The coronavirus disease 2019 pandemic affected breastfeeding women in various ways. Understanding their experiences during the pandemic is crucial for informing actionable recommendations, evidence-based strategies and future policies to support breastfeeding during global pandemics. This review aimed to synthesise qualitative evidence on women's breastfeeding perceptions, experiences and support needs during the pandemic. The Joanna Briggs Institute's (JBI) guidelines on systematic reviews of qualitative evidence were followed. MEDLINE, Embase, CINAHL and Web of Science Core Collection databases were searched. Methodological quality of included papers was assessed using JBI's checklist for qualitative research. The synthesised findings were generated using JBI's meta-aggregation approach. The JBI ConQual process was used to rank each synthesised finding. Fifty-two papers were included. The synthesised findings included: (1) women's awareness and commitment to breastfeeding during the pandemic, (2) the multifaceted breastfeeding experiences of women during the pandemic, (3) breastfeeding practices and challenges for working women, (4) professional support during the pandemic: navigating breastfeeding in an evolving health care context and (5) family and peer support groups during the challenging times of the pandemic. Breastfeeding women require clear information, accessible in-person lactation support, family emotional support, food security and protection of psychological well-being. The review reported diverse breastfeeding experiences, from social support challenges to positive aspects like remote work. Breastfeeding support and lactation consultants should be considered as essential services in future pandemics. Food security is crucial for breastfeeding households. Lactation services could prioritise face-to-face consultations for physical challenges and providing online informational support. Future research could explore innovative breastfeeding education strategies.

Objective: To examine and synthesise qualitative evidence of women's, peer supporters' and healthcare professionals' views and experiences of breastfeeding peer support. Design: The Joanna Briggs Institute (JBI) approach to systematic reviews of qualitative studies was followed. Seven databases: CINAHL, MEDLINE, EMBASE, PsycINFO, Scopus, Maternal & Infant Care, and Web of Science were searched. Included papers were critically appraised using the JBI Critical Appraisal Checklist for Qualitative Research. JBI's meta-aggregation approach was used to synthesise findings. JBI's ConQual process was followed to assess confidence of evidence. Participants and setting: Primiparous and multiparous women, lay breastfeeding peer supporters, and healthcare professionals based in high, middle, and low income countries. Findings: Twenty-three papers presenting findings from 22 studies were included. The synthesised findings included: (1) Positive characteristics, approaches and benefits of peer support(ers); (2) Relationships between healthcare professionals and peer supporters; (3) Improving women's access to peer support services; (4) Barriers and enablers to provide peer support. Key conclusions and implications for practice: Breastfeeding peer support increased women's self-esteem and confidence in breastfeeding while reducing social isolation. Peer supporters valued the experience, which gave them a sense of purpose and confidence, and felt good about helping the women they supported. Women appreciated peer supporters who were caring, spent time with them, shared experiences, provided realistic information, practical and emotional support. Although there were tensions between some healthcare professionals and peer supporters, many valued the mutual support offered. Embedding peer supporters in healthcare systems for them to work alongside healthcare professionals, combined with good communications and building trusty relationships could be a useful strategy to reduce tensions between them. (C) 2022 Elsevier Ltd. All rights reserved.

This review aimed to synthesize qualitative evidence of views and experiences of partners and other family members who provided breastfeeding support for a relative. The Joanna Briggs Institute (JBI) methodology for systematic reviews of qualitative evidence was followed. Seven databases: CINAHL, MEDLINE, EMBASE, PsycINFO, Scopus, Maternal and Infant Care, and Web of Science were searched. Partners and other family members (e.g. grandmothers, siblings) of women in any countries were included. Included papers were critically appraised. The JBI meta-aggregative approach was used to analyze data and form synthesized findings. Seventy-six papers from 74 studies were included. Five synthesized findings were: (i) spectrum of family members' breastfeeding knowledge, experiences and roles; (ii) the complexity of infant feeding decision making; (iii) the controversy of breastfeeding in front of others; (iv) impact of breastfeeding on family; and (v) it takes more than just family members: support for family members. Partners' and family members’ views and experiences of breastfeeding support reflected multi-faceted personal, social, financial, cultural, religious, emotional, psychological, and societal factors of the support they provided (or not). Healthcare professionals should engage them in breastfeeding discussions with the woman, and offer tailored and practical guidance relevant to help them to appropriately support the woman. This article is part of the theme issue ‘Multidisciplinary perspectives on social support and maternal–child health’.

