The publication of the Francis report (Francis, 2013) led to a recommendation for greater emphasis on interventions to support frontline clinical teams to perform effectively. The Patients First programme is one such intervention. The Foundation of Nursing Studies operates UK-wide and across all health-care settings, dedicated to working with nurses and health-care teams to develop and share innovative ways of improving practice. This enables staff to provide care that is high-quality and evidence-based, and meets the needs of service users.
A survey of nearly 1400 mothers, conducted by parenting website Netmums in collaboration with the Royal College of Midwives (RCM) (2011), found evidence of a social divide developing in UK maternity services. Women with a lower income are getting a poor deal from maternity services during pregnancy and postnatally, with those in poverty left feeling unsupported, and over a quarter feeling anxious or depressed during their pregnancy. Almost three quarters did not attend antenatal classes (nearly half were not offered them) and felt unprepared for—and unsupported during—labour and childbirth.
It has been difficult to retain participants on programmes at the children's centre on Turlin Moor Estate, Poole, and pregnant women in this area have tended not to attend the NHS antenatal classes offered in the area. These consist of 2.5-hour sessions spread over three evenings, or a whole day session. A survey at the children's centre, carried out as part of a Building Community Capacity university module, showed that there was interest in local, tailored antenatal education provision (Evans and Hughes, 2010). Women stated during this process that they prefer to stay on ‘the Moor’ and tend not to attend evening groups provided in other locations in the town. As such, there was potential for local women to benefit from being in control of such a programme.
Hamworthy and Turlin Moor are areas of Poole with a large number of families in which children are subject to a child protection plan. The project has been set up to meet the specific needs of mothers, as described by the Department of Health (DH), 2011: 4):
‘Pregnancy is a window of opportunity, as parents are receptive to learning and making changes. Parents, especially mothers, are instinctively motivated to protect their child.’
The service improvement project described in this article is an NHS Patients First practice development programme managed by the Foundation of Nursing Studies, with funding from the Burdett Trust for Nursing, using an established format of funding, workshops and facilitator support.
Most women have continued attending the group after their babies have been born, and may continue to do so up to the babies' first birthdays. These mothers have given support and information to pregnant women and to each other, with the facilitator (midwife/health visitor) present to offer guidance where it has been felt useful. This constitutes an unforeseen added value to the group, which has come about because of local ‘ownership’ of the group to the extent that some sessions are now run by mothers sharing their particular skills.
Literature review
Many parents described as ‘hard to reach’ are those most in need of family support services, but often the least likely to access them. Younger mothers and lone parents are less likely to attend parent support groups than older mothers and mothers from couple families (Anderson et al, 2007).
Anderson et al (2007) identified that service users want services that are reliable, accessible, sensitive to individual needs and well-coordinated. The key factors seem to be whether parents can build up a trusting relationship with frontline service providers and the degree to which parents feel they are in control of the help they are receiving. The effectiveness of consulting and involving parents has not been rigorously researched; however, Anderson's work suggests that a participant-led service is most likely to promote trusting relationships and locally appropriate content.
Younger mothers and parents in lower-income households can be more wary of professional support or intervention than older mothers, and those in couples and may be less likely to seek out help and advice from them (Anderson et al, 2007). Paradoxically, respondents in the former groups are also more likely to suggest that professionals do not offer enough parenting advice and support. Lone parents and young mothers are most likely to seek advice from informal sources, particularly their own parents (Katz et al, 2007).
A recent report, Building Great Britons (All Party Parliamentary Group for Conception to Age 2, 2015), brings together evidence to help parents understand their role and what to expect physically and emotionally as parents. This help needs to be effective, timely, consistent and non-judgemental. Parents who are able to understand their baby's cues and tune into its needs are best placed to provide the responses and experiences needed to support optimal development of their baby's brain (All Party Parliamentary Group for Conception to Age 2, 2015).
Staff and service user involvement
A need for antenatal education was identified as part of a Building Community Capacity exercise, from which this project has extended. In the planning stages, ad hoc discussions with small groups of mothers in the children's centre suggested that several would have appreciated midwife or health visitor presence at the weekly group that had existed previously, called Bumps and Babies. All pregnant women were written to, asking if they would attend Bumps and Babies if there was content designed to help them prepare for labour and early motherhood, and were asked to indicate which activities they would like from a list including music, craft, dance/exercise and relaxation. No replies were received by post. We have learned from experience that sending text messages is the most effective way to get replies.
The Foundation of Nursing Studies practice development facilitator assisted in running a stakeholder meeting, which included the project team, family outreach workers, matron for community midwifery, Head of Midwifery and the Director of Nursing at Poole NHS Foundation Trust. This served to clarify the values of the group through the use of a values clarification exercise. This was done by asking participants to complete the sentence:
‘I believe that the purpose of support for pregnant women and new mums is…’
A confirmed set of shared values was acknowledged, with the range of responses condensed into a single statement:
‘We believe that the purpose of support for pregnant women and new mums is to prepare women for labour and early motherhood; to make them aware of their choices and responsibilities by sharing information and helping to build a network of resources, both of information and relationships (with professionals and amongst themselves).’
