J Wray

A qualitative study of the experiences and expectations of women receiving in-patient postnatal care in one English maternity unit

BackgroundStudies consistently highlight in-patient postnatal care as the area of maternity care women are least satisfied with. As part of a quality improvement study to promote a continuum of care from the birthing room to discharge home from hospital, we explored womens expectations and experiences of current in-patient care.MethodsFor this part of the study, qualitative data from semi-structured interviews were transcribed and analysed using content analyses to identify issues and concepts. Women were recruited from two postnatal wards in one large maternity unit in the South of England, with around 6,000 births a year.ResultsTwenty women, who had a vaginal or caesarean birth, were interviewed on the postnatal ward. Identified themes included; the impact of the ward environment; the impact of the attitude of staff; quality and level of support for breastfeeding; unmet information needs; and womens low expectations of hospital based postnatal care. Findings informed revision to the content and planning of in-patient postnatal care, results of which will be reported elsewhere.ConclusionsWomens responses highlighted several areas where changes could be implemented. Staff should be aware that how they inter-act with women could make a difference to care as a positive or negative experience. The lack of support and inconsistent advice on breastfeeding highlights that units need to consider how individual staff communicate information to women. Units need to address how and when information on practical aspects of infant care is provided if women and their partners are to feel confident on the womans transfer home from hospital.

Guideline for blood grouping and antibody testing in pregnancy

A review for the British Committee for Standards in Haematology Blood Transfusion Task Force. The purpose of the guideline is to define the red cell immunohaematology tests which should be applied in pregnancy. The aim of the testing programme is the prevention of haemolytic disease of the foetus and the newborn. Because the majority of publications use the term haemolytic disease of the newborn (HDN) to refer to both foetus and newborn, it is used here.

A review of the clinical effectiveness of routine antenatal anti-D prophylaxis for rhesus-negative women who are pregnant.

In its mildest form, haemolytic disease of the newborn is detectable only in laboratory tests. However, severe disease causes physical disabilities and often mental retardation; in its most severe form, it causes intrauterine death. Haemolytic disease of the newborn therefore has potentially very serious consequences for human health and happiness. Haemolytic disease of the newborn is caused by the transplacental passage of anti-D antibodies from a RhDnegative mother to a RhD-positive fetus. Any feto-maternal haemorrhage in a RhD-negative mother pregnant with a RhD-positive fetus, whether at or before delivery of that infant, may stimulate the production of anti-D antibodies (a process known as sensitisation). The first RhD-positive infant is not harmed if the mother is sensitised at delivery, but may be affected if the mother is sensitised during pregnancy: one study found that, of 20 infants born to primigravidae who had antibodies before or at delivery, two were moderately affected (requiring exchange transfusion) and 16 were mildly affected. Because the severity of the disease is related to the level of antibodies in the maternal blood and the length of time for which the infant is exposed to them, subsequent RhD-positive infants born to a sensitised mother are likely to be progressively more severely affected. Some women do not have detectable anti-D after the index pregnancy, but nonetheless give a secondary immune response during a later pregnancy; they are described as having been ‘sensibilised’, rather than sensitised, by the index pregnancy. Prophylactic anti-D can suppress primary RhD immunisation. Routine postpartum anti-D immunoprophylaxis was introduced in the United Kingdom in 1969. Prophylaxis was extended in 1976 to include abortions and spontaneous miscarriages, and in 1981 to include a number of other potentially sensitising events. – 4 The guidelines were updated in 1991. Despite this, some women in the United Kingdom continued to become sensitised prior to delivery of the first pregnancy. In some cases, this could be attributed to failure to adhere to existing guidelines through lack of administration of (a) any, (b) enough or (c) timely anti-D in response to potential sensitising events in pregnancy. Audits found that guidelines were followed fully in only 59% to 79% of potentially sensitising events, and in one study only 11 out of 44 RhD-negative women undergoing amniocentesis (25%) received anti-D. A questionnaire survey found that, in the early 1990s, 77% of Accident and Emergency departments in England and Wales did not have a policy for treating with anti-D women who bled in early pregnancy. However, other women, estimated at between 55% and 80% of sensitised women, appeared to be sensitised in the absence of any identifiable risk event such as should have prompted the administration of anti-D (so-called silent sensitisation). As prophylactic anti-D has no effect in women who have already developed anti-D, however weak, it appeared that the most stringent adherence to existing guidelines could not prevent some instances of sensitisation. Attention therefore turned to routine antenatal anti-D prophylaxis as a possible means of reducing sensitisation rates. Owing to the lack of clarity concerning the available evidence for routine antenatal anti-D prophylaxis, and consequent ambiguity of guidance supporting its introduction, in 2001 the UK National Institute for Clinical Excellence (NICE) commissioned a systematic review of the available evidence for the clinical and cost effectiveness of a community programme of routine antenatal anti-D prophylaxis in pregnant RhD-negative women. This article is an abridged version of the systematic review; a more detailed review of the clinical effectiveness and cost effectiveness of such a programme is contained within the monograph.

