Improving the working lives of maternity healthcare workers to enable delivery of higher quality care for women: a feasibility study of a multiprofessional participatory intervention

Over 275,000 women died of pregnancy related causes in 2015. Most occur in resource-poor settings and are preventable. This study aimed to improve the working lives of maternity healthcare workers in Malawi to enable delivery of higher quality care, using Appreciative Inquiry (AI); a positive-focused, participatory action cycle. Following a systematic review and narrative synthesis of AI, an ethnographic study and Interpretative Phenomenological perspective were utilised to understand working lives. Before the intervention was implemented, working lives were assessed through validated questionnaires for staff and patient satisfaction surveys. AI has been used in healthcare, but little empirical evidence for its effectiveness exists. Staff wanted to do a good job, but were confined by a lack of resources, knowledge and support. The longitudinal survey of staff showed significant improvements in general wellbeing and home-work interface, and patient satisfaction improved. AI also improved staff relationships and made work easier and happier. Qualitative work suggested this was because staff were working better together, underpinned by everyone meeting together. From these findings a theory of change was developed. AI showed great promise. However, further research, in the form of a large-scale trial, is needed to empirically demonstrate the effectiveness of AI in healthcare

Exploring the scope of practice and training of obstetricians and gynaecologists in England, Italy and Belgium:a qualitative study

&lt;p&gt;&lt;b&gt;INTRODUCTION: &lt;/b&gt;This study explores the scope of practice of Obstetrics and Gynaecology specialists in Italy, Belgium and England, in light of the growth of professional and patient mobility within the EU which has raised concerns about a lack of standardisation of medical speciality practice and training.&lt;/p&gt;&lt;p&gt;&lt;b&gt;METHODS: &lt;/b&gt;Semi-structured qualitative interviews were conducted with 29 obstetricians and gynaecologists from England, Belgium and Italy, exploring training and scope of practice, following a common topic guide. Interviews were recorded, transcribed and coded following a common coding framework in the language of the country concerned. Completed coding frames, written summaries and key quotes were then translated into English and were cross-analysed among the researchers to identify emerging themes and comparative findings.&lt;/p&gt;&lt;p&gt;&lt;b&gt;RESULTS: &lt;/b&gt;Although medical and specialty qualifications in each country are mutually recognised, there were great differences in training regimes, with different emphases on theory versus practice and recognition of different subspecialties. However all countries shared concerns about the impact of the European Working Time Directive on trainees&#039; skills development. Reflecting differences in models of care, the scope of practice of OBGYN varied among countries, with pronounced differences between the public and private sector within countries. Technological advances and the growth of co-morbidities resulting from ageing populations have created new opportunities and greater links with other specialties. In turn new ethical concerns around abortion and fertility have also arisen, with stark cultural differences between the countries.&lt;/p&gt;&lt;p&gt;&lt;b&gt;CONCLUSION: &lt;/b&gt;Variations exist in the training and scope of practice of OBGYN specialists among these three countries, which could have significant implications for the expectations of patients seeking care and specialists practising in other EU countries. Changes within the specialty and advances in technology are creating new opportunities and challenges, although these may widen existing differences. Harmonisation of the training and scope of practice of OBGYN within Europe remains a distant goal. Further research on the scope of practice of medical professionals would better inform future policies on professional mobility.&lt;/p&gt;</p

Cross Sectional Survey of Antenatal Educators' Views About Current Antenatal Education Provision

Antenatal education (ANE) is part of National Health Service (NHS) care and is recommended by The National Institute for Health and Care Excellence (NICE) to increase birth preparedness and help pregnant women/birthing people develop coping strategies for labour and birth. We aimed to understand antenatal educator views about how current ANE supports preparedness for childbirth, including coping strategy development with the aim of identifying targets for improvement. A United Kingdom wide, cross-sectional online survey was conducted between October 2019 and May 2020. Antenatal educators including NHS midwives and private providers were purposively sampled. Counts and percentages were calculated for closed responses and thematic analysis used for open text responses. Ninety-nine participants responded, 62% of these did not believe that ANE prepared women for labour and birth. They identified practical barriers to accessing ANE, particularly for marginalised groups, including financial and language barriers. Educators believe class content is medically focused, and teaching is of variable quality with some midwives being ill-prepared to deliver antenatal education. 55% of antenatal educators believe the opportunity to develop coping strategies varies between location and educators and only those women who can pay for non-NHS classes are able to access all the coping strategies that can support them with labour and birth. Antenatal educators believe current NHS ANE does not adequately prepare women for labour and birth, leading to disparities in birth preparedness for those who cannot access non-NHS classes. To reduce this healthcare inequality, NHS classes need to be standardised, with training for midwives in delivering ANE enhanced. [Abstract copyright: © 2024. The Author(s).

