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Prevention of mother-to-child transmission programs have been one of the hallmarks of success in the fight against HIV/AIDS. In Brazil, access to antiretroviral therapy (ART) during pregnancy has increased, leading to a reduction in new infections among children. Currently, lifelong ART is available to all pregnant, however yet challenges remain in eliminating mother-to-child transmission. In this paper, we focus on the role of near-infrared (NIR) spectroscopy to analyse blood plasma samples of pregnant women with HIV infection to differentiate pregnant women without HIV infection. Seventy-seven samples (39 HIV-infected patient and 38 healthy control samples) were analysed. Multivariate classification of resultant NIR spectra facilitated diagnostic segregation of both sample categories in a fast and non-destructive fashion, generating good accuracy, sensitivity and specificity. This method is simple and low-cost, and can be easily adapted to point-of-care screening, which can be essential to monitor pregnancy risks in remote locations or in the developing world. Therefore, it opens a new perspective to investigate vertical transmission (VT). The approach described here, can be useful for the identification and exploration of VT under various pathophysiological conditions of maternal HIV. These findings demonstrate, for the first time, the potential of NIR spectroscopy combined with multivariate analysis as a screening tool for fast and low-cost HIV detection.

Key points1 Maternity services across Europe during the pandemic has undergone changes to limit virus transmission; however, many changes are not evidence-based.2 Although these changes were introduced to keep women, babies and healthcare staff safe, the exclusion of companions and the separation of mothers and babies is particularly antithetical to a human rights-based approach to quality care.3 A poll of COST Action 18211 network members showed that inconsistency in the application of restrictions was high, and there were significant deviations from the recommendations of authoritative bodies.4 Concerns have emerged that restrictions in practice may have longer term negative impacts on mothers and their families and, in particular, may impact on the long-term health of babies.5 When practice changes deviate from evidence-based frameworks that underpin quality care, they must be monitored, appraised and evaluated to minimise unintended iatrogenic effects.

The United Nations Sustainable Development Goals 2030 aim to reduce health care inequity and maternal and infant mortality rates amongst marginalized populations. To provide adequate and culturally relevant maternity care for minority ethnic groups, it is imperative to examine health care providers' views on care for migrant women. We reviewed published accounts of views and experiences of maternity health care providers providing maternity care for migrant women as a way of exploring their cultural competency. A qualitative meta-synthesis was conducted. Systematic searches were conducted in five electronic databases from inception dates through February 2021. Qualitative data were analyzed using a framework thematic analysis based on Campinha-Bacote's five-component cultural competency model. Eleven studies were included. Findings were presented according to Campinha-Bacote's model: cultural awareness, cultural knowledge (personal responsibility, familial role and cultural influence, the influence of social and system factors, conflicting maternity care expectations), cultural encounter (language and communication), and cultural desire (establishing trust and going the extra mile, resources to boost culturally competent care). Our findings can inform the design of high-quality behavioral change, health care management, sociological, and other relevant studies, along with reviews of what matters to service users about cultural responsiveness. Our data also suggest that health system constraints can exacerbate the lack of cultural competency. Improving the quality of care for migrant communities will necessitate a joint effort between health care organizations, health care providers, policymakers, and researchers in developing and implementing more culturally relevant maternity care policies and management interventions. [Abstract copyright: © 2021 Wiley Periodicals LLC.]

Background Caesarean sections (CS) in Bangladesh have risen eight-fold in the last 15 years. Few studies have explored why. Anecdotally, physicians suggest maternal request for CS is a reason. Women and families suggest physicians influence their decision-making. The aim of this research was to understand more about the decision-making process surrounding CS by exploring physician–patient communication leading to informed-consent for the operation. Methods We conducted a mixed-method study using structured observations with the Option Grid Collaborative’s OPTION5 tool and interviews with physicians and women between July and December 2018. Study participants were recruited from eight district public-sector hospitals. Eligibility criteria for facilities was ≥ 80 births every month; and for physicians, was that they had performed CSs. Women aged ≥ 18 years, providing consent, and delivering at a facility were included in the observation component; primigravid women delivering by CS were selected for the in-depth interviews. Quantitative data from observations were analysed using descriptive statistics. Following transcription and translation, a preliminary coding framework was devised for the qualitative data analysis. We combined both inductive and deductive approaches in our thematic analysis. Results In total, 306 labour situations were observed, and interviews were conducted with 16 physicians and 32 women who delivered by CS (16 emergency CS; 16 elective CS). In 92.5% of observations of physician–patient communication in the context of labour situations, the OPTION5 mean scores were low (5–25 out of 100) for presenting options, patient partnership, describing pros/cons, eliciting patient preferences and integrating patient preferences. Interviews found that non-clinical factors prime both physicians and patients in favour of CS prior to the clinical encounter in which the decision to perform a CS is documented. These interactions were both minimal in content and limited in purpose, with consent being an artefact of a process involving little communication. Conclusions Insufficient communication between physicians and patients is one of many factors driving increasing rates of caesarean section in Bangladesh. While this single clinical encounter provides an opportunity for practice improvement, interventions are unlikley to impact rates of CS without simultaneoulsy addressing physician, patient and health system contextual factors too.

Background When certain complications arise during the second stage of labour, assisted vaginal delivery (AVD), a vaginal birth with forceps or vacuum extractor, can effectively improve outcomes by ending prolonged labour or by ensuring rapid birth in response to maternal or fetal compromise. In recent decades, the use of AVD has decreased in many settings in favour of caesarean section (CS). This review aimed to improve understanding of experiences, barriers and facilitators for AVD use. Methods Systematic searches of eight databases using predefined search terms to identify studies reporting views and experiences of maternity service users, their partners, health care providers, policymakers, and funders in relation to AVD. Relevant studies were assessed for methodological quality. Qualitative findings were synthesised using a meta-ethnographic approach. Confidence in review findings was assessed using GRADE CERQual. Findings from quantitative studies were synthesised narratively and assessed using an adaptation of CERQual. Qualitative and quantitative review findings were triangulated using a convergence coding matrix. Results Forty-two studies (published 1985–2019) were included: six qualitative, one mixed-method and 35 quantitative. Thirty-five were from high-income countries, and seven from LMIC settings. Confidence in the findings was moderate or low. Spontaneous vaginal birth was most likely to be associated with positive short and long-term outcomes, and emergency CS least likely. Views and experiences of AVD tended to fall somewhere between these two extremes. Where indicated, AVD can be an effective, acceptable alternative to caesarean section. There was agreement or partial agreement across qualitative studies and surveys that the experience of AVD is impacted by the unexpected nature of events and, particularly in high-income settings, unmet expectations. Positive relationships, good communication, involvement in decision-making, and (believing in) the reason for intervention were important mediators of birth experience. Professional attitudes and skills (development) were simultaneously barriers and facilitators of AVD in quantitative studies. Conclusions Information, positive interaction and communication with providers and respectful care are facilitators for acceptance of AVD. Barriers include lack of training and skills for decision-making and use of instruments.

Objective Physiological length of labour is highly variable and population norms have low sensitivity and specificity for individuals. The birth history of mothers may provide a basis for personalized assessment of labour progress in their nulliparous daughters. This study was designed to investigate the relationship between length of labour in nulliparous daughters and in their mother's first birth, as a basis for constructing individualised labour prediction models in future. Study design A mother-daughter matched cohort study was conducted in two Israeli maternity hospitals. Recruitment took place between September 2014 and June 2015 via antenatal clinics. Inclusion criteria were nulliparous daughters with singleton pregnancies at ≥32 weeks' gestation and mothers of included daughters who had a first birth in hospital prior to 1997. Data were collected prospectively for daughters by questionnaire and from electronic hospital records, and through retrospective recall questionnaires for mothers. Mother-daughter length of labour data were analysed using parametric and non-parametric tests and logistic regression. Length of labour was categorized as ≤10 h and >10 h. Other factors influencing daughters' length of labour were also examined. Results Data from 323 mother-daughter pairs were analysed. Univariate logistic regression analysis showed that daughters of mothers who were in active labour for more than 10 h showed increased likelihood of having a longer labour [OR1.91 (95 % CI 1.19, 3.05, P = 0.007)]. Controlling for infant gender increased the effect size [OR3.23 (95 % CI 1.55, 6.74, P = 0.002)]. Multivariable logistic regression indicated that mothers' length of labour [OR1.88 (95 % CI 1.12, 3.17)] and daughters' age [OR1.08 (95 % CI 1.02, 1.14)], weight gain in pregnancy [OR1.10 (95 % CI 1.04, 1.16)] and use of anesthesia, were statistically significant factors for daughters' length of labour, with sensitivity, specificity, and positive and negative predictive values of 74 %, 56 %, 66 %, and 64 %, respectively. Conclusions A strong positive association between mother and daughter lengths of labour was found. A model that includes length of labour in their mother's first birth might be useful for labour progress prediction for nulliparous women. Practitioners could inquire about maternal first birth patterns as an additional heuristic to guide practice and increase precision in the clinical management of nullipara women's labour and delivery.

In many high‐income countries such as the United Kingdom, inequalities in breastfeeding initiation and continuation rates exist, whereby socio‐economically advantaged mothers are most likely to breastfeed. Breastfeeding peer support interventions are recommended to address this inequality, with non‐profit breastfeeding organisations providing such support in areas of deprivation. As these organisations' roots and membership are often formed of relatively highly resourced women who have different backgrounds and experiences to those living in areas of deprivation, it is important to understand their practices in this context. In order to explore how UK non‐profit organisations practice breastfeeding peer support in areas of socio‐economic deprivation, a systematic review and meta‐ethnography of published and grey literature was undertaken. Sixteen texts were included, and three core themes constructed: (1) ‘changing communities’ reveals practices designed to generate community level change, and (2) ‘enabling one to one support’, explains how proactive working practices enabled individual mothers' access to supportive environments. (3) ‘forging partnerships with health professionals’, describes how embedding peer support within local health services facilitated peer supporters' access to mothers. While few breastfeeding peer support practices were directly linked to the context of socio‐economic deprivation, those described sought to influence community and individual level change. They illuminate the importance of interprofessional working. Further work to consolidate the peer‐professional interface to ensure needs‐led care is required.

