Breastfeeding rates in England during the Covid-19 pandemic and the previous decade: Analysis of national surveys and routine data.

BACKGROUND: Few studies have compared breastfeeding rates before and during the pandemic using comparable data across time. We used data from two national maternity surveys (NMS) to compare breastfeeding rates in England before and during the pandemic. METHODS: Analysis was conducted using the NMS from 2018 (pre-pandemic; n = 4,509) and 2020 (during the pandemic; n = 4,611). The prevalence of breastfeeding initiation, and 'any' breastfeeding and exclusive breastfeeding (EBF) at 6 weeks and 6 months were compared between these surveys. Data were interpreted in the context of underlying trends in these prevalences from previous NMS (from 2010 and 2014), and annual routine data for England (from 2009-10 to 2020-21). Modified Poisson regression was used to estimate adjusted risk ratios (aRR) for the effect of birth during the pandemic (2020 versus 2018) on breastfeeding, with adjustment for sociodemographic and birth-related factors. RESULTS: Breastfeeding initiation and any breastfeeding at 6 weeks remained relatively constant in the NMS and the routine data. Birth during the pandemic was associated with a 3 percentage point decrease in EBF at 6 weeks in the NMS (aRR 0.92, 95%CI: 0.87, 0.98 for pandemic versus pre-pandemic), but a smaller decrease in the routine data. Birth during the pandemic was associated with a 3 percentage point increase in any breastfeeding at 6 months in the NMS (aRR 1.05, 95%CI: 1.00, 1.10). Breastfeeding varied across different groups of women in the NMS (i.e. marked inequalities), but the small changes observed between the pandemic and pre-pandemic NMS were broadly similar across the sociodemographic and birth-related factors examined (i.e. no change in inequalities). CONCLUSION: Breastfeeding initiation and any breastfeeding at 6 weeks in England were unaffected by the pandemic, and the persistent inequalities in breastfeeding did not widen. Services should aim to reduce these inequalities in breastfeeding which have been documented since the 1970s.

Community-based perinatal mental health peer support: a realist review.

BACKGROUND: Peer support has been suggested as an alternative or complement to professional support for mothers with perinatal mental health difficulties. The aim of this realist review was to synthesise the evidence on perinatal mental health peer support programmes outside mental health services, to understand what is it about community-based perinatal mental health peer support that works, for whom, in what circumstances, in what respects, and why. METHODS: Applying realist methodology, an initial theoretical model was tested against evidence from empirical studies. 29 empirical studies were included, covering 22 antenatal and postnatal mental health interventions that offered one-to-one or group peer support, in person or by telephone. Data extraction identified the configurations of contexts (C), mechanisms (M) and outcomes (O) relevant to mothers' use of peer support and to the positive and negative effects of using peer support. RESULTS: 13 C-M-O configurations explained take-up of peer support. These were based on mothers' perceptions that peer support would offer empathetic understanding and non-judgemental acceptance outside their social circle; their relationships with primary health professionals; their cultural background and perspectives on mental health; their desire for professional support; overcoming practical barriers; the format of the support; and the use of volunteers. A further 13 C-M-O configurations explained positive impact on mothers. These were based on receiving empathetic listening, acceptance, affirmation and normalisation; peers sharing ideas about self-care, coping, and services; peers using therapeutic techniques; the opportunity to give support to others; meaningful social relationships with volunteers and other mothers; and other benefits of attending a group. There were 8 C-M-O configurations explaining negative impact. These were based on lack of validation; self-criticism from downward and upward social comparison; a culture of negativity; peers being judgemental or directive; not feeling heard; peer support as a stressful social relationship; and distress at endings. CONCLUSIONS: Peer support works in complex ways that are affected by personal and social contexts. Providers, commissioners and evaluators can use this review to understand and maximise the valuable benefits of peer support, to minimise potential risks, and to devise ways of reaching mothers who do not currently engage with it.

Learning from a crisis: a qualitative study of the impact on mothers' emotional wellbeing of changes to maternity care during the COVID-19 pandemic in England, using the National Maternity Survey 2020.

