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Background: Birth environments can help support women through labour and birth. Home-like rooms which encourage active birthing are embraced in midwifery-led settings. However, this is often not reflected in obstetric settings for women with more complex pregnancies. Aim: To investigate the impact of the birth environment for women with complex pregnancies. Methods: This was a mixed-methods systematic review, incorporating qualitative and quantitative research. A literature search was implemented across three databases (Medline, CINAHL, Embase) from the year 2000 to June 2021. Studies were eligible if they were based in an Organisation for Economic Cooperation and Development country and reported on birth environments for women with complex pregnancies. Papers were screened and quality appraised by two researchers independently. Findings: 30,345 records were returned, with 15 articles meeting inclusion criteria. Studies were based in Australia, the UK, and the USA. Participants included women and health professionals. Five main themes arose: Quality of care and experience; Supportive spaces for women; Supportive spaces for midwives; Control of the space; Design issues. Discussion: Women and midwives found the birth environment important in supporting, or failing to support, a positive birth experience. Obstetric environments are complex spaces requiring balance between space for women to mobilise and access birthing aids, with the need for medical teams to have easy access to the woman and equipment in emergencies. Conclusion: Further research is needed investigating different users’ needs from the environment and how safety features can be balanced with comfort to provide high-quality care and positive experiences for women.

Problem: Women in early labour are typically encouraged to delay maternity unit admission, but they may find this challenging without appropriate professional support. Background: Despite pre-pandemic research which identified potential advantages of video-calling in early labour, implementation of such service has not been reported. Aim: To explore mothers’ perspectives on potential use of video-calls during early labour. Methods: A multi-centre descriptive qualitative study was undertaken in UK and Italy. Ethical approval was gained and ethical processes were followed. Six virtual focus groups were conducted with 37 participants, 24 mothers who gave birth in the UK and 13 who gave birth in Italy. Line-by-line thematic analysis was performed and themes agreed. Findings: Two themes emerged: 1) women's expectations of video-calls’ content and features; 2) technological challenges and solutions. Mothers responded positively to the concept of video-calling in early labour. Receiving guidance, information on coping with pain and advice on timely access in early labour was perceived as key. Women highlighted the importance of accessible, reliable and user-friendly technology. Equitable access, technological literacy, acceptability and privacy were considered as challenges to implementation, with solutions proposed to overcome disparities. Discussion and conclusion: Guidance and training should be provided to midwives, with designated resources to build a service that is accessible, acceptable, safe, individualised and respectful for mothers and birth companions. Further research should explore feasibility, acceptability, clinical and cost-effectiveness.

IntroductionMany women experience symptoms during pregnancy. Elevated and prolonged anxiety can have negative effects on the woman and baby. The RAPID intervention aims to provide suitable, timely support for women with mild-moderate anxiety. The RAPID intervention is based on social support, relational continuity, psychological and relaxation response theory, and comprises midwife facilitated group discussions, one-to-one support and directed self-help materials.Methods and analysisFour National Health Service Trusts in England that provide maternity care will be cluster randomised to the RAPID intervention plus usual care or usual care. At each intervention site, two midwives and two maternity support workers will facilitate the intervention over a 12-week period. Eligibility includes nulliparous women at 16–20 weeks of pregnancy (n=50) with self-report symptoms of mild-moderate anxiety. Community midwives will signpost women to the study. The aim of the study is to establish the feasibility of conducting a definitive trial to examine the effectiveness of the RAPID intervention in addition to usual care. The objectives are to assess recruitment and completion rates, and a qualitative assessment of women’s and facilitators’ experiences of participation. An estimation of change in the seven-item Generalised Anxiety Disorder scale will inform the sample size for a definitive cluster trial.Ethics and disseminationEthical approval was given by East Midlands—Derby Research Ethics Committee 14 March 2022 (REC Reference: 22/EM/0018). Findings will be made available through publication in peer-reviewed journals, conferences and to participants. A final report will be submitted to HEE/NIHR ICA awards committee for publication.Trial registration numberISRCTN12834758.

Compassion in nursing and interventions to support it are of international relevance and concern. Prior care experience as a prerequisite for entry into pre-registration nurse education is suggested as a means of improving compassion. The impact of prior care experience has not been comprehensively reviewed, therefore the potential effectiveness of prior care experience as a means of improving compassion is unknown. The scoping review question was 'What is known about the impact of care experience prior to commencing pre-registration nurse education and training?' The primary objective was to scope and synthesise existing literature relating to the topic and ascertain key themes pertaining to impact. A secondary objective was to appraise literature, to contextualise findings and assess the state and stage of knowledge and research in the area.The review was guided by Arksey and O'Malley's methodological framework and is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews Checklist.Health sciences databases CINAHL, Medline and PubMed.Databases were searched in February 2019, updated August 2021. Data (study characteristics, findings, methodological observations) were extracted from papers meeting inclusion criteria (including peer-reviewed empirical papers with English language, electronic full-text available) and findings thematically analysed.Forty-five papers from 14 countries were included. The majority (64.4 %) were published in Europe (31.1 % in the United Kingdom) between 2010 and 2021 (69 %), 60 % from 2013. Four qualitative themes (compassionate care, commitment, competence and communication) describe the impact of prior care experience, which was variable.Evidence to support the effectiveness of prior care experience as a prerequisite for entry into nurse education to improve compassion, is inconsistent and insufficient. The literature displays methodological limitations and conclusions should be interpreted in light of these caveats. Recommendations are made for future research, to improve quality and comparability.

