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Midwifery continuity of care models for women at low and mixed risk of complications have been shown to improve women's experiences of care. However, there is limited research on care experiences among women at increased risk of preterm birth. We aimed to explore the experiences of care among women with risk factors for preterm birth participating in a pilot trial (POPPIE) of a midwifery continuity of care model which included a specialist obstetric clinic. A total of 334 pregnant women identified at increased risk of preterm birth were randomly allocated to either midwifery continuity of care (POPPIE group) or standard maternity care. Women in both groups were followed up at six-to-eight weeks postpartum and were invited to complete a postnatal survey either online or by post. An equal status exploratory sequential mixed method design was chosen to collect and analyse the quantitative postnatal survey data and qualitative interviews data. The postnatal survey included measures of social support, trust, perceptions of safety, quality of care, control during childbirth, bonding and quality of life. Categorical data were analysed with chi-squared tests and continuous data were analysed with t-tests and/or Mann-Whitney U test to measure differences in measures scores among groups. The qualitative interview data were subjected to a thematic framework analysis. Data triangulation brought quantitative and qualitative data together at the interpretation stage. A total of 166 women completed the survey and 30 women were interviewed (90 and 16 in POPPIE group; 76 and 14 in standard group). We found survey respondents in the POPPIE group, compared to respondents in the standard group, were significantly more likely to report greater trust in midwives (Mann-Whitney U, p<0.0001), greater perceptions of safety during the antenatal care (t-test, p = 0.0138), have a particular midwife to contact when they needed during their pregnancy (t-test, p<0.0001) and the postnatal period (chi-squared, p<0.0001). They reported increased involvement in decisions regarding antenatal, intrapartum and postnatal care (t-test, p = 0.002; p = 0.008; p = 0.006 respectively); and greater postnatal support and advice about: feeding the baby (chi-squared, p<0.0001), handling, settling and looking after the baby (chi-squared, p<0.0001), baby's health and progress (chi-squared, p = 0.039), their own health and recovery (chi-squared, p = 0.006) and who to contact about any emotional changes (chi-squared, p = 0.005). There were no significant differences between groups in the reporting of perceptions of safety during birth and the postnatal period, concerns raised during labour and birth taken seriously, being left alone during childbirth at a time of worries, control during labour, bonding, social support, and physical and mental health related quality of life after birth. Results from qualitative interviews provided insight and depth into many of these findings, with women in the POPPIE group reporting more positive experiences of bonding towards their babies and more positive physical health postnatally. Compared with standard maternity care, women at increased risk of PTB who received midwifery continuity of care were more likely to report increased perceptions of trust, safety and quality of care. ISRCTN (Number: 37733900); UK CRN (ID: 31951).

ObjectiveTo assess whether the implementation of an intrapartum training package (PROMPT (PRactical Obstetric Multi-Professional Training)) across a health service reduced the proportion of term babies born with Apgar score <7 at 5 min (<75mins).DesignStepped-wedge cluster randomised controlled trial.SettingTwelve randomised maternity units with ≥900 births/year in Scotland. Three additional units were included in a supplementary analysis to assess the effect across Scotland. The intervention commenced in March 2014 with follow-up until September 2016.InterventionThe PROMPT training package (Second edition), with subsequent unit-level implementation of PROMPT courses for all maternity staff.Main outcome measuresThe primary outcome was the proportion of term babies with Apgar<75mins.Results87 204 eligible births (99.2% with an Apgar score), of which 1291 infants had an Apgar<75mins were delivered in the 12 randomised maternity units. Two units did not implement the intervention. The overall Apgar<75mins rate observed in the 12 randomised units was 1.49%, increasing from 1.32% preintervention to 1.59% postintervention. Once adjusted for a secular time trend, the ‘intention-to-treat’ analysis indicated a moderate but non-significant reduction in the rate of term babies with an Apgar scores <75mins following PROMPT training (OR=0.79 95%CI(0.63 to 1.01)). However, some units implemented the intervention earlier than their allocated step, whereas others delayed the intervention. The content and authenticity of the implemented intervention varied widely at unit level. When the actual date of implementation of the intervention in each unit was considered in the analysis, there was no evidence of improvement (OR=1.01 (0.84 to 1.22)). No intervention effect was detected by broadening the analysis to include all 15 large Scottish maternity units. Units with a history of higher rates of Apgar<75mins maintained higher Apgar rates during the study (OR=2.09 (1.28 to 3.41)) compared with units with pre-study rates aligned to the national rate.ConclusionsPROMPT training, as implemented, had no effect on the rate of Apgar <75mins in Scotland during the study period. Local implementation at scale was found to be more difficult than anticipated. Further research is required to understand why the positive effects observed in other single-unit studies have not been replicated in Scottish maternity units, and how units can be best supported to locally implement the intervention authentically and effectively.Trial registration number ISRCTN11640515.

