Educational interventions targeting pregnant women to optimise the use of caesarean section: What are the essential elements? A qualitative comparative analysis

BACKGROUND

Caesarean section (CS) rates are increasing globally, posing risks to women and babies. To reduce CS, educational interventions targeting pregnant women have been implemented globally, however, their effectiveness is varied. To optimise benefits of these interventions, it is important to understand which intervention components influence success. In this study, we aimed to identify essential intervention components that lead to successful implementation of interventions focusing on pregnant women to optimise CS use.

METHODS

We re-analysed existing systematic reviews that were used to develop and update WHO guidelines on non-clinical interventions to optimise CS. To identify if certain combinations of intervention components (e.g., how the intervention was delivered, and contextual characteristics) are associated with successful implementation, we conducted a Qualitative Comparative Analysis (QCA). We defined successful interventions as interventions that were able to reduce CS rates. We included 36 papers, comprising 17 CS intervention studies and an additional 19 sibling studies (e.g., secondary analyses, process evaluations) reporting on these interventions to identify intervention components. We conducted QCA in six stages: 1) Identifying conditions and calibrating the data; 2) Constructing truth tables, 3) Checking quality of truth tables; 4) Identifying parsimonious configurations through Boolean minimization; 5) Checking quality of the solution; 6) Interpretation of solutions. We used existing published qualitative evidence synthesis to develop potential theories driving intervention success.

RESULTS

We found successful interventions were those that leveraged social or peer support through group-based intervention delivery, provided communication materials to women, encouraged emotional support by partner or family participation, and gave women opportunities to interact with health providers. Unsuccessful interventions were characterised by the absence of at least two of these components.

CONCLUSION

We identified four key essential intervention components which can lead to successful interventions targeting women to reduce CS. These four components are 1) group-based delivery, 2) provision of IEC materials, 3) partner or family member involvement, and 4) opportunity for women to interact with health providers. Maternal health services and hospitals aiming to better prepare women for vaginal birth and reduce CS can consider including the identified components to optimise health and well-being benefits for the woman and baby.

The Case for Targeted Parenting Interventions with Reference to Intergenerational Transmission of Parenting: Qualitative Evidence from Three Studies of Marginalised Mothers’ and Fathers’ Participation in Parenting Programmes

The idea that how you were parented is key to how you parent your own children is widely recognisable. It is present in popular cultural references, underpins much policy on families and parenting in the UK, and is supported by a substantive body of academic literature. We explore this concept of intergenerational transmission of parenting, understanding it as the context in which parenting interventions have been implemented. We draw on interview data from three Scottish samples of marginalised parents (n = 54) to explore how participants think their own parenting behaviours have been shaped by their experience of being parented and how they talk about participation in a parenting intervention in relation to this. We find that how these parents have been parented is salient in considering their own parenting behaviour, and is a key context for their engagement with the intervention. We make the case for parenting interventions targeted at marginalised parents, arguing that they are acceptable to, and useful for, these parents and may, potentially, be effective in breaking cycles of negative parenting. Policy-makers should not shy away from implementing targeted parenting programmes as part of endeavours to address negative parenting.

Developing a complex intervention to support pregnant women with mild to moderate anxiety: application of the Medical Research Council framework

Background

To design and develop an intervention to support women with symptoms of mild to moderate anxiety in pregnancy.

Methods

The development followed the MRC framework for complex interventions, utilising psychological theory, review level evidence and professional and public involvement. Two systematic reviews were completed which helped identify potentially beneficial intervention components. The theory underpinning the components was explored to consider the potential benefit for women with mild to moderate anxiety symptoms in pregnancy. Methods of delivering the intervention within maternity services were explored. The intervention comprised: group discussions, one to one support and assisted self-help resources. Midwives were identified as ideally placed to facilitate the intervention supported by midwifery support workers. A bespoke training package was provided by subject experts to prepare the facilitators.

Results

The absence of established interventions and a paucity of evidence based approaches for pregnant women with symptoms of mild to moderate anxiety indicated the need for a rigorous and systematic approach to the intervention design. This approach led to the development of an intervention feasible for implementation in maternity care systems tailored to the needs of pregnant women. The involvement of a multi-professional advisory team and active engagement of service users helped to consider the acceptability of the intervention for women and the feasibility of delivering the intervention in the context of maternity care.

Conclusion

The MRC Framework provided useful overarching guidance to develop a midwife facilitated intervention for women with symptoms of anxiety in pregnancy. The framework assisted the development of a robust rationale for each intervention component and considered the processes of evaluation and implementation into maternity care systems.

Feasibility of a psychoeducational group intervention to improve parental reflective functioning and bonding in pregnancy: a randomised trial

OBJECTIVE

To develop and evaluate Baby CHAT, a single-session psychoeducational intervention for expectant parents. Baby CHAT aims to improve parental reflective functioning (RF) and bonding.

BACKGROUND

The early years of a child's life, including pregnancy, are vital for healthy physical and emotional development. Caregivers who provide responsive parenting, enhanced through strong bonds and good RF, can aid healthy development.. However, limited interventions exist to enhance RF and bonding in expectant parents.

