Midwives' experiences of discussing health behaviour change within routine maternity care: A qualitative systematic review and meta-synthesis.

PROBLEM: Behaviours, such as smoking, alcohol use, unhealthy diet, lack of physical activity and vaccination non-adherence may lead to adverse pregnancy outcomes. BACKGROUND: Pregnancy has been identified as an opportune time for midwives to support women to make health behaviour changes. AIM: To synthesise existing qualitative research exploring midwives' experiences of discussing health behaviour change with women within routine care. METHODS: A systematic search was conducted across: Maternity and Infant Care, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, and Applied Social Sciences Index and Abstracts. Thematic analysis was used to synthesise the data. A professional and public advisory group provided feedback during the synthesis stage. FINDINGS: Twenty-two studies, published between 2005 and 2023, which represented findings from eight countries, were included in the review. The meta-synthesis revealed three themes: The midwife-woman relationship; Reflective and tailored behaviour change communication; Practical barriers to behaviour change conversations. This led to one overarching theme: Although midwives recognised the importance of behaviour change discussions, these conversations were not prioritised in clinical practice. CONCLUSION: Health behaviour change discussions were de-prioritised in midwives' clinical practice. Future research should explore intervention development to support midwives with their health behaviour change communication.

Exploring the STEP-uP to practice: A survey of UK Lead Midwives for Education views of the STudent midwife Extended Practice Placement during the first wave of the COVID-19 pandemic.

OBJECTIVE: to assess the effect of implementation of the extended placement option available to midwifery students during the first wave of the COVID-19 pandemic. DESIGN: Online survey open from 2nd June 2020 to 15th July 2020. SETTING: United Kingdom. PARTICIPANTS: Lead Midwives for Education (LMEs). FINDINGS: A total of 38 of 55 LMEs responded (response rate 69%). The majority of Approved Education Institutions (AEIs) offered an extended placement to students, but with some variation in the choices offered, unrelated to geographical location or size of student cohort. AEIs appeared to provide the majority of decisional support for students. Many practice learning environments became unavailable, particularly community, gynaecology/medical wards and neonatal units. LMEs experienced both internal and external pressures to instigate rapid change. KEY CONCLUSIONS: The impact of COVID-19 on midwifery education is significant and will need continual scrutiny to minimise future detriment. The pressures of providing midwifery education throughout the early phase of COVID-19 were substantial, but it is important that we learn from the immediate changes made, value and pursue the changes that have been beneficial, and learn from those that were not. IMPLICATIONS FOR PRACTICE/RESEARCH: Student learning experiences have undergone significant change during the pandemic. It is essential to assess what effect the extended placement has had on student readiness for practice, their confidence, resilience, mental health, and attrition and retention. Educators transitioned to remote working, and rapidly assimilated new skills for online education; exploration of the impact of this is recommended.

Exploring Lived Experiences of Adolescents Presenting with Self-Harm and Their Views about Suicide Prevention Strategies: A Qualitative Approach.

Suicide is a serious global public health problem and the third leading cause of death in those 15-35 years old. Self-harm is the major predictor of future suicide attempts and completed suicide yet remains poorly understood. There is limited evidence on effective interventions for adolescents who present with self-harm. To identify and develop acceptable preventive and therapeutic interventions it is essential to understand the factors that contribute to self-harm and suicide in young people, in the context of their emotions, interpersonal difficulties, available support and prevention strategies. This qualitative study aimed at exploring the lived experiences of adolescents presenting with self-harm and their views about potential prevention strategies. Semi-structured interviews with 16 adolescents (12-18 years) presenting with a self-harm episode in a public hospital in Pakistan. A topic guide was developed to facilitate the interviews. The following themes emerged using the framework analysis; predisposing factors (interpersonal conflicts, emotional crisis etc.), regret and realization that self-harm is not the only option, perceived impact of self-harm, and suggestions for suicide prevention strategies (sharing, distraction techniques, involvement of family). This study may help in refining a contextual and culturally based explanatory model of self-harm in adolescents and in informing development of culturally acceptable interventions.

A mixed methods investigation of an online intervention to facilitate student midwives' engagement in effective conversations about weight-related behaviour change with pregnant women.

