Background Breastfeeding has significant health benefits for mothers and babies. Severe mental illness (SMI) affects around 3 % of women giving birth but very little is currently known about their infant feeding experiences. Due to a paucity of evidence, support needs are largely unknown. Aim To explore the infant feeding experiences and supports needs of women with SMI. Methods Semi structured interviews were conducted online and in person from 2022 to 2023 with 20 women under care of perinatal mental health teams in England. Interviews were audio-recorded, transcribed and anonymised. Reflective thematic analysis was used to analyse the data. Findings Four key themes were identified; (1) The intersection between infant feeding and mental health; (2) Infant feeding support from maternity services; (3) Infant feeding preparation; and (4) Specific considerations for women with SMI. The concept of ‘collaborative practice to support infant feeding and mental health’ draws the themes together and is marked by a disconnect in collaborative care supporting both infant feeding and mental health. Discussion SMI can manifest itself in beliefs and emotions related to infant feeding. Experiences of support highlighted the need for better anticipatory guidance around infant feeding for women with SMI, including contexts specific to perinatal SMI like psychiatric inpatient settings, psychotropic medication use, and the challenges associated with sleep deprivation. Conclusions Negative experiences with infant feeding and poor support have a significant impact on women with SMI. Support should focus on the emotional and practical demands of breastfeeding and how women can manage this alongside their illness.

QuestionDoes the use of peer support by video call, compared with standard care, increase exclusive breastfeeding rates and maternal breastfeeding self-efficacy scores during the first 6 months post partum?FindingsIn this randomized clinical trial involving 442 first-time mothers, technology-based breastfeeding peer support did not increase the exclusive breastfeeding rate at 6 months, but it resulted in a significantly higher exclusive breastfeeding rate at 2 months and a significantly higher breastfeeding self-efficacy at 4 months compared with standard care.MeaningThese findings suggest that integrating video call peer support into existing programs may improve maternal and infant outcomes by increasing breastfeeding rates and duration, as well as enhancing maternal confidence. This randomized clinical trial evaluates the impact of a structured video call peer support intervention on exclusive breastfeeding and maternal breastfeeding self-efficacy among first-time mothers in Hong Kong during the first 6 months post partum. ImportancePeer support is a promising strategy to improve breastfeeding outcomes, but evidence for online formats is limited.ObjectiveTo evaluate whether structured peer support delivered via video calls improves exclusive breastfeeding rates and maternal breastfeeding self-efficacy.Design, Setting, and ParticipantsThis multicenter, randomized clinical trial enrolled first-time mothers with low breastfeeding confidence from 4 public postnatal wards in Hong Kong from January 31, 2021, to June 30, 2024. Participants were randomly assigned (1:1) to intervention or control. The primary analysis was conducted from July 1 to 31, 2024, with final data analysis completed by December 31, 2025.InterventionThe intervention included usual postnatal care, consisting of access to lactation consultants and standard breastfeeding information from the Department of Health, plus at least 2 video call sessions with trained peer support volunteers at 10 days and 1 month post partum.Main Outcomes and MeasuresThe primary outcome was the proportion of infants who were exclusively breastfed at 6 months post partum. Secondary outcomes included exclusive breastfeeding at 1, 2, and 4 months post partum and maternal self-efficacy (measured using the Breastfeeding Self-Efficacy Scale-Short Form) at 2 and 4 months. All outcomes were analyzed on an intention-to-treat basis.ResultsAmong 442 participants, 224 were allocated to the intervention group and 218 were allocated to the control group. The mean (SD) maternal age was 32.4 (4.0) years (32.4 [4.2] years in the intervention group and 32.3 [3.9] years in the control group). The primary 6-month outcome did not differ significantly between groups (37 of 184 [20.1%] vs 29 of 186 [15.6%]; adjusted odds ratio [AOR], 1.57 [95% CI, 0.85-2.89]; P = .15); however, exclusive breastfeeding at 2 months (a secondary outcome) was significantly higher in the intervention group (54 of 199 [27.1%] vs 38 of 200 [19.0%]; AOR, 1.80 [95% CI, 1.08-3.01]; P = .02). Longitudinal analysis confirmed higher odds of exclusive breastfeeding in the intervention group over time, with the largest difference at 2 months. Breastfeeding self-efficacy showed significantly greater improvement in the intervention group (time & times; intervention interaction: beta = 1.01 [95% CI, 0.21-1.81]; P = .01), with a higher score at 4 months (adjusted beta, 4.65 [95% CI, 1.60-7.70]; P = .01).Conclusions and RelevanceIn this randomized clinical trial, video call-based peer support did not increase exclusive breastfeeding at 6 months; however, it significantly increased exclusive breastfeeding at 2 months and improved maternal breastfeeding self-efficacy, offering a scalable model for postnatal care integration.Trial RegistrationClinicalTrials.gov Identifier: NCT04621266

Hypertensive disorders of pregnancy affect around 10

Importance:Peer support is a promising strategy to improve breastfeeding outcomes, but evidence for online formats is limited. Objective:To evaluate whether structured peer support delivered via video calls improves exclusive breastfeeding rates and maternal breastfeeding self-efficacy. Design, Setting, and Participants:This multicenter, randomized clinical trial enrolled first-time mothers with low breastfeeding confidence from 4 public postnatal wards in Hong Kong from January 31, 2021, to June 30, 2024. Participants were randomly assigned (1:1) to intervention or control. The primary analysis was conducted from July 1 to 31, 2024, with final data analysis completed by December 31, 2025. Intervention:The intervention included usual postnatal care, consisting of access to lactation consultants and standard breastfeeding information from the Department of Health, plus at least 2 video call sessions with trained peer support volunteers at 10 days and 1 month post partum. Main Outcomes and Measures:The primary outcome was the proportion of infants who were exclusively breastfed at 6 months post partum. Secondary outcomes included exclusive breastfeeding at 1, 2, and 4 months post partum and maternal self-efficacy (measured using the Breastfeeding Self-Efficacy Scale-Short Form) at 2 and 4 months. All outcomes were analyzed on an intention-to-treat basis. Results:Among 442 participants, 224 were allocated to the intervention group and 218 were allocated to the control group. The mean (SD) maternal age was 32.4 (4.0) years (32.4 [4.2] years in the intervention group and 32.3 [3.9] years in the control group). The primary 6-month outcome did not differ significantly between groups (37 of 184 [20.1%] vs 29 of 186 [15.6%]; adjusted odds ratio [AOR], 1.57 [95% CI, 0.85-2.89]; P = .15); however, exclusive breastfeeding at 2 months (a secondary outcome) was significantly higher in the intervention group (54 of 199 [27.1%] vs 38 of 200 [19.0%]; AOR, 1.80 [95% CI, 1.08-3.01]; P = .02). Longitudinal analysis confirmed higher odds of exclusive breastfeeding in the intervention group over time, with the largest difference at 2 months. Breastfeeding self-efficacy showed significantly greater improvement in the intervention group (time × intervention interaction: β = 1.01 [95% CI, 0.21-1.81]; P = .01), with a higher score at 4 months (adjusted β, 4.65 [95% CI, 1.60-7.70]; P = .01). Conclusions and Relevance:In this randomized clinical trial, video call-based peer support did not increase exclusive breastfeeding at 6 months; however, it significantly increased exclusive breastfeeding at 2 months and improved maternal breastfeeding self-efficacy, offering a scalable model for postnatal care integration. Trial Registration:ClinicalTrials.gov Identifier: NCT04621266.