© 2020 John Wiley & Sons Ltd Aims: To evaluate the effectiveness of non-pharmacological non-invasive supportive interventions for impacts on women's comfort and well-being during induction of labour. Design: A quantitative systematic review without meta-analysis. Data Sources: Databases were searched for primary research published in English between 2000–2019: AMED, CINAHL, Medline, Maternity and Infant Care database, PsycINFO, and ProQuest. The quality of studies was evaluated using JBI levels of evidence and established critical appraisal tools. Studies describing measures of comfort, coping, and well-being for women during induction of labour were included. Results: Two articles met the criteria for inclusion. There is limited evidence to suggest that women having outpatient cervical priming were more satisfied with their experience than women having inpatient cervical priming and that outpatient cervical priming did not increase women's anxiety. A specifically designed information brochure explaining the induction process improved women's knowledge and understanding. Review Methods: The quantitative systematic review followed the Centre for Reviews and Dissemination guidelines and Cochrane Effective Practice and Organisation of Care guidance. Quality appraisal was conducted using JBI levels of evidence, Cochrane Risk of Bias, and other established tools. A narrative description of the quantitative data was undertaken. There was insufficient evidence to perform a narrative synthesis or meta-analysis due to the nature of the study designs and insufficient outcome data. Conclusions: Globally, the number of women having an induction of labour is increasing and there is a lack of evidence on the effectiveness of supportive interventions. Components of supportive care for women having induction of labour require urgent evaluation. Measurement tools which capture the complexity of supportive care for women having induction of labour need to be developed and validated. Impact: This is the first review to evaluate non-pharmacological, non-invasive supportive interventions for women having induction of labour. The findings of this review identify the urgent need to develop an evidence base for effective supportive.

To investigate childbearing women's views, experiences and decision-making related to epidural analgesia in labour.Mixed-methods systematic review.A comprehensive literature search was implemented across Medline, CINAHL and EMBASE from 2000 to September 2018. The literature search was undertaken in January 2018 and updated in September 2018. Thirty papers were selected.Four overarching synthesized findings were identified: (a) choice; (b) pain management experience; (c) lack of information; and (d) information provision and consent.Quality appraisal was conducted using JBI levels of evidence and other established tools. NVivo was used to independently dual code and thematically synthesize qualitative data. A narrative synthesis of the quantitative findings from the included studies was undertaken. The GRADE-CERQual approach was used to assess confidence in the review findings based on the qualitative data. A set of integrated mixed-methods synthesized findings was produced.Recommendations for practice based on the systematic review findings are that midwives should dedicate time to discuss epidural with women and birth partners, ideally during the second or third trimester of pregnancy, asking women what coping strategies or pain relief they have been considering, if any. The factors which may influence the woman's choice of epidural, including pain threshold, ability to cope with pain, timing of epidural and length of labour should be continuously evaluated during labour. The midwife should remain with women after an epidural has been sited, demonstrating understanding of the woman's choice and providing an opportunity for discussion of plans for the remaining labour and birth.The findings of this systematic review can inform both healthcare professionals and service users on various aspects of the decision-making process about the use of epidural analgesia in labour. Data can be transferable to similar settings in high-income countries.目的: 调查育龄妇女对分娩时硬膜外镇痛的看法、经验和决策。 设计: 混合法系统评价。 数据来源: 2000年至2018年9月期间,在数据库Medline、CINAHL和EMBASE上实施了全面的文献检索。文献检索于2018年1月进行,2018年9月更新。选取了30篇论文。 结果: 确定了四项主要综合调查结果:(a)选择;(b)疼痛管理经验;(c)缺乏信息;以及(d)信息提供和同意。 审查方法: 利用JBI证据等级和其他既定工具进行质量评价。使用NVivo分析软件对定性数据进行独立的对偶码和主题综合。对纳入的研究中的定量结果进行了叙述性综合。采用GRADE-CERQual方法评估基于定性数据的审查结果的置信水平。编制了一套综合的混合法综合调查结果。 结论: 根据系统评价调查结果提出的实践建议是,助产士应专门抽出时间与妇女和分娩陪护人员讨论硬膜外麻醉,最好是在怀孕的第二个月或第三个月,询问产妇一直考虑的应对策略或疼痛减轻措施(如有)。在分娩过程中应持续评估可能影响产妇选择硬膜外镇痛的因素,包括疼痛阈值、应对疼痛的能力、硬膜外镇痛时间和分娩时间。在硬膜外麻醉已到位后,助产士应继续陪在产妇身边,对产妇的选择表示理解,并提供机会讨论后续分娩和生产计划。 影响: 本系统评价的调查结果可以为医疗保健专业人员和服务用户提供关于分娩时使用硬膜外镇痛的决策过程的各个方面的信息。在高收入国家的类似环境中,此类数据亦可转用。.

