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Background: Pregnancy at a young age is a continuing public health concern strongly associated with socioeconomic deprivation, social isolation, and stigma. The objectives were to see whether, compared with women aged 21 or more, women aged 20 years or younger worried more about labor and birth, and had poorer maternal outcomes. Another objective was to investigate the extent to which worries about labor and birth mediated the associations between young age and outcomes., Methods: A secondary analysis of data was conducted relating to 2,598 primiparous women's experience of maternity care in England in 2010. The survey collected data on care in the antenatal, intrapartum, and postnatal periods, and sociodemographic factors. A validated checklist measured worries about labor and birth., Results: Compared with women aged 21 or more, women aged 20 years or younger worried more about labor and birth. The pain and duration of labor worried all women and those aged 20 years or younger were particularly worried about the uncertainty of labor onset, cesarean section birth, and about embarrassment. In logistic regression, after adjusting for potential confounders, young age was a significant independent risk factor for worries about pain and distress in labor, and self-reported depression at 1 and 3 months. However, young age was also significantly associated with having a normal vaginal delivery., Conclusions: It may be appropriate to focus support on women experiencing multiple disadvantage, rather than young age alone., (© 2016 Wiley Periodicals, Inc.)

Background: young parenthood continues to be an issue of concern in terms of clinical and psychosocial outcomes for mothers and their babies, with higher rates of medical complications such as preterm labour and hypertensive disease and a higher risk of depression. The aim of this study was to investigate how young age impacts on women's experience of intrapartum care., Methods: secondary analysis of data collected in a population based survey of women who had recently given birth in Queensland, comparing clinical and interpersonal aspects of the intrapartum maternity care experience for 237 eligible women aged 15-20 years and 6534 aged more than 20 years. Descriptive and multivariate analyses were undertaken., Results: in the univariate analysis a number of variables were significantly associated with clinical aspects of labour and birth and perceptions of care: young women were more likely to birth in a public facility, to travel for birth and to live in less economically advantaged areas, to have a normal vaginal birth and to have one carer through labour. They were also less likely to report being treated with respect and kindness and talked to in a way they could understand. In logistic regression models, after adjustment for parity, other socio-demographic factors and mode of birth, younger mothers were still more likely to birth in a public facility, to travel for birth, to be more critical about interpersonal and aspects of care and the hospital or birth centre environment., Conclusion: this study shows how experience of care during labour and birth is different for young women. Young women reported poorer quality interpersonal care which may well reflect an inferior care experience and stereotyping by health professionals, indicating a need for more effective staff engagement with young women at this time., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Aim: to describe the timing, type and duration of initial infant contact and associated demographic and clinical factors in addition to investigating the impact of early contact on breastfeeding and maternal health and well being after birth., Method: data from a recent population survey of women birthing in Queensland, Australia were used to describe the nature of the first hold and associated demographic characteristics. Initial comparisons, with subsequent adjustment for type of birthing facility and mode of childbirth, were used to assess associations between timing, type and duration of initial contact and outcomes. Further analyses were conducted to investigate a dose-response relationship between duration of first contact and outcomes., Findings: women who had an unassisted vaginal birth held their infant sooner, and for longer than women who had an assisted vaginal birth or caesarean and were more satisfied with their early contact. Multivariate models showed a number of demographic and clinical interventions contributing to timing, duration and type of first contact with type of birthing facility (public/private), area of residence, and assisted birth as prominent factors. For women who had a vaginal birth; early, skin-to-skin, and longer duration of initial contact were associated with high rates of breastfeeding initiation and breastfeeding at discharge, but not breastfeeding at 13 weeks. Some aspects of early contact were associated with improved maternal well being. However, these associations were not found for women who had a caesarean birth. With longer durations of first contact, a dose-response effect was found for breastfeeding., Conclusion: results of the study provide a description of current practice in Queensland, Australia and factors impacting on early contact. For vaginal births, findings add to the evidence in support of early skin-to-skin contact for an extended period. It is suggested that all research in this area should consider the effects of early contact separately for women having vaginal and caesarean births., Implications for Practice: care providers should consider extending the period of early contact in routine care following vaginal birth and explore the way in which women having a caesarean birth might be better supported in benefitting from early contact with their infant., (Copyright © 2014. Published by Elsevier Ltd.)