The World Conference of the International Society of Psychosomatic Obstetrics and Gynecology held in The Hague, Netherlands in October 2019 ran a dedicated session debating the global research prio...

Background High numbers of women experience a traumatic birth, which can lead to childbirth-related post-traumatic stress disorder (CB-PTSD) onset, and negative and pervasive impacts for women, infants, and families. Policies, suitable service provision, and training are needed to identify and treat psychological morbidity following a traumatic birth experience, but currently there is little insight into whether and what is provided in different contexts. The aim of this knowledge mapping exercise was to map policy, service and training provision for women following a traumatic birth experience in different European countries. Methods A survey was distributed as part of the COST Action “Perinatal mental health and birth-related trauma: Maximizing best practice and optimal outcomes”. Questions were designed to capture country level data; care provision (i.e., national policies or guidelines for the screening, treatment and/or prevention of a traumatic birth, service provision), and nationally mandated pre-registration and post-registration training for maternity professionals. Results Eighteen countries participated. Only one country (the Netherlands) had national policies regarding the screening, treatment, and prevention of a traumatic birth experience/CB-PTSD. Service provision was provided formally in six countries (33%), and informally in the majority (78%). In almost all countries (89%), women could be referred to specialist perinatal or mental health services. Services tended to be provided by midwives, although some multidisciplinary practice was apparent. Seven (39%) of the countries offered ‘a few hours’ professional/pre-registration training, but none offered nationally mandated post-registration training. Conclusions A traumatic birth experience is a key public health concern. Evidence highlights important gaps regarding formalized care provision and training for care providers.

The coronavirus (COVID-19) pandemic has resulted in rapid changes in many areas of health care worldwide.1 Some organisational and governance controls on innovation have been relaxed, to enable rapid adaptation to changing circumstances. The speed of innovation raises a range of ethical, governance and organisational issues. It is important to assess what changes have been instituted, which ones should be maintained, and how to encourage effective innovations in future. Maternity care provides an exemplar case within the broader health care setting, given the imperative to provide both safe and personalised care for optimal outcomes. Some pandemic-related changes in maternity services, such as restricting women’s opportunities for companionship during ultrasound scans or throughout labour, or limiting parental visiting to neonatal units, have been associated with psychological harm.2 Other changes provide more positive impacts, including reports of more individualised and efficient care associated with the increased use of telemedicine.3 We undertook a documentary analysis of national policy and service-user organisation responses to the pandemic in the United Kingdom (UK) and the Netherlands (NL), as part of the Achieving Safe and Personalised Maternity Care In Response to Epidemics (ASPIRE COVID-19) study. The overall aim of ASPIRE COVID-19 is to identify ‘what works’ in providing maternity care during the current and future pandemics, or similar health crises. The NL was chosen as the comparator to the UK because there were known differences in the organisation of maternity services during the COVID-19 pandemic between the two countries, especially for place of birth. Here we report on activities described as new or expanded innovations in 290 documents produced by seventeen key professional and service-user organisations in the NL and the UK between February and December 2020 (see Table 1). We included strategic papers, guidelines, protocols, and updates for health care professionals, such as newsletters.

Background: Parents of infants born premature and/or sick and who require neonatal care are at risk of poor mental health. Currently there is no comprehensive knowledge about interventions (i.e. types, evidence, resources) that have been exclusively designed to improve the psychosocial wellbeing of this population group. Purpose: To undertake a systematic scoping review of interventions focused on improving the psychosocial wellbeing of parents of sick/premature infants who required neonatal care to identify the: a) types of interventions, b) evidence of the interventions; and c) level of resources required to deliver the interventions. Search strategy: Following an initial pilot search, we searched seven databases (Medline, CINAHL, PsychInfo, Cochrane, Embase, Web of Science and Global Index), reviewed references and followed up key authors. Results: From 10516 hits, 38 papers met the inclusion criteria (36 different studies/interventions). Studies were categorised into creative oriented (11), group or peer support (4), relaxation or mindfulness (3), spiritual/religious (4), psychotherapeutic-based (11), and ‘other’ (3) (e.g. sleep, acupuncture). Most interventions had been undertaken in high-income settings with mothers and required varying levels of resources both within and between the different intervention types. While some interventions were effective, there was high heterogeneity with similar interventions using different designs, protocols and outcomes. Most intervention types included studies that highlighted what parents valued, e.g. self-care, relaxation, social opportunities. Implications for research: Evidence highlights a wide range of potential interventions for nursing and other specialist staff to consider and offers insights into potential mechanisms of effectiveness to underpin future intervention design.

Background WHO has recognised the need to improve its guideline methodology to ensure that guideline decision-making processes are transparent and evidence based, and that the resulting recommendations are relevant and applicable. To help achieve this, WHO guidelines now typically enhance intervention effectiveness data with evidence on a wider range of decision-making criteria, including how stakeholders value different outcomes, equity, gender and human rights impacts, and the acceptability and feasibility of interventions. Qualitative evidence syntheses (QES) are increasingly used to provide evidence on this wider range of issues. In this paper, we describe and discuss how to use the findings from QES to populate decision-making criteria in evidence-to-decision (EtD) frameworks. This is the second in a series of three papers that examines the use of QES in developing clinical and health system guidelines. Methods WHO convened a writing group drawn from the technical teams involved in its recent (2010–2018) guidelines employing QES. Using a pragmatic and iterative approach that included feedback from WHO staff and other stakeholders, the group reflected on, discussed and identified key methods and research implications from designing QES and using the resulting findings in guideline development. Results We describe a step-wise approach to populating EtD frameworks with QES findings. This involves allocating findings to the different EtD criteria (how stakeholders value different outcomes, equity, acceptability and feasibility, etc.), weaving the findings into a short narrative relevant to each criterion, and inserting this summary narrative into the corresponding ‘research evidence’ sections of the EtD. We also identify areas for further methodological research, including how best to summarise and present qualitative data to groups developing guidelines, how these groups draw on different types of evidence in their decisions, and the extent to which our experiences are relevant to decision-making processes in fields other than health. Conclusions This paper shows the value of incorporating QES within a guideline development process, and the roles that qualitative evidence can play in integrating the views and experiences of relevant stakeholders, including groups who may not be otherwise represented in the decision-making process. Electronic supplementary material The online version of this article (10.1186/s12961-019-0468-4) contains supplementary material, which is available to authorized users.

Objective Our objectives were to study the association between epidural analgesia and risk of severe perineal laceration (SPL), and identify additional risk factors for SPL. This multicentre study consisted of an analysis of data from the MidconBirth Phase I Database, on the use of EA and perineal results during childbirth. (World Health Organization, International Clinical Trials Registry Platform, 2016: http://apps.who.int/trialsearch/Trial2.aspx?TrialID=ISRCTN17833269). Methods We conducted a prospective study of pregnant women at term between July 2016 and July 2017 in 30 public maternity hospitals in Catalonia, Spain. Inclusion criteria were an uncomplicated singleton pregnancy, in cephalic presentation and vaginal birth. Data was analysed separately for instrumental births and spontaneous vaginal births, as the former is more frequently associated with episiotomy and more perineal lacerations. Risk factors as well as protective factors in each cohort of women (instrumental and spontaneous vaginal birth), were identified. Multivariate logistic regression model was performed to study the association between epidural analgesia and SPL to identify potential confounders. Odds ratios (OR), using 95% confidence intervals (CI) were constructed. Findings During the study period, 5497 eligible women gave birth, 77.46% of them received epidural analgesia. SPL occurred in 1.63% of births. The univariate analysis showed births with epidural analgesia had significantly higher rates of inductions, augmentation of labour, lithotomy position for birth and episiotomy. However, this association disappeared when the variable "type of vaginal birth" was introduced. In multivariate logistic regression, nulliparity was the major predictor for SPL (OR: 0.17; CI 95%: 0.08–0.34, p: 0.000). Key conclusions Epidural analgesia was not associated with SPL once confounding factors were included. Other interesting factors associated with SPL were identified. Implications for practice This paper identifies important practice areas which contribute to SPL and which have the potential to be rectified. It offers evidence on the role that EA plays on pelvic floor injuries and it adds to existing evidence about the disadvantages of using the lithotomy position for birth, especially in relation to SPL. It highlights the need for practice change in Catalonia from what can be considered a medical model of care to one more aligned with the midwifery philosophy of care through the development of clinical guidelines. It also signals the need to provide women with evidence base upon which to make informed choices on the use of EA, specifically in relation to SPL.

