Women's experiences and views of routine assessment for anxiety in pregnancy and after birth: A qualitative study.

BACKGROUND: Anxiety in pregnancy and postnatally is highly prevalent but under-recognized. To identify perinatal anxiety, assessment tools must be acceptable to women who are pregnant or postnatal. METHODS: A qualitative study of women's experiences of anxiety and mental health assessment during pregnancy and after birth and views on the acceptability of perinatal anxiety assessment. Semi-structured interviews were conducted with 41 pregnant or postnatal women. Results were analysed using Sekhon et al.'s acceptability framework, as well as inductive coding of new or emergent themes. RESULTS: Women's perceptions of routine assessment for perinatal anxiety were generally favourable. Most participants thought assessment was needed and that the benefits outweighed potential negative impacts, such as unnecessary referrals to specialist services. Six themes were identified of: (1) Raising awareness; (2) Improving support; (3) Surveillance and stigma; (4) Gatekeeping; (5) Personalized care and (6) Trust. Assessment was seen as a tool for raising awareness about mental health during the perinatal period and a mechanism for normalizing discussions about mental health more generally. However, views on questionnaire assessments themselves were mixed, with some participants feeling they could become an administrative 'tick box' exercise that depersonalizes care and does not provide a space to discuss mental health problems. CONCLUSION: Routine assessment of perinatal anxiety was generally viewed as positive and acceptable; however, this was qualified by the extent to which it was informed and personalized as a process. Approaches to assessment should ideally be flexible, tailored across the perinatal period and embedded in continuity of care.

Clinicians' perspectives and experiences of providing cervical ripening at home or in-hospital in the United Kingdom.

Induction of labour, or starting labour artificially, is offered when the risks of continuing pregnancy are believed to outweigh the risks of the baby being born. In the United Kingdom, cervical ripening is recommended as the first stage of induction. Increasingly, maternity services are offering this outpatient or 'at home', despite limited evidence on its acceptability and how different approaches to cervical ripening work in practice. There is also a paucity of literature on clinicians' experiences of providing induction care in general, despite their central role in developing local guidelines and delivering this care. This paper explores induction, specifically cervical ripening and the option to return home during that process, from the perspective of midwives, obstetricians and other maternity staff. As part of a process evaluation involving five case studies undertaken in British maternity services, interviews and focus groups were conducted with clinicians who provide induction of labour care. The thematic findings were generated through in-depth analysis and are grouped to reflect key points within the process of cervical ripening care: 'Implementing home cervical ripening', 'Putting local policy into practice', 'Giving information about induction' and 'Providing cervical ripening'. A range of practices and views regarding induction were recorded, showing how the integration of home cervical ripening is not always straightforward. Findings demonstrate that providing induction of labour care is complex and represents a significant workload. Home cervical ripening was seen as a solution to managing this workload; however, findings highlighted ways in which this expectation might not be borne out in practice. More comprehensive research is needed on workload impacts and possible lateral effects within other areas of maternity services.

Experience of induction of labour: a cross-sectional postnatal survey of women at UK maternity units.

OBJECTIVES: This study explored women's views and experiences of key elements of the induction of labour (IOL) process, including at home or in hospital cervical ripening (CR). DESIGN: A questionnaire-based postnatal survey undertaken as part of the CHOICE Study process evaluation. The questionnaire was administered online and included fixed response and free-text options. SETTING: National Health Service maternity units in the UK. PARTICIPANTS: 309 women who had an IOL. OUTCOME MEASURES: The primary outcome measure was experience of IOL. Few women returned home during CR, meaning that statistical comparison between those who experienced home-based and hospital-based CR was not possible. Findings are reported as descriptive statistics with content analysis of women's comments providing context. RESULTS: Information to support choice and understand what to expect about IOL is often inadequate or unavailable. Having IOL can create anxiety and remove options for birth that women had hoped would enhance their experience. Although it can provide a more comfortable environment, home CR is not always an acceptable solution. Women described maternity care negatively impacted by staffing shortages; delays to care sometimes led to unsafe situations. Women who had a positive experience of IOL described supportive interaction with staff as a significant contribution to that. CONCLUSIONS: Women do not experience IOL as a benign and consequence free intervention. There is urgent need for research to better target IOL and optimise safety and experience for women and their babies. Relatively few women were offered CR at home and further research is needed on this experience.