Background: Young motherhood is commonly associated with vulnerabilities, stereotyping of young women's behavior, and poor outcomes for them and their children. The objective was to understand how maternity care is experienced by this group in the transition to parenthood., Methods: Data from a large-scale 2010 survey of women's experience of maternity care were analyzed using qualitative methods with open text responses., Results: Overall, 7,193 women responded to the survey: 237 were aged 20 years or less. Most (83%) of these young women provided open text responses. The main themes were: "being a consumer," "the quality of care," "needing support," and "pride in parenthood" whereas subthemes included "being young" and "how staff made me feel," "testimonials for staff," "not being left," and "it is all worthwhile.", Conclusion: Many young women responding described a positive experience. For many first-time mothers this feeling marked a change in their identity. Nevertheless, staff perceptions and attitudes affected how they saw themselves and what they took away from their experience of maternity care. A key message for other women is offered, supporting and reinforcing their role as active and involved consumers who, in engaging with services, have to stand up for themselves and make their needs and wishes known., (© 2014, Copyright the Authors Journal compilation © 2014, Wiley Periodicals, Inc.)

Objective: To investigate women's experience of induction of labor., Design: Mixed methods study., Setting: English maternity units., Sample: Women who gave birth in a two-week period in late 2009, excluding women aged less than 16 years and women whose baby had died., Methods: This study involved secondary analysis of data from questionnaires relating to care in childbirth. Women's experience of induction of labor was compared with that of women who had spontaneous labor by analysis of responses to structured survey questions. Responses to open questions relating to induction were analysed qualitatively., Main Outcome Measures: Satisfaction with care, mode of delivery, experience of induction of labor., Results: The response rate to the survey was 55.1% representing 5333 women, 20% of whom were induced. Nulliparous women, those with long-term health problems, or specific pregnancy-related problems were significantly more likely to be induced. Women who were induced were generally less satisfied with aspects of their care and significantly less likely to have a normal delivery. In the qualitative analysis the main themes that emerged concerned delay, staff shortages, neglect, pain and anxiety in relation to getting the induction started and once it was underway; and in relation to failed induction, the main themes were plans not being followed, wasted effort and pain, and feeling let down and disappointed., Conclusions: Women having an induction were generally less satisfied with their care, suggesting the need for a focused service for these women to address their additional needs., (© 2013 Nordic Federation of Societies of Obstetrics and Gynecology.)

Background: Poor outcomes after childbirth are associated with physical ill health and with an absence of a positive sense of well-being. Postnatally poor physical health is thought to be influenced by the care received, the nature of the birth, and associated complications. The aim of this study was to estimate the effects of a range of clinical and other factors on positive outcome and well-being 3 months after childbirth., Methods: This study used data on more than 5,000 women from a 2010 National Maternity Survey about their experiences of maternity care, and health and well-being 3 months after childbirth. Positive outcome was defined as women reporting no problems and feeling "very well" at the time of the survey., Results: In the univariate analysis, several variables were significantly associated with positive outcome, including sociodemographic, antenatal, intrapartum, and postnatal factors. In the final logistic regression model, young mothers, those without physical disability and those with no or few antenatal or early postnatal problems, were most likely to have positive outcomes. Other significant factors included a positive initial reaction to the pregnancy, not reporting antenatal depression, fewer worries about the labor and birth, and access to information about choices for care., Conclusions: This study shows how positive outcomes for women after childbirth may be influenced by health, social, and care factors. It is important for caregivers to bear these factors in mind so that extra support may be made available to those women who are likely to be susceptible to poor outcome., (© 2013, Copyright the Authors Journal compilation © 2013, Wiley Periodicals, Inc.)

