Health professionals, implementation and outcomes: reflections on a complex intervention to improve breastfeeding rates in primary care

Breastfeeding mothers' experiences with community physicians in Israel: a qualitative study

BACKGROUND

The guidelines of all leading professional organizations recommend providing adequate support and education regarding breastfeeding; yet many mothers feel that they receive inadequate information from their health care providers in the primary care setting. This is in line with studies that demonstrate that physicians' knowledge about breastfeeding is lacking. The aim of this study was to expand our understanding of the breastfeeding-related experiences of mothers with primary care physicians (PCPs).

METHODS

In this qualitative study, we interviewed breastfeeding mothers in Israel in the first six months after delivery. The interviews were conducted between December 2020 and May 2021. We used thematic analysis to explore women's attitudes and experiences with their PCPs regarding breastfeeding concerns. All authors read the transcribed interviews and independently marked statements regarding breastfeeding. Then, in a joint process, codes, subthemes and themes were defined. Each subtheme was backed up with a quote from the interviews.

RESULTS

We interviewed 13 women aged 24 to 37. We identified four main themes. The first of these was physicians' inconsistent attitudes toward breastfeeding. Some were indifferent, while others related to breastfeeding solely in the context of infant development. Some were supportive, while others opposed breastfeeding. Several women revealed physicians' inappropriate and disturbing attitudes to breastfeeding. The second theme was physicians' lack of knowledge regarding medical treatment for breastfeeding issues. This theme included lack of knowledge, incorrect treatment of breastfeeding problems, and contradictions among HCPs. The third was mothers' preference for alternative resources, including individualized breastfeeding counselling, maternity and childcare nurses, mothers' groups (in person or online), and family and friends over medical treatment for breastfeeding problems. The fourth theme involved mothers' suggestions for PCPs, which highlighted the importance of communication, prenatal physician-initiated dialogue on breastfeeding, expanding professional knowledge on breastfeeding, and increasing the availability of treatment for breastfeeding problems.

CONCLUSION

The women in this study reported unsatisfactory breastfeeding support by PCPs and incorrect or inadequate treatment of medical problems related to breastfeeding. They also felt they had no medical experts to approach with breastfeeding-related problems. We believe that physicians should expand their knowledge on breastfeeding medicine so that they can provide comprehensive patient-centered treatment to both mothers and infants. Education programs for improving knowledge and skills in breastfeeding issues should be implemented throughout the medical training.

Women's experiences of infant feeding support: Findings from a cross-sectional survey in Victoria, Australia

OBJECTIVE

To evaluate new mothers' experiences of infant feeding support.

DESIGN

A postal survey developed for this study was sent to all new mothers in ten local government areas in Victoria, Australia when their baby was six months of age. Questions explored infant feeding methods, feeding support services, and experiences of infant feeding support. This survey made up one component of the Supporting breastfeeding In Local Communities (SILC) cluster randomised controlled trial.

FINDINGS

997/4127 women (24%) completed the survey between 15 April 2013 and 31 July 2013. Women received infant feeding support from multiple sources, including professionals, family members, and peers. Overall, 88% reported receiving adequate infant feeding support. Women who reported not receiving adequate infant feeding support were less likely to be giving any breast milk at six months compared to those reporting adequate support (OR = 0.59; 95% CI 0.40, 0.88). Adjusting for breastfeeding intention and parity did not alter the association (Adj. OR = 0.60; 95% CI 0.40, 0.90). Women were most satisfied when they received accessible, available, consistent professional infant feeding support provided in a non-judgemental and reassuring way. Women were dissatisfied when there were barriers restricting access to support, or when they received conflicting advice or support that made them feel guilty, pressured or judged.

KEY CONCLUSIONS

Regardless of infant feeding method, women wanted accessible, non-judgemental support. Given that receiving adequate support was associated with more breast milk feeding at six months, care providers should ensure accessible infant feeding support is available to all new mothers.

Challenging procedures used in systematic reviews by promoting a case-based approach to the analysis of qualitative methods in nursing trials

This methodological discussion invites critical reflection about the procedures used to analyze the contribution of qualitative and mixed methods research to nursing trials by mounting an argument that these should rest on multiple publications produced about a project, rather than a single article. We illustrate the value-added of this approach with findings from a qualitative, cross-case analysis of three critical case exemplars from nursing researchers that each used a qualitative approach with a mixed method phase. The holistic lens afforded by a case-based approach informs nursing inquiry by documenting that the critical case exemplars presented evidence of (a) a sustained commitment of resources and expertise for the qualitative methods that extended across more than one phase of the trial, (b) the impact of the qualitative methods on the trial or its aftermath, (c) deploying a theoretical or conceptual framework for a variety of purposes, and (d) integrating qualitative and quantitative data for purposes of extending explanatory power. Findings challenge the practice of linking purposes served by qualitative and mixed methods to a single trial phase.

