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Background: English maternity care policy has supported offering women choice of birth setting for over twenty years, but only 13% of women in England currently give birth in settings other than obstetric units (OUs). It is unclear why uptake of non-OU settings for birth remains relatively low. This paper presents a synthesis of qualitative evidence which explores influences on women's experiences of birth place choice, preference and decision-making from the perspectives of women using maternity services.Methods: Qualitative evidence synthesis of UK research published January 1992-March 2015, using a 'best-fit' framework approach. Searches were run in seven electronic data bases applying a comprehensive search strategy. Thematic framework analysis was used to synthesise extracted data from included studies.Results: Twenty-four papers drawing on twenty studies met the inclusion criteria. The synthesis identified support for the key framework themes. Women's experiences of choosing or deciding where to give birth were influenced by whether they received information about available options and about the right to choose, women's preferences for different services and their attributes, previous birth experiences, views of family, friends and health care professionals and women's beliefs about risk and safety. The synthesis additionally identified that women's access to choice of place of birth during the antenatal period varied. Planning to give birth in OU was straightforward, but although women considering birth in a setting other than hospital OU were sometimes well-supported, they also encountered obstacles and described needing to 'counter the negativity' surrounding home birth or birth in midwife-led settings.Conclusions: Over the period covered by the review, it was straightforward for low risk women to opt for hospital birth in the UK. Accessing home birth was more complex and contested. The evidence on freestanding midwifery units (FMUs) is more limited, but suggests that women wanting to opt for an FMU birth experienced similar barriers. The extent to which women experienced similar problems accessing alongside midwifery units (AMUs) is unclear. Women's preferences for different birth options, particularly for 'hospital' vs non-hospital settings, are shaped by their pre-existing values, beliefs and experience, and not all women are open to all birth settings. [ABSTRACT FROM AUTHOR]

Background: Expectant parents worldwide have experienced changes in the way they give birth as a result of COVID-19, including restrictions relating to access to birthing units and the presence of birthing partners during the birth, and changes to birth plans. This paper reports the experiences of women in England.Methods: Data were obtained from both closed- and open-ended responses collected as part of the national COVID in Context of Pregnancy, Infancy and Parenting (CoCoPIP) Study online survey (n = 477 families) between 15th July 2020 - 29th March 2021. Frequency data are presented alongside the results of a sentiment analysis; the open-ended data was analysed thematically.Results: Two-thirds of expectant women reported giving birth via spontaneous vaginal delivery (SVD) (66.1%) and a third via caesarean section (CS) (32.6%) or 'other' (1.3%). Just under half (49.7%) of the CS were reported to have been elective/planned, with 47.7% being emergencies. A third (37.4%) of participants reported having no changes to their birth (as set out in their birthing plan), with a further 25% reporting COVID-related changes, and 37.4% reporting non-COVID related changes (e.g., changes as a result of birthing complications). One quarter of the sample reported COVID-related changes to their birth plan, including limited birthing options and reduced feelings of control; difficulties accessing pain-relief and assistance, and feelings of distress and anxiety. Under half of the respondents reported not knowing whether there could be someone present at the birth (44.8%), with 2.3% of respondents reporting no birthing partner being present due to COVID-related restrictions. Parental experiences of communication and advice provided by the hospital prior to delivery were mixed, with significant stress and anxiety being reported in relation to both the fluctuating guidance and lack of certainty regarding the presence of birthing partners at the birth. The sentiment analysis revealed that participant experiences of giving birth during the pandemic were predominately negative (46.9%) particularly in relation to the first national lockdown, with a smaller proportion of positive (33.2%) and neutral responses (19.9%).Conclusion: The proportion of parents reporting birthing interventions (i.e., emergency CS) was higher than previously reported, as were uncertainties related to the birth, and poor communication, leading to increased feelings of anxiety and high levels of negative emotions. The implications of these findings are discussed. [ABSTRACT FROM AUTHOR]

Background: There are limited data describing adverse infant outcomes in infants born to women with a low risk of complications during pregnancy, such as those who may be enrolled in maternal immunization trials. This retrospective study estimated incidence proportions of infant outcomes in different cohorts of liveborn infants in England between 2005 and 2017. Methods: The incidence proportions of 10 infant outcomes were calculated for liveborn infants from pregnancies represented in the Clinical Practice Research Datalink (CPRD) Mother-Baby Link (MBL) and linkage to Hospital Episode Statistics (HES). Three infant cohorts were designed: (1) the all pregnancies infants cohort (N = 185,119), (2) the all pregnancies with a gestational age (GA) ≥ 24 weeks infants cohort (N = 183,869), and (3) the low-risk pregnancies infants cohort (LR infants cohort, N = 121,871), which included pregnancies with a GA ≥ 24 weeks and no diagnosis of predefined high-risk medical conditions until 24 weeks GA. Results: The most common adverse infant outcome in the three infant cohorts was macrosomia (e.g., 1,085.9/10,000 live births in the LR infants cohort), followed by minor congenital anomalies (e.g., 800.6/10,000 in the LR infants cohort), very low/low birth weight (e.g., 400.6/10,000 in the LR infants cohort), and major congenital anomalies (e.g., 270.4/10,000 in the LR infants cohort). The incidence proportions for early-onset sepsis, very low/low birth weight, and minor and major congenital anomalies were lower in the LR infants than in the other cohorts (non-overlapping confidence intervals [CIs]). The incidence proportions of neonatal death, infant death, late-onset sepsis, macrosomia, small for GA, and large for GA were similar between cohorts (overlapping CIs). Conclusions: This study generated background rates of adverse infant outcomes from liveborn infants of all and low-risk pregnancies represented in the CPRD Pregnancy Register MBL and linkage to HES. The results indicate lower incidence proportions of several adverse infant outcomes in infants from low-risk pregnancies compared to all pregnancies, illustrating the importance of considering maternal risk factors. These background rates may facilitate the interpretation of safety data from maternal immunization trials and of pharmacovigilance data from maternal vaccines. They may also be of interest for other interventions studied in pregnant women. [ABSTRACT FROM AUTHOR]

Background: The COVID-19 pandemic caused various disruptions to NHS maternity services in England. Changes were made to antenatal and postnatal care and the way that information was shared with maternity service users during these times. Fewer face-to-face appointments, increased virtual appointments and changes in guidance about the suitability of the COVID-19 vaccine without appropriate information sharing and evidence caused concern. Methods: This study took a blended inductive-deductive approach to secondary data analysis using a population subset of 16 from a wider study that sought to understand the impact of COVID-19 on maternity services in England. Participants of this study were aged 28–44 and gave birth using NHS maternity services in England. The data were collected and coded using Rapid Analysis Procedure sheets, which generated key themes, which are used here to structure the results. Results: Four main themes were generated from the analysis: 1) service restrictions to antenatal and postnatal appointments 2) access to information and changes to antenatal and postnatal care 3) inconsistencies in the implementation of government and NHS policy and 4) limited information about COVID-19 vaccine provided by NHS trusts and hesitancy in vaccine acceptance. Conclusion: Participants experienced poor communication that affected their understanding of maternity service changes and there was limited general and maternal health information provided. Vaccine information was also inadequate, and participants expressed a desire for clearer guidance. The UK Government, Royal College of Obstetricians and Gynaecologists, and NHS must collaborate with maternity service users to ensure that there are evidence-based guidelines and policies that can be understood and standardised across all NHS maternity trusts. [ABSTRACT FROM AUTHOR]

