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Ismaila Y, Bayes S, Geraghty S. Midwives' experiences of the consequences of navigating barriers to maternity care. Health Care Women Int 2023; 45:1102-1122. [PMID: 38032686 DOI: 10.1080/07399332.2023.2284771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 11/14/2023] [Accepted: 11/14/2023] [Indexed: 12/01/2023]
Abstract
Midwives in Low- and middle-income countries, experience myriad barriers that have consequences for them and for maternity care. This article provides insight into the consequences of the barriers that Ghanaian midwives face in their workplaces. Glaserian Grounded Theory methodology using semi-structured interviews and non-participant observations was applied in this study. The study participants comprised of 29 midwives and a pharmacist, a social worker, a health services manager, and a National Insurance Scheme manager in Ghana. Data collection and analysis occurred concurrently while building on already analyzed data. In this study it was identified that barriers to Ghanaian midwives' ability to provide maternity care can have physiological, psychological, and socioeconomic consequences for midwives. It also negatively impacted maternity care. Implementing new ameliorating measures to mitigate the barriers that Ghanaian midwives encounter, and the consequences that those barriers have on them would improve midwife retention and care quality.
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Affiliation(s)
- Yakubu Ismaila
- School of Nursing and Midwifery, Edith Cowan University, Joondalup, Western Australia, Australia
| | - Sara Bayes
- School of Nursing and Midwifery, Edith Cowan University, Joondalup, Western Australia, Australia
| | - Sadie Geraghty
- School of Nursing and Midwifery, Edith Cowan University, Joondalup, Western Australia, Australia
- Faculty of Medicine, Nursing, Midwifery and Health Sciences, The University of Notre Dame, Fremantle, Western Australia, Australia
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Midwives’ views of changing to a Continuity of Midwifery Care (CMC) model in Scotland: A baseline survey. Women Birth 2020; 33:e409-e419. [DOI: 10.1016/j.wombi.2019.08.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 08/12/2019] [Accepted: 08/12/2019] [Indexed: 11/23/2022]
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“Doing Magic With Very Little”: Barriers to Ghanaian Midwives' Ability to Provide Quality Maternal and Neonatal Care. INTERNATIONAL JOURNAL OF CHILDBIRTH 2020. [DOI: 10.1891/ijcbirth-d-19-00028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSEThis study identified barriers that affected Ghanaian midwives' ability to provide quality care to prevent maternal and neonatal mortality.DESIGNGlaserian Grounded Theory was the framework of this study. Interviews were conducted with 33 participants from 10 facilities in seven districts in one region in southern Ghana.FINDINGSMidwives are committed to do their best to provide quality care to women and newborns. Barriers to their care included a lack of resources of care, unsupportive facility management, and client related barriers.CONCLUSIONSMeasures to reduce barriers for midwives to provide quality care must improve health financing at a national and facility level; the encouragement of supportive supervision and management at a facility level; and actions to enhance midwife engagement with clients and communities.
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Abstract
Objective To explore the definition of autonomy, its significant features and impacts on midwifery practice. Method Combined keywords searched were performed on electronic databases: Scopus, Science Direct and Medline within EBSCOhost and Google Scholar. Data were extracted and analysed corresponding to the objectives of this review. Findings A total of eight studies (n=8) were included (one quantitative and seven qualitative). Autonomy is the central element in midwifery that is commonly linked with informed choices; decision-making and power to control over a situation. In order for a midwife to be autonomous, important attributes include knowledge and skills (being confident, and the ability to think critically). It was also found that infrastructure and culture at work impacts autonomy in midwifery practice. Conclusion Albeit a limited number of studies were included in the review, this review provides an important platform for understanding the principles and concepts that underpin autonomy in midwifery practice.
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Affiliation(s)
| | | | - Deeni Rudita Idris
- Lecturer, PAPRSB Institute of Health Sciences, Universiti Brunei Darussalam
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Walsh D, Spiby H, McCourt C, Coleby D, Grigg C, Bishop S, Scanlon M, Culley L, Wilkinson J, Pacanowski L, Thornton J. Factors influencing utilisation of ‘free-standing’ and ‘alongside’ midwifery units for low-risk births in England: a mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2020. [DOI: 10.3310/hsdr08120] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
Midwifery-led units (MUs) are recommended for ‘low-risk’ births by the National Institute for Health and Care Excellence but according to the National Audit Office were not available in one-quarter of trusts in England in 2013 and, when available, were used by only a minority of the low-risk women for whom they should be suitable. This study explores why.