"They Just Need to Come Down a Little Bit to your Level": A Qualitative Study of Parents' Views and Experiences of Early Life Interventions to Promote Healthy Growth and Associated Behaviours

The first 1000 days is a critical window of opportunity to promote healthy growth and associated behaviours. Health professionals can play an important role, in part due to the large number of routine contacts they have with parents. There is an absence of research on the views of parents towards obesity prevention and the range of associated behaviours during this time period. This study aimed to elicit parents’ views on early life interventions to promote healthy growth/prevent childhood obesity, particularly those delivered by health professionals. Semi-structured interviews were conducted with 29 parents (24 mothers, 5 fathers) who were resident in Ireland and had at least one child aged under 30 months. Data were analysed using reflexive thematic analysis. Two central themes were generated: (1) navigating the uncertainty, stress, worries, and challenges of parenting whilst under scrutiny and (2) accessing support in the broader system. Parents would welcome support during this critical time period; particularly around feeding. Such support, however, needs to be practical, realistic, evidence-based, timely, accessible, multi-level, non-judgemental, and from trusted sources, including both health professionals and peers. Interventions to promote healthy growth and related behaviours need to be developed and implemented in a way that supports parents and their views and circumstances.

A focus group study of women's views and experiences of maternity care as delivered collaboratively by midwives and health visitors in England

BACKGROUND

Research suggests that collaboratively delivered maternity care can positively impact health outcomes. However, women's perspectives on models of care involving interprofessional collaboration between midwives and health visitors are not well understood. Accounts of women's maternity care experiences are key to improving maternity services. This study considered women's views and experiences of maternity care as collaboratively provided by midwives and health visitors in England.

METHODS

A qualitative focus group study with an exercise exploring women's ideal maternity care pathway was conducted. Three focus groups were conducted in London, England between June and August 2017 with women who had had a child within 18 months prior to the study. The participants (n = 12) were recruited from two Children's Centres in London, England. Data were analysed using thematic analysis.

RESULTS

Four themes were identified: 'Women's experiences of maternity care from midwives and health visitors', 'Midwife-health visitor communication', 'Midwife-health visitor collaboration for tailored care', and 'Women's ideal maternity care pathway'. Regarding women's experiences of interprofessional collaboration between midwives and health visitors, this was rarely encountered, but welcomed by women. Women's observations of limited tailored care and co-ordination led to several suggestions to improve maternity care, including secure, shared medical recordkeeping systems, clarity on midwives' and health visitors' roles, as well as increased communication.

CONCLUSIONS

Maternity care that is collaboratively delivered by midwives and health visitors, from the perspectives of the women in this study, is not routinely provided. However, women recognise the potential benefits of midwife-health visitor collaboration. Future research should explore service configurations that support integrated maternity care pathways, and evaluate the impact of midwife-health visitor collaboration on health and service outcomes.

Introducing Evidence Through Research "Push": Using Theory and Qualitative Methods

A multitude of factors can influence the uptake and implementation of complex interventions in health care. A plethora of theories and frameworks recognize the need to establish relationships, understand organizational dynamics, address context and contingency, and engage key decision makers. Less attention is paid to how theories that emphasize relational contexts can actually be deployed to guide the implementation of an intervention. The purpose of the article is to demonstrate the potential role of qualitative research aligned with theory to inform complex interventions. We detail a study underpinned by theory and qualitative research that (a) ensured key actors made sense of the complex intervention at the earliest stage of adoption and (b) aided initial engagement with the intervention. We conclude that using theoretical approaches aligned with qualitative research can provide insights into the context and dynamics of health care settings that in turn can be used to aid intervention implementation.

[Support of breastfeeding by health professionals: integrative review of the literature]

OBJECTIVE

To review the literature in order to evaluate how health professionals promote and support breastfeeding.

DATA SOURCES

Studies from the following databases were retrieved: Scopus, PubMed, Medline, Lilacs, SciELO, Web of Science and Cumulative Index to Nursing and Allied Health Literature (Cinahl). The descriptors "breastfeeding", "professional role" and "patient care team" were used in the research. The review was limited to articles in Portuguese, Spanish, and English published between 1997 and 2013.

