An exploration of midwives' views of the current system of maternity care in England.

OBJECTIVE: to explore, in-depth, the views of midwives working in maternity services about birth setting, models of care and philosophy of care. DESIGN: an Appreciative Inquiry approach was adopted utilising focus group interviews as the method of data collection. SETTING: 15 focus group interviews were conducted at 14 sites in England. PARTICIPANTS: a purposive sample of 120 midwives and six student midwives who were serving women in different birth settings (home, free-standing maternity units, midwife-led units, and traditional obstetric units) participated, in 2001/2002. FINDINGS: the main themes generated by the midwives were: cultural changes; midwifery leadership; appropriate role models; training in normality; appropriate responsibility of care divisions; choice for women; equity of care provision between women considered to be at high or low risk; and staff morale. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: this study highlighted the consistency of views amongst midwives working in different settings. Midwives wanted support to practice autonomously in an environment that facilitated equity of care for women and job satisfaction for midwives. Suggestions were put forward by midwives on how to improve maternity services. A unified approach is required to develop these suggestions into strategies, that will remove the identified barriers and promote normality.

Maternal blood pressure in pregnancy, birth weight, and perinatal mortality in first births: prospective study.

OBJECTIVE: To investigate the relation of diastolic blood pressure in pregnancy with birth weight and perinatal mortality. DESIGN: Prospective study. SETTING: 15 maternity units in one London health region, 1988-2000. PARTICIPANTS: 210 814 first singleton births of babies weighing more than 200 g among mothers with no hypertension before 20 weeks' gestation and without proteinuria, delivering between 24 and 43 weeks' gestation. MAIN OUTCOME MEASURES: Birth weight and perinatal mortality. RESULTS: The mean (SD) birth weight of babies born to mothers with no hypertension before 20 weeks' gestation or proteinuria was 3282 g (545 g) and there were 1335 perinatal deaths, compared with 94 perinatal deaths among women with proteinuria or a history of hypertension. Diastolic blood pressure at booking for antenatal checks was progressively higher from weeks 34 to 40 of gestation. The birth weight of babies being delivered after 34 weeks was highest for highest recorded maternal diastolic blood pressures of between 70 and 80 mm Hg and lower for blood pressures outside this range. Both low and high diastolic blood pressures were associated with statistically significantly higher perinatal mortality. Using a linear quadratic model, 94 of 825 (11.4%) perinatal deaths could be attributed to mothers having blood pressure differing from the optimal blood pressure (82.7 mm Hg) predicted by the fitted model. Most of these excess deaths occurred with blood pressures below the optimal value. CONCLUSIONS: Both low and high diastolic blood pressures in women during pregnancy are associated with small babies and high perinatal mortality.