Objectives
To map the provision of MUs in England and explore barriers to and facilitators of their development and use; and to ascertain stakeholder views of interventions to address these barriers and facilitators.
Design
Mixed methods – first, MU access and utilisation across England was mapped; second, local media coverage of the closure of free-standing midwifery units (FMUs) were analysed; third, case studies were undertaken in six sites to explore the barriers and facilitators that have an impact on the development of MUs; and, fourth, by convening a stakeholder workshop, interventions to address the barriers and facilitators were discussed.
Setting
English NHS maternity services.
Participants
All trusts with maternity services.
Interventions
Establishing MUs.
Main outcome measures
Numbers and types of MUs and utilisation of MUs.
Results
Births in MUs across England have nearly tripled since 2011, to 15% of all births. However, this increase has occurred almost exclusively in alongside units, numbers of which have doubled. Births in FMUs have stayed the same and these units are more susceptible to closure. One-quarter of trusts in England have no MUs; in those that do, nearly all MUs are underutilised. The study findings indicate that most trust managers, senior midwifery managers and obstetricians do not regard their MU provision as being as important as their obstetric-led unit provision and therefore it does not get embedded as an equal and parallel component in the trust’s overall maternity package of care. The analysis illuminates how provision and utilisation are influenced by a complex range of factors, including the medicalisation of childbirth, financial constraints and institutional norms protecting the status quo.
Limitations
When undertaking the case studies, we were unable to achieve representativeness across social class in the women’s focus groups and struggled to recruit finance directors for individual interviews. This may affect the transferability of our findings.
Conclusions
Although there has been an increase in the numbers and utilisation of MUs since 2011, significant obstacles remain to MUs reaching their full potential, especially FMUs. This includes the capacity and willingness of providers to address women’s information needs. If these remain unaddressed at commissioner and provider level, childbearing women’s access to MUs will continue to be restricted.
Future work
Work is needed on optimum approaches to improve decision-makers’ understanding and use of clinical and economic evidence in service design. Increasing women’s access to information about MUs requires further studies of professionals’ understanding and communication of evidence. The role of FMUs in the context of rural populations needs further evaluation to take into account user and community impact.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 12. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Denis Walsh
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Helen Spiby
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | | | - Dawn Coleby
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Celia Grigg
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Simon Bishop
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Miranda Scanlon
- School of Health Sciences, City, University of London, London, UK
| | - Lorraine Culley
- Faculty of Health and Life Sciences, De Montfort University, Leicester, UK
| | | | | | - Jim Thornton
- School of Health Sciences, University of Nottingham, Nottingham, UK
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Crowther S, Deery R, Daellenbach R, Davies L, Gilkison A, Kensington M, Rankin J. Joys and challenges of relationships in Scotland and New Zealand rural midwifery: A multicentre study. Women Birth 2018; 32:39-49. [PMID: 29693545 DOI: 10.1016/j.wombi.2018.04.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Revised: 03/26/2018] [Accepted: 04/02/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Globally there are challenges meeting the recruitment and retention needs for rural midwifery. Rural practice is not usually recognised as important and feelings of marginalisation amongst this workforce are apparent. Relationships are interwoven throughout midwifery and are particularly evident in rural settings. However, how these relationships are developed and sustained in rural areas is unclear. AIM To study the significance of relationships in rural midwifery and provide insights to inform midwifery education. METHODS/DESIGN Multi-centre study using online surveys and discussion groups across New Zealand and Scotland. Descriptive and template analysis were used to organise, examine and analyse the qualitative data. FINDINGS Rural midwives highlighted how relationships with health organisations, each other and women and their families were both a joy and a challenge. Social capital was a principal theme. Subthemes were (a) working relationships, (b) respectful communication, (c) partnerships, (d) interface tensions, (e) gift of time facilitates relationships. CONCLUSIONS To meet the challenges of rural practice the importance of relationship needs acknowledging. Relationships are created, built and sustained at a distance with others who have little appreciation of the rural context. Social capital for rural midwives is thus characterised by social trust, community solidarity, shared values and working together for mutual benefit. Rural communities generally exhibit high levels of social capital and this is key to sustainable rural midwifery practice. IMPLICATIONS Midwives, educationalists and researchers need to address the skills required for building social capital in rural midwifery practice. These skills are important in midwifery pre- and post-registration curricula.
