Community postnatal care delivery in England since Covid-19: A qualitative study of midwifery leaders' perspectives and strategies.

PROBLEM: COVID-19 impacted negatively on maternity care experiences of women and staff. Understanding the emergency response is key to inform future plans. BACKGROUND: Before the COVID-19 pandemic, experts highlighted concerns about UK community postnatal care, and its impact on long-term health, wellbeing, and inequalities. These appear to have been exacerbated by the pandemic. AIM: To explore community postnatal care provision during and since the pandemic across a large diverse UK region. METHODS: A descriptive qualitative approach. Virtual semi-structured interviews conducted November 2022-February 2023. All regional midwifery community postnatal care leaders were invited to participate. FINDINGS: 11/13 midwifery leaders participated. Three main themes were identified: Changes to postnatal care (strategic response, care on the ground); Impact of postnatal care changes (staff and women's experiences); and Drivers of postnatal care changes (COVID-19, workforce issues). DISCUSSION: Changes to postnatal care during the pandemic included introduction of virtual care, increased role of Maternity Support Workers, and moving away from home visits to clinic appointments. This has largely continued without evaluation. The number of care episodes provided for low and high-risk families appears to have changed little. Those requiring additional support but not deemed highest risk appear to have been most impacted. Staffing levels influenced amount and type of care provided. There was little inter-organisation collaboration in the postnatal pandemic response. CONCLUSION: Changes to postnatal care provision introduced more efficient working practices. However, evaluation is needed to ensure ongoing safe, equitable and individualised care provision post pandemic within limited resources.

Perceptions and experiences of maternity care workers during COVID-19 pandemic in Lagos State, Nigeria; a qualitative study.

BACKGROUND: The COVID-19 (coronavirus disease 2019) pandemic challenges provision and access to essential maternity care in low-resilience health systems. The aim of this study was to explore maternity healthcare workers' experiences of, and perceptions about providing maternity care during the COVID-19 outbreak in Lagos State, Nigeria. METHODS: This qualitative study conducted individual, remote, semi-structured interviews with midwives and traditional birth attendants (TBAs). Eligible participants spoke English, and provided maternity care during COVID-19 in Lagos, Nigeria. Participants were recruited via purposive and snowball sampling, from primary health facilities in seven Local Government Areas of Lagos State. Interview transcripts were analysed thematically following the framework method. RESULTS: Sixteen midwives (n = 11) and TBAs (n = 5) were interviewed from March to April 2021. Two overarching themes were identified from the data. 'Maternity care workers' willingness and ability to work during the COVID-19 pandemic' outlined negative influences (fear and uncertainty, risk of infection, burnout, transport difficulties), and positive influences (professional duty, faith, family and employer support). Suggestions to improve ability to work included adequate protective equipment, training, financial support, and workplace flexibility. 'Perceived impact of COVID-19 on women's access and uptake of maternity care' highlighted reduced access and uptake of antenatal and immunisation services by women. Challenges included overstretched health services, movement and cost barriers, and community fear of health facilities. Participants reported delayed healthcare seeking and unattended home births. Midwives and TBAs identified a need for community outreach to raise awareness for women to safely access maternity services. Participants highlighted the responsibility of the government to improve staff welfare, and to implement public health campaigns. CONCLUSIONS: Despite disruption to maternity care access and delivery due to COVID-19, midwives and TBAs in Lagos remained committed to their role in caring for women and babies. Nevertheless, participants highlighted issues of understaffing and mistrust in Lagos' underfunded maternity care system. Our findings suggest that future resilience during outbreaks depends on equipping maternity care workers with adequate working conditions and training, to rebuild public trust and improve access to maternity care.

Community midwives views of postnatal care in the UK; A descriptive qualitative study.