BACKGROUND: Pregnancy and the postnatal period can be times of psychosocial stress and insecurity, but high quality maternity care and social support can help mothers cope with stress and feel more secure. The COVID-19 pandemic and associated social and economic disruption increased rates of antenatal and postnatal stress, anxiety and depression, and also had profound impacts on the organisation of maternity services in England. METHODS: This was a qualitative descriptive study of the impact of pandemic-related changes to maternity care on mothers' emotional wellbeing, using inductive thematic analysis of open text responses to the National Maternity Survey (NMS) 2020 in England. A random sample of 16,050 mothers who gave birth 11-24th May 2020 were invited to take part in the survey, and 4,611 responded, with 4,384 answering at least one open text question. RESULTS: There were three themes: 'Chaos: impact of uncertainty', 'Abandoned: impact of reduction in care', and 'Alone: impact of loss of social support'. Mothers valued maternity care and many experienced additional stress from chaotic changes and reduction in care during the pandemic; from health professionals' own uncertainty and anxiety; and from restrictions on essential social support during pregnancy, labour and birth. Others felt that health professionals had communicated and cared for them well despite the changes and restrictions, and these mothers felt psychologically safe. CONCLUSIONS: Planning for future crises should include considering how necessary adaptations to care can be implemented and communicated to minimise distress; ensuring that mothers are not deprived of social support at the time when they are at their most vulnerable; and supporting the psychological welfare of staff at a time of enormous pressure. There are also lessons for maternity care in 'normal' times: that care is highly valued, but trust is easily lost; that some mothers come into the maternity system with vulnerabilities that can be ameliorated or intensified by the attitudes of staff; that every effort should be made to welcome a mother's partner or chosen companion into maternity care; and that high quality postnatal care can make a real difference to mothers' wellbeing.

'She come like a sister to me': a qualitative study of volunteer social support for disadvantaged women in the transition to motherhood in England.

This qualitative study explores the ways in which disadvantaged women benefit from social support from a trained volunteer during pregnancy and the postnatal period, using the theoretical frameworks of stress and coping and a multi-dimensional model of social support. Forty-seven mothers took part in semi-structured interviews. The mothers, who had received social support through nine volunteer projects in England, faced many potentially stressful challenges besides having a baby (such as poverty, poor housing, histories of abuse, motherhood at a young age, living with physical or mental health difficulties, migration and insecure immigration status). Analysis was in two distinct stages: first, an inductive thematic analysis of mothers' experiences, and second, mapping of the results onto the theoretical frameworks chosen. Volunteers built relationships of trust with mothers and gave skilled emotional support, positive appraisal support, informational support and practical support according to mothers' individual needs, thereby assisting mothers exposed to multiple stressors with problem-focused, emotion-focused and perception-focused coping. This helped to reduce social isolation, increase effective access to services and community resources, and build mothers' confidence, self-esteem and self-efficacy. Volunteer social support may have particular salience for mothers who lack structural support and need skilled functional support. This article is part of the theme issue 'Multidisciplinary perspectives on social support and maternal-child health'.

Challenges of a simplified opt-out consent process in a neonatal randomised controlled trial: qualitative study of parents' and health professionals' views and experiences.

BACKGROUND: More effective recruitment strategies like alternative approaches to consent are needed to facilitate adequately powered trials. Witholding Enteral feeds Around Transfusion was a multicentre, randomised, pilot trial that compared withholding and continuing feeds around transfusion. The primary clinical outcome was necrotising enterocolitis. The trial used simplified opt-out consent with concise parent information and no consent form. OBJECTIVE: To explore the views and experiences of parents and health professionals on the acceptability and feasibility of opt-out consent in randomised comparative effectiveness trials. METHODS: A qualitative, descriptive interview-based study nested within a randomised trial. Semistructured interview transcripts were analysed using inductive thematic analysis. SETTING: Eleven neonatal units in England. PARTICIPANTS: Eleven parents and ten health professionals with experience of simplified consent. RESULTS: Five themes emerged: 'opt-out consent operationalised as verbal opt-in consent', 'opt-out consent normalises participation while preserving parental choice', 'opt-out consent as an ongoing process of informed choice', 'consent without a consent form' and 'choosing to opt out of a comparative effectiveness trial', with two subthemes: 'wanting "normal care"' and 'a belief that feeding is better'. CONCLUSION: Introducing a novel form of consent proved challenging in practice. The principle of a simplified, opt-out approach to consent was generally considered feasible and acceptable by health professionals for a neonatal comparative effectiveness trial. The priority for parents was having the right to decide about trial participation, and they did not see opt-out consent as undermining this. Describing a study as 'opt-out' can help to normalise participation and emphasise that parents can withdraw consent.

