An investigation of the relationship between the caseload model of midwifery for socially disadvantaged women and childbirth outcomes using routine data – A retrospective, observational study

Continuous Support from the Same Public Health Nurse and Parental Perception and Use of Health Care Services: A Retrospective Observational Study

OBJECTIVE

Continuity is considered essential for high-quality maternal and child health care services, but studies to show this effect on parental well-being are still rare. We studied whether receiving support from the same public health nurse has a beneficial effect on parental perceptions of health care professionals and the use of childcare support services.

METHODS

Maternal and child health care services were provided by different nurses in a Japanese municipality until March 2019. From April 2019, all families with infants received continuous support from the same assigned nurse. A questionnaire covering parental perception and the use of services was sent by postal mail to 1,341 families with infants. The data were analyzed using χ2-test, t-test and logistic regression producing odds ratios (OR) with 95% confidence intervals (CI).

RESULTS

Parental perceptions of the availability of professionals to discuss children's issues, the degree of understanding about available other childcare support services, the degree of utilizing other services, and satisfaction with health care services were higher in parents who received continuous support from the same assigned nurse compared to those who did not receive continuous support. Continuous support was associated with parental perceptions of the availability of professionals to discuss children's issues (OR = 1.97, 95% CI 1.34-2.91) and the degree of understanding about available other child-care support services (OR = 1.65, 95% CI 1.11-2.44) after adjusting the results for socioeconomic factors.

CONCLUSIONS

Continuous support from the same assigned nurse has benefits for parents. This offers a cost-effective way to improve parental well-being.

Midwife continuity of care models versus other models of care for childbearing women

BACKGROUND

Midwives are primary providers of care for childbearing women globally and there is a need to establish whether there are differences in effectiveness between midwife continuity of care models and other models of care. This is an update of a review published in 2016.

OBJECTIVES

To compare the effects of midwife continuity of care models with other models of care for childbearing women and their infants.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Trials Register, ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform (ICTRP) (17 August 2022), as well as the reference lists of retrieved studies.

SELECTION CRITERIA

All published and unpublished trials in which pregnant women are randomly allocated to midwife continuity of care models or other models of care during pregnancy and birth.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed studies for inclusion criteria, scientific integrity, and risk of bias, and carried out data extraction and entry. Primary outcomes were spontaneous vaginal birth, caesarean section, regional anaesthesia, intact perineum, fetal loss after 24 weeks gestation, preterm birth, and neonatal death. We used GRADE to rate the certainty of evidence.

MAIN RESULTS

We included 17 studies involving 18,533 randomised women. We assessed all studies as being at low risk of scientific integrity/trustworthiness concerns. Studies were conducted in Australia, Canada, China, Ireland, and the United Kingdom. The majority of the included studies did not include women at high risk of complications. There are three ongoing studies targeting disadvantaged women. Primary outcomes Based on control group risks observed in the studies, midwife continuity of care models, as compared to other models of care, likely increase spontaneous vaginal birth from 66% to 70% (risk ratio (RR) 1.05, 95% confidence interval (CI) 1.03 to 1.07; 15 studies, 17,864 participants; moderate-certainty evidence), likelyreduce caesarean sections from 16% to 15% (RR 0.91, 95% CI 0.84 to 0.99; 16 studies, 18,037 participants; moderate-certainty evidence), and likely result in little to no difference in intact perineum (29% in other care models and 31% in midwife continuity of care models, average RR 1.05, 95% CI 0.98 to 1.12; 12 studies, 14,268 participants; moderate-certainty evidence). There may belittle or no difference in preterm birth (< 37 weeks) (6% under both care models, average RR 0.95, 95% CI 0.78 to 1.16; 10 studies, 13,850 participants; low-certainty evidence). We arevery uncertain about the effect of midwife continuity of care models on regional analgesia (average RR 0.85, 95% CI 0.79 to 0.92; 15 studies, 17,754 participants, very low-certainty evidence), fetal loss at or after 24 weeks gestation (average RR 1.24, 95% CI 0.73 to 2.13; 12 studies, 16,122 participants; very low-certainty evidence), and neonatal death (average RR 0.85, 95% CI 0.43 to 1.71; 10 studies, 14,718 participants; very low-certainty evidence). Secondary outcomes When compared to other models of care, midwife continuity of care models likely reduce instrumental vaginal birth (forceps/vacuum) from 14% to 13% (average RR 0.89, 95% CI 0.83 to 0.96; 14 studies, 17,769 participants; moderate-certainty evidence), and may reduceepisiotomy 23% to 19% (average RR 0.83, 95% CI 0.77 to 0.91; 15 studies, 17,839 participants; low-certainty evidence). When compared to other models of care, midwife continuity of care models likelyresult in little to no difference inpostpartum haemorrhage (average RR 0.92, 95% CI 0.82 to 1.03; 11 studies, 14,407 participants; moderate-certainty evidence) and admission to special care nursery/neonatal intensive care unit (average RR 0.89, 95% CI 0.77 to 1.03; 13 studies, 16,260 participants; moderate-certainty evidence). There may be little or no difference in induction of labour (average RR 0.92, 95% CI 0.85 to 1.00; 14 studies, 17,666 participants; low-certainty evidence), breastfeeding initiation (average RR 1.06, 95% CI 1.00 to 1.12; 8 studies, 8575 participants; low-certainty evidence), and birth weight less than 2500 g (average RR 0.92, 95% CI 0.79 to 1.08; 9 studies, 12,420 participants; low-certainty evidence). We are very uncertain about the effect of midwife continuity of care models compared to other models of care onthird or fourth-degree tear (average RR 1.10, 95% CI 0.81 to 1.49; 7 studies, 9437 participants; very low-certainty evidence), maternal readmission within 28 days (average RR 1.52, 95% CI 0.78 to 2.96; 1 study, 1195 participants; very low-certainty evidence), attendance at birth by a known midwife (average RR 9.13, 95% CI 5.87 to 14.21; 11 studies, 9273 participants; very low-certainty evidence), Apgar score less than or equal to seven at five minutes (average RR 0.95, 95% CI 0.72 to 1.24; 13 studies, 12,806 participants; very low-certainty evidence) andfetal loss before 24 weeks gestation (average RR 0.82, 95% CI 0.67 to 1.01; 12 studies, 15,913 participants; very low-certainty evidence). No maternal deaths were reported across three studies. Although the observed risk of adverse events was similar between midwifery continuity of care models and other models, our confidence in the findings was limited. Our confidence in the findings was lowered by possible risks of bias, inconsistency, and imprecision of some estimates. There were no available data for the outcomes: maternal health status, neonatal readmission within 28 days, infant health status, and birth weight of 4000 g or more. Maternal experiences and cost implications are described narratively. Women receiving care from midwife continuity of care models, as opposed to other care models, generally reported more positive experiences during pregnancy, labour, and postpartum. Cost savings were noted in the antenatal and intrapartum periods in midwife continuity of care models.

AUTHORS' CONCLUSIONS

Women receiving midwife continuity of care models were less likely to experience a caesarean section and instrumental birth, and may be less likely to experience episiotomy. They were more likely to experience spontaneous vaginal birth and report a positive experience. The certainty of some findings varies due to possible risks of bias, inconsistencies, and imprecision of some estimates. Future research should focus on the impact on women with social risk factors, and those at higher risk of complications, and implementation and scaling up of midwife continuity of care models, with emphasis on low- and middle-income countries.

Systematic review of women's experiences of planning home birth in consultation with maternity care providers in middle to high-income countries

AIM

To synthesise findings from published studies, which reported on women's experiences of planning a home birth in consultation with maternity care providers.

DESIGN

Systematic Review DATA SOURCES: We searched seven bibliographic databases, (Ovid Medline, Embase, PsycInfo, CINAHL plus, Scopus, ProQuest and Cochrane (Central and Library), from January 2015 to 29th April 2022.

REVIEW METHODS

Primary studies were included if they investigated women's experiences of planning a home birth with maternity care providers, in upper-middle and high-income countries and written in English language. Studies were analysed using thematic synthesis. GRADE-CERQual was used to assess the quality, coherence, adequacy and relevance of data. The protocol is registered on PROSPERO registration ID: CRD 42018095042 (updated 28th September 2020) and published.

RESULTS

1274 articles were retrieved, and 410 duplicates removed. Following screening and quality appraisal, 20 eligible studies (19 qualitative and 1 survey) involving 2,145 women were included.

KEY CONCLUSIONS

Women's prior traumatic experience of hospital birth and a preference for physiological birth motivated their assertive decision to have a planned home birth despite criticisms and stigmatisation from their social circle and some maternity care providers. Midwives' competence and support enhanced women's confidence and positive experiences of planning a home birth.

IMPLICATIONS FOR PRACTICE

This review highlights the stigma that some women feel and the importance of support from health professionals, particularly midwives when planning a home birth. We recommend accessible evidence-based information for women and their families to support women's decision-making for planned home birth. The findings from this review can be used to inform woman-centred planned home birth services, particularly in the UK, (although evidence is drawn from papers in eight other countries, so findings are relevant elsewhere), which will impact positively on the experiences of women who are planning home birth.

Comparing the views of caseload midwives working with First Nations families in an all-risk, culturally responsive model with midwives working in standard caseload models, using a cross-sectional survey design

PROBLEM

Little is known about midwives' views and wellbeing when working in an all-risk caseload model.

BACKGROUND

Between March 2017 and December 2020 three maternity services in Victoria, Australia implemented culturally responsive caseload models for women having a First Nations baby.

AIM

Explore the views, experiences and wellbeing of midwives working in an all-risk culturally responsive model for First Nations families compared to midwives in standard caseload models in the same services.