OBJECTIVE: To explore views and experiences of community midwives delivering postnatal care. DESIGN: A descriptive qualitative study design undertaking focus groups with community midwives and community midwifery team leaders. SETTING: All focus groups were carried out in community midwifery care settings, across four hospitals in two NHS organisations, April to June 2018 in the West Midlands, UK. PARTICIPANTS: 47 midwives: 34 community midwives and 13 community midwifery team leaders took part in 7 focus groups. FINDINGS: Inductive framework analysis of data led to the development of themes and sub-themes relating to factors influencing discharge from hospital, strategies to address increases in discharge and the broader challenges to providing care. Conditions on the postnatal ward and women's experiences of care in the hospital were factors influencing timing of discharge from hospital that resulted in community midwives managing women and babies with more complex needs. In order to manage increased workloads, there was growing but varied use of flexible approaches to providing care such as telephone consultations, postnatal clinics, and maternity support workers. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: In a context of short postnatal hospital stays, community midwives appear to be responding to women's needs and service pressures in the postnatal period. Wider implementation of specific strategies to organise and deliver support to women and babies may further improve care and outcomes.

Can rapid approaches to qualitative analysis deliver timely, valid findings to clinical leaders? A mixed methods study comparing rapid and thematic analysis.

OBJECTIVES: This study compares rapid and traditional analyses of a UK health service evaluation dataset to explore differences in researcher time and consistency of outputs. DESIGN: Mixed methods study, quantitatively and qualitatively comparing qualitative methods. SETTING: Data from a home birth service evaluation study in a hospital in the English National Health Service, which took place between October and December 2014. Two research teams independently analysed focus group and interview transcript data: one team used a thematic analysis approach using the framework method, and the second used rapid analysis. PARTICIPANTS: Home birth midwives (6), midwifery support workers (4), commissioners (4), managers (6), and community midwives (12) and a patient representative (1) participated in the original study. PRIMARY OUTCOME MEASURES: Time taken to complete analysis in person hours; analysis findings and recommendations matched, partially matched or not matched across the two teams. RESULTS: Rapid analysis data management took less time than thematic analysis (43 hours vs 116.5 hours). Rapid analysis took 100 hours, and thematic analysis took 126.5 hours in total, with interpretation and write up taking much longer in the rapid analysis (52 hours vs 8 hours). Rapid analysis findings overlapped with 79% of thematic analysis findings, and thematic analysis overlapped with 63% of the rapid analysis findings. Rapid analysis recommendations overlapped with 55% of those from the thematic analysis, and thematic analysis overlapped with 59% of the rapid analysis recommendations. CONCLUSIONS: Rapid analysis delivered a modest time saving. Excessive time to interpret data in rapid analysis in this study may be due to differences between research teams. There was overlap in outputs between approaches, more in findings than recommendations. Rapid analysis may have the potential to deliver valid, timely findings while taking less time. We recommend further comparisons using additional data sets with more similar research teams.

Task shifting Midwifery Support Workers as the second health worker at a home birth in the UK: A qualitative study.

OBJECTIVE: Traditionally two midwives attend home births in the UK. This paper explores the implementation of a new home birth care model where births to low risk women are attended by one midwife and one Midwifery Support Worker (MSW). DESIGN AND SETTING: The study setting was a dedicated home birth service provided by a large UK urban hospital. PARTICIPANTS: Seventy-three individuals over 3 years: 13 home birth midwives, 7 MSWs, 7 commissioners (plan and purchase healthcare), 9 managers, 23 community midwives, 14 hospital midwives. METHOD: Qualitative data were gathered from 56 semi-structured interviews (36 participants), 5 semi-structured focus groups (37 participants) and 38 service documents over a 3 year study period. A rapid analysis approach was taken: data were reduced using structured summary templates, which were entered into a matrix, allowing comparison between participants. Findings were written up directly from the matrix (Hamilton, 2013). FINDINGS: The midwife-MSW model for home births was reported to have been implemented successfully in practice, with MSWs working well, and emergencies well-managed. There were challenges in implementation, including: defining the role of MSWs; content and timing of training; providing MSWs with pre-deployment exposure to home birth; sustainability (recruiting and retaining MSWs, and a continuing need to provide two midwife cover for high risk births). The Service had responded to challenges and modified the approach to recruitment, training and deployment. CONCLUSIONS: The midwife-MSW model for home birth shows potential for task shifting to release midwife capacity and provide reliable home birth care to low risk women. Some of the challenges tally with observations made in the literature regarding role redesign. Others wishing to introduce a similar model would be advised to explicitly define and communicate the role of MSWs, and to ensure staff and women support it, consider carefully recruitment, content and delivery of training and retention of MSWs and confirm the model is cost-effective. They would also need to continue to provide care by two midwives at high risk births.

