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Author’s Accepted Manuscript

Postnatal care in the context of decreasing length of stay in hospital after birth: The perspectives of community midwives

Laura Goodwin, Beck Taylor, Farina Kokab, Sara Kenyon

PII: S0266-6138(18)30036-6

DOI: https://doi.org/10.1016/j.midw.2018.02.006 Reference: YMIDW2194

To appear in: Midwifery Received date: 9 January 2018 Accepted date: 8 February 2018

Cite this article as: Laura Goodwin, Beck Taylor, Farina Kokab and Sara Kenyon, Postnatal care in the context of decreasing length of stay in hospital after birth: The perspectives of community midwives, Midwifery, https://doi.org/10.1016/j.midw.2018.02.006

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Postnatal care in the context of

decreasing length of stay in hospital after birth: The perspectives of community

midwives

Dr Laura Goodwin * corresponding author BSc, PhD

Research Fellow

Institute of Applied Health Research

Public Health, Epidemiology and Biostatistics University of Birmingham

Birmingham B15 2TT United Kingdom

Email: L.Goodwin@bham.ac.uk

Dr Beck Taylor

BMedSc, MBChB, MPH, PhD, FFPH Clinical Research Fellow

Email: R.Taylor.3@bham.ac.uk

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Dr Farina Kokab BSc, MSc, MA, PhD Research Fellow

Email: KokabF@adf.bham.ac.uk

Professor Sara Kenyon RM, MA, PhD

Professor of Evidence Based Maternity Care Institute of Applied Health Research,

Email: S.Kenyon@bham.ac.uk

The UK, along with many other Western countries, has seen a significant decrease in postnatal length of stay over the last four decades (Health and Social Care Information Centre, 2015). Whilst 45% of postnatal women in England remained in hospital for 7 days or more after birth in 1975, only 2% of women remained in hospital after birth for the same

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period of time between 2013 and 2014 (Health and Social Care Information Centre, 2015).

Currently, in the UK, 20% of women go home the same day of birth (‘day 0’), with a further 38% on day one and 23% on day two, making a total of 82% of women being discharged by day three after birth (NHS Digital, 2016).

Similar trends in the shortening of postnatal length of stay in hospital are seen in countries such as the United States (Fink, 2011), Sweden (Johansson et al., 2010; OECD, 2014), and the Netherlands (OECD, 2014). For example, in Sweden, the average hospital postnatal length of stay decreased from 6 days in the 1970s to 2 days in 2005 (Johansson et al., 2010).

Internationally, decreasing postnatal stay is driven by a number of factors, including financial pressures on maternity services, hospital bed availability and a movement toward ‘de-

medicalisation’ of childbirth (Benahmed et al., 2017). In the UK, these factors are accompanied by a dramatic increase in birth rates and a concurrent rise in complex pregnancies (Schmied and Bick, 2014), further adding to the shortage of postnatal beds available. Alternatively, shorter duration of stay may also be requested by women who want to spend more time with their families in the comfort of their own homes (Brown et al., 2002).

Decreasing length of hospital postnatal stay inarguably increases demands on community postnatal services; the quantity and quality of which appears to vary globally. For example, in Iceland, women are offered eight home visits in the first 10 days postpartum, and report positively on their postnatal care (Askelsdottir et al., 2013). In Australia, however, women are meant to receive at least two weeks of postnatal support within their homes but continue to report low satisfaction with their postnatal care compared to antenatal and intrapartum services (Morrow et al., 2013).

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In the UK context, community postnatal care is provided by midwives, and although the National Institute for Health and Clinical Excellence (NICE) previously recommended a minimum of three home contacts post-birth (NICE, 2006), many women are now asked to attend postnatal clinics instead, and there are no standards regarding the total number of postnatal contacts women should receive (NMPA project team, 2017). As such, wide variation is found in the number of postnatal contacts experienced by women in the UK; a recent report from the National Maternity and Perinatal Audit project team (NMPA project team, 2017) found that the number of planned postnatal contacts for healthy women and babies ranged from 2 to 6, with a median of 3. In an earlier survey by the Royal College of Midwives (RCM), 14% of women in the UK reported that they only received one visit and a small minority reported no visit whatsoever (Royal College of Midwives, 2014a).

