Dr Juliet Rayment

This study examined the main factors that influence B angladeshi women living in L ondon's decisions to partially breastfeed their children, including the influence of older women within the community. Fifty‐seven women of B angladeshi origin living in the L ondon B orough of T ower H amlets took part in seven discussion groups between A pril and J une 2013. Five groups were held with women of child‐bearing age and two groups with older women in the community. A further eight younger women and three older women took part in one‐on‐one interviews. Interviews were also carried out with eight local health care workers, including public health specialists, peer support workers, breastfeeding coordinators and a health visitor. The influences on women's infant feeding choices can be understood through a ‘socio‐ecological model’, including public health policy; diverse cultural influences from B angladesh, London and the B angladeshi community in L ondon; and the impacts of migration and religious and family beliefs. The women's commitment to breastfeeding was mediated through the complexity of their everyday lives. The tension between what was ‘best’ and what was ‘possible’ leads them not only to partially breastfeed but also to sustain partial breastfeeding in a way not seen in other socio‐cultural groups in the United Kingdom.

Aim: To test the feasibility of introducing a group antenatal care initiative (Pregnancy Circles) in an area with high levels of social deprivation and cultural diversity by exploring the views and experiences of midwives and other maternity care providers in the locality before and after the implementation of a test run of the group model. Design: (i) Pre-implementation semi-structured interviews with local stakeholders. (ii) Post-implementation informal and semi-structured interviews and a reflective workshop with facilitating midwives, and semi-structured interviews with maternity managers and commissioners. Data were organised around three core themes of organisational readiness, the acceptability of the model, and its impact on midwifery practice, and analyzed thematically. Setting: A large inner-city National Health Service Trust in the United Kingdom. Participants: Sixteen stakeholders were interviewed prior to, and ten after, the group model was implemented. Feedback was also obtained from a further nine midwives and one student midwife who facilitated the Pregnancy Circles. Intervention: Four Pregnancy Circles in community settings. Women with pregnancies of similar gestation were brought together for antenatal care incorporating information sharing and peer support. Women undertook their own blood pressure and urine checks, and had brief individual midwifery checks in the group space. Findings: Dissatisfaction with current practice fuelled organisational readiness and the intervention was both possible and acceptable in the host setting. A perceived lack of privacy in a group setting, the ramifications of devolving blood pressure and urine checks to women, and the involvement of partners in sessions were identified as sticking points. Facilitating midwives need to be adequately supported and trained in group facilitation. Midwives derived accomplishment and job satisfaction from working in this way, and considered that it empowered women and enhanced care. Key conclusions: Participants reported widespread dissatisfaction with current care provision. Pregnancy Circles were experienced as a safe environment in which to provide care, and one that enabled midwives to build meaningful relationships with women. Implications for practice: Pre-registration education inadequately prepared midwives for group care. Addressing sticking points and securing management support for Pregnancy Circles is vital to sustain participation in this model of care.

Alongside midwifery units (AMUs) are managed by midwives and proximate to obstetric units (OUs), offering a home-like birth environment for women with straightforward pregnancies. They support physiological birth, with fast access to medical care if needed. AMUs have good perinatal outcomes and lower rates of interventions than OUs. In England, uptake remains lower than potential use, despite recent changes in policy to support their use. This article reports on experiences of access from a broader study that investigated AMU organisation and care. Organisational case studies in four National Health Service (NHS) Trusts in England, selected for variation geographically and in features of their midwifery units. Fieldwork (December 2011 to October 2012) included observations (>100 h); semi-structured interviews with staff, managers and stakeholders (n = 89) and with postnatal women and partners (n = 47), on which this paper reports. Data were analysed thematically using NVivo10 software. Women, partners and families felt welcome and valued in the AMU. They were drawn to the AMUs’ environment, philosophy and approach to technology, including pain management. Access for some was hindered by inconsistent information about the existence, environment and safety of AMUs, and barriers to admission in early labour. Key barriers to AMUs arise through inequitable information and challenges with admission in early labour. Most women still give birth in obstetric units and despite increases in the numbers of women birthing on AMUs since 2010, addressing these barriers will be essential to future scale-up.

