A national cross sectional survey of heads of midwifery services of uptake, benefits and barriers to use of obstetric early warning systems (EWS) by midwives.

OBJECTIVE: to identify the extent to which Early Warning Systems (EWS) are used by midwives in the United Kingdom (UK), the maternity settings they are used in, physiological parameters used to 'trigger' referral, training provision, barriers to implementation and role in preventing maternal morbidity. DESIGN: cross-sectional survey of heads of midwifery services. An email questionnaire was sent in September 2012. SETTING: UK NHS secondary care organisations providing maternity care. FINDINGS: heads of midwifery from 107 (68%) of 157 NHS organisations responded, with 108 questionnaires returned as two organisations had recently merged. All organisations, apart from one which only had a free-standing midwifery unit, had introduced EWS. Nearly all respondents (99%) reported EWS were used by midwives antenatally, 76% in labour and 100% on the postnatal ward. All EWS charts included body temperature, heart rate, respiratory rate, systolic blood pressure and oxygen saturation although parameters for escalation varied widely. Barriers to use of EWS by midwives included overlap with the partogram in labour, and staff shortages and delays obtaining clinical review when referral was triggered. Two-thirds considered EWS prevented maternal morbidity although few could provide supporting evidence, for example, audit findings. Training for midwives in use of EWS was available in 83% of organisations. CONCLUSION: most UK midwives are using EWS, with the highest use in obstetric units. The heterogeneity of EWS currently used potentially limits collation of evidence to inform appropriate system level responses. Research is needed to evaluate the role of EWS to prevent maternal morbidity during and after pregnancy in different maternity settings.

Caseload midwifery in a multi-ethnic community: the women's experiences.

OBJECTIVE: to evaluate caseload midwifery in a relatively deprived and ethnically diverse inner-city area. DESIGN AND SETTING: semi-structured interviews were undertaken with 24 women from diverse ethnic backgrounds, 12 of whom had received caseload care and 12 women from an adjacent area who had received conventional maternity care in a large inner-city maternity unit. Framework analysis was adopted drawing on links with the authors' previous work on women's views of caseload midwifery. FINDINGS: key themes from previous work fitted well with the themes that emerged from this study. Themes included 'knowing and being known', 'person-centred care', 'social support', 'gaining trust and confidence', 'quality and sensitivity of care' and 'communication'. KEY CONCLUSIONS AND IMPLICATIONS: women from this socially and ethnically diverse group of women had similar views and wanted similar care to those in previous studies of caseload midwifery. Many of the women receiving caseload care highlighted the close relationship they had with the midwives and as a result of this felt more able to discuss their concerns with them. This has the potential not only for improved quality of care but also improved safety.

A mixed methods study to develop and pilot a competency assessment tool to support midwifery care of women with intellectual disabilities.

BACKGROUND: Recent reports have highlighted the poor quality of health care received by people with intellectual disabilities (otherwise known as 'learning disabilities') in the United Kingdom (UK). UK Confidential Enquiries into maternal deaths have highlighted adverse pregnancy outcomes for women with intellectual disabilities and need for timely and appropriate clinical care. OBJECTIVES: To develop and test a competency assessment tool to support midwifery care of women with intellectual disabilities. DESIGN: A mixed methods study. SETTING: Large inner city maternity unit. PARTICIPANTS: Midwives and key experts in intellectual disabilities, maternity policy and midwifery education. METHODS: Phase one comprised a systematic narrative review of the literature. Evidence identified informed phase two which included focus groups and interviews. Emergent themes informed the development of a competency assessment tool which was piloted in phase three. RESULTS: Phase one: Four primary research papers and two systematic reviews met the review inclusion criteria. Support to develop parenting skills of women with intellectual disabilities was highlighted as was the need to optimise organisation of maternity services. No studies specifically considered midwifery competencies to support women with intellectual disabilities. Phase two: 23 midwives attended three focus groups and individual interviews were conducted with national leaders in intellectual disability (n=6) and midwifery policy and education (n=7). Themes identified included need for individualised care provided by a known midwife, the importance of effective communication skills and need for clear knowledge and understanding of the legislative framework relevant to intellectual disability. Phase three: A convenience sample of 60 midwives was asked to participate in a pilot study to test the tool, 46 (77%) of whom responded. Thirty midwives (65%) felt competent in their ability to recognise intellectual disability and 37 (80%) competent or expert in understanding women have the right to be offered choice and make informed decisions. A high proportion (n=40, 87%) reported little or no knowledge regarding consent issues. CONCLUSION: Work to inform timely and appropriate care of women with intellectual disability has been neglected in the UK maternity services. Use of a tool could aid assessment of midwifery competencies to support women with intellectual disability and highlight where further midwifery education and development are needed. Evidence of optimal care for women with intellectual disabilities and their families across the continuum of pregnancy and birth is required.

Revising care to meet maternal needs post birth: an overview of the hospital to home postnatal study.

