Search

Additional file 1.

Additional file 1: S1 - Search strategy for each database. S2 - Table created to display checklist authored by Walsh and Downe. S3- Summary of Quality Assessment of Studies.

Additional file 1: Figure S1. Psychological outcomes (Women). Figure S2. Psychological outcomes (Partners). Table S1. Summary of utility values derived from the EQ-5D-5L for women and partners at baseline (recruitment), follow up (late pregnancy) and postnatal (4-6 weeks) post birth.

Background\ud 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.\ud \ud Objective\ud To evaluate the quality and perceptions of ANC in Nepal to understand the compliance with Nepalese standards.\ud \ud Study Design\ud 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.\ud \ud Results\ud 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).\ud \ud Conclusions\ud 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.

Objective: To understand the complexities surrounding unexplained stillbirth for the development and implementation of culturally acceptable interventions to underpin care in Tanzania and Zambia.\ud Design: Mixed-methods.\ud Setting: Tertiary, secondary and primary care facilities in Mansa, Zambia and Mwanza, Tanzania.\ud Sample: Quantitative; 1997 women giving birth at two tertiary care facilities (one in each country). Qualitative; 48 women and 19 partners from tertiary, secondary and primary care facilities.\ud Methods: Case review using data from a 2000 consecutive case record target. Qualitative interviews with a purposive sample of women and partners, using a grounded theory approach.\ud Results: A total of 261 stillbirths were recorded; Tanzania rate 16%, Zambia 10%, higher than previous country estimates of 2.24% and 2.09%, respectively. Women in both countries who reported a previous stillbirth were more likely to have stillbirth (RR (95% CI): 1.86 (1.23 – 2.81)). Cause of death was unexplained in 28% of cases. \ud Qualitative findings indicated that not knowing what caused the baby to be stillborn prevented women from grieving. This was compounded by poor communication skills of health professionals who displayed little empathy and skill when counselling bereaved families.\ud Conclusion: Stillbirth risk in both facilities was far higher than national data, with women reporting a previous stillbirth at higher risk. Women want to know the cause of stillbirth and exploration of appropriate investigations in this setting is required. Providing health professionals with support and ongoing training is key to improving the experiences of women and future care.\ud Funding: National Institute for Health Research. \ud Keywords: Stillbirth, autopsy, communication, grief, sub-Saharan Africa, mixed-methods.

Additional file 1: Supplementary Figure 1. Theoretical Directed Acyclic Graph to identify potential relationships between social, behavioural and medical factors and stillbirth. Factors in blue are outcome variables, those in green with an arrow are exposures of interest and those in grey are unmeasured factors. Diagram created in Dagitty Version Version 3.0.8 SES = Socioeconomic status, HIV – Human Immunodeficiency Virus, Syph/Tet – Syphilis serology and Tetanus vaccination.

Additional file 2: Supplementary Table 1. Singleton pregnancy model findings based on complete case data from postnatal ward sample (percentages exclude unknown cases).

Additional file 2: Table 1. Country-specific comparison of characteristics of those with and without intrapartum transfer.

Additional file 1. Interview topic Guide.

Additional file 3: Figure 1. Conceptual Model of Journey of Vulnerability during intrapartum transfers.

Breastfeeding has copious health benefits for both mother and child, but rates of initiation and maintenance amongst women with a BMI ≥30kg/m2 are low. Few interventions aiming to increase these rates have been successful, suggesting that breastfeeding behaviour in this group is not fully understood. Therefore, this review aimed to systematically identify and synthesise the qualitative literature which explored the perceptions and experiences of women with a BMI ≥30kg/m2 who breastfed. The search identified five eligible papers, and a meta-ethnographic approach was taken to synthesise the findings. One theme was identified: ‘weight amplifies breastfeeding difficulties’, revealing that women with a BMI ≥30kg/m2 experience common breastfeeding difficulties to a greater degree. In particular, women with a BMI ≥30kg/m2 struggle with the impact of medical intervention, doubt their ability to breastfeed, and need additional support. These findings can inform understanding of breastfeeding models, future research directions, intervention development and antenatal and postnatal care for women with a BMI ≥30kg/m2.

Breastfeeding has copious health benefits for both mother and child, but rates of initiation and maintenance amongst women with a BMI ≥30kg/m2 are low. Few interventions aiming to increase these rates have been successful, suggesting that breastfeeding behaviour in this group is not fully understood. Therefore, this review aimed to systematically identify and synthesise the qualitative literature which explored the perceptions and experiences of women with a BMI ≥30kg/m2 who breastfed. The search identified five eligible papers, and a meta‐ethnographic approach was taken to synthesise the findings. One theme was identified: ‘weight amplifies breastfeeding difficulties’, revealing that women with a BMI ≥30kg/m2 experience common breastfeeding difficulties to a greater degree. In particular, women with a BMI ≥30kg/m2 struggle with the impact of medical intervention, doubt their ability to breastfeed, and need additional support. These findings can inform understanding of breastfeeding models, future research directions, intervention development and antenatal and postnatal care for women with a BMI ≥30kg/m2.