ObjectivesWe compared intrapartum interventions and outcomes for mothers, neonates and children up to 16 years, for induction of labour (IOL) versus spontaneous labour onset in uncomplicated term pregnancies with live births.DesignWe used population linked data from New South Wales, Australia (2001–2016) for healthy women giving birth at 37+0 to 41+6 weeks. Descriptive statistics and logistic regression were performed for intrapartum interventions, postnatal maternal and neonatal outcomes, and long-term child outcomes adjusted for maternal age, country of birth, socioeconomic status, parity and gestational age.ResultsOf 474 652 included births, 69 397 (15%) had an IOL for non-medical reasons. Primiparous women with IOL versus spontaneous onset differed significantly for: spontaneous vaginal birth (42.7% vs 62.3%), instrumental birth (28.0% vs 23.9%%), intrapartum caesarean section (29.3% vs 13.8%), epidural (71.0% vs 41.3%), episiotomy (41.2% vs 30.5%) and postpartum haemorrhage (2.4% vs 1.5%). There was a similar trend in outcomes for multiparous women, except for caesarean section which was lower (5.3% vs 6.2%). For both groups, third and fourth degree perineal tears were lower overall in the IOL group: primiparous women (4.2% vs 4.9%), multiparous women (0.7% vs 1.2%), though overall vaginal repair was higher (89.3% vs 84.3%). Following induction, incidences of neonatal birth trauma, resuscitation and respiratory disorders were higher, as were admissions to hospital for infections (ear, nose, throat, respiratory and sepsis) up to 16 years. There was no difference in hospitalisation for asthma or eczema, or for neonatal death (0.06% vs 0.08%), or in total deaths up to 16 years.ConclusionIOL for non-medical reasons was associated with higher birth interventions, particularly in primiparous women, and more adverse maternal, neonatal and child outcomes for most variables assessed. The size of effect varied by parity and gestational age, making these important considerations when informing women about the risks and benefits of IOL.

Background: In recent years, higher than the recommended rate of oxytocin use has been observed among low-risk women. This study examines the relationship between oxytocin administration and birth outcomes in women and neonates. Methods: A retrospective analysis of birth and neonatal outcomes for women who received oxytocin versus those who did not. The sample included 322 women with a low-risk pregnancy. Results: Oxytocin administration was associated with cesarean section (aOR 4.81, 95% CI: 1.80–12.81), instrumental birth (aOR 3.34, 95% CI: 1.45–7.67), episiotomy (aOR 3.79, 95% CI: 2.20–6.52) and length of the second stage (aOR 00:18, 95% CI: 00:04–00:31). In neonatal outcomes, oxytocin in labor was associated with umbilical artery pH ≤ 7.20 (OR 3.29, 95% CI: 1.33–8.14). Admission to neonatal intensive care unit (OR 0.56, 95% CI: 0.22–1.42), neonatal resuscitation (OR 1.04, 95% CI: 0.22–1.42), and Apgar score &lt, 7 (OR 0.48, 95% CI: 0.17–1.33) were not associated with oxytocin administration during labor. Conclusions: Oxytocin administration during labor for low-risk women may lead to worse birth outcomes with an increased risk of instrumental birth and cesarean, episiotomy and the use of epidural analgesia for pain relief. Neonatal results may be also worse with an increased proportion of neonates displaying an umbilical arterial pH ≤ 7.20.

To explore and describe what women who have given birth in Norway emphasise as important aspects of care during childbirth.The study is based on data from the Babies Born Better online survey, version 2.The maternity care system in Norway.Women who gave birth in Norway between 2013 and 2018.Descriptive statistics were used to describe sample characteristics and to compare data from the B3 survey with national data from the Medical Birth Registry of Norway. The open-ended questions were analysed with an inductive thematic analysis.Themes developed from two open-ended questions.The final sample included 8401 women. There were no obvious differences between the sample population and the national population with respect to maternal age, marital status, parity, mode of birth and place of birth, except for the proportion of planned home births. Four themes and one overarching theme were identified; Compassionate and Respectful Care, A Family Focus, Sense of Continuity and Consistency, and Sense of Security. Overarching theme: Coherence in Childbearing.Norwegian women across all birth settings emphasise maternity care that authentically focuses on both socio-cultural and psychological aspects of care, and physical and clinical factors. If the positive aspects of care identified in this study are adopted at all levels of the maternity care system and from all care providers, there is a high chance that most women will have a safe outcome, and a strong sense of coherence related to a positive birth and motherhood experience.Having a baby is a pivotal life changing experience and not just a clinical event, according to a survey of 8400 women in Norway. Positive birth and motherhood experiences depend on maternity staff who are both skilled and kind.

Summary box Relations of power are intrinsic to the social determinants of sexual and reproductive health (SRH); they influence the content, quality and outcomes of SRH care; and they shape the negotiation and realisation of sexual and reproductive health and rights (SRHR) more broadly. Power dynamics pervade how SRHR is understood, studied and acted on, in ways that are distinct from other health issues.1 For example, the deeply held personal beliefs about women’s sexuality and childbearing, cultural mores regarding adolescent sexuality and state goals related to fertility all mark SRHR as a sphere with distinct and deeply contested power dynamics. Unmasking power as a central element in SRHR research is therefore crucial to developing a research agenda that can produce …

Although breastfeeding is known to improve health, economic and environmental outcomes, breastfeeding initiation and continuation rates are low in the United Kingdom. The global WHO/UNICEF Baby Friendly Hospital Initiative (BFHI) aims to reverse declining rates of breastfeeding by shifting the culture of infant feeding care provision throughout hospital maternity settings. In the United Kingdom, the global BFHI has been adapted by UNICEF UK reflecting a paradigm shift towards the experiences of women and families using maternity services. This research used a critical ethnographic approach to explore the influence of the national UNICEF UK Baby Friendly Initiative (BFI) standards on the culture of one typical maternity service in England, over a period of 8 weeks, across four phases of data collection between 2011 and 2017. Twenty‐one staff and 26 service users were recruited and engaged in moderate‐level participant observation and/or guided interviews and conversations. Basic, organising and a final global theme emerged through thematic network analysis, describing the influence of the BFI on providing, receiving and leading infant feeding care in a hospital maternity setting. Using Antonovsky's sense of coherence construct, the findings discussed in this paper highlight how the BFI offers ‘informational’ (comprehensible), ‘practical’ (manageable) and ‘emotional’ (meaningful) support for both staff and service users, strengthened by effective, local leadership and a team approach. This is juxtaposed against the tensions and demands of the busy hospital maternity setting. It is recommended that ongoing infant feeding policy, practice and leadership balance relational and rational approaches for positive infant feeding care and experiences to flourish.

Background Most qualitative research on breastfeeding the preterm or low-birthweight (LBW) infant has focused on negative insights; there are no comprehensive insights into how, when and why mothers experience positive breastfeeding experiences. We aimed to address this knowledge gap by exploring what characterizes and facilitates a positive breastfeeding experience in mothers of preterm and/or LBW infants. Methods A systematic review using meta-ethnographic methods was conducted. Search strategies involved a comprehensive search strategy on six bibliographic databases, citation tracking and reference checking. The analysis involved a reciprocal level of translation and a line of argument synthesis. Results Searches identified 1774 hits and 17 articles from 14 studies were included, representing the views of 697 mothers. A positive breastfeeding experience was identified as being ‘attuned’. Three themes and eight sub-themes were developed to describe what characterizes attuned breastfeeding. ‘Trusting the body and what it can do’, concerned how attuned breastfeeding was facilitated through understanding the bodily responses and capacity and feeling comfortable with holding the infant and to breastfeed. ‘Being emotionally present – in the here and now’ described the importance of feeling relaxed and reassured. ‘Experiencing mutual positive responses’, illuminated how attunement was related to feelings of mutuality - when the mother recognises the infant’s cues, responds to these signals and receives a positive response from the infant. The key factors to facilitate attuned breastfeeding were opportunities for prolonged close physical contact with the infant, positive relationships with and support from staff and peers, and being facilitated to breastfeed when the infant showed feeding cues. Conclusions This study provides new insights into what characterizes a positive breastfeeding experience and how staff can facilitate and enable mothers to achieve attuned breastfeeding. Improvements in units’ design, such as for rooming-in and having prolonged skin-to-skin contact, and care provided by knowledgeable, supportive and encouraging staff and peers, are crucial. The mother’s physical and emotional states and the infant’s behavioural responses and physiological signals should guide the process towards positive breastfeeding practices.

Background A lack of perceived social support influences women’s infant feeding behaviours. The Infant Feeding Genogram is a visual co-constructed diagram which details people/services that can provide support to women and can facilitate a connection between mothers and their existing assets landscape. The aim of this study is to explore women’s and infant feeding helpers’ experiences and use of an infant feeding genogram delivered to the intervention group of the “Assets-based infant feeding help Before and After birth (ABA)” randomised feasibility trial. Methods 103 primiparous mothers aged 16+ years were recruited to the trial (trial registration number) in two sites (Site A and Site B) with low breastfeeding prevalence in the UK. Infant feeding helpers (IFHs) co-constructed a genogram at the first antenatal meeting for the intervention group (n = 50), and then provided proactive, woman-centered support from ~ 32 weeks gestation to up to 5 months postnatal. Infant feeding helpers' and women’s experiences of the infant feeding genogram were collected via interviews or focus groups. Completed genograms were shared with researchers. Content analysis of the genograms and qualitative data from the interviews and focus groups were analysed thematically. Results Data comprised 32 completed genograms, and qualitative insights from all 13 infant feeding helpers (two focus groups; 4 interviews) and interviews with a purposive sample of 21 of 50 intervention group women between 4 and 21 weeks after birth. Content analysis of the genograms highlighted variations, with more personal, individualised genograms completed at Site B compared to Site A. The perceived impact of the genogram was related to the IFHs’ application of the tool. The genogram was either used as intended to raise women’s awareness of available assets and motivate help-seeking behaviour, or as a data collection tool with limited perceived utility. Negative and positive unintended consequences of genogram use were highlighted. Conclusions The genogram has the potential to offer a woman, family and community-centred approach that focusses on building assets for infant feeding. However, variations in genogram application indicate that revised training is required to clarify the purpose and ensure it is used as intended. Trial registration ISRCTN ISRCTN14760978; Registered 30 January 2017.