Background: One in five women in the UK are survivors of rape and sexual assault, and four in five women will give birth. This implies that a substantial number of women experience rape and sexual assault before pregnancy. We highlight and explore the voices and lived experiences of survivors during pregnancy and birth, to better understand the relationship between sexual violence, biomedicine, and pregnancy and to inform maternity care practice. Methods: This qualitative research took an intersectional feminist approach. We conducted in-depth individual interviews in England with fourteen women who self-identified as survivors of rape or sexual assault, and who had experienced pregnancy and birth after the assault. We conducted open line-by-line coding of the interview transcripts, and identified key themes and sub-themes inductively. Results: Three themes help summarise the narratives: control, safety and trauma. Maintaining a sense of control was important to survivors but they often reported objectification by healthcare staff and lack of consent or choice about healthcare decisions. Participants' preferences for giving birth were often motivated by their desire to feel in control and avoid triggering traumatic memories of the sexual assault. Survivors felt safer when they trusted staff. Many participants said it was important for staff to know they were survivors but none were asked about this. Pregnancy and birth experiences were triggering when they mirrored the assault, for instance if the woman was prevented from moving. Many of our participants reported having unmet mental health care needs before, during or after pregnancy. Conclusions: Survivors of sexual violence have specific maternity care needs. For our participants, these needs were often not met, leading to negative or traumatic experiences of pregnancy and birth. Systemic biases and poor birth experience jeopardise both psychological and physical safety. Funding for maternity and mental health services must be improved, so that they meet minimum staffing and care standards. Maternity services should urgently introduce trauma-informed models of care. [ABSTRACT FROM AUTHOR]

Background: Transabdominal cerclage (TAC) is a relatively uncommon intervention for preventing preterm birth. This study aimed to investigate the experience of women who had undergone this procedure. Methods: The survey was designed in collaboration with a preterm birth studies public and patient involvement (PPI) group and ethical approval was granted by KCL BDM Research Ethics Panel (LRS-19/20-13205). Members of closed Facebook group, UK TAC Support, were invited to complete an online questionnaire about their experience of TAC, and pregnancies before and after having it placed. The survey was open between December 2019 and May 2020. Open and closed questions provided both qualitative and quantitative data for analysis, which was carried out using NVivo Pro 2020 v.1.4.1 qualitative data management software and SPSS Statistics 27 (IBM). Results: One hundred eighty-three participants completed the survey, having had TAC procedures carried out in 36 hospitals. Altogether, participants had experienced 287 preterm births (PTB) and late miscarriages (LM), equating to an average of 1.6 each (range 0–5), including 18 stillbirths. TAC was indicated in 123 (67%) for previous PTB and/or LM, 29 (16%) for cervical surgery and 31 (17%) for both. 151 (83%) TAC procedures were open, 32 (17%) laparoscopic. 86% (n = 157) were placed outside pregnancy. Of those placed in pregnancy, gestation at TAC ranged from 7 to 16 weeks. When comparing earliest pre- and post-TAC pregnancy gestation (excluding first trimester losses), median gestational weeks gained following TAC was 15.5 weeks (SD 6.89). Qualitative themes included: the struggle to get treatment; lack of TAC knowledge amongst clinicians; gratitude, hope and feeling protected; possible detrimental effects of TAC. Conclusions: This very high-risk group found having a TAC gave great reassurance and hope, and were very grateful to have found the care they needed. However, they often struggled to get this support, frequently due to lack of clinician awareness. This may improve following roll-out of NHS England's Saving Babies Live Care Bundle and NHS commissioning guidelines for care of women at risk of PTB. [ABSTRACT FROM AUTHOR]

Background: Incentive or reward schemes are becoming increasingly popular to motivate healthy lifestyle behaviours. In this paper, insights from a qualitative and descriptive study to investigate the uptake, impact and meanings of a breastfeeding incentive intervention integrated into an existing peer support programme (Star Buddies) are reported. The Star Buddies service employs breastfeeding peer supporters to support women across the ante-natal, intra-partum and post-partum period. Methods: In a disadvantaged area of North West England, women initiating breastfeeding were recruited by peer supporters on the postnatal ward or soon after hospital discharge to participate in an 8 week incentive (gifts and vouchers) and breastfeeding peer supporter intervention. In-depth interviews were conducted with 26 women participants who engaged with the incentive intervention, and a focus group was held with the 4 community peer supporters who delivered the intervention. Descriptive analysis of routinely collected data for peer supporter contacts and breastfeeding outcomes before and after the incentive intervention triangulated and retrospectively provided the context for the qualitative thematic analysis. Results: A global theme emerged of 'incentives as connectors', with two sub-themes of 'facilitating connections' and 'facilitating relationships and wellbeing'. The incentives were linked to discussion themes and gift giving facilitated peer supporter access for proactive weekly home visits to support women. Regular face to face contacts enabled meaningful relationships and new connections within and between the women, families, peer supporters and care providers to be formed and sustained. Participants in the incentive scheme received more home visits and total contact time with peer supporters compared to women before the incentive intervention. Full participation levels and breastfeeding rates at 6-8 weeks were similar for women before and after the incentive intervention. Conclusion: The findings suggest that whilst the provision of incentives might not influence women's intentions or motivations to breastfeed, the connections forged provided psycho-social benefits for both programme users and peer supporters. [ABSTRACT FROM AUTHOR]

Background: Postnatal and antenatal anti-D prophylaxis have dramatically reduced maternal sensitisations and cases of rhesus disease in babies born to women with RhD negative blood group. Recent scientific advances mean that non-invasive prenatal diagnosis (NIPD), based on the presence of cell-free fetal DNA in maternal plasma, could be used to target prophylaxis on "at risk" pregnancies where the fetus is RhD positive. This paper provides the first assessment of cost-effectiveness of NIPD-targeted prophylaxis compared to current policies. Methods: We conducted an economic analysis of NIPD implementation in England and Wales. Two scenarios were considered. Scenario 1 assumed that NIPD will be only used to target antenatal prophylaxis with serology tests continuing to direct post-delivery prophylaxis. In Scenario 2, NIPD would also displace postnatal serology testing if an RhD negative fetus was identified. Costs were estimated from the provider's perspective for both scenarios together with a threshold royalty fee per test. Incremental costs were compared with clinical implications. Results: The basic cost of an NIPD in-house test is £16.25 per sample (excluding royalty fee). The two-dose antenatal prophylaxis policy recommended by NICE is estimated to cost the NHS £3.37 million each year. The estimated threshold royalty fee is £2.18 and £8.83 for Scenarios 1 and 2 respectively. At a £2.00 royalty fee, mass NIPD testing would produce no saving for Scenario 1 and £507,154 per annum for Scenario 2. Incremental costeffectiveness analysis indicates that, at a test sensitivity of 99.7% and this royalty fee, NIPD testing in Scenario 2 will generate one additional sensitisation for every £9,190 saved. If a single-dose prophylaxis policy were implemented nationally, as recently recommended by NICE, Scenario 2 savings would fall. Conclusions: Currently, NIPD testing to target anti-D prophylaxis is unlikely to be sufficiently cost-effective to warrant its large scale introduction in England and Wales. Only minor savings are calculated and, balanced against this, the predicted increase in maternal sensitisations may be unacceptably high. Reliability of NIPD assays still needs to be demonstrated rigorously in different ethnic minority populations. First trimester testing is unlikely to alter this picture significantly although other emerging technologies may. [ABSTRACT FROM AUTHOR]

