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Social factors associated with poor childbirth outcomes and experiences of maternity care include minority ethnicity, poverty, young motherhood, homelessness, difficulty speaking or understanding English, migrant or refugee status, domestic violence, mental illness and substance abuse. It is not known what specific aspects of maternity care work to improve the maternal and neonatal outcomes for these under-served, complex populations. This study aimed to compare maternal and neonatal clinical birth outcomes for women with social risk factors accessing different models of maternity care. Quantitative data on pregnancy and birth outcome measures for 1000 women accessing standard care, group practice and specialist models of care at two large, inner-city maternity services were prospectively collected and analysed using multinominal regression. The level of continuity of care and place of antenatal care were used as independent variables to explore these potentially influential aspects of care. Outcomes adjusted for women's social and medical risk factors and the service attended. Women who received standard maternity care were significantly less likely to use water for pain relief in labour (RR 0.11, CI 0.02-0.62) and have skin to skin contact with their baby shortly after birth (RR 0.34, CI 0.14-0.80) compared to the specialist model of care. Antenatal care based in the hospital setting was associated with a significant increase in preterm birth (RR 2.38, CI 1.32-4.27) and low birth weight (RR 2.31, CI 1.24-4.32), and a decrease in induction of labour (RR 0.65, CI 0.45-0.95) compared to community-based antenatal care, this was despite women's medical risk factors. A subgroup analysis found that preterm birth was increased further for women with the highest level of social risk accessing hospital-based antenatal care (RR 3.11, CI1.49-6.50), demonstrating the protective nature of community-based antenatal care. This research highlights how community-based antenatal care, with a focus on continuity of carer reduced health inequalities and improved maternal and neonatal clinical outcomes for women with social risk factors. The findings support the current policy drive to increase continuity of midwife-led care, whilst adding that community-based care may further improve outcomes for women at increased risk of health inequalities. The relationship between community-based models of care and neonatal outcomes require further testing in future research. The identification of specific mechanisms such as help-seeking and reduced anxiety, to explain these findings are explored in a wider evaluation.

Background Women from ethnic minority backgrounds are at greater risk of adverse maternal outcomes. Antenatal care plays a crucial role in reducing risks of poor outcomes. The aim of this study was to identify, appraise, and synthesise the recent qualitative evidence on ethnic minority women’s experiences of accessing antenatal care in high-income European countries, and to develop a novel conceptual framework for access based on women’s perspectives. Methods We conducted a comprehensive search of seven electronic databases in addition to manual searches to identify all qualitative studies published between January 2010 and May 2021. Identified articles were screened in two stages against the inclusion criteria with titles and abstracts screened first followed by full-text screening. Included studies were quality appraised using the Critical Appraisal Skills Programme checklist and extracted data were synthesised using a ‘best fit’ framework, based on an existing theoretical model of health care access. Results A total of 30 studies were included in this review. Women’s experiences covered two overarching themes: ‘provision of antenatal care’ and ‘women's uptake of antenatal care’. The ‘provision of antenatal care’ theme included five sub-themes: promotion of antenatal care importance, making contact and getting to antenatal care, costs of antenatal care, interactions with antenatal care providers and models of antenatal care provision. The ‘women's uptake of antenatal care’ theme included seven sub-themes: delaying initiation of antenatal care, seeking antenatal care, help from others in accessing antenatal care, engaging with antenatal care, previous experiences of interacting with maternity services, ability to communicate, and immigration status. A novel conceptual model was developed from these themes. Conclusion The findings demonstrated the multifaceted and cyclical nature of initial and ongoing access to antenatal care for ethnic minority women. Structural and organisational factors played a significant role in women’s ability to access antenatal care. Participants in majority of the included studies were women newly arrived in the host country, highlighting the need for research to be conducted across different generations of ethnic minority women taking into account the duration of stay in the host country where they accessed antenatal care. Protocol and registration The review protocol was registered on PROSPERO (reference number CRD42021238115).