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Affiliation(s)
- Susan Crowther
- School of Nursing and Midwifery, Robert Gordon University, Garthdee Road, Aberdeen, AB10 7AQ, United Kingdom.
| | - Ruth Deery
- Institute for Healthcare Policy and Practice, University of the West of Scotland, United Kingdom.
| | - Rea Daellenbach
- School of Midwifery, Dept. Nursing, Midwifery & Allied Health, Ara Institute of Canterbury, Christchurch, New Zealand.
| | - Lorna Davies
- School of Midwifery, Dept. Nursing, Midwifery & Allied Health, Ara Institute of Canterbury, Christchurch, New Zealand.
| | - Andrea Gilkison
- Midwifery Department, Auckland University of Technology, Wellesley St, Auckland, PB 92006, New Zealand.
| | - Mary Kensington
- School of Midwifery, Dept. Nursing, Midwifery & Allied Health, Ara Institute of Canterbury, Christchurch, New Zealand.
| | - Jean Rankin
- School of Health, Nursing and Midwifery, University of the West of Scotland, High Street, Paisley, PA1 2BE, United Kingdom.
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Sosa GA, Crozier KE, Stockl A. The experiences of midwives and women during intrapartum transfer from one-to-one midwife-led birth environments to obstetric-led units. Midwifery 2018; 65:43-50. [PMID: 30055404 DOI: 10.1016/j.midw.2018.07.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Revised: 06/13/2018] [Accepted: 07/02/2018] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To explore the transition from midwifery one-to-one support in labour within a midwife-led birth environment to an obstetric-led unit from the perspectives of midwives and women. DESIGN Ethnographic study. Data was collected from eleven transfers to an obstetric-led unit. The transfer process was observed for four women. Semi-structured interviews were completed following the births with eleven women and eleven midwives. Nine maternity records were also analysed. SETTING An alongside midwife-led unit, freestanding midwife-led unit, women's homes in England. FINDINGS Territorial behaviour was the main theme experienced by midwives when transferring women to obstetric-led units. Territorial behaviour manifested itself as a feeling of 'us versus them' behaviours, 'feeling under scrutiny' and being aware of 'conflicting ideologies'. For women there were four themes that had an impact on their experiences of transfer obstetric-led units including: (1) their midwife continuing the care on the labour ward, (2) having time to adjust to their new situation, (3) all staff introducing themselves and (4) not being separated from their baby for long periods of time. CONCLUSION AND IMPLICATIONS FOR PRACTICE Transfer from a midwife-led birth environment to an obstetric-led unit is a stressful situation for midwives and women. This paper highlights how territorial behaviours impacted negatively for midwives during transfer to an obstetric-led unit. More research is required to understand territorial behaviours within the maternity services and how more respectful compassionate working relationships can be created. Additionally, from the perspective of women this paper highlights four aspects of care that positively impacted on the experiences of women and even helped them to build resilience to cope with the change of location, situation, medical interventions and new carers when transferring to an obstetric-led unit.
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Affiliation(s)
- Georgina A Sosa
- Faculty of Medicine and Health Sciences, University of East Anglia, Norwich Research Park, NR4 7TJ England, United Kingdom.
| | - Kenda E Crozier
- Faculty of Medicine and Health Sciences, University of East Anglia, Norwich Research Park, NR4 7TJ, England, United Kingdom.
| | - Andrea Stockl
- Faculty of Medicine and Health Sciences, University of East Anglia, NR4 7TJ, England, United Kingdom.
