Antenatal Contact Research Articles

Protocol for a two-arm feasibility RCT to support postnatal maternal weight management and positive lifestyle behaviour in women from an ethnically diverse inner city population: the SWAN feasibility trial

IntroductionA high BMI during and after pregnancy is linked to poor pregnancy outcomes and contributes to long-term maternal obesity, hypertension, and diabetes. Evidence of feasible, effective postnatal interventions is lacking. This randomised controlled trial will assess the feasibility of conducting a future definitive trial to determine effectiveness and cost-effectiveness of lifestyle information and access to Slimming World® (Alfreton, UK) groups for 12 weeks commencing from 8 to 16 weeks postnatally, in relation to supporting longer-term postnatal weight management in women in an ethnically diverse inner city population.Methods/analysisWomen will be recruited from one maternity unit in London. To be eligible, women will be overweight (BMI 25–29.9 kg/m2) or obese (BMI ≥ 30 kg/m2) as identified at their first antenatal contact, or have a normal BMI (18.5–24.9 kg/m2) at booking but gain excessive gestational weight as assessed at 36 weeks gestation. Women will be aged 18 and over, can speak and read English, expecting a single baby, and will not have accessed weight management groups in this pregnancy. Women will be randomly allocated to standard care plus lifestyle information and access to Slimming World® (Alfreton, UK) groups or standard care only. A sample of 130 women is required.Feasibility trial objectives reflect those considered most important inform a decision about undertaking a definitive future trial. These include estimation of impact of lifestyle information and postnatal access to Slimming World® (Alfreton, UK) on maternal weight change between antenatal booking weight and weight at 12 months postbirth, recruitment rate and time to recruitment, retention rate, influence of lifestyle information and Slimming World® (Alfreton, UK) groups on weight management, diet, physical activity, breastfeeding, smoking cessation, alcohol intake, physical and mental health, infant health, and health-related quality of life 6 and 12 months postnatally. An embedded process evaluation will assess acceptability of study processes and procedures to women.Ethics/disseminationLondon–Camberwell St Giles Research Ethics Committee, reference: 16/LO/1422. Outcomes will be disseminated in peer-reviewed journals and presentations at national and international conferences.Trial registrationTrial registration number: ISRCTN 39186148. Protocol version number: v7, 13 August 17. Trial sponsor: King’s College London.

Is maternity care in Scotland equitable? Results of a national maternity care survey

ObjectiveHigh-quality maternity care is key to long-term improvements in population health. However, even within developed welfare systems, some mothers and babies experience poorer care and outcomes. This study aimed to...

Women's views on contact with a health visitor during pregnancy: an interview study.

To explore recent mothers' views of the health visiting antenatal contact in England. English health visitors are mandated to be in contact with all women in the third trimester of pregnancy. The aim of this antenatal contact is to assess the needs of the family before the birth and support preparation for parenthood. Recent data show that this contact is provided fragmentarily and not always face-to-face. More information on how women view this contact could inform service provision. Twenty-nine mothers with a baby less than 1 year old were recruited via social media and word of mouth. Having had antenatal contact with a health visitor was not a requirement to participate in the study. Women took part in face-to-face or phone interviews and all recordings were transcribed verbatim. Data were analysed using systematic thematic analysis. Eleven women had contact with a health visitor during pregnancy: nine through a home visit, one via a letter and one via a phone call. The remaining 18 women were asked about what they would have wanted from an antenatal contact. Three themes were identified: relationship building, information provision, and mode and time of contact. Some participants who had experienced a home visit reported building rapport with their health visitor before the postnatal period, but not everyone had this experience. Women reported requesting and receiving information about the health visiting service and the role of the health visitor. Finally, women suggested different modes of contact, suggesting a letter or that the information about health visiting could be provided by a midwife. A few women preferred a home visit. These study findings show women were unclear regarding the aim of the health visitor antenatal contact. As such, the contact is unlikely to reach its full potential in supporting parents-to-be.

Feasibility and acceptability of a motivational interviewing breastfeeding peer support intervention.

