Maternity Units In England Research Articles

The relationship between severe maternal morbidity and psychological health symptoms at 6-8 weeks postpartum: a prospective cohort study in one English maternity unit.

BackgroundThe incidence of severe maternal morbidity is increasing in high-income countries. However, little has been known about the impact on postnatal morbidity, particularly on psychological health outcomes. The objective of this study was to assess the relationship between severe maternal morbidity (ie. major obstetric haemorrhage, severe hypertensive disorders or intensive care unit/obstetric high dependency unit admission) and postnatal psychological health symptoms, focusing on post-traumatic stress disorder (PTSD) symptoms at 6–8 weeks postpartum.MethodA prospective cohort study was undertaken of women who gave birth over six months in 2010 in an inner city maternity unit in England. Primary outcomes were prevalence of PTSD symptoms namely: 1) intrusion and 2) avoidance as measured using the Impact of Event Scale at 6 – 8 weeks postpartum via a self-administered postal questionnaire. Secondary outcomes included probable depression. Data on incidence of severe maternal morbidity were extracted from maternity records. Multivariable logistic regression analysis examined the relationship between severe maternal morbidity and PTSD symptoms taking into account factors that might influence the relationship.ResultsOf women eligible to participate (n=3509), 52% responded. Prevalence of a clinically significant level of intrusion and avoidance were 6.4% (n=114) and 8.4% (n=150) respectively. There was a higher risk of PTSD symptoms among women who experienced severe maternal morbidity compared with women who did not (adjusted OR = 2.11, 95%CI = 1.17-3.78 for intrusion; adjusted OR = 3.28, 95%CI = 2.01-5.36 for avoidance). Higher ratings of reported sense of control during labour/birth partially mediated the risk of PTSD symptoms. There were no statistically significant differences in the prevalence or severity of symptoms of depression.ConclusionThis is one of the largest studies to date of PTSD symptoms among women who had recently given birth. Findings showed that an experience of severe maternal morbidity was independently associated with symptoms of PTSD. Individually tailored care that increases women’s sense of control during labour may be a protective factor with further work required to promote effective interventions to prevent these symptoms. Findings have important implications for women’s health and the content and organisation of maternity services during and after the birth.

High dependency care: Education of midwives and preparation for practice

This paper explores issues around the education and competencies of midwives who are involved in the delivery of high dependency care. It argues that all midwives who provide this specialist care should possess the appropriate clinical skills and knowledge relevant to the management of this cohort of women. It also discusses the rational for the development of high dependency care in midwifery and the role of the midwife, as well as the location for care delivery and preparation for practice. The evidence base for this paper comes from research currently being undertaken into the organisation, provision and education of high dependency care within the midwifery setting. The study is being conducted in maternity units in England with a delivery rate in excess of 3000 per year, and is using a series of individual semi-structured interviews with midwives, consultant obstetricians, consultant obstetric anaesthetists and midwifery educationalists. The study will contribute to the debate on the delivery of high dependency care in the maternity setting and highlights the importance of specialist education relating to this area of practice.

Information shared with mothers prior to caesarean section: A national audit of compliance with recommended information

We assessed how information on complications at caesarean section was shared with mothers undergoing this operation and determined whether this information was within the NICE and RCOG guidelines. A postal questionnaire survey, involving 170 consultant-led maternity units in England, was sent out. We analysed the methods of giving this information and compliance with National guidelines and explored the need to standardise this information nationally. A response rate of 84.11% was achieved (143/170). A total of 50/143 (34.97%) units share information using risk stickers, pre-typed or standard checklist forms, which aim to achieve consistency of information sharing. In contrast 92/143 (64.34%) units rely on information given from memory of doctors. Subgroup analysis of 23 hospitals revealed large heterogeneity in information provided to women before caesarean section. Our survey indicated a large variation in the information given to women prior to caesarean section and thus the need for standardised written information.

PL.59 Factors to Overcome Delayed Discharge Following Caesarean Section with an Enhanced Recovery Pathway

Enhanced recovery (ER) pathways improve clinical outcomes, the Department of Health (DoH) suggesting several applications. Current published data within obstetrics is limited. Increased pressure on maternity beds; 39% of maternity...

PP.48 The Impact of Severe Maternal Morbidity on Psychological Health at 6–8 Weeks Postpartum – a Prospective Cohort Study in England

BackgroundThe incidence of severe maternal morbidity (SMM) is increasing in high-income countries as a consequence of higher caesarean section rates and more complex health needs of women who become pregnant....

A methodological study to compare survey-based and observation-based evaluations of organisational and safety cultures and then compare both approaches with markers of the quality of care.

