8/31/2020 0 Comments Care model comparison & IDACare Model Comparison I will firstly describe two of the models of care available to women at this health service: the maternity group practice (MGP) and general practitioner (GP) shared care. I will then compare these options using evidence-based material to support her making an informed choice 1,2. MGP, also known as caseload midwifery, is a maternity model where all pregnancy, birth and postnatal care are provided by a primary midwife with the assistance of a backup or secondary midwife 1. GP shared care is a collaboration between a qualified community GP and the local hospital. The GP sees the woman for most of the antenatal care with selected appointments and the birth taking place at the nominated hospital with shift midwives 3. Under MGP, midwives are trained to support and be attuned to the normal physiological processes of pregnancy, birth and breastfeeding and can detect deviations from this 4. This model enables care and support by a known midwife in a continuity of care approach. It has decreased rates of instrumental birth, episiotomy, regional analgesia use, and amniotomy, and higher rate of spontaneous vaginal birth 5,6. It also has higher incidences of water immersion, physiological third stage, second-degree tears 6, longer labours and less likelihood of adverse fetal and neonatal outcomes 5. It is therefore not surprising that this mode of care is in high demand and consequently can be difficult to access 3. A more accessible choice is the GP shared care model offering some continuity of care, especially in the broader lifespan context. With this model the woman can choose their general practitioner who can offer convenience in location and access to appointments, as well as offer more culturally and language appropriate choices 7. However, GPs need to complete extra specialist training in maternity care to offer this option 8 and are often not equipped to offer satisfactory breastfeeding and nutritional information 9,10. Both models cover the standard pre-, post- and intra-partum care through public funding 1. They offer intrapartum care in a local hospital predominantly supported by midwives and they both adhere to timely consultation and referral guidelines 11. The GP program reports positive satisfaction levels 9, but the outcomes for babies and maternal satisfaction rate is higher in MGP models than in standard care, including GP shared care 5,12. Satisfaction also comes when a woman feels she has sufficient information to choose a model of maternity care 13. These two options would give her a choice of continuity of care led by midwives with higher rates of normal physiological birth or familiarity of care with her own general practitioner. Offering a woman informed choice typically enables collaboration and the right to autonomy and self-determination. Iron Deficiency Anamia Case Study I will describe how therapeutic information will be provided within a midwifery group practice model of care to a woman found to have iron deficiency anaemia, and how care will be planned in partnership with her relating to this. As early antenatal care providers, group practice midwives are in an important position to identify anaemia in pregnant women, determine the underlying causes and guide best choice management of the condition 14. Iron deficiency anaemia (IDA) is characterised by a haemoglobin level below 110 g/L in the first and third trimesters or below 105 g/L in the second trimester 15,16, along with a serum ferritin level less than 30 μg/L 17. In this woman’s case, her ferritin levels were under 15 μg/L which indicated iron depletion 18. After review, the midwife can discuss the results with the woman at her next antenatal visit 19. This can include explaining that iron is required to transport oxygen around our body and that these levels can drop in pregnancy due to increased blood volume and demand, but that her results were outside of what would be expected. In order to provide quality continuity of care, this woman’s whole clinical story needs to be considered to make suitable recommendations 20. Firstly, this can done by asking how she is feeling and validating any linked common symptoms such as general fatigue, weakness and depression 21. Assessing her health literacy around the diagnosis and ensuring she comprehends what these results mean is important 22. The midwife can invite the woman to express what she understands and provide more or clearer information if necessary. When this understanding is established, the midwife can also explain how low iron levels are linked to premature and small babies, increased infection, birth