Objectives: To explore and understand perspectives of women expecting their first child and why they wanted to attend NHS antenatal education. This included what worries and concerns they wanted to be addressed and why this would be beneficial. It also included what they wanted their partners to be able to gain from attending classes. Design: A longitudinal qualitative study using Template Analysis was undertaken with data collection during pregnancy and postpartum. A semi-structured topic guide was used to guide data collection, either via focus groups or one to one interviews which were audio recorded and transcribed. Setting: National Health Service Trusts providing maternity services to women for labour and birth, purposively selected to allow the perspectives of specific groups of women to be included. Participants: Women expecting their first child from one of three groups: Women from the general population aged 20 years or more, women from ethnic minority groups and young women aged 16 to 19 years. Findings: Eighty-two pregnant women participated. Three substantive themes are reported: the search for information, the functions of antenatal classes, and the specific information desired. Women wanted to attend NHS antenatal education to access trustworthy information that would reassure, increase confidence, and help them feel prepared. Women wanted to meet others in the same situation to help normalise concerns and offer the potential for ongoing relationships. Classes were seen as a way to help partners engage more fully with the transition to parenthood. Specific information required and shared by all groups was around understanding the stages of labour, managing labour, and common interventions. Conclusions: Access to a wide range of information increases women's anxieties about labour that women want addressed through antenatal education. However, antenatal classes serve broader functions beyond information- giving and women anticipate that attending antenatal classes will address both their own and their partners’ needs. Implications: Service providers should ensure their antenatal education provision provides the information required and is structured in a way that enables women to develop relationships and supports partners’ engagement in the transition to parenthood.

Background Symptoms of anxiety are common in pregnancy, with severe symptoms associated with negative outcomes for women and babies. Low-level psychological therapy is recommended for women with mild to moderate anxiety, with the aim of preventing an escalation of symptoms and providing coping strategies. Remotely delivered interventions have been suggested to improve access to treatment and support and provide a cost-effective, flexible, and timely solution. Objective This study identifies and evaluates remotely delivered, digital, or web-based interventions to support women with symptoms of anxiety during pregnancy. Methods This mixed methods systematic review followed a convergent segregated approach to synthesize qualitative and quantitative data. The ACM Digital Library, Allied and Complementary Medicine Database, Applied Social Sciences Index and Abstracts, Centre for Reviews and Dissemination database, the Cochrane Central Register of Controlled Trials, the Cochrane Library, CINAHL, Embase, Health Technology Assessment Library, IEEE Xplore, Joanna Briggs Institute, Maternity and Infant Care, MEDLINE, PsycINFO, and the Social Science Citation Index were searched in October 2020. Quantitative or qualitative primary research that included pregnant women and evaluated remotely delivered interventions reporting measures of anxiety, fear, stress, distress, women’s views, and opinions were included. Results Overall, 3 qualitative studies and 14 quantitative studies were included. Populations included a general antenatal population and pregnant women having anxiety and depression, fear of childbirth, insomnia, and preterm labor. Interventions included cognitive behavioral therapy, problem solving, mindfulness, and educational designs. Most interventions were delivered via web-based platforms, and 62% (8/13) included direct contact from trained therapists or coaches. A meta-analysis of the quantitative data found internet-based cognitive behavioral therapy and facilitated interventions showed a beneficial effect in relation to the reduction of anxiety scores (standardized mean difference −0.49, 95% CI −0.75 to −0.22; standardized mean difference −0.48, 95% CI −0.75 to −0.22). Due to limitations in the amount of available data and study quality, the findings should be interpreted with caution. Synthesized findings found some evidence to suggest that interventions are more effective when women maintain regular participation which may be enhanced by providing regular contact with therapists or peer support, appropriate targeting of interventions involving components of relaxation and cognitive-based skills, and providing sufficient sessions to develop new skills without being too time consuming. Conclusions There is limited evidence to suggest that women who are pregnant may benefit from remotely delivered interventions. Components of interventions that may improve the effectiveness and acceptability of remotely delivered interventions included providing web-based contact with a therapist, health care professional, or peer community. Women may be more motivated to complete interventions that are perceived as relevant or tailored to their needs. Remote interventions may also provide women with greater anonymity to help them feel more confident in disclosing their symptoms.

Background Internet-based research is increasing in popularity, but concerns remain about ethical issues and guidance is sparse in relation to generating data using online forums. Aim To describe and discuss ethical considerations concerning the collecting of data through online forums by using the authors' research exploring women's views and experiences of birth plans. Discussion Using online discussion forums helped to generate data rapidly. However, ethical concerns required attention throughout the study. The authors engage with debates about the public/private nature of online research, the complexities of ensuring consent in this context is informed, and questions about anonymity and confidentiality, where data are traceable and identifiable through search engines. Conclusion Research undertaken using online forums generates ethical issues similar to those seen in 'real world' studies. Implications for practice Researchers need to explore how the designs of their studies are affected by issues such as ensuring informed consent and mitigating for the publicly viewable and searchable nature of the data obtained.