A cross sectional study to evaluate antenatal care service provision in three hospitals in Nepal

Background Globally too many mothers and their babies die during pregnancy and childbirth, a key element of optimizing outcomes is high-quality antenatal care (ANC). The Government of Nepal have significantly improved ANC and health outcomes through high-level commitment and investment, but still only 69% attend four recommended antenatal appointments. Objective To evaluate the quality and perceptions of ANC in Nepal to understand the compliance with Nepalese standards. Study Design This cross-sectional study took place at a tertiary referral and private hospital in Kathmandu, and a secondary hospital in Makwanpur. It recruited 538 female inpatients on postnatal wards during the two-week data collection period in May/June 2019. A case note review and verbal survey of women to understand the pregnancy information they received and their satisfaction with ANC was performed. We created a summary score of the completeness of ANC services received ranging 0-50 (50 indicating complete accordance with standards) and investigated the determinants of attending 4 ANC visits and patient satisfaction. Results The median ANC attendance was 4 visits at the secondary and referral hospitals and 8 at the private hospital. 24% attended less than 4 visits. 22% (117/538) attended a first trimester visit and 12% (65/538) attended visits at all points recommended in the standards. Over 90% of women had blood pressure monitoring, hemoglobin estimation, blood grouping and Rhesus typing, HIV and syphilis screening. 50% of women had urinalysis at every visit (IQR 20 to 100). 95% (509/538) reported receiving pregnancy information, but retention was variable: 93% (509/538) received some information about danger signs, 58% (290/502) remembered headaches whereas 98% (491/502) remembered fluid leaking. The ANC completeness score revealed the private hospital offered the most complete clinical services (mean 28.7, SD=7.1) with the secondary hospital performing worst (mean 19.1, SD=7.1). The factors influencing attendance at 4 ANC visits in the multivariable model were beginning ANC in the first trimester (OR 2.74 (95% CI 1.36, 5.52) and having a lower level of education (no-school OR 0.46 (95% CI 0.23, 0.91), Grades 1-5 OR 0.49 (95%CI 0.26, 0.92)). Overall 56% (303/538) of women were satisfied with ANC. The multivariable analysis revealed satisfaction was more likely in women attending the private hospital compared to the referral hospital (OR 3.63 95% CI 1.68 to 7.82) and lower in women who felt the ANC facilities were not adequate (OR 0.35 95% CI 0.21 to 0.63) and who wanted longer antenatal appointments (OR 0.5 95% CI 0.33 to 0.75). Conclusions Few women achieved full compliance with the Nepali ANC standards, however, some services were delivered well. To improve, each antenatal contact needs to meet its clinical aims and be respectful. To achieve this communication and counselling training for staff, investment in health promotion and delivery of core services is needed. It is important that these interventions address key issues, such as attendance in the first trimester, improving privacy and optimizing communication around danger signs. However, they must be designed alongside staff and service users and their efficacy tested prior to widespread investment or implementation

Codesign and refinement of an optimised antenatal education session to better inform women and prepare them for labour and birth

Objective: Our objective was to codesign, implement, evaluate acceptability and refine an optimised antenatal education session to improve birth preparedness. Design: There were four distinct phases: codesign (focus groups and codesign workshops with parents and staff); implementation of intervention; evaluation (interviews, questionnaires, structured feedback forms) and systematic refinement. Setting: The study was set in a single maternity unit with approximately 5500 births annually. Participants: Postnatal and antenatal women/birthing people and birth partners were invited to participate in the intervention, and midwives were invited to deliver it. Both groups participated in feedback. Outcome measures: We report on whether the optimised session is deliverable, acceptable, meets the needs of women/birthing people and partners, and explain how the intervention was refined with input from parents, clinicians and researchers. Results: The codesign was undertaken by 35 women, partners and clinicians. Five midwives were trained and delivered 19 antenatal education (ACE) sessions to 142 women and 94 partners. 121 women and 33 birth partners completed the feedback questionnaire. Women/birthing people (79%) and birth partners (82%) felt more prepared after the class with most participants finding the content very helpful or helpful. Women/birthing people perceived classes were more useful and engaging than their partners. Interviews with 21 parents, a midwife focus group and a structured feedback form resulted in 38 recommended changes: 22 by parents, 5 by midwives and 11 by both. Suggested changes have been incorporated in the training resources to achieve an optimised intervention. Conclusions: Engaging stakeholders (women and staff) in codesigning an evidence-informed curriculum resulted in an antenatal class designed to improve preparedness for birth, including assisted birth, that is acceptable to women and their birthing partners, and has been refined to address feedback and is deliverable within National Health Service resource constraints. A nationally mandated antenatal education curriculum is needed to ensure parents receive high-quality antenatal education that targets birth preparedness

