Women's experiences of maternity care in England: preliminary development of a standard measure

BACKGROUND

As maternity services evolve and the population of women served also changes, there is a continuing need to effectively document the views of women with recent experience of care. A woman's maternity experience can have a positive or negative effect upon her emotional well-being and health, in the immediate and the long-term, which can also impact the infant and the wider family system. Measuring women's perceptions of maternity services is an important way of monitoring the quality of care provision, as well as providing key indicators to organisations of the services that they are providing. It follows that, without information identifying possible areas in need of improvement, it is not clear what changes should be made to improve the experiences of women during their journey through maternity services from pregnancy to the early weeks at home with a new baby . The objective is to describe the development process and psychometric properties of a measure of women's experience of maternity care covering the three distinctly different phases of maternity - pregnancy, labour and birth, and the early postnatal period.

METHODS

Data from a national survey of women who had recently given birth (n = 504) were used. Exploratory and confirmatory factor analytic methods were employed. The measure was assessed for underlying latent factor structure, as well as for reliability, internal consistency, and validity (predictive, convergent and discriminant).

RESULTS

The models developed confirmed the use of three separate, but related scales about experience of maternity care during pregnancy, labour and birth and the postnatal period. Data reduction was effective, resulting in a measure with 36 items (12 per scale).

CONCLUSION

The need for a psychometrically robust and qualitatively comprehensive measure of women's experience of maternity care has been addressed in the development and validation of this prototype measure. The whole measure can be used at one time point, or the three separate subscales used as individual measures of experience during particular phases of the maternity journey with identified factor structures in their own right.

Exploring English speaking Muslim women's first-time maternity experiences: a qualitative longitudinal interview study

Background

Muslim women of child-bearing age make up a fair part of the UK society, however, literature addressing their health needs or experiences of health services have not been extensively researched. The term ‘Muslim’ is often combined with ethnic group identity, rather than used to refer to people distinguished by beliefs or affiliations. Muslim women commonly observe certain religious and cultural practices during their maternity journey. The little research there is in this area suggests that more could be done from a service provision perspective to support Muslim women through this significant life event. The aim of this study was to investigate Muslim women’s perceived needs and the factors that influence their health seeking decisions when engaging with maternity services located in North-West of England.

Methods

The study used longitudinal semi-structured interviews with seven English-speaking first-time pregnant Muslim women receiving maternity care in North-West of England. Total of 21 interview; each woman was interviewed during the antenatal (29 to 40 weeks of pregnancy), immediate postnatal (within the first 2 months after birth) and later postnatal (4 months after birth) period. Audio-recorded interviews were transcribed and thematically analysed using Braun & Clark (2006) as a guide to forming a systematic approach to handling raw data.

Results

Muslim women associated most aspects of the maternity journey with their religious beliefs. Religion was not the primary reason for them becoming pregnant, yet it was an aspiration for them becoming mothers. Emerging themes include: 1) a spiritual perspective; 2) expression of religious requirements; 3) perceptions of healthcare professionals. Religious values and practices provided a positive resource for women during their maternity journey. They described how healthcare professionals approached their needs, while highlighting their concerns of the negative presentation of Muslims in Western media.

Conclusion

Muslim women need to feel confident to express their needs within a maternity setting. Lack of awareness amongst healthcare professionals around religious values and how Muslim women may feel when expressing their needs can inhibit them getting optimal care that acknowledges their needs. The study concludes that educating healthcare professionals about Muslim women’s worldview would enhance the quality of maternity care for Muslim women.

Fellowship or Family? A Comparison of Residency Leave Policies With the Family and Medical Leave Act

BACKGROUND

In 1993, the Family and Medical Leave Act (FMLA) mandated 12 weeks of unpaid, job-protected leave. The current impact of taking 12 weeks of leave during residency has not been evaluated.

METHODS

We examined the 2018 Accreditation Council for Graduate Medical Education (n = 24) specialty leave policies to determine the impact of 6- and 12-week leave on residency training, board eligibility, and fellowship training. We compared our findings with a 2006 study.

RESULTS

In 2018, five (21%) specialties had policy language regarding parental leave during residency, and four (16%) had language regarding medical leave. Median leave allowed was 4 weeks (IQR 4-6). Six specialties (25%) decreased the number of weeks allowed for leave from 2006 to 2018. In 2006, a 6-week leave would cause a 1-year delay in board eligibility in six specialties; in 2018, it would not cause delayed board eligibility in any specialty. In 2018, a 12-week (FMLA) leave would extend training by a median of 6 weeks (mean 4.1, range 0-8), would delay board eligibility by 6-12 months in three programs (mean 2.25, range 0-12), and would delay fellowship training by at least 1 year in 17 specialties (71%). The impact of a 12-week leave was similar between medical and surgical specialties.