INTRODUCTION: The aim of the QUIDS study is to develop a decision support tool for the management of women with symptoms and signs of preterm labour, based on a validated prognostic model using quantitative fetal fibronectin (fFN) concentration, in combination with clinical risk factors.METHODS AND ANALYSIS: The study will evaluate the Rapid fFN 10Q System (Hologic, Marlborough, Massachusetts, USA) which quantifies fFN in a vaginal swab. In QUIDS part 2, we will perform a prospective cohort study in at least eight UK consultant-led maternity units, in women with symptoms of preterm labour at 22+0 to 34+6 weeks gestation to externally validate a prognostic model developed in QUIDS part 1. The effects of quantitative fFN on anxiety will be assessed, and acceptability of the test and prognostic model will be evaluated in a subgroup of women and clinicians (n=30). The sample size is 1600 women (with estimated 96-192 events of preterm delivery within 7 days of testing). Clinicians will be informed of the qualitative fFN result (positive/negative) but be blinded to quantitative fFN result. Research midwives will collect outcome data from the maternal and neonatal clinical records. The final validated prognostic model will be presented as a mobile or web-based application.ETHICS AND DISSEMINATION: The study is funded by the National Institute of Healthcare Research Health Technology Assessment (HTA 14/32/01). It has been approved by the West of Scotland Research Ethics Committee (16/WS/0068).VERSION: Protocol V.2, Date 1 November 2016.TRIAL REGISTRATION NUMBER: ISRCTN 41598423andCPMS: 31277.

INTRODUCTION: The aim of the QUIDS study is to develop a decision support tool for the management of women with symptoms and signs of preterm labour, based on a validated prognostic model using quantitative fetal fibronectin (qfFN) concentration, in combination with clinical risk factors. METHODS AND ANALYSIS: The study will evaluate the Rapid fFN 10Q System (Hologic, Marlborough, Massachusetts) which quantifies fFN in a vaginal swab. In part 1 of the study, we will develop and internally validate a prognostic model using an individual participant data (IPD) meta-analysis of existing studies containing women with symptoms of preterm labour alongside fFN measurements and pregnancy outcome. An economic analysis will be undertaken to assess potential cost-effectiveness of the qfFN prognostic model. The primary endpoint will be the ability of the prognostic model to rule out spontaneous preterm birth within 7 days. Six eligible studies were identified by systematic review of the literature and five agreed to provide their IPD (n=5 studies, 1783 women and 139 events of preterm delivery within 7 days of testing). ETHICS AND DISSEMINATION: The study is funded by the National Institute of Healthcare Research Health Technology Assessment (HTA 14/32/01). It has been approved by the West of Scotland Research Ethics Committee (16/WS/0068). PROSPERO REGISTRATION NUMBER: CRD42015027590. VERSION: Protocol version 2, date 1 November 2016.

Breastfeeding can play a key role in the reduction of obesity, but initiation and maintenance rates in women with a Body Mass Index (BMI) of ≥30kg/m2 are low. Psychological factors influence breastfeeding behaviours in the general population, but their role is not yet understood in women with a BMI ≥30kg/m2. Therefore, this review aimed to systematically search and synthesise the literature which has investigated the association between any psychological factor and breastfeeding behaviour in women with a BMI ≥30kg/m2. The search identified twenty eligible papers, reporting sixteen psychological factors. Five psychological factors were associated with breastfeeding behaviours: intentions to breastfeed, belief in breastmilk’s nutritional adequacy and sufficiency, belief about other’s infant feeding preferences, body image and social knowledge. It is therefore recommended that current care should encourage women to plan to breastfeed, provide corrective information for particular beliefs, and address their body image and social knowledge. Recommendations for future research include further exploration of several psychological factors (i.e. expecting that breastfeeding will enhance weight loss, depression, anxiety and stress) and evidence and theory based intervention development.

Background: Participation in the UK Newborn Bloodspot Screening Programme (NBSP) requires parental consent but concerns exist about whether or not this happens in practice and the best methods and timing to obtain consent at reasonable cost.Objectives: To collate all possible modes of prescreening communication and consent for newborn (neonatal) screening (NBS); examine midwives', screening professionals' and users' views about the feasibility, efficiency and impact on understanding of each; measure midwives' and parents' preferences for information provision; and identify key drivers of cost-effectiveness for alternative modes of information provision.Design: Six study designs were used: (1) realist review - to generate alternative communication and consent models; (2) qualitative interviews with parents and health professionals - to examine the implications of current practice for understanding and views on alternative models; (3) survey and observation of midwives - to establish current costs; (4) stated preference surveys with midwives, parents and potential future parents - to establish preferences for information provision; (5) economic analysis - to identify cost-effectiveness drivers of alternative models; and (6) stakeholder validation focus groups and interviews - to examine the acceptability, views and broader impact of alternative communication and consent models.Setting: Providers and users of NBS in England.Participants: Study 2: 45 parents and 37 health professionals; study 3: 22 midwives and eight observations; study 4: 705 adults aged 18-45 years and 134 midwives; and study 6: 12 health-care professionals and five parents.Results: The realist review identified low parental knowledge and evidence of coercive consent practices. Interview, focus group and stated preference data suggested a preference for full information, with some valuing this more than choice. Health professionals preferred informed choice models but parents and health professionals queried whether or not current consent was fully informed. Barriers to using leaflets effectively were highlighted. All studies indicated that a 'personalised' approach to NBS communication, allowing parents to select the mode and level of information suited to their learning needs, could have added value. A personalised approach should rely on midwife communication and should occur in the third trimester. Overall awareness was identified as requiring improvement. Starting NBS communication by alerting parents that they have a choice to make and telling them that samples could be stored are both likely to enhance engagement. The methods of information provision and maternal anxiety causing additional visits to health-care professionals were the drivers of relative cost-effectiveness. Lack of data to populate an economic analysis, confirmed by value of information analysis, indicated a need for further research.Limitations: There are some limitations with regard to the range of participants used in studies 2 and 3 and so caution should be exercised when interpreting some of the results.Conclusions: This project highlighted the importance of focusing on information receipt and identified key communication barriers. Health professionals strongly preferred informed consent, which parents endorsed if they were made aware of sample storage. Uniform models of information provision were perceived as ineffective. A choice of information provision was supported by health professionals and parents, which both enhances cost-effectiveness and improves engagement, understanding and the validity of consent. Remaining uncertainties suggest that more research is needed before new communication modes are introduced into practice. Future research should measure the impact of the suggested practice changes (informing in third trimester, information toolkits, changed role of midwife).Trial registration: Current Controlled Trials ISRCTN70227207.Funding: This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 55. See the NIHR Journals Library website for further project information.