Patient safety concerns have focused attention on organisational and safety cultures, in turn directing attention to the measurement of organisational and safety climates. First, to compare levels of agreement between survey- and observation-based measures of organisational and safety climates/cultures and to compare both measures with criterion-based audits of the quality of care, using evidence-based markers drawn from national care standards relating to six common clinical conditions. (This required development of an observation-based instrument.) Second, to examine whether observation-based evaluations could replace or augment survey measurements to mitigate concerns about declining response rates and increasing social desirability bias. Third, to examine mediating factors in safety and organisational climate scores. The study had three strands: (A) a postal questionnaire survey to elicit staff perceptions of organisational and safety climates, using six prevalidated scales; (B) semistructured non-participant observation of clinical teams; and (C) a retrospective criterion-based audit carried out by non-clinical auditors to minimise hindsight bias. Standardised summary scores were created for each strand, and pairs of measurements were compared (strand A with strand B, strand A with strand C, and strand B with strand C) using Bland-Altman plots to evaluate agreement. Correlations were also examined. Multilevel modelling of Strand A scores explored mediating factors. Eight emergency departments and eight maternity units in England, UK. None. Examination of feasibility, correlation and agreement. Strand A: the overall response rate was 27.6%, whereas site-specific rates ranged from 9% to 47%. We identified more mediating factors than previous studies; variable response rates had little effect on the results. Organisational and safety climate scores were strongly correlated (r = 0.845) and exhibited good agreement [standard deviation (SD) differences 0.449; 14 (88%) within ± 0.5; one large difference]. Two commonly used scales had high levels of positive responses, suggesting positive climates or social desirability bias. Strand B: scoring on a four-point scale was feasible. Observational evaluation of teamwork culture was good but too limited for evaluating organisational culture. Strand C: a total of 359-399 cases were audited per condition. The results varied widely between different markers for the same condition, so selection matters. Each site performed well on some markers but not others, with few consistent patterns. Some national guidelines were contested. Comparisons: the comparison of safety climate (survey) and teamwork culture (observation) revealed a moderately low correlation (r = 0.316) and good agreement [SD differences 1.082; 7 (44%) within ±0.5; one large difference]. The comparison of safety climate (survey) and performance (audit) revealed lower correlation (r = 0.150, i.e. relationship not linear) but reasonably good agreement [SD differences 0.992; 9 (56%) within ± 0.5; two large differences]. Comparisons between performance (audit) and both organisational climate (survey) and teamwork culture (observation) showed negligible correlations (< 0.1) but moderately good agreement [SD differences 1.058 and 1.241; 6 (38%) and 7 (44%) within ± 0.5; each with two large differences (at different sites)]. Field notes illuminated large differences. Climate scores from staff surveys are not unduly affected by survey response rates, but increasing use risks social desirability bias. Safety climate provides a partial indicator of performance, but qualitative data are needed to understand discrepant results. Safety climate (surveys) and, to a lesser degree, teamwork culture (observations) are better indicators of performance than organisational climate (surveys) or attempts to evaluate organisational culture from time-limited observations. Scoring unobtrusive, time-limited observations to evaluate teamwork culture is feasible, but the instrument developed for this study needs further testing. A refined observation-based measure would be useful to augment or replace surveys. The National Institute for Health Research Health Technology Assessment programme.

Management of epilepsy in labour

Epilepsy is the commonest neurological disorder in pregnancy. With appropriate management there is no increase in complications. We performed a telephonic survey to find if maternity units had a policy...

‘You need that loving tender care’: maternity care experiences and expectations of ethnic minority women born in the United Kingdom

To explore the maternity care experiences and expectations of United Kingdom (UK)-born ethnic minority women. Qualitative in-depth interviews with 34 UK-born mothers of Black Caribbean, Black African, Indian, Pakistani, Bangladeshi and Irish descent, recruited mainly from nine National Health Service (NHS) maternity units in England. Overall, women felt that their ethnic background did not matter at all with respect to the care they received. UK-born women's familiarity with the system and the absence of language barriers were felt to be influential in getting treated the same as White women. Women stressed the need for professionals to be 'sensitive' and 'delicate' in their interactions and wanted 'continuity of care'. In general, they were positive about the adequacy of the information given during their antenatal appointments, but some women found it difficult to get access to antenatal classes. Women valued good communication and consistent information, with their views acknowledged and their questions answered consistently. They also expressed the need for better physical environments in maternity units. Our findings contribute to the growing evidence about the need to improve maternity and postnatal care, and to develop more sensitive and women-centred care for all women irrespective of ethnic background.

