'Just an extra pair of hands'? A qualitative study of obstetric service users' and professionals' views towards 24/7 consultant presence on a single UK tertiary maternity unit

Working with suicidal mothers during the perinatal period: a reflexive thematic analysis study with mental health professionals

BACKGROUND

Suicide is the leading cause of death in mothers postpartum and one of the most common causes of death during pregnancy. Mental health professionals who work in perinatal services can offer insights into the factors they perceive as being linked to mothers' suicidal ideation and behaviour, support offered to mothers and improvements to current practices. We aimed to explore the experiences and perceptions of perinatal mental health professionals who have worked with suicidal mothers during the perinatal period.

METHOD

Semi-structured interviews were conducted face-to-face or via telephone with mental health professionals working in perinatal mental health inpatient or community services across England. Data were analysed using reflexive thematic analysis.

RESULTS

From the professionals' (n = 15) accounts three main themes were developed from their interview data. The first, factors linked to suicidal ideation and behaviour, overarched two sub-themes: (1.1) the mother's context and (1.2) what the baby represents and what this means for the mother. These sub-themes described factors that professionals assessed or deemed contributory in relation to suicidal ideation and behaviour when a mother was under their care. The second main theme, communicating about and identifying suicidal ideation and behaviour, which outlined how professionals enquired about, and perceived, different suicidal experiences, encapsulated two sub-themes: (2.1) how to talk about suicide and (2.2) types of suicidal ideation and attempts. The third main theme, reducing suicidal ideation through changing how a mother views her baby and herself, focused on how professionals supported mothers to reframe the ways in which they viewed their babies and in turn themselves to reduce suicidal ideation.

CONCLUSION

Professionals highlighted many factors that should be considered when responding to a mother's risk of suicide during the perinatal period, such as the support around her, whether the pregnancy was planned and what the baby represented for the mother. Professionals' narratives stressed the importance of adopting a tailored approach to discussing suicidal experiences with mothers to encourage disclosure. Our findings also identified psychological factors that professionals perceived as being linked to suicidal outcomes for mothers, such as self-efficacy; these factors should be investigated further.

Hospital Mortality and Trainee Experiences: How General Medical Council Survey Findings Correlate With Summary Hospital-Level Mortality Indicator

OBJECTIVES

This study aimed to investigate whether components of junior doctor satisfaction are associated with patient mortality within the United Kingdom.

METHODS

We conducted a cross-sectional study of publicly available data (the General Medical Council [GMC] National Survey and the Summary Hospital-level Mortality Indicator [SHMI]) pertaining to subjective physician trainee satisfaction and patient mortality within 80 United Kingdom-based healthcare institutions. The direction and strength of correlation between components of the GMC National Survey and relative patient mortality as described by the SHMI were calculated. Additional outcomes included mean GMC survey scores for reported domains and mean SHMI by healthcare institution.

RESULTS

SHMI for included healthcare institutions ranged from 0.69 to 1.21 (mean [SD], 1.01 [0.1]). Mean GMC domain scores ranged between 44.61 and 88.62 (mean [SD], 71.16 [10.84]). Statistically significant correlations were observed for clinical supervision, clinical supervision out of hours, rota design, overall satisfaction, and teamwork. After application of Bonferroni correction, statistically significant correlations remained for both clinical supervision and clinical supervision out of hours.

CONCLUSIONS

There is a significant association between components of subjective trainee satisfaction and patient mortality within the United Kingdom. Further investigation to examine these relationships, perhaps to target intervention, may prevent avoidable patient harm.

What makes a perinatal woman suicidal? A grounded theory study

BACKGROUND

Suicide is a leading cause of maternal death during pregnancy and up to a year after birth. Psychological and psychosocial risk factors for maternal suicide ideation and behaviour have been identified but do not account for why mothers begin to experience suicidal thoughts. Qualitative research offers a way of identifying what might drive mothers to initially consider suicide and then go on to act on such thoughts; crucial for the development of assessments to identify, and interventions to target, maternal suicide ideation and behaviour. We aimed to develop a grounded theory outlining what makes women think about suicide and/or engage in suicidal behaviour during pregnancy and the first 12 months following birth?

METHOD

Semi-structured interviews were conducted with 12 mothers in the UK who had suicidal thoughts during pregnancy and/or the first year following birth. A constructivist approach to grounded theory was adopted which guided the data collection and analysis processes.

