Factors influencing the utilisation of free-standing and alongside midwifery units in England: a qualitative research study

OBJECTIVE: To identify factors influencing the provision, utilisation and sustainability of midwifery units (MUs) in England. DESIGN: Case studies, using individual interviews and focus groups, in six National Health Service (NHS) Trust maternity services in England. SETTING AND PARTICIPANTS: NHS maternity services in different geographical areas of England Maternity care staff and service users from six NHS Trusts: two Trusts where more than 20% of all women gave birth in MUs, two Trusts where less than 10% of all women gave birth in MUs and two Trusts without MUs. Obstetric, midwifery and neonatal clinical leaders, managers, service user representatives and commissioners were individually interviewed (n=57). Twenty-six focus groups were undertaken with midwives (n=60) and service users (n=52). MAIN OUTCOME MEASURES: Factors influencing MU use. FINDINGS: The study findings identify several barriers to the uptake of MUs. Within a context of a history of obstetric-led provision and lack of decision-maker awareness of the clinical and economic evidence, most Trust managers and clinicians do not regard their MU provision as being as important as their obstetric unit (OU) provision. Therefore, it does not get embedded as an equal and parallel component in the Trust's overall maternity package of care. The analysis illuminates how implementation of complex interventions in health services is influenced by a range of factors including the medicalisation of childbirth, perceived financial constraints, adequate leadership and institutional norms protecting the status quo. CONCLUSIONS: There are significant obstacles to MUs reaching their full potential, especially free-standing midwifery units. These include the lack of commitment by providers to embed MUs as an essential service provision alongside their OUs, an absence of leadership to drive through these changes and the capacity and willingness of providers to address women's information needs. If these remain unaddressed, childbearing women's access to MUs will continue to be restricted

Immorality and Irrationality

Does immorality necessarily involve irrationality? The question is often taken to be among the deepest in moral philosophy. But apparently deep questions sometimes admit of deflationary answers. In this case we can make way for a deflationary answer by appealing to dualism about rationality, according to which there are two fundamentally distinct notions of rationality: structural rationality and substantive rationality. I have defended dualism elsewhere. Here, I’ll argue that it allows us to embrace a sensible – I will not say boring – moderate view about the relationship between immorality and irrationality: roughly, that immorality involves substantive irrationality, but not structural irrationality. I defend this moderate view, and argue that many of the arguments for less moderate views turn either on missing the distinction between substantive and structural rationality, or on misconstruing it

N incorporation and associated localized vibrational modes in GaSb

We present results of electronic structure calculations on the N-related localized vibrational modes in the dilute nitride alloy GaSb1−xNx. By calculating the formation energies of various possible N incorporation modes in the alloy, we determine the most favorable N configurations, and we calculate their vibrational mode frequencies using density functional theory under the generalized gradient approximation to electron exchange and correlation, including the effects of the relativistic spin-orbit interactions. For a single N impurity, we find substitution on an Sb site, NSb, to be most favorable, and for a two-N-atom complex, we find the N-N split interstitial on an Sb site to be most favorable. For these defects, as well as, for comparison, defects comprising two N atoms on neighboring Sb sites and a N-Sb split interstitial on an Sb site, we find well-localized vibration modes (LVMs), which should be experimentally observable. The frequency of the triply degenerate LVM associated with NSb is determined to be 427.6 cm−1. Our results serve as a guide to future experimental studies to elucidate the incorporation of small concentrations of N in GaSb, which is known to lead to a reduction of the band gap and opens the possibility of using the material for long-wavelength applications

Factors influencing utilisation of ‘free-standing’ and ‘alongside’ midwifery units for low-risk births in England: a mixed-methods study

Background Midwifery-led units (MUs) are recommended for ‘low-risk’ births by the National Institute for Health and Care Excellence but according to the National Audit Office were not available in one-quarter of trusts in England in 2013 and, when available, were used by only a minority of the low-risk women for whom they should be suitable. This study explores why. Objectives To map the provision of MUs in England and explore barriers to and facilitators of their development and use; and to ascertain stakeholder views of interventions to address these barriers and facilitators. Design Mixed methods – first, MU access and utilisation across England was mapped; second, local media coverage of the closure of free-standing midwifery units (FMUs) were analysed; third, case studies were undertaken in six sites to explore the barriers and facilitators that have an impact on the development of MUs; and, fourth, by convening a stakeholder workshop, interventions to address the barriers and facilitators were discussed. Setting English NHS maternity services. Participants All trusts with maternity services. Interventions Establishing MUs. Main outcome measures Numbers and types of MUs and utilisation of MUs. Results Births in MUs across England have nearly tripled since 2011, to 15% of all births. However, this increase has occurred almost exclusively in alongside units, numbers of which have doubled. Births in FMUs have stayed the same and these units are more susceptible to closure. One-quarter of trusts in England have no MUs; in those that do, nearly all MUs are underutilised. The study findings indicate that most trust managers, senior midwifery managers and obstetricians do not regard their MU provision as being as important as their obstetric-led unit provision and therefore it does not get embedded as an equal and parallel component in the trust’s overall maternity package of care. The analysis illuminates how provision and utilisation are influenced by a complex range of factors, including the medicalisation of childbirth, financial constraints and institutional norms protecting the status quo. Limitations When undertaking the case studies, we were unable to achieve representativeness across social class in the women’s focus groups and struggled to recruit finance directors for individual interviews. This may affect the transferability of our findings. Conclusions Although there has been an increase in the numbers and utilisation of MUs since 2011, significant obstacles remain to MUs reaching their full potential, especially FMUs. This includes the capacity and willingness of providers to address women’s information needs. If these remain unaddressed at commissioner and provider level, childbearing women’s access to MUs will continue to be restricted. Future work Work is needed on optimum approaches to improve decision-makers’ understanding and use of clinical and economic evidence in service design. Increasing women’s access to information about MUs requires further studies of professionals’ understanding and communication of evidence. The role of FMUs in the context of rural populations needs further evaluation to take into account user and community impact. Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 12. See the NIHR Journals Library website for further project information