Clarification of shared values helped to move into a discussion of ‘claims, concerns and issues’ (Guba and Lincoln, 1989). In this exercise, participants share what they believe the intervention is achieving and what they see as the current problems and pitfalls. The statements they write are then made into questions starting with how, why, what, will and when. For example:
‘How will we reach the women who are nervous to come to the children's centre and who have never engaged in groups?’
‘Who will take responsibility for contacting women?’
‘Will it be possible to send staff out to call on and walk with them to the group?’
The rolling programme, which the project officially started with in June 2015, contained elements for which there is specific evidence and accepted best practice, along with elements chosen by participants, such as manicures and facials.
Independent evaluation
Hardy et al (2013: 169) suggest that, in the context of practice development, the three main reasons for undertaking an evaluation are to:
An independent midwife researcher carried out an initial evaluation with women attending the group on two occasions. She used individual, semi-structured interviews, the format of which had been pre-approved by the Trust patient and liaison service panel. She collected video footage and photographs with written consent of the women.
For the team, participation in this project has strengthened professional relationships, interagency team-working and communication. The reports and exercises provided leaders with evidence and partnership, which has been presented as justification for extra resources, including an early learning development practitioner (ELDP) to the team for 4 hours per week and continued use of the children's centre as a venue.
Content of the sessions
Every session began with a discussion over lunch. The chosen topic was negotiated with the group to ensure it was relevant to group members' needs. In studies carried out in the 1980s, diets of pregnant women from low socioeconomic groups were found to be far below the reference values for most nutrients, especially iron, vitamins A and C, and folic acid (Hallam, 2008). Poorer pregnant women were consuming a less varied, less nutrient-dense diet than those with adequate incomes.
Women who are obese during their pregnancies are at increased risk of suffering from gestational diabetes, pre-eclampsia, miscarriage and stillbirth. Research also shows that the children of these women are at greater risk of obesity from child-hood to adulthood. The Bumps and Babies programme uses the free online resource from Tommy's, ‘Managing your Weight in Pregnancy’ (www.tommys.org/page.aspx?pid=763). Providing advice and information alone is not enough to change dietary behaviour—the more intensive and direct the intervention, the greater the chance of improving nutrition (Anderson et al, 1995). Sharing a nutritious lunch, including oily sea fish (vitamin D), vegetables and fruit (vitamin C and dietary iron) is an important social and health-promoting element of this intervention (Odent et al, 1996). In the feedback collected after the first session, participants were all in agreement that sharing lunch together before the activities was an enjoyable experience:
‘It's so nice to have food you don't have to prepare yourself!’ (First-time mother with 6-week-old baby)
They all agreed it made the group more sociable:
‘It's a good way to meet each other first.’ (First-time mother with 5-week-old baby)
Labour and emotional control
When pregnant women are in attendance, a hypnobirthing session is offered in a quiet room with the midwife. One randomised controlled trial found that women who are taught self-hypnosis have lower actual than anticipated levels of fear and anxiety between baseline and 2 weeks postnatal (Downe et al, 2015). It is reasonable to accept that the skill of learning to control emotional responses to labour pain is transferable to dealing with the stress of a crying baby and other challenges of motherhood.
Communicating with babies before birth
Ireland and Oakland (2013) draw together evidence of singing on wellbeing, and for childbirth and parenting in particular. Singing evokes the optimal hormonal response for calm birth and parenting. This response is what is required to help babies develop into secure adults who can manage their own emotions (and thus behaviour) in a way that helps them socially and educationally. In a study by Carolan et al (2012), a group of pregnant women joined a group and learned three lullabies over a course of classes. They reported feeling more ‘connected’ with their unborn babies and a sense of belonging to the group.
Studies have used more detailed analysis of musical elements in mother–baby communication, including qualities of rhythmic attunement, reciprocity, pitch, timing and ‘singing’ voice quality, concluding that communicative musicality is vital for companionable parent–infant communication (Malloch, 1999). A study by Robb (1999) showed depressed mothers produced quieter, less ‘singing’ voice quality and lower-pitched vocalisations, punctuated by longer pauses. Turn-taking behaviour was also disrupted. Matching of pitch, low arousal, less ‘joining in’ and negative mood states in the infant of the depressed mother suggested corresponding low effect in the baby. These characteristics of the depressed dyad's communication improved as clinical symptoms declined. This knowledge strengthens the rationale for using music in the group.
It is now accepted that children gather memories from their earliest years (including in the womb) that remain with them (Sunderland, 2007). Reviews have found that a diverse array of parenting programmes addressing emotional and mental health are successful. One small study (n = 10) showed greater frequency of maternal attachment behaviours when specific maternal attachment preparation was included in the classes, compared with standard classes without this component (National Institute for Health and Care Excellence (NICE), 2016).
