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Background: Air pollution harms health across the life course. Children are at particular risk of adverse effects during development, which may impact on health in later life. Interventions that improve air quality are urgently needed both to improve public health now, and prevent longer-term increased vulnerability to chronic disease. Low Emission Zones are a public health policy intervention aimed at reducing traffic-derived contributions to urban air pollution, but evidence that they deliver health benefits is lacking. We describe a natural experiment study (CHILL: Children's Health in London and Luton) to evaluate the impacts of the introduction of London's Ultra Low Emission Zone (ULEZ) on children's health., Methods: CHILL is a prospective two-arm parallel longitudinal cohort study recruiting children at age 6-9 years from primary schools in Central London (the focus of the first phase of the ULEZ) and Luton (a comparator site), with the primary outcome being the impact of changes in annual air pollutant exposures (nitrogen oxides [NOx], nitrogen dioxide [NO 2 ], particulate matter with a diameter of less than 2.5micrograms [PM 2.5 ], and less than 10 micrograms [PM 10 ]) across the two sites on lung function growth, measured as post-bronchodilator forced expiratory volume in one second (FEV 1 ) over five years. Secondary outcomes include physical activity, cognitive development, mental health, quality of life, health inequalities, and a range of respiratory and health economic data., Discussion: CHILL's prospective parallel cohort design will enable robust conclusions to be drawn on the effectiveness of the ULEZ at improving air quality and delivering improvements in children's respiratory health. With increasing proportions of the world's population now living in large urban areas exceeding World Health Organisation air pollution limit guidelines, our study findings will have important implications for the design and implementation of Low Emission and Clean Air Zones in the UK, and worldwide., Clinicaltrials: GOV: NCT04695093 (05/01/2021)., (© 2023. The Author(s).)

Introduction: Policy implementation can be affected by what individuals believe to be right and wrong. When implementing abortion policies, providers' moral beliefs can be relevant in the success of the implementation process. Considering that midwives and nurses are direct providers of abortion care, exploring their experiences related to abortion policy implementation could provide helpful information to prevent policy failure., Methods: Systematic integrative review. The studies were identified through an electronic search strategy and the screening of the reference lists of all selected articles. Studies were retrieved from eight medical and social sciences databases. Thirty-one studies focused on midwives' and nurses' experiences of implementing abortion policies, irrespective of setting or age of study were included in this review. Studies included used qualitative, quantitative and mixed methods. Study quality was appraised using the Mixed Method Appraisal Tool version 2018. No study was excluded from this review based on its quality appraisal., Results: In terms of their quality, most studies included in this review were conducted appropriately. Three superordinate themes represent the main elements that challenge midwives and nurses when providing abortion care. The first superordinate theme identified that many midwives and nurses believed fetuses are sentient beings, making them worthy of compassionate treatment. The next superordinate theme was focused on preferences and expectations about abortion care. Finally, the third superordinate theme illustrates midwives' and nurses' experiences with other team members, highlights their creativity when challenged with insufficient resources and provides a glimpse of the numerous techniques used for coping with work-related stress., Conclusion: Midwives and nurses worldwide face multiple challenges when providing abortion care. Guidelines aiming to support policy implementation should consider how abortion affects healthcare providers and suggest appropriate measures to reduce these and other barriers. Midwives and nurses technical and ethical competencies for abortion provision should be strengthened., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Introduction: Since the inception of the COVID-19 pandemic, telebehavioral health services have been a key contributor to continuation of care in rural and underserved areas of southeastern Idaho. Providers of telebehavioral health services faced numerous challenges as they navigated rapidly shifting regulations, variable access to internet and their own personal understandings of practice., Objective: This study aimed to characterize provider experiences, generate policy- and practice-level recommendations, and raise awareness among community stakeholders regarding telebehavioral health in southeastern Idaho., Methods: Using a newly developed conceptual/analytical framework, a research-as-intervention strategy was employed to conduct and analyze semi-structured interviews, short writings, and photographs from 7 primary care and behavioral health providers in the region., Results: Providers shared examples from practice that addressed technology and training, access-to-care, safety, changing provider roles, payment for services, treatments that are not well suited to telehealth and the nuances of living and working in newly forged spaces of care., Conclusions: Providers found promise in telebehavioral health's utility as a hybrid model of care, but it must be supported by flexible legislation and policy. For example, it would help to make reimbursement expansions permanent and to simplify inter-jurisdictional practice options. Cross-sharing of information between licensing boards could help providers from various disciplines understand the parameters within which their colleagues must work.

