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Public health is defined as “the art and science of preventing disease, prolonging life and promoting health through the organised efforts of society” (Acheson, 1988; WHO)

In other words, public health seeks to identify risks to health and find the best ways to minimise them, in order to give everyone the best chance of leading a healthy life.   This is generally undertaken by work such as:

  • Health protection -  protecting people's health from a variety of issues, including disease and infection
  • Health improvement -  improving people's health, for example, by helping people quit smoking or reduce their weight
  • Healthcare and public health -  ensuring that our health services are effective, efficient and equally accessible to all

In light of this, it's apparent that public health is a core part of the work that midwives do every day. The RCM commissioned a report in 2017, with funding from the Department of Health, England, to examine how midwives are working with public health in greater detail.

Stepping up to Public Health – project summary

The main aim of the project was to conduct a scoping and needs analysis; mapping the current public health activities of midwives and MSWs, services users and student midwives, using both qualitative exploratory work and quantitative surveys based on 35 core topic areas.

This was followed by the translation of the project findings into practical outputs to support improvements in the provision of care. These included the development of a public health model and associated resources, designed to assist practitioners in their work with women and their families. More information on the model and outputs can be seen below.

Overall there was general agreement across the four UK countries that a large proportion of midwives' work does fall under the remit of public health. Practitioners had a wide definition for the types of interventions and information topics that fell within this remit, and saw midwives' role as crucial for both the immediate care being provided and for the health of the family unit.

The project also found that midwives needed more time, confidence and training to discuss public health with women, to ensure information was given in a consistent and timely manner and that follow up was supported by continuity of care in conjunction with the multidisciplinary team. There were discussions on the difficulties experienced in getting tailored, specialist care and advice for women in areas including mental health and maternal weight, even if the vital referral pathways were established and available. Some of the accessibility issues stemmed from the waiting time for being seen after referral to the lack of expertise of a public health lead. The report concluded that the need for leadership at a consultant midwife level was a key factor in supporting successful public health work in maternity services.

What is Public Health?

Visit these sites for more information about public health:

  • Health Careers, NHS Health Education England
  • Public Health Services, World Health Organisation
  • Public Health, Royal College of Nursing
  • Knowledge and skills career framework, Public Health England

Improving Prevention and Population Health

The Maternity Transformation Programme’s Workstream 9 focuses on a range of initiatives to improve wellbeing, reduce risk and tackle inequalities from preconception to 6-8 weeks postpartum. The aim is to ensure every woman is fit for and during pregnancy, and that every family is well-supported to give children the best start in life.

The NHS Long Term Plan commits to strengthening its contribution towards prevention and tackling health inequalities, with specific action in a range of areas including smoking, obesity, infant feeding, maternal and paternal mental health.

How is the RCM involved?

Immunisation, including in pregnancy.

  • the fetus, including prematurity, low birth weight and stillbirth
  • the mother, due to serious complications of flu, in especially late pregnancy
  • Pregnant women are offered the inactivated influenza vaccine to protect themselves and provide passive immunity to their baby in the first few months of life. Because of the changing nature of influenza viruses, they are modified according to the latest virus strains and in line with World Health Organisation (WHO) recommendations. Immunisation must be repeated with every pregnancy
  • In 2011-2012 there was a marked increase in the number of cases of pertussis (whooping cough) in England. To help prevent further infant deaths, an emergency programme of maternal pertussis immunisation was introduced in October 2012. The vaccine is offered from 16 to 38 weeks gestations, although the optimal time is 16 to 32 weeks.

The RCM collaborates with the NHS and public health partners to support national campaigns aimed at maximising the uptake of vaccines during pregnancy. We also support public health initiatives encouraging NHS staff to be vaccinated.

Stopping smoking in pregnancy

  • Smoking during pregnancy is closely associated with socioeconomic factors and is therefore a major health inequality. Supporting women to have a smoke-free pregnancy is vitally important for reducing infant mortality. It is the main modifiable risk factor for a range of poor pregnancy outcomes
  • Smoking in pregnancy increases the risk of premature delivery and stillbirth. Maternal smoking postpartum is associated with a threefold increase in the risk of sudden infant death syndrome
  • Smoking prevalence varies significantly between communities and social groups, with pregnant women in more disadvantaged groups being more likely to smoke than in more affluent groups, similarly those aged under 20 being more likely to smoke than those who are older
  • Children who grow up with a smoking parent are also more likely to become smokers themselves, further perpetuating the cycle of inequality
  • Interventions to help women to quit smoking have been shown to be cost-effective, and stopping smoking early in pregnancy can almost entirely prevent damage to the baby and help prevent additional treatment costs
  • Babies born to smoking mothers who quit early in their pregnancy have the same or similar rates of stillbirth, prematurity, low birth weight and small for gestational age, when compared to babies born to non-smoking mothers

The RCM is a member of the Smoking in Pregnancy Challenge Group , working alongside the Royal College of Obstetricians and Gynaecologists , the Royal College of Paediatrics and Child Health , the voluntary sector and academia. It was established in 2012 in response to a challenge from the then Public Health Minister to reduce smoking in pregnancy rates to 6% by 2022. Further information on this ambition can be found in the Tobacco Control Plan .

For more information, read the NICE guidance on stopping smoking in pregnancy . This recommends routine carbon monoxide screening of all pregnant women to assist in identifying smokers and referral for specialist support to quit.

The RCM’s new position statement on  support to quit smoking in pregnancy  sets out some of the actions that are needed to help this to happen. 

Infant Feeding

Breastfeeding is a public health priority. Midwives and maternity support workers have a central role in providing breastfeeding promotion and support.

The RCM recently refreshed and re-launched its position statement on infant feeding .

The NHS Long Term Plan contains a commitment to delivering evidence-based infant feeding programmes in all maternity services and the RCM is supportive of an outcomes-based approach to increase breastfeeding rates in the UK.

Baby Friendly Initiative is a scheme offered by Unicef to maternity units and other public bodies, including universities and local authorities, on a commercial basis, comprising a programme of training and accreditation of standards.

The NHS provides comprehensive advice on breastfeeding and bottle feeding with links to local support groups.

The Baby Feeding Law Group UK is a group of organisations working together to protect infant, young child and maternal health by ending marketing practices which commercialise infant feeding, mislead consumers and threaten breastfeeding. While its aim is to protect breastfeeding, it does not seek to limit the accessibility of safe and appropriate infant formulas for those who need or want them.

The RCM is represented on the committee of  Becoming Breastfeeding Friendly  (BBF) England, which has developed an evidence-based toolkit through highly structured technical and academic collaboration, led by Yale University. This aims to guide countries in assessing their breastfeeding status, and their readiness to scale up.

The RCM is also a member of the Baby Feeding Law Group, which works to strengthen UK baby feeding laws in line with UN recommendations.

The RCM recognises that many factors influence infant feeding decisions and is committed to supporting women’s choices. We will continue to campaign for high-quality services, improved employment rights and societal acceptance to encourage breastfeeding to continue for longer.

Maternal Obesity

The NHS Long Term Plan has a strong focus on obesity and mapping work is underway to identify best practice in weight management services for pregnant women.

Stepping Up to Public Health describes obesity prevention as healthy eating advice that is generally part of a broad-based discussion on healthy lifestyle behaviours.   Clearly there are health promotion opportunities for midwives and maternity support workers in relation to weight, physical exercise and nutrition.

The RCM and Slimming World jointly undertook research amongst midwives which showed some of the barriers and tools required for effective weight management in pregnancy. 

The RCM is a member of the Obesity Health Alliance , which is a coalition of over 40 organisations who have joined together to reduce obesity.

There are currently no UK-specific guidelines on safe weight gain in pregnancy, although there is NICE guidance on weight management before, during and after pregnancy available .

Antenatal and newborn screening

Stepping up to Public Health identified screening as an integral part of midwives' public health role. NICE guidelines apply to the management of screening, as part of routine antenatal care.

Antenatal and newborn screening programmes  offer tests to pregnant women and their babies at various stages of pregnancy and in the newborn period. These include:

  • infectious diseases in pregnancy screening programme
  • fetal anomaly screening programme (ultrasound)
  • newborn bloodspot screening programme

The RCM supports members with an i-learn module on delivering unexpected news in pregnancy which covers the subject of screening .

Other RCM Public Health initiatives

Homelessness.

The RCM has produced guidance for midwives on the Homelessness Reduction Act and the new Duty to Refer . These regulations came into effect on October 1 and apply to all public services, including maternity.

Women accessing midwifery care may be disclosing housing circumstances that put them at risk of homelessness. A referral to the local authority should be made at this early point to prevent, as far as possible, a difficult situation from becoming a crisis. Consent must always be obtained. Scenarios may include women who are ‘sofa surfing’, experiencing rent arrears or domestic abuse. The referral process is not intended to be onerous and the RCM has suggested relevant questions to ask women and a model pathway to use.

Midwives have a unique opportunity to support women and the RCM is working to support midwives. 

Violence Against Women and Girls

Midwives have a duty to support each and every individual who seeks help as a result of violence, treating them with compassion, respect and dignity and referring them on to appropriate support and treatment in the areas of both health and psychological care.

Learn more about the RCM's work to stop Violence Against Women and Girls .

The RCM supports and promotes ad hoc and seasonal campaigns, including Stoptober, flu & whooping cough vaccination, World Breastfeeding Day and the fortification of flour with folic acid.

Public Health resources across the UK

Nhs health scotland.

NHS Health Scotland has a focussed remit for the reduction of health inequalities .  

The range of public health resources on the  Health Scotland website  relating to pregnancy include information about screening, smoking and substance misuse. 

Health Scotland have a number of online learning resources for midwives, designed to help develop their skills in relation to behaviour change approaches, including motivational interviewing techniques and an online hub for leadership in reducing health inequalities.

MCQIC is the maternity part of the Scottish Patient Safety Programme, which has led focussed national improvement work relating to smoking cessation support during pregnancy . 

The Scottish Public Health Observatory

This organisation gathers together key information and data about public health in Scotland .

Getting it right for every child

This is the Scottish Government’s overarching programme of work designed to improve the chances of all children in Scotland, through improving the identification of babies and families that require additional support beyond universal services.

National Babybox Scheme

This Scottish Government Babybox initiative is an example of a national public health strategy with the aim of reducing inequalities at the start of life.

Public Health Wales

Public Health Wales is the national public health agency in Wales and exists to protect and improve health and wellbeing and reduce health inequalities for people in Wales.

Northern Ireland

Public health agency.

The Public Health Agency works with partners in many different sectors, as well as directly with communities, to reduce health inequalities and ensure collective resources are used effectively.

The Northern Ireland Government publish health and well-being information and advice on their website , including guidance on a broad range of subjects, including vaccinations, screening and making healthy lifestyle choices.

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  • Research article
  • Open access
  • Published: 08 November 2012

Public health interventions in midwifery: a systematic review of systematic reviews

  • Jenny McNeill 1 ,
  • Fiona Lynn 1 &
  • Fiona Alderdice 1  

BMC Public Health volume  12 , Article number:  955 ( 2012 ) Cite this article

26k Accesses

20 Citations

10 Altmetric

Metrics details

Maternity care providers, particularly midwives, have a window of opportunity to influence pregnant women about positive health choices. This aim of this paper is to identify evidence of effective public health interventions from good quality systematic reviews that could be conducted by midwives.

Relevant databases including MEDLINE, Pubmed, EBSCO, CRD, MIDIRS, Web of Science, The Cochrane Library and Econlit were searched to identify systematic reviews in October 2010. Quality assessment of all reviews was conducted.

Thirty-six good quality systematic reviews were identified which reported on effective interventions. The reviews were conducted on a diverse range of interventions across the reproductive continuum and were categorised under: screening; supplementation; support; education; mental health; birthing environment; clinical care in labour and breast feeding. The scope and strength of the review findings are discussed in relation to current practice. A logic model was developed to provide an overarching framework of midwifery public health roles to inform research policy and practice.

Conclusions

This review provides a broad scope of high quality systematic review evidence and definitively highlights the challenge of knowledge transfer from research into practice. The review also identified gaps in knowledge around the impact of core midwifery practice on public health outcomes and the value of this contribution. This review provides evidence for researchers and funders as to the gaps in current knowledge and should be used to inform the strategic direction of the role of midwifery in public health in policy and practice.

Peer Review reports

The reproductive period offers maternity care providers the opportunity to maximise the health and well-being of women and their families potentially impacting on public health outcomes, both short and long term. Although all maternity care providers who engage with pregnant women are presented with such opportunities, it is the midwife that could have the most significant impact from regular contact and building of relationships through continuity of care. There are interventions that could be implemented by midwives, which potentially would have a public health impact but it is important such interventions are evidence based. Recognition of the importance of the relationship between public health and midwifery was highlighted when a general review of midwifery in the UK [ 1 ], named public health as one of five key areas of interest. While the review specifically focused on midwifery in the UK, the importance of preventative public health interventions during pregnancy and the postnatal period has been emphasized on a wider scale. Millennium Development Goal 5 focuses on improving maternal health specifying a secondary target aim to achieve universal access to reproductive health by 2015 [ 2 ]. Antenatal care and adolescent pregnancy are specifically mentioned as key to achieving this target, both of which are acknowledged widely, as areas of interest to public health [ 3 , 4 ]. Other areas of national and international interest, which impact on population health (both women and families), include rising caesarean section rates and other interventions during childbirth [ 5 – 7 ], the importance of positive parenting in the early postnatal period [ 8 ] and perinatal mental health [ 9 ]. Within these areas there is opportunity for evidence based public health interventions to be implemented with a view to potentially improving the long term health of women and families.

Aim of the review

This paper presents an update of a systematic review of systematic reviews conducted in 2009. The aim of the 2009 review was to evaluate the effectiveness of interventions relevant to the public health role of the midwife. The 2009 review was commissioned and conducted within the context of the Midwifery 2020 initiative. The final report of the Midwifery 2020 initiative (Delivering Expectations) and full report of the systematic review of reviews [ 10 ] are available freely online from: http://www.midwifery2020.org . A systematic review of systematic reviews was selected as the methodology, given the breadth of this topic area and the timescale of the project. This paper outlines the review methodology and builds on the original review findings by providing new and updated information about effective high quality public health interventions which could be implemented by midwives or other health care providers for women during pregnancy and the postnatal period who have a similar role, for example, public health nurses, obstetric nurses, labour and delivery nurses or health visitors.

The Preferred Reporting Items of Systematic reviews Meta-Analyses (PRISMA) guidelines was adhered to when conducting this review [ 11 ]. A systematic search strategy was formulated and definitive search terms used relative to key public health topics within midwifery following consultation with Expert Advisory Group members and Midwifery 2020 Public Health Work Stream members. Seven key areas were identified as relevant to the public health role of the midwife, which included: screening; vulnerable groups; breast feeding; mental health and wellbeing; education and support; childbirth and lifestyle factors. The complete list of search terms is available from McNeill et al. [ 10 ].

Search strategy

Databases searched included: MEDLINE, PubMed, EBSCO (CINAHL/British Nursing Index), MIDIRS Online Database, Web of Science, The Cochrane Library, CRD (NHS EED/DARE/HTA) and EconLit. Eligibility criterion included reviews published from 1999 onwards; English language publications and reviews originating from economically developed countries as indicated by membership of the Organisation for Economic Co-operation and Development (OECD). An additional search was conducted of the National Institute for Health and Clinical Excellence, UK (NICE) website to identify key publications or findings from systematic reviews within guidelines. Reference lists of identified reviews were manually searched for additional relevant reviews. The searches were initially conducted in November 2009 and updated in October 2010. The titles and abstracts were obtained and the decision process for eligibility was conducted by all members of the project team in collaboration (JM, FL & FA). Full text was obtained of all eligible reviews and those whose eligibility could not be discerned from reading the abstract. Eligible systematic reviews also had to publish a clearly identified search strategy or detail the reference databases used.

Data extraction

Data were extracted on: number of papers included in the review; methodological details; midwifery intervention; outcome measures and results. Data were systematically extracted using a data extraction form by individual project team members and verified by one other project team member. The project team subsequently met to discuss and achieve consensus regarding any contentious issues. A parallel process of developing a logic model to act as an overarching framework to inform forward planning was also conducted. Logic models are essentially a conceptual framework, which can be used for evidence‐based decision making and planning [ 12 ]. The model is composed of midwifery inputs and activities, producing a logical pathways to short, medium and long term public health outputs.

Quality assessment and effectiveness of reviews

It is important to consider both the type of evidence included in reviews i.e. was the review restricted to randomised trials only or were other types of studies included and also assess how well the review was conducted methodologically. As such, a two stage process was employed: initially the level of evidence was graded and secondly, the methodological quality was assessed. Recognised frameworks were used to support this process [ 13 , 14 ]. In the hierarchy of evidence, randomised controlled trials are perceived as the gold standard and as the aim of this paper is to present high quality evidence, an evidence grade was given to each review based on the Scottish Intercollegiate Guidelines Network [ 13 ] framework in order to distinguish between different levels of evidence. This framework grades the associated risk of bias based on the level of evidence in a hierarchal manner from a grade of 1++ (meta analysis and RCT evidence) through to 4 (expert opinion), as outlined in Table 1 . The SIGN framework was modified as this review was restricted to systematic reviews and therefore reviews could only be graded as 1++, 1+, 1- or 2++. This paper only presents evidence which was graded 1- or above; any review graded below 1- was not deemed eligible for inclusion. Following selection of the type of evidence, the second stage focused on the methodology of eligible reviews. Clarke [ 15 ] suggests the successful interpretation of results from systematic reviews should consider the methodological conduct of the review. The methodological quality of included reviews was assessed and rated as low, medium or high quality. Appraisal of methodological quality was based on Smith et al. [ 14 ], which contains similar elements to other tools used to assess review quality, for example, the AMSTAR tool [ 16 ]. Reviews were graded as high quality if they included evidence of a search strategy, selection and inclusion criterion, assessment of publication bias and assessment of heterogeneity. Reviews were rated as medium quality if no evidence of assessment of heterogeneity or publication bias was provided and low quality reviews were those which provided evidence of a search strategy only. Effectiveness of interventions was evaluated using a similar approach to van Sluijs et al. [ 17 ]. A differentiation was made between reviews which reported a statistically significant difference (P<0.05), therefore referred to as effective and those which reported no difference in effect between control and intervention group and are referred to as inconclusive or not effective (as appropriate). This paper focuses specifically on interventions which are evidenced by a statistically significant meta analysis or where the intervention is supported by a generally positive trend of results when a meta analysis was not possible. Reviews have been included where a small number of studies reported statistically significant positive effect of the intervention however the wider interpretation of these results is limited. As outlined previously, the aim of the original review was to identify any public health intervention relevant to midwifery. However for the purpose of this paper the focus was to report on public health interventions relating to midwifery that demonstrated a statistically significant effect in favour of the intervention (referred to subsequently as effective interventions for the sake of brevity). Reviews graded 1- or above and of high methodological quality which reported evidence of no effect, are not discussed in this paper. However, they have been summarised in Table 2 [ 18 – 23 ]. In the case of any disagreement regarding grading of evidence, quality appraisal of reviews or effectiveness of the intervention, consensus was reached by discussion between all three authors.

Data synthesis

A narrative review is provided for each of the systematic reviews and in table format the number and date range of papers included, intervention(s), primary outcome or other public health outcomes of interest, results (including key statistical findings e.g. p values or odds ratios) are described and whether the review included a meta analysis or not. It was not expected that a quantitative analyses would be conducted given the diversity of interventions across the broad subject of public health.

