Infant and young child feeding in emergencies: Organisational policies and activities during the refugee crisis in Lebanon.

Appropriate infant and young child feeding (IYCF) is key to reducing mortality amongst children aged under 2. Facilitating adherence to recommended IYCF practices during emergencies includes having relevant policies to support breastfeeding and complementary feeding as well as regulating the distribution of breast milk substitutes. In the current crisis, more than 1.2 million Syrian refugees are in Lebanon and it is timely to examine organisational IYCF policies and programmes. One hundred and thirty-five non-governmental organisations providing humanitarian aid in Lebanon were invited to participate in an online survey about organisational policies and programmatic activities on IYCF. Responses were obtained from 54 organisations: 29 International Non-Governmental Organisations (INGOs) and 25 Local Non-Governmental Organisations (LNGOs). In total, 8 (15%) reported having a written policy on IYCF, but only 1 policy (in draft format) was available for inspection. Twelve (8 INGOs and 4 LNGOs) indicated endorsing an external IYCF policy, but only 6 listed a valid policy. Four organisations (3 INGOs and 1 LNGO) had programme objectives that indicate protection, promotion, and support of IYCF. Three LNGOs reported receiving infant formula donations and 5 organisations (2 INGOs and 3 LNGOs) indicated distributing infant formula; 2 (1 INGO and 1 LNGO) did so in accordance with international and national policies. Few organisations violated IYCF guidance but organisational policies and activities on IYCF are not well established. In order to improve response in the current refugee crisis in Lebanon, there is a need to ensure policies are in place and implemented so that interventions support, promote, and protect IYCF.

An exploratory study to assess the acceptability of an antenatal quality-of-life instrument (the Mother-generated Index).

OBJECTIVE: to assess whether the Mother-generated Index (MGI), a validated postnatal tool, was acceptable during late pregnancy; minor modifications to the wording of the existing tool were made. The MGI allows for qualitative and quantitative assessment. DESIGN: face-to-face interviews were conducted by a single researcher using the modified MGI and the General Health Questionnaire (GHQ-30). The women wrote up to eight comments describing the most important areas of their lives, indicated whether these were positive, negative or neither, and then scored and ranked them. SETTING: two health centres in East Scotland, during a scheduled antenatal clinic visit. PARTICIPANTS: 35 women (20 nulliparous and 15 parous) in the third trimester of pregnancy. FINDINGS: interviews lasted for 15-25 mins and none of the women found the MGI difficult to complete. The mean number of comments was 4.9 (standard deviation 1.1); most were directly related to the pregnancy and some were life issues that remained pertinent during the pregnancy. Face validity was good; criterion validity could not be assessed formally, but the MGI scores and the GHQ-30 scores were well correlated (Pearson r=-0.62; p<0.001). While some comment categories were universally positive ('looking forward to baby', 'relationship with partner') and others were universally negative ('tiredness', 'aches and pains'), other categories were mixed (e.g. 'social life', 'work'). Women who expected their birth partner to be 'very helpful' had significantly higher MGI scores than women without such expectations (t=2.5, degrees of freedom=33; p=0.018). KEY CONCLUSIONS: in this comparatively small study, the MGI was acceptable to pregnant women as an assessment tool during late pregnancy. While the sample size precluded definitive statistical evaluation, the apparently logical associations between overall MGI scores and particular comments, and the good correlation between MGI and GHQ-30 scores suggest that the MGI is a feasible tool for use in late pregnancy. IMPLICATIONS FOR PRACTICE: holistic care is advocated; this subjective tool allows pregnant women to state what is most important to them, thus avoiding a 'top-down' pathological approach. The MGI can help to uncover important quality-of-life issues that may not appear obvious to the midwife, and which may otherwise be missed. A larger study is required for formal evaluation of the quantitative potential of the antenatal MGI.

An exploratory mixed-methods study of Scottish midwives' understandings and perceptions of clinical near misses in maternity care.

