Striving for excellence in maternity care: The Maternity Stream of the City of Sanctuary.

yesAsylum-seeking and refugee (AS&R) women living in the UK often have complex health and social care needs, with poor underlying mental and physical health and an increased risk of negative pregnancy outcomes. Despite this, AS&R women are less likely to attend for timely maternity care and when they do, care may be poor, with staff not understanding their specific needs and displaying poor attitudes. This article discusses the Maternity Stream of the City of Sanctuary and how this charity aims to work with statutory and voluntary sector maternity-related services and groups to develop services that are inclusive for AS&R women and meet their specific needs. Volunteer AS&R women are central to the activities of the Maternity Stream and this article discusses how they engage with midwives and other maternity workers to facilitate the development of services that may ultimately improve pregnancy outcomes for AS&R women

Midwives' attitudes towards giving weight-related advice to obese pregnant women

It is estimated that 1 in 5 pregnant women are obese, this poses a significant risk to maternal, fetal and newborn mortality and morbidity and as such, maternal obesity is recognised as a challenge for contemporary and prospective maternity services. As key practitioners in maternity care, midwives are seen as frontline professionals delivering weight-related advice to obese pregnant women. This study aimed to explore midwives' attitudes towards offering obese pregnant women weight-related advice during pregnancy and the puerperium. Nine midwives were interviewed using an in-depth interview schedule. Data were analysed using Colaizzi's (1978) seven-stage thematic approach. Midwives' knowledge of risk associated with maternal obesity was good; advice giving was mainly confined to community practice; the amount and consistency of advice was determined by: women's responses, women's apparent motivation to change and midwives' self-perception as a role model. Four key themes emerged: challenges for practice; perceived proficiency; advice giving skills and midwives' perceived relationship with a woman. Midwives need to address personal issues around body image, as they appear to hinder advice giving, before they can develop effective communication techniques to be able to offer obese pregnant women weight-related advice. The recommendation is to investigate ways in which issues of body image influence midwives ability to offer weight-related advice

Reporting errors, incidence and risk factors for postpartum haemorrhage and progression to severe PPH:a prospective observational study

OBJECTIVE: To quantify reporting errors, measure incidence of postpartum haemorrhage (PPH) and define risk factors for PPH (≥500 ml) and progression to severe PPH (≥1500 ml). DESIGN: Prospective observational study. SETTING: Two UK maternity services. POPULATION: Women giving birth between 1 August 2008 and 31 July 2009 (n = 10 213). METHODS: Weighted sampling with sequential adjustment by multivariate analysis. MAIN OUTCOME MEASURES: Incidence and risk factors for PPH and progression to severe PPH. RESULTS: Errors in transcribing blood volume were frequent (14%) with evidence of threshold preference and avoidance. The incidences of PPH ≥500, ≥1500 and ≥2500 ml were 33.7% (95% CI 31.2–36.2), 3.9% (95% CI 3.3–4.6) and 0.8% (95% CI 0.6–1.0). New independent risk factors predicting PPH ≥ 500 ml included Black African ethnicity (adjusted odds ratio [aOR] 1.77, 95% CI 1.31–2.39) and assisted conception (aOR 2.93, 95% CI 1.30–6.59). Modelling demonstrated how prepregnancy- and pregnancy-acquired factors may be mediated through intrapartum events, including caesarean section, elective (aOR 24.4, 95% CI 5.53–108.00) or emergency (aOR 40.5, 95% CI 16.30–101.00), and retained placenta (aOR 21.3, 95% CI 8.31–54.7). New risk factors were identified for progression to severe PPH, including index of multiple deprivation (education, skills and training) (aOR 1.75, 95% CI 1.11–2.74), multiparity without caesarean section (aOR 1.65, 95% CI 1.20–2.28) and administration of steroids for fetal reasons (aOR 2.00, 95% CI 1.24–3.22). CONCLUSIONS: Sequential, interacting, traditional and new risk factors explain the highest rates of PPH and severe PPH reported to date

Spot protein-creatinine ratio and spot albumin-creatinine ratio in the assessment of pre-eclampsia: a diagnostic accuracy study with decision-analytic model-based economic evaluation and acceptability analysis.