An uncontrolled study with process evaluation was conducted in three U.K. community maternity sites to establish the feasibility and acceptability of delivering a novel breastfeeding peer-support intervention informed by motivational interviewing (MI; Mam-Kind). Peer-supporters were trained to deliver the Mam-Kind intervention that provided intensive one-to-one peer-support, including (a) antenatal contact, (b) face-to-face contact within 48hr of birth, (c) proactive (peer-supporter led) alternate day contact for 2weeks after birth, and (d) mother-led contact for a further 6weeks. Peer-supporters completed structured diaries and audio-recorded face-to-face sessions with mothers. Semistructured interviews were conducted with a purposive sample of mothers, health professionals, and all peer-supporters. Interview data were analysed thematically to assess intervention acceptability. Audio-recorded peer-support sessions were assessed for intervention fidelity and the use of MI techniques, using the MITI 4.2 tool. Eight peer-supporters delivered the Mam-Kind intervention to 70 mothers in three National Health Service maternity services. Qualitative interviews with mothers (n=28), peer-supporters (n=8), and health professionals (n=12) indicated that the intervention was acceptable, and health professionals felt it could be integrated with existing services. There was high fidelity to intervention content; 93% of intervention objectives were met during sessions. However, peer-supporters reported difficulties in adapting from an expert-by-experience role to a collaborative role. We have established the feasibility and acceptability of providing breastfeeding peer-support using a MI-informed approach. Refinement of the intervention is needed to further develop peer-supporters' skills in providing mother-centred support. The refined intervention should be tested for effectiveness in a randomised controlled trial.

Women's views and experiences of having their mental health needs considered in the perinatal period

ObjectiveTo explore women's views and experiences of having their mental health needs considered in the perinatal period in an Irish maternity hospital setting. DesignA qualitative design using semi-structured interviews was used to explore women's views and experiences. Data were analysed using Thematic Analysis (Braun and Clarke, 2006). SettingA voluntary maternity hospital in Dublin, Ireland which had access to a perinatal mental health team. ParticipantsIn total 8 women who met the inclusion criteria were recruited and participated in this study. The women were interviewed in the early postpartum period. FindingsThe study offers important insights into how women feel about having their mental health needs considered in the perinatal period. Women reported pregnancy was an emotional time, feeling expected to be happy, and women with significant mental health histories preferred not to be referred to available services unless they asked for help. Women reported barriers to disclosure including stigma/shame, lack of time. Screening tools were viewed with mixed opinions. In getting help, the baby was a motivator for some women, attitudes of healthcare professionals and lack of time affected this. Key ConclusionsWomen appreciated all methods of enquiry about their mental health and being given time to discuss concerns with healthcare professionals. Perceived busy staff workloads was a barrier in asking for help, as was lack of continuity of care. Screening tools were viewed as a tick box exercise, but also as a ‘modality’ to assist detection of women at risk. Mental health enquiry focused on depression and anxiety, with little or no enquiry about less common disorders. Women with significant histories were less likely to engage or accept referral to perinatal mental health services, preferring to access help if they felt they needed to. Implications for practiceHCPs should enquire regularly about women's emotional wellbeing at every antenatal and postnatal contact, offering support where required. Detailed enquiry about mental health should encompass the broad spectrum of perinatal mental health problems, including but not limited to depression and anxiety. Screening tools can assist in the identification of women at risk of developing perinatal mental health problems. A specialist mental health midwife should link with high-risk women at the first antenatal booking visit and provide information on early intervention and access to services.

Meeting the contraceptive and sexual health needs of women in the postnatal period

Pregnancy and childbirth is a special period in a woman's life and involves significant physical, hormonal, psychological, social and cultural changes. Maintaining health and wellbeing during this time is imperative for both mother and child. Holistic care for new mothers includes all aspects of health, and sexual health is an important part of this. The antenatal contact is an ideal opportunity for health visitors to discuss contraception options, particularly if the client is seen on her own. This article will discuss the role of the health visitor in providing evidence-based information on contraception and sexual health to women in the postnatal period.

Promoting the antenatal contact: A leadership journey

A project to increase antenatal visits led to a valuable leadership journey for Rebecca Kirby. In this article, she reflects on how the project evolved and its positive outcomes, both personal and professional.