The rapid development of COVID-19 has completely altered the context of health care across the UK and around the world. The speed and severity of the pandemic has taken us all by surprise, priorities have shifted and the balance of risks has changed. Things that seemed to be of the greatest importance only a few weeks ago have been swept away. Practice environments have changed almost beyond recognition, especially in hospitals, and a heightened sense of urgency and even fear can, understandably, predominate. The public health and medical imperative is such that there is a perception that the needs, preferences and decisions of childbearing women and even their rights and those of their babies are less important or even irrelevant (Birthrights, 2020). At such a time of rapidly changing priorities and heightened awareness of risk, and despite the overwhelming sense of crisis, a focus on evidence is essential to inform decision-making and to avoid harm. Making swift, if well intentioned, changes without evidence of effectiveness may lead to unanticipated consequences which could seriously compromise the quality of care and outcomes. Maternity workload pressures have increased as a result of the pandemic. Staff have had to self-isolate to protect their own health or when family members are infected. The priority of keeping women and babies – and staff - safe in a pandemic means that we must have the ability to balance the restrictions required to control the spread of infection with the essential, evidence-informed principles of safe, effective, equitable, respectful, kind and compassionate care (Renfrew et al., 2014). Is this a dilemma? No, there must be no trade-off between protecting the health and wellbeing of midwives and other health workers, and the rights of women and babies. Both are imperative. If we fail there is a real risk that the safety and rights of women and babies will be seriously compromised (Human Rights Watch, 2020; International Confederation of Midwives, 2020a; International Confederation of Midwives, 2020b). In this paper we reflect on the immediate response of the maternity services in the UK to the coronavirus pandemic, and the evidence-informed developments that are now emerging (May 2020). We propose a way forward that includes seeking the views of women themselves and their families and the staff who care for them in designing safe and sustainable maternity and neonatal services in the context of coronavirus, recognising that the impact of COVID-19 will last for some years. We present a set of core principles that should be at the heart of care planning and delivery both during and after the pandemic.

Objectives To test whether providing psychological self‐help materials would significantly lower the incidence of post‐traumatic stress disorder (PTSD) at 6–12 weeks postnatally. Design Open‐label randomised controlled trial, with blinded outcome assessment. Setting Community midwifery services in two National Health Service (NHS) trusts in the North West. Sample A cohort of 2419 women receiving normal NHS postnatal care. Methods Midwives screened women for traumatic birth experience; 678 women who screened positively (28.1%) were randomly allocated to self‐help with usual care (n = 336) or to usual care alone (n = 342). The self‐help materials were a leaflet and online film designed to prevent the development of PTSD after trauma exposure through explaining how to manage early psychological responses. Main outcome measure The primary outcome was a composite of diagnostic and subdiagnostic PTSD at 6–12 weeks postnatally using the gold‐standard Clinician‐Administered PTSD Scale (CAPS‐5) interview. Results Of the 678 women correctly randomised plus the nine women randomised in error, 478 (70.5%) were followed up. Diagnostic or subdiagnostic PTSD rates at follow‐up did not differ between groups who received self‐help (26.7%, 65/243) or usual care alone (26.2%, 64/244) (intention‐to‐treat analysis: RR 1.02, 95% CI 0.68–1.53). Findings remained consistent in the per‐protocol analysis (RR 1.04, 95% CI 0.85–1.27). Women viewed the materials very positively. There were no adverse effects. Health economic micro‐costing indicated implementation would be very low cost. Conclusions Many women experience a traumatic birth and risk developing PTSD, but self‐help strategies without professional support are insufficient and should not be routinely introduced. Tweetable abstract Self‐help information alone does not reduce the number of women developing PTSD after a traumatic childbirth.

Globally, the COVID-19 pandemic has already led to major increases in unemployment and is expected to lead to unprecedented increases in poverty and food and nutrition insecurity, as well as poor health outcomes. Families where young children, youth, pregnant and lactating women live need to be protected against the ongoing protracted pandemic and the aftershocks that are very likely to follow for years to come. The future wellbeing of the vast majority of the world now depends on reconfiguring the current ineffective food, nutrition, health, and social protection systems to ensure food and nutrition security for all. Because food, nutrition, health, and socio-economic outcomes are intimately inter-linked, it is essential that we find out how to effectively address the need to reconfigure and to provide better intersecoral coordination among global and local food, health care, and social protection systems taking equity and sutainability principles into account. Implementation science research informed by complex adaptive sytems frameworks will be needed to fill in the major knowledge gaps. Not doing so will not only put the development of individuals at further risk, but also negatively impact on the development potential of entire nations and ultimately our planet.

Background\ud The United States (US) spends more on health care than any other high‐resource country. Despite this, their maternal and newborn outcomes are worse than all other countries with similar levels of economic development. Our purpose was to describe maternal and newborn outcomes and organization of care in four high‐resource countries (Australia, Canada, the Netherlands, and United Kingdom) with consistently better outcomes and lower health care costs, and to identify opportunities for emulation and improvement in the United States.\ud \ud Method\ud We examined resources that described health care organization and financing, provider types, birth settings, national, clinical guidelines, health care policies, surveillance data, and information for consumers. We conducted interviews with country stakeholders representing the disciplines of obstetrics, midwifery, pediatrics, neonatology, epidemiology, sociology, political science, public health, and health services. The results of the analysis were compared and contrasted with the US maternity system.\ud \ud Results\ud The four countries had lower rates of maternal mortality, low birthweight, and newborn and infant death than the United States. Five commonalities were identified as follows: (1) affordable/ accessible health care, (2) a maternity workforce that emphasized midwifery care and interprofessional collaboration, (3) respectful care and maternal autonomy, (4) evidence‐based guidelines on place of birth, and (5) national data collections systems.\ud \ud Conclusions\ud The findings reveal marked differences in the other countries compared to the United States. It is critical to consider the evidence for improved maternal and newborn outcomes with different models of care and to examine US cultural and structural failures that are leading to unacceptable and substandard maternal and infant outcomes.

Although induction of labor can be crucial for preventing morbidity and mortality, more and more women (andtheir offspring) are being exposed to the disadvantages of this intervention while the benefit is at best small or evenuncertain. Characteristics such as an advanced maternal age, a non-native ethnicity, a high Body Mass Index, anartificially assisted conception, and even nulliparity are increasingly considered an indication for induction oflabor. Because induction of labor has many disadvantages, a debate is urgently needed on which level of riskjustifies routine induction of labor for healthy women, only based on characteristics that are associated withstatistically significant small absolute risk differences, compared to others without these characteristics. Thiscommentary contributes to this debate by arguing why induction of labour should not routinely be offered to allwomen where there is a small increase in absolute risk, and no any other medical risks or complications duringpregnancy. To underpin our statement, national data from the Netherlands were used reporting stillbirth rates ingroups of women based on their characteristics, for each gestational week from 37 weeks of gestation onwards.

The UK has low breastfeeding rates, with socioeconomic disparities. The Assets‐based feeding help Before and After birth (ABA) intervention was designed to be inclusive and improve infant feeding behaviours. ABA is underpinned by the behaviour change wheel and offers an assets‐based approach focusing on positive capabilities of individuals and communities, including use of a Genogram. This study aimed to investigate feasibility of intervention delivery within a randomised controlled trial (RCT). Nulliparous women ≥16 years, (n = 103) from two English sites were recruited and randomised to either intervention or usual care. The intervention – delivered through face‐to‐face, telephone and text message by trained Infant Feeding Helpers (IFHs) – ran from 30‐weeks' gestation until 5‐months postnatal. Outcomes included recruitment rates and follow‐up at 3‐days, 8‐weeks and 6‐months postnatal, with collection of future full trial outcomes via questionnaires. A mixed‐methods process evaluation included qualitative interviews with 30 women, 13 IFHs and 17 maternity providers; IFH contact logs; and fidelity checking of antenatal contact recordings. This study successfully recruited women, including teenagers, from socioeconomically disadvantaged areas; postnatal follow‐up rates were 68.0%, 85.4% and 80.6% at 3‐days, 8‐weeks and 6‐months respectively. Breastfeeding at 8‐weeks was obtained for 95.1% using routine data for non‐responders. It was possible to recruit and train peer supporters to deliver the intervention with adequate fidelity. The ABA intervention was acceptable to women, IFHs and maternity services. There was minimal contamination and no evidence of intervention‐related harm. In conclusion, the intervention is feasible to deliver within an RCT, and a definitive trial required.