complications and ante- and post-natal depression 15. The midwife can revisit the woman’s current nutrition and supplement intake and can offer a recommendation 24 to consume more lean red meat, eggs and chicken. Other great iron-rich foods to recommend, especially if the woman does not eat animal products, are fermented wholegrain foods, fortified cereals, dried fruit, roasted nuts, seeds, green leafy vegetables, blackstrap molasses, Marmite, Vegemite and soaked legumes 25. To assist in iron absorption, food rich in vitamin-C can also be added to this list, such as citrus fruits, kiwifruit and broccoli 25. The midwife can also recommend limiting the intake of calcium, zinc, black tea, and red wine in conjunction with iron intake; these substances can inhibit iron uptake into the body 25,15. It is unlikely that diet alone can offer improvements given the woman’s circulating and stored iron levels and reasonably common for midwives practicing continuity of care to prescribe supplementation 26. It is recommended that she commence oral iron supplementation of 100 mg as a first line treatment to be taken separately instead of in a multivitamin. This recommendation can be offered while encouraging the woman to ask questions to make a fully informed decision about taking them. Some of this conversation can include sharing the side effects and hazards of the supplements and how to minimise their effect. Side effects include constipation, diarrhoea, nausea and vomiting 27 with hazards of a raised haemoglobin risking placental insufficiency and secondary haemochromatosis 28. Recommendations to increase tolerance would include taking them at bedtime, with food that does not decrease absorption and lowering the dose or frequency 15,29. It is also worth considering and discussing what other barriers the woman may have in obtaining and taking the supplements and consuming iron-rich foods, such as financial, logistical or cultural difficulties. The midwife can document the information and offer a plan to the woman in light of this diagnosis and discussion. It is anticipated that her haemoglobin levels should increase by about 10-20 g/L over the next three to four weeks while taking the supplements 30. This plan would include retesting in about two weeks 14 and again at 36 weeks gestation 19. If the follow-up blood tests do not show expected improvements, intravenous iron supplementation should be offered 14. If any tests show her haemoglobin level has dropped below 90 g/L, the midwife should seek consultation with a medial practitioner 31. All this clinical information can be conveyed to the woman at the appropriate times as their relationship is built. Through close investigation of the journey of this woman’s IDA diagnosis, it is clear to see the benefits of continuity of care in ensuring safe, evidence-based, woman-centred midwifery care. This has been achieved with holistic, therapeutic communication of the relevant information with key decisions made in close partnership with the woman and the MGP midwife. References (1) COAG Health Council. Woman-Centred Care: Strategic Directions for Australian Maternity Services. Department of Health August 2019. (2) International Confederation of Midwives. International Code of Ethics for Midwives. (3) Homer, C. S. Models of Maternity Care: Evidence for Midwifery Continuity of Care. Med. J. Aust. 2016, 205 (8), 370–374. https://doi.org/10.5694/mja16.00844. (4) Frye, A. Holistic Midwifery: A Comprehensive Textbook for Midwives in Homebirth Practice; Labrys Press: Portland, Or. (7528 NE Oregon St., Portland 97213), 1995. (5) Sandall, J.; Soltani, H.; Gates, S.; Shennan, A.; Devane, D. Midwife-Led Continuity Models versus Other Models of Care for Childbearing Women. Cochrane Database Syst. Rev. 2016. https://doi.org/10.1002/14651858.CD004667.pub5. (6) Gidaszewski, B.; Khajehei, M.; Gibbs, E.; Chua, S. C. Comparison of the Effect of Caseload Midwifery Program and Standard Midwifery-Led Care on Primiparous Birth Outcomes: A Retrospective Cohort Matching Study. Midwifery2019, 69, 10–16. https://doi.org/10.1016/j.midw.2018.10.010. (7) Better Health Channel. Pregnancy and birth care options https://www.betterhealth.vic.gov.au/health/ServicesAndSupport/pregnancy-and-birth-care-options (accessed Aug 15, 2020). (8) Conjoint Committee; CCDOG. Shared Maternity Care Obstetric Patients; Conjoint Committee for the Diploma of Obstetrics and Gynaecology, 2016. (9) Lucas, C.; Charlton, K.; Brown, L.; Brock, E.; Cummins, L. Review of Patient Satisfaction with Services Provided by General Practitioners in an Antenatal Shared Care Program. 