In total 214 systematic reviews were eligible of which 91 reported on effective interventions and 117 found no effect or were inconclusive. This paper only reports on high quality reviews with a level of evidence grading above 1-. Of the 91 systematic reviews which reported on effective interventions, 36 were identified which were graded as evidence level 1- or above and rated as high quality. The flow chart in Figure 1 presents the sequential process of identifying reviews eligible for inclusion in this paper. An overview of the key findings in relation to interventions demonstrating a statistically significant effect in favour of the intervention from good quality reviews will be presented in the following sections. A summary of included reviews is provided in Table 3 . The findings in this paper are presented chronologically through the reproductive period: preconceptual; antenatal; intranatal and postnatal. Within each section the reviews on similar broad topics have been further categorised: antenatal (screening; supplementation; support; education; mental health); intranatal (clinical care; environment); postnatal (breast feeding; mental health; education; support). The findings section also presents the logic model which was developed in parallel with the searching and analysis of reviews. Logic models enable the visualisation of how interventions or programmes work and the expected outcomes [ 24 ] and have been used to consider the strategic public health benefit of midwifery practice both in the short and long term [ 25 ].

figure 1

Identification of effective reviews of high quality *some reviews which were included at the request of funder have been excluded from this paper eg economic reviews (n=6) **non significant, non effective or inconclusive reviews, reviews graded 2++,2+ or 2- and medium or low quality reviews are not discussed in this paper.

Findings -effective interventions

Pre conceptual.

There were no high quality reviews that reported on effective interventions in the pre conceptual period.

The majority of reviews reporting effective interventions were relevant to the antenatal period (n=20). Included reviews have been grouped into screening, supplementation, support, education and mental health.

Reviews (n=4) related to screening reported on interventions relating to ultrasound [ 26 , 27 ], lower genital tract infection screening [ 28 ] and the use of decision making aids [ 29 ]. Bricker et al. [ 26 ] conducted a large Health Technology Assessment review on the clinical and cost effectiveness and women’s views of USS. The review comprised of three systematic reviews on routine ultrasound in early pregnancy, routine ultrasound in late pregnancy and routine Doppler ultrasound in pregnancy which were published in the Cochrane database around the time of Bricker et al. [ 26 ] however, all have since been updated or revised in the Cochrane database, one of which has been included in this paper. The final conclusions of Bricker et al. [ 26 ] indicated that a two stage regimen of USS in pregnancy, one in early pregnancy (booking USS) and a second anomaly USS around 20 weeks, was recommended. Whitworth et al. [ 27 ] reviewed the use of ultrasound for fetal assessment in early pregnancy and concluded that it reduces failure to detect multiple pregnancy (RR 0.07 95% CI 0.03-0.17) and accuracy of gestational dating may reduce the number of inductions of labour for post term gestation (RR 0.59; 95% CI 0.42-0.83). The authors also reported there was no reduction in adverse outcomes or health service use by mothers or infants and long term follow up did not indicate detrimental effect on children’s physical or mental development. The impact of antenatal screening for lower genital tract infection for preventing preterm delivery was reviewed by Sangkomkamhang et al . [ 28 ]. The review included one large RCT (n=4155), which indicated that preterm birth before 37 weeks was significantly lower in a group of women randomised to a screening programme before 20 weeks’ gestation (RR 0.55; 95% CI 0.41-0.75). The review provides evidence to suggest there may be some benefit to introducing a universal screening programme for lower genital tract infection; however the results are based on the findings of one study. O’Connor et al. [ 29 ] conducted a review on the use of decision aids for people facing screening decisions. The meta analysis indicated that the use of decision aids, such as leaflets or DVD’s are better than usual care and resulted in: greater knowledge (MD 15.2 out of 100; 95%CI 11.7 to 18.7), perception of risk (RR 0.6; 95% CI 0.5 to 0.8), lower decisional conflict related to feeling uninformed (MD −8.3 of 100; 95% CI −11.9 to −4.8), lower decisional conflict related to personal values (MD −6.4; 95% CI −10.0 to −2.7), reduced the proportion of people who were passive in decision making (RR 0.6; 95% CI 0.5-0.8) and reduced the proportion of people who remained undecided post intervention (RR 0.5; 95% CI 0.3-0.8). Although the results suggest decision aids are effective, the effect size was not consistent across studies and only three of the included studies related directly to antenatal screening.

Supplementation

Eight reviews [ 30 – 37 ] considered supplementation during pregnancy including iron, micronutrients, folic acid, calcium and Long Chain-Poly Unsaturated Fatty Acids (LC-PUFA’s). Two reviews [ 30 , 31 ] focused on folic acid supplementation, both of which concurred that the risk of neural tube defect was significantly reduced with supplementation: Blencowe et al., [ 30 ]; 70% reduction; 95% CI 35-86 and Lumley et al., [ 31 ]; RR 0.28; 95% CI 0.13-0.58. Iron supplementation during pregnancy was reviewed by Pena-Rosas and Viteri [ 32 ] who included 49 trials relating to the prevention of iron deficiency or anaemia at term. The authors concluded that daily iron supplementation was associated with increased haemoglobin before birth (MD 6.00; 95% CI 2.75-9.25) and reduced risk of anaemia at term (RR 0.46; 95% CI 0.29- 0.72) based on meta analyses of high quality trials only. Shah et al. [ 33 ] reviewed multi-micronutrient supplementation on pregnancy outcomes and reported there was a reduction in the risk of low birth weight amongst women given micronutrient supplementation (12 studies, RR 0.81; 95% CI 0.73-0.91) and iron-folic acid supplementation (RR 0.83; 95% CI 0.74-0.93) compared to placebo. The mean birth weight was higher (11 studies; WMD 54g; 95% CI 36-72g) in infants born to mothers who had micronutrient supplementation compared to iron-folic acid supplementation (no difference with placebo).

Calcium supplementation was the focus of three reviews [ 34 – 36 ]. Hofmeyr et al. [ 34 ] reported a reduction in pre-eclampsia (RR 0.68; 95% CI 0.57-0.81) and fewer babies born <2500g (RR 0.83; 95% CI 0.71-0.98). However the benefits seen were from small trials and not observed in the largest trial included. Hofmeyr et al. [ 35 ] reported that with supplementation a reduction in blood pressure (RR 0.7; 95% CI 0.57-0.86), pre-eclampsia (RR 0.48; 95% CI 0.33-0.69) and maternal death/morbidity (RR 0.80; 95% CI 0.65-0.97) was noted and advocated research to investigate calcium supplementation at community level. The most recent review [ 36 ] conducted by several of the same authors as Hofymeyr et al. [ 34 ] on calcium supplementation concluded that there was a reduced risk of increased blood pressure (RR 0.65; 95% CI 0.53-0.81) and preeclampsia (RR 0.45; 95% CI 0.31-0.65). The effect was greatest for high risk women (RR 0.22; 95% CI 0.12-0.42) and women with low baseline calcium (RR 0.36; 95% CI 0.20-0.65). Maternal death or serious morbidity was reduced (RR 0.80; 95% CI 0.65-0.97) although this was mostly in low risk women and women with low calcium and there was no effect on preterm births, stillbirth or death before discharge. Horvath et al. [ 37 ] reviewed the effect of advising high-risk pregnant women to take LC-PUFA supplementation on a number of pregnancy outcomes. The authors found a significantly lower rate of PTD <34 wks (RR 0.39; 95% CI 0.18-0.84) although this result was based on two trials (n=291). There was no effect on duration of pregnancy, PTD <37 wks, infant birth weight or the occurrence of IUGR. Although significant, the authors concluded that there was not enough evidence to recommend routine use of LC-PUFA supplements by high-risk women and that further research involving larger sample sizes was needed.

Three reviews [ 38 – 40 ] considered different types of supportive interventions for women during pregnancy. These ranged from using midwifery models of care to provision of emotional support to reduce the risk of preterm delivery or low birth weight infants. Hatem et al. [ 38 ] reviewed midwife led models of care versus other models of care and concluded that the majority of women should be offered midwifery led care. Women who had midwife led models of care were less likely to experience antenatal hospitalisation (RR 0.90; 95% CI 0.81-0.99), use of regional analgesia (RR 0.81; 95% CI 0.73-0.91), episiotomy (RR 0.82; 95% CI 0.77-0.88) and instrumental delivery (RR 0.86; 95% CI 0.78 to 0.96) and were more likely to experience no intrapartum analgesia/anaesthesia (RR 1.16; 95% CI 1.05-1.29), vaginal delivery (RR 1.04; 95% CI 1.02-1.06), to feel in control during childbirth (RR 1.74; 95% CI 1.32-2.30), attendance at birth by a known midwife (RR 7.84; 95% CI 4.15-14.81) and initiate breastfeeding (RR 1.35; 95% CI 1.03 to 1.76). In addition, women who were randomised to receive midwife-led care were less likely to experience fetal loss before 24 weeks’ gestation (RR 0.79; 95% CI 0.65-0.97). There was no difference between groups for birth by caesarean section (RR 0.96; 95% CI 0.87-1.06) and no statistically significant differences in fetal loss/neonatal death of at least 24 weeks (RR 1.01; 95% CI 0.67-1.53) or fetal/neonatal death overall (RR 0.83; 95% CI 0.70-1.00) and their babies were more likely to have a shorter length of hospital stay (mean difference in days: -2.00; 95% CI −2.15 to −1.85). Hodnett & Fredericks [ 39 ] assessed the value of emotional support to women who were judged, by a health professional, to be at increased risk of preterm delivery or having a low birth weight baby. No significant effect was detected for either outcome, however, women receiving support interventions were significantly less likely to undergo a caesarean section (RR 0.88; 95% CI 0.79-0.98) and were more likely to terminate their pregnancy (RR 2.96; 95% CI 1.42-6.17). There was also a trend towards improvement in maternal psychosocial outcomes although this was not significant. Denis & Kingston [ 40 ] reviewed the effect of telephone support during pregnancy and early postpartum period specifically on smoking, preterm birth, low birth weight, breast feeding and postpartum depression. The authors report a positive effect on breast feeding (3 trials; n=618; RR=1.18; 95% CI 1.05-1.33), low birth weight (3 trials; n=2,027; RR=0.78; 95% CI 0.63-0.97) and postpartum depression at 4 weeks (RR 0.24; 95% CI 0.06-1.00) and 8 weeks (RR 0.30; 95% CI 0.10-0.92), although all were from small numbers of trials and the finding on postpartum depression was from one pilot trial including 42 women.

Educational interventions in the antenatal period were the focus of four systematic reviews [ 41 – 44 ] that considered education about pelvic floor muscle training (PFMT) and promotion of smoking cessation in pregnancy Lumley et al. [ 41 ] reviewed the effect of interventions for promoting smoking cessation and included 72 studies of which 56 were RCT’s. Interventions to encourage cessation of smoking had a significant effect on the number of women smoking; 6 out of every 100 stopped, and a reduction in the number of cigarettes smoked by women was also evident. There was a significant reduction of smoking in late pregnancy (RR 0.94; 95% CI 0.93-0.96), reduction in LBW (RR 0.83; 95% CI 0.73 -0.95), preterm birth (RR 0.86; 95% CI 0.74-0.98) and an increase in mean birth weight (53.91g; 95% CI 10.44g - 95.38g). Naughton et al. , [ 42 ] reviewed the use of self help interventions for smoking and reported greater likelihood of quitting compared to usual care (13.2% v 4.9%; OR 1.83; 95% CI 1.23-2.73). The cost effectiveness of this method was also emphasised, however, further research is necessary to determine the intensity level of the intervention to maximise effectiveness. Hay-Smith et al. [ 43 ] and Lemos et al. [ 44 ] reviewed pelvic floor muscle training and concluded that for primigravida women PFMT was effective. Hay-Smith et al. [ 43 ] reported that women without prior incontinence were less likely to report incontinence in late pregnancy (RR 0.44; 95% CI 0.30-0.65) and up to 6 months postpartum (RR 0.71; 95% CI 0.52-0.97) similar to Lemos et al. [ 44 ] who reported significantly reduced development of urinary incontinence from 6 weeks to 3 months after delivery (OR 0.45; 95% CI 0.3-0.66; 4x RCT; n=675). Pregnant women with persistent incontinence 3 months after delivery and received PMFT were less likely to report urinary incontinence at 12 months post delivery (RR 0.79; 95% CI 0.70-0.90) and less likely to report faecal incontinence at 12 months (RR 0.52; 95%CI 0.31-0.87) [ 43 ].

Mental health

One review by Dennis & Creedy [ 45 ] considered interventions to prevent postnatal depression and all but one involved an intervention from a health professional. The authors reported that preliminary evidence suggests that intensive postnatal nursing home visits with at risk mothers assisted prevention of postpartum depression (RR 0.67; 95%CI 0.51-0.89).

Eligible systematic reviews relevant to the intranatal period yielded the smallest number in comparison to either the antenatal or postnatal periods. Five reviews [ 46 – 50 ] were included in this section and considered either clinical care during labour/delivery or the birthing environment.

Clinical care

Cluett & Burns [ 46 ] reviewed immersion in water for labour or birth (n=11) and reported from a meta analysis of 6 RCT’s. There was evidence to indicate that immersion in water for the first stage of labour significantly reduced the rate of epidural, spinal, paracervical analgesia and anaesthetic analgesia (478/1254 versus 529/1245; OR 0.82; 95% CI 0.70-0.98; p 0.025). However further research is required on other outcomes where there was no difference identified including assisted vaginal deliveries, C/S, perineal trauma, maternal infection, Apgar score < 7 at 5 mins, neonatal unit admissions or neonatal infection rates. Rabe et al. [ 47 ] reviewed delayed umbilical cord clamping and indicated from a meta analysis that there are benefits for both term and preterm infants. A delay of 30–120 seconds of cord clamping reduced the need for transfusions (RR 2.01; 95% CI 1.24-3.27, p=0.0049) and intraventricular haemorrhage (RR 1.74; 95% CI 1.08-2.81, p=0.022) in infants born <37 weeks [ 47 ]. Although the short term benefits are clear, further longitudinal work is needed to clarify the long term benefits.

Environment

The birth setting was the subject of four reviews although all were on different aspects. Hodnett et al. [ 48 ] reviewed the evidence regarding alternative versus conventional institutional settings for birth, which did not include any trials conducted in free standing birth centres. The review reported that for women allocated to the intervention (alternative setting) there was a significant increased likelihood of no analgesia/anaesthesia (RR 1.17; 95% CI 1.01-1.35), spontaneous vaginal delivery (RR 1.04; 95% CI 1.02-1.06), very positive views of care (RR 1.96; 95% CI 1.78-2.15), breastfeeding rates at 6–8 weeks (RR 1.04; 95% CI 1.02-1.06) and decreased episiotomy rate (RR 0.83; 95% CI 0.77-0.90). There was no effect on serious perinatal or maternal morbidity or mortality. Continuous support during childbirth was reviewed by Hodnett et al. [ 49 ]. The intervention involved one to one support during labour and found increased likelihood of shorter labour (WMD −0.43 hours; 95% CI −0.83 to −0.04), spontaneous vaginal delivery (RR 1.07; 95% CI 1.04 to 1.12) and were less likely to have intrapartum analgesia (RR 0.89; 95% CI 0.82- 0.96) or report dissatisfaction with childbirth experience (RR 0.73; 95% CI 0.65- 0.83). The authors only reported on outcomes where at least four trials were included in the meta analysis and highlighted that, generally, continuous intrapartum support was associated with greater benefits when it was not a member of hospital staff, when it began in early labour and in settings where epidural was not routinely available. Hodnett et al. [ 49 ] concluded that continuous support should be the norm rather than the exception for all women and further research is required as to the effectiveness of doula or lay support.

One review considered interventions aimed at reducing caesarean section rates [ 50 ]. Chaillet & Dumont [ 50 ] reported from a meta analysis that regular audit, detailed feedback regarding aspects of caesarean section performance (responsibility for decision making, rates, review of cases in clinical practice and multi faceted strategy approaches, such as development of guidelines, education of health professionals and women about vaginal birth after caesarean section (VBAC) were effective for reducing the caesarean section rate (RR 0.81; 95% CI 0.75-0.87). Details of relative risk for each type of strategy are included in Table 3 .

Eleven reviews [ 51 – 61 ] reporting on effective interventions related to the postnatal period. The reviews ranged across four areas: breast feeding; mental health; education and support.

Breast feeding

Reviews on this topic generally related to either support or promotion of breastfeeding. Britton et al. [ 51 ] reviewed the evidence in relation to support for breastfeeding mothers and key findings indicated that all forms of extra support for any breastfeeding (exclusive or partial) increased the duration of breastfeeding (RR 0.91; 95% CI 0.86-0.96) and the effect was greater for exclusive breastfeeding (RR 0.81; 95% CI 0.74-0.89). These findings were supported by Chung et al. [ 52 ] and Sikorski et al. [ 53 ]. Breastfeeding interventions included in both Britton et al. [ 51 ] and Chung et al. [ 52 ] involved formal or structured breastfeeding education, informal breastfeeding education or breastfeeding support either lay or professional. Chung et al. [ 52 ] from a meta analysis of 34 studies reported that breastfeeding interventions were effective in relation to increasing short term (1-3mths) and long-term (6-8mths) exclusive breastfeeding (RR 1.28; 95% CI 1.11-1.48 and RR 1.44; 95% CI 1.13-1.84) although statistically significant heterogeneity was noted for short term exclusive breast feeding (I 2 =55%; p= 0.006). The authors also highlighted an increased rate (22%) of any (RR 1.22; 95%CI 1.08-1.37) and exclusive (RR 1.65; 95%CI 1.03-2.63) short term breastfeeding with interventions that included a component of lay support. Sikorski et al. [ 53 ] reviewed additional support versus standard care and concluded that additional professional support was more beneficial than standard care for duration of any breastfeeding (RR 0.89, 95% CI 0.81-0.97; 10xRCT; n=19,696) and additional lay support was effective in reducing the cessation of exclusive breastfeeding (RR 0.66; 95% CI 0.49-0.89; 5xRCT; n=2530). Effect sizes for interventions with an antenatal education element (RR 0.85; 95% CI 0.70-1.04) were not statistically significant, while those with a postnatal element alone were (RR 0.80; 95% CI 0.80-0.96). Four trials using WHO/UNICEF training showed significant benefit in prolonging exclusive breastfeeding (RR 0.70; 95% CI 0.53-0.93), but were highly heterogeneous. The authors highlight the need to assess support in different settings especially with low rates, conduct economic analyses and use qualitative research to explore specific elements of support. Dyson et al. [ 54 ] focused on breastfeeding initiation rates and indicated from a meta analysis of five studies (n=582) that breastfeeding education had a significant effect on increasing initiation rates (RR 1.57, 95% CI 1.15-2.15, p=0.005) compared to standard care in low income groups although substantial statistical heterogeneity was noted (I 2 =53.4%). Early skin to skin contact was reviewed by Moore et al. [ 55 ] who reported statistically significant effects of early skin to skin on breastfeeding at one to four months post birth (OR 1.82, 95% CI 1.08-3.07) and breastfeeding duration (WMD 42.55, 95% CI −1.69 -86.79). In this review, data from more than two trials were only available for a small number of outcomes (8/64). Ahmed & Sands [ 56 ] reviewed breast feeding interventions. While the authors were unable to conduct a meta analysis they found from individual trials, statistically significant results relating to kangaroo care, peer counselling, in home breast milk measurement, and post discharge lactation support for improving breast feeding outcomes.