OBJECTIVE: (1) To identify whether an online training intervention could increase midwifery students' knowledge of behaviour change techniques (BCTs) and intentions to use them in practice. (2) To identify students' views and current experiences of talking to women about weight-related behaviour change. DESIGN: Mixed methods study involving pre- and post-training assessments, and qualitative interviews with midwifery students. SETTING: Online training course delivered at a University in the North of England, UK. PARTICIPANTS: Midwifery students in the third year of their undergraduate degree during 2015-2016. INTERVENTION: Online training focused on equipping students with knowledge of theoretically-informed BCTs, and the skills to use them opportunistically in existing practice settings. MEASUREMENTS: Likelihood of discussing obesity with women was assessed via a 12-item, 7-point Likert scale assessing students' attitudes, subjective norms, perceived behavioural control, and intentions. A 14-item checklist was used to assess BCT knowledge whereby students selected recognised BCTs (of 7 correct, 7 false). Students' views and experiences of current practice was explored through in-depth, semi-structured one-on-one interviews with a member of the research team. FINDINGS: Students' subjective norms, perceived behavioural control, and knowledge of BCTs increased post-training but intention and attitudes did not. Interviews revealed three themes accounting for students experiences and views of behaviour change practice: (1) 'How training fits with current encounters with maternal obesity in midwifery training' (2) 'TEnT PEGS prepares students for practice', and (3) 'Value of tailored training'. KEY CONCLUSIONS: Online BCT training can improve the midwifery students' confidence, knowledge and beliefs that this is part of their role. They also reported finding the training helpful in better preparing them for this challenging element of their routine practice. IMPLICATIONS FOR PRACTICE: Online BCT training can be used to prepare undergraduate midwifery students for practice.

Group psychological intervention for maternal depression: A nested qualitative study from Karachi, Pakistan.

AIM: To understand the experience of maternal depression, the factors implicated in accessing health, and the acceptability of the psychosocial intervention. METHODS: The participants were recruited from the paediatrics outpatient department of Civil Hospital Karachi, Pakistan. The study started in December 2009 and completed in December 2010. Women with maternal depression, aged 18-44 years with children aged 0-30 mo who had received nutritional supplements, and participated in the intervention programme [called Learning through Play (LTP) plus] were included in the study. Qualitative interviews were conducted with 8 participants before the intervention and 7 participants after the intervention. A semi structured topic guide was used to conduct the interviews. RESULTS: Framework analysis procedures were used to analyse the qualitative data. Four themes emerged: (1) the women's contextual environment: Interpersonal conflicts, lack of social support and financial issues being the major barriers in assessing healthcare; (2) women's isolation and powerlessness within the environment: Sense of loneliness was identified as a restricting factor to access healthcare; (3) the impact of the intervention (LTP-Plus): Women felt "listened to" and seemed empowered; and (4) empowered transformed women within the same contextual environment: The facilitator provided a "gardening role" in nurturing the women resulting in a positive transformation within the same environment. The women's homes seemed to be more happy homes and there was a positive change in their behaviour towards their children. CONCLUSION: Findings informed the further development and testing of culturally-appropriate psychosocial intervention (LTP+) for addressing maternal depression.

Student midwives' awareness, knowledge, and experiences of antenatal anxiety within clinical practice.

OBJECTIVE: The current study aimed to explore student midwives' awareness, knowledge, and experiences of supporting women with antenatal anxiety (ANA) within clinical practice. BACKGROUND: ANA is associated with negative outcomes for mother and baby. Midwives play a key role in the screening of antenatal mental health and care of women suffering from ANA. METHODS: This study was conducted with student midwives at one UK university in the north-west of England. Twenty-five midwifery students completed a brief online survey informed by National Institute of Health and Care Excellence (NICE) guidelines. Of these, seven volunteered to participate in semi-structured interviews exploring the survey data. The interview topic guide was designed based on the findings of the survey. RESULTS: Thematic analysis of the seven interviews revealed four overarching themes: Perpetuating factors, Barriers to care, Skills required in role and Suggestions for future directions. Midwives had a varied knowledge and understanding of ANA and expressed a desire to learn more about their role in supporting women with ANA. CONCLUSION: Although a small study, the results highlight the need for education to be improved in order to best prepare student midwives for cases of ANA, with emphasis on integrating psychology and mental health information into teaching as well as time spent in clinical practice. Midwives are key in the screening of women for ANA and are in an ideal position to signpost for specialist care.

Testing HIV positive in pregnancy: A phenomenological study of women's experiences.