To assess women’s views on the acceptability of and satisfaction with non-pharmacological interventions to reduce the symptoms of anxiety in pregnant women. A systematic review and narrative synthesis (Prospero protocol number CRD42015017841). Fourteen included studies were conducted in Australia, Canada, Germany, New Zealand, UK and USA. Interventions were cognitive behavioural therapy, mindfulness, yoga, psychological assessment, supportive and educational based interventions. Studies included women from general antenatal populations and women with anxiety or depression symptoms or risk factors for anxiety or depression. The findings were limited due to the small number of studies evaluating different types of interventions using various study methods. Some studies had too little procedural reporting to allow a full quality assessment. Women’s views on the acceptability of and satisfaction with interventions were overwhelmingly positive. The review highlights women’s motivations for and barriers to participation as well as the benefit women perceived from peer support and individual discussions of their situation. Interventions need to be further evaluated in randomised controlled trials. The inclusion of women’s views and experiences illuminates how and why intervention components contribute to outcomes. Women’s initial concerns about psychological screening and the benefit derived from peer support and individual discussion should be noted by providers of maternity care.

The purpose of this project was to identify gaps in the current evidence base and to identify research priorities in the local context during the Covid-19 pandemic. This paper reports on the application and adaptation of the CHNRI methodology which follows a series of criteria setting, filtering and scoring exercises. The views of maternity care professionals, midwifery managers and leaders, women and families were continually sought throughout the project stages. We found the CHNRI methodology to be a useful framework to highlight topics with greater or smaller consensus within a relatively short time frame and with minimal burden to participants. The criteria were defined to focus on research topics where no existing or on-going studies were identified and topics likely to lead to improvements in care with relevance beyond the Covid-19 pandemic.

BACKGROUND Symptoms of anxiety are common in pregnancy, with severe symptoms associated with negative outcomes for women and babies. Low-level psychological therapy is recommended for women with mild to moderate anxiety, with the aim of preventing an escalation of symptoms and providing coping strategies. Remotely delivered interventions have been suggested to improve access to treatment and support and provide a cost-effective, flexible, and timely solution. OBJECTIVE This study identifies and evaluates remotely delivered, digital, or web-based interventions to support women with symptoms of anxiety during pregnancy. METHODS This mixed methods systematic review followed a convergent segregated approach to synthesize qualitative and quantitative data. The ACM Digital Library, Allied and Complementary Medicine Database, Applied Social Sciences Index and Abstracts, Centre for Reviews and Dissemination database, the Cochrane Central Register of Controlled Trials, the Cochrane Library, CINAHL, Embase, Health Technology Assessment Library, IEEE Xplore, Joanna Briggs Institute, Maternity and Infant Care, MEDLINE, PsycINFO, and the Social Science Citation Index were searched in October 2020. Quantitative or qualitative primary research that included pregnant women and evaluated remotely delivered interventions reporting measures of anxiety, fear, stress, distress, women’s views, and opinions were included. RESULTS Overall, 3 qualitative studies and 14 quantitative studies were included. Populations included a general antenatal population and pregnant women having anxiety and depression, fear of childbirth, insomnia, and preterm labor. Interventions included cognitive behavioral therapy, problem solving, mindfulness, and educational designs. Most interventions were delivered via web-based platforms, and 62% (8/13) included direct contact from trained therapists or coaches. A meta-analysis of the quantitative data found internet-based cognitive behavioral therapy and facilitated interventions showed a beneficial effect in relation to the reduction of anxiety scores (standardized mean difference −0.49, 95% CI −0.75 to −0.22; standardized mean difference −0.48, 95% CI −0.75 to −0.22). Due to limitations in the amount of available data and study quality, the findings should be interpreted with caution. Synthesized findings found some evidence to suggest that interventions are more effective when women maintain regular participation which may be enhanced by providing regular contact with therapists or peer support, appropriate targeting of interventions involving components of relaxation and cognitive-based skills, and providing sufficient sessions to develop new skills without being too time consuming. CONCLUSIONS There is limited evidence to suggest that women who are pregnant may benefit from remotely delivered interventions. Components of interventions that may improve the effectiveness and acceptability of remotely delivered interventions included providing web-based contact with a therapist, health care professional, or peer community. Women may be more motivated to complete interventions that are perceived as relevant or tailored to their needs. Remote interventions may also provide women with greater anonymity to help them feel more confident in disclosing their symptoms. CLINICALTRIAL

Iron deficiency and anaemia are global health problems and major causes of morbidity in women. Current definitions of anaemia in women are historic and have been challenged by recent data from observational studies. Menstrual loss, abnormal uterine bleeding and pregnancy put women at risk of developing iron deficiency which can result in severe fatigue, reduced exercise capacity and poor work performance. Iron deficiency and anaemia during pregnancy are associated with adverse maternal and fetal outcomes, including neurocognitive deficits in children born to iron-deficient mothers. Both iron deficiency and anaemia are common in women undergoing surgery but their association with poor outcomes remains uncertain. The enduring burden of iron deficiency and anaemia in women suggests that current strategies for recognition, prevention and treatment are limited in their utility. Improvements in our understanding of iron homeostasis and the development of new iron preparations, which are better absorbed with fewer side-effects, may improve therapeutic effectiveness of oral iron. Intravenous iron is efficacious for correcting anaemia rapidly but high-quality data on patient-centred outcomes and cost-effectiveness are currently lacking. Many recommendations for the treatment of iron deficiency and anaemia in national guidelines are not supported by high-quality evidence. There is a need for robust epidemiological data and well-designed clinical trials. The latter will require collaborative working between researchers and patients to design studies in ways that incorporate patients' perspectives on the research process and target outcomes that matter to them.