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'Living the rural experience-preparation for practice': The future proofing of sustainable rural midwifery practice through midwifery education. Nurse Educ Pract 2018; 31:143-150. [PMID: 29902743 DOI: 10.1016/j.nepr.2018.06.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 06/05/2018] [Accepted: 06/05/2018] [Indexed: 11/22/2022]
Abstract
Rural practice presents unique challenges and skill requirements for midwives. New Zealand and Scotland face similar challenges in sustaining a rural midwifery workforce. This paper draws from an international multi-centre study exploring rural midwifery to focus on the education needs of student midwives within pre-registration midwifery programmes in order to determine appropriate preparation for rural practice. The mixed-methods study was conducted with 222 midwives working in rural areas in New Zealand (n = 145) and Scotland (n = 77). Midwives' views were gathered through an anonymous online survey and online discussion forums. Descriptive analysis was used for quantitative data and thematic analysis was conducted with qualitative data. 'Future proofing rural midwifery practice' using education was identified as the overarching central theme in ensuring the sustainability of rural midwives, with two associated principle themes emerging (i) 'preparation for rural practice' and (ii) 'living the experience and seeing the reality'. The majority of participants agreed that pre-registration midwifery programmes should include a rural placement for students and rural-specific education with educational input from rural midwives. This study provides insight into how best to prepare midwives for rural practice within pre-registration midwifery education, in order to meet the needs of midwives and families in the rural context.
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Gilkison A, Rankin J, Kensington M, Daellenbach R, Davies L, Deery R, Crowther S. A woman's hand and a lion's heart: Skills and attributes for rural midwifery practice in New Zealand and Scotland. Midwifery 2017; 58:109-116. [PMID: 29331533 DOI: 10.1016/j.midw.2017.12.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Revised: 11/24/2017] [Accepted: 12/06/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE the complex and challenging nature of rural midwifery is a global issue. New Zealand and Scotland both face similar ongoing challenges in sustaining a rural midwifery workforce, and understanding the best preparation for rural midwifery practice. This study aimed to explore the range of skills, qualities and professional expertise needed for remote and rural midwifery practice. DESIGN online mixed methods: An initial questionnaire via a confidential SurveyMonkey® was circulated to all midwives working with rural women and families in New Zealand and Scotland. A follow-up online discussion forum offered midwives a secure environment to share their views about the specific skills, qualities and challenges and how rural midwifery can be sustained. Data presented were analysed using qualitative descriptive thematic analysis. SETTING AND PARTICIPANTS 222 midwives participated in this online study with 145 from New Zealand and 77 from Scotland. FINDINGS underpinning rural midwifery practice is the essence of 'fortitude' which includes having the determination, resilience, and resourcefulness to deal with the many challenges faced in everyday practice and to safeguard midwifery care for women within their rural communities. KEY CONCLUSIONS rural midwives in New Zealand and Scotland who work in rural practice specifically enhance skills such as preparedness, resourcefulness and developing meaningful relationships with women and other colleagues which enables them to safeguard rural birth. IMPLICATIONS FOR PRACTICE findings will inform the preparation of midwives for rural midwifery practice.
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Affiliation(s)
- Andrea Gilkison
- Midwifery Department, Auckland University of Technology, PB 92006, Wellesley St, Auckland, New Zealand.
| | - Jean Rankin
- School of health, Nursing and Midwifery, University of the West of Scotland, High Street, Paisley PA1 2BE, United Kingdom.
| | - Mary Kensington
- School of Midwifery, Dept. Nursing, Midwifery&Allied Health, Ara Institute of Canterbury, Christchurch, New Zealand.
| | - Rea Daellenbach
- School of Midwifery, Dept. Nursing, Midwifery&Allied Health, Ara Institute of Canterbury, Christchurch, New Zealand.
| | - Lorna Davies
- School of Midwifery, Dept. Nursing, Midwifery&Allied Health, Ara Institute of Canterbury, Christchurch, New Zealand.
| | - Ruth Deery
- Maternal Health Institute for Healthcare Policy and Practice, University of the West of Scotland, United Kingdom.
| | - Susan Crowther
- School of Nursing and Midwifery, Robert Gordon University, Garthdee Road, Aberdeen AB10 7AQ, United Kingdom.