There is mixed literature regarding the safety of reducing length of stay post birth for women and babies. A Cochrane Review (Brown et al., 2002), updated in 2008, reviewed ten

randomised controlled trials which compared early discharge from hospital of healthy mothers and term infants with standard care (a total of 4489 women included). No

statistically significant differences in infant or maternal readmissions were found in the eight trials reporting data on these outcomes (Brown et al., 2002). In line with this review , a recent systematic review of the literature on hospital discharge following vaginal delivery

(Benahmed et al., 2017) reported no statistical difference in maternal and neonatal morbidity, maternal and neonatal readmission rates, infant mortality, newborn weight gain, neonatal hyperbilirubinemia, or breastfeeding rates when comparing groups under ‘early discharge’

care policies with control groups with ‘standard’ policies. However, in both reviews, authors cited a number of limitations to these findings; including a lack of statistical power (Brown et al., 2002), differing definitions of ‘early discharge’ across studies (Benahmed et al., 2017;

Brown et al., 2002), poor methodology of the studies included (Benahmed et al., 2017;

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Brown et al., 2002), lack of compliance with the discharge protocol (Brown et al., 2002), and variation in the support package provided after discharge (Brown et al., 2002). As such, further research is required to establish the relationship between the safety of women and babies, and the duration of postnatal stay after a normal vaginal or caesarean birth (Jones et al., 2016).

Postnatal Care: The views of women

Along with a lack of clarity regarding the safety of reduced postnatal stay, women in the UK consistently report lower satisfaction with the quality of their postnatal care, compared to that given during pregnancy and birth (Bhavnani and Newburn, 2010; Care Quality Commission, 2015; Redshaw and Henderson, 2015). Similar feelings of dissatisfaction from women are reported in reviews of postnatal care in Australia (Biro et al., 2012; Brown et al., 2005;

Fenwick, et al., 2010).

In the UK, the recent National Maternity Review (National Maternity Review, 2016) reports on an extensive programme of engagement with the public, users of services, staff, and other stakeholders between 2015 and 2016. During this review, women reported a need for more postnatal support and shared a feeling that services are inadequately resourced for midwives to provide empathetic and comprehensive care (National Maternity Review, 2016). Indeed, while many women said that they received lots of care and support in the antenatal period, they suggested that this was not continued after birth (National Maternity Review, 2016).

Breastfeeding support was also seen as lacking, with many women reporting that they had received conflicting information and as a result felt confused, and at times pressurised (National Maternity Review, 2016). This is in line with findings from the most recent NHS Digital ‘Infant feeding survey’ where 63% of 10,768 women surveyed reported that they had

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stopped breastfeeding before they wanted to (McAndrew et al., 2012), and suggested that more support and guidance from hospital staff, midwives and family could have facilitated them to breastfeed for longer (McAndrew et al., 2012). Similar findings were also reported by the 2010 National Childbirth Trust (NCT) Survey of 1260 first-time mothers (Bhavnani and Newburn, 2010), where less than half of first-time mothers felt they received all the help and support they needed with feeding their baby in the first month after birth, and 52% felt they had not received consistent information and advice in relation to feeding during this time frame. In a recent survey of women who gave birth in New South Wales, Australia (Bureau of Health Information, 2017), around one-third of women said that after giving birth, they received conflicting advice about feeding their baby (32%) or about caring for themselves or their baby (32%).

International research also suggests concerns from women regarding the physical health needs of both themselves and their babies during the postnatal period: in a UK NCT survey, one in five women said they received little or none of the physical care they needed, and around one in seven said they had received little or none of the information they needed about their baby’s health (Bhavnani and Newburn, 2010). A similar survey of women’s maternity experiences in the UK, published by the NPEU in 2015 (Redshaw and Henderson, 2015), found that some women did not always have confidence in the staff caring for them after discharge (27%) and a few (4%) did not have confidence in these staff at all. When asked about the number of postnatal home visits received, 23% of women found this lacking (Redshaw and Henderson, 2015). In an Australian focus group study, first-time mothers reported that a hospital stay of less than 24 hours was ‘scary’ (Forster et al., 2008, p. 5) and expressed the need for a longer stay in hospital to develop confidence in their ability to care for and feed their newborn (Forster et al., 2008).

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Previous literature has also highlighted a need for additional emotional support in the

postnatal period, with one UK survey suggesting that one third of women receive little or no emotional support in the first month after birth (Bhavnani and Newburn, 2010). In the recent UK National Maternity Review, women reported a similar need for more support and better access to counselling and therapy for those who have difficult or traumatic experiences, particularly those who have experienced stillbirth or neonatal death (National Maternity Review, 2016). In these instances, bereaved parents told of how communication between the hospital and community based services were poor, and many encountered health

professionals who were not aware that their baby had died (National Maternity Review, 2016). Research conducted in Australia suggests similar frustrations regarding a lack of professional support, with women commenting that staff were often too busy or unavailable to provide the care that they expected (Forster et al., 2008).