Background: In 2013, an estimated 2.8 million newborns died and 2.7 million were stillborn. A much greater number suffer from long term impairment associated with preterm birth, intrauterine growth restriction, congenital anomalies, and perinatal or infectious causes. With the approaching deadline for the achievement of the Millennium Development Goals (MDGs) in 2015, there was a need to set the new research priorities on newborns and stillbirth with a focus not only on survival but also on health, growth and development. We therefore carried out a systematic exercise to set newborn health research priorities for 2013–2025. Methods: We used adapted Child Health and Nutrition Research Initiative (CHNRI) methods for this prioritization exercise. We identified and approached the 200 most productive researchers and 400 program experts, and 132 of them submitted research questions online. These were collated into a set of 205 research questions, sent for scoring to the 600 identified experts, and were assessed and scored by 91 experts. Results: Nine out of top ten identified priorities were in the domain of research on improving delivery of known interventions, with simplified neonatal resuscitation program and clinical algorithms and improved skills of community health workers leading the list. The top 10 priorities in the domain of development were led by ideas on improved Kangaroo Mother Care at community level, how to improve the accuracy of diagnosis by community health workers, and perinatal audits. The 10 leading priorities for discovery research focused on stable surfactant with novel modes of administration for preterm babies, ability to diagnose fetal distress and novel tocolytic agents to delay or stop preterm labour. Conclusion: These findings will assist both donors and researchers in supporting and conducting research to close the knowledge gaps for reducing neonatal mortality, morbidity and long term impairment. WHO, SNL and other partners will work to generate interest among key national stakeholders, governments, NGOs, and research institutes in these priorities, while encouraging research funders to support them. We will track research funding, relevant requests for proposals and trial registers to monitor if the priorities identified by this exercise are being addressed publishedVersion

BACKGROUND: In 2013, an estimated 2.8 million newborns died and 2.7 million were stillborn. A much greater number suffer from long term impairment associated with preterm birth, intrauterine growth restriction, congenital anomalies, and perinatal or infectious causes. With the approaching deadline for the achievement of the Millennium Development Goals (MDGs) in 2015, there was a need to set the new research priorities on newborns and stillbirth with a focus not only on survival but also on health, growth and development. We therefore carried out a systematic exercise to set newborn health research priorities for 2013-2025. METHODS: We used adapted Child Health and Nutrition Research Initiative (CHNRI) methods for this prioritization exercise. We identified and approached the 200 most productive researchers and 400 program experts, and 132 of them submitted research questions online. These were collated into a set of 205 research questions, sent for scoring to the 600 identified experts, and were assessed and scored by 91 experts. RESULTS: Nine out of top ten identified priorities were in the domain of research on improving delivery of known interventions, with simplified neonatal resuscitation program and clinical algorithms and improved skills of community health workers leading the list. The top 10 priorities in the domain of development were led by ideas on improved Kangaroo Mother Care at community level, how to improve the accuracy of diagnosis by community health workers, and perinatal audits. The 10 leading priorities for discovery research focused on stable surfactant with novel modes of administration for preterm babies, ability to diagnose fetal distress and novel tocolytic agents to delay or stop preterm labour. CONCLUSION: These findings will assist both donors and researchers in supporting and conducting research to close the knowledge gaps for reducing neonatal mortality, morbidity and long term impairment. WHO, SNL and other partners will work to generate interest among key national stakeholders, governments, NGOs, and research institutes in these priorities, while encouraging research funders to support them. We will track research funding, relevant requests for proposals and trial registers to monitor if the priorities identified by this exercise are being addressed.