Introduction: Postoperative morbidity and mortality in older patients with comorbidities undergoing gastrointestinal surgery are a major burden on healthcare systems. Infections after surgery are common in such patients, prolonging hospitalisation and reducing postoperative short-term and long-term survival. Optimal management of perioperative intravenous fluids and inotropic drugs may reduce infection rates and improve outcomes from surgery. Previous small trials of cardiac-output-guided haemodynamic therapy algorithms suggested a modest reduction in postoperative morbidity. A large definitive trial is needed to confirm or refute this and inform widespread clinical practice., Methods: The Optimisation of Perioperative Cardiovascular Management to Improve Surgical Outcome II (OPTIMISE II) trial is a multicentre, international, parallel group, open, randomised controlled trial. 2502 high-risk patients undergoing major elective gastrointestinal surgery will be randomly allocated in a 1:1 ratio using minimisation to minimally invasive cardiac output monitoring to guide protocolised administration of intravenous fluid combined with low-dose inotrope infusion, or usual care. The trial intervention will be carried out during and for 4 hours after surgery. The primary outcome is postoperative infection of Clavien-Dindo grade II or higher within 30 days of randomisation. Participants and those delivering the intervention will not be blinded to treatment allocation; however, outcome assessors will be blinded when feasible. Participant recruitment started in January 2017 and is scheduled to last 3 years, within 50 hospitals worldwide., Ethics/dissemination: The OPTIMISE II trial has been approved by the UK National Research Ethics Service and has been approved by responsible ethics committees in all participating countries. The findings will be disseminated through publication in a widely accessible peer-reviewed scientific journal., Trial Registration Number: ISRCTN39653756., Competing Interests: Competing interests: MRE has received an honorarium for lecturing for Edwards Lifesciences and is Chief Investigator of the NIHR-funded FLO-ELA trial of cardiac output-guided haemodynamic therapy in patients undergoing emergency abdominal surgery. MPWG reports serving as Medical Advisory Board, Sphere Medical Ltd; Director, EBPOM Social Enterprise; Director, Oxygen Control Systems Ltd; Director, EBPOM USA. UK NIHR CRN National Specialty Lead for Anaesthesia, Perioperative Medicine and Pain. Joint Editor-in-Chief, Perioperative Medicine. MGM reports personal fees from Deltex Medical, personal fees from Edwards Lifesciences, personal fees from Baxter, grants from Smiths Medical, outside the submitted work. In addition, MGM has a patent ’QUENCH' (clinical hydration solutions limited) a patient hydration device (issued). MS reports grants from Edwards Lifesciences, during the conduct of the study; grants from Medtronic, grants from AMOMED, grants from Edwards Lifesciences, grants from Gettinge Group, outside the submitted work. TDP reports grants from Australian and New Zealand College of Anaesthetists, during the conduct of the study. LE reports personal fees from Cogstate, outside the submitted work. DAM reports personal fees from Edwards Lifesciences, outside the submitted work. JR-M reports personal fees from Edwards Lifesciences, during the conduct of the study; personal fees and non-financial support from Edwards Lifesciences, from Fresenius Kabi, from Deltex Medical, outside the submitted work. RMP holds research grants, and has given lectures and/or performed consultancy work for Nestle Health Sciences, BBraun, Medtronic, Glaxo Smithkline, Intersurgical, and Edwards Lifesciences, and is a member of the Associate editorial board of the British Journal of Anaesthesia. RMP is supported in part by an NIHR Professorship. The OPTIMISE II trial is adopted by the UK Perioperative Medicine Clinical Trials Network. DNW is supported in part by a New Investigator Award from the Canadian Institutes of Health Research and a Merit