Caseload midwifery in a multi-ethnic community: The women's experiences

Objective: To evaluate caseload midwifery in a relatively deprived and ethnically diverse inner-city area. Design and setting: Semi-structured interviews were undertaken with 24 women from diverse ethnic backgrounds, 12 of whom had received caseload care and 12 women from an adjacent area who had received conventional maternity care in a large inner-city maternity unit. Framework analysis was adopted drawing on links with the authors’ previous work on women’s views of caseload midwifery. Findings: Key themes from previous work fitted well with the themes that emerged from this study. Themes included ‘knowing and being known’, ‘person-centred care’, ‘social support’, ‘gaining trust and confidence’, ‘quality and sensitivity of care’ and ‘communication’. Key conclusions and implications: Women from this socially and ethnically diverse group of women had similar views and wanted similar care to those in previous studies of caseload midwifery. Many of the women receiving caseload care highlighted the close relationship they had with the midwives and as a result of thisfelt more able to discuss their concerns with them. This has the potential not only for improved quality of care but also improved safety

Resonant line transfer in a fog: Using Lyman-alpha to probe tiny structures in atomic gas

Motivated by observational and theoretical work which both suggest very small scale ($\lesssim 1\,$pc) structure in the circum-galactic medium of galaxies and in other environments, we study Lyman-$\alpha$ (Ly$\alpha$) radiative transfer in an extremely clumpy medium with many "clouds" of neutral gas along the line of sight. While previous studies have typically considered radiative transfer through sightlines intercepting $\lesssim 10$ clumps, we explore the limit of a very large number of clumps per sightline (up to $f_{\mathrm{c}} \sim 1000$). Our main finding is that, for covering factors greater than some critical threshold, a multiphase medium behaves similar to a homogeneous medium in terms of the emergent Ly$\alpha$ spectrum. The value of this threshold depends on both the clump column density and on the movement of the clumps. We estimate this threshold analytically and compare our findings to radiative transfer simulations with a range of covering factors, clump column densities, radii, and motions. Our results suggest that (i) the success in fitting observed Ly$\alpha$ spectra using homogeneous "shell models" (and the corresponding failure of multiphase models) hints towards the presence of very small-scale structure in neutral gas, in agreement within a number of other observations; and (ii) the recurrent problems of reproducing realistic line profiles from hydrodynamical simulations may be due to their inability to resolve small-scale structure, which causes simulations to underestimate the effective covering factor of neutral gas clouds.Comment: 18 pages, 21 figures; submitted to A&A; animations available at http://bit.ly/a-in-a-fo

Barriers to women's access to alongside midwifery units in England

Background: Alongside midwifery units (AMUs) are managed by midwives and proximate to obstetric units (OUs), offering a home-like birth environment for women with straightforward pregnancies. They support physiological birth, with fast access to medical care if needed. AMUs have good perinatal outcomes and lower rates of interventions than OUs. In England, uptake remains lower than potential use, despite recent changes in policy to support their use. This article reports on experiences of access from a broader study that investigated AMU organisation and care. Methods: Organisational case studies in four National Health Service (NHS) Trusts in England, selected for variation geographically and in features of their midwifery units. Fieldwork (December 2011 to October 2012) included observations (>100 h); semi-structured interviews with staff, managers and stakeholders (n = 89) and with postnatal women and partners (n = 47), on which this paper reports. Data were analysed thematically using NVivo10 software. Results: Women, partners and families felt welcome and valued in the AMU. They were drawn to the AMUs’ environment, philosophy and approach to technology, including pain management. Access for some was hindered by inconsistent information about the existence, environment and safety of AMUs, and barriers to admission in early labour. Conclusions:Key barriers to AMUs arise through inequitable information and challenges with admission in early labour. Most women still give birth in obstetric units and despite increases in the numbers of women birthing on AMUs since 2010, addressing these barriers will be essential to future scale-up

An analysis of media reporting on the closure of freestanding midwifery units in England

PROBLEM: Despite clinical guidelines and policy promoting choice of place of birth, 14 Freestanding Midwifery Units were closed between 2008 and 2015, closures justified by low use and financial constraints. BACKGROUND: The Birthplace in England Programme found that freestanding midwifery units provided the most cost-effective birthplace for women at low risk of complications. Women planning birth in a freestanding unit were less likely to experience interventions than those planning obstetric unit birth, with no difference in outcomes for babies. METHODS: This paper uses an interpretative technique developed for policy analysis to explore the representation of these closures in 191 news articles, to explore the public climate in which they occurred. FINDINGS AND DISCUSSION: The articles focussed on underuse by women and financial constraints on services. Despite the inclusion of service user voices, the power of framing was held by service managers and commissioners. The analysis exposed how neoliberalist and austerity policies has privileged representation of individual consumer choice and market-driven provision as drivers of changes in health services. This normative framing makes the reasons given for closure as hard to refute and cultural norms persist that birth is safest in an obstetric setting, despite evidence to the contrary. CONCLUSION: The rise of neoliberalism and austerity in contemporary Britain has influenced the reform of maternity services, in particular the closure of midwifery units. Justifications given for closure silence other narratives, predominantly from service users, that attempt to present women's choice in terms of rights and a social model of care

What makes alongside midwifery-led units work? Lessons from a national research project

The findings of the Birthplace in England Research Programme showed that midwife-led units are providing the safest and most cost-effective care for low risk women in England. Since the publication of the updated National Institute for Health and Care Excellence (NICE) intrapartum guidelines, there is likely to be even more interest in the development of midwife-led units to promote birth outside obstetric units (OUs) for low-risk women. Professional bodies, policy makers and trusts have focused their energies on alongside midwife-led units (AMUs), which are seen to provide the 'best of both worlds' between home and an OU. Between 2012 and 2013, we carried out a study of the organisation of four AMUs in England and the experiences of midwives and women who worked and birthed there. Learning from their experiences, this article presents five key factors which help make AMUs work

