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.

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.

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.

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.

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.

Who is actually asked about their mental health in pregnancy and the postnatal period? Findings from a national survey.

BACKGROUND: Pregnancy and the postnatal period is a period of potential vulnerability for women and families. It is UK policy that all women are asked about their mental health and wellbeing early in pregnancy and following the birth to help detect potential problems and prevent serious adverse outcome. However, identification of mental health problems in pregnancy may be less than 50 %. The aim of the study was to find out which women are asked about their mood and mental health during pregnancy and postnatally, and about offer and uptake of treatment. METHODS: Secondary analysis of a national maternity survey carried out in 2014 which asked about sociodemographic factors, care in pregnancy, childbirth, and the postnatal period with specific questions on emotional and mental health. RESULTS: The usable response rate to the survey was 47 % (4571 women). Most women recalled being asked about their mental health in pregnancy (82 %) and in the postnatal period (90 %). However, antenatally, Asian and older women were less likely to be asked and to be offered treatment. In the postnatal period, differences were more marked. Non-white women, those living in more deprived areas, and those who had received less education were less likely to be asked about their mental health, to be offered treatment, and to receive support. Women with a trusting relationship with their midwife were more likely to be asked about their mental health. CONCLUSION: The inequities described in this study suggest that the inverse care law is operating in relation to this aspect of maternity care. Those women most likely to be in need of support and treatment are least likely to be offered it and may be at risk of serious adverse outcomes.

Worries About Labor and Birth: A Population-Based Study of Outcomes for Young Primiparous Women.

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

Sixteen per cent of women have depression symptoms in the year after childbirth and are more likely to report physical symptoms, including tiredness and back pain.

Implications for practice and research: The importance of physical and mental health in the postnatal period has been recognised in this study and in other research. Postnatal visiting has declined in the UK and satisfaction with postnatal care is low compared to other aspects of maternity care. Further research should focus on cost-effective strategies to improve this.

On the observation of intervalence charge transfer bands in hydrogen-bonded mixed-valence complexes.

Ruthenium clusters of the type [Ru3(µ3-O)(OAc)6(CO)(L)(nic)], where L = 4-dimethylaminopyridine (dmap) and nic = isonicotinic acid, form hydrogen-bonded mixed-valence dimers upon a single electron reduction. Electrochemical responses show two overlapping reduction waves, indicating the presence of a thermodynamically stable mixed-valence dimer with considerable electronic coupling across the hydrogen bond. Electronic spectra of the singly reduced hydrogen-bonded mixed-valence dimer reveal two intervalence charge transfer bands in the near-infrared region consistent with a Robin-Day class II system. These bands are assigned as metal-to-metal and metal-to-bridge charge transfer, and their behavior is best described by a semiclassical three state model. Infrared spectroscopy suggests localized behavior indicating electron transfer between the two clusters is slower than 10(10) s(-1).

Photoinduced mixed valency in zinc porphyrin dimer of triruthenium cluster dyads.

The preparation, electrochemistry, and spectroscopic characterization of three new species, (ZnTPPpy)Ru3O(OAc)6(CO)-pz-Ru3O(OAc)6(CO)L, where ZnTPPpy = zinc(II) 5-(4-pyridyl)-10,15,20-triphenylporphyin, L = pyridyl ligand, and pz = pyrazine, are reported. These porphyrin-coordinated Ru3O­BL­Ru3O (BL = bridging ligand) dyads are capable of undergoing intramolecular electron transfer from the photoexcited Zn porphyrin to Ru3O donor­bridge­acceptor dimer systems. Seven reversible redox processes are observed in the cyclic voltammograms of the newly synthesized dyads, showing no significant electrochemical interaction between the redox active porphyrin and the pyrazine-bridged ruthenium dimer of Ru3O trimers. From the electrochemical behavior of the dyads, large comproportionation constants (Kc = 6.0 × 10(7) for L = dmap) were calculated from the reduction potentials of the Ru(III)Ru(III)Ru(II) clusters, indicating a stable mixed-valence state. Electronic absorption spectra of the singly reduced mixed-valence species show two intervalence charge transfer (IVCT) bands assigned within the Brunschwig­Creutz­Sutin semiclassical three-state model as metal-to-bridge and metal-to-metal in character. The progression from most to least delocalized mixed-valence dimer ions, as determined by the divergence of the IVCT bands and in agreement with electrochemical data, follows the order of L = 4-dimethylaminopyridine (dmap) > pyridine (py) > 4-cyanopyridine (cpy). These systems show dynamic coalescence of the infrared spectra in the ν(CO) region of the singly reduced state. This sets the time scale of electron exchange at <10 ps. The electron transfer from the S1 excited state of the coordinated porphyrin to the dimer is predicted to be thermodynamically favorable, with ΔGFET(0) ranging from −0.54 eV for L = dmap to −0.62 eV for L = cpy. Observation of IVCT band growth under continual photolysis (λexc = 568 nm) confirms a phototriggered intramolecular electron transfer process resulting in a strongly coupled singly reduced mixed-valence species.