DATA SYNTHESIS

The search retrieved 1,396 studies, 18 of which were selected for being directly relevant to the main question. The review showed that breastfeeding is a challenge for health professionals, regardless of their specialization, as they have to face a demand that requires skill and sensibility, for which they are not prepared. Health professionals have considered breastfeeding a purely instinctive and biological act. Moreover, it is noticeable that many of them possess theoretical expertise on the subject, but lack the practical skills.

CONCLUSIONS

Health professionals need to be better trained to work on promoting breastfeeding, whether by health and medical schools or by healthcare administrators, in order to consolidate multiprofessional teams committed to maternal-infant health.

The organisation and delivery of health improvement in general practice and primary care: a scoping study

Background

This project examines the organisation and delivery of health improvement activities by and within general practice and the primary health-care team. The project was designed to examine who delivers these interventions, where they are located, what approaches are developed in practices, how individual practices and the primary health-care team organise such public health activities, and how these contribute to health improvement. Our focus was on health promotion and ill-health prevention activities.

Aims

The aim of this scoping exercise was to identify the current extent of knowledge about the health improvement activities in general practice and the wider primary health-care team. The key objectives were to provide an overview of the range and type of health improvement activities, identify gaps in knowledge and areas for further empirical research. Our specific research objectives were to map the range and type of health improvement activity undertaken by general practice staff and the primary health-care team based within general practice; to scope the literature on health improvement in general practice or undertaken by health-care staff based in general practice and identify gaps in the evidence base; to synthesise the literature and identify effective approaches to the delivery and organisation of health improvement interventions in a general practice setting; and to identify the priority areas for research as defined by those working in general practice.

Methods

We undertook a comprehensive search of the literature. We followed a staged selection process involving reviews of titles and abstracts. This resulted in the identification of 1140 papers for data extraction, with 658 of these papers selected for inclusion in the review, of which 347 were included in the evidence synthesis. We also undertook 45 individual and two group interviews with primary health-care staff.

Findings

Many of the research studies reviewed had some details about the type, process or location, or who provided the intervention. Generally, however, little attention is paid in the literature to examining the impact of the organisational context on the way services are delivered or how this affects the effectiveness of health improvement interventions in general practice. We found that the focus of attention is mainly on individual prevention approaches, with practices engaging in both primary and secondary prevention. The range of activities suggests that general practitioners do not take a population approach but focus on individual patients. However, it is clear that many general practitioners see health promotion as an integral part of practice, whether as individual approaches to primary or secondary health improvement or as a practice-based approach to improving the health of their patients. Our key conclusion is that there is currently insufficient good evidence to support many of the health improvement interventions undertaken in general practice and primary care more widely.

Future Research

Future research on health improvement in general practice and by the primary health-care team needs to move beyond clinical research to include delivery systems and be conducted in a primary care setting. More research needs to examine areas where there are chronic disease burdens – cancer, dementia and other disabilities of old age. Reviews should be commissioned that examine the whole prevention pathway for health problems that are managed within primary care drawing together research from general practice, pharmacy, community engagement, etc.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Why health visiting? Examining the potential public health benefits from health visiting practice within a universal service: a narrative review of the literature

INTRODUCTION

There is increasing international interest in universal, health promoting services for pregnancy and the first three years of life and the concept of proportionate universalism. Drawing on a narrative review of literature, this paper explores mechanisms by which such services might contribute to health improvement and reducing health inequalities.

OBJECTIVES

Through a narrative review of empirical literature, to identify: (1) What are the key components of health visiting practice? (2) How are they reflected in implementing the universal service/provision envisaged in the English Health Visitor Implementation Plan (HVIP)?

DESIGN

The paper draws upon a scoping study and narrative review.

REVIEW METHODS

We used three complementary approaches to search the widely dispersed literature: (1) broad, general search, (2) structured search, using topic-specific search terms, (3) seminal paper search. Our key inclusion criterion was information about health visiting practice. We included empirical papers from United Kingdom (UK) from 2004 to February 2012 and older seminal papers identified in search (3), identifying a total of 348 papers for inclusion. A thematic content analysis compared the older (up to 2003) with more recent research (2004 onwards).