Background This study aimed to assess the potential for a whole-family intervention for domestic violence and abuse (DVA) - the For Baby's Sake programme - to address both parenting and abusive behaviours in families experiencing DVA. This objective is achieved by investigating parents' perspective. This trauma-informed programme works separately with mothers and fathers and is intended to start in pregnancy and continue for two years.Methods Three sets of individual interviews were conducted with mothers and fathers both at the start of the programme (during pregnancy); one year after programme enrolment and at programme end. Reflexive Thematic Analysis was employed. 26 mothers and 13 fathers participated with a total of 83 interviews.Results Parents reported perceived improvements in parenting knowledge and behaviours, notably through psychoeducation on child development and feedback on video recordings of parent-child interactions. Mothers acknowledged experiences of DVA, and found psychoeducation, insights into intergenerational transmission, and safety planning activities beneficial. Some fathers acknowledged perpetration of violent behaviours. Fathers embraced change by addressing their own Adverse Childhood Experiences (ACEs), acquiring emotional regulation skills, and committing to anger management. Both fathers and mothers stressed the importance of a non-judgmental environment and a desire to enhance parenting as motivating factors for acknowledging DVA and committing to change.Conclusions The findings suggest that whole-family approach interventions - such as the For Baby's Sake programme - holds promise in addressing both parenting and abusive behaviours in families experiencing DVA.

ABSTRACT Poor teamwork is often implicated in serious healthcare delivery failings, leading to calls for effective team improvement interventions. Taking a complex, adaptive systems perspective, we adapted an oncology team quality improvement program to make it appropriate for other areas of clinical care. Study phases included: (1) meetings with National Health Service, policy and service user representatives ( n = 19), a rapid review of existing maternity teamwork interventions, and mapping of the proposed program content to an evidence‐based model of team effectiveness; (2) feasibility and acceptability testing of the team questionnaire component, and content analysis of free‐text responses with four maternity teams within two NHS Trusts ( n = 26). Meetings with representatives highlighted the importance of non‐punitive, continuous team‐led assessment, and the ability to compare performance to similar teams while enabling adaptability to different team types. Program content mapped well to known components of team effectiveness. Internal consistency of the questionnaire was acceptable (Cronbach alpha = 0.79–0.92). Most team members (76.9%) reported benefits in identifying priorities for improvement. Preliminary proof of concept was supported but larger‐scale evaluation including testing in other clinical areas is warranted.

(Abstracted from Lancet 2024;405:1743-1756) Shoulder dystocia is associated with several maternal and neonatal complications and is a common reason for litigation in obstetrics. Maternal complications include hemorrhage and third- and fourth-degree perineal severe tears; neonatal complications include fractures, brachial plexus injury, hypoxic ischemic encephalopathy, and neonatal death.

BACKGROUND:Inflammatory Bowel Disease (IBD) is a long-term condition affecting the digestive tract and is an umbrella term for two main conditions: ulcerative colitis (UC) and Crohn's Disease (CD), which can cause diarrhoea, anaemia, weight loss, rectal bleeding and abdominal pain. Approximately 500,000 people live with IBD in the UK, with half being diagnosed before the age of 35 years (Ferguson, Mahsud-Dornan, and Patterson 2008). IBD increases the risk of pregnancy complications, with symptoms being unpredictable during pregnancy. METHODS:A mixed methods study was undertaken exploring what shaped the experiences of pregnancy for women living with IBD, including an on-line survey and one-to-one interviews. Data from the interviews were analysed using Interpretative Phenomenological Analysis. FINDINGS:Expectations, control and care emerged as key themes which shape the experiences of pregnancy. These included expectations about pregnancy and of those providing care during pregnancy, the positive and negative impact of experienced lack of control and the effects of primary care providers during pregnancy. CONCLUSION:This novel study enabled women living with IBD to share what shaped their experiences of pregnancy and recommendations about midwifery care to be made. Midwives need to be mindful of the additional risks for women and their babies, and ensure care involves multidisciplinary specialists.

To explore the experiences and opinions of women with breast cancer-related arm lymphoedema (BCRL), a common sequela of breast cancer treatment, and of lymphoedema practitioners regarding current lymphoedema treatment in the UK, priority outcomes and assessment methods, and acceptability of a future trial of lymphoedema treatment and use of intensive-decongestive lymphoedema treatment (DLT) for women presenting with BCRL. Two focus groups were conducted with 13 women and three focus groups with 13 lymphoedema practitioners. Discussions were transcribed and analysed using framework analysis. Usual UK lymphoedema care was self-treatment with hosiery. Women and practitioners supported the notion of early intervention although practitioners reported lack of capacity to provide intensive-DLT. All groups considered arm volume an important outcome but were unsure what treatment outcomes could be expected. Participants supported the need for a trial to identify effective treatment for women with previously untreated BCRL but could not describe criteria for a good clinical outcome. Study findings demonstrate the need and desire of women and practitioners for robust research to determine the most effective treatment for women with early-BCRL, that is, within 12 months of BCRL onset, including intensive-DLT. However, UK lymphoedema services lack capacity to provide intensive-DLT, so the potential to conduct a future trial of effectiveness is likely to be limited. Women with arm BCRL can expect to receive self-treatment with hosiery. There is a need to identify effective treatment for women with arm lymphoedema and criteria for a good clinical outcome.

