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

Factors influencing utilisation of ‘free-standing’ and ‘alongside’ midwifery units for low-risk births in England: a mixed-methods study

Background Midwifery-led units (MUs) are recommended for ‘low-risk’ births by the National Institute for Health and Care Excellence but according to the National Audit Office were not available in one-quarter of trusts in England in 2013 and, when available, were used by only a minority of the low-risk women for whom they should be suitable. This study explores why. Objectives To map the provision of MUs in England and explore barriers to and facilitators of their development and use; and to ascertain stakeholder views of interventions to address these barriers and facilitators. Design Mixed methods – first, MU access and utilisation across England was mapped; second, local media coverage of the closure of free-standing midwifery units (FMUs) were analysed; third, case studies were undertaken in six sites to explore the barriers and facilitators that have an impact on the development of MUs; and, fourth, by convening a stakeholder workshop, interventions to address the barriers and facilitators were discussed. Setting English NHS maternity services. Participants All trusts with maternity services. Interventions Establishing MUs. Main outcome measures Numbers and types of MUs and utilisation of MUs. Results Births in MUs across England have nearly tripled since 2011, to 15% of all births. However, this increase has occurred almost exclusively in alongside units, numbers of which have doubled. Births in FMUs have stayed the same and these units are more susceptible to closure. One-quarter of trusts in England have no MUs; in those that do, nearly all MUs are underutilised. The study findings indicate that most trust managers, senior midwifery managers and obstetricians do not regard their MU provision as being as important as their obstetric-led unit provision and 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 provision and utilisation are influenced by a complex range of factors, including the medicalisation of childbirth, financial constraints and institutional norms protecting the status quo. Limitations When undertaking the case studies, we were unable to achieve representativeness across social class in the women’s focus groups and struggled to recruit finance directors for individual interviews. This may affect the transferability of our findings. Conclusions Although there has been an increase in the numbers and utilisation of MUs since 2011, significant obstacles remain to MUs reaching their full potential, especially FMUs. This includes the capacity and willingness of providers to address women’s information needs. If these remain unaddressed at commissioner and provider level, childbearing women’s access to MUs will continue to be restricted. Future work Work is needed on optimum approaches to improve decision-makers’ understanding and use of clinical and economic evidence in service design. Increasing women’s access to information about MUs requires further studies of professionals’ understanding and communication of evidence. The role of FMUs in the context of rural populations needs further evaluation to take into account user and community impact. Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 12. See the NIHR Journals Library website for further project information

Supersonic combustion engine testbed, heat lightning

The design of a supersonic combustion engine testbed (SCET) aircraft is presented. The hypersonic waverider will utilize both supersonic combustion ramjet (SCRAMjet) and turbofan-ramjet engines. The waverider concept, system integration, electrical power, weight analysis, cockpit, landing skids, and configuration modeling are addressed in the configuration considerations. The subsonic, supersonic and hypersonic aerodynamics are presented along with the aerodynamic stability and landing analysis of the aircraft. The propulsion design considerations include: engine selection, turbofan ramjet inlets, SCRAMjet inlets and the SCRAMjet diffuser. The cooling requirements and system are covered along with the topics of materials and the hydrogen fuel tanks and insulation system. A cost analysis is presented and the appendices include: information about the subsonic wind tunnel test, shock expansion calculations, and an aerodynamic heat flux program

Impact of metastable defect structures on carrier recombination in solar cells

The efficiency of a solar cell is often limited by electron-hole recombination mediated by defect states within the band gap of the photovoltaic (PV) semiconductor. The Shockley-Read-Hall (SRH) model considers a static trap that can successively capture electrons and holes. In reality however, true trap levels vary with both the defect charge state and local structure. Here we consider the role of metastable structural configurations in capturing electrons and holes, taking the tellurium interstitial in CdTe as an illustrative example. Consideration of the defect dynamics, and symmetry-breaking, changes the qualitative behaviour and activates new pathways for carrier capture. Our results reveal the potential importance of metastable defect structures in non-radiative recombination, in particular for semiconductors with anharmonic/ionic-covalent bonding, multinary compositions, low crystal symmetries or highly-mobile defects

