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Cesarean section rates worldwide are rising, driven by medically unnecessary cesarean use. The new World Health Organization Labour Care Guide (LCG) aims to improve the quality of care for women during labor and childbirth. Using the LCG might reduce overuse of cesarean; however, its effects have not been evaluated in randomized trials. We conducted a stepped-wedge, cluster-randomized pilot trial in four hospitals in India to evaluate the implementation of an LCG strategy intervention, compared with routine care. We performed this trial to pilot the intervention and obtain preliminary effectiveness data, informing future research. Eligible clusters were four hospitals with >4,000 births annually and cesarean rates ≥30%. Eligible women were those giving birth at ≥20 weeks’ gestation. One hospital transitioned to intervention every 2 months, according to a random sequence. The primary outcome was the cesarean rate among women in Robson Group 1 (that is, those who were nulliparous and gave birth to a singleton, term pregnancy in cephalic presentation and in spontaneous labor). A total of 26,331 participants gave birth. A 5.5% crude absolute reduction in the primary outcome was observed (45.2% versus 39.7%; relative risk 0.85, 95% confidence interval 0.54–1.33). Maternal process-of-care outcomes were not significantly different, though labor augmentation with oxytocin was 18.0% lower with the LCG strategy. No differences were observed for other health outcomes or women’s birth experiences. These findings can guide future definitive effectiveness trials, particularly in settings where urgent reversal of rising cesarean section rates is needed. Clinical Trials Registry India number: CTRI/2021/01/030695.

Background/AimsGlobally, 2 million stillbirths occur annually, 98% of which occur in low-income settings. In low-income settings, stillbirth may be associated with maternal perception of reduced fetal movements. However, little is known about maternal experiences of reduced fetal movements and subsequent engagement with health services in low-income settings. This narrative literature review initially aimed to improve understanding of views and experiences of reduced fetal movements in pregnant women in low-income settings using information synthesised from international studies. However, only a small number of articles from low-resource settings were found.MethodsThe literature reviewed qualitative, quantitative and mixed-method studies guided by a systematic approach. The findings were discussed narratively.ResultsA total of 40 studies were identified, only four of which were from low-income settings. The four main themes identified were: maternal perception of fetal movements, facilitators and barriers to seeking healthcare, reduced fetal movements as a predictor of fetal outcomes and knowledge of fetal movements and management strategies.ConclusionsA variety of factors may influence maternal perception of reduced fetal movements and experience of care. As most studies were conducted in high-income settings, it is imperative to describe women's experiences of reduced fetal movements in low-income settings.

Intravenous meperidine is the most commonly used opioid for treating the pain of childbirth, according to a review of 48 studies covering more than 9,800 women. Its effectiveness is questionable, but it is inexpensive and there is no evidence that other opioids are more effective.

Background/aimsEffective labour monitoring is integral to intrapartum care. Yet, to date, tools to facilitate this have not reached their potential. This study aims to explore midwives' initial reactions to the latest World Health Organization labour care guide, which is a replacement to the existing partograph, to enable adaptations to be made and to inform implementation strategies.MethodsThis was a qualitative study that used interviews and focus groups to gather data from a convenience sample of midwife delegates from six sub-Saharan Africa countries who were attending a midwifery conference in Malawi. Data were analysed thematically.ResultsA total of 43 participants participated; six focus groups and 12 individual interviews were conducted. Participants expressed both positive and negative views of the guide. Three main themes were found. The theme ‘sticking to what is familiar’ demonstrated reluctance to change; ‘chart based on usual or optimum practice’ suggested that midwives wanted a chart that reflects the routine care provided as opposed to the evidence-based care they should provide; and ‘measures for effective implementation’ highlighted the importance of having carefully considered and robust strategies for implementing the guide.ConclusionsThis rapid evaluation provided a snapshot of midwives' initial reactions to the new labour care guide. Although the existing partograph has not reached its full potential, midwives showed a reluctance to change it for something new. Feedback from participants has been fed into the development phase of the guide, informing its presentation, contents and field testing.