Objectives To investigate midwifery students’ experiences of viewing childbirth on mainstream factual television and to explore implications for student career intentions and potential pedagogical uses of television excerpts in midwifery education. Design Twenty-two undergraduate midwifery students at one of two universities took place in focus groups between February and June 2019. Ethical approval was obtained at both sites. Thematic analysis was employed to generate key themes from the data. Setting Two UK universities based in the East Midlands and East Yorkshire regions of England. Participants Twenty-two midwifery students at any stage of their studies. Findings Researchers generated four key themes from the data a) Changed Perspectives on Televised Childbirth, b) Representations of Midwives and Social Implications, c) Representation of Childbirth and Social Implications and d) The Role of Televising Childbirth in Midwifery Education. Key conclusions Midwifery students often experience a change of perspective on birth on television as they acquire new knowledge and skills. They recognise the potential social implications of how childbirth and midwifery are represented on television. Pedagogical use of televised birth has potential benefits but needs further investigation in the context of midwifery education. Implications for practice Midwifery students are likely to begin their studies with pre-existing views and experiences around how birth is represented on mainstream factual television. They may need support to reflect on these to consider their expectations of the profession, to effectively support childbearing women and to potentially influence future production of media images of childbirth.

Background To design and develop an intervention to support women with symptoms of mild to moderate anxiety in pregnancy. Methods The development followed the MRC framework for complex interventions, utilising psychological theory, review level evidence and professional and public involvement. Two systematic reviews were completed which helped identify potentially beneficial intervention components. The theory underpinning the components was explored to consider the potential benefit for women with mild to moderate anxiety symptoms in pregnancy. Methods of delivering the intervention within maternity services were explored. The intervention comprised: group discussions, one to one support and assisted self-help resources. Midwives were identified as ideally placed to facilitate the intervention supported by midwifery support workers. A bespoke training package was provided by subject experts to prepare the facilitators. Results The absence of established interventions and a paucity of evidence based approaches for pregnant women with symptoms of mild to moderate anxiety indicated the need for a rigorous and systematic approach to the intervention design. This approach led to the development of an intervention feasible for implementation in maternity care systems tailored to the needs of pregnant women. The involvement of a multi-professional advisory team and active engagement of service users helped to consider the acceptability of the intervention for women and the feasibility of delivering the intervention in the context of maternity care. Conclusion The MRC Framework provided useful overarching guidance to develop a midwife facilitated intervention for women with symptoms of anxiety in pregnancy. The framework assisted the development of a robust rationale for each intervention component and considered the processes of evaluation and implementation into maternity care systems.

Original article http://dx.doi.org/10.1136/bmjopen-2019-033895 In the fourth and final instalment of this series, this article focuses on our research exploring the barriers and facilitators affecting midwifery units (MUs) in England. We conclude that they are still not available in about 25% of hospitals, and where they are available, they are underused. After 10 years of good-quality evidence supporting them as the preferred option for low-risk women, MUs are still not viewed as an equal and complementary provision alongside the traditional labour ward. Based on findings from our research, this article discusses why and what can be done about it.

The rapid development of COVID-19 has completely altered the context of health care across the UK and around the world. The speed and severity of the pandemic has taken us all by surprise, priorities have shifted and the balance of risks has changed. Things that seemed to be of the greatest importance only a few weeks ago have been swept away. Practice environments have changed almost beyond recognition, especially in hospitals, and a heightened sense of urgency and even fear can, understandably, predominate. The public health and medical imperative is such that there is a perception that the needs, preferences and decisions of childbearing women and even their rights and those of their babies are less important or even irrelevant (Birthrights, 2020). At such a time of rapidly changing priorities and heightened awareness of risk, and despite the overwhelming sense of crisis, a focus on evidence is essential to inform decision-making and to avoid harm. Making swift, if well intentioned, changes without evidence of effectiveness may lead to unanticipated consequences which could seriously compromise the quality of care and outcomes. Maternity workload pressures have increased as a result of the pandemic. Staff have had to self-isolate to protect their own health or when family members are infected. The priority of keeping women and babies – and staff - safe in a pandemic means that we must have the ability to balance the restrictions required to control the spread of infection with the essential, evidence-informed principles of safe, effective, equitable, respectful, kind and compassionate care (Renfrew et al., 2014). Is this a dilemma? No, there must be no trade-off between protecting the health and wellbeing of midwives and other health workers, and the rights of women and babies. Both are imperative. If we fail there is a real risk that the safety and rights of women and babies will be seriously compromised (Human Rights Watch, 2020; International Confederation of Midwives, 2020a; International Confederation of Midwives, 2020b). In this paper we reflect on the immediate response of the maternity services in the UK to the coronavirus pandemic, and the evidence-informed developments that are now emerging (May 2020). We propose a way forward that includes seeking the views of women themselves and their families and the staff who care for them in designing safe and sustainable maternity and neonatal services in the context of coronavirus, recognising that the impact of COVID-19 will last for some years. We present a set of core principles that should be at the heart of care planning and delivery both during and after the pandemic.