Objective: the objective of the Birthplace in England Case Studies was to explore the organisational and professional issues that may impact on the quality and safety of labour and birth care in different birth settings: Home, Freestanding Midwifery Unit, Alongside Midwifery Unit or Obstetric Unit. This analysis examines the factors affecting the readiness of community midwives to provide women with choice of out of hospital birth, using the findings from the Birthplace in England Case Studies. Design: organisational ethnographic case studies, including interviews with professionals, key stakeholders, women and partners, observations of service processes and document review. Setting: a maximum variation sample of four maternity services in terms of configuration, region and population characteristics. All were selected from the Birthplace cohort study sample as services scoring 'best' or 'better' performing in the Health Care Commission survey of maternity services (HCC 2008). Participants: professionals and stakeholders (n=86), women (64), partners (6), plus 50 observations and 200 service documents. Findings: each service experienced challenges in providing an integrated service to support choice of place of birth. Deployment of community midwives was a particular concern. Community midwives and managers expressed lack of confidence in availability to cover home birth care in particular, with the exception of caseload midwifery and a 'hub and spoke' model of care. Community midwives and women's interviews indicated that many lacked home birth experience and confidence. Those in midwifery units expressed higher levels of support and confidence. Key conclusions and implications for practice: maternity services need to consider and develop models for provision of a more integrated model of staffing across hospital and community boundaries.

Objective: The aim of this study was to explore midwifery students and health visitor practice mentors experiences of a health visiting placement for midwifery students, focusing on the student-mentor relationship. Design: Interview study Setting: East London, United Kingdom Participants: Eighteen students and eighteen mentors were invited to take part in an interview. Ten midwifery students (55.5%) and fifteen health visitor practice mentors (83.3%) took part in interviews or provided information via email. Thematic analysis was used to analyse findings. Findings: The main study finding was that students reported valuing practice mentors who took the time to get to know them, were welcoming and enthusiastic and planned their time in advance. The mentors in turn spoke highly of the students who were keen and enthusiastic about the placement, but noted that not all students had appeared interested. Key conclusions: The findings from this small interview study show that taking time to make the students feel welcome was important to facilitate a student-mentor relationship. Another important factor in whether a student enjoyed their placement was the mentors' advance planning.

BackgroundThe prevalence of anaemia in pregnancy in Europe is 25% and that resulting from iron deficiency is estimated at 40%. The maternal and fetal morbidity of non-anaemic iron deficiency (NAID) in pregnancy is likely to be significant. ObjectivesTo determine the views and opinions of health service users and clinicians concerning NAID in pregnancy in order to inform future research. MethodsTwo semi-structured focus groups were carried out to determine health service users' views on anaemia and NAID in pregnancy. A questionnaire was administered to obstetricians, haematologists, midwives and anaesthetists to elucidate their views on NAID in pregnancy. ResultsThe study indicated that health service users and clinicians were interested in implementing testing for NAID in pregnancy with serum ferritin, if proven to be effective at reducing the effects of anaemia and improving maternal and neonatal outcomes. Clinicians had reservations in the use of intravenous iron supplementation for NAID in pregnancy. ConclusionNAID is now accepted as a target condition for research by health service users and clinicians. The focus of future research should be on screening for NAID and its treatment.

This article is based on analysis of a series of ethnographic case studies of midwifery units in England. Midwifery units(1) are spaces that were developed to provide more home-like and less me dically oriented care for birth that would support physiological processes of labour, women's comfort and a positive experience of birth for women and their families. They are run by midwives, either on a hospital site alongside an obstetric unit (Alongside Midwifery Unit - AMU) or a freestanding unit away from an obstetric unit (Freestanding Midwifery Unit - FMU). Midwifery units have been designed and intended specifically as locations of wellbeing and although the meaning of the term is used very loosely in public discourse, this claim is supported by a large epidemiological study, which found that they provide safe care for babies while reducing use of medical interventions and with better health outcomes for the women. Our research indicated that midwifery units function as a protected space, one which uses domestic features as metaphors of home in order to promote a sense of wellbeing and to re-normalise concepts of birth, which had become inhabited by medical models and a preoccupation with risk. However, we argue that this protected space has a function for midwives as well as for birthing women. Midwifery units are intended to support midwives' wellbeing following decades of professional struggles to maintain autonomy, midwife-led care(2) and a professional identity founded on supporting normal, healthy birth. This development, which is focused on place of birth rather than other aspects of maternity care such as continuity, shows potential for restoring wellbeing on individual, professional and community levels, through improving rates of normal physiological birth and improving experiences of providing and receiving care. Nevertheless, this very focus also poses challenges for health service providers attempting to provide a 'social model of care' within an institutional context.