Background: The link between maternal factors and birth outcomes is well established. Substantial changes in society and medical care over time have influenced women's reproductive choices and health, subsequently affecting birth outcomes. The objective of this study was to describe temporal changes in key maternal and fetal factors affecting birth outcomes in Newcastle upon Tyne over three decades, 1961-1992. Methods: For these descriptive analyses we used data from a population-based birth record database constructed for the historical cohort Particulate Matter and Perinatal Events Research (PAMPER) study. The PAMPER database was created using details from paper-based hospital delivery and neonatal records for all births during 1961-1992 to mothers resident in Newcastle (out of a total of 109,086 singleton births, 97,809 hospital births with relevant information). In addition to hospital records, we used other sources for data collection on births not included in the delivery and neonatal records, for death and stillbirth registrations and for validation. Results: The average family size decreased mainly due to a decline in the proportion of families with 3 or more children. The distribution of mean maternal ages in all and in primiparous women was lowest in the mid 1970s, corresponding to a peak in the proportion of teenage mothers. The proportion of older mothers declined until the late 1970s (from 16.5% to 3.4%) followed by a steady increase. Mean birthweight in all and term babies gradually increased from the mid 1970s. The increase in the percentage of preterm birth paralleled a two-fold increase in the percentage of caesarean section among preterm births during the last two decades. The gap between the most affluent and the most deprived groups of the population widened over the three decades. Conclusion: Key maternal and fetal factors affecting birth outcomes, such as maternal age, parity, socioeconomic status, birthweight and gestational age, changed substantially during the 32-year period, from 1961 to 1992. The availability of accurate gestational age is extremely important for correct interpretation of trends in birthweight. [ABSTRACT FROM AUTHOR]

Background: Uncertainty around the risk of COVID-19 to pregnant women and their babies prompted precautionary restrictions on their health and care during the pandemic. Maternity services had to adapt to changing Government guidance. Coupled with the imposition of national lockdowns in England and restrictions on daily activities, women's experiences of pregnancy, childbirth and the postpartum period, and their access to services, changed rapidly. This study was designed to understand women's experiences of pregnancy, labour and childbirth and caring for a baby during this time. Methods: This was an inductive longitudinal qualitative study, using in-depth interviews by telephone with women in Bradford, UK, at three timepoints during their maternity journey (18 women at timepoint one, 13 at timepoint two and 14 at timepoint three). Key topics explored were physical and mental wellbeing, experience of healthcare services, relationships with partners and general impact of the pandemic. Data were analysed using the Framework approach. A longitudinal synthesis identified over-arching themes. Results: Three longitudinal themes captured what was important to women: (1) women feared being alone at critical points in their maternity journey, (2) the pandemic created new norms for maternity services and women's care, and (3) finding ways to navigate the COVID-19 pandemic in pregnancy and with a baby. Conclusions: Modifications to maternity services impacted significantly on women's experiences. The findings have informed national and local decisions about how best to direct resources to reduce the impact of COVID-19 restrictions and the longer-term psychological impact on women during pregnancy and postnatally. [ABSTRACT FROM AUTHOR]

Background: The perinatal period is a vulnerable time, with one in five women experiencing mental health problems. Antenatal and postnatal appointments are key contact points for identifying women in need of support. Since 2014, the UK National Institute for Health and Care Excellence (NICE) has recommended that all women be asked about their mental health at their antenatal booking appointment and early in the postnatal period. The aim of this study was to assess the proportions of women who reported being asked about their mental health during the perinatal period across consecutive national maternity surveys (NMS) in England and to evaluate sociodemographic disparities in who was asked. Methods: Secondary analysis was performed on cross-sectional data from the NMS in 2014–2020. In each survey, women reported whether they had been asked about their mental health antenatally (during their booking appointment) and postnatally (up to six months after giving birth). The proportions of women in each survey who reported being asked about their mental health were calculated and compared according to key sociodemographic characteristics and across survey years. Logistic regression was conducted to identify disparities in who was asked. Results: The proportion of women who reported being asked about their mental health antenatally increased from 80.3% (95%CI:79.0–81.5) in 2014 to 83.4% (95%CI:82.1–84.7) in 2020, yet the proportion of women who reported being asked postnatally fell from 88.2% (95%CI:87.1–89.3) in 2014 to 73.7% (95%CI:72.2–75.2) in 2020. Ethnic minority women (aOR range:0.20 ~ 0.67) were less likely to report being asked about their mental health antenatally and postnatally across all surveys compared to White women. Women living in less socioeconomically advantaged areas (aOR range:0.65 ~ 0.75) and women living without or separately from a partner (aOR range:0.61 ~ 0.73) were also less likely to report being asked about their mental health, although there was less consistency in these disparities across the antenatal and postnatal periods and across surveys. Conclusions: Despite NICE recommendations, many women are still not asked about their mental health during the perinatal period, particularly after giving birth. Women from ethnic minority backgrounds are less likely to be asked and these disparities have persisted over time. [ABSTRACT FROM AUTHOR]

Background: Women who enter pregnancy with a Body Mass Index above 30 kg/m2 face an increased risk of complications during pregnancy and birth. National and local practice recommendations in the UK exist to guide healthcare professionals in supporting women to manage their weight. Despite this, women report inconsistent and confusing advice and healthcare professionals report a lack of confidence and skill in providing evidence-based guidance. A qualitative evidence synthesis was conducted to examine how local clinical guidelines interpret national recommendations to deliver weight management care to people who are pregnant or in the postnatal period. Methods: A qualitative evidence synthesis of local NHS clinical practice guidelines in England was conducted. National Institute for Health and Care Excellence and Royal College of Obstetricians and Gynaecologists guidelines for weight management during pregnancy constructed the framework used for thematic synthesis. Data was interpreted within the embedded discourse of risk and the synthesis was informed by the Birth Territory Theory of Fahy and Parrat. Results: A representative sample of twenty-eight NHS Trusts provided guidelines that included weight management care recommendations. Local recommendations were largely reflective of national guidance. Consistent recommendations included obtaining a weight at booking and informing women of the risks associated with being obese during pregnancy. There was variation in the adoption of routine weighing practices and referral pathways were ambiguous. Three interpretive themes were constructed, exposing a disconnect between the risk dominated discourse evident in the local guidelines and the individualised, partnership approach emphasised in national level maternity policy. Conclusions: Local NHS weight management guidelines are rooted in a medical model rather than the model advocated in national maternity policy that promotes a partnership approach to care. This synthesis exposes the challenges faced by healthcare professionals and the experiences of pregnant women who are in receipt of weight management care. Future research should target the tools utilised by maternity care providers to achieve weight management care that harnesses a partnership approach empowering pregnant and postnatal people in their journey through motherhood. [ABSTRACT FROM AUTHOR]

