The social and healthcare professional support drawn upon by women antenatally during the COVID-19 pandemic: A recurrent, cross-sectional, thematic analysis.

OBJECTIVE: To explore antenatal experiences of social and healthcare professional support during different phases of social distancing restriction implementation in the UK. DESIGN: Semi-structured interviews were conducted via telephone or video-conferencing software between 13 July 2020 - 2 September 2020. Interviews were transcribed and a recurrent, cross-sectional, thematic analysis was conducted. PARTICIPANTS: Twelve antenatal women were interviewed during UK social distancing restrictions (Timepoint 1; T1) and a separate sample of twelve women were interviewed in the initial easing of these restrictions (Timepoint 2; T2). FINDINGS: T1 themes were: 'Maternity care as non-essential' and 'Pregnancy is cancelled'. T2 themes were: 'Technology is a polarised tool' and 'Clinically vulnerable, or not clinically vulnerable? That is the question'. KEY CONCLUSIONS: At T1, anxieties were ascribed to the exclusion of partners from routine care, and to perceived insensitivity and aggression from the public. For T2, insufficient Governmental transparency led to disillusionment, confusion, and anger. Covert workplace discrimination also caused distress at T2. Across timepoints: deteriorated mental wellbeing was attributed to depleted opportunities to interact socially and scaled back maternity care. IMPLICATIONS FOR PRACTICE: Recommendations are made to: protect maternal autonomy; improve quality of mental health and routine care signposting; prioritise parental community support in the re-opening of 'non-essential' services; prioritise the option for face-to-face appointments when safe and legal; and protecting the rights of working mothers.

Virtual reality interventions designed to support parents during and throughout the first year after birth: A scoping review.

Objective: Virtual reality (VR) has become increasingly popular in clinical and health settings where it has been used for a wide range of purposes. A recent scoping review explored VR applications to assist pregnant women and found that VR was a useful method to be used for a range of different purposes in both pregnancy and labour. However, no such review exists for the period after birth. Method: We aimed to search for studies that used VR to support parents during birth and in the first year postpartum (Population) in different settings (Context), and finally provided data on the characteristics, reported effectiveness and experience of VR interventions (Concept). Two hundred and fifty-one studies were identified, of which ten were eligible. Two authors independently extracted data including study design, participants and results. Results: Findings indicate that VR has been used effectively in this context to alleviate depression anxiety, and multiple domains of pain and to improve childbirth satisfaction. The majority of the studies explored the use of VR technology on outcomes such as pain and anxiety during labour and birth. The studies included used a broad range of VR hardware and software. All of the studies reported positive experiences of using VR. Conclusions: Across these studies, VR was found to be effective in terms of both physiological and psychological outcomes. There are many unexplored maternal and infant focused applications of VR which warrant further investigation as emerging evidence indicates this is becoming an increasingly accessible method to improve maternal and infant health outcomes from pregnancy through to parenthood.

A consensus statement on perinatal mental health during the COVID-19 pandemic and recommendations for post-pandemic recovery and re-build.

Introduction: The COVID-19 pandemic posed a significant lifecourse rupture, not least to those who had specific physical vulnerabilities to the virus, but also to those who were suffering with mental ill health. Women and birthing people who were pregnant, experienced a perinatal bereavement, or were in the first post-partum year (i.e., perinatal) were exposed to a number of risk factors for mental ill health, including alterations to the way in which their perinatal care was delivered. Methods: A consensus statement was derived from a cross-disciplinary collaboration of experts, whereby evidence from collaborative work on perinatal mental health during the COVID-19 pandemic was synthesised, and priorities were established as recommendations for research, healthcare practice, and policy. Results: The synthesis of research focused on the effect of the COVID-19 pandemic on perinatal health outcomes and care practices led to three immediate recommendations: what to retain, what to reinstate, and what to remove from perinatal mental healthcare provision. Longer-term recommendations for action were also made, categorised as follows: Equity and Relational Healthcare; Parity of Esteem in Mental and Physical Healthcare with an Emphasis on Specialist Perinatal Services; and Horizon Scanning for Perinatal Mental Health Research, Policy, & Practice. Discussion: The evidence base on the effect of the pandemic on perinatal mental health is growing. This consensus statement synthesises said evidence and makes recommendations for a post-pandemic recovery and re-build of perinatal mental health services and care provision.