Improving the quality and content of midwives' discussions with low-risk women about their options for place of birth: Co-production and evaluation of an intervention package.

OBJECTIVE: Women's planned place of birth is gaining increasing importance in the UK, however evidence suggests that there is variation in the content of community midwives' discussions with low risk women about their place of birth options. The objective of this study was to develop an intervention to improve the quality and content of place of birth discussions between midwives and low-risk women and to evaluate this intervention in practice. DESIGN: The study design comprised of three stages: (1) The first stage included focus groups with midwives to explore the barriers to carrying out place of birth discussions with women. (2) In the second stage, COM-B theory provided a structure for co-produced intervention development with midwives and women representatives; priority areas for change were agreed and the components of an intervention package to standardise the quality of these discussions were decided. (3) The third stage of the study adopted a mixed methods approach including questionnaires, focus groups and interviews with midwives to evaluate the implementation of the co-produced package in practice. SETTING: A maternity NHS Trust in the West Midlands, UK. PARTICIPANTS: A total of 38 midwives took part in the first stage of the study. Intervention design (stage 2) included 58 midwives, and the evaluation (stage 3) involved 66 midwives. Four women were involved in the intervention design stage of the study in a Patient and Public Involvement role (not formally consented as participants). FINDINGS: In the first study stage participants agreed that pragmatic, standardised information on the safety, intervention and transfer rates for each birth setting (obstetric unit, midwifery-led unit, home) was required. In the second stage of the study, co-production between researchers, women and midwives resulted in an intervention package designed to support the implementation of these changes and included an update session for midwives, a script, a leaflet, and ongoing support through a named lead midwife and regular team meetings. Evaluation of this package in practice revealed that midwives' knowledge and confidence regarding place of birth substantially improved after the initial update session and was sustained three months post-implementation. Midwives viewed the resources as useful in prompting discussions and aiding communication about place of birth options. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Co-production enabled development of a pragmatic intervention to improve the quality of midwives' place of birth discussions with low-risk women, supported by COM-B theory. These findings highlight the importance of co-production in intervention development and suggest that the place of birth package could be used to improve place of birth discussions to facilitate informed choice at other Trusts across the UK.

A systematic review to examine the evidence regarding discussions by midwives, with women, around their options for where to give birth.

BACKGROUND: Discussion of place of birth is important for women and maternity services, yet the detail, content and delivery of these discussions are unclear. The Birthplace Study found that for low risk, multiparous women, there was no significant difference in neonatal safety outcomes between women giving birth in obstetric units, midwifery-led units, or home. For low risk, nulliparous women giving birth in a midwifery-led unit was as safe as in hospital, whilst birth at home was associated with a small, increased risk of adverse perinatal outcomes. Intervention rates were reduced in all settings outside hospital. NICE guidelines recommend all women are supported in their choice of birth setting. Midwives have the opportunity to provide information to women about where they choose to give birth. However, research suggests women are sometimes unaware of all the options available. This systematic review will establish what is known about midwives' perspectives of discussions with women about their options for where to give birth and whether any interventions have been implemented to support these discussions. METHODS: The systematic review was PROSPERO registered (registration number: CRD42015017334). The PRISMA statement was followed. Medline, Cochrane, CINAHL, PsycINFO, Popline and EMBASE databases were searched between 2000-March 2015 and grey literature was searched. All identified studies were screened for inclusion. Qualitative data was thematically analysed, whilst quantitative data was summarised. RESULTS: The themes identified relating to influences on midwives' place of birth discussions with women were organisational pressures and professional norms, inadequate knowledge and confidence of midwives, variation in what midwives told women and the influence of colleagues. None of the interventions identified provided sufficient evidence of effectiveness and were of poor quality. CONCLUSIONS: The review has suggested the need for a pragmatic, understandable place of birth dialogue containing standard content to ensure midwives provide low risk women with adequate information about their place of birth options and the need to improve midwives knowledge about place of birth. A more robust, systematic evaluation of any interventions designed is required to improve the quality of place of birth discussions. By engaging with co-produced research, more effective interventions can be designed, implemented and sustained.