The UK Midwifery Study System (UKMidSS): a programme of work to establish a research infrastructure to carry out national studies of uncommon conditions and events in midwifery units.

BACKGROUND: Midwifery-led care during labour and birth in the UK is increasingly important given national commitments to choice of place of birth, reduction of unnecessary intervention and improving women's experience of care, and evidence on safety and benefits for 'low risk' women. Further evidence is needed on safety and potential benefits of midwifery-led care for some groups of 'higher risk' women and about uncommon adverse outcomes or 'near-miss' events. Uncommon obstetric events and conditions have been investigated since 2005 using the UK Obstetric Surveillance System. This programme of research will establish the UK Midwifery Study System (UKMidSS) in all UK alongside midwifery units (AMUs) and carry out the first two UKMidSS studies investigating: (i) outcomes in severely obese women admitted to AMUs, and (ii) risk factors for neonatal unit admission following birth in an AMU. METHODS: We will carry out national cohort and case-control studies using UKMidSS, a national data collection platform which we will establish to collect anonymised information from all UK AMUs. Reporting midwives in each AMU will actively report cases or nil returns in response to monthly notification emails. Denominator data on the number of women admitted to and giving birth in each AMU will also be collected. Anonymised data on risk factors, management and outcomes for cases and controls/comparators as appropriate for each study, will be collected electronically using information from medical records. We will calculate incidence and prevalence with 95% confidence intervals (CIs), tabulate descriptive data using frequencies and proportions, and use logistic regression to estimate odds ratios with 95% CIs comparing specific outcomes in case and comparison women and to investigate risk factors for conditions or outcomes. DISCUSSION: As the first national infrastructure facilitating research into uncommon events and conditions in women starting labour in midwifery-led settings, UKMidSS builds on the success of other national research systems. UKMidSS studies will extend the evidence base regarding the quality and safety of midwifery-led intrapartum care and investigate extending the benefits of midwifery-led care to more women. As a national collaboration of midwives contributing to high quality research, UKMidSS will provide an infrastructure to support midwifery research capacity development.

Service configuration, unit characteristics and variation in intervention rates in a national sample of obstetric units in England: an exploratory analysis.

OBJECTIVES: To explore whether service configuration and obstetric unit (OU) characteristics explain variation in OU intervention rates in 'low-risk' women. DESIGN: Ecological study using funnel plots to explore unit-level variations in adjusted intervention rates and simple linear regression, stratified by parity, to investigate possible associations between unit characteristics/configuration and adjusted intervention rates in planned OU births. Characteristics considered: OU size, presence of an alongside midwifery unit (AMU), proportion of births in the National Health Service (NHS) trust planned in midwifery units or at home and midwifery 'under' staffing. SETTING: 36 OUs in England. PARTICIPANTS: 'Low-risk' women with a 'term' pregnancy planning vaginal birth in a stratified, random sample of 36 OUs. MAIN OUTCOME MEASURES: Adjusted rates of intrapartum caesarean section, instrumental delivery and two composite measures capturing birth without intervention ('straightforward' and 'normal' birth). RESULTS: Funnel plots showed unexplained variation in adjusted intervention rates. In NHS trusts where proportionately more non-OU births were planned, adjusted intrapartum caesarean section rates in the planned OU births were significantly higher (nulliparous: R(2)=31.8%, coefficient=0.31, p=0.02; multiparous: R(2)=43.2%, coefficient=0.23, p=0.01), and for multiparous women, rates of 'straightforward' (R(2)=26.3%, coefficient=-0.22, p=0.01) and 'normal' birth (R(2)=17.5%, coefficient=0.24, p=0.01) were lower. The size of the OU (number of births), midwifery 'under' staffing levels (the proportion of shifts where there were more women than midwives) and the presence of an AMU were associated with significant variation in some interventions. CONCLUSIONS: Trusts with greater provision of non-OU intrapartum care may have higher intervention rates in planned 'low-risk' OU births, but at a trust level this is likely to be more than offset by lower intervention rates in planned non-OU births. Further research using high quality data on unit characteristics and outcomes in a larger sample of OUs and trusts is required.

Duration and urgency of transfer in births planned at home and in freestanding midwifery units in England: secondary analysis of the birthplace national prospective cohort study.

