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.

(Non-)disclosure of lifetime sexual violence in maternity care: Disclosure rate, associated characteristics and reasons for non-disclosure.

BACKGROUND: In maternity care, disclosure of a past sexual violence (SV) experience can be helpful to clients to discuss specific intimate care needs. Little evidence is available about the disclosure rates of SV within maternity care and reasons for non-disclosure. AIM: The aim of this study was to examine (1) the disclosure rate of SV in maternity care, (2) characteristics associated with disclosure of SV and (3) reasons for non-disclosure. METHODS: We conducted a descriptive mixed method study in the Netherlands. Data was collected through a cross-sectional online questionnaire with both multiple choice and open-ended items. We performed binary logistic regression analysis for quantitative data and a reflexive thematic analysis for qualitative data. RESULTS: In our sample of 1,120 respondents who reported SV, 51.9% had disclosed this to a maternity care provider. Respondents were less likely to disclose when they received obstetrician-led care for high-risk pregnancy (vs midwife-led care for low-risk pregnancy) and when they had a Surinamese or Antillean ethnic background (vs ethnic Dutch background). Reasons for non-disclosure of SV were captured in three themes: 'My SV narrative has its place outside of my pregnancy', 'I will keep my SV narrative safe inside myself', and 'my caregiver needs to create the right environment for my SV narrative to be told'. CONCLUSIONS: The high level of SV disclosure is likely due to the Dutch universal screening policy. However, some respondents did not disclose because of unsafe care conditions such as the presence of a third person and concerns about confidentiality. We also found that many respondents made a positive autonomous choice for non-disclosure of SV. Disclosure should therefore not be a goal in itself, but caregivers should facilitate an inviting environment where clients feel safe to disclose an SV experience if they feel it is relevant for them.

'What do I do?' A study to inform development of an e-resource for maternity healthcare professionals and students caring for people with lived experience of childhood sexual abuse.

BACKGROUND: The impact of childhood sexual abuse can last a lifetime. It is more prevalent than many common complexities that require additional care during the childbirth cycle but is rarely part of the education of healthcare professionals and students. This study informed the development of an e-resource to support maternity healthcare professionals and students caring for people with lived experience of childhood sexual abuse. OBJECTIVES: To identify any previous learning of pre-registration students and healthcare professionals in relation to care of survivors of childhood sexual abuse, explore their clinical experience in caring for survivors, identify related learning needs, explore what survivors of childhood sexual abuse would like healthcare professionals to know about their maternity care needs. DESIGN: A qualitative descriptive study using focus groups and interviews. Data derived qualitative content analysis was employed to address the objectives. SETTING: The study was designed in consultation with The Survivors Trust and took place in South London, UK PARTICIPANTS: Thirty seven health care professionals and students participated, comprising 25 students of midwifery, health visiting and medicine; 9 midwives, health visitors and doctors with specialist obstetric training. Eight women with lived experience took part in focus groups. FINDINGS: Care of women and birthing people who have experienced childhood sexual abuse had not been part of the undergraduate/pre-registration curricula, nor in specialist training for obstetricians. Many practitioners felt unprepared to care for those with lived experience of abuse and their learning needs were wide-ranging. The need for a learning resource was acknowledged and the outline plan that had been produced following the focus groups was endorsed by participants with lived experience. CONCLUSION: Care for women and birthing people with lived experience of childhood sexual abuse can be challenging for both personal and professional reasons. This study confirmed the need for a resource that could facilitate the classroom teaching of students and be used for the Continuous Professional Development of qualified practitioners.

Targeted health and social care interventions for women and infants who are disproportionately impacted by health inequalities in high-income countries: a systematic review.

