Development and early validation of questionnaires to assess system level factors affecting male partners' attendance at childbirth in LMICs.

BACKGROUND: There is evidence that a woman who receives continuous labour support from a chosen companion can have shorter labour duration, is more likely to give birth without medical interventions, and report a satisfying childbirth experience. These outcomes result from the beneficial effects of emotional and practical support from the woman's chosen companion, and care provided by health providers. When a woman's chosen companion is her male partner, in addition to the above benefits, his presence can promote his bonding with the baby, and shared parenthood. However, there may be healthcare system barriers, including organisational, management and individual (staff) factors, that inhibit or restrict women's choice of companion. There are currently no suitable survey tools that can be used to assess the system level factors affecting the implementation of male partners' attendance at childbirth in low- and middle- income countries (LMICs). METHODS: We designed two questionnaires to help to address that gap: the Male Partners' Attendance at Childbirth-Questionnaire for Heads of Maternity Units (MPAC-QHMUs); and the Male Partners' Attendance at Childbirth-Questionnaire for Maternity Staff (MPAC-QMS). We carried out an extensive review to generate initial items of the two questionnaires. We assessed the content and face validity of the two questionnaires in a three-round modified Delphi study. RESULTS: The Male Partners' Attendance at Childbirth-Questionnaire for Heads of Maternity Units (MPAC-QHMUs) focused on organisational and management factors. The Male Partners' Attendance at Childbirth-Questionnaire of Maternity Staff (MPAC-QMS) focused on individual staff factors. The final MPAC-QHMUs and MPAC-QMS included items which garnered over 80% content relevance according to the experts' rating. After all three consensus rounds of the Delphi study, 43 items were retained for the MPAC-QHMUs and 61 items were retained for the MPAC-QMS. CONCLUSIONS: The MPAC-QHMUs and the MPAC-QMS may help understanding of barriers affecting male partners' attendance at childbirth in LMICs in order to devise implementation strategies to enable wider availability and to maximize women's choices during labour and childbirth. The MPAC-QHMUs and the MPAC-QMS as newly-developed questionnaires require further validation of their acceptability and feasibility in different cultural contexts, and languages.

Barriers to and Facilitators of Using eHealth to Support Gestational Diabetes Mellitus Self-management: Systematic Literature Review of Perceptions of Health Care Professionals and Women With Gestational Diabetes Mellitus.

BACKGROUND: Gestational diabetes mellitus (GDM) is one of the most common medical complications during pregnancy. eHealth technologies are proving to be successful in supporting the self-management of medical conditions. Digital technologies have the potential to improve GDM self-management. OBJECTIVE: The primary objective of this systematic literature review was to identify the views of health professionals (HPs) and women with GDM regarding the use of eHealth for GDM self-management. The secondary objective was to investigate the usability and user satisfaction levels when using these technologies. METHODS: Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) approach, the search included primary papers in English on the evaluation of technology to support self-management of GDM from January 2008 to September 2021 using MEDLINE, CINAHL, Embase, ACM, and IEEE databases. The lists of references from previous systematic literature reviews, which were related to technology and GDM, were also examined for primary studies. Papers with qualitative, quantitative, and mixed methodologies were included and evaluated. The selected papers were assessed for quality using the Cochrane Collaboration tool, National Institute for Health and Care Excellence clinical guidelines, Critical Appraisal Skills Programme Qualitative Checklist, and McGill University Mixed Methods Appraisal Tool. NVivo (QSR International) was used to extract qualitative data, which were subjected to thematic analysis. Narrative synthesis was used to analyze the quantitative data. RESULTS: A total of 26 papers were included in the review. Of these, 19% (5/26) of studies used quantitative research methodologies, 19% (5/26) used qualitative methods, and 62% (16/26) used mixed methods. In all, 4 themes were identified from the qualitative data: the benefits of using technology, engagement with people via technology, the usability of technology, and discouragement factors for the use of technology. The thematic analysis revealed a vast scope of challenges and facilitators in the use of GDM self-management systems. The challenges included usability aspects of the system, technical problems, data privacy, lack of emotional support, the accuracy of reported data, and adoption of the system by HPs. Convenience, improved GDM self-management, peer support, increased motivation, increased independence, and consistent monitoring were facilitators to use these technologies. Quantitative data showed that there is potential for improving the usability of the GDM self-management systems. It also showed that convenience, usefulness, increasing motivation for GDM self-management, helping with GDM self-management, and being monitored by HPs were facilitators to use the GDM self-management systems. CONCLUSIONS: This novel systematic literature review shows that HPs and women with GDM encountered some challenges in using GDM self-management systems. The usability of GDM systems was the primary challenge derived from qualitative and quantitative results, with convenience, consistent monitoring, and optimization of GDM self-management emerging as important facilitators.