A qualitative study of first time mothers' experiences of postnatal social support from health professionals in England.

PROBLEM: Many women experience the transition to motherhood as stressful and find it challenging to cope, contributing to poor emotional wellbeing. BACKGROUND: Postnatal social support from health professionals can support new mothers in coping with this transition, but their social support role during the postnatal period is poorly defined. AIM: To explore how first time mothers in England experienced social support from health professionals involved in their postnatal care. METHODS: A qualitative descriptive study, theoretically informed by phenomenological social psychology, based on semi-structured, in-depth interviews with 32 mothers from diverse backgrounds. These were analysed using inductive thematic analysis, with themes subsequently mapped on to the four dimensional model of social support (emotional, appraisal, informational, practical). FINDINGS: There were nine themes connected to social support, with the strongest mapping to appraisal and informational support: for appraisal support, 'Praise and validation', 'Criticism and undermining', and 'Made to feel powerless'; for informational support, 'Is this normal?', 'Need for proactive information', and 'Confusion about postnatal care'; for emotional support, 'Treated as an individual and heard' and 'Impersonal care and being ignored'; for practical support, 'Enabling partners to provide practical support'. CONCLUSIONS: Health professionals can play an important role postnatally in helping first time mothers to cope, develop confidence and to thrive, by taking every opportunity to give appropriate and personalised appraisal, informational and emotional social support alongside clinical care. Training and professional leadership may help to ensure that all health professionals are able and expected to offer the positive social support already offered by some.

First-Time Mothers' Expectations and Experiences of Postnatal Care in England.

Postnatal care is the aspect of maternity care with which women in England are least satisfied. Little is known about first-time mothers' expectations of postnatal care, or how these expectations relate to their experiences and appraisal of care. Thirty-two first-time mothers took part in a longitudinal qualitative descriptive study, based on two semi-structured interviews-the first in pregnancy, and the second 2 to 3 months after birth. Trajectory analysis was used to identify the thematic patterns in the relationships between postnatal care expectations, needs, experiences, and confidence. Five trajectories were identified, showing that mothers' satisfaction with postnatal care and confidence were primarily influenced not by the extent to which their expectations were met but the varied extent to which their individual postnatal needs were met. Rapid and responsive assessment of needs both antenatally and postnatally, and appropriate adjustment of care, is key in supporting women effectively at this time.

Women's ideal and real expectations of postnatal care during their first pregnancy: An online survey in England.

BACKGROUND: There are many studies of women's experiences of care during the postnatal period, however little is known about women's expectations of postnatal care. OBJECTIVE: This study explores first-time pregnant women's expectations, both ideal and real life, of postnatal care in England. DESIGN: a descriptive, cross-sectional online survey design was used. The questionnaire took approximately 10 minutes to complete and was developed specifically for this survey. It included an informed consent section, socio-demographic questions and closed tick-box questions on where they had received information on postnatal care, and real and ideal expectations of postnatal care in hospital/birth centre and at home. SETTING: The survey was hosted on the National Perinatal Epidemiology Unit website and advertised through a number of third sector and commercial organisations in 2017. PARTICIPANTS: Women who were pregnant, had not given birth before, were aged 16 years and over, and living in England were eligible to participate. ANALYSIS: Survey data were analysed using descriptive statistics and, where appropriate, chi square test using SPSS Version 23. Data from open ended questions were analysed by two researchers separately then codes and themes were discussed until consensus was reached. RESULTS: 283 women responded to the survey of whom 200 were eligible and included in the analysis. Most had received information on postnatal care from multiple sources, with pregnancy classes and midwives being most common. Most expected to stay one day or less in hospital or birth centre after normal delivery. Real life expectations were lower than ideal expectations, and hospital/birth centre real life expectations were higher than home real life expectations for physical health advice/checks and information/help with feeding. Categories developed from the open text answers were 'Respect, compassion and individualised care at a vulnerable time', 'The ward environment', 'Feeling ready for hospital discharge' and 'Help to find support in the community'. KEY CONCLUSIONS: Women in this survey had high ideal world expectations of their postnatal care but in real life expected more focus on checking on their health and that of their baby and on giving information about the new challenges of how to breastfeed and look after a baby. While women valued checks of their health and that of their baby, ideally they wanted easy access to reassurance that they were feeding and looking after their baby well, that they were 'doing it right', and that what was happening to them was normal. IMPLICATIONS FOR PRACTICE: As well as the necessary checks in the immediate postpartum period, consideration also needs to be given to the best way to meet the informational and support needs of women to optimise their wellbeing and transition to parenthood. A number of resources are used by women that could be enhanced to inform expectations of postnatal care and to provide valuable information to support their postnatal care.

