Women's information needs, decision-making and experiences of membrane sweeping to promote spontaneous labour

© 2019 Objective: To explore and synthesise evidence of women's information needs, decision-making and experiences of membrane sweeping to promote spontaneous labour. Design: A systematic review following the Joanna Briggs Institute (JBI) meta-aggregative approach to qualitative evidence synthesis. Relevant databases were searched for literature published in English between 2000–19. Study quality was assessed using the JBI quality assessment tool for qualitative studies. Setting: Qualitative research conducted in OECD countries describing women's information needs, decision-making and/or experiences of membrane sweeping to promote spontaneous labour. Findings: One article met the criteria for inclusion. This article describes the experience of a membrane sweep given without consent. Key conclusions and Implications for practice: There is a lack of evidence around women's information needs, decision-making and experiences of membrane sweeping. This is concerning, especially in the context of rising rates of formal induction of labour. Further research is needed to investigate how women are being offered membrane sweeping and what information women need to make informed choices about membrane sweeping to promote spontaneous labour

A systematic review of supportive interventions to promote women's comfort and well-being during induction of labour

© 2020 John Wiley & Sons Ltd Aims: To evaluate the effectiveness of non-pharmacological non-invasive supportive interventions for impacts on women's comfort and well-being during induction of labour. Design: A quantitative systematic review without meta-analysis. Data Sources: Databases were searched for primary research published in English between 2000–2019: AMED, CINAHL, Medline, Maternity and Infant Care database, PsycINFO, and ProQuest. The quality of studies was evaluated using JBI levels of evidence and established critical appraisal tools. Studies describing measures of comfort, coping, and well-being for women during induction of labour were included. Results: Two articles met the criteria for inclusion. There is limited evidence to suggest that women having outpatient cervical priming were more satisfied with their experience than women having inpatient cervical priming and that outpatient cervical priming did not increase women's anxiety. A specifically designed information brochure explaining the induction process improved women's knowledge and understanding. Review Methods: The quantitative systematic review followed the Centre for Reviews and Dissemination guidelines and Cochrane Effective Practice and Organisation of Care guidance. Quality appraisal was conducted using JBI levels of evidence, Cochrane Risk of Bias, and other established tools. A narrative description of the quantitative data was undertaken. There was insufficient evidence to perform a narrative synthesis or meta-analysis due to the nature of the study designs and insufficient outcome data. Conclusions: Globally, the number of women having an induction of labour is increasing and there is a lack of evidence on the effectiveness of supportive interventions. Components of supportive care for women having induction of labour require urgent evaluation. Measurement tools which capture the complexity of supportive care for women having induction of labour need to be developed and validated. Impact: This is the first review to evaluate non-pharmacological, non-invasive supportive interventions for women having induction of labour. The findings of this review identify the urgent need to develop an evidence base for effective supportive

Mixed-methods systematic review: Childbearing women's views, experiences, and decision-making related to epidural analgesia in labour

© 2020 John Wiley & Sons Ltd Aims: To investigate childbearing women's views, experiences and decision-making related to epidural analgesia in labour. Design: Mixed-methods systematic review. Data Sources: A comprehensive literature search was implemented across Medline, CINAHL and EMBASE from 2000 to September 2018. The literature search was undertaken in January 2018 and updated in September 2018. Thirty papers were selected. Results: Four overarching synthesized findings were identified: (a) choice; (b) pain management experience; (c) lack of information; and (d) information provision and consent. Review Methods: Quality appraisal was conducted using JBI levels of evidence and other established tools. NVivo was used to independently dual code and thematically synthesize qualitative data. A narrative synthesis of the quantitative findings from the included studies was undertaken. The GRADE-CERQual approach was used to assess confidence in the review findings based on the qualitative data. A set of integrated mixed-methods synthesized findings was produced. Conclusion: Recommendations for practice based on the systematic review findings are that midwives should dedicate time to discuss epidural with women and birth partners, ideally during the second or third trimester of pregnancy, asking women what coping strategies or pain relief they have been considering, if any. The factors which may influence the woman's choice of epidural, including pain threshold, ability to cope with pain, timing of epidural and length of labour should be continuously evaluated during labour. The midwife should remain with women after an epidural has been sited, demonstrating understanding of the woman's choice and providing an opportunity for discussion of plans for the remaining labour and birth. Impact: The findings of this systematic review can inform both healthcare professionals and service users on various aspects of the decision-making process about the use of epidural analgesia in labour. Data can be transferable to similar settings in high-income countries