BACKGROUND: Disadvantaged populations (such as women from minority ethnic groups and those with social complexity) are at an increased risk of poor outcomes and experiences. Inequalities in health outcomes include preterm birth, maternal and perinatal morbidity and mortality, and poor-quality care. The impact of interventions is unclear for this population, in high-income countries (HIC). The review aimed to identify and evaluate the current evidence related to targeted health and social care service interventions in HICs which can improve health inequalities experienced by childbearing women and infants at disproportionate risk of poor outcomes and experiences. METHODS: Twelve databases searched for studies across all HICs, from any methodological design. The search concluded on 8/11/22. The inclusion criteria included interventions that targeted disadvantaged populations which provided a component of clinical care that differed from standard maternity care. RESULTS: Forty six index studies were included. Countries included Australia, Canada, Chile, Hong Kong, UK and USA. A narrative synthesis was undertaken, and results showed three intervention types: midwifery models of care, interdisciplinary care, and community-centred services. These intervention types have been delivered singularly but also in combination of each other demonstrating overlapping features. Overall, results show interventions had positive associations with primary (maternal, perinatal, and infant mortality) and secondary outcomes (experiences and satisfaction, antenatal care coverage, access to care, quality of care, mode of delivery, analgesia use in labour, preterm birth, low birth weight, breastfeeding, family planning, immunisations) however significance and impact vary. Midwifery models of care took an interpersonal and holistic approach as they focused on continuity of carer, home visiting, culturally and linguistically appropriate care and accessibility. Interdisciplinary care took a structural approach, to coordinate care for women requiring multi-agency health and social services. Community-centred services took a place-based approach with interventions that suited the need of its community and their norms. CONCLUSION: Targeted interventions exist in HICs, but these vary according to the context and infrastructure of standard maternity care. Multi-interventional approaches could enhance a targeted approach for at risk populations, in particular combining midwifery models of care with community-centred approaches, to enhance accessibility, earlier engagement, and increased attendance. TRIAL REGISTRATION: PROSPERO Registration number: CRD42020218357.

(Re)activation of survival strategies during pregnancy and childbirth following experiences of childhood sexual abuse.

OBJECTIVES: To explore the pregnancy and childbearing experiences of women-survivors of childhood sexual abuse [CSA]. We aimed to generate a theory explaining those experiences for this population (women), this phenomenon (pregnancy and childbirth), and this context (those who have survived CSA). METHOD: Participants (N=6) were recruited to semi-structured interviews about their experiences of CSA and subsequent pregnancy and childbirth. Data saturated early, and were analysed using Grounded Theory (appropriate to cross-disciplinary health research). Coding was inductive and iterative, to ensure rigour and achieve thematic saturation. RESULTS: Open and focused coding led to the generation of super-categories, which in-turn were collapsed into three distinct, but related themes. These themes were: Chronicity of Childhood (Sexual) Abuse; Pregnancy and Childbirth as Paradoxically (Un)safe Experiences; Enduring Nature of Survival Strategies. The relationship between these themes was explained as the theory of: (Re)activation of Survival Strategies during Pregnancy and Childbirth following Experiences of Childhood Sexual Abuse. CONCLUSION: Pregnancy and childbirth can be triggering for women-survivors of CSA. Survival strategies learnt during experiences of CSA can be (re)activated as a way of not only coping, but surviving (the sometimes unconsented) procedures, such as monitoring and physical examinations, as well as the feelings of lack of control and bodily agency.

Navigating uncertainty alone: A grounded theory analysis of women's psycho-social experiences of pregnancy and childbirth during the COVID-19 pandemic in London.

PROBLEM: Maternity care underwent substantial reconfiguration in the United Kingdom during the COVID-19 pandemic. BACKGROUND: COVID-19 posed an unprecedented public health crisis, risking population health and causing a significant health system shock. AIM: To explore the psycho-social experiences of women who received maternity care and gave birth in South London during the first 'lockdown'. METHODS: We recruited women (N = 23) to semi-structured interviews, conducted virtually. Data were recorded, transcribed, and analysed by hand. A Classical Grounded Theory Analysis was followed including line-by-line coding, focused coding, development of super-categories followed by themes, and finally the generation of a theory. FINDINGS: Iterative and inductive analysis generated six emergent themes, sorted into three dyadic pairs: 1 & 2: Lack of relational care vs. Good practice persisting during the pandemic; 3 & 4: Denying the embodied experience of pregnancy and birth vs. Trying to keep everyone safe; and 5 & 6: Removed from support network vs. Importance of being at home as a family. Together, these themes interact to form the theory: 'Navigating uncertainty alone'. DISCUSSION: Women's pregnancy and childbirth journeys during the pandemic were reported as having positive and negative experiences which would counteract one-another. Lack of relational care, denial of embodied experiences, and removal from support networks were counterbalanced by good practice which persisted, understanding staff were trying to keep everyone safe, and renewed importance in the family unit. CONCLUSION: Pregnancy can be an uncertain time for women. This was compounded by having to navigate their maternity journey alone during the COVID-19 pandemic.

