A systematic review to examine the evidence regarding discussions by midwives, with women, around their options for where to give birth

BACKGROUND: Discussion of place of birth is important for women and maternity services, yet the detail, content and delivery of these discussions are unclear. The Birthplace Study found that for low risk, multiparous women, there was no significant difference in neonatal safety outcomes between women giving birth in obstetric units, midwifery-led units, or home. For low risk, nulliparous women giving birth in a midwifery-led unit was as safe as in hospital, whilst birth at home was associated with a small, increased risk of adverse perinatal outcomes. Intervention rates were reduced in all settings outside hospital. NICE guidelines recommend all women are supported in their choice of birth setting. Midwives have the opportunity to provide information to women about where they choose to give birth. However, research suggests women are sometimes unaware of all the options available. This systematic review will establish what is known about midwives’ perspectives of discussions with women about their options for where to give birth and whether any interventions have been implemented to support these discussions. METHODS: The systematic review was PROSPERO registered (registration number: CRD42015017334). The PRISMA statement was followed. Medline, Cochrane, CINAHL, PsycINFO, Popline and EMBASE databases were searched between 2000-March 2015 and grey literature was searched. All identified studies were screened for inclusion. Qualitative data was thematically analysed, whilst quantitative data was summarised. RESULTS: The themes identified relating to influences on midwives’ place of birth discussions with women were organisational pressures and professional norms, inadequate knowledge and confidence of midwives, variation in what midwives told women and the influence of colleagues. None of the interventions identified provided sufficient evidence of effectiveness and were of poor quality. CONCLUSIONS: The review has suggested the need for a pragmatic, understandable place of birth dialogue containing standard content to ensure midwives provide low risk women with adequate information about their place of birth options and the need to improve midwives knowledge about place of birth. A more robust, systematic evaluation of any interventions designed is required to improve the quality of place of birth discussions. By engaging with co-produced research, more effective interventions can be designed, implemented and sustained

Provision of interpreting support for cross-cultural communication in UK maternity services:A Freedom of Information request

Background: Language, communication and understanding of information are central to safe, ethical and efficient maternity care. The National Health Service (NHS) commissioning board, NHS England, describes how healthcare providers should obtain language support through professionally trained interpreters. Providers of interpreters are commissioned to deliver remote/face to face interpretation across the NHS. Services can be booked in advance or calls can be made in real time. However, women report infrequent use of professionally trained interpreters during their maternity care, often relying on friends and family as interpreters which can compromise confidentiality, disclosure and accuracy.Methods: To determine the demand for, and provision of, professionally trained interpreters in practice, we sent a Freedom of Information (FOI) request to 119 NHS Trusts delivering maternity services in England in November 2022. For the financial years 2020/2021 and 2021/2022, we asked how many women in the maternity service were identified as needing an interpreter, the number and mode of interpreter sessions, and the annual spend on interpreting services. Datawere analysed using descriptive statistics.Results: One hundred maternity Trusts responded by 21st April 2023 (response rate 100/119–84 %). Of these, 56 (56 %) recorded a woman’s need for an interpreter. Nineteen Trusts relied on documentation in paper notes and 37 Trusts recorded the information on a digital system. From the 37 Trusts where this information could be digitally retrieved, women requiring interpretersupport reflected between 1 and 25 % of the annual birth rate of the Trust (average 9 %) and received an average of three interpreter sessions across their pregnancy, birth and postnatal journey. Telephone was the dominant mode used for interpreting sessions, though 11 Trusts favoured face to face interpreting. Financial spend on interpreting services varied across Trusts; some funded their own in-house interpreting services, or worked with local community groups inaddition to their contracted interpreting provider.Conclusion: Information obtained from this FOI request suggests that Documentation of a woman’s interpreting need is not complete or consistent across NHS maternity services. As a result, it is not clear how many women require an interpreter, the mode of provision or how frequently it is provided, and the cost involved. However, the limited information available suggests a failure to provide interpreter support to women at each scheduled care encounter. This raises questions about, the risk of women not understanding the care being offered, and the increased risk of uninformed, unconsented care as women traverse pregnancy and birth