Perceptions and attitudes of parents and healthcare professionals about the option of using infant massage in neonatal intensive care units.

BACKGROUND: Infant moderate pressure massage is an effective evidence-based intervention that counters the consequences of prematurity and exposure to the Neonatal Intensive Care Unit (NICU) environment. This touch-based therapy reduces physiological stress and improves physical, cognitive and neurological development in stable preterm and low birth weight (LBW) infants. Currently, little is known about the barriers and facilitators that surround its implementation. AIMS: This study explored the cultural, organisational and contextual factors perceived by parents and healthcare professionals (HCPs) about the option of implementing infant massage in the Lebanese context. METHODS: A qualitative exploratory approach informed by normalisation process theory (NPT) was used; 22 parents and 38 HCPs were recruited from three university hospitals over 7-month period. COREQ guidelines were used to inform reporting and as a quality appraisal checklist. Framework approach was used for data analysis of the focus groups (seven with parents, six with HCPs) and non-participant observation. The four constructs of NPT guided data collection and analysis, interpretation of the findings and understanding of the implementation issues. FINDINGS: Four themes emerged: understanding infant massage; perception of massage benefits and risks; perceived barriers for engaging in the practice of massage, and strategies to facilitate future implementation. Participants were accepting of the massage concept. However, HCPs were concerned that workload and lack of time would make implementation difficult and interfere with daily care. Both groups highlighted parental fear and anxiety, entry to NICU, and space availability as main contextual and organisational implementation barriers. Communication, gradual implementation, encouragement and support were potential facilitators perceived by parents while adequate preparation, commitment, and establishing protocol and guidelines were the identified facilitators for HCPs. CONCLUSION: Study findings provide important insights into the barriers and facilitators for the implementation of massage to assist in future evidence-based interventions within and beyond the Lebanese NICU context.

Routinely collected infant feeding data: Time for global action.

The importance of breastfeeding is clear. However, global action to support breastfeeding is hindered by the lack of reliable standard data, which continues to impede progress. Routinely collected data can monitor the effectiveness of health policy, evaluate interventions, and enhance international research collaboration and comparisons. Use of routine data to support effective public health initiatives such as smoking cessation has been demonstrated. However, the data collected about infant feeding practices worldwide is inconsistent in timing, methods, definitions, detail, storage, and consistency. Improvements to the reach and quality of routinely collected data about infant feeding are needed to strengthen the global evidence and policy base. An international collaborative effort is called for to progress this.

Breastfeeding education and support for women with twins or higher order multiples.

