Juliet Rayment

Women's safety alerts in maternity care: is speaking up enough?

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 womens 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.

Involving seldom-heard groups in a PPI process to inform the design of a proposed trial on the use of probiotics to prevent preterm birth: a case study.

Plain English summaryWhen 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.AbstractBackground 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.

Better together: a qualitative exploration of women’s perceptions and experiences of group antenatal care

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 womens 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.

`It makes sense and it works': Maternity care providers' perspectives on the feasibility of a group antenatal care model (Pregnancy Circles)

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.

NICE says caesarean section is not available on demand unless clinically indicated.

We were alarmed by the letter from Mascarenhas and colleagues entitled, “NICE promises on infertility and caesarean section are unmet.”1 We agree with the authors that current underfunding in the NHS is having grave consequences on national maternal health service provision and deserves careful scrutiny and critical comment, …

PL.13 Experiences of Women and Families in Alongside Midwifery Units; Tackling the Bottlenecks and Critical Touchpoints

Background Alongside midwifery units (AMUs) provide care for women deemed ‘low-risk’ and Birthplace in England found that low risk women received significantly fewer interventions in AMUs compared to obstetric units with no difference in perinatal outcomes. The number of AMUs are increasing, however, little is known regarding How to organise services to improve quality, safety and women’s experiences. Women’s experiences Aim and Methods A Birthplace follow-on study investigated AMU organisation from users’ and professionals’ perspectives. Case study of AMU in 4 NHS Trusts across England. Data collected November 2011 - October 2012: observations (>100 hours); semi-structured interviews with staff, managers and stakeholders (n = 89) and postnatal women and birth partners (n = 47). Results We found several critical touchpoints. Women had unequal access to information enabling them to choose and engage with midwife-led care. Women often experienced care inside AMUs as excellent, but system and provider generated issues in admission and transfer led to difficulties for some in gaining access in early labour. Factors enabling women to feel safe included accompaniment by partners; perception of personalised assessment of progress in labour; being assured of appropriate pain relief, timely transfer if required, and staff prepared to listen, inform, and acknowledge their concerns and needs. Conclusion Greater attention needs to be given to woman-centred care at the critical interface between midwife led settings with antenatal services and OUs.