Aims and background: Alongside midwifery units (AMUs, also known as hospital or co-located birth centres) were identified as a novel hybrid organisational form in the Birthplace in England Research Programme. This follow-on study aimed to investigate how AMUs are organised, staffed and managed, the experiences of women, and maternity staff including those who work in AMUs and in adjacent obstetric units. This article focuses on study findings relating to the organisation and management of AMUs. Methods: An organisational ethnography approach was used, incorporating case studies of four AMUs, selected for maximum variation on the basis of geographical context, length of establishment, size of unit, leadership and physical design. Interviews were conducted between December 2011 and October 2012 with service managers and key stakeholders (n = 35), with professionals working within and in relation to AMUs (n = 54) and with postnatal women and birth partners (n = 47). Observations were conducted of key decision-making points in the service (n = 20). Findings: Managers saw four key areas as vital to developing and sustaining good quality midwifery unit care: finance and service management support, staffing, training, and appropriate guidelines. Development of AMUs was often opportunistic, with service leaders making use of service reconfigurations to achieve change, including development of MUs and new care pathways. Midwives working in AMUs valued the environment, approach and the opportunity to exercise greater clinical judgement but relations between groups of midwives in different units could be experienced as problematic. Key potential challenges for the quality, safety and sustainability of AMU care included: boundary work and management; professional issues; developing appropriate staffing models and relationships; midwives' skills and confidence; and information and access for women. Responses to such challenges included greater focus on interdisciplinary skills training, and integrated models of midwifery and care pathways. Positive leadership and appropriate development and use of guidelines were important to underpin the development and sustainability of midwifery units. Conclusions: The units studied had been developed to form a key part of the maternity service, and their role was increasingly being recognised as valid and as maintaining the quality and safety of care in the maternity service as a whole. However, each was providing birth care for only about a third of women who had been classified as eligible to plan birth outside an obstetric unit at the end of pregnancy. Developing midwifery units involves aligning physical, professional and philosophical boundaries. However, this poses challenges when managing the service, to ensure it is sustainable, of high quality and safe. In order to fulfil evidence-based guidelines on providing midwifery unit care, further attention is needed to stafftraining and support; the development of integrated, continuity-based staffing models; and ensuring AMUs are positioned as a core service rather than a marginal one.

BackgroundThere is growing interest in the benefits of group models of antenatal care. Although clinical reviews exist, there have been few reviews that focus on the mechanisms of effect of this model.MethodsWe conducted a realist review using a systematic approach incorporating all data types (including non-research and audiovisual media), with synthesis along Context-Intervention-Mechanism-Outcome (CIMO) configurations.ResultsA wide range of sources were identified, yielding 100 relevant sources in total (89 written and 11 audiovisual). Overall, there was no clear pattern of 'what works for whom, in what circumstances' although some studies have identified clinical benefits for those with more vulnerability or who are typically underserved by standard care. Findings revealed six interlinking mechanisms, including: social support, peer learning, active participation in health, health education and satisfaction or engagement with care. A further, relatively under-developed theory related to impact on professional practice. An overarching mechanism of empowerment featured across most studies but there was variation in how this was collectively or individually conceptualised and applied.ConclusionsMechanisms of effect are amplified in contexts where inequalities in access and delivery of care exist, but poor reporting of populations and contexts limited fuller exploration. We recommend future studies provide detailed descriptions of the population groups involved and that they give full consideration to theoretical underpinnings and contextual factors.RegistrationThe protocol for this realist review was registered in the International Prospective Register of Systematic Reviews (PROSPERO CRD42016036768).

Problem: Despite clinical guidelines and policy promoting choice of place of birth, 14 Freestanding Midwifery Units were closed between 2008 and 2015, closures reported in the media as justified by low use and financial constraints. Background: The Birthplace in England Programme found that freestanding midwifery units provided the most cost-effective birthplace for women at low risk of complications. Women planning birth in a freestanding unit were less likely to experience interventions and serious morbidity than those planning obstetric unit birth, with no difference in outcomes for babies. Methods: This paper uses an interpretative technique developed for policy analysis to explore the representation of these closures in 191 news articles, to explore the public climate in which they occurred. Findings and discussion: The articles focussed on underuse by women and financial constraints on services. Despite the inclusion of service user voices, the power of framing was held by service managers and commissioners. The analysis exposed how neoliberalist and austerity policies have privileged representation of individual consumer choice and market-driven provision as drivers of changes in health services. This normative framing presents the reasons given for closure as hard to refute and cultural norms persist that birth is safest in an obstetric setting, despite evidence to the contrary. Conclusion: The rise of neoliberalism and austerity in contemporary Britain has influenced the reform of maternity services, in particular the closure of midwifery units. Justifications given for closure silence other narratives, predominantly from service users, that attempt to present women's choice in terms of rights and a social model of care. (C) 2018 Published by Elsevier Ltd on behalf of Australian College of Midwives.