INTRODUCTION:Returning to paid employment is one of the reasons women stop breastfeeding earlier than they planned to. This systematic review aimed to provide insight into the experiences and views of women and employers on breastfeeding and returning to paid employment, with findings used to inform practice and policy.METHODS:The review was guided by the Joanna Briggs Institute (JBI) methodology for systematic reviews of qualitative evidence. Medline, CINAHL, PsycINFO, and Web of Science databases were searched for studies published in English. JBI's meta-aggregative approach informed data analysis. The studies in this analysis included women who stopped breastfeeding before, and those who continued breastfeeding after, returning to paid employment and the employers, work managers, or supervisors of women who continued breastfeeding after returning to paid employment.RESULTS:Twenty-six articles presenting findings from 25 studies were included and critically appraised. Synthesized findings showed that women experienced physical and emotional difficulties and described gender and employment inequalities in accessing and receiving the support they needed. Women reported that the importance of their own motivation and having workplace legislation in place facilitated breastfeeding during employment. Support from employers, colleagues, and family members, as well as access to convenient child care, helped women continue breastfeeding on return to paid employment. Employers' personal experiences influenced their views on breastfeeding and working, and the need for more education and communication between employers and employers on breastfeeding in the workplace was recognized.DISCUSSION:Support from family, work colleagues, and employers was important to reduce the physical and emotional challenges women experienced when combing breastfeeding with return to paid employment. Gender inequalities, especially in low- and middle-income countries, in accessing support exacerbated the difficulties women experienced. Limited data were identified regarding employers' experiences and views, suggesting an urgent need for further research to explore employers' and work colleagues' experiences and views.

Women who are overweight or obese have increased health risks during and beyond pregnancy, with consequences for their infants' shorter and longer term health. Exclusive breastfeeding to 6 months has many benefits for women and their infants. However, women who are overweight or obese have lower rates of breastfeeding intention, initiation, and duration compared with women with normal weight. This systematic review aimed to examine evidence of (a) breastfeeding barriers and support experienced and perceived by women who are overweight or obese, (b) support shown to be effective in increasing breastfeeding initiation and duration among these women, and (c) perceptions of health care professionals, peer supporters, partners, and family members regarding providing breastfeeding support to these women. Sixteen quantitative and qualitative papers were included and critically appraised. Thematic synthesis was undertaken to obtain findings. Maternal physical barriers such as larger breasts, difficulties of positioning to breastfeed, delayed onset of lactation, perceived insufficient supply of breast milk, and impact of caesarean birth were evident. Maternal psychological barriers including low confidence in ability to breastfeed, negative body image, embarrassment at breastfeeding in public, and experiencing stigma of obesity were also described. Support from health care professionals and family members influenced breastfeeding outcomes. Education for maternity care professionals is needed to enable them to provide tailored, evidence-based support to women who are overweight or obese who want to breastfeed. Research on health care professionals, partners, and family members' experiences and views on supporting this group of women to breastfeed is needed to support development of appropriate interventions.

Abstract Women who are overweight or obese have increased health risks during and beyond pregnancy, with consequences for their infants' shorter and longer term health. Exclusive breastfeeding to 6 months has many benefits for women and their infants. However, women who are overweight or obese have lower rates of breastfeeding intention, initiation, and duration compared with women with normal weight. This systematic review aimed to examine evidence of (a) breastfeeding barriers and support experienced and perceived by women who are overweight or obese, (b) support shown to be effective in increasing breastfeeding initiation and duration among these women, and (c) perceptions of health care professionals, peer supporters, partners, and family members regarding providing breastfeeding support to these women. Sixteen quantitative and qualitative papers were included and critically appraised. Thematic synthesis was undertaken to obtain findings. Maternal physical barriers such as larger breasts, difficulties of positioning to breastfeed, delayed onset of lactation, perceived insufficient supply of breast milk, and impact of caesarean birth were evident. Maternal psychological barriers including low confidence in ability to breastfeed, negative body image, embarrassment at breastfeeding in public, and experiencing stigma of obesity were also described. Support from health care professionals and family members influenced breastfeeding outcomes. Education for maternity care professionals is needed to enable them to provide tailored, evidence‐based support to women who are overweight or obese who want to breastfeed. Research on health care professionals, partners, and family members' experiences and views on supporting this group of women to breastfeed is needed to support development of appropriate interventions.