Postnatal Care: The midwife’s perspective

In contrast to the wealth of literature on women’s views of postnatal care, there is relatively little exploring the perceptions and experiences of the midwives providing this care. This is particularly evident when it comes to the context of community-based care; whilst there has been some international research with hospital midwives concerning postnatal care in ward settings (Bick et al., 2011; McLachlan et al., 2008; Rayner et al., 2008), there remains a lack of documented perspective from community midwives. This seems especially apparent in the UK context: after systematically reviewing the literature (search terms and database lists included in Figure 1), we could not find any peer-reviewed, qualitative research which directly explored the knowledge, beliefs and attitudes of UK community midwives on the early discharge and postnatal care of mothers and babies.

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Despite the lack of representation from this particular workforce, there is evidence to suggest that midwives as a whole report concerns with postnatal care in both the UK and abroad (Bick et al., 2011; Morrow et al., 2013; Stewart-Moore et al., 2012), and highlight the challenges associated with increased workloads, busy work environments, and limited staff resources (McLachlan et al., 2008; Morrow et al., 2013; Schmied et al., 2008), as well as routine clinical cover and responsibilities towards safeguarding women in their care (Royal College of Midwives, 2014a). In fact, midwives report that staff and resources are often directed from postnatal care to antenatal clinics or labour ward (Bowers & Cheyne, 2016), and a recent survey of UK midwives, conducted by the RCM, found that 65% of respondents reported that organisational pressures were the key determinant of postnatal care planning rather than individual care needs of mothers and babies (Royal College of Midwives, 2014a).

Midwives in this survey also felt there was limited amount of time to provide women with all the information they needed about their postnatal recovery and care for their babies, and felt like they were stretching their resources and discharging women under pressure to meet time demands (Royal College of Midwives, 2014a).

These issues present themselves as hurdles and barriers to providing good quality care, where resources are spread thinly amongst community midwifery teams (Royal College of

Midwives, 2014b). For instance, community midwives working in Northern Ireland and the Republic of Ireland report giving priority to certain groups of women during visits (Stewart- Moore et al., 2012); providing more visits to first-time mothers, women who were

breastfeeding, women with jaundiced babies/infections, and those discharged within six- hours of birth (Stewart-Moore et al., 2012). This unofficial organisation of resources not only demonstrates the community midwives’ need to allocate services on a needs based system, due to a lack of capacity, but also highlights their perception of short hospital postnatal stay as a factor which is likely to result in a need for additional postnatal support.

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Having to compromise the level of care that women receive appears to be a stressful

experience for midwives, who report feeling anxious and worried about women leaving their care (Stewart-Moore et al., 2012). The complexities and challenges of trying to provide postnatal care can result in job dissatisfaction and demotivation to continue working,

especially if midwives are not able to spend more time listening to women and providing the support they felt women need (Morrow et al., 2013). Indeed, persistent issues surrounding working conditions and limited interactions with women have been reported to result in low morale and poor retention of midwives in their posts (Stewart-Moore et al., 2012).

Furthermore, where efforts have been made to test alternative ways to provide postnatal care, midwives report continuing difficulties regarding the documentation and information that is available when women are discharged from hospitals to community care, or when alerting other healthcare professionals to an emergency or high risk situation (Hunter et al., 2015).

Postnatal care in the UK: The Future

There is a widely held perception that postnatal care has long been a neglected aspect of maternity care (Royal College of midwives, 2014c; Wray, 2006), and in 2014 the RCM (Scotland) Professor of Midwifery, Helen Cheyne stated that postnatal care had been

‘starved’ of resources over recent years (Royal College of Midwives, 2014d). Indeed, a lack of funding in postnatal care is reflected in previous distribution of payments for services in NHS England (Bowers and Cheyne, 2016; Royal College of Midwives, 2014b), where maternity service funding has traditionally been focussed on antenatal and intrapartum services, and hospitals have received only around a quarter of the estimated costs for providing postnatal care (Bowers and Cheyne, 2016). This is worrying, given that the

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decreasing postnatal length of stay in hospital after birth means that more funding is needed for postnatal care in the community.

Whilst postnatal care has historically been viewed as the ‘Cinderella service’ in maternity care (Royal College of midwives, 2014c; Wray, 2006), the recent National Maternity Review (National Maternity Review, 2016) provides an opportunity to assess and revise postnatal care in England. The corresponding report, ‘Better Births’ states that “caring for the woman and baby after birth is equally as important as during pregnancy and birth” (National

Maternity Review, 2016 pg. 61) and that there should be “better postnatal [care] and perinatal mental health care, to address the historic underfunding and provision in these two vital areas, which can have a significant impact on the life chances and wellbeing of the woman, baby and family” (National Maternity Review, 2016 pg. 10). As such, the report calls for “an upgrade to postnatal services” (National Maternity Review, 2016 pg. 62) which includes a consideration of women’s individual needs.