The partograph (sometimes called partogram) is a labour monitoring tool that is used in countries worldwide to enable early detection of complications, so that referral, action or closer observations can ensue. While the partograph has received global support, from health professionals, there are concerns that it has not reached its full potential in improving clinical outcomes. This has resulted in several variations of the tool and a plethora of studies aimed at exploring the barriers and facilitators to its use. In this chapter, we will discuss the history of the partograph, outlining how it has evolved over time. We will also suggest reasons why the tool may not be meeting the needs of all practitioners. In particular, we will explore partograph use as a complex intervention, suggesting that its success is likely to be dependent on multiple contextual factors.

Pelvic organ prolapse is a significant quality of life issue for many women. Prolapse can be managed effectively with a mechanical device called a pessary therefore many women choose this as a conservative treatment option. Despite the extent to which pessaries are used in the UK, there are no clear guidelines regarding the training required for pessary practitioners. This article reviews literature related to pessary practitioner training. Methods: 13 publications were reviewed. Results: eight themes were identified, namely ‘prevalence of pessary training’, ‘type of pessary training’, confidence in pessary care provision’, ‘impact on pessary care’, ‘skills and knowledge required to be a pessary practitioner’, ‘barriers’, ‘speciality of pessary care providers’, and ‘ongoing support’. Conclusion: at present practitioners report a lack of pessary training, which impacts on care. Effective training includes didactic learning of agreed knowledge requirements, practice of clinical skills and ongoing support.

Background:Maternal mortality and morbidity rates remain high in sub-Saharan Africa, yet with appropriate management, these rates could be reduced significantly. Midwifery training to improve the management of women during intrapartum period is often lacking, calling for innovative training methods in midwifery clinical care.Aims:To develop and evaluate a game, aimed at the prevention and management of the main causes of maternal morbidity and mortality.Methods:In collaboration with the Lugina Africa Midwives Research Network (LAMRN), the authors developed an educational board game and field tested the final version in Kenya, Tanzania and Malawi with midwives (n=56) and student midwives (n=32).Findings:Qualitative and quantitative evaluation demonstrated that the game was well liked for its ease of use, acceptable appearance and relevance to practice.Conclusions:The board game, named ‘Crisis’, has potential to influence practice; however, further research is required to assess its ability to improve outcomes.

Background:Clinical are an assessment of working practice against an agreed standard, with the intention of identifying areas for improvement and recommending interventions to address them (Mancey-Jones and Brugha, 1997). However, audits are not widely used in low or middle income countries. LAMRN set out to strengthen the capacity of midwives in Kenya to carry out clinical auditsAim:To describe the development of an audit project in Kenyatta National Hospital and Pumwani Maternity Hospital.Methods:Midwives were asked to identify auditable areas from clinical practice, which were ranked in order of priority. The problem with the highest score following ranking was chosen for audit and discussed with the management and clinical teams in each hospital. An audit protocol was then designed and an audit completed. This article highlights how the audit was undertaken; results are due to follow.Findings:Midwives in both hospitals agreed to audit postpartum haemorrhage and developed an audit proposal. This outlined the audit objectives, critical standards for the management of postpartum haemorrhage, data collection methods, timelines, roles of each team member and expected outcomes.Conclusions:Using a systematic approach, midwives in Kenya were able to identify an auditable problem, set clear objectives and standards to conduct the audit and develop methods to carry out the audit successfully.

ObjectivePostpartum haemorrhage (PPH) is a significant cause of maternal morbidity and mortality. The most common cause is an inability of the uterus to contract adequately after childbirth. In bimanual compression (BMC), one hand is placed within the vagina and the other hand is on the abdominal wall to compress the uterus. It is effective, but very uncomfortable for the woman. We designed a device that could replicate BMC without inserting a hand vaginally, therefore being less invasive. It could also help in diagnosing the source of the bleeding.DesignMixed methods, combining an iterative design process with input from clinicians in simulations, and focus groups of clinicians and consumers.SettingDepartment of Women's and Children's Health and Department of Medical Physics and Clinical Engineering, University of Liverpool, UK.MethodsA multidisciplinary team developed the design, using an obstetric manikin. Clinician and consumer groups also gave input on the concept and design. A healthcare product company and prototype manufacturer provided input into strategy, design and manufacture.ResultsThe PPH Butterfly is a single piece, plastic medical device that replicates BMC. It is designed to be easy to use and low-cost and allows for smooth insertion and removal. It is acceptable to clinicians and consumers and performs well in tests.ConclusionsThis is the first device designed to replicate BMC while being less invasive. It could potentially be an effective form of PPH management, while also diagnosing the source of the bleeding. The device will now be tested in humans.