Objectives: to examine evidence of women's, labour companions' and health professionals' experiences of management of early labour to consider how this could be enhanced to better reflect women's needs. Design: a systematic review of qualitative evidence. Setting and participants: women in early labour with term, low risk singleton pregnancies, not booked for a planned caesarean birth or post-dates induction of labour, their labour companions, and health professionals responsible for early labour care (e.g. midwives, nurse-midwives, obstetricians, family doctors). Studies from high and middle income country settings were considered. Findings: 21 publications were included from the UK, Ireland, Scandinavia, USA, Italy and New Zealand. Key findings included the impact of communication with health professionals (most usually midwives) on women's decision making; women wanting to be listened to by sympathetic midwives who could reassure that symptoms and signs of early labour were 'normal' and offer clear advice on what to do. Antenatal preparation which included realistic information on what to expect when labour commenced was important and appreciated by women and labour companions. Views of the optimal place for women to remain and allow early labour to progress differed and the perceived benefit of support and help offered by labour companions varied. Some were supportive and helped women to relax, while others were anxious and encouraged women to seek early admission to the planned place of birth. Web-based sources of information are increasingly used by women, with mixed views of the value of information accessed. Key conclusions and implications for practice: women, labour companions and health professionals find early labour difficult to manage well, with women unsure of how decisions about admission to their planned place of birth are taken. It is unclear why women are effectively left to manage this aspect of their labour with minimal guidance or support. Tailoring management to meet individual needs, with provision of effective communication could reassure women and facilitate timely admission from perspectives of women, their companions, midwives and other health professionals. Information on labour onset and progress, and approaches to pain management, should be shared with women's labour companions to enable them to feel more confident to better support women. Further research is needed of the impact of different models of care and increasing use of webbased information on women's approaches to self-management when labour commences.

Introduction Pregnancy and the first few years of a child’s life are important windows of opportunity in which to equalize life chances. A Better Start (ABS) is an area-based intervention being delivered in five areas of socioeconomic disadvantage across England. This protocol describes an evaluation of the impact and cost-effectiveness of ABS. Methods and analysis The evaluation of ABS comprises a mixed-methods design including impact, cost effectiveness and process components. It involves a cohort study in the five ABS areas and 15 matched comparison sites (n=2885), beginning in pregnancy in 2017 and ending in 2024 when the child is age 7, with a separate cross-sectional baseline survey in 2016/17. Process data will include a profiling of the structure and services being provided in the five ABS sites at baseline and yearly thereafter, and data regarding the participating families and the services that they receive. Eligible participants will include pregnant women living within the designated sites, with recruitment beginning at 16 weeks of pregnancy. Data collection will involve interviewer-administered and self-completion surveys at eight time-points. Primary outcomes include nutrition, socio-emotional development, speech, language and learning. Data analysis will include the use of propensity score techniques to construct matched programme and comparison groups, and a range of statistical techniques to calculate the difference in differences between the intervention and comparison groups. The economic evaluation will involve a within-cohort study economic evaluation to compare individual-level costs and outcomes, and a decision analytic cost-effectiveness model to estimate the expected incremental cost per unit change in primary outcomes for ABS in comparison to usual care. Ethics and dissemination Ethical approval to conduct the study has been obtained. The learning and dissemination workstream involves working within and across the sites to generate learning via communities of practice and a range of learning and dissemination events. STRENGTHS AND LIMITATIONS OF STUDY • The study involves a large longitudinal design with matched comparison sites • The designation of ABS areas was not random, and statistical matching will be used to select comparison areas and propensity score techniques will be used to match individual in ABS areas to individuals in comparison areas • Concurrent implementation data will provide important information about systems level change • Recruitment in pregnancy of disadvantaged women will present many difficulties and uptake may be low • Loss to follow-up by 7 years may be high