OptiBreech collaborative care versus standard care for women with a breech-presenting fetus at term: A pilot parallel group randomised trial to evaluate the feasibility of a randomised trial nested within a cohort.

OptiBreech collaborative care is a multi-disciplinary care pathway for breech presentation at term, with continuity from a breech specialist midwife, including where chosen, for vaginal breech birth (VBB). Pilot randomised trial using unblinded 1:1 parallel group allocation to OptiBreech versus standard care, within a cohort. Participants were women with a breech-presenting fetus > 33 weeks, at four sites in England, January-June 2022. A two-stage consent process was used. Participants consented to undergo random selection to be offered a 'new care process', with a choice to accept it, or not. Primary objectives were to identify recruitment, acceptance, and attrition rates. Randomisation procedures and potential primary outcomes for a substantive study were also feasibility-tested. 68 women were randomised between January-June 2022. The consent process was acceptable to participants, but randomisation was unacceptable to women who specifically sought OptiBreech care. Two women withdrew due to concerns about sharing personal information. More women planned a VBB when randomised to OptiBreech Care (23.5% vs 0, p = .002, 95% CI = 9.3%,37.8%). Women randomised to OptiBreech care had: lower rates of cephalic presentation at birth (38.2% vs 54.5%), higher rates of vaginal birth (32.4% vs 24.2%), lower rates of in-labour caesarean birth (20.6% vs 36.4%), lower rates of neonatal intensive care (5.9% vs 9.1%), and lower rates of severe neonatal morbidity (2.9% vs 9.1%). Randomisation was stopped on the advice of the steering committee before the planned sample of 104, as lack of access to VBB within standard care prohibited comparison of outcomes. Demand for VBB is sufficient for a cohort study, but comparison of outcomes by 1:1 randomisation is not feasible. OptiBreech care would be best evaluated using stepped wedge cluster randomisation. Funded by the United Kingdom National Institute for Health and Care Research (NIHR300582). Clinical trial registration: ISRCTN 14521381.

Psychometric evaluation of the postpartum specific anxiety scale - research short-form among iranian women (PSAS-IR-RSF).

BACKGROUND: The increasing prevalence of postpartum anxiety as a common psychological problem affects a large part of women's lives. Despite the existence of tools in this field, but due to the lack of specificity in reflecting postpartum anxiety, it is necessary to have a specific tool to screen it. Since the psychometric evaluation of the Postpartum Specific Anxiety Scale-Research Short-Form (PSAS-RSF) among Iranian women has not been assessed in Iran until now, so we decided to conduct this study with the aim of psychometric evaluation of the PSAS-IR-RSF. METHODS: We included 180 women (six weeks to six months postpartum) in the study by random sampling during the period from December 2021 to June 2022. We examined the validity of the PSAS-IR-RSF tool in terms of face, content and construct (through exploratory and confirmatory factor analyses). We used internal consistency and test-retest reliability to determine the reliability of the scale. RESULTS: In the present study, content validity index (CVI) and content validity ratio (CVR) of the PSAS-IR-RSF tool were equal to 0.91 and 0.97, respectively. We extracted a four-factor structure through the process of exploratory factor analysis. The values of fitting indices confirmed the validity of the model. Cronbach's alpha coefficient was equal to 0.72 and intra-class correlation coefficient (with 95% confidence interval) was 0.97 (0.98 to 0.93). CONCLUSIONS: The Persian version of the PSAS-IR-RSF is a valid and reliable tool for the specific evaluation of postpartum anxiety among Iranian women.

The antenatal psychological experiences of women during two phases of the COVID-19 pandemic: A recurrent, cross-sectional, thematic analysis.