Metastatic Lobular Breast Carcinoma in a Meningioma: A Case Study

Hormonal relationships between breast carcinoma and meningioma have long been reported in the literature. This association may be related to the widespread expression of progesterone receptors in meningiomas. Indeed, meningiomas are more common in women and may demonstrate increased growth during pregnancy. Women have an increased risk of meningioma following breast carcinoma diagnosis and vice versa. However, much more uncommon is a tumor to tumor metastases of breast carcinoma into a meningioma. We report a case of a 56 year old female with a past medical history of breast cancer, found to have a right sphenoorbital meningioma with metastatic lobular carcinoma. Pathological findings include a WHO grade 1, transitional meningioma with IHC staining for EMA, marking not only a meningioma but also linearly arranged epithelioid cells. Determined to be metastases of invasive lobular carcinoma, these epithelioid cells were E-cadherin negative and GATA3, GCDFPmammoglobin, and ER positive. Progesterone receptor staining was inconclusive due to the strongly progesterone staining meningioma. Radiographic studies lack the sensitivity or specificity to diagnose intrameningioma metastases. Furthermore, because meningiomas and breast carcinomas are often both steroid receptor and EMA positive, careful histopathologic analysis of the entire meningioma may help to overcome challenges in diagnosing such metastases

Task shifting Midwifery Support Workers as the second health worker at a home birth in the UK: A qualitative study

Objective: Traditionally two midwives attend home births in the UK. This paper explores the implementation of a new home birth care model where births to low risk women are attended by one midwife and one Midwifery Support Worker (MSW). Design and setting: The study setting was a dedicated home birth service provided by a large UK urban hospital. Participants: Seventy-three individuals over 3 years: 13 home birth midwives, 7 MSWs, 7 commissioners (plan and purchase healthcare), 9 managers, 23 community midwives, 14 hospital midwives. Method: Qualitative data were gathered from 56 semi-structured interviews (36 participants), 5 semi-structured focus groups (37 participants) and 38 service documents over a 3 year study period. A rapid analysis approach was taken: data were reduced using structured summary templates, which were entered into a matrix, allowing comparison between participants. Findings were written up directly from the matrix (Hamilton, 2013). Findings: The midwife-MSW model for home births was reported to have been implemented successfully in practice, with MSWs working well, and emergencies well-managed. There were challenges in implementation, including: defining the role of MSWs; content and timing of training; providing MSWs with pre-deployment exposure to home birth; sustainability (recruiting and retaining MSWs, and a continuing need to provide two midwife cover for high risk births). The Service had responded to challenges and modified the approach to recruitment, training and deployment. Conclusions: The midwife-MSW model for home birth shows potential for task shifting to release midwife capacity and provide reliable home birth care to low risk women. Some of the challenges tally with observations made in the literature regarding role redesign. Others wishing to introduce a similar model would be advised to explicitly define and communicate the role of MSWs, and to ensure staff and women support it, consider carefully recruitment, content and delivery of training and retention of MSWs and confirm the model is cost-effective. They would also need to continue to provide care by two midwives at high risk births

Systematic exploration of local reviews of the care of maternal deaths in the UK and Ireland between 2012 and 2014: A case note review study

Objectives Local reviews of the care of women who die in pregnancy and post-birth should be undertaken. We investigated the quantity and quality of hospital reviews. DesignAnonymised case notes review. Participants All 233 women in the UK and Ireland who died during or up to 6 weeks after pregnancy from any cause related to or aggravated by pregnancy or its management in 2012-2014. Main outcome measures The number of local reviews undertaken. Quality was assessed by the composition of the review panel, whether root causes were systematically assessed and actions detailed. Results The care of 177/233 (76%) women who died was reviewed locally. The care of women who died in early pregnancy and after 28 days post-birth was less likely to be reviewed as was the care of women who died outside maternity services and who died from mental health-related causes. 140 local reviews were available for assessment. Multidisciplinary review was undertaken for 65% (91/140). External involvement in review occurred in 12% (17/140) and of the family in 14% (19/140). The root causes of deaths were systematically assessed according to national guidance in 13% (18/140). In 88% (123/140) actions were recommended to improve future care, with a timeline and person responsible identified in 55% (77/140). Audit to monitor implementation of changes was recommended in 14% (19/140). Conclusions This systematic assessment of local reviews of care demonstrated that not all hospitals undertake a review of care of women who die during or after pregnancy and in the majority quality is lacking. The care of these women should be reviewed using a standardised robust process including root cause analysis to maximise learning and undertaken by an appropriate multidisciplinary team who are given training, support and adequate time

