,increased need for analgesia oranesthesia,instrumentalassistance duringvaginaldeliv、ery and cesarean section (Blackburn,2013; Field et al.,1997; Ha11et al.,2012; simMn et al.,2010; sleutel,2002)、

Assisted-vaginal and cesarean・section deliveries putWomen andbabies at additionalrisk. Risksindudeinfec、

tion, perinealtrauma,incontinence, and uterine rupturein mothers and l0刃Ver Apgar scores, sepsis, and poorrates ofbreastfeeding initiation among newborn infants

Clobal f行orts and lnterventions

Latin America and the caribbean is one,of the 丘rst

regionS 加 the Global south to specifica11y addressthe human ri3hts needs and desires ofwomen duringChildbirth (Bowser &H田,201の. The earliestweⅡ、doc、

Umented projectto humanize chⅡdbirth, project0 ιUZ("projed ofLight") took place in Brazil between 1996and 2001 (Bowser & HiⅡ,2010; Misago et al.,2001;Page,20OD. The Bowser and H辺(201の report, pub、Iished nearly a decade later,is the most comprehensiveglobalassessment ofdisrespect and abuse in maternityCare to date. Authors point to behaviors 、vhich healthCare providers can directly and immediately addressin their 0叉Vn practice-such as honoring cultural biTthPreferences, when safe to do so for mother andbaby asWe11 as avoidjng disrespectful or abusive actionS 凡Vhichare contradictory to cultural preferences (Bowser &HiⅡ,201の. sped丘C examples indude provision ofempathetic support by providers, not just medicalmanagementas weⅡ asaⅡOwin今awomanherchojce ofbirth companion, bitthing position, and the freedomto move around and consume nuttitious beveragesduring labor (Bowser & HiⅡ,201の.

In 2011, the white Ribbon AⅡiance (W'RA),

founded on the prindple, aⅡ Women have the ri名httoSafe childbirth, published the υπiverS41 Rights qf'child、hearl'πg w'0111e11 Which correspond to the seven com、Ponents of disrespeCぜUl and abusive care identi6ed byBowserandHiⅡ(2010; WRA,20ID.1n 2014,thewHO

Published a statement ca11ing for 丘Ve actions which

must be taken to prevent al)d eliminate disrespectfuland abusive care in maternity services:

1. Greater support from governments and

development partners for research and

action on disrespect and abuse;

2.1nitiate, support, and sustain programs

designed to improve the quality of mater・

nal health care, with a strong focus on

respectful care as an essential component of

quality care;

3. Enlphasizin8 the rights ofwomen to digni・負ed゛'espeCぜUl health care throughout preg・

nancy and childbirth;4. Generating data related to respectful and

disrespectful care practices, systelns of

accountability, and meaningful professional

Support are required; and5.1nvolve a11Stakeholda'S,indudil)g 刃Vomen,

in e仔orts to inlprove quality of care andeliminate disrespect丘11 and abusive practices.

(WHO,2014, PP.2-3)

Humanized childbirth and cultural Humi"ty sreenivas et a/.191

5.1ntrodudng and practidn8 Patient・focusedinterviewing; and

6. presenting the healthcare encounter as a

dynamic,2・way communication and feed・

back loop、(Fa11ey et al.,20B, P.39)

Both the wHo and wRA diredly address theChanges which providers can make to improve currentConditions aS 凡VeⅡ as policy changes needed at the sys・temslevel(WHO,2014; WRA,20ID.

PRONTo lnternational recently adapted theirStandard simulation and team・training course forObstetric and neonatal emergencies for health careWorkers in Guatemala to indude a structured compo・nent on humanized childbirth and cu}tural humility(Fahey et al.,2013).1n the pRONTo training, SM11S inCulturalhumility ate fostered by

Fahey et al.(2013) suggest the way in whichan individual behaves is related to his or her level of

Openness and curiosity of self and others. Therefore,to practice cultural humility and humanized childbirthCare, the providet must engage in open dialogue withWomen bybeing curious about each individualwomal)'Sknowledse, a廿itudes, and beliefs. providers must alsoSelf・reaed to ensure he or she is being unbiased andtreaung others and selfjusdy (Fahey et al.,2013).

Ihe case of Mexico

1. promoting understandin名 tl)e healthcare

encounter is a仟ected by cultural contexv

back名round ofbot11 Patient and provider;

2. Minimizin名 focus on acquisition of dis・

Crete kno、vledge/facts regarding indigenousCulture b11t rather focusing on dlan8ing

the approach a provider takes to tl)e entitehealthcare encounter;

3. providi113 activities 、vhich pronloteSelf・reaection,

4. underscoring on1γ the individualwomankno、vs what components of cultlu'al back-

ground and context m'e releVιU北 and impor-tnnt to h引、1)ealthcare encounter

Maternal mortality rates (MIYIR) in Mexico rangefrom 16 t0 90 per loo,00O Hve births, ranking thenation 76th in the 、vorld (center for lnteⅡigenceAgency,2013; 1nstituto Nadonal de Estadistica Geo・

grafia,2013a,2013b; united Nations DevelopmentProgramme,2013). The widerangeinMMR reaectstheSignificant economic and sodal disparities seen acrossMexico, with the MMR highest amon3 indigenousand marginalized populations (Brentlinger et al.,2005;Castro & Erviti,2003; KendaⅡ,2009; simth・oka,2009;

Ordaz・Nlartinez, Rangel,& Hern会ndez・Gir6n,2010).Although infant mortality continues to decline steadilyin Mexico, maternalmortality sho、vs variable and insuf・丘dent progress toward achieving Mi11ennium Devel・Opment Goal no.5 (to reduce maternal mortality bythree quarters between 1990 and 2015;工Ozano, G6mez・Danes, castro, Franco・Marina,& santos・predado,

2011; UN,200の.

In 2013, the lNsp publjshed a report on obstetricViolence across Mexico, E1 4buso h4Ci4 1αS 111Ujeres e11Sα1αS de 柳4terπid4d: Nueν4 ew'de11Ci4 Sohre U11 νiejoProhle1π4 (Theabuse ofwomen inmaternitywards: Newevidence about an old problem). The report sheds li8htOn tbe range of disresped and abuse experienced byMexican 、vomen and their families, exploresthe barriersto providjng humanized childbirth care, and hi号hli3htsthe strengthS刃Vhichprovidersin Mexicopossessto createChange qNSR 2013). Broadly, researcherS 血Und disre・Sped and abuse in maternal health care comes largelyin the form of unnecessary medicalintervenuons (e.g.,routine episiotomies, moving to cesarean section too

192 Humanized childbirth and cultural HumⅡity sreenivas et a/

quicMy, rouune 6.1ndalpressure) and unethicalpractices(e.g., multゆle vaginal examinations wjthout indication,Iack of anesthesia durin3 routine episiotomies, physicaland/or verbal abuse,1ack of privacy or con6dentiality;INSR 2013; Matthias et al.,2013). Autl〕ors of previ、Ous studies in Mexico have also found mistreatment in

maternal health services indudes verbal, psychosodal飢d physical abuse, poor quality services, withholdingOf critical information preventin号 informed consent,Iack of shared dedsion making, and no e丘orts to pro、mote autonomous understanding of onds own condi、tion (castro & Erviti,2003; KendaⅡ,2009). Deleterious

intra・/interprofessional dynamics such as bUⅡyin8 andgender・/dass・based discrimination among health carePersonnelarealsoprevalentinMexico. Researchershave

found having less seniority in the workplace and beingfヒmale are assodated with higher levels ofstress amonghealth care 、vorkers (P6rez・Guzm会n, zonana、Nacach,&

Va11es・Medina,2009).

Cultural humiHty. Existing health professional cutricu、Iums require in・petson facilitation, are not forma廿edfor web・based instruction, do not address humanized

Childbirth and cultural humility, or fail to target healthProviders 、vorking limited・resource settings (Ahn et al.,2013; Antes,2014; Fahey et al.,2013; Health Educationand Training,2011; Hummel & peters,1994; juatezet al.,2006; Karkowsky & cha20廿e,2013; Matiu &BaiⅡie,2011; Metzl & Hansen,2014; perinatal Educa、

tion pr0σramme,2009; RCN,2013; Renzaho, Romios,

Crock,&Sのnderlund,2013; USAID,2013; W'HO,2008).Increasing global access to the lnternet and a

Strong desire to use sustainable, cost・e丘ective, and ef負、Cient methods oftrainins health care personnelhas ledProgram developers and health mjnistries to considerthe use of web・based courses (Frehywot et al.,2013).Suchcourseshavebeenusedto incteasecompetendesinmanyareas,induding professionaljsm, medicalgenetics,and hands・on clinicalsM11S (DeBate et al.,2013; Health

Foundation,2012; Nelson & Blenkin,2007; succar et al.,

2013). There are a range ofstrategies used by developetsOf online courses, induding pure web・based modules,hybrid coursework (also hlown as hleπded lear11iπ8,i,e., partly online and pardy in person), online mentor、Ship programs, and downloadable multimedia software(FrehNot et al.,2013).

Based on available evidence, a web・based course is

a realistic solution to building competencies in human、ized childbirth and cultural humility among maternalhea1壮I care providers in low・resource settings. By usingan automated facilitator^the s0丘Ware applicauon^anOnline course is hypothesized to be a cost・e丘ectiveand sustainable approach to addressing disresped andabuse W北houtthe added human and 6nandalresources

requiredto fadlitate andimplement an in・person course(Frehywot et al.,2013). Educators have found pureWeb・based instruction can projed realistic clinical sce、narios and promote criticalthinking regardin8 PatientCare among diverse learners (Nelson & BlenMn,2007).

Quantitative studies demonstrate web・based learningCan increase hlowledge, SMⅡS, and self・ef丘Cacy (DeBateet al.,2013; Health Foundation,2012; succar et al.,2013).

In low・ and middle・income countries, institu、

tional readiness,、vhich indudes institutional support,information and communication techn010gy expertise,faculty en8agement, student involvement, and infra、Strudute and support systems, facjlitates the successOf web・based learning amon留 health care workets(FrehNot et al.,2013). The lNSR Mexicds lar8estScho010f public Health accredited by the council onEducation in public HeaRh, has demonstrated many

An Evidence.Based solution

There are many barriers to changing the status quoWithin the health care profession. commonly citedObstades indude limited 6nandal, human, and infra、

Strudural resources; intra-/interptofessional dynamicsSuch asbU11ying; andgender・/dass・based discriminationin health care (Anderson,2011; Bowser & HiⅡ,2010;

Cleary, Hunt,& Horsfa11,2010; Darmstadt et al.,2008;

johnson,2009; jowe廿,2000; Mumtaz, salway, waseem,& umer,2003; ortega・cebaⅡOs et al.,2007; prata, BeⅡ,&凡I×1eidert,2013; prata, sreenivas, Greig,いlalsh &P0杜S,2010; Grenny,2009; Rosenstein & 0'Daniel,200&

Rosenstein,2011; The Joint commission,2008; vessey,DeMarco,& DiFazio,2011; wong,2009; WRA,2012).A杜ention 丘om institutjon, provider, and womeds per、Spectives is necessary to tacNe existing barriers to prac、tjdng humanized childbirth and culturalhumility.

Although policy documents to pl'omote systems、Ievel changes to ensure t11e human right to healthexist, these do not address behavioral changes provid、ers need to make in their own practice (coaliuon forImproving lvlaternity servjces,1997; cooperative forAssistance and Relief Everywhere Malawi,2013; 1nsti-tute of child Health,2001; National Dignity council,2013; Royal c0Ⅱe8e Nursing 限CN],2009; USAID,2013; WHO,2014; windau・Melmer,2013; WRι、.,2011,

2012). unfortunately,there is a dearth ofin、person and/Or online training opportunities for health profession、als to foster competencies in humanized childbirth and

Of the elements of institutional readiness, making itParticularly weⅡ Suited to c011aborate in the develop、ment and the dissemination of an online course.1NSP

Currentlyoffers aplentitude of、veb・based coursesin dif、

fel'ent formats,induding completely online, blended orahybrid" coursework, mobile applications, and massiveOpen online courseS σNSR 2014; Ma8afia, suarez,Hern会ndez,& Gudifio).1n an e丘ort to strengthen andenhance scalability of pRONTo lnternational's train、加g e丘orts, the lNsp and pRONTo lnternational have

also partnered to design a 、veb・based course re名ardingObstetric and neonatal emer号ency management.1naddition,1Nsp has a team of technical experts to sup、Portthe implementation ofan online course and docu、

mented interest in 、veb・based learning strategies fromfaculty and students in health professional pr08rams(PRONTO,2013). Although infrastrudure to supporta web・based course, induding 丘nandal and humanresourcesto develop,implement and evaluatethe courseare sti11needed,1eaders atthe lNsp are ea号erto establishinfrastructural and support systems.

Humanized childbirth and cultural Humility smenivas et a/,193

TAB王El coursecompetendes

Bγ小e end of 小e course, the learner should be able to:

1. summarize current disrespectful and abU5ive health carePractices, which exist in intrapartum care

2. De5a山e the major component50f humanized childblr小Care

3. critica11γ asseS5 the physi010glcalimplications of routineCare ln your current pradice(S).

4. APP1γ transformaⅡona11earnin8 and mutualrespedt1ⅡOU8h self・refledion and birth care application andSynthe51S exercises'

5. 1dentify specific actions health care provl(1ers can take todlan8e the culture of maternity care.

6. Demon5trate culturanwmility, kindness and resped inmaternity care in self・assessment5 and course actiV川es

Designing the 、veb・Based course

The blueprint for the course on humanized childbirth

and cultural humility was designed by consideringdifferentlearner types, the multiple waysin which newinformation is adopted aS 刃VeⅡ as studied approaches tobuild desired ski11S among learners. Evidence supportsthese methods of course design are assodated withbe杜er outcomes,induding chan8e in behavior and careProcesses (Fahey et al.,2013; Health Foundation,2012;1Ⅱeris,2009; Matiti & BaiⅡie,2011; Mazmanian, Davis,& Galbraith,2009; Towse,2009). As such, this courseemploys multiple media, harnesses different meth、Ods of instruction, engages the learner via interactiveCourse activities, and provides the learner with manyOpportunities to review key concepts throU8hout theCourse.1n addition, this course uses outcome、oriented

activities and competition through educationa18amin8,to increase attention and hold interest 、vhile simultane、

Ously helping the learner achieve course competencies(Blakely, skirton, coope二 AⅡUm,& Nelmes,2008;Yoon, Rodriguez, Faselis & Liappis,2014).

This course reaects self・directed learning the、Ory and uses technical scaffoldin名 in its design. self、ditected learning theory functions on three ptindples:(a) the learner is responsible for his/her learning,(b)transformationa11earnin8is causedbyself・reaection,and (C) emandpatory learning and sodal action is the

Iearner'S 丘nal goal(Merriam,20OD. sca任oldin8 is 0丘enUsed to describe the guidance received by learners. ASthe term implies, scqが'oldi11g refers to the assistanceProvided by an instructor to enable "a novice to solve

a problem, carry out a task, or achieve a goal whichWould be beyond his unassisted e丘orts"(叉Ivood, Bruner,

& ROSS,1978).1ncorporating our growth within theinformation age, Ye11and and Masters (2007) rede丘neSca丘olding to indude "technjcal sca丘olding"-that is,the use ofcomputeT techn010gy to assistin the learningProcess, where the computer becomes the facilitator.

Via technicalsca丘olding,the course helpslearnersObtain new knowledge and skiⅡS by creating a com、Puter・based support system around them (much like

the sca丘olding used in construction) and assisting themin climbing to the nextlevelofhlowled8e synthesis andbehavioralchan8e. To achieve course competencies (seeTable D, the course is setup t08Uide learners tbrougha series of modules (see Table 2) lvhich chaⅡenge theIearner to self・reaect, darify values, and progressivelyde負ne and rede丘ne 、vhat is humanized chⅡdbirth and

TAB王E2 CourseModules

To achieve coul'se 0可edives,1eamers wi" be 8Uidedthr010~ving modules

Module l:1ntroduction & course objectivesModule 2: problem & significance (global and local context)Module 3: Medica11mplications of Dlsrespect and AbuseModule 4: slmula!ed Role・playing came:"came of Dignity"MO(1Ule 5: Bal'riers to C1ねnging Behaviors and Atti[udes

Module 6: score Yourself Acuvily (score your most recentexperience providing childbirth care)

MO(1Ule 7: Humanized chⅡdbirth & cultural HumilityModule & summa1γ of Key 1コ0ints

194 Humanized C晰ldbirth and cU1加ral Humility sreenivas et a/

Cultural humility. These activities ensure the learner is

Self・directing his or her olvn learning needs and providethe sca丘olding necessary to help learners understandhow disresped and abuse can shape clinical outcomesandhowproviders maychan号eawomadsbirthingexpe、rience.1ncorporatedthroU号houtthe course modules areboth formative and summative evaluation tools. pre、

and poS廿ests offer the learner a method to assess howhe or she is doing and in what areas he or she needs toimprove. course exercises emphasize the cornerstonesOfculturalhumility and humanized childbirth-thatis,recosnition of the belief conunuum in childbirth care,

Communication with empathy regardless of disparitiesOrculturalbiases, and empowerment ofwomen tl)roughShared dedsion maMn号.

Sped6Ca11y, the course 負rst introduces the courseCompetendes and asks the learner to introduce himseH

Or herself. The computerized facilitator then providesa brief preassessment for monitoring and evaluationPurposes. This is f0ⅡOwed by an introdudory moduleOn the problem and signi丘Cance ofdisrespect and abuseand evidence regarding the medicalimPⅡCations ofdisrespect and abuse in maternal health. once learn、

ers have a foundation to understand the purpose ofthe course and the computerized facilitator has learned

about the student, a highly interactive role、playinggame to test hlowledσe and foster competendes inhumanized childbirth andculturalhumilityis unlocked.Leaners can play the game as often as desired withthe opportunity to f0ⅡOw different story lines withinthe same narrauve^Similar to the concept behindEdwardpackardandRaymondAlmiran入10ntegomery、"choose Your own AdventU鵜"(CYOA) popular bookSeries (CYOA,2014). F0ⅡOwin8 the game,1earners areasked to self・refled on their scores and how they couldhave acted differently to chan留e outcomes. Througha combinauon of didactic and cha11enges,1earners arethen asked to consider common barriers to changingthe status quo in maternal health care given Hmitedhuman,丘nandal, and infrastructural resources. This is

f0110wed by a toolto score oneselfproviding childbirthin onds most recent experience providing matetnalhealth care. The course didactic condudes by of企ringSome standardized de6nitions ofhumanized childbirth

and cultural humility for the learner's reference as weⅡ

as askin8 the learner to complete a postassessment quiz.After submi廿ing quiz results, a summary ofthe materi、als covered is provided, with a messase describing tan、gible acuons a provider can take to provide respedfuland kind care to women despite the cha11enges healthCare providers may face in their olvn practices.

Future vvork

Subjed to funding, PRONTo lntel'national wiⅡ WorkWith software developers to write the code and create

a prototype for pilot testing. The lNsp currently usesdiverse educational platforms, such as Blackboard,Moodle, and 刃、1ebEX, to teach health professional stu、dents. Technical development of the course wiⅡ beSuch that transferability between users is protected forSustainable use. This means creatin今 modules which areStatic, embeddable applica廿ons and therefore plaぜormindependent, which wi11Save tremendously on serverCosts. only applicauons requiring c0Ⅱection of usagedata for evaluation purposes wiⅡ require server、sideStorage.1n addition, aⅡ Code wi11 be nonpToprietary soit may be made available to anyone who wishes to useit. public avajlabilityW辺 ensure the course is updatable.

Once live, implementers of the course wiⅡ be

responsible for disseminating and updating the onlineCourse to health care workers from aⅡ disdplinesand levels across the targeted region. Evaluation ofthe course 、vi11 focus on assessin号 its effectiveness inacquiring newh)owledge, developing sMⅡS, and chang、ing a廿itudes in the simulated environment alnong

novice to expert health care providers and the adultIearner with resped to childbirth and maternity care,PRONTo lnternationalhopesthe course wi11also trans、

fぞr to other nations and groups interested in fosteringhumanized childbirth training amon留 their maternalhealth workers、

DISCUSSION

Disresped and abuse in maternity care is a globalhealthProblem with medicalimPⅡCations for mothers andnewborns alike. ongoin名 tolerance ofdisrespectful andabusive treatment in the health care setting demandsa杜ention 丘om many perspectives, induding maternalhealth fadlities andproviders. Limited 介nandal, human,

and in丘astrudutal resources, inter・/intraprofessionaldynamics, induding bUⅡying and gender、/dass、baseddiscrimination, as we11 as inadequate trainin80n kindand respectful care are barriers to changing the sta、tus quo. However, the pRONTo lnternational onⅡne

Coutse, developed in partnership with lNSR has thePotential to 0丘er maternal health providers practicalSolutions for changing the practice of disresped andabuse within limited・resource settin8S.

Self・reaection and values dari負Cation is an

evidence・based approach to assist in adult learning

(Fahey et al.,2013; Matiu & Bai11ie,20ID.1n the course,Iearners are given muluple opportunities to translateCourse competencies through self・directed learnin8and simulated practice 血r optimal retention of thePresented material. Evidence to suppott course content,On80ing reminders of the physi010gicalimplications ofdisrespect6.11 and abusive care as we11 as the bene丘ts ofhumanized maternity care are presented to learners toaid in the transformative learning process.

Limitations of the coutse indude the f0ⅡOW・

in3 barriers to its realization and sustainabHity:Development, implementation, and evaluation of theCourse require institutional readiness, induding theinfrastructure to support the web・based application(Frehywot et al.,2013). The success of the course notOnly relies upon user・centered software development,but the environment in which to launch the projed,induding lnternet, suf丘dent band、vidth, and com・Puter access. Last, the effectiveness of the proposedCourse cannot be definitively determjned 、vithout 丘rstPiloung the course and ultimately conducung a lar号e・Scale evaluation.

