Background
Methods
Design
Recruitment
Participants
Occupation | State | Method | Facility | Banking option |
---|---|---|---|---|
Midwife | QLD | Phone | Public Hospital; Regional | Private |
Midwife | QLD | Phone | Public Hospital: Regional | Private |
Midwife | QLD | Phone | Public Hospital; Regional | Private |
Midwife | QLD | Phone | Public Hospital; Regional | Private |
Midwife | QLD | Phone | Public Hospital; Metro | Private and Public Cord Blood Bank |
Midwife | QLD | Face to Face | Private Hospital/Clinic; Metro | Private |
Midwife | QLD | Phone | Public Hospital; Regional | Private |
Midwife | NSW | Phone | Public Hospital/Community Setting; Regional | Private |
Midwife | NSW | Phone | Public Hospital; Regional | Private |
Midwife | VIC | Phone | Private Hospital; Regional | Private |
Midwife | WA | Phone | Public Community Setting; Metro | Private |
Obstetrician | QLD | Face to Face | Private Hospital; Metro | Private |
Obstetrician | QLD | Phone | Private Hospital; Regional | Private |
GP Obstetrician | QLD | Phone | Public Hospital; Regional | Private |
Data collection
Data analysis
Results
Topic one: cord clamp timing
Theme one: information provision for parent-centred care
Obstetric participants demonstrated differing levels of engagement regarding initiation and discussion of cord clamp timing with parents as part of routine antenatal and/or intrapartum care. One regional-based private practice obstetrician incorporated discussions about cord clamp timing into his antenatal discussions with parents:Absolutely it is important to discuss cord clamp timing, even if there is an education gap there, parents need to know the benefits of DCC versus ECC. (Midwife)
Although most obstetricians supported DCC, one obstetric participant who worked in private practice appeared ambivalent to the practice, for example:DCC is part of my routine, so it is not something that I have started doing recently. So, I tell them I routinely defer the cord clamping. (Obstetrician)
I don’t offer too much negative feedback about it because they want it done and it does no harm, it is easy to do so I say fine…..I just give them the facts. (Obstetrician)
Theme two: emerging health literacy
It is becoming increasingly something that people bring up……and funnily enough it is being brought up by people who are looking at doing cord blood banking. I tell them they can do one or the other but not both. Because if they want to do CBB, they need a decent amount there. (Obstetrician)
Theme three: elusive practice and ambiguous evidence
Some midwifery participants also identified that their practice of DCC was not guided by a specific time frame. Disparities in practice of cord clamp timing were not only evident between midwifery and obstetric participants but also identified within the disciplines. DCC practices are therefore ambiguous and dependent on individual clinicians’ perceptions or perspectives about what constitutes DCC. Evidence based practice and clear definitions were rarely used to justify practice.I just do DCC if the patients want it ….so if people want me to do deferred cord clamping, I will do it, but I just clamp the cord whenever. (Obstetrician)
Although, participants identified the need for more definitive practice guidelines related to the optimal time interval to clamp the cord, it was evident that a more holistic and patient centred approach be considered. Many midwifery participants voiced their belief that the cord should only be clamped after pulsations have ceased.More solid recommendations around cord clamp timing is needed as there remains so much variation in recommendations out there. Such as some say DCC is 60 seconds, others say optimal is 1 – 3 minutes, others say wait until the cord stops pulsating so it would be good to have consistency with more clear evidence around that. (Midwife)
A regional based midwife working in both the public hospital system and community practice verbalised that cord clamp timing should be reframed, and that DCC needed to be regarded as normal practice.Just that it annoys me that some health care professionals stick to the 1 – 3 minutes rigidly for DCC, when really just let the cord pulsate until the end then clamp it. I also believe it can pulsate for much longer than this time and still provide benefit to the baby. (Midwife)
And I think that we need to do some more research on what the effects are of early cord clamping (ECC) because really that is the intervention, not the DCC …I think that we need to reframe how we are talking about our research. I think instead of talking about the benefits of DCC, talking about the risks of ECC and putting the physiological um back, like reframing that (deferred clamping) as being normal. (Midwife)
Theme four: institutional influence over parental preference
DCC in the case of a compromised infant may promote better outcomes for the infant [20] and some participants were aware of this. However, DCC if the infant required resuscitation was not practised. This was often overridden in favour of traditional resuscitation processes of early cord clamping and removing the infant to the resuscitaire.I would never not uphold parents’ wishes for DCC, it would only be in the situation where the baby needs resus or the mother is having a bleed. (Midwife)
