Margaret Redshaw

Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: The Birthplace in England national prospective cohort study

Objective To compare perinatal outcomes, maternal outcomes, and interventions in labour by planned place of birth at the start of care in labour for women with low risk pregnancies. Design Prospective cohort study. Setting England: all NHS trusts providing intrapartum care at home, all freestanding midwifery units, all alongside midwifery units (midwife led units on a hospital site with an obstetric unit), and a stratified random sample of obstetric units. Participants 64 538 eligible women with a singleton, term (≥37 weeks gestation), and “booked” pregnancy who gave birth between April 2008 and April 2010. Planned caesarean sections and caesarean sections before the onset of labour and unplanned home births were excluded. Main outcome measure A composite primary outcome of perinatal mortality and intrapartum related neonatal morbidities (stillbirth after start of care in labour, early neonatal death, neonatal encephalopathy, meconium aspiration syndrome, brachial plexus injury, fractured humerus, or fractured clavicle) was used to compare outcomes by planned place of birth at the start of care in labour (at home, freestanding midwifery units, alongside midwifery units, and obstetric units). Results There were 250 primary outcome events and an overall weighted incidence of 4.3 per 1000 births (95% CI 3.3 to 5.5). Overall, there were no significant differences in the adjusted odds of the primary outcome for any of the non-obstetric unit settings compared with obstetric units. For nulliparous women, the odds of the primary outcome were higher for planned home births (adjusted odds ratio 1.75, 95% CI 1.07 to 2.86) but not for either midwifery unit setting. For multiparous women, there were no significant differences in the incidence of the primary outcome by planned place of birth. Interventions during labour were substantially lower in all non-obstetric unit settings. Transfers from non-obstetric unit settings were more frequent for nulliparous women (36% to 45%) than for multiparous women (9% to 13%). Conclusions The results support a policy of offering healthy women with low risk pregnancies a choice of birth setting. Women planning birth in a midwifery unit and multiparous women planning birth at home experience fewer interventions than those planning birth in an obstetric unit with no impact on perinatal outcomes. For nulliparous women, planned home births also have fewer interventions but have poorer perinatal outcomes.

Nurse staffing in relation to risk-adjusted mortality in neonatal care

Objective: To assess whether risk-adjusted mortality in very low birthweight or preterm infants is associated with levels of nursing provision. Design: Prospective study of risk-adjusted mortality in infants admitted to a random sample of neonatal units. Setting: Fifty four UK neonatal intensive care units stratified by: patient volume; consultant availability; nurse:cot ratios. Patients: A group of 2585 very low birthweight (birthweight <1500 g) or preterm (<31 weeks gestation) infants. Main Outcome Measure: Death before discharge or planned deaths at home, excluding lethal malformations, after adjusting for initial risk 12 hours after birth using gestation at birth and measures of illness severity in relation to nursing provision calculated for each baby’s neonatal unit stay. Results: A total of 57% of nursing shifts were understaffed, with greater shortages at weekends. Risk-adjusted mortality was inversely related to the provision of nurses with specialist neonatal qualifications (OR 0.67; 95% CI 0.42 to 0.97). Increasing the ratio of nurses with neonatal qualifications to intensive care and high dependency infants to 1:1 was associated with a decrease in risk-adjusted mortality of 48% (OR: 0.52, 95% CI: 0.33, 0.83). Conclusions: Risk-adjusted mortality did not differ across neonatal units. However, survival in neonatal care for very low birthweight or preterm infants was related to proportion of nurses with neonatal qualifications per shift. The findings could be used to support specific standards of specialist nursing provision in neonatal and other areas of intensive and high dependency care.