OBJECTIVE: globally women receive HIV testing in pregnancy; however, limited information is available on their experiences of this potentially life-changing event. This study aims to explore women's experiences of receiving a positive HIV test result following antenatal screening. DESIGN: a qualitative, phenomenological approach. SETTING: two public National Health Service (NHS) hospitals and HIV support organisations. PARTICIPANTS: a purposive sampling strategy was used. Thirteen black African women with a positive HIV result, in England, participated. METHODS: data were collected using in-depth semi-structured interviews. An interpretive phenomenological approach to data analysis was used. FINDINGS: the emergent phenomenon was transition and transformation of 'being,' as women accepted HIV as part of their lives. Paired themes support the phenomenon: shock and disbelief; anger and turmoil; stigma and confidentiality issues; acceptance and resilience. Women had extreme reactions to their positive HIV diagnosis, compounded by the cultural belief that they would die. Initial disbelief of the unexpected result developed into sadness at the loss of their old self. Turmoil was evident, as women considered termination of pregnancy, self-harm and suicide. Women felt isolated from others and relationship breakdowns often occurred. Most reported the pervasiveness of stigma, and how this was managed alongside living with HIV. Coping strategies included keeping HIV 'secret' and making their child(ren) the prime focus of life. Growing resilience was apparent with time. KEY CONCLUSIONS: this study gives midwives unique understanding of the complexities and major implications for women who tested positive for HIV. Women's experiences resonated with processes of bereavement, providing useful insight into a transitional and transformational period, during which appropriate support can be targeted. IMPLICATIONS: midwives are crucial in improving the experience of women when they test HIV positive and to do this they need to be appropriately trained. Midwives need to acknowledge the social and psychological impact of HIV and pathways should be developed to support early referral for appropriate support.

Women's experiences of cervical ripening as inpatients on an antenatal ward.

OBJECTIVE: To gain an insight into women's lived experiences of inpatient cervical ripening, in the context of usual care, whilst they were admitted as inpatients on an antenatal ward. METHODS: A qualitative design was used guided by an interpretative phenomenological approach. Seven women who had experienced inpatient cervical ripening on an antenatal ward in Wales (UK) agreed to participate in the study. Data were gathered from semi-structured interviews and analysed thematically. RESULTS: Four overarching themes were identified relating to participants' support from significant others, their understanding of the procedure, perception of their own physiological sensations, and their sense of freedom within the ward environment. CONCLUSIONS: Strict adherence to ward rules and procedures appeared to undermine women's experiences of cervical ripening as inpatients on an antenatal ward. Facilitating the continued presence of family members, improving the provision of information, listening to women and enhancing their perception of freedom within the ward environment are strategies that may have a positive influence on women's experiences of inpatient cervical ripening. This study has provided an insight into women's experiences of usual care, during the cervical ripening procedure, as inpatients on an antenatal ward.

A narrative review of fathers' involvement during labour and birth and their influence on decision making.

OBJECTIVE: to identify and critically review the research literature that has examined fathers׳ involvement during labour and birth and their influence on decision making. DESIGN: the review follows the approach of a narrative review. Systematic searches of electronic databases Social Services Abstract, Sociological Abstracts, ASSIA, CINAHL Medline, Cochrane library, AMED, BNI, PsycINFO, Embase, Maternity and Infant care, DH-Data and the Kings Fund Database were combined with manual searches of key journals and reference lists. Studies published between 1992 and 2013 examining fathers׳ involvement during intrapartum care were included in the review. FINDINGS: the findings of this review suggest that fathers׳ level of involvement during labour ranges from being a witness or passive observer of labour and birth to having an active supporting and coaching role. The findings also suggest that there are a number of facilitators and barriers to fathers׳ involvement during labour and birth. There are a limited number of studies that have examined fathers׳ involvement in decision making and specifically how fathers׳ influence decision making during labour and birth. KEY CONCLUSIONS: future research needs to address the gap in the literature regarding fathers׳ involvement and influence on decision making to help midwives and obstetricians understand the process in order enhance the transition to parenthood for women and men.

The experiences of midwives when caring for obese women in labour, a qualitative study.