Objectives To test whether providing psychological self‐help materials would significantly lower the incidence of post‐traumatic stress disorder (PTSD) at 6–12 weeks postnatally. Design Open‐label randomised controlled trial, with blinded outcome assessment. Setting Community midwifery services in two National Health Service (NHS) trusts in the North West. Sample A cohort of 2419 women receiving normal NHS postnatal care. Methods Midwives screened women for traumatic birth experience; 678 women who screened positively (28.1%) were randomly allocated to self‐help with usual care (n = 336) or to usual care alone (n = 342). The self‐help materials were a leaflet and online film designed to prevent the development of PTSD after trauma exposure through explaining how to manage early psychological responses. Main outcome measure The primary outcome was a composite of diagnostic and subdiagnostic PTSD at 6–12 weeks postnatally using the gold‐standard Clinician‐Administered PTSD Scale (CAPS‐5) interview. Results Of the 678 women correctly randomised plus the nine women randomised in error, 478 (70.5%) were followed up. Diagnostic or subdiagnostic PTSD rates at follow‐up did not differ between groups who received self‐help (26.7%, 65/243) or usual care alone (26.2%, 64/244) (intention‐to‐treat analysis: RR 1.02, 95% CI 0.68–1.53). Findings remained consistent in the per‐protocol analysis (RR 1.04, 95% CI 0.85–1.27). Women viewed the materials very positively. There were no adverse effects. Health economic micro‐costing indicated implementation would be very low cost. Conclusions Many women experience a traumatic birth and risk developing PTSD, but self‐help strategies without professional support are insufficient and should not be routinely introduced. Tweetable abstract Self‐help information alone does not reduce the number of women developing PTSD after a traumatic childbirth.

Background Midwifery-led units (MUs) are recommended for ‘low-risk’ births by the National Institute for Health and Care Excellence but according to the National Audit Office were not available in one-quarter of trusts in England in 2013 and, when available, were used by only a minority of the low-risk women for whom they should be suitable. This study explores why. Objectives To map the provision of MUs in England and explore barriers to and facilitators of their development and use; and to ascertain stakeholder views of interventions to address these barriers and facilitators. Design Mixed methods – first, MU access and utilisation across England was mapped; second, local media coverage of the closure of free-standing midwifery units (FMUs) were analysed; third, case studies were undertaken in six sites to explore the barriers and facilitators that have an impact on the development of MUs; and, fourth, by convening a stakeholder workshop, interventions to address the barriers and facilitators were discussed. Setting English NHS maternity services. Participants All trusts with maternity services. Interventions Establishing MUs. Main outcome measures Numbers and types of MUs and utilisation of MUs. Results Births in MUs across England have nearly tripled since 2011, to 15% of all births. However, this increase has occurred almost exclusively in alongside units, numbers of which have doubled. Births in FMUs have stayed the same and these units are more susceptible to closure. One-quarter of trusts in England have no MUs; in those that do, nearly all MUs are underutilised. The study findings indicate that most trust managers, senior midwifery managers and obstetricians do not regard their MU provision as being as important as their obstetric-led unit provision and therefore it does not get embedded as an equal and parallel component in the trust’s overall maternity package of care. The analysis illuminates how provision and utilisation are influenced by a complex range of factors, including the medicalisation of childbirth, financial constraints and institutional norms protecting the status quo. Limitations When undertaking the case studies, we were unable to achieve representativeness across social class in the women’s focus groups and struggled to recruit finance directors for individual interviews. This may affect the transferability of our findings. Conclusions Although there has been an increase in the numbers and utilisation of MUs since 2011, significant obstacles remain to MUs reaching their full potential, especially FMUs. This includes the capacity and willingness of providers to address women’s information needs. If these remain unaddressed at commissioner and provider level, childbearing women’s access to MUs will continue to be restricted. Future work Work is needed on optimum approaches to improve decision-makers’ understanding and use of clinical and economic evidence in service design. Increasing women’s access to information about MUs requires further studies of professionals’ understanding and communication of evidence. The role of FMUs in the context of rural populations needs further evaluation to take into account user and community impact. Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 12. See the NIHR Journals Library website for further project information.

Background Contemporary higher education requires that all midwifery students have insight and understanding of global health practice and demonstrate intercultural sensitivity. However, the mobility models currently offered do not often fit the lives of large numbers of midwifery students. Objectives To investigate midwifery students' international physical mobility activities and factors that affect mobility; to determine midwifery students' learning needs and preferences for related e-learning packages. Design Multi-centre, descriptive quantitative survey. Settings Four European Higher Education Institutions based in the United Kingdom, Estonia, Italy and the Netherlands offering an undergraduate midwifery programme. Participants The sample included 205 midwifery students from Italy (n = 93), the Netherlands (n = 51); United Kingdom (n = 35) and Estonia (n = 26). Methods Data were collected in June–July 2020 through an online cross-sectional, bespoke questionnaire and analysed using summary statistical analysis. Results There is a high level of interest across a range of mobility opportunities, especially those of shorter duration. Barriers to mobility comprised finance, caring responsibilities, concerns about fitting mobility activities into the midwifery programme, negative impact on studies and language barriers. The most frequently identified facilitators of mobility included professional perspectives such as interest in other cultures and midwifery in other settings and an endorsement that mobility would add value to their development as a midwife. When engaging in virtual learning, the most preferred resources mentioned by the students were videos, video calls with peers, choice quiz and discussion forum. Conclusions The barriers identified require new approaches to enable all midwifery students to benefit from transnational learning. The survey findings provide insights into midwifery students' perspectives from which a new mobility model can be developed.