RESULTS

We developed a model outlining the theorised process of psychological factors that culminates in mothers experiencing suicidal thoughts and then making a suicide attempt during the perinatal period. The process was initiated when mothers felt attacked by motherhood which led to feeling like a failure, self-identifying as a "bad mother" and subsequent appraisals of entrapment and/or defeat. When nothing resolved the distress and as mothers collated reasons for why they perceived they needed to die, suicidal behaviour became a viable and appealing option. We theorised that mothers might make a suicide attempt when they entered a state of intense "darkness" brought on by a trigger, followed by a temporary lapse in the conflict between the desire to live and desire to die and an opportunity to attempt.

CONCLUSIONS

Participants stressed the rapid onset of suicidal thoughts. We suggest that healthcare professionals enquire about the mother's feelings towards the baby and of isolation, how she views herself as a mother, feelings of entrapment and defeat during routine contacts to aid identification and prevention of suicidal ideation/behaviour. Suggested interventions to prevent suicidal thoughts and behaviour include helping women manage their expectations for pregnancy and the postpartum period.

24 hour consultant obstetrician presence on the labour ward and intrapartum outcomes in a large unit in England: A time series analysis

Objectives

To explore the effect of introducing 24/7 resident labour ward consultant presence on neonatal and maternal outcomes in a large obstetric unit in England.

Design

Retrospective time sequence analysis of routinely collected data.

Setting

Obstetric unit of large teaching hospital in England.

Participants

Women and babies delivered between1 July 2011 and 30 June 2017. Births <24 weeks gestation or by planned caesarean section were excluded.

Main outcome measures

The primary composite outcome comprised intrapartum stillbirth, neonatal death, babies requiring therapeutic hypothermia, or admission to neonatal intensive care within three hours of birth. Secondary outcomes included markers of neonatal and maternal morbidity. Planned subgroup analyses investigated gestation (<34 weeks; 34–36 weeks; ≥37 weeks) and time of day.

Results

17324 babies delivered before and 16110 after 24/7 consultant presence. The prevalence of the primary outcome increased by 0.65%, from 2.07% (359/17324) before 24/7 consultant presence to 2.72% (438/16110, P < 0.001) after 24/7 consultant presence which was consistent with an upward trend over time already well established before 24/7 consultant presence began (OR 1.09 p.a.; CI 1.04 to 1.13). Overall, there was no change in this trend associated with the transition to 24/7. However, in babies born ≥37 weeks gestation, the upward trend was reversed after implementation of 24/7 (OR 0.67 p.a.; CI 0.49 to 0.93; P = 0.017). No substantial differences were shown in other outcomes or subgroups.

Conclusions

Overall, resident consultant obstetrician presence 24/7 on labour ward was not associated with a change in a pre-existing trend of increasing adverse infant outcomes. However, 24/7 presence was associated with a reversal in increasing adverse outcomes for term babies.

Impact of consultant obstetric presence on serious incidents

Purpose

Many organisations, including the Royal College of Obstetricians and Gynaecologists, have recommended increasing the number of hours of consultant obstetric presence in UK National Health Service maternity units to improve patient care. St Mary’s Hospital, Manchester implemented 24-7 consultant presence in September 2014. The paper aims to discuss these issues.

Design/methodology/approach

To assess the impact of 24-7 consultant presence upon women and babies, a retrospective review of all serious clinical intrapartum incidents occurring between September 2011 and September 2017 was carried out by two independent reviewers; disagreements in classification were reviewed by a senior Obstetrician. The impact of consultant presence was classified in a structure agreed a priori.

Findings

A total of 72 incidents were reviewed. Consultants were directly involved in the care of 75.6 per cent of cases before 24-7 consultant presence compared to 96.8 per cent afterwards. Negative impact due to a lack of consultant presence fell from 22 per cent of the incidents before 24-7 consultant presence to 9.7 per cent after implementation. In contrast, positive impact of consultant presence increased from 14.6 to 32.3 per cent following the introduction of 24-7 consultant presence.

Practical implications

Introduction of 24-7 consultant presence reduced the negative impact caused by a lack of, or delay in, consultant presence as identified by serious untoward incident (SUI) reviews. Consultant presence was more likely to have a positive influence on care delivery.

Originality/value

This is the first assessment of the impact of 24-7 consultant presence on the SUIs in obstetrics.