Adding content to contacts: measurement of high quality contacts for maternal and newborn health in Ethiopia, north east Nigeria, and Uttar Pradesh, India.

BackgroundFamilies in high mortality settings need regular contact with high quality services, but existing population-based measurements of contacts do not reflect quality. To address this, in 2012, we designed linked household and frontline worker surveys for Gombe State, Nigeria, Ethiopia, and Uttar Pradesh, India. Using reported frequency and content of contacts, we present a method for estimating the population level coverage of high quality contacts.Methods and FindingsLinked cluster-based household and frontline health worker surveys were performed. Interviews were conducted in 40, 80 and 80 clusters in Gombe, Ethiopia, and Uttar Pradesh, respectively, including 348, 533, and 604 eligible women and 20, 76, and 55 skilled birth attendants. High quality contacts were defined as contacts during which recommended set of processes for routine health care were met. In Gombe, 61% (95% confidence interval 50-72) of women had at least one antenatal contact, 22% (14-29) delivered with a skilled birth attendant, 7% (4-9) had a post-partum check and 4% (2-8) of newborns had a post-natal check. Coverage of high quality contacts was reduced to 11% (6-16), 8% (5-11), 0%, and 0% respectively. In Ethiopia, 56% (49-63) had at least one antenatal contact, 15% (11-22) delivered with a skilled birth attendant, 3% (2-6) had a post-partum check and 4% (2-6) of newborns had a post-natal check. Coverage of high quality contacts was 4% (2-6), 4% (2-6), 0%, and 0%, respectively. In Uttar Pradesh 74% (69-79) had at least one antenatal contact, 76% (71-80) delivered with a skilled birth attendant, 54% (48-59) had a post-partum check and 19% (15-23) of newborns had a post-natal check. Coverage of high quality contacts was 6% (4-8), 4% (2-6), 0%, and 0% respectively.ConclusionsMeasuring content of care to reflect the quality of contacts can reveal missed opportunities to deliver best possible health care.

Data re-entry overload: time for a paradigm shift in maternity information technology?

I read with interest the comprehensive review by Fawdry et al.1 Many of the issues resonate with management of general hospital notes, while some are specific to maternity notes. Recent advances in management of records offer some glimmer of hope. The authors say “paperless” offices benefit only those “logged on in one place for most of the time”. Session mobility is now being delivered in the clinical environment – this allows a session to be suspended on a given PC (free to be used by others) and to be opened again seamlessly on another PC.2 Secondly, many believe that a slavish transition to fully electronic data will lose some of the narrative and richness inherent in the paper record. We have scanned 750,000 volumes of general hospital and 70,000 maternity records, and both are now available to view electronically. Although not structured, this allows colleagues to view records simultaneously across sites and to seamlessly view data from other specialties relevant to the care of the patient. Finally, Portsmouth have implemented a digital pen solution allowing hand written forms to be completed at the ante-natal contact, data to be transferred securely via Blackberry and then entered into the maternity system at the hospital Trust.3 The ability to continue to produce and store images of paper using Document Management Systems appears to be gathering traction for preserving the richness of complex records. Fawdry et al. clearly speak with authority on the absence of standardization in maternity records. Standards for records in secondary care have been produced, but these are not widely implemented.4 In their absence, a more pragmatic approach to electronic patient records is developing using scanned records, session mobility and novel data collection. Informed discussion on these issues is more crucial than ever.

The effect of health visitors’ postpartum home visit frequency on first-time mothers: Cluster randomised trial