However, there are issues surrounding the ability to provide seamless individualised care that transitions from hospital to community, as this requires regular, comprehensive

communication between service providers at the hospital and community whilst taking into account each woman’s views and experiences; something which has been identified as problematic in the literature (Hunter et al., 2015). This type of care would also require flexibility on the part of the infrastructure of the services, to present additional support (in terms of time and information) when requested, and not only for women with greater risk or increased clinical needs.

Local Maternity Systems are tasked with a number of steps to begin local implementation of the Better Births recommendations in England, which are outlined in the recently published document ‘Implementing Better Births’ (NHS England, 2017). For improvements to postnatal

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care, these steps include bringing together NHS maternity services, health visitors and GPs, identifying opportunities for and barriers to improving postnatal care, working with local service users to identify expectations for postnatal care, and improving transition between maternity services and the health visiting team (NHS England, 2017).

England is not the only place where increasing attention is being paid to postnatal services. In their recently published five-year forward plan for maternity and neonatal care, ‘Best Start’

(The Scottish Government, 2017) the Scottish government also cited “high quality postnatal care” as part of their key recommendations for improving maternity care, stating that “The provision of high quality routine postnatal care should be afforded a high priority, with staffing models being reviewed in conjunction with the introduction of the continuity of carer model” (The Scottish Government, 2017 pg. 65). Similarly, Northern Ireland’s current

strategy for maternity care (Department of Health, 2012) acknowledges the need to focus maternity resources on community postnatal care, due to decreasing length of hospital stay, and suggests that “the potential to improve health and well-being for both mother and baby during the postnatal period is significant” (Department of Health, 2012 pg. 66). In the most recent ‘Strategic Vision for Maternity Services in Wales’ (Welsh Government, 2011) postnatal care is not uniquely identified as an area of action, but rather incorporated in to plans to “provide a range of high quality choices of care as close to home as is safe and sustainable to do so…and place the needs of the mother and family at the centre” (Welsh Government, 2011, p. 3). A recent Welsh Government-funded survey of women’s experiences of pregnancy and birth in Wales (Welsh Government, 2017) will be used to inform the next report, which is due for update in March 2018.

At a time where services are over-stretched and resources are scarce (Royal College of Midwives, 2014b), there is a need to explore what is realistic and feasible when planning

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services, so as to meet the needs of both women and service providers. As discussed, research on postnatal care has so far neglected to explore the role and responsibilities of community midwives in a focused and meaningful way. Indeed, it appears that the only opportunity for community midwives to reflect on their experiences of delivering postnatal care during qualitative research has been whilst discussing other topics, such as breastfeeding, or maternity care as a series of interactions between various healthcare professionals as part of continuing support for women during their pregnancy, childbirth and postnatal period (Askelsdottir et al., 2013; Barimani and Hylander, 2008). We argue that this misses an

important opportunity to explore practical issues as well as potential solutions, and could hold the key to improving service provision.

In addition to an exploration of the views of midwives, we suggest that co-production work with community/postnatal ward midwives, women, and maternity managers has the potential to provide credible ideas for improving postnatal care in the context of decreasing length of stay in the UK. This work is currently underway at the University of Birmingham as part of the Collaboration for Leadership in Applied Health Research and Care (CLAHRC) West Midlands Initiative. This research will have added value in its potential to influence and inform the delivery and implementation of current government policy on postnatal services.

Acknowledgements

The authors were funded by the National Institute for Health Research (NIHR) through the Collaborations for Leadership in Applied Health Research and Care for West Midlands (CLAHRC-WM) programme. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.

Ethical Statement

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Ethical Approval

Not applicable

Funding Sources

The authors were funded by the National Institute for Health Research (NIHR) through the Collaborations for Leadership in Applied Health Research and Care for West Midlands (CLAHRC-WM) programme. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.

Clinical Trial Registry and Registration number

Not applicable

Conflict of Interest

None declared.

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Figure 1: Search terms and databases searched for literature review

Search terms Databases

- Hospital stay - Postnatal - Postnatal care - Postpartum period - Postnatal stay - Length of stay - Early discharge - Patient discharge - Discharge

MEDLINE PubMed PsychInfo Embase CINAL ASSIA HMIC

- Midwi*

- Experiences - Views - Attitudes - Perceptions - Knowledge - Belief - Feeling - Thought - Impact - Influence - Effect

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Midwifery

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‘Keeping birth normal’: Exploratory evaluation of a training package for midwives in an inner-city, alongside midwifery unit

Shawn Walker, MA, BA, RM Midwifery Lecturer^⁎, Laura Batinelli, MSc, BSc, RM Research Midwife, Lucia Rocca-Ihenacho, PhD, MSc, BSc, RM NIHR Research Fellow and Midwifery Lecturer, Christine McCourt, PhD, BA Professor of Maternal and Child Health

City, University of London, Centre for Maternal and Child Health Research, London, United Kingdom

A R T I C L E I N F O

Keywords:

Birth centres Consultant midwives Evaluation Models of care Normal birth Training

A B S T R A C T

Objectives: to gain understanding about how participants perceived the value and eﬀectiveness of ‘Keeping Birth Normal’ training, barriers to implementing it in an along-side midwifery unit, and how the training might be enhanced in future iterations.