BACKGROUND:Pregnant women and their unborn babies are at an increased risk of hospitalisation, morbidity, and mortality from illness. However, uptake of influenza, pertussis and Covid-19 vaccinations offered during pregnancy is below the desired rate. This research aims to explore UK midwives' experiences of approaching and discussing vaccinations with pregnant women, and their perceived role in pregnant women's vaccination decisions. METHODS:Midwives in the West Midlands, UK were recruited via participating hospitals and midwife specific social media groups. Interviews were conducted remotely from April to July 2023 and analysed with a deductive codebook coding strategy using thematic analysis. FINDINGS:Semi-structured interviews were conducted with 16 midwives identifying the following key themes: Recommendations to have vaccinations reported on the contents of recommendations and how they are communicated; Messages and guidance included the importance of up-to-date informational needs for midwives to administer vaccinations and the barriers caused by uncertainty and conflicting messages about the Covid-19 vaccine during pregnancy; Delivery of vaccinations included the convenience of offering vaccinations during standard antenatal appointments; and Midwives' barriers explored the pandemic specific and other barriers midwives face in the administering of vaccinations. DISCUSSION:These findings contribute to the understanding of how midwives discuss the topic of vaccinations with pregnant women. This research highlights the importance for midwives to receive clear and consistent information. A strong emphasis on why vaccines are important when recommending to pregnant women in addition to standard information on the availability and timing may have a bearing in helping women to make informed decisions about accepting vaccinations.

Background:Perinatal mental health disorders affect one in five mothers during pregnancy or within 2 years post childbirth. These disorders can lead to poor pregnancy and childbirth outcomes and maternal deaths. Additionally, they negatively affect a child's cognitive, social and emotional development. Stigma and a lack of specialised services have limited access to mental health care. National Health Service England invested £365M in community perinatal mental health teams, but their impact on women and infants' outcomes are not known. Develop a taxonomy of community perinatal mental health teams (work package 1). Compare and validate two assessments of quality of mother-infant interaction for use by community perinatal mental health teams (work package 2). Evaluate the effectiveness and cost-effectiveness of community perinatal mental health teams (work packages 3 and 4). Design:Mixed-methods study. Setting:Community perinatal mental health teams in England. Participants:Women who were pregnant or within 2 years postnatal. Methods and outcome measures:Work package 1: Typology of community perinatal mental health teams in England. Work package 2: Reliability and validity of two observational assessments of parent-infant interaction. Work package 3: Realist evaluation interviews with women, partners/close others, and staff to determine effective community perinatal mental health team components. Work package 4: Analysis of linked data: Association of community perinatal mental health teams with access to secondary care mental health services. Risk of acute relapse and improved obstetric and neonate outcomes for women with pre-existing severe disorders in areas with community perinatal mental health teams compared to generic services. Economic analysis of cost of community perinatal mental health teams. Results:Objective 1: Community perinatal mental health team typologies revealed in 2020, 84% had basic staffing levels and 63% had more multi-professionals. Objective 2: The 'Parent Infant Interaction Observation Scale' and 'National Institute of Child Health and Human Development' assessments of mother-infant interaction were reliable and valid; the National Institute of Child Health and Human Development is more suitable for community perinatal mental health teams. Objective 3: Work package 3: Interviews with 139 women, 55 partners/close others and 80 health workers highlighted the importance of specialist perinatal knowledge, responding in a warm and non-judgemental way, working closely with other healthcare providers, optimising medication, supporting mothers to reduce conflict and improve social support, helping mother-infant bonding, and teaching emotional management. Work package 4: Analysis of linked health data revealed higher risks for obstetric and neonate problems in women with severe mental health disorders, particularly recent or very serious episodes. Work package 4: Areas with community perinatal mental health teams saw increased mental health access among perinatal women and reduced need for acute care, albeit at a higher cost and with greater neonatal risks. Limitations:High levels of missing data on diagnosis and mental health outcomes in existing health and service data. Lack of data on child outcomes. Evaluation occurred during community perinatal mental health team changes and the coronavirus disease discovered in 2019 pandemic limiting a full assessment of the impact of community perinatal mental health teams on maternal and child outcomes. Conclusions:Community perinatal mental health teams can support perinatal women with complex, moderate/severe mental health disorders, but further attention to women's physical needs is essential. The use of observational assessments of parent-infant relationships will enhance the evaluation of community perinatal mental health teams' impact on infant outcomes. Future work:Research should focus on prospective studies that gather mental health and child outcomes from community perinatal mental health teams and primary care mental health, to assess broader impacts of perinatal-specific treatment across care pathways. Study registration:This study is registered on Research Registry as researchregistry5463. Funding:This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 17/49/38) and is published in full in Health and Social Care Delivery Research; Vol. 13, No. 38. See the NIHR Funding and Awards website for further award information.

Background: Since 2020, the General Medical Services contract requires GP practices in England to offer women a GP appointment 6-8 weeks after birth: the '6-8 week postnatal check' or 'consultation'. Historically, provision of checks was variable, and women still frequently report poor experiences. Aim: To explore GPs' and women's perspectives of the 6-8 week postnatal check, including key components and timing. Design & setting: A mixed- methods study was undertaken with focus groups of GPs and women, and an online survey of GPs in England. Method: Focus groups explored GPs' and women's experiences of postnatal consultations. An online survey explored GPs' clinical approach, organisation, and improvement potential. Quantitative analysis examined associations between demographics and clinical approach. Thematic framework analysis was used for qualitative data. Results: In total, 18 women and 14 GPs participated in focus groups; 671 GPs completed the survey. Mental wellbeing and contraception were reported as important topics, although some women were not asked about mental health. GP survey responses indicated most recommendations from national guidance were 'always' or 'very often' covered by most, but not all GPs. Clinical coverage was higher for GPs who used clinical templates, had awareness of guidance, were female, or were a parent. Many GPs (n = 326/670, 49%) needed more time than they were allocated for the consultation (n = 524/670 [78%] allocated <= 15 minutes; n = 351/670 [52%] completed in <= 15 minutes). Conclusion: This study suggests GPs are allocated insufficient time for postnatal consultations, with substantial variation in practice. Specifying consultation duration and consideration of template usage in policy may improve care and outcomes for women.