The role of support and other factors in early breastfeeding cessation: an analysis of data from a maternity survey in England.

BACKGROUND: Although the majority of women in England initiate breastfeeding, approximately one third cease breastfeeding by six weeks and many of these women report they would like to have breastfed for longer. METHODS: Data from a survey of women ≥16 years who gave birth to singleton term infants in 2009 in England; questionnaires were completed approximately three months postnatally. Logistic regression was used to investigate the association between postnatal support and other factors, and breastfeeding cessation at 10 days and six weeks. Population attributable fractions (PAFs) were calculated to estimate the relative contribution of breastfeeding support factors to overall breastfeeding cessation at these two time points. RESULTS: Of the 3840 women who initiated breastfeeding and reported timing of breastfeeding cessation, 13% had stopped by 10 days; and of the 3354 women who were breastfeeding at 10 days, 17% had stopped by six weeks. Socio-demographic factors (maternal age, ethnicity, country of birth, deprivation, education) and antenatal feeding intention were all independently associated with breastfeeding cessation at 10 days and six weeks. Women who did not receive feeding advice or support from a parent or peer support group, voluntary organisation, or breastfeeding clinic were more likely to stop breastfeeding by 10 days. Perceived active support and encouragement from midwives was associated with a lower odds of breastfeeding cessation at both 10 days and six weeks. Estimated PAFs suggest that 34-59% of breastfeeding cessations by 10 days could be avoided if more women in the study population received breastfeeding support. CONCLUSION: Although multiple factors influence a mother's likelihood of continuing breastfeeding, it is clear that socio-demographic factors are strongly associated with breastfeeding continuation. However, there is evidence that breastfeeding support, including that delivered by peer or lay support workers, may have an important role in preventing cessations in the first few weeks.

Labouring women who used a birthing pool in obstetric units in Italy: prospective observational study.

BACKGROUND: For women at low risk of childbirth complications, water immersion during labour is a care option in many high income countries. Our aims were (a) to describe maternal characteristics, intrapartum events, interventions, maternal and neonatal outcomes for all women who used a birthing pool during labour who either had a waterbirth or left the pool and had a landbirth, and for the subgroup of women who had a waterbirth in 19 obstetric units, and (b) to compare maternal characteristics, intrapartum events, interventions, and maternal and neonatal outcomes for women who used a birthing pool with a control group of women who did not use a birthing pool for whom we prospectively collected data in a single centre. METHODS: Prospective observational study in 19 Italian obstetric units 2002-2005. Participants were: (a) 2,505 women in labour using a birthing pool in 19 obstetric units; and (b) 114 women in labour using a birthing pool and 459 women who did not use a birthing pool in one obstetric unit. Descriptive statistics were calculated for the sample as a whole and, separately, for those women who gave birth in water. Categorical data were compared using Chi square statistics and continuous data by T-tests. RESULTS: Overall, 95.6% of women using a birthing pool had a spontaneous vertex delivery, 63.9% of which occurred in water. Half of nulliparas and three quarters of multiparas delivered in water. Adverse maternal and neonatal outcomes were rare. There were two cases of umbilical cord snap with waterbirth. Compared with controls, significantly more women who used a birthing pool adopted an upright birth position, had hands off delivery technique, and a physiological third stage. Significantly fewer nulliparas had an episiotomy, and more had a second degree perineal tear, with no evidence of a difference for extensive perineal tears. CONCLUSIONS: Birthing pool use was associated with spontaneous vaginal birth. The increase in second degree tears was balanced by fewer episiotomies. Undue umbilical cord traction should be avoided during waterbirth.

Fathers' engagement in pregnancy and childbirth: evidence from a national survey.