Introduction Pregnancy and the first few years of a child's life are important windows of opportunity in which to equalise life chances. A Better Start (ABS) is an area-based intervention being delivered in five areas of socioeconomic disadvantage across England. This protocol describes an evaluation of the impact and cost-effectiveness of ABS. Methods and analysis The evaluation of ABS comprises a mixed-methods design including impact, cost-effectiveness and process components. It involves a cohort study in the 5 ABS areas and 15 matched comparison sites (n=2885), beginning in pregnancy in 2017 and ending in 2024 when the child is age 7, with a separate cross-sectional baseline survey in 2016/2017. Process data will include a profiling of the structure and services being provided in the five ABS sites at baseline and yearly thereafter, and data regarding the participating families and the services that they receive. Eligible participants will include pregnant women living within the designated sites, with recruitment beginning at 16 weeks of pregnancy. Data collection will involve interviewer-administered and self-completion surveys at eight time points. Primary outcomes include nutrition, socioemotional development, speech, language and learning. Data analysis will include the use of propensity score techniques to construct matched programme and comparison groups, and a range of statistical techniques to calculate the difference in differences between the intervention and comparison groups. The economic evaluation will involve a within-cohort study economic evaluation to compare individual-level costs and outcomes, and a decision analytic cost-effectiveness model to estimate the expected incremental cost per unit change in primary outcomes for ABS in comparison to usual care. Ethics and dissemination Ethical approval to conduct the study has been obtained. The learning and dissemination workstream involves working within and across the sites to generate learning via communities of practice and a range of learning and dissemination events.

Rates of breastfeeding uptake are lower after a caesarean birth than vaginal birth, despite caesarean rates increasing globally over the past 30 years, and many high-income countries reporting overall caesarean rates of above 25%. A number of factors are likely to be associated with women's infant feeding decisions following a caesarean birth such as limited postoperative mobility, postoperative pain, and ongoing management of medical complications that may have triggered the need for a caesarean birth. The aim of this systematic review was to evaluate evidence of interventions on the initiation and duration of any and exclusive breastfeeding among women who had a planned or unplanned caesarean birth. Seven studies, presenting quantitative and qualitative evidence, published in the English language from January 1994 to February 2016 were included. A limited number of interventions were identified relevant to women who had had a caesarean birth. These included immediate or early skin-to-skin contact, parent education, the provision of sidecar bassinets when rooming-in, and use of breast pumps. Only one study, an intervention that included parent education and targeted breastfeeding support, increased initiation and continuation of breastfeeding, but due to methodological limitations, findings should be considered with caution. There is a need to better understand the impact of caesarean birth on maternal physiological, psychological, and physical recovery, the physiology of lactation and breastfeeding and infant feeding behaviors if effective interventions are to be implemented.

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The Confidential Enquiries into Maternal Deaths in the UK have recommended obstetric early warning systems for early identification of clinical deterioration to reduce maternal morbidity and mortality. This survey explored early warning systems currently used by maternity units in the UK. An electronic questionnaire was sent to all 205 lead obstetric anaesthetists under the auspices of the Obstetric Anaesthetists' Association, generating 130 (63%) responses. All respondents reported use of an obstetric early warning system, compared with 19% in a similar survey in 2007. Respondents agreed that the six most important physiological parameters to record were respiratory rate, heart rate, temperature, systolic and diastolic blood pressure and oxygen saturation. One hundred and eighteen (91%) lead anaesthetists agreed that early warning systems helped to prevent obstetric morbidity. Staffing pressures were perceived as the greatest barrier to their use, and improved audit, education and training for healthcare professionals were identified as priority areas.

Background: More women with an increased risk of poor pregnancy outcome due to pre-existing medical conditions are becoming pregnant. Although clinical care provided through multi-disciplinary team (MDT) working is recommended, little is known about the structure or working practices of different MDT models, their impact on maternal and infant outcomes or healthcare resources. The objectives of this review were to consider relevant international evidence to determine the most appropriate MDT models of care to manage complex medical conditions during and after pregnancy, with a specific focus on pre-existing diabetes or cardiac disease in high income country settings.Methods: Quantitative and qualitative evidence of MDT models of care for the management of pregnant/postnatal women with pre-existing diabetes and cardiac disease was considered. A search of the literature published between January 2002 - January 2014 was undertaken. Methodological quality was assessed using checklists developed by the Joanna Briggs Institute. Given limited primary and secondary research evidence, guidelines and opinion papers were included. Two independent reviewers conducted critical appraisal of included papers.Results: Nineteen papers were included from UK, Canada, USA, the Netherlands and Singapore. No studies were found which had compared MDT models for pregnant/postnatal women with pre-existing diabetes or cardiac disease. Two small retrospective studies reported better outcomes for women with cardiac disease if an MDT approach was used, although evidence to support this was limited. Due to study heterogeneity it was not possible to meta-analyse data. No evidence was identified of MDT management in the postnatal period or impacts of MDT working on healthcare resources.Conclusions: Despite widespread promotion of MDT models of care for pregnant and postnatal women with pre-existing diabetes or cardiac disease, there is a dearth of primary evidence to inform structure or working practices or beneficial impact on maternal and infant outcomes or healthcare resources. Primary research into if or how MDT models of care improve outcomes for women with complex pregnancies is urgently needed.

