'This is time we'll never get back': a qualitative study of mothers' experiences of care associated with neonatal death.

AIMS: To explore the perceptions and experience of women whose baby died in the neonatal period about their care in the perinatal period, on delivery suite, in the neonatal unit and afterwards, expressed in their own words. DESIGN: Secondary analysis of the Listening to Parents study, using thematic analysis based on the open text responses from a postal survey of parents whose baby died in the neonatal period in England. Women were asked about care during the pregnancy, labour and birth, around the time the baby died and about neonatal care. Women whose pregnancy was terminated for fetal abnormality were excluded from this analysis. RESULTS: Completed questionnaires were received from 249 mothers of whom most (78%) responded with open text. Overarching themes identified were 'the importance of proximity', 'recognition of role and identity as a parent' and 'the experience of care' and subthemes included 'hours and moments', 'barriers to contact', ' being able to parent, even for a short time', 'missed opportunities', 'being heard' and 'sensitive and responsive care'. CONCLUSION: The findings identify what is most important for mothers in experiencing the life and death of a baby as a newborn. Physical contact with the baby was paramount, as was being treated as a mother and a parent and being able to function as such. The way in which healthcare staff behaved and how their babies were cared for was critical to how mothers felt supported and enabled at this time. If all women whose babies die in the neonatal period after birth are to receive the responsive care they need, greater understanding of the primary need for closeness and proximity, for active recognition of their parental role and staff awareness of the limited time window available is essential.

Impact of obstetric unit closures, travel time and distance to obstetric services on maternal and neonatal outcomes in high-income countries: a systematic review.

OBJECTIVES: To systematically review (1) The effect of obstetric unit (OU) closures on maternal and neonatal outcomes and (2) The association between travel distance/time to an OU and maternal and neonatal outcomes. DESIGN: Systematic review of any quantitative studies with a comparison group. DATA SOURCES: Embase, MEDLINE, PsycINFO, Applied Social Science Index and Abstracts, Cumulative Index to Nursing and Allied Health and grey literature were searched. METHODS: Eligible studies explored the impact of closure of an OU or the effect of travel distance/time on prespecified maternal or neonatal outcomes. Only studies of women giving birth in high-income countries with universal health coverage of maternity services comparable to the UK were included. Identification of studies, extraction of data and risk of bias assessment were undertaken by at least two reviewers independently. The risk of bias checklist was based on the Cochrane Effective Practice and Organisation of Care criteria and the Newcastle-Ottawa scale. Heterogeneity across studies precluded meta-analysis and synthesis was narrative, with key findings tabulated. RESULTS: 31 studies met the inclusion criteria. There was some evidence to suggest an increase in babies born before arrival following OU closures and/or associated with longer travel distances or time. This may be associated with an increased risk of perinatal or neonatal mortality, but this finding was not consistent across studies. Evidence on other maternal and neonatal outcomes was limited but did not suggest worse outcomes after closures or with longer travel times/distances. Interpretation of findings for some studies was hampered by concerns around how accurately exposures were measured, and/or a lack of adjustment for confounders or temporal changes. CONCLUSION: It is not possible to conclude from this review whether OU closure, increased travel distances or times are associated with worse outcomes for the mother or the baby. PROSPERO REGISTRATION NUMBER: CRD42017078503.

First-Time Mothers' Expectations and Experiences of Postnatal Care in England.

Postnatal care is the aspect of maternity care with which women in England are least satisfied. Little is known about first-time mothers' expectations of postnatal care, or how these expectations relate to their experiences and appraisal of care. Thirty-two first-time mothers took part in a longitudinal qualitative descriptive study, based on two semi-structured interviews-the first in pregnancy, and the second 2 to 3 months after birth. Trajectory analysis was used to identify the thematic patterns in the relationships between postnatal care expectations, needs, experiences, and confidence. Five trajectories were identified, showing that mothers' satisfaction with postnatal care and confidence were primarily influenced not by the extent to which their expectations were met but the varied extent to which their individual postnatal needs were met. Rapid and responsive assessment of needs both antenatally and postnatally, and appropriate adjustment of care, is key in supporting women effectively at this time.