BACKGROUND: In England, there is a policy of offering healthy women with straightforward pregnancies a choice of birth setting. Options may include home or a freestanding midwifery unit (FMU). Transfer rates from these settings are around 20%, and higher for nulliparous women. The duration of transfer is of interest because of the potential for delay in access to specialist care and is also of concern to women. We aimed to estimate the duration of transfer in births planned at home and in FMUs and explore the effects of distance and urgency on duration. METHODS: This was a secondary analysis of data collected in a national prospective cohort study including 27,842 'low risk' women with singleton, term, 'booked' pregnancies, planning birth in FMUs or at home in England from April 2008 to April 2010. We described transfer duration using the median and interquartile range, for all transfers and those for reasons defined as potentially urgent or non-urgent, and used cumulative distribution curves to compare transfer duration by urgency. We explored the effect of distance for transfers from FMUs and described outcomes in women giving birth within 60 minutes of transfer. RESULTS: The median overall transfer time, from decision to transfer to first OU assessment, was shorter in transfers from home compared with transfers from FMUs (49 vs 60 minutes; p < 0.001). The median duration of transfers before birth for potentially urgent reasons (home 42 minutes, FMU 50 minutes) was 8-10 minutes shorter compared with transfers for non-urgent reasons. In transfers for potentially urgent reasons, the median overall transfer time from FMUs within 20 km of an OU was 47 minutes, increasing to 55 minutes from FMUs 20-40 km away and 61 minutes in more remote FMUs. In women who gave birth within 60 minutes after transfer, adverse neonatal outcomes occurred in 1-2% of transfers. CONCLUSIONS: Transfers from home or FMU commonly take up to 60 minutes from decision to transfer, to first assessment in an OU, even for transfers for potentially urgent reasons. Most transfers are not urgent and emergencies and adverse outcomes are uncommon, but urgent transfer is more likely for nulliparous women.

Women's experience of transfer from midwifery unit to hospital obstetric unit during labour: a qualitative interview study.

BACKGROUND: Midwifery units offer care to women with straightforward pregnancies, but unforeseen complications can arise during labour or soon after birth, necessitating transfer to a hospital obstetric unit. In England, 21% of women planning birth in freestanding midwifery units are transferred; in alongside units, the transfer rate is 26%. There is little high quality contemporary evidence on women's experience of transfer. METHODS: We carried out a qualitative interview study, using semi-structured interviews, with women who had been transferred from a midwifery unit (freestanding or alongside) in England up to 12 months prior to interview. Maximum variation sampling was used. Interviews with 30 women took place between March 2009 and March 2010. Thematic analysis using constant comparison and exploration of deviant cases was carried out. RESULTS: Most women hoped for or expected a natural birth and did not expect to be transferred. Transfer was disappointing for many; sensitive and supportive care and preparation for the need for transfer helped women adjust to their changing circumstances. A small number of women, often in the context of prolonged labour, described transfer as a relief. For women transferred from freestanding units, the ambulance journey was a "limbo" period. Women wondered, worried or were fearful about what was to come and could be passive participants who felt like they were being "transported" rather than cared for. For many this was a direct contrast with the care they experienced in the midwifery unit. After transfer, most women appreciated the opportunity to talk about their experience to make sense of what happened and help them plan for future pregnancies, but did not necessarily seek this out if it was not offered. CONCLUSIONS: Transfer affects a significant minority of women planning birth in midwifery units and is therefore a concern for women and midwives. Transfer is not expected by women, but sensitive care and preparation can help women adjust to changing circumstances. Particular sensitivity around decision-making may be required by midwives caring for women during prolonged labour. Some apparently straightforward changes to practice have the potential to make an important difference to women's experience of ambulance transfer.

Local guidelines for the transfer of women from midwifery unit to obstetric unit during labour in England: a systematic appraisal of their quality.

BACKGROUND: A proportion of women planning to give birth in a midwifery unit will experience complications during labour that necessitate transfer to an obstetric unit. Local guidelines for the transfer of women in labour have the potential to impact on quality of care and the safety of the transfer process. OBJECTIVE: To systematically appraise the quality of local NHS guidelines on the transfer of women from midwifery unit to obstetric unit during labour. METHODS: Guidelines were requested from all 52 NHS hospital trusts in England with midwifery units. The Appraisal of Guidelines for Research and Evaluation Instrument was used to evaluate the quality of the guidelines received. RESULTS: Relevant guidelines were received from 34 (65%) trusts. No guidelines scored on the 'editorial independence' domain. The mean score on 'scope and purpose' (56.2%), concerned with the aims, clinical questions and target patient population of the guideline, was higher than for other domains: 'clarity and presentation' (language and format) 45.3%, 'stakeholder involvement' (representation of users' views) 15.3%, 'rigour of development' (process used to develop guideline) 15.0%, 'applicability' (organisational, behavioural and cost implications of applying guideline) 7.1%. Only three guidelines were recommended for use in clinical practice. CONCLUSIONS: We believe this to be the first systematic appraisal of the quality of local NHS guidelines. Overall these local guidelines were of poor quality. It is not clear whether the quality of these midwifery guidelines is typical of local guidelines in other clinical areas, but this study raises fundamental questions about the appropriate development of high-quality local clinical guidelines.

