Dr Louise Hunter

Background
There 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.

Methods
We 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.

Results
A 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.

Conclusions
Mechanisms 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.

Registration
The protocol for this realist review was registered in the International Prospective Register of Systematic Reviews (PROSPERO CRD42016036768).

Background

An ethnically diverse workforce has been identified as a key component of safe, compassionate maternity care, and yet midwifery remains a predominantly White profession across the Global North. Understanding the experiences of Black, Asian and Minority Ethnic midwifery students is key to addressing this disparity.

Objective

To capture the university and placement experiences of Black, Asian and Minority Ethnic midwifery students in a culturally White environment.

Methods

A qualitative approach underpinned by a feminist, inductive, interpretivist paradigm informed a  study undertaken with student midwives studying at three separate universities in South East England. Five virtual focus groups and two semi-structured interviews were conducted with thirteen current student midwives and one preceptee (recently graduated) midwife self-identifying as Black, Asian or Minority Ethnic. Analysis was inductive, data-driven and thematic. Standards for Reporting Qualitative Research recommendations have been used to formulate this report.

Findings

Although some participants reported positive experiences and felt well-supported, an overarching narrative emerged of midwifery as an exclusive and White profession. Institutionalised Whiteness was experienced in university, in placement and within individual student cohorts. Four themes were identified: ‘being an outsider’, ‘prejudice, discrimination and racism’, ‘nowhere to turn’ and ‘positive forces’.

Conclusions

Racist and discriminatory beliefs and practices in some midwifery education and placement settings negatively impact student experience and are likely to result in poorer care being provided to Global Ethnic Majority women and families. An unwillingness among some White educators and students to recognise the presence and impact of inequitable and racist environments, and a lack of clear, acceptable, and effective pathways for students to use to raise and discuss concerns, makes it difficult to challenge and change this injustice.

Aim: to explore recruitment to UK midwifery programmes from the perspective of applicants from Black, Asian and Minority Ethnic (BAME) groups, and describe the perceptions and experiences of the application process for these applicants and those from white backgrounds.

Background: Midwifery in the Global North is an overwhelmingly white profession. This lack of diversity has been cited as a factor in the poorer outcomes experienced by women from non-white backgrounds. There is a need for midwifery programmes to recruit and support more ethnically and racially diverse cohorts if this situation is to be addressed. Very little is currently known about the recruitment experiences of midwifery applicants.

Design:  A mixed methods study comprising a survey and individual interview or focus group. The study was conducted between September 2020 and March 2021 in three universities in South East England. Participants comprised 440 applicants to midwifery programmes, and 13 current or recently qualified BAME midwifery students

Findings:  Although many survey findings in respect to choosing a midwifery programme were broadly similar between candidates from BAME and non-BAME backgrounds, some trends were noted. More BAME applicants cited school/college rather than family as encouraging. More BAME applicants also indicated that they would consider issues of diversity when selecting a place of study, and BAME respondents appeared less likely to consider location and university life. Survey and focus group findings combined may indicate deficits in social capital available to BAME midwifery applicants. Focus group findings in particular suggest multiple experiences of challenge and inequity at all stages of the application process, together with a perception that midwifery is a niche and white profession. Applicants value proactive support from universities and would appreciate increased diversity, opportunities for mentorship and an individualised approach to recruitment.

Conclusions: BAME applicants to midwifery can face additional challenges which impact their ability to secure a place. There is a need to reposition midwifery as an inclusive and welcoming option for people from all backgrounds, and to develop equitable recruitment processes that value a range of skills and life experiences.

Empowerment is a key aspect of relational, partnership-based care, and has been highlighted as a key outcome of group antenatal care (gANC). In order to explore how gANC facilitates empowerment, a systematic search and framework analysis of evaluations of gANC was undertaken. Findings from retrieved papers were mapped onto Zimmerman’s theory of empowerment. This suggested that gANC facilitates empowerment through helping others, knowledge about resources, self-efficacy and perceived control. However, situational awareness, decision making and problem solving were less apparent, indicating that birthing people might be further empowered if these mechanisms were incorporated into their care.

Globally, 5-30% of children have eczema; this could be partly attributable to skin cleansing routines. Evidence-based international guidance on this topic is lacking and dated national UK guidelines may not reflect best practice. We conducted a mixed method, UK-wide (England, Scotland, Northern Ireland and Wales) cross-sectional survey to investigate parental cleansing of their newborn’s skin; 973 responses were suitable for inclusion. 60% of participants delayed first cleansing after birth for 48 hours and 79.4% of participants cleansed their newborn’s nappy area with each change.  Participants from Scotland were more likely to cleanse their newborn within the first 48 hours (X22 = 29.3, p

Aims: To systematically review literature investigating parents’ and carers’ newborn skin cleansing practices in order to describe these practices and their underlying rationales.