Developing the midwifery Unit Self-Assessment (MUSA) Framework: A mixed methods study in six European midwifery units.

OBJECTIVE: Evidence indicates that midwifery units are associated with improved health outcomes and experiences; however, there are barriers to their development and scale-up. Guidelines are crucial to their implementation, ensuring that they are developed and integrated sustainably and safely. This study aimed to evaluate and explore the use of a self-assessment tool and improvement process for midwifery units in Europe. METHODS: A mixed methods study was conducted with six midwifery units located in Europe. Quantitative and qualitative data were collected and analysed concurrently, and each informed the other, making the approach both interactive and iterative. The six midwifery units were invited to complete the self-assessment tool, the responses of which were analysed descriptively, and implement an improvement process into practice. Interviews were conducted with midwives using the tool and analysed thematically. RESULTS: Findings indicate benefits and potential feasibility of an improvement process for midwifery units, and suggest that the self-assessment tool is a generative and reflexive practice for midwives. However, issues were identified around limitations of the tool, structural barriers and professional autonomy. Midwifery units require a framework to guide and support their implementation, improvement and scale-up. CONCLUSION: Results highlight the need for more consideration of how macro-level barriers, encompassing social, legal and political dimensions of maternity care, factor locally in the implementation and scale-up of midwifery units. More research is needed to evaluate the feasibility and outcomes of implementing a self-assessment and improvement framework in midwifery units across Europe.

A Box to Put the Baby in: UK Parent Perceptions of Two Baby Box Programmes Promoted for Infant Sleep.

Between 2016 and 2019, two different infant sleeping-box interventions were implemented in England: (1) shallow polypropylene baby boxes were distributed via a feasibility study to families with Sudden Infant Death Syndrome (SIDS) risk factors; and (2) a commercial-health system partnership scheme distributed cardboard baby boxes to new mothers in particular locations. We conducted parent evaluations of both interventions at the time of implementation. The views of 79 parents receiving polypropylene boxes and 77 parents receiving cardboard boxes were captured using online questionnaires and telephone interviews. Participants provided feedback on education received about using the box, their perception of the box design and materials, their experiences of using the box they received, and whether they would recommend it to others. Parents appreciated that both boxes provided a portable space to place their baby near them anywhere in the home, discouraging other riskier practices. The polypropylene box was rated more favourably regarding transparency, hygiene, and portability outside the home. A minority of parents found the idea of putting their baby in any box unappealing; however, younger mothers and smokers particularly appreciated the ability to safely co-sleep with their babies using the shallower box. Overall, the versatility of the polypropylene box scheme was more positively evaluated than the cardboard baby box scheme, which, stripped of its social value as part of a larger welfare provision, had minimal value for parents that received it.

Cervical ripening at home or in-hospital-prospective cohort study and process evaluation (CHOICE) study: a protocol.