Objective: To examine the effects of pregnancy planning, time to conception (TTC), and assisted reproductive technologies (ART) on child behavior., Design: Prospective cohort study., Setting: Not applicable., Patient(s): A total of 12,380 singletons recruited at 9 months and followed-up at 5 and 7 years. Conceptions were divided into "unplanned" (unplanned, unhappy), "mistimed" (unplanned, happy), "planned" (planned, TTC <12 months), "subfertile" (planned, TTC ≥ 12 months), "ovulation induced" (received clomiphene citrate), and "ART" (IVF or intracytoplasmic sperm injection)., Intervention(s): None., Main Outcome Measure(s): Child behavior (Strengths and Difficulties Questionnaire [SDQ])., Result(s): Mistimed and unplanned children had higher average SDQ scores at age 5 and 7 years and were significantly more likely to have a clinically relevant behavioral problem compared with the planned group. The ART children had significantly higher average SDQ scores at both 5 and 7 years compared with the planned group. An increase in clinically relevant behavioral problems was observed at 5 years (odds ratio 2.05 [95% confidence interval 0.96, 4.42]) but failed to reach statistical significance. No effects were observed in the subfertile and ovulation-induced groups., Conclusion(s): Unplanned and mistimed children exhibit more behavioral problems than their planned peers. Though ART children have higher mean total difficulties scores, this did not translate into a statistically significant increase in clinically relevant behavioral problems., (Copyright © 2013 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Physical and psychological problems after childbirth are common, and may have a significant negative and long-term impact on women's wellbeing and daily functioning. The method of birth may be a particularly important factor influencing women's health and wellbeing following birth, however, population-wide evidence is limited. This study uses data from 5,332 women who responded to a national survey of women's experiences of maternity care in England. We examined women's postnatal wellbeing in the first three months after birth, and whether these varied by mode of birth., Methods: This is a secondary analysis of survey data using a random sample of women selected from birth registration. We used multinomial logistic regression models to examine the association between women's self-reported psychological symptoms, health problems and mode of birth., Results: Women who had forceps-assisted vaginal births and unplanned caesarean section births reported the poorest health and wellbeing, while those of women who had unassisted vaginal births and planned caesarean section births were less affected by the birth process. Most women's physical and emotional health appeared to improve with time, however, those who had a forceps-assisted vaginal birth were more likely to report ongoing posttraumatic-type symptoms several months after the birth., Conclusions: Mode of birth was associated with differences in outcomes at three months. By comparison to women who had unassisted vaginal births, the risk of reduced postnatal health and wellbeing was higher amongst the women who had forceps-assisted vaginal births but not amongst women who had ventouse-assisted vaginal births. This would suggest that it is important to differentiate the different types of instrumental birth in outcome studies. Of concern was the higher rate of posttraumatic-type symptoms among women who had forceps-assisted vaginal births relative to the other modes of birth. Women who have forceps-assisted births should be monitored carefully by health professionals in the postnatal period, and in the months after childbirth, when they could be offered the opportunity to discuss their labour and birth.

Background: Maternity services should take into account the needs of all women, including those related to disability. No reliable information, however, exists on the extent and characteristics of disability in this population in the UK. This brief report provides an overview of the prevalence of disability in women giving birth in the UK as measured by the presence of a limiting longstanding illness (LLI). The demographic, socio-economic, lifestyle and pregnancy related characteristics and child health outcomes are summarised to inform maternity and postnatal care service planning, and policy development., Methods: Secondary analysis of data on 18,231 mother-child pairs from the nationally representative UK Millennium Cohort Study. The baseline interviews with families were carried out in 2001-2002. The LLI prevalence in women who had recently delivered was estimated, and relevant characteristics and differences in outcomes compared using descriptive statistics taking into account the study design and non-response., Results: 9.4% (95% CI 8.7-10.0) of women who had recently given birth reported having an LLI. Musculoskeletal, respiratory and mental disorders accounted for most of the health problems. A significantly higher proportion of women with an LLI received means-tested financial benefits, had no educational qualifications and suffered from intimate partner violence compared to women who did not have an LLI (49.3% vs 35.3%, 20.4% vs 15.0%, 6.0% vs 3.3%, respectively). They were also more likely to smoke throughout pregnancy than women without an LLI (29.2% vs 20.8%), have a preterm birth (10.9% vs 6.8%) and be lone parents (19.5% vs 13.9%). Only 25.6% of children of mothers with an LLI were breastfed for more than three months compared to 33.4% of infants of mothers who did not have an LLI. At the age of seven years, 12.0% of children of mothers with an LLI had an activity limiting health problem themselves compared to 6.2% of children of mothers without an LLI., Conclusions: Disability in women who had recently delivered is relatively common. It is associated with social and economic inequalities and worse pregnancy and child related outcomes. Apart from condition-specific support during and after pregnancy, disabled women may require extra help from health professionals to quit smoking, continue breastfeeding, and reduce intimate partner violence.