VLASSICK: The VLA Sky Survey in the Central Kiloparsec

At a distance of 8 kpc, the center of our Galaxy is the nearest galactic nucleus, and has been the subject of numerous key projects undertaken by great observatories such as Chandra, Spitzer, and Herschel. However, there are still no surveys of molecular gas properties in the Galactic center with less than 30" (1 pc) resolution. There is also no sensitive polarization survey of this region, despite numerous nonthermal magnetic features apparently unique to the central 300 parsecs. In this paper, we outline the potential the VLASS has to fill this gap. We assess multiple considerations in observing the Galactic center, and recommend a C-band survey with 10 micro-Jy continuum RMS and sensitive to molecular gas with densities greater than 10^4 cm^{-3}, covering 17 square degrees in both DnC and CnB configurations ( resolution ~5"), totaling 750 hours of observing time. Ultimately, we wish to note that the upgraded VLA is not just optimized for fast continuum surveys, but has a powerful correlator capable of simultaneously observing continuum emission and dozens of molecular and recombination lines. This is an enormous strength that should be fully exploited and highlighted by the VLASS, and which is ideally suited for surveying the center of our Galaxy.Comment: 13 pages, 3 figures, a White Paper submitted to provide input in planning the Very Large Array Sky Surve

Homogenisation and analysis of an expanded long-term monthly rainfall network for the Island of Ireland (1850-2010)

Long-term precipitation series are critical for understanding emerging changes to the hydrological cycle. To this end we construct a homogenised Island of Ireland Precipitation (IIP) network comprising 25 stations and a composite series covering the period 1850-2010, providing the second- longest regional precipitation archive in the British-Irish Isles. We expand the existing catalogue of long-term precipitation records for the island by recovering archived data for an additional eight stations. Following bridging and updating of stations HOMER homogenisation software is used to detect breaks using pairwise and joint detection. Twenty-five breakpoints are detected across 14 stations, and the majority (20) are corroborated by metadata. Assessment of variability and change in homogenised and extended precipitation records reveal positive (winter) and negative (summer) trends. Trends in records covering the typical period of digitisation (1941 onwards) are not always representative of longer records. Furthermore, trends in post-homogenisation series change magnitude and even direction at some stations. While cautionary flags are raised for some series, confidence in the derived network is high given attention paid to metadata, coherence of behaviour across the network and consistency of findings with other long-term climatic series such as England and Wales precipitation. As far as we are aware, this work represents the first application of HOMER to a long- term precipitation network and bodes well for use in other regions. It is expected that the homogenised IIP network will find wider utility in benchmarking and supporting climate services across the Island of Ireland, a sentinel location in the North Atlantic

Interviewing suspects: examining the association between skills, questioning, evidence disclosure, and interview outcomes

The interviewing of suspects is an important element in the investigation of crime. However, studies concerning actual performance of investigators when undertaking such interviews remain sparse. Nevertheless, in England and Wales, since the introduction of a prescribed framework over 20 years ago, field studies have generally shown an improvement in interviewing performance, notwithstanding ongoing concerns largely relating to the more demanding aspects (such as building/maintaining rapport, intermittent summarising and the logical development of topics). Using a sample of 70 real-life interviews, the present study examined questioning and various evidence disclosure strategies (which have also been found demanding), examining their relationships between interview skills and interview outcomes. It was found that when evidence was disclosed gradually (but revealed later), interviews were generally both more skilled and involved the gaining of comprehensive accounts, whereas when evidence was disclosed either early or very late, interviews were found to be both less skilled and less likely to involve this outcome. These findings contribute towards an increased research base for the prescribed framework

Quantum tomographic cryptography with Bell diagonal states: non-equivalence of classical and quantum distillation protocols

We present a generalized tomographic quantum key distribution protocol in which the two parties share a Bell diagonal mixed state of two qubits. We show that if an eavesdropper performs a coherent measurement on many quantum ancilla states simultaneously, classical methods of secure key distillation are less effective than quantum entanglement distillation protocols. We also show that certain Bell diagonal states are resistant to any attempt of incoherent eavesdropping.Comment: 9 pages. 2 figures There was an error in the formula 4 (transformation of Bell states). This error does not change the main result of the paper, namely, that quantum distillation is more powerful than classical advantage distillatio