Design: A systematic literature review

Data sources: CINAHL, Medline, BND and PubMed databases were searched in February 2020. Primary research articles written in English and relevant to the topic were included regardless of country of publication.

Review Methods: Primary research papers published between 2009 and 2020 were reviewed using the Mixed Methods Appraisal Tool. Relevant results from retrieved studies were extracted and tabulated. Qualitative data were analysed using the first two steps of Thomas and Harden’s (2008) method of thematic analysis.A basic meta-integration process similar to that proposed by Frantzen and Fetters (2015) was performed and the limited quantitative findings were reported within the relevant qualitative theme.

Results: Seven studies were included and the following themes generated: bathing after birth, frequency of cleansing, substances used for bathing/cleansing, vernix removal and beliefs and culture. A wide range of newborn skin cleansing practices exist across the countries and cultures studied, and the rationales for these practices are deeply rooted in common belief systems and culture of the study area.

Conclusion: Cultural influences appear to drive parental practice, and many parents are unwilling to break away from these. In addition to further research into safe and effective newborn skin cleansing methods, there is a call for new, large scale, research which addresses gaps in current knowledge about the skin cleansing practices of different groups of parents with newborn babies. This research would also seek to determine how these practices might be influenced if they are shown not to be optimal, and guide planning effective dissemination of evidence-based information.

In this fourth article of our Advancing practice education series, a novel initiative regarding the engagement of service-users to student midwife recruitment is outlined. Whilst the NMC mandates service user involvement, it can be challenging to implement. We at Oxford Brookes University introduced an initiative involving group discussions between candidates and service users. Feedback was sought via an evaluation form which 68 candidates and six service users completed. Candidates enjoyed the opportunity to question mothers in an informal group setting, and women felt valued through sharing their stories and making a meaningful contribution to the recruitment process.

There is a clear link between the development of obesity with poor diet and exercise behaviours. In the UK, excess weight is more prevalent among men than women: 41% of men and 31% of women are classed as overweight (BMI 25.0 -29.9 kg/m2); 68% and 58% of men and women respectively are overweight or obese (BMI≥ 25 kg/m2). An increase in BMI is also associated with a greater risk of mortality in men than in women however men are under-represented in lifestyle interventions for weight loss: In 2016, 7% of Slimming World members were men. It has been argued that men may perceive larger bodies to be more masculine and more desirable to women. Furthermore, factors contributing to male obesity such as eating large portions and consuming large volumes of alcohol, can be viewed as quintessentially masculine behaviours.

To promote weight loss and reduce obesity among men, it is useful to understand which social interactions influence male weight loss behaviours. It is known that men in heterosexual relationships often gain weight after getting married, however the extent of women’s influence on men’s food intake and weight is unclear. Research studies investigating the influence that women and female partners have on male dietary and weight loss have been mixed; while some suggests they have a positive impact, other research suggests the impact is mixed or negative. Friends, peers and colleagues are also referenced regarding men’s diet and physical activity behaviours and behavioural intentions. The qualitative literature in the UK which explores how social relationships influence men’s weight and weight-related behaviours is, however, limited, therefore this research study sought to address this literature gap. The primary research question was to explore men’s perceptions and attitudes of dietary and physical activity behaviours in relation to weight and weight management.

Background. Pelvic girdle pain is a prevalent condition during pregnancy. The associated pain can be constant and extremely distressing for women; however, the pathogenesis is still unclear. It is important to gain insight into women’s experiences of pelvic girdle pain in order to improve these with a view to impacting positively on their physical symptoms, while also improving overall wellbeing and mental health throughout pregnancy and the puerperium. Aims and Objectives. To use published literature to gain an insight into how pelvic girdle pain can impact on a woman’s experience of pregnancy and the puerperium, to provide meaningful, evidence-based, recommendations for midwifery practice. Method. A systematic literature review of qualitative research was undertaken. Database searches using Cumulative Index to Nursing and Allied Health, British Nursing Index, PsycINFO, and PubMed identified seven studies published between 2005 and 2014 in Sweden and England. Each paper was quality appraised in order to inform assessment of the credibility of findings. Following Noblit and Hare’s (1988) seven-step process for metaethnography, findings from each paper were synthesised into key themes which were then developed into a new conceptual model. Results. A conceptual model, consisting of five key themes, was identified. The central theme is ‘loss of identity and control’, the themes leading on from this are: ‘adapting to pain’, ‘inadequacy and independence’, ‘expectations and perceptions of others’, and ‘psychological strain’. The model highlights the link between mental wellbeing and perceived intensity of pain. Conclusions. Pelvic girdle pain has a debilitating impact on the lives of pregnant women and further research is necessary to identify effective treatment methods. 