In 2014, the EU funded a four-year European Cooperation in Science and Technology (COST) Action to address the topic of childbirth. The COST Birth Action was a cross-European network, that brought together over 120 scientists, practitioners, activists and policy makers from 34 countries to work on intrapartum care. The central aim was to advance the state of research and practice in a specific area of great clinical and social importance, intrapartum care. The Action used inter and trans-disciplinary approaches to address birth from multiple perspectives and drew on complexity theory and the concept of salutogenesis (wellbeing). This special collection presents six papers produced from the Action and gives a sense of the range and depth of the work conducted. The Collection illustrates the knowledge that can be generated when a diverse group of people come together with a similar goals and perspectives., This article is based upon work funded by the COST Action IS1405 BIRTH: "Building Intrapartum Research Through Health - An interdisciplinary whole system approach to understanding and contextualising physiological labour and birth"., peer-reviewed

ObjectivesTo explore women’s experiences of remifentanil or pethidine for labour pain and infant feeding behaviours at 6weeks post partum.DesignQualitative postnatal sub-study to the randomised controlled trial of remifentanil intravenous patient controlled analgesia (PCA) versus intramuscular pethidine for pain relief in labour (RESPITE). Semistructured telephone interviews were conducted at 6 weeks post partum, and thematic analysis was undertaken.SettingWomen recruited to the RESPITE trial from seven UK hospitals.ParticipantsEighty women consented and 49 (30 remifentanil group and 19 pethidine group) completed the interview.ResultsEight themes emerged which encompassed women’s antenatal plans for pain management (Birth Expectations) through to their future preferences for pain relief (Reflections for Future Choices). Many women who used remifentanil felt it provided effective pain relief (Effectiveness of Pain Relief), whereas women in the pethidine group expressed more mixed views. Both groups described side effects, with women using pethidine frequently reporting nausea (Negative Physiological Responses) and women using remifentanil describing more cognitive effects (Cognitive Effects). Some women who used remifentanil reported restricted movements due to technical aspects of drug administration and fear of analgesia running out (Issues with Drug Administration). Women described how remifentanil enabled them to maintain their ability to stay focused during the birth (Enabling a Sense of Control). There was little difference in reported breastfeeding initiation and continuation between pethidine and remifentanil groups (Impact on Infant Behaviour and Breastfeeding).ConclusionsQualitative insights from a follow-up study to a trial which explored experiences of intravenous remifentanil PCA with intramuscular pethidine injection found that remifentanil appeared to provide effective pain relief while allowing women to remain alert and focused during labour, although as with pethidine, some side effects were noted. Overall, there was little difference in reported breastfeeding initiation and duration between the two groups.Trial registration numberISRCTN29654603.

Objective The World Maternal Antifibrinolytic (WOMAN) Trial was the first in the UK to use the option of waiver of informed consent at the time of an obstetric emergency. This qualitative study aimed to investigate participants’ views of the acceptability of the recruitment methods used. Design Qualitative study using in‐depth interviews with women who did and did not give consent at the time of their recruitment to the WOMAN Trial. Setting Highest UK recruitment site for the WOMAN Trial (129/569). Interviews were conducted in participants’ homes. Population About 40 of the 129 women who were recruited to the WOMAN Trial at one UK site were invited to take part, 15 women were interviewed. Methods Qualitative, interview study. Main outcome measures Facilitators and barriers to successful recruitment during obstetric emergencies. Guidance for future researchers. Results Findings revealed that what is important is not so much the consent process used or a signature on a form, but the way in which consent is obtained. Clinicians who successfully negotiate consent to research during childbirth emergencies engage in a ‘humane choreography’ of words and actions. This emphasises the importance of prompt decision‐making and treatment, while respecting the woman's personal situation and experience. Conclusions Our findings do not support a single pathway to consent in the context of an obstetric emergency. Women understand that consent to research in an emergency is complex. Clinicians’ skills in considering the clinical, ethical, and emotional aspects within the context of the clinical emergency can hamper or promote women's satisfaction. Tweetable abstract Study reports on women's views of consent to research in an obstetric emergency. Plain Language Summary Why and how was the study carried out? We undertook this study to find out what women thought about being included in a research study called the WOMAN Trial at the time they were being treated for heavy bleeding after giving birth. Some women had been asked if they wanted to be a part of the research at the time they were bleeding. Others were asked later, after they had recovered. We conducted interviews with 15 women who had been involved and asked what they thought about the way they had been asked, their preferences and ideas for improvements in future similar studies What were the main findings? Women understood how difficult it was for their doctors and midwives to ask them about the research study. They were pleased to have been included in the research and were mostly happy with the way they gave consent. Women's views were similar whether they were asked about the research at the time of the bleeding or after they had recovered. The most important thing was that doctors and midwives carefully thought about the situation the woman found herself in and how this might make her feel, so they could tailor their approach accordingly. What are the limitations of the work? This study only involved women from one hospital. The WOMAN Trial included women from many areas of the UK and other countries around the world. We do not know how their experiences or views may differ. What is the implication for professionals? Careful use of actions and words by birth attendants was the difference between a good or bad experience for the woman and her family. This is an important skill that could be developed as part of professional training., Tweetable abstract Study reports on women's views of consent to research in an obstetric emergency.

Spontaneous vaginal birth rates are decreasing worldwide, while cesarean delivery, instrumental births, and medical birth interventions are increasing. Emerging evidence suggests that birth interventions may have an effect on children's health. Therefore, the aim of our study was to examine the association between operative and medical birth interventions on the child's health during the first 28 days and up to 5 years of age. In New South Wales (Australia), population-linked data sets were analyzed, including data on maternal characteristics, child characteristics, mode of birth, interventions during labor and birth, and adverse health outcomes of the children (ie, jaundice, feeding problems, hypothermia, asthma, respiratory infections, gastrointestinal disorders, other infections, metabolic disorder, and eczema) registered with the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification codes. Logistic regression analyses were performed for each adverse health outcome. Our analyses included 491 590 women and their children; of those 38% experienced a spontaneous vaginal birth. Infants who experienced an instrumental birth after induction or augmentation had the highest risk of jaundice, adjusted odds ratio (aOR) 2.75 (95% confidence interval [CI] 2.61-2.91) compared with spontaneous vaginal birth. Children born by cesarean delivery were particularly at statistically significantly increased risk for infections, eczema, and metabolic disorder, compared with spontaneous vaginal birth. Children born by emergency cesarean delivery showed the highest association for metabolic disorder, aOR 2.63 (95% CI 2.26-3.07). Children born by spontaneous vaginal birth had fewer short- and longer-term health problems, compared with those born after birth interventions. [Abstract copyright: © 2018 the Authors. Birth published by Wiley Periodicals, Inc.]

Background Evidence based practice has been associated with better quality of care in many situations, but it has not been able to address increasing need and demand in healthcare globally and stagnant or decreasing healthcare resources. Implementation of value-based healthcare could address many important challenges in health care systems worldwide. Scaling up exemplary high value care practices offers the potential to ensure values-driven maternal and newborn care for all women and babies. Discussion Increased use of healthcare interventions over the last century have been associated with reductions in maternal and newborn mortality and morbidity. However, over an optimum threshold, these are associated with increases in adverse effects and inappropriate use of scarce resources. The Quality Maternal and Newborn Care framework provides an example of what value based maternity care might look like. To deliver value based maternal and newborn care, a system-level shift is needed, ‘from fragmented care focused on identification and treatment of pathology for the minority to skilled care for all’. Ideally, resources would be allocated at population and individual level to ensure care is woman-centred instead of institution/ profession centred but oftentimes, the drivers for spending resources are ‘the demands and beliefs of the acute sector’. We argue that decisions to allocate resources to high value activities, such as continuity of carer, need to be made at the macro level in the knowledge that these investments will relieve pressure on acute services while also ensuring the delivery of appropriate and high value care in the long run. To ensure that high value preventive and supportive care can be delivered, it is important that separate staff and money are allocated to, for example, models of continuity of carer to prevent shortages of resources due to rising demands of the acute services. Summary To achieve value based maternal and newborn care, mechanisms are needed to ensure adequate resource allocation to high value maternity care activities that should be separate from the resource demands of acute maternity services. Funding arrangements should support, where wanted and needed, seamless movement of women and neonates between systems of care.

Little is known about the physiology of labour onset at term, and there is a debate about what signs and symptoms should be used to define it. In low resource settings and, particularly, for remote and rural communities, delay in recognising labour onset may mean a delay in seeking a skilled birth attendant. This chapter presents the most recent evidence about the physiology of labour onset, including the complex neuro-hormonal, biophysical, psychological and emotional factors that contribute. The symptoms of labour onset are explored from the perspective of both pregnant women and service providers in a range of sociocultural contexts. Early labour presents challenges for pregnant women, their families, communities and health care professionals. The chapter discusses how maternity care services should be designed, and delivered to ensure that women get the optimum advice and care at the beginning of labour.

BackgroundIn neonatal care, assessment of the temperature of the neonate is essential to confirm on-going health, and as an early signal of potential pathology. However, some methods of temperature assessment involve disturbing the baby, disrupting essential sleep patterns, and interrupting maternal/infant interaction. Thermal imaging is a completely non-invasive and non-contact method of assessing emitted temperature, but it is not a standard method for neonatal thermal monitoring. To examine the potential utility of using thermal imaging in neonatal care, we conducted a comprehensive systematic scoping review of thermal imaging applications in this context.MethodsWe searched EMBASE, MEDLINE and MIDIRS.ResultsFrom 442 hits, 21 met the inclusion criteria and were included in the review. A significant number (n = 9) were published in the last 8 years. All the studies were observational studies, with 20 out of 21 undertaken in North America or Europe. Most of them had small cohorts (range 4–29 participants). The findings were analysed narratively, to establish the issues identified in the included studies. Five broad themes emerged for future examination. These were: general thermal physiology; heat loss and respiratory monitoring; identification of internal pathologies, including necrotising enterocolitis; other uses of thermal imaging; and technical concerns. The findings suggest that thermal imaging is a reliable and non-invasive method for continuous monitoring of the emitted temperature of the neonates, with potential for contributing to the assurance of wellbeing, and to the diagnosis of pathologies, including internal abnormalities. However, the introduction of thermal imaging into everyday neonatology practice has several methodological challenges, including environmental parameters, especially when infants are placed in incubators or open radiant warmers.ConclusionIn conclusion, although the first attempt at using thermal imaging in neonatal care started in the early-1970s, with promising results, and subsequent small cohort studies have recently reinforced this potential, there have not been any large prospective studies in this area that examine both the benefits and the barriers to its use in practice.