BACKGROUND: maternal obesity is a significant public health challenge for maternity services, especially those in developed countries. Obesity presents an increased risk of mortality and morbidity during the childbearing continuum. Caring for the obese woman in labour is challenging for midwives and there is a dearth of qualitative research which examines their experiences. OBJECTIVES: to explore the experiences of midwives caring for obese women in labour. DESIGN: a qualitative, phenomenological approach was used to enable in-depth exploration of midwives' experiences. SETTING: one maternity centre in the North of England. PARTICIPANTS: a purposive sampling approach was used. Eleven midwives who had experience of caring for obese women in labour were interviewed using in depth, digitally recorded semi-structured interviews for data collection. METHODS: interpretative Phenomenological Analysis was performed, and underlying themes emerged from the data resulting in an exhaustive description of midwives' experiences of caring for obese women in labour. FINDINGS: the heart sinking phenomena when caring for obese women in labour emerged from the data from these midwives. Midwives were faced with a constant challenge to promote normality during childbearing in a medicalised environment. Mobilisation of the obese woman was a significant factor for midwives who were striving for normality for the woman. A sense of loss of control and helplessness underlying their care provision was apparent. Perceptions of obesity differed, with confusion between embarrassment and empathy emerging. Difficulties of how and when is the best opportunity to address obesity with the women arose. Different provisions of care amongst midwives were discussed. KEY CONCLUSIONS: the findings suggest that midwives have different levels of understanding of the complexities associated with the condition. There was a sense of frustration at the 'loss' of normality for this group of women. Different provisions of care emerged with the need for more explicit guidelines to guide and support midwives. Communication and education were identified as key concepts when addressing the increasing prevalence of obesity. IMPLICATIONS FOR PRACTICE: it is evident that the maternal obesity phenomenon is growing rapidly and that midwives feel that they are ill equipped to address it. Support must be provided for the practitioners striving for normality for the women. Continuity of care must be encouraged to enable practitioners to build up a rapport with these vulnerable women through the childbirth continuum. Midwives involvement in developing multidisciplinary guidelines should be encouraged to determine the roles and responsibilities of practioners. Antenatal education is key if women are to be made aware of the problems associated with obesity and interdisciplinary learning must be encouraged to ensure support is consistent, appropriate and available to all women.

Using Framework Analysis in nursing research: a worked example.

AIMS: To demonstrate Framework Analysis using a worked example and to illustrate how criticisms of qualitative data analysis including issues of clarity and transparency can be addressed. BACKGROUND: Critics of the analysis of qualitative data sometimes cite lack of clarity and transparency about analytical procedures; this can deter nurse researchers from undertaking qualitative studies. Framework Analysis is flexible, systematic, and rigorous, offering clarity, transparency, an audit trail, an option for theme-based and case-based analysis and for readily retrievable data. This paper offers further explanation of the process undertaken which is illustrated with a worked example. DATA SOURCE AND RESEARCH DESIGN: Data were collected from 31 nursing students in 2009 using semi-structured interviews. DISCUSSION: The data collected are not reported directly here but used as a worked example for the five steps of Framework Analysis. Suggestions are provided to guide researchers through essential steps in undertaking Framework Analysis. The benefits and limitations of Framework Analysis are discussed. IMPLICATIONS FOR NURSING: Nurses increasingly use qualitative research methods and need to use an analysis approach that offers transparency and rigour which Framework Analysis can provide. Nurse researchers may find the detailed critique of Framework Analysis presented in this paper a useful resource when designing and conducting qualitative studies. CONCLUSION: Qualitative data analysis presents challenges in relation to the volume and complexity of data obtained and the need to present an 'audit trail' for those using the research findings. Framework Analysis is an appropriate, rigorous and systematic method for undertaking qualitative analysis.

Antenatal interventions for reducing weight in obese women for improving pregnancy outcome.