BACKGROUND: The National Institute for Health and Care Excellence (NICE) guidelines highlighted the need for 'large, high-quality prospective studies comparing the various methods of measuring proteinuria in women with new-onset hypertensive disorders during pregnancy'. OBJECTIVES: The primary objective was to evaluate quantitative assessments of spot protein-creatinine ratio (SPCR) and spot albumin-creatinine ratio (SACR) in predicting severe pre-eclampsia (PE) compared with 24-hour urine protein measurement. The secondary objectives were to investigate interlaboratory assay variation, to evaluate SPCR and SACR thresholds in predicting adverse maternal and fetal outcomes and to assess the cost-effectiveness of these models. DESIGN: This was a prospective diagnostic accuracy cohort study, with decision-analytic modelling and a cost-effectiveness analysis. SETTING: The setting was 36 obstetric units in England, UK. PARTICIPANTS: Pregnant women (aged ≥ 16 years), who were at > 20 weeks' gestation with confirmed gestational hypertension and trace or more proteinuria on an automated dipstick urinalysis. INTERVENTIONS: Women provided a spot urine sample for protein analysis (the recruitment sample) and were asked to collect a 24-hour urine sample, which was stored for secondary analysis. A further spot sample of urine was taken immediately before delivery. MAIN OUTCOME MEASURES: Outcome data were collected from hospital records. There were four index tests on a spot sample of urine: (1) SPCR test (conducted at the local laboratory); (2) SPCR test [conducted at the central laboratory using the benzethonium chloride (BZC) assay]; (3) SPCR test [conducted at the central laboratory using the pyrogallol red (PGR) assay]; and (4) SACR test (conducted at the central laboratory using an automated chemistry analyser). The comparator tests on 24-hour urine collection were a central test using the BZC assay and a central test using the PGR assay. The primary reference standard was the NICE definition of severe PE. Secondary reference standards were a clinician diagnosis of severe PE, which is defined as treatment with magnesium sulphate or with severe PE protocol; adverse perinatal outcome; one or more of perinatal or infant mortality, bronchopulmonary dysplasia, necrotising enterocolitis or grade III/IV intraventricular haemorrhage; and economic cost and outcomes. Health service data on service use and costs followed published economic models. RESULTS: In total, 959 women were available for primary analysis and 417 of them had severe PE. The diagnostic accuracy of the four assays on spot urine samples against the reference standards was similar. The three SPCR tests had sensitivities in excess of 90% at prespecified thresholds, with poor specificities and negative likelihood ratios of ≥ 0.1. The SACR test had a significantly higher sensitivity of 99% (confidence interval 98% to 100%) and lower specificity. Receiver operating characteristic (ROC) curves were similar (area under ROC curve between 0.87 and 0.89); the area under the central laboratory's SACR curve was significantly higher (p = 0.004). The central laboratory's SACR test was the most cost-effective option, generating an additional 0.03 quality-adjusted life-years at an additional cost of £45.07 compared with the local laboratory's SPCR test. The probabilistic analysis showed it to have a 100% probability of being cost-effective at the standard willingness-to-pay threshold recommended by NICE. LIMITATIONS: Implementation of NICE guidelines has led to an increased intervention rate in the study population that affected recruitment rates and led to revised sample size calculations. CONCLUSIONS: Evidence from this clinical study does not support the recommendation of 24-hour urine sample collection in hypertensive pregnant women. The SACR test had better diagnostic performance when predicting severe pre-eclampsia. All four tests could potentially be used as rule-out tests for the NICE definition of severe PE. FUTURE WORK: Testing SACR at a threshold of 8 mg/mmol should be studied as a 'rule-out' test of proteinuria. TRIAL REGISTRATION: Current Controlled Trials ISRCTN82607486. FUNDING: This project was funded by the National Institute Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 61. See the NIHR Journals Library website for further project information.This project was funded by the National Institute Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 61. See the NIHR Journals Library website for further project information

Pregnant and seeking asylum; exploring experiences ‘from booking to baby’

YesPregnant women seeking asylum in the UK may be particularly vulnerable with poor underlying health, more complex pregnancies and an increased risk of maternal and perinatal mortality. Studies have shown that some women seeking asylum have poor experiences of maternity care. This is despite the implementation of NICE guidelines to improve care for women with complex social factors. This article reports on a phenomenological study undertaken in West Yorkshire, aiming to explore the maternity care experiences of local pregnant asylum seeking women, to inform service development. Six women were interviewed over a three-month period. The findings focused more broadly on their experiences of living in the UK whilst being an asylum seeker and pregnant rather than focusing on maternity care, although this was included. Five key themes emerged: ‘pre-booking challenges’, ‘inappropriate accommodation’, ‘being pregnant and dispersed’, ‘being alone and pregnant’ and ‘not being asked or listened to’. These findings could be used as the basis for training midwives to understand how the difficulties women experience can impact on their health and social needs

Eating for 1, Healthy and Active for 2; feasibility of delivering novel, compact training for midwives to build knowledge and confidence in giving nutrition, physical activity and weight management advice during pregnancy