BACKGROUND:Since 2020, GP maternal postnatal consultations 6-8 weeks after birth have been mandatory under England's General Medical Services contract. Previously, provision and quality of these consultations was inconsistent, often inadequate. The impact of the mandate is unknown. AIM:To develop an understanding of facilitators and barriers to GPs providing high quality 6-8-week maternal postnatal checks through exploration of views and experiences of women and GPs. METHOD:Mixed methods study focus groups of GPs and women, and an online survey of GPs in England. Qualitative data collection was via focus groups exploring GPs' and women's experiences of postnatal consultations, and an online survey of GPs. Thematic framework analysis was used, with the Capability, Opportunity, Motivation - Behaviour (COM-B) model as an overarching thematic structure. Inductively developed subthemes were mapped to relevant constructs of the COM-B model. RESULTS:Focus groups included 18 women and 14 GPs, the GP survey received 671 responses. Twelve subthemes mapped to six domains of the COM-B model, comprising influences that could be facilitators or barriers to good care. Some influences related to both GPs and women. Some were specific to GPs, such as 'GPs' knowledge', or to women, such as 'Women's social context'. GPs' lived experience impacted their knowledge and motivation. CONCLUSION:GPs and women experienced barriers to good postnatal consultations. Organisational interventions could address; for example, adequate appointment duration, and improved information transfer. Application of the Behaviour Change Wheel to prioritise and develop interventions based on findings could improve women's experience and outcomes.

Early treatment is advised for breast cancer–related arm lymphoedema (BCRL), a common sequelae of breast cancer treatment. Expert guidance recommends two-phase decongestive lymphoedema treatment (DLT), although evidence is lacking for current treatment protocols and UK women are routinely offered self-treatment with hosiery. This systematic review considered evidence regarding treatment of early BCRL, that is, within 12 months of developing BCRL. A systematic review of evidence for clinical effectiveness of DLT for women with less than 12-month BCRL duration (early BCRL) was undertaken using the Joanna Briggs Institute (JBI) method. Studies included women with < 12-month or mean < 9-month BCRL duration; some studies reported only one eligible group. The original search was conducted in 2016 and updated in 2018 and 2022. Methodological quality of identified studies was assessed using JBI critical appraisal instruments. Outcomes of interest were extracted with eligible results displayed in narrative and tabular format. Strength of evidence was rated using the GRADE system. Seven trials and three descriptive studies provided weak evidence (grade B) for effectiveness of DLT for early BCRL. Heterogeneous protocols limited comparison of findings. There was no evidence for the most effective treatment or treatment combination or optimal frequency or duration of treatment. There is no evidence to justify change in current lymphoedema treatment, whether self-treatment with hosiery (UK) or two-phase DLT (other countries). Further research for the early BCRL population is required. Women with early BCRL require early and effective treatment although this updated review shows there is still no evidence for what that treatment should be.

Background Obstetric anal sphincter injury is the most common cause of anal incontinence for women, which often has profound impacts on women’s lives. GPs offer a first line of contact for many women, but we know that very few women experiencing anal incontinence postnatally report discussing it with their GPs. Aim To identify key ways in which GPs can support women with anal incontinence caused by childbirth injuries. Design and setting A qualitative study investigating women’s experiences with their GP, and GPs’ perspectives about providing such care. Method This qualitative study combined two phases: first, a series of in-depth semi-structured interviews with women experiencing anal incontinence caused by childbirth injuries ( n = 41); and second, focus groups with GPs ( n = 13) stratified by experience. Thematic analysis was conducted and relevant themes from across the two datasets were examined. Results Mediating factors in GP care for women with anal incontinence caused by childbirth injuries centred around three key themes: the role of the GP, access and pathways, and communication. Conclusion The findings demonstrate multifactorial challenges in identifying the problem and supporting women experiencing anal incontinence after childbirth injury in primary care settings. Many GPs lacked confidence in their role in supporting women, and women were often reluctant to seek help. Those women who did seek help often experienced frustrations consulting with their GPs. In a context where women are often reluctant to ask for help, their concerns are not always taken seriously, and where GPs do not routinely ask about anal incontinence, potential anal incontinence after childbirth injury appears to be often missed in a primary care setting.

Introduction Breastfeeding is associated with many health benefits for both women and their newborns. Exclusive breastfeeding has been recommended for at least 6 months to optimise infant growth, development and health. In addition to standard care, community-based peer support is recommended to help mothers improve breastfeeding. A recent survey reveals that the rate of exclusive breastfeeding at 6 months post partum in Hong Kong is low, and half of all breastfeeding mothers never exclusively breastfeed. Taking into account the local practice for women to stay home during the first month post partum and social isolation during and post-COVID-19 pandemic, a home-based peer support programme with the aid of Zoom or Facetime is proposed. This study aims to evaluate the effectiveness of a home-based breastfeeding peer support programme in improving breastfeeding practices and achieving exclusive breastfeeding rate among women with low breastfeeding self-efficacy.Methods and analysis The study is a two-armed randomised control trial and will include a total of 442 participants. Potential cases will be recruited and screened at four postnatal wards in Hong Kong public hospital. Eligible and consented cases will be randomly allocated into intervention or control groups at a 1:1 ratio. Control group (n=221) will receive standard care, while the intervention group (n=221) will receive home-based peer support as well as standard care. Trained peer counsellors will provide breastfeeding-related support through Zoom or Facetime at 10 days and 1 month post partum. Telephone follow-ups will be conducted at 1 month, 2 months, 3 months and 6 months post partum. Breastfeeding status, mother’s breastfeeding self-efficacy and postpartum depression will be assessed and compared between the two arms.Ethics and dissemination The study has been reviewed and approved by the Institutional Review Board of the University of Hong Kong and Hospital Authority Hong Kong West Cluster (UW 20-564). The findings will be updated in trial registries and disseminated in peer-reviewed journals and academic conferences.Trial registration number NCT04621266.