Objective: to explore the experiences of White British and South East Asian women with type 1 and type 2 diabetes, and the perceived impact of diabetes on their reproductive health. Design: a hermeneutic phenomenological approach was used to explore the perceptions of women with diabetes from two different cultural backgrounds with varied reproductive health experiences. Focus groups and one-to-one interviews were used to elicit women's experiences. An interpretive analytical approach was conducted by two researchers. Setting: obstetric and diabetes clinics in three hospital sites in the North West of England. Participants: a purposive sample of 22 women with type 1 or type 2 diabetes of different parity and ethnicity. Findings: the main themes were relinquishing personal control, pregnancy overshadowed by diabetes and haphazard preconception care. Key conclusions: strategies should be developed to ensure that whilst safety is maintained, the pregnancy focus is not lost. Women should be supported to optimise their experience as well as clinical outcomes. The convergence of professional roles needs consideration; individual members of multidisciplinary diabetes teams should provide a unique and complementary contribution to care. Preconception care needs to be accessible and responsive to women; this should include recognition of socio-cultural differences. © 2009 Elsevier Ltd.

There is little consensus regarding the use of partograms and labour charts in the western world. As a consequence there are variations in practices within and between units. Prior to implementation of the National Institute for Clinical Excellence (NICE) Intrapartum Care Guidelines we conducted a survey of all Heads of Midwifery exploring the current status of labour documentation across England. This enabled a baseline of current practice to be established and offers insight into disparities. The results indicated general support for the partogram, although some units chose not to use it for certain women. There was some consistency in recorded quantifiable details, although most charts lacked any psychological data. A minority of units had pre-printed alert or action lines although often the associated guidelines were similar. Few units provided evidence to support their particular guidelines. Awareness of national variations in partogram use highlighted useful variations in partogram designs which may assist midwives in their own practice. Units should re-evaluate their own charts in line with the recommendations of the National Intrapartum Care Guidelines.

BackgroundIn 2013, an estimated 2.8 million newborns died and 2.7 million were stillborn. A much greater number suffer from long term impairment associated with preterm birth, intrauterine growth restriction, congenital anomalies, and perinatal or infectious causes. With the approaching deadline for the achievement of the Millennium Development Goals (MDGs) in 2015, there was a need to set the new research priorities on newborns and stillbirth with a focus not only on survival but also on health, growth and development. We therefore carried out a systematic exercise to set newborn health research priorities for 2013–2025.MethodsWe used adapted Child Health and Nutrition Research Initiative (CHNRI) methods for this prioritization exercise. We identified and approached the 200 most productive researchers and 400 program experts, and 132 of them submitted research questions online. These were collated into a set of 205 research questions, sent for scoring to the 600 identified experts, and were assessed and scored by 91 experts.ResultsNine out of top ten identified priorities were in the domain of research on improving delivery of known interventions, with simplified neonatal resuscitation program and clinical algorithms and improved skills of community health workers leading the list. The top 10 priorities in the domain of development were led by ideas on improved Kangaroo Mother Care at community level, how to improve the accuracy of diagnosis by community health workers, and perinatal audits. The 10 leading priorities for discovery research focused on stable surfactant with novel modes of administration for preterm babies, ability to diagnose fetal distress and novel tocolytic agents to delay or stop preterm labour.ConclusionThese findings will assist both donors and researchers in supporting and conducting research to close the knowledge gaps for reducing neonatal mortality, morbidity and long term impairment. WHO, SNL and other partners will work to generate interest among key national stakeholders, governments, NGOs, and research institutes in these priorities, while encouraging research funders to support them. We will track research funding, relevant requests for proposals and trial registers to monitor if the priorities identified by this exercise are being addressed.

Since the introduction of coffee to Europe in the early 17th century its popularity has steadily increased and, water apart, is the most widely consumed beverage globally. Being derived from a plant, a cup of coffee represents a complex mixture of naturally occurring chemicals such as caffeine, coffee oils and chlorogenic acid. As the popularity for coffee has grown so too has the interest surrounding its possible biological and pharmacological effects. A small number of studies suggest potential risks and benefits associated with coffee consumption in pregnancy; however these have yet to provide definitive conclusions. Furthermore government advice does not directly address coffee intake during pregnancy and there is no information regarding womens’ and midwives’ views and opinions on this increasingly important issue. This was a mixed-method research study, with both a qualitative and quantitative components. Firstly, I aimed to gain insight into womens’ and midwives’ views and opinions on coffee consumption during pregnancy. Informed written consent was obtained from women attending the hospital for their antenatal care. These women were of varying gestational age, ethnic background, socioeconomic status and age. Informed written consent was also obtained from midwives from varying disciplines and experience levels; those from academia, research and practicing midwives included. I recruited twenty participants in each group. Information and perspectives were gathered through semi-structured face-to-face or telephone interviews. Interviews were analysed with the Framework method of analysis. The second quantitative arm of my study investigated the effect of specific coffee chemicals on placental and myometrial vascular function. Human chorionic plate arteries, isolated from placental biopsies, and maternal myometrial arteries isolated from myometrial biopsies, were assessed by wire myography. Contraction and relaxation were determined to incremental doses of caffeic acid, chlorogenic acid and caffeine. The antioxidative properties of these chemicals were also assessed in response to application of reactive oxygen species.My findings indicated that women and midwives’ were unsure of the information surrounding coffee consumption. Pregnant women and midwives’ discussed the provision of information, sources of information and supplementing information. Findings also indicated that the relationship between health care professional and pregnant women can influence willingness to accept information and womens’ level of pregnancy stress. My laboratory studies indicated that the active coffee chemicals did not significantly impact on placental or myometrial arterial function. The chemicals investigated did not elicit any significant protective antioxidative effects. Combining methods allowed for a more comprehensive primary study to be completed. My literature search indicated that there was a clear gap in the knowledge surrounding coffee and its consumption during pregnancy. There is a clear lack of evidence-based information accessible to women regarding consumption. Midwives feel ill-equipped to provide women with information on coffee but err on the side of caution with their advice. Laboratory studies indicate that the coffee chemicals investigated did not induce an effect and cast doubts on the potential antioxidative effects that have been previously quoted in the literature.