2015, 5. (10) Walker, R.; Choi, T. S. T.; Alexander, K.; Mazza, D.; Truby, H. ‘Weighty Issues’ in GP-Led Antenatal Care: A Qualitative Study. BMC Fam. Pract. 2019, 20 (1), 148. https://doi.org/10.1186/s12875-019-1026-4. (11) Women’s Health Committee. Maternal Suitability for Models of Care, and Indications for Referral within and between Models of Care. The Royal Austraian and New Zealand College of Obstetricians and Gynaecologists March 2018. (12) Forster, D. A.; McLachlan, H. L.; Davey, M.-A.; Biro, M. A.; Farrell, T.; Gold, L.; Flood, M.; Shafiei, T.; Waldenström, U. Continuity of Care by a Primary Midwife (Caseload Midwifery) Increases Women’s Satisfaction with Antenatal, Intrapartum and Postpartum Care: Results from the COSMOS Randomised Controlled Trial. BMC Pregnancy Childbirth 2016, 16 (1), 28. https://doi.org/10.1186/s12884-016-0798-y. (13) Stevens, G.; Miller, Y. D.; Watson, B.; Thompson, R. Choosing a Model of Maternity Care: Decision Support Needs of Australian Women. Birth 2016, 43 (2), 167–175. https://doi.org/10.1111/birt.12212. (14) Frayne, J.; Pinchon, D. Anemia in Pregnancy. Hematol. Oncol. Clin. North Am. 2019, 25 (2), 241–259. https://doi.org/10.1016/j.hoc.2011.02.001. (15) Milman, N.; Paszkowski, T.; Cetin, I.; Castelo-Branco, C. Supplementation during Pregnancy: Beliefs and Science. Gynecol. Endocrinol. 2016, 32 (7), 509–516. https://doi.org/10.3109/09513590.2016.1149161. (16) Daru, J.; Cooper, N. A. M.; Khan, K. S. Systematic Review of Randomized Trials of the Effect of Iron Supplementation on Iron Stores and Oxygen Carrying Capacity in Pregnancy. Acta Obstet. Gynecol. Scand. 2016, 95 (3), 270–279. https://doi.org/10.1111/aogs.12812. (17) RCPA. Iron Studies Standardised Reporting Protocol; The Royal College of Pathologists of Australia, 2013; p 16. (18) Pavord, S.; Myers, B.; Robinson, S.; Allard, S.; Strong, J.; Oppenheimer, C.; on behalf of the British Committee for Standards in Haematology. UK Guidelines on the Management of Iron Deficiency in Pregnancy. Br. J. Haematol.2012, 156 (5), 588–600. https://doi.org/10.1111/j.1365-2141.2011.09012.x. (19) Department of Health. Clinical Practice Guidelines: Pregnancy Care; Australian Government Department of Health: Canberra, 2018. (20) Grigg, C. Working with Women in Pregnancy. In Midwifery : preparation for practice; Elsevier Australia: Chatswood, AUSTRALIA, 2019; p 44. (21) Milman, N. Oral Iron Prophylaxis in Pregnancy: Not Too Little and Not Too Much! J. Pregnancy 2012, 2012, 1–8. https://doi.org/10.1155/2012/514345. (22) Australian Commission on Safety and Quality in Health Care. HEALTH LITERACY: Taking Action to Improve Safety and Quality; ACSQHC: Sydney, 2014. (23) Chatterjee, N.; Fernandes, G. ‘This Is Normal during Pregnancy’: A Qualitative Study of Anaemia-Related Perceptions and Practices among Pregnant Women in Mumbai, India. Midwifery 2014, 30 (3), e56–e63. https://doi.org/10.1016/j.midw.2013.10.012. (24) Chatterjee, R.; Shand, A.; Nassar, N.; Walls, M.; Khambalia, A. Z. Iron Supplement Use in Pregnancy – Are the Right Women Taking the Right Amount? Clin. Nutr. 2016, 35 (3), 741–747. https://doi.org/10.1016/j.clnu.2015.05.014. (25) Wratten, J.; Gibbons, M. Nutrition and Physical Activity Foundations for Pregnancy, Childbirth and Lactation. In Midwifery Preparation for Practice; Pairman, S., Tracy, S. K., Dahlen, H. G., Dixon, L., Eds.; 2019; pp 404–423. (26) Hunter, M.; Davis, D. Pharmacology and Prescribing. In Midwifery Preparation for Practice; Pairman, S., Tracy, S. K., Dahlen, H. G., Dixon, L., Eds.; 2019; pp 707–733. (27) Peña-Rosas, J. P.; De-Regil, L. M.; Dowswell, T.; Viteri, F. E. Daily Oral Iron Supplementation during Pregnancy. In Cochrane Database of Systematic Reviews; The Cochrane Collaboration, Ed.; John Wiley & Sons, Ltd: Chichester, UK, 2012; p CD004736.pub4. https://doi.org/10.1002/14651858.CD004736.pub4. (28) Ribot, B.; Aranda, N.; Giralt, M.; Romeu, M.; Balaguer, A.; Arija, V. Effect of Different Doses of Iron Supplementation during Pregnancy on Maternal and Infant Health. Ann. Hematol. 2013, 92 (2), 221–229. https://doi.org/10.1007/s00277-012-1578-z. (29) Peña-Rosas, J. P.; De-Regil, L. M.; Gomez Malave, H.; Flores-Urrutia, M. C.; Dowswell, T. Intermittent Oral Iron Supplementation during Pregnancy. Cochrane Database Syst. Rev. 2015. https://doi.org/10.1002/14651858.CD009997.pub2. (30) Percy, L.; Mansour, D.; Fraser, I. Iron Deficiency and Iron Deficiency Anaemia in Women. Best Pract. Res. Clin. Obstet. Gynaecol. 2017, 40, 55–67. https://doi.org/10.1016/j.bpobgyn.2016.09.007. (31) Australian College of Midwives Ltd. ACM C&R Guidelines; Australian College of Midwives Ltd.: Apple App store, 2016. it. marked: 72/100
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