CONCLUSIONS

While leave policies have improved since 2006, most specialties allow for 6 weeks of leave, less than half of what is mandated by the FMLA. Moreover, a 12-week, FMLA-mandated leave would cause significant delays in board certification and entry into fellowship for most residency programs.

Motivators and challenges to research recruitment - A qualitative study with midwives

OBJECTIVE

To explore midwives' experiences of recruiting participants to research studies conducted by other researchers.

DESIGN

An inductive qualitative study.

METHODS

Individual face-to-face or telephone interviews using a semi-structured interview guide. Interviews were analysed thematically.

SETTINGS

One large urban maternity hospital in Ireland.

PARTICIPANTS

A purposive sample of 19 midwives FINDINGS: Three co-dependent themes emerged: intrinsic motivations, extrinsic motivations and challenges. Intrinsic motivations included midwives' personal beliefs about the value of research in general, its potential to improve practice, and their perceptions of how robust a particular study was and how it might impact on an individual woman and her baby. This included an inherent desire to shield some women, those who were perceived to have ongoing health issues or be anticipating a sub-optimal pregnancy outcome, from being offered study information. Extrinsic motivations related to the complexity of a research study and a specific researcher's characteristics. Challenges to offering potential participants research study information and, therefore, to successful recruitment included time constraints, workload and the volume of research being conducted simultaneously.

KEY CONCLUSIONS

Participants navigated the two, sometimes competing, worlds of clinical practice and clinical research. Set in the context of workload and the volume of research being conducted simultaneously, midwives' perceptions of a study's robustness, clarity, its potential impact on individual women and ability to improve practice governed their motivation to offer information on research studies to potential participants.

IMPLICATIONS FOR PRACTICE

Inviting clinicians to assess the study information may improve its clarity and create opportunities to discuss the potential value and recruitment bias. Researchers should be available to address clinicians' questions about particular research studies. At an organisational level, a system for managing the volume of research activity is required.

Migrant Polish women overcoming communication challenges in Scottish maternity services: A qualitative descriptive study

BACKGROUND

Migrant women are more likely to experience sub-optimal maternity outcomes and are often described in a problematised way. Communication is crucial in maternity and can be compromised if the language of that service is delivered in a language incomprehensible to migrant women.

METHODS

Qualitative descriptive study using 9 in-depth individual interviews with Polish women who recently had experience of local maternity services. Recorded interviews were transcribed and thematically analysed. A salutogenic conceptual framework was adopted for data analysis.

FINDINGS

Three descriptive themes: 'Communication and understanding', 'Relationships matter' and Values and expectations'. Seven related subthemes where identified.

DISCUSSION

Vulnerability in this study is understood as uncertainty, risk and emotional exposure to situations that are not understandable. Applying a salutogenic lens to analysis reveals the significance of quality communication, relationship and culturally sensitive practices as ways of mitigating feelings of vulnerability in the host country. Antonovski's Sense of Coherence' (SoC) highlights migrant women's ability to comprehend and capacity to understand their unique experiences of communication challenges. Participant's psychosocial, cultural, and individual beliefs reveal an ability to trust maternity systems that are different from their own cultural values and help them move towards a Sense of Coherence (SOC) and face their vulnerability.

CONCLUSION

Working with migrant women requires a salutary focus. Maternity care professionals involved in the care of this population need to consider individual internal and external resources and avoid treating migrant women as a problematic group. Maternity care provision needs to acknowledge migrant women's strengths, values and expectations and adapt local services. This is done by addressing individual woman's needs through a salutary focus, person-centredness and a system of care that values relationships and social connectedness.

How communication about risk and role affects women's decisions about birth after caesarean

OBJECTIVE

This study investigated how health care provider communication of risk information, and women's role in decision-making, influenced women's preferences for mode of birth after a previous caesarean birth.

METHODS

Women (N = 669) were randomised to one of eight conditions in a 2 (selectivity of risk information) × 2 (format of risk information) × 2 (role in decision making) experimental design. After exposure to a hypothetical decision scenario that varied information communicated by an obstetrician to a pregnant woman with a previous caesarean birth across the three factors, women were asked to decide their preferred hypothetical childbirth preference.

RESULTS

Women provided with selective information (incomplete/biased toward repeat caesarean) and relative risk formats (ratio of incidence being compared e.g. 2.5 times higher), perceived lower risk for caesarean and were significantly more likely to prefer repeat caesarean birth than those provided with non-selective information (complete/unbiased) and absolute risk formats (incidence rate e.g. 0.01 per 100). Role in decision-making did not significantly influence childbirth preferences CONCLUSIONS: Modifiable aspects of healthcare provider communication may influence women's decision-making about childbirth preferences PRACTICE IMPLICATIONS: Optimised communication about risks of all options may have an impact on over-use of repeat CS.

Clostridium difficile infection in pregnant and postpartum women in 2 hospitals and a review of literature

BACKGROUND

Healthcare-associated Clostridium difficile infection (CDI) in pregnant/postpartum women is underreported, especially outside of North America. We report a cluster of cases in 2 neighboring secondary care hospitals in South-East England. The objective of this study was to identify the epidemiology and risk factors for infection.