Background Perinatal outcomes are poor among migrant women in vulnerable situations, but little is known about their health preconception. We investigated preconception health inequalities between migrant women in vulnerable situations and non-migrant women. Methods This national cross-sectional study used data from the NHS Maternity Services Data Set (MSDS) version 1.5, incorporating NHS maternity services in England. All 652,880 women with an antenatal booking appointment between 1/4/2018 and 31/3/2019 were included. Migration category data were available for 66.2 % (n = 432,022). Odds ratios were calculated comparing preconception indicators among probable migrants in vulnerable situations (English not their first language with complex social factors (CSF)), probable migrants not in vulnerable situations (English not their first language without CSF), probable non-migrants in vulnerable situations (English their first language with CSF) and probable non-migrants not in vulnerable situations (English their first language without CSF). CSF include recent migrants, asylum seekers, refugees, difficulty reading/speaking English; alcohol and/or drugs misuse; aged under 20; and/or experiencing domestic abuse. Findings We identified 3.8 % (25,070 women) of the study population as probable migrants in vulnerable situations, 10.2 % (66,783 women) as probable migrants not in vulnerable situations, 5.6 % (36,433 women) as probable non-migrants in vulnerable situations, 46.5 % (303,737 women) as probable non-migrants not in vulnerable situations, and 33.8 % as having missing migration category data. Probable migrants in vulnerable situations (n = 25,070) had over twice the odds of not taking folic acid preconception compared to probable non-migrants not in vulnerable situations (odds ratio 2.15, 95 % confidence interval 2.06–2.25). They had increased odds of previous obstetric complications and being underweight, but lower odds of physical and mental health conditions (apart from diabetes and hepatitis b), smoking and overweight or obesity. Interpretation Inequalities exist across many preconception indicators, highlighting opportunities to improve preconception health in this population to reduce health inequalities and improve perinatal and neonatal outcomes. Funding Medical Research Council.