Although limitations ofthe proposed course exist,So do many strengths. The format, content, and designOfthe course are supported by a strong theoreticalbaseandwere createdthrough aniterativeprocess ofcreation,assessment, and redesign with maternal-newborn careexperts induding stakeholders 、vho wi11 be involvedin piloting the When live. sped負CaⅡy, theCourse

evidence reviewed for this manuscript supports the(a) e丘ectiveness of the web・based course jor1π4t onincreasinghlowled名einhealth care,(b) proposed courseContent to help leatners achieve course competen・Cies, and (C) theory・driven course desi811 to facilitatebehavior change jn atl adult learner. The coutse alsoaddresses a significant 8ap in health professionaltrain・ingpr0三rams globaⅡy Last,theblueprintforthe coursdstechnicaldesign reaects a consdous e丘ortt010凡Ver costsfor sustainability and scalability as weⅡ as maintainaccess to valuable evaluauon data.

Humanlzed childbirth and cultural HumⅡity S舶enivas et a/.195

A]though maternal health workers are faced with manyChaⅡenges to providing high quality childbirth care,they have the ability to positively change a womal)'Sbirthin今 experience throU8h heigbtened aNvareness ofSelf and the 、vomen they serve.1n this humanizedChildbirth and culturalhumility course, maternalhealthWorkers can develop and practice these skiⅡS via highlyinteractive exercises which emphasize self・reaectionand values dari6Cauon. Role・simulation cha11enges inthe course are designed to provide the structure neededfor learners to navigate through techniques in com・munication and engagement with laboring women.1tis hypothesized this course wiⅡ assist providers to makehumani2ed childbirth and culturalhumility an essentialPart oftheir clinicalpracuce.

Childbirth is one of the most vulnerable times in a

Woma11's life. Yet, safe motherhood cannot be achieved

Un田 Women feel physicaⅡy and psych010今icaⅡy safe.Recognizing the beliefconunuum as it relates to chⅡd・birth, communicatin今 With empathy, and empo、veringWomen thtoush shared dedsion maMn8 are the corner・Stones of cultural humility and humani2ed childbirth.

REFERfNCES

Ahn, R., Alpert, E.1., purce11, G., Konstantopoulos, W M.,MCGahan, A., cafferw. E. Burke, T. F.(2013)

Human traf負CMng: Review ofeducationalresourcesforhealth professionals. A111eriC411 jour11αl qf'preve11t4tiveMediciπe,44(3),283-289

Anderson, K.(20ID. workplace aggression and violence:Nurses and midwives say NO. Australiα11 Nursiπ宮jourπα1,19(1),26-29

Antes, A. L.(2014). A systematic apptoach to instruction inresearch ethics. ACC01ιπtability iπ Research,21(D,50-67.

Blackburn, S.(2013). Neur010gic, muscular, and sensory sys、tems. M4ter11α1, jetα1,611e0π4talphysi0108y: A dinicalPerspedive (4th ed., PP、 509-559). M訂yland Hei8hts,MO: Elsevier saundets.

Blakely G., SMrton, H., cooper, S., AⅡ山n, R,& Nehnes, R

(2008). Educationa1名alningi11thehealthsciences: system・atic TeⅥew./our11αlqf'Adν411Ced Nursiπg,65(2),259-269.

Bowser, D.& HiⅡ, K.(201の. Explori11g evide11Cejor disrespedα11d ahuse iπ f4Ciht),・みαSed childhirth; Report qfa laπd、Scape a"α1γSis、 washjngton, DC: united states Agencyfor lnternationalDevelopment.

Brentlinger, R E., satlchez・perez, H.j., cedeiio, M, A., Morales, L

G., Hernan, M. A., Micek, M. A.,& Ford, D.(2005). PTeg、nancyoutcomes,site ofdelivery, andcommuniwschismsin regions a丘ected by 血e armed con価d in chiapas,Mexico. soci41ScieπCe 6 Mediciπe,61,1001-1114.

Cassel, E.}. a982). The nature of suffering and the goalsOf medidne、 The New Eπ81aπd lourπα1 ψ Mediciπe,306aD,639-645.

Castro, R.& Erviu,1,(2003)' violations ofreprodudive rightsduring hospital births in Mexico. Heα1仇αnd HU111411Rights,フ(D,90-110.

CONCLUSION

196 Humanized childbirth and cultural Humnity S舶enルas et a/

Conte, fo,1nt0Ⅱigen'O Agency.(2013). The Wのld j4dbook2ω3-2ω4. Retrieved from ht中S://WWW.cia.gov/1ibrary/Publications/the・world・fadbook/jndex.html

ChooseYOU,ownAdvont山e.(2014).Hist0ぴQf'cyoA. Retriovod丘omh如ゾ/WWW.cyoa.comゆa8es/history・of・CYOA

Cleary, M., Hunt, G. E.,& HorsfaⅡ,1.(201の.1den廿fyin8 andaddressing bUⅡying in nursing.1SsueS 加 Me11t41HealthNursiHg,31,331-335.

Coalition foT lmproving Maternity services. a997). Themother・丘ien田y childbirth initiative. The 6rst consen、

Sus initiative of the coalition for improvin8 maternityServices.10ur1141 qf'Nurse Mid1νifのy,42(]),59-63

Cooperative for Assistance and Relief Ever},where. Malawi.(2013). The c01π1"Uπity score card (CSC), A geπeric8研dejor i111Ple"1e11h11g cARE太 Csc process to i加ProveqU41ity qfservices. Lilongwe, Malawi: Author

Darmstadt,エ., walker, N.,上awn, E., BhU廿a, A., Haws, A',&

Cousens, S.(2008). saving newborn lives in Asia and

Africa: cost and impad ofphased scale・UP 0丘nterven、tions within the continuum of care、 Health policy 411dPlaππiπg,23(2),10]-117.

DeBate, R., severson, H., cragun, D., Gau,1., Merre11, L.,Bleck,1.,... Hendricson, W.(2013). Evaluation of a

theory・drjven e・1earning intervention for future oTalhealthcare providers on secondary prevention of dis、Ordered eaung behaviors. Health Educati011 Research,28(3),472-487

Fahey l., cohen, S., Hob11e, F., Buttrick, E., Detti;1ger, J., Kesuer E.,& walker D.(2013). prom0廿ng cultural h血ility durin名Iabora11dbir血;PU出ngtheoryitltoadionduri11gpRONTOObstettic a11d neonatalemer8encytrainhlg jour11alqf'peri-παt414πdNeo"4t41Nursiπg,27(D,36-42.

Field, T., Hernandez・Reif, M., Taylot, S., Quintino,0.,&Burman,1.(1997). Labor pain is reduced by massagetherapy. jourπαlqf'psychos0柳4tic ohstetricS 4Hd Gyπ4e、mlogy,18(4),286-291.

Frehywot, S., vovides,Υ, Talib, Mikhail, N., ROSS, H.,wohltjen,H.,...& SC0杜, J.(2013). E・1earning in medical educa、tion in resource constrained low・ and middle、income

Countries. HU111α11 Resourcesjbr Health,11,4.

Grenny, J.@009). crudal conversations: The most potentforce for eliminating disruptive behavior. critical C4ルNursiπg QU4rterly,32(1),58-61.

HaⅡ, A., st0Ⅱ, K., HUせon, K.,& BTown, H.(2012). A prospec、tive study of effects of psych010gical fadors and sleepOn obstetric interventions, mode ofbirth, and neonatal

Outcomes among low・tisk Br北ish columbian women.BMc preg11411Cy α11d childhirth,12,78.

HealthEducationandTraining.(20ID.Ethiopia11FederalMiπ、istry qf'He41th; He41th Mahα8e1πeπt, EthicS 4πd Rese4πhBle11ded ιeRrhiπg Module jor the He41th Exte那i0π

Pr08rα抗"1e. Retrieved from h廿P:ノ/WWW.open.ac.uk/africa/heavheat・resources

Health Foundation.(2012). EvideπCe sC4π: QU4hty ilHP地νe、111e11t tr4i"iπg jor he41thcare prqf'essi011αIS. London,United K加gdom: Author

Hummel, E,& peters, D. a994). Bafa! baf舐 A culturalaware、

ness game. Nurse Educator,19(2),8.

111eris, K.(Ed.).(2009). C011te111Porary theories qf le4r11iπgιear11i11g theorists ... i11their owh words. New York, NY:Taylor & Francis Group

Inst北Ute of child Health.(20OD. How t0 1παke 1れαte柳α1

health services "10re 1ν01πe1けrie11dly A pradiC418Uide.London, united Kingdom: university c0Ⅱege london.

Instituto Nadonal de Estadistica Geografia、(20Ba) Bancode informad6n lNEGI: Razon de mortaⅡdad maternal

(defundones por cada loo mils naddos vivos estima、

dos).[1NEGIDatabank Matanalmortali可(deaths per100,ooo estimated live births)、] Retrieved from h廿Pゾ/IVWW3.inegi.OTgmx/sistemas/biinegv?ind=6300000085

Instituto Nadonal de Estadistica Geografia.(20Bb).Poblad6n, Hogares y vivienda: Mortalidad; Tasa demortalidad infantilpor en廿dad federativa,20oo a 20B.

[population, homes, and housing: Mortality; infantmortality 稔te by state,20oo t020B.] Retrieved from

h廿P:ノ/WWIV3.inegi.or号.mx/sistemas/sisepvDefault.aspx?t=mdem055&S=est&C=23602

Insututo Nadonal de salud pliblica.(2013).Ξ1 4buso hαα'α 14S

抗川eres e11S41αS de 111αterπidad: Nueνα evideHcia sohre Uπ

Vicl'o pmhle111a: Resu"1eπ動'ecutivo [Abuse agaitlst women加 maternity wards: New evidence about arl old problem:Executivesulnmary]. asted.).cuernavaca,Nlexico:AU杜)or.

Instituto N■Cionaldo S飢Ud pobli仏.(2014). oje加"cadど抗ica.

[Academicprograms] Retrieved from ht中ゾノWWW.espm.nⅨ/oferta・academica

10hn, L. B., Nischintha, S.,&Ghose, S.(2014). outcome offor、

Ceps deliveryin a teaching hospital: A 2year experience10ur11αl qf' N4加ral scieHce Bi0108y 畍 Mediciπe,5(D,155-157. h杜P://dx.doi.0弔/10.4103/0976-9668.127316

johnson,エ.(2009).1nternational perspectives on workplacebUⅡyjn8 釘nong nurses: A review.1πterHah011αINursi11gRevieH,,56,34-40.

jowe廿 M.(200の. safe motherhood interventions in low、

income countries: An economic justi丘Cation and evi、dence ofcost effectiveness. Health polic),,53(3),201-228.

Juarez,}. A., Mal'vel, K., Brezinski, K. L., Glazner, C.,

Towbin, M. M、,& laMon, S.(2006). Bridging the gap.A curriculum to teacb residents culturalhumility Resi、deπCy 三duC4ti0π,38(2),97-102.

K釘koW■ky,C.E.&ch能otto,C.(2013).simul.廿on江mpmⅥ00Communication with patients. se111iπαrs iπ Peh114t010gy,37(3),157-160.

KendaⅡ, T.(2009). Reprodudive rights violations rep0此ed byMexican women with HIV Health 4"d HU井1411 Ri8hts,11(2),フフ-87.

工Ozal)0, R., G6mez・Dancs, H., castro, V, Franco、Marina, F.,&

Santos・ptedado,1.(2011). Avences en los objectivos dedesarr0Ⅱo del mileni04 y 5 Mesoamerica lAdV釘Ices inMi11enni山IDevelopmentgoalS4飢d5inMesoalnerical.Salud pU6b'ca de Mξχico,53(SUPPI.3), S295-S302、

Magafia, L., suarez, j., Hern会ndez, M.,& Gudifio, M.(2014).La Escuela de salud poblica de M6Xico: innovad6n

educativa y tecn0168ica en el Nuevo milenio [TheScho010f public Health in Mexico: Techn010gical andeducationalinnovation in the new mi11enniuml. Sα1記dP記hlica de Mξχico.56(6),660-665.

Matthias, S、, Maria, S.,& M6nica, G.(2013). calidad de laatend6n durante el parto normal en establedmientos

Poblicos de salud en el estado de 0鯉aca [Qualiw ofCare during norma11abor in public health establish、ments in the state of oaxaca]. Revista de 111νestなαCi011MediC4 de 04χαC4,1(D,17-36.

Mauti, M, R.,& BaiⅡie, L.(20ID. Dなπi砂加 health ι4reA pradiC414Ppr04Chjor πUrseS 4πd "1id1νives, London,United Kingdom: Raddiffe.

Matsubara, S、, Mita, E, Kikkawa,1.,& suzuki, M.(2012).Maternalrib fracture after manualuterine fundal pres、Sure. Rurα1 α11d Re1110te He41th,12,2062

Matsuo, K., shiki, Y., Yamasaki, M.& shimoya, K.(2009). useOfuterine fundalpressure maneuver atvaginaldeliveryand risk ofsevere perinea11aceration. Archives qf'GyHe、ω10sy a"d ohstetrics,280(5),781-786.

Mazmanian, R E., Davis, D. A.,& Galbraitb, R.(2009). con_tinuing medical education effect on clinical outcomes

Effectiveness ofcontinuing medical education: Ameri、Can c011e8e ofchest physida11S; Evidence、based educa、

tional guidelines. chest, B5(SUPPI.3),42S-48S. h杜P://dx.doi.org/10.B78/chest.08-2517

Merhi, Z.0.,&A、vonU8a, A.0.(2005). Therole ofuterine 6.1n、

dal pressure in the management ofthe second sta8e ofIabor: A reappraisal. ohstetriC416 Gy11ec010宮icalS術'vey,60(9),599-603.

Merriam, S. B.(Ed.).(20OD. Andragogy and self、directedIe雛nin3: pi11ars of adult learning theory The 11ewUpdate 011αdν4Hcedlear11iπ8theory NewDhecti0πSjorAdult 4πd c0πtiHuiπg Educati0π(V01.89, PP.3-13).Retrieved from http://umsl.edu/~wilmarthp/modla・1inks・201νMerriam_pi11ars%20of%20anrdagogypdf

Metzl, M.,& Hansen, H.(2014). strudural competenCヌTheorizing a new medicalengagement with stigma andinequality. sodalscieπCe d・ Medicme,103,126-B3.

Misago, C., Kenda11, C., Freitas, P., Haneda, K., silveira, D.,Onuki, D., Umenai, T.(20OD. From 'culture of

Humanized childbirth and cultural Humility sreenivas et a/.197

dehumanization of childbjrtH to 'childbjTth as a trans、

formative experience': changes in 6Ve municipalities innorth・east Brazil.111ter11αti01141 /'our11αl q1サ Gy114eι0108yα11d ohstetrics,75, S67-S72.

Misa80, C., umenai, T., onuki, D., Haneda, K.,&~vagner, M.a999)' Humanised materni智 Care.ι4πCet,354(9187),B91-B92. h廿Pゾ/dx.doj.org/10.1016/S0140-6736(05)76250-4

Mumtaz, Z., salway, S., waseem, M.,& umer, N.(2003).Gender・basedbarriersto primaryhealth care provisionin pakistan: The experience offemale providers. HealthPolicy aHd P1απ"iれ8,18(3),261-269、

National Di8nity council.@013). The Di8'πi沙 iπ C4ル C4"1_Pai811. Retrieved from h廿P://WWW.dignityincare、org.UWDignity_in_care_campaign/

Nelson, D.& Blenkin, C.(2007) The power ofonline role、playSimulations: Techn010gy in nursing education.1πterπ4、ti01141 /our11αl qf' Nursiπg 三ducati011 Sch014rship,4(D,1-12.

Njuki, R., obare, F、, warren, C., Abuya, T., okal,}., Mukuna, W,& Be110WS, B.(2013). community expetiences

and perceptions of reproductive health vouchers inKenya. BMcpublicHe41th,13,1027-1037. http://dx.doi.org/10.H86/1471-2458、B、660

0'Mahony, E, Hofmeyr,1.,& Menon, V (201の. choice ofinstruments for assisted vaginal delivery cochr4πeD4t"h4S■ qf' syst'加4ti' Rew'WS,(1D. h杜Pゾノdx.doiOrg/10.1002/14651858.CDO05455.pub2

Ordaz・Martinez, Y., Ra11gel, R.,&Hern会ndez、Gir6n, C.(201の.Fadores deriesgo asodados con mortalidad matetnaenel estado de Morelos, Mexico [Nsk fadors assodated

With maternalmortalityin the state oflYlorelos,入lexico]Giπec010宮i4 y ohstehici4 de M亘χico,78(フ),357-364.

Ortega・ceba110S, A., Mudgal,1., Flores, Y., Rivera、Nvera, L.,Diaz・Montiel, C.,& salmer6n,).(2007). Detel・minantsOfpartnerviolence 血 health workers oflMSS, Morelos.Salud puhlica de Mどχico,49(5),357-66.

Page, L.(2001). The humanization ofbirth.111terhati0π4110ur、π41qf'Gyπec010gy 606StetガCS,75, S55-S58

P6rez・GU2m会n,1. D., zonana・Nacach, A.,& vaⅡes、Medina,M.(2009). stress levels in health care workers from

Primary care units [Article in spanish]. Revista Mどdicade11πStituto MexiC4110 delseguro sodα1,47(5),575-579.

Perinatal Education progralmne.(2009). Mother 介iendly careduTinglabour,delivery紅)dthepuerperiuln.1nMotherα11dh4hyjrieたdly mre; A leanliπS'prog41π"1ejのPmルSsi0π4b(PP.25-39). cape Town, south Africa. EB~V Hea1血Care.

Prata, N., Be11, S., weidert, K.(2013). prevention of Post・

P釘'tum hemorrha8e in low・resource setungs: currentPerspectives.111ter11αti01141 /our11αl qf' W0柳e11、 Heahh,13(5),乃7ーフ52

198 Humani2ed childbirth and cultural Humnity sreeniva5 et a/

Prata, N., sreenivas, A., Grei今, E, walsb,1.,& potts, M.(201の.Settin3 Priorities for safe motherhood interven廿ons in

resource・scarce settings. He41th policy,94(D,1-B.

Pr08ra11)adeRescateobstetricoyNeonat飢:Tratalnientooptjlnoy opor[utlo lnternational.(2013). About us. Retrieved

丘om h如://wwwprontointernational,org/about、US/

Pri0二 E., santhakumaran, S., Gale, C、, philipps, L., Modi, N.,& Hyde, j.(2012). Breastfeeding a丘er cesarean deliv、ery: a systematic review and meta、analysis of worldIiterature. AIHeriC4πノ0urπ41 qf'cliπicalNutriti011,95(5),11B-1135. http://dx.doi.orgn03945/ajcn.111,030254

Rahangdale, L., Banandur p., sreenivas, A., Turan,1. M.,

Washington, R.& craig, C. R.(20]の. sti8ma as expe、rienced by women accessing prevention of parent、to、Child transmission ofHlv servicesin Karnataka,1ndiaAIDS C4re,22イフ),836-842.

Renzaho, M., Romios, P., crock, C.,& Sのnderlund,1.(2013).The effectiveness of cultural Competence pr08rams in

ethnic minority patjent・centered health care-A sys、tematic review ofthe literature.1Hter114ti011αljour11αl qfQU41ity iπ Health cqre,25(3),261-269

Rosenstein, A. H.(20ID. Ma11aging disruptive behaviors in thehealth care se廿ing Focus on obstetricsservices.A111erl'C4n

/ourπαlql'ohstehicS 411d Gyπec010幻,,204(3),187-192.

Rosenstein, A. H.,& 0'Daniel, M.(2008). A survey of theimpact of disruptive behaviors and communicationdefects on patient safety.ノ'oiHt c0111"1issioH 011Accredita、ti011 qi'HealthC4re orgαπiZ4ti0れS,34(8),464-471.

Royal c011e8e of Nursing (2009). S111411 dlaπgeS 柳αke 4 h1宮diが'ereHce; How you C4π iπjlueπCe to deliver digπifledCare. London, united Kingdom: Author.

Royal c0Ⅱege of Nursing (2013). Dig'たiり, iπ he41thcare.Retrieved 丘om http://WWW.rcn.org.uk/developmenvPractice/cpd_online_1earning/dignity_in_health_care

SimMn, R (20ID. pain, SU仔ering, and trauma in labor andPrevention ofsubsequent posttraumatic stress disorder.10ur1141 qf'periπ4tal EduC4ti011,20(3),166-176.

Simkin, P., Bolding, A., Keppler, A., Durham,1.,& whaⅡey,1.(201の.pre8παπCy, childbirth,απdthe11eWみom Theω抗、Plete g記ide.(4th ed.). New York, NY, MeadowbrookPress.

Sleutel, R.(2002). Development a11dtestingofthelabotsupportScale. joul'παl qf'Nursiπ8' Measure111e11t,10(3),249-262

Smai11, M.,& Grive11, M.(2014). Anubiotic prophylaxis versusno prophylaxis for preventing infection after cesareanSecuon. cochr4πe Datah4Se qj' syste抗αtic RevieH,S,(D, CDO07482. http:ノ/dx.doi.org/10.1002/14651858CDO07482.pub3

Sm北h・oka, V (2009). unintended consequences: Explor、jng the tensions between development pr08ramsand indi名enous women in Mexico in the context of

reproducuve health. sod41 ScieπCe 6 Mediciπe,68,2069-207フ.