Systematic exploration of local reviews of the care of maternal deaths in the UK and Ireland between 2012 and 2014:a case note review study

ObjectivesLocal reviews of the care of women who die in pregnancy and post-birth should be undertaken. We investigated the quantity and quality of hospital reviews.DesignAnonymised case notes review.ParticipantsAll 233 women in the UK and Ireland who died during or up to 6 weeks after pregnancy from any cause related to or aggravated by pregnancy or its management in 2012–2014.Main outcome measuresThe number of local reviews undertaken. Quality was assessed by the composition of the review panel, whether root causes were systematically assessed and actions detailed.ResultsThe care of 177/233 (76%) women who died was reviewed locally. The care of women who died in early pregnancy and after 28 days post-birth was less likely to be reviewed as was the care of women who died outside maternity services and who died from mental health-related causes. 140 local reviews were available for assessment. Multidisciplinary review was undertaken for 65% (91/140). External involvement in review occurred in 12% (17/140) and of the family in 14% (19/140). The root causes of deaths were systematically assessed according to national guidance in 13% (18/140). In 88% (123/140) actions were recommended to improve future care, with a timeline and person responsible identified in 55% (77/140). Audit to monitor implementation of changes was recommended in 14% (19/140).ConclusionsThis systematic assessment of local reviews of care demonstrated that not all hospitals undertake a review of care of women who die during or after pregnancy and in the majority quality is lacking. The care of these women should be reviewed using a standardised robust process including root cause analysis to maximise learning and undertaken by an appropriate multidisciplinary team who are given training, support and adequate time

When choice becomes limited:Women's experiences of delay in labour

Choice and patient involvement in decision-making are strong aspirations of contemporary healthcare. One of the most striking areas in which this is played out is maternity care where recent policy has focused on choice and supporting normal birth. However, birth is sometimes not straightforward and unanticipated complications can rapidly reduce choice. We draw on the accounts of women who experienced delay during labour with their first child. This occurs when progress is slow, and syntocinon is administered to strengthen and regulate contractions. Once delay has been recognised the clinical circumstances limit choice. Drawing on Mol’s work on the logics of choice and care, we explore how, although often upsetting, women accepted that their choices and plans were no longer feasible. The majority were happy to defer to professionals who they regarded as having the necessary technical expertise, while some adopted a more traditional medical model and actively rejected involvement in decision making altogether. Only a minority wanted to continue active involvement in decision-making, although the extent to which the possibility existed for them to do so was questionable. Women appeared to accept that their ideals of choice and involvement had to be abandoned, and that clinical circumstances legitimately changed events

The effect of a monetary incentive on return of a postal health and development questionnaire: a randomised trial [ISRCTN53994660]

BACKGROUND: Postal questionnaires are widely used to collect data in healthcare research but a poor response rate may reduce the validity and reliability of results. There was a lack of evidence available relating to use of a monetary incentive to improve the response rate in the healthcare setting. METHODS: The MRC ORACLE Children Study is assessing the health and development of nearly 9000 seven year old children whose mothers' joined the MRC ORACLE Trial. We carried out a randomised controlled trial of inclusion of monetary incentive (five pound voucher redeemable at many high street stores) with the reminder questionnaire to parents. This trial took place between April 2002 and November 2003. When the parents were sent the reminder questionnaire about their child's health and development they were randomly assigned by concealed computer-generated allocation stratified by week of birthday to receive a five pound voucher or no incentive. The population were 722 non-responders to the initial mailing of a 12-page questionnaire. Main outcome measures: Difference in response rate between the two groups. RESULTS: Inclusion of the voucher with the reminder questionnaire resulted in a 11.7%(95% CI 4.7% to 18.6%) improvement in the response rate between the two groups. CONCLUSION: This improvement in response rate and hence the validity and reliability of results obtained appears to be justified ethically and financially