Introduction and aim: In Zimbabwe, a one-year midwifery-training programme, based on a competency-based curriculum, aims to develop essential competencies for midwifery clinical practice and sound professional judgement, as required by the International Confederation of Midwives (ICM) Global Standards for Midwifery Education. This study aimed to explore midwives’ preparation for practice to the level defined by ICM core competencies in Zimbabwe. Methods: A critical realist mixed-method study included an exploratory correlational approach for the quantitative phase and classical grounded theory for the qualitative phase. In the quantitative phase, complete sampling was used to recruit a cohort of 85 midwives from three midwifery schools (School A, School C and School B; recruitment rate 53.8%) before they received the results of their state final examinations. Confidence and competence data were collected from participants, their ward supervisors/senior midwives, peers and clinical instructors using a 360° assessment tool developed for the study, based on one currently used for assessment at the participating schools. This consisted of a checklist of 20 ICM competencies each scored as a rating scale from 0-10 in six areas of midwifery care. Data were collected at initial recruitment, after the participants had received their examination results and after three months of clinical practice, with 58 from School A and School C providing data at the final time point (68.2% retention rate). The qualitative study used in-depth interviews to explore the knowledge views and practices of midwives regarding ICM core competencies, using theoretical sampling to recruit 36 participants (21 newly qualified midwives, 4 tutors, 5 ward supervisors, 3 clinical instructors, and 3 acting clinical instructors) from School A and School C until data saturation was reached. Data analysis: IBM SPSS Statistics 22 was used to analyse quantitative data. Cronbach’s alpha was used to estimate the internal consistency of subscales and the overall scale of the 360° assessment tool. Most analyses were descriptive, and Pearson’s chi-square, Fisher’s exact and the Mann-Whitney U test was used to compare data by school. Kendall’s correlation and multiple linear regressions were used to explore which variables were associated with total confidence and competence scores. Constant comparative analysis was used on the qualitative data to develop categories to build a grounded theory of social processes facilitating or hindering competence and confidence development in midwives. Results: The 360° assessment tool was reliable although some assessors appeared not to have observed the participant performing an episiotomy or resuscitating a new born. Participants’ confidence scores were generally higher than their assessors’ competence scores. Confidence and competence scores at School C generally increased over time, but confidence scores at School A fell after the midwives had spent three months in clinical practice. The number completing the quantitative phase limited the generalisability and precision of the multiple regressions but the main predictor of confidence and competence was school. The qualitative phase explained the difference between schools in terms of school policies, the way facilitators planned and organised clinical settings to facilitate student learning, and facilitator characteristics. Students at School A were allowed to pass assessments without reaching the required standard while those at School C were marked more harshly, but were subsequently appreciative of this approach, recognising its necessity for competence development. Following transduction, a Competence and Confidence Development Model was proposed to explain how the dualistic nature of an individual and their confidence and competence were related via a student learning typology combining individualism-collectivism and rate of learning with six phases of skill acquisition. Conclusions: Midwifery schools in Zimbabwe must consider policies, the training environment, student learning styles and the teaching processes required for students to acquire the clinical skills and theoretical knowledge necessary to become competent qualified practitioners.

Exploring the lived experience of first-time breastfeeding women: A phenomenological study in GhanaBackground: Breastfeeding is globally recognised as a gold standard of nutrition, recommended for the first six months of an infant’s life. Despite its benefits, most women in Ghana do not breastfeed, as recommended by World Health Organization (WHO) and United Nations International Children Emergency Fund (UNICEF). Aim: To gain in-depth understanding of first-time Ghanaian mother lived experience of breastfeeding. Design/Method: A longitudinal qualitative design was adopted, underpinned by the hermeneutic phenomenological approach, as described by van Manen (1990). The study explored the lived experiences of thirty first-time women recruited from antenatal clinic. A series of three semi-structured, in-depth interviews were conducted; the first in late pregnancy, the second in the first week following childbirth and the final one between four and six months postpartum.Findings: Inductive thematic analysis informed by van Manen (1990) and principles of hermeneutic interpretation allowed the emergence of four main themes: the ‘Breastfeeding Assumption,' Breastfeeding as Women’s Business,’ the Postnatal Experience of Breastfeeding and ‘Family as Enabler or Disabler’. Within the context of this study, breastfeeding is expressed as an activity within the family and social environment. The overall phenomenon that emerged was ‘Social Conformity’. This demonstrates an understanding of the breastfeeding experience suffused with emotions as women project an image of themselves as successful breast feeders in order to conform to family and social expectations. Conclusion: Findings from the study demonstrated the multifactorial dimensions of breastfeeding. Most importantly, it was identified that first-time breastfeeding women use emotion work to cope with their experience of breastfeeding, within the social context. It was suggested that midwives play a pivotal role in helping women develop realistic expectations prior to breastfeeding. Furthermore encouraging family centered education that promotes holistic support for women. The findings therefore suggested the need for better antenatal education based on evidence-based practice. Breastfeeding women require individualised support that assesses their emotional needs and offers encouragement. Developing policies that ensure training of midwives and breastfeeding advocates was recommended. Future research could explore the impact of these interventions on breastfeeding practices, helping first time women to breastfeed effectively. The research explored the lived experience of breastfeeding women in Ghana. Hermeneutic phenomenological method was used. A longitudinal approach to the data collection allowed participants to be followed at different time points and what I found was; breastfeeding assumption, breastfeeding as women’s business, postnatal experience of breastfeeding and family as enabler and disabler; and from this I can recommend; effective antenatal education that is family centered, active midwives support during the early postnatal period. Not Applicable Not Applicable