Interventions, outcomes and outcome measurement instruments in stillbirth care research: A systematic review to inform the development of a core outcome set

Background: A core outcome set could address inconsistent outcome reporting and improve evidence for stillbirth care research, which has been identified as an important research priority. Objectives To identify outcomes and outcome measurement instruments reported by studies evaluating interventions after the diagnosis of a stillbirth. Search strategy Amed, BNI, CINAHL, ClinicalTrials.gov, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Embase, MEDLINE, PsycINFO, and WHO ICTRP from 1998 to August 2021. Selection criteria Randomised and non-randomised comparative or non-comparative studies reporting a stillbirth care intervention. Data collection and analysis Interventions, outcomes reported, definitions and outcome measurement tools were extracted. Main results 40 randomised and 200 non-randomised studies were included. 58 different interventions were reported, labour and birth care (52 studies), hospital bereavement care (28 studies), clinical investigations (116 studies), care in a multiple pregnancy (2 studies), psychosocial support (28 studies) and care in a subsequent pregnancy (14 studies). 391 unique outcomes were reported and organised into 14 outcome domains: labour and birth; postpartum; delivery of care; investigations; multiple pregnancy; mental health; emotional functioning; grief and bereavement; social functioning; relationship; whole person; subsequent pregnancy; subsequent children and siblings and economic. 242 outcome measurement instruments were used, with 0-22 tools per outcome. Conclusions: Heterogeneity in outcome reporting, outcome definition and measurement tools in care after stillbirth exists. Considerable research gaps on specific intervention types in stillbirth care were identified. A core outcome set is needed to standardise outcome collection and reporting for stillbirth care research

Protocol for the development of a core outcome set for stillbirth care research (iCHOOSE Study)

IntroductionStillbirth is associated with significant physical, psychosocial and economic consequences for parents, families, wider society and the healthcare system. There is emerging momentum to design and evaluate interventions for care after stillbirth and in subsequent pregnancies. However, there is insufficient evidence to inform clinical practice compounded by inconsistent outcome reporting in research studies. To address this paucity of evidence, we plan to develop a core outcome set for stillbirth care research, through an international consensus process with key stakeholders including parents, healthcare professionals and researchers.Methods and analysisThe development of this core outcome set will be divided into five distinct phases: (1) Identifying potential outcomes from a mixed-methods systematic review and analysis of interviews with parents who have experienced stillbirth; (2) Creating a comprehensive outcome long-list and piloting of a Delphi questionnaire using think-aloud interviews; (3) Choosing the most important outcomes by conducting an international two-round Delphi survey including high-income, middle-income and low-income countries; (4) Deciding the core outcome set by consensus meetings with key stakeholders and (5) Dissemination and promotion of the core outcome set. A parent and public involvement panel and international steering committee has been convened to coproduce every stage of the development of this core outcome set.Ethics and disseminationEthical approval for the qualitative interviews has been approved by Berkshire Ethics Committee REC Reference 12/SC/0495. Ethical approval for the think-aloud interviews, Delphi survey and consensus meetings has been awarded from the University of Bristol Faculty of Health Sciences Research Ethics Committee (Reference number: 116535). The dissemination strategy is being developed with the parent and public involvement panel and steering committee. Results will be published in peer-reviewed specialty journals, shared at national and international conferences and promoted through parent organisations and charities.PROSPERO registration numberCRD42018087748.</jats:sec

Improving the working lives of maternity healthcare workers to enable delivery of higher quality care for women: a feasibility study of a multiprofessional participatory intervention