OBJECTIVE: adverse outcomes and near misses are believed to share many characteristics in terms of clinical situations and care management problems. Little is documented concerning what prevents adverse outcomes from happening once the 'accident trajectory' begins. This two-stage pilot study set out to investigate midwives' understandings and recollections of clinical near misses. DESIGN: anonymous self-completion questionnaire and follow-up group interviews. SETTING/PARTICIPANTS: clinically based midwives working in four maternity units in Scotland (questionnaire [n = 34]; interviews [n = 26]). FINDINGS: despite a low response rate to the questionnaire, the cited examples seem to confirm that near misses and adverse outcomes follow essentially similar routes until the former are halted by a saving intervention. Dangerous situations are created by heavy workloads, and are aggravated by sub-optimal skill-mix, poor communication and individuals making mistakes or not following accepted procedures. Overwhelmingly, what prevents this situation from resulting in an adverse outcome is an intervention by another practitioner--often reported to be by chance and not design. In the interviews, these situations were discussed with reference to unit culture, the causes of errors and near misses, helping to prevent mistakes, the consequences of near misses and staff confiding in one another. CONCLUSIONS/IMPLICATIONS FOR PRACTICE: this limited study reaffirms the view that clinical near misses have the same origins as actual poor outcomes. Practitioners need to be able to discuss clinical and operational matters openly with colleagues. Although the 'blame culture' was reported to be less prevalent when things go wrong, not all midwives feel comfortable about discussing incidents or near misses. This exploratory study makes no claim to encapsulate this complex and sensitive subject. Further detailed research into the nature and extent of near misses is required. Identifying what prevents a poor outcome from happening may be a valuable clinical resource.

The significance of time factors in cerebral palsy litigation.

OBJECTIVE: to demonstrate the significance of the lengths of time taken to initiate and conclude litigation concerning cerebral palsy. DESIGN: documentary analysis of 142 closed legal files (92 Scottish; 50 English) relating to births from 1980-1996. Claim outcome, and the dates of birth, legal notification and conclusion of the claim, were analysed using Microsoft Excel. SETTING: health service legal offices in Scotland and England. FINDINGS: successful claims were raised more quickly (on average two years compared with 3.6 years for unsuccessful claims). They also took longer to be decided (six years compared with three years). On average the children of successful and unsuccessful litigants were, respectively, 7.8 and 6.6 years old by the time the claim was decided. Over the period studied there was a steady reduction in the length of time taken to initiate litigation, although successful claims were on average raised more quickly. Overall success rate was 27%. CONCLUSIONS/IMPLICATIONS FOR PRACTICE: most cerebral palsy claims do not satisfy the requirements of the law of medical negligence. Lengthy periods of time are involved irrespective of outcome: while successful litigants continue to sue more quickly, their claims take longer to be resolved. The extensive period from birth to closure of claim, and uncertainty over the legal outcome, may cause significant distress for practitioners and parents of children with cerebral palsy. Knowledge of the likely duration of the legal process can help practitioners and the families involved to come to terms with this important feature of litigation. Health service claims managers may also be helped in terms of understanding the more likely duration (and therefore cost implications) of cerebral palsy claims. For successful litigants there are questions about the justice of having to wait, on average, nearly eight years for compensation.

A qualitative study of pregnant teenagers' perceptions of the acceptability of a nutritional education intervention.

OBJECTIVE: in order to assess the feasibility of nutritional education intervention sessions for pregnant teenagers, standard dietary assessment schedules were supplemented by a qualitative appraisal. Reported in this paper are the perceptions of pregnant teenagers who attended one or more of these sessions. DESIGN: qualitative study using a phenomenological approach. Data were collected using semi-structured tape-recorded group interviews. SETTING: two community centres and one maternity unit in Tayside, Scotland. PARTICIPANTS: ten pregnant teenagers aged 16-18 years. INTERVENTIONS: all had attended one or more of a series of food preparation sessions led by a midwife. Food to take away was provided, as were supermarket vouchers. FINDINGS: those who attended found the sessions to be social, educational, and practical. These young women appreciated being in a group which did not include 'older' pregnant women. To a limited extent they had changed their dietary habits at home. Food to take home was a significant attraction. Some of the teenagers sought maternity-related information from the midwife leading the session. KEY CONCLUSIONS: nutritional education remains an important public health issue. Despite offering a range of incentives, attracting teenagers to these sessions was difficult, making their economic feasibility questionable. IMPLICATIONS FOR PRACTICE: with better recruitment, such sessions could form an important part of improving nutrition and overall health for current and future generations.

Unique and proforma birth plans: a qualitative exploration of midwives׳ experiences.

BACKGROUND: birth plans detailing a woman׳s preferences for intrapartum care are a common feature in British maternity units, and are a means of encouraging the implementation of choice. Proforma versions may be incorporated routinely in antenatal case notes, or the woman may devise her own unique birth plan. Although women׳s views of birth plans have been explored, the views of midwives have not to date been evaluated. The growth of midwife-led units in the UK has highlighted different philosophies of care, some of which can be reflected in the different types of birth plan. Given the increasingly diverse nature of UK midwifery workplaces we set out to explore and compare the experience of midwives working in midwife-led and obstetric-led settings in relation to unique and proforma birth plans. METHOD: qualitative study using focus groups of midwives in a midwife-led unit (MLU; n=5) and obstetric-led unit (OLU; n=4) in the East of England. We used an interpretative phenomenological analytical approach. FINDINGS: three main themes arose from the data. Firstly, the term 'birth plan' can be misleading, and was criticised for encouraging the belief that birth can be 'planned'. In addition, midwives claimed that 'unique' birth plans, especially those influenced by some consumer advocacy groups, are becoming standardised in their rejection of policies and procedures and requests for intervention-free birth. Secondly, birth plans were a source of irritation for midwives in both groups, although the cause of the irritation differed between groups. Finally, it was found that midwives in both groups felt that birth plans put pressure on them, although again, the source of the pressure, and therefore the way in which midwives reacted to this pressure, differed between groups. CONCLUSIONS: the term 'birth plan' can be misleading and create false expectations. If 'unique' birth plans are becoming 'standardised' in the sense that they routinely request the same things, they are little different to proforma birth plans. Some midwives perceive pressure both from women and the wider multidisciplinary team as a result of birth plans, a perception that causes some irritation.