Women's ideal and real expectations of postnatal care during their first pregnancy: An online survey in England.

BACKGROUND: There are many studies of women's experiences of care during the postnatal period, however little is known about women's expectations of postnatal care. OBJECTIVE: This study explores first-time pregnant women's expectations, both ideal and real life, of postnatal care in England. DESIGN: a descriptive, cross-sectional online survey design was used. The questionnaire took approximately 10 minutes to complete and was developed specifically for this survey. It included an informed consent section, socio-demographic questions and closed tick-box questions on where they had received information on postnatal care, and real and ideal expectations of postnatal care in hospital/birth centre and at home. SETTING: The survey was hosted on the National Perinatal Epidemiology Unit website and advertised through a number of third sector and commercial organisations in 2017. PARTICIPANTS: Women who were pregnant, had not given birth before, were aged 16 years and over, and living in England were eligible to participate. ANALYSIS: Survey data were analysed using descriptive statistics and, where appropriate, chi square test using SPSS Version 23. Data from open ended questions were analysed by two researchers separately then codes and themes were discussed until consensus was reached. RESULTS: 283 women responded to the survey of whom 200 were eligible and included in the analysis. Most had received information on postnatal care from multiple sources, with pregnancy classes and midwives being most common. Most expected to stay one day or less in hospital or birth centre after normal delivery. Real life expectations were lower than ideal expectations, and hospital/birth centre real life expectations were higher than home real life expectations for physical health advice/checks and information/help with feeding. Categories developed from the open text answers were 'Respect, compassion and individualised care at a vulnerable time', 'The ward environment', 'Feeling ready for hospital discharge' and 'Help to find support in the community'. KEY CONCLUSIONS: Women in this survey had high ideal world expectations of their postnatal care but in real life expected more focus on checking on their health and that of their baby and on giving information about the new challenges of how to breastfeed and look after a baby. While women valued checks of their health and that of their baby, ideally they wanted easy access to reassurance that they were feeding and looking after their baby well, that they were 'doing it right', and that what was happening to them was normal. IMPLICATIONS FOR PRACTICE: As well as the necessary checks in the immediate postpartum period, consideration also needs to be given to the best way to meet the informational and support needs of women to optimise their wellbeing and transition to parenthood. A number of resources are used by women that could be enhanced to inform expectations of postnatal care and to provide valuable information to support their postnatal care.

Trends in response rates and respondent characteristics in five National Maternity Surveys in England during 1995-2018.

BACKGROUND: The National Perinatal Epidemiology Unit in England has conducted five National Maternity Surveys (NMS) at varying intervals since 1995. This paper aims to describe the changes in NMS response rates over time and to compare the demographic characteristics of respondents to each NMS. METHODS: This paper is based on secondary data analysis of the NMS (cross-sectional postal surveys) from 1995 to 2018. All women aged 16 years and over who gave birth in England (and Wales in 1995) during specified time periods from 1995 to 2018 were eligible to be selected. For each survey, between 3570 and 16,000 women who were 3-6 months postpartum were selected at random by the Office for National Statistics, using birth registrations. Women could participate on paper, by telephone (from 2006) or online (from 2010). RESULTS: The response rate to the NMS decreased from 67% in 1995 to 29% in 2018. The decline was evident across demographic groups. In all NMS, response rates were higher in women who were older (crude prevalence ratios (PR) for 16-24 years versus 30-34 years = 0.51-0.73 (across surveys)), married (crude PR for sole versus married registrants = 0.41-0.62), born in the UK (crude PR for non UK-born versus UK-born = 0.70-0.84), and living in less deprived areas (crude PR for least versus most deprived = 0.42-0.63). However, the association between each demographic characteristic and response varied across surveys, with the youngest women, women who registered the birth of the baby in their sole name, and women living in the most deprived areas becoming relatively less likely to respond over time. In multivariable analysis in 2014 and 2018, the effects of age, marital status, country of birth and level of area deprivation on response were attenuated but all four demographic characteristics remained statistically significantly associated with response. CONCLUSIONS: Response rates to the NMS have declined significantly during the last 23 years. The demographic characteristics associated with response were consistent across surveys, but the size of the effect varied significantly, with underrepresented groups becoming relatively less likely to participate over time. It is important to find strategies to increase response rates, particularly amongst underrepresented groups, and to validate the data collected.