Objective: to identify the extent to which Early Warning Systems (EWS) are used by midwives in the United Kingdom (UK), the maternity settings they are used in, physiological parameters used to 'trigger' referral, training provision, barriers to implementation and role in preventing maternal morbidity.Design: cross-sectional survey of heads of midwifery services. An email questionnaire was sent in September 2012.Setting: UK NHS secondary care organisations providing maternity care.Findings: heads of midwifery from 107 (68%) of 157 NHS organisations responded, with 108 questionnaires returned as two organisations had recently merged. All organisations, apart from one which only had a free-standing midwifery unit, had introduced EWS. Nearly all respondents (99%) reported EWS were used by midwives antenatally, 76% in labour and 100% on the postnatal ward. All EWS charts included body temperature, heart rate, respiratory rate, systolic blood pressure and oxygen saturation although parameters for escalation varied widely. Barriers to use of EWS by midwives included overlap with the partogram in labour, and staff shortages and delays obtaining clinical review when referral was triggered. Two-thirds considered EWS prevented maternal morbidity although few could provide supporting evidence, for example, audit findings. Training for midwives in use of EWS was available in 83% of organisations.Conclusion: most UK midwives are using EWS, with the highest use in obstetric units. The heterogeneity of EWS currently used potentially limits collation of evidence to inform appropriate system level responses. Research is needed to evaluate the role of EWS to prevent maternal morbidity during and after pregnancy in different maternity settings. (C) 2014 Elsevier Ltd. All rights reserved

Background: Recent reports have highlighted the poor quality of health care received by people with intellectual disabilities (otherwise known as 'learning disabilities') in the United Kingdom (UK). UK Confidential Enquiries into maternal deaths have highlighted adverse pregnancy outcomes for women with intellectual disabilities and need for timely and appropriate clinical care.Objectives: To develop and test a competency assessment tool to support midwifery care of women with intellectual disabilities.Design: A mixed methods study.Setting: Large inner city maternity unit.Participants: Midwives and key experts in intellectual disabilities, maternity policy and midwifery education.Methods: Phase one comprised a systematic narrative review of the literature. Evidence identified informed phase two which included focus groups and interviews. Emergent themes informed the development of a competency assessment tool which was piloted in phase three.Results: Phase one: Four primary research papers and two systematic reviews met the review inclusion criteria. Support to develop parenting skills of women with intellectual disabilities was highlighted as was the need to optimise organisation of maternity services. No studies specifically considered midwifery competencies to support women with intellectual disabilities.Phase two: 23 midwives attended three focus groups and individual interviews were conducted with national leaders in intellectual disability (n = 6) and midwifery policy and education (n = 7). Themes identified included need for individualised care provided by a known midwife, the importance of effective communication skills and need for clear knowledge and understanding of the legislative framework relevant to intellectual disability. Phase three: A convenience sample of 60 midwives was asked to participate in a pilot study to test the tool, 46 (77%) of whom responded. Thirty midwives (65%) felt competent in their ability to recognise intellectual disability and 37 (80%) competent or expert in understanding women have the right to be offered choice and make informed decisions. A high proportion (n=40, 87%) reported little or no knowledge regarding consent issues.Conclusion: Work to inform timely and appropriate care of women with intellectual disability has been neglected in the UK maternity services. Use of a tool could aid assessment of midwifery competencies to support women with intellectual disability and highlight where further midwifery education and development are needed. Evidence of optimal care for women with intellectual disabilities and their families across the continuum of pregnancy and birth is required. (C) 2012 Elsevier Ltd. All rights reserved.