Background: National guidance (Saving Babies Lives Care Bundle Version 2 (SBLCBv2) Element 5) was published in 2019, with the aim to standardise preterm care in England. We plan to identify how many preterm birth surveillance clinics there are in England, and to define current national management in caring for women who are both asymptomatic and high-risk of preterm birth, and who arrive symptomatically in threatened preterm labour, to assist preterm management both nationally and internationally. Methods: An online survey comprising of 27 questions was sent to all maternity units in England between February 2021 to July 2021. Results: Data was obtained from 96 units. Quantitative analysis and free text analysis was then undertaken. We identified 78 preterm birth surveillance clinics in England, an increase from 30 preterm clinics in 2017. This is a staggering 160% increase in 4 years. SBLCBv2 has had a considerable impact in increasing preterm birth surveillance clinic services, with the majority (61%) of sites reporting that the NHS England publication influenced their unit in setting up their clinic. Variations exist at every step of the preterm pathway, such as deciding which risk factors warrant referral, distinguishing within particular risk factors, and offering screening tests and treatment options. Conclusions: While variations in care still do persist, hospitals have done well to increase preterm surveillance clinics, under the difficult circumstances of the COVID pandemic and many without specific additional funding. [ABSTRACT FROM AUTHOR]

Background: Minoritised ethnic perinatal women can experience judgemental and stigmatising care due to systemic racism. Discriminatory care contributes to increased risks of poor maternal and infant outcomes, including higher rates of mental ill-health. This study aimed to explore minoritised ethnic women's experiences of maternity services, including maternity care and mental health support, within a North-West England locality. Here we use an equity lens to report the findings that describe if and how women's personal, cultural, and spiritual needs were met, their experiences of discriminatory and prejudicial care, and to identify recommendations for service provision. Methods: A mixed-methods study was undertaken comprising an online survey, interviews, and community consultations. Questions explored access to and experiences of antenatal care and education; information, communication, and choice; experiences of (dis)respect and judgement; mental health needs and support; cultural/religious needs and support; and overall experiences of maternity care. Eligibility criteria were: women, 18+ years, from self-reported minoritised ethnic backgrounds, who had given birth in the previous 2 years and received maternity care in the locality. Surveys were available in seven languages and distributed via social media, mother-baby groups, and community locations. English-speaking survey participants were invited to take part in a follow-up interview. Community staff were approached to collect data on behalf of the study team. Quantitative data were analysed descriptively (n, %) and merged with qualitative data into descriptive themes. Results: Overall, 104 women provided data; most self-identified as Asian (65.0%) or Black (10.7%) and were aged between 30–34 (32.0%) or 25–29 years (23.3%). Four descriptive themes are reported: 'accessing care' details variations and barriers in accessing maternity care; 'communication needs, and resources' describes views on adaptions and resources for specific communication needs; 'meeting religious and cultural needs' outlines how various religious and cultural needs were met by maternity providers; 'discriminatory or stigmatising care' reports on experiences of pejorative and inequitable care. Conclusions: An equity lens helped identify areas of discriminatory and inequitable care. Key recommendations include cultural safety training for staff; service-user engagement and co-production of research and resources, and appropriate facilities and recording systems to facilitate individualised, needs-based maternity care. [ABSTRACT FROM AUTHOR]

Background: Pregnancy and the postnatal period can be times of psychosocial stress and insecurity, but high quality maternity care and social support can help mothers cope with stress and feel more secure. The COVID-19 pandemic and associated social and economic disruption increased rates of antenatal and postnatal stress, anxiety and depression, and also had profound impacts on the organisation of maternity services in England.Methods: This was a qualitative descriptive study of the impact of pandemic-related changes to maternity care on mothers' emotional wellbeing, using inductive thematic analysis of open text responses to the National Maternity Survey (NMS) 2020 in England. A random sample of 16,050 mothers who gave birth 11-24th May 2020 were invited to take part in the survey, and 4,611 responded, with 4,384 answering at least one open text question.Results: There were three themes: 'Chaos: impact of uncertainty', 'Abandoned: impact of reduction in care', and 'Alone: impact of loss of social support'. Mothers valued maternity care and many experienced additional stress from chaotic changes and reduction in care during the pandemic; from health professionals' own uncertainty and anxiety; and from restrictions on essential social support during pregnancy, labour and birth. Others felt that health professionals had communicated and cared for them well despite the changes and restrictions, and these mothers felt psychologically safe.Conclusions: Planning for future crises should include considering how necessary adaptations to care can be implemented and communicated to minimise distress; ensuring that mothers are not deprived of social support at the time when they are at their most vulnerable; and supporting the psychological welfare of staff at a time of enormous pressure. There are also lessons for maternity care in 'normal' times: that care is highly valued, but trust is easily lost; that some mothers come into the maternity system with vulnerabilities that can be ameliorated or intensified by the attitudes of staff; that every effort should be made to welcome a mother's partner or chosen companion into maternity care; and that high quality postnatal care can make a real difference to mothers' wellbeing. [ABSTRACT FROM AUTHOR]

Introduction: One in 10 women have hypertensive disorders in pregnancy (HDP) and are at risk of adverse short- and long-term health outcomes, yet there is limited information on their postnatal health and care needs. This study aimed to look at postnatal physical and psychological morbidity in women with HDP, compared to women without HDP, and the postnatal care received in both groups.Methods: Within a prospective cohort study, women with and without HDP were identified and recruited on the postnatal ward of 17 maternity units across England and invited to complete a short baseline questionnaire. At 3 months postpartum, women were sent a follow-up questionnaire, with reminders. The principal outcomes were the mean score at 3 months for the Edinburgh Postnatal Depression Scale (EPDS) and the EuroQol Group 5-dimension (EQ-5D) scale.Results: One thousand eight hundred twenty-nine women agreed to participate. Of these, 1757 (96%) completed the baseline questionnaire: 769 (44%) women had HDP and 988 (56%) women did not. Despite a difference in health-related quality of life and symptoms of depression at baseline between the two groups, at 3 months postnatal, within the 653 women who completed their follow-up questionnaire (37.2% of those who completed the baseline questionnaire) there were no significant differences between the groups (median EQ-5D VAS: 85 in women with HDP, 85 in women without HDP, p = 0.99 and mean EPDS score 5.5 in women with HDP, 5.0 in women without HDP, p = 0.80). Overall levels of physical postnatal morbidity were high, with 89% reporting one or more morbidities. Approximately 9% of women were re-admitted within 3 months after birth, higher in the HDP group (13.1%) higher compared to women without HDP (5.5%; RR 2.41; 95% CI 1.44-4.05).Conclusion: Overall levels of physical and psychological morbidity were high in this postnatal population. Although there were increased needs of women with HDP in the immediate postnatal period (compared to other women), their health assessments were similar at 3 months. This study highlights the unmet needs of women in the postnatal period, in addition to a missed opportunity to influence future pregnancies and improve the longer-term health of women and their babies. [ABSTRACT FROM AUTHOR]