Maternal obesity and ethnic groups: trends in 552 303 births over 13 years in England, UK

IntroductionInternational evidence shows that Asians have increased diabetes risk at a lower body mass index (BMI) than European Whites.1 UK guidance for routine gestational diabetes screening does not consider this...

A simple tool to measure patient perceptions of operative birth

To assess the feasibility and validity of a maternal satisfaction measurement tool, the SaFE study Patient Perception Score (PPS), after operative delivery. Cross-sectional survey. A large maternity unit in England. 150 women who had had an operative birth. We recruited women within 24 hours of birth and quantified their satisfaction with two questionnaires: PPS, and the Mackey Childbirth Satisfaction Rating Scale (CSRS; modified). Participation rate to determine feasibility; Cronbach's alpha as measure of internal consistency; PPS satisfaction scores for groups of accoucheurs of different seniority to assess construct validity; correlation coefficient of PPS scores with total scores from the CSRS questionnaire to establish criterion validity. Participation rate approached 85%. We observed high scores for most births except a few outliers. Internal consistency of the PPS was high (Cronbach's alpha=0.83). Total PPS scores correlated strongly with total CSRS scores (Spearman's r=0.64, P<0.001). The PPS is a simple and valid tool for patient-centred assessments. High scores were observed for most births but there were a small minority of accoucheurs who consistently scored poorly and these data could be used during appraisal and training.

A national survey of the use of TENS in labour

Transcutaneous electrical nerve stimulation (TENS) is a non-invasive method of pain relief, regularly used by women in labour. The National Institute for Health and Clinical Excellence (NICE) intrapartum care guidelines do not recommend its use on grounds of ineffectiveness to reduce pain. However, the recent Cochrane review challenges this guidance, as previous studies have limited capability to exclude an effect, and there is evidence that some women choose TENS as their preferred method of pain relief. We aimed to explore whether the NICE guidelines have impacted on health professionals' support for the use of TENS, and to determine support for a possible clinical trial of TENS. We therefore conducted a national survey of all maternity units in England; responses were received from 139 (76%) of the units. The findings demonstrate overwhelming support for TENS use. Furthermore, the survey identified a willingness among midwives to conduct a multi-centre trial of TENS versus usual care. We conclude that the combination of a dearth of robust evidence together with midwives' beliefs that TENS should be an available pain relieving option, confirms the need for a randomized controlled trial.

‘They're more like ordinary stroppy British women’: Attitudes and expectations of maternity care professionals to UK-born ethnic minority women

To explore the attitudes and expectations of maternity care professionals to UK-born ethnic minority mothers. Qualitative in-depth interviews with 30 professionals from eight NHS maternity units in England that provide services for large proportions of women of black Caribbean, black African, Indian, Pakistani and Irish descent. All the professionals reported providing care to both UK-born and migrant mothers from ethnic minorities. Most of them felt that they could differentiate between UK-born and migrant mothers based mainly on language fluency and accent. 'Westernized dress' and 'freedom' were also cited as indicators. Overall, professionals found it easier to provide services to UK-born mothers and felt that their needs were more like those of white English mothers than those of migrant mothers. UK-born mothers were generally thought to be assertive and expressive, and in control of care-related decision-making whereas some South Asian Muslim women were thought to be constrained by family influences. Preconceived ideas about ethnic minority mothers' tolerance of pain in labour, use of pharmacological pain relief measures and mode of delivery were recurring themes. Women's education and social class were felt to be major influences on the uptake of maternity care, regardless of ethnicity. Professionals appeared to equate the needs of UK-born ethnic minority women with those of white English women. Overall, this has positive implications for care provision. Despite this, specific behavioural expectations and unconscious stereotypical views were evident and have the potential to affect clinical practice.

Have Women Become More Willing to Accept Obstetric Interventions and Does This Relate to Mode of Birth? Data from a Prospective Study