Design: exploratory interpretive.

Setting: inner-city maternity service.

Participants: 31 midwives attending a one-day training package on one of three occasions.

Methods: data were collected using semi-structured observation of the training, a short feedback form (23/31 participants), and focus groups (28/31 participants). Feedback form data were analysed using summative content analysis, following which all data sets were pooled and thematically analysed using a template agreed by the researchers.

Findings: We identiﬁed six themes contributing to the workshop's eﬀectiveness as perceived by participants.

Three related to the workshop design: (1) balanced content, (2) sharing stories and strategies and (3)‘less is more.’ And three related to the workshop leaders: (4) inspiration and influence, (5) cultural safety and (6) managing expectations. Cultural focus on risk and low prioritisation of normal birth were identified as barriers to implementing evidence-based practice supporting normal birth. Building a community of practice and the role of consultant midwives were identified as potential opportunities.

Key conclusions and implications for practice: a review of evidence, local statistics and practical skills using active educational approaches was important to this training. Two factors not directly related to content appeared equally important: catalysing a community of practice and the perceived power of workshop leaders to inﬂuence organisational systems limiting the agency of individual midwives. Cyclic, interactive training involving consultant midwives, senior midwives and the multidisciplinary team may be recommended to be most eﬀective.

Introduction

In the last decade, much work has focused on reducing childbirth interventions in order to minimise maternal morbidity, improve service users’ experiences of care and reduce costs (Healthcare Commission, 2008; Khunpradit et al., 2011). Midwifery units (commonly referred to as birth centres) have demonstrated improvements in maternal outcomes, transition to parenthood and satisfaction, and lower rates of intervention while maintaining neonatal outcomes equivalent to those on obstetric-led labour wards (Birthplace in England Collaborative Group, 2011; Overgaard et al., 2012; Macfarlane et al., 2014a, 2014b).

They are also cost-effective (Schroeder et al., 2011, 2017). For staff, midwifery units offer opportunities for midwives and doctors to become familiar with the physiological processes of birth, due to the high concentration of normal births which occur in these settings (Hodnett et al., 2012; Stone, 2012; Walsh and Devane, 2012).

Alongside midwifery units (AMUs) integrated within a hospital setting can face additional challenges in developing midwives’ conﬁdence to support physiological birth due to their proximity to the obstetric unit (OU) and frequent lack of core staﬀ (McCourt et al., 2011, Rayment et al., 2015). The ability of midwifery units to provide the safer, more personalised care required of maternity services depends on successful

https://doi.org/10.1016/j.midw.2018.01.011

Received 30 June 2017; Received in revised form 15 January 2018; Accepted 18 January 2018

⁎Correspondence to: King's College London, 57 Waterloo Road, London SE1 8WA, United Kingdom.

E-mail address:Shawn.Walker@kcl.ac.uk(S. Walker).

Midwifery 60 (2018) 1–8

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strategies to develop midwives’ skills and conﬁdence to work in these settings (McCourt et al., 2012, 2016).

The AMU on which this study is focused opened in 2008 within a London hospital as part of the service's commitment to oﬀering high quality, safe and personalised care to women and their families, tailored around their needs, and in line with United Kingdom national recommendations (NICE, 2014). In order to develop midwifery services further within St George's University Hospital NHS Foundation Trust, two Consultant Midwives, for Normality and Public Health, were appointed in 2014. The role of the consultant midwife in the United Kingdom is to provide clinical leadership, analogous to the consultant obstetrician role within a maternity service, rather than service management (Robinson, 2012). Together they created a training package for midwives and maternity support workers, entitled,‘Birth centres: the hub for a social model of maternity services,’ designed to strengthen physiological birth skills and knowledge within the team, create a base for a shared philosophy and culture, empower midwives to feel ownership of the service, promote woman centred care, and develop midwives’ critical thinking and communication skills.

The overall training package included workshops devoted to antenatal education, communication skills, and baby massage, and a core workshop, called‘Keeping Birth Normal’ (KBN). City, University of London, as an academic partner, was funded to evaluate the KBN training. The workshop structure was divided into three main themes:

‘Why?’ to remind participants why normality matters; ‘How?’ to provide tools to promote a KBN culture; and ‘What?’ to enhance recognition of normal physiology and strategies to enhance it.