Background There is increasing interest in promoting young people’s health by modifying the school environment. However, existing research offers little guidance on how the school context enables or constrains students’ health behaviours, or how students’ backgrounds relate to these processes. For these reasons, this paper reports on a meta-ethnography of qualitative studies examining: through what processes does the school environment (social and physical) influence young people’s health? Methods Systematic review of qualitative studies. Sixteen databases were searched, eliciting 62, 329 references which were screened, with included studies quality assessed, data extracted and synthesized using an adaptation of Noblit and Hare’s meta-ethnographic approach. Results Nineteen qualitative studies were synthesised to explore processes through which school-level influences on young people’s health might occur. Four over-arching meta-themes emerged across studies focused on a range of different health issues. First, aggressive behaviour and substance use are often a strong source of status and bonding at schools where students feel educationally marginalised or unsafe. Second, health-risk behaviours are concentrated in unsupervised ‘hotspots’ at the school. Third, positive relationships with teachers appear to be critical in promoting student wellbeing and limiting risk behaviour; however, certain aspects of schools’ organisation and education policies constrain this, increasing the likelihood that students look for a sense of identity and social support via health-risk behaviours. Fourth, unhappiness at school can cause students to seek sources of ‘escape’, either by leaving school at lunchtime or for longer unauthorized spells or through substance use. These meta-themes resonate with Markham and Aveyard’s theory of human functioning and school organisation, and we draw on these qualitative data to refine and extend this theory, in particular conceptualising more fully the role of young people’s agency and student-led ‘systems’ in constituting school environments and generating health risks. Conclusion Institutional features which may shape student health behaviours such as lack of safety, poor student-staff relationships and lack of student voice are amenable to interventions and should be the subject of future investigation. Future qualitative research should focus on health behaviours which are under-theorised in this context such as physical activity, sexual and mental health.

Background Interventions that engage communities have been shown to improve health and wellbeing in disadvantaged groups internationally, but there is little evidence on current community-led practice, particularly in relation to the process of community engagement. This paper presents a qualitative cross-case analysis of barriers & facilitators in six UK community engagement projects, using different models of community engagement. Methods The primary sampling criteria was the type of approach to community engagement, using a conceptual framework with four main groups: Strengthening communities; Volunteer and peer roles; Collaborations and partnerships; Connecting to community resources. Qualitative interview-based methods (semi-structured interviews and focus groups) explored community and professional perspectives in depth. Thematic analysis was used to analyse the data, building within-case studies before comparing findings and using an iterative process to build explanations in a cross-case analysis. Results Fifty-five people (28 community stakeholders and 27 professional stakeholders) from six selected case study projects took part in the research. Key themes related to successful community engagement were: trust within the community and between community members and service providers; respect for community members’ expertise; allowing sufficient time for relationships to establish and for outcomes to be seen; commitment of key people; and flexibility. Conclusions This qualitative case study research found that in successful community engagement projects, community expertise is respected and valued, allowing community members to be fully involved and take ownership of the projects. Sufficient time should be allowed for this process. Flexibility and adaptation of project materials, protocols and role descriptions is important in overcoming barriers to community engagement.

Background Black and minority ethnic women and those with social risk factors such as deprivation, refugee and asylum seeker status, homelessness, mental health issues and domestic violence are at a disproportionate risk of poor birth outcomes. Language barriers further exacerbate this risk, with women struggling to access, engage with maternity services and communicate concerns to healthcare professionals. To address the language barrier, many UK maternity services offer telephone interpreter services. This study explores whether or not women with social risk factors find these interpreter services acceptable, accessible and safe, and to suggest solutions to address challenges. Methods Realist methodology was used to refine previously constructed programme theories about how women with language barriers access and experience interpreter services during their maternity care. Twenty-one longitudinal interviews were undertaken during pregnancy and the postnatal period with eight non-English speaking women and their family members. Interviews were analysed using thematic framework analysis to confirm, refute or refine the programme theories and identify specific contexts, mechanisms and outcomes relating to interpreter services. Results Women with language barriers described difficulties accessing maternity services, a lack of choice of interpreter, suspicion around the level of confidentiality interpreter services provide, and questioned how well professional interpreters were able to interpret what they were trying to relay to the healthcare professional during appointments. This resulted in many women preferring to use a known and trusted family member or friend to interpret for them where possible. Their insights provide detailed insight into how poor-quality interpreter services impact on their ability to disclose risk factors and communicate concerns effectively with their healthcare providers. A refined programme theory puts forward mechanisms to improve their experiences and safety such as regulated, high-quality interpreter services throughout their maternity care, in which women have choice, trust and confidence. Conclusions The findings of this study contribute to concerns highlighted in previous literature around interpreter services in the wider healthcare arena, particularly around the lack of regulation and access to high-quality interpretation. This is thought to have a significant effect on pregnant women who are living socially complex lives as they are not able to communicate their concerns and access support. This not only impacts on their safety and pregnancy outcomes, but also their wider holistic needs. The refined program theory developed in this study offers insights into the mechanisms of equitable access to appropriate interpreter services for pregnant women with language barriers.