Succar, T., zebington, G., Bi11Son, F., Byth, K., Barrje, S.,Mccluskey, R,& Grigg,j.(2013). Theimpad ofthevir、tual ophthalm0108y dinic on medicalstudents' 1earn、ing: A randomized contr011ed trial. Eye,27,1151-1157.

TO、vse, M.(2009). Best pradices: crea廿ng succesS6.110nlinemodules.ιear111'π宮 Soluti0πS M48αZiπe. Retrieved fromhttp:/ノ、vwwjearningsolutionsmag.com/articles/56/best・practices・creating・succesS丘11-online、modules

United Nations.(200の. ResolutioH adopted 6), the Geπerα1Asse1れhly uN dedarα力'0π A/RES/55/2, A8eπd4 ite規60イ五). New York, NY: Author.

United Nations.(2006). Mi11eππ地111 DeveloP111eπt G041S.Retrieved from h廿P://WWW.unmiⅡenniumprojed.or8/goals/index.htm

United Nations Development programme.(2013). HUI"4πdeveloP1πe11t rep0π 2013: The ガSe qfthe south: HU1π4hPm8ルSs iπα diverse 1νorld. New York, NY: Author

United states Agency for lnternauonalDevelopment.(2013).Respectf'UI"1αterπity care toolkit. Retrieved from: h廿PS:/ノWWW.k4health.org/toolkits/rmc

Vaheijen, E. C., Raven, j. H.,& Hofmeyr, G. J.(2009). FundalPressure duting the second stage of labour. cochraHe

Dntabase syste柳αtic Review,(4), CDO06067. httPゾ/dx.doi.org/10.1002/14651858.CDO06067

Vessey,1., DeMarco, R.,& DiFazio, R.(20ID. BU11yin号 harass、ment, and horizontalviolence in the nursing 、vorkforce:The state of廿le science.1n A. Debise廿e &j. vessey(Eds.),A1111Uα1 ルνiew qf'π1ιrsiHg rese4rch (V01.28). New York,NY: springer publishin8.

Walker, D. M., cohen, S. R., Estrada, F., Monterroso, M. E.,

jenny, A., Fritz, j.,& Fahey,1.0.(2012). PRONTO

training for obstetric and neonatal emergendes inMexico.1πter114tioHα1/'our11αl qf'Gy11ec0108'y α11d ohstet、rics,116,128-133、

、varren, C., NjuM, R., Abuya, T., Ndwi8a, C., Maingi, G.,Serwan3a, j.,... Be110WS, B.(2013). study protocol forPromoting respedfulmaternity care initiative to assess,

measure and design intervenuons to reduce disrespedand abuse during childbirth in Kenya. BMc preSπa11CyC11ildBirth.13,21-30.

气Vindau・Melmer, T.(2013). Ag伽dejor 4dv0ιαti118'jor ルSped、fU11114terπit), C4re. wash血8ton, DC: Futures Group,Health policy project.

凡Vhite Ribbon A11iance.(2011). RespectfU1 1παterπit), C4re:The UπiverS41 rights qf' childheariπg w0111eπ ChのterWashin名ton, DC: Author.

White Ribbon A11iance.(2012, February 29). Bルαk the silence,RespectfU1 1Haterπiり, care.[vide0 丘le]. Retrieved fromh杜PS://WWW.γOutube.com/watch?V=KI05F903Htu

Wodd Hoalth 0鴫ani誠ion.(2008). The 抗idW加加 thec0抗、柳U11此y MidWびery eduC4ti011 1"odule 1 σOU11d4ti011抗odule). Geneva, switzerland: Author.

World Health organization.(2014). The preveπti0π 4πdeli111iπ4ti0π qf'disresped 411d α6Use dιιri118jhci五りノ、hasedChildみirth. Geneva, switzerland: Author.

Wong, Y. L.(2009). Review paper: Gender competendes inthe medical curriculum: Addressing gender bias inmedidne. Asia・P4Ciflc jour11αl qf' PU61ic He41th,21(4),359-376.

Wood, D., Brune二}.,& ROSS, G. a978). The role oftutoringin P如blem solving./ourπ41 qf' child psych0108'y aHdPsychi4try,17',89-100.

YeⅡand, N.,& Masters,1.(2007). Rethinking sca丘oldingin the information age. C0111PuterS 6 Educah011,48,362-382.

Yoon, B., Rodri8Uez, L., Faselis, C. J.,上iappis, A. P.(2014).Using a board game to teinforce learning. jour1141

Humanized childbirth and cultural Humility sreenivas et a/.199

qf co"tiπ1ι1'π8' EduC4ti011 iπ Nursm8,45(3),110-111.h杜P://dx.doi.or8/03928/00220124-20140224-14

Correspondence regardin8 this article should be directed to

A111itasreenivas,DNRuniversityofwashington,1241、Jwca11田Street, ste.3, seattle, WA 98107. E、maⅡ: almねCnm@uwedu

Amita sreenjvas, DNR MPH, CNM,8raduate ofNurse、Midwifery atthe university of、vashington, sea廿le.

Susanna cohen, DNR CNM, board ofdirectors ofpRONTO

Internauonal, assistant clinicalprofessor, university ofutah,C011ege ofNursing

Laura Magaha・vaⅡadares, phD, academic dean,1nstitutoNadonal de salud poblica, Mexico.

Dilys walker, MD, executive diredor, PRONTo lnterna、

tional, assodate professor, OB/GYN and GlobalHealth,University of刃、1ashington, seattle.

Comparisonofpolidesfor血eMana客ementOfcareforwomenandNewbornsDur註lgtheThirdstage ofl'aborAmon号lapanese Hospital.S,Cli11ics, and Midwifery Birth centers}heko Kat40ka, k40riNak4ya"14, yuk4ri》hju, Hironli五to,4πdShiseko Hのiuchi

OBjECTIVE: To determine the caTe polides for both mothers and newbornsimplemented during anda丑er the thitd sta号e of labor and to compare the rate of adoption ofthese cate policies among hospitals,dinics, and midwifery birth centers in Japan.

METHOD: A cross・sectionalsurvey ofthe care polides affecting mothers and newborns durin anda丘er the third stage oflabor was conducted ftom odober 2010 to July 2011. A postalquestionnaireWith f0ⅡOW・up wassentto aⅡ 684 maternity institutionsin Tokyo metropoliねn areas

RESUI、TS: The overa11response rate waS 255 (379,、0). Most hospitals and dinics had a policy of earlyCord damping; however, nearly 70% ofthe midwiferybirth centers adopted the policy ofwaiting untilthe cord stopped pulsating. The policy ofadministering prophylactic uterotonics was adopted by 50%Ofthe hospi仏Is and 63% ofthe dinics, although midwifery birth centers did not adoptthis policy NImidwifery birth centers,50% ofthe hospitals, and 50% ofthe dinics routinely adopted the polic ofearly sMn・to-skin contact.

CONCIUSION: Adoption ofvarious care policies di丘ered considerably among the hospitals, clinics,飢dmidwifery birth centers.1n addiuon,仕lere were severalgaps between eⅥdence、based care and care polides.

KEYWORDS: third stage oflabor; management policy;sutvey; postpaTtum hemorrhage; neonatalasphyxia; skin-to・SMn contad

ダ発.電C生、,"

INTRODUCTION

Postpartum hemorrhage (PPH) continues to make

a worldNvide contribution to maternal mortalityand morbidi可(Khan, wojdyla, say, G田mezoglu,&Van Look,2006; sheldon et al.,2014). Therefore, to

Prevent or 留ready diminish ppH, clinical practicesduring the third stage of labor should be 8Uided byappropriate policies for those interventions that areClinica11y effective, safe, and based on evidence. Thequestion addressed in this study is, to what extent arethjrd・stage labor evidenced・based pradices recogni乞ed

200

and adopted or implemented in hospital, clinics, andbirth centers in lapan.

Immediately after delivery is an important timefor mothers and their newborns to initiate bondingand begin their initialinteractions outside the 刃Vomb.Yet atthe same time,the mother may also be atrisk forIifヒ・threatening events such as ppH and the infant for

neonatal asphyxia. Although this third sta8e of laborgeneraⅡy means the care of the mother, clinicians aretypica11yinteractin号Withand carin8forbothmotherandnewborn,therefore to re丑ed adual practice, we used abroader conceptualization of the third stage period to

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住◎ 2側5 Springer publishing company, LLC VVWW.springerpub.comh廿P:ガdx.doi、org/10.189V2156-5287.5.4200

indude the events for the mother-baby unit. polides toguide safe practice during this vulnerable time shouldbe based on the best evidence available. During andjust after the third sta目e of labor, research has identi・丘ed several standard care, preventive, and therapeuticinterventionsforwomen andbabiesto prevent ppH andPromote their health.

To prevent poS中artum hemorrhage, active man・agementofthethirdstageoflaborespedaⅡyforhigh・riskWomen is reported as effective (Begley, Gyte, Devane,MCGuire,&刃Xleeks,20ID. Guidelinesfromvarioushealth

agencies recommend active mana号ement indudingadministrauon of uterotonics as weⅡ as contr0Ⅱed cord

traction (Americarl c0Ⅱege of obstetridans and Gyne・C010gists,2006; Nationa11nstitute forHealth and clinicalExceⅡence,2014; sodety ofobstetridans and Gynaec01・08ists ofcanada [SOGC],2009; W'orld Health organiza・tion [×1×1HO],2012). othereffectiveinterventionsforppH

Prevention 、vere the prophylactic use ofuterotonics: oxy・todn (いlesthoff, C0廿er,& T010sa,2013), ergot alkaloids(liabsuetrakul, choobun, peeyananjarassri,& 1Slam,2007),prostaglandins(Tungalp,Hofmeyr,&G田mezoglu,2012), and breast nipple stimulation (Kavana3h, KeⅡy,&Thomas,2005).

Regarding the fetus, a systematic review aboutneonatal hypoxia found using electronic fetal monitor・ing led to more instrumental vaginal births and cesar・ean sections and a reduction of only neonatal seizures(1Ufirevic, Devane,&Gyte,2013). Amnioinfusionto pre・Vent cord compressing thereby redudng fetalheart ratedecelerations and lo、vering the use of cesarean sections(Hofmeyr & lawrie,2012) might also be effective.1naddition, besides the care to prevent neonatal hypoxia,earlyskin・to・skin contactis e丘ective care for infantther・moregulation during the third sta8e of labor (入10ore,Anderson, Bergman,& DowsweⅡ,2012).

On the other hand,some prevenuve interventionsduring and after the third stage oflabor were reportedas not effective, or the e丘ectiveness was equivocal. EvenSO, they established into clinical practice as routineCare. Examples of such practices are as f0110WS: uterinemassage (chen et al.,2013; Hofmeyr, Abdel・Aleem,&Abdel・Aleem,2013; sheldon,Duroche二Winikoff,Blum,

& TrusseⅡ,2013) and early cord damping (MCDonald,Middleton, DO、vsweⅡ,& Morris,2013).1n japan, uter・ine cooling with ice packs is sometimes seen in clinicalPractice for its e丘ed to promote uterine contracuon toPrevent ppH despite the lack of evidence suggestingeffectiveness (osumi & Horiuchi,2007). For neonates,

Oxy8en administration to women during second stageOflabor(Fawole &Hofmeyr,2012) and nasalsuctioning

Comparison of policies forthe Management of care for vvomen and Ne、vborns Kataoka et a/.201

Ofamniotic auid (Gungor et al.,2005; vain et al.,2004)Were not found to be ef企Ctive in prevenung neonatalasphyxia. Based on this evidence,itwodd be prudenttoChange the polides to eliminate those practices that aredearly not e丘ective; this in turn may lead to decreas・ing the potential for harm and improve the quality ofIi企 durin号 the third stage oflabor for both women andne、vborns.

IaP飢 is among the countries having the low・est perinatal and infant mortality in the 、vorld at 2 Per1,ooo live birthsin 2011(WHO,2013). Yetjapa心 mater・nal mortaljず rate at 5.o per loo,ooo is higher thanexpected for a developed country (入10thers' a11d chil・dreds Hea1壮〕& welfare Assodation,2014). A low birth

rate under 2.o has existed since 1975 (Ministry ofHealth,ιabour and welfare,2012), and like many other devel、Oped countries, women be8innin号 their pregnancy areOlder(Mothers' a11dchildrelfsHealth &welfareAssoda、

tion,2014).凡I×10men have a choice ofthree types offadli、ties for birthing in lapan: hospitals, obstetridads clinics,and independent midwives mana8ed birth centers a11dhome deliveries. They must aⅡ会.1nction withil〕the legaⅡydetermined scope ofpractice.1n lapan, the obstetricianlsClinic and hospital dif丘t based on the number of beds.Most、vomen choose to birth at a hospital or clinic.

Most mid、vives 、vork at obstetridans' clinics or

bospitals, which accept both high・risk and low、riskIvomen.1apanese midwives are licensed to pradiceindependently ifthey choose so. However,1e8aⅡy,inde・Pendent midwives must restrid their practice t010W、risk women. By 2012, the totalbirths with independentmidwives 、vere l.0%(birth centers o.8%, home births

0.8%), obstetridarゞs clinicS 463%, and hospitalS 52.フ%(Mothers' and childreds Health & welfare Assoda、

tion,2014). Approximately 5% of midwives work asindependent midwives. They independently managematernal-infant care throughout pre8nancy, birth, andthe postpartum. They use expectant or physi010号icalChildbirth pradices focusing on the mothers' naturalProcesses with minimal medicalinterventions exceptin the case of an emergency (Gepshtein, Horiuchi,&Eto,2007).

In 2011,the japan society,ofobstetrics and Gyne、C010gy and the lapan Assodation of obstettidans andGynec0108ists published the evidence・based prenatalCljnical care 8Uideline in Japan (入linakami et al.,20ID.The8Uideline was mainlyforhigh・riskpregnantwomenWho may require medicalintervention during pre3・nancy and delivery The 今Uideline also addressed medi・Calinterventions for ppH during and after the thirdSta3e of labor, treatment of severe ppH induded rjsk

202 Comparison of policles for the Management of care for vvomen and Ne、vborns Kataoka et a/

factors for severe ppH, treatment to stop bleedin8, anddirection for providin今 blood transfusion.1n addition,re企rral criteria to hospitals 、vere detailed. HO、vever,no clinical recommendations were induded concern、

ing the use of prophyladic interventions for ppH in

this guideline. on the other hand, the lapan AcademyOf Midwifery established a care guideline mainly for10W・risk women (Kataoka et al.,2012). ThiS 今Uidelineinduded care policies for prophylactic interventions forPPH andneonatalcare such as oropharyngealandnaso,Pharyngealsuction, SMn・to・skin contact, and uming ofCord damping. AlthoU8hthese tw03Uidelines are some、What overlapped,theydealwith differentwpe ofd加icalquestions. From this perspective, there is no universalStandard for care espedaⅡy in terms ofpreventive inter、Ventions during the third sta号e oflabor.

Ii廿le is hlown regardin今 the extent ofdif61Sion ofthese relevant operational policies for 、vomen and new、borns among japanese hospitals, clinics, and midwiferyb辻th centers during and a丑er the third stage of labor.To establish the quality of care based on these PI'evl-

Ously mentioned low・risk and high・risk guidelines,it isimportant to reveal what types of operauonal policieshave been adopted among hospitals, clinics, and mid、Wifery birth centeTS. These data wi11 be needed when

We evaluate the 名Uidelines during and a丑er third stagemanagement.

The objectives ofthis study 、vere to ascertain andCompare l'eports of polides re3arding care during andafter the third stage of labor among hospitals, CHnics,and midwifery birth centers; severa11arge metropolitanareas of japan were tar8eted. For this study, we use theterm iπdepe11de11t 抗idwives to denote managing birthCenter and birthins in their birth centers or home、birth.

Questionnaire

The mailed questionnaire consisted of14 questions aboutCare polides during and a丘er the third stage of laborfor women and newborns and the charaderistics ofthe

institution. Questions about care polides induded tim、ing ofdampin8 壮)e cord, contr0Ⅱed cord traction, use of

Uterotonics (types and timing), uterine massage, uterineCooling, use oforalergometrine duringpostpartum, oro、Pharyngeal and nasopharyngealsuction for ne、vbornsWith a11d without meconium staining, and early sMn、to・skin contad (timing, duration, and use of pulseOximeter). Questions could be answered by selectingfrom three choices:(a) almost a11 Cases,(b) dependingOn the case, or (C) not implemented.いlhen the answer,adepending on the casd' was selected, an additional

quesuon asked:(d) in 、vhat cases 、vere care polidesimplemented. Questions aboutthe characteristics ofeach

institution included the f0110wing:(a) the category oftheinstitution (hospital, clinic, and midwifery birth center);(b) the number of vaginal deliveries per year,(C) thenumber ofmidwives;(d)type ofobstetrics unitindudingOnly obstetrics, obstetrics, and gynec010gy unit 01' otherSuch as a mixedpatients unit; and (e)the number ofbeds.

凡Ve conduded a pilot test on the questionnaireby having 丘Ve midwives answer the questions; we thenmodiaed those expressions and Nvords that they didnot understand. This provided face vaHdity for thequestionnaire.

MfTHOD

Data Analysis

Data analysis was performed using lBM spss statisticsVersion 19.0. Descriptive statistics were provided andtested differences using the chi・squate test or Fishers'

Design and partlcipants

This study 刃Vas a cross・secuonalsurvey using the 8eo、graphical areas of Tokyo and the Kanagawa, saitama,and chiba pr旦f'edures (a political desi今nation similarto a province or county). Tokyo, the capital of japan,has the largest population a3 mi11ion) f0ⅡOwed by theContiguous regions of Kanagawa (9 mi11ion), saitama(7 mi11ion), and chiba (6 mi11ion). participants weremana合ers (either obstetridan, mid、vife, or head nurse),in charge ofhospitals or clinics, and independent mid、Ivives within the areas. The institutional revle、v coln-

mittee approved this study (NO.10 -1002). The surveyPeriod was from october 2010 to july 2011.

Survey procedure

Our sample frame induded yeⅡOw pages website, web、Sites of the hospitals and dinic list (h杜P://shusanM.org/area.htmD, and tbe national midwifety birth cen、ter map (http://midwife.or.jp/birthcenter_1ist.htmD forhospjtals and clinics and midwiferybirth centers, whichhad an obstetrics ward and dealt with biTths. The search

idenU6ed 684 institutions in the area.~~7e mailed the

Consent form to managers in charge ofhospitals, clinics,and independent midwives.叉/×1e made a reminder tele、

Phone caⅡ to aⅡ managers who had notreplied to con、6rm iftheywere sti11Wi11ing to partidpate. Replies wereanonymized. The survey quesuonnaire wasthen senttothe managers who had agreed to partidpate.

exacttest and values ofp く.05 Were considered statisti、CaⅡy signiacant.

RESU[1S

Charaderistics of cooperating lnst託Utions

Of the 684 institutions,255 Partidpated in the survey(response rate 3ブ.3%): H8 hospitals (502%),66 d加ics(20.8%), and 71 midwifery birth centers (542%). Theresponse rate by region was not computed owing to theSimilariues ofthe areas.

Most (81%) of the hospitals had less than l,000Va8inal deljveries per year,15% had between l,ooo and1,999, and only 4% had greater than 2,000. Almost aⅡClinics and midwifery birth centers had less than l,000Vaginaldeliveries per year. The average numbet ofvagi・nal deliveries per year 刃Vas hospitals,738 (SD = 528),Clinics,371 (SD = 289), and mid凡Viferybirth centers,37(SD = 45). Approxim飢ely 44% of hospitals employed10-19 midwives,25% employed 20-29 midwives, and2 hospitals employed more than loo midwives. AmongClinics, most (フフ%) had less than lo midwives and

20% had lo-19 midwives. Almost aⅡ midwifery birthCenters had less than lo mid、vives. The average num・ber of hospital・based midwives waS 22 (SD = 18); inClinics,フ(SD = 5.1); and in midwifery birth centers,3 (SD = 15.D. Among hospitals,39% were maternityUnits,31% were maternityand gynec010名yunit, and theOthers (31%) wete mixed units that indude maternity,8ynec0108y, and other spedalties.

Comparison of policies forthe Management of care for vvomen and Ne、vborns Kataoka et a/.203

Underthejr care. Although midwives codd use an utero-tonic ifit was for a woman showing risk fadors and wasbythe ditection ofarlobstetridan. However,50% ofhos、

Pitals a11d 63% ofdinics did have such a policy AmongClinics and midwifery birth centers, er名ometrine was thetype most commonly used for "a11Cases" or "depends onthe casd'(Table 2). oxytodn alone and ergometrine orOxytodn wasthe next most commonly used. ThistrendWassimilar among hospitals, clinics, and midwiferybirthCenters.1n addition, the timing of prophylacuc utero・tonic administration a1110ng hospitals was a丑er deHveryOfplacenta and during the 仕)ird stage oflabor. The mostCommon uming to admi11ister uterotonics among clin・icS 刃Vas during 仕le third sta号e of labor. For independentmidwives, uterotonics were most commonly used a丑erdelivery of the placenta. Replies to the question aboutProphyladic oral me杜lylergometrine at poS中art山n sU8・gested thatthis、vas common in hospitals (50%) and clin、ics (52%) but not midwifery birth centers (0%).

It 刃Vas a policy to coolthe uterus lvith an ice packa丘er the delivery of placenta to accelerate contractionsin a minority ofthe faciljties. Reporting use ofice packsWere 25% ofclinics,10% ofhospitals, and 7% fot mid、Wifery birth centers.

Policies for Mothers' care During and AfterThird stage of Labor

Table l sho、vs the policies guiding mothers' care duringand a丘er third sta名e oflabor. statistica11y si3ni丘Cant dif・ferences were found related to aⅡ Polides for mothers'Careamonghospitals, clinics, andindependentmidNvives.