Award from the Department of Anesthesia at the University of Toronto., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The UK guideline recommends 3-yearly surveillance for patients with intermediate-risk (IR) adenomas. No study has examined whether or not this group has heterogeneity in surveillance needs., Objectives: To examine the effect of surveillance on colorectal cancer (CRC) incidence; assess heterogeneity in risk; and identify the optimum frequency of surveillance, the psychological impact of surveillance, and the cost-effectiveness of alternative follow-up strategies., Design: Retrospective multicentre cohort study., Setting: Routine endoscopy and pathology data from 17 UK hospitals ( n  = 11,944), and a screening data set comprising three pooled cohorts ( n  = 2352), followed up using cancer registries., Subjects: Patients with IR adenoma(s) (three or four small adenomas or one or two large adenomas)., Primary Outcomes: Advanced adenoma (AA) and CRC detected at follow-up visits, and CRC incidence after baseline and first follow-up., Methods: The effects of surveillance on long-term CRC incidence and of interval length on findings at follow-up were examined using proportional hazards and logistic regression, adjusting for patient, procedural and polyp characteristics. Lower-intermediate-risk (LIR) subgroups and higher-intermediate-risk (HIR) subgroups were defined, based on predictors of CRC risk. A model-based cost-utility analysis compared 13 surveillance strategies. Between-group analyses of variance were used to test for differences in bowel cancer worry between screening outcome groups ( n  = 35,700). A limitation of using routine hospital data is the potential for missed examinations and underestimation of the effect of interval and surveillance., Results: In the hospital data set, 168 CRCs occurred during 81,442 person-years (pys) of follow-up [206 per 100,000 pys, 95% confidence interval (CI) 177 to 240 pys]. One surveillance significantly lowered CRC incidence, both overall [hazard ratio (HR) 0.51, 95% CI 0.34 to 0.77] and in the HIR subgroup ( n  = 9265; HR 0.50, 95% CI 0.34 to 0.76). In the LIR subgroup ( n  = 2679) the benefit of surveillance was less clear (HR 0.62, 95% CI 0.16 to 2.43). Additional surveillance lowered CRC risk in the HIR subgroup by a further 15% (HR 0.36, 95% CI 0.20 to 0.62). The odds of detecting AA and CRC at first follow-up (FUV1) increased by 18% [odds ratio (OR) 1.18, 95% CI 1.12 to 1.24] and 32% (OR 1.32, 95% CI 1.20 to 1.46) per year increase in interval, respectively, and the odds of advanced neoplasia at second follow-up increased by 22% (OR 1.22, 95% CI 1.09 to 1.36), after adjustment. Detection rates of AA and CRC remained below 10% and 1%, respectively, with intervals to 3 years. In the screening data set, 32 CRCs occurred during 25,745 pys of follow-up (124 per 100,000 pys, 95% CI 88 to 176 pys). One follow-up conferred a significant 73% reduction in CRC incidence (HR 0.27, 95% CI 0.10 to 0.71). Owing to the small number of end points in this data set, no other outcome was significant. Although post-screening bowel cancer worry was higher in people who were offered surveillance, worry was due to polyp detection rather than surveillance. The economic evaluation, using data from the hospital data set, suggested that 3-yearly colonoscopic surveillance without an age cut-off would produce the greatest health gain., Conclusions: A single surveillance benefited all IR patients by lowering their CRC risk. We identified a higher-risk subgroup that benefited from further surveillance, and a lower-risk subgroup that may require only one follow-up. A surveillance interval of 3 years seems suitable for most IR patients. These findings should be validated in other studies to confirm whether or not one surveillance visit provides adequate protection for the lower-risk subgroup of intermediate-risk patients., Study Registration: Current Controlled Trials ISRCTN15213649., Funding: The National Institute for Health Research Health Technology Assessment programme.