One review focused on improving maternal mental health and considered postnatal psychological and psychosocial interventions [ 57 ]. Dennis & Hodnett [ 57 ] reported that any psychosocial or psychological intervention compared to usual postpartum care was associated with a reduction in the likelihood of continued depression from their review of nine trials. Examples of psychosocial and psychological interventions reviewed included non-directive counselling, supportive interactions, delivered via telephone, home or clinic visits, or individual or group sessions in the postpartum period by a health professional or lay person, cognitive behavioural therapy and interpersonal psychotherapy.

Education and support

One review considered support for women in relation to weight reduction in the post partum period [ 58 ] focusing on the effect of diet or exercise or both for reducing weight after childbirth. They found that women who took part in a diet (1 trial; n=45; WMD −1.70 kg; 95% CI −2.08 to −1.32; z=8.73; p<0.00001), and women on a diet plus exercise programme (4 trials; n=169; WMD −2.89 kg; 95% CI −4.83 to −0.95; z=2.92; p<=0.00049), lost significantly more weight than women in the usual care. The authors also noted that there was no adverse effect on breastfeeding, although cautioned that further research is necessary to confirm this finding. Three reviews considered extra support for vulnerable groups of women in the form of home visiting or parenting interventions [ 59 – 61 ]. Corcoran & Pillai [ 59 ] reviewed rates in repeat pregnancy following the introduction of hospital-based programmes providing education and counselling to a sample of adolescent mothers. They found that although there was a 50% reduction in the odds of repeat pregnancy compared to comparison-control conditions at 19months (OR 0.474; 95% CI 0.322-0.695), the effect had dissipated by 31 months. All studies were US based and the majority conducted in low income groups (74%) and African Americans (60%). Two reviews focused on parenting interventions [ 60 , 61 ]. Pinquart and Teubert [ 60 ] reported small effects on parenting, parental stress, child abuse, health promoting behaviour, cognitive, social development, motor development, child mental health, parental mental health & couple adjustment from parenting education interventions. Vanderveen et al. [ 61 ] demonstrated an overall positive effect on neurodevelopment from early parental interventions (all involved teaching or enhancing parental skills) lasting up to 36 months. Meta analysis of twelve studies indicated higher cognitive scores at 12 months (WMD 5.57; 95% CI 2.29-8.86; p=0.0009), at 24 months (7 studies; WMD 7.59; 95% CI 5.01-14.31; p=0.0003) and at 36 months (2 studies; WMD 9.66; 95% CI 5.01-14.31; p=0.0001), but not at 5 yrs (3 studies p=0.24). The authors suggest further research is needed to clarify the most effective interventions and the long term effect.

Logic model

The parallel development of the logic model resulted in a summary model (Figure 2 ) provides a framework to visualise interventions across the perinatal period and the potential short, medium and long term impact on the health of women, their families and the community. Logic models display relationships between the core elements (context; inputs; outputs and outcomes) and the basic concept is to read from left to right, following a sequence of reasoning. An example of this is provision of education and information about screening in the antenatal period; an aspect of care where inequalities are known to occur [ 62 ]. The context in this example refers to the cultural, political, social circumstances in which the provision of screening is situated. Reading from left to right on the model indicates that the midwifery public health intervention is next so for example if a midwife provides information about antenatal screening for HIV (input), then uptake of screening may improve and at risk women will be identified earlier (outputs) and the effect will improve maternal and infant health during pregnancy. The medium and longer term outcomes are the resultant reduction in morbidity and or mortality in the local population.

figure 2

Summary Logic Model.

The focus of this paper is the development of the public health role of the midwife based on effective interventions and highlighting the short, medium and long term effects that these interventions could bring about. Any intervention must be considered within the context in which it is to be delivered as inequalities, resources, culture and vulnerable groups can influence the choice of intervention to best suit the population of women being served. The second column represents the inputs or activities; these are the interventions which are intended to bring about the change in outcomes. In relation to public health and midwifery these are interventions that may impact on public health primarily through education, screening and support. The outputs are the products or the targets of the service delivered and can been seen in the boxes entitled organisation of care under short and medium term outcomes. While the logic model provides a visual outline of midwifery public health roles, using this approach facilitates understanding of how public health programs can be planned and subsequently evaluated. Conducting the data synthesis in tandem with developing the logic model has also highlighted where the gaps in knowledge are and identified areas where midwives could potentially have a much greater role and subsequent impact on public health.

This paper sought to report on systematic reviews providing high quality evidence of effective interventions, in essence the ‘cream of the crop’. Reviews reporting on effective interventions were those which presented a statistically significant meta analysis or where the intervention was supported by a generally positive trend of results when a meta analysis was not possible to ensure the recommendations of the paper are based on strong evidence of good quality. There were a number of reviews included which presented statistically significant positive findings. However, in some cases these were limited by small numbers of participants or small numbers of trials included in the review. As a result of conducting the review and analyzing eligible systematic review evidence, three key areas for future consideration were identified including: recommendation and implementation of effective evidence; gaps in knowledge and developing the role of the midwife in public health which are discussed further in the following sections.

Recommendation and implementation of effective evidence

It is clear from this review of effective interventions, there are areas where evidence has been incorporated into guidelines and thus recommended for implementation into routine practice. However, it has also highlighted many areas where it has not. There has been extensive debate and commentary in the literature about knowledge transfer and translation of knowledge into practice, however, this paper confirms that despite the existence of good quality evidence, the gap remains. From this review, several effective interventions were identified, which are already recommended as routine practice, for example education about folic acid supplementation and pelvic floor muscle training to prevent or reduce the risk of urinary incontinence are advocated by current practice guidelines in the UK [ 63 ] and further afield [ 64 , 65 ]. However, to evaluate fully the extent to which guidelines have been applied it is essential to audit practice in order to provide evidence for knowledge transfer. To encourage implementation of NICE guidelines, audit support tools have been developed by NICE on antenatal care or diabetes in pregnancy for use at local level. Effective interventions were also identified which could easily be implemented by a midwife and could potentially impact on public health, such as education programs for parents of preterm infants and implementation of specific strategies to reduce caesarean section rates. Although there is recognition by health professionals these areas are important, this review provides definitive evidence and examples from systematic reviews, of interventions that are effective. Further consideration needs to be given to how to translate these effective interventions into practice using appropriate channels which are effective to facilitate knowledge transfer. These may include stronger collaborations between clinicians and academics and increasing the exposure students have to systematic reviews in education curricula at undergraduate level. Other effective interventions have been implemented on an ad hoc basis for example additional lay or professional support for breast feeding women and strategies to reduce caesarean section rates, which need to be included specifically in policy and strategy documents to ensure widespread implementation and thus contribute to an evidence based public health agenda to improve the health of women and families. Although this paper has focused on reporting effective interventions it is also important to take cognisance of those interventions that are not effective i.e. those which do not work and sometimes are deeply embedded into practice, for example, routine antenatal CTG for fetal assessment [ 20 ]. It was not possible to discuss reviews that demonstrated no effect within this current paper, however, Table 2 provides summary details of the areas where this was the case.

Gaps in knowledge

The review identified many gaps in systematic review literature relating to core midwifery practice, which potentially could impact on public health population goals. The UK Department of Health, Public Health Strategy [ 66 ] emphasizes the importance of improving maternal health and the subsequent impact on reducing infant mortality and premature births and yet this review identified limited systematic review evidence to support the implementation of midwifery interventions that could impact on perinatal morbidity and mortality. The review also highlighted it was difficult to accurately assess the potential public health impact in terms of effectiveness as some interventions were not well evaluated, evidenced by the large number of inconclusive reviews and reviews demonstrating no effect. The review of reviews identified some interventions that were effective but were limited in terms of methodological quality of included studies, for example, small numbers and design flaws, thus demonstrating the need for robust research and evaluation. One example of this is systematic review evidence in relation to weight management or obesity; a topic of growing concern to maternity care providers and yet the evidence from systematic reviews is limited in terms of quality. The systematic reviews included in the original review generally indicated that additional support related to diet or exercise for women in the postnatal period was effective, however, only one review was of a high quality. Another example of this is the evidence around home visiting for vulnerable groups of women in the postnatal period. While a significant body of research, including longitudinal studies has been published on parenting interventions indicating generally positive effects [ 67 , 68 ] the evidence from this current systematic review of reviews is mixed. Current early years governmental policy in the UK focuses on giving children the best start in life and various interventions have been, or are currently being rolled out, for example, SureStart and the Family Nurse Partnership, however the longer term impact on women and families remains to be seen. Logic models highlight the causal linkage between inputs, outputs and outcomes (24). This is illustrated very clearly in relation to support for parents in the form of parenting interventions (input) which can result in the short term outcome of increasing support for women to improve health and lifestyle; optimize lifestyle and child development beyond the immediate perinatal period (medium term) and in the long term improve family health and wellbeing for this generation and those to come.

Developing the role of the midwife in public health

In order for midwives to utilise their potential in relation to public health it is important not only to consider the interventions that could be implemented but also take cognisance of wider strategies and policy relating to public health. The logic model (Figure 2 ), which was developed as a parallel process to the review, provides an overarching framework that should be used by midwives to visualise their contribution to public health. The model illustrates possible future roles but also facilitates recognition of the current contribution of midwives to improving the health of women and their families as part of their core role. An example of this is how vulnerable women (either social or medical) could be identified in the antenatal period by midwives and a supportive or educational intervention implemented which would result in improved outcomes in the short term i.e. reduced pre term birth or improved birth weight. A medium term outcome of this intervention would focus on optimising lifestyle beyond the perinatal period for example collaborating with health visiting services to provide education and support that would potentially have a longer term outcome of improved family health and well being. The review did not identify any systematic reviews which specifically focused on interventions relating to midwifery public health roles, highlighting a gap in review evidence. Biro [ 69 ] suggests it may be challenging for midwives to think beyond individual women but ultimately necessary in order to meet the challenge of public health to improve population health. Reframing routine midwifery activities in a public health context, identifying midwives as public practitioners and building on existing activities, such as collaboration, organisation of care and interagency working are essential to clearly define the relationship between midwifery and public health. An earlier, wider review on health-led parenting interventions in pregnancy and the first three years of life [ 8 ] suggested that many interventions, particularly in relation to supporting parenting, could be provided as part of routine care and that although the optimal time to start programmes was not clear, there was some consensus that those initiated in the antenatal period were more effective. Development of the public health role of the midwife will also require strategic thinking and support from planners and commissioners of maternity services to ensure that midwives can influence policy and effectively implement public health strategies. This will involve dedicating time and resources to develop local policies, providing training for midwives and building good relationships with other healthcare disciplines to work together.

Limitations

There are a number of methodological challenges in using systematic review evidence which must be taken into account. It is difficult to summarise the evidence from systematic reviews as often there is significant diversity between interventions included in individual reviews or outcome measures used. In addition the results presented may be inconsistent between reviews or inconclusive, however, Smith et al. [ 14 ] suggest the strength of systematic reviews of reviews is that the best quality reviews can be highlighted in a single document. Systematic reviews are generally limited to published work and thus may be subject to publication bias. In addition, more recent, potentially conflicting, research may be available since the review was published or there may be effective interventions that have not been evaluated in a systematic review. A recent Cochrane overview of systematic reviews [ 70 ] highlighted that such reviews provide an accessible summary on the totality of the evidence in the area and minimised the need for referral to individual reviews, however suggested that readers may wish to do so for specific details. This review was similar in that it covered a broad scope of the evidence in relation to public health, providing a strategic overview while also providing a valuable resource for those who wish to consult individual reviews for additional specific details. In this paper, only high quality reviews (based on level of included evidence and methodology of review) reporting on effective interventions were included. While this provides reassurance regarding review findings, in that the conclusions are based on top level evidence, some interventions demonstrating effect may have been excluded because the review itself did not meet either the quality or level of evidence criteria for inclusion. In most cases this relates to areas worthy of future investigation, which need more robust evaluations. The search strategy utilised in the review was specifically focused on the public health role of the midwife and therefore incorporated key terms relative to key areas. However in doing so, some postnatal interventions, which extend beyond the role of the midwife, for example, parenting interventions that continue into early childhood may not have been included. In addition, due to the inclusion and exclusion criteria applied, it is possible that extensive broad reviews on particular topics have been excluded from this review due to the nature of evidence included within them, for example, the NICE Guideline on Antenatal and Postnatal Mental Health [ 9 ]. However, it is recognised these are valuable resources and contribute to wider understanding on specific subjects.

This paper has reported on high quality effective interventions identified from a larger systematic review on public health interventions that could be delivered primarily by midwives or maternity care providers. From the effective interventions identified it is clear that while some have been recommended for implementation into routine practice, others have not. This highlights the continuing gap between evidence and practice and the need for professionals and researchers to work better together to ensure specific interventions that are effective, are translated into practice and subsequently audited to provide evidence of knowledge translation. The public health role of the midwives has not been well researched or reviewed and the impact of everyday midwifery practice on longer term, holistic maternal and family well-being outcomes is poorly articulated in review literature. A shift in research, policy and practice is needed to fully articulate the public health role of the midwife. This systematic review of systematic reviews identifies a number of effective interventions that provide a useful starting point on which to build future practice. The logic model demonstrates the need to fill in major gaps in our knowledge on effective interventions to achieve both short and long term public health benefits for women and their families. Such benefits will remain elusive without investment in a collaborative, strategic approach to the role of public health in midwifery.

Advisory group members

Ms Liz Bannon , Senior Midwife, & Co Director of Maternity Services, Social Services, Family & Child Care Belfast Health and Social Care Trust, Belfast, Northern Ireland; Professor Debra Bick , Professor of Evidence Based Midwifery Practice, Kings College London, England; Dr Helen Cheyne , Nursing, Midwifery & Allied Professions Research Unit, University of Stirling, Scotland; Professor Mike Clarke , then Professor of Clinical Epidemiology & Director of UK Cochrane Centre, now Professor/Director of MRC Methodology Hub, Queen’s University Belfast; Ms Joanne Gluck , Consumer Representative; Professor Billie Hunter , Professor of Midwifery, Swansea University, Wales; Dr Dermot O’Riley , Centre of Excellence for Public Health Northern Ireland, Queen’s University Belfast, Northern Ireland.

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Acknowledgements

We would like to thank all members of the Advisory Group for their contribution and guidance throughout the project. In addition, we would like to thank Midwifery 2020 for funding the original review and in particular, The Public Health Workstream Group who commissioned the original review.

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The original review was funded by NHS Education for Scotland, Midwifery 2020, UK.

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JM extracted and interpreted data and wrote the first draft of the manuscript. FL conducted the searches of the literature, extracted and interpreted data and assisted with the manuscript. FA extracted and interpreted data and assisted with the manuscript. All authors read and approved the final manuscript.

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McNeill, J., Lynn, F. & Alderdice, F. Public health interventions in midwifery: a systematic review of systematic reviews. BMC Public Health 12 , 955 (2012). https://doi.org/10.1186/1471-2458-12-955

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Public health interventions in midwifery: a systematic review of systematic reviews

Jenny mcneill.

1 School of Nursing & Midwifery, Queen’s University Belfast, Medical Biology Centre, 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland

Fiona Alderdice

Maternity care providers, particularly midwives, have a window of opportunity to influence pregnant women about positive health choices. This aim of this paper is to identify evidence of effective public health interventions from good quality systematic reviews that could be conducted by midwives.

Relevant databases including MEDLINE, Pubmed, EBSCO, CRD, MIDIRS, Web of Science, The Cochrane Library and Econlit were searched to identify systematic reviews in October 2010. Quality assessment of all reviews was conducted.

Thirty-six good quality systematic reviews were identified which reported on effective interventions. The reviews were conducted on a diverse range of interventions across the reproductive continuum and were categorised under: screening; supplementation; support; education; mental health; birthing environment; clinical care in labour and breast feeding. The scope and strength of the review findings are discussed in relation to current practice. A logic model was developed to provide an overarching framework of midwifery public health roles to inform research policy and practice.

Conclusions

This review provides a broad scope of high quality systematic review evidence and definitively highlights the challenge of knowledge transfer from research into practice. The review also identified gaps in knowledge around the impact of core midwifery practice on public health outcomes and the value of this contribution. This review provides evidence for researchers and funders as to the gaps in current knowledge and should be used to inform the strategic direction of the role of midwifery in public health in policy and practice.

The reproductive period offers maternity care providers the opportunity to maximise the health and well-being of women and their families potentially impacting on public health outcomes, both short and long term. Although all maternity care providers who engage with pregnant women are presented with such opportunities, it is the midwife that could have the most significant impact from regular contact and building of relationships through continuity of care. There are interventions that could be implemented by midwives, which potentially would have a public health impact but it is important such interventions are evidence based. Recognition of the importance of the relationship between public health and midwifery was highlighted when a general review of midwifery in the UK [ 1 ], named public health as one of five key areas of interest. While the review specifically focused on midwifery in the UK, the importance of preventative public health interventions during pregnancy and the postnatal period has been emphasized on a wider scale. Millennium Development Goal 5 focuses on improving maternal health specifying a secondary target aim to achieve universal access to reproductive health by 2015 [ 2 ]. Antenatal care and adolescent pregnancy are specifically mentioned as key to achieving this target, both of which are acknowledged widely, as areas of interest to public health [ 3 , 4 ]. Other areas of national and international interest, which impact on population health (both women and families), include rising caesarean section rates and other interventions during childbirth [ 5 - 7 ], the importance of positive parenting in the early postnatal period [ 8 ] and perinatal mental health [ 9 ]. Within these areas there is opportunity for evidence based public health interventions to be implemented with a view to potentially improving the long term health of women and families.

Aim of the review

This paper presents an update of a systematic review of systematic reviews conducted in 2009. The aim of the 2009 review was to evaluate the effectiveness of interventions relevant to the public health role of the midwife. The 2009 review was commissioned and conducted within the context of the Midwifery 2020 initiative. The final report of the Midwifery 2020 initiative (Delivering Expectations) and full report of the systematic review of reviews [ 10 ] are available freely online from: http://www.midwifery2020.org . A systematic review of systematic reviews was selected as the methodology, given the breadth of this topic area and the timescale of the project. This paper outlines the review methodology and builds on the original review findings by providing new and updated information about effective high quality public health interventions which could be implemented by midwives or other health care providers for women during pregnancy and the postnatal period who have a similar role, for example, public health nurses, obstetric nurses, labour and delivery nurses or health visitors.

The Preferred Reporting Items of Systematic reviews Meta-Analyses (PRISMA) guidelines was adhered to when conducting this review [ 11 ]. A systematic search strategy was formulated and definitive search terms used relative to key public health topics within midwifery following consultation with Expert Advisory Group members and Midwifery 2020 Public Health Work Stream members. Seven key areas were identified as relevant to the public health role of the midwife, which included: screening; vulnerable groups; breast feeding; mental health and wellbeing; education and support; childbirth and lifestyle factors. The complete list of search terms is available from McNeill et al. [ 10 ].