Initial COVID-19-related social distancing restrictions, imposed in the UK in March 2020, and the subsequent lifting of restrictions in May 2020 caused antenatal disruption and stress which exceeded expected vulnerabilities associated with this lifecourse transition. The current study aimed to explore the antenatal psychological experiences of women during different phases of pandemic-related lockdown restrictions in the UK. Semi-structured interviews were held with 24 women about their antenatal experiences: twelve were interviewed after the initial lockdown restrictions (Timepoint 1; T1), and a separate twelve women were interviewed after the subsequent lifting of those restrictions (Timepoint 2; T2). Interviews were transcribed and a recurrent, cross-sectional thematic analysis was conducted. Two themes were identified for each timepoint, and each theme contained sub-themes. T1 themes were: 'A Mindful Pregnancy' and 'It's a Grieving Process', and T2 themes were: 'Coping with Lockdown Restrictions' and 'Robbed of Our Pregnancy'. COVID-19 related social distancing restrictions had an adverse effect on women's mental health during the antenatal period. Feeling trapped, anxious, and abandoned were common at both timepoints. Actively encouraging conversations about mental wellbeing during routine care and adopting a prevention opposed to cure attitude toward implementing additional support provisions may serve to improve antenatal psychological wellbeing during health crises.

The feasibility of team care for women seeking to plan a vaginal breech birth (OptiBreech 1): an observational implementation feasibility study in preparation for a pilot trial.

BACKGROUND: OptiBreech Care is a care pathway for breech presentation at term, including where chosen, physiological breech birth attended by professionals with advanced training and/or proficiency. We aimed to assess the feasibility of implementing OptiBreech team care prior to proceeding with a planned pilot randomised controlled trial. METHODS: Our design was an observational implementation feasibility assessment across England and Wales, January 2021-June 2022. Our objectives were to determine whether Trusts could provide attendants with advanced training (implementation feasibility), who deliver protocol-consistent care (fidelity), within existing resources (costs), while maintaining low neonatal admission rates (safety) and adequate recruitment rates (trial feasibility). Participants included women > 37 weeks pregnant with a breech-presenting foetus, requesting support for a vaginal breech birth following standard counselling, and staff involved in the study. No randomisation occurred in this first stage of feasibility work. RESULTS: Thirteen National Health Service sites were recruited. A total of 82 women planned births in the study. Sites with a breech specialist midwife recruited at double the rate of sites without (0.90/month, 95% CI 0.64-1.16 vs 0.40, 95% CI 0.12-0.68). Referrals into the study came from midwives (46%), obstetricians (34%) and women themselves (20%). Vaginal births were attended by staff with OptiBreech training at 87.5% (35/40, 95% CI 0.732-0.958) and by staff who met additional proficiency criteria at 67.5% (27/40, 95% CI 0.509-0.814). Fidelity criteria were more consistently met by staff who also met proficiency criteria. There were four neonatal admissions (4.9%, 4/82), including one serious adverse outcome (1.2%, 1/82). CONCLUSIONS: A prospective observational cohort of OptiBreech collaborative care, which could potentially support nested or cluster randomisation, appears feasible in sites willing to establish a dedicated clinic and strategically develop further proficient members of staff, with back-up plans for supporting rapidly progressing births. Randomisation procedures remain to be feasibility tested. It is funded by the NIHR (NIHR300582).

Breech specialist midwives and clinics in the OptiBreech Trial feasibility study: An implementation process evaluation.

BACKGROUND: Attendance of skilled and experienced professionals at breech births has been associated with a reduction in adverse perinatal outcomes. We aimed to determine whether United Kingdom National Health Service (NHS) sites could reliably provide attendants with OptiBreech training and/or advanced proficiency (intervention feasibility) and consistent care (fidelity) that meets women's needs (acceptability), with low neonatal admission rates (safety) and recruitment adequate to support a clinical trial (trial feasibility). METHODS: Mixed methods implementation evaluation was used. Settings were 13 services in England and Wales. Participants were 82 women requesting support for a vaginal breech birth (VBB) at term. Outcomes were descriptively analyzed. Twenty-one women were interviewed, and transcripts were analyzed using the Theoretical Framework of Acceptability. Iterative analysis informed subsequent interviews and the ongoing process of implementation across sites. RESULTS: Although we initially suggested multidisciplinary teams, actively recruiting Trusts yielded services where VBB care was provided through a dedicated clinic, organized and delivered primarily by a lead midwife who functioned as a specialist. This model achieved 87.5% fidelity with the intervention's goal of ensuring the attendance of OptiBreech-trained professionals. Neonatal outcomes remained stable, with an admission rate of 5.5%. Women reported care from specialist midwives as highly acceptable, but the model is vulnerable without a strategic effort to develop additional proficient team members. CONCLUSIONS: Dedicated clinics coordinated by specialist midwives appear to be an acceptable and feasible implementation strategy to test the safety and effectiveness of proficient team care for VBB in a clinical trial. Back-up arrangements should be maintained while additional members of the team develop proficiency.