Family centred care? Facilities, information and support for parents in UK neonatal units

Objective To assess how UK neonatal units address parent communication, support and information needs during neonatal care and the early months after discharge. Design All units were invited to participate in a survey of practice and policy relating to the needs of parents with babies admitted for neonatal care. Setting Neonatal care, UK. Main Outcome Measures Proportions of units by unit level providing specific facilities, information, policies and support mechanisms. Results Facilities, information and support for parents vary and can be quite limited: units may have as many as 10 babies receiving intensive or high dependency care in one room; 24% have no rooms in which to accommodate one or two babies only; 96% have at least one room for parents to stay overnight, 27% of rooms have ensuite amenities; 72% have written information about the equipment used, 64 % on ventilation and 91% on breastfeeding; parents have free access to notes in 20% of units and in 14% parents are excluded from ward rounds; 27% have a policy on keeping in contact with parents, 47% did not have the services of a social worker, psychologist, counsellor or psychiatrist and only 15% have a unit-based family care nurse. Conclusions Elements of unit policy and practice that support family-centred care are variably in place currently and units need to address the gaps.

Developmental care in the UK: a developing initiative

Aim:  To review developmental care over time in the UK.

A randomised trial of granulocyte-macrophage colony-stimulating factor for neonatal sepsis: outcomes at 2 years

Objective The authors performed a randomised trial in very preterm small-for-gestational age (SGA) babies to determine if prophylaxis with granulocyte-macrophage colony-stimulating factor (GM-CSF) improves outcomes (the PROGRAMS trial). Despite increased neutrophil counts following GM-CSF, the authors reported no significant difference in neonatal sepsis-free survival. Patients and methods 280 babies born <31 weeks of gestation and SGA were entered into the trial. Outcome was determined at 2 years to determine neurodevelopmental and general health outcomes, including economic costs. Results The authors found no significant differences in health outcomes or health and social care costs between the trial groups. In the GM-CSF arm, 87 of 134 (65%) babies survived to 2 years without severe disability compared with 87 of 131 (66%) controls (RR: 1·0, 95% CI 0·8 to 1·2). Marginally, more children receiving GM-CSF were reported to have cough (RR 1·7, 95% CI 1·1 to 2·6) and had signs of chronic respiratory disease (Harrisons sulcus; RR 2·0, 95% CI 1·0 to 3·9) though this was not reflected in bronchodilator use or need for hospitalisation for respiratory disease. Overall, the rate of neurologic abnormality (7%–9%) was similar but mean overall developmental scores were lower than expected for gestational age. Conclusions The administration of GM-CSF to very preterm SGA babies is not associated with improved or more adverse outcomes at 2 years of age. The apparent excess of developmental impairment in the entire PROGRAMS cohort, without corresponding increase in neurological abnormality, may represent diffuse brain injury attributable to intrauterine growth restriction.

Experiences, utilisation and outcomes of maternity care in England among women from different socio‐economic groups: findings from the 2010 National Maternity Survey

The objective of this analysis was to explore the healthcare‐seeking behaviours and experiences of maternity care among women from different socio‐economic groups in order to improve understanding of why socially disadvantaged women have poorer maternal health outcomes in the UK.

Does family-centred neonatal discharge planning reduce healthcare usage? A before and after study in South West England

Objective To implement parent-oriented discharge planning (Train-to-Home) for preterm infants in neonatal care. Design Before and after study, investigating the effects of the intervention during two 11-month periods before and after implementation. Setting Four local neonatal units (LNUs) in South West England. Participants Infants without major anomalies born at 27–33 weeks’ gestation admitted to participating units, and their parents. Train-to-Home intervention A family-centred discharge package to increase parents’ involvement and understanding of their babys needs, comprising a train graphic and supporting care pathways to facilitate parents’ understanding of their babys progress and physiological maturation, combined with improved estimation of the likely discharge date. Main outcome measures Perceived Maternal Parenting Self-Efficacy (PMP S-E) scores, infant length of stay (LOS) and healthcare utilisation for 8 weeks following discharge. Results Parents reported that the Train-to-Home improved understanding of their babys progress and their preparedness for discharge. Despite a lack of change in PMP S-E scores with the intervention, the number of post-discharge visits to emergency departments (EDs) fell from 31 to 20 (p<0.05), with a significant reduction in associated healthcare costs (£3400 to £2200; p<0.05) after discharge. In both study phases, over 50% of infants went home more than 3 weeks before their estimated date of delivery (EDD), though no reduction in LOS occurred. Conclusions Despite the lack of measurable effect on the parental self-efficacy scores, the reduction in ED attendances and associated costs supports the potential value of this approach.