Workshop content was guided by previous evaluations of normal birth training packages (Sandall et al., 2010) and by on-going research about AMUs and factors contributing to their success (McCourt et al., 2014).

Three KBN workshops were delivered all by the consultant midwives who designed the training, including the third author, on three dates in January/February 2015.

Methods

Our evaluation strategy aimed to gain understanding about how participants perceived the value and eﬀectiveness of the training they received, barriers they perceived to implementing it, and how the training might be enhanced in future iterations. It followed an exploratory interpretive design.

Ethical considerations

Ethics approval was obtained through the City, University of London, School of Health Sciences Research Ethics Committee.

Participants gave consent to participate. Although their participation in the workshop necessarily entailed involvement in the observational aspects of the evaluation, additional participation in focus

groups and completion of the feedback forms were voluntary. The research team included: one midwifery lecturer (author 1, lead) and a midwife aﬃliated with St George's Hospital (author 2), who collected and analysed the data; one of the consultant midwives who designed and delivered the training (author 3), who contributed to the design and writing up of the paper; and a Professor of Maternal and Child Health (author 4), who provided guidance at all stages of the research. Digital data were stored on a password-protected, en- crypted laptop and shared drive on the university network, as per ethics approval. Physical data were stored in a locked cabinet in an oﬃce within the university.

Recruitment

A total of 31 midwives participated in the training, in roughly equal groups across the three days. Participants were recruited to participate in the training through a call for expressions of interest that included information about the evaluation. All 37 staff who applied were invited onto the training; no midwifery support workers applied. Staff were given paid leave to attend the training, and all evaluation activities were scheduled to take place within the day. The 31 midwives who participated held various roles within St George's maternity services, including AMU midwives, the AMU manager, members of the home birth team and their team leader, senior midwife co-ordinators working on the obstetric unit (OU), and newly qualified rotational midwives. An attempt was made to involve midwives working across settings so that all could contribute to promoting and protecting the AMU's philosophy. This strategy also addressed research examining the high rate of tensions between AMU and OU midwifery colleagues, stemming at least partly from the lack of confidence or understanding amongst midwives working in other areas (McCourt et al., 2014).

Data collection

Methods of data collection included a short anonymous feedback form containing open-ended questions [Table 1], observation of the training days, and focus groups with the participants at the end of the training days. The observation notes and focus groups were guided by a semi-structured list of prompts and questions [Tables 2 and 3].

Questions and guidance notes were based on Kirkpatrick's four-level model for evaluating training programmes (Yardley and Dornan, 2012) and agreed by the research team. Data collection forms had been designed and pilot-tested by the same research team in an earlier pilot study of KBN workshops delivered in another maternity service. The forms were found by researchers to be easy to use and suitable to capture key relevant data. The feedback forms were completed by participants within ﬁve minute sessions immediately following the pilot-test workshops with a good completion rate and no concerns Table 1

Questions included in the Anonymous Evaluation Sheet.

1. What did you think about the workshop?

How did the workshop leaders put the content across?

Was this helpful/convincing?

What did you think about the balance between diﬀerent activities and content?

What part did you enjoy orﬁnd most helpful?

What did youﬁnd less helpful?

If you were leading such a workshop in future, what would you include?

2. Potential impact?

Did it have any impact for you personally?

e.g. conﬁdence, practice, knowledge

Which aspect do you think will be most useful to you in practice?

What do you think will help to make an impact in practice generally from the workshops?

What do you think the main barriers will be?

Any other comments you would like to add to help our evaluation?

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expressed regarding clarity or acceptability. These were amended and agreed by the research team for this evaluation in light of this previous experience.

Observational notes of the workshops were undertaken by theﬁrst and second authors throughout each of the three training days. The researchers were introduced as non-participant observers, and sat separately but aside from the participants, who sat in a circle together.

The training was not video recorded. Approximately 30 minutes was allocated at the end of each workshop for a focus group discussion, facilitated by the first author, with the second author providing practical support. The focus groups were video recorded and tran- scribed by the first author. The first two researchers met after each workshop to review the data collected and enhance consistency in recording observations.

The three methods of data collection by two researchers enabled data triangulation (Flick, 2011), providing multiple perspectives from which to compare and conﬁrm our interpretations. On anonymous feedback forms, participants could provide individual comments and note anything they were reluctant or unable to discuss in a group setting. Focus groups provided researchers a chance to delve into key topics more thoroughly and check group responses, as well as further opportunities for participants to discuss their feelings and under- standings with each other (Wibeck et al., 2007). Observational notes taken during the study days and on reviewing the focus group discussions helped to highlight aspects of the training that worked particularly well, resulting in high levels of engagement, and also areas of tension or lack of focus.