The economics of routine antenatal anti-D prophylaxis for pregnant women who are rhesus negative.

Objective  To investigate the economics of routine antenatal anti‐D prophylaxis in the prevention of haemolytic disease of the newborn, in support of the NICE appraisals process.

Routine follow-up after treatment for ovarian cancer in the United Kingdom (UK): patient and health professional views.

PURPOSE The aim of this study was to explore patients and health professionals perceptions of follow-up service provision following treatment for ovarian cancer. In the United Kingdom, where this study took place, ovarian cancer is the most common gynaecological cancer in women. The causes are unknown, symptoms are often vague and most cases are diagnosed at an advanced stage. There is a high likelihood of disease progression and little evidence on the benefits of routine follow-up after treatment for gynaecological cancer. METHOD Two focus groups were conducted with patients (n=6) and health professionals (n=7) at a hospital in North-West England. RESULTS From the patient group, three main themes emerged: reassurance, the need for support and information, and alternative approaches to follow-up care. Three main themes emerged from the health professional group: patient attendance at outpatient clinics to monitor for disease progression; the need to modernise the current system; and patients should be encouraged to self-manage their disease. CONCLUSIONS There were similarities and differences in perceptions of follow-up care procedures between the two focus groups. Patients placed importance on clinical examination in indicating disease recurrence, whereas health professionals viewed this as historical practice with no evidence base. Accurate information on how disease progression is monitored should be communicated to patients. A modified approach to follow-up procedures is suggested as a useful strategy to tailor services to individual needs and preferences, whilst responding to service demands.

Improving inpatient postnatal services: midwives views and perspectives of engagement in a quality improvement initiative

BackgroundDespite major policy initiatives in the United Kingdom to enhance womens experiences of maternity care, improving in-patient postnatal care remains a low priority, although it is an aspect of care consistently rated as poor by women. As part of a systems and process approach to improving care at one maternity unit in the South of England, the views and perspectives of midwives responsible for implementing change were sought.MethodsA Continuous Quality Improvement (CQI) approach was adopted to support a systems and process change to in-patient care and care on transfer home in a large district general hospital with around 6000 births a year. The CQI approach included an initial assessment to identify where revisions to routine systems and processes were required, developing, implementing and evaluating revisions to the content and documentation of care in hospital and on transfer home, and training workshops for midwives and other maternity staff responsible for implementing changes. To assess midwifery views of the quality improvement process and their engagement with this, questionnaires were sent to those who had participated at the outset.ResultsQuestionnaires were received from 68 (46%) of the estimated 149 midwives eligible to complete the questionnaire. All midwives were aware of the revisions introduced, and two-thirds felt these were more appropriate to meet the womens physical and emotional health, information and support needs. Some midwives considered that the introduction of new maternal postnatal records increased their workload, mainly as a consequence of colleagues not completing documentation as required.ConclusionsThis was the first UK study to undertake a review of in-patient postnatal services. Involvement of midwives at the outset was essential to the success of the initiative. Midwives play a lead role in the planning and organisation of in-patient postnatal care and it was important to obtain their feedback on whether revisions were pragmatic and achieved anticipated improvements in care quality. Their initial involvement ensured priority areas for change were identified and implemented. Their subsequent feedback highlighted further important areas to address as part of CQI to ensure best quality care continues to be implemented. Our findings could support other maternity service organisations to optimise in-patient postnatal services.

Revising acute care systems and processes to improve breastfeeding and maternal postnatal health: a pre and post intervention study in one English maternity unit

BackgroundMost women in the UK give birth in a hospital labour ward, following which they are transferred to a postnatal ward and discharged home within 24 to 48 hours of the birth. Despite policy and guideline recommendations to support planned, effective postnatal care, national surveys of women’s views of maternity care have consistently found in-patient postnatal care, including support for breastfeeding, is poorly rated.MethodsUsing a Continuous Quality Improvement approach, routine antenatal, intrapartum and postnatal care systems and processes were revised to support implementation of evidence based postnatal practice. To identify if implementation of a multi-faceted QI intervention impacted on outcomes, data on breastfeeding initiation and duration, maternal health and women’s views of care, were collected in a pre and post intervention longitudinal survey. Primary outcomes included initiation, overall duration and duration of exclusive breastfeeding. Secondary outcomes included maternal morbidity, experiences and satisfaction with care. As most outcomes of interest were measured on a nominal scale, these were compared pre and post intervention using logistic regression.ResultsData were obtained on 741/1160 (64%) women at 10 days post-birth and 616 (54%) at 3 months post-birth pre-intervention, and 725/1153 (63%) and 575 (50%) respectively post-intervention. Post intervention there were statistically significant differences in the initiation (p = 0.050), duration of any breastfeeding (p = 0.020) and duration of exclusive breastfeeding to 10 days (p = 0.038) and duration of any breastfeeding to three months (p = 0.016). Post intervention, women were less likely to report physical morbidity within the first 10 days of birth, and were more positive about their in-patient care.ConclusionsIt is possible to improve outcomes of routine in-patient care within current resources through continuous quality improvement.