Expectations and experiences of hospital postnatal care in the UK: a systematic review of quantitative and qualitative studies.

OBJECTIVES: To report on women's and families' expectations and experiences of hospital postnatal care, and also to reflect on women's satisfaction with hospital postnatal care and to relate their expectations to their actual care experiences. DESIGN: Systematic review. SETTING: UK. PARTICIPANTS: Postnatal women. PRIMARY AND SECONDARY OUTCOMES: Women's and families' expectations, experiences and satisfaction with hospital postnatal care. METHODS: Embase, MEDLINE, PsycINFO, Applied Social Sciences Index and Abstracts, Cumulative Index to Nursing and Allied Health (CINAHL Plus), Science Citation Index, and Social Sciences Citation Index were searched to identify relevant studies published since 1970. We incorporated findings from qualitative, quantitative and mixed-methods studies. Eligible studies were independently screened and quality-assessed using a modified version of the National Institutes of Health Quality Assessment Tool for quantitative studies and the Critical Appraisal Skills Programme for qualitative studies. Data were extracted on participants' characteristics, study period, setting, study objective and study specified outcomes, in addition to the summary of results. RESULTS: Data were included from 53 studies, of which 28 were quantitative, 19 were qualitative and 6 were mixed-methods studies. The methodological quality of the included studies was mixed, and only three were completely free from bias. Women were generally satisfied with their hospital postnatal care but were critical of staff interaction, the ward environment and infant feeding support. Ethnic minority women were more critical of hospital postnatal care than white women. Although duration of postnatal stay has declined over time, women were generally happy with this aspect of their care. There was limited evidence regarding women's expectations of postnatal care, families' experience and social disadvantage. CONCLUSION: Women were generally positive about their experiences of hospital postnatal care, but improvements could still be made. Individualised, flexible models of postnatal care should be evaluated and implemented. PROSPERO REGISTRATION NUMBER: CRD42017057913.

Factors associated with maternal postpartum fatigue: an observationalstudy.

OBJECTIVES: To assess the prevalence of postpartum fatigue at 10 days, 1 month and 3 months, and to describe the sociodemographic and clinical characteristics of women with fatigue and the associations with infant characteristics, maternal-infant attachment, and partner and midwifery support. SETTING: Maternity care in England. Secondary analysis of 2014 National Maternity Survey. PARTICIPANTS: Participants were a random sample of 10 000 women selected by the Office for National Statistics using birth registration records. Women aged less than 16 years or if their baby had died were excluded. Questionnaires were sent to women at 3 months post partum and asked about well-being and care during pregnancy, labour, birth and post partum. Specifically, women were asked whether they experienced fatigue/severe tiredness at 10 days, 1 month or 3 months post partum. Responses were received from 4578 women (47% response rate). RESULTS: Decreasing but substantial proportions of women, 38.8%, 27.1% and 11.4%, experienced fatigue/severe tiredness at 10 days, 1 month and 3 months, respectively. These figures varied significantly by maternal age, level of deprivation, education and parity. Women reporting depression, anxiety, sleep problems and those breast feeding were at significantly increased risk (eg, OR for depression in women with fatigue at 3 months: 2.99 (95% CI 2.13 to 4.21)). Significantly more negative language was used by these women to describe their babies, and they perceived their baby as more difficult than average (eg, two or more negative adjectives used by women with fatigue at 3 months: OR 1.86 (95% CI 1.36 to 2.54)). Women with postpartum fatigue had greater partner support but were significantly less likely to report seeing the midwife as much as they wanted. CONCLUSIONS: Postpartum fatigue is not inevitable or universal, although early in the postnatal period it affects a substantial proportion of women. Predictors include age and parity, but practical help and support from partners and midwives may be protective factors.

Methods to increase response rates to a population-based maternity survey: a comparison of two pilot studies.