On the Emergent Spectra of Hot Protoplanet Collision Afterglows

We explore the appearance of terrestrial planets in formation by studying the emergent spectra of hot molten protoplanets during their collisional formation. While such collisions are rare, the surfaces of these bodies may remain hot at temperatures of 1000-3000 K for up to millions of years during the epoch of their formation. These object are luminous enough in the thermal infrared to be observable with current and next generation optical/IR telescopes, provided that the atmosphere of the forming planet permits astronomers to observe brightness temperatures approaching that of the molten surface. Detectability of a collisional afterglow depends on properties of the planet's atmosphere -- primarily on the mass of the atmosphere. A planet with a thin atmosphere is more readily detected, because there is little atmosphere to obscure the hot surface. Paradoxically, a more massive atmosphere prevents one from easily seeing the hot surface, but also keeps the planet hot for a longer time. In terms of planetary mass, more massive planets are also easier to detect than smaller ones because of their larger emitting surface areas. We present preliminary calculations assuming a range of protoplanet masses (1-10 M_\earth), surface pressures (1-1000 bar), and atmospheric compositions, for molten planets with surface temperatures ranging from 1000 to 1800 K, in order to explore the diversity of emergent spectra that are detectable. While current 8- to 10-m class ground-based telescopes may detect hot protoplanets at wide orbital separations beyond 30 AU (if they exist), we will likely have to wait for next-generation extremely large telescopes or improved diffraction suppression techniques to find terrestrial planets in formation within several AU of their host stars.Comment: 28 pages, 6 figures, ApJ manuscript format, accepted into the Ap

Midwives’ perspectives of continuity based working in the UK: A cross-sectional survey

Objective: UK policy is advocating continuity of midwife throughout the antenatal, intrapartum and postnatal period in order to improve outcomes. We explored the working patterns that midwives are willing and able to adopt, barriers to change, and what would help midwives to work in continuity models of care.Design: A cross-sectional survey.Setting: 27 English maternity providers in the seven geographically-based ‘Early Adopter’ sites, which have been chosen to fast-track national policy implementation. Participants: All midwives working in the ‘Early Adopter’ sites were eligible to take part.Method: Anonymous online survey disseminated by local and national leaders, and social media, in October 2017. Descriptive statistics were calculated for quantitative survey responses. Qualitative free text responses were analysed thematically.Findings: 798 midwives participated (estimated response rate 20% calculated using local and national NHS workforce headcount data for participating sites). Being willing or able to work in a continuity model (caseloading and/or team)was lowest where this included intrapartum care in both hospital and home settings (35%, n = 279). Willingness to work in a continuity model of care increased as the range of intrapartum care settings covered decreased (home births only 45%, n = 359; no intrapartum care at all 54%, n = 426). A need to work on the same day each week was reported by 24% (n = 188). 31% (n = 246) were currently working 12 h shifts only, while 37% (n = 295) reported being unable to work any on-calls and/or nights. Qualitative analysis revealed multiple barriers to working in continuity models: the most prominent was caring responsibilities for children and others. Midwives suggested a range of approaches to facilitate working differently including concessions in the way midwife roles are organised, such as greater autonomy and choice in working patterns.Conclusions: Findings suggest that many midwives are not currently able or willing to work in continuity models, which includes care across antenatal, intrapartum and postnatal periods as recommended by UK policy.Implications for Practice: A range of approaches to providing continuity models should be explored as the implementation of ‘Better Births’ takes place across England. This should include studies of the impact of the different models on women, babies and midwives, along with their practical scalability and cost