The Postpartum Specific Anxiety Scale: Confirmatory factor analyses and relationships with birth experience.

The Postpartum Specific Anxiety Scale [PSAS] was developed and validated as a research tool with a four-factor structure; with predictive validity corroborated in studies examining infant-feeding and maternal bonding outcomes. The PSAS has not been examined in relation to birth experiences. We aimed to confirm the PSAS four-factor structure and examine these domains of anxiety in relation to subjective and objective birth experiences. Postpartum mothers (≤ 12-months; N = 500) completed the PSAS alongside measures of subjective birth satisfaction and objective obstetric interventions/complications. Confirmatory factor analyses [CFA] tested eight models, theoretically derived from the preceding exploratory work. Structural equation modelling [SEM] tested associations between each PSAS factor and birth experience variables in the best-fitting model. An identical 51-item four-factor model fits the data well. SEM analyses revealed associations between lower perceptions of quality of intrapartum care and increased maternal competence and attachment anxieties, practical infant care anxieties, and infant safety and welfare anxieties. High subjective stress and negative emotional response to labour were associated with increased psychosocial adjustment to motherhood anxieties. Specific associations were found between neonatal care unit admission and practical infant care anxieties; and infant asphyxia and infant safety and welfare anxieties. Findings confirm construct and convergent validity of the four-factor PSAS and its use in measuring postpartum anxiety. Unique associations were also identified, indicating specific subjective and objective experiences occurring during birth may elicit a differential anxiety response, in that they are related to specific forms of postpartum anxiety which occur during the first postpartum year.

Exclusive Breastfeeding Duration and Perceptions of Infant Sleep: The Mediating Role of Postpartum Anxiety.

(1) Background: Existing literature has identified associations between exclusive breastfeeding, maternal mental health, and infant sleep. This study aims to examine these relationships simultaneously and consider the mediating role of postpartum anxiety. (2) Methods: Participants completed validated measures of postpartum anxiety, infant sleep, and reported exclusive breastfeeding duration. Postpartum mothers with infants between six and twelve months (n = 470) were recruited to a cross-sectional online survey containing a battery of psychological measures. (3) Results: Correlation analyses examined the relationships between the predictor (exclusive breastfeeding duration), outcome (perceptions of infant sleep), and mediator (postpartum anxiety). Exclusive breastfeeding duration was significantly associated with postpartum anxiety (p < 0.05), postpartum anxiety was significantly associated with perceptions of infant sleep (p < 0.001), and exclusive breastfeeding duration was significantly associated with perceptions of infant sleep (p < 0.001). A simple mediation model was conducted, showing a significant total (B = −0.029 (0.010), p < 0.05), direct (B = −0.035 (0.009), p < 0.001), and indirect effect (B = 0.007, SE = 0.003, 95% CI = 0.000 to 0.014) of exclusive breastfeeding duration on perceptions of infant sleep via postpartum anxiety. (4) Conclusions: Associations were identified between exclusive breastfeeding duration, postpartum anxiety, and perceptions of infant sleep. The mediation model suggests postpartum anxiety may be an underlying mechanism which reduces exclusive breastfeeding duration and negatively affects maternal perceptions of infant sleep quality.

Preventive Digital Mental Health for Children in Primary Schools: Acceptability and Feasibility Study.