BACKGROUND: Being obese and pregnant is associated with substantial risks for the mother and her child. Current weight management guidance for obese pregnant women is limited. The latest recommendations suggest that obese pregnant women should gain between 5.0 and 9.1 kg during the pregnancy period, and weight loss is discouraged. However, observational studies indicate that some obese pregnant women, especially those who are heavier, lose weight during pregnancy. Furthermore, some obese pregnant women may intentionally lose weight. The safety of weight loss when pregnant and obese is not substantiated; some observational studies suggest that risks associated with weight loss such as pre-eclampsia are improved, but others indicate that the incidence of small- for-gestational infants are increased. It is important to evaluate interventions that are designed to reduce weight in obese pregnant women so that the safety of weight loss during this period can be established. OBJECTIVES: To evaluate the effectiveness of interventions that reduce weight in obese pregnant women. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 July 2012) and contacted experts in the field. SELECTION CRITERIA: Randomised controlled trials, 'quasi-random' studies and cluster-randomised trials comparing a weight-loss intervention with routine care or more than one weight loss intervention. Cross-over trials were not eligible for inclusion. DATA COLLECTION AND ANALYSIS: We identified no studies that met the inclusion criteria for this review. MAIN RESULTS: There were no included trials. AUTHORS' CONCLUSIONS: There are no trials designed to reduce weight in obese pregnant women. Until the safety of weight loss in obese pregnant women can be established, there can be no practice recommendations for these women to intentionally lose weight during the pregnancy period. Further study is required to explore the potential benefits, or harm, of weight loss in pregnancy when obese before weight loss interventions in pregnancy can be designed. Qualitative research is also required to explore dietary habits of obese pregnant women, especially those who are morbidly obese.

What can qualitative studies tell us about the experiences of women who are pregnant that have an eating disorder?

OBJECTIVE: pregnancy is a life-stage during which women undergo significant changes to their body and can feel acute responsibility for the development and well-being of the fetus. A synthesis of qualitative studies was conducted to increase our understanding of pregnancy experiences among women with an eating disorder. DESIGN: a systematic search of eight electronic databases was carried out to identify relevant investigations. Studies were appraised by two authors. Data were combined using framework analysis. From 459 references, seven papers were included in the review. FINDINGS: an overriding concept of inner turmoil transpired from the synthesis. This personal conflict related to the fear and guilt expressed by interviewees and stemmed from their association of self-worth with their body, concerns about their child's health and worries about others' response to their eating and weight control practices. KEY CONCLUSIONS: participants reported vacillating between wanting to do the best for their child, being motivated by social pressures and feeling the need to control their body for self-preservation purposes. This created the inner turmoil they experienced while pregnant. IMPLICATIONS FOR PRACTICE: midwives should be sensitive to the possibility of an eating disorder among pregnant women. In such cases, practitioners could act as a conduit for any assistance required, guiding these mothers towards appropriate nutritional and psychological support. To do this, professionals must have knowledge of such conditions and be aware of services available for women disclosing disordered eating behaviours.

The challenges and realties of diaper area cleansing for parents.

OBJECTIVE: To explore the complexities of diaper area cleansing reported by women participating in a randomized controlled trial designed to compare optimally formulated baby wipes (Johnson's Baby Skincare fragrance free wipe) with cotton wool and water. DESIGN: A mixed-method design incorporating quantitative and qualitative methods to explore maternal views and experiences of using baby wipes or cotton wool and water to cleanse their newborn's diaper area over an 8-week period. SETTING: Participants were recruited from a large regional maternity hospital in Northern England. PARTICIPANTS: Participants included 280 women and their healthy term newborns; 252 provided 4-week data (90.0%) and 237 provided 8-week data (85.0%). METHODS: Data from diaries and structured face-to-face interviews at 4 weeks and telephone interviews at 8 weeks were transcribed and thematically analyzed to identify themes. Quantitative data were compared between randomized groups using descriptive statistics and two-group tests, where appropriate. RESULTS: Major themes identified highlighted the practical realities of diaper area cleansing, diaper area cleansing and everyday life, and living with the rhetoric that water is best. Baby wipes were perceived as more convenient efficient at cleansing. Some women using cotton wool and water did not cleanse skin after urination alone. Diaper changing was significantly more frequent in the baby wipes group at 4 weeks, but there was no significant difference between the groups at 8 weeks. CONCLUSION: Women are faced with a complex environment regarding diaper area cleansing and need clear evidence-based advice and guidance on effective diaper area cleansing.

Effect on skin hydration of using baby wipes to clean the napkin area of newborn babies: assessor-blinded randomised controlled equivalence trial.

