What are the characteristics of perinatal events perceived to be traumatic by midwives?

Objective: there is potential for midwives to indirectly experience events whilst providing clinical care that fulfil criteria for trauma. This research aimed to investigate the characteristics of events perceived as traumatic by UK midwives. Methods: as part of a postal questionnaire survey conducted between December 2011 and April 2012, midwives (n=421) who had witnessed and/or listened to an account of an event and perceived this as traumatic for themselves provided a written description of their experience. A traumatic perinatal event was defined as occurring during labour or shortly after birth where the midwife perceived the mother or her infant to be at risk, and they (the midwife) had experienced fear, helplessness or horror in response. Descriptions of events were analysed using thematic analysis. Witnessed (W; n=299) and listened to (H; n=383) events were analysed separately and collated to identify common and distinct themes across both types of exposure. Findings: six themes were identified, each with subthemes. Five themes were identified in both witnessed and listened to accounts and one was salient to witnessed accounts only. Themes indicated that events were characterised as severe, unexpected and complex. They involved aspects relating to the organisational context; typically limited or delayed access to resources or personnel. There were aspects relating to parents, such as having an existing relationship with the parents, and negative perceptions of the conduct of colleagues. Traumatic events had a common theme of generating feelings of responsibility and blame Finally for witnessed events those that were perceived as traumatic sometimes held personal salience, so resonated in some way with the midwife's own life experience Key conclusions: midwives are exposed to events as part of their work that they may find traumatic. Understanding the characteristics of the events that may trigger this perception may facilitate prevention of any associated distress and inform the development of supportive interventions

The experience and impact of traumatic perinatal event experiences in midwives: A qualitative investigation

Background: Through their work midwives may experience distressing events that fulfil criteria for trauma. However, there is a paucity of research examining the impact of these events, or what is perceived to be helpful/unhelpful by midwives afterwards. Objective: To investigate midwives’ experiences of traumatic perinatal events and to provide insights into experiences and responses reported by midwives with and without subsequent posttraumatic stress symptoms. Design: Semi-structured telephone interviews were conducted with a purposive sample of midwives following participation in a previous postal survey. Methods: 35 midwives who had all experienced a traumatic perinatal event defined using the Diagnostic and Statistical Manual of Mental Disorders (version IV) Criterion A for posttraumatic stress disorder were interviewed. Two groups of midwives with high or low distress (as reported during the postal survey) were purposefully recruited. High distress was defined as the presence of clinical levels of PTSD symptomatology and high perceived impairment in terms of impacts on daily life. Low distress was defined as any symptoms of PTSD present were below clinical threshold and low perceived life impairment. Interviews were analysed using template analysis, an iterative process of organising and coding qualitative data chosen for this study for its flexibility. An initial template of four a priori codes was used to structure the analysis: event characteristics, perceived responses and impacts, supportive and helpful strategies and reflection of change over time codes were amended, integrated and collapsed as appropriate through the process of analysis. A final template of themes from each group is presented together with differences outlined where applicable. Results: Event characteristics were similar between groups, and involved severe, unexpected episodes contributing to feeling ‘out of a comfort zone.’ Emotional upset, self-blame and feelings of vulnerability to investigative procedures were reported. High distress midwives were more likely to report being personally upset by events and to perceive all aspects of personal and professional lives to be affected. Both groups valued talking about the event with peers, but perceived support from senior colleagues and supervisors to be either absent or inappropriate following their experience; however, those with high distress were more likely to endorse this view and report a perceived need to seek external input. Conclusion: Findings indicate a need to consider effective ways of promoting and facilitating access to support, at both a personal and organisational level, for midwives following the experience of a traumatic perinatal event

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

Defining the latent phase of labour: is it important?

Background and rationale: The latent phase of labour is recognised as a period of uncertainty for both women and midwives. There is evidence from the literature of considerable variation in labour definitions and practice. Stimulated by discussion at an international maternity research conference, we set out to explore opinions regarding the need for labour stage definitions. Aim: to identify health professionals’ views regarding the need for a definition of the onset and the end of the latent phase of labour. Methods: This was an opportunistic, semi-structured, online survey of attendees at a maternity care research conference, which included midwives, other clinicians, academics, advocates and user representatives. Attendees (approximately 100) were invited to participate through a single email invitation sent by the conference committee and containing a link to the survey. Consent was sought on the landing page. Ethical approval was obtained from Bournemouth University’s research ethics committee. Quantitative questions were analysed using simple descriptive statistics using IBM SPSS Statistics Version 24. Open questions were analysed using content analysis and where participants gave a more detailed answer, these were analysed using a thematic approach. Findings: Participants in the survey (n = 21) came from twelve countries. Most of the participants thought that there was a need to define the onset of the latent phase (n = 15, 71%). Common characteristics were cited, but the main theme in the open comments referred to the importance of women’s perceptions of labour onset. Most participants (n = 18, 86%) thought that there was a need to define the end of the latent phase. This was felt necessary because current practice within facilities is usually dictated by a definition. The characteristics suggested were also not unexpected and there was some consensus; but the degree of cervical dilatation that signified the end of the latent phase varied among participants. There was significant debate about whether a prolonged latent phase was important; for example, was it associated with adverse consequences. Most participants thought it was important (n = 15, 71%), but comments indicated that the reasons for this were complex. Themes included the value that women attached to knowing the duration of labour and the need to support women in the latent phase. Implications for practice: The findings from this small, opportunistic survey reflect the current debate within the maternal health community regarding the latent phase of labour. There is a need for more clarity around latent phase labour (in terms of both the definition and the support offered) if midwives are to provide care that is both woman centred and evidence-based. The findings will inform the development of a larger survey to explore attitudes towards labour definitions

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

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

Do antenatal preparation and obstetric complications and procedures interact to affect birth experience and postnatal mental health?