BACKGROUND: Early involvement of fathers with their children has increased in recent times and this is associated with improved cognitive and socio-emotional development of children. Research in the area of father's engagement with pregnancy and childbirth has mainly focused on white middle-class men and has been mostly qualitative in design. Thus, the aim of this study was to understand who was engaged during pregnancy and childbirth, in what way, and how paternal engagement may influence a woman's uptake of services, her perceptions of care, and maternal outcomes. METHODS: This study involved secondary analysis of data on 4616 women collected in a 2010 national maternity survey of England asking about their experiences of maternity care, health and well-being up to three months after childbirth, and their partners' engagement in pregnancy, labour and postnatally. Data were analysed using descriptive statistics, chi-square, binary logistic regression and generalised linear modelling. RESULTS: Over 80% of fathers were 'pleased or 'overjoyed' in response to their partner's pregnancy, over half were present for the pregnancy test, for one or more antenatal checks, and almost all were present for ultrasound examinations and for labour. Three-quarters of fathers took paternity leave and, during the postnatal period, most fathers helped with infant care. Paternal engagement was highest in partners of primiparous white women, those living in less deprived areas, and in those whose pregnancy was planned. Greater paternal engagement was positively associated with first contact with health professionals before 12 weeks gestation, having a dating scan, number of antenatal checks, offer and attendance at antenatal classes, and breastfeeding. Paternity leave was also strongly associated with maternal well-being at three months postpartum. CONCLUSIONS: This study demonstrates the considerable sociodemographic variation in partner support and engagement. It is important that health professionals recognise that women in some sociodemographic groups may be less supported by their partner and more reliant on staff and that this may have implications for how women access care.

Women's experience of induction of labor: a mixed methods study.

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

Experiencing maternity care: the care received and perceptions of women from different ethnic groups.

BACKGROUND: According to the Office for National Statistics, approximately a quarter of women giving birth in England and Wales are from minority ethnic groups. Previous work has indicated that these women have poorer pregnancy outcomes than White women and poorer experience of maternity care, sometimes encountering stereotyping and racism. The aims of this study were to examine service use and perceptions of care in ethnic minority women from different groups compared to White women. METHODS: Secondary analysis of data from a survey of women in 2010 was undertaken. The questionnaire asked about women's experience of care during pregnancy, labour and birth, and the postnatal period, as well as demographic factors. Ethnicity was grouped into eight categories: White, Mixed, Indian, Pakistani, Bangladeshi, Black Caribbean, Black African, and Other ethnicity. RESULTS: A total of 24,319 women completed the survey. Compared to White women, women from minority ethnic groups were more likely to be younger, multiparous and without a partner. They tended to access antenatal care later in pregnancy, have fewer antenatal checks, fewer ultrasound scans and less screening. They were less likely to receive pain relief in labour and, Black African women in particular, were more likely to deliver by emergency caesarean section. Postnatally, women from minority ethnic groups had longer lengths of hospital stay and were more likely to breastfeed but they had fewer home visits from midwives. Throughout their maternity care, women from minority ethnic groups were less likely to feel spoken to so they could understand, to be treated with kindness, to be sufficiently involved in decisions and to have confidence and trust in the staff. CONCLUSION: Women in all minority ethnic groups had a poorer experience of maternity services than White women. That this was still the case following publication of a number of national policy documents and local initiatives is a cause for concern.

Who is well after childbirth? Factors related to positive outcome.

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

Learning the hard way: expectations and experiences of infant feeding support.

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

'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.

Cost-effectiveness of therapeutic hypothermia to treat neonatal encephalopathy.

OBJECTIVE: To estimate the cost-effectiveness (CE) of total body hypothermia plus intensive care versus intensive care alone to treat neonatal encephalopathy. METHODS: Decision analytic modeling was used to synthesize mortality and morbidity data from three randomized controlled trials, the Total Body Hypothermia for Neonatal Encephalopathy Trial (TOBY), National Institute of Child Health and Human Development (NICHD), and CoolCap trials. Cost data inputs were informed by TOBY, the sole source of prospectively collected resource utilization data for encephalopathic infants. CE was expressed in terms of incremental cost per disability-free life year (DFLY) gained. Probabilistic sensitivity analysis was performed to generate CE acceptability curves (CEACs). RESULTS: Cooling led to a cost increase of £3787 (95% confidence interval [CI]: -2516, 12,360) (€5115; 95% CI: -3398-16,694; US$5344; 95% CI: -3598, 26,356; using 2006 Organisation for Economic Co-operation and Development (OECD) purchasing power parities) and a DFLY gain of 0.19 (95%CI: 0.07-0.31) over the first 18 months after birth. The incremental cost per DFLY gained was £19,931 (€26,920; US$28,124). The baseline CEAC showed that if decision-makers are willing to pay £30,000 for an additional DFLY, there is a 69% probability that cooling is cost-effective. The probability of CE exceeded 99% at this threshold when the throughput of infants was increased to reflect the national incidence of neonatal encephalopathy or when the time horizon of the economic evaluation was extended to 18 years after birth. CONCLUSIONS: The probability that cooling is a cost-effective treatment for neonatal encephalopathy is finely balanced over the first 18 months after birth but increases substantially when national incidence data or an extended time horizon are considered.