Objective: To appraise the relationship between the length of exposure to epidural analgesia and the risk of non-spontaneous birth, and to identify additional risk factors. This study is framed within the MidconBirth project. Study design: A multicentre prospective study was conducted between July 2016 and November 2017 in three maternity hospitals in different Spanish regions. The independent variable of the study was the length of exposure to epidural analgesia, and the dependent variable was the type of birth in women with uncomplicated pregnancies. The data was analyzed separately by parity. A multivariate logistic regression was performed. The odds ratios (OR), using 95% confidence intervals (CI) were constructed. Main outcome measures: During the study period, 807 eligible women gave birth. Non-spontaneous births occurred in 29.37% of the sample, and 75.59% received oxytocin for augmentation of labour. The mean exposure length to epidural analgesia when non-spontaneous birth happened was 8.05 for primiparous and 6.32 for multiparous women (5.98 and 3.37 in spontaneous birth, respectively). A logistic regression showed the length of exposure to epidural during labour was the major predictor for non-spontaneous births in primiparous and multiparous women followed by use of oxytocin (multiparous group). Conclusions: The length of exposure to epidural analgesia during labour is associated with non-spontaneous births in our study. It highlights the need for practice change through the development of clinical guidelines, training programs for professionals and the continuity of midwifery care in order to support women to cope with labour pain using less invasive forms of analgesia. Women also need to be provided with evidence-based information.

Background Antenatal care (ANC) is a core component of maternity care. However, both quality of care provision and rates of attendance vary widely between and within countries. Qualitative research can assess factors underlying variation, including acceptability, feasibility, and the values and beliefs that frame provision and uptake of ANC programmes. This synthesis links to the Cochrane Reviews of the effectiveness of different antenatal models of care. It was designed to inform the World Health Organization guidelines for a positive pregnancy experience and to provide insights for the design and implementation of improved antenatal care in the future. Objectives To identify, appraise, and synthesise qualitative studies exploring: · Women’s views and experiences of attending ANC; and factors influencing the uptake of ANC arising from women’s accounts; · Healthcare providers’ views and experiences of providing ANC; and factors influencing the provision of ANC arising from the accounts of healthcare providers. Search methods To find primary studies we searched MEDLINE, Ovid; Embase, Ovid; CINAHL, EbscoHost; PsycINFO, EbscoHost; AMED, EbscoHost; LILACS, VHL; and African Journals Online (AJOL) from January 2000 to February 2019. We handsearched reference lists of included papers and checked the contents pages of 50 relevant journals through Zetoc alerts received during the searching phase. Selection criteria We included studies that used qualitative methodology and that met our quality threshold; that explored the views and experiences of routine ANC among healthy, pregnant and postnatal women or among healthcare providers offering this care, including doctors, midwives, nurses, lay health workers and traditional birth attendants; and that took place in any setting where ANC was provided. We excluded studies of ANC programmes designed for women with specific complications. We also excluded studies of programmes that focused solely on antenatal education. Data collection and analysis Two authors undertook data extraction, logged study characteristics, and assessed study quality. We used meta‐ethnographic and Framework techniques to code and categorise study data. We developed findings from the data and presented these in a 'Summary of Qualitative Findings' (SoQF) table. We assessed confidence in each finding using GRADE‐CERQual. We used these findings to generate higher‐level explanatory thematic domains. We then developed two lines of argument syntheses, one from service user data, and one from healthcare provider data. In addition, we mapped the findings to relevant Cochrane effectiveness reviews to assess how far review authors had taken account of behavioural and organisational factors in the design and implementation of the interventions they tested. We also translated the findings into logic models to explain full, partial and no uptake of ANC, using the theory of planned behaviour. Main results We include 85 studies in our synthesis. Forty‐six studies explored the views and experiences of healthy pregnant or postnatal women, 17 studies explored the views and experiences of healthcare providers and 22 studies incorporated the views of both women and healthcare providers. The studies took place in 41 countries, including eight high‐income countries, 18 middle‐income countries and 15 low‐income countries, in rural, urban and semi‐urban locations. We developed 52 findings in total and organised these into three thematic domains: socio‐cultural context (11 findings, five moderate‐ or high‐confidence); service design and provision (24 findings, 15 moderate‐ or high‐confidence); and what matters to women and staff (17 findings, 11 moderate‐ or high‐confidence) The third domain was sub‐divided into two conceptual areas; personalised supportive care, and information and safety. We also developed two lines of argument, using high‐ or moderate‐confidence findings: For women, initial or continued use of ANC depends on a perception that doing so will be a positive experience. This is a result of the provision of good‐quality local services that are not dependent on the payment of informal fees and that include continuity of care that is authentically personalised, kind, caring, supportive, culturally sensitive, flexible, and respectful of women’s need for privacy, and that allow staff to take the time needed to provide relevant support, information and clinical safety for the woman and the baby, as and when they need it. Women’s perceptions of the value of ANC depend on their general beliefs about pregnancy as a healthy or a risky state, and on their reaction to being pregnant, as well as on local socio‐cultural norms relating to the advantages or otherwise of antenatal care for healthy pregnancies, and for those with complications. Whether they continue to use ANC or not depends on their experience of ANC design and provision when they access it for the first time. The capacity of healthcare providers to deliver the kind of high‐quality, relationship‐based, locally accessible ANC that is likely to facilitate access by women depends on the provision of sufficient resources and staffing as well as the time to provide flexible personalised, private appointments that are not overloaded with organisational tasks. Such provision also depends on organisational norms and values that overtly value kind, caring staff who make effective, culturally‐appropriate links with local communities, who respect women’s belief that pregnancy is usually a normal life event, but who can recognise and respond to complications when they arise. Healthcare providers also require sufficient training and education to do their job well, as well as an adequate salary, so that they do not need to demand extra informal funds from women and families, to supplement their income, or to fund essential supplies. Authors' conclusions This review has identified key barriers and facilitators to the uptake (or not) of ANC services by pregnant women, and in the provision (or not) of good‐quality ANC by healthcare providers. It complements existing effectiveness reviews of models of ANC provision and adds essential insights into why a particular type of ANC provided in specific local contexts may or may not be acceptable, accessible, or valued by some pregnant women and their families/communities. Those providing and funding services should consider the three thematic domains identified by the review as a basis for service development and improvement. Such developments should include pregnant and postnatal women, community members and other relevant stakeholders., Provision and uptake of routine antenatal services What is the aim of this review? The aim of this Cochrane qualitative evidence synthesis is to explore women’s and healthcare workers’ views and experiences of antenatal care. We collected and analysed all relevant qualitative studies to answer this question, and include 85 studies. The synthesis links to the Cochrane Reviews of the effectiveness of different antenatal models of care. The synthesis was designed to inform the World Health Organization guidelines for a positive pregnancy experience. Key messages Three areas of antenatal care are important to both women and service providers in all regions of the world. These are: the need to recognise and take account of the socio‐cultural context in which care is provided; the need to ensure that service design and provision are appropriate, accessible, acceptable and of high quality: and that what matters to women and staff is personalised supportive care, information, and safety. What was studied in this review? Antenatal care is the health care women get while they are pregnant. During antenatal care visits, pregnant women are provided with support, reassurance, and information about pregnancy and birth, as well as tests and examinations to see if they and their baby are healthy. If any issues or problems are discovered, these can be managed during the clinic visit. If needed, women can be referred to other care providers. Different types of healthcare workers can give antenatal care. These include midwives, doctors, nurses, and, sometimes, traditional birth attendants. The World Health Organization recommends that all pregnant women get antenatal care, but pregnant women do not always use this care. This may be because they do not think it is important, or because they cannot get to the healthcare facility. It may also be because the antenatal care they receive is of poor quality or because they are badly treated when they are there. By looking at studies of women’s and healthcare workers’ views and experiences of antenatal care, we aimed to learn more about what might help women to use antenatal care, and what might stop them using it. What are the main findings of this review? We include 85 studies in our synthesis. Forty‐six studies explored the views and experiences of women who were pregnant or who had recently given birth. 17 studies explored the views and experiences of healthcare providers, including lay or community health workers, and 22 studies included the views of both women and healthcare providers. The studies took place in eight high‐income countries, 18 middle‐income countries and 12 low‐income countries, in rural and urban locations. Our findings suggest that women use antenatal care if they find it is a positive experience that fits with their beliefs and values, is easy for them to access, affordable, and treats them as an individual. They want care that helps them to feel that they and their baby are safe, and that is provided by kind, caring, culturally sensitive, flexible, and respectful staff that have time to give them support and reassurance about the health and well‐being of them and their babies. They also value tests and treatments that are offered when they need them, and information and advice that is relevant to them. Our findings also suggest that healthcare staff want to be able to offer this kind of care. They would like to work in antenatal services that are properly funded, and that give them proper support, pay, training and education. They believe this will help them to have enough time to treat each pregnant woman as an individual, and to have the knowledge, skills resources and equipment to do their job well. How up‐to‐date is this review? The review authors searched for studies that had been published up to February 2019.