Background Becoming parents for the first time is challenging. Mothers need both social and professional support to handle these challenges. Professionals’ attitudes affect quality of care and support. So to improve professional support, an intervention consisting of a process-oriented training was performed. Due to the positive results of the intervention there is a need to illuminate the methodological approach further. The overall aim was therefore to describe a methodological approach to improve and evaluate health care professionals’ attitudes toward breastfeeding and parental support in order to improve quality of care in childbearing. Methods This study was a longitudinal randomized control intervention study, in which groups of mothers received care in childbearing from midwives and child health nurses. These health professionals had gone through a process-oriented training, or not. In order to improve attitudes of health professionals the training was based on evidence, practical skills and reflective processes (both private and professional experiences) in relation to breastfeeding and parental support. Included in the longitudinal study were health professionals from five intervention municipalities n  = 36 and health professionals from five control municipalities n  = 45. All mothers who fulfilled the inclusion criteria were consecutively identified from the hospital register and asked to participate in the study. Mothers who accepted to participate were included in the interventions group ( n  = 206) or control groups ( n  = 162, n  = 172 respectively) based on which municipality they belonged to. Results The results of the process-oriented training improved the professionals’ attitudes toward breastfeeding and parental support. These improved attitudes in health professionals increased intervention-group mother’s satisfaction with professional and social support. Intervention-group mother’s relation to and feelings for their baby as well as breastfeeding was also improved. Conclusion These results stress the importance of professionals’ attitude in quality of care during childbearing, as well as pointing to the possibility to improve professionals’ attitudes with a process-oriented training. Trial registration Australian New Zealand Clinical Trials Registry (ANZCTR), trial registration: ACTRN12611000354987 .

Background: Patient safety culture/climate in maternity units has been linked to better safety outcomes. Nurses have a crucial role in patient safety and represent the majority of staff in maternity units. In many countries, nurses are recruited from abroad, bringing their own perceptions of patient safety culture. Nonetheless, little is known about the relationship between perceptions of patient safety culture and nurses' nationality. Understanding this relationship will assist stakeholders in designing a responsive programme to improve patient safety culture. Aims: To investigate the association between nurses' nationality and their perceptions about patient safety culture in maternity units in Ministry of Health hospitals in Oman. Methods: In 2017, the Safety Attitude Questionnaire (SAQ) was distributed to all staff (892 distributed, 735 returned) in 10 maternity units. Results: About three-quarters (74%, 541/735) of the returned SAQs were completed by nurses, of whom 34% were non-Omani, 21.8% were Omani and 44.7% did not report their nationality (missing). Overall, the mean safety score for non-Omani nurses was significantly higher than for the Omani nurses: 3.9 (SD 1.3) vs 3.6 (SD 1.2) (P< 0.001). The mean safety score for stress recognition was significantly lower for non-Omani nurses: 2.8 (SD 1.5) vs 3.2 (SD 1.3) (P< 0.001). Conclusion: Non-Omani nurses have a more positive perception of patient safety culture than Omani nurses except in respect of stress recognition. Decision-makers, directors, and clinicians should consider these differences when designing interventions to improve patient safety culture.

We evaluated whether Nurse-Family Partnership might serve as a cost-effective social policy for improving health. Using data from studies of randomized controlled trials as well as real-world data, we conducted a Monte Carlo simulation to estimate cost-effectiveness of Nurse-Family Partnership in a hypothetical cohort of first-born children in the United States. Analyses were conducted in 2015. Were all new mothers eligible for Nurse-Family Partnership, the program would produce 0.11 QALYs (95% confidence interval [CI]=0.06, 0.17) at an additional cost of $1,021 (95% CI=-$2,831, $4,414) per nurse-visited child's lifetime relative to the comparison-group children or $14,642 (95% CI = Savings, $71,877) per QALY gained. However, if applied to high-risk mothers, it would generate 0.19 QALYs (95% CI = 0.09, 0.44) and a net benefit of $2,764 (95% CI =-$1,210, $7,092) per nurse-visited child. Nurse-Family Partnership should be considered as a policy investment, particularly in an era of investments in the social determinants of health.