Institutionswere asked、vhentheydampedandcutthe coTd. Most of the hospitals (89%) and dinics (88%)had a policy of damping the cord immediately a丘erbirth. By contrast, nearly 70% ofmidwifery birth centershad polides ofwaiting untilthe cord stopped pulsating.上ess common was implementing contr0Ⅱed cord trac・tion:15% hospitals,24% clinics, and 4% midwiferybirthCenters and uterus massa8e was,24% at hospitals,33% atClinics, and 7% at midlvifery bitth centers.

Respondents reported various polides for prevent・ing ppH.1t was the policy of independent midwivesto not administer prophylactic uterotonicS 血r women

Policies for Ne、Nborn care lmmediatelyAfter Delivery

Table 3 Sho、vs the policies for ne、vborn care immedi、ately a丑er delivery A11 results indicated statistica11ySigni丘Cant differences among hospitals, clinics, andmidwifery birth centers.

Polides of oropharyngeal and nasopharyn今ealSuctionfornewbornswithoutmeconiumwerecommon

(hospita1 69.0%, clinicS 76.6%) but not for midwiferybirthcenters(2.9%). oropharyngealandnasopharyngealSuction for ne刃Vborns with meconium before shoulder

delivery was a policy among 45% of hospitals,43% ofClinics, and 24% ofmidwifery birth centers.

Early skin・to・skin contad 血r mothers and 廿leirnewborns 、vas routine care in midW迂ery bir壮I centers四4%), with a slight majority of 52% for hospitals, and42% in d血ics. Table 4 Shows the timing al)d durationOf sMn・to・SMn contact. Genera11y, the timing to beginto sMn・to・SMn contad was immediately a丑er deliveryDuration of sMn・to・skin contact 凡Vas atound 30 min in

haH of institutions a11d 60 min in 20% of insti加tions.

Around30% ofhosP武als al)dd血icsindicated routine useOfapulse oximeterforinfal)ts duringsMn・to・skin contad,Whereas only 6% ofmidwifery bir壮Icenters did.(Table 3Shows care polides for ne、vbornsjust a丑er delNery.)

204 Comparison of policies for the Management of care for women and Ne、vborns Kataoka et a/

TABIEI

VARIAB【ES

CarepoHdesforMothers Durin牙如d脈erthelhirdsta客eof王abotbyGroups(N= 255)

Cord clamping

Immediale1γ afler deⅡVery o"コabyAfter the cord stops pulsatingOthers

Not stated

Conlr011ed cord lradion

Almost a11 Ca5e5

Dependin80n lhe case~olimplementedNot 5tated

Uterine massageAlmost aⅡ Case5

Depending on the case

NotimplementedNot stated

Coolin8 for uterineAlmost aⅡ Cases

Dependlng on the case

NotimplementedNot slated

Adminlstration of propbyladicUter010nlcs

Almost aⅡ Cases

Depending on the case

NotimplementedNot stated

Prophyladic oral methylergomelrineOn postpartum

Almosl a11 Cases

Depending on the case

NotimplementedNot stated

n=118

HOSPITALS

105

10

3

四向

(89.の

(8.5)

(2.5)

(50.0)

BO.5)

a 9.5)

n = 66

CUNICS

58

(14.5)

(65.8)

(19.フ)

WO)

<.001

MID、NIFERY

引RTH CENTERS

(87.9)

(6.1)

(6.1 )

(63.1)

促4.6)

(123)

n = 71

(23.9)

(53.0)

(23.1)

001

Policles for care of Mothers During and After theThird stage of 【abor

Cord cla柳Ping

Several yeaTs ago, early cord damping in lapan was thePolicy in haH of tbe dinics,(Akai,1Watani, uchiy飢la,Kagitani,& Yamakawa,2004) and hospitals (Akai,Yamakawa,1Watani, uchiyalna,& Kagita11i,2006); how、ever,in thissurvey more than 80% ofboth hospitals anddinics had adopted the policy of early cord dalnping.Inotherwords,thed廿員Isionofearlycorddampin今amon8

促42)

(54,5)

(21.2)

DISCUSSION

四向

(フ.1)

(42.9)

(50,0)

(103)

(71.8)

(17.9)

(15.フ)

(71.4)

(12.9)

In lapan, the Guideliπesjor ohstetriC41 Pr4dice by the}apan sodety of obstetrics and Gynec010gy and lapanAssodauon of obstetricians and Gynec010gists tookeffed in 2011. H0刃Vever, there is no nationalsystematic今athering of obstetric data in lapan that would providedirect or indired evidence of the impact of the policyChanges. Therefore, this study was the most recentinvestigation to identify the care polides for mothers

and infants durin8 and after the third stage of labor.The study focused on practices in hospitals, clinics, andmidwifery biTth centers in Tokyo and the surroundingareas of Kanagawa, saitama, and chiba in lapan. con、Siderable differences were discovered in the ado tion

(0)

a 8.6)

(81.4)

<.001

B3.3)

(36.4)

(30.3)

P

<.001

(51,5)

BO.3)

(18.2)

(50,4)

B3.3)

(162)

(43)

B5.刀

(60.0)

Of the policies among hospitals, clinics, and midwiferybirth centers, althoU3h there were some similarities inadopted policies ofhospitals and dinics.

a .4)

a5.5)

(83.1)

(24.2)

(56.1)

(19.フ)

<.001

<.001

(フ.1)

(543)

B8.6)

9 1

44

8 1

フ 7 3 1

ーフ 2

827ー

?』 6 2

6 6 4

1 3 1

241ー

1 8 2

1 0

1 5

2 4 0

2 2 2

9991

5 3 1

3521

24

6 7 3

1 3 1

587ー

32

9 6 3

5 3 2

1 6

5051

33

N⑳n

ーー 9

1 5

037ー

1 5

T沖e andTimingofprophylacticuterotonicsbyGroupsTABIE2

VARIABLES

Type of prophyladic uterotonicsOxytocin alone

Ergometrine alone

Oxylocin or ergometrineOthers

Not stated

Timing of prophyladic uterotonic administrationImmediately after delivery of baby

During the third st弔e of labor

At delivery of placenね

Aner delivery of placentaNot stated

Comparison of policies forthe Management of care for women and Ne、vborns Kataoka et a/.205

Note.11:1nstitutions where almost a11 Cases or depending on the case administTated prophylactic uterotonics.

hospitals a11dclinics has becomemorewidespread. ontheOtherh飢d, according to thisst口dy, most midwiferybirthCenters adopted late damping.入lidwives usuaⅡy supportmothers by initiating ski11・to・SMn contact with their new・bornbeforedampin8釘ldcU廿ing仕lecord;supportin8thebonding process is considered crudal. A丑er the motherandbabyaretogether,the midwifヒthen con6rmS 壮le ces・Sation of pulsauon and damps the cord. This trend lvasSimilar atnong midwives in canada (Tan, Nein, S飢eⅡ,Shirkoohy,& Asrat,2008) and in the united Nn3dom(Farr紅, TuffileⅡ, Airey,& Duley,201の. Evidence fromral)domized contr011ed trials (RCTS) suggested 仕lat late

HOSPITAIS

n

(94.4)

(5.6)

(0)

WO)

(27.6)

(50.0)

(143)

(82)

CUNICS

(2.9)

促5.0)

(72.1)

n

P

(202)

(29.鋤

(14.9)

(35.1 )

げ0)

Cate policlesforNewbornsAfterDelivery (N= 255)TAB王E3

(879)

(6.1)

(6.1 )

(14.0)

MID、VIFERY

引RTH CENlfRS

VARIABLfs

<.001

n

Sudion for ne~vborn5 Without meconium

Almost a11 Cases

Depending on the case

NotimplementedNot stated

Sudlon for nevvboms with meconium

before delivery of should引Almost a" ca5es

Depending on 小e case

NotimplementedN015tated

εarly skin・to・skin contadAlmost an case5

Depending on the case

NotimplemenledNot stated

Cord damP血g had bene丘ts, such as higher iron reservesand birth weight, despite evidence ofpolycy仕lemia, whichWasjudged to be beni3n (HU杜on & Hassa11,2007), andhyperbilirubinemia (1VICDonald et al.,2013), which woddrequire available phototherapy when the cord should bedamped, early or late, and under what drcumstances injapa11ese infants has yetto be determined.

6幼

(182)

(40.0)

(182)

(23.6)

(9.1 )

(63.6)

(273)

(0)

(0)

a 82)

(の

(81.8)

C0πhoued cord l'r4Cti011

Contr0Ⅱed cord traction facilitates placental separa・tion and lead to birth.1t is a manual application of

HOSPITALS

n=118

<.001

WO)

(69.0)

(19.0)

(12.1)

n = 66

CUNICS

(41.5)

(262)

B2.3)

49

(9'0)

(44.8)

(18.1)

B7.1)

MID、VIFERY

剖RTH CENTERS

(23 '8)

(42.9)

B3.3)

(76.6)

四.4)

(14.1)

n = 71

67(51.フ)

B I,4)

(16.9)

004

(%)

(43.1)

(292)

(27.フ)

ーフ30

0 ?』 0 9 1

6 9 2

40

7 9 4 8

2 4 1

98434

1213

2618

1 2 1

02032

121ー

0242

8 つ一 1

2132

5 2 4

ーフ 0

6 3 2

8981

2 1 ー

2793

フフーー

2 1 2

5718

1 2 2

206 Comparison of policiesforthe Management of care for vvomen and N b

TABIE4 Timin号andDurationofEaTlyskin、to、skincontadb G

VARIAB【ES

Timing for start to skin、to、skin contad

Immediately after delivery of baby (52.6) 26

W川lin 30 minB6.1)

W川lin 60 min(9.3)

Within 120 min(2.1)

Not stated

Duratlon of skin、to、skin conlad30 min

(45.4)60 min

(13.4)120 min

B7.1)

Until breastfeeding started (4.1)Not slated

Use of pulse oximeter during skin、10、skinConねCt

Almost a11 Case5 B2.刀 14

Dependin80n the case (673) 31

Notimplemented 6

Note・ 11:1nstitutions where almost a11 Cases or depending oD the case rovided earl sk・_t _ k・

genae downward tension on the umbilical cord whilemaintaining counter pressure on u)e uterus and is a

Component of acuve management of third stage ofIabor・ 1n japan, polides ofcontr0Ⅱed cord traction werenot so common among midwifery birth centers. Evenin hospitals and clinics, only around 20% adopted thisPolicy By contrast,in the united Kin8dom, more than90% ofboth midwives and obstetridans used contr0ⅡedCord traction (Farrar et al.,201の. some studies exam_ined 北S effect but results On ppH risk were equivocal.For example, two recentlarge RCTsindicated there wasno effect on the risk of severe bemorrha8e (Deneux_Tharaux et al.,2013; Galmezoglu et al.,2012).1n c。n_trast, another RCT found that contr0Ⅱed cord tracti。n

Produced a 50% reduction of ppH risk (Khan, john,Wani, Doherty、&sibai,1997).1n addition, sheldon et al.(2013) sug号ested that the contr0Ⅱed cord traction dur_

ing third sta8e labor has the effed of preventing ppHWhen oxytodn prophy1餓is is unavailable. contr0ⅡedCord traction does not have enough consistent positiveOutcomes evidence to qualify as an evidenced、basedPractice and remains a controversialissue.

HOSPITA玲

n

BI'1)

(68.9)

Kataoka et a/

や向(%)

Proph),14Ctic uterot0πicsThis is the flrst report to show independent mid、Wives care polides for using prophylactic uterotonicsin lapan. Most ofthe midwives did not use prophyladicUterotonics. only one independent midwife routinely

CⅡNICS

n

(92.4)

(フ,6)

(0)

(0)

Usedprophylacticuterotonicsand 16% ofmid、vives used

them 'depending on the casel' Although midwives ofJapan are lega11y prohibited from medicalinterventions,if an obstetridan provides superⅥSion, or if it is onlforemergency cases, when the woman and/orinfant arein danger, then they may use ptophylactic uterotonics.Thisisthe mostprobable reason 、vhymostindependentmid、vives did not use prophylactic uterotonics.

Onthe otherhand, mosthospitalsand clinicshad aPolicy to use prophylactic uterotonics.1n this study, halfOf hospitals and clinics provided routine prophylacticOral methyler80metrine a丘et delivery Yet, prophylac_tic oral methylergometrine after delivery has not beenShown to be effective (Andersen, Andersen,& S口rensen,199& Yaju, Kataoka, Eto, Horiuchi&Mori,20B); hence,We should change this practice as soon as possible.

WO)

(492)

(292)

(15.4)

(6.2)

(57.8)

(42,2)

(0)

(の

MID、1VIFERY

剖RTH cfNT更RS

Uterine1ιepacb

Several clinics, some hospitals, a11d midwifery birthCenters used ice packs on the abdomen as a rouune cal・e

to cool and shrink the uterus musde tba・eby dampinthe blood vessels to prevent bleeding. so far, no studies

Wri壮en in En今lish have assessed the effed ofcooling theUterus to accelerate contractions. There was only oneObservational study in Japan and it sho、ved no signi6_Cant difference ofblood loss between the ice pack rouand the no ice pack 名roup (osumi & Horiuchi,2007).An RCT is needed to assessits benefits and harms.

n

(5.9)

四4.1)

61

(55.8)

(20.9)

(20.9)

(2 ' 3 )

5001

9000

1

1

9 2 5

44

1 5

53

4 3 6

4 1 3

絵鮎 5

02032

121ーー

訟円円4扣

4 酔 3

Policies for care of Ne、vboms

Oroph4r)'π宮'e41απd Nasoph41),11genlsucti011In the japanese "Guidelines of neonatal cardiopulmo、nary resuscitation, sucuoning of newborns withoutevidence ofmeconium was notrecommended as arou、

tine care (Tamura,2010); h0刃Vever, our survey resultsindicated that the policy of 01'opharyngeal and naso、Pharyngeal suction was stiⅡ工Videspread in hospitalsand espeda11y clinics. There are major gaps in evidenceaboutthe optimalmanagementofsuctioningnewborns.

Comparison of policies forthe Mana8ement of care for vvomen and Ne、vboms Kataoka et a/.207

Ski↑1・to・ski" C0πt4d

Earlyskin・to・SMncontadformothersandtheirnewborn

infants positivelyaffectsbreastfeeding,thermoregulation,and cardiorespiratory stability and had no adverse e丘ectsaccording to a recent systematic reⅥew (Nloore et al.,2012). Based on this evidence,japanese guidelines, whichbad been published in 2009 (Kangaroo care Guide、Iine 刃XI'orMng Group,2009), tecommended skin、to、SMnContact for both preterm and term infants. ski11、to、skiπC0πt4dwas de負ned asthe immediate orsoon a丑er birth

Pladng ofthe naked infant prone on the mother's bareChest for continuous contact (Moore et al.,2012).1n this

Study, ahnost aⅡ independent midwives replied that itWas routine care to initiate early sMn・to・skin contad formothers and their newborns; howeve二 only 52% ofhos、Pitals and 42% ofclinics replied that it 刃Vas routine care.Similarly, in most midwifery birth centers, skin、to、skinContad started immediatelya丘er birth, butit was evident

in only half of hospitals and clinics. of those providingSkin・to・SMn contact,the duration was around 30 min.

Recently, some mother-infant acddents 、verereported durjng sMn・to・SMn contad (ohM et al.,2012)

induding sudden infant death or asphyxia (pejovic& Herlenius,2013). Effecuve management durin名 SMn、to・SMn contad mustindude adequate supervision andShould be incorporated into the guidelines. Appro、Priate care and uming of skin・to・SMn contad couldbecome widespread espeda11y in hospitals and d加icsifevidenced・based guidelines were widely implemented.

The existence ofguidelines isimperative. Further、more, training for health care providers in evidence、based care and the audit system is needed to reducethe gaps.

Of women who received care among hospitals, clinics,and midwifery birth centers. Therefore, we cannot

assume that the results of this survey indicate that a11PolideS 凡Vere translated into practice. The questionnairemay also require additional psychometric evaluation toassure stronger validity and to establish the reliability ofitems. surveys that compare adualpractice are needed.Although a limitation was the lo、v tesponse rates, par、ticularly of the clinics, dearly a national survey 、vi11 beimportant to understand maternal-infant care for the

third sta号e oflabor in the various regions ofjapan.

CONC【.USIONS

Thisstudyprovidesupdatedinfotmationaboutthepres、ence ofjapanese care polides for women and newbornsdurin8 and a丘er the third stage of labor a丘er nelvjapanese national guidelines Nvere introduced. There

exist considerable differences between the Tokyo andSurrounding prefecture hospitals, clinics, and midwiferybirth centers. some of these differences result from

their professional philosophy and the legal restrictionsOf medicalinterventions shaping midwives' scope ofPractice.1ndependent midwives' policies Nvere consis、tent with expectant or physi010gica11abor management,Whereas active management policies were more in evi、dence in hospitals and clinics. There lvere also nlany

gaps bet、veen evidence-based care and care policiesSuch as uterine cooling and nasopharyngealsuctioning;therefore, nelv strategies to realign care polides 、vithevidenced・based outcomes are needed.

STUDY ⅡMnATIONS

This survey revealed institutions' stated care polides,not their adual practice such as the average percentage

RfFfRENCES

Akai, Y.,1Watani, S., uchiyama, K., Kagitani, H.,&Yamakawa,M.(2004). The quaHty of maternity care of dinics inJapan based on the pradica1 8Uide: care in normalbirth by wHO. jaPαπese jour1141 qf' MaterπαI He41th,45(D,67ーフ5.

Akai, Y., Yamakawa, M.,1Watani, S., uchiyama, K.,& Kagitani,H.(2006). The realityofpractidng care in n01'malbirth:'入 Practica18Uidず in lapan: A study of hospitals andClinics from a perspective of a number of midwives.jnPαπese jour11αl qf'M4ter1141 Health,47(2),304-312.

N丘revic, Z., Devane, D.,& Gyte, G. M.(2013). continuousCardiotocography (CTG) as a f01'm of electtonic fetal

monitoring (EFM) for fetal assessment during labour.Cochrα11eDnmb4Seqf'syste叛4ticReviews,(5),CDO06066.

http://dx.doi.or名no.1002/14651858.CDO06066.pub2

208 Comparison of policies forthe Mana8ement ofcare for vvomen and N b

American c0Ⅱe8e of obstetrjdans and Gynec010gists.(2006). ACOG practice bUⅡeti比 Clinical managementgujdelines for obstetrician・g沖ec010gists number 76,October 2006: postpartum hemorrhage.06StetricS απdGyπec010gy,108(4),1039-1047

Andersen, B., Andersen,1.. L.,& S必rensen, T. a998). Methy_Iergometrine during the early puerperium: A ptospec、tive 玲ndomized double bⅡnd study Acta ohstetガCia etGyπec010呂'iια SCα11diπανiC4,フ7a),54-57

Begley, C. M., Gyte, G. M,, Devane, D., MCGuire, W,&weeks,A・(2011). Acuve versus expectant management forWomen in the third stage oflabour. cochrαπe D4t464Se

げ Syste抗"tic R卯i■W', aD, CDO07412. httPゾ/d".d。i.org/10.1002/14651858.CDO07412.pub3

Chen, M., chang, Q., Duan, T., He, j., zhan昌上.,& Liu, X.(2013). uterine massa8e to reduce blood loss a丘er vagi_nal delivery: A randomized contr011ed trial. ohstetricsα11d G)'πec010gy,122(2, pt. D,290-295. http://dx.doiOrg/10.1097/AOG.ob013e3182999085

Deneux・Tharaux, C., sentilhes,上., Mai11ard, F., closset, E.,Vardon, D.,1,epercq,1.,& Gofnnet, F.(2013). Effed 。froutine contr0Ⅱed c01'd traction as part of the activemanagement ofthethird stage oflabour onpostpartumhaemorrhage: Multicentre randomized contr011ed trial(TRACOR). British MediC4リ0urπal,346. h廿Pゾ/dx.d。iOrgno,1136/bmj.f1541

FarTar, D., TU丘neⅡ, D., Airey, R.,& Duley,1..(201の. caredurjng the third stage oflabour: A postalsurvey ofuKmidwives and obstetridans. BMCP光8π411Cy and child_birth,10,23. h杜P://dx.doi.org/10.1186/1471-2393_10_23

Fawole, B.,& Hofmeyr, G. j.(2012). Maternal Oxygen

adm血istrauon for fetal distress. cochr4πe DataBaseψSyゞte抗"h" R即iews, a2), CDO0OB6. h杜Pゾ/d".doi.org/10.1002/14651858'CDO00136.pub2

Gepshtein, Y., Horiuchi, S.,& Eto, H.(2007).1ndependentIapanese midwives: A qualitauve study oftheir practiceand beliefs./4P4πノ0ur11αl qf'Nursi11g scieπCe,4,85_93.

Gulme20glu, A. M., lumbiganon, P., Landoulsi, S., widmer,M., Abdel・Aleem, H., Festin, M., Elbourne, D.

(2012). Active management ofthe third stage oflab。urWith and without contr011ed cord traction: A ran_

domised, contr011ed, non・inferiority trial.ιαπCet,379(9827), 1721-1727. httPゾノdx.doi.OTg/10.1016/S0140-6乃6a2)60206-2

Gun80r, S., Teksoz, E., ceyhan, T., Kurt, E., Goktol a, U.,& Baser,1.(2005). oronasopharyngealsuction versusno suction in normal,term and vasinaⅡy born infants:A PTospective randomised contr011ed trial. A1ιStraliaπ

aHdNewzeα14πd/ourπαlqj'0●StetガCS α11d Gy11aec0108y,45(5),453-456.