Background: In contrast to other pregnancy complications the economic impact of stillbirth is poorly understood. We aimed to carry out a preliminary exploration of the healthcare costs of stillbirth from the time of pregnancy loss and the period afterwards; also to explore and include the impact of a previous stillbirth on the healthcare costs of the next pregnancy.Methods: A structured review of the literature including cost studies and description of costs to health-care providers for care provided at the time of stillbirth and in a subsequent pregnancy. Costs in a subsequent pregnancy were compared in three alternative models of care for multiparous women developed from national guidelines and expert opinion: i) "low risk" women who had a live birth, ii) "high risk" women who had a live birth and iii) women with a previous stillbirth.Results: The costs to the National Health Service (NHS) for investigation immediately following stillbirth ranged from £1,242 (core recommended investigations) to £1,804 (comprehensive investigation). The costs in the next pregnancy following a stillbirth ranged from £2,147 (low-risk woman with a previous healthy child) to £3,751 (Woman with a previous stillbirth of unknown cause). The cost in the next pregnancy following a stillbirth due to a known recurrent or an unknown cause is almost £500 greater than the pregnancy following a stillbirth due to a known non-recurrent cause.Conclusions: The study has highlighted the paucity of evidence regarding economic issues surrounding stillbirth. Women who have experienced a previous stillbirth are likely to utilise more health care services in their next pregnancy particularly where no cause is found. Every effort should be made to determine the cause of stillbirth to reduce the overall cost to the NHS. The cost associated with identifying the cause of stillbirth could offset the costs of care in the next pregnancy. Future research should concentrate on robust studies looking into the wider economic impact of stillbirth. [ABSTRACT FROM AUTHOR]

Background: Following a perinatal death, a formal standardised multi-disciplinary review should take place, to learn from the death of a baby and facilitate improvements in future care. It has been recommended that bereaved parents should be offered the opportunity to give feedback on the care they have received and integrate this feedback into the perinatal mortality review process. However, the MBRRACE-UK Perinatal Confidential Enquiry (2015) found that only one in 20 cases parental concerns were included in the review. Although guidance suggests parental opinion should be sought, little evidence exists on how this may be incorporated into the perinatal mortality review process. The purpose of the PARENTS study was to investigate bereaved parents' views on involvement in the perinatal mortality review process.Methods: A semi-structured focus group of 11 bereaved parents was conducted in South West England. A purposive sampling technique was utilised to recruit a diverse sample of women and their partners who had experienced a perinatal death more than 6 months prior to the study. A six-stage thematic analysis was followed to explore parental perceptions and expectations of the perinatal mortality review process.Results: Four over-arching themes emerged from the analysis: transparency; flexibility combined with specificity; inclusivity; and a positive approach. It was evident that the majority of parents were supportive of their involvement in the perinatal mortality review process and they wanted to know the outcome of the meeting. It emerged that an individualised approach should be taken to allow flexibility on when and how they could contribute to the process. The emotional aspects of care should be considered as well as the clinical care. Parents identified that the whole care pathway should be examined during the review including antenatal, postnatal, and neonatal and community based care. They agreed that there should be an opportunity for parents to give feedback on both good and poor aspects of their care.Conclusion: Parents were unaware that a review of their baby's death took place in the hospital. Parental involvement in the perinatal mortality review process would promote an open culture in the healthcare system and learning from adverse events including deaths. Further research should focus on designing and evaluating a perinatal mortality review process where parental feedback will be integral. [ABSTRACT FROM AUTHOR]

Background: Late access to antenatal care increases risks of adverse outcomes including maternal and perinatal mortality. There is evidence that BMI influences patient engagement with health services, such as cancer screening services and delayed access to treatment; this association has not been fully explored in the context of antenatal care. This study investigated the association between the stage of pregnancy women access antenatal care, BMI, and other socio-demographic factors.Methods: Retrospective analysis of routine hospital data from 34 NHS maternity units in England, UK, including 619,502 singleton births between 1989 and 2007. Analyses used logistic regression to investigate the association between maternal BMI categories and stage of pregnancy women accessed antenatal care. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were used to estimate associations, adjusting for maternal age, ethnic group, parity, Index of Multiple Deprivation score and employment status. The primary outcome was late access to antenatal care (>13+6 weeks). Secondary outcomes were trimester of access, and the association between late access and other socio-demographic variables.Results: Women with an overweight or obese BMI accessed antenatal care later than women with a recommended BMI (aOR 1.11, 95%CI 1.09-1.12; aOR 1.04, 95%CI 1.02-1.06 respectively), and underweight women accessed care earlier (aOR 0.77, 95%CI 0.74-0.81). Women with obesity were 42% more likely to access care in the third trimester compared with women with a recommended BMI. Additional significant socio-demographic associations with late access included women from minority ethnic groups, teenagers, unemployment and deprivation. The greatest association was observed among Black/Black British women accessing care in the third trimester (aOR 5.07, 95% CI 4.76, 5.40).Conclusions: There are significant and complex socio-demographic inequalities associated with the stage of pregnancy women access maternity care, particularly for women with obesity accessing care very late in their pregnancy, and among BME groups, teenagers, deprived and unemployed women. These populations are at increased risk of adverse maternal and fetal outcomes and require support to address inequalities in access to antenatal care. Interventions to facilitate earlier access to care should address the complex and inter-related nature of these inequalities to improve pregnancy outcomes among high-risk groups. [ABSTRACT FROM AUTHOR]

Background: For the past decade, Maternal Mortality Reports, published in the United Kingdom every three years, have consistently raised concerns about maternal observations in maternity care. The reports identify that observations are not being done, not being completed fully, are not recorded on Early Warning Score systems, and/or are not escalated appropriately. This has resulted in delays in referral, intervention and increases the risk of maternal morbidity or mortality. However there has been little exploration of the possible reasons for non-completion of maternal observations.Methods: The aim of this study was to explore midwives' experiences of performing maternal observations and escalating concerns in rural and urban maternity settings in the West Midlands of England. A qualitative design involving a series of six focus groups with midwives and Supervisors of Midwives was employed to investigate the facilitators of, and barriers to the completion of maternal observations.Results: Eighteen Midwives and 8 Supervisors of Midwives participated in a total of 6 focus groups. Three key themes emerged from the data: (1) Organisation of Maternal Observations (including delegation of tasks to Midwifery Support Workers, variation in their training, the care model used e.g. one to one care, and staffing issues); (2) Prioritisation of Maternal Observations (including the role of professional judgement and concerns expressed by midwives that they did not feel equipped to care for women with complex clinical needs; and (3) Negotiated Escalation (including the inappropriate response from senior staff to use of Modified Early Warning Score systems, and the emotional impact of escalation).Conclusions: A number of organisational and cultural barriers exist to the completion of maternal observations and the escalation of concerns. In order to address these the following actions are recommended: standardised training for Midwifery Support Workers, review of training of midwives to ensure it addresses the increasing complexity of the maternal population, identification and agreement regarding the organisation of maternal observations among staff, an emphasis on increasing the priority placed on maternal observations in all clinical settings, and clarification and reinforcement of escalation procedures for both midwives and senior clinicians. [ABSTRACT FROM AUTHOR]