Objective: to explore how midwives׳ personal involvement in clinical negligence litigation affects their midwifery practice., Design: descriptive phenomenological study using semi-structured interviews., Setting: in 2006-2007 in-depth interviews were conducted in participants׳ homes or at their place of work and focused on participants׳ experience of litigation. Participants were recruited from various regions of England., Participants: 22 National Health Service (NHS) midwives who had been alleged negligent., Findings: clinical practice affected was an increase in documentation, fear of practising outside clinical guidelines and electronic fetal monitoring of women at low obstetric risk; these changes were not widespread. Changes in practice were sometimes perceived negatively and sometimes positively. Forming a good relationship with childbearing women was judged to promote effective midwifery care but litigation had affected the ability of a minority of midwives to advocate for women if this relationship had not been established. Litigation could result in loss of confidence leading to self-doubt, isolation, increased readiness to seek medical assistance and avoidance of working in the labour ward, perceived as an area with a high risk of litigation. A blame culture in the NHS was perceived by several midwives. In contrast an open non-punitive culture resulted in midwives readily reporting mistakes to risk managers. Litigation lowered midwifery morale and damaged professional reputations, particularly when reported in the newspapers. Some midwives expressed thoughts of leaving midwifery or taking time off work because of litigation but only one was actively seeking other employment, another took sick leave and one had left midwifery and returned to nursing., Key Conclusions: litigation can have a negative effect on midwives׳ clinical practice and morale and fosters a culture of blame within the NHS., Implications for Practice: education regarding appropriate documentation, use or non-use of electronic fetal monitoring and the legal status of clinical guidelines will enable midwives to respond proportionately to the threat of litigation. A culture of openness and sharing the problem when adverse events occur would help to extinguish the current blame culture in the National Health Service. Litigation must be recognised by management as capable of inducing loss of confidence and reluctance to work in the labour ward. Promoting teamwork will help support these midwives. The potential for litigation in maternity care could affect retention of the midwifery workforce., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Objective: to explore how midwives' personal involvement in clinical negligence litigation affects their emotional and psychological well-being., Design: descriptive phenomenological study using semi-structured interviews., Setting: in-depth interviews were conducted in participants' homes or at their place of work and focused on participants' experience of litigation. Participants were recruited from various regions of England., Participants: 22 National Health Service (NHS) midwives who had been alleged negligent., Findings: unfamiliarity with the legal process when writing statements, attending case conferences and being a witness in court provoked significant stress for midwives. This was exacerbated by the prolonged nature of maternity claims. Support ranged from good to inadequate. Participants who no longer worked for the defendant Trust felt unsupported. Stress could manifest as physical and mental ill-health. Some midwives internalised the allegations of negligence believing their whole career had become worthless. Previous knowledge of the legal process ameliorated the experience. Midwives also exhibited anger and resentment when litigation concluded and some took years to heal from the experience., Key Conclusions: midwives come from a caring and relational paradigm. When interfacing with the adversarial and contentious paradigm of tort law, midwives can abreact and suffer emotional, physical and psychological harm. Support for midwives experiencing litigation must be improved., Implications for Practice: Understanding the effects of personal involvement in litigation is important in order to improve the quality of support for this group of midwives. It will also aid development of targeted education for undergraduate, post-graduate and in-service midwives. In the longer term it may help policy makers when considering reform of clinical negligence litigation and NHS employers to structure support mechanisms for staff involved., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Objective: to describe the incidence of maternal death by age, marital status, timing and place of death in Ibadan North and Ido Local Government Areas of Oyo State, Nigeria., Design: a retrospective study using multistage sampling with stratification and clustering to select local government areas, political wards and households. We included one eligible subject by household in the sample. Data on maternal mortality were collected using the principles of the indirect sisterhood method., Setting: Ibadan city of Oyo state, Nigeria. We included eight randomly selected political wards from Ibadan North LGA (urban) and Ido LGA (rural)., Participants: 3028 participants were interviewed using the four questions of the indirect sisterhood method: How many sisters have you ever had who are ever married (or who survived until age 15)? How many are dead? How many are alive? How many died while they were pregnant, during childbirth, or within six weeks after childbirth (that is, died of maternal causes)? We also included other questions such as place and timing of death, age of women at death and number of pregnancies., Findings: 1139 deaths were reported to be related to pregnancy, childbirth or the puerperium. Almost half were aged between aged 25-34 years. More deaths occurred to women who were pregnant for the first time (33.4%, n=380) than for any other number of pregnancies, with 49.9% (n=521) dying within 24 hours after childbirth or abortion and 30.9% (n=322) dying after 24 hours but within 72 hours after childbirth or abortion. Only 71.5% (n=809) were reported to have been admitted to health-care facilities before their death, the percentage being higher in the urban LGA (72.4%, n=720) than the rural LGA (65.4%, n=89). The percentage being admitted varied from one political ward to another (from 42.9% to 80.4%), the difference being statistically significant (χ(2)=17.55, df=7, p=0.014). The majority of the deaths occurred after childbirth (63.5%, n=723). Most deaths were said to have occurred in the hospital (38.6%) or private clinic (28.2%), with 16.0% dying at home and 6.5% on the way to hospital., Key Conclusions: maternal mortality in Nigeria is still unacceptably high., Implications for Practice: ensure adequate training, recruitment and deployment of midwives and others with midwifery skills. Ensure midwives and other skilled birth attendants are backed up with functioning and well equipped health-care facilities. Provide health education and information to the public with regard to reproductive health and ensure the development and dissemination of a policy regarding attendance at birth by only health workers who have midwifery skills., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Background: Severe nausea and vomiting in pregnancy (hyperemesis gravidarum) can be a distressing and debilitating condition when it is uncontrolled. For all concerned, hyperemesis gravidarum can be difficult to treat satisfactorily, and women tend to be admitted to a hospital several times during early pregnancy. Our research objectives were to describe the experience of hyperemesis gravidarum from the perspective of affected women and to explore with health care professionals the barriers and facilitators to caring for women with the condition., Methods: A qualitative research design was used. A total of 18 women were interviewed, of whom 8 had two or more interviews. Seven focus groups were conducted with health care professionals. Thematic data analysis was undertaken., Results: The main themes emerging from the women's data were the effect and burden of the symptoms of the condition and feeling unpopular with staff. From the practitioner data, the main themes were the validity (or invalidity) of hospitalization for women, skepticism of the severity of symptoms, the psychological and social dimensions of the condition, and inadequate primary care services., Conclusions: The main findings revealed that hyperemesis gravidarum is a debilitating condition and that the unhelpful attitudes of practitioners may affect whether women access timely and appropriate care. Many women appear to be unsupported by primary care services and are distressed when perceived either as "time wasters" or someone else's responsibility. We propose that a tailored assessment and care plan for each woman is needed to help them control their symptoms, which ideally should be delivered in the community.