Background:Peer support interventions (PSIs) are increasingly being used to promote health and wellbeing in different contexts.Aims:This paper reviews literature on existing PSIs aimed at improving the health and wellbeing of women and their families in sub-Saharan Africa to determine whether such programmes could be used to promote recovery from obstetric fistula—a debilitating condition that leaves women isolated, stigmatised, disempowered, and with poor physical and mental health.Methods:A systematic, thematic literature search was conducted.Findings:The review finds PSI offers positive outcomes through several mechanisms including: empowering women with knowledge and agency, treating them holistically, reducing feelings of stigmatisation, and improving health behaviours/outcomes for themselves and their families.Conclusions:In view of the findings, it is proposed that a peer support intervention is trialled with women recovering from obstetric fistula.

Progesterone administration has been shown to reduce the risk of preterm birth and neonatal morbidity in women at high risk, but there is uncertainty about longer term effects on the child.

Variation in stillbirth rates across high-income countries and large equity gaps within high-income countries persist. If all high-income countries achieved stillbirth rates equal to the best performing countries, 19 439 late gestation (28 weeks or more) stillbirths could have been avoided in 2015. The proportion of unexplained stillbirths is high and can be addressed through improvements in data collection, investigation, and classification, and with a better understanding of causal pathways. Substandard care contributes to 20–30% of all stillbirths and the contribution is even higher for late gestation intrapartum stillbirths. National perinatal mortality audit programmes need to be implemented in all high-income countries. The need to reduce stigma and fatalism related to stillbirth and to improve bereavement care are also clear, persisting priorities for action. In high-income countries, a woman living under adverse socioeconomic circumstances has twice the risk of having a stillborn child when compared to her more advantaged counterparts. Programmes at community and country level need to improve health in disadvantaged families to address these inequities.

In this paper the authors will discuss the randomised controlled trial in the context of evidence-based practice. This paper aims to provide health professionals with some insight into what makes a good trial paper, highlighting the main areas where there are often misunderstandings of the appropriateness of trial methodology within individual studies. Being able to determine what constitutes good trial evidence is important in determining which evidence should be applied to practice.

In the UK, fear of birth (FoB) is considered a valid reason to request an elective caesarean section, and the National Institute for Health and Care Excellence (NICE, 2011) provided guidance in respect of women with a FoB requesting operative delivery. However, it was not clear how many maternity units in the UK offered support for women in line with this guidance. Consequently, a national online audit survey was undertaken to determine current service provision in maternity units. Hence in 2013, 202 maternity units were surveyed over 9 weeks; there was a 63% (n=128) response rate.It was evident that 47.3% (n=52) of all units did not offer specialist support for women with FoB. However, where support was available, this varied from the benchmark recommendation for referral to a consultant obstetrician (NICE, 2001) to specialist midwifery clinics and psychological support services. Overall, the survey revealed that care pathways for FoB had not been widely implemented in the UK.

In this paper the authors will discuss the randomised controlled trial, in the context of evidence-based practice. This paper aims to provide clinical midwives with some insight into what makes a good trial paper, highlighting the main areas where there are often misunderstandings of the appropriateness of trial methodology within individual studies. Being able to determine what constitutes good trial evidence is important in determining which evidence should be applied to practice.

Objective:In sub-Saharan Africa, midwifery input into the generation of important research questions is limited. The authors aimed to address this issue by enabling midwives to set their own research priorities with the intention of developing a research strategy to conduct studies relevant to clinical practice.Methods:A survey was carried out in six countries (Kenya, Malawi, Uganda, Zambia, Zimbabwe and Tanzania). The Delphi method was used with six panels of midwives (n=118) to attain a convergence of opinion on midwifery research priorities. Consensus-building was achieved by using a series of questionnaires delivered using multiple iterations to collect data. Data were analysed using ranked means and proportions.Findings:Consensus was reached on 11 research questions which were considered regional priorities. These covered three key areas: midwifery training, clinical care and organisational issues. Conclusions: Midwives prioritised areas of research that had direct applicability to their own practice. All questions were at the applied end of the research spectrum. Priorities tended to cover broad areas within reproductive health, as opposed to being disease-focused. This is likely to reflect the desire to provide quality care that embraces the social aspects of health. Some of these research priorities are being taken forward by midwives in the group.