Aims and objectives: To examine how the concept of compassion is socially constructed within UK discourse, in response to recommendations that aspiring nurses gain care experience prior to entering nurse education. Background: Following a report of significant failings in care, the UK government proposed prior care experience for aspiring nurses as a strategy to enhance compassion amongst the profession. Media reporting of this generated substantial online discussion, which formed the data for this research. There is a need to define how compassion is constructed through language as a limited understanding exists, of what compassion means in healthcare. This is important, for any meaningful evaluation of quality, compassionate practices. Design: A corpus‐informed discourse analysis. Methods: A 62626‐word corpus of data was analysed using Laurence Anthony software ‘AntCon’, a free corpus analysis toolkit. Frequent words were retrieved and used as a focal point for further analysis. Concordance lines were computed and analysed in the context of which frequent word‐types occurred. Patterns of language were revealed and interpreted through researcher immersion. Results: Findings identified that compassion was frequently described in various ways as a natural characteristic attribute. A pattern of language also referred to compassion as something that was not able to be taught, but could be developed through the repetition of behaviours observed in practice learning. In the context of compassion, the word‐type ‘nurse’ was used positively. Conclusion: This paper adds to important debates highlighting how compassion is constructed and defined in the context of nursing. Compassion is constructed as both an individual, personal trait and a professional behaviour to be learnt. Educational design could include effective interpersonal skills training, which may help enhance and develop compassion from within the nursing profession. Likewise, ways of thinking, behaving and communicating should also be addressed by established practitioners in order to maintain compassionate interactions between professionals as well as nurse‐patient relationships. Future research should focus on how compassionate practice is defined by both health professionals and patients. Relevance to clinical practice: In order to maintain nursing as an attractive profession to join, it is important that nurses are viewed as compassionate. This holds implications for professional morale, associated with the continued retention and recruitment of the future workforce. Existing ideologies within the practice placement, the prior care experience environment, as well as the educational and organisational design are crucial factors to consider, in terms of their influences on the expression of compassion in practice.

Background: Over recent years there has been criticism within the United Kingdom’s health service regarding a lack of care and compassion, resulting in adverse outcomes for patients. The impact of emotional intelligence in staff on patient health care outcomes has been recently highlighted. Many recruiters now assess emotional intelligence as part of their selection process for health care staff. However, it has been argued that the importance of emotional intelligence in health care has been overestimated.\ud Objectives: To explore relationships between emotional intelligence in health care professionals, and caring behaviour. To further explore any additional factors related to emotional intelligence that may impact upon caring behaviour.\ud Design: An integrative review design was used.\ud Data sources: Psychinfo, Medline, CINAHL Plus, Social Sciences Citation Index, Science Citation Index, and Scopus were searched for studies from 1995 to April 2017.\ud Review methods: Studies providing quantitative or qualitative exploration of how any healthcare professionals’ emotional intelligence is linked to caring in healthcare settings were selected.\ud Results: Twenty two studies fulfilled the inclusion criteria. Three main types of health care professional were identified: nurses, nurse leaders, and physicians. Results indicated that the emotional intelligence of nurses was related to both physical and emotional caring, but emotional intelligence may be less relevant for nurse leaders and physicians. Age, experience, burnout, and job satisfaction may also be relevant factors for both caring and emotional intelligence.\ud Conclusions: This review provides evidence that developing emotional intelligence in nurses may positively impact upon certain caring behaviours, and that there may be differences within groups that warrant further investigation. Understanding more about which aspects of emotional intelligence are most relevant for intervention is important, and directions for further large scale research have been identified.

Aim To assess the effectiveness of non-pharmacological interventions for pregnant women with symptoms of mild to moderate anxiety. Background Many pregnant women experience mild to moderate symptoms of anxiety and could benefit from additional support. Non-pharmacological interventions have been suggested for use during pregnancy. Design A systematic review of randomized controlled trials. Data sources Randomized controlled trials published since 1990, identified from electronic databases: Medline; CINAHL; Maternity and Infant Care; PsycINFO; Cochrane Database of Systematic Reviews; CENTRAL; EMBASE; Centre for Reviews and Dissemination; Social Sciences Citation Index; ASSIA; HTA Library; Joanna Briggs Institute Evidence-Based Practice database; Allied and Complementary Medicine. Review methods Conducted according to the Centre for Reviews and Dissemination procedure. Papers were screened (N = 5,222), assessed for eligibility (N = 57) and selected for inclusion (N = 25). The Cochrane Collaboration's tool for assessing risk of bias was used. Papers were assessed for clinical and statistical heterogeneity and considered for meta-analysis. Descriptive analysis of the data was conducted. Results Psychological, mind-body, educational and supportive interventions were delivered individually and to groups of pregnant women over single or multiple sessions. The State-Trait Anxiety Inventory was the most commonly used anxiety measure. In 60% of studies there were fewer than 40 participants. Meta-analysis of three studies indicated no observed beneficial effect in the reduction of anxiety. Conclusion There was insufficient evidence from which to draw overall conclusions regarding the benefit of interventions. Results were predominantly based on small samples. Many papers provided an inadequate description of methods which prevented a full assessment of methodological quality.

