Maternal Health Policy, Systems and Implementation
Pregnancy and the early postnatal weeks and months are optimal times to introduce preventative measures which set out to maximise every opportunity that the health service has with a woman to improve general health in pregnancy, birth and beyond. There are inter-generational effects associated with poor maternal outcome, and a life-course approach for women’s health care will ultimately improve maternal and infant outcomes irrespective of her situation in society. Adverse perinatal experiences and morbidity of both parents have a profound effect on maternal and infant health and childhood development. Socio-demographic factors, ethnicity, clinical and social risk, poor lifestyle behaviours and poor quality of care result in inequitable distribution of maternal and infant health outcomes which persist over the life-course of the mother and the child.
NHS maternity care services are unique in that they are the only universal public service for women and their babies during pregnancy and the early period of an infant’s life. There is a substantial body of high quality evidence of what is known to improve health outcomes, but the challenge is translation, implementation, and scale up into frontline primary and secondary care services.
Our strategy assumes a life-course approach which is engaged with basic and clinical science research that has the potential to improve health care quality and outcomes from bench to population health, through policy relevant world class evidence synthesis, implementation and service delivery science. Our group draws on social and health sciences and conducts theoretically informed research into health systems, health outcomes and service delivery. Our group uses a mixed methods approach includes evidence synthesis of qualitative and quantitative data, linking with Cochrane and the Joanna Briggs Institute, modelling and data linkage, clinical trials, hybrid effectiveness trials of complex interventions, qualitative research includes interviews, focus groups and ethnographic methods,
We bring together academics, clinicians and service users across King’s Faculties of Life Sciences and Medicine, IOPPN, Florence Nightingale Faculty of Nursing & Midwifery and King's Health Partners to work towards the improvement of the health of women and their infants in our local, multicultural inner-city population and worldwide. Jane Sandall is a member of the senior leadership team in the Centre for Implementation Science and NIHR CLAHRC South London leading capacity building, education and training and the maternity and women’s health theme. Jane Sandall also leads a programme of research in King’s Improvement Science which funds 12 Post-Doctoral Fellows to work on implementation and improvement research. Debra Bick is Editor in Chief of the journal ‘Midwifery’.
We contribute social and implementation science theoretical perspectives and research methodologies to programmes of research led by Lucilla Poston, Lucy Chappell, Andrew Shennan and Louise Howard and lead our own programmes on service delivery and health system research. We are actively engaged with the policy community and sit on DH, NHS England and NICE advisory groups, on local London and maternity networks. Such work raises unanswered questions and informs new research, and offers opportunities for our research to inform policy. We work with a range of existing third sector partners including Tommy’s, National Childbirth Trust, Fatherhood Institute, APEC, and we have a memorandum of understanding with NCT researchers.
Methods
Research
Our strategy is currently focusing on two areas: healthcare quality and safety with a focus on novel technologies, and health system and service delivery with a focus on disparities in health and women with social and medical complexity. Cross cutting themes include assessment of improvement and implementation initiatives in clinical trials, and system level evaluation, and evidence synthesis.
Healthcare Quality and Safety and New Technologies
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Implementation of innovative safety technologies and practices and role of |
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| Evaluation of implementation of telemedicine in intensive care | |
| Early recognition and response to maternal complications during pregnancy and in the postnatal period among women with perinatal mental health problems |
King's Improvement Science Team |
Health System and Service Delivery
We are contributing to research of complex interventions where we are leading process evaluations and implementation research.