Data analysis

Anonymous survey data were analysed descriptively, using summative content analysis (Hsieh and Shannon, 2005). Data from the open-ended questions was initially coded as positive, neutral or negative. Following this, individual response items for each question were recorded on a Microsoft® Excel programme spreadsheet. We grouped similar responses together, under a title using the language of the respondents wherever possible, in order to record the frequency with which similar responses appeared within the collection of feedback forms.

Data from the observational notes and focus group transcripts were analysed using a template (King, 2004) informed by the aims of the research and our initial analysis of the survey data. All data were extracted and included within the template on a Microsoft® Excel programme spread sheet. This enabled comparison within and across themes (King, 2004). Following the independent coding and extraction process, the two researchers met to discuss the results, and make adjustments to the template, in consultation with the other authors.

Ourfinal thematic analysis was also informed by Massey's descrip- tion of three types of data and interpretations when using focus groups in evaluation research (Massey, 2011). Articulated data, that given in response to a specific question from researchers, we analysed descriptively as described above. Attributional data, emerging from theory- driven thematic coding, we analysed by looking at inconsistencies, discrepancies and tensions between what people said and what they did, or what they did not say. This particularly informed our analysis of possible barriers to implementing the training. Emergent data are described by Massey as touching on ‘larger themes and unifying concepts that are invisible before the study begins but that offer explanatory power for events related by the group’ (p. 25).

Identiﬁcation and further exploration of unanticipated themes informed our understanding of emergent data, which we report below Table 2

Observation Guide: Questions and Examples of Data Collected.

Observation Guide Focus of the observation

The aim is to be semi-structured: open note taking, but with particular aims and questions in mind. This will be used to:

•

Guide the design of the workshops in future

•

Assist in evaluating the eﬀectiveness of the training

•

Develop/deﬁne research tools for future research Key questions to frame the note taking:

1. What is the style of this workshop?

How are the workshop leaders putting the content across?

What is the balance between leader and participants talking?

What is the balance between talking and activity?

Is the tone facilitative or authoritative? (record how they talk, etc) What is the content? (additional observation to the written materials) Balance of research knowledge, philosophy, practical skills, expert voice 2. How do participants react?

How are participants responding to this?

e.g. Do they look interested, switched-oﬀ, sceptical, defensive?

Are they keen to participate actively?

Do they respond to direct questions or come up with their own?

Do they raise concerns they have?

If so, what kind of concerns?

Do they respond more positively to some activities rather than others?

Do you notice any change in response from beginning to end of day?

3. Your own reactions as an external observer What is most noticeable to you?

Anything surprise you?

Did you observe what you expected?

Examples of Data Collected:

(Day 1) Instructors seem very comfortable with each other.

(Day 1) Lots of talking among participants. Invited to say one thing they wanted to learn→ renewed interest.

(Day 2) Participants now nodding to more impassioned speeches from facilitators.

They seem a lot more on board with philosophical issues, issues around consent, etc.

The practical activities have warmed them up.

(Day 3) Today the room is smaller, the seats closer in a semi-circle. Introductions are friendly, intimate.

(Day 3) Workshop leader is talking about how theﬁlm [of a home birth] makes her feel emotional.

(Day 3) Consultant midwives seem quite down on the situation, but participants say how much it is encouraging them to have the consultant midwives now working for change.

Table 3

Focus Group Discussion Guide: Questions and Examples of Data Collected.

Key questions to frame the evaluation discussion:

The intention is to facilitate a reﬂective discussion on how the participants found taking part in the workshop, their ideas for improving it and their views on facilitators and barriers to implementation and eﬀectiveness in practice.

1. What did they think about the style of this workshop?

How did the workshop leaders put the content across?

Was this helpful/convincing?

What did you think about the balance between diﬀerent activities and content?

Do you have ideas or suggestions for improving the workshop design and delivery in future?

2. How do participants react?

What part did you enjoy orﬁnd most helpful?

What did youﬁnd less helpful?

If you were leading such a workshop in future, what would you change?

3. Views on potential impact?

Did it change anything for you personally?

e.g. conﬁdence, practice, knowledge

What do you think will help to make an impact in practice from the workshops?

What do you think the main barriers will be?

Examples of Data Collected:

(Day 1) Sometimes with the best will in the world, you can get women to do all these things and they just are not progressing. [Other participants looking down to their papers.]

(Day 1) I might make us little badges.

(Day 2) [Discussion around wanting junior midwives to have someone visible to refer to for help in care planning with a normality focus.]

(Day 2) [Discussion around being able to voice what they are scared of.] It's doing it in a safe space. That's the diﬀerence. When you are at work, with other people around you, it's not private, it's not quiet…

(Day 3) On [the AMU] you may [be able to implement new practices] because it's a smaller team. You can bounce oﬀ your other midwives … But if you are gonna go back to Delivery Suite [negative face]…

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as potential opportunities. The ﬁndings reported below reﬂect our synthesis of themes observed across the three sets of data.