BACKGROUND: There are rising rates of multiple births worldwide with associated higher rates of complications and more hospital care, often due to prematurity. While there is strong evidence about the risks of not breastfeeding, rates of breastfeeding in women who have given birth to more than one infant are lower than with singleton births. Breastfeeding more than one infant can be more challenging because of difficulties associated with the birth or prematurity. The extra demands on the mother of frequent suckling, coordinating the needs of more than one infant or admission to the neonatal intensive care unit can lead to delayed initiation or early cessation. Additional options such as breast milk expression, the use of donor milk or different methods of supplementary feeding may be considered. Support and education about breastfeeding has been found to improve the duration of any breastfeeding for healthy term infants and their mothers, however evidence is lacking about interventions that are effective to support women with twins or higher order multiples. OBJECTIVES: To assess effectiveness of breastfeeding education and support for women with twins or higher order multiples. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 June 2016), ClinicalTrials.gov (30 June 2016), the WHO International Clinical Trials Registry Platform (ICTRP) (1 July 2016), the excluded studies list from the equivalent Cochrane review of singletons, and reference lists of retrieved studies. SELECTION CRITERIA: Randomised or quasi-randomised trials comparing extra education or support for women with twins or higher order multiples were included. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We planned to assess the quality of evidence using the GRADE approach, but were unable to analyse any data. MAIN RESULTS: We found 10 trials (23 reports) of education and support for breastfeeding that included women with twins or higher order multiples. The quality of evidence was mixed, and the risk of bias was mostly high or unclear. It is difficult to blind women or staff to group allocation for this intervention, so in all studies there was high risk of performance and high or unclear risk of detection bias. Trials recruited 5787 women (this included 512 women interviewed as part of a cluster randomised trial); of these, data were available from two studies for 42 women with twins or higher order multiples. None of the interventions were specifically designed for women with more than one infant, and the outcomes for multiples were not reported separately for each infant. Due to the scarcity of evidence and the format in which data were reported, a narrative description of the data is presented, no analyses are presented in this review, and we were unable to GRADE the evidence.The two trials with data for women with multiple births compared home nurse visits versus usual care (15 women), and telephone peer counselling versus usual care (27 women). The number of women who initiated breastfeeding was reported (all 15 women in one study, 25 out of 27 women in one study). Stopping any breastfeeding before four to six weeks postpartum, stopping exclusive breastfeeding before four to six weeks postpartum, stopping any breastfeeding before six months postpartum andstopping exclusive breastfeeding before six months postpartum were not explicitly reported, and there were insufficient data to draw any meaningful conclusions from survival data. Stopping breast milk expression before four to six weeks postpartum, andstopping breast milk expression before six months postpartum were not reported. Measures ofmaternal satisfaction were reported in one study of 15 women, but there were insufficient data to draw any conclusions; no other secondary outcomes were reported for women with multiple births in either study. No adverse events were reported. AUTHORS' CONCLUSIONS: We found no evidence from randomised controlled trials about the effectiveness of breastfeeding education and support for women with twins or higher order multiples, or the most effective way to provide education and support . There was no evidence about the best way to deliver the intervention, the timing of care, or the best person to deliver the care. There is a need for well-designed, adequately powered studies of interventions designed for women with twins or higher order multiples to find out what types of education and support are effective in helping these mothers to breastfeed their babies.

Antenatal care trial interventions: a systematic scoping review and taxonomy development of care models.

BACKGROUND: Antenatal care models vary widely around the world, reflecting local contexts, drivers and resources. Randomised controlled trials (RCTs) have tested the impact of multi-component antenatal care interventions on service delivery and outcomes in many countries since the 1980s. Some have applied entirely new schemes, while others have modified existing care delivery approaches. Systematic reviews (SRs) indicate that some specific antenatal interventions are more effective than others; however the causal mechanisms leading to better outcomes are poorly understood, limiting implementation and future research. As a first step in identifying what might be making the difference we conducted a scoping review of interventions tested in RCTs in order to establish a taxonomy of antenatal care models. METHODS: A protocol-driven systematic search was undertaken of databases for RCTs and SRs reporting antenatal care interventions. Results were unrestricted by time or locality, but limited to English language. Key characteristics of both experimental and control interventions in the included trials were mapped using SPIO (Study design; Population; Intervention; Outcomes) criteria and the intervention and principal outcome measures were described. Commonalities and differences between the components that were being tested in each study were identified by consensus, resulting in a comprehensive description of emergent models for antenatal care interventions. RESULTS: Of 13,050 articles retrieved, we identified 153 eligible articles including 130 RCTs in 34 countries. The interventions tested in these trials varied from the number of visits to the location of care provision, and from the content of care to the professional/lay group providing that care. In most studies neither intervention nor control arm was well described. Our analysis of the identified trials of antenatal care interventions produced the following taxonomy: Universal provision model (for all women irrespective of health state or complications); Restricted 'lower-risk'-based provision model (midwifery-led or reduced/flexible visit approach for healthy women); Augmented provision model (antenatal care as in Universal provision above but augmented by clinical, educational or behavioural intervention); Targeted 'higher-risk'-based provision model (for woman with defined clinical or socio-demographic risk factors). The first category was most commonly tested in low-income countries (i.e. resource-poor settings), particularly in Asia. The other categories were tested around the world. The trials included a range of care providers, including midwives, nurses, doctors, and lay workers. CONCLUSIONS: Interventions can be defined and described in many ways. The intended antenatal care population group proved the simplest and most clinically relevant way of distinguishing trials which might otherwise be categorised together. Since our review excluded non-trial interventions, the taxonomy does not represent antenatal care provision worldwide. It offers a stable and reproducible approach to describing the purpose and content of models of antenatal care which have been tested in a trial. It highlights a lack of reported detail of trial interventions and usual care processes. It provides a baseline for future work to examine and test the salient characteristics of the most effective models, and could also help decision-makers and service planners in planning implementation.