Beam alignment techniques based on the current multiplication effect in photoconductors Third summary technical progress report, 15 Nov. 1966 - 15 Oct. 1967

Beam alignment techniques developed for infrared sensitive single crystal germanium to study multiplication effect in photoconductor

Rationality as the Rule of Reason

The demands of rationality are linked both to our subjective normative perspective (given that rationality is a person-level concept) and to objective reasons or favoring relations (given that rationality is non-contingently authoritative for us). In this paper, I propose a new way of reconciling the tension between these two aspects: roughly, what rationality requires of us is having the attitudes that correspond to our take on reasons in the light of our evidence, but only if it is competent. I show how this view can account for structural rationality on the assumption that intentions and beliefs as such involve competent perceptions of downstream reasons, and explore various implications of the account

Antiferromagnetism at T > 500 K in the Layered Hexagonal Ruthenate SrRu2O6

We report an experimental and computational study of magnetic and electronic properties of the layered Ru(V) oxide SrRu2O6 (hexagonal, P-3 1m), which shows antiferromagnetic order with a N\'eel temperature of 563(2) K, among the highest for 4d oxides. Magnetic order occurs both within edge-shared octahedral sheets and between layers and is accompanied by anisotropic thermal expansivity that implies strong magnetoelastic coupling of Ru(V) centers. Electrical transport measurements using focused ion beam induced deposited contacts on a micron-scale crystallite as a function of temperature show p-type semiconductivity. The calculated electronic structure using hybrid density functional theory successfully accounts for the experimentally observed magnetic and electronic structure and Monte Carlo simulations reveals how strong intralayer as well as weaker interlayer interactions are a defining feature of the high temperature magnetic order in the material.Comment: Physical Review B 2015 accepted for publicatio

Band energy control of molybdenum oxide by surface hydration

EPSRC (Grants EP/M009580/1, EP/J017361/1, EP/I01330X/1, and EP/I028641/1), the Royal Society, and the European Research Council. The work benefited from the University of Bath's High Performance Computing Facility, and access to the HECToR supercomputer through membership of the UKs HPC Materials Chemistry Consortium, which is funded by EPSRC (Grant No. EP/F067496) and the UltraFOx grant

Recent La Plata basin drought conditions observed by satellite gravimetry

The Gravity Recovery and Climate Experiment (GRACE) provides quantitative measures of terrestrial water storage (TWS) change. GRACE data show a significant decrease in TWS in the lower (southern) La Plata river basin of South America over the period 2002-2009, consistent with recognized drought conditions in the region. GRACE data reveal a detailed picture of temporal and spatial evolution of this severe drought event, which suggests that the drought began in lower La Plata in around austral spring 2008 and then spread to the entire La Plata basin and peaked in austral fall 2009. During the peak, GRACE data show an average TWS deficit of ~12 cm (equivalent water layer thickness) below the 7 year mean, in a broad region in lower La Plata. GRACE measurements are consistent with accumulated precipitation data from satellite remote sensing and with vegetation index changes derived from Terra satellite observations. The Global Land Data Assimilation System model captures the drought event but underestimates its intensity. Limited available groundwater-level data in southern La Plata show significant groundwater depletion, which is likely associated with the drought in this region. GRAC-observed TWS change and precipitation anomalies in the studied region appear to closely correlate with the ENSO climate index, with dry and wet seasons corresponding to La Ni\~na and El Ni\~no events, respectively

Hypersonic simulations using open-source CFD and DSMC solvers

Hypersonic hybrid hydrodynamic-molecular gas flow solvers are required to satisfy the two essential requirements of any high-speed reacting code, these being physical accuracy and computational efficiency. The James Weir Fluids Laboratory at the University of Strathclyde is currently developing an open-source hybrid code which will eventually reconcile the direct simulation Monte-Carlo method, making use of the OpenFOAM application called dsmcFoam, and the newly coded open-source two-temperature computational fluid dynamics solver named hy2Foam. In conjunction with employing the CVDV chemistry-vibration model in hy2Foam, novel use is made of the QK rates in a CFD solver. In this paper, further testing is performed, in particular with the CFD solver, to ensure its efficacy before considering more advanced test cases. The hy2Foam and dsmcFoam codes have shown to compare reasonably well, thus providing a useful basis for other codes to compare against