Findings

A total of 28/31 midwives participated in the focus groups, and 23/

31 returned the anonymous feedback forms. The training overran slightly on thefirst two training days, and some participants needed to leave early; two were called to a home birth. This influenced the participation and return rates, but answers provided were similar across the three days. Significant themes are explored below [Fig. 1].

Direct quotations are in italics, identiﬁed by an anonymous participant number (P) and the day of the workshop they attended (D).

Facilitators: Workshop design

We identiﬁed three themes relevant to workshop design, which appeared to contribute to the eﬀectiveness of the training: (1) balanced content, (2) sharing stories and strategies, and (3)‘less is more.’ When discussing the content of the training, participants expressed apprecia- tion of the balance of materials, mentioning in particular videos, lectures, and small group activities. Videos explored the movement of the maternal pelvis with positional changes, labour support activities, and atmosphere in normal births. Small group activities included role plays, discussions and opportunities to practice skills such as massage.

Participants also valued references, statistics and the course packet containing the presentation materials, seen as useful tools to take away.

A lively debate occurred in one session when the normal birth rates for St. George's were presented. Participants seemed engaged with collec- tive self-knowledge: Statistics … make us realise that our work is making a diﬀerence or not (P10 D1). When asked what they would recommend for future workshops, 11 participants recommended more information relevant to the multidisciplinary team and/or obstetric unit (OU). This included how to support more normal birth on the OU, and working across boundaries, such as during transfers from the AMU to OU.

Time spent sharing stories and strategies appeared particularly important to participants: It's not just the knowledge. It's the sharing (P20 D2). Interaction among the participants contributed to the perceived community-building and relational aspects of the training.

Participants valued establishing a group identity: I think I’ll ﬁnd it really useful in practice looking around me and seeing my colleagues here today… I’ve got my sort of KBN colleagues that would support me (P3 D1). The experienced midwives who shared their own stories were also clearly energised by doing so. Although the large majority of comments about workshop content were positive, negative and neutral comments revealed a desire for more interaction, case studies and practical skills components, each of which involved small group work.

The theme‘less is more,’ a phrase used by multiple participants, appeared repeatedly within survey responses and focus groups. Small groups oﬀered safety and relationship building: The group today – quite intimate (P28 D3).‘Less is more’ also pertained to content: There

was a lot to do. It was too much in one day. It's such a political and philosophical bag of worms (P6 D1). The ambitious goals set for the training sometimes meant that the schedule overran. Although the participants acknowledged that the area needing to be covered was very wide, they suggested bite-sized chunks (P8 D1) to address over a period of time. Rather than gaining large amounts of new knowledge, participants’ comments indicated the training reminded them of important things they already knew: Reminds us of a sense of midwifery care that we forget because of the environment we are exposed to (P10 D1). They felt it was important this was reinforced with regular workshops. Some felt a smaller focus would be particularly important in multidisciplinary training:

If people aren’t on the same sheet to start with, keep it quite focused, actually less content in the day. Less would be more in that context (P12 D2).

Facilitators: workshop leaders

We identified three themes pertaining to the workshop leaders that appeared to influence the effectiveness of the training: (1) inspiration and influence, (2) cultural safety, and (3) managing expectations.

The perception of the workshop leaders as a source of inspiration and inﬂuence within the organisation appeared to contribute to participants’ openness to their message:

As a junior midwife, hearing some of the discussions from the consultant midwives– it's like years of experience that have come into these conversations (P9 D1).

On the anonymous surveys [Table 1], 16/23 participants referred to the workshop leaders as being engaging, encouraging and/or inspiring in response to what they enjoyed most. The knowledge that workshop leaders held positions of inﬂuence within the organisation contributed to a sense of hope:

I think there is fundamental change coming now, with these two new consultant midwives who are extremely dedicated and motivated. And they’ve actually managed this project really, really eﬃciently (P24 D3).

The theme of cultural safety encompasses physical, emotional and social well-being. In presenting their strategy for increasing the normal birth rate, the workshop leaders discussed safety aspects of midwifery- led care at length. This was a clear priority, for women and babies, but also for the training participants. The small numbers and tone set by the workshop leaders fostered a sense of safety to participate openly in debates and to make mistakes in the role plays, as one participant noted: Nice that the group's not too big … You could really say anything. You don’t have a room of people looking at you (P25 D3).

Participants responded most enthusiastically to models of good practice which they could praise; negative examples that participants were invited to criticise diminished the overall mood of the group, possibly because it diminished the sense of safety. While many participants Fig. 1. Thematic evaluation of Keeping Birth Normal training: facilitators, barriers and opportunities.

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