BACKGROUND: Surveys are established methods for collecting population data that are unavailable from other sources; however, response rates to surveys are declining. A number of methods have been identified to increase survey returns yet response rates remain low. This paper evaluates the impact of five selected methods on the response rate to pilot surveys, conducted prior to a large-scale National Maternity Survey in England. METHODS: The pilot national maternity surveys were cross-sectional population-based questionnaire surveys of women who were three months postpartum selected at random from birth registrations. Women received a postal questionnaire, which they could complete on paper, online or verbally over the telephone. An initial pilot survey was conducted (pilot 1, n = 1000) to which the response rate was lower than expected. Therefore, a further pilot survey was conducted (pilot 2, n = 2000) using additional selected methods with the specific aim of increasing the response rate. The additional selected methods used for all women in pilot 2 were: pre-notification, a shorter questionnaire, more personable survey materials, an additional reminder, and inclusion of quick response (QR) codes to enable faster access to the online version of the survey. To assess the impact of the selected methods, response rates to pilot surveys 1 and 2 were compared. RESULTS: The response rate increased significantly from 28.7% in pilot 1 to 33.1% in pilot 2 (+ 4.4%, 95%CI:0.88-7.83, p = 0.02). Analysis of weekly returns according to time from initial and reminder mail-outs suggests that this increase was largely due to the additional reminder. Most respondents completed the paper questionnaire rather than taking part online or over the telephone in both pilot surveys. However, the overall response to the online questionnaire almost doubled from 1.8% in pilot 1 to 3.5% in pilot 2, corresponding to an absolute difference of 1.7% (95%CI:0.45-2.81, p = 0.01), suggesting that QR codes might have facilitated online participation. CONCLUSIONS: Declining survey response rates may be ameliorated with the use of selected methods. Further studies should evaluate the effectiveness of each of these methods using randomised controlled trials and identify novel strategies for engaging populations in survey research.

Psychosocial factors that mediate the association between mode of birth and maternal postnatal adjustment: findings from a population-based survey.

BACKGROUND: Mode of birth has been found to be associated with maternal postnatal adjustment with women who have Caesarean Sections (CS) thought to be at higher risk of emotional distress. However the relationship is complex and studies have demonstrated mixed findings. The aim of this study is to evaluate a model that explores the direct relationship between mode of birth and postnatal maternal adjustment at 3 months and indirect relationships through psychosocial variables. METHODS: A secondary analysis of a population-based survey conducted in England, UK in 2014. The analysis included primiparous women with singleton babies who provided information about mode of birth (n = 2139). RESULTS: Maternal postnatal adjustment, as measured by Maternal postnatal wellbeing and Satisfaction with care during labour and birth, varied by mode of birth. Women who had an unplanned CS had the poorest postnatal adjustment. Mode of birth was not associated with Maternal/infant sense of belonging. Four out of the five proposed mediation variables (Perceived control, Maternal expectation, Support in labour, How long until the mother held her baby), showed partial mediation of the relationship between mode of birth and both Maternal postnatal wellbeing and Satisfaction with care during labour and birth. The strongest mediator was Perceived control and the only variable not to show a significant mediation effect was Health of the infant at 3 months. CONCLUSIONS: Birth by unplanned, but not planned, caesarean section was associated with poorer maternal adjustment and instrumental birth was associated with lower maternal satisfaction with labour and birth. These relationships were found to be partially mediated by psychosocial variables. Psychosocial interventions in the perinatal period should be considered to optimise maternal postnatal adjustment.

Identifying postnatal depression: Comparison of a self-reported depression item with Edinburgh Postnatal Depression Scale scores at three months postpartum.