METHODS

An investigation into a cluster of cases of confirmed CDI in pregnant/postpartum women was performed over a 12-month period, from June 2016 to June 2017.

RESULTS

Eleven cases, in 10 patients, were identified, including 1 patient who had a relapse. Eight of 10 patients developed symptoms after hospital discharge. All patients had received broad-spectrum antibiotics prior to CDI onset. Environmental vectors, such as labor room mattresses, that were found difficult to effectively decontaminate after heavy contamination with blood, feces, and other body fluids may have been possible reservoirs. An infection control care bundle was successful in preventing further cases.

CONCLUSIONS

Antibiotic use and exposure to the organism in a contaminated labor room environment are likely risk factors for healthcare-associated CDI in postpartum women. Active surveillance is necessary to prevent these infections, as these cases often present after hospital discharge.

Refugee women's experiences negotiating motherhood and maternity care in a new country: A meta-ethnographic review

OBJECTIVES

The aim of this meta-ethnographic review was to examine refugee women's experiences negotiating motherhood and maternity services in a new country with a view to identifying the specific needs of refugee women accessing maternity care in high income countries.

DESIGN

A meta-ethnographic synthesis of qualitative research.

DATA SOURCES

Five databases were searched for papers published in English between January 2000 and January 2017.

REVIEW METHODS

The synthesis process was guided by the seven steps of meta-ethnography. The quality of included studies was assessed using the COREQ tool.

RESULTS

One overarching theme and three major themes emerged from the synthesis. The overarching theme "Living between two cultures" conveyed women's experience of feeling "in between" cultures and described refugee women's experience of striving to maintain a strong cultural identity from their country of origin while simultaneously adapting to their new context and country. This theme permeated the following three major themes: 1) "Constructing maternal identity across cultures" which discusses the cultural conflict experienced by refugees accessing maternity services in their host country; 2) "Understanding in practice" which describes reciprocal issues in communication between women and health professionals; and 3) "Negotiating care" which illustrates a mix of coping mechanisms which refugee women utilise to navigate health services in the context of high income countries.

CONCLUSION

Liminality is a ubiquitous experience for refugee women seeking maternity care in high income countries. It impacts feelings of belonging and connection to services and society. It is often a challenging experience for many women and a time in which they reformulate their identity as a citizen and a mother. This review found that the experience of liminality could be perpetuated by social factors, and inequality of healthcare provision, where communication and cultural barriers prevented women accessing care that was equal, accessible, and meaningful. Findings revealed both positive and negative experiences with maternity care. Continuity, culturally appropriate care, and healthcare relationships played an important role in the positive experiences of women. The review also revealed the damaging effects of disparities in care experienced by refugee women.

The Indigenous Birthing in an Urban Setting study: the IBUS study : A prospective birth cohort study comparing different models of care for women having Aboriginal and Torres Strait Islander babies at two major maternity hospitals in urban South East Queensland, Australia

BACKGROUND

With persisting maternal and infant health disparities, new models of maternity care are needed to meet the needs of Aboriginal and Torres Strait Islander people in Australia. To date, there is limited evidence of successful and sustainable programs. Birthing on Country is a term used to describe an emerging evidence-based and community-led model of maternity care for Indigenous families; its impact requires evaluation.

METHODS

Mixed-methods prospective birth cohort study comparing different models of care for women having Aboriginal and Torres Strait Islander babies at two major maternity hospitals in urban South East Queensland (2015-2019). Includes women's surveys (approximately 20 weeks gestation, 36 weeks gestation, two and six months postnatal) and infant assessments (six months postnatal), clinical outcomes and cost comparison, and qualitative interviews with women and staff.

DISCUSSION

This study aims to evaluate the feasibility, acceptability, sustainability, clinical and cost-effectiveness of a Birthing on Country model of care for Aboriginal and Torres Strait Islander families in an urban setting. If successful, findings will inform implementation of the model with similar communities.

TRIAL REGISTRATION

Australian New Zealand Clinical Trial Registry # ACTRN12618001365257 . Registered 14 August 2018 (retrospectively registered).

Neonatal abstinence syndrome in countries with no to low medical opioid consumption: a scoping review

AIM

To describe the current state of evidence on the care of neonates with neonatal abstinence syndrome in countries with low to virtually no medical opioid analgesic consumption.

BACKGROUND

While access to opioids for medical use improves globally, misuse grows as a health concern. One unintended consequence has been an increase in the incidence of neonatal abstinence syndrome. Because most evidence is generated in countries with adequate opioid analgesic consumption, a picture of evidence in lower opioid-consuming countries is not available.

DESIGN

A scoping review methodology was employed and augmented with principles of international development literature review. Electronic database searches (PubMed and CINAHL) located 1106 articles. Google was employed to access an additional 17 non-indexed articles. From the total of 1123 articles located, 27 articles from 15 countries were included.