Undisturbed Physiological Birth: Insights from Women Who Freebirth in the United Kingdom.

OBJECTIVE: To understand women's experiences of undisturbed physiological birth by exploring the narratives of women who have freebirthed their babies in the United Kingdom (intentionally giving birth without midwives or doctors present). DESIGN: Unstructured narrative face-to-face interviews were carried out and data were analysed using the Voice Centred Relational Method (VCRM). PARTICIPANTS: Sixteen women who had freebirthed their babies. FINDINGS: Women discussed a range of phenomena including birth positions, the fetus ejection reflex, pain, altered states of consciousness, physiological third stages and postnatal experiences that were physically and emotionally positive. KEY CONCLUSIONS: There is a paucity of literature on physiological birth and limited opportunity for practitioners to witness it. Further research is required on phenomena related to physiological birth so as to better understand how to promote it within the maternity setting and when intervention is justified. IMPLICATIONS FOR PRACTICE: Standard maternity settings and practice may not be conducive to or reflective of physiological birth. Better understanding of physiological birth is required so that pregnant women and people can be appropriately supported during labour and birth.

Co-production of an e-resource to help women who have experienced childhood sexual abuse prepare for pregnancy, birth, and parenthood.

BACKGROUND: This paper reports the development of a co-produced e-resource to support those who have experienced childhood sexual abuse through pregnancy, birth, and parenthood. These are times of major transition for any woman but can present particular challenges for those who have experienced childhood sexual abuse. Re-traumatisation during the perinatal period is common and can occur in ways that may not be anticipated by those involved. Survivors often do not disclose their abuse and the childbearing journey can be lonely. METHODS: The work was conducted in collaboration with The Survivors Trust and in keeping with the Survivor's Charter. A participatory approach was used. There were two phases: the generation of new qualitative data and development of the resource. To encourage participation from this hidden population, data were collected by a variety of means including focus groups, telephone interviews and an on-line survey. Survivors who had children and those who hoped to one day participated. Resource development was facilitated by two workshops and email feedback. RESULTS: Overall, 37 women participated, all of whom were positive about development of the resource. Although many issues identified during data collection were specific to the participants' history of abuse other areas of concern would be relevant for any woman contemplating the journey to parenthood. Women often assumed that they were alone in their concerns and were reassured to discover that others shared their experiences. The final resource is hosted on The Survivors Trust Website and is accessible from all electronic devices. It follows the journey from deciding to have a baby, pregnancy, labour, birth, and the postnatal period through to parenthood. Links are provided to further information and sources of support. The process of developing the resource used trauma-informed principles and it speaks with women's words in a peer-to-peer voice. CONCLUSIONS: This paper describes the development of an innovative and accessible e-resource that is based on the words and experiences of survivors of childhood sexual abuse. It recognises the importance of control and feeling safe and aims to empower those who use the resource as they embark on pregnancy, birth, and parenthood.

Disclosure of non-recent (historic) childhood sexual abuse: What should researchers do?

Non-recent (historic) childhood sexual abuse is an important issue to research, though often regarded as taboo and frequently met with caution, avoidance or even opposition from research ethics committees. Sensitive research, such as that which asks victim-survivors to recount experiences of abuse or harm, has the propensity to be emotionally challenging for both the participant and the researcher. However, most research suggests that any distress experienced is usually momentary and not of any clinical significance. Moreover, this type of research offers a platform for voices which have often been silenced, and many participants report the cathartic effect of recounting their experiences in a safe, non-judgemental space. With regard to the course of such research, lines of inquiry which ask adult participants to discuss their experiences of childhood sexual abuse may result in a first-time disclosure of that abuse by the victim-survivor to the researcher. Guidance about how researchers should respond to first-time disclosure is lacking. In this article, we discuss our response to one research ethics committee which had suggested that for a qualitative study for which we were seeking ethical approval (investigating experiences of pregnancy and childbirth having previously survived childhood sexual abuse), any disclosure of non-recent (historic) childhood sexual abuse which had not been previously reported would result in the researcher being obliged to report it to relevant authorities. We assess this to be inconsistent with both law and professional guidance in the United Kingdom; and provide information and recommendations for researchers and research ethics committees to consider.