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 Parents/carers of children with complex neurodisability continue to lack appropriate family-centred care. “Encompass” is a community-based group programme that was co-adapted from “Baby Ubuntu” in Uganda. It is an example of a “decolonised healthcare innovation” as it is a low-cost solution from a low-income country for use in a resource-constrained UK National Health Service (NHS). Methods and analysis We will conduct a mixed-methods pilot feasibility study to determine the feasibility and acceptability of delivering and evaluating “Encompass” with parents/carers of children under 5 years with complex neurodisability in the UK. We aim to recruit 20 parents/carers of children from two NHS trusts in England serving urban areas where there is high social deprivation and ethnic diversity. Recruited parents/carers will attend the 10-modular, participatory group programme over a 6-month period. Groups will be facilitated by a trained allied health professional and an “expert parent” with lived experience. The primary outcomes of interest are the feasibility of delivering and evaluating the programme (recruitment, retention rates, acceptability as perceived by the parents/carers, facilitators and wider key NHS partners), intervention fidelity and participant adherence. Results will be collectively assessed against traffic light criteria. Pre-, post- and follow-up data collection questionnaires will include the Family Empowerment Scale (FES), the Power Ladder Question, the Parent Patient Activation Measure (P-PAM), Warwick-Edinburgh Mental Wellbeing Scale (WEMWBS), EuroQoL-5D-5-level (EQ-5D-5L) and parent/carer greatest needs and goals questionnaire. Post-intervention semi-structured interviews will be conducted with parents/carers, facilitators and key NHS partners. Discussion A community-based participatory group programme is a potentially affordable and sustainable way for the NHS to provide family-centred support. The programme aims to improve outcomes for parents/carers of children with complex neurodisability. Example outcomes include knowledge, skills, confidence, wellbeing and quality of life. The programme also provides opportunities for peer support and aims to empower parents/carers in navigating community health systems. Registration The protocol is registered on clinical trials.gov (ID: NCT06310681). Ethical approval Health Research Authority ref. 23/EM/0213.

Our ability to address inequities in health outcomes is hampered by the under-representation of underserved groups in research. Research exploring this topic has focused on observational studies in the American context. This is a pivotal concern for maternity research in the UK as perinatal outcome variables vary by ethnicity, socioeconomic and linguistic background. This paper reports the findings of an analysis of the diversity achieved by different recruitment strategies used within a feasibility study and pilot trial of group antenatal care (Pregnancy Circles). A pilot randomised controlled trial involved implementation of Pregnancy Circles across three maternity services in an area of high ethnic, socioeconomic and linguistic diversity. Following findings of high ethnic diversity but low levels of educational and linguistic diversity amongst participants recruited in our prior feasibility study, equity-informed strategies were put into place to attempt to increase recruitment diversity in the pilot trial, addressing organisational barriers (additional language support); attitudinal barriers (staff training to counteract recruitment bias) and practical barriers (extending the recruitment period to reach women accessing care late). Women who declined participation were invited to complete a short anonymous questionnaire covering demographic details and reasons for declining. The demographic characteristics of participants in the feasibility and pilot studies, and the pilot study decliners, were compared using descriptive statistics and free-text reasons for declining were analysed thematically. The targeted recruitment processes were successful in widening the diversity of participants in this study, in particular for women with limited English proficiency and low educational achievement. Nevertheless, comparison of participants to those who declined showed some barriers persisted. The most common reason to decline was lack of time, most commonly due to caring responsibilities, and this was more likely to be cited by ethnically minoritized women. Recruitment plans focused on widening diversity can be effective but are likely to require additional resources such as funding longer recruitment periods or interpreting services. The gendered nature of maternity research poses particular challenges, and our study suggests that addressing barriers such as those around childcare would enhance the recruitment of socio-economically deprived and minoritized women. Our study team included two service user representatives as co-investigators, feeding into all aspects of the study. The focus of the work reported here was to increase the participation of underserved communities in the pilot trial and to inform the Pregnancy Circles RCT, to enable them to contribute their data and lived experience to the findings and evaluation of this intervention. Due to an administrative oversight, trial registration for this pilot trial was applied for during the 6-week recruitment period, rather than before recruitment commencing (ISRCTN66925258. Retrospectively registered 3 April 2017). Registration occurred before programme intervention, outcomes and process data collection and all data analysis.