BACKGROUND: The incidence of mental health problems in children and adolescents in the United Kingdom has significantly increased in recent years, and more people are in contact with mental health services in Greater Manchester than in other parts of the country. Children and young people spend most of their time at school and with teachers. Therefore, schools and other educational settings may be ideal environments in which to identify those experiencing or those at the risk of developing psychological symptoms and provide timely support for children most at risk of mental health or related problems. OBJECTIVE: This study aims to test the feasibility of embedding a low-cost, scalable, and innovative digital mental health intervention in schools in the Greater Manchester area. METHODS: Two components of a 6-week digital intervention were implemented in a primary school in Greater Manchester: Lexplore, a reading assessment using eye-tracking technology to assess reading ability and detect early atypicality, and Lincus, a digital support and well-being monitoring platform. RESULTS: Of the 115 children approached, 34 (29.6%) consented and took part; of these 34 children, all 34 (100%) completed the baseline Lexplore assessment, and 30 (88%) completed the follow-up. In addition, most children were classified by Lincus as regular (≥1 per week) survey users. Overall, the teaching staff and children found both components of the digital intervention engaging, usable, feasible, and acceptable. Despite the widespread enthusiasm and recognition of the potential added value from staff, we met significant implementation barriers. CONCLUSIONS: This study explored the acceptability and feasibility of a digital mental health intervention for schoolchildren. Further work is needed to evaluate the effectiveness of the digital intervention and to understand whether the assessment of reading atypicality using Lexplore can identify those who require additional help and whether they can also be supported by Lincus. This study provides high-quality pilot data and highlights the potential benefits of implementing digital assessment and mental health support tools in a primary school setting.

Creation and validation of the Postpartum Specific Anxiety Scale Research Short-Form (PSAS-RSF).

The Postpartum Specific Anxiety Scale (PSAS) is a valid, reliable measure of postpartum anxiety (PPA). However, it contains 51 items, so is limited by its length. This study aimed to reduce the number of items in the PSAS, produce a small number of high-performing short-form tools, and confirm the factor structure of the most statistically and theoretically meaningful model. A pooled sample of English-speaking mothers (N = 2033) with infants up to 12 months were randomly split into three samples. (1) A principal component analysis (PCA) was conducted to initially reduce the items (n = 672). (2) Four short-form versions of varying length (informed by statistical, theoretical, lay-person, and expert-guided feedback) were developed and their factor structure examined (n = 673). (3) A final confirmatory factor analysis (CFA) was performed to confirm the factor structure of the PSAS Research Short-Form (PSAS-RSF) (n = 688). PCA and theoretical review reduced the items from 51 to 34 (version 1). Statistical review retained 22 items (version 2). Quantitative expert panel data retained 17 items (version 3). Qualitative expert panel data retained 16 items (version 4). The 16-item version was deemed the most theoretically and psychometrically robust. The resulting 16-item PSAS-RSF demonstrated good psychometric properties and reliability. The PSAS-RSF is the first brief research tool which has been validated to measure PPA. Our findings demonstrate it is theoretically meaningful, statistically robust, reliable, and valid. This study extends the use of the measure up to 12 months postpartum, offering broader opportunity for measurement while further enhancing accessibility through brevity.

Maternal-infant bonding and perceptions of infant temperament: The mediating role of maternal mental health.

BACKGROUND: There are associations between maternal mental health (anxiety and depression), maternal-infant bonding, and infant temperament. However, few studies have examined these variables simultaneously, and none have applied a parallel mediation analysis to consider maternal mental health as an explanatory variable. We aimed to examine these relationships, and whether mental health (anxiety and/or depression) mediates the observed association between maternal-infant bonding and infant temperament. METHODS: Mothers with babies between zero and twelve months (N=527) were recruited to a cross-sectional online survey containing a battery of psychometric measures. RESULTS: Correlation analyses examined relationships between the predictor (maternal-infant bonding), outcome (infant temperament), and mediator (maternal mental health; anxiety and/or depression). All associations were highly significant (p<.001). A parallel mediation (anxiety and/or depression) model was conducted, showing a significant indirect effect of maternal-infant bonding on infant temperament through anxiety, B = .04 (SE= .01) 95% CI= .01 to .07, but not through depression. LIMITATIONS: Homogeneous sampling was an issue with mainly UK, married mothers, with higher socio-economic status and educational attainment participating. Therefore, further replication in diverse samples is required. CONCLUSION: Associations were identified between maternal-infant bonding, infant temperament, and maternal mental health (anxiety and depression). However, only anxiety mediated the relationship between bonding and temperament. Healthcare professionals should consider the role of maternal anxiety when working with mothers who present with relational issues or report their infant as excessively challenging. These results signify the need to address maternal anxious and depressive symptoms as distinct issues considering their differential effects on parenting behaviour.