There have been limited improvements in care and support for women post-birth despite publication of National Institute of Health and Clinical Excellence (NICE) guidelines for routine postnatal care (NICE 2006). NICE recommendations included that care should be individualised to women's physical and psychological health needs, the content of care should be relevant to the time of recovery post birth and information should be offered regarding life-threatening conditions and more commonly experienced morbidity. A study was conducted in one maternity unit informed by a quality improvement approach to implement NICE guidance. Revisions were introduced to hospital systems and processes relevant to the continuum of pregnancy, birth and beyond to improve individualised care and women's views of this.

Vigilance must be a priority: maternal genital tract sepsis.

Although very rare in the UK, sepsis was the leading cause of direct maternal deaths during 2006-2008, with an increase in community acquired Group A streptococcal infection (CMACE 2011). Most deaths occurred in the postnatal period and were often preceded by a sore throat or other upper respiratory infection, with a clear seasonal pattern. An associated factor was women of BME origin (black or minority ethnic origin). More than half of the deaths followed birth by caesarean section. All antenatal and postnatal women should be offered advice on the signs and symptoms of life threatening conditions, including sepsis. Information should include the importance of good hand and perineal hygiene and of the need to seek immediate medical care if feeling unwell. Relevant NICE guidance should be disseminated and implemented as widely as possible. Greater priority should be given to ensuring all women, particularly those in the most vulnerable groups, are aware of how to access timely and appropriate care.

Midwives' reflections on their educational programme: a traditional or problem-based learning approach?

OBJECTIVE: to explore the longer-term effect of a problem-based learning (PBL) programme on midwives in practice. DESIGN: qualitative study. Graduates involved in an earlier study of the implementation of a PBL programme were interviewed between 5 and 6 years after graduating to explore the possible longer-term effect of a PBL programme on their practice as midwives. SETTING: Thames Valley University with graduates who had completed an 18-month programme on one of two campuses on a variety of clinical sites. PARTICIPANTS: interviews were held with four graduates who had completed their programme before the implementation of PBL and five who had completed a PBL programme. Key themes were identified and compared cross-sectionally. FINDINGS: midwives who had graduated from a PBL programme found that the approach was valuable in enabling them to access information and to develop a critical questioning approach. Some felt anxious at the beginning of their programme and said that they would have benefited from more direction and feedback from the facilitator early on in the programme. The focus on individual presentations sometimes inhibited the students learning from others in the group. The success of the PBL approach was felt to be dependent on the way in which the group worked together. The quality of the clinical placement, and the support of mentors and link teachers in the clinical setting, was a key factor in learning for students from both programmes. CONCLUSIONS: PBL has been incorporated into some programmes because it is thought to benefit practice disciplines, especially in a world of uncertain and changing evidence. However, no clear picture has emerged about the benefits of a PBL programme for midwifery education. IMPLICATIONS FOR PRACTICE: our findings have implications for curriculum development to ensure the potential benefits of PBL are realised in practice. This may include providing further guidance and feedback to students, particularly at the start of their programme. Further research using innovative methodologies is needed to critically assess the longer-term effect of this approach to education.

Problem based learning in midwifery--the students' perspective.

Problem based learning (PBL) has been adopted in many settings for the education of health professionals. It has generally been evaluated well by students although much of the literature comes from medical education. The aim of this study was to ascertain the views of student midwives at the beginning and at the end of their programme and three months after graduation about the use of a PBL based programme in midwifery. Eight focus groups were conducted with students whilst undertaking a PBL programme from both a shortened and three year programme across two sites. A questionnaire was sent 3 months after graduation to midwives who had completed the programme. Key themes which emerged from this study were that although students gained skills in information retrieval and critique some did not always feel well prepared for practice. The focus on individual presentations in the tutorial tended to be interpreted as performance rather than discussion in a spirit of enquiry. Students reported being particularly anxious at the beginning of their programme about their learning. They felt that their experience was dependent upon the participation and motivation of the group members.

Evaluation of the use of health care assistants to support disadvantaged women breastfeeding in the community.

There is little experience of the use of health care assistants in the community to support breastfeeding in the UK. The aim of this project was to evaluate the implementation of a small-scale pilot project using health care assistants in the community to support disadvantaged women breastfeeding. The evaluation was funded as part of the Department of Health's Infant Feeding Initiative. A longitudinal observational and quasi-experimental design was used. The project involved women, who had recently given birth, living in an area of London identified by the government's Sure Start scheme as socio-economically disadvantaged. This paper focuses mainly on the findings drawn from the qualitative data focusing on the process of implementation, the role of the Support Worker and women's perceptions of the support. The findings suggest that the use of health care assistants in the community may offer a practical and encouraging approach in supporting breastfeeding which is acceptable to both breastfeeding women and health care professionals. More research is needed to establish whether the intervention significantly increases breastfeeding rates.