METHODS

Feasibility of Baby CHAT was assessed using a mixed methods randomised controlled trial design. It evaluated uptake and retention of participants, effect size calculations, and acceptability and satisfaction with Baby CHAT.

RESULTS

Participants (N = 20) were aged 30-39 years (n = 17) in their third trimester of pregnancy (n = 12). Nine males and 11 females were recruited. Content analysis of qualitative feedback after the intervention resulted in four themes; positive group aspects, group improvements, 4D scan footage and relating content to my baby.

CONCLUSIONS

Baby CHAT can help expectant parents think about their baby as a separate person and has potential to improve prenatal RF and bonding. However, further research is required to assess the effectiveness of Baby CHAT to improve bonding and RF.

Non-pharmacological interventions to reduce the symptoms of mild to moderate anxiety in pregnant women. A systematic review and narrative synthesis of women's views on the acceptability of and satisfaction with interventions

To assess women's views on the acceptability of and satisfaction with non-pharmacological interventions to reduce the symptoms of anxiety in pregnant women. A systematic review and narrative synthesis (Prospero protocol number CRD42015017841). Fourteen included studies were conducted in Australia, Canada, Germany, New Zealand, UK and USA. Interventions were cognitive behavioural therapy, mindfulness, yoga, psychological assessment, supportive and educational based interventions. Studies included women from general antenatal populations and women with anxiety or depression symptoms or risk factors for anxiety or depression. The findings were limited due to the small number of studies evaluating different types of interventions using various study methods. Some studies had too little procedural reporting to allow a full quality assessment. Women's views on the acceptability of and satisfaction with interventions were overwhelmingly positive. The review highlights women's motivations for and barriers to participation as well as the benefit women perceived from peer support and individual discussions of their situation. Interventions need to be further evaluated in randomised controlled trials. The inclusion of women's views and experiences illuminates how and why intervention components contribute to outcomes. Women's initial concerns about psychological screening and the benefit derived from peer support and individual discussion should be noted by providers of maternity care.

Parental reactions, distress, and sense of coherence after prenatal versus postnatal diagnosis of complex congenital heart disease

INTRODUCTION

A diagnosis of congenital heart disease (CHD) in offspring triggers psychological distress in parents. Results of previous studies have been inconsistent regarding the psychological impact of a prenatal versus a postnatal diagnosis. The aim of this study was to evaluate the influence of the time of diagnosis on levels of parental distress.

METHODS

Pregnant women and their partners with a fetus diagnosed with complex CHD, parents of children with postnatally diagnosed CHD, and pregnant women and their partners with uncomplicated pregnancies were invited to participate. Data were collected during pregnancy and 2-6 months after delivery using the Hospital Anxiety and Depression Scale, sense of coherence, life satisfaction, and Dyadic Adjustment Scale.

RESULTS

During pregnancy, the prenatal group scored lower sense of coherence compared to controls (p=0.044). Postnatally the prenatal group scored lower on sense of coherence compared to the postnatal group and controls (p=0.001; p=0.001). Postnatally, the prenatal and postnatal groups had higher levels of anxiety compared to controls (p=0.025; p=0.0003). Life satisfaction was lower in the prenatal group compared to that in the postnatal group and in controls (p=0.000; p=0.0004).

CONCLUSION

Parents with a prenatal diagnosis of CHD in offspring report a low sense of coherence already during pregnancy which decreased further at follow-up. The same group reported a lower satisfaction with life compared to parents of a child with postnatal diagnosis of CHD and parents of a healthy child. This motivates further efforts to improve counselling and support during pregnancy and for parents after a prenatal diagnosis.

A realist process evaluation of Enhanced Triple P for Baby and Mellow Bumps, within a Trial of Healthy Relationship Initiatives for the Very Early years (THRIVE): study protocol for a randomized controlled trial

Background

THRIVE is a three-arm randomised controlled trial (RCT) that aims to evaluate whether antenatal and early postnatal interventions, Enhanced Triple B for Baby (ETPB) plus care as usual (CAU) or Mellow Bumps (MB) plus CAU (versus CAU alone), can: 1) improve the mental health and well-being of pregnant women with complex health and social care needs; 2) improve mother-infant bonding and interaction; 3) reduce child maltreatment; and 4) improve child language acquisition. This paper focuses on THRIVE’s realist process evaluation, which is carefully monitoring what is happening in the RCT.

Methods

Realistic evaluation provides the theoretical rationale for the process evaluation. We question: 1) how faithfully are MB and ETPB implemented? 2) What are the mechanisms by which they work, if they do, and who do they work for and how? 3) What contextual factors are necessary for the programmes to function, or might prevent them functioning?

The mixed-methods design includes quantitative measures, which are pre- and post-training/intervention questionnaires for facilitators and mothers-to-be, and post-session evaluation forms. Qualitative data collection methods include participant observation of facilitator training and the delivery of a series of antenatal sessions in selected intervention groups (n = 3 for ETPB and n = 3 for MB), semi-structured interviews with facilitators, pregnant women, partners, and referring facilitators, and telephone interviews examining the content of the postnatal components of ETPB and MB.