Midwifery-led antenatal care models: mapping a systematic review to an evidence-based quality framework to identify key components and characteristics of care.

BACKGROUND: Implementing effective antenatal care models is a key global policy goal. However, the mechanisms of action of these multi-faceted models that would allow widespread implementation are seldom examined and poorly understood. In existing care model analyses there is little distinction between what is done, how it is done, and who does it. A new evidence-informed quality maternal and newborn care (QMNC) framework identifies key characteristics of quality care. This offers the opportunity to identify systematically the characteristics of care delivery that may be generalizable across contexts, thereby enhancing implementation. Our objective was to map the characteristics of antenatal care models tested in Randomised Controlled Trials (RCTs) to a new evidence-based framework for quality maternal and newborn care; thus facilitating the identification of characteristics of effective care. METHODS: A systematic review of RCTs of midwifery-led antenatal care models. Mapping and evaluation of these models' characteristics to the QMNC framework using data extraction and scoring forms derived from the five framework components. Paired team members independently extracted data and conducted quality assessment using the QMNC framework and standard RCT criteria. RESULTS: From 13,050 citations initially retrieved we identified 17 RCTs of midwifery-led antenatal care models from Australia (7), the UK (4), China (2), and Sweden, Ireland, Mexico and Canada (1 each). QMNC framework scores ranged from 9 to 25 (possible range 0-32), with most models reporting fewer than half the characteristics associated with quality maternity care. Description of care model characteristics was lacking in many studies, but was better reported for the intervention arms. Organisation of care was the best-described component. Underlying values and philosophy of care were poorly reported. CONCLUSIONS: The QMNC framework facilitates assessment of the characteristics of antenatal care models. It is vital to understand all the characteristics of multi-faceted interventions such as care models; not only what is done but why it is done, by whom, and how this differed from the standard care package. By applying the QMNC framework we have established a foundation for future reports of intervention studies so that the characteristics of individual models can be evaluated, and the impact of any differences appraised.

Encouraging breastfeeding: financial incentives.

The NOSH (Nourishing Start for Health) three-phase research study is testing whether offering financial incentives for breastfeeding improves six-eight-week breastfeeding rates in low-rate areas. This article describes phase one development work, which aimed to explore views about practical aspects of the design of the scheme. Interviews and focus groups were held with women (n = 38) and healthcare providers (n = 53). Overall both preferred shopping vouchers over cash payments, with a total amount of £200-250 being considered a reasonable amount. There was concern that seeking proof of breastfeeding might impact negatively on women and the relationship with their healthcare providers. The most acceptable method to all was that women sign a statement that their baby was receiving breast milk: this was co-signed by a healthcare professional to confirm that they had discussed breastfeeding. These findings have informed the design of the financial incentive scheme being tested in the feasibility phase of the NOSH study.

Healthcare providers' views on the acceptability of financial incentives for breastfeeding: a qualitative study.