Search strategy

Databases searched included: MEDLINE, PubMed, EBSCO (CINAHL/British Nursing Index), MIDIRS Online Database, Web of Science, The Cochrane Library, CRD (NHS EED/DARE/HTA) and EconLit. Eligibility criterion included reviews published from 1999 onwards; English language publications and reviews originating from economically developed countries as indicated by membership of the Organisation for Economic Co-operation and Development (OECD). An additional search was conducted of the National Institute for Health and Clinical Excellence, UK (NICE) website to identify key publications or findings from systematic reviews within guidelines. Reference lists of identified reviews were manually searched for additional relevant reviews. The searches were initially conducted in November 2009 and updated in October 2010. The titles and abstracts were obtained and the decision process for eligibility was conducted by all members of the project team in collaboration (JM, FL & FA). Full text was obtained of all eligible reviews and those whose eligibility could not be discerned from reading the abstract. Eligible systematic reviews also had to publish a clearly identified search strategy or detail the reference databases used.

Data extraction

Data were extracted on: number of papers included in the review; methodological details; midwifery intervention; outcome measures and results. Data were systematically extracted using a data extraction form by individual project team members and verified by one other project team member. The project team subsequently met to discuss and achieve consensus regarding any contentious issues. A parallel process of developing a logic model to act as an overarching framework to inform forward planning was also conducted. Logic models are essentially a conceptual framework, which can be used for evidence‐based decision making and planning [ 12 ]. The model is composed of midwifery inputs and activities, producing a logical pathways to short, medium and long term public health outputs.

Quality assessment and effectiveness of reviews

It is important to consider both the type of evidence included in reviews i.e. was the review restricted to randomised trials only or were other types of studies included and also assess how well the review was conducted methodologically. As such, a two stage process was employed: initially the level of evidence was graded and secondly, the methodological quality was assessed. Recognised frameworks were used to support this process [ 13 , 14 ]. In the hierarchy of evidence, randomised controlled trials are perceived as the gold standard and as the aim of this paper is to present high quality evidence, an evidence grade was given to each review based on the Scottish Intercollegiate Guidelines Network [ 13 ] framework in order to distinguish between different levels of evidence. This framework grades the associated risk of bias based on the level of evidence in a hierarchal manner from a grade of 1++ (meta analysis and RCT evidence) through to 4 (expert opinion), as outlined in Table ​ Table1. 1 . The SIGN framework was modified as this review was restricted to systematic reviews and therefore reviews could only be graded as 1++, 1+, 1- or 2++. This paper only presents evidence which was graded 1- or above; any review graded below 1- was not deemed eligible for inclusion. Following selection of the type of evidence, the second stage focused on the methodology of eligible reviews. Clarke [ 15 ] suggests the successful interpretation of results from systematic reviews should consider the methodological conduct of the review. The methodological quality of included reviews was assessed and rated as low, medium or high quality. Appraisal of methodological quality was based on Smith et al. [ 14 ], which contains similar elements to other tools used to assess review quality, for example, the AMSTAR tool [ 16 ]. Reviews were graded as high quality if they included evidence of a search strategy, selection and inclusion criterion, assessment of publication bias and assessment of heterogeneity. Reviews were rated as medium quality if no evidence of assessment of heterogeneity or publication bias was provided and low quality reviews were those which provided evidence of a search strategy only. Effectiveness of interventions was evaluated using a similar approach to van Sluijs et al. [ 17 ]. A differentiation was made between reviews which reported a statistically significant difference (P<0.05), therefore referred to as effective and those which reported no difference in effect between control and intervention group and are referred to as inconclusive or not effective (as appropriate). This paper focuses specifically on interventions which are evidenced by a statistically significant meta analysis or where the intervention is supported by a generally positive trend of results when a meta analysis was not possible. Reviews have been included where a small number of studies reported statistically significant positive effect of the intervention however the wider interpretation of these results is limited. As outlined previously, the aim of the original review was to identify any public health intervention relevant to midwifery. However for the purpose of this paper the focus was to report on public health interventions relating to midwifery that demonstrated a statistically significant effect in favour of the intervention (referred to subsequently as effective interventions for the sake of brevity). Reviews graded 1- or above and of high methodological quality which reported evidence of no effect, are not discussed in this paper. However, they have been summarised in Table ​ Table2 2 [ 18 - 23 ]. In the case of any disagreement regarding grading of evidence, quality appraisal of reviews or effectiveness of the intervention, consensus was reached by discussion between all three authors.

Evidence level of systematic reviews

From Scottish Intercollegiate Guidelines Network [ 13 ].

Excluded High Quality Reviews Reporting Interventions with no effect

Acronyms used: USS=Ultrasound Scan; CI=confidence interval; RR=relative risk; UTI=urinary tract infection; OR=odds ratio; LBW=low birth weight; CS=caesarean section; NICU=neonatal intensive care unit; ICU=intensive care unit; SCU=special care unit; FHR=fetal heart rate; IOL=induction of labour; CTG=cardiotocography; PTD=preterm delivery; WMD=weighted mean difference; APH=antepartum haemorrhage; PPH=postpartum haemorrhage; SGA=small for gestational age.

Data synthesis

A narrative review is provided for each of the systematic reviews and in table format the number and date range of papers included, intervention(s), primary outcome or other public health outcomes of interest, results (including key statistical findings e.g. p values or odds ratios) are described and whether the review included a meta analysis or not. It was not expected that a quantitative analyses would be conducted given the diversity of interventions across the broad subject of public health.

In total 214 systematic reviews were eligible of which 91 reported on effective interventions and 117 found no effect or were inconclusive. This paper only reports on high quality reviews with a level of evidence grading above 1-. Of the 91 systematic reviews which reported on effective interventions, 36 were identified which were graded as evidence level 1- or above and rated as high quality. The flow chart in Figure ​ Figure1 1 presents the sequential process of identifying reviews eligible for inclusion in this paper. An overview of the key findings in relation to interventions demonstrating a statistically significant effect in favour of the intervention from good quality reviews will be presented in the following sections. A summary of included reviews is provided in Table ​ Table3. 3 . The findings in this paper are presented chronologically through the reproductive period: preconceptual; antenatal; intranatal and postnatal. Within each section the reviews on similar broad topics have been further categorised: antenatal (screening; supplementation; support; education; mental health); intranatal (clinical care; environment); postnatal (breast feeding; mental health; education; support). The findings section also presents the logic model which was developed in parallel with the searching and analysis of reviews. Logic models enable the visualisation of how interventions or programmes work and the expected outcomes [ 24 ] and have been used to consider the strategic public health benefit of midwifery practice both in the short and long term [ 25 ].

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Identification of effective reviews of high quality *some reviews which were included at the request of funder have been excluded from this paper eg economic reviews (n=6) **non significant, non effective or inconclusive reviews, reviews graded 2++,2+ or 2- and medium or low quality reviews are not discussed in this paper.

Included Reviews

Acronyms used: USS=Ultrasound Scan; MD=mean difference; NTD=neural tube defect; CI=confidence interval; IOL=induction of labour; RR=relative risk; B/P=blood pressure; C/S=caesarean section; ICU=intensive care unit; LBW=low birth weight; SGA=small for gestational age; NICU=neonatal intensive care unit; PTD=preterm delivery; IUGR=intrauterine growth retardation; RCT=randomised controlled trial; Hb=haemoglobin; MA=meta analysis; WMD=weighted mean difference; APH=antepartum haemorrhage; SVB=spontaneous vaginal birth; PPH=postpartum haemorrhage; SCU=special care unit; OR=odds ratio; IVH=intraventricular haemorrhage; ARM=artificial rupture of membranes; EFM=electronic fetal monitoring; PND=postnatal depression.

Findings -effective interventions

Pre conceptual.

There were no high quality reviews that reported on effective interventions in the pre conceptual period.

The majority of reviews reporting effective interventions were relevant to the antenatal period (n=20). Included reviews have been grouped into screening, supplementation, support, education and mental health.

Reviews (n=4) related to screening reported on interventions relating to ultrasound [ 26 , 27 ], lower genital tract infection screening [ 28 ] and the use of decision making aids [ 29 ]. Bricker et al. [ 26 ] conducted a large Health Technology Assessment review on the clinical and cost effectiveness and women’s views of USS. The review comprised of three systematic reviews on routine ultrasound in early pregnancy, routine ultrasound in late pregnancy and routine Doppler ultrasound in pregnancy which were published in the Cochrane database around the time of Bricker et al. [ 26 ] however, all have since been updated or revised in the Cochrane database, one of which has been included in this paper. The final conclusions of Bricker et al. [ 26 ] indicated that a two stage regimen of USS in pregnancy, one in early pregnancy (booking USS) and a second anomaly USS around 20 weeks, was recommended. Whitworth et al. [ 27 ] reviewed the use of ultrasound for fetal assessment in early pregnancy and concluded that it reduces failure to detect multiple pregnancy (RR 0.07 95% CI 0.03-0.17) and accuracy of gestational dating may reduce the number of inductions of labour for post term gestation (RR 0.59; 95% CI 0.42-0.83). The authors also reported there was no reduction in adverse outcomes or health service use by mothers or infants and long term follow up did not indicate detrimental effect on children’s physical or mental development. The impact of antenatal screening for lower genital tract infection for preventing preterm delivery was reviewed by Sangkomkamhang et al . [ 28 ]. The review included one large RCT (n=4155), which indicated that preterm birth before 37 weeks was significantly lower in a group of women randomised to a screening programme before 20 weeks’ gestation (RR 0.55; 95% CI 0.41-0.75). The review provides evidence to suggest there may be some benefit to introducing a universal screening programme for lower genital tract infection; however the results are based on the findings of one study. O’Connor et al. [ 29 ] conducted a review on the use of decision aids for people facing screening decisions. The meta analysis indicated that the use of decision aids, such as leaflets or DVD’s are better than usual care and resulted in: greater knowledge (MD 15.2 out of 100; 95%CI 11.7 to 18.7), perception of risk (RR 0.6; 95% CI 0.5 to 0.8), lower decisional conflict related to feeling uninformed (MD −8.3 of 100; 95% CI −11.9 to −4.8), lower decisional conflict related to personal values (MD −6.4; 95% CI −10.0 to −2.7), reduced the proportion of people who were passive in decision making (RR 0.6; 95% CI 0.5-0.8) and reduced the proportion of people who remained undecided post intervention (RR 0.5; 95% CI 0.3-0.8). Although the results suggest decision aids are effective, the effect size was not consistent across studies and only three of the included studies related directly to antenatal screening.

Supplementation

Eight reviews [ 30 - 37 ] considered supplementation during pregnancy including iron, micronutrients, folic acid, calcium and Long Chain-Poly Unsaturated Fatty Acids (LC-PUFA’s). Two reviews [ 30 , 31 ] focused on folic acid supplementation, both of which concurred that the risk of neural tube defect was significantly reduced with supplementation: Blencowe et al., [ 30 ]; 70% reduction; 95% CI 35-86 and Lumley et al., [ 31 ]; RR 0.28; 95% CI 0.13-0.58. Iron supplementation during pregnancy was reviewed by Pena-Rosas and Viteri [ 32 ] who included 49 trials relating to the prevention of iron deficiency or anaemia at term. The authors concluded that daily iron supplementation was associated with increased haemoglobin before birth (MD 6.00; 95% CI 2.75-9.25) and reduced risk of anaemia at term (RR 0.46; 95% CI 0.29- 0.72) based on meta analyses of high quality trials only. Shah et al. [ 33 ] reviewed multi-micronutrient supplementation on pregnancy outcomes and reported there was a reduction in the risk of low birth weight amongst women given micronutrient supplementation (12 studies, RR 0.81; 95% CI 0.73-0.91) and iron-folic acid supplementation (RR 0.83; 95% CI 0.74-0.93) compared to placebo. The mean birth weight was higher (11 studies; WMD 54g; 95% CI 36-72g) in infants born to mothers who had micronutrient supplementation compared to iron-folic acid supplementation (no difference with placebo).

Calcium supplementation was the focus of three reviews [ 34 - 36 ]. Hofmeyr et al. [ 34 ] reported a reduction in pre-eclampsia (RR 0.68; 95% CI 0.57-0.81) and fewer babies born <2500g (RR 0.83; 95% CI 0.71-0.98). However the benefits seen were from small trials and not observed in the largest trial included. Hofmeyr et al. [ 35 ] reported that with supplementation a reduction in blood pressure (RR 0.7; 95% CI 0.57-0.86), pre-eclampsia (RR 0.48; 95% CI 0.33-0.69) and maternal death/morbidity (RR 0.80; 95% CI 0.65-0.97) was noted and advocated research to investigate calcium supplementation at community level. The most recent review [ 36 ] conducted by several of the same authors as Hofymeyr et al. [ 34 ] on calcium supplementation concluded that there was a reduced risk of increased blood pressure (RR 0.65; 95% CI 0.53-0.81) and preeclampsia (RR 0.45; 95% CI 0.31-0.65). The effect was greatest for high risk women (RR 0.22; 95% CI 0.12-0.42) and women with low baseline calcium (RR 0.36; 95% CI 0.20-0.65). Maternal death or serious morbidity was reduced (RR 0.80; 95% CI 0.65-0.97) although this was mostly in low risk women and women with low calcium and there was no effect on preterm births, stillbirth or death before discharge. Horvath et al. [ 37 ] reviewed the effect of advising high-risk pregnant women to take LC-PUFA supplementation on a number of pregnancy outcomes. The authors found a significantly lower rate of PTD <34 wks (RR 0.39; 95% CI 0.18-0.84) although this result was based on two trials (n=291). There was no effect on duration of pregnancy, PTD <37 wks, infant birth weight or the occurrence of IUGR. Although significant, the authors concluded that there was not enough evidence to recommend routine use of LC-PUFA supplements by high-risk women and that further research involving larger sample sizes was needed.

Three reviews [ 38 - 40 ] considered different types of supportive interventions for women during pregnancy. These ranged from using midwifery models of care to provision of emotional support to reduce the risk of preterm delivery or low birth weight infants. Hatem et al. [ 38 ] reviewed midwife led models of care versus other models of care and concluded that the majority of women should be offered midwifery led care. Women who had midwife led models of care were less likely to experience antenatal hospitalisation (RR 0.90; 95% CI 0.81-0.99), use of regional analgesia (RR 0.81; 95% CI 0.73-0.91), episiotomy (RR 0.82; 95% CI 0.77-0.88) and instrumental delivery (RR 0.86; 95% CI 0.78 to 0.96) and were more likely to experience no intrapartum analgesia/anaesthesia (RR 1.16; 95% CI 1.05-1.29), vaginal delivery (RR 1.04; 95% CI 1.02-1.06), to feel in control during childbirth (RR 1.74; 95% CI 1.32-2.30), attendance at birth by a known midwife (RR 7.84; 95% CI 4.15-14.81) and initiate breastfeeding (RR 1.35; 95% CI 1.03 to 1.76). In addition, women who were randomised to receive midwife-led care were less likely to experience fetal loss before 24 weeks’ gestation (RR 0.79; 95% CI 0.65-0.97). There was no difference between groups for birth by caesarean section (RR 0.96; 95% CI 0.87-1.06) and no statistically significant differences in fetal loss/neonatal death of at least 24 weeks (RR 1.01; 95% CI 0.67-1.53) or fetal/neonatal death overall (RR 0.83; 95% CI 0.70-1.00) and their babies were more likely to have a shorter length of hospital stay (mean difference in days: -2.00; 95% CI −2.15 to −1.85). Hodnett & Fredericks [ 39 ] assessed the value of emotional support to women who were judged, by a health professional, to be at increased risk of preterm delivery or having a low birth weight baby. No significant effect was detected for either outcome, however, women receiving support interventions were significantly less likely to undergo a caesarean section (RR 0.88; 95% CI 0.79-0.98) and were more likely to terminate their pregnancy (RR 2.96; 95% CI 1.42-6.17). There was also a trend towards improvement in maternal psychosocial outcomes although this was not significant. Denis & Kingston [ 40 ] reviewed the effect of telephone support during pregnancy and early postpartum period specifically on smoking, preterm birth, low birth weight, breast feeding and postpartum depression. The authors report a positive effect on breast feeding (3 trials; n=618; RR=1.18; 95% CI 1.05-1.33), low birth weight (3 trials; n=2,027; RR=0.78; 95% CI 0.63-0.97) and postpartum depression at 4 weeks (RR 0.24; 95% CI 0.06-1.00) and 8 weeks (RR 0.30; 95% CI 0.10-0.92), although all were from small numbers of trials and the finding on postpartum depression was from one pilot trial including 42 women.

Educational interventions in the antenatal period were the focus of four systematic reviews [ 41 - 44 ] that considered education about pelvic floor muscle training (PFMT) and promotion of smoking cessation in pregnancy Lumley et al. [ 41 ] reviewed the effect of interventions for promoting smoking cessation and included 72 studies of which 56 were RCT’s. Interventions to encourage cessation of smoking had a significant effect on the number of women smoking; 6 out of every 100 stopped, and a reduction in the number of cigarettes smoked by women was also evident. There was a significant reduction of smoking in late pregnancy (RR 0.94; 95% CI 0.93-0.96), reduction in LBW (RR 0.83; 95% CI 0.73 -0.95), preterm birth (RR 0.86; 95% CI 0.74-0.98) and an increase in mean birth weight (53.91g; 95% CI 10.44g - 95.38g). Naughton et al. , [ 42 ] reviewed the use of self help interventions for smoking and reported greater likelihood of quitting compared to usual care (13.2% v 4.9%; OR 1.83; 95% CI 1.23-2.73). The cost effectiveness of this method was also emphasised, however, further research is necessary to determine the intensity level of the intervention to maximise effectiveness. Hay-Smith et al. [ 43 ] and Lemos et al. [ 44 ] reviewed pelvic floor muscle training and concluded that for primigravida women PFMT was effective. Hay-Smith et al. [ 43 ] reported that women without prior incontinence were less likely to report incontinence in late pregnancy (RR 0.44; 95% CI 0.30-0.65) and up to 6 months postpartum (RR 0.71; 95% CI 0.52-0.97) similar to Lemos et al. [ 44 ] who reported significantly reduced development of urinary incontinence from 6 weeks to 3 months after delivery (OR 0.45; 95% CI 0.3-0.66; 4x RCT; n=675). Pregnant women with persistent incontinence 3 months after delivery and received PMFT were less likely to report urinary incontinence at 12 months post delivery (RR 0.79; 95% CI 0.70-0.90) and less likely to report faecal incontinence at 12 months (RR 0.52; 95%CI 0.31-0.87) [ 43 ].

Mental health

One review by Dennis & Creedy [ 45 ] considered interventions to prevent postnatal depression and all but one involved an intervention from a health professional. The authors reported that preliminary evidence suggests that intensive postnatal nursing home visits with at risk mothers assisted prevention of postpartum depression (RR 0.67; 95%CI 0.51-0.89).

Eligible systematic reviews relevant to the intranatal period yielded the smallest number in comparison to either the antenatal or postnatal periods. Five reviews [ 46 - 50 ] were included in this section and considered either clinical care during labour/delivery or the birthing environment.

Clinical care

Cluett & Burns [ 46 ] reviewed immersion in water for labour or birth (n=11) and reported from a meta analysis of 6 RCT’s. There was evidence to indicate that immersion in water for the first stage of labour significantly reduced the rate of epidural, spinal, paracervical analgesia and anaesthetic analgesia (478/1254 versus 529/1245; OR 0.82; 95% CI 0.70-0.98; p 0.025). However further research is required on other outcomes where there was no difference identified including assisted vaginal deliveries, C/S, perineal trauma, maternal infection, Apgar score < 7 at 5 mins, neonatal unit admissions or neonatal infection rates. Rabe et al. [ 47 ] reviewed delayed umbilical cord clamping and indicated from a meta analysis that there are benefits for both term and preterm infants. A delay of 30–120 seconds of cord clamping reduced the need for transfusions (RR 2.01; 95% CI 1.24-3.27, p=0.0049) and intraventricular haemorrhage (RR 1.74; 95% CI 1.08-2.81, p=0.022) in infants born <37 weeks [ 47 ]. Although the short term benefits are clear, further longitudinal work is needed to clarify the long term benefits.