Background Breastfeeding peer support is advocated in national and international guidelines, but the evidence base is mixed. In the UK, breastfeeding peer support was found to be ineffective in randomised controlled trials, while women report positive impacts on breastfeeding experiences in qualitative studies. A key criticism levied against breastfeeding peer support is the lack of theory underpinning intervention design. Here we use the Behaviour Change Wheel to structure the analysis of evaluation data from an infant feeding peer support service in one area in North West England. We aimed to provide theoretically informed insights into how peer support can be operationalised to influence women’s breastfeeding experiences. Methods A 2 year mixed-methods evaluation (2014–2016) comprised surveys and interviews (individual or group) with peer supporters, health and community professionals, project leads and women, and routinely collected infant feeding data. We used the three layers (policies, intervention functions and behaviour-related components) of the Behaviour Change Wheel to structure and interpret the data. Results Overall data comprised 23 interviews (n = 14 - individual; n = 9 - group) and 409 completed surveys. The findings are presented in three sections. First, the ‘policies’ (outer) layer of the Behaviour Change Wheel provides insights into the existing context, infrastructure and resources that underpinned peer support delivery. Then the second (intervention functions) and inner (behaviour components) layers of the Behaviour Change Wheel are used to present three themes, ‘developing capabilities for infant feeding’, ‘motivating guidance and support’ and ‘opportunities for support’. These findings highlight that a peer support service delivered in a context of effective interdisciplinary partnerships, Baby Friendly Initiative accreditation, and flexible service planning, with peer support provided via different types of instrumental, social, practical and emotional support was perceived to be highly beneficial on women’s breastfeeding experiences. In the final section key challenges faced by the service are outlined. Conclusion While gaps and areas for development were highlighted, the service enhanced women’s capabilities, motivations and opportunities for breastfeeding. These theoretically informed insights into an organic and responsive peer support service help build the evidence base for breastfeeding peer support and to identify positive delivery features for future testing.

Background\ud \ud Many women use pharmacological or non-pharmacological pain relief during childbirth. Evidence from Cochrane reviews shows that effective pain relief is not always associated with high maternal satisfaction scores. However, understanding women’s views is important for good quality maternity care provision. We undertook a qualitative evidence synthesis of women’s views and experiences of pharmacological (epidural, opioid analgesia) and non-pharmacological (relaxation, massage techniques) pain relief options, to understand what affects women’s decisions and choices and to inform guidelines, policy, and practice.\ud \ud Methods\ud \ud We searched seven electronic databases (MEDLINE, CINAHL, PsycINFO, AMED, EMBASE, Global Index Medicus, AJOL), tracked citations and checked references. We used thematic and meta-ethnographic techniques for analysis purposes, and GRADE-CERQual tool to assess confidence in review findings. We developed review findings for each method. We then re-analysed the review findings thematically to highlight similarities and differences in women’s accounts of different pain relief methods.\ud \ud Results\ud \ud From 11,782 hits, we screened full 58 papers. Twenty-four studies provided findings for the synthesis: epidural (n = 12), opioids (n = 3), relaxation (n = 8) and massage (n = 4) – all conducted in upper-middle and high-income countries (HMICs). Re-analysis of the review findings produced five key themes. ‘Desires for pain relief’ illuminates different reasons for using pharmacological or non-pharmacological pain relief. ‘Impact on pain’ describes varying levels of effectiveness of the methods used. ‘Influence and experience of support’ highlights women’s positive or negative experiences of support from professionals and/or birth companions. ‘Influence on focus and capabilities’ illustrates that all pain relief methods can facilitate maternal control, but some found non-pharmacological techniques less effective than anticipated, and others reported complications associated with medication use. Finally, ‘impact on wellbeing and health’ reports that whilst some women were satisfied with their pain relief method, medication was associated with negative self-reprisals, whereas women taught relaxation techniques often continued to use these methods with beneficial outcomes.\ud \ud Conclusion\ud \ud Women report mixed experiences of different pain relief methods. Pharmacological methods can reduce pain but have negative side-effects. Non-pharmacological methods may not reduce labour pain but can facilitate bonding with professionals and birth supporters. Women need information on risks and benefits of all available pain relief methods.

Background In an attempt to design an educational programme targeting caregivers of children aged 6 to 59 months in internally displaced persons camps in Somalia, the objective of this study was twofold. First, to explore the nutritional situation of all children aged 6–59 months enrolled in a nutrition programme provided by Save the Children in 2017 in internally displaced persons camps. Second, to identify gaps in the caregivers’ hygiene and feeding practices. Methods In a study of 1655 households, 1655 caregivers for 2370 children aged 6 to 59 months enrolled in a nutrition programme provided by Save the Children answered an adapted questionnaire on hygiene and feeding practices. At the same time, based on standard criteria in the questionnaire, naturalistic observations of caregivers’ hygiene practices were conducted. Every child in the study was measured with anthropometric Mid-Upper-Arm Circumference measurements for the classification of Moderate Acute Malnutrition, Severe Acute Malnutrition and Global Acute Malnutrition. Descriptive statistics were used for analysis. Results 1) There was Severe (12.1%) and Global Acute (19.9%) Malnutrition among children included in the nutrition programme, more frequently in the 6–24 month age group compared to the 25–59 month age group (p Conclusion Child malnutrition might derive from gaps in the caregiver’s knowledge, attitudes, and practices regarding hygiene and infant feeding. An awareness of these gaps can be helpful in designing future educational programmes that target caregivers, particularly in at-risk population groups.

This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Background Intermittent auscultation (IA) is the technique of listening to and counting the fetal heart rate (FHR) for short periods during active labour and continuous cardiotocography (CTC) implies FHR monitoring for longer periods. Although the evidence suggests that IA is the best way to monitor healthy women at low risk of complications, there is no scientific evidence for the ideal device, timing, frequency and duration for IA. We aimed to give an overview of the field, identify and describe methods and practices for performing IA, map the evidence and accuracy for different methods of IA, and identify research gaps. Methods We conducted a systematic scoping review following the Joanna Briggs methodology. Medline, EMBASE, Cinahl, Maternity & Infant Care, Cochrane Library, SveMed+, Web of Science, Scopus, Lilacs and African Journals Online were searched for publications up to January 2019. We did hand searches in relevant articles and databases. Studies from all countries, international guidelines and national guidelines from Denmark, United Kingdom, United States, New Zealand, Australia, The Netherlands, Sweden, Denmark, and Norway were included. We did quality assessment of the guidelines according to the AGREEMENT tool. We performed a meta-analysis assessing the effects of IA with a Doppler device vs. Pinard device using methods described in TheCochrane Handbook, and we performed an overall assessment of the summary of evidence using the GRADE approach. Results The searches generated 6408 hits of which 26 studies and 11 guidelines were included in the review. The studies described slightly different techniques for performing IA, and some did not provide detailed descriptions. Few of the studies provided details of normal and abnormal IA findings. All 11 guidelines recommended IA for low risk women, although they had slightly different recommendations on the frequency, timing, and duration for IA, and the FHR characteristics that should be observed. Four of the included studies, comprising 8436 women and their babies, were randomised controlled trials that evaluated the effect of IA with a Doppler device vs. a Pinard device. Abnormal FHRs were detected more often using the Doppler device than in those using the Pinard device (risk ratio 1.77; 95% confidence interval 1.29–2.43). There were no significant differences in any of the other maternal or neonatal outcomes. Four studies assessed the accuracy of IA findings. Normal FHR was easiest to identify correctly, whereas identifying periodic FHR patterns such as decelerations and saltatory patterns were more difficult. Conclusion Although IA is the recommended method, no trials have been published that evaluate protocols on how to perform it. Nor has any study assessed interrater agreements regarding interpretations of IA findings, and few have assessed to what degree clinicians can describe FHR patterns detected by IA. We found no evidence to recommend Doppler device instead of the Pinard for IA, or vice versa. Intermittent auscultation fetal monitoring during labour: A systematic scoping review to identify methods, effects, and accuracy

ObjectiveTo establish the views and experiences of healthcare professionals in relation to interventions targeted at them to reduce unnecessary caesareans.DesignQualitative evidence synthesis.SettingStudies undertaken in high-income, middle-income and low-income settings.Data sourcesSeven databases (CINAHL, MEDLINE, PsychINFO, Embase, Global Index Medicus, POPLINE and African Journals Online). Studies published between 1985 and June 2017, with no language or geographical restrictions. We hand-searched reference lists and key citations using Google Scholar.Study selectionQualitative or mixed-method studies reporting health professionals’ views.Data extraction and synthesisTwo authors independently assessed study quality prior to extraction of primary data and authors’ interpretations. The data were compared and contrasted, then grouped into summary of findings (SoFs) statements, themes and a line of argument synthesis. All SoFs were Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) assessed.Results17 papers were included, involving 483 health professionals from 17 countries (nine high-income, six middle-income and two low-income). Fourteen SoFs were identified, resulting in three core themes: philosophy of birth(four SoFs); (2)social and cultural context(five SoFs); and (3)negotiation within system(five SoFs). The resulting line of argument suggests three key mechanisms of effect for change or resistance to change: prior beliefs about birth; willingness or not to engage with change, especially where this entailed potential loss of income or status (including medicolegal barriers); and capacity or not to influence local community and healthcare service norms and values relating to caesarean provision.ConclusionFor maternity care health professionals, there is a synergistic relationship between their underpinning philosophy of birth, the social and cultural context they are working within and the extent to which they were prepared to negotiate within health system resources to reduce caesarean rates. These findings identify potential mechanisms of effect that could improve the design and efficacy of change programmes to reduce unnecessary caesareans.PROSPERO registration numberCRD42017059455.

The context of healthcare and of healthcare education has radically changed as a result of the Covid-19 pandemic. To identify positive strategies for midwifery education in this context, five case studies from the UK and beyond were conducted using an appreciative enquiry approach, from the perspectives of students, the maternity services, cross-university collaboration, and digital learning. A health system analysis was used to identify strategies to cope, adapt, and transform for the future, at the levels of individuals, teams, and the whole system.\ud\udFindings showed that the implementation of effective responses was possible. Responding effectively and rapidly to a shock as profound as this pandemic requires courageous, respectful, evidence-based, innovative, collaborative, cross-sectoral working and leadership across education institutions, practice settings, the regulator, government, and with students themselves. Pre-existing trusting relationships and collaborative systems supported rapid responses. Effective digital learning requires a pro-active, student-centred approach, and addressing the problems of inequitable access to equipment and space. Joint problem-solving and focussing on the key outcomes that matter contribute to developing successful strategies and robust processes. The pandemic provides an opportunity for student midwives to be re-imagined as essential members of midwifery teams and not ‘just students’. Transformative actions identified include whole-system working, tackling longstanding problems including racism, poverty, prejudice, and systemic discrimination, and keeping students at the heart of the education system.