Objective: to explore the use of language by midwives reporting their experiences of baby-feeding practice., Design: A qualitative approach incorporating a secondary analysis of data previously collected in a study based on grounded theory principles. Data were collected using in-depth interviews. The secondary analysis involved a content analysis method., Setting: two maternity services in the north of England., Participants: 30 midwives who worked across all clinical areas., Findings: these midwives' explanations of how they supported women with baby feeding suggest that they used language to direct women towards decisions that the midwives thought best, without prior exploration of the woman's understanding and beliefs of baby feeding. Women were often described as 'girls' and 'ladies' indicating the power differentials in their relationship. The midwives were aware that, at times, the language they used was contradictory to woman-centred maternity care., Key Conclusions: language may be used to control childbearing women and direct them to decisions that the midwife wants, rather than enabling the woman to make her own decisions. The terms used by midwives to relate to women, such as 'girls' and 'ladies', may be a strategy used to improve a midwife's perception of her status in maternity care., Implications for Practice: language may be used to undermine women. It is important that the language used when interacting with women is considered carefully in order to facilitate an unbiased perspective and to promote partnership. The word 'women', rather than 'girls' or 'ladies', should be used when referring to users of the maternity services., (Copyright 2008 Elsevier Ltd. All rights reserved.)

An intensive study of 443 isolates of Campylobacter jejuni and Campylobacter coli from 2031 fecal samples excreted by animal sources including cattle, sheep, and pigs, a range of wild and domesticated avian species and pets is described. The prevalence found in the majority of animal sources ranged from 22% to 28% with poultry being highest at 41% and cats and dogs lowest (<5%). The average count excreted for each animal source was found not to be significantly different ranging from approximately 10(2) to 10(5) cfu/g. Multilocus sequence typing (MLST) identified phylogenies that exhibited host specificity. A number of clonal complexes (CCs) and sequence types (STs) were characteristic of particular hosts (e.g., CC-179, ST-637, and ST-1341 found only in pigeons and gulls). Analysis of genetic distance demonstrated numerous significant differences in the distribution of MLST types (CC, ST, and allele) between animal sources. Host association was quantified using structure that correctly assigned the nine animal sources with accuracies of 28%, 24%, and 55% at the CC, ST, and allele levels, respectively. This is substantially higher than would be expected by random allocation (11%) but farmyard poultry had the lowest assignment accuracy (13%, 13%, and 21%) suggesting that isolates were shared with a wide range of other animals. This study demonstrates the link between MLST type and host and provides data that can be used in risk assessment and food attribution models. Further, it demonstrates the applicability of MLST to characterize Campylobacter strains from a broad range of environmental sources.