Background Antenatal pelvic floor muscle exercises are effective in reducing postnatal urinary incontinence. Midwives, however, lack training and confidence to promote these exercises and often do not provide information or support to women to do the exercises. Objectives Objectives were to: (1) investigate current antenatal care in relation to pelvic floor muscle exercise support from midwives for women; (2) develop an intervention to increase the likelihood of midwives supporting women to do pelvic floor muscle exercises during pregnancy; and (3) test the intervention in a feasibility and pilot cluster randomised controlled trial with numerous trial and process evaluation outcomes. Design Study designs included critical interpretive synthesis, ethnography and other methods (interviews, focus groups, behaviour change theory mapping, stakeholder and patient/public involvement activities) and piloting questionnaires to develop an intervention to test in a feasibility and pilot cluster randomised controlled trial. Clusters were community midwife teams. Setting Main setting: two National Health Service hospital trusts providing maternity care in Birmingham. Participants Participants included pregnant women and midwives. Pilot trial participants included women who gave birth during a prespecified month in study maternity units. Midwives participated in trial process evaluation. Interventions Midwives in teams randomised to the intervention were trained how to teach pelvic floor muscle exercises to women and support them in undertaking these exercises throughout pregnancy. Midwife teams allocated to control provided standard antenatal care. Main outcome measures Early-phase outcomes were whether current antenatal midwife care supported women to undertake pelvic floor muscle exercises, and a midwife pelvic floor muscle exercise training intervention. Main feasibility and pilot trial outcomes included return rates and associated intraclass correlation coefficient; whether midwives provided pelvic floor muscle exercise support to women during antenatal care; women’s adherence to undertaking pelvic floor muscle exercises antenatally; and prevalence estimates of urinary incontinence at 10–12 weeks post partum. Other process outcomes included intervention midwives’ confidence in pelvic floor muscle exercise knowledge and views on intervention delivery; women’s views on pelvic floor muscle exercise support received; and control midwives’ views on pelvic floor muscle exercises in standard care. Results The critical interpretive literature synthesis showed that current antenatal pelvic floor muscle support was constrained by numerous factors including women’s and healthcare professionals’ capacity to implement pelvic floor muscle exercises. Reform of healthcare policy and service delivery was recommended to provide opportunity to genuinely support women and healthcare professionals. Main findings of early-phase qualitative research showed that women and midwives ‘know’ that pelvic floor muscle exercises are important, but that midwives infrequently communicate to women the large ‘gains’ available from undertaking these exercises. There was lack of confidence among women and midwives on when and how to initiate discussion on pelvic floor muscle exercises and urinary incontinence. A systematic review of diagnostic tests for midwives to use to support women’s practice of pelvic floor muscle exercises identified no available studies. Qualitative research with women and midwives, mapping to behaviour change theory, and stakeholder and patient/public involvement activities followed by a practice training event showed that the intervention should consist of five steps: raising the topic of incontinence and pelvic floor muscle exercises; screening for symptoms; teaching the exercises; reminding and supporting women to do the exercises; and knowing when and how to refer. Midwife training evaluation findings showed median positive change following training of 1 point (0–5 scale) for each of eight questions related to confidence about pelvic floor muscle exercise knowledge and teaching the exercises. In the cluster trial, 17 clusters were randomised and 95 midwives in intervention clusters were trained. Of 998 women included in the trial, 175 returned a questionnaire: 15.8% in intervention and 16.4% in control clusters. Based on women’s responses to the post-partum postal questionnaire, 65% of those in intervention clusters said their midwife explained how to do pelvic floor muscle exercises compared to 38% of those in control clusters. Among women in intervention clusters, 50% undertook the exercises in a manner likely to improve symptoms compared to 38% of women in control clusters, and 44% of women in intervention clusters reported urinary incontinence compared to 54% in control clusters. Interviews with midwives and women generally supported trial findings and emphasised the importance of service change for ensuring time to implement the Antenatal Preventative Pelvic floor Exercises And Localisation intervention into antenatal appointments. Limitations There was a low questionnaire return rate. A definitive trial, which would have provided evidence of effectiveness not possible from a pilot trial, could not be undertaken because of changes to standard midwife antenatal care due to National Health Service England’s new perinatal pelvic health service. Conclusions Training midwives to appropriately support women to undertake pelvic floor muscle exercises in pregnancy is feasible, acceptable and could improve exercise adherence and reduce post-partum urinary incontinence. Future work Implementation work with National Health Service England has begun. Study registration This study is registered as ISRCTN10833250. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research Programme (NIHR award ref: RP-PG-0514-20002) and is published in full in Programme Grants for Applied Research; Vol. 12, No. 9. See the NIHR Funding and Awards website for further award information. Plain language summary After having a baby, it is very common to leak urine. We know that pelvic floor muscle exercises, when done correctly during pregnancy, can help. The problem is that midwives lack confidence to teach, or do not always explain how to do pelvic floor muscle exercises very well. Even when they do, women may not do them as it is unclear why they should. By talking to many women, midwives and researchers, we developed a way of training midwives to teach and support women during pregnancy to do these exercises. After their training, we found that midwives knew more about pelvic floor muscle exercises and were more confident to teach and support women. To test how well the training worked, we did a pilot trial where midwife teams were randomly selected to be given this training or continue with usual antenatal care. We sent a questionnaire to women when their baby was 3 months old. This asked what advice and support their midwife had given them about pelvic floor muscle exercises during pregnancy, whether they did the exercises, and whether they leaked urine over the last 4 weeks. We found that more women who had antenatal care from a midwife who had been trained were told why and how to do pelvic floor muscle exercises, more of these women did these exercises, and not as many leaked urine. These consistent outcomes are promising, but it was only a pilot trial and not many women returned their questionnaire, so we cannot be certain of these results. We interviewed some women: most were pleased about getting help with pelvic floor muscle exercises and all wanted this help. We interviewed some of the trained midwives. They were keen to help women but said lack of time meant it could be difficult to fit teaching these exercises into antenatal appointments. We could not progress to doing a definitive trial because a new National Health Service perinatal pelvic health service is being set up. However, we have provided the training developed in this programme to many of the lead staff who are setting up the new services. Scientific summary Background A Cochrane Review published when planning this programme showed that antenatal pelvic floor muscle exercises (PFME) in women without urinary incontinence (UI) were effective in reducing postnatal UI. Most interventions in the trials were undertaken by specialist healthcare professionals (HCPs), specifically physiotherapists. It is important to consider whether midwives who provide antenatal care for women could incorporate a suitable PFME intervention into their routine antenatal care since in the UK all women are seen throughout pregnancy by a midwife. Work by the team prior to starting the programme showed that many midwives do not advise women on how to undertake PFME, often due to lack of confidence in how to support women to perform PFME. We also found that women often do not do these exercises in a manner likely to improve their UI symptoms. Objectives To improve the implementation of antenatal PFME and thus reduce the likelihood of UI following childbirth. This was addressed by the following research questions and work packages (WPs): WP1 Particular context awareness: identifying barriers and enablers Why, in the context of organisational practices and cultural norms, do HCPs and women behave the way they do in relation to PFME? WP2 Performance measurement: determining relevant and acceptable measures What is the most accurate and acceptable objective test for pelvic floor muscle (PFM) localisation in pregnancy, and the most appropriate way to capture health economic impact of an intervention? WP3 Plans for change: developing constituents and means of delivery of the intervention What are the suitable means for delivering PFME training to midwives so they can teach and support women during routine antenatal contacts to undertake PFME? What are the most appropriate constituents of a training intervention to enhance PFME implementation, and how should training delivery be optimised? WP4 Piloting the intervention What is the return rate for women’s questionnaires and what is the intraclass correlation coefficient (ICC)? Is it feasible to undertake a full cluster randomised controlled trial (RCT) to assess antenatal midwife PFME implementation, women’s PFME adherence and prevalence of postnatal UI? What do process outcomes show us about intervention implementation and effects? Methods Design WP1.1 Systematic review using critical interpretive synthesis of individual, professional and organisational issues that enable or hinder implementation of PFME training during childbearing years. WP1.2 Qualitative research using ethnographic methods including interviews with pregnant women, some followed postnatally; interviews with midwives and other HCPs and observations of midwives and HCPs in antenatal care. WP2.1 Systematic review of diagnostic accuracy tests to assess PFM localisation. WP2.2 Preliminary decision-analytic model to compare alternative diagnostic and treatment pathways for antenatal prevention of UI. WP3 Intervention development using a range of qualitative methods including focus groups, mapping data to behaviour change theory, and stakeholder and patient and public involvement and engagement (PPIE) activities. WP4.1 Pilot study to test women’s post-partum questionnaires, including individual RCT of long versus short questionnaire. WP4.2 Feasibility and pilot cluster RCT to test the intervention on midwives’ and women’s behaviour in relation to PFME. WP4.3 Process evaluation of RCT using qualitative and quantitative methods. Data sources, study selection, data extraction and data synthesis WP1.1 Sources for review inclusion were identified through databases and purposive searches. Titles and abstracts were screened and appraised using a mixed-methods appraisal tool by two independent reviewers. Findings of included studies were coded using a framework based on initial research questions; patterns and themes were identified; and new constructs were linked to theory developed to explain overall findings. WP1.2 Interview data from pregnant and post-partum women, midwives and HCPs and antenatal care observations were obtained. Analysis included reflexivity, with initial coding to develop a coding framework and to identify emerging themes to guide theme development. The analysis was inductive and deductive in addressing the Antenatal Preventative Pelvic floor Exercises and Localisation (APPEAL) programme objectives. WP2.1 A search strategy was developed in consultation with an international PFME expert and databases, ongoing trials registers and abstracts/conference proceedings were searched from inception to October 2016. All study designs were considered for inclusion except diagnostic case–control studies which are known to overestimate test accuracy. Titles, abstracts and