| MRC Joint Health Systems Research Initiative, Integrating places of worship (PoW) into the primary care pathway to prevent and control non-communicable diseases (NCDs) in the Caribbean, 2016-2019 | |
| NIHR Programme Grant, Optimising the monitoring and management of raised blood pressure during and after pregnancy,2016-2021 | |
| MRC/DFID/DBT Global Research Programme, Evaluation of the introduction of a novel device in the management of hypertension and shock in pregnancy in low-resource settings, 2015-2018 | |
| Bill and Melinda Gates Foundation Grand Challenge Explorations, CRADLE: Community Blood Pressure Monitoring in Rural Africa, 2013-2016 | |
| PHOENIX, Planned Delivery for Pre-eclampsia between 34 and 37 weeks of gestation, 2013-2019 | |
| King's Improvement Science: Using a health systems approach to evaluate the implementation of integrated care pathways for frail elderly people in Lambeth and Southwark, South London | |
| King's Improvement Science: Influence of outer contextual factors on implementing policies in emergency care |
Alexandra Zeiman |
| King's Improvement Science: Developing a targeted, theory-informed implementation intervention to increase uptake of delayed cord clamping NICE guidelines | |
| NIHR CLAHRC: Supporting women who are likely to give birth | |
| NIHR CLAHRC: Improving postnatal planning, management and shorter and longer-term physical and psychological health outcomes for women who experience medically complex pregnancies |
CLAHRC South London -Improving postnatal care |
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Birthplace Choices Qualitative Evidence Synthesis What influences birth place preferences, choices and decision making amongst healthy women with straightforward pregnancies in the UK? A qualitative evidence synthesis using a 'best-fit' framework approach. This is a component study of the 'Birthplace Choices' work. Based at the Policy Research Unit in Maternal Health and Care, NPEU, University of Oxford |
Project team for Birthplace Choices: Dr Jennifer Hollowell (Principal Investigators, NPEU) Dr Rachel Rowe (NPEU) Dr Kirstie Coxon (King’s College London) Dr Lisa Hinton*(Health Experiences Research Group) Miranda Dodwell*(BirthChoiceUK) |
| NIHR Public Health Research Programme: A two arm feasibility trial of lifestyle information and Slimming World groups to promote weight management and positive lifestyle behaviour in postnatal women (the SWAN feasibility study). | Professor Debra Bick |
| Daiwa Anglo-Japanese Foundation Award. Debra Bick (joint PI), Developing a collaborative research programme to support breastfeeding in UK and Japan. | Professor Debra Bick |
| Stefanou Foundation: Healthy Relationships: Healthy Baby (HRHB) programme. K.Trevallion (PI), L.Howard, D.Bick, S.Byford, M.Hesslin. | Professor Debra Bick |
| The Burdett Trust for Nursing: Empowering midwives and health visitors to reduce maternal and child obesity through tailored breastfeeding support: a co-designed pilot study. Funded by The Burdett Trust for Nursing Maternal and Childhood Obesity Empowerment Programme. | Professor Debra Bick |
| NIHR Programme Grant for Applied Research: Antenatal Prophylactic Pelvic floor Exercises And Localisation (APPEAL) Programme. | Professor Debra Bick |
| BIG Lottery: Fulfilling Lives: A Better Start: Evaluation and Learning Contract. | Professor Debra Bick |
| NIHR Programme Grant for Applied Research: The effectiveness and cost effectiveness of perinatal mental health services. | Professor Debra Bick |
Research infrastructure programmes include:
| Guy’s and St Thomas and Maudsley Charity, King’s Improvement Science Capacity Building Programme, 2014-2019 |
King's Improvement Science Team |
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NIHR South London Collaboration for Leadership in Applied Health Research and Care, 2014-2019 Improving the management of medical problems in pregnancy, and preterm labour where the overarching goal is to assess the effectiveness and implementation of new care pathways, technologies to improve overall outcomes for pregnant women and their children. |
Professor Jane Sandall |
Summary of Findings
Healthcare Quality and Safety and New Technologies
- One-stop first trimester prenatal screening: social implications of an emerging technology 2001-2004
- Social, ethical and cultural impacts of genetic prenatal screening technologies on experience and personhood: synthesising Biochemistry and Ultrasound technologies with Live Performance, Visual and Aural Media 2005-2006
- Facilitating choice, framing choice: the experiences of staff working in pre-implantation genetic diagnosis 2005-2007
- Ethical frameworks for embryo donation: views, values & practices of IVF/PGD staff 2007-2009
- Wellcome Trust Investment in People Award to develop programme of research on patient safety in maternity care 2003-2004
- Patient safety issues for minority groups of women know to be at higher risk of maternal death during pregnancy and childbirth, A scoping review, 2003-2004
- The Estimation Of Access - Development Of Key Access Markers In Maternity Care 2004-2006
- Comparison of patient safety culture tools with a holistic evaluation of impact of organisation’s patient safety culture 2007-2010
- STOP: Surveillance and Training in the Treatment of Postpartum haemorrhage 2007-2012
- NIHR King’s Patient Safety and Service Quality Research Centre 2007-2012
- From bench to bedside: evaluation of a research translator pilot scheme, 2008-2010
- Epidemiological inquiry into the consequences of the unnecessary caesarean section in Brazil 2009-2010
Health System and Service Delivery
Workforce
- A scoping exercise to conceptualise the actual and potential contribution of nurses, midwives and health visitors to child health and child health services 2004-2005
- The contribution of nursing, midwifery and health visiting to protocol based care and its variants on organisation, patient and staff outcomes, quality and costs of care 2004 - 2007
- Evaluating the nature, impact and nursing contribution to clinical decision-making using protocols 2005 - 2007
- Workforce Analysis of Maternity Support Workers - A National Scoping Study 2006 – 2007
- A review of Workforce Deployment and Skill Mix impact on intrapartum safety 2009 – 2010
- The efficient use of the maternity workforce and the implications for safety & quality in maternity care: An economic perspective, 2012-2013
- Improving MDT work in cancer and translating learning into other clinical areas. 2012- 2013.