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Crowther S, Smythe E. Open, trusting relationships underpin safety in rural maternity a hermeneutic phenomenology study. BMC Pregnancy Childbirth 2016; 16:370. [PMID: 27881105 PMCID: PMC5122205 DOI: 10.1186/s12884-016-1164-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 11/15/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There are interwoven personal, professional and organisational relationships to be navigated in maternity in all regions. In rural regions relationships are integral to safe maternity care. Yet there is a paucity of research on how relationships influence safety and nurture satisfying experiences for rural maternity care providers and mothers and families in these regions. This paper draws attention to how these relationships matter. METHODS This research is informed by hermeneutic phenomenology drawing on Heidegger and Gadamer. Thirteen participants were recruited via purposeful sampling and asked to share their experiences of rural maternity care in recorded unstructured in-depth interviews. Participants were women and health care providers living and working in rural regions. Recordings were transcribed and data interpretively analysed until a plausible and trustworthy thematic pattern emerged. RESULTS Throughout the data the relational nature of rural living surfaced as an interweaving tapestry of connectivity. Relationships in rural maternity are revealed in myriad ways: for some optimal relationships, for others feeling isolated, living with discord and professional disharmony. Professional misunderstandings undermine relationships. Rural maternity can become unsustainable and unsettling when relationships break down leading to unsafeness. CONCLUSIONS This study reveals how relationships are an important and vital aspect to the lived-experience of rural maternity care. Relationships are founded on mutual understanding and attuned to trust matter. These relationships are forged over time and keep childbirth safe and enable maternity care providers to work sustainably. Yet hidden unspoken pre-understandings of individuals and groups build tension in relationships leading to discord. Trust builds healthy rural communities of practice within which everyone can flourish, feel accepted, supported and safe. This is facilitated by collaborative learning activities and open respectful communication founded on what matters most (safe positive childbirth) whilst appreciating and acknowledging professional and personal differences.
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Affiliation(s)
- Susan Crowther
- School of Nursing and Midwifery, Robert Gordon University, Garthdee Road, Aberdeen, Scotland, UK.
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Feltham C, Foster J, Davidson T, Ralph S. Student midwives and paramedic students' experiences of shared learning in pre-hospital childbirth. NURSE EDUCATION TODAY 2016; 41:73-78. [PMID: 27138486 DOI: 10.1016/j.nedt.2016.03.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Revised: 03/09/2016] [Accepted: 03/23/2016] [Indexed: 06/05/2023]
Abstract
AIM To explore the experiences of midwifery and paramedic students undertaking interprofessional learning. METHOD A one day interprofessional learning workshop incorporating peer assisted learning for undergraduate pre-registration midwifery and paramedic students was developed based on collaborative practice theory and simulation based learning. Twenty-five student midwives and thirty-one paramedic students participated in one of two identical workshops conducted over separate days. Videoed focus group sessions were held following the workshop sessions in order to obtain qualitative data around student experience. Qualitative data analysis software (ATLAS.ti) was used to collate the transcriptions from the focus group sessions and the video recordings were scrutinised. Thematic analysis was adopted. RESULTS Four main themes were identified around the understanding of each other's roles and responsibilities, the value of interprofessional learning, organisation and future learning. Students appeared to benefit from a variety of learning opportunities including interprofessional learning and peer assisted learning through the adoption of both formal and informal teaching methods, including simulation based learning. A positive regard for each other's profession including professional practice, professional governing bodies, professional codes and scope of practice was apparent. Students expressed a desire to undertake similar workshops with other professional students. CONCLUSION Interprofessional learning workshops were found to be a positive experience for the students involved. Consideration needs to be given to developing interprofessional learning with other student groups aligned with midwifery at appropriate times in relation to stage of education.