Background:Obstetric fistula has been defined as an ‘abnormal communication’ between the vagina and the bladder or rectum of a woman which results in continuous leakage of urine and/or faeces. The most common cause of obstetric fistula is obstetric trauma. Obstetric fistula is a highly stigmatising condition; often the women are neglected and or ostracised.Aim:To establish the knowledge and awareness of fistula among men and women living in an area where fistula prevalence is rising.Methods:In this cross-sectional study, women and their partners were recruited purposefully in two counties Kenya: Nyamira and Kisii and interviewed using structured interviews. Data were cleaned and entered into Excel. SPSS was used for descriptive data analysis. Chi2test was conducted to compare responses according to gender and level of education.Results:Three hundred participants (253 women and 47 men) were interviewed over a 3-month period. Responses from women and men were similar. Few (32%) participants reported having seen a woman with fistula in their community. Just over half (53%) said that they knew what causes fistula, of which 89% said they knew that fistula could be treated. Only 27% said that the health care provider mentioned fistula during health education talks. Participants educated to a level above secondary school were more knowledgeable about fistula.Conclusion:Fistula information is lacking among community members. There is a need to scale up training and community awareness campaigns to help eradicate fistula from Kenya.

Pregnancy can be both a time of change and increased stress for women. Through taking part in a research study and attending an antenatal lifestyle programme for women with a body mass index (BMI) ≥30kg/m2, a group of eight women formed a reference group and became a strong and effective source of social support for each other. This article discusses the role of social support from reference groups in engaging in postnatal healthy behaviours, such as physical activity (social learning theory) and protection against stressful situations (social support as a buffer for psychosocial stress), by presenting some observations and data from a number of women taking part in a larger research study and the literature base. Two conclusions are made in this discussion article and require further research attention in the opinion of the research team. First, health professionals should educate women about the different sources of social support that they may need during and after pregnancy; and second, they should provide antenatal opportunities for women to meet others with whom they can form a social support group (e.g. BMI can be the basis for a reference group).

As part of a larger study, maternal hair samples from 56 drug using women were collected within 24 hours of parturition and assayed using gas chromatography and/or mass spectrometry for cannabis, heroin, methadone, cocaine, amphetamine, methamphetamineand benzodiazepines. Reported and observed drug use was compared: a Cohens Kappa coefficient of 0.732 was obtained indicating substantial agreement between reported and observed use. Interesting practice issues emerged. These included the wish to please health practitioners and to avoid negative judgements or removal from services. Also, concerns that confidentiality would be breached or that children would be removed from their care and dissatisfaction with information provided by healthcare practitioners when prescribing medication was communicated.

Caesarean section at maternal request remains a contentious issue, fuelled by reports of associated morbidity. To explore the motivations behind women’s expression of preference for a planned caesarean birth, an internet survey was conducted using semi-structured questionnaires available via a UK-based international website, www.electivecesarean.com,over a 9-month period. A convenience sample of 359 pregnant women who stated that their preferred delivery method was ‘elective caesarean section through my own choice’ was included. Data were analyzed descriptively and thematically. Women from 16 countries were included. Two main themes were identified: 1) anti-vaginal birth; and 2) physical and psychological validation. Women who were anti-vaginal birth had a fear of morbidity (maternal and neonatal) and of the birth experience. They viewed vaginal birth as unpredictable and saw planned caesarean birth as a safer alternative. Some women justified their decision of birth mode by referring to either a physical or psychological issue that related to a previous birth or an existing medical complication. Respondents had similar views regardless of country of residence. We concluded that women have multiple reasons for wanting a caesarean birth. These reasons are usually considered, and motivated by a genuine desire to avoid the potential problems of vaginal birth. Individualized birth consultations should include discussion of the risks and benefits of vaginal and caesarean birth as they relate to individual women.