Background Postpartum home visiting by nurses can benefit higher-risk families. Yet, little is known about the effects of universal services which provide care for all families including those at lowest risk (e.g. provision by health visitors-United Kingdom specialist community public health nurses). Objective It was to determine the effect of frequency of health visitors’ home visits on ‘low-risk’ first-time families’ outcomes to 8 weeks postpartum and 7 months follow-up. Design A cluster randomised controlled trial. Setting Within one health and social care managerial area in Northern Ireland. Participants First-time ‘low risk’ mothers who had given birth during 2002–2004 and were visited by a health visitor who had agreed to take part in the study, were invited to participate. In total, n = 39 health visitors were allocated to ‘intervention’ and n = 41 to ‘control’. Of n = 295 ‘low-risk’ first-time mothers who agreed to take part, n = 136 with intervention health visitors were offered six home visits 2–8 weeks postpartum and n = 159 within the control group were offered one planned visit. Methods Self-completed measures of parenting, maternal wellbeing and service use were gathered pre-intervention, 8 weeks and 7 months postpartum. The main outcome was the Edinburgh Postnatal Depression Scale (EPDS). At 8 weeks and 7 months postpartum, n = 129 and n = 115 intervention mothers, also n = 151 and n = 141 control mothers completed outcome measures. Results An intention to treat analysis was performed using multilevel modelling analysis which statistically controlled for pre-home visit outcomes, clinic attendance and antenatal contact. The intervention had no impact on most outcomes, however, it was associated with an increased EPDS score (after adjustment: 0.16, 2.36 95%CI) at 8 weeks (before accounting for outliers) but not at 7 months (−0.62,1.65 95%CI). Intervention mothers had higher service satisfaction (7.7, 21.28, 95%CI 8 weeks; 4.69, 22.71, 7 months) and were less likely to have used emergency medical services for their infants to 8 weeks (OR: 0.15, 0.85, 95%CI). Conclusion Weekly postpartum visits to ‘low-risk’ mothers had variable effects, therefore, practitioners and researchers should consider further development and application of effective, evidence based home visiting content.

Management of postnatal depression in primary care: a window of opportunity

The postnatal period is a particularly distressing time to experience mental health problems. Detection and appropriate treatment of psychiatric symptoms at this critical time in family life is perhaps more important than at any other time. Postnatal depression (PND) affects more than one in 10 women;1,2 it significantly impacts on partners;3 is associated with an impaired mother–infant bond;4 and has been linked to poor cognitive and emotional development in the infant,5 thus contributing to the inter-generational transmission of poor health. Suicide is a leading cause of maternal death in the UK; the largest proportion due to PND and puerperal psychosis,6 and completed suicides are thought to be the tip of the iceberg in terms of ‘near miss’ events. However, many women are reluctant to disclose PND symptoms to healthcare professionals.7 Strategies for identifying PND and supporting women and their families are therefore very important and must be timely, holistic, and appropriate to new mothers. The perinatal period provides many opportunistic occasions within which to identify and manage mild, moderate, and severe mental illness. This is due to the increased level of health professional contact through routine antenatal and postnatal contact, which does not occur in the non-postpartum population. Although GPs are often the first port of call for women8 or their families seeking help during pregnancy and postnatally, all healthcare professionals in contact with pregnant or postpartum women should be alert to possible symptoms, either those of new onset or of a more chronic nature. Given the evidence for the effectiveness of both pharmacological and psychological interventions in improving health outcomes when PND is identified, there is much to be gained from early identification and management in primary care. …

Social inequalities in preterm birth in Scotland 1980–2003: findings from an area‐based measure of deprivation

The preterm birth rate in Scotland has been increasing in recent years. Although preterm birth rates show a social gradient, it is unclear how this gradient has been affected by the overall increase. We examined time trends in singleton live preterm birth rates in relation to area-based socio-economic indicators. Population-based retrospective cohort study. Scotland. All singleton live births delivered in Scottish hospitals between 1980 and 2003 (n= 1 423 993). Singleton live preterm birth rates in each deprivation quintile were derived. Subgroup analyses of those born moderately preterm (32-36 weeks), very preterm (28-31 weeks) and extremely preterm (24-27 weeks) were performed. The rate of singleton live preterm births increased from 49.7 per 1000 live births in the 5-year period 1980-84 to 56.1 per 1000 in the 4-year period 2000-03, a relative increase of 12.9%. A marked social gradient was apparent at all time periods: relative indices of inequality were 1.63 (95% CI 1.38-1.92) in 1980-84 and 1.55 (1.44-1.66) in 2000-03. Similar social gradients existed for all gestational age subgroups. Smoking status at first antenatal contact and increased obstetric intervention, possibly reflecting improvements in fetal monitoring and neonatal care, appeared to explain some but not all the social gradient. Social inequalities in preterm birth were apparent in Scotland between 1980 and 2003. In addition to helping pregnant women to stop smoking, other means to reduce social inequalities are required.