METHODS

A survey was sent to all midwives in the culturally responsive (CR) model six-months and two years after commencement (or on exit), and to standard caseload (SC) midwives two years after the culturally responsive model commenced. Measures used included the Midwifery Process Questionnaire and Copenhagen Burnout Inventory (CBI).

FINDINGS

35 caseload midwives (19 CR, 16 SC) participated. Both groups reported positive attitudes towards their professional role, trending towards higher median levels of satisfaction for the culturally responsive midwives. Midwives valued building close relationships with women and providing continuity of care. Around half reported difficulty maintaining work-life balance, however almost all preferred the flexible hours to shift work. All agreed that a reduced caseload is needed for an all-risk model and that supports around the model (e.g. nominated social workers, obstetricians) are important. Mean CBI scores showed no burnout in either group, with small numbers of individuals having burnout in both groups.

DISCUSSION AND CONCLUSION

Midwives were highly satisfied working in both caseload models, but decreased caseloads and more organisational supports are needed in all-risk models.

Effectiveness of midwifery-led care on pregnancy outcomes in low- and middle-income countries: a systematic review and meta-analysis

BACKGROUND

Midwifery-led care is an evidence-based practice in which a qualified midwife provides comprehensive care for low-risk pregnant women and new-borns throughout pregnancy, birth, and the postnatal period. Evidence indicates that midwifery-led care has positive impacts on various outcomes, which include preventing preterm births, reducing the need for interventions, and improving clinical outcomes. This is, however, mainly based on studies from high-income countries. Therefore, this systematic review and meta-analysis aimed to assess the effectiveness of midwifery-led care on pregnancy outcomes in low- and middle-income countries.

METHODS

We used the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. Three electronic databases (PubMed, CINAHL, and EMBASE) were searched. The search results were systematically screened by two independent researchers. Two authors independently extracted all relevant data using a structured data extraction format. Data analysis for the meta-analysis was done using STATA Version 16 software. A weighted inverse variance random-effects model was used to estimate the effectiveness of midwifery-led care on pregnancy outcomes. Odds ratio with a 95% confidence interval (CI) was presented using a forest plot.

RESULTS

Ten studies were eligible for inclusion in this systematic review, of which five studies were eligible for inclusion in the meta-analysis. Women receiving midwifery-led care had a significantly lower rate of postpartum haemorrhage and a reduced rate of birth asphyxia. The meta-analysis further showed a significantly reduced risk of emergency Caesarean section (OR = 0.49; 95% CI: 0.27-0.72), increased odds of vaginal birth (OR = 1.14; 95% CI: 1.04-1.23), decreased use of episiotomy (OR = 0.46; 95% CI: 0.10-0.82), and decreased average neonatal admission time in neonatal intensive care unit (OR = 0.59; 95% CI: 0.44-0.75).

CONCLUSIONS

This systematic review indicated that midwifery-led care has a significant positive impact on improving various maternal and neonatal outcomes in low- and middle-income countries. We therefore advise widespread implementation of midwifery-led care in low- and middle-income countries.

Project20: maternity care mechanisms that improve access and engagement for women with social risk factors in the UK - a mixed-methods, realist evaluation

OBJECTIVES

To evaluate how women access and engage with different models of maternity care, whether specialist models improve access and engagement for women with social risk factors, and if so, how?

DESIGN

Realist evaluation.

SETTING

Two UK maternity service providers.

PARTICIPANTS

Women accessing maternity services in 2019 (n=1020).

METHODS

Prospective observational cohort with multinomial regression analysis to compare measures of access and engagement between models and place of antenatal care. Realist informed, longitudinal interviews with women accessing specialist models of care were analysed to identify mechanisms.

MAIN OUTCOME MEASURES

Measures of access and engagement, healthcare-seeking experiences.

RESULTS

The number of social risk factors women were experiencing increased with deprivation score, with the most deprived more likely to receive a specialist model that provided continuity of care. Women attending hospital-based antenatal care were more likely to access maternity care late (risk ratio (RR) 2.51, 95% CI 1.33 to 4.70), less likely to have the recommended number of antenatal appointments (RR 0.61, 95% CI 0.38 to 0.99) and more likely to have over 15 appointments (RR 4.90, 95% CI 2.50 to 9.61) compared with community-based care. Women accessing standard care (RR 0.02, 95% CI 0.00 to 0.11) and black women (RR 0.02, 95% CI 0.00 to 0.11) were less likely to have appointments with a known healthcare professional compared with the specialist model. Qualitative data revealed mechanisms for improved access and engagement including self-referral, relational continuity with a small team of midwives, flexibility and situating services within deprived community settings.

CONCLUSION

Inequalities in access and engagement with maternity care appears to have been mitigated by the community-based specialist model that provided continuity of care. The findings enabled the refinement of a realist programme theory to inform those developing maternity services in line with current policy.

Creating coherent perinatal care journeys: An ethnographic study of the role of continuity of care for Danish parents in a vulnerable position

BACKGROUND

While continuity of care is a core element of high-quality maternity care, it is potentially even more important for pregnant women and their partners who are at risk of adverse health outcomes because of psychosocial vulnerability. However, little is known about how a coherent care journey can be ensured for women and families who may require interdisciplinary and inter-sectoral services during pregnancy and the postnatal period.

AIM

To explore the role of continuity of care in creating a coherent care journey for vulnerable parents during pregnancy and the postnatal period.

METHODS

An ethnographic study conducted in Denmark based on interviews with, and field observations, of 26 mothers and 13 fathers receiving services due to mental health problems, young age, past substance abuse and/or adverse childhood experiences.

FINDINGS

Three key findings emerged: 1). Developing relationships allowed parents to know and feel known by care providers, which helped them feel secure and reach out for support. 2). Handover of information allowed parents to feel secure as their need for support was recognised by care providers; some parents, however, felt exposed when information was shared 3). Receiving relevant services allowed parents to have their needs for support addressed, which requires easy referral pathways and coordination of services.

CONCLUSION

All forms of continuity of care should be prioritised in the organisation of maternity care services for women and families in vulnerable positions. While relational continuity is important, continuity of care must also reach across providers, sectors and services to ensure coherent care journeys.

"She was there all the time". A qualitative study exploring how women at higher risk for preterm birth experience midwifery continuity of care

PROBLEM

There is a paucity of research on experiences and views of women at higher risk of preterm birth of midwifery continuity of care.

BACKGROUND

Midwifery continuity of care (MCoC) has been associated with improved maternal outcomes and with lower levels of preterm births and stillbirths. The majority of MCoC studies have focused on women without risk factors and little has been published on women with obstetric complexities. The aim of this study is to explore the views and experiences of women identified as a higher risk of preterm birth who have had continuity of care from midwives.

DESIGN

Face-to-face, semi-structured interviews with 16 women identified as at increased risk of preterm birth and experienced continuity of midwifery care across pregnancy, birth and the postnatal period. Care had been provided by the pilot intervention group for the pilot study of midwifery practice in preterm birth including women's experiences (POPPIE) trial.

FINDINGS

Women valued continuity of midwifery care across the care pathway and described the reassurance provided by having 24 h a day, seven days a week access to known midwives. Consistency of care, advocacy and accessibility to the team were described as the main factors contributing to their feelings of safety and control.

KEY CONCLUSIONS

Recognising that known midwives were 'there all the time' made women feel listened to and actively involved in clinical decision making, which contributed to women feeling less stressed and anxious during their pregnancy, birth and early parenthood. When developing MCoC models for women with obstetric complexities: access, advocacy and time should be embedded to ensure women can build trusting relationships and reduce anxiety levels.

A Comprehensive Review on Social Inequalities and Pregnancy Outcome-Identification of Relevant Pathways and Mechanisms

Scientific literature tends to support the idea that the pregnancy and health status of fetuses and newborns can be affected by maternal, parental, and contextual characteristics. In addition, a growing body of evidence reports that social determinants, measured at individual and/or aggregated level(s), play a crucial role in fetal and newborn health. Numerous studies have found social factors (including maternal age and education, marital status, pregnancy intention, and socioeconomic status) to be linked to poor birth outcomes. Several have also suggested that beyond individual and contextual social characteristics, living environment and conditions (or "neighborhood") emerge as important determinants in health inequalities, particularly for pregnant women. Using a comprehensive review, we present a conceptual framework based on the work of both the Commission on Social Determinants of Health and the World Health Organization (WHO), aimed at describing the various pathways through which social characteristics can affect both pregnancy and fetal health, with a focus on the structural social determinants (such as socioeconomic and political context) that influence social position, as well as on intermediary determinants. We also suggest that social position may influence more specific intermediary health determinants; individuals may, on the basis of their social position, experience differences in environmental exposure and vulnerability to health-compromising living conditions. Our model highlights the fact that adverse birth outcomes, which inevitably lead to health inequity, may, in turn, affect the individual social position. In order to address both the inequalities that begin in utero and the disparities observed at birth, it is important for interventions to target various unhealthy behaviors and psychosocial conditions in early pregnancy. Health policy must, then, support: (i) midwifery availability and accessibility and (ii) enhanced multidisciplinary support for deprived pregnant women.

Project20: Maternity care mechanisms that improve (or exacerbate) health inequalities. A realist evaluation

BACKGROUND

Women with low socioeconomic status and social risk factors are at a disproportionate risk of poor birth outcomes and experiences of maternity care. Specialist models of maternity care that offer continuity are known to improve outcomes but underlying mechanisms are not well understood.

AIM

To evaluate two UK specialist models of care that provide continuity to women with social risk factors and identify specific mechanisms that reduce, or exacerbate, health inequalities.