"Reassurance that you're doing okay, or guidance if you're not": A qualitative descriptive study of pregnant first time mothers' expectations and information needs about postnatal care in England.

OBJECTIVE: To explore what first time mothers in England expect from postnatal care while they are pregnant, what they would ideally like, where they get their information on postnatal care, and their views on the sufficiency of this information. DESIGN: A qualitative descriptive interview-based study. SETTING: England PARTICIPANTS: A maximum variation sample of 40 women who were currently in the third trimester of pregnancy; aged 16 or over; planning to give birth in England and had not given birth previously. METHODS: Semi structured interviews were carried out between October 2017 and March 2018, by telephone (n = 32) and face to face (n = 8). Interviews were analysed using thematic analysis. RESULTS: There were six themes and twelve subthemes. The themes were: (1) 'Piecing together snippets of information' containing subthemes 'Incomplete official sources' and 'Other mothers' stories'; (2) 'Planning ahead or going with the flow' containing subthemes 'Wanting more information' and 'Postnatal care not a priority'; (3) 'Judgement or reassurance' containing subthemes 'Real: Being judged', 'Ideal: Reassurance and non-judgmental advice'; (4) 'Focus of care' containing subthemes 'Real: A focus on checks and feeding', 'Ideal: More focus on mother's wellbeing'; (5) 'A system under pressure' containing subthemes 'Real: Busy midwives, reactive care', 'Ideal: Reliable, proactive information'; (6) 'Deciding about discharge', containing subthemes 'Real: Confusion about decision-making', 'Ideal: More control over length of hospital stay'. KEY CONCLUSIONS: First time mothers' experience of the transition to parenthood could be improved by antenatal access to comprehensive information about the timing, location, content and purpose of postnatal care. Information should take a woman-centred perspective and cover all settings (hospitals, birth centres, home, community), including the roles and responsibilities of all the professionals who may be involved. IMPLICATIONS FOR PRACTICE: Clear and comprehensive information about postnatal care should be provided to all women in ways that are accessible at any stage of pregnancy or the postnatal period. As women pregnant for the first time worry about being judged if they seek professional advice and reassurance postnatally, information about postnatal care should aim to address this.

First genetic evidence that invasive bullhead (Cottus L. 1758) in Scotland is of English origin and the difficulty of resolving the European Cottus species taxonomy.

The European bullhead (Cottus gobio) is widely distributed across Europe, and within the UK is native to England and Wales, where it is protected under the Habitats Directive. In Scotland, however, the species is considered invasive and thriving populations are recorded in the Forth and Clyde river catchments, and the Ale Water in the Scottish Borders. The genetic identity of the Scottish populations has not been established. There is also debate about the status of the European bullhead and its validity as single species, a species complex with several unresolved species, or distinct different species in its European distribution range. There is therefore a need to determine the taxonomy and likely source of the novel Scottish populations. Genetic analyses using cytochrome oxidase 1 (COI) mitochondrial DNA sequences were undertaken on specimens from the Forth and Clyde catchments, and combined with the results of morphological characteristics to provide a comprehensive assessment of the taxonomic classification for Scottish bullheads. There was considerable variation in morphological characteristics between populations within Scotland and a wider range of variability than previously recorded for English populations. Genetically the Scottish populations were very closely related to English specimens, supporting the hypothesis of introduction directly from England to Scotland. In terms of broader relationships, Scottish specimens are genetically more closely related to the ostensible species Chabot fluviatile Cottus perifretum, which has been suggested as one of a complex of species across Europe. Morphologically they exhibit characteristics on the spectrum between C. perifretum and C. gobio. There is an urgent need for the clarification of the taxonomy of Cottus sp(p). to avoid confusion in future publications, legislation and management practices relating to bullheads throughout the UK and Europe.

The WHEAT pilot trial-WithHolding Enteral feeds Around packed red cell Transfusion to prevent necrotising enterocolitis in preterm neonates: a multicentre, electronic patient record (EPR), randomised controlled point-of-care pilot trial.