Over 275,000 women died of pregnancy related causes in 2015. Most occur in resource-poor settings and are preventable. This study aimed to improve the working lives of maternity healthcare workers in Malawi to enable delivery of higher quality care, using Appreciative Inquiry (AI); a positive-focused, participatory action cycle. Following a systematic review and narrative synthesis of AI, an ethnographic study and Interpretative Phenomenological perspective were utilised to understand working lives. Before the intervention was implemented, working lives were assessed through validated questionnaires for staff and patient satisfaction surveys. AI has been used in healthcare, but little empirical evidence for its effectiveness exists. Staff wanted to do a good job, but were confined by a lack of resources, knowledge and support. The longitudinal survey of staff showed significant improvements in general wellbeing and home-work interface, and patient satisfaction improved. AI also improved staff relationships and made work easier and happier. Qualitative work suggested this was because staff were working better together, underpinned by everyone meeting together. From these findings a theory of change was developed. AI showed great promise. However, further research, in the form of a large-scale trial, is needed to empirically demonstrate the effectiveness of AI in healthcare

Does Provision of Antenatal Care in Southern Asia Improve Neonatal Survival? A Systematic Review and Meta-Analysis

BackgroundSouthern Asia has one of the highest burdens of neonatal mortality worldwide (26/1000 live births). Ensuring that women receive antenatal care from a skilled provider may play an important role in reducing this burden.ObjectiveThis study aimed to determine whether antenatal care received from a skilled provider could reduce neonatal mortality in Southern Asia by systematically reviewing existing evidence.Study designSeven databases were searched (MEDLINE, Embase, Cochrane Library, CINAHL, PubMed, PsycINFO, and International Bibliography of the Social Sciences [IBSS]). The key words included: "neonatal mortality," "antenatal care," and "Southern Asia." Nonrandomized comparative studies conducted in Southern Asia reporting on neonatal mortality in women who received antenatal care compared with those who did not were included. Two authors carried out the screening and data extraction. The Risk of Bias Assessment tool for Non-randomized Studies (RoBANS) was used to assess quality of studies. Results were reported using a random-effects model based on odds ratios with 95% confidence intervals.ResultsFour studies were included in a meta-analysis of adjusted results. The pooled odds ratio was 0.46 (95% confidence interval, 0.24 to 0.86) for neonatal deaths among women having at least 1 antenatal care visit during pregnancy compared with women having none. In the final meta-analysis, 16 studies could not be included because of lack of adjustment for confounders, highlighting the need for further higher-quality studies to evaluate the true impact.ConclusionThis review suggests that in Southern Asia, neonates born to women who received antenatal care have a lower risk of death in the neonatal period compared with neonates born to women who did not receive antenatal care. This should encourage health policy to strengthen antenatal care programs in Southern Asia

Interventions to enhance medication adherence in pregnancy- a systematic review

Abstract Background Sub-optimal medication adherence in pregnant women with chronic disease and pregnancy-related indications has the potential to adversely affect maternal and perinatal outcomes. Adherence to appropriate medications is advocated during and when planning pregnancy to reduce risk of adverse perinatal outcomes relating to chronic disease and pregnancy-related indications. We aimed to systematically identify effective interventions to promote medication adherence in women who are pregnant or planning to conceive and impact on perinatal, maternal disease-related and adherence outcomes. Methods Six bibliographic databases and two trial registries were searched from inception to 28th April 2022. We included quantitative studies evaluating medication adherence interventions in pregnant women and women planning pregnancy. Two reviewers selected studies and extracted data on study characteristics, outcomes, effectiveness, intervention description (TIDieR) and risk of bias (EPOC). Narrative synthesis was performed due to study population, intervention and outcome heterogeneity. Results Of 5614 citations, 13 were included. Five were RCTs, and eight non-randomised comparative studies. Participants had asthma (n = 2), HIV (n = 6), inflammatory bowel disease (IBD; n = 2), diabetes (n = 2) and risk of pre-eclampsia (n = 1). Interventions included education +/− counselling, financial incentives, text messaging, action plans, structured discussion and psychosocial support. One RCT found an effect  of the tested intervention on self-reported antiretroviral adherence but not objective adherence. Clinical outcomes were not evaluated. Seven non-randomised comparative studies found an association between the tested intervention and at least one outcome of interest: four found an association between receiving the intervention and both improved clinical or perinatal outcomes and adherence in women with IBD, gestational diabetes mellitus (GDM), and asthma. One study in women with IBD reported an association between receiving the intervention and maternal outcomes but not for self-reported adherence. Two studies measured only adherence outcomes and reported an association between receiving the intervention and self-reported and/or objective adherence in women with HIV and risk of pre-eclampsia. All studies had high or unclear risk of bias. Intervention reporting was adequate for replication in two studies according to the TIDieR checklist. Conclusions There is a need for high-quality RCTs reporting replicable interventions to evaluate medication adherence interventions in pregnant women and those planning pregnancy. These should assess both clinical and adherence outcomes. </jats:sec