METHODS

Realist informed interviews were undertaken throughout pregnancy and the postnatal period with 20 women with social risk factors who experienced a specialist model of care.

FINDINGS

Experiences of stigma, discrimination and paternalistic care were reported when women were not in the presence of a known midwife during care episodes. Practical and emotional support, and evidence-based information offered by a known midwife improved disclosure of social risk factors, eased perceptions of surveillance and enabled active participation. Continuity of care offered reduced women's anxiety, enabled the development of a supportive network and improved women's ability to seek timely help. Women described how specialist model midwives knew their medical and social history and how this improved safety. Care set in the community by a team of six known midwives appeared to enhance these benefits.

CONCLUSION

The identification of specific maternity care mechanisms supports current policy initiatives to scale up continuity models and will be useful in future evaluation of services for marginalised groups. However, the specialist models of care cannot overcome all inequalities without improvements in the maternity system as a whole.

Effect of an Australian community-based caseload midwifery group practice service on maternal and neonatal outcomes for women from a refugee background

BACKGROUND

Women from a refugee background who resettle in high-income countries experience poorer perinatal outcomes in comparison to women from host countries. There is a paucity of research on how best to improve these outcomes.

AIM

To report on the effectiveness of an Australian Refugee Midwifery Group Practice service on perinatal outcomes.

METHODS

We used inverse probability of treatment weighting to balance confounders and calculate treatment effect and compare maternal and neonatal outcomes for women from a refugee background who received Refugee Midwifery Group Practice care (n = 625), to those receiving standard care (n = 634) at a large tertiary hospital (1 January 2016-31 December 2019). Prespecified primary outcomes included: proportion of women attending ≥ 5 antenatal visits, preterm birth (<37 weeks), spontaneous onset of labour, epidural analgesia in the first stage of labour, normal birth (term, spontaneous onset, vertex, spontaneous vaginal birth, no epidural, no episiotomy), and exclusively breast-feeding at discharge.

FINDINGS

Women who received Refugee Midwifery Group Practice care were more likely to have spontaneous onset of labour (adjusted odds ratio 2·20, 95% CI 1·71-2·82; p < 0·0001), normal birth (1·55, 1·23-1·95; p < 0·0001), and less likely to use epidural analgesia (0·67, 0·50-0·89; p = 0·0067) and have a preterm baby (0·60, 0·36-0·99; p = 0·047). There was no difference between groups in women attending ≥ 5 antenatal visits and exclusive breastfeeding at discharge from hospital.

DISCUSSION

A Refugee Midwifery Group Practice is feasible and clinically effective.

CONCLUSION

Similar services could potentially improve outcomes for women from a refugee background who resettle in high-income countries.

Adult Daughters of Alcoholic Parents-A Qualitative Study of These Women's Pregnancy Experiences and the Potential Implications for Antenatal Care Provision

The adult children of alcoholic parents are at increased risk of having health problems compared to the adult children of nonalcoholic parents. Little is known about how growing up with alcoholic parents affects women’s experiences when pregnant. The objectives of this study were to explore how adverse childhood experiences related to parental alcohol abuse affect women during their pregnancy and to assess the potential implications of women’s experiences for antenatal care provision. Twelve in-depth interviews were performed with women who were brought up by an alcoholic mother and/or father. Systematic text condensation was used to analyse the data. Two main categories were identified: ‘establishing relationships and having social support’ and ‘antenatal care encounters and concerns during pregnancy’. Women’s trust in others in adult life was impacted by their upbringing. Strained relationships with their parents and few friends meant that the women primarily relied on their partners for support. Neither antenatal care providers nor women talked about women’s childhood experiences at the visits. The women described concerns related to the baby’s health, lack of predictability and control during the pregnancy, as well as apprehensiveness regarding birth and motherhood. The potential implications for practice include systematic screening for adverse childhood experiences, antenatal preparation classes, parenting courses, and post-graduate training.

Can birth outcome inequality be reduced using targeted caseload midwifery in a deprived diverse inner city population? A retrospective cohort study, London, UK

OBJECTIVES

(1) To report maternal and newborn outcomes of pregnant women in areas of social deprivation in inner city London. (2) To compare the effect of caseload midwifery with standard care on maternal and newborn outcomes in this cohort of women.

DESIGN

Retrospective observational cohort study.

SETTING

Four council wards (electoral districts) in inner city London, where over 90% of residents are in the two most deprived quintiles of the English Index of Multiple Deprivation (IMD) (2019) and the population is ethnically diverse.

PARTICIPANTS

All women booked for antenatal care under Guys and St Thomas' National Health Service Foundation Trust after 11 July 2018 (when the Lambeth Early Action Partnership (LEAP*) caseload midwifery team was implemented) until data collection 18 June 2020. This included 523 pregnancies in the LEAP area, of which 230 were allocated to caseload midwifery, and 8430 pregnancies from other areas.

MAIN OUTCOME MEASURES

To explore if targeted caseload midwifery (known to reduce preterm birth) will improve important measurable outcomes (preterm birth, mode of birth and newborn outcomes).

RESULTS

There was a significant reduction in preterm birth rate in women allocated to caseload midwifery, when compared with those who received traditional midwifery care (5.1% vs 11.2%; risk ratio: 0.41; p=0.02; 95% CI 0.18 to 0.86; number needed to treat: 11.9). Caesarean section births were significantly reduced in women allocated to caseload midwifery care, when compared with traditional midwifery care (24.3% vs 38.0%; risk ratio: 0.64: p=0.01; 95% CI 0.47 to 0.90; number needed to treat: 7.4) including emergency caesarean deliveries (15.2% vs 22.5%; risk ratio: 0.59; p=0.03; 95% CI 0.38 to 0.94; number needed to treat: 10) without increase in neonatal unit admission or stillbirth.

CONCLUSION

This study shows that a model of caseload midwifery care implemented in an inner city deprived community improves outcome by significantly reducing preterm birth and birth by caesarean section when compared with traditional care. This data trend suggests that when applied to targeted groups (women in higher IMD quintile and women of diverse ethnicity) that the impact of intervention is greater.

Midwife-led continuity of care improved maternal and neonatal health outcomes in north Shoa zone, Amhara regional state, Ethiopia: A quasi-experimental study

BACKGROUND

In a low-resource setting, information on the effect of midwife-led continuity of care (MLCC) is limited. Therefore, this study aimed to determine the effect of MLCC on maternal and neonatal health outcomes in the Ethiopian context.

METHOD

A study with a quasi-experimental design was conducted from August 2019 to September 2020 in four primary hospitals of the north Shoa zone, Amhara regional state, Ethiopia. A total of 1178 low risk women were allocated to one of two groups; the midwife-led continuity of care (MLCC or intervention group) (received all antenatal, labour, birth, and immediate postnatal care from a single midwife or backup midwife) (n = 589) and the Shared model of care (SMC or comparison group) (received care from different staff members at different times) (n = 589). The two outcomes studied were Spontaneous vaginal birth and preterm birth. Outcome variables were compared using multivariate generalized linear models (GLMs) and reported using adjusted risk ratios (aRR) with 95% confidence intervals.

FINDINGS

Women in MLCC were, in comparison with women in the SMC group more likely to have spontaneous vaginal birth (aRR of 1.198 (95% CI 1.101-1.303)). Neonates of women in MLCC were in comparison with those in SMC less likely to be preterm (aRR of 0.394; 95% CI (0.227-0.683)).

CONCLUSION

In this study, use of the MLCC model improved maternal and neonatal health outcomes. To scale up and further investigate the effect and feasibility of this model in a low resource setting could be of considerable importance in Ethiopia and other Sub-Saharan Africa countries.

A realist review to explore how midwifery continuity of care may influence preterm birth in pregnant women

BACKGROUND

Midwifery continuity of care models are the only health system intervention associated with both a reduction in preterm birth (PTB) and an improvement in perinatal survival; however, questions remain about the mechanisms by which such positive outcomes are achieved. We aimed to uncover theories of change by which we can postulate how and why continuity of midwifery care models might affect PTB.

METHODS

We followed Pawson's guidance for conducting a realist review and performed a comprehensive search to identify existing literature exploring the impact of continuity models on PTB in all pregnant women. A realist methodology was used to uncover the context (C), mechanisms (M), and outcomes (O) and to develop a group of CMO configurations to illuminate middle-range theories.

RESULTS

Eleven papers were included from a wide variety of settings in the United Kingdom, Australia, and the United States. The majority of study participants had low socioeconomic status or social risk factors and received diverse models of midwifery continuity of care. Three themes-woman-midwife partnership, maternity pathways and processes, and system resources-encompassed ten CMO configurations. Building relationships, trust, confidence, and advocacy resulted in women feeling safer, less stressed, and more secure and respected, and encouraged them to access and engage in antenatal care with more opportunities for early prevention and diagnosis of complications, which facilitated effective management when compliance to guidelines was ensured. Organizational infrastructure, innovative partnerships, and robust community systems are crucial to overcome barriers, address women's complex needs, ensure quality of care, and reduce PTB risk.

CONCLUSIONS

Pregnant women living in different contexts in the United Kingdom, Australia, and the United States at low and mixed risk of complications and with low socioeconomic status or social risk factors experienced continuity models in similar ways, and similar underlying mechanisms may have influenced PTB outcomes. Further research is required to understand how continuity models may influence behavioral change, physiological stress levels, ethnic disparities in PTB and care coordination, and navigation of health services.