RESULTS

Minimal evidence was produced in low to virtually no medical opioid-consuming countries. Sources were primarily review articles, descriptive, comparative or case reports. Seventy-one per cent of the articles identified at least one specific clinical practice related to the care of infants with neonatal abstinence syndrome.

CONCLUSIONS

As opioid analgesic use increases globally, a subsequent increase in neonatal abstinence syndrome is likely. It will be beneficial for providers and policymakers to be proactive in considering implications for neonatal and maternal populations and collaborate with providers who have been gaining experience in this area. A number of these countries are heroin-growing regions and already experiencing issues.

IMPLICATIONS FOR NURSING PRACTICE AND HEALTH POLICY

Policymakers may use these findings to support data collection and reporting, context and resource relevant guideline development, and advocacy for inclusion of the maternal-infant population in global opioid research priority setting. International collaboration for establishing gender and culturally appropriate practices globally is critical.

The Growing Impact of Legionella in the Flint Water Crisis

The water crisis in Flint, Michigan raised national awareness about lead- tainted drinking water, particularly its harm to children and pregnant and lactating women. However, according to recent findings, there may be another by-product of this man-made crisis. Failure to use anticorrosive material in the water, a practice mandated by the 1978 Clean Water Act, is being linked to an outbreak of Legionnaires' disease, an illness detrimental primarily to adults over 65 years of age. While Legionnaires' disease is relatively rare, it is also likely to remain undiagnosed. Clinicians, therefore, are urged to consider this diagnosis in adults with pneumonia that does not respond to typical antibiotic treatment, and in newborns with respiratory distress along with other non-typical symptoms as well as those who have had water births or who were exposed to ultrasonic, cool-mist humidification.

Prevalence of disrespect and abuse of women during child birth and associated factors in Bahir Dar town, Ethiopia

OBJECTIVES

Disrespect and abuse are an often-unacknowledged cause of maternal mortality and morbidity globally. The objective of this study was to assess the prevalence and associated factors of disrespect and abuse of women during childbirth at a health facility in the town of Bahir Dar, Ethiopia.

METHODS

In this community-based cross-sectional study, 422 mothers were interviewed from March 1 to 30, 2017 using a systematic random sampling technique with the kth value of 23 calculated based on the number of households in each sub-city and the expected sample size from sub-cities. Data were collected using a structured face-to-face interview questionnaire. EpiData version 3.1 was used to code and enter data, which were analyzed using SPSS version 22. Descriptive statistics were calculated for each variable, and binary logistic regression analysis with 95% confidence intervals (CIs) was carried out to determine the associations between predictor variables and outcome variables.

RESULTS

A total of 410 women participated in the study, with a response rate of 97.2%. The overall prevalence of disrespect and abuse was 67.1% (95% CI, 63.0 to 72.0). Disrespect and abuse were more prevalent in women with a monthly income less than 2,000 Ethiopian birr (adjusted odds ratio [aOR], 1.74; 95% CI, 1.08 to 2.80), mothers who stayed in a health facility after delivery (aOR, 5.14; 95% CI, 2.23 to 11.82), those who received care at a governmental hospital (aOR, 2.49; 95% CI, 1.15 to 5.40), and those who attended fewer than 4 antenatal care visits (aOR, 1.97; 95% CI, 1.15 to 3.40).

CONCLUSIONS

The prevalence of disrespect and abuse was high in this study setting. To decrease the prevalence of this phenomenon, appropriate interventions should be designed, focusing on increasing the number of antenatal care visits, increasing the incomes of mothers, and improving the relationship between health workers and mothers during mothers' stay at health facilities.

Evaluation of community-level interventions to increase early initiation of antenatal care in pregnancy: protocol for the Community REACH study, a cluster randomised controlled trial with integrated process and economic evaluations

Background

The provision of high-quality maternity services is a priority for reducing inequalities in health outcomes for mothers and infants. Best practice includes women having their initial antenatal appointment within the first trimester of pregnancy in order to provide screening and support for healthy lifestyles, well-being and self-care in pregnancy. Previous research has identified inequalities in access to antenatal care, yet there is little evidence on interventions to improve early initiation of antenatal care. The Community REACH trial will assess the effectiveness and cost-effectiveness of engaging communities in the co-production and delivery of an intervention that addresses this issue.

Methods/design

The study design is a matched cluster randomised controlled trial with integrated process and economic evaluations. The unit of randomisation is electoral ward. The intervention will be delivered in 10 wards; 10 comparator wards will have normal practice. The primary outcome is the proportion of pregnant women attending their antenatal booking appointment by the 12th completed week of pregnancy. This and a number of secondary outcomes will be assessed for cohorts of women (n = approximately 1450 per arm) who give birth 2–7 and 8–13 months after intervention delivery completion in the included wards, using routinely collected maternity data. Eight hospitals commissioned to provide maternity services in six NHS trusts in north and east London and Essex have been recruited to the study. These trusts will provide anonymised routine data for randomisation and outcomes analysis. The process evaluation will examine intervention implementation, acceptability, reach and possible causal pathways. The economic evaluation will use a cost-consequences analysis and decision model to evaluate the intervention. Targeted community engagement in the research process was a priority.

