Background: Growing international research evidence, mainly from the acute general service sector, suggested that there was a strong link between nurse staffing and patient outcomes. There was a gap in the literature addressing other clinical and non-clinical workforce groups outside acute hospitals. Aim: To investigate the relationship between mode of birth and maternity staffing levels in NHS trusts in England, after accounting for maternal socio-demographic characteristics, individual clinical risk and structural characteristics including type and configuration of trusts. Method: This cross sectional study used Hospital Episode Statistics (HES) 2010/11 and NHS Information Centre 2010/11 maternity workforce datasets. The study population comprised women aged 15-45, who were nulliparous and had a term, singleton, live birth (n=261,481 deliveries in 143 NHS trusts for emergency caesarean section and instrumental deliveries; and n=214,920 deliveries in 127 NHS trusts for normal birth). Multilevel logistic models were fitted separately for each outcome. Risk-adjustment for case mix included maternal age, ethnicity, IMD, gestational age, birth weight and NICE 2007 derived definition of clinical risk. Standardized FTE/birth ratios for obstetricians, midwives, healthcare assistants and other trust characteristics were used as trust level predictors. The percentages of the total variation in outcomes attributable to between trusts variation were calculated. Results: For this sample of women only around 2% of the residual variation in outcomes was due to unobserved trust characteristics. Between trusts and for all women, the standardized consultant FTE/birth ratio was positively related to the probability of instrumental delivery (OR=1.08, 95%CI 1.03-1.13, p < .05), and the standardized midwives FTE/birth ratio was positively related to the probability of normal birth (OR=1.06, 95%CI 1.01-1.11, p < .05). 1 SD increase in FTE doctors increased the odds of emergency CS for high risk women by 5.1% (OR=1.05, 95%CI 1.01-1.10, p < .05); while 1 SD increase in FTE midwives increased the odds of normal birth for low risk women by 7.6% (OR=1.08, 95%CI 1.02-1.14, p < .05). Conclusion: The analyses established significant independent effects of staffing on the three outcomes, although only a small percentage of the total variability in the outcomes was attributable to variations between trusts. The positive association between midwifery staffing and normal birth has policy implications in terms of current and future investment in the profession. More than anything else, women’s outcomes were determined by their characteristics and clinical risk. Other unaccounted for factors such as obesity, smoking, organisational culture and models of care may be able to explain further the variations in outcomes.

Background: The majority of women who have given birth will develop affection for their infants, however some have prolonged problems developing a loving attitude, leading to impaired mother-infant bonding. Some studies have found an association between postnatal depression and poor mother-infant bonding. On the other hand, little is known about the antenatal predictors of this problem. Aim: The aim of this study was to determine if it is possible to predict during pregnancy which women will develop impaired mother-infant bonding; and to assess whether having a high risk pregnancy could affect this bond. Method: A prospective cohort study was conducted with women who were recruited from one London Hospital between 2008 and 2012. Psychometric data were collected from 300 women in late pregnancy; 223 were followed up at six weeks postnatal using self-administered questionnaires. Sixty-six of these women had a high risk pregnancy. Saliva samples were collected from a subsample of participants (N=46) as part of a pilot study to physiologically measure cortisol and alpha-amylase (as biological markers of maternal stress and depression) embedded within the main study. Results: There was a lower risk of impaired mother-infant bonding at six weeks postnatal, if the woman had good fetal bonding in late pregnancy(OR=0.89, 95%CI=0.83-0.94, p&lt;0.001), but a higher risk of impaired maternal bonding at this time, if the woman had symptoms of depression during pregnancy (OR=1.12, 95%CI=1.11-1.41, p&lt;0.05). Another determinant of poor motherinfant bonding in the study was postnatal depressive symptoms and having an epidural analgesia during labour and birth, although reasons for this need further consideration. There were no significant differences in mother to infant bonding status between women who had a high or a low risk pregnancy. Conclusion: Maternal mental health and fetal bonding emerged as the strongest predictors of impaired maternal-infant bonding, together with the negative association with having an epidural analgesia. The findings from this study highlight the importance of training for clinicians to be aware that mother-infant bonding problem can develop during pregnancy. The negative effect of epidural analgesia on mother-infant bonding warrants further investigation.

No description available.

Background: Evidence from midwifery research, policy and guidelines indicates that trust within the midwife-mother relationship is an important element of care provision, yet it is poorly defined as a concept. Aim: The aim of the study was to explore the concept of trust within the midwife-mother relationship increasing understanding of the individual’s experience of trust and its meaning to women. Methodology: The Hybrid model for concept analysis was the framework for the study, combining theory and empirical data enabled the researcher to develop a deeper analytic understanding of the phenomenon and the meaning behind how it was experienced. Longitudinal semi-structured interviews were carried out at the beginning of pregnancy, thirty-seven weeks and eight weeks postnatal with a purposive sample of ten women with straightforward pregnancy. Participants were a mix of first time mothers and those having subsequent babies selected from a Health Board that provides midwife-led care. Analysis: Data analysis was conducted using Nvivo 9 software to organise the data into initial themes. Themes were taken back to participants to guide subsequent interviews clarifying their meaning, authenticity and ensuring that the data gathered reflected their personal insight. Findings: “Building blocks” were an analogy identified within the participant interviews which capture the evolving nature of trust. The participants described an initial trust associated with an expectation of assumed competence in the midwife. The core attribute was identified as the relationship between midwife and mother. The concept of trust was interwoven with women’s agency, women expressed a desire to develop a two-way trust that included the midwife trusting the woman. Implications: In order to develop evolved trust, maternity services need to develop systems that allow midwives to establish empathetic, reciprocal relationships and work in partnership with the women.