Introduction: Studies have shown that long-term positive behavioural and physiological changes are induced in connection with vaginal, physiological birth, and skin-to-skin contact after birth in mothers and babies. Some of these effects are consistent with the effect profile of oxytocin. This scoping review explores whether epigenetic changes of the oxytocin gene and of the oxytocin receptor gene (OTR) are involved in these effects. Methods: We searched Pubmed, Medline, BioMed Central, Cochrane Library, OVID, and Web of Science for evidence of epigenetic changes in connection with childbirth in humans, with a particular focus on the oxytocin system. Results: There were no published studies identified that were related to epigenetic changes of oxytocin and its receptor in connection with labour, birth, and skin-to-skin contact after birth in mothers and babies. However, some studies were identified that showed polymorphisms of the oxytocin receptor influenced the progress of labour. We also identified studies in which the level of global methylation was measured in vaginal birth and caesarean section, with conflicting results. Some studies identified differences in the level of methylation of single genes linked to various effects, for example, immune response, metabolism, and inflammation. In some of these cases, the level of methylation was associated with the duration of labour or mode of birth. We also identified some studies that demonstrated long-term effects of mode of birth and of skin-to-skin contact linked to changes in oxytocin function. Conclusion: There were no studies identified that showed epigenetic changes of the oxytocin system in connection with physiological birth. The lack of evidence, so far, regarding epigenetic changes did not exclude future demonstrations of such effects, as there was a definite role of oxytocin in creating long-term effects during the perinatal period. Such studies may not have been performed. Alternatively, the oxytocin linked effects might be indirectly mediated via other receptors and signalling systems. We conclude that there is a significant lack of research examining long-term changes of oxytocin function and long-term oxytocin mediated adaptive effects induced during physiological birth and skin-to-skin contact after birth in mothers and their infants., peer-reviewed

Increasing breastfeeding rates would improve maternal and child health, but multiple barriers to breastfeeding persist. Breast pump provision has been used as an incentive for breastfeeding, although effectiveness is unclear. Women's use of breast pumps is increasing and a high proportion of mothers express breastmilk. No research has yet reported women's and health professionals' perspectives on breast pumps as an incentive for breastfeeding. In the Benefits of Incentives for Breastfeeding and Smoking cessation in pregnancy (BIBS) study, mixed methods research explored women's and professionals' views of breast pumps as an incentive for breastfeeding. A survey of health professionals across Scotland and North West England measured agreement with ‘a breast pump costing around £40 provided for free on the NHS’ as an incentive strategy. Qualitative interviews and focus groups were conducted in two UK regions with a total of 68 participants (pregnant women, new mothers, and their significant others and health professionals) and thematic analysis undertaken. The survey of 497 health professionals found net agreement of 67.8% (337/497) with the breast pump incentive strategy, with no predictors of agreement shown by a multiple ordered logistic regression model. Qualitative research found interrelated themes of the ‘appeal and value of breast pumps’, ‘sharing the load’, ‘perceived benefits’, ‘perceived risks’ and issues related to ‘timing’. Qualitative participants expressed mixed views on the acceptability of breast pumps as an incentive for breastfeeding. Understanding the mechanisms of action for pump type, timing and additional support required for effectiveness is required to underpin trials of breast pump provision as an incentive for improving breastfeeding outcomes. © 2016 The Authors. Maternal & Child Nutrition published by John Wiley & Sons Ltd.

Many studies highlight how health is influenced by the settings in which people live, work, and receive health care. In\ud particular, the setting in which childbirth takes place is highly influential. The physiological processes of women’s labor\ud and birth are enhanced in optimal (“salutogenic,” or health promoting) environments. Settings can also make a difference\ud in the way maternity staff practice. This paper focuses on how positive examples of Italian birth places incorporate principles\ud of healthy settings. The “Margherita” Birth Centre in Florence and the Maternity Home “Il Nido” in Bologna were\ud purposively selected as cases where the physical-environmental setting seemed to reflect an embedded model of care that\ud promotes health in the context of childbirth. Narrative accounts of the project design were collected from lead professional\ud and direct inspections performed to elicit the key salutogenic components of the physical layout. Comparisons\ud between cases with a standard hospital labor ward layout were performed. Cross-case similarities emerged. The physical\ud characteristics mostly related to optimal settings were a result of collaborative design decisions with stakeholders and\ud users, and the resulting local intention to maximize safe physiological birth, psychosocial wellbeing, facilitate movement\ud and relaxation, prioritize space for privacy, intimacy, and favor human contact and relationships. The key elements\ud identified in this paper have the potential toinform further investigations for the design or renovation of all birth places\ud (including hospitals) in order to optimize the salutogenic component of any setting in any country.\ud (Cite this article as: Setola N, Iannuzzi L, Santini M, Cocina GG, Naldi E, Branchini L, et al. Optimal settings for childbirth.\ud Minerva Ginecol 2018;70:000-000. DOI : 10.23736/S0026-4784.18.04327-7)

Background Midwifery students can experience events on clinical placements that they perceive to be traumatic. There is currently no requirement to provide training about the nature of trauma, normal responses, or the most helpful ways of self-managing these. The POPPY programme, developed for qualified midwives, incorporates educational (the POPPY workshop) and supportive resources to prevent the development of Post-Traumatic Stress Disorder in midwives. As part of the feasibility evaluation of POPPY, the POPPY workshop element was adapted for pre-registration midwifery students (PreR-POPPY). Attention to this issue during pre-registration education could improve student experience and support student retention. Objectives To identify students' perspectives on the contents (clarity, understandability, organisation of the workshop, utility, relevance), their understanding of trauma and psychological responses, and confidence in recognising and managing early signs of distress following participation in a PreR-POPPY workshop. Perspectives on preferred timing in their midwifery programmes, and methods of delivery were also sought. Design In keeping with educational evaluations, anonymous feedback was collected from students. Setting Two higher education institutes. Participants Midwifery undergraduate students on the three year or shortened programme for registered nurses (n = 131), and midwifery educators (n = 5). Methods Students participated in the workshop and provided feedback immediately. Midwifery educators participated in a meeting with the researchers to provide feedback. Results High levels of satisfaction with the contents of the workshop were identified. Ninety-nine percent of students would recommend the workshop to other midwifery students. Provision of the workshop early in midwifery programmes, revisited at later points, was strongly endorsed. Learning outcomes were very positive for understanding trauma/early stress responses, and recognising and managing early responses to trauma. Strong endorsement for the provision of the workshop was received from the midwifery educators. Conclusions The pre-registration adapted POPPY workshop should be routinely provided in preregistration midwifery.

Publisher's version (útgefin grein), Objective To synthesise qualitative studies on women's psychological experiences of physiological childbirth. Design Meta-synthesis. Methods Studies exploring women's psychological experiences of physiological birth using qualitative methods were eligible. The research group searched the following databases: MEDLINE, CINAHL, PsycINFO, PsycARTICLES, SocINDEX and Psychology and Behavioural Sciences Collection. We contacted the key authors searched reference lists of the collected articles. Quality assessment was done independently using the Critical Appraisal Skills Programme (CASP) checklist. Studies were synthesised using techniques of meta-ethnography. Results Eight studies involving 94 women were included. Three third order interpretations were identified: 'maintaining self-confidence in early labour', 'withdrawing within as labour intensifies' and 'the uniqueness of the birth experience'. Using the first, second and third order interpretations, a line of argument developed that demonstrated 'the empowering journey of giving birth' encompassing the various emotions, thoughts and behaviours that women experience during birth. Conclusion Giving birth physiologically is an intense and transformative psychological experience that generates a sense of empowerment. The benefits of this process can be maximised through physical, emotional and social support for women, enhancing their belief in their ability to birth and not disturbing physiology unless it is necessary. Healthcare professionals need to take cognisance of the empowering effects of the psychological experience of physiological childbirth. Further research to validate the results from this study is necessary., European Cooperation in Science and Technology

© 2018 Wiley Periodicals, Inc. Despite decades of considerable economic investment in improving the health of families and newborns world-wide, aspirations for maternal and newborn health have yet to be attained in many regions. The global turn toward recognizing the importance of positive experiences of pregnancy, intrapartum and postnatal care, and care in the first weeks of life, while continuing to work to minimize adverse outcomes, signals a critical change in the maternal and newborn health care conversation and research prioritization. This paper presents “different research questions” drawing on evidence presented in the 2014 Lancet Series on Midwifery and a research prioritization study conducted with the World Health Organization. The results indicated that future research investment in maternal and newborn health should be on “right care,” which is quality care that is tailored to individuals, weighs benefits and harms, is person-centered, works across the whole continuum of care, advances equity, and is informed by evidence, including cost-effectiveness. Three inter-related research themes were identified: examination and implementation of models of care that enhance both well-being and safety; investigating and optimizing physiological, psychological, and social processes in pregnancy, childbirth, and the postnatal period; and development and validation of outcome measures that capture short and longer term well-being. New, transformative research approaches should account for the underlying social and political-economic mechanisms that enhance or constrain the well-being of women, newborns, families, and societies. Investment in research capacity and capability building across all settings is critical, but especially in those countries that bear the greatest burden of poor outcomes. We believe this call to action for investment in the three research priorities identified in this paper has the potential to achieve these benefits and to realize the ambitions of Sustainable Development Goal Three of good health and well-being for all.