Objectives: To estimate the cost effectiveness of alternative planned places of birth., Design: Economic evaluation with individual level data from the Birthplace national prospective cohort study., Setting: 142 of 147 trusts providing home birth services, 53 of 56 freestanding midwifery units, 43 of 51 alongside midwifery units, and a random sample of 36 of 180 obstetric units, stratified by unit size and geographical region, in England, over varying periods of time within the study period 1 April 2008 to 30 April 2010., Participants: 64,538 women at low risk of complications before the onset of labour., Interventions: Planned birth in four alternative settings: at home, in freestanding midwifery units, in alongside midwifery units, and in obstetric units., Main Outcome Measures: Incremental cost per adverse perinatal outcome avoided, adverse maternal morbidity avoided, and additional normal birth. The non-parametric bootstrap method was used to generate net monetary benefits and construct cost effectiveness acceptability curves at alternative thresholds for cost effectiveness., Results: The total unadjusted mean costs were £1066, £1435, £1461, and £1631 for births planned at home, in freestanding midwifery units, in alongside midwifery units, and in obstetric units, respectively (equivalent to about €1274, $1701; €1715, $2290; €1747, $2332; and €1950, $2603). Overall, and for multiparous women, planned birth at home generated the greatest mean net benefit with a 100% probability of being the optimal setting across all thresholds of cost effectiveness when perinatal outcomes were considered. There was, however, an increased incidence of adverse perinatal outcome associated with planned birth at home in nulliparous low risk women, resulting in the probability of it being the most cost effective option at a cost effectiveness threshold of £20 000 declining to 0.63. With regards to maternal outcomes in nulliparous and multiparous women, planned birth at home generated the greatest mean net benefit with a 100% probability of being the optimal setting across all thresholds of cost effectiveness., Conclusions: For multiparous women at low risk of complications, planned birth at home was the most cost effective option. For nulliparous low risk women, planned birth at home is still likely to be the most cost effective option but is associated with an increase in adverse perinatal outcomes.

Background: Breastfeeding involves learning for women and their infants. For emotional, social, and developmental reasons this type of feeding is recommended for all newborn infants but for those in exceptional circumstances. The objective of this study was to gain a better understanding of what is needed in the early days to enable women to initiate and continue breastfeeding their infants., Methods: Data from a large-scale national survey of women's experience of maternity care in England were analyzed using qualitative methods, focusing on the feeding-related responses., Results: A total of 2,966 women responded to the survey (62.7% response rate), 2,054 of whom wrote open text responses, 534 relating to infant feeding. The main themes identified were "the mismatch between women's expectations and experiences" and "emotional reactions" at this time, "staff behavior and attitudes," and "the organization of care and facilities." Subthemes related to seeking help, conflicting advice, pressure to breastfeed, the nature of interactions with staff, and a lack of respect for women's choices, wishes, previous experience, and knowledge., Conclusions: Many women who succeeded felt that they had "learned the hard way" and some of those who did not, felt they were perceived as "bad mothers" and women who had in some way "failed" at one of the earliest tasks of motherhood. What women perceived to be staff perceptions affected how they saw themselves and what they took away from their early experience of infant feeding., (© 2012, Copyright the Authors. Journal compilation © 2012, Wiley Periodicals, Inc.)

Objective: To compare perinatal outcomes, maternal outcomes, and interventions in labour by planned place of birth at the start of care in labour for women with low risk pregnancies., Design: Prospective cohort study., Setting: England: all NHS trusts providing intrapartum care at home, all freestanding midwifery units, all alongside midwifery units (midwife led units on a hospital site with an obstetric unit), and a stratified random sample of obstetric units., Participants: 64,538 eligible women with a singleton, term (≥37 weeks gestation), and "booked" pregnancy who gave birth between April 2008 and April 2010. Planned caesarean sections and caesarean sections before the onset of labour and unplanned home births were excluded., Main Outcome Measure: A composite primary outcome of perinatal mortality and intrapartum related neonatal morbidities (stillbirth after start of care in labour, early neonatal death, neonatal encephalopathy, meconium aspiration syndrome, brachial plexus injury, fractured humerus, or fractured clavicle) was used to compare outcomes by planned place of birth at the start of care in labour (at home, freestanding midwifery units, alongside midwifery units, and obstetric units)., Results: There were 250 primary outcome events and an overall weighted incidence of 4.3 per 1000 births (95% CI 3.3 to 5.5). Overall, there were no significant differences in the adjusted odds of the primary outcome for any of the non-obstetric unit settings compared with obstetric units. For nulliparous women, the odds of the primary outcome were higher for planned home births (adjusted odds ratio 1.75, 95% CI 1.07 to 2.86) but not for either midwifery unit setting. For multiparous women, there were no significant differences in the incidence of the primary outcome by planned place of birth. Interventions during labour were substantially lower in all non-obstetric unit settings. Transfers from non-obstetric unit settings were more frequent for nulliparous women (36% to 45%) than for multiparous women (9% to 13%)., Conclusions: The results support a policy of offering healthy women with low risk pregnancies a choice of birth setting. Women planning birth in a midwifery unit and multiparous women planning birth at home experience fewer interventions than those planning birth in an obstetric unit with no impact on perinatal outcomes. For nulliparous women, planned home births also have fewer interventions but have poorer perinatal outcomes.