Gold OABackground: Women in Wales are more likely to be obese in pregnancy than in any other United Kingdom (UK) country. Midwives are ideally placed to explore nutrition, physical activity and weight management concerns however qualitative studies indicate they lack confidence in raising the sensitive issue of weight. Acknowledging this and the reality of finite time and resources, this study aimed to deliver compact training on nutrition, physical activity and weight management during pregnancy to increase the knowledge and confidence of midwives in this subject. Methods A compact training package for midwives was developed comprising of evidence based nutrition, physical activity and weight management guidance for pregnancy. Training was promoted via midwifery leads and delivered within the Health Board. Questionnaires based on statements from national public health guidance were used to assess changes in self-reported knowledge and confidence pre and post training. Descriptive statistics were applied and 95% confidence intervals were calculated. Results 43 midwives registered for training, 32 (74%) attended and completed the questionnaires. Although, pre training knowledge and confidence varied between participants, statistically significant improvements in self-reported knowledge and confidence were observed post training. 97% indicated knowledge of pregnancy specific food and nutrition messages as ‘better’ (95% CI 85 to 100), as opposed to 3% stating ‘stayed the same’ – 60% stated ‘much better’. 83% indicated confidence to explain the risks of raised BMI in pregnancy was either ‘much’ or ‘somewhat better’ (95% CI 66 to 93), as opposed to 17% stating ‘stayed the same’. 89% indicated confidence to discuss eating habits and physical activity was ‘much’ or ‘somewhat better’ (95% CI 73 to 97) as opposed to 11% stating ‘stayed the same’. Emergent themes highlighted that training was positively received and relevant to midwifery practice. Conclusions This study provides early indications that a compact nutrition, physical activity and weight management training package improves midwives self-reported knowledge and confidence. Cascading training across the midwifery service in the Health Board and conducting further studies to elicit longer term impact on midwifery practice and patient outcomes are recommended

Evaluating the impact of befriending for pregnant asylum seeking and refugee women

NoPregnant asylum-seeking and refugee women are a particularly vulnerable group in society, who may be possibly living alone in poverty in inappropriate accommodation (Dunne, 2007) and experiencing hostile attitudes (Hynes and sale, 2010). They may have poor physical and mental health, placing them at an increased risk of poor pregnancy outcomes (National Institute for Health and Care Excellence (NICE), 2010). Despite this, they are less likely to attend for timely maternity care. This article discusses the evaluation to date of an ongoing befriending project located in Northern england, targeting pregnant asylum-seeking and refugee women and helping to address difficulties that they may face. Volunteer befrienders, who themselves are asylum-seeking and refugee mothers, receive training to provide support and guidance to clients. Preliminary data suggest that befriending has advantages for both client and volunteer: clients appear to develop a trusting relationship with their befriender which facilitates self-confidence and helps overcome social isolation; and the volunteers feel that they are undertaking a worthwhile role and often move onto paid employment. Befriending may be a useful resource for midwives and ultimately improve pregnancy outcomes for asylum-seeking and refugee women

The cost of local, multi-professional obstetric emergencies training

INTRODUCTION: We aim to outline the annual cost of setting up and running a standard, local, multi-professional obstetric emergencies training course, PROMPT (PRactical Obstetric Multi-Professional Training), at Southmead Hospital, Bristol, UK - a unit caring for approximately 6500 births per year. MATERIAL AND METHODS: A retrospective, micro-costing analysis was performed. Start-up costs included purchasing training mannequins and teaching props, printing of training materials and assembly of emergency boxes (real and training). The variable costs included administration time, room hire, additional printing and the cost of releasing all maternity staff in the unit, either as attendees or trainers. Potential, extra start-up costs for maternity units without established training were also included. RESULTS: The start-up costs were €5574 and the variable costs for 1 year were €143 232. The total cost of establishing and running training at Southmead for 1 year was €148 806. Releasing staff as attendees or trainers accounted for 89% of the total first year costs, and 92% of the variable costs. The cost of running training in a maternity unit with around 6500 births per year was approximately €23 000 per 1000 births for the first year and around €22 000 per 1000 births in subsequent years. CONCLUSIONS: The cost of local, multi-professional obstetric emergencies training is not cheap, with staff costs potentially representing over 90% of the total expenditure. It is therefore vital that organizations consider the clinical effectiveness of local training packages before implementing them, to ensure the optimal allocation of finite healthcare budgets

How do women with social risk factors experience United Kingdom maternity care? A realist synthesis

Background Echoing international trends, the most recent United Kingdom reports of infant and maternal mortality found that pregnancies to women with social risk factors are over 50% more likely to end in stillbirth or neonatal death and carry an increased risk of premature birth and maternal death. The aim of this realist synthesis was to uncover the mechanisms that affect women's experiences of maternity care. Methods Using realist methodology, 22 papers exploring how women with a wide range of social risk factors experience maternity care in the United Kingdom were included. The data extraction process identified contexts (C), mechanisms (M), and outcomes (0). Results Three themes, Resources, Relationships, and Candidacy, overarched eight CMO configurations. Access to services, appropriate education, interpreters, practical support, and continuity of care were particularly relevant for women who are unfamiliar with the United Kingdom system and those living chaotic lives. For women with experience of trauma, or those who lack a sense of control, a trusting relationship with a health care professional was key to regaining trust. Many women who have social care involvement during their pregnancy perceive health care services as a system of surveillance rather than support, impacting on their engagement. This, as well as experiences of paternalistic care and discrimination, could be mitigated through the ability to develop trusting relationships. Conclusions The findings provide underlying theory and practical guidance on how to develop safe services that aim to reduce inequalities in women's experiences and birth outcomes