Hofmeyr, G.1., Abdel・Aleem, H.,& Abdel、Aleem, M. A、(2013). uterine massage for preventing postpartum

haemorrhage. cochr4πeD4ta64Se qf'syste柳αh'CReviews,(フ), CDO06431. http:ノ/dx.doi.orgno.1002/14651858.CDO06431.pub3

Hofmeyr, G. J.,& Lawrie, T A.(2012). Amnioinfusion f。rPotential or suspected umbilical cord Colnpresslon

in labour. cochr411e D4tah4Se qf' syste柳atic Reviews,(D, CDO00013. h廿P://dx.doi.org/10.1002n4651858.CDO00OB.pub2

Hutton, E. K.,& Hassan, E. S.(2007). Late vs early dalnpingOf the umbilical cord in丘111・term neonates: systema廿Creview and meta、analysis of contr0Ⅱed trials. j'0ιιr11α1AIHeriC411MedicalAssod4tio",297aD,1241-1252

Kangaroo care Guideline worMng Group.(2009). EvideπCe411d c0πSe11Sus based kαナ1g4roo C4re g加deliπe. osaka,japan: Medicus shuppan. Retrieved from h廿P://mindS4.jcqhc.or.jp/minds/kc/fukyu/1_kc.pdf

Kataoka, Y., Eto, H.,1ida, M. Yaju, Y., Asai, H., sakurai, A.,Horiuchi, S.(2012).Evidence・base guidelines for mid_Wifery care during childbirth./ourπ41qf'ノαPα11AC4de111yψM'dWが'のy,26(2),275-283.

Kavanagh,1., Ke11y,A.j.,&Thomas,1.(2005).Breaststimulationfor cervicalripening and induction oflabour. cochl・α11e

D4t肋4'■ qf'syst肌4tic R卯i'WS,5(3), CDO03392. httPゾ/dx.doi.org/10.1002/14651858.CDO03392Pub2

Khan, G. Q.,10hn,1. S., wani, S., Doherty, T、,& sibai, B. M.a997). contt011ed cord traction versus minimalinter_Vention techniques in delivery of the placenta: A ran_domized contr011ed trial. AlheriCαπノ'our1141 qf'ohstetrics4πd Gy"ec0108y,17フ(4),フ70-フ74.

Khan, K' S., wojdyla, D., say l., Galmezoglu, A. M.,& van上ook, R F.(2006). WHo analysis of causes ofmaternaldeath● Asystematicreview.ιαπCet,367四516),1066-1074.

Liabsuetrakul, T., choobun, T、, peeyananjarassri, K.,& 1Slam,Q・ M・(2007). prophyladic use ofergot alkaloids in thethird stage of labour. C0ιhr411e D4t464Se Qf'syste柳4ticReview,S,(2), CDO05456.

MCDonald, S. j., Middleton, R, DowsweⅡ, T.,& Morris,R S.(2013). Effect of 廿ming of umbilical corddamping of term infants on maternal and neonatalOutcomes. C0ιhr411e D4tabase qf' syste抗αtic Revie1νS,(フ), CDO04074. hせPゾ/dx.doi.or3/10.1002/14651858.CDO04074Pub3

Mjnakami, H., Hjralnatsu, Y., Koresawa, M., Fujii, T., Hamada,H・, ntsuka, Y;,... Yoshikawa, H.(2011). Guidelines forObstetrical Pradice in lapan: japan sodety of obstet、rics and Gynec010部 and lapan Association of obste_trjcians and Gynec010gistS 2011 editjon./our1141 qfObstetガCS απd Gyπ4ec010gyRese4rch,37(9), H74一Ⅱ97.

Ministry ofHealth, Labour and welfare.(2012). Geπeral wel_jare α11d 1α60川. Retrieved from h杜P:ノ/WWW.mhlw.go.jp/english/WP/WP・hW6/d1川le.pdf

Kataoka et a/

Moore, E. R., Anderson, G. C., Bergman, N.,& DowsweⅡ,T.(2012). Early skin・to・SMn contad for mothers andtheir healthy newborn infants. cochra11e D4t4b4Seげ Syste柳4tic Re"i.W',(5), CDO03519、 httPゾ/dx.doi.orgno.1002/14651858.CDO03519.pub3

Mothers' and childreds Health &welfareAssodation.(2014).Boshi hoke11 110 0111011aru toukei[Maternal and child

health statistics ofJapan]. Tokyo, Japan: Author

Nationa1 1nstitute for Healtb and clinical Exce11ence.

(2014).1πtr4P4rtU111 C4re: C4re qf' he41thy 1ν0111eH411d their み4みies durl'Hg childみirth. Retrieved fromhttp://WWW.nice.or8.uk/guidance/cg190/evjdence/C号190・intrapartum・care・fUⅡ・guideline3

OhM, S., Kajiwara, M., Amizuka, T.,1Shida, A., Kabe, K.,

Kusuda, S.,...~vatabe, S,@012). surveystudy ofappar・ent life・threatening events of low risk neonates in the

maternity wards in lapan./aPαπノ0ur1141 qf'societyjωPre柳αture απd NeWみor11Mediιiπe,24(1),73-81

Osumi, K.,& Horiuchi, S.(2007). The physi010gical andemotional responses to the care for postpart山n uterineContraction: The beNeen coldColnparlson Conlpress

application 釘ld observation withoutthe application.jour・π41qfst.ιUk6 Socie砂jbrNursiπξResearch,11(D,10-18.

Pejovic, N.1.,& Herlenius, E.(2013). unexpeded c011apseOf healthy newborn infants: Risk fadors, supervisionand hypothermia treatment. Ada P4edi4trica,2(フ),680-688. http://dx.doi.org/10.H 11/apa.12244

Sheldon, W. R., Blum,1., vogel,1. R, souza, J. R, G田mezoglu,A. M.,& winik0丘 B.(2014). postpartum haemorrhagemanagement, risks, and maternal outcomes: Find・

ings from the wotld Health or8anization Multicoun、try survey on Maternal and Newborn Health. BjoG、

121(SUPPI. D,5-B.

Sheldon, W R., Durocher, j', winikoff, B., Blum,〕.,&

TTusseⅡ,1.(2013). How effective are the componentsOf active management of the third stage of labor?BMc preSπα11Cy 411d childhirth, B,46. h杜P://dx.doi.org/10.H86/1471-2393、B、46

Societyofobstettidans andGynaec010gistsofcanada、(2009).Adive 1πα114ge111eπt qf the third stage qf'1αbour: preveπ・tioH α11d tre4t"1e11t qf'postPα1'tU111 he1110rrhage. Retrievedfrom h杜P://sogc.or今/WP・contenvuploads/20B/0νgui235CPG0910.pdf

Tamura, M.(201の. shi那e加 Soseiho tekisuto [Textbook ofneonatal resuscita廿on](2nd ed.). Tokyo,1apan: Medi・Calview.

Tan,~V. M., Klein, M. C., S鯉e11,1., shirkoohy, S. E.,& Asrat,G.(2008). How do physicians and midwives managethe third stage of labor? Bhth,35(3),220-229. h杜Pゾ/dx.doi.org/10.1111/j.巧23-536×2008.00243.X

Comparison of p0ⅡCiesforthe Management of care for vvomen and Newborns Kataoka et a/.209

Tun〒alp,0., Hofmeyr, G. j.,& Gulmezoglu, A. M.@012).Prostaglandins for preventin8 Postpartum haem・Orrha今e. cochrα11e D4t4hase qf' syste柳αtic Reviews,(8), CDO00494. h廿P://dx,doi.otg/10.1002/1465玲58.CDO00494、pub4

Vain, N. E., szyld, E. G., prudent, L. M., wiswe11, T. E., A号ailar,A. M.,& vivas, N.1.(2004). orophat沖geal and naso・Pharyngeal suctioning of meconium・stained neonatesbefore delivery of their shoulders: Multicentre, ran、domised contr011ed trial.ι411Cet,364(9434),597-602.

~vesthoff, G、, C0廿er, A. M.,& T010sa,1. E.@013). pro、

Phyladic oxytodn for the thitd sta8e of labour toPrevent postpartum haemorrhage. cochr4πe Dat4baseげ Syst肌"t北 R卯i.WS, aの, CDO01808' h廿Pゾ/d".doi.org/10.1002/14651858.CDO01808.pub2

World Health organization.(2012). WHo reω"1111e11dnti011S

jor the preveπti011 4πd treat111e11t qf'postpartU111 hae111・Orrhage. Retrieved 丘om http://apps.wbo.int/iris/bitstreamn0665/75411n/9789241548502_engpdf

World Health 0熔anization.(2013). world he41th statistics2013: part 3 glohal health iπdiC4tors. Retrieved fromhせP://WWW.who.invgho/publications/world_health_Statistics/EN_WHS20B_part3.pdaua=1

Yaju, Y., Kataoka, Y., Eto, H., Horiuchi, S、,& Mori, R,(2013).

Prophyladic interventions afteT delivery ofplacenta forredudn今bleedingduringthepostnatalperiod. cochrα11eD4tabase syste柳αtic Revie",S, CDO09328. http:ノ/dx.doi.or今ノ10.1002/14651858.CDO09328Pub2

AckπOwledg1πeHts. This study was conducted with assistancefrom a G仏nt・in・Aid for sdenti金C Research (NO.21659524)

from the Ministry ofEducation, culture, sports, science andTechn010gy,Japan.

Correspondence regarding this article should be directedto Yaeko Kataoka, CMN, phD, st. Lukds lnternauonal uni、

Vetsity、 10-1 Akashi・cho, chuo・ku, Toky0 104-0044,1apanE・mail: yaeko・kataoka@slcn.ac.jp

Yaeko Kataoka, CNM, phD, st. Lukdslnternauonal

University、 Tokyo,}apan.

KaoriNakayatna, CNM, MS, st. Lukds lnternational Hospital,Tobo,1apan.

YukariYaju, MPH, phD, st. Lukds lnternational university,Tokyo,1apan.

HiromiEto, CNM, phD, NagasaM universit又Nagasaki,1apan.

Shigeko Horiuchi, CNM, phD, st.1'uk心 lnternationaluniversityTokyo,1apal)

叉NhatMakesforGoodc0Ⅱaborationand

Communication in Maternity care?ASCOP血gS加dyIsabe1 ν411 He11π011d,1re11e KorsTjeπS, jessiC4 MeS111侃11,M4riaππeNieuweπhUガZeK1侃Sie11Horstη14π,Huhertiπas h ,Marc spaa11der1114π,ノ'udit Keuleπ, aπd Ray1110πd de vries

BACKGROUND: Goodcommunicationandc0Ⅱaborationarecr't' alt f f゜BjECTIVE: To identi丘 factors assodated with good c0Ⅱaboration and c。mmunicati。n am。nmaternity care professionals and beNeen both professionals and arents.

METHOD:scopingstudywesearchedpubMedandweb。fsc' f ,andqualitative,ori3inal,primaryreseaTchinwesternsodetiesonc。mmun' t・ d 11 bmaternity care among professionals (search D and beNeen professionals and arents (sea h 2).FINDINGS: The40studies a4insearch l;26血 Search2)血atmet。urs l t・・ h・Severalfactorsassodatedwithgoodcommunicationandc011ab。ra廿。n.we d h f6 Categories: Expertise, partnership, context,Attitude, Trust, and c。mmunicat. t l. s dmunicationandc011aborationamon8Professionalsforegroundedwork_related t, hexamining c0ⅡaboTation betweenprofessionals andparents aidm。re attent' taspects・Before 2012,fewstudiescoveredpositiveaspects ofcommunicati。 d Ⅱ bfound an undeTreplesentation ofparentsin study populati。ns.

C゜NC王USION: ourstudyis part ofa growing trend ofidentifyinothe 。sitive a ect fc m_municationandc011aborationinmaternitycare.Asthestudyofc。Ⅱab。rati。,researchers need to be sure to involve aⅡ Stakeholders,indudin arents.

KEYWORDS:communication;C0Ⅱaboration;midwifer;mate 't ; b ;

INTRODUC110N

Problemslvith communicationand c0Ⅱaboration am。n

Perinatal caregivers threaten the quality and safety 。fCare given to mothers and babieS σoint commissi。n

On Accreditation of Healthcare organizations,2004;Simpson & Knox,2003). concern with perinatal mor_tality in the Netherlands,1ed policymakers there to rec_Ommend that maternity care8ivers pay spedala廿entionto the centralrole of mother and chⅡd, empowermentOfdients, and 6etter c011αみor4ガ011 bet"/ee114111114ter11itC4resivers (van der velden,2009). Earlier reviews 。f

210

maternity care w01'k focused on tools to measure c。1_

Iabora廿on (DO、vne, Finlayson,& Fleming,201の andOn historic developmentsin c011aborauon in the unitedStates (Avery, Montgornery,& Brandl、salutz,2012;Kin号 Laros,& parer,2012). Nlthree of these reviewsemphasized the need for be杜er interprofessional c01_Iaborauon in maternity caTe to provide patient、centeredCare over the course ofchildbearin号

E丘orts to maintain a11d improve tbe quality ofCommunication and c0Ⅱaboration in maternity caremust begin with an exploration of what is hlownaboutthe fadors that are assodated witb 80od woTking

//VTER/VA刀0/VAι JOUR/VAι OFCH/ιD8/月TH VO/ume 5,/ssue 4,2015◎ 2015 Springer publishing cornpany, LLC VVWW.springerpub.C。m

h廿P://dx.doi.org/10.189ν2156-5287.5.4,210

,

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relationshゆS 血ere.1n safety and quality research, mostStudies begin from the premise that、ve can imptove ourPractices by identifying al)d eliminating causes oferrors,rather than examjning and learning 丘om whatis goingWeⅡ(Mesman,2008).刃Xle take a diffヒrent approach.1nOur exploration of the research, we focused on studiesexamining thefadors assodatedW北h good communica・tion and c0Ⅱaboration asthey occurin working routhlesin maternity care practice. Although we C4111earn fromfailures, it is equa11y important to identify and build onexisting-but 0丑en overlooked or forg0廿en-C0Ⅱabora・tive competenciesin care practice. Thisla杜er approach-known aseχ110ναガ011 qedema, Mesmat),& carr0Ⅱ,2013;

Mesman,200& Mesman,20ID-pays a杜ention to themundatle,implicit routines ofcare, the invisible but nec、essaryaspects ofcare 、vork 杜lat promote quality. The aimOfeX110vation is to uncover and use the already availableCompetendes ofcare providers to improve practices. Animpottant feature of this approach is that it demandsConsideration of the fact that different parties in mater・nity care-that is, midwives, obstetricians,8eneral prac・Utioners, nurses, researchers, pregnant、vomen, and theirPartners-have their o、vn versions of "best" care (De

Vries, Nieuwenhuijze,&van crjmpen,20ID.The study presented here was done in preparation

for our ethnograpbic study of the nature of good c01・Iaboration and communication in maternity care as car-ried out in midwi企ry pradices and obstetric 、vards、 TOguide our、vork in the 丘eld, we did a "scoping study" thataⅡOwed us to identify appropriate "sensiti乞ing concepts"(BO、ven,2006). This technique provides us with the pos、Sibility to map the understandin8S of今ood c011aborationand communication already available in the literature(Anderson, AⅡen, peckham,& Goodwin,2008; Arkey& 0'Ma11ey,2005; Armstrong, HaⅡ, Doyle,& waters,2011; Davis, Drey,& Gould,2009). The advantage of aScoping studyover a systematic review isthatit aⅡOws forthe indusion ofdifferentstudy designs and abroad set ofParameters.1n addition, a scoping study is iterative arldas such aⅡ0、vs for adjustments and repeating steps. LikeSystematic revie刃VS, scopin8 Studies require method010gi・Cal rigor. Given our focus on eX110vation, our scopingStudy breaks new ground, providing a positive startingPointforresearch forimproving and maintaining qualityOfcommunicauon and c0Ⅱaboration in maternity care.

What Makes for cood c0Ⅱaboration and communication in Maternity care? van He/mond et a/.211

Iiterature and a qualitative analysis t0 丘nd factors asso、dated with good communication and c0Ⅱaboration in

maternity care. To ensute the method010gical ri80r ofOur scoping study, we used the framework as sU号gestedby Arksey and o'MaⅡey (2005) and strudured ourresearch in 丘Ve stages:(a) identifying the researcb ques・tion;(b) identifying relevantstudies;(C) study seledion;(d) charting the data;(e) C0Ⅱaung, summarizjng, andreporung the results.

Identifying the Research Question

The purpose of our larger research projed is the iden・ti6Cation ofthe aspects ofgood c0Ⅱaboration and com、munication. This objective motivated us to identifyand map already available hlowledge and experienceas described in the literature. Therefore, our research

question was,"いlhat fadors are assodated with goodC0Ⅱaboration and communication as mentioned in lit、

erature about maternity care?"

Ideπti6,ingRelevant studies

To a110w for differences in understanding,、ve did notbe今in lvith fixed de負nitions of"C0Ⅱaboratiod' and "com、

municauonl' This prevented exdusion ofstudies usingde負njtions that would not match ours. For the sa111e

reasons, we did not de6ne at the outset "posiuve" andadesired" aspects of communication and c0Ⅱaboration.Because ourswas an exploratoryS加dy, werestricted ourSearch to articles in publYled and ~~1'eb ofsdence (叉/×10S)Up unul Apri1 2014 (Table D. Despite this limitation,Our 丘rst search found more than halfa miⅡion artides

On c0Ⅱaboration and communication. To eliminate the

Iarge number ofirrelevant articles, we further restricted

Our search to maternity care and added Major MESHteTms (pubNled) and Topics (凡I×10S) related to mater、nity care、 search l focused on interprofessional com、munication and c0Ⅱaboration among maternity careProfessionals. seaTch 2 aimed at communication and

C0Ⅱaboration between maternity care professionals andParents.~×1e performed two separate searches to iden、tify possible djfferences in fadors assodated lvith goodCommunication and c0Ⅱabora廿on among professionalsand bet、veen professionals and parents. HO、vever, inboth searches, the Major Mesh Terms and Topics didnotl'esttid indusion ofone ofthe groups, professionals,and parents. Therefore, a11induded studies in our scop、in8 review had the potentialto indude both maternityCare professionals and parents.

MflHOD

In our scoping study, we used systematic strategiesfor searching, selection, and data extraction 丘om the

212 Vvhat Makes for cood coNaboration and communicati。n in

TAB兀E 1 1ndudedstudies Fromsearchesland2inPubMedandwebofsdence(訟= 40)

Search l:1nterdisciplinary communication 引ld c011aborationam01唱 maternity care professionals

Communication oR C011aborationo

Cynec010g oR midwif oR obstetが

Interdisciplinary oR interprofessionalOR crevv resource managementOR teamworkb

1ηCluded 7

Search 2: communlcation and c011aborauon betⅥ,eenmaternily care profe5Sionals and P討enls

PUI〕Med

216,517

2905

17フ

8

Communicatlon oR C011aborationo

Pre8nancy oR mothers oR parentsoCynec01080R midwif oR obstetrioIncluded

Maternity caret van He/mond et a/

PubMed

216.517

884

1 12

゜MajoT MesH termsin pubMed,topicsin、VOS

A]16eld termsin pubMed,topics in wos.1nduded studies afterremoved duplicates and exduded studies not 員11611in名 Selection criteria.

VVOS

370.637

1.721

101

ChartihgtheD4t4To organize our material, we summarized the data from

the primary studies being reviewed by chatting the rel_evant information into different tables. The 負rst authorqvH) extracted the data, whereas the second and thirdauthorS σK,11VI) performed duplicate extractions fromrandom samples.

TableS 2 and 3 display the characteristics of thearticles found in search l and search 2:6rst author

and year ofpublication, objective ofthe study country,Population, study design, method, and involvement of

Partidpants.1n addition, we created a file to displathe fadors assodated with good communication andC0Ⅱaboration as reported in the induded studies (seeAppendix).

Study seledi0π

To further refine and focus our search,、ve develo edindusion and exdusion criteria.い7e dedded to indude

Peer、reviewed quantitative and qualitative, original,Primal'y research in maternity care, and applied noIimits for language or type of research population (i.e.,Socloeconomic aspects, ethnicity, and gender), TOProvide reasonably consistent and comparable healthCare strudutes and cultural contexts, we indudedStudies from 凡IV'estern high-resource societies in NorthAmerica, oceania, and North・凡I×1estern Europe andexduded studies from lo、V-resource countries andCountries with a non・W'estern culture.刃~re induded

Publications on everyday maternity care populationsthat might vary from healthy to high、risk pregnancand childbirth and exduded publications which ar_Ucularly focused on sped丘C patient populations inmaternity care dealing with defined issues such as rare

(medicaD conditions. we also exduded secondaryresearch and publications on communication and c。1_Iaboration in health care education. A丑er removal 。fduplicate pubHcations, the 6rst three authors qvH,1K,j入1) independendy assessed the publications derived丘om the databases for eligibility (title, keywords,abstract, and fUⅡ text) exduding aⅡ Publications thatdid not meet our selection cTiteria.1n subsequentrounds, they discussed their 丘ndings until consensusWas reached on the 負nalindusion of 40 studies f。rreview (search l:11 = 14; search 2:π= 26).