Objective. The principal objective was to test the effectiveness of an online learning tool to improve midwives’ accuracy of blood loss estimations in a birthing pool environment. The secondary objective was to assess the acceptability of the online learning tool to the midwives using it. Design. A one group pre-test post-test experiment with immediate and six weeks follow-up to test ability together with an online questionnaire to assess perceived usefulness of an online learning tool. Setting. A large NHS maternity hospital comprising an acute care obstetric unit, a small district unit labour ward, one alongside midwifery-led unit and three freestanding midwifery-led units. Participants. Volunteer NHS employed midwives who had experience in caring for women labouring and giving birth in water (n=24). Intervention. An online learning tool comprising six randomly ordered short video simulations of blood loss in a birthing pool in real time, and a tutorial giving verbal and pictorial guidance on making accurate blood loss estimations in water was developed then piloted. Midwives’ accuracy scores for estimating blood loss in each of the videos were calculated at three timepoints; pre and immediately post the learning component, and six weeks later. The estimated blood loss volume was subtracted from the actual blood loss volume, to give the difference between estimated and real blood loss in millilitres(ml) which was then converted to percentage difference to standardise comparison across the six volumes. The differences between pre- and post-learning for each of the six blood volumes was analysed using a repeated measures ANOVA. Statistical significance was set at p

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.

Stress and burnout are endemic within the NHS and midwifery profession and have a negative impact on the health and well-being of individual midwives and on retention and recruitment for the profession as a whole. Furthermore, stress can have a negative impact on the care of childbearing women as midwives seek to manage their stress levels by employing strategies such as task orientation. As part of a larger project to engage staff in personal and workplace wellbeing, The Oxford University Hospitals NHS Foundation Trust (OUHFT) maternity services provided staff with the opportunity to learn the practice of mindfulness meditation.  An eight week course was made available with the intention of supporting staff to manage stress and anxiety, increase resilience and self-compassion and improve the culture of the organisation as a whole. Evaluations carried out immediately post course and after 4-6 weeks indicated a positive impact in both personal and organisational domains.

Aims and Objectives: to explore qualitative literature to ascertain whether and how nurses and midwives perceive that mindfulness impacts on their practice, particularly their interactions with patients.

Background: Stress and burnout, which negatively impact patient care, are widely reported among nurses and midwives, who face unique stressors as professionals who often hold little organisational power but are expected to shoulder the burden of resource cuts and an increasingly complex workload. Mindfulness is increasingly used as a tool to decrease stress and burnout in health professionals, and may also increase practitioner compassion and improve patient interactions.

Design: a critical interpretative synthesis.

Methods: a systematic search was undertaken to identify qualitative studies where the majority of participants were qualified nurses and/or midwives who had attended mindfulness training. Retrieved literature was read and re-read to identify relevant material, which was then coded into themes. Related themes were grouped into synthetic constructs, and a synthetic argument was produced to illustrate the relationships between these.

Results: five relevant papers were identified. Findings indicate that mindfulness training enables nurses and midwives to gain some control over their thoughts and stress levels. This then creates a quiet mental space giving them agency and perspective and leading to improved caring, including a more patient-centred focus and increased presence and listening. Mindfulness appears to alter the way nurses and midwives operate within a stressful work environment, thereby changing the way the environment is experienced by themselves and, potentially, the people in their care.

Conclusions: Further research is needed, but current qualitative research suggests mindfulness may enable nurses and midwives to work with compassion in stressful and demanding work environments.

Relevance to clinical practice: Mindfulness may offer an enabling way of coping with stress, in contrast to longstanding strategies such as task-orientation and depersonalisation.

Objective: To identify elements in the environment of a postnatal ward which impacted on the introduction of a breastfeeding support intervention.

Design: A concurrent, realist evaluation including practice observations and semi-structured interviews.

Setting: A typical British maternity ward.

Participants: Five midwives and two maternity support workers were observed. Seven midwives and three maternity support workers were interviewed. Informed consent was obtained from all participants. Ethical approval was granted by the relevant authorities.

Findings: A high level of non-compliance with the intervention was driven by a lack of time and staff, and the ward staffs’ lack of control of the organisation of their time and space. This was compounded by a propensity towards task orientation, workload reduction and resistance to change – all of which supported the existing medical approach to care. Limited support for the intervention was underpinned by staff willingness to reconsider their views and a widespread frustration with current ways of working.

Key conclusions: This small, local study suggests that the environment and working conditions on a typical British postnatal ward present significant barriers to the introduction of breastfeeding support interventions requiring a relational approach to care.

Implications for practice: Midwives and maternity support workers need to be able to control their time and space, and feel able to provide the relational care they perceive that women need, before breastfeeding support interventions can be successfully implemented in practice. Frustration with current ways of working, and a willingness to consider other approaches, could be harnessed to initiate change that would benefit health professionals and the women and families in their care. However, without appropriate leadership or facilitation for change, this could alternatively encourage learned helplessness and passive resistance.