Some midwives expressed that regardless of whether the infant appeared to be slow to respond to extrauterine life, they would still defer the clamping of the cord to uphold parent wishes for deferred cord clamping. One obstetric participant employed in the public hospital system revealed that she was also supportive of not immediately clamping the cord to allow some time to see if infants’ “pick up” while receiving the support of continued placental transfusion that deferred cord clamp facilitates. However generally, parents’ decisions about DCC when infants were slow to respond at birth were often overridden by other health professionals who reverted to ECC practices and active resuscitation.If the baby needs immediate resuscitation then we tell parents they probably won’t have DCC although research shows this is probably beneficial to have DCC in these situations. (Midwife)
Overall, universal support for and practice of DCC in healthy, robust infants was evident. However, in emergent clinical scenarios such as neonatal resuscitation, cord clamp timing practices varied with a feeling of uncertainty and interdisciplinary conflict apparent. Individual preferences were voiced, frequently unsubstantiated by evidence.Um, sadly you know when there are other health professionals in the room like paediatricians or obstetricians, they override that choice of DCC and resuscitation with an intact cord. If it is just me, I would wait a minute before I clamped if it needed resus but if there are other health professionals there you don’t get to make that decision. (Midwife)
Topic two: cord blood banking and donation
Theme one: protective steering
Obstetric participants also revealed that discussing or informing parents about CBB was not a priority or part of their routine antenatal discussions. Midwives in this study held strong perspectives about the value of cord blood, and these perspectives often underpinned the rationale for why CBB was not initiated as part of routine antenatal education and care.I don’t initiate the conversation about CBB because I think it is a private thing and to be honest, it doesn’t occur to me to bring up the conversation. (Midwife)
When parents did initiate the conversation about the option of CBB, some midwifery participants identified that this was not within their scope of practice and directed parents to do their own research.I think it is unethical to mention CBB. If there is a real reason that they need that, they would have already researched it and um I don’t want to sound like I am endorsing it in anyway. Most people don’t know all the things around DCC, but they know that it is a good thing and they do it. (Midwife)
Participants used educational resources such as cord blood bank brochures to inform interested parents about CBB.We would just get them google it to be honest. I don’t think I have ever seen any information on CBB or seen any brochures anywhere sort of lurking around in the hospital either. (Midwife)
Similarly, by a regional-based obstetrician in private practice stated:We don’t actively promote CBB but we have brochures in our clinics. If they ask questions, we tell them to go away and do their own research. (Midwife)
A more balanced approach to information sharing about cord blood donation was revealed. Parents make informed decisions about either DCC or CBD. A midwife who worked in a hospital where the option of CBD was available to parents stated:Increasingly people are asking about it and we have literature in the rooms which we give out……… if they bring it up that is fine. I give a fairly neutral overview as I don’t want to be seen to be promoting an increased expense for parents. (Obstetrician)
Some of them do ask about CBD. And we certainly talk about it to the women and say that it is available, it is altruistic, you are giving your cord blood for the purpose of research and it is no benefit to you but it is potentially helping other people and they use it to try and find cures for all sorts of different things. There certainly are people that are interested but I wouldn’t say it is the majority, I would say it is the majority are keen to hang onto their own cord blood. ……. (Midwife)
Theme two: paucity of information
Yet, despite the self-identified lack of knowledge about cord blood banking or the possible benefits, participants were more likely to promote DCC over CBB.In regard to CBB and CBD – I don’t think any of us know anything about that. We are in the dark as much as our patients are most of the time. (Midwife)
Knowledge of CBB was limited in this study and there were limited attempts to engage in professional development and increase awareness and knowledge for the benefit of parent education. Knowledge about reasons for CBB was also often inadequate or incorrect in this study, perhaps informed by media anecdotes or fictional stories.If someone asked me about it, I would say it is a personal choice or decision, I don’t know much about CBB so I would direct them to the internet for more information. If anyone asked me my opinion, then I would recommend DCC because there is much more evidence surrounding it than CBB. (Midwife)
Participants did not appear to be aware of the potential use of cord blood stem cells for regenerative medicine and other therapies. In contrast some participants identified a need for more information on CBB, in particular evidenced-based information.The only reason for CBB is if it they needed a sibling’s cord blood. (Midwife)
In regard to CBB it would be great to get some honest and unbiased information on what the benefits actually are. (Midwife)