Background: Previous research has demonstrated the likely benefits of partograph use in low-resourced settings. However, the challenges of completing a partograph are also reported. The objective of this study was to examine students’ views and experiences of partograph use to gain understanding of the realities of using this tool in the labour ward. Methods: In a qualitative study, 51 student nurses, undertaking their maternity placement at a university in Nairobi, Kenya, participated in five focus group discussions. Data were audio recorded, transcribed verbatim and analysed thematically. Results: Four main themes emerged from the analyses: challenges to ‘doing the right thing’; theory-practice disconnectedness; negative role models; and retrospective recording. Conclusions: The results provide insight into the challenges faced by students when practising in the labour ward environment. A more effective approach to partograph training and implementation should be adopted to support students. However, student midwife training is unlikely to be implemented into practice unless the qualified team supports their learning. Given that the partograph had little status in the labour ward, change may only happen when senior health professionals (midwives and obstetricians) lead by example. Further research is required to explore the views of obstetricians and qualified midwives on partograph use. Appropriate implementation strategies also warrant further investigation.

Olive oil is commonly recommended by health professionals to new parents for use in the prevention and treatment of the term baby's dry skin, and for baby massage. There is no evidence to support this practice. The use of olive oil may be harmful to skin, affecting skin barrier function. This effect may be a contributory factor in the prevalence of childhood conditions such as atopic eczema. This paper discusses a national online audit of UK maternity hospitals (n = 67) and neonatal units (n = 33) performed between November 2010 and January 2011. Our findings confirm that oil use on babies' skin is common practice. As the direct cost to the NHS for treatment of atopic eczema is high, it is imperative that further research in this area is performed, preferably in the form of a randomized controlled trial. Health professionals will then be in a position to provide accurate information to parents with regard to oil in baby skin care regimens.

Transcutaneous electrical nerve stimulation (TENS) is a non-invasive method of pain relief, regularly used by women in labour. The National Institute for Health and Clinical Excellence (NICE) intrapartum care guidelines do not recommend its use on grounds of ineffectiveness to reduce pain. However, the recent Cochrane review challenges this guidance, as previous studies have limited capability to exclude an effect, and there is evidence that some women choose TENS as their preferred method of pain relief. We aimed to explore whether the NICE guidelines have impacted on health professionals' support for the use of TENS, and to determine support for a possible clinical trial of TENS. We therefore conducted a national survey of all maternity units in England; responses were received from 139 (76%) of the units. The findings demonstrate overwhelming support for TENS use. Furthermore, the survey identified a willingness among midwives to conduct a multi-centre trial of TENS versus usual care. We conclude that the combination of a dearth of robust evidence together with midwives' beliefs that TENS should be an available pain relieving option, confirms the need for a randomized controlled trial.

The aim of this study was to explore and synthesize the experience of maternity care by female asylum seekers and refugees. The approach was a longitudinal exploratory multiple case study that used a series of interviews, photographs taken by the women, field notes and observational methods to contextualize data obtained during 2002 and 2003. Data was collected in the women's home and a hospital trust. Four women agreed to participate, three women were asylum seekers and one woman was a refugee.Three key themes were generated: the perception of ‘self’ understanding in practice, and the influence of social policy. The women perceived ‘self’ as a response to social interaction. At times, ‘taken for granted’ communication in practice created a barrier to understanding for the women. Social policy related to seeking asylum, dispersement, housing and health directly affecting the lives and subsequent maternity experiences of the women.The theory of symbolic interactionism and transformational educational theory was applied to the findings, highlighting that self-awareness is of paramount importance in care delivery. The strength and resilience of migrating women is acknowledged and should be used as a starting point to develop partnerships in care and to build the woman's self-esteem during their maternity experiences.

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.

The Cochrane Collaboration is internationally renowned as the leading organization for the production of systematic reviews of healthcare interventions. Since the mid-1990s, Cochrane reviews have become synonymous with randomized controlled trials (RCTs), contributing to the elevation of RCTs as the gold standard for research in healthcare. However, this article demonstrates how the inclusion of non-randomized data in Cochrane Reviews is now up for debate. The Cochrane Review of ‘Caesarean section for non-medical reasons at term’ is the first from the Cochrane Pregnancy and Childbirth Group (PCG) to strongly recommend research methods, other than an RCT, to gather future data. Here, two of the review authors assert that Cochrane reviews with no trials may have their place in the work of the PCG.