INTRODUCTION: Necrotising enterocolitis (NEC) is a potentially devastating neonatal disease. A temporal association between red cell transfusion and NEC is well described. Observational data suggest that withholding enteral feeds around red cell transfusions may reduce the risk of NEC but this has not been tested in randomised trials; current UK practice varies. Prevention of NEC is a research priority but no appropriately powered trials have addressed this question. The use of a simplified opt-out consent model and embedding trial processes within existing electronic patient record (EPR) systems provide opportunities to increase trial efficiency and recruitment. METHODS AND ANALYSIS: We will undertake a randomised, controlled, multicentre, unblinded, pilot trial comparing two care pathways: continuing milk feeds (before, during and after red cell transfusions) and withholding milk feeds (for 4 hours before, during and for 4 hours after red cell transfusions), with infants randomly assigned with equal probability. We will use opt-out consent. A nested qualitative study will explore parent and health professional views. Infants will be eligible if born at <30+0 gestational weeks+days. Primary feasibility outcomes will be rate of recruitment, opt-out, retention, compliance, data completeness and data accuracy; clinical outcomes will include mortality and NEC. The trial will recruit in two neonatal networks in England for 9 months. Data collection will continue until all infants have reached 40+0 corrected gestational weeks or neonatal discharge. Participant identification and recruitment, randomisation and all trial data collection will be embedded within existing neonatal EPR systems (BadgerNet and BadgerEPR); outcome data will be extracted from routinely recorded data held in the National Neonatal Research Database. ETHICS AND DISSEMINATION: This study holds Research Ethics Committee approval to use an opt-out approach to consent. Results will inform future EPR-embedded and data-enabled trials and will be disseminated through conferences, publications and parent-centred information. TRIAL REGISTRATION NUMBER: ISRCTN registry ISRCTN62501859; Pre-results.

"Being the best person that they can be and the best mum": a qualitative study of community volunteer doula support for disadvantaged mothers before and after birth in England.

BACKGROUND: Disadvantaged pregnant women and new mothers are at increased risk of psychosocial stress, anxiety and depression. As well as affecting birth outcomes and child development, poor maternal emotional wellbeing can inhibit the development of parenting self-efficacy and successful adjustment to the maternal role. Social support is a protective factor against antenatal and postnatal depression, anxiety and stress, and improves mothers' confidence in infant care. Community doula programmes have been developed to meet the social support and information needs of disadvantaged women. In these programmes trained volunteer doulas support mothers during pregnancy, at birth and for a short period postnatally. METHODS: This was a descriptive qualitative study, informed by phenomenological social psychology, exploring mothers' and doulas' experiences of antenatal and postnatal community doula support. Semi-structured qualitative interviews were undertaken with 13 disadvantaged mothers and 19 doulas at three community volunteer doula projects in England. Interviews were audio-recorded and transcripts were analysed using inductive thematic analysis. RESULTS: The overarching theme emerging from the analysis was "Supporting the mother to succeed and flourish". There were five subthemes: "Overcoming stress, anxiety and unhappiness", "Becoming knowledgeable and skilful", "Developing self-esteem and self-efficacy", "Using services effectively", and "Becoming locally connected". Doulas believed that their community role was at least as important as their role at births. Their support was highly valued by vulnerable mothers and helped to improve their parenting confidence and skills. CONCLUSIONS: Volunteer doula support before and after birth can have a positive impact on maternal emotional wellbeing, by reducing anxiety, unhappiness and stress, and increasing self-esteem and self-efficacy. Doulas help mothers feel more knowledgeable and skilful, support them to make effective use of maternity services, and enable them to build social ties in their community. To facilitate the best service for vulnerable mothers at the end of doula support, doula projects should consider formalising their relationship with other community organisations that can offer ongoing one-to-one or group support. They might also alleviate some of the potential distress caused by the ending of the doula relationship by increasing the flexibility of the ending, or by organising or permitting informal low level contact.

Maternity experiences of mothers with multiple disadvantages in England: A qualitative study.

