A qualitative study of the experiences and expectations of women receiving in-patient postnatal care in one English maternity unit

Background Studies consistently highlight in-patient postnatal care as the area of maternity care women are least satisfied with. As part of a quality improvement study to promote a continuum of care from the birthing room to discharge home from hospital, we explored women’s expectations and experiences of current inpatient care. Methods For this part of the study, qualitative data from semi-structured interviews were transcribed and analysed using content analyses to identify issues and concepts. Women were recruited from two postnatal wards in one large maternity unit in the South of England, with around 6,000 births a year. Results Twenty women, who had a vaginal or caesarean birth, were interviewed on the postnatal ward. Identified themes included; the impact of the ward environment; the impact of the attitude of staff; quality and level of support for breastfeeding; unmet information needs; and women’s low expectations of hospital based postnatal care. Findings informed revision to the content and planning of in-patient postnatal care, results of which will be reported elsewhere. Conclusions Women’s responses highlighted several areas where changes could be implemented. Staff should be aware that how they inter-act with women could make a difference to care as a positive or negative experience. The lack of support and inconsistent advice on breastfeeding highlights that units need to consider how individual staff communicate information to women. Units need to address how and when information on practical aspects of infant care is provided if women and their partners are to feel confident on the woman’s transfer home from hospital

Experiences of early labour management from perspectives of women, labour companions and health professionals: a systematic review of qualitative evidence

Objectives: To examine evidence of women's, labour companions’ and health professionals’ experiences of management of early labour to consider how this could be enhanced to better reflect women's needs. Design: A systematic review of qualitative evidence. Setting and participants: Women in early labour with term, low risk singleton pregnancies, not booked for a planned caesarean birth or post-dates induction of labour, their labour companions, and health professionals responsible for early labour care (e.g. midwives, nurse-midwives, obstetricians, family doctors). Studies from high and middle income country settings were considered. Findings: 21 publications were included from the UK, Ireland, Scandinavia, USA, Italy and New Zealand. Key findings included the impact of communication with health professionals (most usually midwives) on women's decision making; women wanting to be listened to by sympathetic midwives who could reassure that symptoms and signs of early labour were ‘normal’ and offer clear advice on what to do. Antenatal preparation which included realistic information on what to expect when labour commenced was important and appreciated by women and labour companions. Views of the optimal place for women to remain and allow early labour to progress differed and the perceived benefit of support and help offered by labour companions varied. Some were supportive and helped women to relax, while others were anxious and encouraged women to seek early admission to the planned place of birth. Web-based sources of information are increasingly used by women, with mixed views of the value of information accessed. Key conclusions and implications for practice: Women, labour companions and health professionals find early labour difficult to manage well, with women unsure of how decisions about admission to their planned place of birth are taken. It is unclear why women are effectively left to manage this aspect of their labour with minimal guidance or support. Tailoring management to meet individual needs, with provision of effective communication could reassure women and facilitate timely admission from perspectives of women, their companions, midwives and other health professionals. Information on labour onset and progress, and approaches to pain management, should be shared with women's labour companions to enable them to feel more confident to better support women. Further research is needed of the impact of different models of care and increasing use of web-based information on women's approaches to self-management when labour commences

Improving inpatient postnatal services: midwives views and perspectives of engagement in a quality improvement initiative

Background: despite major policy initiatives in the United Kingdom to enhance women's experiences of maternity care, improving in-patient postnatal care remains a low priority, although it is an aspect of care consistently rated as poor by women. As part of a systems and process approach to improving care at one maternity unit in the South of England, the views and perspectives of midwives responsible for implementing change were sought. Methods: a Continuous Quality Improvement (CQI) approach was adopted to support a systems and process change to in-patient care and care on transfer home in a large district general hospital with around 6000 births a year. The CQI approach included an initial assessment to identify where revisions to routine systems and processes were required, developing, implementing and evaluating revisions to the content and documentation of care in hospital and on transfer home, and training workshops for midwives and other maternity staff responsible for implementing changes. To assess midwifery views of the quality improvement process and their engagement with this, questionnaires were sent to those who had participated at the outset. Results: questionnaires were received from 68 (46%) of the estimated 149 midwives eligible to complete the questionnaire. All midwives were aware of the revisions introduced, and two-thirds felt these were more appropriate to meet the women's physical and emotional health, information and support needs. Some midwives considered that the introduction of new maternal postnatal records increased their workload, mainly as a consequence of colleagues not completing documentation as required. Conclusions: this was the first UK study to undertake a review of in-patient postnatal services. Involvement of midwives at the outset was essential to the success of the initiative. Midwives play a lead role in the planning and organisation of in-patient postnatal care and it was important to obtain their feedback on whether revisions were pragmatic and achieved anticipated improvements in care quality. Their initial involvement ensured priority areas for change were identified and implemented. Their subsequent feedback highlighted further important areas to address as part of CQI to ensure best quality care continues to be implemented. Our findings could support other maternity service organisations to optimise in-patient postnatal services

Relatively speaking? Partners’ and family members’ views and experiences of supporting breastfeeding : a systematic review of qualitative evidence