Discussion

Community REACH aims to increase early initiation of antenatal care using an intervention that is co-produced and delivered by local communities. This pragmatic cluster randomised controlled trial, with integrated process and economic evaluation, aims to rigorously assess the effectiveness of this public health intervention, which is particularly complex due to the required combination of standardisation with local flexibility. It will also answer questions about scalability and generalisability.

Trial registration

ISRCTN registry: registration number 63066975. Registered on 18 August 2015.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2526-6) contains supplementary material, which is available to authorized users.

Midwives' perceptions of women's preferences related to midwifery care in Germany: A focus group study

OBJECTIVE

To explore how midwives perceive patient preferences related to midwifery care in Germany.

DESIGN

This qualitative study, which was part of a larger study, used a hermeneutic-interpretive approach and involved focus group interviews with midwives. Data collection and analysis were done in a conjoined fashion between April 2015 and September 2016.

SETTING

Four focus group interviews were conducted in four different federal states of Germany.

PARTICIPANTS

The sample of 20 qualified midwives was heterogeneous with regards to age, educational level, professional experience, type of midwifery care provided, and setting (employed, caseload, education) in which they provided services.

FINDINGS

Three main themes were identified: Strengths and limitations of midwives' present professional profile (midwives' area of responsibility, range of services, and competency); lack of midwives and midwifery services; women's experiences of conflict in interprofessional care. Each main theme is broken down into several aspects of content. Many women are not aware of the scope of professional knowledge and expertise of midwives. Moreover, the poor delineation of midwives' and obstetricians' areas of competency in Germany's hospitals seems to be disadvantageous for the women. Midwives feel that due to context implications they cannot live up to the quality of midwifery care they aspire to. Lack of midwives results in midwives being overwhelmed, women underserved, and both disappointed.

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

On the one hand, new models of midwifery/maternity care need to be developed to solve some of the existing problems; on the other hand, new forms of interprofessional cooperation and management of transition of care points are required. Overall it is important that changes are implemented in such a way that women are enabled, and welcome, to clearly state their preferences for midwifery and maternity care. Particularly in Germany, tertiary education of midwives is needed to broaden their expertise and place them on an equal footing with obstetricians.

Improving communication at handover and transfer reduces retained swabs in maternity services

OBJECTIVE

To reduce the incidence of retained vaginal swabs and near misses.

STUDY DESIGN

A review of previous retained swab incidents and near misses in a large maternity unit identified handovers and transfers as a key point of vulnerability. Interventions were introduced to improve communication at handover from the delivery suite to theatre and from theatre to the high dependency unit. Process data was collected to monitor compliance. The outcome measures were the incidence of retained swab never events and the incidence of near misses. Chi-squared analysis was used to test the significance of the results.

RESULTS

For transfers from delivery suite to theatre, verbal handover significantly increased from 28.8% to 75.6% (p<0.0001), and written handover significantly increased from 4.4% to 62.9% (p<0.0001). There were 291 transfers to theatre post-intervention: in 88 (30.2%) of these transfers a vaginal swab was already in situ. In 70/88 (79.5%) of cases the presence of the swab was communicated to theatre staff in three ways (verbally, written and transfer of opened swab packets) according to the new policy. In the post-intervention period there were 56 women transferred from theatre to the high-dependency unit with a vaginal pack in situ: 52 (92.9%) of these women had a sticker in place serving as a constant reminder of the presence of the vaginal pack to staff. Following a baseline of four near misses in two months, there has been only one near miss in the 15 months since the interventions were implemented, (33.3% vs. 1.1%, p<0.0001). There have been no retained swab incidents since the project commenced.

CONCLUSIONS

Simple interventions to improve communication at handover and transfer can reduce the incidence of retained vaginal swabs and near misses. Further work is needed to raise the profile of swab counting in maternity settings: swab counting needs to be the responsibility of all disciplines, not just the responsibility of theatre staff.

Improving non-technical skills (teamwork) in post-partum haemorrhage: A grouped randomised trial

OBJECTIVE

To determine the effect of a decision support technology on teamwork and associated non-technical (NTS) and technical skills when teams manage post-partum haemorrhage (PPH) in the simulated environment.

METHODS

Multidisciplinary (MDT) maternity teams were taught how to manage post partum haemorrhage. They were randomised to the intervention: using a decision support mobile digital platform or a control group. Each team managed a post-partum simulation, which was recorded and reviewed by assessors. Primary outcome measures to assess teams NTS were the validated Global Assessment of Obstetric Team Performance (GAOTP) and Clinical Teamwork Scale (CTS). Secondary outcome measures were the 'friends and family test', technical skills, and the System Usability Scale (SUS). Sample size estimation was calculated by using 80% power 5% significance two tailed test (p1=85% p2=40%) n=34.

