Systematic review of barriers to, and facilitators of, the provision of high-quality midwifery services in India.

BACKGROUND: The Indian government has committed to implementing high-quality midwifery care to achieve universal health coverage and reduce the burden of maternal and perinatal mortality and morbidity. There are multiple challenges, including introducing a new cadre of midwives educated to international standards and integrating midwifery into the health system with a defined scope of practice. The objective of this review was to examine the facilitators and barriers to providing high-quality midwifery care in India. METHODS: We searched 15 databases for studies relevant to the provision of midwifery care in India. The findings were mapped to two global quality frameworks to identify barriers and facilitators to providing high-quality midwifery care in India. RESULTS: Thirty-two studies were included. Key barriers were lack of competence of maternity care providers, lack of legislation recognizing midwives as autonomous professionals and limited scope of practice, social and economic barriers to women accessing services, and lack of basic health system infrastructure. Facilitators included providing more hands-on experience during training, monitoring and supervision of staff, utilizing midwives to their full scope of practice with good referral systems, improving women's experiences of maternity care, and improving health system infrastructure. CONCLUSIONS: The findings can be used to inform policy and practice. Overcoming the identified barriers will be critical to achieving the Government of India's plans to reduce maternal and neonatal mortality through the introduction of a new cadre of midwives. This is unlikely to be effective until the facilitators described are in place.

Counselling interventions to enable women to initiate and continue breastfeeding: a systematic review and meta-analysis.

Background: Many infants worldwide are not breastfeeding according to WHO recommendations and this impacts on the health of women and children. Increasing breastfeeding is identified as a priority area supported by current policy targets. However, interventions are complex and multi-component and it is unclear which elements of interventions are most effective to increase breastfeeding in which settings. Breastfeeding counselling is often part of complex interventions but evidence is lacking on the specific effect of counselling interventions on breastfeeding practices. The aim of this systematic review is to examine evidence on effectiveness of breastfeeding counselling to inform global guidelines. Methods: A systematic search was conducted of six electronic databases in January 2018. Randomised controlled trials comparing breastfeeding counselling with no breastfeeding counselling or different formulations of counselling were included if they measured breastfeeding practices between birth and 24 months after birth. Results: From the 5180 records identified in searches and a further 11 records found by hand searching, 63 studies were included. Of these, 48 were individually-randomised trials and 15 were cluster-randomised trials. A total of 69 relevant comparisons were reported involving 33,073 women. There was a significant effect of counselling interventions on any breastfeeding at 4 to 6 weeks (Relative risk [RR] 0.85, 95% CI 0.77, 0.94) and 6 months (RR 0.92, 95% CI 0.87, 0.94). Greater effects were found on exclusive breastfeeding at 4 to 6 weeks (RR 0.79, 95% CI 0.72, 0.87) and 6 months (RR 0.84, 95% CI 0.78, 0.91). Counselling delivered at least four times postnatally is more effective than counselling delivered antenatally only and/or fewer than four times. Evidence was mostly of low quality due to high or unclear risk of bias of the included trials and high heterogeneity. Conclusions: Breastfeeding counselling is an effective public health intervention to increase rates of any and exclusive breastfeeding. Breastfeeding counselling should be provided face-to-face, and in addition, may be provided by telephone, both antenatally and postnatally, to all pregnant women and mothers with young children. To inform scale-up globally there is a need to further understand the elements of breastfeeding interventions such as counselling and their effectiveness in different contexts and circumstances. Study registration: This systematic review was registered in Prospero (CRD42018086494).

Evaluating the 'Focus on Normal Birth and Reducing Caesarean section Rates Rapid Improvement Programme': A mixed method study in England.

BACKGROUND: caesarean section plays an important role in ensuring safety of mother and infant but rising rates are not accompanied by measurable improvements in maternal or neonatal mortality or morbidity. The 'Focus on Normal Birth and Reducing Caesarean section Rates Rapid Improvement Programme' was a facilitative initiative developed to promote opportunities for normal birth and reduce caesarean section rates in England. OBJECTIVE: to evaluate the 'Focus on Normal Birth and Reducing Caesarean section Rates' programme, by assessment of: impact on caesarean section rates, use of service improvements tools and participants׳ perceptions of factors that sustain or hinder work within participating maternity units. DESIGN: a mixed methods approach included analysis of mode of birth data, web-based questionnaires and in-depth semi-structured telephone interviews. PARTICIPANTS: twenty Hospital Trusts in England (selected from 68 who applied) took part in the 'Focus on Normal Birth and Reducing Caesarean section Rates Rapid Improvement Programme' initiative. In each hospital Trust, the head of midwifery, an obstetrician, the relevant lead for organisational development, a supervisor of midwives, or a clinical midwife and a service user representative were invited to participate in the independent evaluation. METHODS: collection and analysis of mode of birth data from 20 participating hospital Trusts, web-based questionnaires administered to key individuals in all 20 Trusts and in-depth semi-structured telephone interviews conducted with key individuals in a sample of six Trusts. FINDINGS: there was a marginal decline of 0.5% (25.9% from 26.4%) in mean total caesarean section rate in the period 1 January 2009 to 31 January 2010 compared to the baseline period (1 July-31 December 2008). Reduced total caesarean section rates were achieved in eight trusts, all with higher rates at the beginning of the initiative. Features associated with lower caesarean section rates included a shared philosophy prioritising normal birth, clear communication across disciplines and strong leadership at a range of levels, including executive support and clinical leaders within each discipline. CONCLUSIONS: it is important that the philosophy and organisational context of care are examined to identify potential barriers and facilitative factors.