Environment

The birth setting was the subject of four reviews although all were on different aspects. Hodnett et al. [ 48 ] reviewed the evidence regarding alternative versus conventional institutional settings for birth, which did not include any trials conducted in free standing birth centres. The review reported that for women allocated to the intervention (alternative setting) there was a significant increased likelihood of no analgesia/anaesthesia (RR 1.17; 95% CI 1.01-1.35), spontaneous vaginal delivery (RR 1.04; 95% CI 1.02-1.06), very positive views of care (RR 1.96; 95% CI 1.78-2.15), breastfeeding rates at 6–8 weeks (RR 1.04; 95% CI 1.02-1.06) and decreased episiotomy rate (RR 0.83; 95% CI 0.77-0.90). There was no effect on serious perinatal or maternal morbidity or mortality. Continuous support during childbirth was reviewed by Hodnett et al. [ 49 ]. The intervention involved one to one support during labour and found increased likelihood of shorter labour (WMD −0.43 hours; 95% CI −0.83 to −0.04), spontaneous vaginal delivery (RR 1.07; 95% CI 1.04 to 1.12) and were less likely to have intrapartum analgesia (RR 0.89; 95% CI 0.82- 0.96) or report dissatisfaction with childbirth experience (RR 0.73; 95% CI 0.65- 0.83). The authors only reported on outcomes where at least four trials were included in the meta analysis and highlighted that, generally, continuous intrapartum support was associated with greater benefits when it was not a member of hospital staff, when it began in early labour and in settings where epidural was not routinely available. Hodnett et al. [ 49 ] concluded that continuous support should be the norm rather than the exception for all women and further research is required as to the effectiveness of doula or lay support.

One review considered interventions aimed at reducing caesarean section rates [ 50 ]. Chaillet & Dumont [ 50 ] reported from a meta analysis that regular audit, detailed feedback regarding aspects of caesarean section performance (responsibility for decision making, rates, review of cases in clinical practice and multi faceted strategy approaches, such as development of guidelines, education of health professionals and women about vaginal birth after caesarean section (VBAC) were effective for reducing the caesarean section rate (RR 0.81; 95% CI 0.75-0.87). Details of relative risk for each type of strategy are included in Table ​ Table3 3 .

Eleven reviews [ 51 - 61 ] reporting on effective interventions related to the postnatal period. The reviews ranged across four areas: breast feeding; mental health; education and support.

Breast feeding

Reviews on this topic generally related to either support or promotion of breastfeeding. Britton et al. [ 51 ] reviewed the evidence in relation to support for breastfeeding mothers and key findings indicated that all forms of extra support for any breastfeeding (exclusive or partial) increased the duration of breastfeeding (RR 0.91; 95% CI 0.86-0.96) and the effect was greater for exclusive breastfeeding (RR 0.81; 95% CI 0.74-0.89). These findings were supported by Chung et al. [ 52 ] and Sikorski et al. [ 53 ]. Breastfeeding interventions included in both Britton et al. [ 51 ] and Chung et al. [ 52 ] involved formal or structured breastfeeding education, informal breastfeeding education or breastfeeding support either lay or professional. Chung et al. [ 52 ] from a meta analysis of 34 studies reported that breastfeeding interventions were effective in relation to increasing short term (1-3mths) and long-term (6-8mths) exclusive breastfeeding (RR 1.28; 95% CI 1.11-1.48 and RR 1.44; 95% CI 1.13-1.84) although statistically significant heterogeneity was noted for short term exclusive breast feeding (I 2 =55%; p= 0.006). The authors also highlighted an increased rate (22%) of any (RR 1.22; 95%CI 1.08-1.37) and exclusive (RR 1.65; 95%CI 1.03-2.63) short term breastfeeding with interventions that included a component of lay support. Sikorski et al. [ 53 ] reviewed additional support versus standard care and concluded that additional professional support was more beneficial than standard care for duration of any breastfeeding (RR 0.89, 95% CI 0.81-0.97; 10xRCT; n=19,696) and additional lay support was effective in reducing the cessation of exclusive breastfeeding (RR 0.66; 95% CI 0.49-0.89; 5xRCT; n=2530). Effect sizes for interventions with an antenatal education element (RR 0.85; 95% CI 0.70-1.04) were not statistically significant, while those with a postnatal element alone were (RR 0.80; 95% CI 0.80-0.96). Four trials using WHO/UNICEF training showed significant benefit in prolonging exclusive breastfeeding (RR 0.70; 95% CI 0.53-0.93), but were highly heterogeneous. The authors highlight the need to assess support in different settings especially with low rates, conduct economic analyses and use qualitative research to explore specific elements of support. Dyson et al. [ 54 ] focused on breastfeeding initiation rates and indicated from a meta analysis of five studies (n=582) that breastfeeding education had a significant effect on increasing initiation rates (RR 1.57, 95% CI 1.15-2.15, p=0.005) compared to standard care in low income groups although substantial statistical heterogeneity was noted (I 2 =53.4%). Early skin to skin contact was reviewed by Moore et al. [ 55 ] who reported statistically significant effects of early skin to skin on breastfeeding at one to four months post birth (OR 1.82, 95% CI 1.08-3.07) and breastfeeding duration (WMD 42.55, 95% CI −1.69 -86.79). In this review, data from more than two trials were only available for a small number of outcomes (8/64). Ahmed & Sands [ 56 ] reviewed breast feeding interventions. While the authors were unable to conduct a meta analysis they found from individual trials, statistically significant results relating to kangaroo care, peer counselling, in home breast milk measurement, and post discharge lactation support for improving breast feeding outcomes.

One review focused on improving maternal mental health and considered postnatal psychological and psychosocial interventions [ 57 ]. Dennis & Hodnett [ 57 ] reported that any psychosocial or psychological intervention compared to usual postpartum care was associated with a reduction in the likelihood of continued depression from their review of nine trials. Examples of psychosocial and psychological interventions reviewed included non-directive counselling, supportive interactions, delivered via telephone, home or clinic visits, or individual or group sessions in the postpartum period by a health professional or lay person, cognitive behavioural therapy and interpersonal psychotherapy.

Education and support

One review considered support for women in relation to weight reduction in the post partum period [ 58 ] focusing on the effect of diet or exercise or both for reducing weight after childbirth. They found that women who took part in a diet (1 trial; n=45; WMD −1.70 kg; 95% CI −2.08 to −1.32; z=8.73; p<0.00001), and women on a diet plus exercise programme (4 trials; n=169; WMD −2.89 kg; 95% CI −4.83 to −0.95; z=2.92; p<=0.00049), lost significantly more weight than women in the usual care. The authors also noted that there was no adverse effect on breastfeeding, although cautioned that further research is necessary to confirm this finding. Three reviews considered extra support for vulnerable groups of women in the form of home visiting or parenting interventions [ 59 - 61 ]. Corcoran & Pillai [ 59 ] reviewed rates in repeat pregnancy following the introduction of hospital-based programmes providing education and counselling to a sample of adolescent mothers. They found that although there was a 50% reduction in the odds of repeat pregnancy compared to comparison-control conditions at 19months (OR 0.474; 95% CI 0.322-0.695), the effect had dissipated by 31 months. All studies were US based and the majority conducted in low income groups (74%) and African Americans (60%). Two reviews focused on parenting interventions [ 60 , 61 ]. Pinquart and Teubert [ 60 ] reported small effects on parenting, parental stress, child abuse, health promoting behaviour, cognitive, social development, motor development, child mental health, parental mental health & couple adjustment from parenting education interventions. Vanderveen et al. [ 61 ] demonstrated an overall positive effect on neurodevelopment from early parental interventions (all involved teaching or enhancing parental skills) lasting up to 36 months. Meta analysis of twelve studies indicated higher cognitive scores at 12 months (WMD 5.57; 95% CI 2.29-8.86; p=0.0009), at 24 months (7 studies; WMD 7.59; 95% CI 5.01-14.31; p=0.0003) and at 36 months (2 studies; WMD 9.66; 95% CI 5.01-14.31; p=0.0001), but not at 5 yrs (3 studies p=0.24). The authors suggest further research is needed to clarify the most effective interventions and the long term effect.

Logic model

The parallel development of the logic model resulted in a summary model (Figure ​ (Figure2) 2 ) provides a framework to visualise interventions across the perinatal period and the potential short, medium and long term impact on the health of women, their families and the community. Logic models display relationships between the core elements (context; inputs; outputs and outcomes) and the basic concept is to read from left to right, following a sequence of reasoning. An example of this is provision of education and information about screening in the antenatal period; an aspect of care where inequalities are known to occur [ 62 ]. The context in this example refers to the cultural, political, social circumstances in which the provision of screening is situated. Reading from left to right on the model indicates that the midwifery public health intervention is next so for example if a midwife provides information about antenatal screening for HIV (input), then uptake of screening may improve and at risk women will be identified earlier (outputs) and the effect will improve maternal and infant health during pregnancy. The medium and longer term outcomes are the resultant reduction in morbidity and or mortality in the local population.

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Summary Logic Model.

The focus of this paper is the development of the public health role of the midwife based on effective interventions and highlighting the short, medium and long term effects that these interventions could bring about. Any intervention must be considered within the context in which it is to be delivered as inequalities, resources, culture and vulnerable groups can influence the choice of intervention to best suit the population of women being served. The second column represents the inputs or activities; these are the interventions which are intended to bring about the change in outcomes. In relation to public health and midwifery these are interventions that may impact on public health primarily through education, screening and support. The outputs are the products or the targets of the service delivered and can been seen in the boxes entitled organisation of care under short and medium term outcomes. While the logic model provides a visual outline of midwifery public health roles, using this approach facilitates understanding of how public health programs can be planned and subsequently evaluated. Conducting the data synthesis in tandem with developing the logic model has also highlighted where the gaps in knowledge are and identified areas where midwives could potentially have a much greater role and subsequent impact on public health.

This paper sought to report on systematic reviews providing high quality evidence of effective interventions, in essence the ‘cream of the crop’. Reviews reporting on effective interventions were those which presented a statistically significant meta analysis or where the intervention was supported by a generally positive trend of results when a meta analysis was not possible to ensure the recommendations of the paper are based on strong evidence of good quality. There were a number of reviews included which presented statistically significant positive findings. However, in some cases these were limited by small numbers of participants or small numbers of trials included in the review. As a result of conducting the review and analyzing eligible systematic review evidence, three key areas for future consideration were identified including: recommendation and implementation of effective evidence; gaps in knowledge and developing the role of the midwife in public health which are discussed further in the following sections.

Recommendation and implementation of effective evidence

It is clear from this review of effective interventions, there are areas where evidence has been incorporated into guidelines and thus recommended for implementation into routine practice. However, it has also highlighted many areas where it has not. There has been extensive debate and commentary in the literature about knowledge transfer and translation of knowledge into practice, however, this paper confirms that despite the existence of good quality evidence, the gap remains. From this review, several effective interventions were identified, which are already recommended as routine practice, for example education about folic acid supplementation and pelvic floor muscle training to prevent or reduce the risk of urinary incontinence are advocated by current practice guidelines in the UK [ 63 ] and further afield [ 64 , 65 ]. However, to evaluate fully the extent to which guidelines have been applied it is essential to audit practice in order to provide evidence for knowledge transfer. To encourage implementation of NICE guidelines, audit support tools have been developed by NICE on antenatal care or diabetes in pregnancy for use at local level. Effective interventions were also identified which could easily be implemented by a midwife and could potentially impact on public health, such as education programs for parents of preterm infants and implementation of specific strategies to reduce caesarean section rates. Although there is recognition by health professionals these areas are important, this review provides definitive evidence and examples from systematic reviews, of interventions that are effective. Further consideration needs to be given to how to translate these effective interventions into practice using appropriate channels which are effective to facilitate knowledge transfer. These may include stronger collaborations between clinicians and academics and increasing the exposure students have to systematic reviews in education curricula at undergraduate level. Other effective interventions have been implemented on an ad hoc basis for example additional lay or professional support for breast feeding women and strategies to reduce caesarean section rates, which need to be included specifically in policy and strategy documents to ensure widespread implementation and thus contribute to an evidence based public health agenda to improve the health of women and families. Although this paper has focused on reporting effective interventions it is also important to take cognisance of those interventions that are not effective i.e. those which do not work and sometimes are deeply embedded into practice, for example, routine antenatal CTG for fetal assessment [ 20 ]. It was not possible to discuss reviews that demonstrated no effect within this current paper, however, Table ​ Table2 2 provides summary details of the areas where this was the case.

Gaps in knowledge

The review identified many gaps in systematic review literature relating to core midwifery practice, which potentially could impact on public health population goals. The UK Department of Health, Public Health Strategy [ 66 ] emphasizes the importance of improving maternal health and the subsequent impact on reducing infant mortality and premature births and yet this review identified limited systematic review evidence to support the implementation of midwifery interventions that could impact on perinatal morbidity and mortality. The review also highlighted it was difficult to accurately assess the potential public health impact in terms of effectiveness as some interventions were not well evaluated, evidenced by the large number of inconclusive reviews and reviews demonstrating no effect. The review of reviews identified some interventions that were effective but were limited in terms of methodological quality of included studies, for example, small numbers and design flaws, thus demonstrating the need for robust research and evaluation. One example of this is systematic review evidence in relation to weight management or obesity; a topic of growing concern to maternity care providers and yet the evidence from systematic reviews is limited in terms of quality. The systematic reviews included in the original review generally indicated that additional support related to diet or exercise for women in the postnatal period was effective, however, only one review was of a high quality. Another example of this is the evidence around home visiting for vulnerable groups of women in the postnatal period. While a significant body of research, including longitudinal studies has been published on parenting interventions indicating generally positive effects [ 67 , 68 ] the evidence from this current systematic review of reviews is mixed. Current early years governmental policy in the UK focuses on giving children the best start in life and various interventions have been, or are currently being rolled out, for example, SureStart and the Family Nurse Partnership, however the longer term impact on women and families remains to be seen. Logic models highlight the causal linkage between inputs, outputs and outcomes (24). This is illustrated very clearly in relation to support for parents in the form of parenting interventions (input) which can result in the short term outcome of increasing support for women to improve health and lifestyle; optimize lifestyle and child development beyond the immediate perinatal period (medium term) and in the long term improve family health and wellbeing for this generation and those to come.

Developing the role of the midwife in public health

In order for midwives to utilise their potential in relation to public health it is important not only to consider the interventions that could be implemented but also take cognisance of wider strategies and policy relating to public health. The logic model (Figure ​ (Figure2), 2 ), which was developed as a parallel process to the review, provides an overarching framework that should be used by midwives to visualise their contribution to public health. The model illustrates possible future roles but also facilitates recognition of the current contribution of midwives to improving the health of women and their families as part of their core role. An example of this is how vulnerable women (either social or medical) could be identified in the antenatal period by midwives and a supportive or educational intervention implemented which would result in improved outcomes in the short term i.e. reduced pre term birth or improved birth weight. A medium term outcome of this intervention would focus on optimising lifestyle beyond the perinatal period for example collaborating with health visiting services to provide education and support that would potentially have a longer term outcome of improved family health and well being. The review did not identify any systematic reviews which specifically focused on interventions relating to midwifery public health roles, highlighting a gap in review evidence. Biro [ 69 ] suggests it may be challenging for midwives to think beyond individual women but ultimately necessary in order to meet the challenge of public health to improve population health. Reframing routine midwifery activities in a public health context, identifying midwives as public practitioners and building on existing activities, such as collaboration, organisation of care and interagency working are essential to clearly define the relationship between midwifery and public health. An earlier, wider review on health-led parenting interventions in pregnancy and the first three years of life [ 8 ] suggested that many interventions, particularly in relation to supporting parenting, could be provided as part of routine care and that although the optimal time to start programmes was not clear, there was some consensus that those initiated in the antenatal period were more effective. Development of the public health role of the midwife will also require strategic thinking and support from planners and commissioners of maternity services to ensure that midwives can influence policy and effectively implement public health strategies. This will involve dedicating time and resources to develop local policies, providing training for midwives and building good relationships with other healthcare disciplines to work together.

Limitations

There are a number of methodological challenges in using systematic review evidence which must be taken into account. It is difficult to summarise the evidence from systematic reviews as often there is significant diversity between interventions included in individual reviews or outcome measures used. In addition the results presented may be inconsistent between reviews or inconclusive, however, Smith et al. [ 14 ] suggest the strength of systematic reviews of reviews is that the best quality reviews can be highlighted in a single document. Systematic reviews are generally limited to published work and thus may be subject to publication bias. In addition, more recent, potentially conflicting, research may be available since the review was published or there may be effective interventions that have not been evaluated in a systematic review. A recent Cochrane overview of systematic reviews [ 70 ] highlighted that such reviews provide an accessible summary on the totality of the evidence in the area and minimised the need for referral to individual reviews, however suggested that readers may wish to do so for specific details. This review was similar in that it covered a broad scope of the evidence in relation to public health, providing a strategic overview while also providing a valuable resource for those who wish to consult individual reviews for additional specific details. In this paper, only high quality reviews (based on level of included evidence and methodology of review) reporting on effective interventions were included. While this provides reassurance regarding review findings, in that the conclusions are based on top level evidence, some interventions demonstrating effect may have been excluded because the review itself did not meet either the quality or level of evidence criteria for inclusion. In most cases this relates to areas worthy of future investigation, which need more robust evaluations. The search strategy utilised in the review was specifically focused on the public health role of the midwife and therefore incorporated key terms relative to key areas. However in doing so, some postnatal interventions, which extend beyond the role of the midwife, for example, parenting interventions that continue into early childhood may not have been included. In addition, due to the inclusion and exclusion criteria applied, it is possible that extensive broad reviews on particular topics have been excluded from this review due to the nature of evidence included within them, for example, the NICE Guideline on Antenatal and Postnatal Mental Health [ 9 ]. However, it is recognised these are valuable resources and contribute to wider understanding on specific subjects.

This paper has reported on high quality effective interventions identified from a larger systematic review on public health interventions that could be delivered primarily by midwives or maternity care providers. From the effective interventions identified it is clear that while some have been recommended for implementation into routine practice, others have not. This highlights the continuing gap between evidence and practice and the need for professionals and researchers to work better together to ensure specific interventions that are effective, are translated into practice and subsequently audited to provide evidence of knowledge translation. The public health role of the midwives has not been well researched or reviewed and the impact of everyday midwifery practice on longer term, holistic maternal and family well-being outcomes is poorly articulated in review literature. A shift in research, policy and practice is needed to fully articulate the public health role of the midwife. This systematic review of systematic reviews identifies a number of effective interventions that provide a useful starting point on which to build future practice. The logic model demonstrates the need to fill in major gaps in our knowledge on effective interventions to achieve both short and long term public health benefits for women and their families. Such benefits will remain elusive without investment in a collaborative, strategic approach to the role of public health in midwifery.

Competing interests

The authors declare that they have no competing interest.