This paper offers a critical perspective on issues around gender and sexual transformation within the context of UK Higher Education. Drawing on qualitative data carried out by undergraduate and postgraduate students, the analysis explores some of the diverse and often challenging ways in which young/er women and men are thinking and talking about gender, sexuality and feminism, as well as their strategies for turning ideas into political action. The research focuses on the activities and opinions of students belonging to an anti-sexist organisation within one UK university, who are engaged in campaigns to raise awareness about the damaging effects of gender and sexual inequalities, as well as promoting the popular appeal of contemporary feminisms. Locating the voices and research findings of the students themselves at the centre of the discussion, the paper is produced collaboratively between students and teachers who are involved in both the activist and research elements of this project. The paper also argues for (and provides evidence of) the transformative potential of alternative and critical forms of student engagement and student/ staff collaboration in relation to gender informed academic activism.

Plain English summary When designing clinical trials it is important to involve members of the public, who can provide a view on what may encourage or prevent people participating and on what matters to them. This is known as Public and Patient Involvement (PPI). People from minority ethnic groups are often less likely to take part in clinical trials, but it is important to ensure they are able to participate fully so that health research and its findings are relevant to a wide population. We are preparing to conduct a randomised controlled trial (RCT) to test whether taking probiotic capsules can play a role in preventing preterm birth. Women from some minority ethnic groups, for example women from West Africa, and those who are from low-income groups are more likely to suffer preterm births. Preterm birth can lead to extra costs to health services and psychosocial costs for families. In this article we describe how we engaged women in discussion about the design of the planned trial, and how we aim to use our findings to ensure the trial is workable and beneficial to women, as well as to further engage service users in the future development of the trial. Four socially and ethnically diverse groups of women in East London took part in discussions about the trial and contributed their ideas and concerns. These discussions have helped to inform and improve the design of a small practice or ‘pilot’ trial to test the recruitment in a ‘real life’ setting, as well as encourage further PPI involvement for the future full-scale trial. Background Patient and public involvement (PPI) is an important tool in approaching research challenges. However, involvement of socially and ethnically diverse populations remains limited and practitioners need effective methods of involving a broad section of the population in planning and designing research. Methods In preparation for the development of a pilot randomised controlled trial (RCT) on the use of probiotics to prevent preterm birth, we conducted a public consultation exercise in a socially disadvantaged and ethnically diverse community. The consultation aimed to meet and engage local service users in considering the acceptability of the proposed protocol, and to encourage their participation in future and ongoing patient and public involvement activities. Four discussion groups were held in the community with mothers of young children within the proposed trial region, using an inclusive approach that incorporated a modified version of the Nominal Group Technique (NGT). Bringing the consultation to the community supported the involvement of often seldom-heard participants, such as those from minority ethnic groups. Results The women involved expressed a number of concerns about the proposed protocol, including adherence to the probiotic supplement regimen and randomisation. The proposal for the RCT in itself was perceived as confirmation that probiotic supplements had potentially beneficial effects, but also that they had potentially harmful side-effects. The complexity of the women’s responses provided greater insights into the challenges of even quite simple trial designs and enabled the research team to take these concerns into account while planning the pilot trial. Conclusions The use of the NGT method allowed for a consultation of a population traditionally less likely to participate in medical research. A carefully facilitated PPI exercise can allow members to express unanticipated concerns that may not have been elicited by a survey method. Findings from such exercises can be utilised to improve clinical trial design, provide insight into the feasibility of trials, and enable engagement of often excluded population groups.

The psycho-social elements of labour and delivery are central to any woman's birth experience, but international efforts to reduce maternal mortality in low-income contexts have neglected these aspects and focused on technological birth. In many contexts, maternity care is seen as dehumanised and disrespectful, which can have a negative impact on utilisation of services. We undertook a systematic review and meta-synthesis of the growing literature on women's experiences of facility-based delivery in sub-Saharan Africa to examine the drivers of disrespectful intrapartum care. Using PRISMA guidelines, databases were searched from 1990 to 06 May 2015, and 25 original studies were included for thematic synthesis. Analytical themes, that were theoretically informed and cognisant of the cultural and social context in which the dynamics of disrespectful care occur, enabled a fresh interpretation of the factors driving midwives' behaviour. A conceptual framework was developed to show how macro-, meso- and micro-level drivers of disrespectful care interact. The synthesis revealed a prevailing model of maternity care that is institution-centred, rather than woman-centred. Women's experiences illuminate midwives' efforts to maintain power and control by situating birth as a medical event and to secure status by focusing on the technical elements of care, including controlling bodies and knowledge. Midwives and women are caught between medical and social models of birth. Global policies encouraging facility-based delivery are forcing women to swap the psycho-emotional care they would receive from traditional midwives for the technical care that professional midwives are currently offering. Any action to change the current performance and dynamic of birth relies on the participation of midwives, but their voices are largely missing from the discourse. Future research should explore their perceptions of the value and practice of interpersonal aspects of maternity care and the impact of disrespectful care on their sense of professionalism and personal ethics. (C) 2016 Elsevier Ltd. All rights reserved.