INTRODUCTION: The aim of the cervical ripening at home or in-hospital-prospective cohort study and process evaluation (CHOICE) study is to compare home versus in-hospital cervical ripening to determine whether home cervical ripening is safe (for the primary outcome of neonatal unit (NNU) admission), acceptable to women and cost-effective from the perspective of both women and the National Health Service (NHS). METHODS AND ANALYSIS: We will perform a prospective multicentre observational cohort study with an internal pilot phase. We will obtain data from electronic health records from at least 14 maternity units offering only in-hospital cervical ripening and 12 offering dinoprostone home cervical ripening. We will also conduct a cost-effectiveness analysis and a mixed methods study to evaluate processes and women/partner experiences. Our primary sample size is 8533 women with singleton pregnancies undergoing induction of labour (IOL) at 39+0 weeks' gestation or more. To achieve this and contextualise our findings, we will collect data relating to a cohort of approximately 41 000 women undergoing IOL after 37 weeks. We will use mixed effects logistic regression for the non-inferiority comparison of NNU admission and propensity score matched adjustment to control for treatment indication bias. The economic analysis will be undertaken from the perspective of the NHS and Personal Social Services (PSS) and the pregnant woman. It will include a within-study cost-effectiveness analysis and a lifetime cost-utility analysis to account for any long-term impacts of the cervical ripening strategies. Outcomes will be reported as incremental cost per NNU admission avoided and incremental cost per quality adjusted life year gained. RESEARCH ETHICS APPROVAL AND DISSEMINATION: CHOICE has been funded and approved by the National Institute of Healthcare Research Health Technology and Assessment, and the results will be disseminated via publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER: ISRCTN32652461.

Relationships and trust: Two key pillars of a well-functioning freestanding midwifery unit.

BACKGROUND: Despite strong evidence supporting the expansion of midwife-led unit provision, as a result of optimal maternal and perinatal outcomes, cost-effectiveness, and positive service user and staff experiences, scaling-up has been slow. Systemic barriers associated with gender, professional, economic, cultural, and social factors continue to constrain the expansion of midwifery as a public health intervention globally. This article aimed to explore relationships and trust as key components of a well-functioning freestanding midwifery unit (FMU). METHOD(S): A critical realist ethnographic study of an FMU located in East London, England, was conducted over a period of 15 months. Recruitment of the 82 participants was purposive. Data collection included participant observation and semi-structured interviews, and data were analyzed thematically along with relevant local guidelines and documents. RESULTS: Twelve themes emerged. Relationships and Trust were identified as a core theme. The other 11 themes were grouped into six families, three of which: Ownership, Autonomy, and Continuous Learning; Team Spirit, Interdependency, and Power Relations; and Salutogenesis will be covered in this paper. The remaining three families: Friendly Environment; Having Time and Mindfulness; and Social Capital, will be covered in a separate paper. CONCLUSIONS: A relationship-based model of care was crucial for both the functioning of the FMU and service users' satisfaction and may offer a compelling response to high levels of stress and burnout among midwives.

Women's experiences of decision-making and informed choice about pregnancy and birth care: a systematic review and meta-synthesis of qualitative research.

BACKGROUND: The purpose of this systematic review (PROSPERO Ref: CRD42017053264) was to describe and interpret the qualitative research on parent's decision-making and informed choice about their pregnancy and birth care. Given the growing evidence on the benefits of different models of maternity care and the prominence of informed choice in health policy, the review aimed to shed light on the research to date and what the findings indicate. METHODS: a systematic search and screening of qualitative research concerning parents' decision-making and informed choice experiences about pregnancy and birth care was conducted using PRISMA guidelines. A meta-synthesis approach was taken for the extraction and analysis of data and generation of the findings. Studies from 1990s onwards were included to reflect an era of policies promoting choice in maternity care in high-income countries. RESULTS: Thirty-seven original studies were included in the review. A multi-dimensional conceptual framework was developed, consisting of three analytical themes ('Uncertainty', 'Bodily autonomy and integrity' and 'Performing good motherhood') and three inter-linking actions ('Information gathering,' 'Aligning with a birth philosophy,' and 'Balancing aspects of a choice'). CONCLUSIONS: Despite the increasing research on decision-making, informed choice is not often a primary research aim, and its development in literature published since the 1990s was difficult to ascertain. The meta-synthesis suggests that decision-making is a dynamic and temporal process, in that it is made within a defined period and invokes both the past, whether this is personal, familial, social or historical, and the future. Our findings also highlighted the importance of embodiment in maternal health experiences, particularly when it comes to decision-making about care. Policymakers and practitioners alike should examine critically current choice frameworks to ascertain whether they truly allow for flexibility in decision-making. Health systems should embrace more fluid, personalised models of care to augment service users' decision-making agency.