Service Delivery
- Birthplace in England Research Programme 2006-2011
- Meeting women’s postnatal needs in hospital and on transfer home 2007-2010
- Two centre double blind randomised controlled trial comparing IM diamorphine with pethidine for analgesia in labour 2009-2012
- Upright compared with supine positions for primiparous women in labour with epidural analgesia: a randomised controlled trial 2010-2015
- An ethnographic organisational study of alongside midwifery units: a follow-on study from the Birthplace in England programme, 2011-2013
- The Birthplace in England Research Programme: further analyses to enhance policy and service delivery decision-making for planned place of birth, 2012-2014
- What is the effectiveness, appropriateness, meaningfulness and feasibility of demand side financing (DSF) measures that aim to increase maternal health service utilisation and outcomes with particular reference to rural, poor and socially excluded women? 2012-2014.
- Optimising identification, referral and care of trafficked people within the NHS. 2013-2015
- Experiences of breastfeeding support among women who have had caesarean birth, 2014-2015
Implementation
- Development and evaluation of implementation of a community based caseload midwifery programme in a disadvantaged area 2005 - 2007
- Perineal Assessment and Management Longitudinal Study (PEARLS). A National Clinical Quality Improvement Project. 2006-2013
- Supporting women to have a normal birth: Field testing and pre-trial stage evaluation of a multi-media, interactive workshop package for maternity staff 2007-2010
- Research into the ability of maternity providers to support physiologic birth and implement the NHS Innovations Self-Improvement Toolkit to reduce caesarean birth rates 2008-2009
- UPBEAT : Improving Pregnancy Outcome in Obese Women : Process evaluation 2008-2013
- PErineal Assessment and Repair e-Learning System: an internet based training package (PEARLS.net).2011-2013
- NIHR Knowledge Mobilisation Fellowship, Development of a communication tool for communication of risk and place of birth, Kirstie Coxon, 2013-2014
Impact
We already have a substantial track record of policy engagement and related research impact in maternal health. For example, our research on maternal postnatal health which includes (for example) identification and management of commonly experienced maternal morbidity, revisions to models of care leading to more clinically and cost effective outcomes of community based midwifery-led postnatal care, increased uptake of evidence into practice to manage perineal trauma and use of mobile epidurals in labour to increase spontaneous vaginal birth, has influenced policy and practice in the UK and internationally, including NICE and WHO guidance. We were the first to demonstrate how postnatal health problems affected women and how clinical care could be improved and costs reduced by redesigning community services (i) . Our guidelines on postnatal health have been translated into several languages. Several members of group were involved in the recent MOH report on Women’s Health focusing on the importance of a life course approach (ii)(iii). Our work to support implementation of evidence-based management of birth related perineal trauma (MaternityPEARLS) is a core e-learning module hosted by The Royal College of Obstetricians and Gynaecologists and The Royal College of Midwives. Debra Bick is leading a work group to support postnatal care for the NHS England Strategic Clinical Network for London.
Our Cochrane review on midwife-led models of continuity of care for childbearing women and their infantsc (iv) is the 7th most cited Cochrane review, was identified as a priority review by WHO and has informed changes in policy and services in UK Policy Reviews and NHS guidelines and reviews of maternity services in the USA, Brazil and Australia and Canada which suggest a scale-up of models of midwife-led care on the grounds of improved quality and safety. The review was drawn upon by the Better Birth Initiative led by the Royal College Midwives, the Ministerial group developing a new 10 year maternity strategy for Ireland, by the NHS England five year forward view maternity strategy and was cited in both publications. Sandall leads a workgroup developing a toolkit and metric to measure on continuity of care rolled out by NHS England Strategic Clinical Network for London in June 2015 based on the above evidence. Our research on maternity staffing and skill mix was a major evidence source cited in NICE guideline NG4 Safe midwifery staffing for maternity settings. Lancet series on Midwifery which aimed to inform future workforce and health system development MDG plans for the future. The review informs our programme of work in CLAHRC South London regarding improving outcomes for Women with social and medical complexity and ongoing research and modelling of longer term economic impact on preterm birth prevention (v).
Principal Investigators
Professor of Social Science and Women's Health
Senior Lecturer in Medical Statistics
Vice Dean (Research & Impact)
Reader in Perinatal Mental Health
Investigators
Tommy's Chair in Maternal and Fetal Health
NIHR Research Professor in Obstetrics
Professor of Social Epidemiology