Social class, ethnicity and attendance for antenatal care in the United Kingdom: a systematic review.

BACKGROUND: Evidence from outside the United Kingdom points to several socio-demographic factors associated with late initiation of antenatal care or fewer antenatal visits, but it is not clear how generalizable these studies are to the UK context. This systematic review addresses the question of whether there are social or ethnic inequalities in attendance for antenatal care in the United Kingdom. METHODS: We identified and reviewed UK studies assessing attendance for antenatal care according to any measure of social class, social deprivation or ethnicity. A wide range of electronic databases was searched for published and unpublished studies. Further studies were identified from reference lists, citation searches and key organizations. RESULTS: From over 1300 identified papers, 20 were potentially relevant. Nine were included in the review. Most studies were of poor quality, with only one study controlling for the effect of potential confounders such as age, parity and clinical risk factors. All but one were based on data collected around 20 years ago. Three of the five studies looking at antenatal attendance and social class found that women from manual classes were more likely to book late for antenatal care and/or make fewer antenatal visits than other women. All four studies reporting on antenatal attendance and ethnicity found that women of Asian origin were more likely to book late for antenatal care than white British women. CONCLUSIONS: There is little good quality evidence on social and ethnic inequalities in attendance for antenatal care in the United Kingdom. Recommendations for further research are suggested.

Successful prospective prediction of type 1 diabetes in schoolchildren through multiple defined autoantibodies: an 8-year follow-up of the Washington State Diabetes Prediction Study.

OBJECTIVE: Almost 90% of type 1 diabetes appears in individuals without a close family history. We sought to evaluate the best current predictive strategy, multiple defined autoantibodies, in a long-term prospective study in the general population. RESEARCH DESIGN AND METHODS: Autoantibodies to pancreatic islets (islet cell antibodies [ICAs]) and defined autoantibodies (d-aab) to human GAD, IA2/ICA512, and insulin were tested in 4,505 Washington schoolchildren. Eight years later, 3,000 (67%) subjects were recontacted, including 97% of subjects with any test >99th percentile. RESULTS: Six subjects developed diabetes (median interval 2.8 years), all from among the 12 individuals with multiple d-aab, representing 50% positive predictive value (95% CI 25-75%) and 100% sensitivity (58-100%). Among the others, diabetes occurred in 0 of 6 with one d-aab plus ICA, 0 of 26 with ICA only, 0 of 7 with one d-aab equaling the 99th percentile and another d-aab equaling the 97.5th percentile, 0 of 86 with one d-aab, and 0 of 2,863 with no d-aab or ICA. Adjusted for verification bias, multiple d-aab were 99.9% specific (99.86-99.93%). At this age, new d-aab seldom appeared. Once present, d-aab usually persisted regardless of disease progression, although less so for insulin autoantibodies. Insulin secretion by sequential glucose tolerance testing remained normal in four multiple d-aab subjects not developing diabetes. Of children developing diabetes, five of six (83%) would be included if HLA-DQ genotyping preceded antibody testing, but HLA-DQ did not explain outcomes among high-risk subjects, even when considered along with other genetic markers. CONCLUSIONS: Multiple d-aab were established by age 14 years and prospectively identified all schoolchildren who developed type 1 diabetes within 8 years.

Improving communication between health professionals and women in maternity care: a structured review.

OBJECTIVE: To review trials of the effectiveness of interventions aimed at improving communication between health professionals and women in maternity care. SEARCH STRATEGY: The electronic databases Medline, PsycLit, The Cochrane Library, BIDS Science and Social Science Indexes, Cinahl and Embase were searched. Final searches were carried out in April 2000. INCLUSION CRITERIA: Controlled trials of interventions explicitly aimed at improving communication between health professionals and women in maternity care were included. Other trials were included where two reviewers agreed that this was at least part of the aim. DATA EXTRACTION AND SYNTHESIS: 95 potentially eligible papers were identified, read by one reviewer and checked against the inclusion criteria. The 11 included trials were read, assessed for quality and summarized in a structured tabular form. RESULTS: The included trials evaluated interventions to improve the presentation of information about antenatal testing, to promote informed choice in maternity care, woman-held maternity records and computer-based history taking. Four trials in which women were provided with extra information about antenatal testing in a variety of formats suggested that this was valued by women and may reduce anxiety. Communication skills training for midwives and doctors improved their information giving about antenatal tests. The three trials of woman-held maternity records suggested that these increase women's involvement in and control over their care. CONCLUSIONS: The trials identified by this review addressed limited aspects of communication and focused solely on antenatal care. Further research is required in several areas, including trials of communication skills training for health professionals in maternity care and other interventions to improve communication during labour and in the postnatal period.