RESULTS

38 teams from August 2014-February 2016, were recruited, technical issues with failure of recording equipment meant 4 teams were excluded from teamwork analysis (1 intervention 3 control). Teamwork improved across all domains with the intervention (using a decision support mobile digital platform) p <0.01. CTS improved between 6.7-16.8% (average 14.2%) and GAOTP between 8.6-17.1% (average 13.5%) for all domains. Using the control group as baseline, the intervention improved teamwork by 25% using CTS and 22% using GAOTP. Fewer technical skills were missed with the intervention (p<0.01). There was no statistical difference in the time technical skills were achieved. Assessors were more likely to recommend intervention teams 87.5% (77/88) than control teams 63.6% (56/88) p<0.01 to their friends or family. The SUS was 'Good' (69) becoming excellently 'Usable' (81.6) over the study period.

CONCLUSION

We report a decision support system, which improved NTS when managing PPH. Lack of teamwork is often cited as the cause of failures in care and we report a usable technology that assists with and improves teamwork during an emergency.

Women with a BMI ≥ 30kg/m² and their experience of maternity care: A meta ethnographic synthesis

OBJECTIVE

this paper is a report of a systematic review and meta-ethnography of the experiences of women with body mass index (BMI) ≥ 30kg/m² and their experience of maternity care.

METHOD

systematic review methods identified 12 qualitative studies about women's experiences of maternity care when their BMI ≥ 30kg/m². Findings from the identified studies were synthesised into themes, using metaethnography. SYNTHESIS AND FINDINGS: the meta-ethnography produced four key concepts; Initial encounters, Negotiating risk, Missing out and The positive intervention, which represent the experiences of maternity care for women with BMI ≥ 30kg/m² KEY CONCLUSION: many women with BMI ≥ 30kg/m² appear to be dissatisfied with the approaches taken to discuss weight status during maternity encounters. When weight is not addressed during these encounters women appear to be equally dissatisfied. The absence of open and honest discussions about weight, the feeling of being denied of a normal experience, and an over emphasis on the risks imposed upon pregnancy and childbirth by obesity, leave women feeling dissatisfied and disenfranchised. Sensitive care and practical advice about diet and exercise can help women move towards feeling more in control of their weight management.

"They must understand we are people": Pregnancy and maternity service use among signing Deaf women in Cape Town

BACKGROUND

Women with disabilities are at disproportionate risk for adverse pregnancy outcomes, however, there is limited information on their pregnancy histories. This mixed-methods study focuses on signing Deaf women whose access to health care may be compromised by language barriers related to their disability.

OBJECTIVE

To describe and compare the pregnancy outcomes and maternity service use of a sample of signing Deaf women of child-bearing age in Cape Town to the population of the Western Cape of South Africa.

METHODS

We interviewed 42 Deaf women selected by non-probability snowball sampling, using a structured questionnaire in South African Sign Language in Cape Town in July 2016.

RESULTS

Average parity of the sample was similar to that of the Western Cape population. Most women had one or two children (74%). Thirty-one percent of women had experienced a miscarriage and 19% had terminated a pregnancy. Almost all women (96%) attended at least one antenatal appointment during their pregnancies, and all deliveries occurred at a health facility. Women primarily relied on writing to communicate during antenatal visits and labor/delivery. The majority of women reported communication issues due to limited interpretation services, and some reported experiencing mistreatment from hospital staff.

CONCLUSION

This study provides novel information on the pregnancy histories of Deaf women. While maternal service usage was high, the quality of services were inadequate with reports of linguistic barriers and mistreatment. Findings suggest the need to improve maternity care for Deaf women through implementing interpretation services and providing sensitivity training to health care providers.

Vital signs and other observations used to detect deterioration in pregnant women: an analysis of vital sign charts in consultant-led UK maternity units

BACKGROUND

Obstetric early warning systems are recommended for monitoring hospitalised pregnant and postnatal women. We decided to compare: (i) vital sign values used to define physiological normality; (ii) symptoms and signs used to escalate care; (iii) type of chart used; and (iv) presence of explicit instructions for escalating care.

METHODS

One-hundred-and-twenty obstetric early warning charts and escalation protocols were obtained from consultant-led maternity units in the UK and Channel Islands. These data were extracted: values used to determine normality for each maternal vital sign; chart colour-coding; instructions following early warning system triggering; other criteria used as triggers.

