Alternative versus conventional institutional settings for birth

Background: Alternative institutional settings have been established for the care of pregnant women who prefer and require little or no medical intervention. The settings may offer care throughout pregnancy and birth, or only during labour; they may be part of hospitals or freestanding entities. Specially designed labour rooms include bedroom-like rooms, ambient rooms, and Snoezelen rooms. Objectives: Primary: to assess the effects of care in an alternative institutional birth environment compared to care in a conventional institutional setting. Secondary: to determine if the effects of birth settings are influenced by staffing, architectural features, organizational models or geographical location. Search strategy: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 May 2010). Selection criteria: All randomized or quasi-randomized controlled trials which compared the effects of an alternative institutional maternity care setting to conventional hospital care. Data collection and analysis: We used standard methods of the Cochrane Collaboration Pregnancy and Childbirth Group. Two review authors evaluated methodological quality. We performed double data entry and have presented results using risk ratios (RR) and 95% confidence intervals (CI). Main results: Nine trials involving 10684 women met the inclusion criteria. We found no trials of freestanding birth centres or Snoezelen rooms. Allocation to an alternative setting increased the likelihood of: no intrapartum analgesia/anaesthesia (five trials, n = 7842; RR 1.17, 95% CI 1.01 to 1.35); spontaneous vaginal birth (eight trials; n = 10,218; RR 1.04, 95% CI 1.02 to 1.06); breastfeeding at six to eight weeks (one trial, n = 1147; RR 1.04, 95% CI 1.02 to 1.06); and very positive views of care (two trials, n = 1207; RR 1.96, 95% CI 1.78 to 2.15). Allocation to an alternative setting decreased the likelihood of epidural analgesia (seven trials, n = 9820; RR 0.82, 95% CI 0.75 to 0.89); oxytocin augmentation of labour (seven trials, n = 10,020; RR 0.78, 95% CI 0.66 to 0.91); and episiotomy (seven trials, n = 9944; RR 0.83, 95% CI 0.77 to 0.90). There was no apparent effect on serious perinatal or maternal morbidity/mortality, other adverse neonatal outcomes, or postpartum hemorrhage. No firm conclusions could be drawn regarding the effects of variations in staffing, organizational models, or architectural characteristics of the alternative settings. Authors' conclusions: When compared to conventional settings, hospital-based alternative birth settings are associated with increased likelihood of spontaneous vaginal birth, reduced medical interventions and increased maternal satisfactio

Preventing Domestic Abuse for Children and Young People (PEACH): A Mixed Knowledge Scoping Review

Background: A range of interventions that aim to prevent domestic abuse has been developed for children and young people in the general population. While these have been widely implemented, few have been rigorously evaluated. This study aimed to discover what was known about these interventions for children and what worked for whom in which settings. Review methods: This mixed knowledge review was informed by realist principles and comprised four overlapping phases: an online mapping survey to identify current provision; a systematic review of the existing literature; a review of the UK ‘grey’ literature; and consultation with young people and experts. Information from these four sources of evidence informed analysis of costs and benefits. Results: The evidence for interventions achieving changes in knowledge and attitudes was stronger than that for behavioural change. Shifting social norms in the peer group emerged as a key mechanism of change. Media campaigns act to influence the wider social climate within which more targeted interventions are received, and they are also a source for programme materials. While most interventions are delivered in secondary schools, they are increasingly targeted at younger children. The review emphasised the importance of a school’s ‘readiness’ to introduce preventative interventions which need to be supported across all aspects of school life. Involving young people in the design and delivery of programmes increases authenticity and this emerged as a key ingredient in achieving impact. Longer interventions delivered by appropriately trained staff appeared likely to be more effective. Teachers emerged as well placed to embed interventions in schools but they require training and support from those with specialist knowledge in domestic abuse. There was evidence that small groups of students who were at higher risk might have accounted for some results regarding effectiveness and that programme effectiveness may vary for certain subgroups. Increasingly, boys are being identified as a target for change. The study identified a need for interventions for disabled children and children and young people from black, Asian, minority ethnic and refugee groups and a particular lack of materials designed for lesbian, gay, bisexual and transgender young people. Limitations: Very little evidence was identified on costs and cost-effectiveness. Few studies showed an effect at the level of significance set for the review. Where it did exist, the effect size was small, except in respect of improved knowledge. The inability to calculate a response rate for the mapping survey, which used a snowballing approach, limits the ability to generalise from it. Conclusions: While it is appropriate to continue to deliver interventions to whole populations of children and young people, effectiveness appeared to be influenced by high-risk children and young people, who should be directed to additional support. Programmes also need to make provision to manage any resulting disclosures. Interventions appear to be context specific, and so those already being widely delivered in the UK and which are likely to be acceptable should be robustly tested. Funding: The National Institute for Health Research Public Health Research programme