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Hollowell J, Rowe R, Townend J, Knight M, Li Y, Linsell L, Redshaw M, Brocklehurst P, Macfarlane A, Marlow N, McCourt C, Newburn M, Sandall J, Silverton L. The Birthplace in England national prospective cohort study: further analyses to enhance policy and service delivery decision-making for planned place of birth. HEALTH SERVICES AND DELIVERY RESEARCH 2015. [DOI: 10.3310/hsdr03360] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundEvidence from the Birthplace in England Research Programme supported a policy of offering ‘low risk’ women a choice of birth setting, but a number of unanswered questions remained.AimsThis project aimed to provide further evidence to support the development and delivery of maternity services and inform women’s choice of birth setting: specifically, to explore maternal and organisational factors associated with intervention, transfer and other outcomes in each birth setting in ‘low risk’ and ‘higher risk’ women.DesignFive component studies using secondary analysis of the Birthplace prospective cohort study (studies 2–5) and ecological analysis of unit/NHS trust-level data (studies 1 and 5).SettingObstetric units (OUs), alongside midwifery units (AMUs), freestanding midwifery units (FMUs) and planned home births in England.ParticipantsStudies 1–4 focused on ‘low risk’ women with ‘term’ pregnancies planning vaginal birth in 43 AMUs (n = 16,573), in 53 FMUs (n = 11,210), at home in 147 NHS trusts (n = 16,632) and in a stratified, random sample of 36 OUs (n = 19,379) in 2008–10. Study 5 focused on women with pre-existing medical and obstetric risk factors (‘higher risk’ women).Main outcome measuresInterventions (instrumental delivery, intrapartum caesarean section), a measure of low intervention (‘normal birth’), a measure of spontaneous vaginal birth without complications (‘straightforward birth’), transfer during labour and a composite measure of adverse perinatal outcome (‘intrapartum-related mortality and morbidity’ or neonatal admission within 48 hours for > 48 hours). In studies 1 and 3, rates of intervention/maternal outcome and transfer were adjusted for maternal characteristics.AnalysisWe used (a) funnel plots to explore variation in rates of intervention/maternal outcome and transfer between units/trusts, (b) simple, weighted linear regression to evaluate associations between unit/trust characteristics and rates of intervention/maternal outcome and transfer, (c) multivariable Poisson regression to evaluate associations between planned place of birth, maternal characteristics and study outcomes, and (d) logistic regression to investigate associations between time of day/day of the week and study outcomes.ResultsStudy 1 – unit-/trust-level variations in rates of interventions, transfer and maternal outcomes were not explained by differences in maternal characteristics. The magnitude of identified associations between unit/trust characteristics and intervention, transfer and outcome rates was generally small, but some aspects of configuration were associated with rates of transfer and intervention. Study 2 – ‘low risk’ women planning non-OU birth had a reduced risk of intervention irrespective of ethnicity or area deprivation score. In nulliparous women planning non-OU birth the risk of intervention increased with increasing age, but women of all ages planning non-OU birth experienced a reduced risk of intervention. Study 3 – parity, maternal age, gestational age and ‘complicating conditions’ identified at the start of care in labour were independently associated with variation in the risk of transfer in ‘low risk’ women planning non-OU birth. Transfers did not vary by time of day/day of the week in any meaningful way. The duration of transfer from planned FMU and home births was around 50–60 minutes; transfers for ‘potentially urgent’ reasons were quicker than transfers for ‘non-urgent’ reasons. Study 4 – the occurrence of some interventions varied by time of the day/day of the week in ‘low risk’ women planning OU birth. Study 5 – ‘higher risk’ women planning birth in a non-OU setting had fewer risk factors than ‘higher risk’ women planning OU birth and these risk factors were different. Compared with ‘low risk’ women planning home birth, ‘higher risk’ women planning home birth had a significantly increased risk of our composite adverse perinatal outcome measure. However, in ‘higher risk’ women, the risk of this outcome was lower in planned home births than in planned OU births, even after adjustment for clinical risk factors.ConclusionsExpansion in the capacity of non-OU intrapartum care could reduce intervention rates in ‘low risk’ women, and the benefits of midwifery-led intrapartum care apply to all ‘low risk’ women irrespective of age, ethnicity or area deprivation score. Intervention rates differ considerably between units, however, for reasons that are not understood. The impact of major changes in the configuration of maternity care on outcomes should be monitored and evaluated. The impact of non-clinical factors, including labour ward practices, staffing and skill mix and women’s preferences and expectations, on intervention requires further investigation. All women planning non-OU birth should be informed of their chances of transfer and, in particular, older nulliparous women and those more than 1 week past their due date should be advised of their increased chances of transfer. No change in the guidance on planning place of birth for ‘higher risk’ women is recommended, but research is required to evaluate the safety of planned AMU birth for women with selected relatively common risk factors.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Jennifer Hollowell
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Rachel Rowe
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - John Townend
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Marian Knight
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Yangmei Li
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Louise Linsell
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Maggie Redshaw