BACKGROUND: Early identification of postnatal depression is important in order to minimize adverse outcomes. The Edinburgh Postnatal Depression Scale (EPDS) is commonly used as a screening tool but a single, direct question on depression may offer an alternative means of identifying women in need of support. This study examines the agreement between these methods and characteristics of women who self-identify as depressed and those with EPDS ≥ 13. METHODS: Secondary analysis of two national maternity surveys conducted in England and Northern Ireland. Agreement between the direct question and EPDS scores was assessed using Cohen's kappa. Logistic regression was used to identify characteristics of women in each group. RESULTS: 6752 women were included. At three months postpartum, 6.1% of women self-identified as having depression, 9.1% scored EPDS ≥ 13, 2.8% were positive on both. Agreement between the two methods was minimal (Cohen's kappa < 0.3). Women who self-identified as having depression had higher odds of being aged > 40 years (OR 1.8; 95% CI 1.2-2.8). EPDS ≥ 13 was associated with < 16 years of education (OR 1.4; 95% CI 1.1-1.8), minority ethnicity (OR 1.4; 95% CI 1.1-1.9), living without a partner (OR 1.7; 95% CI 1.3-2.2), and a less than happy reaction to the pregnancy (OR 1.7; 95% CI 1.4-2.1). LIMITATIONS: Low survey response limits the representativeness of findings. The absence of a diagnostic interview limits conclusions on accuracy or internal validity of the measures. CONCLUSIONS: A direct question about postnatal depression may offer a valuable addition to screening tools to identify women in need of support.

Mothers' experience of maternity and neonatal care when babies die: A quantitative study.

BACKGROUND: The death of a newborn baby is devastating. While clinical issues may be a primary concern, interpersonal aspects can impact significantly. Mothers in this situation are not easy to access for research and little quantitative evidence is available. In this study we aimed to describe their experience of care, emphasising associations with infant gestational age. METHODS: Secondary analysis of population-based survey data collected through the Office for National Statistics following neonatal death in England in 2012-13. Women were asked about clinical events and care during pregnancy, labour and birth, when the baby died, postnatally and in the neonatal unit. RESULTS: 249 mothers returned completed questionnaires (30% response rate), 50% of births were at 28 weeks' gestation or less and 66% had babies admitted for neonatal care. 24% of women were left alone and worried during labour and 18% after birth. Only 49% felt sufficiently involved in decision-making at this time. Postnatally only 53% were cared for away from other mothers and babies, 47% could not have their partner stay with them, and 55% were not located close to their baby. Mothers of term babies were significantly less likely to report confidence in staff, feeling listened to and having concerns taken seriously during labour, and postnatally many felt insufficiently informed about their baby's condition, and that neonatal staff were not always aware of parental needs. However, most mothers (84%) were satisfied with neonatal care. CONCLUSIONS: There is room for improvement if women whose babies die in the neonatal period are to receive the care and support they need. Women who have a baby admitted to a neonatal unit should be cared for nearby, with room for their partner and with greater involvement in decision-making, particularly where withdrawal of life support is considered.

Recency of migration, region of origin and women's experience of maternity care in England: Evidence from a large cross-sectional survey.

BACKGROUND: In the UK, changes to legislation in 2003 regarding the free movement of people in the European Union resulted in an increase in immigration from countries that joined the EU since 2004, the Accession countries. OBJECTIVE: To describe and compare the maternity experiences of recent migrant mothers to those who had been resident in the UK for longer, and to UK-born women, while taking into account their region of origin. DESIGN: Cross-sectional national survey. SETTING: England, 2009. PARTICIPANTS: Random sample of postpartum women. MEASUREMENTS: Questionnaires asked about demographic characteristics, care during pregnancy, labour, birth and postnatally, about country of origin and, if not born in the UK, when they came to the UK. Country of origin was grouped into UK, Accession countries, and rest of the world. Recency of migration was grouped into recent arrivals (0-3 years), and earlier arrivals (4 or more years since arrival). Descriptive statistics and binary logistic regression were used to explore women's experiences of care. Stratified analyses were used to account for the strong correlation between recency of migration and region of origin. FINDINGS: Overall, 5332 women responded to the survey (a usable response rate of 54%). Seventy-nine percent of women were UK-born. Of the 21% born outside the UK, a third were born in Accession countries. All migrants reported a poorer experience of care than UK-born women. In particular, recent migrants from the Accession countries were significantly less likely to feel that they were spoken to so they could understand and treated with kindness and respect. CONCLUSIONS: Given the rising population of non-UK-born women of childbearing age resident in the UK and the relatively high proportion from Accession countries, it is important that staff are able to communicate effectively, through interpreters if necessary. IMPLICATIONS FOR PRACTICE: The differences in clinical practice between women's home countries and the UK should be discussed so that women's expectations of care are informed about the options available to them.