A mixed-methods study to investigate feasibility and acceptability of an early warning score for preterm infants in neonatal units in Kenya: results of the NEWS-K study

Preterm birth (\u3c 37 weeks gestation) complications are the leading cause of neonatal mortality. Early-warning scores (EWS) are charts where vital signs (e.g., temperature, heart rate, respiratory rate) are recorded, triggering action. To evaluate whether a neonatal EWS improves clinical outcomes in low-middle income countries, a randomised trial is needed. Determining whether the use of a neonatal EWS is feasible and acceptable in newborn units, is a prerequisite to conducting a trial. We implemented a neonatal EWS in three newborn units in Kenya. Staff were asked to record infants’ vital signs on the EWS during the study, triggering additional interventions as per existing local guidelines. No other aspects of care were altered. Feasibility criteria were pre-specified. We also interviewed health professionals (n = 28) and parents/family members (n = 42) to hear their opinions of the EWS. Data were collected on 465 preterm and/or low birthweight (\u3c 2.5 kg) infants. In addition to qualitative study participants, 45 health professionals in participating hospitals also completed an online survey to share their views on the EWS. 94% of infants had the EWS completed at least once during their newborn unit admission. EWS completion was highest on the day of admission (93%). Completion rates were similar across shifts. 15% of vital signs triggered escalation to a more senior member of staff. Health professionals reported liking the EWS, though recognised the biggest barrier to implementation was poor staffing. Newborn unit infant to staff ratios varied between 10 and 53 staff per 1 infant, depending upon time of shift and staff type. A randomised trial of neonatal EWS in Kenya is possible and acceptable, though adaptations are required to the form before implementation

Feasibility of using an Early Warning Score for preterm or low birthweight infants in a low-resource setting: Results of a mixed-methods study at a national referral hospital in Kenya

© 2020 BMJ Publishing Group. All rights reserved. Introduction Fifteen million babies are born prematurely, before 37 weeks gestational age, globally. More than 80% of these are in sub-Saharan Africa and Asia. 35% of all deaths in the first month of life are due to prematurity and the neonatal mortality rate is eight times higher in low-income and middle-income countries (LMICs) than in Europe. Early Warning Scores (EWS) are a way of recording vital signs using standardised charts to easily identify adverse clinical signs and escalate care appropriately. A range of EWS have been developed for neonates, though none in LMICs. This paper reports the findings of early work to examine if the use of EWS is feasible in LMICs.Methods We conducted an observational study to understand current practices for monitoring of preterm infants at a large national referral hospital in Nairobi, Kenya. Using hospital records, data were collected over an 8-week period in 2019 on all live born infants born a

Parents, healthcare professionals and other stakeholders’ experiences of caring for babies born too soon in a low resource setting: A qualitative study of essential newborn care for preterm infants in Kenya

Objectives: Prematurity is the leading cause of global neonatal and infant mortality. Many babies could survive by the provision of essential newborn care. This qualitative study was conducted in order to understand, from a family and professional perspective, the barriers and facilitators to essential newborn care. The study will inform the development of an early warning score for preterm and LBW infants in low and middle income countries (LMICs).Setting: Single-centre, tertiary referral hospital in Nairobi, Kenya.Participants: Nineteen mothers and family members participated in focus group discussions and twenty key-informant interviews with professionals (healthcare professionals and policy-makers) were conducted. Focus group participants were identified via postnatal wards, the Newborn Unit and Kangaroo Mother Care Unit. Convenience and purposive sampling was used to identify professionals. Outcome measures: Understanding facilitators and barriers to provision of essential newborn care in preterm infants.Results: From 27 themes, three global themes emerged from the data; mothers’ physical and psychological needs, system pillars and kangaroo mother care. Conclusion: Meeting mothers’ needs in the care of their babies is important to mothers, family members and professionals, and deserves greater attention. Functioning system pillars depended on a standardised approach to care and low cost, universally applicable interventions are needed to support the existing care structure. Kangaroo Mother Care (KMC) was effective in both meeting mothers’ needs, supporting existing care structures and also provided a space for the resolution of the dialectical relationship between families and hospital procedures. Lessons learnt from the implementation of KMC could be applied to the development of an early warning score in LMICs