Background: Women and their relatives can play an important role in early detection and help seeking for acute perinatal events. Recent UK reports indicate that patient-professional partnership in 'working for safety' can be difficult to achieve in practice, sometimes with catastrophic consequences. This research explored the experiences of women and relatives who had experienced early warning signs about their condition and sought help in escalating care.Methods: Secondary analysis of case study data which included qualitative interviews with 22 women purposively sampled on account of experiencing a step up in care and 4 of their relatives from two NHS Trusts in England during 2010. Analysis focused on the type of safety work participants engaged in, and the opportunities and challenges reported by women and family members when negotiating safety at home and in hospital.Results: Women and relatives took on a dual responsibility for self-diagnosis, self-care and seeking triage, whilst trying to avoid overburdening stretched services. Being informed, however, did not necessarily enable engagement from staff and services. The women's narratives highlighted the work that they engaged in to build a case for clinical attention, the negotiations that took place with health care professionals and the strategies women and partners drew on (such as objective signs and symptoms, use of verbal insistence and repetition) to secure clinical help. For some women, the events left them with a lasting feeling that their concerns had been disregarded. Some described a sense of betrayal and loss of trust in an institution they believed had failed to care for them.Conclusion: The notion of 'safety partnerships' which suggests a sense of equality and reciprocity was not borne out by our data, especially with regards to the experiences of teenage women. To enable women and families to secure a rapid response in clinical emergencies, strategies need to move beyond the provision of patient information about warning signs. Effective partnerships for safety may be supported by system level change such as improved triage, continuity of care, self-referral pathways and staff training to address asymmetries of power that persist within the health system. [ABSTRACT FROM AUTHOR]

Background: For low risk women, there is good evidence that planned birth in a midwifery unit is associated with a reduced risk of maternal interventions compared with planned birth in an obstetric unit. Findings from the Birthplace cohort study have been interpreted by some as suggesting a reduced risk of interventions in planned births in freestanding midwifery units (FMUs) compared with planned births in alongside midwifery units (AMUs). However, possible differences have not been robustly investigated using individual-level Birthplace data.Methods: This was a secondary analysis of data on 'low risk' women with singleton, term, 'booked' pregnancies collected in the Birthplace national prospective cohort study. We used logistic regression to compare interventions and outcomes by parity in 11,265 planned FMU births and 16,673 planned AMU births, adjusted for potential confounders, using planned AMU birth as the reference group. Outcomes considered included adverse perinatal outcomes (Birthplace primary outcome measure), instrumental delivery, intrapartum caesarean section, 'straightforward vaginal birth', third or fourth degree perineal trauma, blood transfusion and maternal admission for higher-level care. We used a significance level of 1% for all secondary outcomes.Results: There was no significant difference in adverse perinatal outcomes between planned AMU and FMU births. The odds of instrumental delivery were reduced in planned FMU births (nulliparous: aOR 0.63, 99% CI 0.46-0.86; multiparous: aOR 0.41, 99% CI 0.25-0.68) and the odds of having a 'straightforward vaginal birth' were increased in planned FMU births compared with planned AMU births (nulliparous: aOR 1.47, 99% CI 1.17-1.85; multiparous: 1.86, 99% CI 1.35-2.57). The odds of intrapartum caesarean section did not differ significantly between the two settings (nulliparous: p = 0.147; multiparous: p = 0.224). The overall pattern of findings suggested a trend towards lower intervention rates and fewer adverse maternal outcomes in planned FMU births compared with planned AMU births.Conclusions: The findings support the recommendation that 'low risk' women can be informed that planned birth in an FMU is associated with a lower rate of instrumental delivery and a higher rate of 'straightforward vaginal birth' compared with planned birth in an AMU; and that outcomes for babies do not appear to differ between FMUs and AMUs. [ABSTRACT FROM AUTHOR]

Background: Pregnancy termination for fetal abnormality (TFA) may have profound psychological consequences for those involved. Evidence suggests that women's experience of care influences their psychological adjustment to TFA and that they greatly value compassionate healthcare. Caring for women in these circumstances presents challenges for health professionals, which may relate to their understanding of women's experience. This qualitative study examined health professionals' perceptions of women's coping with TFA and assessed to what extent these perceptions are congruent with women's accounts.Methods: Fifteen semi-structured interviews were carried out with health professionals in three hospitals in England. Data were analysed using thematic analysis and compared with women's accounts of their own coping processes to identify similarities and differences.Results: Health professionals' perceptions of women's coping processes were congruent with women's accounts in identifying the roles of support, acceptance, problem-solving, avoidance, another pregnancy and meaning attribution as key coping strategies. Health professionals regarded coping with TFA as a unique grieving process and were cognisant of women's idiosyncrasies in coping. They also considered their role as information providers as essential in helping women cope with TFA. The findings also indicate that health professionals lacked insight into women's long-term coping processes and the potential for positive growth following TFA, which is consistent with a lack of aftercare following TFA reported by women.Conclusions: Health professionals' perceptions of women's coping with TFA closely matched women's accounts, suggesting a high level of understanding. However, the lack of insight into women's long-term coping processes has important clinical implications, as research suggests that coping with TFA is a long-term process and that the provision of aftercare is beneficial to women. Together, these findings call for further research into the most appropriate ways to support women post-TFA, with a view to developing a psychological intervention to better support women in the future. [ABSTRACT FROM AUTHOR]

Background: The transition to parenthood is a potentially vulnerable time for mothers' mental health and approximately 9-21% of women experience depression and/or anxiety at this time. Many more experience sub-clinical symptoms of depression and anxiety, as well as stress, low self-esteem and a loss of confidence. Women's emotional wellbeing is more at risk if they have little social support, a low income, are single parents or have a poor relationship with their partner. Peer support can comprise emotional, affirmational, informational and practical support; evidence of its impact on emotional wellbeing during pregnancy and afterwards is mixed.Methods: This was a descriptive qualitative study, informed by phenomenological social psychology, exploring women's experiences of the impact of organised peer support on their emotional wellbeing during pregnancy and in early parenthood. Semi-structured qualitative interviews were undertaken with women who had received peer support provided by ten projects in different parts of England, including both projects offering 'mental health' peer support and others offering more broadly-based peer support. The majority of participants were disadvantaged Black and ethnic minority women, including recent migrants. Interviews were audio-recorded and transcripts were analysed using inductive thematic analysis.Results: 47 mothers were interviewed. Two key themes emerged: (1) 'mothers' self-identified emotional needs', containing the subthemes 'emotional distress', 'stressful circumstances', 'lack of social support', and 'unwilling to be open with professionals'; and (2) 'how peer support affects mothers', containing the subthemes 'social connection', 'being heard', 'building confidence', 'empowerment', 'feeling valued', 'reducing stress through practical support' and 'the significance of "mental health" peer experiences'. Women described how peer support contributed to reducing their low mood and anxiety by overcoming feelings of isolation, disempowerment and stress, and increasing feelings of self-esteem, self-efficacy and parenting competence.Conclusion: One-to-one peer support during pregnancy and after birth can have a number of interrelated positive impacts on the emotional wellbeing of mothers. Peer support is a promising and valued intervention, and may have particular salience for ethnic minority women, those who are recent migrants and women experiencing multiple disadvantages. [ABSTRACT FROM AUTHOR]