Concern has increased about rising rates of cesarean section and other obstetric interventions, and it has been suggested that a change in women's attitudes may be partly responsible. Our objectives were, first, to examine changes in women's antenatal willingness to accept obstetric interventions between 1987 and 2000 and, second, to look at the relationship between willingness to accept obstetric interventions and mode of birth. Data on willingness to accept obstetric interventions were collected at 35-36 weeks of pregnancy using postal questionnaires, and follow-up of women was conducted 6 weeks postnatally. Data are presented for 977 women drawn from 8 maternity units in England who were due to give birth in April to May 2000. To address the first objective, data were compared with the parent study carried out in 1987. The sample had significantly more positive antenatal attitudes toward obstetric interventions than the comparable sample in 1987 (F= 42.25, df= 1, p < 0.001). Willingness to accept obstetric interventions was related to mode of birth. Binary logistic regression controlling for age, education, and parity showed that women with high "willingness to accept intervention" scores had a nearly twofold increase in the odds of an operative or instrumental birth (OR 1.94, 95% CI 1.28-2.95) compared with women who had low scores. These attitudes also predicted epidural analgesia use, and differences in mode of birth were no longer significant when epidural use was included in the regression model. A shift toward greater willingness to accept obstetric interventions appears to have occurred since 1987, and this shift does appear to relate to mode of birth in the 2000 cohort but not in 1987. The findings suggest that epidural analgesia use mediates the link.

Midwives and the Fetal Nuchal Cord: A Survey of Practices and Perceptions

A systematic search of studies of intrapartum management of the nuchal umbilical cord at term found no published controlled studies in this area. A postal survey containing both structured and open questions and a request for local protocols and guidelines was sent to all 637 midwives in 7 maternity units in England. There were 401 (63%) responses. There appeared to be no unit guidelines for this area of practice. Midwife approaches to nuchal cord during birth varied, and included clamping and cutting of loose nuchal cords and a hands-off approach to tight nuchal cords. Reasons for specific actions included doing what had been taught during midwifery training and learning from previous personal experiences. Theories of diffusion of innovation and of planned behaviour may provide a conceptual basis for understanding the adoption of specific practices. Future qualitative and controlled studies are needed to explore the nature and consequences of varying approaches to intrapartum nuchal cord management.

The use of complementary therapies in maternity services: A survey

The aim of this study was to establish the extent of use of complementary therapies in the maternity services in England and to determine the views of heads of midwifery to the integration of these therapies into midwifery practice. The questionnaire was sent to 221 heads of midwifery in all NHS maternity units in England. A response rate of 75% was achieved. Sixty four percent of the maternity units who responded provided a complementary therapy service in a variety of combinations to mothers, babies and staff. However, only 9% provided a service to all three groups. The four therapies offered most widely were massage, aromatherapy, reflexology and acupuncture. Attitudes were positive with 70% of respondents convinced of the benefits and 94% believing it important for them to be available in the NHS. Respondents felt that complementary therapies had an important role, particularly in relation to increasing consumer satisfaction, promoting normal childbirth, decreasing medical intervention and increasing midwives’ job satisfaction.

Midwives’ perception of intrapartum risk in England, Belgium and France

The second half of the last century saw remarkable changes in the delivery of maternity care services, with the introduction of antibiotics and safe anaesthesia. This was associated with a continued decrease in maternal and perinatal mortality and some were quick to establish a cause-and-effect relationship. However, this was challenged by statisticians and technological developments have also been challenged later by some, though embraced by others. An initial study of midwives’ practice and perception of risk had demonstrated not only a slight link between higher intrapartum intervention rate and higher perception of risk but also an over-pessimistic evaluation of the chances of normal women to progress normally and an over-optimistic risk perception of the outcomes associated with interventions. Known variations in obstetric practice and caesarean section rates suggested that this study might benefit from replication in other European Union member states. The replication of the initial English study aimed at comparing the intrapartum care provided by midwives in the Belgian Flanders and the French regions of Alsace and Lorraine, as well as their intrapartum risk perception for the outcomes of spontaneous labour of nulliparous women suitable for midwifery-led care. A survey by questionnaire was administered to midwives in England, Belgium and France. In England, the midwives were selected on the basis that they worked in maternity units that made their maternity data available centrally on an annual basis. This enabled the analysis of the level of intrapartum interventions for healthy nulliparous women suitable for midwifery-led care and the subsequent comparison of the level of recommended intrapartum care and risk perception by midwives working in maternity units classified as either “lower” or “higher” intrapartum intervention units. The opportunities to replicate the study in Belgium and France were limited to the survey of midwives’ recommended intrapartum care and perception of risk, without the comparison of the actual intrapartum care and outcomes of the maternity units where they practise. All midwives working in the 11 relevant maternity units in England were surveyed. In Belgium, midwives attending the annual Flemish midwives’ conference were surveyed, whereas in France the collaboration of two midwifery schools meant that all midwives involved in intrapartum care in two regions – Alsace and Lorraine – were surveyed. The computerised St Mary’s Maternity Information System data were subjected to systematic data reduction to analyse the data of healthy Caucasian women at term of a healthy pregnancy and in spontaneous labour. The remaining data were then subjected to descriptive statistics to examine the rate of various intrapartum interventions and to establish an intrapartum score that was used to categorise maternity units as either “lower” or “higher” intrapartum intervention units (Mead and Kornbrot, Midwifery 20(1):61–71, 2004). The midwives’ surveys were subjected to descriptive statistical analysis. Major differences in midwifery practice were observed in the three countries: English midwives were more likely to monitor the maternal condition than French and Belgian midwives but less likely to use continuous electronic fetal monitoring, restrict maternal nutrition or recommend epidural analgesia. They were also generally more pessimistic about women’s ability to progress normally in labour. If the variations in methods of delivery observed in England parallel those of France and Belgium, the midwives in all three countries systematically overestimated the benefits of intrapartum intervention and, in particular, epidural analgesia. There are major differences in midwifery practice and in obstetric outcomes in these three countries. It is unlikely that the practices alone can explain the variations in outcomes and, in particular, the differences in caesarean section rates. More research is necessary to examine how the health care systems, perception of risk and attitudes to risk aversion may affect midwifery and obstetric practices and maternity services outcomes.