Exploring the conceptualisation and study of freebirthing as a historical and social phenomenon: a meta-narrative review of diverse research traditions.

Freebirthing is a clandestine practice whereby women intentionally give birth without healthcare professionals (HCPs) present in countries where there are medical facilities available to assist them. Women who make this decision are frequently subjected to stigma and condemnation, yet research on the phenomenon suggests that women's motivations are often complex. The aim of this review was to explore how freebirth has been conceptualised over time in the English-language academic and grey literature. The meta-narrative methodology employed enables a phenomenon to be understood within and between differing research traditions, as well as against its social and historical context. Our research uncovered nine research traditions (nursing, autobiographical text with birthing philosophy, midwifery, activism, medicine, sociology, law and ethics, pregnancy and birth advice, and anthropology) originating from eight countries and spanning the years 1957-2018. Most of the texts were written by women, with the majority being non-empirical. Empirical studies on freebirth were usually qualitative, although there were a small number of quantitative medical and midwifery studies; these texts often focused on women's motivations and highlighted a range of reasons as to why a woman would decide to give birth without HCPs present. Motivations frequently related to women's previous negative maternity experiences and the type of maternity care available, for example medicalised and hospital-based. The use of the meta-narrative methodology allowed the origins of freebirth in 1950s America to be traced to present-day empirical studies of the phenomenon. This highlighted how the subject and the publication of literature relating to freebirth are embedded within their social and historical contexts. From its very inception, freebirth aligns with the medicalisation of childbirth, the position of women in society, the provision of maternity care and the way in which women experience maternity services.

Montgomery on informed consent: an inexpert decision?

Montgomery v Lanarkshire HB is a deeply troubling decision when read closely. Paradoxically, its ruling supporting the principle of autonomy could be justified only by disregarding the individual patient's actual choices and characteristics in favour of a stereotype. The decision demonstrates a lack of expertise in dealing with specific clinical issues and misrepresents professional guidance. More fundamentally, it fails to appreciate the nature of professional expertise. This calls into question the competence of the courts to adjudicate on matters of clinical judgement and makes an attractive formulation of the test for disclosure obligations inherently unpredictable.

Current evidence on antenatal care provision for women with intellectual disabilities: A systematic review.

BACKGROUND: changing attitudes, alongside integration, more independent living and recognition of rights to family life have meant a steady rise in women with intellectual disabilities becoming pregnant. However, existing evidence shows that women with intellectual disabilities are less likely to seek or attend for regular antenatal care. This population experiences poorer maternal wellbeing and worse pregnancy outcomes compared to the general population, including preterm and low-birthweight babies. PURPOSE: to identify and review the existing evidence on the provision of antenatal care among women with intellectual disabilities. METHODS: a systematic search strategy was formulated using key Medical Sub-Headings terms and related text words for pregnancy, antenatal care and intellectual disability. Comprehensive searches dating back to 1980 using pre-determined criteria followed by a hand search of reference lists and citations were undertaken. Data were extracted using a data extraction form and methodological quality assessed using the framework developed by Caldwell et al. (2011). A three stage textual narrative synthesis was used to integrate the findings from the included studies. RESULTS: searches identified 16 papers that met the inclusion criteria. A majority of the papers focused on women's experience of pregnancy and antenatal care with a paucity of papers identified on midwives knowledge and experience. The four broad themes of the analysis and synthesis performed included: In the Family Way ('I've a baby inside. I've got a life inside of me.׳); Knowledge and advocacy ('...everyone was looking at one another and no one was talking to me...'); Midwives educational needs ('...helpful to have guidance...') and Midwives Attitudes ('...women with [intellectual disabilities]...should not be pregnant'). KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: significant gaps in the evidence base were apparent, however evidence was identified which showed that intellectually disabled pregnant women struggle to understand antenatal information communicated during pregnancy which was often text based. Maternity care providers need to make adjustments to their services so that antenatal communication, information and care is appropriate for this group of women. Midwives identified that they lacked knowledge in this area and wanted antenatal guidance on how to meet the care and communication needs of women with intellectual disabilities.

The re-enactment of childhood sexual abuse in maternity care: a qualitative study.