Background: Preterm infants have an immature sucking behavior and the capacity to be exclusively breastfed may be reduced for a period of weeks or months, depending on gestational age. Nipple shields have been used, not only as a device to help mothers with sore nipples, but also to facilitate the infant's latch on to the breast. However, the benefits of using nipple shields have been debated. The aim of this study was to explore perceptions and experiences of using a nipple shield among parents and staff in neonatal units in Sweden and England.Methods: An ethnographic study was undertaken where observations and interviews were conducted in four neonatal units in Sweden and England. The data were analyzed using a thematic networks analysis.Result: The global theme was developed and named, 'Nipple shield in a liminal time'. This comprised of two organizing themes: 'Relational breastfeeding' and 'Progression'. 'Relational breastfeeding' was underpinned by the basic themes, 'good enough breast', 'something in between' and 'tranquil moment'. 'Progression' was underpinned by the basic themes, 'learning quicker', 'short-term solution' and 'rescue remedy'. Although breastfeeding was seen primarily as a nutritive transaction, the relational aspects of breastfeeding were of crucial importance. These two organizing themes show the tension between acknowledging the relational aspects of breastfeeding and yet facilitating or supporting the progression of breastfeeding in the period from tube feeding or cup feeding to breastfeeding. It is a liminal time as mothers and their infants are "in between" phases and the outcome, in terms of breastfeeding, is yet to be realized.Conclusion: This study demonstrates parents' and staffs' perceptions of the nipple shield as a short term solution to help initiation of breastfeeding but also as a barrier between the mother and infant. It is important that the mother and baby's own particular needs are taken into account, in a person-centred way and on an ongoing basis. Furthermore, we need to emphasise the importance of the 'relational' whilst understanding the need for 'progression'. Holding these in balance may be the key to appropriate use of the nipple shield. [ABSTRACT FROM AUTHOR]

Background: Despite the importance attributed to good pre-pregnancy care and its potential to improve pregnancy and child health outcomes, relatively little is known about why women invest in pre-pregnancy health and care. We sought to gain insight into why women invested in pre-pregnancy health and care.Methods: We carried out 20 qualitative in-depth interviews with pregnant or recently pregnant women who were drawn from a survey of antenatal clinic attendees in London, UK. Interviewees were purposively sampled to include high and low investors in pre-pregnancy health and care, with variation in age, partnership status, ethnicity and pre-existing medical conditions. Data analysis was conducted using the Framework method.Results: We identified three groups in relation to pre-pregnancy health and care: 1) The "prepared" group, who had high levels of pregnancy planning and mostly positive attitudes to micronutrient supplementation outside of pregnancy, carried out pre-pregnancy activities such as taking folic acid and making changes to diet and lifestyle. 2) The "poor knowledge" group, who also had high levels of pregnancy planning, did not carry out pre-pregnancy activities and described themselves as having poor knowledge. Elsewhere in their interviews they expressed a strong dislike of micronutrient supplementation. 3) The "absent pre-pregnancy period" group, had the lowest levels of pregnancy planning and also expressed anti-supplement views. Even discussing the pre-pregnancy period with this group was difficult as responses to questions quickly shifted to focus on pregnancy itself. Knowledge of folic acid was poor in all groups.Conclusion: Different pre-pregnancy care approaches are likely to be needed for each of the groups. Among the "prepared" group, who were proactive and receptive to health messages, greater availability of information and better response from health professionals could improve the range of pre-pregnancy activities carried out. Among the "poor knowledge" group, better response from health professionals might yield greater uptake of pre-pregnancy information. A different, general health strategy might be more appropriate for the "absent pre-pregnancy period" group. The fact that general attitudes to micronutrient supplementation were closely related to whether or not women invested in pre-pregnancy health and care was an unanticipated finding and warrants further investigation. [ABSTRACT FROM AUTHOR]

Background According to the Office for National Statistics, approximately a quarter of women giving birth in England and Wales are from minority ethnic groups. Previous work has indicated that these women have poorer pregnancy outcomes than White women and poorer experience of maternity care, sometimes encountering stereotyping and racism. The aims of this study were to examine service use and perceptions of care in ethnic minority women from different groups compared to White women. Methods Secondary analysis of data from a survey of women in 2010 was undertaken. The questionnaire asked about women's experience of care during pregnancy, labour and birth, and the postnatal period, as well as demographic factors. Ethnicity was grouped into eight categories: White, Mixed, Indian, Pakistani, Bangladeshi, Black Caribbean, Black African, and Other ethnicity. Results A total of 24,319 women completed the survey. Compared to White women, women from minority ethnic groups were more likely to be younger, multiparous and without a partner. They tended to access antenatal care later in pregnancy, have fewer antenatal checks, fewer ultrasound scans and less screening. They were less likely to receive pain relief in labour and, Black African women in particular, were more likely to deliver by emergency caesarean section. Postnatally, women from minority ethnic groups had longer lengths of hospital stay and were more likely to breastfeed but they had fewer home visits from midwives. Throughout their maternity care, women from minority ethnic groups were less likely to feel spoken to so they could understand, to be treated with kindness, to be sufficiently involved in decisions and to have confidence and trust in the staff. Conclusion Women in all minority ethnic groups had a poorer experience of maternity services than White women. That this was still the case following publication of a number of national policy documents and local initiatives is a cause for concern. [ABSTRACT FROM AUTHOR]

Background: Becoming a parent of a preterm baby requiring neonatal care constitutes an extraordinary life situation in which parenting begins and evolves in a medical and unfamiliar setting. Although there is increasing emphasis within maternity and neonatal care on the influence of place and space upon the experiences of staff and service users, there is a lack of research on how space and place influence relationships and care in the neonatal environment. The aim of this study was to explore, in-depth, the impact of place and space on parents' experiences and practices related to feeding their preterm babies in Neonatal Intensive Care Units (NICUs) in Sweden and England.Methods: An ethnographic approach was utilised in two NICUs in Sweden and two comparable units in England, UK. Over an eleven month period, a total of 52 mothers, 19 fathers and 102 staff were observed and interviewed. A grounded theory approach was utilised throughout data collection and analysis.Results: The core category of 'the room as a conveyance for an attuned feeding' was underpinned by four categories: the level of 'ownership' of space and place; the feeling of 'at-homeness'; the experience of 'the door or a shield' against people entering, for privacy, for enabling a focus within, and for regulating socialising and the; 'window of opportunity'. Findings showed that the construction and design of space and place was strongly influential on the developing parent-infant relationship and for experiencing a sense of connectedness and a shared awareness with the baby during feeding, an attuned feeding.Conclusions: If our proposed model is valid, it is vital that these findings are considered when developing or reconfiguring NICUs so that account is taken of the influences of spatiality upon parent's experiences. Even without redesign there are measures that may be taken to make a positive difference for parents and their preterm babies. [ABSTRACT FROM AUTHOR]