Background Late access to antenatal care is a contributor to excess mortality and morbidity among ethnic minority mothers compared to White British in the UK. While individual ethnicity and socioeconomic disadvantage are linked to late antenatal care initiation, studies have seldom explored patterns of late initiation and associated factors in ethnically dense socially disadvantaged settings. This study investigated disparities in the timing of antenatal care initiation, and associated factors in an ethnically dense socially disadvantaged maternal cohort. Methods A retrospective cross-sectional study using routinely collected anonymous data on all births between April 2007—March 2016 in Luton and Dunstable hospital, UK ( N  = 46,307). Late initiation was defined as first antenatal appointment attended at > 12 weeks of gestation and further classified into moderately late (13–19 weeks) and extremely late initiation (≥ 20 weeks). We applied logistic and multinomial models to examine associations of late initiation with maternal and sociodemographic factors. Results Overall, one fifth of mothers (20.8%) started antenatal care at > 12 weeks of gestation. Prevalence of late initiation varied across ethnic groups, from 16.3% (White British) to 34.2% (Black African). Late initiation was strongly associated with non-White British ethnicity. Compared to White British mothers, the odds of late initiation and relative risk of extremely late initiation were highest for Black African mothers [adjusted OR = 3.37 (3.05, 3.73) for late initiation and RRR = 4.03 (3.51, 4.64) for extremely late initiation]. The odds did not increase with increasing area deprivation, but the relative risk of moderately late initiation increased in the most deprived ([RRR = 1.53 (1.37, 1.72)] and second most deprived areas [RRR = 1.23 (1.10, 1.38)]. Late initiation was associated with younger mothers and to a lesser extent, older mothers aged > 35 years. Mothers who smoked during pregnancy were at higher odds of late initiation compared to mothers who did not smoke. Conclusions There is a need to intensify universal and targeted programmes/services to support mothers in ethnically dense socially disadvantaged areas to start antenatal care on time. Local variations in ethnic diversity and levels of social disadvantage are essential aspects to consider while planning services and programmes to ensure equity in maternity care provision.

Recent years have seen an increase in contributions to the criminal justice system through expert testimony regardingskeletal trauma analysis and interpretation. In order to scientifically validate skeletal trauma analysis methods and ensure the dependability of interpretations to support expert testimonies, the reliability of generally accepted concepts must be determined. This research focused on the traditional assumption that extrinsic factors influence fracture characteristics in human bone. The objective of this study was to investigate the influence of loading rate on fracture characteristics by evaluating the effect of two dynamic loading rates in blunt-force trauma to human ribs. The sample consisted of mid-level human ribs in which fracture characteristics were evaluated in bilateral rib pairs experimentally tested in precisely the same loading scenario (anterior to posterior bending) at different dynamic loading rates. These comparisons demonstrated that the difference between 1 m/s and 2 m/s had no independent influence on fracture characteristics, despite the large difference in impact energy associated with these rates (27.2 J and 108.8 J, respectively). The general assumption that greater impact speed and energy leads to increased injury severity and more complex fracture characteristics was not supported in ribs loaded at 1 m/s versus 2 m/s.