Background: Breastfeeding prevalence in the United Kingdom is one of the lowest in Europe. The midwife provides feeding support for new mothers but research suggests that midwives' knowledge of breastfeeding is limited., Objective: To discover the views of English midwives in relation to their breastfeeding support role., Design: Qualitative design., Settings: Two maternity hospitals in Northwest England., Participants: Thirty midwives who cared for normal, healthy babies. Midwives were selected for interview using theoretical sampling principles from a pool of midwives who volunteered. Volunteers were accessed using a poster exhibited in relevant clinical areas., Methods: Data were collected using audiotaped, in-depth interviews and were analysed using constant comparison techniques., Results: The study highlights that differing professional knowledge and beliefs about breastfeeding support created intense, mainly negative, emotions for these midwives. Irritation and despair was experienced with the greater emphasis placed on research, rather than practice knowledge in policy and recommendations for practice. Disappointment was experienced when mothers did not conform to midwives' expectations. Conflict with differing peer-based knowledge generated feelings of intimidation and annoyance for some midwives. Some midwives demonstrated that they can sustain clinical decisions whilst based in a hostile environment, but others conformed to the practice expectations of their peers. Happiness was experienced when midwives described positive relationships with mothers, rather than their professional colleagues., Conclusions: The utilisation of professional knowledge in breastfeeding practice was a highly complex issue, and generated significant negative emotional distress, for these midwives.

Despite breastfeeding prevalence increasing, many mothers in developed countries are dissatisfied with care provided by midwives. However, a paucity of research exists related to midwives' experiences of supporting breastfeeding mothers. This study explored the experiences of English midwives' during their breastfeeding support role. A qualitative study using grounded theory principles was used. Data were collected using in-depth interviews and analysed using constant comparative techniques. The setting was two maternity hospitals in the North of England, UK. Thirty midwives who cared for normal, healthy babies participated. Volunteers were recruited using theoretical sampling techniques. The core category that emerged is called 'surviving baby feeding' and relates to midwives' experiences when supporting mothers. The results reported in this paper refer to one category called 'doing well with feeding' which has three main themes: (1) communicating sensitively, (2) facilitating breastfeeding, and (3) reducing conflicting advice. Participating midwives reported practice that suggests that they valued breastfeeding, attempted to provide realistic information and advice, and tried to minimise confusion for mothers. However, some midwives used an authoritative manner when conversing with mothers. English midwives' reported practice demonstrates that these midwives appreciated that breastfeeding mothers required specific support. However, breastfeeding education that encourages midwives to develop effective skills in ascertaining mother's needs, but also encourages mothers to effectively participate in their care, should be provided. Further research is needed to clarify breastfeeding mothers' expectations and needs.

Background: Reduction of maternal mortality is one of the major goals of several recent international conferences and has been included within the Millennium Development Goals. However, because measuring maternal mortality is difficult and complex, reliable estimates of the dimensions of the problem are not generally available and assessing progress towards the goal is difficult in some countries. Reliable baseline data are crucial to effectively track progress and measure that targets or goals of reducing maternal mortality have been met., Objectives: The objectives of this pilot study were: to test adequacy of research instruments; to improve research techniques; to determine an appropriate workload; to determine the time required for interviews; and to assess the feasibility of a (full-scale) study/survey., Methods: This pilot study was conducted between 11(th) April and 22(nd) April 2005. 420 houses were visited and interviews of 420 respondents between the ages of 15-49 were conducted in a randomly pre-selected Local Government Area of Oyo state using a structured instrument developed using the principles of the Sisterhood Method., Results: There was willingness of the public to participate in the study. The response rate was 100%. There was no issue raised as regards the structure, wording and translation of the questionnaire. This pilot study uncovered local political problems and other issues that may be encountered during the main study., Conclusions: The pilot raised a number of fundamental issues related to the process of designing the research instrument, identifying and recruiting Data Collectors, training and supervision of Data Collectors and the research project, gaining access to respondents and obtaining support and approval from "gatekeepers". This paper highlights the lessons learned and reports practical issues that occurred during pilot study.