RESULTS

The analysis revealed health visiting practice as potentially characterized by a particular 'orientation to practice.' This embodied the values, skills and attitudes needed to deliver universal health visiting services through salutogenesis (health creation), person-centredness (human valuing) and viewing the person in situation (human ecology). Research about health visiting actions focuses on home visiting, needs assessment and parent-health visitor relationships. The detailed description of health visitors' skills, attitudes, values, and their application in practice, provides an explanation of how universal provision can potentially help to promote health and shift the social gradient of health inequalities.

CONCLUSIONS

Identification of needs across an undifferentiated, universal caseload, combined with an outreach style that enhances uptake of needed services and appropriate health or parenting information, creates opportunities for parents who may otherwise have remained unaware of, or unwilling to engage with such provision. There is a lack of evaluative research about health visiting practice, service organization or universal health visiting as potential mechanisms for promoting health and reducing health inequalities. This paper offers a potential foundation for such research in future.

Challenges to evaluating complex interventions: a content analysis of published papers

BACKGROUND

There is continuing interest among practitioners, policymakers and researchers in the evaluation of complex interventions stemming from the need to further develop the evidence base on the effectiveness of healthcare and public health interventions, and an awareness that evaluation becomes more challenging if interventions are complex.We undertook an analysis of published journal articles in order to identify aspects of complexity described by writers, the fields in which complex interventions are being evaluated and the challenges experienced in design, implementation and evaluation. This paper outlines the findings of this documentary analysis.

METHODS

The PubMed electronic database was searched for the ten year period, January 2002 to December 2011, using the term "complex intervention*" in the title and/or abstract of a paper. We extracted text from papers to a table and carried out a thematic analysis to identify authors' descriptions of challenges faced in developing, implementing and evaluating complex interventions.

RESULTS

The search resulted in a sample of 221 papers of which full text of 216 was obtained and 207 were included in the analysis. The 207 papers broadly cover clinical, public health and methodological topics. Challenges described included the content and standardisation of interventions, the impact of the people involved (staff and patients), the organisational context of implementation, the development of outcome measures, and evaluation.

CONCLUSIONS

Our analysis of these papers suggests that more detailed reporting of information on outcomes, context and intervention is required for complex interventions. Future revisions to reporting guidelines for both primary and secondary research may need to take aspects of complexity into account to enhance their value to both researchers and users of research.

Systematic review and meta-analysis of randomized controlled trials evaluating primary care-based interventions to promote breastfeeding in low-income women

BACKGROUND

Given the benefits of breastfeeding (BF), health care institutions recommend that a child should be breastfed for the first 6 months of its life. However, differences between social groups as regards BF behaviour are very prevalent.

OBJECTIVES

To identify effective programmes that can be implemented by GPs to promote BF in low-income women.

METHODS

A review of the literature was based on the Medline, Cochrane and Public Health databases (1985-2009), using index terms relating to BF, general medicine and social inequalities in health. Randomized controlled trials were included in our analysis. Two people independently selected which studies would be used by rating the quality of the articles. The results of these studies were presented in raw form and in terms of a pooled relative risk.

RESULTS

We analysed 10 studies (of the 343 articles originally selected) involving a population of 1445 'mother and child' pairs. The studies that assessed ways of encouraging the initiation of any form of BF showed that educational programmes are effective [relative risk (RR) for starting BF, 1.46, 95% confidence interval (CI): 1.03-2.08]. As regards the studies that involved ways to encourage mothers to continue BF, the programmes used showed significant success rates after 3-month postpartum (RR: 1.15, 95% CI: 1.01-1.30). The successful programmes usually involved multiple 'short' follow-up appointments (<20 to 30 minutes).

CONCLUSIONS

Educational programmes delivered in the context of ongoing personal contact with a health professional are effective in promoting BF in low-income women.

Midwifery factors associated with successful breastfeeding

BACKGROUND

It is well recognized that breast milk is the best form of nutrition for babies. However, many women do not breastfeed or give up soon after birth. Some report feeling unsupported in the post-natal period and many stop breastfeeding earlier than they would have wished. This study aimed to estimate the separate effects of midwifery factors in the overall context of sociodemographic and clinical influences on breastfeeding.

METHODS

Data from a national survey conducted in England in 2006 were used. Questionnaires were sent to a random sample of 4800 new mothers (63% response rate). Questions relating to infant feeding allowed calculation of rates of initiation of breastfeeding and rates of exclusive and any breastfeeding in the first few days and at 3 months. Univariate analyses were carried out to estimate the associations between sociodemographic, clinical and midwifery factors and breastfeeding. Logistic regression was used to estimate the specific effects of midwifery factors, while adjusting for other significant variables.