Perinatal mortality and congenital anomalies in babies of women with type 1 or type 2 diabetes in England, Wales, and Northern Ireland: population based study

Objective To provide perinatal mortality and congenital anomaly rates for babies born to women with type 1 or type 2 diabetes in England, Wales, and Northern Ireland.Design National population based...

How much variation in CS rates can be explained by case mix differences?

To quantify the amount of variation in caesarean section (CS) rates between maternity units explained by case mix differences. Cross-sectional study. All 216 maternity units in England and Wales. Women giving birth at these maternity units between May and July 2000. Logistic regression models were developed to investigate the relationship between case mix characteristics, and odds of (i) CS before labour, (ii) CS in labour. Using these results, overall CS rates standardised for case mix were calculated for each maternity unit. Random-effects meta-analysis was used to examine heterogeneity between maternity units. CS before labour and CS during labour. Adjustment for case mix differences between maternity units explained 34% of the variance in CS rates. Odds of CS (before and in labour) increased with maternal age. Women from ethnic minority groups had lower odds of CS before labour, and increased odds of CS in labour. Women with a previous vaginal delivery had lower odds of CS, although the magnitude of this for CS before and in labour is markedly different. Case mix adjustment is important to enable understanding of the factors that influence the CS rate. These include organisational and staffing levels as well as women's preferences for childbirth and clinician's attitudes. An understanding of how these factors influence the CS rate is essential for evaluation of quality and appropriateness of obstetric care provided to women.

‘Supply’ and ‘demand’: breastfeeding as labour

This paper presents findings from a recent critical ethnographic study conducted in two maternity units in England, UK. The study explored the influences upon 61 women's experiences of breastfeeding within the postnatal ward setting. Participant observations of 97 encounters between midwives and postnatal women, 106 focused interviews with postnatal women and 37-guided conversations with midwives were conducted. Basic, organising and global themes were constructed utilising thematic networks analysis. The metaphor of the production line, with its notions of demand and efficient supply, illustrated the experiences of breastfeeding women. They conceptualised breastfeeding as a ‘productive’ project, yet expressed deep mistrust in the efficacy of their bodies. Their emphasis centred upon breast milk as nutrition rather than relationality and breastfeeding. Women referred to the demanding and unpredictable ways in which their baby breached their temporal and spatial boundaries. They sought strategies to cope with the uncertainty of this embodied experience in combination with their concerns regarding returning to a ‘normal’ and ‘productive’ life. The hospital setting and health worker practices played a contributing and reinforcing role. The paper discusses ways of re-establishing trust in women's bodies and breastfeeding, while respecting difference and diversity. It argues for embracing the concepts of embodiment and relationality whilst avoiding a return to essentialism. This requires collective efforts to erode deeply embedded cultural understandings of women's bodies centring upon disembodied and efficient production.

National survey for intrapartum and postpartum bladder care: assessing the need for guidelines.

Variation in the practice of intrapartum and postpartum bladder care reported by 189 maternity units in England and Wales hospitals was evaluated by analysing the data obtained from a postal questionnaire completed by labour ward managers or heads of midwifery. The survey revealed that there was no consensus of opinion about the diagnostic criteria for postpartum urinary retention and therefore the optimum management for voiding dysfunction remains controversial. In spite of the increasing awareness of the risk management issues involved, the majority of the units were found to be non-compliant with the limited RCOG recommendations currently available. Although further research is needed to develop evidence-based guidelines, all units should be timing and measuring the voided volume and ideally checking the first post-void residual volume to ensure that retention does not go unrecognised.