Discussion

The findings of this process evaluation will help researchers and decision makers interpret the outcomes of THRIVE. It will provide a greater understanding of: how the interventions work (if they do); the extent and quality of their implementation; contextual factors facilitating and constraining intervention functioning; variations in response within and between subgroups of vulnerable parents; and benefits or unintended consequences of either intervention. Few studies to date have published detailed research protocols illustrating how realist process evaluation is designed and conducted as an integral part of a randomised controlled trial.

Trial registration

ISRCTN, ISRCTN21656568. Registered on 8 November 2013.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3395-3) contains supplementary material, which is available to authorized users.

The reflective component of the Mellow Bumps parenting intervention: Implementation, engagement and mechanisms of change

Understanding why parenting programmes work or do not work, and for whom, is crucial for development of more effective parenting interventions. In this paper we focus on a specific component of Mellow Bumps: reflection on one's own childhood/past/life. We explore how this component was implemented, how participants engaged with it, the facilitating and constraining factors shaping this, whether and how it appeared to work, or not, and for whom. The paper analyses data from the Process Evaluation of the Trial of Healthy Relationships Initiatives for the Very Early years, which is evaluating two antenatal interventions delivered to vulnerable women, one of which is Mellow Bumps. Data were collected from January 2014 to June 2018 for 28 groups, 108 participants and 24 facilitators in a comprehensive and rigorous Process Evaluation designed to complement the Outcome Evaluation. Data were gathered at various time points using multiple methods, and were synthesised to triangulate findings. The reflective component was implemented with fidelity and participants engaged with it to varying degrees, dependent largely on the coherence of the group. Patchy attendance compromised the coherence of some groups, with the development of rapport, which is key to delivering reflective exercises, more difficult when group composition varied from week to week. Where there was a coherent group, powerful mechanisms of change, leading to stress reduction, included: relief through unburdening, empowerment through support given and received, reduced isolation through sharing anxieties, and control through self-care advice. A minority of highly vulnerable mothers seemed not to benefit from the reflective exercises and were marginalised within their groups. In order to minimise potential harmful effects of such exercises, allocation of participants to groups should strive to maximise group homogeneity. More research is needed to explore how very vulnerable parents can be supported in attending parenting interventions from start to finish.

Experience of care for mental health problems in the antenatal or postnatal period for women in the UK: a systematic review and meta-synthesis of qualitative research

PURPOSE

Pregnancy and the first postnatal year can be a difficult and distressing period for women with mental health problems, particularly if they are not able to access appropriate and timely assessment and treatment. The aim of this systematic review was to synthesise qualitative evidence on experiences of care for women with (or at risk of developing) antenatal or postnatal mental health problems across a range of disorders (including non-psychotic mental disorders).

METHODS

Six electronic databases were searched for papers published from 2000 to April 2014. Thirty-nine studies were identified that met the inclusion criteria. Findings were synthesised using secondary framework and thematic analysis approaches.

RESULTS

Seven key themes were identified across mental disorder groups: an unmet need for collaborative and integrated care; stigma and fears about loss of custody; healthcare professionals unable or unwilling to address psychological needs; focus on babies over mothers; importance of non-judgmental and compassionate support; an unmet need for information; importance of service user involvement in treatment decisions.

CONCLUSIONS

Women's experience of accessing and engaging with care for mental health problems could be improved if given the opportunity to develop trusting relationships with healthcare professionals who acknowledge and reinforce the woman's role in caring for her baby in a non-judgmental and compassionate manner, and foster hope and optimism about treatment. Information for women, their families and healthcare professionals, and the provision of individualised care and treatment, are also crucial to enable full implementation of a person-centred programme of care.

Mellow Parenting: systematic review and meta-analysis of an intervention to promote sensitive parenting

AIM

To review and meta-analyse Mellow Parenting interventions for parent-child dyads at high risk of adverse developmental outcomes.

METHOD

Using Preferred Reporting Items of Systematic reviews and Meta-Analyses (PRISMA) guidelines, we extracted all published evaluations of Mellow Parenting and Mellow Babies programmes. We identified published studies with randomized controlled trials, quasi-experimental or within-subject pre-post designs. We incorporated 'grey literature' for unpublished publicly available evaluations. Effect sizes were calculated for impact of Mellow Parenting on parental mental health and child behaviour. Data were extracted on demographics, age of participants, country, and potential sources of bias.

RESULTS

We identified eight papers, representing nine data sets, from five of which we calculated effect sizes. There was evidence of a medium treatment effect of Mellow Parenting compared with comparison groups on maternal well-being and child problems. Drop-out from treatment was variable. However, data were heterogeneous and there was evidence of methodological bias.

INTERPRETATION

Our data give some support to claims for effectiveness of Mellow Parenting as a group intervention for families with multiple indices of developmental adversity. Given the methodological weaknesses of literature in the area, novel approaches are needed in future trials of low-budget complex interventions in non-commercial settings.