Is partners' mental health and well-being affected by holding the baby after stillbirth? Mothers' accounts from a national survey.

OBJECTIVE: This study aimed to assess the effects on partners' health and well-being of holding a stillborn baby. BACKGROUND: Findings from quantitative and qualitative studies have produced inconsistent results concerning the effects of holding a stillborn baby on parents. METHODS: Secondary analyses were conducted on postal questionnaire data relating to 455 partners of women who had a stillbirth. Women answered questions about their partners' behaviour, perceptions of care, mental health and well-being at three and nine months after the stillbirth. Demographic, clinical and care characteristics were compared between partners who, according to the mothers, did and did not hold their baby. Sub-group analyses assessed hypothesised moderating effects. RESULTS: Mothers reported that most partners saw (92%) and held (82%) their stillborn baby. However, partners born outside the UK were less likely to have held their baby. Higher gestational age, shorter time interval between antepartum death and delivery, and mother's holding the baby all predicted a higher rate of partner's holding. There was a consistent negative effect of holding the baby across mental health and well-being outcomes, although after adjustment only higher odds of depression (OR 2.72, 95% CI 1.35-5.50) and post-traumatic stress type symptoms (OR 1.95, 95% CI 1.01-3.78) at 3 months were significantly associated with having held the baby following stillbirth. CONCLUSIONS: This study is the first to assess the impact of holding the baby on partners' mental health and well-being. The prevalence of depression and anxiety were high, and the negative effects of holding the baby were significant 3 months later.

Care associated with stillbirth for the most disadvantaged women: A multi-method study of care in England.

BACKGROUND: Most research on women experiencing stillbirth relies on online user group surveys or qualitative interviews. The objective of this study was to investigate the experience of women who are at a higher risk of stillbirth, living in areas of greatest deprivation, and are commonly not well represented. METHODS: This study used birth and death registrations in 2012-2013 to identify a sample of mothers whose babies had died as a result of stillbirth. These women were sent a survey 6-9 months after the stillbirth. We undertook descriptive analysis of quantitative data and used binary logistic regression with the Index of Multiple Deprivation as a measure of disadvantage. We used thematic analysis to describe free text responses. RESULTS: The survey response rate was 30% (N = 473). Ethnic minority, younger age, and single parenthood were associated with disadvantage. Women residents in the most deprived areas perceived care more negatively: during labor they were significantly less likely to be spoken to by medical staff so they could understand (73% compared with 90%, adjusted odds ratio [aOR] 0.33 [95% confidence interval {CI} 0.18-0.65]), or treated with respect by midwives (79% compared with 90%, aOR 0.41 [95% CI 0.22-0.77]). The qualitative themes identified were: "Difficulty in accessing care," "More could have been done," "Ineffective communication," and "Cared for and not cared for" which support the quantitative findings. CONCLUSION: Women living in the most deprived areas reported poorer experiences of care compared with more advantaged women. All women need compassionate and sensitive care around the time of a stillbirth.

Care and self-reported outcomes of care experienced by women with mental health problems in pregnancy: Findings from a national survey.

BACKGROUND: mental health problems in pregnancy and the postnatal period are relatively common and, in pregnancy, are associated with an increase in adverse outcome. It is recommended that all women are asked about their emotional and mental health and offered treatment if appropriate. OBJECTIVES: to describe the care received by women self-identifying with mental health problems in pregnancy, and to describe the effects of support, advice and treatment on outcomes in the postnatal period. DESIGN: this study used cross-sectional survey data collected in 2014 which described women's experience of maternity care. SETTING: England PARTICIPANTS: a random sample of women who had a live birth in January 2014. MEASUREMENTS: the questionnaire asked about sociodemographic characteristics, whether women were asked about emotional and mental health in pregnancy, support and treatment offered, about postnatal wellbeing, and questions relating to attachment to their baby. Descriptive statistics and logistic regression were used to examine the associations between mental health and outcomes taking account of sociodemographic characteristics. FINDINGS: the survey response rate was 47%. Women with antenatal mental health problems were significantly more worried at the prospect of labour and birth, had lower satisfaction with the experience of birth, worse postnatal mental health, and indications of poorer attachment to their baby. They received substantially more care than other women but they did not always view this positively. Support, advice and treatment for mental health problems had mixed effects. CONCLUSIONS: this study describes the significant additional care provided to women self-identifying with mental health problems in pregnancy, the mixed effects of support, advice and treatment, and the poor perception of staff interaction among women with mental health problems. IMPLICATIONS FOR PRACTICE: health care professionals may need additional training to effectively support women with mental health problems during the perinatal period.