Advisory group members

Ms Liz Bannon , Senior Midwife, & Co Director of Maternity Services, Social Services, Family & Child Care Belfast Health and Social Care Trust, Belfast, Northern Ireland; Professor Debra Bick , Professor of Evidence Based Midwifery Practice, Kings College London, England; Dr Helen Cheyne , Nursing, Midwifery & Allied Professions Research Unit, University of Stirling, Scotland; Professor Mike Clarke , then Professor of Clinical Epidemiology & Director of UK Cochrane Centre, now Professor/Director of MRC Methodology Hub, Queen’s University Belfast; Ms Joanne Gluck , Consumer Representative; Professor Billie Hunter , Professor of Midwifery, Swansea University, Wales; Dr Dermot O’Riley , Centre of Excellence for Public Health Northern Ireland, Queen’s University Belfast, Northern Ireland.

Authors’ contributions

JM extracted and interpreted data and wrote the first draft of the manuscript. FL conducted the searches of the literature, extracted and interpreted data and assisted with the manuscript. FA extracted and interpreted data and assisted with the manuscript. All authors read and approved the final manuscript.

Pre-publication history

The pre-publication history for this paper can be accessed here:

http://www.biomedcentral.com/1471-2458/12/955/prepub

Acknowledgements

We would like to thank all members of the Advisory Group for their contribution and guidance throughout the project. In addition, we would like to thank Midwifery 2020 for funding the original review and in particular, The Public Health Workstream Group who commissioned the original review.

Source of funding

The original review was funded by NHS Education for Scotland, Midwifery 2020, UK.

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Public Health in Midwifery: Reflective Essay Sample

In this reflection essay sample, we explore not just the art of midwifery, but the heart and soul of public health promotion within it.

PUBLIC HEALTH IN MIDWIFERY: A REFLECTION

Introduction

Public health promotion is critical in midwifery practice (Soucy et al., 2023). It ensures that mothers and newborns receive best clinical outcomes (Smith et al., 2017). As such, midwives must understand the principles and practices of public health promotion. This knowledge enables midwives to work with mothers, families, and communities to improve their health and well-being (De Leo et al., 2019; McLellan et al., 2019). This reflection focuses on my experience of developing a health promotion poster for Sudden Infant Death Syndrome (SIDS) using the Gibbs reflective model. It will explore the importance of effective communication and collaboration. It also outlines the significance of using health promotion models in promoting midwifery practice. Additionally, it evaluates the influence of psychological, social, cultural, political, and economic factors on women and their families.

Reflection is an essential component of professional development in midwifery practice (Koshy et al., 2017). It enables midwives to examine their practice, identify areas for improvement, and take action to enhance their skills and knowledge (Sweet et al., 2019). Reflective practice also provides midwives with an opportunity to learn from their experiences (Sweet et al., 2019). It integrates new knowledge and skills into their practice and improves the quality of care they provide (Sweet et al., 2019). I have selected Gibbs’ reflective model for this evaluation.  It consists of six stages, which are description, feelings, evaluation, analysis, conclusion, and action plan (Gibbs, 1988). This model provides a structured approach to reflection. As such, it facilitates the evaluation of experiences and development of actionable insights for application in future practices (Gibbs, 1988).

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Description

The task of developing a health promotion poster was an opportunity to raise awareness about a critical public health issue affecting infants. Sudden infant death syndrome (SIDS) is the sudden and unexpected death of a baby under one year of age (Jullien, 2021). It is the leading cause of infant mortality in developed countries (Osei-Poku et al., 2021). As such, healthcare organizations prioritize promoting the use of safe sleep practices to reduce the risk of SIDS. As part of the development process, I worked with a team of health promotion specialists who were responsible for developing and implementing health campaigns. The team was made up of individuals with skill sets. These skills include graphic design, content development, and project management. We had regular team meetings to discuss the progress of the project (Persson et al., 2021). During the meetings, we shared ideas on how to improve the poster’s content and design.

However, we encountered challenges that tested our teamwork and communication skills. For instance, we had to balance the workload of the different team members. We ensured that team members had equal shares of the responsibilities (Rosen et al., 2018). Also, we communicated effectively to ensure that team members understood the project’s objectives and goals (Schilling et al., 2022). There were significant technical difficulties that arose during the project’s execution. For example, we initially faced difficulties with incorporating the relevant information into the poster design in a visually appealing and easy to read manner. However, we overcome these challenges by working collaboratively (Schmutz et al., 2018). This teamwork enabled us to develop a poster that effectively communicated the key messages about SIDS prevention.

The experience of working with the team had a positive impact on my professional development. It taught me the importance of teamwork and communication in achieving a common goal (Rosen et al., 2018). I realized that working collaboratively leads to a more effective and efficient outcome than working alone (Rosen et al., 2018). Additionally, working in a team environment enabled me to learn new skills from my colleagues such as graphic design and project management. These skills are essential since I can use them in my future projects. This experience had a positive impact on my professional development. It taught me the importance of teamwork and communication in achieving a collective objective (Rosen et al., 2018).

Throughout the process, I experienced a range of emotions. At first, I felt overwhelmed and unsure about where to start. I was unsure if I had the necessary skills to create an effective poster. This was due to my limited experience in health promotion and graphic design. However, I began to feel more confident in my abilities after delving deeper into the topic. I found the research process to be enjoyable and engaging. During this process, I learned more about the risk factors and prevention strategies for SIDS. I was motivated by the idea that the poster we were creating could raise awareness SIDS and potentially save lives.

As the project progressed, I experienced a range of emotions related to teamwork and communication. At times, I felt frustrated by the workload and the pressure of meeting deadlines. I also felt uncertain about how to communicate effectively with my team members. The team members had different skill sets and perspectives (Gander et al., 2022). However, I recognized that these challenges were an opportunity to develop my communication and teamwork skills. In addition, I experienced a sense of satisfaction by seeing the project take shape. Seeing the information and graphics come together and communicate the key messages about SIDS prevention effectively was rewarding.

However, I felt a sense of pressure to ensure that the final product was quality and would be well-received by the target audience. In reflection, I believe that my initial feelings of inadequacy and uncertainty were due to inexperience in health promotion and graphic design. However, I engaged with the research process and collaborated with my team members (Anderson et al., 2021). This enabled me to overcome the feelings and develop the necessary skills to contribute effectively to the project. Regardless, I developed positive emotions such as enjoyment and satisfaction. These emotions emerged from my sense of purpose and motivation to contribute to a critical public health issue. I believe that having a sense of purpose and meaning in an individual’s work is essential for achieving job satisfaction and personal fulfillment.

The negative emotions I experienced such as frustration and pressure were due to the challenges inherent in the project’s development process. Challenges such as workload and communication difficulties are common in team-based projects (Zajac et al., 2021). However, they are an opportunity to develop communication and teamwork skills. These skills are valuable in future projects. On that note, the process of developing a health promotion poster for SIDS was an emotional journey. It taught me valuable lessons about communication, teamwork, and personal growth. These lessons and experiences enable me to develop a greater appreciation for the importance of preparedness and teamwork in achieving a common goal... Read more

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Reference List

Abebe, H., Beyene, G.A. and Mulat, B.S., 2021. Harmful cultural practices during perinatal period and associated factors among women of childbearing age in Southern Ethiopia: community based cross-sectional study. PloS One, 16 (7), pp.1-14. https://doi.org/10.1371/journal.pone.0254095

Ackley, B.J., Ladwig, G.B., Makic, M.B.F., Martinez-Kratz, M.R. and Zanotti, M., 2021. Nursing diagnosis handbook (12th ed.) . London: Elsevier Health Sciences.

Ahn, Y.M., Yang, K.M., Ha, H.I. and Cho, J.A., 2021. Cultural variation in factors associated with sudden infant death during sleep. BMC Pediatrics, 21 (1), pp.443-456. https://doi.org/10.1186/s12887-021-02894-8

Anderson, J.E., Lavelle, M. and Reedy, G., 2021. Understanding adaptive teamwork in health care: progress and future directions. Journal of Health Services Research & Policy, 26 (3), pp.208–214. https://doi.org/10.1177/1355819620978436  

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Integrating public health practice into the graduate's role through pre-registration education

Christine Furber

Reader and Lead Midwife for Education, University of Manchester

View articles

Helen Pusey

Senior lecturer in mental health, University of Manchester

Alison Busby

Senior lecturer in midwifery, University of Manchester

Eileen Stringer

Consultant midwife in public health, Pennine Acute Hospitals NHS Trust

Public health is now clearly defined in policy and statute as an integral part of the midwife's role and this work continues to develop as health challenges emerge and diversify.

To clarify the knowledge and skills required by contemporary midwives, this article provides an overview of health promotion and public health concepts and discusses how these are embedded in midwifery policy. The approaches and processes midwives should adopt are considered and an analysis of public health learning in midwifery education highlights areas that need to be addressed. This paper concludes with recommendations for midwifery pre-registration education to develop the underpinning public health knowledge and skills that midwives require for optimum practice.

Midwifery public health practice has significant potential for minimising mortality and morbidity in future populations. Many debilitating health conditions such as diabetes, heart disease, and some cancers may be prevented if lifestyle choices and the environmental conditions people live in are improved ( Power et al, 2013 ). This article reviews how public health has been incorporated into the midwife's role over time, and discusses the effectiveness of midwifery education in preparing students for this aspect of their work. We also offer some recommendations for integrating public health theory and practice into contemporary pre-registration midwifery education.

Public health and health promotion concepts

The historical emphasis on the prevention of infectious disease, through access to clean water and safe disposal of sewage, illustrates the medical and social policy roots of public health ( Phin, 2009 ). Epidemiology is closely aligned to public health as it provides data about the factors associated with different health problems ( Adetunji, 2009 ). The notion of ‘educating the public for the good of its health’ emerged early in the 20th century, ( Naidoo and Wills, 2009 ). Early examples include posters and lectures to educate First World War military about venereal disease. These and other education strategies were used increasingly through the 20th century to tackle lifestyle diseases such as heart disease, stroke, and cancer ( Naidoo and Wills, 2009 ). However, health education methods are often criticised for their ‘victim blaming’ and lack of awareness of the impact of social context on individual's behaviours ( Scriven, 2010 ).

The terms ‘health promotion’ and ‘public health’ are often used interchangeably, although health promotion is sometimes seen as a means of achieving public health goals ( Naidoo and Wills, 2009 ). The Ottawa Charter ( World Health Organisation (WHO), 1986 ) outlined five key areas for health promotion practice (see Box 1 ).

‘In maternity care, public health practice has moved from simply providing information (education) to facilitating informed decision-making (empowerment), to partnership working with women and families to develop community initiatives together’

These key areas indicate how health promotion has a much broader remit than just education, and involves working with communities and wider populations as well as individuals. Today, health promotion is used as an umbrella term, encompassing strategies such as education, advocacy, using models of behaviour change, facilitating informed decision-making, empowerment, environmental health, community development initiatives, political lobbying, mass media communication, health needs assessment, audit, and practice development ( Piper, 2005 ; Scriven, 2010 ; Hubley et al, 2013 ).

Public health in midwifery policy

Since the signing of the Ottawa Charter ( WHO, 1986 ), UK health services have placed increasing emphasis on the prevention of disease and the promotion of health, and a range of public health practices have developed. In maternity care, public health practice has moved from simply providing information (education) to facilitating informed decision-making (empowerment), to partnership working with women and families to develop community initiatives together (e.g. breastfeeding support groups).

Over the last 25 years, successive UK government policies on maternity care, such as Changing Childbirth ( Department of Health (DH), 1993 ), Making a Difference ( DH, 1999 ), A Framework for Maternity Services in Scotland ( Scottish Executive 2001 ), National Service Frameworks for Children, Young People and Maternity Services ( DH, 2004 ), Maternity Matters: Choice, Access and Continuity of Care in a Safe Service ( DH, 2007 ) have all called for the development of the midwife's role in health promotion. The Midwifery 2020: Delivering Expectations report ( Chief Nursing Officers (CNO) of England, Northern Ireland, Scotland and Wales, 2010 ) again emphasises that future midwives must have a greater focus on public health and should become actively involved in developing services that work towards minimising health inequalities.

Similarly, the Marmot Review (2010) stresses that tackling heath inequalities is a key challenge for health professionals and recommends that focusing efforts at timely points along the health continuum may achieve maximum gain. For example, the provision of effective antenatal care for a disadvantaged woman not only improves her health but significantly improves the health and life chances of her child across their whole life course ( The Scottish Government, 2010 ).

Considerable evidence from high-income countries indicates that poor perinatal outcomes are associated with low socioeconomic backgrounds. For example, Vos et al (2014) conclude that living in a deprived neighbourhood is associated with preterm birth, being small-for-gestational-age and stillbirth. While this association is recognised, it must also be acknowledged that the women most at risk of poor outcomes are often the least likely and least able to access antenatal care ( Kapaya et al, 2015 ; Phillimore, 2016 ). Improving access to antenatal care and ensuring that this provision is strongly focused on health promotion must be seen as a vital contribution to the wider public health strategy ( Public Health England (PHE), 2014 ). Furthermore, in an era of austerity and service reform, the fact that this approach can lead to significant financial savings cannot be ignored. For example, the Scottish strategy to reduce poor health outcomes recognises that promotion of healthier pregnancies and management of comorbidities leading to premature births will reduce demand on neonatal and paediatric services in the short-term and a wider range of public services in the long-term ( The Scottish Government, 2010 ).

The role of the midwife

The Midwifery 2020: Delivering Expectations report ( CNO, 2010 ), describing the changing picture of UK maternity services, highlights that midwives are caring for growing numbers of women with complex health needs such as older mothers, obese women and those with significant mental health conditions. There are also increasing numbers of pregnant women with limited English and significant social disadvantage ( Knight et al, 2016 ). Similarly Sanders et al (2016), when exploring midwives' public health role, confirmed the complexity and breadth of health challenges that they encounter. It is clear that in today's society, the woman's social context and its consequences should be considered as carefully as her medical and obstetric risk.

Public Health England (PHE, 2014 ) has clearly articulated how the midwife's role may enhance health and wellbeing for individuals, communities, and wider populations. Firstly, midwives are to directly affect perinatal mortality by following strategies such as reducing smoking rates, lowering the incidence of infection, and improving antenatal surveillance. To achieve these goals, they are encouraged to ‘make every contact count’—a key concept in the strategy to ‘help people to stay independent, maximise wellbeing and improve health outcomes’ ( DH, 2013 ). The recent review of UK maternity services has been responsible for strengthening the midwives' public health role in key areas such as poor maternal mental health ( National Maternity Review, 2016 ).

These expectations are laudable as midwives clearly have the potential to improve the health and quality of life for mothers and their babies in both the short and long-term, and so influence overall population health. However treating health promotion as a ‘bolt-on’ extra to existing maternity provision may simply foster the development of additional services ( Jones et al, 2002 ). Wwhat in fact is needed is a wholesale transformation of midwifery services that promotes models of working that embed midwifery into the wider social framework of health and wellbeing. For example, midwives working within a social model of care based in community settings such as Children's Centres are much more able to discuss health issues, facilitate interventions and help parents access services that address wider aspects of health, such as young parent outreach, economic, education and employment support, and safeguarding services ( Stringer and Butterfield, 2005 ). However, to achieve the wide-ranging outcomes of the public health agenda, the midwifery workforce needs relevant knowledge and appropriate skills, including the ability and willingness to engaging in multidisciplinary working ( DH, 2013 ).

As public health activity often has a long-term outlook, the outcomes may not be observed for years or even decades into the future, so the benefits of public health practice are often not immediately obvious. Evaluation of such services and research into satisfaction, feasibility, and outcomes is essential to improve the evidence base and inform education and service development.

Incorporating public health activity in midwifery practice is not new. Audrey Wood (1957), then general secretary of the Royal College of Midwives (RCM), persuasively argued that the midwife should be engaged in activities supporting the future health of populations, especially health education and working with multidisciplinary teams. Definitions of the midwife have consistently cited health education and counselling as integral to this role ( Central Midwives Board, 1978 ; NMC, 2009). More recent definitions have encompassed a partnership role with women and families, the promotion of wellbeing ( Chief Nursing Officers of England et al, 2010 ; ICM, 2013 ), and consideration of health across the life-span ( DH 2013 ; Walsh, 2013 ). In midwifery practice today, these activities include smoking cessation, screening tests, nutrition advice, and support regarding the management of raised body mass index. Midwives undertake surveillance to identify those women affected by mental ill-health and domestic abuse, and specialist midwives focus on groups with particularly complex needs, such as asylum seekers, and those affected by HIV. Furthermore, public health practice is now multidisciplinary and includes other health professionals, local authority services, social scientists, the voluntary lay sector and public and private organisations working together ( West-Burnham, 2017 ). The RCM, recognising the need to support existing midwives with this expanding aspect of their work, have devised a public health model for practice and a range of online resources ( RCM, 2016 ).

‘What in fact is needed is a wholesale transformation of midwifery services that promotes models of working that embed midwifery into the wider social framework of health and wellbeing’

Public health in midwifery education

Public health learning in midwifery education was limited until the 1990s, when the Acheson Report ( DH, 1998 ) gave a high priority to reducing inequalities for childbearing women and young children, providing a mandate to embed public health and health promotion within the role of the midwife. In addition, the Labour government put these issues firmly on the agenda with their Making A Difference policy ( DH, 1999 ). However, the literature on public health education in midwifery programmes remains sparse ( McNeill et al, 2012 ). In 1995, public health education in midwifery programmes was based on a medical model using ‘information giving’ strategies to tell people what they needed to do, thus reflecting a top-down approach to health promotion ( Smith et al, 1995 ). The main topics considered to be part of the midwife's remit included smoking, sexually transmitted infections, domestic abuse, parent education, and breastfeeding ( Smith et al, 1995 ). Placements for student midwives were also medically or obstetrically focused with little opportunity to learn about the wider social aspects of health ( Smith et al, 1995 ). McNeill et al (2012) explored the incorporation of public health and health inequalities education in midwifery education programmes across the UK and found this to be very variable. Indeed, three institutions reported that they did not cover the principles of public health; five did not teach any epidemiology, and the topics of homelessness, obesity, diet, and alcohol were only covered in a limited manner ( McNeill et al, 2012 ). McKay (2008) and McNeill et al, (2012) both concluded that student midwives had limited understanding of the midwives' role in health promotion, and lacked awareness of the practical application of public health. In contrast, a small study recently reported that students felt well-prepared for their public health role (Sanders et al, 2016). Sanders et al (2016) noted that student midwives included discussions between midwives and women about flu and whooping cough vaccinations, and intrapartum strategies such as optimal timing of newborn cord clamping after the birth as part of midwives' public health role.

Studies with midwives have revealed variable attitudes and approaches towards their public health role—some considered it to be irrelevant, while others believed it to be very important ( Lavender et al, 2001 ). Furber (2000) found that while midwives stated that they preferred approaches focusing on populations, they were more likely to use individual ‘information giving’ approaches to promoting health. Other evidence indicates that midwives are reticent in addressing some public health topics. For example, Lazenblatt et al (2010) surveyed hospital and community midwives throughout Northern Ireland and although most respondents (92%, n=448) reported that they felt midwives had a role in supporting women who were victims of domestic abuse, only 28% (n=135) had asked women about this. Taylor et al (2013) confirmed that health professionals, including midwives, lacked confidence in discussing domestic abuse with women. Other studies indicate that midwives are hesitant about broaching the subject of smoking because of concern over jeopardising the midwife-woman relationship ( Condliffe et al 2005 ), or beliefs that smoking cessation is not a high priority for women ( Hill et al, 2013 ). More recently, almost a quarter of third-year midwifery students across the UK reported that they do not feel confident in recognising mental illness and emotional wellness ( RCM, 2014 ). This is concerning as psychiatric illness has consistently been reported as a predominant cause of maternal death in the UK over recent years, and inadequate multidisciplinary working is a known contributory factor ( Knight et al, 2015 ). Emerging evidence also stresses the potential impact of poor maternal mental health during the first 1 000 days of a child's life, on mother–child relationships, early development, and on the child's future health and wellbeing ( Leadsom et al, 2013 ; Kingston and Tough, 2014 ). So again, the potential deficit in midwifery skills for recognising those at risk and supporting mothers with mental health challenges is worrying.