BACKGROUND: The process of pregnancy and birth are profound events that can be particularly challenging for women with a history of childhood sexual abuse. The silence that surrounds childhood sexual abuse means that few women disclose it and those caring for them will often not be aware of their history. It is known from anecdotal accounts that distressing memories may be triggered by childbirth and maternity care but research data on the subject are rare. This paper explores aspects of a study on the maternity care experiences of women who were sexually abused in childhood that demonstrate ways that maternity care can be reminiscent of abuse. Its purpose is to inform those providing care for these women. METHODS: The experiences of women were explored through in-depth interviews in this feminist narrative study. The Voice-Centred Relational Method and thematic analysis were employed to examine interview data. RESULTS: Women sometimes experienced re-enactment of abuse through intimate procedures but these were not necessarily problematic in themselves. How they were conducted was important. Women also experienced re-enactment of abuse through pain, loss of control, encounters with strangers and unexpected triggers. Many of these experiences were specific to the woman, often unpredictable and not necessarily avoidable. Maternity care was reminiscent of abuse for women irrespective of whether they had disclosed to midwives and was not necessarily prevented by sensitive care. 'Re-enactment of abuse' occurred both as a result of events that involved the crossing of a woman's body boundaries and more subjective internal factors that related to her sense of agency. CONCLUSIONS: As staff may not know of a woman's history, they must be alert to unspoken messages and employ 'universal precautions' to mitigate hidden trauma. Demonstrating respect and enabling women to retain control is crucial. Getting to know women is important in the building of trusting relationships that will facilitate the delivery of sensitive care and enable women to feel safe so that the re-enactment of abuse in maternity care is minimised.

A feminist narrative study of the maternity care experiences of women who were sexually abused in childhood.

BACKGROUND: One in five women experience childhood sexual abuse and these women may suffer trauma during childbirth. Their maternity care is often reminiscent of their abuse. OBJECTIVE: To inform practice by exploring the impact that childhood sexual abuse has on the maternity care experiences of adult women. DESIGN: This was a narrative study from a feminist perspective. The part of the study reported here utilised in-depth interviews with women. Data were analysed using the Voice-Centred Relational Method of analysis and further thematic analysis. SETTING: Users of one maternity service in the South of England PARTICIPANTS: Nine women were interviewed following purposive sampling. FINDINGS: The main themes identified were women's narratives of self, women's narratives of relationship, women's narratives of context and the childbirth journey. The concept of silence linked all these themes and aspects of the study relating to it are reported here. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Every day midwives will encounter women who were sexually abused in childhood. Most of these women do not disclose to those caring for them and may not respond to a direct question. They will not necessarily be distinguishable from other women accessing maternity services but they may find their experiences deeply traumatic. Silence is a challenge for those providing their care. Open communication and a genuine interest in women as individuals are required. Midwives need to listen for the unspoken messages women are trying to convey. If all women were treated with dignity and respect more may emerge from the experience of childbirth feeling empowered rather than violated.

Feeling safe: a metasynthesis of the maternity care needs of women who were sexually abused in childhood.

BACKGROUND: The impact of childhood sexual abuse on birth experiences was highlighted 20 years ago in Birth. Subsequent accounts in the midwifery press testify to the emotional trauma that women who were sexually abused as children may suffer during childbirth and the potential for caregivers to make the situation worse. This study synthesizes research on the maternity care experiences of women who were sexually abused in childhood to answer the questions: what do women need during their childbearing experiences and what can health care practitioners do about it? METHODS: A metasynthesis was conducted to integrate the findings of several qualitative studies. The eight eligible studies identified by database searches were closely read, recurring themes were extracted and compared across studies, and core themes were identified by means of an interpretative process of synthesis. RESULTS: The key themes identified were control, remembering, vulnerability, dissociation, disclosure, and healing. If women were able to retain control and forge positive, trusting relationships with health care professionals, they felt safe and might experience healing in the process. "Safety" requires that women are not reminded of abusive situations. In the absence of control and trusting relationships, maternity care can be experienced as a re-enactment of abuse. CONCLUSIONS: During their maternity care experience women who were sexually abused in childhood need to "feel safe." Health care professionals can help them achieve this feeling by seeking to ensure that those experiences do not re-enact abuse.