A scoping review protocol: Mapping the range of policy-related evidence influencing maternal health outcomes in a fragile, low-income country.

AIM: The aim of this scoping review is to map the range of policy-related evidence influencing maternal health outcomes and determine the cultural and contextual factors influencing maternal health in Myanmar, a low-income, fragile setting. DESIGN: Eligible studies identified will include maternal health-related policies, policy documents and research. All types of health-related policies aimed at targeting population health and well-being influencing maternal mortality and morbidity will be considered. METHODS: This scoping review has been developed using the Joanna Briggs Institute recommendations. The database search will include MEDLINE, CINAHL, Web of Science, Cochrane Library and the grey literature. Documents published in English and Burmese in the past 10 years will be included. Numerical data will be extracted and summarized in diagrammatic form, and a descriptive format will be used to present narrative accounts. Funding approval was granted by the Economic and Social Research Council in January 2020. This protocol was registered with OSF registries (Open-ended Registration) on 30 March 2021. DISCUSSION: Little is known about which strategies work best as there is less evidence related to health policy and contextual factors in which maternal health care is delivered in fragile, low-income settings. Understanding the context of maternal health is key to the planning and implementation of effective maternal health services designed to address women's needs. IMPACT: This review will map the range of policy-related evidence influencing maternal health outcomes in Myanmar and will underpin future large-scale research in other low-income and fragile settings. The results of this scoping review will provide recommendations for developing and improving practice and education for nurses and midwives working in resource-restricted contexts.

Reflexology: A randomised controlled trial investigating the effects on beta-endorphin, cortisol and pregnancy related stress.

Reflexology is used for various pregnancy related complaints. A three-armed, pilot randomised controlled trial was conducted to test changes in physiological and biochemical stress parameters. Ninety primiparous volunteers experiencing low back and/or pelvic girdle pain (LBPGP) were recruited to receive either six reflexology or footbath treatments or usual care. Primary outcome data included pain intensity and frequency measured on a visual analog scale (VAS), and salivary beta-endorphin and cortisol levels. 61 (68%) women completed the intervention. A clinically important reduction of 1.63 cm occurred for VAS pain frequency following reflexology. Beta-endorphin levels increased by 8.8% and 10.10% in the footbath and usual care groups respectively and decreased by 15.18% for the reflexology group. Cortisol increased by 31.78% for footbath participants, 31.42% in usual care and 18.82% in the reflexology group. Reflexology during pregnancy may help reduce LBPGP, and associated stress. However, antenatal reflexology is under researched and requires further investigation.

The use of complementary and alternative medicine (CAM) for pregnancy related low back and/ or pelvic girdle pain: An online survey.

Low back and pelvic girdle pain (LBPGP) is a common complaint among pregnant women, which increases throughout pregnancy and women use various complementary and alternative medicine (CAM) therapies to manage their pain. Using an online survey, CAM treatments used by pregnant women in the UK and their perceptions of these therapies to relieve LBPGP were investigated. 191 women completed the survey and 70% experienced LBPGP lasting more than one week. Over half of women who sought treatment from a GP or physiotherapist were dissatisfied. 25% of participants used CAM during pregnancy, the most popular being aromatherapy (21%), acupuncture (21%), and reflexology (15%). 81% of women used CAM to manage their LBPGP and 85% found it useful for pregnancy symptoms. Women experience high levels of pain during pregnancy with limited treatment options. Research into effective CAM treatments for LBPGP is required to allow women to make informed decisions regarding treatment options.

Process evaluation for OptiBIRTH, a randomised controlled trial of a complex intervention designed to increase rates of vaginal birth after caesarean section.

BACKGROUND: Complex interventions encompassing several interconnecting and interacting components can be challenging to evaluate. Examining the underlying trial processes while an intervention is being tested can assist in explaining why an intervention was effective (or not). This paper describes a process evaluation of a pan-European cluster randomised controlled trial, OptiBIRTH (undertaken in Ireland, Italy and Germany), that successfully used both quantitative and qualitative methods to enhance understanding of the underlying trial mechanisms and their effect on the trial outcome. METHODS: We carried out a mixed methods process evaluation. Quantitative and qualitative data were collected from observation of the implementation of the intervention in practice to determine whether it was delivered according to the original protocol. Data were examined to assess the delivery of the various components of the intervention and the receipt of the intervention by key stakeholders (pregnant women, midwives, obstetricians). Using ethnography, an exploration of perceived experiences from a range of recipients was conducted to understand the perspective of both those delivering and those receiving the intervention. RESULTS: Engagement by stakeholders with the different components of the intervention varied from minimal intensity of women's engagement with antenatal classes, to moderate intensity of engagement with online resources, to high intensity of clinicians' exposure to the education sessions provided. The ethnography determined that, although the overall culture in the intervention site did not change, smaller, more individual cultural changes were observed. The fidelity of the delivery of the intervention scored average quality marks of 80% and above on repeat assessments. CONCLUSION: Nesting a process evaluation within the trial enabled the observation of the mode of action of the intervention in its practice context and ensured that the intervention was delivered with a good level of consistency. Implementation problems were identified as they arose and were addressed accordingly. When dealing with a complex intervention, collecting and analysing both quantitative and qualitative data, as we did, can greatly enhance the process evaluation. TRIAL REGISTRATION: Current Controlled Trials Register, ISRCTN10612254 . Registered on 3 April 2013.