Evaluation of an enhanced training package to support clinical trials training in low and middle income countries (LMICs): experiences from the Born Too Soon Optimising Nutrition study

Training is essential before working on a clinical trial, yet there is limited evidence on effective training methods. In low and middle income countries (LMICs), training of research staff was considered the second highest priority in a global health methodological research priority setting exercise. Methods We explored whether an enhanced training package in a neonatal feasibility study in Kenya and India, utilising elements of the train-the-trainer approach, altered clinicians and researchers’ clinical trials knowledge. A lead “trainer” was identified at each site who attended a UK-based introductory course on clinical trials. A two-day in-country training session was conducted at each hospital. Sessions included the study protocol, governance, data collection and ICH-Good Clinical Practice (GCP). To assess effectiveness of the training package, participants completed questionnaires at the start and end of the study period, including demographics, prior research experience, protocol-specific questions, informed consent and ICH-GCP. Results Thirty participants attended in-country training sessions and completed baseline questionnaires. Around three quarters had previously worked on a research study, yet only half had previously received training. Nineteen participants completed questionnaires at the end of the study period. Questionnaire scores were higher at the end of the study period, though not significantly so. Few participants ‘passed’ the informed consent and ICH-Good Clinical Practice (GCP) modules, using the Global Health Network Training Centre pass mark of ≥ 80%. Participants who reported having prior research experience scored higher in questionnaires before the start of the study period. Conclusions An enhanced training package can improve knowledge of research methods and governance though only small improvements in mean scores between questionnaires completed before and at the end of the study period were seen and were not statistically significant. This is the first report evaluating a clinical trial training package in a neonatal trial in LMICs. Due to the Covid-19 pandemic, research activity was paused and there was a significant time lapse between training and start of the study, which likely impacted upon the scores reported here. Given the burden of disease in LMICs, developing high-quality training materials which utilise a variety of approaches and build research capacity, is critical

A mixed-methods study to investigate feasibility and acceptability of an early warning score for preterm infants in neonatal units in Kenya: results of the NEWS-K study

Preterm birth (< 37 weeks gestation) complications are the leading cause of neonatal mortality. Early-warning scores (EWS) are charts where vital signs (e.g., temperature, heart rate, respiratory rate) are recorded, triggering action. To evaluate whether a neonatal EWS improves clinical outcomes in low-middle income countries, a randomised trial is needed. Determining whether the use of a neonatal EWS is feasible and acceptable in newborn units, is a prerequisite to conducting a trial. We implemented a neonatal EWS in three newborn units in Kenya. Staff were asked to record infants’ vital signs on the EWS during the study, triggering additional interventions as per existing local guidelines. No other aspects of care were altered. Feasibility criteria were pre-specified. We also interviewed health professionals (n = 28) and parents/family members (n = 42) to hear their opinions of the EWS. Data were collected on 465 preterm and/or low birthweight (< 2.5 kg) infants. In addition to qualitative study participants, 45 health professionals in participating hospitals also completed an online survey to share their views on the EWS. 94% of infants had the EWS completed at least once during their newborn unit admission. EWS completion was highest on the day of admission (93%). Completion rates were similar across shifts. 15% of vital signs triggered escalation to a more senior member of staff. Health professionals reported liking the EWS, though recognised the biggest barrier to implementation was poor staffing. Newborn unit infant to staff ratios varied between 10 and 53 staff per 1 infant, depending upon time of shift and staff type. A randomised trial of neonatal EWS in Kenya is possible and acceptable, though adaptations are required to the form before implementation