Rising caesarean section rates may be partly attributed to women choosing to have a repeat caesarean section. This study explores factors influencing women who chose to have an elective caesarean section following a previous emergency caesarean section. The views of women who had experienced one previous emergency caesarean section were explored during the antenatal phase of a subsequent pregnancy. In-depth, semi-structured interviews involved a purposive sample of 10 women. Analysis used an interpretative approach that searched for recurrent themes and categories. Verification of interpretation was obtained from the women. The study found that women were concerned about safety, and feared vaginal birth as the unknown. Control over childbirth was important to them and the decision on mode of birth happened either shortly after their first birth or early during their current pregnancy. The women relied on discussions with relatives, friends or women who had similar experience rather than on detailed information from health care professionals. The women would have welcomed more and consistent information, which may have altered their decision.

Despite the potential benefits of breastfeeding, only a minority of teenagers choose to breastfeed in the UK. In some areas, local audit has demonstrated that just 1 in 5 teenagers initiate breastfeeding prior to leaving hospital. In an attempt to increase these rates, and with the support of a Department of Health project grant, the authors implemented a system whereby a named midwife was employed to support teenagers to breastfeed. This paper will describe the model of support employed, the project evaluation and subsequent implementation of a system which was deemed successful and was valued by the teenagers.

There has been little change in the provision of postnatal care over the last decade. Yet anecdotal evidence suggests that midwives are increasingly concerned about the service they are providing. This study aimed to explore midwives perceptions of the current provision of postnatal care in the North West of England. A stratified random sample of 26 midwives working in a hospital or community setting attended five focus group interviews. Qualitative analysis was undertaken using an open coding mechanism to identify emergent themes. The main themes generated were priorities in postnatal care, societal influences and job satisfaction.This paper will use the views of midwives to debate the way forward in postnatal care.

This article will describe the developments in midwifery research over the last 10 years. A discussion of midwifery attitudes, educational and academic changes and contributions to practice will be presented. Factors currently driving the midwifery research agenda will be highlighted. The article will then explore the future direction of midwifery research and outline the possibilities for the next 10 years.

NHS consumers need accurate, accessible, evidence-based information from which to make decisions about their care. However, consumer involvement in designing and disseminating this information is greatly neglected. This project aims to enable a group of consumers to work in partnership with a midwife to review and reformat the current recommended best practice. This project will enable information to be disseminated in a number of different formats to suit a wide range of needs. Over the last decade, the issues of choice and informed consent have predominated the midwifery press, with the policy agenda for maternity care prioritizing ‘woman-centred‘ services (Welsh Office, 1991; Department of Health, 1993). Pivotal to this approach is the provision of appropriate information on which women can base their childbirth decisions. Various methods are used in maternity units to disseminate information, however, maternal views on the suitability of this information is inconclusive.

Postnatal support has been discussed in the literature over several decades. However support for women following an obstetric complication has received less attention. A descriptive study was carried out to discover how these women feel about the support that was currently provided in the postnatal period and aimed to discover whether additional support is required after a complicated pregnancy. A group of 49 women were questioned using a specifically designed semistructured questionnaire. The findings suggest that, in general, this group of women felt well supported and highlighted factors that women valued in their individual support frameworks. Although it is known that emotional support given to women in labour is important, this study indicates that this may also be true of the postnatal period. This study recognises that to provide an equitable maternity service, midwives must be aware of the implications for those women who are unsupported and may need the listening abilities provided by effective maternity care.

Evidence-based practice is pivotal to improving maternity care. In the developing world there exist multiple barriers that inhibit midwives from developing their research skills and implementing findings into practice. This article describes an initiative carried out by African midwives to overcome some of these barriers. An ongoing programme is discussed which highlights the achievements made by committed midwives who are striving to improve the health of women.