'I know my place'; a meta-ethnographic synthesis of disadvantaged and vulnerable women's negative experiences of maternity care in high-income countries

OBJECTIVE

During pregnancy and childbirth, vulnerable and disadvantaged women have poorer outcomes, have less opportunities,face barriers in accessing care,and are at a greater risk of experiencing a traumatic birth. A recent synthesis of women's negative experiences of maternity care gathered data from predominantly low-income countries. However, these studies did not focus on vulnerable groups, and are not easily transferable into high-income settings due to differences in maternity care provision. The aim of this study was to synthesise existing qualitative literature focused on disadvantaged and vulnerable women's experience of maternity care in high-income countries.

METHODS

A systematic literature search and meta-ethnographic methods were used. Search methods included searches on four databases, author run, and backward and forward chaining. Searches were conducted in March 2016 and updated in May 2020.

FINDINGS

A total of 13,330 articles were identified and following checks against inclusion / exclusion criteria and quality appraisal 20 studies were included. Meta-ethnographic translation analytical methods were used to identify reciprocal and refutational findings, and to undertake a line of argument synthesis. Three third order reciprocal constructs were identified, 'Prejudiced and deindividualized care', 'Interpersonal relationships and interactions' and 'Creating and enhancing insecurities.' A line of argument synthesis entitled 'I know my place' encapsulates the experiences of disadvantaged and vulnerable women across the studies, acknowledging differential care practices, stigma and judgmental attitudes. A refutational translation was conceptualised as 'Being seen, being heard' acknowledging positive aspects of maternity care reported by women.

CONCLUSION

Insights highlight how women's vulnerability was compounded by complex life factors, judgmental and stigmatizing attitudes by health professionals, and differential care provision. Further research is needed to identify suitable care pathways for disadvantaged and vulnerable women and the development of suitable training to highlight negative attitudes towards these women in maternity care settings.

The effects of continuity of care on the health of mother and child in the postnatal period: a systematic review

BACKGROUND

Continuity of care (COC) is essential for high-quality patient care in the perinatal period. Insights in the effects of COC models on patient outcomes are important to direct perinatal healthcare organization. To our knowledge, no previous review has listed the effects of COC on the physical and mental health of mother and child in the postnatal period.

METHODS

A search was conducted in four databases (PubMed, Web of Knowledge, CENTRAL and CINAHL), from 2000 to 2018. Studies were included if: participants were healthy mothers or newborns with a gestational age between 37-42 weeks; they covered the perinatal period and aimed to measure breastfeeding or any outcome related to the maternal/newborn physical or mental health. At least one of the three COC types (management, informational and relationship) was identified in the intervention. The methodological quality was assessed.

RESULTS

Ten articles were included. COC is mostly present in the identified care models. The effects of COC on the outcomes of mother and child in the postnatal period seem mostly to be positive, although not always significant. The relation between COC and the outcomes can be influenced by confounding factors, like the socio-economic status of the included population. Interventions with COC during pregnancy appear to be more effective for all the studied outcome factors.

CONCLUSION

COC as management, relational and informational continuity starting antenatal has the most impact on the postnatal outcomes of mother and child.

Midwives' insights in relation to the common barriers in providing effective perinatal care to women from ethnic minority groups with 'high risk' pregnancies: A qualitative study

PROBLEM

Childbearing women from ethnic minority groups in the United Kingdom (UK) have significantly poorer perinatal outcomes overall.

BACKGROUND

Childbearing women from ethnic minority groups report having poorer experiences and outcomes in perinatal care, and health professionals report having difficulty in providing effective care to them. Yet barriers in relation to providing such care remain underreported.

AIM

The aim of this study was to elicit midwives' insights in relation to the common barriers in providing effective perinatal care to women from ethnic minority groups with 'high risk' pregnancies and how to overcome these barriers.

METHODS

A qualitative study was undertaken in a single obstetric led unit in London, UK. A thematic analysis was undertaken to identify themes from the data.

FINDINGS

A total of 20 midwives participated. They self-identified as White British (n=7), Black African (n=7), Black Caribbean (n=3) and Asian (n=3). Most (n=12) had more than 10 years' experience practising as a registered midwife (range 2 - 35 years). Four themes were identified: 1) Communication, 2) Continuity of carer, 3) Policy and 4) Social determinants. Racism and unconscious bias underpin many of the findings presented.

DISCUSSION

Co-created community hubs may improve access to more effective care for childbearing women from ethnic minority groups. A focus on robust anti-racism interventions, continuity of carer, staff wellbeing and education along with the provision of orientation and bespoke translation services are also suggested for the reduction of poorer outcomes and experiences.

CONCLUSION

Along with policies designed to promote equality and irradicate racism, there is a need for co-created community hubs and continuity of carer in perinatal services. Further research is also required to develop and evaluate culturally safe, and evidence-based interventions designed to address the current disparities apparent.

Project20: Does continuity of care and community-based antenatal care improve maternal and neonatal birth outcomes for women with social risk factors? A prospective, observational study

BACKGROUND

Social factors associated with poor childbirth outcomes and experiences of maternity care include minority ethnicity, poverty, young motherhood, homelessness, difficulty speaking or understanding English, migrant or refugee status, domestic violence, mental illness and substance abuse. It is not known what specific aspects of maternity care work to improve the maternal and neonatal outcomes for these under-served, complex populations.

METHODS

This study aimed to compare maternal and neonatal clinical birth outcomes for women with social risk factors accessing different models of maternity care. Quantitative data on pregnancy and birth outcome measures for 1000 women accessing standard care, group practice and specialist models of care at two large, inner-city maternity services were prospectively collected and analysed using multinominal regression. The level of continuity of care and place of antenatal care were used as independent variables to explore these potentially influential aspects of care. Outcomes adjusted for women's social and medical risk factors and the service attended.

RESULTS

Women who received standard maternity care were significantly less likely to use water for pain relief in labour (RR 0.11, CI 0.02-0.62) and have skin to skin contact with their baby shortly after birth (RR 0.34, CI 0.14-0.80) compared to the specialist model of care. Antenatal care based in the hospital setting was associated with a significant increase in preterm birth (RR 2.38, CI 1.32-4.27) and low birth weight (RR 2.31, CI 1.24-4.32), and a decrease in induction of labour (RR 0.65, CI 0.45-0.95) compared to community-based antenatal care, this was despite women's medical risk factors. A subgroup analysis found that preterm birth was increased further for women with the highest level of social risk accessing hospital-based antenatal care (RR 3.11, CI1.49-6.50), demonstrating the protective nature of community-based antenatal care.

CONCLUSIONS

This research highlights how community-based antenatal care, with a focus on continuity of carer reduced health inequalities and improved maternal and neonatal clinical outcomes for women with social risk factors. The findings support the current policy drive to increase continuity of midwife-led care, whilst adding that community-based care may further improve outcomes for women at increased risk of health inequalities. The relationship between community-based models of care and neonatal outcomes require further testing in future research. The identification of specific mechanisms such as help-seeking and reduced anxiety, to explain these findings are explored in a wider evaluation.

Providing maternity care for disadvantaged women in Aotearoa New Zealand: The impact on midwives

BACKGROUND

Health inequities and socio-economic disadvantage are causes for concern in Aotearoa New Zealand. Becoming pregnant can increase a woman's vulnerability to poverty, with the potential for an increase in multiple stressful life events. Providing midwifery care to women living in socio-economic deprivation has been found to add additional strains for midwives. Exploring the perspectives of the midwives providing care to women living with socio-economic deprivation can illuminate the complexities of maternity care.

AIM

To explore the impact on midwives when providing care for socio-economically disadvantaged women in Aotearoa New Zealand.

METHOD

Inductive thematic analysis was used to analyse an open-ended question from a survey that asked midwives to share a story around maternal disadvantage and midwifery care.

FINDINGS

A total of 214 stories were received from midwives who responded to the survey. Providing care to disadvantaged women had an impact on midwives by incurring increased personal costs (time, financial and emotional), requiring them to navigate threats and uncertainty and to feel the need to remedy structural inequities for women and their wider families. These three themes were moderated by the relationships midwives held with women and affected the way midwives worked across the different maternity settings.

CONCLUSION

Midwives carry a greater load when providing care to socio-economically deprived women. Enabling midwives to continue to provide the necessary support for women living in socio-economic deprivation is imperative and requires additional resources and funding.

Parents' Active Role and ENgagement in The review of their Stillbirth/perinatal death 2 (PARENTS 2) study: a mixed-methods study of implementation

OBJECTIVE

When a formal review of care takes places after the death of a baby, parents are largely unaware it takes place and are often not meaningfully involved in the review process. Parent engagement in the process is likely to be essential for a successful review and to improve patient safety. This study aimed to evaluate an intervention process of parental engagement in perinatal mortality review (PNMR) and to identify barriers and facilitators to its implementation.

DESIGN

Mixed-methods study of parents' engagement in PNMR.

SETTING

Single tertiary maternity unit in the UK.

PARTICIPANTS

Bereaved parents and healthcare professionals (HCPs).

INTERVENTIONS

Parent engagement in the PNMR (intervention) was based on principles derived through national consensus and qualitative research with parents, HCPs and stakeholders in the UK.

OUTCOMES

Recruitment rates, bereaved parents and HCPs' perceptions.

RESULTS

Eighty-one per cent of bereaved parents approached (13/16) agreed to participate in the study. Two focus groups with bereaved parents (n=11) and HCP (n=7) were carried out postimplementation to investigate their perceptions of the process.Overarching findings were improved dialogue and continuity of care with parents, and improvements in the PNMR process and patient safety. Bereaved parents agreed that engagement in the PNMR process was invaluable and helped them in their grieving. HCP perceived that parent involvement improved the review process and lessons learnt from the deaths; information to understand the impact of aspects of care on the baby's death were often only found in the parents' recollections.