Background: Postpartum haemorrhage (PPH) remains a major cause of maternal mortality and morbidity, and in recent years there has been a temporal increase in the incidence of PPH and associated morbidities in resource rich countries. Individual risk factors for PPH have long been identified but the relative importance of each has been under explored and thus the potential for preventative strategies is unknown. Aim: The aim of this study was to, i) ascertain the incidence of PPH at various thresholds in a South of England population, ii) identify the relative importance of predictor variables associated with PPH at different blood loss thresholds and iii) identify the independent and cumulative association of prepregnancy, pregnancy acquired and intrapartum variables on estimated blood loss following birth. Methodology: A prospective observational study was undertaken in two maternity services. Estimated blood loss data for all women (n=10,213) were imported from NHS electronic summary records. A representative sample of cases (n=1897) was selected for review, using a weighted sampling strategy. Univariate analysis identified variables associated with mean estimated blood loss and PPH at various thresholds. Multivariate regression modelling assessed the association of sequentially acquired variables with PPH ≥500 ml, ≥1000 ml, and ≥1500 ml. Results: The incidence of PPH ≥500 ml, ≥1000 ml ≥1500 ml ≥2000 ml and ≥2500 ml was 33.9% (95%CI 31.4 to 36.5), 9.4% (95%CI 8.5 to 10.4), 4.0% (95%CI 3.4 to 4.6), 2.0% (95%CI 1.6 to 2.4) and 0.8% (95%CI 0.7 to 1.0) respectively. Incidence of PPH ≥1000 ml was investigated by mode of birth. The incidence for spontaneous vaginal birth (SVD) was 4.75% (95%CI0.37 to 3.7) and instrumental vaginal birth, 12.1% (95%CI 9.3 to 14.6). The incidence following abdominal birth was 18.2% (95%CI 15.8 to 20.7); elective CS 11.8% (95%CI8.9 to 14.5), emergency CS 22% (95%CI18.6 to 25.4). Multiple regression analyses identified different independent variables associated with overall PPH at different thresholds. Novel independent variables resulting from this study associated with PPH at varying levels, were Black African ethnicity (≥500 ml and ≥1000 ml) OR 1.68 (95%CI 1.23 to 2.28) and OR 1.50 (95%CI1.13to 1.98), assisted conception (≥500 ml) OR 3.80 (95%CI1.69 to 8.57), antenatal attendance feeling ‘generally unwell’ (≥500 ml) OR 2.03 (95%CI1.18 to 3.49), antenatal steroid administration for fetal reasons (≥1500 ml) OR 2.00 (95%CI 1.17 to 3.41). In addition some previously known variables were confirmed. These were the impact per unit of BMI (Kg/m2) OR 1.04 (95%CI 1.01 to 1.04); previous PPH (≥500, ≥1000, ≥1500) 2.75 (95%CI1.40 to 5.44) 1.88 (96%CI 1.13 to 3.11) 2.39 (95%CI1.33 to4.28) multiple pregnancy (≥1000, ≥1500) 2.33 (95%CI1.23 to 4.41) 2.60(95%CI1.27 o 5.38) retained placenta (≥1000) 7.51 (4.08 to 13.8), interval to suturing (≥1000 ml) 1.74 (95%CI1.46 to 2.08). There was also a liner association with maternal temperature in labour and level of PPH. Conclusion: This study found higher rates of PPH at all thresholds and, with all modes of birth. Which is not fully explained by rising Caesarean section rates. Prepregnancy and pregnancy acquired variables are commonly mediated through intrapartum events, and previous pregnancy management can impact on blood loss in subsequent pregnancies. Novel variables found in this study require further investigation, particularly the impact of Black African ethnicity, assisted conception techniques, antenatal steroid administration, and, feeling “generally unwell”. Modifiable risk factors include preconceptual weight loss, expedient suturing of genital tract trauma and regular recording of maternal temperature in labour, which may alert staff to higher risk of PPH.