RESULTS

The most powerful explanatory factor was antenatal feeding intention. Maternal age, absence of clinical problems in the baby and a short post-natal stay were important in the early days. At 3 months, breastfeeding was associated with sociodemographic and intrapartum factors. At all stages, breastfeeding was significantly associated with either receiving consistent advice, practical help and/or active support and encouragement from midwives.

CONCLUSIONS

The antenatal decision about infant feeding is the most powerful predictor of infant feeding behaviour. Some sociodemographic and clinical factors are also important influences on breastfeeding. However, after adjusting for these, midwifery factors are still influential.

[Factors associated with exclusive breastfeeding: the role of primary health care]

The aim of this study was to assess the association between promotion, protection, and support for breastfeeding in primary health care services and prevalence of exclusive breastfeeding in the first six months of life. A cross-sectional study was conducted in a representative sample of 1,029 mothers of infants younger than six months treated at primary health care facilities in the city of Rio de Janeiro, in southeastern Brazil. Prevalence ratios (PR) were estimated by Poisson regression. Prevalence of exclusive breastfeeding was 58.1%. Factors associated with increased prevalence of exclusive breastfeeding were: white skin color (PR = 1.20; 95% CI: 1.05-1.36); schooling (PR = 1.19; 95% CI: 1.05-1.35); marital status (married or in common-law marriage) (PR = 1.72; 95% IC:1.02-2.90); previous breastfeeding (PR = 1.27; 95% CI: 1.08-1,49); exclusive breastfeeding at the time of hospital discharge (PR = 2.01; 95% CI: 1.20-3.36); group support for the mother (PR = 1.14; 95% CI: 1.01-1.28); and orientation on breastfeeding (PR = 1.20; 95% CI: 1.08-1.33). Prevalence of exclusive breastfeeding decreased 17% per month in the infant's life. Support groups and orientation by primary health care for breastfeeding were associated with increased exclusive breastfeeding prevalence.

A descriptive qualitative review of the barriers relating to breast-feeding counselling

The purpose of this review was to describe barriers in breast-feeding counselling considering it from the viewpoint of health professionals. CINAHL, MEDLINE and Cochrane databases were searched from 1950 to 2008. In total, 40 scientific research articles in English, Swedish or Finnish related to breast-feeding counselling were included and analysed using thematic analysis. The quality of the studies was also assessed. The main barriers were deficits in knowledge, resources, counselling skills and the counsellor's negative attitude. Conflicting advice, lack of guidelines, sufficiency of counselling and perceiving of the personal education needs were examples of the indicated barriers. The most commonly described barriers in breast-feeding counselling were limitations in breast-feeding knowledge. Developing of the measurements to assess the barriers in breast-feeding counselling is needed.

Researcher networking drives change: an autoenthnographic narrative analysis from medical graduate to primary health researcher

This narrative study aims to provide an illustrative example of the role of networking in a career path into doctoral candidature and research. Currently there is a push to build capacity for primary health care research. Mentoring and networking are increasingly relevant for recruitment, retention and research output, as can be seen in the case of this novice rural female researcher. The narrative ofmy career path from a rural general practice trainee, general practice obstetrician and educator through to postgraduate researcher is mapped and analysed. In this light this paper witnesses the development of the cluster-randomised controlled trial that is the basis of my doctoral research. My research topic is the use of a motivational interviewing intervention to increase breastfeeding rates through increased support for mothers. Analysis of connections among researchers who have influenced my career transitions reveals my gradual awareness of parallels with the theoretical framework of motivational interviewing. Themes that arise are related to the spirit of motivational interviewing: linkage and collaboration, exchange and evocation, career direction and autonomy. There are potential public health benefits from promoting such connections that may help to sustain motivation and increase output in both breastfeeding and primary health care research.

Why do interventions work in some places and not others: a breastfeeding support group trial