BACKGROUND: Some national guidelines recommend the use of water alone for napkin cleansing. Yet, there is a readiness, amongst many parents, to use baby wipes. Evidence from randomised controlled trials, of the effect of baby wipes on newborn skin integrity is lacking. We conducted a study to examine the hypothesis that the use of a specifically formulated cleansing wipe on the napkin area of newborn infants (<1 month) has an equivalent effect on skin hydration when compared with using cotton wool and water (usual care). METHODS: A prospective, assessor-blinded, randomised controlled equivalence trial was conducted during 2010. Healthy, term babies (n=280), recruited within 48 hours of birth, were randomly assigned to have their napkin area cleansed with an alcohol-free baby wipe (140 babies) or cotton wool and water (140 babies). Primary outcome was change in hydration from within 48 hours of birth to 4 weeks post-birth. Secondary outcomes comprised changes in trans-epidermal water loss, skin surface pH and erythema, presence of microbial skin contaminants/irritants at 4 weeks and napkin dermatitis reported by midwife at 4 weeks and mother during the 4 weeks. RESULTS: Complete hydration data were obtained for 254 (90.7 %) babies. Wipes were shown to be equivalent to water and cotton wool in terms of skin hydration (intention-to-treat analysis: wipes 65.4 (SD 12.4) vs. water 63.5 (14.2), p=0.47, 95% CI -2.5 to 4.2; per protocol analysis: wipes 64.6 (12.4) vs. water 63.6 (14.3), p=0.53, 95% CI -2.4 to 4.2). No significant differences were found in the secondary outcomes, except for maternal-reported napkin dermatitis, which was higher in the water group (p=0.025 for complete responses). CONCLUSIONS: Baby wipes had an equivalent effect on skin hydration when compared with cotton wool and water. We found no evidence of any adverse effects of using these wipes. These findings offer reassurance to parents who choose to use baby wipes and to health professionals who support their use. TRIAL REGISTRATION: Current Controlled Trials ISRCTN86207019.

A qualitative study of the experiences of women who are obese and pregnant in the UK.

OBJECTIVE: to explore the experiences related to obesity in women with a body mass index (BMI)>35 kg/m(2) during the childbearing process. DESIGN: a qualitative design was used. Data were collected using semi-structured interviews and field notes. Women were interviewed in the third trimester of pregnancy and between three and nine weeks after the birth. Transcribed data were analysed using framework analysis methods. SETTING: one maternity service in the North of England. PARTICIPANTS: 19 women with BMI>35 kg/m(2). FINDINGS: these women highlighted their feelings of humiliation, and the stigma associated with being pregnant, when obese. Interactions with health professionals and the general public reinforced their discomfort about their size. The high-risk status of their pregnancy increased the medicalisation of their pregnancy. The ultrasound scan was a significant source of distress if difficulties imaging the fetus were not clearly explained during the procedure. KEY CONCLUSIONS: pregnant women who are obese are sensitive of their size. The interactions with health professionals and others that they encounter may increase distress. IMPLICATIONS FOR PRACTICE: health professionals should be more aware of the psychological implications of being obese. Communication strategies about care should be clear and honest, and conveyed in a sensitive manner. Written comments related to size on 'hand-held' notes should be explained at the time of writing.

Antenatal interventions for reducing weight in obese women for improving pregnancy outcome.

This is the protocol for a review and there is no abstract. The objectives are as follows: To evaluate the effectiveness of interventions that reduce weight in obese pregnant women.

The power of language: a secondary analysis of a qualitative study exploring English midwives' support of mother's baby-feeding practice.

OBJECTIVE: to explore the use of language by midwives reporting their experiences of baby-feeding practice. DESIGN: A qualitative approach incorporating a secondary analysis of data previously collected in a study based on grounded theory principles. Data were collected using in-depth interviews. The secondary analysis involved a content analysis method. SETTING: two maternity services in the north of England. PARTICIPANTS: 30 midwives who worked across all clinical areas. FINDINGS: these midwives' explanations of how they supported women with baby feeding suggest that they used language to direct women towards decisions that the midwives thought best, without prior exploration of the woman's understanding and beliefs of baby feeding. Women were often described as 'girls' and 'ladies' indicating the power differentials in their relationship. The midwives were aware that, at times, the language they used was contradictory to woman-centred maternity care. KEY CONCLUSIONS: language may be used to control childbearing women and direct them to decisions that the midwife wants, rather than enabling the woman to make her own decisions. The terms used by midwives to relate to women, such as 'girls' and 'ladies', may be a strategy used to improve a midwife's perception of her status in maternity care. IMPLICATIONS FOR PRACTICE: language may be used to undermine women. It is important that the language used when interacting with women is considered carefully in order to facilitate an unbiased perspective and to promote partnership. The word 'women', rather than 'girls' or 'ladies', should be used when referring to users of the maternity services.