The FEED1 trial : protocol for a randomised controlled trial of full milk feeds versus intravenous fluids with gradual feeding for preterm infants (30-33 weeks gestational age)

BACKGROUND: In the UK, approximately 8% of live births are preterm (before 37 weeks gestation), more than 90% of whom are born between 30 and 36 weeks, forming the largest proportion of a neonatal units' workload. Neonatologists are cautious in initiating full milk feeds for preterm infants due to fears of necrotising enterocolitis (NEC). There is now evidence to dispute this fear. Small studies have shown that feeding preterm infants full milk feeds enterally from birth could result in a shorter length of hospital stay, which is important to parents, clinicians and NHS services without increasing the risk of NEC. This trial aims to investigate whether full milk feeds initiated in the first 24 h after birth reduces the length of hospital stay in comparison to introduction of gradual milk feeding with IV fluids or parenteral nutrition. METHODS: FEED1 is a multi-centre, open, parallel group, randomised, controlled superiority trial of full milk feeds initiated on the day of birth versus gradual milk feeds for infants born at 30+0 to 32+6 (inclusive) weeks gestation. Recruitment will take place in around 40 UK neonatal units. Mothers will be randomised 1:1 to full milk feeds, starting at 60 ml/kg day, or gradual feeds, as per usual local practice. Mother's expressed breast milk will always be the first choice of milk, though will likely be supplemented with formula or donor breast milk in the first few days. Feeding data will be collected until full milk feeds are achieved (≥ 140 ml/kg/day for 3 consecutive days). The primary outcome is length of infant hospital stay. Additional data will be collected 6 weeks post-discharge. Follow-up at 2 years (corrected gestational age) is planned. The sample size is 2088 infants to detect a between group difference in length of stay of 2 days. Accounting for multiple births, this requires 1700 women to be recruited. Primary analysis will compare the length of hospital stay between groups, adjusting for minimisation variables and accounting for multiple births. DISCUSSION: This trial will provide high-quality evidence on feeding practices for preterm infants. Full milk feeds from day of birth could result in infants being discharged sooner. TRIAL REGISTRATION: ISRCTN ISRCTN89654042 . Prospectively registered on 23 September 2019: ISRCTN is a primary registry of the WHO ICTRP network, and all items from the WHO Trial Registration dataset are included

Young mothers’ negotiations of infant feeding. A qualitative study with ethnographic methods.

Background: In the UK, mothers under 20 are the group least likely to breastfeed. Recent public health interventions to promote breastfeeding in the under 20s have met with limited success. Suggested factors include cultural constructions of normative behaviour, environmental and practical barriers, and a lack of professional and community support. However, less is known about the journey through infant feeding and the interrelation of the various influences on the experiences of young mothers. Methods: Ethnographic interviews and participant observation were used to explore the lived experience of ten young mothers aged 16-18 and their babies, from pregnancy to weaning. The data were analysed using Thematic Network Analysis and the emerging themes developed into a coherent description of the influences on infant feeding practices and why these influences seem to lead to formula feeding. Results: The influences were found to relate to three broad thematic areas: the immediate context and the importance of family relationships; the external context of public spaces (which could include the public areas of the home) and the themes of the babies and the milk. Discussion: Theories of the interplay of practical experiences of the young mothers with moral discourses of good motherhood were developed. Using the Ricœurdian theory of the narrative of the self (ipse identity) the work of becoming a mother and making feeding decisions in a morally charged environment are explicated. This approach has begun to reframe the discourse on health research on the public health approach to breastfeeding to encompass and integrate personal identities and social relationships with cultural norms of infant feeding. Conclusions: The findings gave new insights into both why breastfeeding rates are low in this group and why existing interventions have not significantly changed behaviour. The need for a consideration of the social, cultural and moral meanings of infant feeding to young mothers has been highlighted. Practical suggestions for supporting young mothers who wish to breastfeed have also been developed from these research findings