Our objective was to explore English midwives' views and experiences of supporting mothers with feeding their newborn baby. Grounded theory methodology was used. Data were collected using in-depth interviews from 30 midwives in the North of England. Data were analyzed using constant comparison techniques. Midwives were theoretically sampled for interview from a pool of volunteers recruited from a poster promoting the study in the clinical areas. Overall, hospital midwives felt that they did not have enough time to support mothers with feeding their neonate. To cope with these time constraints, midwives developed practices of rationing the time that they spent with mothers, and the rationing of resources available to mothers, to help them process mothers through the hospital services. These practices have important implications for the success of breastfeeding in hospitals as the practices by providers who are assigned to help breastfeeding initiation described here may inhibit the breastfeeding process.

Objective: to discover the views of midwives in relation to baby feeding., Design and Method: qualitative using grounded theory. Data collection used in-depth interviews with 30 midwives who volunteered to participate. Field notes of the interaction between the researcher and participant were also recorded as data. The constant comparison process was used to generate codes and subsequent conceptualisations from the data., Setting: two maternity units in the North of England, UK., Findings: the core category of this study is called 'surviving' baby feeding, and the findings reported here are a significant theme that emerged. These midwives described a management strategy termed 'breaking the rules' for supporting mothers with baby feeding. The concept 'breaking the rules' represented practices that were not congruent with evidence-based, baby-feeding policy and recommendations, or with some practices that were usual in the local working environment. These midwives were aware of their actions but described how they 'hid' their behaviour from mothers and from their peers. Some of the behaviour described showed that these midwives 'broke the rules' in relation to professional requirements and the facilitation of informed decision making about feeding practices with the women in their care. However, some midwives reported examples of practice that is woman-centred, and supportive of baby feeding, but this was not acceptable to others in the working environment., Key Conclusions and Implications for Practice: deviant behaviour was described by these midwives in relation to informed decision making and options for mothers in baby-feeding practice. These midwives 'knowingly concealed' their deviant practices from others. These behaviours should be taken seriously as they risk being negligent in relation to UK statutory professional requirements. However, practices that depart from those that are normal in the local working environment are not always negative and detrimental to the recipients of care; they can be positive. There needs to be more research, open discussion and debate about midwifery practice that does not always 'fit in' with professional, and 'normal' expectations. In this study, the term 'baby feeding' relates to how babies' nutritional needs are met.

Over the last 20 years in the United Kingdom, midwives have implemented the routine use of intrapartum fetal monitoring regardless of the risk status of laboring women. This practice is at odds with the published research. The discrepancy between practice and best evidence merits further investigation. A qualitative study was conducted to evaluate midwives' attitudes and experiences about the use of fetal monitoring for women at low obstetric risk. Fifty-eight midwives working in two hospitals in the north of England were interviewed by using a semistructured approach. The taped interviews were transcribed and analyzed by using a general thematic approach. Issues included midwives' perceptions of low-risk status, the socialization of midwives, and the loss of woman-centered care. Midwives subscribed to the notion of woman-centered care, but because of a complexity of factors experienced in their daily working lives, they felt vulnerable when attempting to implement evidence-based fetal monitoring practices. Midwives regretted the loss of a woman-centered approach to care when technologic methods of intrapartum fetal heart rate monitoring were used indiscriminately. An appreciation of the complex factors affecting the ability of midwives to implement evidence-based practice is important when attempting to facilitate the development of appropriate fetal monitoring practices for women at low obstetric risk.