BACKGROUND: Despite a gradual increase in breastfeeding rates, overall in the UK there are wide variations, with a trend towards breastfeeding rates at 6-8 weeks remaining below 40% in less affluent areas. While financial incentives have been used with varying success to encourage positive health related behaviour change, there is little research on their use in encouraging breastfeeding. In this paper, we report on healthcare providers' views around whether using financial incentives in areas with low breastfeeding rates would be acceptable in principle. This research was part of a larger project looking at the development and feasibility testing of a financial incentive scheme for breastfeeding in preparation for a cluster randomised controlled trial. METHODS: Fifty-three healthcare providers were interviewed about their views on financial incentives for breastfeeding. Participants were purposively sampled to include a wide range of experience and roles associated with supporting mothers with infant feeding. Semi-structured individual and group interviews were conducted. Data were analysed thematically drawing on the principles of Framework Analysis. RESULTS: The key theme emerging from healthcare providers' views on the acceptability of financial incentives for breastfeeding was their possible impact on 'facilitating or impeding relationships'. Within this theme several additional aspects were discussed: the mother's relationship with her healthcare provider and services, with her baby and her family, and with the wider community. In addition, a key priority for healthcare providers was that an incentive scheme should not impact negatively on their professional integrity and responsibility towards women. CONCLUSION: Healthcare providers believe that financial incentives could have both positive and negative impacts on a mother's relationship with her family, baby and healthcare provider. When designing a financial incentive scheme we must take care to minimise the potential negative impacts that have been highlighted, while at the same time recognising the potential positive impacts for women in areas where breastfeeding rates are low.

Use of a birth plan within woman-held maternity records: a qualitative study with women and staff in northeast Scotland.

BACKGROUND: Birth plans are written preferences for labor and birth which women prepare in advance. Most studies have examined them as a novel intervention or "outside" formal care provision. This study considered use of a standard birth plan section within a national, woman-held maternity record. METHODS: Exploratory qualitative interviews were conducted with women (42) and maternity service staff (24) in northeast Scotland. Data were analyzed thematically. RESULTS: Staff and women were generally positive about the provision of the birth plan section within the record. Perceived benefits included the opportunity to highlight preferences, enhance communication, stimulate discussions, and address anxieties. However, not all women experienced these benefits or understood the birth plan's purpose. Some were unaware of the opportunity to complete it or could not access the support they needed from staff to discuss or be confident about their options. Some were reluctant to plan too much. Staff recognized the need to support women with birth plan completion but noted practical challenges to this. CONCLUSIONS: A supportive antenatal opportunity to allow discussion of options may be needed to realize the potential benefits of routine inclusion of birth plans in maternity notes.

Isolation and Marginalization: Exploring Attrition of Men in Preregistration Nursing Programs.

BACKGROUND: In Scotland, similar to other countries, male nursing students have a high attrition rate. This study examined the reasons for and ways to decrease the attrition rate. METHOD: This four-phase collaborative study included four Scottish universities. Phase 1 involved three telephone interviews with men who had left a nursing program. Phases 2 through 4 used focus groups and interviews with 18 nursing students (13 men and 5 women) and 12 nurse lecturers. Thematic analysis followed a four-stage process. RESULTS: Male nursing students in this study felt isolated and marginalized, were stereotyped regarding their masculinity and physical attributes, had difficulty communicating, and were reluctant to seek help. Financial pressures and access to learning opportunities also disproportionately affected male students. Resilience and maturity are required to cope with these challenges. CONCLUSION: Proactive measures and visible role models in academic and clinical environments are needed to support male students in completing their nursing education. [J Nurs Educ. 2022;61(4):179-186.].

Understanding factors affecting breastfeeding practices in one city in the Kingdom of Saudi Arabia: an interpretative phenomenological study.

BACKGROUND: Breastfeeding duration has declined in the Kingdom of Saudi Arabia (KSA) in recent decades, although accurate national data about different breastfeeding indicators by infant age are lacking. This qualitative study, the first in KSA, aimed to understand the factors affecting mothers' decisions and experiences regarding any breastfeeding practices. METHODS: A qualitative phenomenological approach was used to investigate mothers' experiences of breastfeeding. Non-probability convenience sampling and snowballing strategies were designed to recruit participants. Semi-structured interviews were conducted with 16 mothers, from two hospitals and three primary health clinics in Al-Madinah city, from December 2017 to March 2018. Interpretative phenomenological analysis was the analysis framework. RESULTS: Three themes were identified: 1) 'Up against the system': policies, staff and systems were the main barriers to exclusive breastfeeding; 2) 'Social support and negativity': family support in the first 40 postpartum days protected breastfeeding continuation and was highly appreciated, but negative comments limited breastfeeding practices thereafter; and 3) 'Managing tensions': mothers' religious beliefs about breastfeeding boosted their decisions; however, the challenge of managing tensions influenced mothers to stop breastfeeding earlier than they wished. The study revealed that mothers had no doubts about wanting to breastfeed their babies; but continuation was adversely affected by unhelpful hospital policies and staff actions, the lack of ongoing social support, and by others people's negativity, rather than by the mothers' own views. Stopping breastfeeding earlier than planned was a complex decision for most mothers. However, mothers said that they intended to breastfeed their next baby successfully. CONCLUSIONS: Healthcare professionals (maternity staff, paediatricians and pharmacists) need education and training to support exclusive breastfeeding effectively. Increasing the number of hospitals with Baby Friendly Hospital Initiative accreditation, which includes staff practice changes, is needed to protect and support exclusive breastfeeding. Ongoing professional and peer support, and improving conditions at workplaces and universities, are needed to help mothers to continue breastfeeding successfully. Effective, coordinated national policies can support mothers' decisions in relation to breastfeeding. Such changes will reduce the tensions experienced by women and help them to achieve their breastfeeding goals and to breastfeed for longer.