To enable midwives to fulfil the public health duties associated with their role, the development of the following knowledge and skills within pre-registration programmes needs to be strengthened by the implemention of:

  • development of communication skills, including cultural competence
  • development of skills for and positive attitude towards multidisciplinary working
  • assessment of the psychosocial context
  • knowledge of support systems focusing on psychosocial challenges
  • promotion of models of care that foster continuity of carer(s)
  • promoting and supporting breastfeeding and responsive parenting
  • supporting women and their partners during the postnatal period and in the transition to parenthood.

Recommendations for integrating public health in pre-registration midwifery education programmes

Whitehead (2007) proposed that public health education should be an obvious theme cutting through curricula. The spiral curriculum model ( Neary, 2002 ), incorporating iterative processes, will facilitate this. Using this model, learning starts at a descriptive level early in the programme, and is revisited several times later in the course at a deeper and more analytical level when topics are reviewed and applied to more complex situations ( Harden and Stamper, 1999 ). The spiral model fosters synthesis as students build on previous knowledge when they have greater expertise through practical experience and intellectual maturation ( Harden and Stamper, 1999 ; Neary, 2002 ). Furthermore, evaluations of spiral curricula indicate that this model makes learning more manageable for students as it facilitates topic familiarity ( Grove et al, 2008 ). Using the example of breastfeeding education early in a 3–year programme, students learn about the physiology of lactation, simple care practices that support breastfeeding and how the psychosocial context affects mothers' feeding choices and practices. Later in the programme, they explore the challenges mothers can experience, and review breastfeeding support needs in more complex scenarios. Finally, using public health principles and concepts within contemporary health policy, they develop their skills for breastfeeding promotion through strategies that support mothers at individual, community and national levels, for example, honing their skills for one-to-one mother-centred discussions about feeding, developing innovations such as establishing local breastfeeding support initiatives and using evidence to lobby for policy change.

Exposure to public health/health promotion knowledge and practice

Education by knowledgeable teachers and public health specialists ( Whitehead, 2007 ) who can accurately link the discussion topic to health inequalities is vital for students to really engage with this material ( Mabhala, 2013 ). For example, a session about mental health disorders should include discussion of how mental health challenges affect women and their children both in the short term and in their future life. This could be followed up with a consideration of the skills midwives need to identify and support at–risk women and examples of relevant local public health initiatives and services developed or used by midwives. The application of theory to practice is an important part of learning and understanding for health professionals (McKay, 1998), so teaching methods should facilitate this, enabling students to meld public health knowledge into their core midwifery understanding ( Mabhala, 2013 ).

Jones et al (2002) argue that if one is to successfully integrate health promotion into care one must move away from the narrow focus on lifestyle and offering ‘heavy-handed advice’, which marginalises the socioeconomic and environmental influences on health. Instead, the universities should be equipping students with the skills to empower women and support them to make small but significant changes to their circumstances and behaviour. Important skills include being able to create an environment where information is a transaction between client and professional and being an effective advocate, representing the interests of women and their families when they cannot speak for themselves because of illness, disability, or disadvantage ( Scriven, 2010 ).

Incorporating the concept of salutogenesis into midwives' public health education is one method that may be utilised to enhance wellbeing ( Lindstrom and Eriksson, 2005 ). Salutogenesis focuses on wellbeing and an individual's capacity to solve problems and develop a ‘sense of coherence’ ( Antonovsky, 1979 ). The utilisation of these principles may support the development of strategies and interventions that may promote health and wellbeing for childbearing women ( Ferguson et al, 2013 ).

Furthermore, in order to assess needs and develop new public health interventions relevant to that population, students require opportunities to gain skills in data collection and analysis ( Naidoo and Wills, 2009 ).

While lectures and reading are important pedagogical methods, in order to develop higher levels of understanding and critical thinking, interactive teaching methods (face-to-face or online) including discussion and debate with peers are important to enable students to engage, consider other viewpoints, and challenge attitudes ( Crookes et al, 2013 ). Case scenario discussion and problem-based learning are particularly useful for critical review of collaborative working and thinking laterally ( Mabhala, 2013 ). Online case study discussions may also promote in-depth learning ( Sheringham et al, 2015 ). The ‘unfolding case study’, using a scenario that progresses through the pregnancy, birth, and postnatal time period, enables discussion, reflection and decision-making on care and management to be reviewed as situations change ( Carr, 2015 ). Workshops, role-play (online and face to face), and video review for practising communication skills will support developing confidence in this area ( Berkhof et al, 2011 ; Warland and Smith, 2012 ). Furthermore, engaging in learning activities with students from other disciplines that midwives may work with, such as mental health nurses, pharmacists, doctors, and social workers, will develop awareness of professional roles, build confidence, and strengthen future multidisciplinary working ( Kilminster et al, 2004 ).

Clinical Placements

Exposure to clinical placements where public health practice can be observed is vital ( Whitehead, 2007 ). Examples include opportunities for students to spend time in children's centres to familiarise themselves with the range of facilities for families. ‘Bespoke placements’ with specialist midwives focusing on safeguarding, mental health, teenage pregnancy support, and sexual health will provide greater understanding of the specialist's role, expertise, and help clarify the students understanding of their role as midwives ( McNeill et al, 2012 ). Shadowing other professionals such as dieticians, social workers, family support workers, and welfare right officers, and visits to charities such as MIND and those supporting ethnic groups or refugees will enable students to broaden their understanding in supporting women and families with complex needs. Finally, exposure to clinical audit processes will improve skills in health needs assessment and service evaluation ( Naidoo and Wills, 2009 ).

Midwives have a key health–promoting function. Developing teaching about the public health role of the midwife within the undergraduate curriculum will enhance the knowledge, skills and motivation of newly qualified midwives and so contribute to improving maternal and infant health outcomes and the reduction of health inequalities.

CPD reflective questions

  • What are the benefits of health promotion for women and families?
  • How do you currently deliver health promotion to women and families in your care?
  • Which public health skills do you use in your current practice?
  • What are the areas of public health/health promotion practice that you need further support with to develop your practice?
  • How can you develop your knowledge, understanding and skills to develop your midwifery role to encompass effective public health practice?
  • Public health is integral to the midwife's role
  • Midwifery education is inconsistent in relation to topics covered, and evidence indicates that midwives lack the confidence to address important public health challenges
  • Key public health skills include empowerment, partnership working, advocacy and community development
  • Midwifery education should integrate public health theory and skill development through curriculum design, pedagogy, and relevant placements that provide opportunities for students to be exposed to wider public health work including addressing the psychosocial needs of women and families

Home — Essay Samples — Nursing & Health — Health Care Policy — The Role of the Midwife in the Healthcare

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The Role of The Midwife in The Healthcare

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Published: Sep 4, 2018

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Works Cited

  • Alberta Association of Midwives. (2012). Midwives in Alberta: Practice Guidelines Handbook.
  • Beattie, A. (1991). Health promotion models and values. Oxford University Press.
  • Bowden, S. (2006). Midwifery and the promotion of normality. Elsevier Health Sciences.
  • Davis, D. (2002). Continuing professional development for midwives: Challenges, opportunities, and strategies. Midwifery, 18(1), 4-8.
  • Dunkley, C. (2000). Health promotion in midwifery practice: A resource for health professionals. Elsevier Health Sciences.
  • Ewles, L., & Simnett, I. (2003). Promoting health: A practical guide. Elsevier Health Sciences.
  • Health Care Providers Handbook. (2010). Cultural sensitivity.
  • Nursing and Midwifery Council. (2008). The Code: Standards of conduct, performance, and ethics for nurses and midwives.
  • Royal College of Midwives. (2000). Vision 2000: A blueprint for the future of midwifery.

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Latitude varies from −90° to 90°. The latitude of the Equator is 0°; the latitude of the South Pole is −90°; the latitude of the North Pole is 90°. Positive latitude values correspond to the geographic locations north of the Equator (abbrev. N). Negative latitude values correspond to the geographic locations south of the Equator (abbrev. S).

Longitude is counted from the prime meridian ( IERS Reference Meridian for WGS 84) and varies from −180° to 180°. Positive longitude values correspond to the geographic locations east of the prime meridian (abbrev. E). Negative longitude values correspond to the geographic locations west of the prime meridian (abbrev. W).

UTM or Universal Transverse Mercator coordinate system divides the Earth’s surface into 60 longitudinal zones. The coordinates of a location within each zone are defined as a planar coordinate pair related to the intersection of the equator and the zone’s central meridian, and measured in meters.

Elevation above sea level is a measure of a geographic location’s height. We are using the global digital elevation model GTOPO30 .

Elektrostal , Moscow Oblast, Russia

  • Open access
  • Published: 18 June 2019

Investigating midwives’ barriers and facilitators to multiple health promotion practice behaviours: a qualitative study using the theoretical domains framework

  • Julie M. McLellan   ORCID: orcid.org/0000-0003-4902-2254 1 ,
  • Ronan E. O’Carroll 1 ,
  • Helen Cheyne 2 &
  • Stephan U. Dombrowski 3  

Implementation Science volume  14 , Article number:  64 ( 2019 ) Cite this article

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In addition to their more traditional clinical role, midwives are expected to perform various health promotion practice behaviours (HePPBes) such as informing pregnant women about the benefits of physical activity during pregnancy and asking women about their alcohol consumption. There is evidence to suggest several barriers exist to performing HePPBes. The aim of the study was to investigate the barriers and facilitators midwives perceive to undertaking HePPBes.

The research compromised of two studies.

Study 1: midwives based in a community setting ( N  = 11) took part in semi-structured interviews underpinned by the theoretical domains framework (TDF). Interviews were analysed using a direct content analysis approach to identify important barriers or facilitators to undertaking HePPBes.

Study 2: midwives ( N  = 505) completed an online questionnaire assessing views on their HePPBes including free text responses ( n  = 61) which were coded into TDF domains. Study 2 confirmed and supplemented the barriers and facilitators identified in study 1.

Midwives’ perceived a multitude of barriers and facilitators to carrying out HePPBes. Key barriers were requirements to perform an increasing amount of HePPBes on top of existing clinical work load, midwives’ cognitive resources, the quality of relationships with pregnant women, a lack of continuity of care and difficulty accessing appropriate training. Key facilitators included midwives’ motivation to support pregnant women to address their health. Study 1 highlighted strategies that midwives use to overcome the barriers they face in carrying out their HePPBes.

Conclusions

Despite high levels of motivation to carry out their health promotion practice, midwives perceive numerous barriers to carrying out these tasks in a timely and effective manner. Interventions that support midwives by addressing key barriers and facilitators to help pregnant women address their health behaviours are urgently needed.

Peer Review reports

Contributions to the literature

This research systematically examines barriers and facilitators midwives perceive in helping pregnant women with multiple health behaviour change

The theoretical domains framework is used to understand midwives’ multiple health promotion practice behaviours across a range of health topics

The barriers and facilitators health care professionals face in addressing multiple health behaviour change topics will help inform interventions to support the uptake of evidence-based guidelines into routine clinical healthcare practice

Introduction

In many developed countries, the public health focus for midwives has extended from health protection issues, such as reducing maternal and infant mortality and preventing the spread of disease, to health promotion topics, such as smoking cessation, and weight management [ 1 ]. In the United Kingdom (UK), midwives are expected to perform multiple health promotion practice behaviours (HePPBes) for a variety of health promotion topics throughout pregnancy and postnatally. Examples of HePPBes include monitoring carbon monoxide levels, discussing recommended daily fruit and vegetable intake or delivering an alcohol brief intervention (in the UK, the booking appointment takes place between 8 and 12 weeks gestation and is the first routine antenatal appointment).

HePPBes are outlined in the various policies, strategies and guidelines published by government and public-sector bodies, which either directly or indirectly implicate midwives as public health professionals [ 2 , 3 , 4 ]. For example, in the UK, the National Institute of Clinical Excellence (NICE) Smoking: stopping in pregnancy and after childbirth guidelines outline that midwives participate in up to 12 different smoking cessation-related HePPBes during pregnancy, such as measuring carbon monoxide levels, asking the woman if they or anyone in their household smokes and referring to NHS Stop smoking services [ 4 ]. Whilst the NICE Weight management before, during and after pregnancy guidelines [ 5 ] outline various HePPBes including measuring weight and height, asking questions about the pregnant women’s diet and physical activity and giving dietary and physical activity advice. For pregnant women with a BMI ≥ 30, midwives are expected to carry out additional HePPBes such as offering referral to a dietitian. Considering the variety of health promotion topics to be addressed during pregnancy, midwives face a high health promotion workload [ 6 , 7 , 8 , 9 , 10 ].

The factors related to midwives performing multiple HePPBes are poorly understood. Previous studies have examined maternal health care professionals’ behaviour using the theoretical domains framework [TDF; 11 [ 11 ]]. However, these studies examined single health-risk topic such as smoking cessation [ 12 ], weight management and obesity [ 13 ] and physical activity [ 14 ]. The TDF provides a comprehensive grouping of the overlapping constructs within behavioural theories. The original version (TDF v1) summarises the main factors of relevant behaviour change theories into 12 independent domains [ 11 ]. The TDF v1 has been validated through the development of a refined version (TDF v2; [ 15 ]).

Midwives experience several challenges in undertaking multiple HePPBes such as a shortage of resources [ 6 ], a lack of clarity about their public health role [ 7 , 8 ] and lack of self-efficacy [ 8 , 9 ]. However, limited evidence exists on the barriers and facilitators midwives perceive in undertaking multiple HePPBes. This study applies a theoretical approach to investigate potentially relevant factors at a multiple behaviour level.

Research aim

The aim of this study is to investigate midwives’ barriers and facilitators to performing multiple HePPBes across various health promotion topics using the theoretical domains framework in qualitative interviews (study 1) and free text questionnaire responses (study 2).

This study reports two different sources of qualitative data gathered through interviews and questionnaires. Interviews obtained detailed evidence about the barriers and facilitators midwives experience in carrying out their HePPBes. The questionnaires used an open-ended question to capture additional comments on barriers and facilitators that midwives may have had about their HePPBes.

Study design

Qualitative semi-structured interview study.

Participants

Midwives working in a community setting were eligible to participate if they were qualified, practising midwives employed by an NHS health board in central Scotland. Recruitment involved JM, a researcher previously unknown to participants, visiting an out-patient maternity clinic and providing 12 midwives with information about the study. The information provided to midwives included the reason for carrying out the research to inform JM’s PhD to develop an intervention to support midwives in addressing health behaviours with pregnant women. Eleven midwives agreed to take part. One midwife opted not to take part in the study.

Interview topic guide

The interview topic guide (see Additional file  1 ) contained (i) demographic questions (number of years of experience and job title) and (ii) questions based on each of the 12 TDF (v1) domains [ 11 ]. The behavioural category of interest, within the topic guide, was specified as: “supporting pregnant women to change their health behaviour” and the questions were designed to elicit beliefs about the behaviour in relation to each domain.

To remind midwives of the target behaviour of interest, an A4 prompt card was placed in front of them outlining typical examples of women’s health behaviours to be addressed (see the prompt card in Additional file  2 ). The behaviour was specified using terms Target, Action, Context and Time, known as the TACT principle [ 16 ]. TACT summarises the behaviour in terms of doing what, to whom, in a given context and at a specific time [ 17 ]. The behaviour was specified as: “All the things you do in a routine antenatal care consultation, including asking questions, to support pregnant woman change their health behaviours”. The TACT specification complements the general TDF definition used within the topic guide by breaking down of what was meant by “supporting pregnant women to change their health behaviour”.

Face-to-face semi-structured interviews were conducted by JM (a female PhD researcher and Health Psychologist with previous experience of supporting midwives’ behaviour change practice) on two separate occasions in October 2016. Interviews took place within consultation rooms at an out-patient maternity clinic in central Scotland. Information about the study was provided verbally and in written format. Interviews lasted between 27 and 76 min (mean ± SD, 43 ± 14). All interviews were audio recorded and anonymously transcribed verbatim. The demographic data was entered into a Microsoft Excel spread sheet. The consolidated criteria for reporting qualitative research (COREQ; [ 18 ]) was used to ensure all aspects of the qualitative research had been reported (a copy of the checklist is provided in Additional file  3 ).

Transcripts were stored as Microsoft Word documents. Qualitative data analysis was based on recommendations for conducting TDF based qualitative research [ 19 ] and involved the following ten steps:

Interviews were read several times by JM to ensure familiarity with the data.

One interview was jointly coded by JM and SD to develop a coding strategy.

Two interviews were coded by JM using a directed content analysis approach [ 20 ] in which interview content was placed in the most relevant TDF domain(s). Responses which could be attributed to more than one domain were coded into multiple domains.

The coding of the two interviews was checked by SD. Where discrepancies in coding occurred, discussion took place to reach a consensus.

The remaining interviews were coded by JM.

Data saturation was reached as the final three transcripts did not introduce any additional barriers and facilitators than those already identified.

Summaries of domain codings were produced by JM and checked by SD.

Identification of relevant theoretical domains was identified by consensus discussion between JM & SD. Relevance of a domain was based on the following criteria: (i) high frequency of specific beliefs and/or (ii) existence of conflicting beliefs and/or (iii) indication of clear beliefs that may influence the behaviour of interest [ 21 ].

Views were generated for relevant domains by JM and coded as being either generic (views which are made in reference to HePPBes in general) or behaviour specific (views which are in reference to a specific health promotion behaviour).

The views generated were checked by HC (a Professor of Midwifery) to ensure they made sense from a midwifery perspective.

Ethical approval

The University of Stirling Psychology Ethics Committee approved the study. NHS Research and Development approval was granted by Greater Glasgow and Clyde Health Board (R&D reference: GN16OG406).

Online questionnaire study including a qualitative open-ended question.

Individuals registered as a qualified midwife or training to be a midwife, worldwide, were eligible to take part. Recruitment took place online between the February and May 2018. Advertisements were placed on discussion forums, email lists and social media pages. The study was endorsed by the Royal College of Midwives on their Facebook and Twitter pages. Advertisements contained an URL link to the online study platform Qualtrics where the questionnaire was hosted. Overall, 719 participants consented to take part in the study and confirmed they were either a qualified or student midwife. Of those, 214 completed less than 95% of the questionnaire and therefore were excluded from further analysis. Complete responses were obtained from 505 participants.

Questionnaire

The questionnaire examined factors relevant to HePPBes. At the end of the questionnaire, participants were asked: “If you have any other comments on your Public Health role then please include them below”. The current paper reports on the qualitative data obtained from this question.

Midwives accessed the questionnaire by clicking on the URL contained within the online advertisement. Following presentation of study information and eligibility criteria, consent was obtained by the midwife selecting an electronic check box. A screening question: “Are you a qualified or student midwife?” was presented as a method of reducing the likelihood of non-midwives completing the questionnaire. If the response was “no”, then participants were thanked for their interest in the study and exited from the questionnaire. At the end of the questionnaire, midwives were offered the opportunity to be entered into a prize draw to win 1 of 4x £25 shopping vouchers.