BACKGROUND: Disadvantaged mothers and their babies are at increased risk of poor perinatal outcomes and have less positive experiences of maternity care. AIM: To explore the maternity care experiences of mothers with multiple disadvantages. METHODS: A qualitative descriptive study based on semi-structured interviews with 40 mothers with multiple disadvantages, using thematic analysis. FINDINGS: Four themes emerged: 'A confusing and frightening time', 'Longing to be respected as an individual', 'The importance of choice and control', and 'Needing trust to feel safe'. Mothers brought feelings of powerlessness and low self-esteem to their encounters with maternity professionals, which could be significantly worsened by disrespectful care. They needed support to navigate the complex maternity system. Positive experiences were much more likely where the mother had received continuity of care from a specialist midwife or small team. DISCUSSION AND CONCLUSION: Mothers with multiple disadvantages value being treated as an individual, making informed choices, and feeling safe, but they may lack the confidence to ask questions or challenge disrespectful treatment. Training and supervision should enable maternity professionals to understand how confusing maternity care can be to very disadvantaged mothers. It should emphasise the need to provide accessible and empowering information and guidance to enable all mothers to make choices and understand the system. Leaders of maternity services need to do more to challenge negative staff attitudes and ensure that that all mothers are treated at all times with kindness, respect and dignity. Specialist midwives can deliver a high quality service to mothers experiencing multiple disadvantages.

A qualitative study of volunteer doulas working alongside midwives at births in England: Mothers' and doulas' experiences.

OBJECTIVE: to explore trained volunteer doulas' and mothers' experiences of doula support at birth and their perceptions of how this related to the midwife's role. DESIGN: a qualitative descriptive study, informed by phenomenological social psychology. METHODS: semi-structured interviews were carried out between June 2015 and March 2016. Interview transcripts were analysed using inductive thematic analysis. SETTING: three community volunteer doula projects run by third sector organisations in England. PARTICIPANTS: 19 volunteer doulas and 16 mothers who had received doula support during labour. FINDINGS: three overarching themes emerged: (1) 'the doula as complementary to midwives', containing subthemes 'skilled physical and emotional support', 'continuous presence', 'woman-centred support', 'ensuring mothers understand and are understood' and 'creating a team for the mother'; (2)'the doula as a colleague to midwives', containing subthemes 'welcomed as a partner', 'co-opted to help the midwives', and 'doulas identify with the midwives'; and (3) 'the doula as challenge to midwives', containing subthemes 'confusion about the doula's role', 'defending informed choice', and 'counterbalancing disempowering treatment'. KEY CONCLUSIONS&IMPLICATIONS FOR PRACTICE: volunteer doulas can play an important role in improving women's birth experiences by offering continuous, empowering, woman-focused support that complements the role of midwives, particularly where the mothers are disadvantaged. Greater clarity is needed about the scope of legitimate volunteer doula advocacy on behalf of their clients, to maximise effective working relationships between midwives and doulas.

'We both just wanted to be normal parents': a qualitative study of the experience of maternity care for women with learning disability.

BACKGROUND: More women with learning disability (LD) are becoming mothers. Women with LD have rights to equal access to maternity care that meets their needs, however, many have poor pregnancy and birth outcomes compared to other women in the UK. Research is limited in this area. OBJECTIVES: The aim of the study was to explore the lived experiences of pregnancy, childbirth, prenatal and postnatal care and services received by this group of women in the UK, including their expressed information and support needs relating to maternity care. METHODS: A qualitative study in which data were generated using in-depth semistructured interviews with learning disabled women who were pregnant or had given birth within the last 3 years in the UK; data were analysed using interpretative phenomenological analysis. RESULTS: 9 women with varying levels of cognitive impairment took part. 4 super-ordinate themes were identified: 'I hate being treated differently', 'I find it harder to understand than other people', 'We've had to prove ourselves' and 'Make sure you've got very good support around you'. Subthemes included: 'Negative attitudes and denial of choice', 'Understanding of normal care', 'Written information' and 'Being judged by professionals'. CONCLUSIONS: With support from family and services, learning disabled women can become confident and successful parents. Maternity services should make reasonable adjustments when providing care to this group, including adapting to their individual communication and learning needs: allowing sufficient time in appointments, offering clear explanations of each aspect of care and sensitive support for autonomy and fully informed choice. Mothers who will be subject to a social care assessment of their parenting skills need clear information about the process, their choices and the level of skill they must demonstrate, as well as access to sufficient antenatal and postnatal support to give them the best possible chance of passing the assessment.

Mothers' accounts of the impact on emotional wellbeing of organised peer support in pregnancy and early parenthood: a qualitative study.