Objective: To synthesise qualitative evidence of views and experiences of partners and other family members who provided breastfeeding support for a relative. Methods: The Joanna Briggs Institute (JBI) methodology for systematic reviews of qualitative evidence was followed. Seven databases: CINAHL, MEDLINE, EMBASE, PsycINFO, Scopus, Maternal & Infant Care, and Web of Science were searched. Partners and other family members (e.g. grandmothers, siblings) of women in any countries were included. Included papers were critically appraised. The JBI meta-aggregative approach was used to analyse data and form synthesised findings. Findings: 76 papers from 74 studies were included. Five synthesised findings were: (1) Spectrum of family members’ breastfeeding knowledge, experiences and roles; (2) The complexity of infant feeding decision making; (3) The controversy of breastfeeding in front of others; (4) Impact of breastfeeding on family; (5) It takes more than just family members: support for family members. Conclusion: Partners’ and family members’ views and experiences of breastfeeding support reflected multi-faceted personal, social, financial, cultural, religious, emotional, psychological, and societal factors of the support they provided (or not). Healthcare professionals should engage them in breastfeeding discussions with the woman, and offer tailored and practical guidance relevant to help them to appropriately support the woman

Revising acute care systems and processes to improve breastfeeding and maternal postnatal health: a pre and post intervention study in one English maternity unit

Background Most women in the UK give birth in a hospital labour ward, following which they are transferred to a postnatal ward and discharged home within 24 to 48 hours of the birth. Despite policy and guideline recommendations to support planned, effective postnatal care, national surveys of women’s views of maternity care have consistently found in-patient postnatal care, including support for breastfeeding, is poorly rated. Methods Using a Continuous Quality Improvement approach, routine antenatal, intrapartum and postnatal care systems and processes were revised to support implementation of evidence based postnatal practice. To identify if implementation of a multi-faceted QI intervention impacted on outcomes, data on breastfeeding initiation and duration, maternal health and women’s views of care, were collected in a pre and post intervention longitudinal survey. Primary outcomes included initiation, overall duration and duration of exclusive breastfeeding. Secondary outcomes included maternal morbidity, experiences and satisfaction with care. As most outcomes of interest were measured on a nominal scale, these were compared pre and post intervention using logistic regression. Results Data were obtained on 741/1160 (64%) women at 10 days post-birth and 616 (54%) at 3 months post-birth pre-intervention, and 725/1153 (63%) and 575 (50%) respectively postintervention. Post intervention there were statistically significant differences in the initiation (p = 0.050), duration of any breastfeeding (p = 0.020) and duration of exclusive breastfeeding to 10 days (p = 0.038) and duration of any breastfeeding to three months (p = 0.016). Post intervention, women were less likely to report physical morbidity within the first 10 days of birth, and were more positive about their in-patient care. Conclusions It is possible to improve outcomes of routine in-patient care within current resources through continuous quality improvement

Scratching the surface: Elastic rotations beneath nanoscratch and nanoindentation tests

In this paper, we investigate the residual deformation field in the vicinity of nanoscratch tests using two orientations of a Berkovich tip on an (001) Cu single crystal. We compare the deformation with that from indentation, in an attempt to understand the mechanisms of deformation in tangential sliding. The lattice rotation fields are mapped experimentally using high-resolution electron backscatter diffraction (HR-EBSD) on cross-sections prepared using focused ion beam (FIB). A physically-based crystal plasticity finite element model (CPFEM) is used to simulate the lattice rotation fields, and provide insight into the 3D rotation field surrounding a nano-scratch experiment, as it transitions from an initial static indentation to a steady-state scratch. The CPFEM simulations capture the experimental rotation fields with good fidelity, and show how the rotations about the scratch direction are reversed as the indenter moves away from the initial indentation

A national cross sectional survey of heads of midwifery services of uptake, benefits and barriers to use of obstetric early warning systems (EWS) by midwives

Objective to identify the extent to which Early Warning Systems (EWS) are used by midwives in the United Kingdom (UK), the maternity settings they are used in, physiological parameters used to ‘trigger’ referral, training provision, barriers to implementation and role in preventing maternal morbidity. Design cross-sectional survey of heads of midwifery services. An email questionnaire was sent in September 2012. Setting UK NHS secondary care organisations providing maternity care. Findings heads of midwifery from 107 (68%) of 157 NHS organisations responded, with 108 questionnaires returned as two organisations had recently merged. All organisations, apart from one which only had a free-standing midwifery unit, had introduced EWS. Nearly all respondents (99%) reported EWS were used by midwives antenatally, 76% in labour and 100% on the postnatal ward. All EWS charts included body temperature, heart rate, respiratory rate, systolic blood pressure and oxygen saturation although parameters for escalation varied widely. Barriers to use of EWS by midwives included overlap with the partogram in labour, and staff shortages and delays obtaining clinical review when referral was triggered. Two-thirds considered EWS prevented maternal morbidity although few could provide supporting evidence, for example, audit findings. Training for midwives in use of EWS was available in 83% of organisations. Conclusion most UK midwives are using EWS, with the highest use in obstetric units. The heterogeneity of EWS currently used potentially limits collation of evidence to inform appropriate system level responses. Research is needed to evaluate the role of EWS to prevent maternal morbidity during and after pregnancy in different maternity settings