Background: The differential effects of using topical oils for the prevention or treatment of baby dry skin on skin barrier function may contribute to the development of childhood atopic eczema. Prevalence of atopic eczema has increased from 5% of children aged 2 to 15 years in the 1940s, to approaching 30% more recently. This increase cannot be attributed to genetic changes. It is likely that increases stem from environmental factors, including the increased use of some inappropriately formulated commercial and natural baby skincare products. Midwives, health visitors and other maternity service health professionals, in the UK, routinely recommend the use of olive oil and sunflower oil for baby dry skin or massage, but the effect of these oils on newborn baby skin has not been studied.Aim: The aim of this research was to assess the feasibility and acceptability of testing the hypothesis that the regular application of sunflower oil, when compared to no oil or olive oil, had an effect on skin barrier function of newborn term babies.Study Design: A pilot, assessor-blinded, single centre, three-arm, randomised controlled trial, with nested qualitative component, underpinned by post-positivism.Methods: Quantitative methods were used to establish proof of concept that the use of topical oils had some effect on newborn baby skin barrier function, and to assess the feasibility of trial processes and parameters. Qualitative methods were used to explore the acceptability to parents of having a newborn baby participating in a randomised controlled trial, and trial design and procedures. The study was conducted in St. Mary’s hospital, a large teaching hospital in North West England. Data were collected between September 2013 and August 2014.The randomised controlled trial included 115 babies who were randomised to three groups: sunflower oil, olive oil and no oil, using a computer-generated varied size block randomisation with concealed allocation. Parents of babies randomised to the oil groups were blinded to which oil they were allocated. Data were collected using standardised case report forms for demographic and clinical observation data, weekly telephone questionnaires and a follow-up questionnaire, informed by previous baby skincare trials.The qualitative study encompassed semi-structured interviews, conducted within six months of birth. The sample was a subset of the trial participants, purposively sampled to incorporate a mix of treatment groups and positive and negative experiences derived from the follow-up questionnaire. Data also included two open-text questions from the follow-up questionnaire.Quantitative data were managed using IBM SPSS Statistics versions 20 and 22 and analysed descriptively. Qualitative data were managed in NVivo 10 and analysed using Framework Analysis.Results: The pilot study found that a definitive randomised controlled trial is not the optimal next step. A longitudinal observational study and further mechanistic work is recommended. Recruitment was challenging and loss to follow-up was higher than anticipated. Protocol adherence was reasonable and the study was acceptable to parents. Some statistically significant results were obtained, which must be interpreted with caution as the study was not powered to detect such a difference. These results showed that both oils may impede the development of the skin barrier function from birth; clinical importance of the results is not known.Conclusion: A longitudinal observational study is required, which maps the diagnosis of atopic eczema with environmental factors such as the use of baby skincare products from birth. Mechanistic work is also required to consider the optimal skincare formulation. As any intervention should do more good than harm, it would be wrong to support the recommendation of topical olive oil or sunflower oil for newborn baby dry skin or massage, based on the study data.

Community participation in improving maternal health: a grounded theory study in Aceh, IndonesiaNovember 2013Indonesia has one of the highest rates of maternal mortality in Southeast Asia. Community participation has been known to reduce maternal mortality in some areas in Indonesia. However, in Aceh Province, the prevalence remains higher than the general Indonesian maternal mortality rate. The aim of this research was to gain an understanding of pregnancy and childbirth experiences from multiple perspectives, in relation to the use of maternal health services in Aceh, Indonesia. The conceptual framework was based on the importance of community engagement in improving maternal health. A qualitative study design with a grounded theory approach was utilised. This approach was chosen in order to gain an understanding of the social processes and ways in which experiences of pregnancy and childbirth are related to maternal death incidents. The process inherent in the method enabled the emergence of important theoretical concepts. A theoretical sampling strategy was employed. The data collection used multiple methods that involved a series of in-depth interviews, observations and focus group discussions with women, family members, a village leader and health professionals. The sample size was determined by data saturation (19 women, 15 family members, 7 health professionals, 3 kaders, 4 student midwives and 1 village leader participated). Ethical approval was gained and the research setting was in the two villages of Aceh Besar District, Aceh Province, Indonesia. Data were coded and analysed by following a constant comparison process.The emergent core category, entitled “maternal death: the elephant in the room” explains the views of the community about maternal death incidents in the research setting. The research findings highlighted that despite the maternal mortality rate still being high in the region, maternal death was not focused upon, as a problem within the community. The research findings revealed that maternal mortality was a hidden problem within the community, and was related to inadequate maternity practices in the village. The core category “maternal death: the elephant in the room” was found to consist of four interrelated categories. The categories of the value of midwifery in the community, desicion-making of maternity care, social control of the childbearing and distancing of maternal deaths; explain maternity practices in the community. Understanding of social processes related to maternal health can assist in informing strategies to improve the quality of maternal healthcare in Aceh Indonesia.