RESULTS

There was considerable variation in the charts, warning systems and escalation protocols. Of 120 charts, 89.2% used colour; 69.2% used colour-coded escalation systems. Forty-one (34.2%) systems required the calculation of weighted scores. Seventy-five discrete combinations of 'normal' vital sign ranges were found, the most common being: heart rate=50-99beats/min; respiratory rate=11-20breaths/min; blood pressure, systolic=100-149mmHg, diastolic ≤89mmHg; SpO₂=95-100%; temperature=36.0-37.9°C; and Alert-Voice-Pain-Unresponsive assessment=Alert. Most charts (90.8%) provided instructions about who to contact following triggering, but only 41.7% gave instructions about subsequent observation frequency.

CONCLUSION

The wide range of 'normal' vital sign values in different systems suggests a lack of equity in the processes for detecting deterioration and escalating care in hospitalised pregnant and postnatal women. Agreement regarding 'normal' vital sign ranges is urgently required and would assist the development of a standardised obstetric early warning system and chart.

Exploring the implementation of an electronic record into a maternity unit: a qualitative study using Normalisation Process Theory

Background

To explore the benefits, barriers and disadvantages of implementing an electronic record system (ERS). The extent that the system has become ‘normalised’ into routine practice was also explored.

Methods

Qualitative semi-structured interviews were conducted with 19 members of NHS staff who represented a variety of staff groups (doctors, midwives of different grades, health care assistants) and wards within a maternity unit at a NHS teaching hospital. Interviews were conducted during the first year of the phased implementation of ERS and were analysed thematically. The four mechanisms of Normalisation Process Theory (NPT) (coherence, cognitive participation, collective action and reflexive monitoring) were adapted for use within the study and provided a theoretical framework to interpret the study’s findings.

Results

Coherence (participants’ understanding of why the ERS has been implemented) was mixed – whilst those involved in ERS implementation anticipated advantages such as improved access to information; the majority were unclear why the ERS was introduced. Participants’ willingness to engage with and invest time into the ERS (cognitive participation) depended on the amount of training and support they received and their willingness to change from paper to electronic records. Collective action (the extent the ERS was used) may be influenced by whether participants perceived there to be benefits associated with the system. Whilst some individuals reported benefits such as improved legibility of records, others felt benefits were yet to emerge. The parallel use of paper and the lack of integration of electronic systems within and between the trust and other healthcare organisations hindered ERS use. When appraising the ERS (reflexive monitoring) participants perceived the system to negatively impact the patient-clinician relationship, time and patient safety.

Conclusions

Despite expectations that the ERS would have a number of advantages, its implementation was perceived to have a range of disadvantages and only a limited number of ‘clinical benefits’. The study highlights the complexity of implementing electronic systems and the associated longevity before they can become ‘embedded’ into routine practice. Through the identification of barriers to the employment of electronic systems this process could be streamlined with the avoidance of any potential detriment to clinical services.

Electronic supplementary material

The online version of this article (doi:10.1186/s12911-016-0406-0) contains supplementary material, which is available to authorized users.

Experiences of motherhood: Unmet expectations of immigrant and native mothers, about the Portuguese health system

Introduction and objectives

This study aims to identify the unmet expectations of Portuguese and immigrant women, for the National Health System, during pregnancy, childbirth and postpartum.

Participants and methods

This is a qualitative, exploratory, descriptive study, using semi structured interviews and content analysis proposed by Bardin, with the categorization of verbatim interviews of 82 Portuguese and immigrant women, supported by NVivo 10.

Results

Major emerging categories of unmet expectations referred to the accessibility, human resources, incentives to maternity, physical and environmental conditions, and organization of the health system. There was a greater representation of dashed expectations among immigrant users when compared to Portuguese women.

Conclusion

The areas of greatest shortage in meeting the needs of users are: surveillance by experts in the health centre and maternity hospital; reduced waiting time for pregnant women in consultations; home visits; more incentives to maternity; longer duration of hospitalization; higher number of professionals and presence of a companion with the parturient.

Maternity health care: The experiences of Sub-Saharan African women in Sub-Saharan Africa and Australia

BACKGROUND

Increasing global migration is resulting in a culturally diverse population in the receiving countries. In Australia, it is estimated that at least four thousand Sub-Saharan African women give birth each year. To respond appropriately to the needs of these women, it is important to understand their experiences of maternity care.

OBJECTIVE

The study aimed to examine the maternity experiences of Sub-Saharan African women who had given birth in both Sub-Saharan Africa and in Australia.

DESIGN

Using a qualitative approach, 14 semi-structured interviews with Sub-Saharan African women now living in Australia were conducted. Data was analysed using Braun and Clark's approach to thematic analysis.

FINDINGS

Four themes were identified; access to services including health education; birth environment and support; pain management; and perceptions of care. The participants experienced issues with access to maternity care whether they were located in Sub-Saharan Africa or Australia. The study draws on an existing conceptual framework on access to care to discuss the findings on how these women experienced maternity care.