This is the fourth and final paper in a series of papers presenting key findings from a regional survey that was undertaken to explore midwives’ views of the recommendations outlined in the Making a Difference(Department of Health, 1999) document. The background and methodology of the study have been outlined in the first paper. This paper will present the findings from the midwives’ open responses. In particular, issues related to perceived barriers will be discussed. Although midwives expressed a strong urge to meet the needs of their local communities they believed that organisational restraints were preventing them from fulfilling this role. Ways of breaking down these barriers will be discussed.

This is the third of four papers examining the opinions of midwives on their expanding role. The first paper explored midwives' views of their role in health promotion, while the second focused on midwives' views of their contribution to public health strategy. This paper studies midwives' views of potential changes in practice, which may result in increased continuity of care. The main findings suggest that midwives believe that improved continuity of care can be achieved by extending the duration of contact they have with women. They also suggest that preconception input and additional postnatal visiting may have a positive impact on health outcomes.

This is the second of four papers focusing on the expanding role of midwives. The first paper published last month, explored midwives' views of their role in health promotion. This paper focuses on midwives' views of their contribution to the public health strategy. The main findings suggest that, generally, midwives recognise and support a public health role. Over half of the midwives surveyed said they had a role in child protection; promoting effective parenting skills, informing young people about healthy lifestyle choices, providing well-women clinics, targeting vulnerable groups and promoting sexual health. Many midwives acknowledged the need for multiprofessional collaborations. Training was an important and consistent issue.

To explore midwives' views of the recommendations outlined in the Making a Difference document, a regional survey was conducted in seven hospitals in the north west of England. Specifically designed, semi-structured questionnaires were administered to all practising clinical midwives from the study hospitals (n=735). Four hundred and sixty eight questionnaires were returned giving a response rate of 66.4%. In particular the study aimed to highlight any midwifery anxieties, identify training needs and explore midwives' perspective of the effect of the expanding role on service provision. The structured data were analysed descriptively. The open responses were analysed using qualitative methods. This, the first of four papers, focuses on the midwives views of their role in health promotion. The main findings suggested that midwives are generally receptive towards the potential changes to their role, however some reservations were reported.

To assess the effect of two different methods of paracetamol administration on perineal pain management a prospective randomised clinical trial was conducted in a regional teaching hospital in the north west of England. Sixty primigravid women following a normal vaginal delivery who had sustained a first or second degree tear were randomised to have their pain managed using either self administration or staff administration of paracetamol. The primary outcome measure was the level of pain experienced at 48hours post delivery. Secondary outcome measures included — level of pain at 24hours, level of pain at 72hours, women's and midwives' satisfaction with the method of administration, number of paracetamol tablets taken, number of women requiring stronger analgesia and length of hospital stay. Data was retrieved from specifically designed questionnaires and a pain assessment chart. There was no difference in the median pain scores, length of hospital stay or number of women requiring additional analgesia. However, women in the self administration arm were more satisfied with their pain management (30/30 vs 20/30, P<0.01) when compared to the women in the staff administration arm. This finding was reinforced by the open responses. Similarly, midwives were more satisfied with self administration than staff administration. As the evidence on which to base the method of administration remains inconclusive further research is required. However, until such time, women should be allowed to choose their method of pain management.

Various methods of supplying women with information are used in maternity units to assist midwives in making childbirth decisions. However, maternal views on the suitability of information provided during maternity care are inconclusive. A longitudinal study was carried out to discover how women feel about the information that is currently provided regarding pregnancy, labour and parenthood. In particular, the study aimed to explore the timing, amount, content and format of information. These issues had been previously highlighted in three focus groups conducted at the hospital. A descriptive longitudinal panel study was employed using semi-structured questionnaires. A group of 80 women from a purposive sample were questioned at five different stages, i.e. first, second and third trimester, and twice during the postnatal period. The structured data were analysed descriptively and the open responses were analysed using qualitative methods. The findings suggest that women did not receive information which met their individual requirements. Information was not always given at an appropriate time and was often unrealistic. The study highlights aspects of information provision which can be improved. Such improvements may enhance the childbirth experience for women.

An exploratory study was conducted In a regional midwifery unit in Liverpool in August 1995 to discover the knowledge and feelings of a group of first-time expectant fathers in their anticipation of labour.The study design was a combination of specifically designed questionnaires and semistructured interviews. The data was presented following qualitative analysis. Three main themes emerged from this analysis — support, information and role conflict.This study demonstrates that the inclusion of expectant fathers in the birth experience needs greater consideration by health professionals.