CONCLUSIONS

Parental engagement in the PNMR process is achievable and useful for parents and HCP alike, and critically can improve patient safety and future care for mothers and babies. To learn and prevent perinatal deaths effectively, all hospitals should give parents the option to engage with the review of their baby's death.

Exploring the value and acceptability of an antenatal and postnatal midwifery continuity of care model to women and midwives, using the Quality Maternal Newborn Care Framework

BACKGROUND

Having a known midwife throughout pregnancy, birth and the early parenting period improves outcomes for mothers and babies. In Australia, midwifery continuity of care has been recommended in all states, territories and nationally although uptake has been slow. Several barriers exist to implementing midwifery continuity of care models and some maternity services have responded by introducing modified models of continuity of care. An antenatal and postnatal continuity of care model without intrapartum care is one example of a modified model of care that has been introduced by health services.

OBJECTIVES

The aim of this study was to explore the value and acceptability of an antenatal and postnatal midwifery program to women, midwives and obstetricians prior to implementation of the model at one hospital in Metropolitan Sydney, Australia.

METHODS

A qualitative descriptive methodology was undertaken to discover the value and acceptability to the implementation of the model. Data was collected via focus groups and one to one interviews from the service users (pregnant women and two partners) and service providers (midwives and obstetricians). We also collected demographic data to demonstrate the diversity of the setting. The Quality Maternal Newborn Care (QMNC) Framework was used to guide the focus groups and analyse the data.

FINDINGS

Four themes emerged from the data that were named feeling safe and connected, having more quality time and being confident, having a sense of community and respecting cultural diversity. The findings were analysed through the lens of the quality components of the QMNC framework. The final findings demonstrate the value and acceptability of implementing this model of care from women's, midwives and obstetrician's perspective.

CONCLUSIONS/IMPLICATIONS

Providing midwifery continuity of care through the antenatal and postnatal period without intrapartum care, is being implemented in Australia without any research. Using the QMNC framework is a useful way to explore the qualities of a new emerging service and the values and acceptability of this model of care for service providers and service users.

"Ashamed, Silent and Stuck in a System"-Applying a Structural Violence Lens to Midwives' Stories on Social Disadvantage in Pregnancy

Historical and enduring maternal health inequities and injustices continue to grow in Aotearoa New Zealand, despite attempts to address the problem. Pregnancy increases vulnerability to poverty through a variety of mechanisms. This project qualitatively analysed an open survey response from midwives about their experiences of providing maternity care to women living with social disadvantage. We used a structural violence lens to examine the effects of social disadvantage on pregnant women. The analysis of midwives' narratives exposed three mechanisms by which women were exposed to structural violence, these included structural disempowerment, inequitable risk and the neoliberal system. Women were structurally disempowered through reduced access to agency, lack of opportunities and inadequate meeting of basic human needs. Disadvantage exacerbated risks inequitably by increasing barriers to care, exacerbating the impact of adverse life circumstances and causing chronic stress. Lastly, the neoliberal system emphasised individual responsibility that perpetuated inequities. Despite the stated aim of equitable access to health care for all in policy documents, the current system and social structure continues to perpetuate systemic disadvantage.

Group antenatal care (Pregnancy Circles) for diverse and disadvantaged women: study protocol for a randomised controlled trial with integral process and economic evaluations

Background

Group antenatal care has been successfully implemented around the world with suggestions of improved outcomes, including for disadvantaged groups, but it has not been formally tested in the UK in the context of the NHS. To address this the REACH Pregnancy Circles intervention was developed and a randomised controlled trial (RCT), based on a pilot study, is in progress.

Methods

The RCT is a pragmatic, two-arm, individually randomised, parallel group RCT designed to test clinical and cost-effectiveness of REACH Pregnancy Circles compared with standard care. Recruitment will be through NHS services. The sample size is 1732 (866 randomised to the intervention and 866 to standard care). The primary outcome measure is a ‘healthy baby’ composite measured at 1 month postnatal using routine maternity data. Secondary outcome measures will be assessed using participant questionnaires completed at recruitment (baseline), 35 weeks gestation (follow-up 1) and 3 months postnatal (follow-up 2). An integrated process evaluation, to include exploration of fidelity, will be conducted using mixed methods. Analyses will be on an intention to treat as allocated basis. The primary analysis will compare the number of babies born “healthy” in the control and intervention arms and provide an odds ratio. A cost-effectiveness analysis will compare the incremental cost per Quality Adjusted Life Years and per additional ‘healthy and positive birth’ of the intervention with standard care. Qualitative data will be analysed thematically.

Discussion

This multi-site randomised trial in England is planned to be the largest trial of group antenatal care in the world to date; as well as the first rigorous test within the NHS of this maternity service change. It has a recruitment focus on ethnically, culturally and linguistically diverse and disadvantaged participants, including non-English speakers.

Trial registration

Trial registration; ISRCTN, ISRCTN91977441. Registered 11 February 2019 - retrospectively registered. The current protocol is Version 4; 28/01/2020.

Midwives' views of caseload midwifery - comparing the caseload and non-caseload midwives' opinions. A cross-sectional survey of Australian midwives

BACKGROUND

Midwife-led continuity of care has substantial benefits for women and infants and positive outcomes for midwives, yet access to these models remains limited. Caseload midwifery is associated with professional satisfaction and lower burnout, but also impacts on work-life boundaries. Few studies have explored caseload midwifery from the perspective of midwives working in caseload models compared to those in standard care models, understanding this is critical to sustainability and upscaling.

AIM

To compare views of caseload midwifery - those working in caseload models and those in standard care models in hospitals with and without caseload.

METHODS

A national cross-sectional survey of midwives working in Australian public hospitals providing birthing services.

FINDINGS

Responses were received from 542/3850 (14%) midwives from 111 hospitals - 20% worked in caseload, 39% worked in hospitals with caseload but did not work in the model, and 41% worked in hospitals without caseload. Regardless of exposure, midwives expressed support for caseload models, and for increased access to all women regardless of risk. Fifty percent of midwives not working in caseload expressed willingness to work in the model in the future. Flexibility, autonomy and building relationships were positive influencing factors, with on-call work the most common reason midwives did not want to work in caseload.

CONCLUSIONS

There was widespread support for and willingness to work in caseload. The findings suggest that the workforce could support increasing access to caseload models at existing and new caseload sites. Exposure to the model provides insight into understanding how the model works, which can positively or negatively influence midwives' views.

Access to appropriate health care for non-English speaking migrant families with a newborn/young child: a systematic scoping literature review

BACKGROUND

Recently arrived culturally and linguistically diverse migrant mothers in Western Industrialised Nations are less likely to access health care and are more likely to report negative healthcare experiences than more established migrant or non-migrant populations. This is particularly an issue in Australia where nearly half of all Australians were born overseas or have at least one parent born overseas.

METHODS

A systematic scoping review was conducted to identify a) the main enablers and barriers to accessing appropriate health care for migrant families with a new baby/young child who speak a language other than English, and b) the effectiveness of interventions that have been tested to improve access to appropriate health care for this group. Three academic databases (CINAHL, Medline and ProQuest) were searched, with additional publications identified through expert knowledge and networks. Data was extracted and analysed according to the Access framework, which conceptualises access to health care as being generated by the interaction of dimensions of accessibility of services (supply side) and abilities of potential users (demand side).

RESULTS

A total of 1964 records were screened for eligibility, with nine of these included in the review. Seven studies only described barriers and enablers to health care access, one study reported on an evaluation of an intervention and one study described the barriers and enablers and the evaluation of an intervention. This review identified that the most significant barriers occurred on the supply side, within the 'appropriateness' domain. Overall, the most frequently cited barrier was a lack of cultural sensitivity/understanding of different cultural practices (five studies). The most significant enablers also occurred on the supply side, but within the 'acceptability' domain. The most frequently cited enabler was cultural sensitivity and understanding.

CONCLUSIONS

There is a dearth of evaluated interventions in the peer reviewed literature to improve appropriate access to postnatal care for migrant families who speak a language other than English. The literature focuses on identifying barriers and enablers to access to healthcare for this population group. Interventions which aim to address barriers within the 'appropriateness' dimension may have the greatest impact on access.

'It requires something drastic': Interviews with health care leaders about organisational responses to social disadvantage

PROBLEM

Persisting disparities in maternal and child health outcomes in high income countries require new insights for health service response.

BACKGROUND

Significant social hardship, including factors related to migration, are associated with perinatal morbidity and mortality. The universality of maternity and child health care offers opportunities to reduce health disparities. Process evaluation of health service initiatives to address refugee health inequalities in Melbourne, Australia, is the setting for the study.

AIM

To explore the views of health service leaders about health system and service capacity to tailor care to address social adversity and reduce disparities in maternal and child health outcomes.

METHODS

In-depth interviews with leaders of maternity and maternal and child health services with questions guided by a diagram to promote discussion. Thematic analysis of transcribed interviews.

FINDINGS

Health care leaders recognised the level of social complexity and diversity of their clientele. The analysis revealed three key themes: grappling with the complexity of social disadvantage; 'clinical risk' versus 'social risk'; and taking steps for system change.

DISCUSSION

Priority given to clinical requirements and routine practices together with the rising demand for services is limiting service response to families experiencing social hardship and hampering individualised care. System change was considered possible only if health service decision makers engaged with consumer and community perspectives and that of front-line staff.

CONCLUSION

Achieving equity in maternal and child health outcomes requires engagement of all key stakeholders (communities, clinicians, managers) to facilitate effective system re-design.