CONCLUSION

The study provides an understanding of Sub-Saharan African women's experiences of maternity care across countries. The findings indicate that these women have maternity health needs shaped by their sociocultural norms and beliefs related to pregnancy and childbirth. It is therefore arguable that enhancing maternity care can be achieved by improving women's health literacy through health education, having an affordable health care system, providing respectful and high quality midwifery care, using effective communication, and showing cultural sensitivity including family support for labouring women.

Barriers to spousal contribution to childbirth pain relief in Nigeria

AIM

The aim of this study was to investigate the barriers inhibiting the use of spousal presence for childbirth pain relief in health facilities and recommendations from three perspectives: the midwife, the woman, and the spouse.

BACKGROUND

Spousal presence is a non-invasive, participatory and inexpensive technique used in pain management during childbirth. Although it contributes to a large extent in relieving childbirth pain, it is underutilized in Nigerian hospitals. Overcoming the challenges impeding spousal presence and participation during childbirth will improve maternal outcome, satisfaction and midwifery care practices.

METHOD

A cross-sectional survey conducted in four hospitals in Nigeria involving midwives (n = 100), women (n = 142) and their spouses (n = 142) from June to December 2014 using pretested questionnaires.

RESULTS

Five themes were identified: poor infrastructural facility, lack of adequate pain management policy, lack of midwife pain management practices, midwives' attitudes towards spousal presence during childbirth and feelings about spousal presence during childbirth pain relief.

CONCLUSION

Infrastructural defects in the health facilities resulting in the lack of privacy in maternity units for both spouses and partners negatively influence the presence of a spouse during childbirth and pain relief. Adopting effective strategies such as good infrastructural facilities, staff training and spouse-friendly hospital policies will encourage spouses to fully participate in and contribute to childbirth pain relief.

IMPLICATIONS FOR NURSING AND HEALTH POLICY

This study identified poor staff attitudes towards pain relief and spousal presence during childbirth as barriers. Providing adequate policies on pain management, continuous staff education and orientation on spousal relationship will improve active spousal participation and maternal satisfaction during childbirth.

Associations of biochemical changes and maternal traits with mutation 1843 (C>T) in the RYR1 gene as a common cause for porcine stress syndrome

Stress syndrome is usually caused by a mutation in the ryanodine receptor gene (ryr1) and it is widely studied in humans and swine populations. The protein product of this gene plays a crucial role in the regulation of calcium transport in muscle cells. A G>T mutation in the human ryr1 gene, which results in the replacement of a conserved arginine at position 614 where a leucine occurs at the same position as the previously identified Arg→Cys mutation reported in all cases of porcine stress syndrome (PSS). Porcine stress syndrome affects biochemical pathways in stress-susceptible individuals during a stress episode and some biochemical parameters that were used as markers for diagnostic purposes. Also, PSS has remarkable influence on the maternal characteristics of sows. This study dealt with different genotypes for PSS and its association with possible biochemical changes and maternal traits of sows. Seventy-three reproductive sows genotyped for PSS by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) were included in this survey. Sixty of them were stress-free (NN), 11 were heterozygous carriers (Nn) and two animals were homozygous (nn) for the 1843 (C>T) mutation. Significant differences in non stress induced animals with different PSS genotypes were found in the values of creatine phoshokinase (CPK), lactate dehydrogenase (LDH), alkaline phosphatase (AP) and aspartate aminotransferase (AST). Regarding the maternal traits, our study showed that stress susceptible animals (nn) have an increased number of stillborn piglets and a reduced number of newborn piglets compared with heterozygous and normal animals.

'The greatest feeling you get, knowing you have made a big difference': survey findings on the motivation and experiences of trained volunteer doulas in England

BACKGROUND

Support from a doula is known to have physical and emotional benefits for mothers, but there is little evidence about the experiences of volunteer doulas. This research aimed to understand the motivation and experiences of volunteer doulas who have been trained to support women during pregnancy, birth and the postnatal period.

METHODS

A postal questionnaire survey was sent to volunteer doulas at five volunteer doula projects working in low-income areas in England. Quantitative and qualitative data were analysed in parallel using summary statistics and content analysis respectively.

RESULTS

Eighty-nine volunteer doulas (response rate 34.5 %) from diverse backgrounds responded to the survey. Major motivators for volunteering included a desire to help others and, to a lesser extent, factors related to future employment. Most reported that the training was effective preparation for their role. They continued volunteering because they derived satisfaction from the doula role, and valued its social aspects. Their confidence, skills, employability and social connectedness had all increased, but many found the ending of the doula-mother relationship challenging. For a minority, negative aspects of their experience included time waiting to be allocated women to support and dissatisfaction with the way the doula service was run.

DISCUSSION AND CONCLUSIONS

Most respondents found the experience rewarding. To maintain doulas' motivation as volunteers, services should: ensure doulas can start supporting women as soon as possible after completing the training; consider the merits of more flexible endings to the support relationship; offer opportunities for ongoing mutual support with other doulas, and ensure active support from service staff for volunteers.