The development and testing of an algorithm to support midwives’ diagnosis of active labour in primiparous women

The research in this thesis aimed to develop an algorithm to support midwives’ diagnosis of active labour in primiparous women and to compare the effectiveness of the algorithm with standard care in terms of maternal and neonatal outcomes. Four linked studies are presented following the template suggested by the Medical Research Council (MRC 2000) Framework for development and evaluation of randomised controlled trials (RCT) for complex interventions to improve health. Study one Aim: To develop an algorithm for diagnosis of active labour in primiparous women. Methods: An informal telephone survey was conducted with senior midwives to assess the need for a decision support tool for the diagnosis of active labour. A literature review identified the key cues for inclusion in the algorithm which was then drafted. Focus group interviews were conducted with midwives to ascertain the cues used by midwives in diagnosing active labour. Findings: Thirteen midwives took part in focus groups. They described using informational cues which could be separated into two categories: those arising from the woman (Physical signs, Distress and coping, Woman's expectations and Social factors) and those from the institution (Midwifery care, Organisational factors and Justifying actions). Study Two Aim: Preliminary testing of the algorithm Methods: Vignettes and questionnaires were used to test the consistency of midwives’ judgements (inter-rater reliability), the content of the algorithm and its acceptability to midwives (face and content validity). The study was conducted in two stages: the first stage (23 midwives) involved vignettes and questionnaires and the second stage (20 midwives) involved vignettes only. Findings: In the first stage a Kappa score of 0.45 indicated only moderate agreement between midwives using the algorithm. After modifying the algorithm, the Kappa score in stage two was 0.86, indicating a high level of agreement. While the majority of the midwives reported that the algorithm was easy to complete, most were able to identify snags or make suggestions for its improvement. Based on the findings of this study the algorithm was modified and the final version was developed. Study three Aim: To assess the feasibility of carrying out a cluster randomised trial (CRT) of the algorithm, in Scotland. Specifically, to identify maternity units potentially willing to participate in a CRT, to test the implementation strategy for the trial and to collect baseline data to inform the sample size calculation. Methods: A questionnaire and interviews were used. The CRT methods were piloted in two maternity units and the algorithm was used for a three-month period in order to test its acceptability and provide estimates of compliance and consent rates. Results: All maternity units surveyed expressed an interest in the proposed study. Midwives’ compliance with study protocol differed between units, although the consent rate of women was high (89% and 84%). Ultimately, one unit achieved 100% of the required sample and the other 60%. The midwives reported that the algorithm was acceptable and was a useful tool, particularly for teaching inexperienced midwives. Study four Aim: To compare the effectiveness of the algorithm for diagnosis of active labour in primiparous women with standard care in terms of maternal and neonatal outcomes. Method: A cluster randomised trial Participants: Fourteen maternity units in Scotland. Midwives in experimental sites used the algorithm to assist their diagnosis of active labour. Seven experimental units collected data from 1029 women at baseline and 896 post intervention. The seven control units had 1291 women at baseline and 1287 after study implementation. Outcomes: The primary outcome was the percentage use of oxytocin for augmentation of labour. Secondary outcomes were medical interventions in labour, labour admission management, unplanned out of hospital births and clinical outcomes for mothers and babies. Results: There was no significant difference between groups in percentage use of oxytocin for augmentation of labour or for the use of medical interventions in labour. Women in the algorithm group were more likely to be discharged from the labour suite following their first labour assessment and subsequently have more pre-labour admissions. Conclusion The studies presented in this thesis represent the full process of developing and testing a complex healthcare intervention (the algorithm). The final study, a national cluster randomised trial, demonstrated that the use of the algorithm did not result in a reduction in the number of women who received oxytocin for augmentation or the use of medical interventions in labour. The results suggest that misdiagnosis of labour is not the main reason for higher rates of intervention experienced by women admitted to labour wards while not yet in active labour. These studies contribute significantly to the debate on care of women in early labour, the organisation of maternity care and to maternity care research

How women can go the full nine months without knowing they're pregnant

First paragraph: It is a “notorious fact”, one so commonly accepted and obvious it requires no evidence to support it in a court of law, that every womanknows when she is pregnant.  In a society that has a low tolerance for uncertainty, cases that challenge our collective notion of the possible fascinate and confuse us. Headlines such as “Baby birth shock for soldier on Afghanistan deployment”, or “I had this extremely painful urge to push and that’s when the head came out” are received with a mix of incredulity and scepticism. Yet cases of “cryptic pregnancy” – also known as “pregnancy denial” – are not particularly rare. In fact, they are estimated to occur in around one in 2,500 cases, suggesting around320 cases in the UK annually, or a potential headline story almost every day. Access this article on The Conversation website: https://theconversation.com/how-women-can-go-the-full-nine-months-without-knowing-theyre-pregnant-5862

Making childbirth risky: an unintended consequence of the normal birth agenda?