full articles were screened by two independent reviewers, with disagreements resolved by a third. A data extraction proforma and quality assessment tool, based on the QUAlity of Diagnostic Accuracy Studies tool, were prepared. WP2.2 To identify model parameters, a search strategy was developed. Databases were searched to identify formal economic evaluation and cost analysis studies which were screened for inclusion using a two-stage categorisation process. Data on resource use and costs were extracted from included studies. To identify effectiveness and health-related quality-of-life data, targeted literature searches were conducted. Collated evidence informed the preliminary decision-analytic model used. WP3 This comprised four iterative phases: Phase 1 Separate focus groups with pregnant/postnatal women and midwives were conducted in various sites. Data were analysed using thematic analysis. Phase 2 Intervention development used data from WP1 and WP3 phase 1. Comprehensive mapping used the behaviour change wheel (BCW), the theoretical domains framework and the behaviour change technique (BCT) taxonomy. PPIE activity included advisory group meetings and ‘citizens’ jury’ assessment of relevant mobile phone apps; and a national stakeholder event was held which considered midwifery training needs and antenatal service provision. Phase 3 A practice training event was held with midwives in a different region to the future trial. A questionnaire designed to assess midwives’ confidence was completed before and after training. Focus groups after training obtained feedback on intervention format, content, and delivery methods. Researchers facilitated these and recorded discussions and recommendations. Phase 4 Intervention refinement used phase 3 findings and PPIE events to refine the format and content of the package. Additional refinements were subsequently made in response to COVID-19. WP4.1 Piloting of the data collection postal questionnaire was completed by women at 10–12 weeks post partum, comparing return rates from long versus short questionnaires. WP4.2. A feasibility and pilot cluster RCT randomised community midwife teams to intervention and control; intervention teams received PFME training, which was evaluated, and then gave advice and support to all women in their care. Women who gave birth during a predefined 1-month period, chosen so that all their antenatal care occurred during the trial, were sent postal questionnaires (refined from WP4.1) at 10–12 weeks post partum. These were linked to baseline data obtained (with consent) from their hospital records. WP4.3 Process measures included questionnaires (Likert scale response options and free-text space) and audio-recorded interviews with midwives and women, observations of training (using checklists) and meeting notes. Some process outcomes were collected in the 10–12-week women’s questionnaires. Quantitative data were summarised, and qualitative data were analysed with content analysis (free-text data) or thematic analysis (transcribed interview data). Results WP1.1 Fifty quantitative and qualitative sources were found. The concept of agency (ability to effect change through interaction with other people, processes, and systems) provided an overarching explanation of how PFME can be implemented during childbearing years. Women and HCPs, maternity services, and policy-makers all have agency, although their capacity to implement PFME is enhanced or diminished by the professional, organisational, and policy environment. Numerous factors constrained women’s and HCPs’ capacity to implement PFME. The implementation of evidence-based PFME requires policy-makers, organisations, HCPs, and women to value prevention of UI by using low-risk, low-cost and proven strategies. WP1.2 From three maternity units in different parts of England, 23 midwives and 15 pregnant women were interviewed; 12 of the women were followed up postnatally. Interviews were carried out with physiotherapists (n = 4), a link worker/translator (n = 1) and obstetricians (n = 2). Seventeen antenatal clinic observations took place. Key findings were that women and midwives knew that PFME training is important, but often midwives did not communicate to women the gains available from PFME. There was a widespread lack of confidence among women and midwives to initiate conversation about PFME and UI, exacerbated by misunderstandings and assumptions and lack of clear guidelines and policy. WP2.1 A total of 9678 unique titles and abstracts were screened, and 1429 full-text articles were retrieved. No studies met the review inclusion criteria due to an absence of an index test in parallel with the reference standard of digital vaginal palpation. In studies where an index test was conducted in parallel with the reference test, the paper did not provide information from which to derive an estimate of accuracy. WP2.2 Initial results from pre-trial economic analysis suggested some potentially helpful information for trial design and proposed data collection. An example was that the time spent by midwives providing the intervention was not likely to be a key driver in the results and allowed the trial team to be non-prescriptive about midwives recording the time spent with women, an initial concern. The planned health economic analysis was discontinued when the decision was made to change from full to feasibility and pilot cluster trial. WP3 In phase 1, four themes emerged from six focus groups (12 women, 14 midwives) regarding designing the intervention: ‘knowing’, ‘doing’, ‘remembering’ and ‘supporting’ antenatal PFME. Suggestions for maximising implementation included: ‘train the trainer’ model; having a midwife PFME champion within each team; and including knowledge about local referral pathways. Phase 2 mapped findings onto the BCW; elements were coded using the BCT taxonomy. Mapping incorporated comments from PPIE advisers (nine meetings with six mothers) and national stakeholders (20 delegates from 18 relevant maternity service organisations). This resulted in the first iteration of the intervention materials: a five-step midwife training programme and resources for midwives to support PFME implementation, and a resource package for women given by midwives during the antenatal booking appointment. The five steps were: (1) raise the topic of PFME; (2) screen for UI; (3) teach PFME; (4) remind women about how to perform PFME and (5) refresh women’s understanding about PFME and refer to specialist services if required. PPIE advisers helped co-develop resources for women. The phase 3 practice training event showed positive evaluation for content and delivery which participating midwives (n = 18) had found useful. Free-text responses acknowledged the importance of midwives leading regarding PFME, but lack of time, confidence, and skills to raise the issue presented challenges for PFME implementation. Midwives showed increased total PFME confidence from 2.70 (range 1.18–3.50 on a 0–4 scale) before training to 3.68 (range 3.37–4.00) after training. Phase 4 resulted in final modifications to the intervention materials, for example: refresher on muscle exercise physiology training principles; resources for women in a cloth bag the size of a clean nappy. Extensive speaker notes were included to facilitate ‘train the trainer’ plans for future implementation, the training session was shortened from a half-day to 2 hours, and extra resources were developed to support PFME champions. Further modifications, due to COVID-19, enabled remote training delivery by trial staff and enabled midwives to deliver intervention elements to women via telephone appointments. The final WP output was the logic model for the feasibility and pilot trial. WP4.1 In piloting the data collection instruments, 777 women were randomised to being sent a long or short questionnaire. Overall response rate was 31.3% (243/777), with 30.8% (119/387) and 31.8% (124/390) responding in the long and short questionnaire arms, respectively [absolute difference in return rate −1.05%, 95% confidence interval (CI) −7.6% to 5.5%]. While not statistically significant, these results rule out any large differences according to questionnaire length. The ICC of response rate was 0.007 (95% CI 0.0005 to 0.094). Of the total responders, 49% (119/243) reported UI and 64.2% (156/243) reported receiving some advice to perform PFME in pregnancy from their midwife. There were 42.4% (103/243) of women who reported doing PFME often enough (a few times a week or more) to possibly reduce post-partum UI. All responses were similar between the long and short questionnaire trial arms. It was realised that a question about explanation of how to do PFME was important for inclusion in the WP4.2 questionnaire. WP4.2 There were 17 midwifery team clusters randomised, comprising 186 midwives and 1304 women. After exclusions, 998 women were sent a post-partum postal questionnaire and 175 (17.5%) were returned from 88/531 (16.6%) women in intervention clusters and 87/467 (18.6%) in control clusters. Baseline characteristics of the women, including maternal, obstetric and infant characteristics, were similar across trial arms. There was some suggestion of differences between those who did and did not return questionnaires in the proportions of women from ethnic minority groups and having second or subsequent babies, but other baseline characteristics were similar. Based on women’s responses to the questionnaire, 65% (95% CI 56.9% to 72.4%) of those in intervention clusters said their midwife explained how to do PFME, compared to 38% (95% CI 24.6% to 51.2%) in control clusters; 50% (95% CI 24.1% to 77.1%) of women in intervention clusters compared to 38% (95% CI 12.4% to 67.1%) in control clusters undertook PFME in a manner likely to reduce symptoms; 44% (95% CI 32.0% to 56.1%) of women in intervention clusters reported UI compared to 54% (95% CI 42.2% to 65.8%) in control clusters; and 18% (95% CI 6.6% to 28.9%) of women reported faecal incontinence in the intervention clusters compared to 13% (95% CI 4.8% to 21.2%) in control clusters. WP4.3 Training was delivered as intended with acceptable fidelity compared to the training protocol checklist (mean score 86.4%, standard deviation 9.2%), with successful training uptake: all 95 intervention cluster midwives received training. Each team appointed a midwife champion. Most midwives reported acceptability for most training aspects although some would have preferred in-person training. Midwives’ confidence about PFME increased following training (median increase at least 1 point on 0–4 scale for each of eight questions). Implementation questionnaire respondents (n = 59) reported raising the topic (89%), giving the resource bag (68%), teaching a PFME contraction (68%), and practising a contraction in antenatal clinic (45%) with most or all of the women. The most frequently reported barriers were lack of time (26%); forgetting (19%); language (17%); other priorities (15%) and not on the maternity records system (12%) to act as prompt. Intervention midwife interviews (n = 13) indicated positive responses (‘I’m enthusiastic about it’), but there was some ambivalence about the burden of implementation mainly due to workload, limited appointment time, remembering everything and opportunity costs (‘so many other priorities’). Minimal evidence of between-group contamination was found in post-trial interviews with midwives (n = 12 control, n = 6 intervention) and women (n = 16 control, n = 13 intervention). Opportunities for improving implementation included: longer appointments; prompts on records; training update; greater women’s resources accessibility (e.g. online leaflets); and more understanding of referral processes and physiotherapy consultations’ content to aid communication. Conclusions This programme has produced consistent data to demonstrate that training and resourcing antenatal care midwives appropriately to teach and support women to undertake PFME in pregnancy is feasible, could improve women’s PFME adherence and might reduce post-partum UI. A definitive trial would have provided best effectiveness evidence, but this was not possible because of changes to standard antenatal midwife care as a result of NHS England’s new perinatal pelvic health service. So, although there were limitations in this programme of research, it probably represents the best available evidence on whether it is feasible to embed a PFME intervention in standard antenatal care in England and how this can be done. Study registration This study is registered as ISRCTN10833250. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research Programme (NIHR award ref: RP-PG-0514-20002) and is published in full in Programme Grants for Applied Research; Vol. 12, No. 9. See the NIHR Funding and Awards website for further award information.