Sociodemographic differences in women's experience of early labour care: a mixed methods study.

OBJECTIVES: To explore women's experiences of early labour care focusing on sociodemographic differences, and to examine the effect of antenatal education, using mixed methods. SETTING: England, 2014. PARTICIPANTS: Women who completed postal questionnaires about their experience of maternity care, including questions about antenatal education, early labour and sociodemographic factors, included space for free-text comments. OUTCOME MEASURES: Worries about labour, contact with midwives in early labour and subsequent care. METHODS: This study was based on secondary analysis of a national maternity survey carried out in England in 2014. Quantitative data were analysed using descriptive statistics and binary logistic regression; qualitative data were analysed using a thematic content analytic approach. RESULTS: Completed questionnaires were received from 4578 women (47% response rate). There were significant differences by sociodemographic factors, particularly ethnicity, in women's worries about early labour. Compared with white women, women from black or minority ethnic groups had an adjusted OR of 1.93 (95% CI 1.56 to 2.39) of feeling worried about not knowing when labour would start. Among women who contacted a midwife at the start of labour, 84% perceived their advice as appropriate, more in older and multiparous women. Overall, 64% of women were asked to come to the hospital at this time, more in multiparous women (adjusted OR 1.63, 95% CI 1.35 to 1.96). Those who did not have access to antenatal education experienced greater worry about early labour. Five themes emerged from the qualitative analysis: 'Differentiating between early and active labour', 'Staff attitudes', 'Not being allowed…', 'Previous labours' and 'Perceived consequences for women'. CONCLUSION: These findings reinforce the importance of providing reassurance to women in early labour, taking care that women do not feel neglected or dismissed. In particular, primiparous and ethnic minority women reported greater worry about early labour and require additional reassurance.

Access and quality of maternity care for disabled women during pregnancy, birth and the postnatal period in England: data from a national survey.

OBJECTIVES: More disabled women are becoming mothers, and yet, their care is rarely the focus of quantitative research. This study aimed to investigate access and quality of maternity care for women with differing disabilities. DESIGN: Secondary analysis was conducted on data from a 2015 national survey of women's experience of maternity care. Descriptive and adjusted analyses were undertaken for five disability groups: physical disability, sensory impairment, mental health disability, learning disability and multiple disability, and comparisons were made with the responses of non-disabled women. SETTING: Survey data were collected on women's experience of primary and secondary care in all trusts providing maternity care in England. PARTICIPANTS: Women who had given birth 3 months previously, among whom were groups self-identifying with different types of disability. Exclusions were limited to women whose baby had died and those who were younger than 16 years at the time of the recent birth. RESULTS: Overall, 20 094 women completed and returned the survey; 1958 women (9.5%) self-identified as having a disability. The findings indicate some gaps in maternity care provision for these women relating to interpersonal aspects of care: communication, feeling listened to and supported, involvement in decision making, having a trusted and respected relationship with clinical staff. Women from all disability groups wanted more postnatal contacts and help with infant feeding. CONCLUSION: While access to care was generally satisfactory for disabled women, women's emotional well-being and support during pregnancy and beyond is an area that is in need of improvement. Specific areas identified included disseminating information effectively, ensuring appropriate communication and understanding, and supporting women's sense of control to build trusting relationships with healthcare providers.

Parents' experience of perinatal post-mortem following stillbirth: A mixed methods study.