ObjectivesTo identify factors predicting use, adherence and attrition with a nurse-moderated web-based group intervention designed to support mothers of infants aged 0–6 months.Design9-Month observational study.SettingCommunity maternal and child health service.Participants240 mothers attending initial postnatal health checks at community clinics who were randomly assigned to the intervention arm of a pragmatic preference randomised trial (total randomised controlled trial, n=819; response rate=45%).InterventionIn the first week (phase I), mothers were assisted with their first website login by a research assistant. In weeks 2–7 (phase II), mothers participated in the web-based intervention with an expectation of weekly logins. The web-based intervention was comparable to traditional face-to-face new mothers’ groups. During weeks 8–26 (phase III), mothers participated in an extended programme at a frequency of their choosing.Primary outcome measuresNumber of logins and posted messages. Standard self-report measures assessed maternal demographic and psychosocial characteristics.ResultsIn phase II, the median number of logins was 9 logins (IQR=1–25), and in phase III, it was 10 logins (IQR=0–39). Incident risk ratios from multivariable analyses indicated that compared to mothers with the lowest third of logins in phase I, those with the highest third had 6.43 times as many logins in phase II and 7.14 times in phase III. Fifty per cent of mothers logged-in at least once every 30 days for 147 days after phase I and 44% logged-in at least once in the last 30 days of the intervention. Frequency of logins during phase I was a stronger predictor of mothers’ level of engagement with the intervention than their demographic and psychosocial characteristics.ConclusionsMothers’ early use of web-based interventions could be employed to customise engagement protocols to the circumstances of individual mothers with the aim of improving adherence and reducing attrition with web-based interventions.Trial registration numberACTRN12613000204741; Results.

Pregnant women have a major role to play in assessing and improving their own quality of care. This study in Tabriz, Islamic Republic of Iran, aimed to assess the effectiveness of an intervention for pregnant women-based on education and support groups and involvement in quality assessment activities-in order to improve the technical quality of public maternity care at public health centres. The intervention phase began in September 2011 and lasted 8 months. The outcome measure was health-care providers' degree of adherence to the Iranian maternity care standards. An intervention group of 92 pregnant women from 10 health centres was compared with a control group of 93 pregnant women from 11 centres. Logistic regression analysis showed that the self-assessed technical quality of maternity care received by the women was significantly better in the intervention that the control group for several of the standards concerning clinical examinations, maternal education and vitamin and mineral supplements.

Introduction A woman's childbirth experience is multifaceted and has a great impact on not only the woman, but also the family's health and well‐being. Changes in childbirth experience over time have been evaluated with a variety of instruments, at different time points, and with inconsistent findings. In Sweden, the rating of birth experience is routinely collected after birth, but it is still unknown which time point is preferred from a clinical perspective. The primary aim was to investigate changes in childbirth experience over time from childbirth to 6 months postpartum, assessed by both a single and a multi‐item instrument. A secondary aim was to test the correlation between these instruments. Material and Methods In a prospective cohort study, 320 women were recruited from two Swedish hospitals. Study participants completed a survey at the maternity ward after giving birth, and again three and 6 months postpartum, rating their overall childbirth experience on a single item 10‐point numeric rating scale (NRS) and a multi‐item instrument, the Childbirth Experience Questionnaire 2 (CEQ2), encompassing four known dimensions of childbirth: Perceived safety, Own capacity, Participation and Professional support. Changes in childbirth experience (NRS and CEQ2) over time were analyzed using the Friedman test. NRS ratings were analyzed in relation to CEQ2 dimensions with Spearman's correlation. Results Overall childbirth experience rated using NRS did not change over time. The total CEQ2 score decreased significantly from childbirth to 6 months postpartum (p < 0.001). This change was driven by decreased scoring of the domains Participation and Professional support. The correlations between NRS and CEQ scores were consistent over time, with a moderate to weak correlation of NRS with Participation and Professional support. Conclusions Women perceive their birthing experience more negatively over time when assessed using the CEQ2 questionnaire, but this was not captured by a single‐item question assessing overall childbirth experience. Using data from 320 women, significant deteriorations in childbirth experience over time were observed using the multi‐item instrument Childbirth Experience Questionnaire 2 (CEQ), but not using a 10‐point numeric rating scale (NRS) representing overall childbirth experience. In order to identify women with support needs after a negative childbirth experience, repeated ratings are warranted. If a 10‐point NRS is used, it needs to be supplemented by a conversation about the experience, since NRS may not capture a decrease in assessment of childbirth experience over time.

The traditional nursing clinical education model of total patient care is becoming inadequate. New models are needed to foster deeper clinical thinking, thereby affecting students' development of clinical judgment. Concept-based learning activities, first introduced in 1990, offer a focus on a specific concept. This study evaluated the effect of concept-based learning activities on the development of clinical judgment in baccalaureate nursing students. The clinical judgment of students who were and were not exposed to concept-based learning activities was compared. Quantitative data were analyzed using a univariate analysis. In addition, a focus group consisting of members of the treatment group provided qualitative data. Results suggest concept-based learning activities are a clinical learning strategy that should be considered by faculty to deepen clinical thinking in preparation for reaching sound clinical judgments.