A pilot randomised controlled trial exploring the effects of antenatal reflexology on labour outcomes.

OBJECTIVE: to investigate the effects of antenatal reflexology on labour outcomes. DESIGN: secondary analysis of a pilot three-armed randomised controlled trial conducted between July 2012 and September 2013. SETTING: a large UK inner city hospital maternity department. PARTICIPANTS: ninety primiparous women with a singleton pregnancy experiencing low back and / or pelvic girdle pain. INTERVENTIONS: six weekly 30-minute reflexology treatments compared to sham (footbath) treatments or usual antenatal care only. MEASUREMENTS: labour outcome data including labour onset, duration of the second stage of labour, epidural and Entonox usage, and mode of delivery. Participant feedback was collected prior to each treatment. FINDINGS: labour outcomes were collected for 61 women (95.3%) who completed the study. The second stage of labour duration data, available for 42 women (62.5%) who had vaginal births, showed a mean reduction of 44minutes in the reflexology group (73.56minutes; SD= 53.78) compared to the usual care (117.92minutes; SD=56.15) (p<0.05) and footbath groups (117.4minutes; SD=68.54) (p=0.08). No adverse effects were reported. KEY CONCLUSIONS: in this trial antenatal reflexology reduced labour duration for primiparous women who had experienced low back and/ or pelvic girdle pain during their pregnancy, compared with usual care and footbaths. IMPLICATIONS FOR PRACTICE: reflexology is suitable for use during pregnancy, is safe and enjoyable and may reduce labour duration. Midwives may wish to recommend reflexology to promote normal childbirth and facilitate women centred care. TRIAL REGISTRATION: this trial was listed with the International Standard Randomised Controlled Trial Number Register (ISRCTN26607527).

Factors Affecting Recruitment and Attrition in Randomised Controlled Trials of Complementary and Alternative Medicine for Pregnancy-Related Issues.

Background. Randomised controlled trials (RCTs) investigating Complementary and Alternative Medicine (CAM) for pregnancy-related issues have encountered issues with recruitment and attrition. Little is known about the cause of these issues. Methods. Data was gathered from an antenatal CAM randomised controlled trial. During foetal anomaly appointments, women meeting inclusion criteria were invited to participate in the trial. Numbers of women invited and eligible were recorded. Reasons for noninterest were noted and analysed. Focus groups exploring trial experience of participants were also conducted. Findings. Of the 428 women invited to participate, 376 were eligible and just under a quarter participated. Reasons for nonparticipation included concerns about CAM and lack of interest in participation in research. Other factors negatively affecting recruitment included recruitment timing, competition for participants, limited support from staff, and inadequate trial promotion. Factors encouraging recruitment included being interested in research and seeking pain relief. Reasons for dropping out were time constraints, travel issues, work commitments, and pregnancy issues. Several women in the sham and usual care group dropped out due to dissatisfaction with treatment allocation. Conclusion. CAM researchers must explore problems encountered with recruitment and attrition so that evidence-based implementation strategies to address the issues can be developed.

Women's experience of low back and/or pelvic pain (LBPP) during pregnancy.

OBJECTIVE: to explore the experiences of women suffering low back and/or pelvic pain during pregnancy. DESIGN: a qualitative design using focus groups. Each group was recorded with a digital audio recorder and analysed using the Newell and Burnard framework for thematic analysis. SETTING: an urban maternity hospital. PARTICIPANTS: a self-selecting sample of 14 women who had taken part in a pilot randomised controlled trial investigating reflexology for pregnancyrelated low back and / or pelvic pain. MEASUREMENTS AND FINDINGS: the group discussions were guided by a pre-determined schedule of questions designed to investigate women's experiences of pregnancyrelated low back and / or pelvic pain. Three main themes emerged: KEY CONCLUSIONS: low back and/ or pelvic pain affected women physically and emotionally during pregnancy. Their attitudes towards, and knowledge about the conditions differed. Women used a range of self-help strategies for their symptoms and there was a general sense of dissatisfaction with routine advice and treatment, a finding supported by a growing body of research. IMPLICATIONS FOR PRACTICE: given that pregnancy-related low back and/ pelvic pain occur across the world, and affects the majority of pregnant women, heath care providers need to ensure that standard care provided is meeting women's needs. Health care professionals may require specific training in order to effectively provide individualised and evidence-based advice and support to pregnant women experiencing this pain.