Barriers and facilitators to recruiting and retaining men on pre-registration nursing programmes in Western countries: A systemised rapid review.

BACKGROUND: The recruitment of men to pre-registration nursing programmes in many Western countries has remained static at approximately 10% per year. AIM: To identify the experiences and attitudes of men on pre-registration nursing programmes in Western countries and the barriers and enablers to their recruitment and retention. DESIGN: Systematized rapid review. METHODS: Searches were undertaken in Medline (Ovid), CINAHL (EBSCO) and PsychINFO (EBSCO) databases. Studies in English were included if they were from Western countries, were published since 2000 and related to men's experiences of, or attitudes to, applying for or studying pre-registration nursing. Included papers were quality appraised and findings were thematically analysed and presented in a narrative synthesis. RESULTS: Records were de-duplicated and 2063 records were screened and 44 articles assessed for eligibility of which 23 articles relating to 22 empirical studies were included in the review. Findings were categorised into the following themes: recruitment experiences/reasons for studying nursing; gender experiences; barriers, difficulties and challenges with programme; and factors affecting retention. CONCLUSION: Evidence suggests that many men who come into nursing have a family member or acquaintance who is a nurse or that they have had contact with a male nurse as a patient or carer. Motivating factors such as financial security, career mobility and the opportunity to have a job in a caring profession were reported. Improved career advice at school is needed and shortened graduate programmes could be attractive. On programme, some clinical areas were easier for male students, while in others, treatment refusal could cause difficulties. Being in a minority and gender stereotyping can affect experiences. Ensuring equitable treatment, providing additional support and placements in clinical areas with more men could minimise these challenges.

An exploration of the influences on under-representation of male pre-registration nursing students.

BACKGROUND: Worldwide, men are under-represented in the nursing profession. In Scotland less than 10% of pre-registration nursing students are male. Reasons for this imbalance need to be understood. OBJECTIVES: To explore the views of male pre-registration nursing students, nursing lecturers and school teachers about this imbalance. DESIGN: Mixed methods study using focus groups and online survey. SETTINGS: Focus groups in four locations across Scotland. Online survey sent to teachers across Scotland. PARTICIPANTS AND METHODS: Eight focus groups with 33 male nursing students; four focus groups with 21 university and college nursing lecturers; 46 school teachers returned the online survey. RESULTS: Although nursing was considered a worthwhile career with job stability and many opportunities, it was also viewed as not being a career for men. Assumptions about the profession and femininity were challenging for men and use of the term 'male nurse' was felt to be anomalous. In some circumstances the provision of intimate care to particular patient groups caused difficulty. Positive encouragement from others, a positive role model or knowledge of nursing from significant others could be helpful. However concerns about low earning potential and negative media publicity about the NHS could be a disincentive. Being mature and having resilience were important to cope with being a male nursing student in a mainly female workplace. Some more 'technical' specialties were felt to be more attractive to men. CONCLUSIONS: Nursing is viewed as a worthwhile career choice for men, but the gendered assumptions about the feminine nature of nursing can be a deterrent.

Mental health nurses' attitudes towards severe perinatal mental illness.