Perinatal and maternal outcomes in planned home and obstetric unit births in women at ‘higher risk’ of complications: secondary analysis of the Birthplace national prospective cohort study

To explore and compare perinatal and maternal outcomes in women at ‘higher risk’ of complications planning home versus obstetric unit (OU) birth.

Qualitative study of the clinician–parent interface in discussing prognosis following MRI and US imaging of preterm infants in the UK

Objective To explore communication and interaction between parents and clinicians following neonatal ultrasound (US) and MRI of the brain of babies born preterm. Setting This qualitative study was undertaken as part of a larger UK study of neonatal brain imaging. 511 infants were cared for in 14 London neonatal units with MR and cerebral US imaging in a specialist centre. Participants Parents with infants born at <33 weeks gestation were randomised to receive prognostic information based on either MRI or US findings on their infants at term-corrected age. Methods Discussions between parents and clinicians about the MRI or US result were audio recorded. Parents were told about the findings and their babys predicted outcome. A topic guide ensured essential aspects were covered. Recordings were fully transcribed. Discussion of the scan results, the content and style of the interaction and parental response were analysed qualitatively in 36 recordings using NVivo V.10. Outcomes Key themes and subthemes were identified in the clinician–parent discussions. Results The overarching theme of ‘the communication interface’ was identified with three key themes: ‘giving information’, ‘managing the conversation’ and ‘getting it right’ and further subthemes. A range of approaches were used to facilitate parental understanding and engagement. There were differences in the exchanges when information about an abnormal scan was given. The overall structure of the discussions was largely similar, though the language used varied. In all of the discussions, the clinicians talked more than the parents. Conclusions The discussions represent a difficult situation in which the challenge is to give and receive complex prognostic information in the context of considerable uncertainty. The study highlights the importance of being able to re-visit specific issues and any potential areas of misunderstanding, of making time to talk to parents appreciating their perspective and level of knowledge. Trial registration number EudraCT 2009-013888-19; Pre-results.

Care and self-reported outcomes of care experienced by women with mental health problems in pregnancy: Findings from a national survey

Background mental health problems in pregnancy and the postnatal period are relatively common and, in pregnancy, are associated with an increase in adverse outcome. It is recommended that all women are asked about their emotional and mental health and offered treatment if appropriate. Objectives to describe the care received by women self-identifying with mental health problems in pregnancy, and to describe the effects of support, advice and treatment on outcomes in the postnatal period. Design this study used cross-sectional survey data collected in 2014 which described womens experience of maternity care. Setting England Participants a random sample of women who had a live birth in January 2014. Measurements the questionnaire asked about sociodemographic characteristics, whether women were asked about emotional and mental health in pregnancy, support and treatment offered, about postnatal wellbeing, and questions relating to attachment to their baby. Descriptive statistics and logistic regression were used to examine the associations between mental health and outcomes taking account of sociodemographic characteristics. Findings the survey response rate was 47%. Women with antenatal mental health problems were significantly more worried at the prospect of labour and birth, had lower satisfaction with the experience of birth, worse postnatal mental health, and indications of poorer attachment to their baby. They received substantially more care than other women but they did not always view this positively. Support, advice and treatment for mental health problems had mixed effects. Conclusions this study describes the significant additional care provided to women self-identifying with mental health problems in pregnancy, the mixed effects of support, advice and treatment, and the poor perception of staff interaction among women with mental health problems. Implications for practice health care professionals may need additional training to effectively support women with mental health problems during the perinatal period.