In a cluster randomised controlled trial of a policy to provide community breastfeeding support groups in Scotland, breastfeeding rates declined in 3 of 7 intervention localities. From a preliminary study, we expected breastfeeding outcomes to vary and we prospectively used qualitative and quantitative methods to ask why. Ethnographic in-depth interviews, focus groups, observations and survey data were analysed to build seven embedded case studies. A pyramidal model of how primary health service organisations implemented the policy was constructed prior to knowing trial outcomes to minimise bias. Informed by a realist approach, the model explained variation in (a) policy implementation (b) the breastfeeding outcomes, whereas the quantity of intervention delivered did not. In the three localities where breastfeeding rates declined, negative aspects of place including deprivation, unsuitable premises and geographical barriers to inter-professional communication; personnel resources including staff shortages, high workload and low morale; and organisational change predominated (the base model tiers). Managers focused on solving these problems rather than delivering the policy and evidence of progress to the higher model tiers was weak. In contrast, where breastfeeding rates increased the base tiers of the model were less problematic, there was more evidence of leadership, focus on the policy, multi-disciplinary partnership working and reflective action cycles (the higher model tiers). We advocate an ethnographic approach to the design and evaluation of complex intervention trials and illustrate how this can assist in developing an explanatory model. More attention should be given to the complex systems within which policies and interventions occur, to identify and understand the favourable conditions necessary for a successful intervention.

Effectiveness of policy to provide breastfeeding groups (BIG) for pregnant and breastfeeding mothers in primary care: cluster randomised controlled trial

OBJECTIVE

To assess the clinical effectiveness and cost effectiveness of a policy to provide breastfeeding groups for pregnant and breastfeeding women.

DESIGN

Cluster randomised controlled trial with prospective mixed method embedded case studies to evaluate implementation processes.

SETTING

Primary care in Scotland.

PARTICIPANTS

Pregnant women, breastfeeding mothers, and babies registered with 14 of 66 eligible clusters of general practices (localities) in Scotland that routinely collect breastfeeding outcome data.

INTERVENTION

Localities set up new breastfeeding groups to provide population coverage; control localities did not change group activity.

MAIN OUTCOME MEASURES

PRIMARY OUTCOME

any breast feeding at 6-8 weeks from routinely collected data for two pre-trial years and two trial years.

SECONDARY OUTCOMES

any breast feeding at birth, 5-7 days, and 8-9 months; maternal satisfaction.

RESULTS

Between 1 February 2005 and 31 January 2007, 9747 birth records existed for intervention localities and 9111 for control localities. The number of breastfeeding groups increased from 10 to 27 in intervention localities, where 1310 women attended, and remained at 10 groups in control localities. No significant differences in breastfeeding outcomes were found. Any breast feeding at 6-8 weeks declined from 27% to 26% in intervention localities and increased from 29% to 30% in control localities (P=0.08, adjusted for pre-trial rate). Any breast feeding at 6-8 weeks increased from 38% to 39% in localities not participating in the trial. Women who attended breastfeeding groups were older (P<0.001) than women initiating breast feeding who did not attend and had higher income (P=0.02) than women in the control localities who attended postnatal groups. The locality cost was pound13 400 (euro14 410; $20 144) a year.

CONCLUSION

A policy for providing breastfeeding groups in relatively deprived areas of Scotland did not improve breastfeeding rates at 6-8 weeks. The costs of running groups would be similar to the costs of visiting women at home.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN44857041.

Linkage in the chain of care: a grounded theory of professional cooperation between antenatal care, postpartum care and child health care

PURPOSE

The purpose of this article is to present a Swedish study exploring health care professionals' cooperation in the chain of care for expectant and new parents between antenatal care (AC), postpartum care (PC) and child health care (CHC). Furthermore, the rationale was to conceptualise barriers and facilitators of cooperation in order to generate a comprehensive theoretical model which may explain variations in the care providers' experiences.

METHODS

Thirty-two midwives and CHC nurses were interviewed in five focus group - and two individual interviews in a suburb of a large Swedish city. Grounded Theory was applied as the research methodology.

RESULTS

ONE CORE CATEGORY WAS DISCERNED: linkage in the chain of care, including six categories with subcategories. Despite the fact that midwives as well as CHC nurses have common visions about linkage, cooperation is not achieved because of interacting barriers that have different influences on the three links in the chain.

CONCLUSIONS

Barriers to linkage are lack of professional gain, link perspective and first or middle position in the chain, while facilitators are chain perspective, professional gain and last position in the chain. As the last link, CHC nurses promote a linkage most strongly and have the greatest gain from such linking.

Quality of neonatal care and outcome

High quality of care in neonatology implies providing an appropriate level of care to well newborn babies as well as more specialised care for the few babies who need it. Audit, surveillance and outcome studies may not always capture the complexity of quality of care and its contribution to outcome, and a more focused approach to standards of care evaluation may be required. Future progress in this field in the UK would benefit from a more coordinated approach from different organisations to bring together expertise in large database, management and analysis, audit and a national profile for feedback, evidence-based guidelines and guidelines development skills, expertise in the practice of changes together with the promotion by credible perinatal authorities of clinical practice.