A pilot randomised controlled trial (RCT) investigating the effectiveness of reflexology for managing pregnancy low back and/or pelvic pain.

Many pregnant women with low back and/or pelvic pain (LBPP) use pain medications to manage this pain, much of which is self-prescribed and potentially harmful. Therefore, there is a need to find effective nonpharmacological treatments for the condition. Reflexology has previously been shown to help nonspecific low back pain. Therefore; a pilot RCT was conducted investigating reflexology in the management of pregnancy-LBPP. 90 primiparous women were randomised to either usual care, a reflexology or footbath intervention. Primary outcome measures were; the Pain Visual Analogue Scale (VAS). 64 women completed the RCT; retention rates for the reflexology group were 80%, usual care group 83.33% and footbath group 50%. The reflexology group demonstrated a Clinically Important Change (CIC) in pain frequency (1.64 cm). Results indicate it is feasible to conduct an RCT in this area, although a footbath is an unsuitable sham treatment. Reflexology may help manage pregnancy-LBPP; however a fully powered trial is needed to confirm this.

A systematic review investigating the effectiveness of Complementary and Alternative Medicine (CAM) for the management of low back and/or pelvic pain (LBPP) in pregnancy.

AIM: To evaluate and summarize the current evidence on the effectiveness of complementary and alternative medicine for the management of low back pain and/or pelvic pain in pregnancy. BACKGROUND: International research demonstrates that 25-30% of women use complementary and alternative medicine to manage low back and pelvic pain in pregnancy without robust evidence demonstrating its effectiveness. DESIGN: A systematic review of randomized controlled trials to determine the effectiveness of complementary and alternative medicine for low back and/or pelvic pain in pregnancy. DATA SOURCES: Cochrane library (1898-2013), PubMed (1996-2013), MEDLINE (1946-2013), AMED (1985-2013), Embase (1974-2013), Cinahl (1937-2013), Index to Thesis (1716-2013) and Ethos (1914-2013). REVIEW METHODS: Selected studies were written in English, randomized controlled trials, a group 1 or 2 therapy and reported pain reduction as an outcome measure. Study quality was reviewed using Risk of Bias and evidence strength the Cochrane Grading of Recommendations and Development Evaluation Tool. RESULTS: Eight studies were selected for full review. Two acupuncture studies with low risk of bias showed both clinically important changes and statistically significant results. There was evidence of effectiveness for osteopathy and chiropractic. However, osteopathy and chiropractic studies scored high for risk of bias. Strength of the evidence across studies was very low. CONCLUSION: There is limited evidence supporting the use of general CAM for managing pregnancy-related low back and/or pelvic pain. However, the restricted availability of high-quality studies, combined with the very low evidence strength, makes it impossible to make evidence-based recommendations for practice.

Normalising birth for women with a disability: the challenges facing practitioners.

UNLABELLED: Previous research on pregnant women with a disability and their experience of maternity care demonstrated that these mothers perceived themselves to be the 'perennial outsiders' with midwives automatically categorising them as 'high risk' because of their disability. They also felt that their ability to make choices, stay in control and have continuity of care was not considered to be part of the mainstream maternity care for them because they did not fit the 'normal' category. OBJECTIVE: this research was undertaken to explore the perceptions of two multiprofessional teams in Irish hospitals as to how maternity services to these mothers can be improved. PARTICIPANTS: nineteen health-care professionals from midwifery, social work and public health nursing were recruited. SETTING: two from two major maternity hospitals, one in the North and one in the South of Ireland. were featured. DESIGN: the method chosen was a qualitative approach, using focus group interviews in which case studies depicting a range and breadth of women's birthing experiences were presented and discussed. Newell and Burnard's (2006) six stage approach to thematic content analysis was used. FINDINGS: the professionals found the disabled women's stories believable, upsetting and challenging. KEY CONCLUSIONS: Staff acknowledged their 'lack of competence, knowledge and skill' regarding disability and felt that, on reflection, their failure to consult and collaborate with disabled women contributed to their failing to provide individualised woman centred care to women with a disability. IMPLICATIONS OF PRACTICe: A series of recommendations for improved practice was agreed.

A Web-based survey of midwives' perceptions of women using the Internet in pregnancy: a global phenomenon.