Objective: To investigate midwives' attitudes, values and beliefs on the use of intrapartum fetal monitoring., Design: Qualitative, semi-structured interviews., Subjects and Setting: Fifty-eight registered midwives in two hospitals in the North of England., Results: In this paper two main themes are discussed, these are: informed choice, and the power of the midwife. Midwives favoured the application of informed choice and shared a unanimous consensus on the definition. However, the idealistic perception of informed choice, which included contemporary notions of empowerment and autonomy for women expressing an informed choice, was not reportedly translated into practice. Midwives had to implement informed choice on intrapartum fetal monitoring within a competing set of health service agendas, i.e. medically driven protocols and a political climate of actively managed childbearing. This resulted in the manipulation of information during the midwives' interactions with women. This ultimately meant that the women often got the choice the midwives wanted them to have., Conclusions: The information that a midwife imparts may consciously or subconsciously affect the woman's uptake and understanding of information. Therefore, the midwife has a powerful role to play in balancing the benefits and risk ratios applicable to fetal heart rate monitoring. However, a deeply ingrained pre-occupation with technological methods of intrapartum fetal monitoring over many years has made it difficult for midwives to offer alternative forms of monitoring. This has placed limits on the facilitation of informed choice and autonomous decision making for women.

Aim: The aim of this paper is to report the development and use of a tool to appraise guidelines for fetal heart rate monitoring and discuss the findings generated in the appraisal process., Background: Expert guidance on the appropriate method of monitoring the fetal heart in labour has been available for some time. However, practices not based on evidence were continuing routinely in the United Kingdom., Methods: We produced an 18-item tool for the appraisal of guidelines. Heads of Midwifery Services were asked to send the guideline currently in use. Twenty-four out of 28 responded, and sent 32 guidelines. Pairs of multidisciplinary reviewers appraised each guideline., Results: A prevalidated generic appraisal instrument was not found to be appropriate for intrapartum fetal monitoring guidelines. When using our own specifically-developed appraisal tool for assessing the quality of fetal monitoring guidelines, only 11 reviewer pairs showed 'good' or 'moderate' agreement in their scores., Conclusions: Generically-validated guidelines may not be sufficiently discriminatory for specialized areas of practice such as intrapartum fetal monitoring.

Acceptance of a paper for publication sometimes appears to be a mountain that has to be climbed. For some it has the height of Everest but for others it is a stroll up a hill. In writing this paper I hope that readers will be able to have an easier job in writing a paper that will be accepted in this journal and that in return the editor's task will be a little easier.

Aim: to determine whether intrapartum fetal monitoring guidelines used by midwives in one region of England for women at low risk of obstetric complications were evidence-based., Objective: to assess the quality of such guidelines using an appraisal tool., Design and Setting: an appraisal of guidelines gained via a postal survey of all National Health Service Trusts supplying maternity services in one region in the north of England, conducted over a six-week period (June-July 2001)., Participants: 28 Trusts were eligible to participate; 32 guidelines were returned from 24 Trusts., Data Analysis: two reviewers from a multi-disciplinary panel appraised each guideline, producing two sets of data that were analysed independently of each other. Each was treated as a separate case (n=64 cases). Inter-reviewer agreement was summarised using descriptive categories., Findings: the highest possible overall quality score was 54, and the lowest 18. Whilst no guideline scored 54, five of the 64 cases scored 18. The mean overall quality score was 26.8. In 36 of the 64 cases, both reviewers rated guidelines as 'definitely not' recommended for practice. Guidelines were scored against specific aspects of evidence-based practice. Forty-one of the 64 cases received the lowest possible quality score (='1') for use of systematic reviews of the literature on electronic fetal monitoring. In 47 cases, guidelines were scored '1' for the quality of evidence-based clinical recommendations. The quality of information on client monitoring preferences was considered low in over half the 64 cases (n=35). There were no instances where the number of cases receiving 'highest possible quality' scores was greater than those receiving 'lowest possible quality' ratings., Conclusions and Implications for Practice: a small number of guidelines were assessed as high quality, but the majority were poorly appraised by the reviewer group in most areas. This has implications for the delivery of evidence-based midwifery care since those midwives practising according to the guidelines surveyed would not have been supported in implementing research into practice.