Out-patient management does not impair outcome of pregnancy in women with type 1 diabetes

In recent years, out-patient protocols have mainly displaced historical obstetric management of diabetic pregnancy. The impact of the change from centralized in-patient to decentralized out-patient treatment on glycaemic control and its effects on the outcome of newborns in diabetic pregnancies was therefore studied using the population-based data on 296 pregnancies in 224 women with type 1 diabetes over 10 years (1986–1995) in the two northernmost provinces of Finland. The area comprises one tertiary level and four other central hospitals. The change of policy was effected in 1990 and to determine the impact of this change, the study period was divided in two (period 1, 1986–1990, n=135; period 2, 1991–1995, n=161). At the first antenatal contact (mean 9.9 weeks of gestation) 73% of women had unsatisfactory glycaemic control, but it improved rapidly with pregnancy and was significantly better ( P<0.05) in the second study period. The incidence of congenital malformations was somewhat greater (NS) in period 2 but perinatal mortality did not change. Out-patient management does not impair outcome in type 1 diabetic pregnancy.

To see or not to see? Midwives' perceptions of reduced antenatal attendances for ‘low-risk’ women

Objective: to explore the views of midwives towards traditional and flexible schedules of antenatal attendance for women at low risk.Design: a qualitative approach using focus groups.Setting: three NHS Trusts providing maternity care in and around Bristol.Sample: 14 midwives who had provided antenatal care to women participating in the Bristol Antenatal Care Study.Findings: midwives generally expressed support for a move away from the traditional schedule of antenatal attendances, suggesting that this represented a move towards the acceptance of pregnancy as a normal life event. They recognised that some women would prefer flexible care and the possibility of a reduction in the number of antenatal attendances. However, they suggested that some women would require additional information in order to feel confident in these circumstances. The midwives also recognised that both they and pregnant women have reservations about reducing contact during the antenatal period. Central to these reservations is a concern that women's psychosocial as well as physical needs may go unmet if antenatal contact is reduced.Implications for practice: although in principle supporting a move away from the traditional schedule of antenatal attendances, the reservations felt by midwives towards a reduction in antenatal attendances are reflected in their practice. These concerns currently impede any radical move away from the traditional schedule of antenatal check-ups and will need to be addressed by midwifery managers prior to the implementation of a more flexible schedule of antenatal attendances, if any such change is to be sustainable.

Retrospective follow-up of maternal deaths and their associated risk factors in a rural district of Tanzania.

To determine the maternal mortality rate in a rural district of Tanzania and to measure the incidence of causes of maternal mortality, the presence of risk factors and the relationship with social and demographic factors. From January to December 1993 a retrospective recording of maternal deaths was completed using verbal autopsy and networking. A total of 76 deaths were found which is equivalent to a maternal mortality ratio of 961 per 100,000 live births for this 12-month period of time. The leading causes of death were postpartum haemorrhage with retained placenta, anaemia, postpartum haemorrhage without retained placenta, AIDS complex and obstructed labour (in descending order of frequency). Maternal deaths were seen irrespective of group factors such as access to a main road, presence of antenatal risk factors and contact with health care personnel or a nearby facility before death. Mortality was also present both in home and hospital deliveries (excluding hospital referrals). Antenatal care had been received by 97.2% of the mothers who died after the second trimester. The referral rate even in the presence of a known antenatal risk factor was 34.6%. Patient compliance to the referral was only 44.4%. Mothers and their families followed strong cultural beliefs even when they were detrimental to the mother's health. Maternal deaths were proportionately higher among women > 40 who were also gravid > or = 5, but there was no significant increase in deaths in women < 19 years of age. Effective antenatal care, appropriate emergency treatment of complications, access to transportation and competent referral level care with adequate equipment encompass the most effective answers to reduction of maternal deaths at a district level.