OBJECTIVES: To analyse quantitative and qualitative data, to describe the experience of parents in relation to post-mortem following stillbirth, looking at offer and uptake of post-mortem, information-giving, the type of post-mortem carried out, receiving the results and any sociodemographic differences in care practices in relation to post-mortem. DESIGN: Secondary analysis of a postal survey which included both open and closed questions allowing for a mixed methods study design. POPULATION: Random sample of women who experienced a stillbirth in 2013. METHODS: A sample of women who experienced a stillbirth in 2013 were selected by staff at the Office for National Statistics and sent a letter and information leaflet about the study followed by a postal questionnaire. The questionnaire included questions about pregnancy, labour and birth, the postnatal period, the time at which the baby died, and also asked about the post-mortem process. RESULTS: Completed questionnaires were received from 477 women. Overall, 95% of women were asked for consent to a post-mortem, almost half prior to birth, and half by a consultant. The majority of women received written information and felt sufficiently informed, and agreed to a full post-mortem. A third of women had to wait longer than 12 weeks for the post-mortem result and this was the most common theme in the free text comments. Women also commented on the manner of being asked for consent, and wrote about issues related to communication and support. There were significant differences between sociodemographic groups in many of these factors. CONCLUSIONS: The inconsistencies in offer and consent to post-mortem following stillbirth suggest inequality in this area. The amount of time that many parents have to wait for post-mortem results is unacceptable and should be prioritised for improvement.

Ecological implications of hypoxia-triggered shifts in secondary metabolism.

Members of the actinomycete genus Streptomyces are non-motile, filamentous bacteria that are well-known for the production of biomedically relevant secondary metabolites. While considered obligate aerobes, little is known about how these bacteria respond to periods of reduced oxygen availability in their natural habitats, which include soils and ocean sediments. Here, we provide evidence that the marine streptomycete strain CNQ-525 can reduce MnO2 via a diffusible mechanism. We investigated the effects of hypoxia on secondary metabolite production and observed a shift away from the antibiotic napyradiomycin towards 8-amino-flaviolin, an intermediate in the napyradiomycin biosynthetic pathway. We purified 8-amino-flaviolin and demonstrated that it is reversibly redox-active (midpoint potential -474.5 mV), indicating that it has the potential to function as an endogenous extracellular electron shuttle. This study provides evidence that environmentally triggered changes in secondary metabolite production may provide clues to the ecological functions of specific compounds, and that Gram-positive bacteria considered to be obligate aerobes may play previously unrecognized roles in biogeochemical cycling through mechanisms that include extracellular electron shuttling.

Change over time in women's views and experiences of maternity care in England, 1995-2014: A comparison using survey data.

BACKGROUND: there have been changes in maternity care policy over the last 20 years and women's experience, continuity and satisfaction with care have become more prominent. However there has been no research examining changes over time in women's reported experience. METHODS: this study used secondary analysis of data collected in four postal surveys of maternity care experiences in 1995, 2006, 2010 and 2014. In each case women who had delivered in a specified time period in England were randomly sampled and sent a questionnaire three months after the birth. Women were excluded if they were aged less than 16 years or their infant had died. The majority of questions were comparable over the different surveys. Descriptive statistics and adjusted odds ratios are presented. FINDINGS: in the antenatal period, an increasing proportion of women had early first contact with a healthcare professional, screening for Down's syndrome, both dating and anomaly scans and the total number of ultrasound scans increased over the period. The proportion of women given explanations about screening and choice regarding interventions during labour and birth both appear to have increased. In the postnatal period, length of hospital stay declined over time but the proportion of women who considered their length of stay too short remained constant. The number of postnatal home visits also declined and there was a substantial increase in the proportion of women who would have liked more visits. Overall satisfaction with care remained high especially for care during pregnancy, labour and birth. CONCLUSIONS: despite fewer antenatal checks, shorter hospital stays and fewer postnatal home visits, women were generally very positive about their care in pregnancy, labour and birth, and the postnatal period. Maternity care has changed in many respects, with earlier contact with health professionals, more scans and more information. However, reduced continuity of care and a need for support in the early weeks with a new infant was expressed by many women and are issues that may be contributing to some of the dissatisfaction expressed.