Objective: to evaluate caseload midwifery in a relatively deprived and ethnically diverse inner-city area.Design and setting: semi-structured interviews were undertaken with 24 women from diverse ethnic backgrounds, 12 of whom had received caseload care and 12 women from an adjacent area who had received conventional maternity care in a large inner-city maternity unit. Framework analysis was adopted drawing on links with the authors' previous work on women's views of caseload midwifery.Findings: key themes from previous work fitted well with the themes that emerged from this study. Themes included 'knowing and being known', 'person-centred care', 'social support', 'gaining trust and confidence', 'quality and sensitivity of care' and 'communication'.Key conclusions and implications: women from this socially and ethnically diverse group of women had similar views and wanted similar care to those in previous studies of caseload midwifery. Many of the women receiving caseload care highlighted the close relationship they had with the midwives and as a result of this felt more able to discuss their concerns with them. This has the potential not only for improved quality of care but also improved safety. (c) 2013 Elsevier Ltd. All rights reserved.

There have been limited improvements in care and support for women post-birth despite publication of National Institute of Health and Clinical Excellence (NICE) guidelines for routine postnatal care (NICE 2006). NICE recommendations included that care should be individualised to women's physical and psychological health needs, the content of care should be relevant to the time of recovery post birth and information should be offered regarding life-threatening conditions and more commonly experienced morbidity. A study was conducted in one maternity unit informed by a quality improvement approach to implement NICE guidance. Revisions were introduced to hospital systems and processes relevant to the continuum of pregnancy, birth and beyond to improve individualised care and women's views of this.

Background Most women in the UK give birth in a hospital labour ward, following which they are transferred to a postnatal ward and discharged home within 24 to 48 hours of the birth. Despite policy and guideline recommendations to support planned, effective postnatal care, national surveys of women’s views of maternity care have consistently found in-patient postnatal care, including support for breastfeeding, is poorly rated. Methods Using a Continuous Quality Improvement approach, routine antenatal, intrapartum and postnatal care systems and processes were revised to support implementation of evidence based postnatal practice. To identify if implementation of a multi-faceted QI intervention impacted on outcomes, data on breastfeeding initiation and duration, maternal health and women’s views of care, were collected in a pre and post intervention longitudinal survey. Primary outcomes included initiation, overall duration and duration of exclusive breastfeeding. Secondary outcomes included maternal morbidity, experiences and satisfaction with care. As most outcomes of interest were measured on a nominal scale, these were compared pre and post intervention using logistic regression. Results Data were obtained on 741/1160 (64%) women at 10 days post-birth and 616 (54%) at 3 months post-birth pre-intervention, and 725/1153 (63%) and 575 (50%) respectively post-intervention. Post intervention there were statistically significant differences in the initiation (p = 0.050), duration of any breastfeeding (p = 0.020) and duration of exclusive breastfeeding to 10 days (p = 0.038) and duration of any breastfeeding to three months (p = 0.016). Post intervention, women were less likely to report physical morbidity within the first 10 days of birth, and were more positive about their in-patient care. Conclusions It is possible to improve outcomes of routine in-patient care within current resources through continuous quality improvement.

BACKGROUND:Despite major policy initiatives in the United Kingdom to enhance women's experiences of maternity care, improving in-patient postnatal care remains a low priority, although it is an aspect of care consistently rated as poor by women. As part of a systems and process approach to improving care at one maternity unit in the South of England, the views and perspectives of midwives responsible for implementing change were sought.METHODS:A Continuous Quality Improvement (CQI) approach was adopted to support a systems and process change to in-patient care and care on transfer home in a large district general hospital with around 6000 births a year. The CQI approach included an initial assessment to identify where revisions to routine systems and processes were required, developing, implementing and evaluating revisions to the content and documentation of care in hospital and on transfer home, and training workshops for midwives and other maternity staff responsible for implementing changes. To assess midwifery views of the quality improvement process and their engagement with this, questionnaires were sent to those who had participated at the outset.RESULTS:Questionnaires were received from 68 (46%) of the estimated 149 midwives eligible to complete the questionnaire. All midwives were aware of the revisions introduced, and two-thirds felt these were more appropriate to meet the women's physical and emotional health, information and support needs. Some midwives considered that the introduction of new maternal postnatal records increased their workload, mainly as a consequence of colleagues not completing documentation as required.CONCLUSIONS:This was the first UK study to undertake a review of in-patient postnatal services. Involvement of midwives at the outset was essential to the success of the initiative. Midwives play a lead role in the planning and organisation of in-patient postnatal care and it was important to obtain their feedback on whether revisions were pragmatic and achieved anticipated improvements in care quality. Their initial involvement ensured priority areas for change were identified and implemented. Their subsequent feedback highlighted further important areas to address as part of CQI to ensure best quality care continues to be implemented. Our findings could support other maternity service organisations to optimise in-patient postnatal services.