Midwives recommend antenatal HIV testing in pregnancy for all women. However,limited information is available on the experience of testing HIV positive in pregnancy.This thesis explored women’s experiences of receiving a positive HIV test resultfollowing antenatal screening in United Kingdom (UK). Black Africa women have highlevels of HIV infection in the UK and notably all participants were African in origin.The theoretical basis for the study was hermeneutic phenomenology, proposed byHeidegger (1962) and further guided by van Manen (1990), exploring essence andmeaning of this lived experience. Thirteen women were recruited and participated in asemi-structured interview. Participants were recruited from two NHS sites, several HIVsupport organisations and a national advert, in order to obtain diversity of this livedexperience.The emergent phenomenon is transition and transformation of “being,” as womenintegrated HIV into their lives. As women transformed with the HIV diagnosis theybalanced major themes. The major themes consisted of shock and disbelief; anger andturmoil; loss of old self; stigma and confidentiality issues and acceptance and resilience.Primary and secondary themes included: extreme reaction on being given a diagnosiswith a cultural belief that they would die; disbelief as the result was unexpected;sadness and loss of their old self; turmoil wanting to terminate the pregnancy; isolationfrom significant others; breakdown of their relationship and considering suicide and selfharm. Most reported the pervasiveness of stigma, and how they managed both thisstigma and HIV in their lives; growing resilience was apparent with time. Copingstrategies included keeping HIV “secret” and their child or children becoming the primefocus of life, with less importance on self.This study gives midwives a unique understanding of the complexities for womentesting HIV positive and supports Bonanno (2009) and Kübler Ross’ (1969 & 2005)findings on personal loss. Additionally this study provides a unique insight into thephenomenon of transition and transformation for women who tested positive inpregnancy and explores the factors and impact of testing HIV positive. The impact of anHIV diagnosis is culturally difficult for African women and had major implications andchallenges for their future life. Midwives are crucial in supporting and improving theexperience of women when they test HIV positive. Midwives recommend antenatal HIV testing in pregnancy for all women. However,limited information is available on the experience of testing HIV positive in pregnancy.This thesis explored women’s experiences of receiving a positive HIV test resultfollowing antenatal screening in United Kingdom (UK). Black Africa women have highlevels of HIV infection in the UK and notably all participants were African in origin.The theoretical basis for the study was hermeneutic phenomenology, proposed byHeidegger (1962) and further guided by van Manen (1990), exploring essence andmeaning of this lived experience. Thirteen women were recruited and participated in asemi-structured interview. Participants were recruited from two NHS sites, several HIVsupport organisations and a national advert, in order to obtain diversity of this livedexperience.The emergent phenomenon is transition and transformation of “being,” as womenintegrated HIV into their lives. As women transformed with the HIV diagnosis theybalanced major themes. The major themes consisted of shock and disbelief; anger andturmoil; loss of old self; stigma and confidentiality issues and acceptance and resilience.Primary and secondary themes included: extreme reaction on being given a diagnosiswith a cultural belief that they would die; disbelief as the result was unexpected;sadness and loss of their old self; turmoil wanting to terminate the pregnancy; isolationfrom significant others; breakdown of their relationship and considering suicide and selfharm. Most reported the pervasiveness of stigma, and how they managed both thisstigma and HIV in their lives; growing resilience was apparent with time. Copingstrategies included keeping HIV “secret” and their child or children becoming the primefocus of life, with less importance on self.This study gives midwives a unique understanding of the complexities for womentesting HIV positive and supports Bonanno (2009) and Kübler Ross’ (1969 & 2005)findings on personal loss. Additionally this study provides a unique insight into thephenomenon of transition and transformation for women who tested positive inpregnancy and explores the factors and impact of testing HIV positive. The impact of anHIV diagnosis is culturally difficult for African women and had major implications andchallenges for their future life. Midwives are crucial in supporting and improving theexperience of women when they test HIV positive.