First paragraph: Zepherina Veitch was a nurse and a midwife in the late 19th century. She was a founder of the Midwives Institute (which ultimately became the Royal College of Midwives), and she worked to improve the training and status of midwives, at a time when maternal and infant mortality in Britain was high; infant mortality was around 150 in 1000 births (1), and approximately 3000 women died in childbirth each year (2). Although at that time it was described as being safer to have a home birth with the attendance of a skilled midwife than to give birth in a hospital under the care of a doctor (2), the high level of maternal mortality associated with childbirth had become a national scandal and through the following century, in the attempt to improve the wellbeing of mothers and babies, institutionalisation and medicalization of childbirth became the norm

Pregnant during the coronavirus crisis? Don't panic

First paragraph: Pregnancy and birth continue in times of crisis. There may be no perfectly convenient moment to give birth but for women who are pregnant in the midst of the global COVID-19 pandemic this must feel like a most uncertain period. So, what does the current situation mean for pregnant mothers in the UK?https://theconversation.com/pregnant-during-the-coronavirus-crisis-dont-panic-13510

Pricing and Hedging Index Options with a Dominant Constituent Stock

In this paper, we examine the pricing and hedging of an index option where one constituents stock plays an overly dominant role in the index. Under a Geometric Brownian Motion assumption we compare the distribution of the relative value of the index if the dominant stock is modeled separately from the rest of the index, or not. The former is equivalent to the relative index value being distributed as the sum of two lognormal random variables and the latter is distributed as a single lognormal random variable. Since these are not equal in distribution, we compare the two models. The validity of this theoretical result is verified against empirical stock market data. We look at two main models representing these cases: first, we use numerical methods to solve the two-dimensional problem directly; second, we make simplifying assumptions to reduce the two-dimensional Black-Scholes problem to a one-dimensional Black-Scholes problem that can be solved analytically. Since the terminal conditions of an option are usually non-smooth the numerical methods are verified by comparison to a Monte Carlo simulated solution. Attributes of the models that we compare are the relative option price differences and expected hedging profits. We compare the models for various volatilities, dominance levels, correlations and risk free rates. This work is significant in options trading because when a stock becomes dominant in its index the distribution of the returns changes. Even if the effect is small, given the millions of dollars exposed to index option trades, it has a material impact

Is maternity care in Scotland equitable? Results of a national maternity care survey

Objective High-quality maternity care is key to long-term improvements in population health. However, even within developed welfare systems, some mothers and babies experience poorer care and outcomes. This study aimed to explore whether women’s experiences of maternity care in Scotland differs by their physical or sociodemographic characteristics. Design Secondary analysis of the 2015 Scottish Maternity Care Experience Survey. The questionnaire was based on the Care Quality Commission English maternity survey. Setting National Health Service maternity care in Scotland. Participants The survey was distributed to 5025 women who gave birth in Scotland during February and March 2015 with 2036 respondents (41%). Main outcome measures The questionnaire explored aspects of care processes and interpersonal care experienced from the first antenatal contact (booking) to 6 weeks following the birth. The analysis investigated whether experiences were related to age, parity, deprivation, rurality, self-reported general health or presence of a health condition that limited daily activities. Analysis used mixed effect multilevel models incorporating logistic regression. Results There were associations between parity, age and deprivation with gestation at booking indicating that younger women, women from more deprived areas and multiparous women booked later. Women reporting generally poorer health were more likely to describe poorer care experiences in almost every domain including continuity, pain relief in labour, communication with staff, support and advice, involvement in decision making, confidence and trust and overall rating of care. Conclusions We found few differences in maternity care experience for women based on their physical or socioeconomic characteristics. Our findings indicate that maternity care in Scotland is generally equitable. However, the link between poorer general health after childbirth and poorer experience of maternity care is an important finding requiring further study

Reducing the length of postnatal hospital stay: implications for cost and quality of care