Purpose This study aimed to explore how pregnant women who experience Domestic Violence and Abuse (DVA) and men who commit DVA understand the impact of their childhood environment on their relationships with their children and co-parents, and how a DVA psychological intervention may shape their parenting. Methods Repeated individual qualitative interviews were conducted with pregnant mothers and fathers who reported DVA and were taking part in a psychological intervention to address DVA. Interviews were carried out at the start (during pregnancy) and end of the intervention (two years post-childbirth). Reflexive Thematic Analysis was used to analyse interviews. Results 56 interviews (26 mothers; 13 fathers) were analysed. Five themes were identified: (1) Acknowledging childhood experiences of DVA; (2) The scars of traumatic experiences; (3) Challenging the silencing of abuse; (4) The transmission of parenting styles and behaviours from one generation to another; (5) Becoming the best parent one can be. The intergenerational transmission of violence was identifiable in most narratives. Despite this, several participants described skills they acquired during the intervention (e.g., emotional regulation strategies) as assisting in interrupting violence and improving their relationships with their children. Conclusions Participants who acknowledged having encountered childhood abuse recognised it as one of several risk factors for DVA in adulthood. They also discussed the potential for trauma-informed interventions to address the intergenerational transmission of violence and poor parenting practices.

Background There is no clear evidence about how to support people with borderline personality disorder (BPD) during the perinatal period. Perinatal emotional skills groups (ESGs) may be helpful, but their efficacy has not been tested. Aims To test the feasibility of conducting a randomised controlled trial (RCT) of perinatal ESGs for women and birthing people with BPD. Method Two-arm parallel-group feasibility RCT. We recruited people from two centres, aged over 18 years, meeting DSM-5 diagnostic criteria for BPD, who were pregnant or within 12 months of a live birth. Eligible individuals were randomly allocated on a 1:1 ratio to ESGs + treatment as usual (TAU), or to TAU. Outcomes were assessed at 4 months post randomisation. Results A total of 100% of the pre-specified sample (n = 48) was recruited over 6 months, and we obtained 4-month outcome data on 92% of randomised participants. In all, 54% of participants allocated to perinatal ESGs attended 75% of the full group treatment (median number of sessions: 9 (interquartile range 6–11). At 4 months, levels of BPD symptoms (adjusted coefficient −2.0, 95% CI −6.2 to 2.1) and emotional distress (−2.4, 95% CI −6.2 to 1.5) were lower among those allocated to perinatal ESGs. The directionality of effect on well-being and social functioning also favoured the intervention. The cost of delivering perinatal ESGs was estimated to be £918 per person. Conclusions Perinatal ESGs may represent an effective intervention for perinatal women and birthing people with BPD. Their efficacy should be tested in a fully powered RCT, and this is a feasible undertaking. Trial registration ISRCTN80470632.