Background: In England, there is a policy of offering healthy women with straightforward pregnancies a choice of birth setting. Options may include home or a freestanding midwifery unit (FMU). Transfer rates from these settings are around 20%, and higher for nulliparous women. The duration of transfer is of interest because of the potential for delay in access to specialist care and is also of concern to women. We aimed to estimate the duration of transfer in births planned at home and in FMUs and explore the effects of distance and urgency on duration.Methods: This was a secondary analysis of data collected in a national prospective cohort study including 27,842 'low risk' women with singleton, term, 'booked' pregnancies, planning birth in FMUs or at home in England from April 2008 to April 2010. We described transfer duration using the median and interquartile range, for all transfers and those for reasons defined as potentially urgent or non-urgent, and used cumulative distribution curves to compare transfer duration by urgency. We explored the effect of distance for transfers from FMUs and described outcomes in women giving birth within 60 minutes of transfer.Results: The median overall transfer time, from decision to transfer to first OU assessment, was shorter in transfers from home compared with transfers from FMUs (49 vs 60 minutes; p < 0.001). The median duration of transfers before birth for potentially urgent reasons (home 42 minutes, FMU 50 minutes) was 8-10 minutes shorter compared with transfers for non-urgent reasons. In transfers for potentially urgent reasons, the median overall transfer time from FMUs within 20 km of an OU was 47 minutes, increasing to 55 minutes from FMUs 20-40 km away and 61 minutes in more remote FMUs. In women who gave birth within 60 minutes after transfer, adverse neonatal outcomes occurred in 1-2% of transfers.Conclusions: Transfers from home or FMU commonly take up to 60 minutes from decision to transfer, to first assessment in an OU, even for transfers for potentially urgent reasons. Most transfers are not urgent and emergencies and adverse outcomes are uncommon, but urgent transfer is more likely for nulliparous women. [ABSTRACT FROM AUTHOR]

Background: Asians are at increased risk of morbidity at a lower body mass index (BMI) than European Whites, particularly relating to metabolic risk. UK maternal obesity guidelines use general population BMI criteria to define obesity, which do not represent the risk of morbidity among Asian populations. This study compares incidence of first trimester obesity using Asian-specific and general population BMI criteria. Method: A retrospective epidemiological study of 502,474 births between 1995 and 2007, from 34 maternity units across England. Data analyses included a comparison of trends over time between ethnic groups using Asian-specific and general population BMI criteria. Logistic regression estimated odds ratios for first trimester obesity among ethnic groups following adjustment for population demographics. Results: Black and South Asian women have a higher incidence of first trimester obesity compared with White women. This is most pronounced for Pakistani women following adjustment for population structure (OR 2.19, 95% C.I. 2.08, 2.31). There is a twofold increase in the proportion of South Asian women classified as obese when using the Asian-specific BMI criteria rather than general population BMI criteria. The incidence of obesity among Black women is increasing at the most rapid rate over time (p=0.01). Conclusion: The twofold increase in maternal obesity among South Asians when using Asian-specific BMI criteria highlights inequalities among pregnant women. A large proportion of South Asian women are potentially being wrongly assigned to low risk care using current UK guidelines to classify obesity and determine care requirements. Further research is required to identify if there is any improvement in pregnancy outcomes if Asian-specific BMI criteria are utilised in the clinical management of maternal obesity to ensure the best quality of care is provided for women irrespective of ethnicity. [ABSTRACT FROM AUTHOR]

Background: Midwifery units offer care to women with straightforward pregnancies, but unforeseen complications can arise during labour or soon after birth, necessitating transfer to a hospital obstetric unit. In England, 21% of women planning birth in freestanding midwifery units are transferred; in alongside units, the transfer rate is 26%.There is little high quality contemporary evidence on women's experience of transfer. Methods: We carried out a qualitative interview study, using semi-structured interviews, with women who had been transferred from a midwifery unit (freestanding or alongside) in England up to 12 months prior to interview. Maximum variation sampling was used. Interviews with 30 women took place between March 2009 and March2010. Thematic analysis using constant comparison and exploration of deviant cases was carried out. Results: Most women hoped for or expected a natural birth and did not expect to be transferred. Transfer was disappointing for many; sensitive and supportive care and preparation for the need for transfer helped women adjust to their changing circumstances. A small number of women, often in the context of prolonged labour, described transfer as a relief. For women transferred from freestanding units, the ambulance journey was a "limbo" period. Women wondered, worried or were fearful about what was to come and could be passive participants who felt like they were being "transported" rather than cared for. For many this was a direct contrast with the care they experienced in the midwifery unit. After transfer, most women appreciated the opportunity to talk about their experience to make sense of what happened and help them plan for future pregnancies, but did not necessarily seek this out if it was not offered. Conclusions: Transfer affects a significant minority of women planning birth in midwifery units and is therefore a concern for women and midwives. Transfer is not expected by women, but sensitive care and preparation can help women adjust to changing circumstances. Particular sensitivity around decision-making may be required by midwives caring for women during prolonged labour. Some apparently straightforward changes to practice have the potential to make an important difference to women's experience of ambulance transfer. [ABSTRACT FROM AUTHOR]

Background: The Medical Research Council (MRC) ORACLE trial evaluated the use of co-amoxiclav 375 mg and/or erythromycin 250 mg in women presenting with preterm rupture of membranes (PROM) ORACLE I or in spontaneous preterm labour (SPL) ORACLE II using a factorial design. The results showed that for women with a singleton baby with PROM the prescription of erythromycin is associated with improvements in short term neonatal outcomes, although co-amoxiclav is associated with prolongation of pregnancy, a significantly higher rate of neonatal necrotising enterocolitis was found in these babies. Prescription of erythromycin is now established practice for women with PROM. For women with SPL antibiotics demonstrated no improvements in short term neonatal outcomes and are not recommended treatment. There is evidence that both these conditions are associated with subclinical infection so perinatal antibiotic administration may reduce the risk of later disabilities, including cerebral palsy, although the risk may be increased through exposure to inflammatory cytokines, so assessment of longer term functional and educational outcomes is appropriate. Methods: The MRC ORACLE Children's Study will follow up UK children at age 7 years born to 4809 women with PROM and the 4266 women with SPL enrolled in the earlier ORACLE trials. We will use a parental questionnaire including validated tools to assess disability and behaviour. We will collect the frequency of specific medical conditions: cerebral palsy, epilepsy, respiratory illness including asthma, diabetes, admission to hospital in last year and other diseases, as reported by parents. National standard test results will be collected to assess educational attainment at Key Stage 1 for children in England. Discussion: This study is designed to investigate whether or not peripartum antibiotics improve health and disability for children at 7 years of age. Trial registration: The ORACLE Trial and Children Study is registered in the Current Controlled Trials registry. ISCRTN 52995660 [ABSTRACT FROM AUTHOR]

Background: In the Confidential Enquiry into Maternal Deaths (CEMD) Report, the very high risk of mortality in women who refuse blood transfusions is highlighted. The objectives were to establish current knowledge about, and views of transfusion in our pregnant population and to establish the level of compliance with the set audit standard. Method: Questionnaire survey of 228 women, including both high and low risk pregnancies, attending ante-natal clinic between 2-9 May 2000 at the North Staffordshire Maternity Hospital, Stoke on Trent. Results: The response rate was 100%. Only 43% were aware of the possible need for blood transfusion in pregnancy. If a blood transfusion was required, 92% stated that they would accept a blood transfusion in pregnancy. Four percent stated that they would not accept a transfusion because of religious reasons and risk of infection and the remaining four percent did not declare a reason. Conclusions: This short survey identified that 57% of women were not aware of the possible need for blood transfusion during pregnancy. There is a need for more information to be shared on this subject with all antenatal women. Women who would refuse a transfusion need to be identified at booking and be referred for counselling and a management plan made for pregnancy, labour and delivery. [ABSTRACT FROM AUTHOR]