Insider Action research as an approach and a method – Exploring institutional encounters from within a birthing context

The aim of this paper was to describe the first person perspective of being a peer midwife and a novice researcher initiating collaborative AR in her own organization to develop knowledge about the first encounters between the labouring woman and her care-givers in a hospital birthing context. It was motivated by the author’s longstanding professional clinical experience of observing and hearing parents’ stories of vulnerability and fear of childbirth, and how staff’s attitudes affected the childbirth experience negatively. Data were collected between 2010 and 2013 and included the researcher’s log with reflections from clinical work, as well as interviews, participant observation, and research group communications. A reflective interpretative lifeworld research approach was used to analyze the data. The experience of being a novice insider action researcher (IARr) consisted of three thematic meanings: ‘‘the struggle to initiate a clinical insider action research project,’’ ‘‘standing alone at the messy front line,’’ and ‘‘being a catalytic counterbalance to the prevailing medico technical focus.’’ The comprehensive understanding was ‘‘learning how to clinically reflect on and to voice the tacit components of care.’’ The strategy used in undertaking this study was influenced by the philosophies of both midwifery care and AR

Cost analysis of the CTLB Study, a multitherapy antenatal education programme to reduce routine interventions in labour

Objective: To assess whether the multitherapy antenatal education ‘CTLB’ (Complementary Therapies for Labour and Birth) Study programme leads to net cost savings. Design: Cost analysis of the CTLB Study, using analysis of outcomes and hospital funding data. Methods: We take a payer perspective and use Australian Refined Diagnosis-Related Group (AR-DRG) cost data to estimate the potential savings per woman to the payer (government or private insurer). We consider scenarios in which the intervention cost is either borne by the woman or by the payer. Savings are computed as the difference in total cost between the control group and the study group. Results: If the cost of the intervention is not borne by the payer, the average saving to the payer was calculated to be $A808 per woman. If the payer covers the cost of the programme, this figure reduces to$A659 since the average cost of delivering the programme was $A149 per woman. All these findings are significant at the 95Conclusion: The CTLB antenatal education programme leads to significant savings to payers that come from reduced use of hospital resources. Depending on which perspective is considered, and who is responsible for covering the cost of the programme, the net savings vary from$A659 to $A808 per woman. Compared with the average cost of birth in the control group, we conclude that the programme could lead to a reduction in birth-related healthcare costs of approximately 9%. Trial registration number: ACTRN12611001126909

The UCLan Engagement and Service User Support (Comensus) project: Valuing authenticity making space for emergence.

Objective  To develop and evaluate service user, carer and community involvement in health and social care education. Background  Despite the high policy profile of involvement issues, there appear to be no published accounts of schemes that have used a systematic whole-faculty approach to community engagement in health and social care higher education. Focus of this paper  The set up and early development of a faculty-wide community engagement project. Setting and participants  Staff from the faculty of health in one University, local service users and carers and community group project workers and local National Health Service (NHS) and public sector staff. Design  Participatory action research including document review, field notes, questionnaires and interviews. Analysis  Thematic analysis. The emerging themes were tested by seeking disconfirming data, and through verification with stake-holders. Results  Prior to the study, there were examples of community engagement in the participating faculty, but they occurred in specific departments, and scored low on the ‘ladder of involvement’. Some previous attempts at engagement were perceived to have failed, resulting in resistance from staff and the community. Despite this, an advisory group was successfully formed, and project framing and development evolved with all stake-holders over the subsequent year. The four themes identified in this phase were: building accessibility; being ‘proper’ service users/carers;moving from suspicion to trust: mutually respectful partnerships as a basis for sustainable change; and responses to challenge and emergence. Conclusions  Successful and sustainable engagement requires authenticity. Many problems and solutions arising from authentic engagement are emergent, and potentially challenging to organizations

Factors that influence the uptake of routine antenatal services by pregnant women: a qualitative evidence synthesis

A B S T R A C T This is a protocol for a Cochrane Review (Qualitative). The objectives are as follows: To identify, appraise, and synthesise qualitative studies exploring: • women’s views and experiences of antenatal care; and • factors influencing the uptake of antenatal care arising from women’s accounts