Objective To assess the effect of three different partograms on caesarean section and maternal satisfaction.

Sixty‐one women making slow progress in the active phase of spontaneous labour with intact membranes were randomised to oxytocin and amniotomy, amniotomy only or expectant management. The data show that oxytocin significantly increases the rate of cervical dilatation and shortens prolonged labour, when compared with amniotomy alone and expectant management (P= 0.144and 0–0.06, respectively). The impact on the operative delivery rate and neonatal outcome is difficult to assess due to the small number of relevant adverse outcomes. Women reported higher satisfaction score in the two groups where intervention followed the diagnosis of dysfunctional labour.

Strengthening the capacity of midwives and nurses in low- and middle-income countries to lead research is an urgent priority in embedding and sustaining evidence-based practice and better outcomes for women and newborns during childbearing. International and local travel restrictions, and physical distancing resulting from the COVID-19 pandemic have compromised the delivery of many existing programmes and challenged international partnerships working in maternal and newborn health to adapt rapidly. In this paper, we share the experiences of a midwife-led research partnership between Kenya, Malawi, Tanzania, Uganda, the UK, Zambia and Zimbabwe in sustaining and enhancing capacity strengthening activities remotely in this period. Whilst considerable challenges arose, and not all were overcome, collectively, we gained new insights and important learning which have shifted perspectives and will impact future design and delivery of learning programmes.

ABSTRACTBackgroundThe 3-Delays Model has helped in the identification of access barriers to obstetric care in low and middle-income countries by highlighting the responsibilities at household, community and health system levels. Critiques of the Model include its one-dimensionality and its limited utility in triggering preventative interventions. Such limitations have prompted a review of the evidence to establish the usefulness of the Model in optimising timely access to intrapartum care.ObjectiveTo determine the current utility of the 3-Delays Model and its potential for supporting a solution-based approach to accessing intrapartum care.MethodsWe conducted a qualitative evidence synthesis across several databases and included qualitative findings from stand-alone studies, mixed-methods research and literature reviews using the Model to present their findings. Papers published between 1994 and 2019 were included with no language restrictions. Twenty-seven studies were quality appraised. Qualitative accounts were analysed using the ‘best-fit framework approach’.ResultsThis synthesis included twenty-five studies conducted in Africa, Asia, Latin America and the Caribbean. Five studies adhered to the original 3-Delays Model’s structure by identifying the same factors responsible for the delays. The remaining studies proposed modifications to the Model including alterations of the delay’s definition, adding of new factors explaining the delays, and inclusion of a fourth delay. Only two studies reported women’s individual contributions to the delays. All studies applied the Model retrospectively, thus adopting a problem-identification approach.ConclusionThis synthesis unveils the need for an individual perspective, for prospective identification of potential issues. This has resulted in the development of a new framework, the Women’s Health Empowerment Model, incorporating the 3 delays. As a basis for discussion at every pregnancy, this framework promotes a solution-based approach to childbirth, which could prevent delays and support women’s empowerment during pregnancy and childbirth.

The year 1993 was momentous for many reasons. Take That won the Brit Awards for the Best British Single with ‘Could It Be Magic’, Tom Hanks was awarded an Oscar for his leading role in ‘Philadelphia’ and Rita Dove was Poet Laureate, one of her poems being ‘Mother Love’. On a more academic note, Richard Roberts and Phillip Sharp were awarded the Nobel Prize in Physiology and Medicine for their discovery of ‘split genes’, the discovery of which has been of fundamental importance for today's basic research in biology, as well as for more medically oriented research.

Partograms are universally used in the active management of maternity labour care throughout the Western world. Not using a partogram is a challenging process for midwives who want to provide greater choices for women in childbirth. However, the reliance on time framing in labour is a real constraint.

To celebrate the International Day of the Midwife a high profile event took place bringing together all the Professors of Midwifery in the UK, as well as esteemed guests and delegates from England, Scotland, Wales and the Isle of Mann. The conference was unique in that it combined educational elements with a celebration of midwifery and fundraising activities. All proceeds of the day were given to the White Ribbon Alliance in Tanzania.