Parents' views on how health professionals should work with them now to get the best for their child in the future.

BACKGROUND: Pregnancy and the first years of life are important times for future child well-being. Early identification of families and children who might be likely to experience poorer outcomes could enable health professionals and parents to work together to promote each child's well-being. Little is known about the acceptability and feasibility of such an approach to parents. OBJECTIVE: To investigate parents' views about how health professionals should identify and work with families who may benefit from additional input to maximize their children's future health and well-being. DESIGN: A qualitative study using focus groups. SETTING AND PARTICIPANTS: Eleven focus groups were conducted with a total of 54 parents; 42 mothers and 12 fathers living in the north of England. RESULTS: Parents welcomed the idea of preventive services. They strongly believed that everyone should have access to services to enhance child well-being whilst recognizing that some families need additional support. Making judgements about who should receive additional services based on specific criteria evoked powerful emotions because of the implication of failure. Parents projected a belief in themselves as 'good parents' even in adverse circumstances. CONCLUSIONS: Targeted additional preventive services can be acceptable and welcome if health professionals introduce them sensitively, in the context of an existing relationship, providing parents are active participants.

Motherhood, breastfeeding and identity.

Breastfeeding becomes part of a woman's identity as she enters the journey into motherhood. As women face the challenge of balancing the care of a new baby with the rest of life they come across many different ideas about the qualities of a 'good mother' from within their social networks. Throughout their journey into motherhood women weigh up information about breastfeeding in relation to this as they decide what to do. This article identifies the kinds of knowledge women draw on that reinforce their idea of themselves as 'good mothers' and the implications of this for midwifery practice.

Association between timing of introducing solid foods and obesity in infancy and childhood: a systematic review.

Determining early-life risk factors for obesity in later life is essential in order to effectively target preventative interventions to reduce obesity. The aim of this systematic review was to investigate current evidence to determine whether the timing of introducing solid foods is associated with obesity in infancy and childhood. Relevant randomized and observational studies from developed countries were identified by searching the following six bio-medical databases (Medline, Embase, British Nursing Index, CINAHL, Maternity and Infant Care, and PsycINFO) and hand-searching reference lists. Studies of pre-term or low birthweight infants were excluded. Twenty-four studies met the inclusion criteria for the systematic review. Data from over 34,000 participants were available for interpretative analysis. No clear association between the age of introduction of solid foods and obesity was found. It is likely that a whole family approach to obesity prevention will be most effective and health professionals should continue to promote healthy infant feeding in line with national recommendations.

Being a 'good mother': managing breastfeeding and merging identities.

Breastfeeding is not simply a technical or practical task but is part of the transition to motherhood, the relationship between mother and baby and the everyday experience of living with a new baby. Discussion of breastfeeding must therefore include the individual's personal and social context. This paper explores how women in England who have chosen to breastfeed their baby accomplish this task during the early stages of motherhood and the relative weight attached to different factors, which impinge on decision-making. Our findings, based on observing 158 interactions between breastfeeding women and midwives or health visitors from one Primary Care Trust in the north of England, UK, and in-depth interviews with a sample of 22 of these women, illustrate the dynamic between breastfeeding, becoming and being a 'good mother' and merging multiple identities as they embrace motherhood. In this context, the value attached to breastfeeding as synonymous with being a 'good mother' is questioned. In managing the balance between ensuring a healthy, contented baby and the reality of their daily lives, women negotiate the moral minefield that defines 'good mothering' and the diverse conceptions and influences that shape it--including health professionals, their social networks and the wider social and structural context of their lives. The implications for policy and practice are discussed.

Turning policy into practice: more difficult than it seems. The case of breastfeeding education.

Breastfeeding is increasingly recognized as a health policy priority. To achieve real change in breastfeeding rates, those who advise and support childbearing women need to be appropriately educated and trained so that they do not disrupt breastfeeding. The aim of this study was to conduct a needs analysis about breastfeeding training among a range of people who advise and support breastfeeding women, including breastfeeding women themselves, to contribute to future provision of education. A qualitative, interview-based study was conducted in one northern UK city with practitioners who support breastfeeding, and breastfeeding women, selected using purposive sampling. Individual (n = 73) and group (n = 9) interviews were conducted. Detailed notes were returned to each respondent for checking. Information was organized into themes. Coding was charted to enable comparison by theme and case. Four main themes emerged: perspectives of breastfeeding women; feeling (un)prepared to support breastfeeding; fragmentation of knowledge; and provision of education about breastfeeding. A deficit in education and training for all professional groups was identified. There was little evidence of informal shared learning among professional groups, and no evidence of usual mechanisms to ensure education and practice standards. Doctors received very little formal education; most relied on other health professionals to provide this expertise. Students encountered a chaotic learning environment where it was not possible to observe sound, consistent practice. Voluntary breastfeeding supporters felt well-prepared. The results call into question the potential for health services to respond to policy recommendations that support increased rates of breastfeeding.