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | | | - Alison Macfarlane
- Centre for Maternal and Child Health Research, City University London, London, UK
| | - Neil Marlow
- Institute for Women’s Health, University College London, London, UK
| | - Christine McCourt
- Centre for Maternal and Child Health Research, City University London, London, UK
| | | | - Jane Sandall
- Division of Women’s Health, King’s College London, London, UK
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Rowe RE, Townend J, Brocklehurst P, Knight M, Macfarlane A, McCourt C, Newburn M, Redshaw M, Sandall J, Silverton L, Hollowell J. Duration and urgency of transfer in births planned at home and in freestanding midwifery units in England: secondary analysis of the birthplace national prospective cohort study. BMC Pregnancy Childbirth 2013; 13:224. [PMID: 24314134 PMCID: PMC4029797 DOI: 10.1186/1471-2393-13-224] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Accepted: 11/27/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In England, there is a policy of offering healthy women with straightforward pregnancies a choice of birth setting. Options may include home or a freestanding midwifery unit (FMU). Transfer rates from these settings are around 20%, and higher for nulliparous women. The duration of transfer is of interest because of the potential for delay in access to specialist care and is also of concern to women. We aimed to estimate the duration of transfer in births planned at home and in FMUs and explore the effects of distance and urgency on duration. METHODS This was a secondary analysis of data collected in a national prospective cohort study including 27,842 'low risk' women with singleton, term, 'booked' pregnancies, planning birth in FMUs or at home in England from April 2008 to April 2010. We described transfer duration using the median and interquartile range, for all transfers and those for reasons defined as potentially urgent or non-urgent, and used cumulative distribution curves to compare transfer duration by urgency. We explored the effect of distance for transfers from FMUs and described outcomes in women giving birth within 60 minutes of transfer. RESULTS The median overall transfer time, from decision to transfer to first OU assessment, was shorter in transfers from home compared with transfers from FMUs (49 vs 60 minutes; p < 0.001). The median duration of transfers before birth for potentially urgent reasons (home 42 minutes, FMU 50 minutes) was 8-10 minutes shorter compared with transfers for non-urgent reasons. In transfers for potentially urgent reasons, the median overall transfer time from FMUs within 20 km of an OU was 47 minutes, increasing to 55 minutes from FMUs 20-40 km away and 61 minutes in more remote FMUs. In women who gave birth within 60 minutes after transfer, adverse neonatal outcomes occurred in 1-2% of transfers. CONCLUSIONS Transfers from home or FMU commonly take up to 60 minutes from decision to transfer, to first assessment in an OU, even for transfers for potentially urgent reasons. Most transfers are not urgent and emergencies and adverse outcomes are uncommon, but urgent transfer is more likely for nulliparous women.
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Affiliation(s)
- Rachel E Rowe
- National Perinatal Epidemiology Unit, University of Oxford, Old Road Campus, Oxford OX3 7LF, UK
| | - John Townend
- National Perinatal Epidemiology Unit, University of Oxford, Old Road Campus, Oxford OX3 7LF, UK
| | - Peter Brocklehurst
- National Perinatal Epidemiology Unit, University of Oxford, Old Road Campus, Oxford OX3 7LF, UK
- Institute for Women’s Health, University College London, London, UK
| | - Marian Knight
- National Perinatal Epidemiology Unit, University of Oxford, Old Road Campus, Oxford OX3 7LF, UK
| | - Alison Macfarlane
- Department of Midwifery and Child Health, City University London, London, UK
| | - Christine McCourt
- Department of Midwifery and Child Health, City University London, London, UK
| | | | - Maggie Redshaw
- National Perinatal Epidemiology Unit, University of Oxford, Old Road Campus, Oxford OX3 7LF, UK
| | - Jane Sandall
- Division of Women’s Health, King’s College London, London, UK
| | | | - Jennifer Hollowell
- National Perinatal Epidemiology Unit, University of Oxford, Old Road Campus, Oxford OX3 7LF, UK
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Bick D. Why midwifery matters. Midwifery 2013; 29:1279-80. [PMID: 24200314 DOI: 10.1016/j.midw.2013.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Debra Bick
- King's College London, Florence Nightingale School of Nursing and Midwifery, James Clerk Maxwell Building, 57 Waterloo Road, London SE1 8WA, UK.
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Yates K, Kelly J, Lindsay D, Usher K. The experience of rural midwives in dual roles as nurse and midwife: “I’d prefer midwifery but I chose to live here”. Women Birth 2013; 26:60-4. [DOI: 10.1016/j.wombi.2012.03.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2011] [Revised: 01/31/2012] [Accepted: 03/19/2012] [Indexed: 10/28/2022]
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Young N. An exploration of clinical decision-making among students and newly qualified midwives. Midwifery 2012; 28:824-30. [DOI: 10.1016/j.midw.2011.09.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2011] [Revised: 09/19/2011] [Accepted: 09/25/2011] [Indexed: 10/15/2022]
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