7

VVOS

370,637

12,886

530

18

TableS 2 and 3 Show the characteristics ofthe indudedStudies for interprofessional communication and

C0114tiπg, SU抗n1αriziれg,411d Reporti11g the ResultsIn this last step of the scoping study, we extracted andanalyzed the data and reported the results using guide_Iines for qualitauve inductive content analysis (EI0 &Kyng社S,2008). This type of analysis aims ato a杜ain aCondensed and broad description of the phenomenonand the outcome is categories describing the phenom_enod'(EI0 & Kyn号as,2008, P I08). The firststep was toextrad from the aResults" seC廿ons of the publicationsaⅡ丘agments in which fadors assodated with goodCommunication and c0Ⅱaboration were mentioned.The Appendix presents aⅡ the fadors menuoned in

these fra8ments. Next, in an iterative process of openCoding, creating cate80ries, and abstraction, the secondand third authors qK, JM)indeP印dendy grouped thefactors Into maln cate80ries and categories (Table 4).Content validation requires the use of dialogue amonCoresearchers to agree upon the way in lvhich the dataare labeled 伍10 & Kyngas,2008). Therefore, in sub_Sequent rounds, the 負rst three authors qvH,1K, jM)Compared and discussed the extracted and categorizeddata unul Consensus was reached aboutthe aspects and(main) categories under which they should be 61ed.Last, aⅡ authors revisited and discussed these main cat_

egories, which can be seen as our sensitizing Conceptsfor our future 6eld刃Vork (BO、ven,2006).

REsukTS

Characteristics of the studies

What Makesfor cood c011aboration and communicati。n

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216 Vvhat Makes for cood conaborati。n

IABIE4 Maincate曹oriesandcate号oriesAssodatedw'i血"G d"CMaternitycareprofessionalsandBeNeenMaternitycarept。fessi。nals dP 号AMONC MATERNITY CAREPROFESSIONA[S

BET、N圧モN MAτεRNnY CARE PROFESSIONA【S AND PARENTS

Expliclt

Expertise

Knowled8eable

Cood atjob, competent, competence in5ti11S confidenceLooking for nonverbal cue5

Exped, support, a1耐 explain vvomen's sound5 andneeded, vigHance

Experti5e and experienceno unnecessary lnterventions Advantage of di仟erent professional

Knowled呂舶bleClinical, re50urces, understandin8 nature of emergency

Awareness

OfC11nical 51tuatlon, team and patient, recognitlon ofeme唱ency sltuatlon

Reliable

Able, competent, UP 【o date,

and communication in

Ti11'1e

、Ni"ingness to invest timeArchitecture

Shared spaces, meeting room5

Maternity carel van He/mond et a/

0唱anization of work

Formal plans and protocols, effedive meetings, distributi。nOf roles and 『esponsibimies, financial, information fl。Wand channels (1CT, regular meetings), multidisciplinary【eamvvork, e(1Ucation and training, safe stafm)atient raⅡ。

PartnershipShal'ed knowledge and decjsion malくin8 Shared dedsion making<Sks my oplnlon,1rusls my jud8ment Choice, time, oppor【unity to discuss,

In 0Ⅵ゛n care

Different but equalDjstr山Ution of、vorkload, involvemenl,1)0、ver, an(1 respect;

On level of expel'tiseRespectful

RespeC150thel'S' commitment, vvhat 、ve do,Openne5S, empo、vermentProadive

Anticipation needs, regular familiarizatjon, ex!)1aining r。1es,abiljties, and resl)01鴨ibⅡ ities in adV引】ce (of emergencies)

Reflexlve

Ability to refled on pradice, acknowledgement of vulnerab"itImPⅡCitA1Ⅱtude

A壮enⅡVeness

Woman、centered, sensitive and responsive to needs,ackno、vledge parlner, a仟irmative, adive ⅡStening,(n。n)explicit lnfo

Empathic

Supportive, empo、ver, patient, understandin8

Nonjudgmental

Respect, open, moral sensitivlty

Consent, parⅡClpation

Context

Time

For info sharing, di5alsslon5, for l)artner, to restAtmosphere

Comfortable, privacy, natural and normal process, pradicalSupport, f0110W・un Safe environment,0、vn envlronmenl

Communication chalmels

Mobile techn0108ies

Calm demeanor

Brin8 Peace and quiet

PaⅡent focus

Woman・centered, caring, kind, courteous

Couegia1卿

Resl)ed, accessjble, commitment, palient, openneS5 (t。。therOpinions, about o~vn limit5), wiⅡingness to cooperate

Task orienlation

Antlcipation, re5Ponsive, S1ねring (info and exl)erⅡSe),Cornm11ment to safety culture

Asserliveness

Flrm, risk、1aking, confidenl, indel)endenl, initiative

Competences

help Yvhen

Reciproci1γ

Rapporl, a仟irmaⅡon and validation of roles and responsibiljties,mutual appreciati0η, connection over surve川ance

Balanced exC1伯ngeSense of contr01,

TAB王E4 Mahlcate名oriesandcategoriesAssodatedwith"Good"comm如icati dC Ⅱ bMaternitycareprofessionals andBe加eenMaternitycareprofessionals a11dpatentsin searchesland2 イ t.)AMONC MATfRNITY CARE PROFESSIONAιS Bモτ、NモモN MATfRNnY CAR壬 PROFfssloNA[SAND PARENTS

Trust

Trustworthy

Authentic,1i5ten and take seriouS1γ, being open 引ld honest,relevant information

Individua11Zed care

Beln8 met as an individual, physicaltouch, ma5Sage, closenessContinuity of care

Personal relationships, consistency throughout chainAvailab川ty

Someone to turn to

Communication styleInfo・sharing

Rel〕orting, advising, consistent, straightfor、、,ard, clear,adapted to level of underSねnding, persona11Zed (notjust心k)information

Form

Calm, use of sma" talk, dlrective, humor, immediatefeedback, clear

Normalizing the situation

Explalning and asking questions, cha11engin8 negativePerceptions,"birth as natural" perspectlve

Info『mative

Explanatory; vvhat is and is expected, information aboutPotential complications

Vocabulary

Re5Pectful,1めndinicalterms (baby), refmme of language("possibility" instead of "ri5k")

Trust

Others professional ability and expertise, confidence

What Makesfor cood c0Ⅱaboration and communication

Open and honest

Open to discuS510ns, open to different vieⅥ、points

Structured and diredlve

Clear and assertive,介rm, focused,10目jcal

Form

Calm, ab所ty to lislen, respectful, with dignity, humor

Empathic

Kind, patient・centered

in Maternity care? van He/mond et a/.217

Note.1CT = information and communication techn010宮y

C0Ⅱaboration among maternity ProfessionalsCare

(search l;"=.14) and for communication and c0Ⅱabo、

ration between maternitycare pT0企Ssionals and parents(search 2;π= 26).

There are several noteNvorthy cbaTacteristics ofthese studies. First, a11 Studies, except one from search2 (MCKay & Roberts,199の, were published relativelyrecentlyin theyearS 1995-2014. second,thestudies、verePerformed in many differentregions within the 叉I×1esternWorld: search l:凡IV'estern Europe (π= 6), united states(π= 6), Australia (π= 2); search 2:气I×1estern Europe(π=フ), Northern Europe (π= 5), united states (π=フ),Canada (π= 2), otAustralia (π= 5; Table 2 and Table 3;

See country). Third, althoU3h aⅡ Studies had the poten、tialto indude maternity care professionals and parents,moststudies induded only one ofthese 号roups. searchI resulted in lo studies lvith populations consisting ofmaternity care professionals and 4 Studies populauonsConsistin留 ofboth professionals andparents (Table 2, seeType partidpants).1n search 2,90f26 Studies induded

both professionals and parentsin their studypopulation(Table 3, see Type pal'tidpants). Fourth, the designs ofthe studies 、vere predominantly qualita廿Ve: search l:qualitative (π= 10), quantitative (π= 2), unsped丘ed(π= 2); search 2: qualitative (π= 18), quantitative(π=& Table 2 and Table 3: see DeS培n). Fi丑h, only 15Out of 40 publications referred to active involvement

in the research projects by partidpants in the form offeedback, evaluation, member check,input, or researchgroup membership (see Table 2 and 3, see lnvolvementPartidpants):10 studies for search l and 5 Studies for

Search 2. These publications are almost equa11y dividedbetween studies that do and do notindude parents intheir studypopulation (see TableS 2 and 3,see Type par、tidpants).1ast, most strikin号 is that search 2, devotedto communication and c011aboration between ptofes、Sionals and parents, indudes only 9 Studies out of 26Ivhere 60th parents and professionals were consulted asPart ofthe study (see Table 3, see Type pattidpants). Aninteresting example ofthis phenomenon is a publication

218 Vvhat Makesfor cood c0Ⅱaboration and communicati。n

(Hunter,2006)that discussesthe theory ofredprodtyinrelationships between midwives and mothers whereasinduding 011h 1πidH/ives in the study populauon.

"ndings of Fadors Associated 、N託h coodCommunication and c011aboration

None oftheS加diesin search land2Wereexplidd aim_ing for identifying factors assodated with80od commu_nication and c0Ⅱaborauon in practice. Their focus 、vasmainly on (solvin8) problems and weahlesses in com_

munication and c0Ⅱaboration.刃、7e found only six arti_des (Beake, Acosta, cooke,& Mccourt,2013; Borders,Wendland, Haozous, Leeman,& Rogers,2013; Browne,0'Brien, Taylor, Bowman,& Davis,2014; Nielsen, et al.,2012; pecd, et al.,2012; van Kelst, spitz, Sermeus,&

Thomson 2013) with a predominant focus On positive

aspects・1nterestingly, some ofthe positive aspects foundWere even described in a negative 、vay (see Appendix),For example, one study described an asped of go。dCommunication as, adoesdt yeⅡ or scream"(simps。n,Iames,&K110×,2006). AISO, mostartides(π= 3D madeno dear disunction between communication and c。1_Iaborauon. Thetefore, it was not possible to cate orizethe positive aspects into aspects of communicauon 。nthe one side and c0Ⅱaboration on the other. None 。ftheauthors expliddy de6ned "good" communication and/Or c0Ⅱaboration. only some artides provided (paTtiaDde6nitions of communication (π= 4; Borders, et al.,2013; Burns, Fenwick, sheehan,& schmied,2013; Risa,上id6n,& Friberg,2011; sinivaara, suominen, Routasal。,&Hupli,2004), C0Ⅱabora廿on (π= 3; Munro, Komelsen,& Grzybowski,2013; Nielsen, et al.,2012; wheaue ,KeⅡey, peacock,& Delgado,2008), or both (π= 2;Sch61merich, et al.,2014; simpson, et al.,2006).

Our examination of the 40 studies revealed sixOverlapping and interconnected main cate今ories for thefadors assodated with good communicauon a11d c。1、Iaboration: Expertise, partnership, context, A廿itude,Trust, and communication style (Table 4).

These Sensiuzing concepts for our fieldwork made

Us aware of the possibility to distinguish two groups 。fPrerequisites for 30od communication and c0Ⅱab。ra_tion: implicit prerequisites and explicit ones. As such,they of企red us new ways ofinterpretin8 and organizinOur data・ The main categories Expertise, partnershi,and contextcanbe grouped underthe heading"ex lidt"Prerequisites ofgood communication and c0Ⅱaborati。n.aEXPHdt"becausetheyare doselylinkedto "doin thin st08ether" and,therefore,0丑enpartofawrittenregulation

m Maternity care? van He/mond et a/

Or topics being discussed. Examples are the distributionOfworNoadamongprofessionals ortherequirementthatPauents pTovide informed consent. The main cate80riesA杜itude, Trust, and communication style, can be gath_ered under the heading "implidt" prerequisites of 。。dCommunication and c0Ⅱaboration, as they assulne an

implicit form of "being togethel" Attitude, Trust, and

Communication style comprise moTe implicit personalCharacteristics or preferences that can be felt by group(S)Or individual(S), for example, resped among c0Ⅱeaguesand between pr0企Ssionals and parents.

Closer examination ofthe categories and their con_tent revealed thatthere are dif企rences between the 6nd_ings from the two searches (Table 4). The studies fbundin search l on intel'professionalcommunication and c。1_

Iaboration had a morepracticalstance, meaningthatthefocusedmoreontheaC加al"doin8"(explicitprerequisites)and placed less emphasis on 、vays of " bein3"("implidt"Prerequisites) comparedto the studies from search 2. F。rexalnple,the main categoryAttit口de in search linduded

the more pradical categories patient focus, C0ⅡegialityTask orientation, and Assertiveness, as ways of dointhe job t08ether.1n search 2, the same main cate 。rAttitude indudedthe categories A壮entiveness, Em athic,Nonjud8mental, and calm demeanor. These cate ories

Can be interpreted as ways of6eiπgtogether emotionaⅡy(notphysicaⅡy). This difference can also be noticed 、vhenWe look atthe cate80ry or今anization ofwork, which is adear exalnple of doiπg the job together; this categor isPresentin search l and absent in search 2. considerinthese 6ndin号S, one should exped that search 1 τeS田tedin a less elaborate list of categories regarding A廿i加de,Trust, and communication style. This expedation wasCon負tmed (Table 4). AI〕other exa111Ple is the main cat_egoty context containing the categories Architedure(search D and Atmosphere (search 2).'ン、.rchiteC加re;,mentioned in two articles (Murray、Davis, MarshaⅡ,&Gordon,2011; simpson & Lyndon,2009), refers to,命rexample,the shared space (such as cof企eroom), whereas'{A、tmosphere;' menuoned in six aTticles (Borders, et al.,2013; Burns, et al.,2013; Fraser,1999; Munro, et al.,2013;Persson, Fridlund, Kvist,& Dykes,2011; sch61merich,et al.,2014)血Cuses on things such as the effed of thebuilt envlronment on someone's mood, emotions, andOveraⅡ birth orNvork experience.

DISCUSSION

This scopin今 Study provides a thoroU8h overview ofthe factors assodated with good communication and

C0Ⅱaborauon in maternity care. The focus of the 40induded studies is predominandy on problems andSolutions; and as these studies hardly de丘ne 、vhat isgood communication and c0Ⅱaboration, they seemto start from the assumption of a common or sharedUnderstanding about these concepts.1nterestingly, theSix studies focusing on positive aspects were aⅡ Pub、Iished in 2012 and 2014,indicatin8 that attention forthePositive aspects ofcommunication and c0Ⅱaboration isa recent development.

凡Ve identi丘ed fadors assodated with good com_munication and c0Ⅱaboration among maternity careProfessionals (search D and between maternity careProfessionals and parents (search 2). on an aggregatedIevel, both searches resulted in the same main catego_ries which can be divided into "explicit" prerequisitesOf 80od communication and c0Ⅱaboration: Expertise,Partnership, context, and implicit prel'equisites: Atti_tude, Trust, and communication style. Analysis on amore detailed level(categories) showed differences inPerspectives on whatfadors exacuy areimportant. ThisSuggests that in maternity care, dif企rent approachesmight be needed for improvement of communica_tion and c0Ⅱaborauon among profヒSsionals comparedto improvement of communicauon and c0Ⅱabora、

tion betlveen professionals and parents. The categoriesrevealed that research on communication and c0Ⅱabo_

rauon bet、veen maternity care professionals results pre、dominantly in aexplidt"、vork・related aspects, whereasimplicit interpersonal aspects receive less a廿ention.These findinss indicate a limited focus of research oninterprofessional communication and c011aborauon.We would like to stress that these studies should alsobe attentive to the "implidf' prerequisites of goodCommunicauon and c011aboration. Likewise, C0Ⅱabora_

tion between maternity care professionals and parentsShould consider "explidt" prerequisites, induding, forexample,the way a11Stakeholders are inauenced by theOr8ani2ation ofwork.

<40st articles ignored parents as partners in com、munication and c0Ⅱaboration by not induding themin the study population. Their underrepresentauonand limited involvement in the form of feedback,evaluation, member checMng, input, or membershipin the research projects indicate the need for moreresearch in maternity care that involves aⅡ Stakehold_ers, rather than just gathering information about them丘om others. Also noteworthyisthe increasing a廿entiongiven to the tangible environment and its inauence onCommunication and c0Ⅱaboration (Architecture and

Atmosphere). Environment plays an important role in

What Makes for cood c011aboration and communication

effective communication and c0Ⅱaboration pradices,espedaⅡy in a time where more and more hospitalsare being (pardy) refurnished and rebuilt to meet therequirements 0ε for example, the uNICEF'S (tevised)Baby・Friendly Hospita11nitiative (2009).1t is note凡Vor_thy 血at although only eight publications addressedArchitecture and Atmosphere, six were published in2011-2014, implying that these aspects have come tomaternity care researchers' attention more recently

Three reviews (Avery et al.,2012; Downe et al.,2010; King et al.,2012) addressed c0Ⅱaboration In

maternity care and seemed to consider communication

and c0Ⅱaboration as being overlapping andmultⅡayeredConcepts. The narrative overvie、v ofDO、vne et al.(2010)descTibed tools desi8ned to measure c0Ⅱaborauon andteamwork in the genetalhealth care context. Theyiden_ti丘ed contextual components (e.g., clear boundaries,Shared responsibilities, cohesion, interdependence,Openness, trust, and conaict resolution) and fadorsOf jnauence (e.g., supportive organizational strudureand resources, history of c0Ⅱaborauon, and positivea杜itude). Avery et al.(2012) conducted a qualitativeanalysis of 12 0ut of 60 artides that 、vere submitteda丘er a competitive ca11 for c0Ⅱaborative articles fromthe American c0Ⅱege of obstetridans and Gynec010_gists and the American c0Ⅱege of Nurse、1Ylidwives.The authors distil five main themes for successful andSustainable models of midwife and obstetrician c0Ⅱab_Orative pracuce: impetus for c011aboratjon, foundauonsOf c011aborative Care, commitment to partnership, careinte8ration, and interprofessional educauon.1n their

review ofthe history of c0ⅡaboTation in maternity carein the united states, King et al.(2012) condude that inthe future, interdisdplinary teams 、viⅡ be required toProvide seamless accesS 血r patients whose health caremay chan号e over the course of childbearing. Accord_in8 to them, the success of interdisdplinary teams isdependent on professional competence, interprofes_Sionalrespect, and a common orientauon to the patient.Our scoping study supports the perspective of com_municauon and c0Ⅱaboration as overlapping and mulu_Iayered concepts. Moreover,itidenti丘es various aspects、vithin the different intert、vined categories of 。。dCommunicauon and c0Ⅱaboration found in research inmaternity care.

气Ue usedtheframework ofa scopingstudyas partOfpreparation for an ethnographic study in maternityCare on c0Ⅱaboration and communication. The advan_

ta8e of a scoping study is its open character, aⅡOwingin our case, the indusion of studies from a range of~vestern high・resource societies with various stud

in Maternity care? van He/mond et a/.219

220 vvhat Make5 for cood c011aboration and communicati。n

desi3ns, and varied levels of analysis. This open_ness provided us the sensitizing concepts needed asguidance fot our 6eldwork. F0ⅡOwing the scopin8Study prindples, we did not appraise the method_010gical quality of the studies and, therefore, cannotexdude selection and information bias. A disadvan_ta8e of the openness of a scoping study is a lack ofdearly de丘ned categories as found in the literature.凡Vhen de丘nin号 main cate80ries, we sometimes raninto problems because of overlap between them;for example, A杜itude is strongly related to partner_Ship, Trust, and communication style. Therefore, theauthors engaged in an extensive dial08Ue to reachConsensus and achlowledged thattbe main categoriesare interconnected. The importance and intercon_nectedness of communication and c0Ⅱaboration inmaternity care can be i11Ustrated by a study, whichdid not primarily focus on communication and c01_Iaborauon (HaⅡ, Tomkinson,& Klein,2012). Thisqualitative study explores caTe providers' and presnantIvomen's approaches to the complicated issues of riskin pregnancy and birth. The authorS 6nd how risk and

integrity can be defined differently and how strategiesto minimize risk and maxlmlze inte8rity were inau、

enced by relationships (e.8., betlveen professionalsand women), evidence, and local health care cultures.These inauencing factors can be categorized in our(explidt) main categories partnership, Expertise, andContext, which are strongly conneded.

In general,it remains undear if血e fadors in the40 selected publications are mentioned as descri tiveOr prescTiptive, and several fadors might be perceivedas "basic, such as listening to sounds and spendinmore time with women. HO、vever, it is important t。Pay a廿ention to the mundane,implicit routines ofcare,the 0丘en overlooked or for80tten but necessary as ectsOf care 、V01'k tbat promote quality qedema et al.,2013;Mesman,200& Mesman,20ID. so in this scopinreview 、ve are not aiming for theoretical articulauons,but for the Practicalidenti負Cation of aspects of goodCommunication and c0Ⅱaboration that can be exploredin interviews and observations in our 6eld、vork. ThisIviⅡ aⅡOw us to develop theory about the interacuonsbetween these aspects in everyday maternity care basedOn our ethnographic 、vork. Therefore, we consider the

丘ndings from our scoping study in their own rightand, moreover, as point ofdeparture for fieldwork thatWiⅡ aⅡOw us to further explore the spectrum offadorsOccurring in practice.

This study raises awareness aboutthe importanceOf learning 丘om stren名ths in maternity care practice,

in Maternity care? van He/mond et a/

notjust weah)esses to strive for be杜er communicauonand c0Ⅱaboration in maternity care.丘 makes dearthatthe study ofcommunication and c0Ⅱaborauon inmaternity care sU丘erS 丘om (a) a lack of attention f。r

the positive (explicit and implidt) aspects involved inCommunication and c011aboration,(b) underrepresen_tauon of parents in study populations, and (C) insuf_丘Cient involvement of aⅡ Stakeholders in the researchProjects.

Studies of c0Ⅱaboration in other health Care

domains have shown that good communication andC0Ⅱaboration have a broad scope of characterisucsand deserve the a廿ention of researchers (Gteenhalgh,200& Greenhalgh et al.,200& Mesman,2009; parker,Vermeulen,&penders,2010; swinglehurst, Greenhalgh,MyaⅡ,&RusseⅡ,201の. Theseinsi留hts havenotyetbeenbroU8ht to the neld of maternity care as evidenced bythe fact that most artides in our scoping study focusedSolely on (solvin8) problems in communication andC0Ⅱaboration. Good communication and c0Ⅱaborationinvolves more than the absence ofundesirable features;the realization and pl'eservation of effective communi_Cation and c0Ⅱaboration also requiresidentification andUnderstanding ofthe elements ofpositive interactionsinthe maternity care arena.