Background: Cesarean section is an increasingly common mode of birth, and although clinical care has improved and the risks reduced, less attention has been paid to the effect of the procedure and the care received. The aim of this study was to gain a better understanding by investigating individual women's recent experiences and reflections on their care., Methods: Views of women who had recently undergone cesarean birth were obtained in a study in which a random sample of women was selected by means of birth registrations in England and invited to complete a questionnaire 3 months after the birth. Text responses to open-ended questions about care during labor and birth, the postnatal period in hospital, and anything else women wished to say about their maternity care were analyzed using qualitative methods., Results: A response rate of 63 percent was achieved; 23 percent of women (n = 682) had a cesarean section birth, 53 percent of which were because of unforeseen problems in labor. A total of 66 percent of women who had a cesarean section responded to one or more open questions. Anticipated themes that were confirmed related to expectations, uncertainty, emotional reactions, pain and discomfort, explanations, support, and adjustment. Emerging themes included "being heard,""how it might have been different,""wasted effort,""just another mother,""wounds and hurt feelings," and "needing to talk.", Conclusions: Women responded as individuals and despite different clinical circumstances, the role of the staff and the institutions in which care was provided were key factors in the way most women constructed their cesarean section experience. The themes described present a powerful argument and reminder about why health professionals working in maternity care need to continue to listen to women.

Background: This study describes the psychometric characteristics, validity and reliability of the revised version of the perceptions of care adjective checklist (PCACL-R) with women who had recently given birth. Data were collected from a national survey of women's experiences of maternity care (n = 2960)., Methods: Internal consistency, predictive validity, convergent validity, discriminant validity and confirmatory factor analyses were applied to the data., Results: Confirmatory factor analysis revealed an excellent fit to a bi-dimensional structure entirely consistent with the negative and positive valencing of adjectives in the measure, supporting the use of the instrument as a two subscale tool comprising positive and negative subscales. The PCACL-R revealed good convergent validity against measures of satisfaction with care and excellent divergent validity characteristics assessed against duration of labour. Discriminant validity was assessed against measures of area-based maternal deprivation, partner status and type of delivery. These analyses revealed commendable discriminant validity of the PCACL-R. Internal consistency characteristics of the positive and negative subscales of the PCACL-R were acceptable. The predictive validity of the PCACL-R was also found to be excellent., Conclusion: The PCACL-R is consequently recommended as a valid, reliable, respondent acceptable and easy to administer instrument to assess women's experiences of their care during labour and childbirth. The measurement characteristics of the PCACL-R suggest that the tool could be incorporated into both clinical and research contexts with confidence. The checklist terms used are applicable to other phases of maternity care and indeed to a wide range of health care contexts. Exploratory use in with other user groups is recommended.

Objective: To compare offer and uptake of prenatal screening for Down syndrome in women from different social and ethnic backgrounds., Method: A total of 4800 randomly selected women in England were sent a survey three months after they had given birth; 2960 women responded. Odds ratios (OR) for reported offer and uptake of screening comparing women by area deprivation and ethnicity were calculated., Results: In all, 65% of women reported having screening; 89% reported being offered screening, and 69% of these reported taking up the offer. There was no evidence of a difference in the reported offer (adjusted OR = 0.88, 95% confidence interval (CI) 0.65-1.19, p = 0.41) or uptake (adjusted OR = 0.84, 95% CI 0.66-1.06, p = 0.15) of screening for women living in the most deprived areas compared with other women. Asian women were less likely to report being offered screening than White women (adjusted OR = 0.61, 95% CI 0.39-0.94, p = 0.02) and were less likely to take up screening when offered (adjusted OR = 0.48, 95% CI 0.33-0.72, p < 0.001)., Conclusions: While most pregnant women in England are offered prenatal screening for Down syndrome, approximately 1 in 10 is not. Asian women are less likely than White women to report being offered Down syndrome screening and are less likely to have a screening test when offered.

The measurement of "satisfaction" has been intrinsic to the models of evaluation of health care. However, a thoughtful approach to its use has not always been evident in which this concept is understood to represent a complex group of theoretical constructs involving attitudes, expectations, and perceptions that may be both positive and critical. These constructs require investigation and evaluation using recognized and developed methodologies. At the same time the importance of listening to patients and to women and their partners in evaluating and carrying out research on maternity care cannot be underestimated if the instruments used are to have construct and face validity. Qualitative data of this kind have a dual function of contributing to a more complex picture of women's experience and of suggesting that researchers need to explore the issues related to "dissatisfaction" at least as much as those arising from a positive overall view of care.