Patients' contributions to safety include speaking up about their perceptions of being at risk. Previous studies have found that dismissive responses from staff discouraged patients from speaking up. A Care Quality Commission investigation of a maternity service where serious incidents occurred found evidence that women had routinely been ignored and left alone in labour. Women using antenatal services hesitated to raise concerns that they felt staff might consider irrelevant. The Birthplace in England programme, which investigated the quality and safety of different places of birth for 'low-risk' women, included a qualitative organisational case study in four NHS Trusts. The authors collected documentary, observational and interview data from March to December 2010 including interviews with 58 postnatal women. A framework approach was combined with inductive analysis using NVivo8 software. Speaking up, defined as insistent and vehement communication when faced with failure by staff to listen and respond, was an unexpected finding mentioned in half the women's interviews. Fourteen women reported raising alerts about safety issues they felt to be urgent. The presence of a partner or relative was a facilitating factor for speaking up. Several women described distress and harm that ensued from staff failing to listen. Women are speaking up, but this is not enough: organisation-focused efforts are required to improve staff response. Further research is needed in maternity services and in acute and general healthcare on the effectiveness of safety-promoting interventions, including real-time patient feedback, patient toolkits and patient-activated rapid response calls.

Introduction: The identification, communication and management of health risk is a core task of Community Health Workers who operate at the boundaries of community and primary care, often through not-forprofit community interest companies. However, there are few opportunities or resources for workforce development. Publicly funded researchers have an obligation to be useful to the public and furthermore, university funding is increasingly contingent on demonstrating the social impact of academic research. Collaborative work with participants and other stakeholders can have reciprocal benefits to all but may be daunting to some researchers, unused to such approaches. Methods: This case study is an account of the co-creation of a (freely accessible) workforce development toolkit, as part of a collaboration between academics, community interest companies, patients and services users and arts practitioners. Results: Our collaborative group produced three short films, fictionalising encounters between Community Health Workers and their clients. These were used within a series of five discussion-led workshops with facilitator guidance to explore issues generated by the films. Two collaborating community-based, not-forprofit organisations piloted the toolkit before its launch. Conclusion: We aim to encourage other academics to maximise the impact of their own research through collaborative projects with those outside of academia, including research participants and to consider the potential value of arts-based approaches to explore and facilitate reflection on complex tasks and tensions that make up daily work practices. Whilst publication of findings from such projects may be commonplace, accounts of the process are unusual. This detailed account highlights some of the benefits and challenges involved.

Problem: Childbearing women from socio-economically disadvantaged communities and minority ethnic groups are less likely to access antenatal care and experience more adverse pregnancy outcomes. Background: Group antenatal care aims to facilitate information sharing and social support. It is associated with higher rates of attendance and improved health outcomes. Aims: To assess the acceptability of a bespoke model of group antenatal care (Pregnancy Circles) in an inner city community in England, understand how the model affects women's experiences of pregnancy and antenatal care, and inform further development and testing of the model. Methods: A two-stage qualitative study comprising focus groups with twenty six local women, followed by the implementation of four Pregnancy Circles attended by twenty four women, which were evaluated using observations, focus groups and semi-structured interviews with participants. Data were analysed thematically. Findings: Pregnancy Circles offered an appealing alternative to standard antenatal care and functioned as an instrument of empowerment, mediated through increased learning and knowledge sharing, active participation in care and peer and professional relationship building. Multiparous women and women from diverse cultures sharing their experiences during Circle sessions was particularly valued. Participants had mixed views about including partners in the sessions. Conclusions: Group antenatal care, in the form of Pregnancy Circles, is acceptable to women and appears to enhance their experiences of pregnancy. Further work needs to be done both to test the findings in larger, quantitative studies and to find a model of care that is acceptable to women and their partners. (C) 2018 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.