The aim of this study was to explore and analyse midwives' rationales for their decision-making in everyday situations. Design A symbolic interactionist study underpinned by Blumer's Symbolic Interactionism Setting Midwifery practice areas in Central and Southern Scotland Methods Midwives were sampled purposively for age, experience and area of practice. Nineteen midwives took part from a variety of practice areas and three different regions in Scotland. Data collection comprised clinical observation of midwives making decisions in a variety of midwifery practice, use of validated interactive scenarios and in-depth interviews based on the observation field notes. Data were analysed using Blumer's principles of Symbolic Interactionism (Blumer, 1969), his concepts of 'self' and 'other' along with Ritchie and Spencer's (1994) five stage framework analysis. Findings The analysis of the data identified four rationales for midwives' decision-making. The first rationale was the individuality of the midwives, as related to Blumer's self 'I'. The second and third rationales were professional persona and compliance with policy and regulation, which were associated with Blumer's self 'me'. The final rationale was the individuality of women and babies, which is affiliated to Blumer's 'other'. Conclusions The individuality of the midwives and women was a major rationale for the decisions made. Individuality as a component of decision-making has not been well explored, and would benefit from further investigation within the research field of midwives' decision-making. Professional persona and compliance were also important rationales for the midwives' decisions. Midwifery and NHS culture influenced midwives in their actions, and these are issues that need to be examined more closely if midwives are to remain autonomous practitioners.

No description available.

This thesis investigates the contribution of the midwifery statutory supervisory review meeting to the core function of the Nursing and Midwifery Council: protection of the public from unfit practitioners. At the outset of the study, the positive influences of . statutory supervision on patient safety and care quality were widely cited in policy and practice literature. Regulatory and local failings by the Nursing and Midwifery Council, Local Supervising Authorities and supervisors' of midwives, highlighted across a number of systematic inquiries into the statutory supervision of midwives, midwifery practice and maternity care, meant that this position changed during the course of the research. The research was undertaken in two phases. In phase one a systematic review investigated midwives' and supervisors of midwives' perceptions of statutory supervision. Review findings informed design of the phase two study. Phase two used Constructivist Grounded Theory methods to explore midwives' and supervisors of midwives' attitudes towards, and understanding of, the statutory supervisory review process, and their views about the impact of the process on subsequent practice. In- depth interviews and focus groups were used to generate data from 34 participants (24 midwives and 10 supervisors of midwives) from two Local Supervising Authority areas in England. Participants included newly qualified midwives; independent midwives and lecturers. Findings suggested that there are several areas where the supervisory review process is fallible. These include the lack of consistency in sources of evidence used to review midwives practice; complexity of the process itself due to the dual regulatory and supportive functions of statutory supervision, and variable midwifery, supervisory and regulatory interpretations of the intention of the statutory supervisory review meeting. As the midwifery profession moves towards a legislative separation of the regulatory and supportive supervisory functions and revalidation, this study highlights the need for further research into revalidation processes to assure the public that only those professionals who are fit to practice are able to continue to do so.

Introduction: Effective pedagogical approaches within professional education, and specifically within midwifery, are fundamental to the provision of evidence-based, reflexive, life-long learners who win have the capacity to navigate dynamic contemporary practice. Therefore, the evaluation of a midwifery educational intervention such as Enquiry Based Learning, that has the potential to nurture such knowledge, skills and behaviour among students, is both timely and warranted. Research Question: The research question asked; ’how does the introduction of EBL as a pedagogical approach within undergraduate midwifery education impact student engagement, student enjoyment and student learning?' Research Objectives; To identify the specific attributes of Enquiry Based Learning that may enhance or impede student engagement, student learning, student enjoyment and whether, as a pedagogical approach, EBL may enhance and progress student midwives’ epistemic and cognitive development. Research Design: A mixed methods sequential transformative (MMST) design was chosen as the most germane approach for this evaluation. MMST is a ’two phase project with a theoretical lens overlaying the sequential procedures’ (Creswell, 2009, p.212; Creswell et al., 2003). The aim of this theoretical perspective is to shape and direct the research question with the ultimate aim of advocating a call for action and promote change (Tashakkori and Teddlie, 2003). The theoretical lens that guided this evaluation was feminist epistemology or women’s ways of knowing and learning (Belenky and colleagues, 1986). Data Collection Process; This evaluation study had two data collection phases, qualitative phase one followed by quantitative phase two. Participants in this study were 14 first year under-graduate student midwives. Findings: Student views of EBL impact in relation to particular aspects that enhanced their engagement, learning, and enjoyment were identified. Specifically, the aspects of EBL that students articulated as enhancing their engagement, enjoyment and learning were intra-group peer work, autonomous relaxed EBL learning environment, ongoing constructive facilitator feedback, emergent pride in knowledge generation and relevance of knowledge and skills for clinical practice. The aspects that proved less educationally effective were detailed as Initial mind-set shift required for active learning praxis, group dysfunction issues and intergroup presentation of knowledge and skills. However, when questioned directly about their enjoyment of the approach, student responses were less affirming than anticipated. Results related to overall enjoyment of EBL portray a general position of ambivalence towards the approach. For some students at least, EBL may appear to be less than the sum of its parts. When mapped against Belenky and colleague's (1986) Women's Ways of Knowing theoretical framework, findings suggest that the core educational tenets of EBL that students found effective, may also promote and enhance the development of women's epistemic and cognitive perspectives.

No description available.