Psychosocial experiences of postnatal women during the COVID-19 pandemic. A UK-wide study of prevalence rates and risk factors for clinically relevant depression and anxiety.

BACKGROUND: When the vulnerabilities of the postnatal period are combined with the impact of the COVID-19 pandemic, psychosocial outcomes are likely to be affected. Specifically, we aim to: a) explore the psychosocial experiences of women in the early postnatal period; b) describe prevalence rates of clinically relevant maternal anxiety and depression; and c) explore whether psychosocial change occurring as a result of COVID-19 is predictive of clinically relevant maternal anxiety and depression. METHODS: A sample of UK mothers (N = 614) with infants aged between birth and twelve weeks were recruited via convenience sampling. A cross-sectional survey design was utilised which comprised demographics, COVID-19 specific questions, and a battery of validated psychosocial measures, including the EPDS and STAI-S which were used to collect prevalence rates of clinically relevant depression and anxiety respectively. Data collection coincided with the UK government's initial mandated "lockdown" restrictions and the introduction of social distancing measures in 2020. FINDINGS: Descriptive findings from the overall sample indicate that a high percentage of mothers self-reported psychological and social changes as a result of the introduction of social distancing measures. For women who reported the presence of psychosocial change, these changes were perceived negatively. Whilst seventy women (11.4%) reported a current clinical diagnosis of depression, two hundred and sixty-four women (43%) reported a score of ≥13 on the EPDS, indicating clinically relevant depression. Whilst one hundred and thirteen women (18.4%) reported a current clinical diagnosis of anxiety, three hundred and seventy-three women (61%) reported a score of ≥40 on STAI-S, indicating clinically relevant anxiety. After accounting for current clinical diagnoses of depression or anxiety, and demographic factors known to influence mental health, only perceived psychological change occurring as a result of the introduction of social distancing measures predicted unique variance in the risk of clinically relevant maternal depression (30%) and anxiety (33%). INTERPRETATION: To our knowledge, this is the first national study to examine the psychosocial experiences of postnatal women during the COVID-19 pandemic in the UK. Prevalence rates of clinically relevant maternal depression and anxiety were extremely high when compared to both self-reported current diagnoses of depression and anxiety, and pre-pandemic prevalence studies. Perceived psychological changes occurring as a result of the introduction of social distancing measures predicted unique variance in the risk for clinically relevant maternal depression and anxiety. This study provides vital information for clinicians, funders, policy makers, and researchers to inform the immediate next steps in perinatal care, policy, and research during COVID-19 and future health crises.

A validation of the Postpartum Specific Anxiety Scale 12-item research short-form for use during global crises with five translations.

BACKGROUND: Global crises inevitably increase levels of anxiety in postpartum populations. Effective and efficient measurement is therefore essential. This study aimed to create a 12-item research short form of the 51-item Postpartum Specific Anxiety Scale [PSAS] and validate it for use in rapid response research at a time of global crises [PSAS-RSF-C]. We also present the same 12-items, in five other languages (Italian, French, Chinese, Spanish, Dutch) to increase global accessibility of a psychometric tool to assess maternal mental health. METHODS: Twelve items from the PSAS were selected on the basis of a review of their factor loadings. An on-line sample of UK mothers (N = 710) of infants up to 12 weeks old completed the PSAS-RSF-C during COVID-19 'lockdown'. RESULTS: Principal component analyses on a randomly split sample (n = 344) revealed four factors, identical in nature to the original PSAS, which in combination explained 75% of the total variance. Confirmatory factor analyses (n = 366) demonstrated the four-factor model fit the data well. Reliability of the overall scale and of the underlying factors in both samples proved excellent. CONCLUSIONS: Findings suggest the PSAS-RSF-C may prove useful as a clinical screening tool and is the first postpartum-specific psychometric scale to be validated during the COVID-19 pandemic. This offers psychometrically sound assessment of postpartum anxiety. By increasing the accessibility of the PSAS, we aim to enable researchers the opportunity to measure maternal anxiety, rapidly, at times of global crisis.