Background Early labour care presents a challenge for maternity services and is a cause of dissatisfaction for women planning birth in an obstetric or midwifery unit who may feel unsupported or unwelcome at their planned place of birth. Little is known about the perspectives of men who support their partner during early labour. Methods Opportunity sample offathers (n = 12) in the UK who had been present during their partner’s labour in the previous twelve months. Semi-structured interviews were audio-recorded and transcribed before thematic analysis. Results Fathers learned about the stages of labour during antenatal education and felt well prepared for early labour but found their knowledge difficult to apply, and relied on their partners to decide when to travel to the planned place of birth. Early labour was described as the ‘calm before the storm’ during which they carried out practical tasks or rested to ensure they could fulfil their role when labour progressed. However, men frequently felt ‘like a spare part’ during the later stages of labour. Discussion The study has implications for antenatal educators, midwives and others supporting couples during pregnancy and labour. It supports reconsideration of how information about labour progress can be most usefully conveyed to couples. Professionals could acknowledge the value of supportive tasks carried out by fathers that might otherwise be experienced as doing ‘nothing’. Further research should recruit more diverse samples of men and same-sex couples. Dyadic data collection methods may be of value.

OBJECTIVE: To describe and summarize the current body of evidence on the subject of birth plans to develop a research agenda.METHOD: A narrative review was undertaken to offer a comprehensive overview of themes emerging from previous research in this area.FINDINGS: Thirty-five papers from 33 studies were retrieved and grouped into three main themes: the impact of birth plans on obstetric outcomes, women’s experiences and opinions of completing and using birth plans, and health care professionals’ beliefs about and experiences of the use of birth plans. Key findings relate to beliefs about the benefits and challenges of birth plans, as described by women and health care professionals and the impact of birth plans on a range of obstetric outcomes.CONCLUSION: This review brings together a range of studies around birth plans and synthesizes key themes. Little homogeneity was seen in the studies identified, and a wide variety of care contexts and childbirth philosophies were represented. Findings suggest the need for further research into whether there are ideal circumstances and environments for the completion of birth plans antenatally and whether disparities between expectations described in women’s plans and experiences in labor and birth can be reduced.

Objective To explore and synthesise evidence of women's information needs, decision-making and experiences of membrane sweeping to promote spontaneous labour. Design A systematic review following the Joanna Briggs Institute (JBI) meta-aggregative approach to qualitative evidence synthesis. Relevant databases were searched for literature published in English between 2000–19. Study quality was assessed using the JBI quality assessment tool for qualitative studies. Setting Qualitative research conducted in OECD countries describing women's information needs, decision-making and/or experiences of membrane sweeping to promote spontaneous labour. Findings One article met the criteria for inclusion. This article describes the experience of a membrane sweep given without consent. Key conclusions and Implications for practice There is a lack of evidence around women's information needs, decision-making and experiences of membrane sweeping. This is concerning, especially in the context of rising rates of formal induction of labour. Further research is needed to investigate how women are being offered membrane sweeping and what information women need to make informed choices about membrane sweeping to promote spontaneous labour.

ObjectiveTo identify factors influencing the provision, utilisation and sustainability of midwifery units (MUs) in England.DesignCase studies, using individual interviews and focus groups, in six National Health Service (NHS) Trust maternity services in England.Setting and participantsNHS maternity services in different geographical areas of England Maternity care staff and service users from six NHS Trusts: two Trusts where more than 20% of all women gave birth in MUs, two Trusts where less than 10% of all women gave birth in MUs and two Trusts without MUs. Obstetric, midwifery and neonatal clinical leaders, managers, service user representatives and commissioners were individually interviewed (n=57). Twenty-six focus groups were undertaken with midwives (n=60) and service users (n=52).Main outcome measuresFactors influencing MU use.FindingsThe study findings identify several barriers to the uptake of MUs. Within a context of a history of obstetric-led provision and lack of decision-maker awareness of the clinical and economic evidence, most Trust managers and clinicians do not regard their MU provision as being as important as their obstetric unit (OU) provision. Therefore, it does not get embedded as an equal and parallel component in the Trust’s overall maternity package of care. The analysis illuminates how implementation of complex interventions in health services is influenced by a range of factors including the medicalisation of childbirth, perceived financial constraints, adequate leadership and institutional norms protecting the status quo.ConclusionsThere are significant obstacles to MUs reaching their full potential, especially free-standing midwifery units. These include the lack of commitment by providers to embed MUs as an essential service provision alongside their OUs, an absence of leadership to drive through these changes and the capacity and willingness of providers to address women’s information needs. If these remain unaddressed, childbearing women’s access to MUs will continue to be restricted.