Background: Kangaroo Mother Care (KMC) is defined as skin-to-skin contact between a mother and her newborn baby, frequent and exclusive or nearly exclusive breastfeeding and early discharge from hospital. This concept was proposed as an alternative to conventional methods of care for low birth weight (LBW) infants, and in response to problems of serious overcrowding in neonatal intensive care units (NICUs). KMC essentially uses the mother as a natural incubator. According to this principle, LBW babies are placed to the mother’s chest in an upright position, where maternal body heat can help control the baby’s body temperature. Although widely used in some parts of the world, this practice is not the norm in the Kingdom of Saudi Arabia (KSA). Aim: The aim was to assess the feasibility and acceptability of running a randomised controlled trial (RCT) to evaluate the effectiveness of KMC in LBW infants in KSA.Study Design: A pilot RCT with supportive qualitative interviews was conducted, underpinned by a post-positivist approach.Methods: This was a mixed methods study. Quantitative methods were used to measure the effectiveness of KMC, and qualitative methods were used to explore women’s and nurses’ experiences of a) KMC and b) trial processes. The study took place in two urban hospitals in Jeddah, KSA. Ethical approval was gained, and data were collected between March and May 2011.The quantitative element comprised a two-group, individually randomised controlled pilot trial with 20 mothers-and-babies per group. The randomisation sequence was computer-generated, and participants were randomised using consecutively numbered, sealed, opaque envelopes. Data were collected using routinely collected case records, specifically designed clinical data sheets and two questionnaires (validated maternal bonding scale and maternal breastfeeding experience questionnaire). For the latter questionnaire, the design was informed by an expectation-fulfilment model. The qualitative element comprised semi-structured interviews, within 48 hours of birth, with a sample of 20 mothers who participated in the pilot RCT and 12 nurses who were attending these mothers. All 40 mothers were also telephoned when their babies were 6 months old to ascertain their feeding method and exclusivity of feeding.Quantitative data were managed using SPSS and analysed descriptively to estimate confidence intervals and effect sizes. Statistical tests and regression models were used to explore associations with potential outcome measures, with findings interpreted with caution as hypothesis-generating rather than hypothesis-confirming, given the small sample size. Qualitative data were analysed manually, using the Framework Approach.Results: The pilot study confirmed that trial processes were efficient, the intervention was acceptable (to mothers and nurses) and that the outcome measures were appropriate; the percentage of women exclusively breastfeeding at 6 months was identified as the most appropriate primary outcome. A large scale trial of KMC would be feasible and acceptable in KSA. However, issues relating to religious and organisational culture would need to be resolved, including improving privacy in the NICU, addressing language issues arising from transcultural nursing and engaging with male partners. A unique finding was the effect of KSA culture on women’s mobility and the impact that this had on their ability to carry out KMC if they were personally discharged but their baby remained in the NICU. Conclusion: A large scale RCT comparing KMC with standard care in KSA is feasible, acceptable and recommended. However, prior to progressing to a large scale study, a thorough planning stage is necessary which considers cultural practices and ward environment. The understandings gained from this research will be transferable to other research within similar settings

Midwives are often the lead providers of maternity care for women. To provide the variety of care required by women, they need to be confident in their role and practice. To date, only limited evidence exists in relation to confidence as experienced by midwives. This thesis aims to explore the phenomena of confidence through the lived experience of midwives. In particular, this will encompass confidence in the context of the intrapartum care setting. The theoretical basis for the study was hermeneutic phenomenology, guided by the work of Heidegger and Gadamer. Midwives were recruited from three clinical settings to obtain a diversity of views and experiences. Rich data from diaries and in-depth interviews, from twelve participants, provided insight into the phenomena of confidence and the factors midwives encountered that affected their confidence. The phenomena of confidence consisted of a dynamic balance, between the cognitive and affective elements of knowledge, experience and emotion. This balance was fragile and easily lost, leading to a loss of confidence. Confidence was viewed as vital to midwifery practice by the participants of the study; however, maintaining their confidence was often likened to a battle. A number of cultural and contextual factors were identified as affecting confidence within the working environment, including trust, collegial relationships and organisational influences. Midwives also described various coping strategies they utilised to maintain their confidence in the workplace environment.This study provides unique insight into the phenomena of confidence for midwives working in intrapartum care, resulting in a number of recommendations. These highlight the importance of leadership, education and support for midwives in the clinical environment in enabling them to develop and maintain confidence in practice.

The University of ManchesterSuzanne ThomasMaster of Philosophy (MPhil)An exploration of women’s experiences of attending a high risk obstetric clinic2011Background: Fetal Growth Restriction (FGR), the failure of a fetus to reach its growth potential, affects 3-5% of pregnancies. FGR is a key cause of stillbirth and has serious short and long term health implications for babies who survive. Currently there is no effective treatment to prevent or reverse established FGR, therefore management is focused on detection, surveillance and timely delivery. The high risk multidisciplinary clinic at the focus of this research provides care for women at risk of placental dysfunction, the leading cause of FGR, and is the first of its kind in the UK. This research sought to explore women’s experiences of attending a high risk obstetric clinic, with the aim of informing care. Ethical approval was given by the local research ethics committee. Methods: A qualitative method, using a hermeneutic phenomenological approach was used. A purposive sample of five women with pregnancies at risk of FGR, were included. Data were collected longitudinally, using three semi-structured interviews, from referral to the high risk clinic through to the postnatal period to capture evolving experiences and needs. Thematic analysis was conducted to identify the emerging phenomena. Findings: Three main themes and several subthemes emerged from the data. These included; ‘Evolving coping strategies’, ‘Management of expectations’ and ‘It doesn’t just happen to me’. Synthesis of the main themes and subthemes led to the emergence of the overarching phenomenon which underpins women’s experiences of attending this particular high risk clinic. This study found that women utilise multiple internal and external factors to negotiate their pregnancies, drawing upon experiences, relationships and evolving coping strategies. Conclusion: In conclusion, this journey provided an opportunity for women to voice their experiences within the context of a high risk obstetric clinic. This has provided a unique phenomenon which adds to the body of knowledge surrounding high risk pregnancies and has informed the future care of other women in the high risk obstetric clinic.