Water VBAC: exploring a new frontier for women's autonomy.

BACKGROUND: although Vaginal Birth After Caesarean section (VBAC) has been promoted successfully as one means of reducing the caesarean section rate, the practice of VBAC using water immersion (Water VBAC) is restricted. Very little valid, reliable research evidence is available on this birth method, although initial small-scale audits indicate that Water VBAC has no adverse effect on maternal and neonatal outcomes. METHOD: in-depth semi-structured interviews were carried out with a purposive sample of eight women who had undergone Water VBAC in one midwife-led unit. The interviews aimed to explore their reasons for requesting this birthing method, and their experience of the process. An interpretative phenomenological analytical approach was adopted. FINDINGS: the women pursued Water VBAC for two main reasons: in order to prevent a repeat of the obstetric events that previously led to a caesarean section, and to counteract their previous negative birth experiences. The women reported improved physical and psychological outcomes from their Water VBAC experience when compared with their previous experience of caesarean section. Three main themes emerged: 'minimising', 'maximising' and 'managing'. Water VBAC entailed an attempt to minimise the medicalisation of the women's childbirth experience. This was achieved by limiting medical staff input in favour of midwife-led care, which was believed to minimise negative physical and psychological experiences. Correspondingly, Water VBAC was perceived as maximising physical and psychological benefits, and as a means of allowing women to obtain choice and assert control over their labour and birth. The women planning a Water VBAC believed they had to manage the potential risks associated with Water VBAC, as well as manage the expectations and behaviour of friends, family and the health care professionals involved in their care. CONCLUSIONS: for the women participating in this research, actively pursuing Water VBAC constituted a means of asserting their autonomy over the childbirth process. The value accorded to being able to exercise choice and control over their childbearing experience was high. These women's accounts indicated that information-giving and shared decision-making require improvement, and that inconsistencies in the attitudes of health care professionals need to be addressed.

Infant feeding in Eastern Scotland: a longitudinal mixed methods evaluation of antenatal intentions and postnatal satisfaction--the Feeding Your Baby study.

BACKGROUND: breast-feeding initiation rates have improved in Scotland, but exclusive and partial breast-feeding rates fall rapidly for several reasons. We aimed to examine whether antenatal feeding intention was associated with satisfaction with infant feeding method; and to explore the similarities and differences in infant feeding experience of women with different antenatal feeding intention scores. METHOD(S): antenatal questionnaire assessment of infant feeding intentions, based on the theory of planned behaviour; two-weekly postnatal follow-up of infant feeding practice by text messaging; final telephone interview to determine reasons for and satisfaction with infant feeding practice. RESULTS: 355 women in eastern Scotland were recruited antenatally; 292 completed postnatal follow up. Antenatal feeding intentions broadly predicted postnatal practice. The highest satisfaction scores were seen in mothers with no breast-feeding intention who formula fed from birth, and those with high breast-feeding intention who breastfed for more than 8 weeks. The lowest satisfaction scores were seen in those with high intention scores who only managed to breast feed for less than 3 weeks. This suggests that satisfaction with infant feeding is associated with achieving feeding goals, whether artificial milk or breast feeding. Reasons for stopping breast feeding were broadly similar over time (too demanding, pain, latching, perception of amount of milk, lack of professional support, sibling jealousy). Perseverance appeared to mark out those women who managed to breast feed for longer; this was seen across the socio-economic spectrum. Societal and professional pressure to breast feed was commonly experienced. CONCLUSIONS: satisfaction with actual infant feeding practice is associated with antenatal intention; levels are higher for those meeting their goals, whether formula feeding from birth or breast feeding for longer periods. Perceived pressure to breast feed raises questions about informed decision making. Identifying those who will benefit most from targeted infant feeding support is crucial.

Evaluating the reliability, validity, acceptability, and practicality of SMS text messaging as a tool to collect research data: results from the Feeding Your Baby project.