OBJECTIVES: to ascertain the views of midwives on Internet use in midwifery practice, to elicit the extent and nature of pregnant women's use of the Internet from a midwifery perspective, and to explore midwives' perceptions of pregnant women using the Internet as an information source. SETTING: 12 online midwifery discussion fora. DESIGN: a cross-sectional exploratory descriptive Web-based survey. METHODOLOGY: midwives from midwifery e-discussion groups who had direct contact with pregnant women were invited to share their experiences of working with women who presented them with information gleaned from the Internet. PARTICIPANTS: an international sample of 303 midwives accessed and completed a Web-based questionnaire. RESULTS: the vast majority of midwives who responded (89%, n=271) perceived an increase in Internet use among pregnant women. Midwives reported that women used the Internet to obtain information on a broad range of pregnancy-related topics. Most (86%, n=260) had experience of a pregnant woman discussing information from the Internet with them in the past year. A concerned minority (19%, n=49) regarded the information retrieved by the women to be either 'not very' or 'not at all' accurate. Two-thirds (67%, n=174) considered that the information had an effect on how the woman thought her pregnancy should be managed. KEY CONCLUSIONS: this study provides evidence of pregnant women accessing the Internet to obtain information related to their pregnancy. Midwives recognise that pregnant women are increasingly using the Internet as an accessible resource for information to inform decision-making in pregnancy. This presents a number of challenges for midwives. IMPLICATIONS FOR PRACTICE: midwives need to keep up-to-date with the latest knowledge. Midwives' skills in Internet use need to be developed so that they can be effective and competent partners in supporting post-modern women.

The managerial and development issues of nurses and midwives in new roles.

RATIONALE: The number of innovative roles in nursing and midwifery has expanded considerably; however, the evidence base for the introduction of these roles is limited. AIM: This study aimed to identify the managerial and developmental issues affecting those in innovative roles. METHODOLOGICAL DESIGN: A self-completion postal questionnaire was distributed to all innovative role holders in Northern Ireland, 450 responses were analysed. This survey was the second phase of a larger investigation into innovative roles in nursing and midwifery. INSTRUMENT: The questionnaire that had been developed for the 'Exploring New Roles in Practice' project was adapted for use in this study. ETHICAL ISSUES: The explanatory letter sent to potential participants clearly detailed that informed consent was assumed on receipt of a completed questionnaire and gave contact details for the research team. The confidentiality and anonymity of responses were assured. RESULTS: Most participants (65%) stated that their innovative role had commenced since the year 2000. There was evidence of preparation for these roles including the development of job descriptions and protocols. Nevertheless, there were issues noted relating to resource allocation and replacement when the role holder was absent. The importance of role evaluation was highlighted, with some participants noting their role had not been assessed since its inception. Support provided by managers and colleagues was key to ensuring role effectiveness. Participants reported high levels of job satisfaction. LIMITATIONS: Innovative role holders were identified by managers in their employing organization: therefore the research team could not verify that all existing innovative roles were included in the study. Innovative roles in private and voluntary sectors were not included. CONCLUSIONS: The evolution of innovative nursing and midwifery roles has been considerable worldwide and they engender job satisfaction to those occupants them. Results support international literature showing that adequate support, especially from administrators, is significant to ensuring the success of new roles. Furthermore, the careful planning for innovative role development and evaluation are important in ensuring the role is effective.

The introduction of innovative nursing and midwifery roles: the perspective of healthcare managers.

AIM: This paper reports a study exploring issues arising from the introduction of innovative nursing and midwifery roles from the perspective of healthcare managers. BACKGROUND: In recent years, the number of innovative roles in nursing and midwifery has increased dramatically across all areas of health care. A comprehensive literature review has shown that there is a scarcity of empirical studies to inform policy or the organizational context of this rapidly changing situation. METHOD: Semi-structured interviews were conducted with all Directors of Nursing, Chief Nurses and Directors of Primary Care in the Health and Social Services Trusts and Boards in Northern Ireland. This study formed the first phase of a larger exploration of innovative roles. Data were collected from July to October 2004. FINDINGS: The findings confirm that in recent years there has been a considerable increase in the number and type of innovative nursing and midwifery roles. Themes that emerged from the data included professional identity and number of innovative roles; stimuli for role development; service commissioning; infrastructure support; and perceived value for money. CONCLUSION: Analysis of the impact of innovative nursing and midwifery roles on other members of staff, notably healthcare assistants, is needed. The internationally increasing number of innovative roles need to be evaluated further with regard to their effect on care outcomes for patients, their families and communities, their cost-effectiveness and to how best to secure the support and commitment of colleagues. Further study should also be undertaken to determine whether innovative role-holders are pioneers in the development of future nursing, or whether they are responding to the workforce needs of the medical profession or to the requirements of the health service to cut costs.