To that end, our study identi負esthe aexplidf' pre_requisitesofgoodc0Ⅱaboration^Expertise,partnership,and context-as weⅡ as the aimplidt" prerequisitesA杜itude, Trust, and communication style. For mater_nity care pracuce and l'esearch, our study ties in withrecent a廿ention for positive jngredients of commu_nication and c011aboration.1t dra凡Vs a廿ention to the

importance of aimplicit" interpersonal aspects of com_munication and c0Ⅱaboration among maternity careProfessionals.1,ikewise, it underlines the importance of'explidt" work・related aspects in communication andC0Ⅱaboration between professionals and parents. Futureethnographic in・depth research on positive aspects,involving aⅡ Stakeholders, wiⅡ Provide 6.1rther insightinto the sped丘C nature and dynamics of the intercon_nected prerequisites of good communica廿on and c01_Iabora廿on in maternity care.

REFfRfNCES

Alkazaleh, E, Thomas, E, Grebenyuk,1., Glaude,上., savage,D', johannesen, j., Windrim, R.(2004). what

Women want: womens preferences ofcaregiver behav_ior when prenatalsonography 丘ndings are abnormalUltr4SOUπd iπ obstetガCS 6 Gyπec010gy,23(D,56_62.

Anderson, S., AⅡen, R, peckh血, S.,& Goodwin, N.(2008).ASMn8 the right questions: scoping studiesin the com、missionin30fresearch on the or8anisation and deliveryOf health services. Health Rese4rch policy α11d syste111S/BioMed ceれtrα1,6(フ).

Arksey, H.,& 0'MaⅡey, L.(2005). scopin名 Studies: Towardsa method010gica1 丘ame、vork.111ter11αh011α1 /'our11αl qfSodalRese4rch Method010gy,8(1),19-32.

Armstrong, R., Ha11, B.1., Doyle,}.,& waters, E.(20ID.Cochrane update.'scoping the scope' of a cochranereview./ourπ41 qf'puhliι Health,33(1),147-150.

AveTy, M. D., Montgomery,0.,& Brandl・salutz, E.(2012).Essential components of successful c011aborauve

maternity care models: The ACOG、ACNM projed.Ohstetrics n11d Gyπec0108y cli11ics qf' N0光h A111eriC4,39(3),423-434.

Bahl, R., Murphy, D, j.,& strachan, B.(201の. Non、technical

SMⅡS for obstetridans conducting forceps and vacuumdeliveries: Qualitative analysis by intervielvs and Ⅵdeorecordings. Europe4H/our11αlqf'0みStetricS 6 Gynec010gy411d Reprodudive Bi0108y,150(2),147-151.

Beake, S., Acosta, L., cooke, P.,& Mccourt, C.(2013). case、10ad midwifery in a multi・e血nic community: TheWomelfs experiences. MidWびery,29(8),996-1002.

BeTridge, E. J., MacMntosh, N. j.,& Freeth, D. S.(201のSupporting patient safety: Examining communica、tion within delivety suite teams through contrastingapproaches to research observation.ハ1id1νif'ery,26(5),512-519.

Borders, N.,、vendland, C., Haozous, E., Leeman,エ.,&

R03ers, R.(2013). Midwives' verbalsupport ofnUⅡipa、rous women in second・stage labor./our11αlqf'ohstetガC,Gyπec010sic,6 Ne0παtalNursiπg,42(3),311-320

BO、ven, G. A.(2006). Grounded theory and sensitizing con、Cepts.111terπ4hoH41/'our11αIQf'Qualitative 入lethods,5(3),12-23

What Makes for cood c011aboration and communication

assodated with early breastfeeding support. Mata71α16 Child Nutガti0π,9(D,57ーフ3.

Bylund, C. L.(2005). Mothers'involvementindecisionmakingduring the birthing process: A quantitative analysis ofWomens online birth stories. Health c01π1?1Uπiι4ti011,18(D,23-39.

Davis, K., Drey, N.,& Gould, D.(2009). what are Scoplng

Studies? A revie、v ofthe nursing literature.111terH4ti01141/our1141 qf'NursiH8' studies,46aの,1386-1400.

de veer, A.j.,& Meijer, W J. a996). obstetric care. compeu、tion o, CO-ope松tion. Midwifのy,12(D,4-10.

Devries, R. G., Nieuwenhuijze, M.,&van crimpen, R'(20ID.The necessity and chaⅡenge ofinternationalmidwiferyScience.1hterπ4ti01141/ourπ41 qf'childhirth,1(1),61-64.

Downe, S., Hnlayson, K.,& Fleming, A.(201の. creating aC0Ⅱaborative culture in maternity care. jourπ41 qf'Mid-Wifのy 6 W0抗'"k H.4hh,55(3),250-254'

EI0, S.,& Kyng盆S, H.(2008). The qualitative Φntent analysisProcess.10ur1141 qf'AdναπCed NurS加& 62(1),107-H5.

Eri, T. S., Blystad, A., Gjengedal, E.,& Blaaka, G.(201の.Negotiating credibiHty: First・time mothers' experiencesOf contact with the labour lvard before hospitalisation.Midwifery,26(6), E25-E30.

Eri, T. S., Blystad, A., Gjengedal, E.,& Blaaka, G.(2011).'stayhome for as long as possible': Midwives' priorities andStrate号les in communicating with 負rst-time mothets in肌dy 1北OU,. MidWず",y,27(6), E286-E292

Forti, A., stapleton, H.,& Kildea, S.(2013). Mobile teC11n010_

8ies and communication strategies in an urban Mid、Wifery Group practice setting An exploratory studyW01πeπαπd Birth,26(4),235-239.

Fraser, D. M. a999). womelfs perceptions ofmidwifery careA longitudinalstudyto shape currjculum development.Birth,26(2),99-107'

GoodaⅡ, K. E., Mcvittie, C.,& Magi11, M.(2009). BirthChoice f0110win号 Primary caesarean section: Mothers'Perceptions ofthe inauence ofhealth professionals ondedsion making.10ur11nl Qf' Reprodudive aπd 111f'αれtPsych0108y,27(D,4-14.

Greenhalgh, T.(2008). Role ofroutines in c0Ⅱaborauve work

in healthcare organisations. British MediC41 /'01ιrπα1,337, a2448.

Greenha18h,T.,stramer,K.,Bratan,T.,Byrne,E.,Mohammad,Y.,& Russe11, j.(2008).1ntroduction of shared electronic

records: Mdu・site case study usin8 di「6」sion ofinnova、tion theory Bガtish Medicaljour11α1,337, a1786.

HaⅡ, W. A., Tomkinson,1.,& Klein, M. C.(2012) canadianCare providers and pregnant womelfs approaches tomanaging birth: Minimizing risk while maximizingintegrity Qualitative He41th Research,22(5),575-586

in Mate『nity care? van He/mond et a/.221

Bristolve, K., siassakos, D., Hambly, H., Angouri, J., Ye11and,A., Drayc0廿, T.1.,& FO×, R.(2012). Teamwork for clini、

Cal emergendes:1nterprofessional focus group analysisand triangulation with simulation. QU4h't4tive He41thRese4rιh,22(1の, B83-B94.

Brown, S' 1., Davey, M. A.,& Bruinsma, E I.(2005). womelゞS

Views and experiences ofpostnatal hospitalcare 血 theVictorian survey of Recent MotherS 2000. MidWびery,21(2),109-126.

Brolvne,1.,0'Brien, M., Taylor,1., Bowman, R.,& Davis,D、(2014).'YOU've 30t it within you'. The politicalad of keeping a weⅡness focus in the antenataltime.M'dwif町y,30(4),420-426

Burns, E., Fenwick,J., sheehan, A.,& schmied, V (2013). Min、ing for liquid 名old: Midwifery lan8Uage and pradices

222 Vvhat Makes for cood c011aboration and communicati。n in

Hunter, B.(2006). The importance of recjprodty in relation、ShゆS between community・based midwives and moth_e郡. MidWザery,22(4),308-322.

Iedema, R., Mesman, j.,& carr011, K.(2013). visU41is_i11g health care pradiιe i1πProvel"e11t:111H0ναガ0π jro"1WithiH.上ondon, united Kin8dom: Raddiffe.

10int Commjssion on Accreditation of Healthcare or8aniza_tions・(2004). prevenunginfantdeath and injuryduringdelivery./oiπt c0111抗issi011 Perspech、ves,24(9),14_15.

jonkers, M., Richters, A., zwart,1., ory, F.,&van Roosmalen,J.(20ID・ severe maternal morbidity among immigrantWomen in the Netherlands: patients' perspectives.Reprodudive He41th M4tters,19(37),144-153

Kennedy, H. P.,& L沖don, A.(2008). Tensions and team_Work in nursing and midwjfery relationships.ノ'ourπalげ ohstetガC Gy加C0108iC 4"d Neo"ω"1 N"おm宮,37(4),426-435.

King, T・ L.,1.aros, R. K., Jt.,& parer, j. T.(2012).1nter_Professional c011aborative pradice in obstetrics andmidwjfery ohstetπ、CS 411d GyHec010gy ch'πics qf'N0光hA111erica,39(3),411-422.

Lerman, S. E, shahar, G., czarkowski, K. A., Kurshan, N.,Magriples, U., Mayes,1'. C.,... Epperson, C. N.(2007).Predictors of satisfacuon lvith obstetric care in hi h_

risk pregnancy: The importance of patient、providerrelationship lour11αl qf' cli11iC41 Psych010gy iπ Mediια1Settiπ宮S,14(4),330-334.

上yndon, A., zlatnik, M. G., Maxneld, D. G., Lewis, A.,MCMiⅡan, C.,& Kennedy, H. P.(2014). contrjbuti0那Of clinical disconnections and unresolved conaict t。failures In lntrapartum safety. jour1141 qf' 0みStetric,Gyπec0108ic,α11d Ne0παtalNursi"g,43(1),2-12.

Mahera,j. M.,& souter, K. T.(2002). Midwiferywork and themakin80fnarrative. Nursiπg1πqUかメ 9a),37-42.

Matthias, M. S.(2009). problematiC 加tegration in pregnancand childbirth: contrastin宮 appl'oaches to uncertaintyand desire in obstetric and midwifery care. He41th c01π_柳Uπicati0π,24(D,60-70

Ma杜hias, M. S.,& Babrow, A. S.(2007). problematic jnte ra_tion ofuncettainty and desire jn pregnancy Q1ιαlitativeHe41th Rese4rch,17(6),786-798.

MCKay, S・,& Roberts,1. a99の. obstetrics by ear. Maternaland caregiver perceptions of the meaning of maternalSounds during second stage labor.ノ'ourπαl qf' Nurse_MidWび町),,35(5),266-273.

Mesman,1・(2008). U"certaiπty iπ 111edicali"110ν4ガ0":三χPe_rl'eπCed pio"eers iπ ne0πat41 C4re. Hampshire, unitedKin8dom: palgrave MacMi11an.

Mesman,1・(2009). The geography ofpatie址 Safety. A topicalanalysis of sterility social scieπCe 畍 Medici訟e,69a2),1705-1712.

Mesman, j.(2011). A sodo・cultural perspective on patientSafety ln E. Rowley & 1. W'aring (Eds.), A SOCI'0、cultur41Persped1νe o" P4tieHt S区feり,(PP.72-92). BurⅡngton,VT: Ash8ate.

Munro, S・, Kornelsen, J.,& Gr2ybowski, S.(2013). ModelsOf maternity care in rural environments: Barriers andattributes of interprofessional c011aboration with mid_WiV郡. M'dwif'のy,29(6),646-652

Murray・Davis, B., MarshaⅡ, M.,& GOTdon, F'(20ID. whatdo midwivesthink aboutinterprofessionalworking andIe町ning? Midwif'.,y,27(3),376-381.

Njelsen, R E., Munroe, M', Foglia, L., piecek, R.1., Backnan,M. R, cypher, R.,& smith, D. C.(2012). C0ⅡaborativePradice model: Madigan army medical center.06Stet_ガ郡 4"d Gy"ec0108y cli"ics qf' Nのth A抗eガm,39(3),399-410.

Parker,1. N., vermeulen, N.,& penders, B.(201の. C011αみ。r4_h'011iπ the πe1レ'1ife scie11Ces. Burlington, VT: Ashgate

Pecci, C・ C., Mottl・santiago, J., culpepper, L., He丘ner, L.,MCMahan, T.,& Lee・parritz, A.(2012). The birth 。f aC0Ⅱaborative modelobstetricians, midwives, and familPhysicians.06Stetrics aHd Gy11ec010gy cliπics Qf'N0光hA加eriια,39(3),323-334.

Persson, E. K., Fridlund, B., Kvist, L.}.,& Dykes, A. K.(20ID.Mothers' sense of security in the 6rst postnatal week:Interview study /ourπαl qf' Adν411Ced Nursm8j 67(D,105-116.

Rei8e二 K. M.,& La11e, K. L.(2009). worMns togetheT. C。1_Iaboration between midwives and dodors in ublichospitals. A那tr41iα11 Health RevieTV,33(2),315_324.

Risa, C. E, Lid6n, E.,& FTiberg, F.(20ID. communicati。nPatterns in antenatal diabetes care: An explorauve anddescripuve study of midwife・1ed consultations.ノ'ourπα1ψC1加mlNUお加g,20a3-14),2053-2063.

Sch61merich, V L., posthumus, A. G., Ghorashi, H., wael ut,A・ 1・, Groenewe号en, P.,& Denktas, S.(2014).1mprov_ing interprofessionalcoordination in Dutch midwiferyand obstetrics: A qualitative study BMc preS11a11Cy α11dChildbirth,14,145.

Siassakos, D., Bristowe, K., Hambly, H., Angouri,1., CI・ofts, j.F・, winter, C.,... Draycott, T.}.(20ID. Team communi_

Cation with patient adotS 丘ndings from a multisite sim_Ulation study si抗U14ti011iπ He41thcare,6(3),143_149.

Simpson, K. R., james, D. C.,& Knox, G. E.(2006). Nurse_Physician communication during labor and birth:ImplicationS 血r patient safety./ourπ41 qf' 0みStetric,Gy11ec010宮ic,4πdNe0π4t41Nursiπg,35(4),547-556'

Simpson, K. R.,& Knox, G. E.(2003). Adverse perinatal out_Comes. Recognizin8, understandin8 &preventing com_mon acddents. Assod4h'0π qf'W01πeπIHealth, ohstehicαπd Ne0παt41N1ιrses,フ(3),224-235.

Maternity care? van He/mond et a/

Simpson, K. R.,& Lyndon, A.(2009). cljnical disagreementsduring labor and birth: How does rea11ife compare tobest pradice? The A111erl'ια1110urπαl qf'M4terπ41、childNursiπg,34(D,31-39.

SinNaara, M., suominen, T., Routasalo, R,& Hupli, M.(2004).How deliveryward sta丘exercise power over women inCommunication./our1141 qf' Adν4πCed N1ιrsiπ8,46(D,33-41

Swinglehurst, D., Greenha13h, T., Mya11, M.,& RusseⅡ, j.(201の. Ethnographic study of lcT・supported c0Ⅱab、Orative work rouunes in general practice. BMC HealthServices Rese4rch,10,348.

Van der velden,1.(2009)' Eeπ goed 加g加. veih:g'e Zのg r0πdZH'411宮erSιh4P eH ge600πe [A 80od start. safe carein pre8nancy and birth]. utrecht, The Netherlands:

Steering committee on pregnancy and Birth.

Van Kelst,上., spitz, B., sermeus, W,& Thomson, A. M.

(2013). A hermeneutic phenomen010gical study ofBelgian midwives' views on ideal and actual maternity仏re. Midwif',y,29(D, e9-017.

、vheatley, R. R., Ke11ey, M. A., peacock, N.,& Delgado, J(2008)' womeds narratives on quality in prenatalCare: A multicultural petspective. Qunlitah've HealthRese4rch,18aD,1586-1598.

World Hea1血 organization & united Nations childrelゞSFund.(2009). B4hyナ'rieπd1γ h0ψit"1i"itmh'地 Revis.d,Upd4ted 4πd exPα11ded jor iπtegated C4re. Geneva,Switzerland. Retrieved from www.who.invnutrition/

Publications/infanぜeeding/bfhi_trainingcourse/en

~viⅡi血S, K., Lago, L., Lainchbury, A.,& Eagar, K.(201の'Mothers' views ofcaseload midwifery and the value ofConunuity of care at an Australian Tegional hospital.Midwifery,26(6),615-621

Ack110wled8抗e11ts. wethankBartpenders, phD,(DepartmentOfHealth, Ethics & society, Maastricht university, Maastricht,The Netherlands) for his contributionst0 血e study

Funding was received 丘om zuyd university, Maas、tricht, The NetheTlands & CAPHN schoolfor public Health

and primary care, Maastricht universit% Maastricht, TheNetherlands. AⅡ authors have contributed signi丘Cantly to the

~vhat Makes for cood c011aboration and communication

Writingandtheconception orinterpretauon ofthemanuscriptand have consented to having their names mentioned on themanuscript. AⅡ authors have approved the 6nalversion ofthemanuscript and dedare thattheyhave no conaict ofinterest.

Correspondence re8ardin8 this artjcle should be directed toIsabel van Helmond MSC, zuyd university, Research cen廿efor Midwifery science, Faculty of Midwifery Education &Studies, P.0. BO× 1256,620I BG Maastricht, the NetherlandsE・mail:1、van.helmond@av、m.nl

in Maternity care? van He/mond et a/.223

Isabelvan Helmond, MSC, Research centre for MidwiferySdence, Faculty ofMidwifery Education & SNdies, zuydUniversity, Maastricht, the Netherlands.

Irene Korsuens, phD, Research centre for MidwiferyScience, Faculty ofMidwifery Education & studies, zuydUniversity, Maastticht, the Netherlands

Jessica Mesman, phD, Department ofTechn010sy andSociety studies, Maastricht university, Maastricht, theNetherlands.

Marianne Nieuwenhuijze, RM, MPH, phD, Research centre

for Midwifery sdence, Faculty ofMidwifery Education &Studies, zuyd university, Maastricbt, the Netherlands.

Klasien Horstman, phD, professor, Department ofHealthEthics sodety, Maastricht university, Maastricht, theNetherlands.

Hubertina scheepers, MD, phD, Department ofobstetrics,Maastricht university Medical centre, Maastricht, theNetherlands.

Marc spaanderman, MD, phD, professor, DepartmentOfobstetrics, Maastricht university Medical centre,Maastricht, the Netherlands.

Iudit Keulen, RM, MSC, Midwifery practice schoffelen,Maastricht, the Netherlands.

Raymond de vries, phD, professor, Reseatch centre for

Midwifery sdence, Faculty ofMidwifery Education &Studies, zuyd unNersity, Maastricht,the Netherlands/CAPHRlschoolfor publjc Hea1血如d ptimary care,Maastricht university, Maastricht, the Netherlands.

Eゆ10ringtheprofessiona11SsueofGroup BStreptococcusscreen血客註IpregnancyShar11a Bicheπo aπd S4die Gera8hり,

Throushoutpregnancy,womenare0丘eredvariousscreeningsanddia nostic r。ced ..G BStreptococcus (GBS) screening is cuTrendy a routine screening process in Australia, but n。t in theUnitedKingdom,whichis offeredtowomenat35-37Weeks estation.Th lt fGBSalter a 、vomans couTse ofcare for laboT and the postnatalperiod. This article is a review 。f 'd ,Policy,andclinicalpracticeandaimsto determinewhetherGBsscreenin isnecessar d h h hScreening has a positive or negative impact on women 釘ld their babies.KEYWORDS: group B shept0卯CCUS;screening; pregnancy; neonatal

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INTRODUCTION

Throughout pregnancy, women are offered a varietyOf screenings and diagnostic procedures. AssessmentsSuch as blood tests, detailed personal histories, ultra_Sounds, S、vabs, and urine samples can be used for eitherScreening or as a diagnostic test.入,1any assessments, forexample, a 、vomanls hemoglobin, hepatitis B, HIV} andblood group are routine at a booMng visit, along withthe 6rst trimester screening and anatomy ultrasound.Others are not rouune and are onlytested ifthe 、vomanis considered at risk, for example, an amniocentesis,Chorionic viⅡisampling, and some sexuaⅡy transmittedinfections (STD. Gtoup B streptococC1ιS (GBS) screeningis currendy a rouune screenin8 PI'ocess in Australia, butnotin tbe united Kin8dom, which is offered to womenat 35-37 WeekS 8estation. GBs culturestake 24-48 hoursto mature, and the results are considered current for

5 Weeks. The results of GBs screening alter a womadsCourse of care for labor and the postnatal period.1f aWoman is GBs positive,she wiⅡ have a cannula inserted

On admissionto thelabor ward andwiⅡhave aregime ofintravenous antibiotics;the baby、vi11be monitored post_nataⅡy,、vhich can lead to interventions indudin目 re8U_Iar monitoring ofobservations and possible blood tests.This artide assesses the current informauon available

regarding GBs screeningandh0凡Vappropriate andeffec_tive the screening method is.1n addition, the midwifer

Care required for GBs positive, negauve, and unhlownWomen is assessed. ultimately, this attide wi11 aim to

determinewhetherthete issuf負dentevidence atpresentto supportthe currentrecommendationsregarding GBSSCI'eening and whether the screening has a positive ornegauve impad on women and their babies.