Normalisation process theory as a conceptual framework for continuity of carer implementation

PROBLEM

Despite long standing strategic level ambitions to increase access to continuity of carer (CoC) models in maternity services, implementation of CoC in the United Kingdom (UK) has been generally small-scale and short lived. This indicates problems in implementing and sustaining CoC as the main model of care provision, and as such a need to better understand the process of implementation itself.

AIM

To use normalisation process theory (NPT) to underpin development of a conceptual implementation framework for CoC in order to improve understanding of the implementation process.

METHODS

Literature review on CoC implementation and NPT development and use, combined with immersion in the implementation of CoC context.

RESULTS AND DISCUSSION

A conceptual framework for the implementation of CoC is developed and individual components discussed, with a view to better understanding the implementation process for CoC models. The will of a critical mass of midwives to work in a CoC model and the provision and maintenance of the 'organisational space' required for CoC within the National Health Service (NHS) emerge as key barriers to mainstreaming CoC in the UK.

CONCLUSION

There is utility in NPT as a means of understanding and conceptualising large scale implementation of CoC. With testing and further development into a practical tool, the conceptual framework developed here could become a useful aid to those involved in implementing and evaluating CoC in the context of renewed strategic direction and Governmental level support in the UK.

Project 20: Midwives' insight into continuity of care models for women with social risk factors: what works, for whom, in what circumstances, and how

INTRODUCTION

Continuity of care models are known to improve clinical outcomes for women and their babies, but it is not understood how. A realist synthesis of how women with social risk factors experience UK maternity care reported mechanisms thought to improve clinical outcomes and experiences. As part of a broader programme of work to test those theories and fill gaps in the literature base we conducted focus groups with midwives working within continuity of care models of care for women with social factors that put them at a higher chance of having poor birth outcomes. These risk factors can include poverty and social isolation, asylum or refugee status, domestic abuse, mental illness, learning difficulties, and substance abuse problems.

OBJECTIVE

To explore the insights of midwives working in continuity models of care for women with social risk factors in order to understand the resources they provide, and how the model of care can improve women's outcomes.

DESIGN

Realist methodology was used to gain a deeper understanding of how women react to specific resources that the models of care offer and how these resources are thought to lead to particular outcomes for women. Twelve midwives participated, six from a continuity of care model implemented in a community setting serving an area of deprivation in London, and six from a continuity of care model for women with social risk factors, based within a large teaching hospital in London.

FINDINGS

Three main themes were identified: 'Perceptions of the model of care, 'Tailoring the service to meet women's needs', 'Going above and beyond'. Each theme is broken down into three subthemes to reveal specific resources or mechanisms which midwives felt might have an impact on women's outcomes, and how women with different social risk factors respond to these mechanisms.

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

Overall the midwives in both models of care felt the service was beneficial to women and had a positive impact on their outcomes. It was thought the trusting relationships they had built with women enabled midwives to guide women through a fragmented, unfamiliar system and respond to their individual physical, emotional, and social needs, whilst ensuring follow-up of appointments and test results. Midwives felt that for these women the impact of a trusting relationship affected how much information women disclosed, allowing for enhanced, needs led, holistic care. Interesting mechanisms were identified when discussing women who had social care involvement with midwives revealing techniques they used to advocate for women and help them to regain trust in the system and demonstrate their parenting abilities. Differences in how each team provided care and its impact on women's outcomes were considered with the midwives in the community-based model reporting how their location enabled them to help women integrate into their local community and make use of specialist services. The study demonstrates the complexity of these models of care, with midwives using innovative and compassionate ways of working to meet the multifaceted needs of this population.

Access to midwifery care for people of low socio-economic status: a qualitative descriptive study

Background

Despite public funding of midwifery care, people of low-socioeconomic status are less likely to access midwifery care in Ontario, Canada, but little is known about barriers that they experience in accessing midwifery care. The purpose of this study was to examine the barriers and facilitators to accessing midwifery care experienced by people of low-socioeconomic status.

Methods

A qualitative descriptive study design was used. Semi-structured interviews were conducted with 30 pregnant and post-partum people of low-socioeconomic status in Hamilton, Ontario from January to May 2018. Transcribed interviews were coded using open coding techniques and thematically analyzed.

Results

We interviewed 13 midwifery care recipients and 17 participants who had never received care from midwives. Four themes arose from the interviews: “I had no idea…”, “Babies are born in hospitals”, “Physicians as gateways into prenatal care”, and “Why change a good thing?”. Participants who had not experienced midwifery care had minimal knowledge of midwifery and often had misconceptions about midwives’ scope of practice and education. Prevailing beliefs about pregnancy and birth, particularly concerns about safety, drove participants to seek care from a physician. Physicians are the entry point into the health care system for many, yet few participants received information about midwifery care from physicians. Participants who had experienced midwifery care found it to be an appropriate match for the needs of people of low socioeconomic status. Word of mouth was a primary source of information about midwifery and the most common reason for people unfamiliar with midwifery to seek midwifery care.

Conclusions

Access to midwifery care is constrained for people of low-socioeconomic status because lack of awareness about midwifery limits the approachability of these services, and because information about midwifery care is often not provided by physicians when pregnant people first contact the health care system. For people of low-socioeconomic status, inequitable access to midwifery care may be exacerbated by lack of knowledge about midwifery within social networks and a tendency to move passively through the health care system which traditionally favours physician care. Targeted efforts to address this issue are necessary to reduce disparities in access to midwifery care.

Preference, knowledge and utilization of midwives, childbirth education classes and doulas among U.S. black and white women: implications for pregnancy and childbirth outcomes

This secondary analysis explored preference, knowledge and utilization of midwifery care, childbirth education and doula care among 627 black and white women at three Midwestern U.S. health clinics. Women who were white, more educated, not living in a high crime neighborhood, and privately insured were more likely to attend childbirth classes. Sociodemographic factors that predicted having heard about doula care included being more educated and having a partner. None of the sociodemographic variables predicted midwifery care. Education about existing childbearing resources and availability of low-cost options should be expanded, particularly for black women and those with low resources.

How do women with social risk factors experience United Kingdom maternity care? A realist synthesis

BACKGROUND

Echoing international trends, the most recent United Kingdom reports of infant and maternal mortality found that pregnancies to women with social risk factors are over 50% more likely to end in stillbirth or neonatal death and carry an increased risk of premature birth and maternal death. The aim of this realist synthesis was to uncover the mechanisms that affect women's experiences of maternity care.

METHODS

Using realist methodology, 22 papers exploring how women with a wide range of social risk factors experience maternity care in the United Kingdom were included. The data extraction process identified contexts (C), mechanisms (M), and outcomes (0).

RESULTS

Three themes, Resources, Relationships, and Candidacy, overarched eight CMO configurations. Access to services, appropriate education, interpreters, practical support, and continuity of care were particularly relevant for women who are unfamiliar with the United Kingdom system and those living chaotic lives. For women with experience of trauma, or those who lack a sense of control, a trusting relationship with a health care professional was key to regaining trust. Many women who have social care involvement during their pregnancy perceive health care services as a system of surveillance rather than support, impacting on their engagement. This, as well as experiences of paternalistic care and discrimination, could be mitigated through the ability to develop trusting relationships.

CONCLUSIONS

The findings provide underlying theory and practical guidance on how to develop safe services that aim to reduce inequalities in women's experiences and birth outcomes.

Informing the development midwifery standards for practice: A literature review for policy development

AIM

To critically appraise and synthesise the literature regarding the role and scope of midwifery practice, specifically to inform the evidence based development of standards for practice for all midwives in Australia.

DESIGN

A structured scoping review of the literature DATA SOURCES: CINAHL Complete, MEDLINE Complete and Cochrane Libraries databases, online and grey literature databases REVIEW METHODS: Comprehensive searches of databases used key words and controlled vocabulary for each database to search for publications 2006-2016. Studies were not restricted by research method.

FINDINGS

There is no substantive body of literature on midwifery competency standards or standards for practice. From 1648 papers screened, twenty-eight papers were identified to inform this review. Eight studies including systematic reviews were annotated with three research papers further assessed as having direct application to this review. To inform the development of Midwife standards for practice, the comprehensive role of the midwife across multiple settings was seen to include: woman centred and primary health care; safe supportive and collaborative practice; clinical knowledge and skills with interpersonal and cultural competence.

KEY CONCLUSIONS

Midwifery practice is not restricted to the provision of direct clinical care and extends to any role where the midwife uses midwifery skills and knowledge. This practice includes working in clinical and non-clinical relationships with the woman and other clients as well as working in management, administration, education, research, advisory, regulatory, and policy development roles.

IMPLICATIONS FOR PRACTICE

This review articulates the definition, role and scope of midwifery practice to inform the development of contemporary standards for practice for the Australian midwife.

POPPIE: protocol for a randomised controlled pilot trial of continuity of midwifery care for women at increased risk of preterm birth

Background

High rates of preterm births remain a UK public health concern. Preterm birth is a major determinant of adverse infant and longer-term outcomes, including survival, quality of life, psychosocial effects on the family and health care costs. We aim to test whether a model of care combining continuity of midwife care with rapid referral to a specialist obstetric clinic throughout pregnancy, intrapartum and the postpartum period is feasible and improves experience and outcomes for women at increased risk of preterm birth.