The group uses various craft media to encourage the development of mental representations of the unborn babies; for example, making a picture frame, a decoration for the baby's room and clothing (Benoit et al, 1997). Music is used as a specific activity or as background sound. Evidence from qualitative research shows that, in general, women view antenatal classes positively (NICE, 2016). While most women appear satisfied with the content of classes in terms of pregnancy, labour and birth information, there is an expressed wish for more information regarding postnatal issues, including general baby care (NICE, 2016). We find that the baby-oriented craft activities lead to talking about the future, beyond labour. This then allows discussion around postnatal and parenting issues.
The two participants who had attended the singing and craft sessions especially enjoyed these; in fact, there were no activities mentioned that were not enjoyed:
‘I like the singing and the crafts I made when I was pregnant.’
In the post-study feedback, participants were asked, ‘Do you know why the activities on offer are available (craft, singing, hypnobirthing, DVD on baby brain development)?’
The answers to this question varied between the participants:
‘They've all got their purpose… it's very demanding having children… It's a way to relax learning a new craft.’ (Mother of three children)
‘Nice things to do… relaxing… beneficial.’
‘Interacting with other mums and mums-to-be.’
The pregnant women and first-time mothers with small babies thought of the activities as a means of interacting with others, while the mother of three children expressed her understanding of the deeper significance of doing a craft when there are lots of demands on you as a parent.
Overall, the range of topics of discussion during the group (alongside the activity) included problems with breastfeeding, sleeping with a newborn and older children, nipple shields, early child development, birth experiences and experiences of living on ‘the Moor’. All the women agreed it was beneficial to meet with other mothers and share information:
‘Although this was my first visit, it is great to meet other mums as a first-time mum and turn up and have a manicure! WOW! It's lovely that the midwife attends, too, in case you have any queries.’
‘It's good to meet other people in the area, as I don't know anyone’.
There were no negative comments offered.
Talking about relationships and emotions
This session evolved out of one in which a mother shared her experience of postnatal depression. She advised the other attendees to seek help as soon as possible if they felt overwhelmed by early motherhood as the support she received from the health visiting team was very helpful. New mothers compared their experiences of their partners' level of understanding regarding the responsibility and time that looking after a newborn involves, and ways in which they could encourage them to take part in baby care. ‘Baby blues’ and postnatal depression are important topics, which this session helps to talk about (Bauer et al, 2014). The midwife and family outreach workers are available to offer time for private discussion.
A study about transition to parenthood found that significant numbers of ‘low-risk’ parents experience psychological stress during this time, and that their concerns were far broader than the issues addressed by traditional antenatal classes (Parr, 1996). Further, a significant number of women were reported to experience common mental health problems, such as anxiety and depression during pregnancy.
One study showed that around 15% of pregnant women experience serious feelings of stress, anxiety or depression (O'Hara and Swaim, 1996). The majority of women experiencing postnatal depression had also experienced antenatal depression, and similarly postnatal anxiety was preceded by antenatal anxiety (O'Hara and Swaim, 1996). Being aware that one is not alone and that it is acceptable to talk to others, especially when there are professionals around, is a very important component of the group.
Smoking during pregnancy
This session was facilitated by a specialist smoking cessation midwife. Smoking tobacco during pregnancy is one of the most important risk factors to fetal growth and development (Mund et al, 2013). There is also growing evidence of a link between maternal smoking during pregnancy and later behavioural problems. The number of mothers smoking remains substantial and is significantly associated with socioeconomic disadvantage. Infants from the most deprived quintile are also more likely to be exposed to smoking in their homes (Anderson et al, 2007). The ‘Smokestop’ specialist midwife encourages women she is seeing in the community to join the group to extend health education and social networking opportunities on offer.
Infant feeding
In a review of initiatives to support breastfeeding, Hallam (2008) concludes that multifaceted interventions appear to be most effective in supporting breastfeeding, especially if they span the antenatal and postnatal periods, and draw on repeated contacts with professionals and peer educators. As a weekly group, there is potential to discuss infant feeding frequently. Research has shown that breastfeeding initiation rates and, in some instances, breastfeeding duration can be improved by antenatal breastfeeding education, particularly if this is interactive and takes place in small informal groups (Arlotti et al, 1998; NICE, 2016).
Conclusion
In the format of a ‘claims, concerns and issues’ framework, the group is effective as a participant-led entity. Some activities are now led by group members sharing their skills. It appears to be acceptable in its format and the activities offered are enjoyed. Newcomers are welcomed and members are communicating with one another between the sessions. As the group continues, there are plans to collate the stories of individual women as a means of encouraging others to join and as evidence of impact. There is a growing group of women who started to attend while pregnant and are still part of the group, and it will be interesting to learn from their stories. However, there is a concern that the group is still not accessible to the ‘hardest to reach’ women.
The recent addition of an ELDP to the team will free up time for another member of staff to call on women on foot and invite them to the group. It is hoped that the participant-led approach is providing an acceptable, appropriate and dynamic vehicle for good-quality information in a context of creativity, support and friendship, which will be open to wider inclusion of those women who may need the benefits the most.