224

BACKCROUND

GBs is a bacterjum which c010nizes the vaginal and/oranoredal aora. The presence ofthe bacteria is transientand is re8arded as normal aora and therefore does notgeneraⅡy cause in企Ction or causethe woman to becomeⅡ1.1t is important to note that GBs is not an sTI yet ls

Inore common in sexuaⅡy active 、vomen (Mclver et al.,2009). A woma11maybe unawarethatshehas contractedGBS, until screenin8 Con負rms it. The concern 、vith aPositive GBs dia8nosisin pregnancyisthatthe newbornWiⅡPassthroughthebirth canalwherethereis an op or_tunity forthe babyto become c010nized durin8birth.

Screening for GBs requires a low vaginaland analSwab to be taken. This is usuaⅡy done by the womanOnce educated h0元V to do so. The swabs are sent to the

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Iaboratoryfbrtesting and a resdtthen takeS 24-48110urs.The procedure only ねkes a fヒW minutes to complete;however,itis somewhatinvasive al)d uncomfortable for

the woman.1tis interestin3 that Australia, united states,and some of Europe al'e the only coul)tries whicb rou、tinely screen for GBS; countries such asthe united Kin号、dom do notscreen for GBs routinely (stee二 2011).

Because a newbordsimmune system jsimmature,they are at risk for developing early onset GBs infectionWhich is within the flrst 24 hours oflife, althoU8h 0丑enOccurs、vithin the 6rst 12 hours. Ne、vborns may acquirean infection up t07 days postbirth, and there is the rarePotentialforthe woman to develop a postpartum infec、tion from GBS (senior,2012).

If a 、voman tests positive to GBS, then the treat、ment recommended is intravenous antjbiotics in labor

Or earlierifher membranes are ruptured. The antibjoticsrequire an intravenous cannula for administrauon and

are generaⅡy 号iven every 4-6 hours.1t is idealthat the

負rst dose be siven 4 hours prior to birth (DepartmentOfHealth,20ID.

Exploring the professiona11Ssue of croup B sheptococcus screening in pregnanC βicheno and cera ht 225

Systemic infection maybe acquired through the umbili、Cal cord, respiratory system, or through skin abra、Sions (park et al.,2011). A neonate may be tested anddiagnosed 、vith GBs through either a blood test, urineSpedmen, or by cerebrospinal auid (Mukhopadhyay,Eichenwald,& PUOP010,2013).

Early onset GBs can cause the neonate to experl・

ence avarietyofsignsand symptoms, which indudelowtemperature (10wer than 36.5゜C), pyrexia (temperatureabove 37.5゜C), bradypnea (respiratory rate less than 40),tachypnea (respiratoryrate 8reaterthan 60), bradycardia(heart rate less than 11の,tachycardia (heart rate greaterthan 16の, appear aoppy, have the inabili切 to feed, andappear pale or irritable (Department ofHealth,20ID.

Nsk factors assodated with early onset GBs inneonates indude prematurity,10w birth weight, pre、mature rupture of membranes (PROM), intrapartumPyrexia, chorioamnionitis, ethnidty (Hispanic andAfrican American women at increased risk), endome、tritis and frequent vaginal examinations, maternal age

being younger than 20 years, dgarette smokin今,10IVSodoeconomic status, and urinary trad infections inthird trimester (Heath & 1ardine,2010).

Neonateswho acquireearly onset GBs mayexperi、ence sepsis, pneumonia, or less commonly meningitis.This severe infection at birth requires an immediateintroduction of interventions and neonatal support.Despite medicaladvances, neonatalGBs complicated bythese in企CtionsstiⅡ Causes great morbiditya11d mortalityfor neonates (入leeks, HaⅡS、vorth,& Yeo,2013). verylowbir壮I wei8ht babies are at greater risk of acquiring GBSand becoming severely unweⅡ. Even with immediateantibiotics forthe infectedverylowbirth刃Veight neonate,there is a mortality rate of30%(Heath & 1ardine,2010).The introduction of prophylactic antibiotic therapy inIabor has resulted in a 70% reduction in early onset GBS,therefore is 0丘en the argument why prevenuon is be壮erthan treatment when deaHng with GBS (Melin,20ID.

Late onset neonatal GBs is not always a廿ainedfrom verticaltransmission but may be caused by envi、ronmental factors or breastfeeding.1n very rare cases,neonates maybecome unweⅡWith ceⅡUlitis and osteoar、ticular infections from GBS.1,ate onset GBs is less fatal

than early onset GBS (Heath & 1ardine,201の.Women who c010nize GBs may be asymptom、

auc in pre8nancy ltis possible, however, for women tobecome un、velHn the postnatalperiod.1nfヒCtions causedby GBS C010nization can indude urinary trad infec、tions, endometrjtis,、vound infections (assodated lvith

Cesarean sections orperineum trauma), puerperalsepsis,menin8itis, and septic thrombophlebitis (Melin,20ID.

IMPACIONTHEVVOMANANDTHE NEVVBORN

From the review of the available literature, the Pro・

fessional issue of the screening of GBs is conten、tious. Australia recommends scTeening and treating aⅡWomen, whereas the united Kingdom screen and treatOn a risk fador basis.1t is possible to identify that theinddence of neonatal GBs infection is relatively low,紅though a positive test for GBs impacts a womadsintrapartum care and postpartum management. A posi、tive GBs result may require a 、voman to be transferredfrom her birthing choice ofhome birth or birth centerand required to have antibiotics which are an interven、

Uon. R is importantto identify the risk of GBs on theWoman and her baby as weⅡ asthe impHcation and sideeffects of antibiotics.

AlthoU8h many neonates may come into contactWith GBS,onbasmaⅡnumberWⅡlbecome unweⅡ,andthe reason for this is unhlown. The GBs bacterium is

the most common cause ofinfecuon for neonates and

Occurs lvithin the first Nveek of life;、vhereas late onset

neonatalinfection occurs between l week and 3 months

Ofage (Melin,20ID. More commonly and 0丑en moreSeverely, neonates suffet from early onset GBs whichis within the 丘rst 24 hours of life and usuaⅡy occursIvithin the 丘rst 12 hours.1nfection 丘om early onsetGBs is obtained eitherthrough fetalaspiration or inges、tion of GBs positive amniotic auid; also during birth, a

226 Explorln8 the professiona11Ssue of croup

Antibiotics administrated during the intrapartumPeriod may produce short・ and lon3・term side effectsand have implicationS 血r a neonate. Although furtherStudies are required, current research has identi6ed the

Possibility to develop food aⅡer号ies, gastrointesunaldisturba11Ces, cardiac arrhythmias, antibiotic resistance,maternal anaphylaxis, and interference with neonates'

immunesystemdevelopment(deTejada,2014).AlthoughPrevention of GBs may outweigh the potential sideeffects ofantibiotics, an issue is that although Nvomen arebeing tested at 35-37 Weeks,the bacteria istransient andtherefore maynot be present at birth.1n the case 、vhere aWoman is positivewhen screened,she maythen be ne8a、tive at birth and then receive unnecessary antibioucS 釘)dtherefore possess avoidable risks from the drug

B sbeptococcus screenlng in pregnancy βicheno and cera8hty

CURRfNT EVIDfNcf

Sheehy, Davis, and Homer (2013) conducted a cri廿Calrevie刃V of avanable evidence and found the approachto early onset of GBs varied from country to countryThe authors assessed three different approaches usedto screen and treat women for GBs lvithin Australia,

New zealand, canada, and the united Kjn今dom. Thefirst approach used in Australia involves screening a11Women for GBs and treatin8 aⅡ Positive results withintrapartum antibiotics. The second approach used inthe united Kin8dom and New zealand encolnpasses

Screening aⅡ Women but only treating positive womenWho also have the identi6ed risk fadors, indudin

Prematurity, PROM (greater than 18 hours), a historyOf GBs in pregnancies, and maternal pyrexia. Fina11ythe last approach used in canada requires screeningWomen only with these idenU負ed risk fadors. This

Criucal review identifled the implications of a positiveresult for GBS, not only on the health of both womanand ne、vborn but also on therestriction it has on where

a woman canbiTth. Manybirth centersand independentPractices do not aⅡOw women to birth in their center

if they provide a posiuve GBs screening. overaⅡ, thisreview conduded th飢 itis importantthat women makeinf01'med choices about being screened for GBs whichmay involve declining screening aⅡ t08ether.

A st口dy conducted in Lebanon assessed the preva、Ience and risk fadors of GBs among women and new_borns (seoud et al.,201の. The data 凡Vas c0Ⅱected from

February to september in 2006 across three hospitals.There were 17.フ% ofwomen with apositivescreening 血rGBS, whereaS 73% ofnewborns tested posiuve. FadorsSuch as maternal a3e, income, graⅥda, temperature in

Iabor, pretermlab0二 orpROMwere notidenU金ed asrjsks

fbr GBS. unfortunately,仕lis studydoes not assisun iden_tifying risk fadors, a1仕10ugh jtis interesuns a11d use611toUnderstand the prevalence ofGBS (seoud et al.,201の.

Building on the outcomes of previous studies, aStudy conducted in lran identi負ed the prevalence ofGBs positive women and subsequently, positive new、borns (shiraziet al.,2014). ofthe 980 women screened,48 had a positive GBs result. AlthoU8h the S加dy identi、負ed Only 4.9% of women who had GBS, interestingly,

Ofthe newborns were symptomauc ofGBS C010ni、50%

Zauon when the mother was tested positive. The stQdyidenti丘es tbe importance ofmonitoring and observingne刃Vborns for infection a丑er birth.

The theory that GBs in a previous Pre8n飢Cy

impacts on 仕le maternaland neonataloutcome for a cur-

rent pregna11Cy has been explored in lsrael. This studyWas aretrospectivestudycomparingpregnancycomPⅡCa、tions ofwomen with and wi仕10ut c010nization with GBS

in a preⅥOus pregnancy from 1988 t02006. The st口dyC0Ⅱected data from 184,266 births, al)d 230 (0.12%) ofthe bitths were ofwomen with a positive GBs culture intheirprevious pregnancy Thestudy's condusion suggeststhat previous GBS C010nization is not assodated withComplications such as pROIVI, chorioamnionitis, orintra_Part山1) pyrexia. Thisin血rmation is bene6dala11d aⅡOWS

the hlowledge that only current positive GBs results arereleva11t to a current pregnal)cy (凡I×1eintraub et al.,20ID.

In the united Kingdom, a study conducted by入4adean (20ID discussed the prevalence of GBS POSI・

tive women and infected newborns. The study rec、08nized the 20%-28% of GBs positive women in theUnited Kin今dom and identi丘ed maternal age, nUⅡParity, and sodoeconomic disadvanta8e as risk fadors.One'third to one・half of newborns become c010nized丘'om positive mothers, but l%-2% ofne、vbornsshowedSigns of early onset infection. Risk fadors for neonatalinfection indude Prematurity, pr010n牙ed labor, and

PROIVI. This information may be usefulifscreening isOnly performed for women with risk fadors; observeneonates who may be at risk for infection.

A largerstudy in the united Kin8dom performeda retrospective analysis over a 4・year period identifyin3missed opportunities fot prevenun8 GBS (vergnanoet al.,201の. The united Kingdom adopts a risk、basedapproach to GBs screeningandtreatmentbecause ofthePerceived low prevalence of GBS、 Risk fadors indude

Prematurity, PROM (greater than 18 hours), historyOf GBs in pregnandes, maternal pyrexia, and hlownGBS C010nization. The study found 48 Cases of GBSOver 4 years and identi6ed 67% ofwomen to have risk

fadors. only six cases received adequate antibioucS 加Iabor. The study conduded thatif aⅡ Women with riskfactors had received anubiotics in labor,48% of cases

mayhave been prevented (vergnano et al.,2010).The prevalence of GBs and neonatalin企Ction

Within a private hospital was assessed in Texas, USA(Faro et al.,201の. ofthe 2,108 Women in the study,89%Were screened for GBS. of those 、vho were screened,

71% tested negative. ofthe 2,135 ne凡Vborns,3 SU丘eredGBs sepsis. This case makes it possible to idenufy thatalthough neonatal GBs is rare, screening and treatmentmaybe necessary

Across Australia, the approach to GBs screeningPolides varies bet刃Veen routine and risk・based screen・

ing. The recommendation currendy suggests screeningOf aⅡ Women between 35-37 Weeks gestation, which isdetected by performin3 a low vaginalswab and a redalSwab which the woman may do herselfa丘erinstructionsby a midwife or doctor. The guidelines state thatifswabsare not obtained, then a risk・based approach must beadopted. prophylacucantibiotictherapyisrecommendedfor women with klown GBS,jnduding bein今 Sylnptom・atic of GBS, having a history of neonatal GBS, or if theWoman has an unhlowl) GBs status. Also induded is if

Iabor is premature, with pROM greaterthan 18 hours orifthewomanbecomesfebrileinlabor刃Vith atemperaturegreater than 38゜C. cutrendy, antibiotics are not requiredifthe woman is planning an elective cesarea11Section orifShe was GBs positive 丘om a previous pregnancy

Exploring the professlona11Ssue of croup B streptococcus screenin8 in pregnancy Bicheno and ce殿ghty 227

The concept ofa vacchle has also been suggested inSomeoftheliteraturewhichmayaidinredudn3thepreva・IenceofmatemalGBS (chen,Avd,&Kaspe二2013). clini、Caltrials have only recendy commenced, and a vacdne isnot 血reseeable in 壮le near 6、1加re; in addition, extensive

education about a newvacdne、voddneedto take place.

SUMMARY

The professionalissue concerning maternal GBs is ulti、mately the e丘ectiveness of the screening to01. BecauseOfthe transient nature ofthe bacteria, a test performedWeeks before a birth is neither appropriate northerapeu・tic for the lvoman or neonate.1t is understandable that

Women choose not to be tested because of potentiaⅡyreceivin8 Unnecessary antibiotics in labor because theresults can impact on a womalゞs chosen birthing envi・ronment. Research and development is required intodifferentscTeenin今 methods, with the antidpation that amore appropriate tool wiⅡ become routine, whether 廿'S

the pcR, NAAT, or avacdne. untilthen,itisimportantfor midwives to continue providing the best educationto women about maternalGBs screening aⅡOwing themto make informed choices.

AΠモRNAnvESFOR FUTURE PRAC11CE

Idea11y, GBs detection requires a screening processWhich can be performed in labor with immediate toPrompt results. This would aⅡOw women to be treated

and managed appropriately depending on their GBSStatus at the time of birth and would prevent womenreceiving unnecessary antibiotics by detecting womenWho are positive but who may have been negative at35-37 Weeks ofpre号nancy The use ofpolymerase chainreaction (PCR) and nudeic add ampli丘Cation tests(NAAT) has been introduced within the past 15 yearsin obstetrics (Daniels et al.,20ID. This type of testin8requires the same swabs 、vithout the incubation 廿me,therefore aⅡOwing quicker results. The testin8 takes lessthan 30 min for results and has greater than 90% accu・racy (Ahmadzia, Heine,& Br0刃Vn,2013). Although thismethod seems ideal, the issue revolves around the cost.

PotentiaⅡy with ume,the cost and e丘icacywiⅡ improveaⅡOwin8 the method to be used in hospitals.

Rモ旺RENCES

Ahmadzia, H. K., Heine, P',& Bro、vn, H. L.(2013). GBS

Screening: An update on guideline and methods.C0πte抗Pofafy ob/Gyπ,58(フ),40-48.

Chen, V; L., Avd, E Y.,& Kasper, D.1.(2013). A maternalvac、dne against 8τOUP B streptococcus: past, present, andfLlture. V4Cci11e,31, D13-D19.

Daniels,1. P., Gray j., pattison, H. M., Gray, R., Hi11S, R. K.,& Khan, K. S.(20ID、 1ntrapartum tests for group BStreptococcus: Accuracy and accePねbility ofscreening.BIOG: Aπ 1πterπati01141 10urπ41 qf' ohstetricS 6 Gyπ、4ec010gy,118(2),257-265. http://dx.doi.org/10.11H/j1471-05282010.02725.X

de Tejada, B. M'(2014). Antibiotic use and misuse durin8Pregnancyanddelivery: Bene丘ts andrisks.111ter11αh'0π41jour11αI Qf' E11νir011111e11t41 Rese4rch 411d puBlic Health,11(8),7993-8009.

DepartmentofHealth.(20ID. shouldlhesCルeπedjor GroupBSheptococcus? Retrieved from hせP://、VWW.google.com.au/url!sa=t&Tct=j&q=&esrc=S&source=web&cd=4&ved=OCDCQFjAD&url=h杜P%3A%2F%2FWWW.health.wa.gov.au%2Fhavingababy%2FdocS962F1202_GroupB_strep.pdf&ei=cqEIVιyeKMrn8AXVVILWDA

228 Exploringthe professionaHssueofcroup Bstreptococcusscreenin in pre nanC βichen。 dc h

&usg=AFQjcNHYnDVOWGSK8g2rKkspDchqcBCXNW&sig2=1PQINb04RDSTQ_BWUIGUA

Faro, S., Brehm, B., smith, F., Mouzoon, M., Greisinger, A.,Wehmanen,0.,& Turrentine, M. A.(201の. screeningfor group B streptococcus: A private hospital's experi、ence. hルdious Dise4Ses iπ ohstetricS α11d GyHec010sy

Heath, R T.,& 1ardine, L. A.(201の、 Neonatalinfections.group B streptococcus. BMlcliπicalEvideHce.

Madean, A. B.(2011). Group B streptococcus.10ur11αl qfOhstehicS 4πd Gyπαec010gy,31(3),203. httPゾノdx.doiOr8/103109/0144361520H.556760

Mclver, C.}., Rismanto, N., smith, C., Naing, Z. W., Rayner, B.,Lusk, M.1.,... Rawlinson, W D.(2009). Multiplex pcRtesting detection ofhi8her・than・expected rates ofcervi、Calmycoplasma, ureaplasma, and trichomonas andviral

a三ent infectionS 血 Sexua11y active Australian women./our1141 qf'ch'πiC41Microhi010g147(5),1358-1363.

Meeks, M., HaⅡSworth, M.,& Yeo, H.(2013). NursiH宮・ theπeoHate (2nd ed.). chichester, united Kjngdom. wiley

Melin, P.(20ID. Neonatal group B streptococcal disease:From pathogenesis to prevenuve strate8ies. chπiC41Miぴohi0108y ""d 1眺di0れ,17(9),1294-B03. h廿Pゾノdx.doi.org/10.1111/j.1469-06912011.03576.X

Mukhopadhyay, S., Eichenwald, E. C.,& PUOP010, K. M.(2013). Neonatal early・onset sepsis evaluations alnong

WeⅡ・appearin8 infants: projected impad of changes inCDC GBs guide1血es./our11αl qf' periπ4t010gy,33(3),198-205. http://dx.doi.or8/10.1038/炉2012.96

Park, K. H., Kim, K. H., Kang,1. H., Nm, K. N., Kim, D. S,,Kim, Y. K., Lee, H.1.(20ID. current status and

Clinical presentations of invasjve neonatal Group BStreptococcal infections in Korea. pedl'atricS 1πter_

π4ti0πal,53(2),236-239. http://dx.doi、or8/10.H11/j.1442-200×2010.03165.X

Senior, K.(2012). Antenatalscreeningfor 8roup B streptococcus.ι"枇et1眺Cti0那D太eases,12(8),589-590.

Seoud, M., Nassar, A. H., za110ua, P., Boghossian, N.,Ezeddine,1., Fakhoury, H.,... Yunis, K.(201の. prenataland neonatal GI'OUP B streptococcus screening and

SerotypinginLebanon:1nddenceandimplications.Ada06Steb'id4etGyπec0108icasmπdiπανiC4,89(3),399-403http://dx.doi.org/103109/00016340903560008

Sheeby, A., Davis, D.,& Homer, C. S.(2013). Assistingwomento make informed choices aboutscreening for Group BStreptococcusinpregn肌Cy: A cri廿Calreviewofthe evi、

dence. W0111eπ 4"d Birth,26(2),152-157. httPゾ/dx.doi.0弔/10.1016/j.wombi2012.10.004

Shirazi, M. M., AbbariM, E. M., Ha丘Zi, A. M., shahbazi, E P.,Bandari, M. B.,& Dast今erdy, E. M.(2014). The preva、Ience of group B streptococcus c010nization in lranianPregnant women and せS subsequent outcome.1πterπa、ti011α1/our1141 qf'Feπilitγ 6 Steri疏17(4),267-270.

Steer, P. J.(20ID. To screen or not to screen: Group B strep、tococcus and prenatal infections、 British jour11αl qf'Midwif" ry,19(3),144-148.

Vergnano, S., Embleton, N., C0Ⅱinson, A., Menson, E., Bed_ford RusseⅡ, A.,& Heath, P.(201の. Missed opPωtuni_ties f0τ Preventing 3roup B stTeptococcus infection.Aπhives qf' Disease iπ Childhood-Fetα1 απd Ne0πα_

tal Editi0π,95(D, F72-F73. h廿P://dx.doi.org/10.Ⅱ36/adC2009.160333

Weintraub, A. Y., Kessous, R., sergienko, R., salem Yaniv, S.,Press, F., wiznitzer, A.,& sheiner, E.(20ID.1S C010ni2a、

tion with GBs in a previous pregnancy assodated withadverse perinatal outcomes? Archives qf'Gy11ec0108・y α11dObstetrics,284(4),787ーフ91、 h壮Pゾノdx.doi.or8/10.100フノSO0404-010-1724-6

Sharna Bicheno, BSCNursing, MMid, RN, RM, Edith cowanUniversity, perth, western Australia.

Sadie Geraghty, BA (Hons), BSC (Hons), MMid, MEd, RM,PhD candidate, coordinator ofMaster ofMidwifery pradice,Edith cowan university, perth, western AustraⅡa.

Correspondence regarding this aTticle should be directed toSadie Geraght% BA (Hons), BSC (Hons), MMid, MEd, RM,PhD candidate, Edith cowan university, perth,~vesternAustralia. E・mail: babycatcher59@gmail、com

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