OBJECTIVE: To test the reliability, validity, acceptability, and practicality of short message service (SMS) messaging for collection of research data. MATERIALS AND METHODS: The studies were carried out in a cohort of recently delivered women in Tayside, Scotland, UK, who were asked about their current infant feeding method and future feeding plans. Reliability was assessed by comparison of their responses to two SMS messages sent 1 day apart. Validity was assessed by comparison of their responses to text questions and the same question administered by phone 1 day later, by comparison with the same data collected from other sources, and by correlation with other related measures. Acceptability was evaluated using quantitative and qualitative questions, and practicality by analysis of a researcher log. RESULTS: Reliability of the factual SMS message gave perfect agreement. Reliabilities for the numerical question were reasonable, with κ between 0.76 (95% CI 0.56 to 0.96) and 0.80 (95% CI 0.59 to 1.00). Validity for data compared with that collected by phone within 24 h (κ =0.92 (95% CI 0.84 to 1.00)) and with health visitor data (κ =0.85 (95% CI 0.73 to 0.97)) was excellent. Correlation validity between the text responses and other related demographic and clinical measures was as expected. Participants found the method a convenient and acceptable way of providing data. For researchers, SMS text messaging provided an easy and functional method of gathering a large volume of data. CONCLUSION: In this sample and for these questions, SMS was a reliable and valid method for capturing research data.

Care and environment in midwife-led and obstetric-led units: a comparison of mothers' and birth partners' perceptions.

BACKGROUND: Health-care design recognises the importance of people-environment interactions, and maternity units have responded by encouraging 'homely' environments. Birthing women and birth partners have been separately surveyed about their experiences of the maternity environment and midwifery care, but not to date as dyads. METHOD(S): Postal return survey of mothers and birth partners from nine maternity units (six midwife-led; three obstetric-led) in England, at eight days postnatally in 2004-5. Questions concerned participants' general and specific impressions of the unit environment and of the care given. A repeated measures analysis of variance was used to explore interactions between mothers and partners and different types of unit. The Wilcoxon signed rank test was used for skewed satisfaction scores. Loglinear models were used to analyse mothers' and partners' cited comments, factoring in types of unit. FINDINGS: 515 Dyads responded (response rate 50%). Mothers and partners were generally positive, but *mothers were more so. They rated the birth surroundings (Z = -8.083; p < 0.001) and the midwifery care (Z = -7.177; p < 0.001) more highly than their partners; these findings were significant in both types of unit. Loglinear analysis found that mothers especially were more likely to find midwife-led units 'homely' (Z = 2.496; p = 0.013), 'calming' (Z = 9.61; p < 0.001): and 'clean' (Z = 4.08, p < 0.001). Obstetric-led units were more likely to be thought 'stuffy' (Z = -3.51, p < 0.001). Partners were more likely to agree that there was a lack of privacy (Z = 3.401; p = 0.001), and that there was a lack of facilities for them, particularly within obstetric-led units. CONCLUSIONS: Although generally positive, birth partners were significantly less positive than the birthing mothers about a range of environmental and care variables. The primary focus is and should be the birthing woman, but the partner nevertheless has an interactive role to play, and improving his experience may assist this function.

Self-rated "no-" and "low-" risk pregnancy: a comparison of outcomes for women in obstetric-led and midwife-led units in England.

BACKGROUND: Debate in the United Kingdom about place of birth often concerns obstetric-led units and midwife-led units and relates to notions of risk and safety. Outcomes for these two types of unit are often not comparable because of the restricted selection criteria for midwife-led units. The purpose of this study was to compare outcomes for women intending to give birth in these different types of unit and whose self-rated pregnancy risk level was "none" or "low." METHODS: Self-completion questionnaires were distributed to mothers 8 days after the birth in 9 units (6 midwife led 3 obstetric led) over a 6-month period. RESULTS: Completed questionnaires were received from 432 women (midwife led = 294, obstetric led = 138). Mothers in midwife-led units spent shorter times in labor in the unit (p < 0.01), received less analgesia (p < 0.01) and had fewer interventions (p < 0.01), and were more likely to have a normal delivery (p < 0.01) than women in obstetric-led units. Similar differences were found for both primiparous and multiparous women. In terms of the number of midwives attending each woman, analysis of covariance suggested different models of care depending on type of unit (p < 0.05) and parity (p < 0.01). CONCLUSIONS: Since these mothers' self-rated risk level was none or low, some comparability of outcomes is permissible. It appears that models of care are significantly different in obstetric-led units compared with midwife-led units, leading to greater likelihood of intrapartum intervention, need for analgesia, and assisted or operative delivery. A randomized controlled trial examining such units would permit a conclusive examination of these outcomes.