Background Antenatal preparation is commonly offered to women in pregnancy in the United Kingdom, but the content is highly variable, with some programmes orientated towards ‘normal birth’, whilst others may incorporate information about complications and procedures (broader focus). However, the impact of this variability on birth experience has not been explored. We examined the relationship between the content of antenatal preparation received and birth experience, taking into account obstetric complications and procedures. As birth experience can have a profound impact on a mother’s postnatal well-being, we also investigated associations with mothers’ postnatal mood and anxiety. Methods N = 253 first-time mothers completed a cross-sectional survey measuring demographic and clinical factors, antenatal preparation content (categorised as normality-focused or broader-focused), obstetric complications and procedures experienced, birth experience (measured using three separate indices; the Childbirth Experience Questionnaire, emotional experiences, and presence/absence of birth trauma), postnatal depression and anxiety, and qualitative information on how the COVID-19 pandemic had affected birth experience. Results Regarding birth experience, receiving more broader-focused preparation was associated with a more positive birth experience irrespective of complications/procedures experienced, while receiving only normality-focused preparation was beneficial in the context of fewer complications/procedures. Regarding birth trauma, receiving more broader-focused preparation was associated with lower likelihood of reporting birth as traumatic only in the context of more complications/procedures. Degree of normality-focused preparation was unrelated to experience of birth trauma. Lastly, while more complications/procedures were associated with greater anxiety and low mood, only greater normality-focused preparation was linked with better postnatal mental health. Conclusions Antenatal preparation including both normality- and broader-focused information is positively related to women’s birth experience. While normality-focused preparation seems most beneficial if fewer complications/procedures are experienced, broader-focused preparation may be most beneficial in the context of a greater number of complications/procedures. As complications/procedures are often unpredictable, offering broader-focused preparation routinely is likely to benefit women’s birth experience. This antenatal preparation should be freely available and easily accessible

Risk factors for PTSD after birth in a normal population: A meta-analysis

Evidence suggests that a proportion of women report posttraumatic stress disorder (PTSD) after childbirth, with between 1 and 3% of women developing the disorder as a direct result of birth (Alcorn, O'Donovan, Patrick, Creedy, & Devilly). A range of factors are associated with postpartum PTSD, including prepartum, birth and postpartum factors. This meta-analysis synthesizes research on posttraumatic stress symptoms after childbirth in order to identify key vulnerability and risk factors. Method: A systematic search was carried out on databases (PsychInfo, PubMed, Scopus and Web of Science) using PTSD terms (posttraumatic stress, post-traumatic stress, trauma*, PTSD) crossed with childbirth-related terms (birth, pregnancy, partum, postpartum, prenatal, postnatal, stillbirth, miscarriage, gestation, partus, labour). Studies were included if they reported primary research examining factors associated with birth-related PTSD symptoms. PTSD had to be measured at least one month after birth to avoid confusion with acute stress disorder symptoms. Research on specific populations was excluded e.g. teenagers, pregnancy loss or stillbirth. Results: Of the 792 records screened, 48 papers reporting results of 43 research studies fulfilled inclusion criteria (N=20,372). Key vulnerability and risk factors were subjective birth experience, particularly negative emotions during birth, a fear of childbirth, and a history of PTSD or depression. Postpartum PTSD was highly comorbid with concurrent symptoms of depression. Conclusion: Identification of vulnerability and risk factors for postpartum PTSD is critical for appropriate screening and prevention. Future research needs to examine the interaction between vulnerability and risk factors, as proposed by theoretical frameworks of postpartum PTSD (Ayers 2004; Slade 2006)

Plans, Preferences or Going with the Flow: an Online Exploration of Women’s Views and Experiences of Birth Plans

Objective To explore women’s views of birth plans, and experiences of their completion and use. Design A qualitative, exploratory study, using Internet-mediated research methods. Setting The discussion boards of two well-known, UK-based, online parenting forums, where a series of questions relating to birth plans were posted. Participants Members of the selected parenting forums who had written and used, or who had chosen not to write or use, a birth plan. Findings Women responded with a range of views and experiences relating to the completion and use of birth plans. The benefits of birth plans were described in terms of communication with healthcare professionals, potentially enhancing awareness of available options, and maintaining a sense of control during labour and birth. However, many respondents believed the idea of ‘planning’ birth was problematic, and described a reluctance to write a formal plan. The support of healthcare professionals, particularly midwives, was considered essential to the success of both writing and using birth plans. Key conclusions Our findings show a continued debate among women on the benefits and challenges involved in writing and using birth plans, suggesting problems for a ‘one size fits all’ approach often seen in the use of birth plan templates. In the context of maternity policy supporting women’s choice and personalised care, and as a way of acknowledging perceived problems of ‘planning’ for birth, a flexible approach to birth plans is required, including the consideration of employing alternative nomenclature. Implications for practice Birth plans remain a point of contention in care contexts around the world. Midwives and other healthcare providers play a central role in supporting women to discuss available options, whether or not they decide to complete a formal birth plan