BACKGROUND: The transition to parenthood is a potentially vulnerable time for mothers' mental health and approximately 9-21% of women experience depression and/or anxiety at this time. Many more experience sub-clinical symptoms of depression and anxiety, as well as stress, low self-esteem and a loss of confidence. Women's emotional wellbeing is more at risk if they have little social support, a low income, are single parents or have a poor relationship with their partner. Peer support can comprise emotional, affirmational, informational and practical support; evidence of its impact on emotional wellbeing during pregnancy and afterwards is mixed. METHODS: This was a descriptive qualitative study, informed by phenomenological social psychology, exploring women's experiences of the impact of organised peer support on their emotional wellbeing during pregnancy and in early parenthood. Semi-structured qualitative interviews were undertaken with women who had received peer support provided by ten projects in different parts of England, including both projects offering 'mental health' peer support and others offering more broadly-based peer support. The majority of participants were disadvantaged Black and ethnic minority women, including recent migrants. Interviews were audio-recorded and transcripts were analysed using inductive thematic analysis. RESULTS: 47 mothers were interviewed. Two key themes emerged: (1) 'mothers' self-identified emotional needs', containing the subthemes 'emotional distress', 'stressful circumstances', 'lack of social support', and 'unwilling to be open with professionals'; and (2) 'how peer support affects mothers', containing the subthemes 'social connection', 'being heard', 'building confidence', 'empowerment', 'feeling valued', 'reducing stress through practical support' and 'the significance of "mental health" peer experiences'. Women described how peer support contributed to reducing their low mood and anxiety by overcoming feelings of isolation, disempowerment and stress, and increasing feelings of self-esteem, self-efficacy and parenting competence. CONCLUSION: One-to-one peer support during pregnancy and after birth can have a number of interrelated positive impacts on the emotional wellbeing of mothers. Peer support is a promising and valued intervention, and may have particular salience for ethnic minority women, those who are recent migrants and women experiencing multiple disadvantages.

"I didn't think we'd be dealing with stuff like this": A qualitative study of volunteer support for very disadvantaged pregnant women and new mothers.

OBJECTIVE: to identify the particular issues associated with volunteer support for very disadvantaged mothers (who were young, had insecure immigration status, were recent migrants whose English was poor,misused drugs or alcohol, or were involved in crime), from the perspective of the volunteers. DESIGN: a qualitative descriptive study, informed by phenomenological social psychology. Semi-structured qualitative interviews were carried out between July 2013 and March 2015. Interview transcripts were analysed using inductive thematic analysis. SETTING: nine volunteer support projects for pregnant women and new mothers, run by third sector organisations in England. PARTICIPANTS: 38 volunteer supporters. MEASUREMENTS AND FINDINGS: three key themes were identified: 'Meeting challenges', 'Needing support' and 'Identifying successes'. 'Meeting challenges' contained the subthemes 'making the relationship of trust','remaining non-judgemental', 'maintaining boundaries' and 'dealing with child protection'. 'Needing support' contained the subthemes 'feeling prepared', 'feeling supported' and 'staying safe'. 'Identifying successes' contained the subthemes 'celebrating the small wins', 'validation as a mother', and 'supporting access to services'. KEY CONCLUSIONS: volunteers were able to build strong, empowering relationships with some very disadvantaged women during pregnancy and afterwards, including where the mothers did not readily engage with professionals. However, supporting women with complex needs is emotionally challenging and volunteers need to be carefully selected, realistically trained and robustly supervised and supported during their volunteering. IMPLICATIONS FOR PRACTICE: third sector organisations offering volunteer support for pregnant women and new mothers can be valuable partners in reaching very disadvantaged women who may find it difficult to engage with services. Volunteers can build up a relationship of trust with vulnerable mothers over time, but need to be well supported to do this safely and effectively.

Evaluation of trained volunteer doula services for disadvantaged women in five areas in England: women's experiences.