AIM: This paper reports on a study exploring the experiences and attitudes of generic mental health nurses towards care of women with severe mental illness during the perinatal period. BACKGROUND: Severe mental disorder in the perinatal period is a global public health concern. However, there are concerns that mental health nurses other than dedicated perinatal mental health teams may lack knowledge, skills and experience in caring for such disorders, because of their low prevalence. METHODS: Sixteen generic Registered Mental Nurses working in public adult mental health services participated in three focus groups during 2007. FINDINGS: Participants did not perceive any difference between symptoms during perinatal and non-perinatal periods. There were mixed attitudes towards caring for women with severe mental illness in the perinatal period. Fear and anxiety was expressed by the nurses when caring or feeling responsible for the babies of clients. Lack of communication between professional groups and decreased clinical decision-making following the introduction of the Edinburgh Post Natal Depression Scale caused frustration. Confidence was displayed when working with known and trusted colleagues. CONCLUSION: Generic mental health nurses would benefit from more education on perinatal mental health and there may be a need for them to be supported by specialist perinatal mental health practitioners.

A longitudinal follow up of women in their practice of perinatal pelvic floor exercises and stress urinary incontinence in North-East Scotland.

OBJECTIVES: to establish the reported practice of pelvic floor exercises and stress urinary incontinence after delivery. DESIGN: a longitudinal study using a postnatal postal questionnaire. PARTICIPANTS: 257 women in the North-East of Scotland were sent questionnaires between June and December 2000, 6-12 months after delivery (previously recruited and interviewed during the last trimester of pregnancy). One hundred and sixty-three women responded (63.4%). FINDINGS: more women reported the practice of pelvic floor exercises after delivery than during pregnancy: 134 (83.2%) compared with 123 (76.4%). Six to 12 months after delivery, 96 (60%) women said that they were still doing the exercises. A third of respondents (n=54, 33.1%) reported stress incontinence at some time since having the baby. Of those reporting incontinence at the time of questionnaire completion, six (19.3%) said the incontinence was moderate or severe, whereas eight (34.7%) reported incontinence once a week or more. Women who had an operative vaginal delivery (forceps or ventouse delivery) were more likely to report the practice of pelvic floor exercises than those having a spontaneous vaginal delivery. No significant difference was found in reported rates of stress incontinence between women who had different modes of delivery. The practice of pelvic floor exercises daily or more often during pregnancy was associated with less reported postnatal incontinence compared with less frequent practice. KEY CONCLUSIONS: self-reported rates of practice of pelvic floor exercises increased from pregnancy to the immediate postnatal period and subsequently declined. A third of women reported the symptoms of stress incontinence after delivery. Daily or more frequent practice of the exercises during pregnancy may be required in order to prevent postnatal incontinence (although further research is required to confirm this finding). IMPLICATIONS FOR PRACTICE: midwives should continue to encourage regular and frequent practice of pelvic floor exercises in the postnatal period and beyond. They also need to ask about symptoms of stress incontinence and refer as necessary.

A cross-sectional study of knowledge and practice of pelvic floor exercises during pregnancy and associated symptoms of stress urinary incontinence in North-East Scotland.

OBJECTIVES: to establish levels of knowledge about pelvic floor exercises during pregnancy; reported practice of pelvic floor exercises in pregnancy; and prevalence of stress urinary incontinence in a sample of women in the third trimester of pregnancy. DESIGN: structured cross-sectional interview survey. PARTICIPANTS: pregnant women over the age of 16 years and more than 30 weeks gestation attending antenatal clinics in North-East Scotland. Of 350 women who agreed to participate, 289 (82.6%) were interviewed between July 1999 and March 2000. FINDINGS: 225 women (77.9%) reported being given or obtaining information about pelvic floor exercises in the current pregnancy. Books were the most frequently mentioned source of information. Midwives were the health professionals most likely to give information about pelvic floor exercises. Younger women, first-time mothers and those from more deprived backgrounds were less likely to report having information about the exercises. A third of women (n=90, 31.1%) said that they would have liked more information about the exercises. Practice of the exercises during pregnancy was reported by just over half the sample (n=156, 54.0%) and more than once a day by 26.3% (n=76). Younger women, and those from more deprived backgrounds, were less likely to report the practice of exercises. No difference was found in reported practice according to parity. More than half (n=157, 54.3%) of the women reported incontinence during the current pregnancy. No relationship was found between reported practice of pelvic floor exercises and stress urinary incontinence. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: the number of women who indicated a desire for more information and the low number who reported practice of the exercises suggest that improvements could be made. The gaps in information provision and practice suggest areas for future health promotion about the exercises, particularly by midwives, as not all women are seen by a physiotherapist during pregnancy. Reported levels of incontinence during pregnancy confirm previous findings and highlight the prevalence of incontinence in pregnancy.