Methods

This pilot, hybrid, type 2 randomised controlled implementation trial will recruit 350 pregnant women at increased risk of preterm birth to a midwifery continuity of care intervention or standard care. The intervention will be provided from recruitment (antenatal), labour, birth and the postnatal period, in hospital and community settings and in collaboration with specialist obstetric clinic care, when required. Standard care will be the current maternity care provision by NHS midwives and obstetricians at the study site. Participants will be followed up until 6–8 weeks postpartum. The composite primary outcome is the appropriate initiation of any specified interventions related to the prevention and/or management of preterm labour and birth. Secondary outcomes are related to: recruitment and attrition rates; implementation; acceptability to women, health care professionals and stakeholders; health in pregnancy and other complications; intrapartum outcomes; maternal and neonatal postnatal outcomes; psycho-social health; quality of care; women’s experiences and health economic analysis. The trial has 80% power to detect a 15% increase in the rate of appropriate interventions (40 to 55%). The analysis will be by ‘intention to treat’ analysis.

Discussion

Little is known about the underlying reasons why and how models of midwifery continuity of care are associated with fewer preterm births, better maternal and infant outcomes and more positive experiences; nor how these models of care can be implemented successfully in the health services. This will be the first study to provide direct evidence regarding the effectiveness, implementation and evaluation of a midwifery continuity of care model and rapid access to specialist obstetric services for women at increased risk of preterm birth.

Trial registration

ISRCTN37733900. Retrospectively registered on 21 August 2017.

Poor antenatal care attendance is associated with intimate partner violence: Multivariate analysis of a pregnancy cohort

OBJECTIVE

Intimate partner violence (IPV) is a common, neglected public health problem and pregnancy is a period of vulnerability. We evaluated the relationship of attendance for antenatal care with the experience of psychological and physical IPV.

STUDY DESIGN

We established a cohort of 779 consecutive mothers who received antenatal care and gave birth in 15 public hospitals, Andalusia, Spain. Trained midwives gathered IPV data using the Index of Spouse Abuse validated in the Spanish language (score ranges: 0-100, higher scores reflect more severe IPV; cut-offs: physical IPV = 10, psychological IPV = 25). Less than eight visits defined the threshold for poor antenatal care attendance. Multivariate logistic regression estimated crude (COR) and adjusted odds ratios (AOR), with 95% confidence intervals (CI), of the relationship between antenatal care attendance and psychological and physical IPV, controlling for socio-demographic and other pregnancy characteristics.

RESULTS

Response rate was 92.2%. Poor antenatal clinic attendance, observed in 76 (9.8%) women, was associated with both physical IPV (n = 26, 39% vs 9%; COR = 6.2, 95%CI = 2.7-14.3; AOR = 3.3, 95%CI = 1.1-9.4) and psychological IPV (n = 149, 20% vs 8%; COR = 2.9, 95%CI = 1.7-4.8; AOR = 1.6, 95%CI = 0.9-3.1), though the latter was not significant in multivariate analysis.

CONCLUSION

Women with a poor antenatal care attendance have higher risk of suffering physical IPV during pregnancy. Clinicians should be vigilant about the risk of IPV in mothers with poor attendance for antenatal care.

Cost-effectiveness of continuity of midwifery care for women with complex pregnancy: a structured review of the literature

BACKGROUND

Critical evaluation of the cost-effectiveness and clinical effectiveness of continuity of midwifery care models for women experiencing complex pregnancy is an important consideration in the review and reform of maternity services. Most studies either focus on women who experience healthy pregnancy or mixed risk samples. These results may not be generalised across the childbearing continuum to women with risk factors. This review critically evaluates studies that measure the cost of care for women with complex pregnancies, with a focus on method and quality.

AIMS / OBJECTIVES

To critically appraise and summarise the evidence relating to the combined cost-effectiveness, resource use and clinical effectiveness of midwifery continuity models for women who experience complex pregnancies and their babies in developed countries.

DESIGN

Structured review of the literature utilising a matrix method to critique the methods and quality of studies.

METHOD

A search of Medline, CINAHL, MIDIRS, DARE, EMBASE, OVID, PubMed, ProQuest, Informit, Science Direct, Cochrane Library, NHS Economic Evaluation Database (NHSEED) for the years 1994 - 2018 was conducted.

RESULTS

Nine articles met the inclusion criteria. The review identified four areas of economic evaluation that related to women who experienced complex pregnancy and continuity of midwifery care. (1) cost and clinical effectiveness comparisons between continuity of midwifery care versus obstetric-led units; (2) cost of continuity of midwifery care and/or team midwifery compared to Standard Care; (3) cost-effectiveness of continuity of midwifery care for Australian Aboriginal women versus standard care; (4) patterns of antenatal care for women of high obstetric risk and comparative provider cost. Cost savings specific to women from high risk samples who received continuity of midwifery care compared with obstetric-led standard care was stated for only one study in the review. Kenny et al. 1994 identified cost savings of AUS $29 in the antenatal period for women who received the midwifery team model from a stratified sub-set of high-risk pregnant woman within a mixed risk sample of 446 women. One systematic review relevant to the UK context, Ryan et al. (2013), applied sensitivity analysis to include women of all risk categories. Where risk ratio for overall fetal/neonatal death was systematically varied based on the 95% confidence interval of 0.79 to 1.09 from pooled studies, the aggregate annual net monetary benefit for continuity of midwifery care ranged extremely widely from an estimated gain of £472 million to a loss of £202 million. Net health benefit ranged from an annual gain of 15 723 QALYs to a loss of 6 738 QALYs. All other studies in this review reported cost savings narratively or within mixed risk samples where risk stratification was not clearly stated or related to the midwifery team model only.

CONCLUSIONS

Studies that measure the cost of continuity of midwifery care for women with complex pregnancy across the childbearing continuum are limited and apply inconsistent methods of economic evaluation. The cost and outcomes of implementing continuity of midwifery care for women with complex pregnancy is an important issue that requires further investigation. Robust cost-effectiveness evidence is essential to inform decision makers, to implement sustainable systems change in comparative maternity models for pregnant women at risk and to address health inequity.

Testing the effectiveness of REACH Pregnancy Circles group antenatal care: protocol for a randomised controlled pilot trial

BACKGROUND

Antenatal care is an important public health priority. Women from socially disadvantaged, and culturally and linguistically diverse groups often have difficulties with accessing antenatal care and report more negative experiences with care. Although group antenatal care has been shown in some settings to be effective for improving women's experiences of care and for improving other maternal as well as newborn health outcomes, these outcomes have not been rigorously assessed in the UK. A pilot trial will be conducted to determine the feasibility of, and optimum methods for, testing the effectiveness of group antenatal care in an NHS setting serving populations with high levels of social deprivation and cultural, linguistic and ethnic diversity. Outcomes will inform the protocol for a future full trial.

METHODS

This protocol outlines an individual-level randomised controlled external pilot trial with integrated process and economic evaluations. The two trial arms will be group care and standard antenatal care. The trial will involve the recruitment of 72 pregnant women across three maternity services within one large NHS Acute Trust. Baseline, outcomes and economic data will be collected via questionnaires completed by the participants at three time points, with the final scheduled for 4 months postnatal. Routine maternity service data will also be collected for outcomes assessment and economic evaluation purposes. Stakeholder interviews will provide insights into the acceptability of research and intervention processes, including the use of interpreters to support women who do not speak English. Pre-agreed criteria have been selected to guide the decision about whether or not to progress to a full trial.

DISCUSSION

This pilot trial will determine if it is appropriate to proceed to a full trial of group antenatal care in this setting. If progression is supported, the pilot will provide authoritative high-quality evidence to inform the design and conduct of a trial in this important area that holds significant potential to influence maternity care, outcomes and experience.

TRIAL REGISTRATION

ISRCTN ISRCTN66925258. Registered 03 April 2017. Retrospectively registered.

Reduced prevalence of small-for-gestational-age and preterm birth for women of low socioeconomic position: a population-based cohort study comparing antenatal midwifery and physician models of care

OBJECTIVE

Our aim was to investigate if antenatal midwifery care was associated with lower odds of small-for-gestational-age (SGA) birth, preterm birth (PTB) or low birth weight (LBW) compared with general practitioner (GP) or obstetrician (OB) models of care for women of low socioeconomic position.

SETTING

This population-level, retrospective cohort study used province-wide maternity, medical billing and demographic data from British Columbia, Canada.

PARTICIPANTS

Our study included 57 872 pregnant women, with low socioeconomic position, who: were residents of British Columbia, Canada, carried a singleton fetus, had low to moderate medical/obstetric risk, delivered between 2005 and 2012 and received medical insurance premium assistance.

PRIMARY AND SECONDARY OUTCOME MEASURES

We report rates, adjusted ORs (aOR), and 95% CIs for the primary outcome, SGA birth (<the 10th percentile), and secondary outcomes, PTB (<37 weeks' completed gestation) and LBW (<2500 g).

RESULTS

Our sample included 4705 midwifery patients, 45 114 GP patients and 8053 OB patients. Odds of SGA birth were reduced for patients receiving antenatal midwifery versus GP (aOR 0.71, 95% CI 0.62 to 0.82) or OB care (aOR 0.59, 95% CI 0.50 to 0.69). Odds of PTB were lower for antenatal midwifery versus GP (aOR 0.74, 95% CI 0.63 to 0.86) or OB patients (aOR 0.53, 95% CI 0.45 to 0.62). Odds of LBW were reduced for midwifery versus GP (aOR 0.66, 95% CI 0.53 to 0.82) or OB patients (aOR 0.43, 95% CI 0.34 to 0.54).

CONCLUSION

Antenatal midwifery care in British Columbia, Canada, was associated with lower odds of SGA birth, PTB and LBW, for women of low socioeconomic position, compared with physician models of care. Results support the development of policy to ensure antenatal midwifery care is available and accessible for women of low socioeconomic position. Future research is needed to determine the underlying mechanisms linking midwifery care to better birth outcomes for women of low socioeconomic position.