Background  UK health services are under pressure to make cost savings while maintaining quality of care. Typically reducing the length of time patients stay in hospital and increasing bed occupancy are advocated to achieve service efficiency. Around 800,000 women give birth in the UK each year making maternity care a high volume, high cost service. Although average length of stay on the postnatal ward has fallen substantially over the years there is pressure to make still further reductions. This paper explores and discusses the possible cost savings of further reductions in length of stay, the consequences for postnatal services in the community, and the impact on quality of care.  Method  We draw on a range of pre-existing data sources including, national level routinely collected data, workforce planning data and data from national surveys of women’s experience. Simulation and a financial model were used to estimate excess demand, work intensity and bed occupancy to explore the quantitative, organisational consequences of reducing the length of stay. These data are discussed in relation to findings of national surveys to draw inferences about potential impacts on cost and quality of care.  Discursive analysis  Reducing the length of time women spend in hospital after birth implies that staff and bed numbers can be reduced. However, the cost savings may be reduced if quality and access to services are maintained. Admission and discharge procedures are relatively fixed and involve high cost, trained staff time. Furthermore, it is important to retain a sufficient bed contingency capacity to ensure a reasonable level of service. If quality of care is maintained, staffing and bed capacity cannot be simply reduced proportionately: reducing average length of stay on a typical postnatal ward by six hours or 17% would reduce costs by just 8%. This might still be a significant saving over a high volume service however, earlier discharge results in more women and babies with significant care needs at home. Quality and safety of care would also require corresponding increases in community based postnatal care. Simply reducing staffing in proportion to the length of stay increases the workload for each staff member resulting in poorer quality of care and increased staff stress.  Conclusions  Many policy debates, such as that about the length of postnatal hospital-stay, demand consideration of multiple dimensions. This paper demonstrates how diverse data sources and techniques can be integrated to provide a more holistic analysis. Our study suggests that while earlier discharge from the postnatal ward may achievable, it may not generate all of the anticipated cost savings. Some useful savings may be realised but if staff and bed capacity are simply reduced in proportion to the length of stay, care quality may be compromised

Strength-based approaches: a realist evaluation of implementation in maternity services in Scotland

Aim Strength-based approaches draw on patients’ strengths and perspectives to partner with them in their own care, recovery and problem solving. The effectiveness of strength-based approaches to address complex health problems has a growing evidence base leading to its incorporation within universal services in many countries. However, practitioners’ understanding of implementation of strength-based approaches, such as how to agenda match, set goals and revise plans within universal services are under-researched. Maternity services are a key point of access to health services and women’s experiences of them have consequences for families’ future willingness to engage with public health provision. This study researched strength-based components of children’s services policy, Getting It Right For Every Child, in maternity care in Scotland. Subject and methods Complex interventions, such as this policy, requires a methodology that captures complex dynamics. Consequently a realist-evaluation-informed case-study approach was adopted across three contrasting health boards comprised of: (1) interviews with women receiving maternity care with heightened risk profiles, (2) a sample of maternity care professionals responsible for implementing the policy and (3) document analysis of policy guidance and training materials. Results Whilst midwives reported adopting more open approaches to raising sensitive issues with women, many midwives were unfamiliar with strength-based approaches and were not drawing upon them, in contrast to a perception amongst managers that training and implementation was common. Conclusion These findings suggest implementation of strength-based approaches within universal services require further attention to training and embedding culture change

Identifying when active labour starts: can we improve the judgement?

First paragraph: There is growing concern about rising intervention rates in childbirth. In the UK a recent consensus statement, Making normal birth a reality, highlighted the importance of avoiding interventions where possible (Maternity Care Working Party 2007), yet intervention may be increased simply by early admission to the delivery suite. Several studies have identified that women admitted when they are not yet in active labour experience increased intervention in labour compared to those who are admitted in the active phase (Hemminki & Simukka 1986, Holmes et al 2001, Jackson et al 2003, Klein et al 2003). This poses a considerable problem, both for women and for the health service. The Birthrate audit first published over ten years ago (Ball & Washbrook 1996) reported that around one third of women admitted to UK labour wards were subsequently found not to be in labour. More recent publications have suggested that admission of women who are not yet in labour or who are in early labour is a continuing trend, despite the introduction of a range of initiatives, such as triage or telephone triage (Spiby et al 2006)

Working in partnership: the application of shared decision making to health visitor practice

Aim and objectives To explore the processes which support shared decision making when health visitors and parents are creating plans to improve the wellbeing of babies and children.  Background  Worldwide, there is a focus on promoting children's wellbeing in order to enhance population health. Within the United Kingdom, health visitors have a key responsibility for working in partnership with parents to support this agenda. Despite evidence that the application of ‘shared decision making’ frameworks can increase patient participation, improve patient satisfaction, and improve health outcomes, there is limited research linking shared decision making with health visitor practice.  Design  A qualitative, descriptive study.  Methods  The study was undertaken in two phases: in Phase 1, two parent: health visitor dyads, who were planning together as part of usual care, were audio-recorded and then the participants’ experiences were sought through individual questionnaires. In Phase 2 semi-structured interviews were conducted with nine health visitors and nine parents in relation to their recent experiences of planning care.  Results  Evidence of supportive processes included having a shared understanding around the issue needing to be addressed; being able to identify interventions which were accessible for the family; engaging in decision making through deep, meaningful conversations using sensitive and responsive approaches; and establishing positive relationships between health visitors and parents, significant others within the family, and other professionals.  Conclusion  Despite evidence of strong, trusting relationships between parents and health visitors, there were times when shared decision making was unable to take place due to the absence of supportive processes