Analysis of the qualitative questionnaire data involved the following five steps:

Responses were read several times by JM to ensure familiarity with the data.

Responses were coded by JM using a directed content analysis approach [ 20 ] in which responses were placed in the most relevant TDF domain. If a response could be coded into more than one domain, a decision was made by JM as to the most appropriate domain.

Coding was checked by SD.

The number of responses coded into each domain was calculated by JM.

JM checked how much the barriers identified reflected those in study 1 and if there were any additional barriers or facilitators identified.

The University of Stirling’s General University Ethics Panel approved the study (GUEP316).

All 11 participants were female, employed as community midwives, except one who worked as a Senior Charge Midwife. The mean number of years of experience as a qualified midwife was 22 (range from 3 to 31).

Reviewing of coding

Agreement between coders for two interviews was 76% and 88% for the first and second interview respectively, and disagreement for the same interviews was 17% and 5% respectively. The mean agreement was 82% and mean disagreement was 11%. An additional 7% of codes were suggested by the second coder for each interview.

Relevant theoretical domains

All barriers and facilitators could be identified within the TDF. Nine of the 12 TDF domains were classified as important in understanding the barriers ( b  = barrier) and facilitators ( f  = facilitator) to undertaking HePPBes. Table  1 lists these domains alongside a domain descriptor.

The identified domains are outlined below and a table containing the associated belief statements are provided in Additional file  4 .

Professional role and identity

Midwives mostly saw HePPBes as part of their professional role (f): “I just see it as my job” (M10) and “I think public health is an essential part our role” (M7). However, some thought that several HePPBes could be addressed prior to conception, especially around weight management (b): “She’s thirty-five and she’s pregnant, so why is it suddenly the midwife that has to look into that?” (M3). Midwives frequently mentioned that the role of the midwife had evolved from providing traditional midwifery care (e.g. measuring the growth of the baby) to having a strong focus on undertaking HePPBes (b): “They seem to keep adding to the list of things we’re expected to do”(M11), and some midwives expressed a feeling that their traditional professional role was being eroded (b): “Our role now, as community midwives, seems to be for referring on … it feels as if your role’s been kind of eroded at” (M10).

Beliefs about consequences

Midwives mentioned several consequences that potentially impact their HePPBes. Contrasting beliefs about how HePPBes impacted on the relationship with the woman were voiced. If performed well, midwives believed it could be useful in gathering information about aspects of the women’s wellbeing (f). However, some stated that performing HePPBes could potentially damage the relationship if they were not carried out carefully, particularly for HePPBes related to weight management (b): “Women get quite offended at that one” (M10).

Similarly, contrasting beliefs about the womens’ receptiveness to HePPBes emerged. Some midwives reported that women expect them to carry out HePPBes (f): “Most women are quite receptive to that because they know they’re pregnant and know it’s not just about their health anymore” (M11). Other midwives said that women were not receptive to HePPBes (b): “It seems to be that everything is piled on to this booking visit and I don’t think it’s fair on the women either” (M3).

The time it takes to perform HePPBes was seen as a clear barrier with appointments over running the allotted time which could impact on other women (b): “You run over and then people are kept waiting.” (M11). Furthermore, midwives held a clear belief that HePPBes had the potential to have positive health benefits for the women and their child (f): “Absolutely, there’s a huge knock-on effect” (M5). Clear views on the short-term impact of HePPBes depended on the behavioural topic. For instance, smoking was perceived as an issue that could be dealt with during pregnancy (f): “This is probably a time, particularly for the smokers, they’ve got that motivation for the baby to change” (M5). Meanwhile, the impact of diet-related HePPBes was considered as unobservable (b): “I’m never going to know whether she’s changed her diet, or even if she did change her diet, whether that’s going to last” (M6). Some midwives expressed a clear belief that it was rewarding for them to observe the benefits of women engaging in health behaviour change attributed to their HePPBes (f): “That is rewarding if you feel like you’ve helped someone make a change in their life.” (M11). Benefits in reducing future workload if HePPBes were carried out effectively were noted (f): “If we do our job well at the booking clinic and women take that on board then we don’t have as much to do” (M2).

Motivation and goals

Midwives frequently reported being highly motivated to undertaking HePPBes to benefit the long-term health of the woman and the baby (f): “I think it’s a huge window of opportunity for midwives” (M5). However, HePPBes were not a priority if there were conflicting clinical risks to the woman and/or baby such as patient safety or adult/child protection issues (b): “I’d say it’s definitely secondary though, obviously check the woman’s blood pressure, making sure she’s well, doing urine analysis, making sure there’s no infections, ruling out pre-eclampsia, listening to baby. That comes first and everything else, I think, would come second to that.” (M11).

Memory/attention and decision processes

Midwives described being prompted by the woman’s maternity notes to cover all HePPB topics (f): “My booking visit would be just going through that book with them because everything I need to tell them is in there, it’s a good thing for me cause it saves me forgetting to stop to talk about things” (M3) which also acted as a prompt to HePPBes at follow-up appointments (f): “I usually always have a wee flick through the notes at the beginning just to check if there’s any kind of outstanding issues to be aware of (M11)”.

If the woman wanted to discuss a particular behaviour, midwives prioritised this (f): “If the woman is worried about her weight, I’m happy to talk about it at every appointment, but if she’s not then I’m not gonna bring it up”, (M6). Some midwives covered a topic in depth if they felt it was of specific relevance (f): “Say I did three bookings yesterday one of them would have had none of these problems, one of them had a BMI was over 35 so that’s the one I concentrated on.” (M5).

Intuition was frequently reported as guiding decision making in relation to HePPBes (f): “If I get vibes from them, that actually they do know” (M5) and “I just have to go with my gut at the time” (M6) . Midwives also based performing HePPBes on the physical health of the woman during the appointment (b): “If they are very sick or they’ve had bleeding, then I’ll just say, ‘we’ll talk about this another time’ because it’s not appropriate to get ahead of ourselves” (M2).

Environmental context and resources

Changes in health care service provision (e.g. changes in timing of booking appointments) were perceived as making it more difficult to carry out HePPBes (b): “… with continuity of care being removed from us we’re not getting the same chance to see the same women again so I find it a bit harder to address things.” (M10).

Some midwives held a belief that accessibility to resources such as training related to HePPB could be improved (b): “It’s quite haphazard how you can get on to these things” (M4). Materials related to HePPBes were generally perceived as high quality (f): “‘Ready Steady Baby’ is I think a fantastic book” (M10). However, some felt the wording of questions within maternity notes made them difficult to ask (b): “That’s a barrier to me asking, because I actually don’t ask the way it’s worded on that because it doesn’t make sense.” (M4). A belief that there were too many HePPBes to undertake in too little time was apparent (b): “We’ve also got to try and work within the time constraints” (M9). Some midwives believed that the woman’s health status at the booking appointment affected the degree to which they could carry out HePPBes (b): “The booking appointment is really difficult for some women to sit there and actually not vomit” (M7). Physical cues were mentioned as prompts to undertake HePPBes (f): “If you pick up a book and it stinks of smoke, you know, you might well say, how you getting on?” (M2).

Social influences

Women were reported as a strong influence on midwives HePPBes and were seen to increasingly inform themselves through online sources. This was perceived as helpful to recommend high-quality information (f): “Get them to use websites because most of them are on computer all the time anyway” (M3) and unhelpful due to the potential to increase stress (b): “A lot of the women have got health anxieties and that’s fuelled by the internet” (M2). Mixed views emerged about how accurately women reported some health behaviours such as alcohol consumption, which impacted on health promotion efforts. Some midwives perceiving accurate accounts (f): and others reporting the opposite (b): “Alcohol, I think, is probably one that’s probably hidden, getting women to be honest is probably very difficult” (M10).

Team working and social support was seen as helpful in resolving issues regarding HePPBes (f): “My kind of closest colleagues, we’d probably have a wee chat and we’ll probably complain about how we’re meant to put this in amongst everything else that people want out of us.” (M10). Intergroup conflict was perceived by some in relation to performing HePPBes (b): “It’s come up in the tearoom and there will be conversations with people saying, ‘Oh public health that’s a load of nonsense’ and I’ll sit there quite openly and say ‘I think it’s one of the best things that’s ever occurred’” (M7).

Midwives described shifting social and group norms useful to normalise addressing health behaviours (f): “There’s very few people that are not happy to answer these questions nowadays because we’ve been doing this for so long they expect it and they do all talk amongst each other” (M7). However, social norms appeared to be unhelpful in normalising obesity (b) “If a lady’s got a BMI of not over 30, I still sort of don’t see it as a huge issue with them” (M7).

Some saw a midwife’s own body mass index (BMI) potentially making it harder to perform weight management HePPBes (b): “I think midwives find it really difficult because if you’re big yourself they’re looking at you thinking: ‘well, she’s got a cheek’, if you’re small they’re looking at you thinking: ‘you have never had a problem in your life’” (M10).

Carrying out HePPBes was associated with a range of positive emotions if these were seen to result in positive outcomes (f): “You feel dead pleased they actually brought it up again” (M9). Some reported concerns about performing specific HePPBes (b): “I do find it causes me anxiety if I know I’m going to tell her today that we’re doing a Social Work referral.” (M10). Carrying out HePPBes was potentially stressful (b): “Sometimes I’m thinking you just want to do the right thing, which is hard sometimes” (M5) and draining (b): “I’m exhausted after a clinic because you feel as if you want to have your senses hyper alert” (M9).

Behavioural regulation

Midwives described using behavioural regulation strategies such as using maternity notes as a prompt to cover all HePPBes, writing notes in SWHMMR as prompt for carrying out HePPBes follow-up appointments, carrying out HePPBes whilst performing clinical tasks, e.g. asking questions about physical activity while taking bloods (f): “I have to say I multi task. I’ll be testing the urine while I’m asking about how they feel in pregnancy and had they had any sickness and how they’re getting on with eating.” (M7). For a list of strategies reported, see Additional file  5 .

Nature of the behaviours

The majority of HePPBes took place at the booking appointment when there is usually the most time to undertake HePPBes (f). Midwives reported HePPBes as being routine practice (f): “We’ve got to tick boxes, we’ve got to tick that we’ve discussed alcohol, we’ve discussed smoking” (M10). The habitual nature of performing HePPBes included the strategies used to regulate health promotion practice as well as the behaviours themselves.

Study 2 results

Forty-seven fully qualified midwives and 14 student midwives provided a statement to the final question. The majority (92%) were based in the UK. The mean number of years of experience as a qualified midwife was 17 (range from 1 month to 40 years).

Responses were coded into seven TDF domains: professional role and identity, beliefs about consequences, motivation and goals, environmental context and resources, social influences, emotion and beliefs about capabilities. The definitions for each domain are the same as those presented in study 1. The domains are presented in terms of (i) the number of responses and (ii) supporting evidence.

Twenty-six responses were coded as environmental context and resources focusing on a need for improved resources, particularly a need for more time, wider access to online materials: “Apps and online mediums for encouraging behaviour change may take the pressure off midwives” and more accessibility to training . Some responses stressed the need for continuity of care.

Nine responses were coded as beliefs about consequences. The potential for weight management HePPBes to impact the midwife-woman relationship was mentioned. Mixed responses about women’s receptiveness to HePPBes emerged .

Nine motivation and goals responses suggested high levels of motivation to carry out HePPBes . Some midwives indicated that the degree to which they were able to support women was not ideal.

Eight responses were coded as social influences and focused on midwives’ own health status in relation to undertaking HePPBes. Some midwives described their own health behaviours and status helping or hindering HePPBes: “My own lifestyle and motivation in public health topics can impact the delivery and communication when approaching topics with women” . Others reported that their health status was irrelevant: “Don’t confuse my welfare with those of the woman and baby I’m caring for... public health roles should not be judged by the delivering midwife”.

Three responses were coded as professional role and identity commenting on a need for health promotion topics to be tackled before pregnancy and the demands placed on midwives to fulfil multiple professional roles.

Three responses coded as emotion focused on the taxing nature of the job and the potential negative health consequences of burn-out.

Beliefs about capabilities

Three responses coded as beliefs about capabilities highlighted that midwives potentially feel more confident in addressing health promotion topics which have greater attention placed on them in health policy and that capability to undertake HePPBes was reliant on resources such as training and time .

Integration of study 1 and 2 findings

Table  2 presents the integration of the findings from both studies by highlighting whether the views demonstrated in study 1 were supported by the responses generated in study 2. The table shows that six of the nine domains identified as important in study 1 were supported by responses from study 2.

Principal findings

Midwives perceived a multitude of barriers and facilitators to carrying out HePPBes. Key barriers were requirements to perform an increasing amount of HePPBes on top of existing clinical work load, which impacted on the time available, midwives’ cognitive resources and the quality of relationships with pregnant women. Organisational issues such as a lack of continuity of care and difficulty accessing appropriate training were also identified. Key facilitators included midwives’ motivation to support pregnant women to address their health. Study 1 also highlighted strategies that midwives use to overcome the barriers they face in carrying out their HePPBes. Some findings were considered both barriers and facilitators as mixed views were expressed about whether certain health promotion topics should be addressed by other health professionals prior to pregnancy, women’s receptiveness to HePPBes during pregnancy and the social influence of midwives’ own health status.

Strengths and limitations

The complimentary nature of the two presented studies is a strength. Study 1 provided detailed insight from a group of midwives working in a community setting which was supplemented in study 2 by free text commentary from a larger sample of midwives, employed within a variety of professional roles.

Limitations include the difficulty to specify target behaviours when simultaneously investigating multiple HePPBes for a variety of health promotion topics at the same time. The use of the TACT principle [ 16 ], and the image within the A4 prompt card provided midwives with a visual aid to remind them of the study focus during the interview. The sample size in study 1 was based on evidence-based guidelines [ 22 ], but is smaller than other qualitative TDF-based studies [ 23 , 24 ]. In addition, the midwives who took part in study 1 were recruited from a single out-patient maternity clinic in Scotland and different and additional barriers and facilitators might have emerged within different contexts.

Study 2 used online recruitment which prevents checking that participating individuals fully met inclusion criteria. The current paper examined HePPBes at a general level but some of the barriers raised were health promotion topics specific (e.g. a lack of dietary services to refer women to). Future research could further explore similarities and differences of HePPBes for different health promotion topics.

Relation to other studies

Limited evidence exists on the psychological factors associated with midwives HePPBes targeting women’s multiple health behaviours. Previously identified barriers to midwives undertaking HePPBes including a lack of time, resources and variability in training quality [ 6 ] were confirmed in the current study and therefore highlight a continued need for midwives to be provided with support. Uncertainty amongst midwives about their public health role [ 7 , 8 ] was also demonstrated through the mixed views midwives expressed regarding whether all HePPBes should fall under the remit of the midwife. Midwives’ use of strategies to overcome the barriers they face in carrying out HePPBes has not been previously reported.

Examining multiple HePPBes increases the complexity of the behavioural influences identified and provides greater understanding of the influences on midwives HePPBes. The complexity of investigating multiple HePPBes is demonstrated by the higher number of barriers identified within the current study compared with studies which have used the TDF to explore midwives’ behaviours in relation to single health risk topics [ 11 , 13 , 14 ].

The TDF [ 10 ] provides an overview of the main psychological constructs explaining health behaviours. However, the theories that these constructs belong to are mainly used to explain single behaviours. Multiple behaviour change processes such as goal facilitation [ 25 ] and goal conflict [ 26 ] and transference [ 27 ] have not been captured by the TDF domain interview questions and therefore might have been missed by the current study.

Possible mechanisms and implications

Barriers such as difficulty to access HePPBe-related training suggest a specific public health component in midwife training or after qualification may be useful. The finding that carrying out HePPBes can be taxing suggests that more support for midwives may be required. Policy makers and key stakeholders commissioning midwives’ continuous professional development opportunities could provide HePPBe support in multiple formats (e.g. through training, handheld materials or peer support).

Given the variations in the type of care that midwives provide, the pressure placed on maternity services by midwives attending training and the limited time that midwives would have to access support, developing handheld (or electronic) materials may be the most feasible option. For example, a leaflet containing examples of the strategies midwives use to carry out their HePPBes, that midwives could refer to during or outwith antenatal consultations, could capitalise on some of the HePPBe facilitators identified within this study.

Unanswered questions and future research

The development of an intervention to support midwives in helping pregnant women address multiple health behaviours is necessary to maximise the effectiveness of public health interventions aimed at behaviour change during pregnancy. Future studies should translate the current findings into acceptable, scalable and effective interventions to support midwives to perform HePPBes.

The findings suggest that despite high levels of motivation to carry out HePPBes, midwives perceive numerous barriers to carrying out these tasks in a timely and effective manner. Interventions that support midwives by addressing key barriers and facilitators to help pregnant women address their health behaviours are urgently needed.

Availability of data and materials

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Abbreviations

Consolidated criteria for reporting qualitative research

Health promotion practice behaviours

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Acknowledgements

The authors are grateful to the Royal College of Midwives and everyone who supported the recruitment of midwives. The authors would like to thank all the midwives who were interviewed and undertook the questionnaire. The authors would also like to thank Angelica Setterington for her support in transcribing the interviews. This work was undertaken by and on behalf of The Scottish Improvement Science Collaborating Centre (SISCC).

This study was funded by the University of Stirling in collaboration with the Scottish Improvement Science Collaborating Centre. The Scottish Improvement Science Collaborating Centre (SISCC) is funded by the Scottish Funding Council (SFC), Chief Scientist’s Office, NHS Education for Scotland and The Health Foundation with in-kind contributions from participating partner universities and health boards. The grant reference number is 242343290 was received from SFC on behalf of all funders.

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Julie M. McLellan & Ronan E. O’Carroll

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Helen Cheyne

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Contributions

JM contributed to the design of the study, carried out data collection and analysis and was primarily responsible for drafting the manuscript. SD contributed to the design of the study, was involved in data analysis and commented on drafts of the manuscript. RO’C and HC were involved in designing the study and commented on drafts of the manuscript. All authors read and approved the final manuscript.

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Ethics approval and consent to participate.

The University of Stirling Psychology Ethics Committee approved study 1 and NHS Research and Development approval was granted by Greater Glasgow and Clyde Health Board (R&D reference: GN16OG406). The University of Stirling’s General University Ethics Panel approved study 2 (GUEP316). Consent to participate was obtained from all midwives who took part in the studies.

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Consent for publication was obtained from all midwives who took part in the studies.

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The authors declare that they have no competing interests.

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Additional files

Additional file 1:.

Study 1 Interview Topic guide. (DOCX 19 kb)

Additional file 2:

Study 1 Prompt card. (DOCX 2283 kb)

Additional file 3:

COREQ checklist. (DOCX 18 kb)

Additional file 4:

Study 1 table of midwives view statements table. (DOCX 18 kb)

Additional file 5:

Study 1 table of midwives HePPBe strategies. (DOCX 16 kb)

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McLellan, J.M., O’Carroll, R.E., Cheyne, H. et al. Investigating midwives’ barriers and facilitators to multiple health promotion practice behaviours: a qualitative study using the theoretical domains framework. Implementation Sci 14 , 64 (2019). https://doi.org/10.1186/s13012-019-0913-3

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DOI : https://doi.org/10.1186/s13012-019-0913-3

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