A Literature Review of Midwifery-Led Care in Reducing Labor and Birth Interventions

Certified nurse-midwives are usually recognized as independently practicing advanced practice registered nurses because they provide maternity care to pregnant women in various states. In the United States, certified nurse-midwives are historically underused. Culture favors physician-led care, with 90% of all births attended by physicians. Midwifery-led care is considered high-touch/low-intervention and is guided by a philosophy of care that regards pregnancy and childbirth as normal life events for most women. Evidence from the literature supports midwifery-led care as being safe, effective, and associated with fewer interventions.

Better together: A qualitative exploration of women's perceptions and experiences of group antenatal care

PROBLEM

Childbearing women from socio-economically disadvantaged communities and minority ethnic groups are less likely to access antenatal care and experience more adverse pregnancy outcomes.

BACKGROUND

Group antenatal care aims to facilitate information sharing and social support. It is associated with higher rates of attendance and improved health outcomes.

AIMS

To assess the acceptability of a bespoke model of group antenatal care (Pregnancy Circles) in an inner city community in England, understand how the model affects women's experiences of pregnancy and antenatal care, and inform further development and testing of the model.

METHODS

A two-stage qualitative study comprising focus groups with twenty six local women, followed by the implementation of four Pregnancy Circles attended by twenty four women, which were evaluated using observations, focus groups and semi-structured interviews with participants. Data were analysed thematically.

FINDINGS

Pregnancy Circles offered an appealing alternative to standard antenatal care and functioned as an instrument of empowerment, mediated through increased learning and knowledge sharing, active participation in care and peer and professional relationship building. Multiparous women and women from diverse cultures sharing their experiences during Circle sessions was particularly valued. Participants had mixed views about including partners in the sessions.

CONCLUSIONS

Group antenatal care, in the form of Pregnancy Circles, is acceptable to women and appears to enhance their experiences of pregnancy. Further work needs to be done both to test the findings in larger, quantitative studies and to find a model of care that is acceptable to women and their partners.

The role of structured Antenatal Risk Management (sARM) on experiences with antenatal care by vulnerable clients

INTRODUCTION

Vulnerable clients (i.e. clients reporting psychopathology, psychosocial problems, or substance use, and/or features of deprivation) represent a challenge in perinatal care, both in term of care process and outcome. Adhering to a structured care process (i.e. structured Antenatal Risk Management [sARM]) has shown to benefit professionals in supporting vulnerable clients, but its effect on client experiences is yet to be determined. As better processes are assumed to benefit outcome, we investigated the relationship between vulnerable clients' experiences with antenatal care in perinatal units adhering to differing degrees of sARM.

METHODS

We combined data from two sources: on the client level antenatal collected survey data from which vulnerability status (Mind2Care instrument) and client experiences (ReproQ questionnaire) were derived, and on the unit level interview data from healthcare providers from which the unit degree of sARM was ascertained.

RESULTS

A total of N = 1.176 clients from N = 38 units were included in the study. Vulnerable clients with psychosocial problems reported more negative experiences than non-vulnerable clients. In high sARM units, vulnerable clients, regardless of type of problems, reported more negative experiences than non-vulnerable clients. In multiple regression analysis this effect disappeared and only vulnerability defined as psychosocial problems remained predictive for negative experiences.

CONCLUSIONS

Vulnerable clients, specifically those with psychosocial problems, present a challenge in perinatal healthcare. Negative appraisal of care might be an unavoidable drawback of adhering to sARM. It also stresses the need for improving caregiver-client expectations and system side improvements.

Maternity experiences of mothers with multiple disadvantages in England: A qualitative study

Background

Disadvantaged mothers and their babies are at increased risk of poor perinatal outcomes and have less positive experiences of maternity care.

Aim

To explore the maternity care experiences of mothers with multiple disadvantages.

Methods

A qualitative descriptive study based on semi-structured interviews with 40 mothers with multiple disadvantages, using thematic analysis.

Findings

Four themes emerged: ‘A confusing and frightening time’, ‘Longing to be respected as an individual’, ‘The importance of choice and control’, and ‘Needing trust to feel safe’. Mothers brought feelings of powerlessness and low self-esteem to their encounters with maternity professionals, which could be significantly worsened by disrespectful care. They needed support to navigate the complex maternity system. Positive experiences were much more likely where the mother had received continuity of care from a specialist midwife or small team.

Discussion and conclusion

Mothers with multiple disadvantages value being treated as an individual, making informed choices, and feeling safe, but they may lack the confidence to ask questions or challenge disrespectful treatment. Training and supervision should enable maternity professionals to understand how confusing maternity care can be to very disadvantaged mothers. It should emphasise the need to provide accessible and empowering information and guidance to enable all mothers to make choices and understand the system. Leaders of maternity services need to do more to challenge negative staff attitudes and ensure that that all mothers are treated at all times with kindness, respect and dignity. Specialist midwives can deliver a high quality service to mothers experiencing multiple disadvantages.

Building capacity and wellbeing in vulnerable/marginalised mothers: A qualitative study

PROBLEM

The persistence of health inequalities in pregnancy and infancy amongst vulnerable/marginalised groups in the UK.

BACKGROUND

During pregnancy and early motherhood some women experience severe and multiple psychosocial and economic disadvantages that negatively affect their wellbeing and make them at increased risk of poor maternal and infant health outcomes.

AIM

To explore vulnerable/marginalised women's views and experiences of receiving targeted support from a specialist midwifery service and/or a charity.

METHODS

A mixed-methods study was undertaken that involved analysis of routinely collected birth-related/outcome data and interviews with a sample of vulnerable/marginalised women who had/had not received targeted support from a specialist midwifery service and/or a charity. In this paper we present in-depth insights from the 11 women who had received targeted support.

FINDINGS

Four key themes were identified; 'enabling needs-led care and support', 'empowering through knowledge, trust and acceptance', 'the value of a supportive presence' and 'developing capabilities, motivation and confidence'.

DISCUSSION

Support provided by a specialist midwifery service and/or charity improved the maternity and parenting experiences of vulnerable/marginalised women. This was primarily achieved by developing a provider-woman relationship built on mutual trust and understanding and through which needs-led care and support was provided - leading to improved confidence, skills and capacities for positive parenting and health.

CONCLUSION

The collaborative, multiagency, targeted intervention provides a useful model for further research and development. It offers a creative, salutogenic and health promoting approach to provide support for the most vulnerable/marginalised women as they make the journey into parenthood.

A qualitative study of volunteer doulas working alongside midwives at births in England: Mothers' and doulas' experiences

OBJECTIVE

to explore trained volunteer doulas' and mothers' experiences of doula support at birth and their perceptions of how this related to the midwife's role.

DESIGN

a qualitative descriptive study, informed by phenomenological social psychology.

METHODS

semi-structured interviews were carried out between June 2015 and March 2016. Interview transcripts were analysed using inductive thematic analysis.

SETTING

three community volunteer doula projects run by third sector organisations in England.

PARTICIPANTS

19 volunteer doulas and 16 mothers who had received doula support during labour.

FINDINGS

three overarching themes emerged: (1) 'the doula as complementary to midwives', containing subthemes 'skilled physical and emotional support', 'continuous presence', 'woman-centred support', 'ensuring mothers understand and are understood' and 'creating a team for the mother'; (2)'the doula as a colleague to midwives', containing subthemes 'welcomed as a partner', 'co-opted to help the midwives', and 'doulas identify with the midwives'; and (3) 'the doula as challenge to midwives', containing subthemes 'confusion about the doula's role', 'defending informed choice', and 'counterbalancing disempowering treatment'. KEY CONCLUSIONS&IMPLICATIONS FOR PRACTICE: volunteer doulas can play an important role in improving women's birth experiences by offering continuous, empowering, woman-focused support that complements the role of midwives, particularly where the mothers are disadvantaged. Greater clarity is needed about the scope of legitimate volunteer doula advocacy on behalf of their clients, to maximise effective working relationships between midwives and doulas.

Working for patient safety: a qualitative study of women's help-seeking during acute perinatal events

BACKGROUND

Women and their relatives can play an important role in early detection and help seeking for acute perinatal events. Recent UK reports indicate that patient-professional partnership in 'working for safety' can be difficult to achieve in practice, sometimes with catastrophic consequences. This research explored the experiences of women and relatives who had experienced early warning signs about their condition and sought help in escalating care.

METHODS

Secondary analysis of case study data which included qualitative interviews with 22 women purposively sampled on account of experiencing a step up in care and 4 of their relatives from two NHS Trusts in England during 2010. Analysis focused on the type of safety work participants engaged in, and the opportunities and challenges reported by women and family members when negotiating safety at home and in hospital.

RESULTS

Women and relatives took on a dual responsibility for self-diagnosis, self-care and seeking triage, whilst trying to avoid overburdening stretched services. Being informed, however, did not necessarily enable engagement from staff and services. The women's narratives highlighted the work that they engaged in to build a case for clinical attention, the negotiations that took place with health care professionals and the strategies women and partners drew on (such as objective signs and symptoms, use of verbal insistence and repetition) to secure clinical help. For some women, the events left them with a lasting feeling that their concerns had been disregarded. Some described a sense of betrayal and loss of trust in an institution they believed had failed to care for them.

CONCLUSION

The notion of 'safety partnerships' which suggests a sense of equality and reciprocity was not borne out by our data, especially with regards to the experiences of teenage women. To enable women and families to secure a rapid response in clinical emergencies, strategies need to move beyond the provision of patient information about warning signs. Effective partnerships for safety may be supported by system level change such as improved triage, continuity of care, self-referral pathways and staff training to address asymmetries of power that persist within the health system.