Disrespectful intrapartum care during facility-based delivery in sub-Saharan Africa: A qualitative systematic review and thematic synthesis of women's perceptions and experiences

The psycho-social elements of labour and delivery are central to any woman's birth experience, but international efforts to reduce maternal mortality in low-income contexts have neglected these aspects and focused on technological birth. In many contexts, maternity care is seen as dehumanised and disrespectful, which can have a negative impact on utilisation of services. We undertook a systematic review and meta-synthesis of the growing literature on women's experiences of facility-based delivery in sub-Saharan Africa to examine the drivers of disrespectful intrapartum care. Using PRISMA guidelines, databases were searched from 1990 to 06 May 2015, and 25 original studies were included for thematic synthesis. Analytical themes, that were theoretically informed and cognisant of the cultural and social context in which the dynamics of disrespectful care occur, enabled a fresh interpretation of the factors driving midwives' behaviour. A conceptual framework was developed to show how macro-, meso- and micro-level drivers of disrespectful care interact. The synthesis revealed a prevailing model of maternity care that is institution-centred, rather than woman-centred. Women's experiences illuminate midwives' efforts to maintain power and control by situating birth as a medical event and to secure status by focusing on the technical elements of care, including controlling bodies and knowledge. Midwives and women are caught between medical and social models of birth. Global policies encouraging facility-based delivery are forcing women to swap the psycho-emotional care they would receive from traditional midwives for the technical care that professional midwives are currently offering. Any action to change the current performance and dynamic of birth relies on the participation of midwives, but their voices are largely missing from the discourse. Future research should explore their perceptions of the value and practice of interpersonal aspects of maternity care and the impact of disrespectful care on their sense of professionalism and personal ethics

Midwives’ perspectives on (dis)respectful intrapartum care during facility-based delivery in sub-Saharan Africa: a qualitative systematic review and meta-synthesis

Background In the past decade, the negative impact of disrespectful maternity care on women’s utilisation and experiences of facility-based delivery has been well documented. Less is known about midwives’ perspectives on these labour ward dynamics. Yet efforts to provide care that satisfies women’s psycho-socio-cultural needs rest on midwives’ capacity and willingness to provide it. We performed a systematic review of the emerging literature documenting midwives’ perspectives to explore the broader drivers of (dis)respectful care during facility-based delivery in the sub-Saharan African context. Methods Seven databases (CINAHL, PsychINFO, PsychArticles, Embase, Global Health, Maternity and Infant Care and PubMed) were systematically searched from 1990 to May 2018. Primary qualitative studies with a substantial focus on the interpersonal aspects of care were eligible if they captured midwives’ voices and perspectives. Study quality was independently assessed by two reviewers and PRISMA guidelines were followed. The results and findings from each study were synthesised using an existing conceptual framework of the drivers of disrespectful care. Results Eleven papers from six countries were included and six main themes were identified. ‘Power and control’ and ‘Maintaining midwives’ status’ reflected midwives’ focus on the micro-level interactions of the mother-midwife dyad. Meso-level drivers of disrespectful care were: the constraints of the ‘Work environment and resources’; concerns about ‘Midwives’ position in the health systems hierarchy’; and the impact of ‘Midwives’ conceptualisations of respectful maternity care’. An emerging theme outlined the ‘Impact on midwives’ of (dis)respectful care. Conclusion We used a theoretically informed conceptual framework to move beyond the micro-level and interrogate the social, cultural and historical factors that underpin (dis)respectful care. Controlling women was a key theme, echoing women’s experiences, but midwives paid less attention to the social inequalities that distress women. The synthesis highlighted midwives’ low status in the health system hierarchy, while organisational cultures of blame and a lack of consideration for them as professionals effectively constitute disrespect and abuse of these health workers. Broader, interdisciplinary perspectives on the wider drivers of midwives’ disrespectful attitudes and behaviours are crucial if efforts to improve the maternity care environment - for women and midwives - are to succeed

Factors influencing the utilisation of free-standing and alongside midwifery units in England: a qualitative research study

OBJECTIVE: To identify factors influencing the provision, utilisation and sustainability of midwifery units (MUs) in England. DESIGN: Case studies, using individual interviews and focus groups, in six National Health Service (NHS) Trust maternity services in England. SETTING AND PARTICIPANTS: NHS 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 MEASURES: Factors influencing MU use. FINDINGS: The 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. CONCLUSIONS: There 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

Influence of a magnetic field on the viscosity of a dilute gas consisting of linear molecules.

The viscomagnetic effect for two linear molecules, N2 and CO2, has been calculated in the dilute-gas limit directly from the most accurate ab initio intermolecular potential energy surfaces presently available. The calculations were performed by means of the classical trajectory method in the temperature range from 70 K to 3000 K for N2 and 100 K to 2000 K for CO2, and agreement with the available experimental data is exceptionally good. Above room temperature, where no experimental data are available, the calculations provide the first quantitative information on the magnitude and the behavior of the viscomagnetic effect for these gases. In the presence of a magnetic field, the viscosities of nitrogen and carbon dioxide decrease by at most 0.3% and 0.7%, respectively. The results demonstrate that the viscomagnetic effect is dominated by the contribution of the jj¯ polarization at all temperatures, which shows that the alignment of the rotational axes of the molecules in the presence of a magnetic field is primarily responsible for the viscomagnetic effect