Disadvantaged childbearing women experience barriers to accessing health and social care services and face greater risk of adverse medical, social and emotional outcomes. Support from doulas (trained lay women) has been identified as a way to improve outcomes; however, in the UK doula support is usually paid-for privately by the individual, limiting access among disadvantaged groups. As part of an independent multi-site evaluation of a volunteer doula service, this study examined women's experiences of one-to-one support from a trained volunteer doula during pregnancy, labour and the post-natal period among women living in five low-income communities in England. A mixed methods multi-site evaluation was conducted with women (total n = 137) who received the service before December 2012, using a combination of questionnaires (n = 136), and individual or group interviews (n = 12). Topics explored with women included the timing and nature of support, its impact, the relationship with the doula and negative experiences. Most women valued volunteer support, describing positive impacts for emotional health and well-being, and their relationships with their partners. Such impacts did not depend upon the volunteer's presence during labour and birth. Indeed, only half (75/137; 54.7%) had a doula attend their birth. Many experienced volunteer support as a friendship, distinct from the relationships offered by healthcare professionals and family. This led to potential feelings of loss in these often isolated women when the relationship ended. Volunteer doula support that supplements routine maternity services is potentially beneficial for disadvantaged women in the UK even when it does not involve birth support. However, the distress experienced by some women at the conclusion of their relationship with their volunteer doula may compromise the service's impact. Greater consideration is needed for managing the ending of a one-to-one relationship with a volunteer, particularly given the likelihood of it coinciding with a period of heightened emotional vulnerability.

'The greatest feeling you get, knowing you have made a big difference': survey findings on the motivation and experiences of trained volunteer doulas in England.

BACKGROUND: Support from a doula is known to have physical and emotional benefits for mothers, but there is little evidence about the experiences of volunteer doulas. This research aimed to understand the motivation and experiences of volunteer doulas who have been trained to support women during pregnancy, birth and the postnatal period. METHODS: A postal questionnaire survey was sent to volunteer doulas at five volunteer doula projects working in low-income areas in England. Quantitative and qualitative data were analysed in parallel using summary statistics and content analysis respectively. RESULTS: Eighty-nine volunteer doulas (response rate 34.5 %) from diverse backgrounds responded to the survey. Major motivators for volunteering included a desire to help others and, to a lesser extent, factors related to future employment. Most reported that the training was effective preparation for their role. They continued volunteering because they derived satisfaction from the doula role, and valued its social aspects. Their confidence, skills, employability and social connectedness had all increased, but many found the ending of the doula-mother relationship challenging. For a minority, negative aspects of their experience included time waiting to be allocated women to support and dissatisfaction with the way the doula service was run. DISCUSSION AND CONCLUSIONS: Most respondents found the experience rewarding. To maintain doulas' motivation as volunteers, services should: ensure doulas can start supporting women as soon as possible after completing the training; consider the merits of more flexible endings to the support relationship; offer opportunities for ongoing mutual support with other doulas, and ensure active support from service staff for volunteers.

'We have beaten HIV a bit': a qualitative study of experiences of peer support during pregnancy with an HIV Mentor Mother project in England.

OBJECTIVES: To explore the experiences of women living with HIV in England who received or gave Mentor Mother (trained mother-to-mother) volunteer peer support during pregnancy and early motherhood. DESIGN: Qualitative descriptive study, using semistructured, in-depth interviews and inductive thematic analysis, theoretically informed by phenomenological social psychology. SETTING: A London-based third sector peer support organisation for people living with HIV. PARTICIPANTS: 12 women living with HIV who had given or received Mentor Mother volunteer peer support (6 had given support and 6 had received support). 11 were black African. RESULTS: The key themes in participants' descriptions of their lives as pregnant women and mothers living with HIV were 'fear and distress', 'stigma and isolation' and 'the gap in maternity care'. The key themes related to Mentor Mother peer support during and after pregnancy were 'support to avoid mother-to-child transmission' (with subthemes 'reinforcing medical advice', 'reframing faith issues', 'prioritisation and problem-solving' and 'practical strategies for managing HIV and motherhood'), and 'emotional support' (with subthemes 'role modelling and inspiring hope', 'openness and non-judgemental acceptance', 'a caring relationship', 'recreating the lost family network', 'being understood from the inside' and 'self-confidence'). The Mentor Mothers' support appeared to be a successful hybrid between the peer education Mentor Mothers programmes in southern Africa and the more general pregnancy volunteer peer support models operating in England. CONCLUSIONS: A Mentor Mother peer support programme is acceptable to, and valued by, black African mothers with HIV in England. Peer support from trained volunteers during and after pregnancy can complement and reinforce medical advice on avoiding mother-to-child transmission of HIV, and can have a multidimensional positive impact on vulnerable mothers' emotional well-being. Mentor Mother peer support should be considered by those designing programmes for the support of pregnant women with HIV and the prevention of mother-to-child transmission of HIV.