Moving Forward: A Qualitative Research Inquiry to Inform the Development of a Resource Pack for Women Following Primary Breast Cancer Treatment

While the UK charity Breast Cancer Care has extensive resources for women with breast cancer, this research partnership developed the first resource driven and informed by primary research with these women, exploring their needs and developing the resource according to need. Data were collected from focus groups with breast cancer survivors and telephone interviews with health professionals and experts, which explored the needs of women after primary cancer treatment, and were analyzed using thematic analysis. As well as information, these women needed resources to help them regain control over life, adapt to a changed body, and restore lost confidence.

Maintaining practice : challenges for nurse educators

To reiterate the purpose of this editorial was not to delve into, and debate, the research evidence to substantiate or refute the purpose of ‘linking with practice’, in fact quite the opposite. Based upon our experiences we hope to encourage further debate on the purpose of nurse educators being in practice. It could be argued that as each author self-selected to work in practice for a week, there was a positive bias towards success. Indeed without exception this opportunity to ‘be a nurse and do nursing’, albeit undersupervision, had the desired outcome in that we achieved our predetermined goals and expectations. On an individual basis, it was a success. We eagerly became learners and absorbed information like a ‘good’ student should and received excellent feedback from practitioners. Moreover, our ability to recall and draw upon our years of nursing experience rapidly came to the fore thus enabling integration and participation in the work of nursing practice from a critical and in-depth perspective. We therefore conclude that being in practice, engaging in nursing and caring for people not only was/is a privilege but serves to enrich nurse educator’s knowledge base. By origin we are all nurses, this was how we began and we feel strongly that this ‘route or link in’ should be strong, valued and respected as meaningful to being a nurse educator. After all we are not, (to coin the phrase rejected by the Royal College of Nursing in 2004) ‘too posh to wash or too clever to care’, in fact the opposite is the reality.

Management of women who are Rhesus D negative in Northern Ireland

In 1998, all 15 maternity hospitals in Northern Ireland participated in a retrospective survey of the management of pregnant women who were Rhesus D (RhD) negative. This area of clinical practice was chosen for study in the knowledge that a policy of routine antenatal prophylaxis had been proposed at the RCP/RCOG Consensus Conference, and that a change in current clinical practice was likely to follow. It was therefore felt prudent to survey critically current practice in order to collect baseline data before the introduction of new guidelines. Data were analysed on 3274 RhD negative women. The findings from this study show that current management of women who are RhD negative is suboptimal. In particular, there is poor adherence to the guidelines relating to the management of potentially sensitising events in pregnancy. Testing to assess the size of a feto-maternal bleed was often omitted, and it was therefore impossible to ascertain whether an appropriate dose of anti-D immunoglobulin had been administered. Recent publications have also identified this as an area of concern. Trauma during pregnancy was often not managed appropriately, as a potentially sensitising event. Better compliance with the current guidelines was noted when management after delivery was considered. The reasons for this apparent inconsistency should be addressed. New guidelines, recommending the use of routine antenatal prophylaxis to all women who are RhD negative, have recently been published. Providers of antenatal care will need to address this issue within the context of their own practice environment. In doing so they should be mindful of current deficits in guideline compliance which may need to be remedied, to avoid building new practices upon fragile foundations.In 1998, all 15 maternity hospitals in Northern Ireland participated in a retrospective survey of the management of pregnant women who were Rhesus D (RhD) negative. This area of clinical practice was chosen for study in the knowledge that a policy of routine antenatal prophylaxis had been proposed at the RCP/RCOG Consensus Conference, and that a change in current clinical practice was likely to follow. It was therefore felt prudent to survey critically current practice in order to collect baseline data before the introduction of new guidelines. Data were analysed on 3274 RhD negative women. The findings from this study show that current management of women who are RhD negative is suboptimal. In particular, there is poor adherence to the guidelines relating to the management of potentially sensitising events in pregnancy. Testing to assess the size of a feto-maternal bleed was often omitted, and it was therefore impossible to ascertain whether an appropriate dose of anti-D immunoglobulin had been administered. Recent publications have also identified this as an area of concern. Trauma during pregnancy was often not managed appropriately, as a potentially sensitising event. Better compliance with the current guidelines was noted when management after delivery was considered. The reasons for this apparent inconsistency should be addressed. New guidelines, recommending the use of routine antenatal prophylaxis to all women who are RhD negative, have recently been published. Providers of antenatal care will need to address this issue within the context of their own practice environment. In doing so they should be mindful of current deficits in guideline compliance which may need to be remedied, to avoid building new practices upon fragile foundations.