Cluster randomised controlled trial of a financial incentive for mothers to improve breast feeding in areas with low breastfeeding rates: the NOSH study protocol.

INTRODUCTION: Breast feeding can promote positive long-term and short-term health outcomes in infant and mother. The UK has one of the lowest breastfeeding rates (duration and exclusivity) in the world, resulting in preventable morbidities and associated healthcare costs. Breastfeeding rates are also socially patterned, thereby potentially contributing to health inequalities. Financial incentives have been shown to have a positive effect on health behaviours in previously published studies. METHODS AND ANALYSIS: Based on data from earlier development and feasibility stages, a cluster (electoral ward) randomised trial with mixed-method process and content evaluation was designed. The 'Nourishing Start for Health' (NOSH) intervention comprises a financial incentive programme of up to 6 months duration, delivered by front-line healthcare professionals, in addition to existing breastfeeding support. The intervention aims to increase the prevalence and duration of breast feeding in wards with low breastfeeding rates. The comparator is usual care (no offer of NOSH intervention). Routine data on breastfeeding rates at 6-8 weeks will be collected for 92 clusters (electoral wards) on an estimated 10,833 births. This sample is calculated to provide 80% power in determining a 4% point difference in breastfeeding rates between groups. Content and process evaluation will include interviews with mothers, healthcare providers, funders and commissioners of infant feeding services. The economic analyses, using a healthcare provider's perspective, will be twofold, including a within-trial cost-effectiveness analysis and beyond-trial modelling of longer term expectations for cost-effectiveness. Results of economic analyses will be expressed as cost per percentage point change in cluster level in breastfeeding rates between trial arms. In addition, we will present difference in resource use impacts for a range of acute conditions in babies aged 0-6 months. ETHICS AND DISSEMINATION: Participating organisations Research and Governance departments approved the study. Results will be published in peer-reviewed journals and at conference presentations. TRIAL REGISTRATION NUMBER: ISRCTN44898617; Pre-results.

'The midwives aren't allowed to tell you': perceived infant feeding policy restrictions in a formula feeding culture - the Feeding Your Baby Study.

OBJECTIVE: to explore the expectations and experiences of postnatal mothers in relation to infant feeding, and to identify how care could be improved. DESIGN: this study used a qualitative, exploratory, descriptive design. Data were collected through one to one in-depth semi-structured interviews and focus groups. SETTING: Tayside area of Eastern Scotland. PARTICIPANTS: seven focus group interviews (n=38 participants) and 40 semi-structured one-to-one interviews with mothers with a range of infant feeding experiences i.e. exclusively breast fed; started breast feeding but changed to formula milk before 16 weeks; exclusively formula fed; or who concurrently breast and formula fed their infant. FINDINGS: a principal theme of 'Mixed and missing messages' emerged, incorporating 'Conflicting advice', 'Information gaps' and 'Pressure to breast feed' with a secondary theme of 'Emotional costs'. Several problems were identified with how women were given information, how infant feeding discussions were held, and the type of support available after the infant is born. KEY CONCLUSIONS: there was a strong perception that some midwives are not 'allowed' to discuss or provide information on formula feeding, and the women reported feeling pressurised to breast feed. Current interpretation of guidance from the UNICEF UK Baby Friendly Initiative may be restricting antenatal discussions about infant feeding. The combination of this partial preparation antenatally and postnatal support that was often inconsistent seems to incur a counter-productive emotional cost. IMPLICATIONS FOR PRACTICE: at strategic, policy and practice levels the infant feeding message needs to change to encourage a more woman-centred focus including discussions about the realities of all types of infant feeding. It is important that health providers continue to promote and support breast feeding; and that effective services are provided to women who wish to breast feed to help them to do so. However provision of information about all aspects of feeding is needed as well as support for women who do not wish to breast feed.