Implementing safe sleep practices in a neonatal intensive care unit

Objective: Sudden infant death syndrome (SIDS) remains the leading cause of death in the postnatal period. Accidental suffocation and strangulation in bed deaths have quadrupled. The American Academy of Pediatrics (AAP) expanded its back to sleep recommendations to include a safe sleep environment. The AAP makes recommendations to healthcare professionals to model safe sleep practices and educate families on SIDS reduction strategies. The dual aims of this project were to develop a safe sleep educational model for our neonatal intensive care unit (NICU), and to increase the percentage of eligible infants in a safe sleep environment.

Method: The NICU Safe Sleep policy was revised to include AAP updated recommendations. Educational updates were provided to staff. A safe sleep packet with a video was created for and shared with families. Wearable blankets were implemented. A safe sleep observation checklist was created. Baseline data and post-education random observations data were collected and shared with staff.

Results: At baseline, 21% of eligible infants were in a safe sleep environment. After education and reported observation, safe sleep compliance increased to 88%.

Conclusions: With formal staff and family education, optional wearable blanket, and data sharing, safe sleep compliance increased and patient safety improved.     

Scoping Review of Barriers and Facilitators of Breastfeeding in Women on Opioid Maintenance Therapy

ObjectiveTo synthesize the literature on the barriers and facilitators of breastfeeding among women on opioid maintenance therapy (OMT) to inform nursing interventions and improve breastfeeding outcomes.Data SourcesWe searched 11 databases using the following key terms: breastfeeding, barriers, facilitators, promotion, and opioid.Study SelectionWe included articles published in English since 2015 that addressed barriers and facilitators of breastfeeding in women on OMT. We did not limit our search to specific types of studies. Our search produced 65 records. After reviewing titles and abstracts, we assessed 21 full-text articles and excluded seven for lack of data related to our key terms. As a result, we included five qualitative studies, three reviews, three mixed-methods studies, two retrospective cohort studies, and one case report (14 articles) in our final review.Data ExtractionWe extracted data from each article and sorted them in a table for analysis and synthesis. Data included study purpose, research questions, design and methodology, and findings specifically pertaining to the identification of barriers and facilitators of breastfeeding for women on OMT.Data SynthesisWe identified three themes related to facilitators of and barriers to breastfeeding: Information, Support, and Health Care System Factors.ConclusionThe results of our review suggest that most barriers and facilitators of breastfeeding in women on OMT are manageable with improved health care practices. Primary and acute care health professionals should modify practices to minimize barriers to breastfeeding. Nurses should provide better breastfeeding education and preparation, sensitive care in the immediate postpartum period, and extended follow-up after hospital discharge for women on OMT.     

Healthcare Clinician and Staff Perspectives on Facilitators and Barriers to Ideal Sexual Health Care to High-Risk Depressed Young Women: A Qualitative Study of Diverse Clinic Systems

Study ObjectiveThis study identified clinician and clinic staff perspectives on facilitators and barriers to providing sexual and reproductive health (SRH) care to depressed young women, a population at increased risk for adverse SRH outcomes.DesignWe conducted in-person semi-structured qualitative interviews, which were audio-recorded, transcribed, and coded by two researchers. We used thematic analysis to identify themes pertaining to care facilitators and barriers within a socio-ecological framework.SettingThis study was conducted in seven diverse clinics in the U.S. New England region.ParticipantsParticipants were 28 clinicians and staff (4/clinic), including behavioral health clinicians (n = 9), nurse practitioners (n = 7), nurses (n = 3), medical doctors (n = 3), administrative associates (n = 2), practice managers (n = 2), family planning counselor (n = 1), and medical assistant (n = 1).Main Outcome MeasuresWe queried how clinicians and clinic staff identify and manage depression and sexual risk, and what they perceive as facilitators and barriers affecting provision of ideal SRH care to depressed young women.ResultsThemes represented facilitators of and barriers to providing ideal SRH care to high-risk depressed young women at five socio-ecological levels: individual (facilitator: trust in providers; barrier: stigma experiences), interpersonal/provider (facilitator: frequent patient–provider communication; barrier: lack of time during clinic visits to build trust), clinic (facilitator: integration of care; barrier: lack of scheduling flexibility), organization/community (facilitator: training for providers; barrier: funding constraints), and macro/societal (facilitator: supportive policies; barrier: mental health stigma).ConclusionOptimizing SRH care to high-risk depressed young women necessitates attention to factors on all socio-ecological levels to remove barriers and bolster existing facilitators of care.     

Barriers and facilitators in antenatal settings to screening and referral of pregnant women who use alcohol or other drugs: A qualitative study of midwives’ experience

BackgroundScreening pregnant women for substance use is highly recommended in antenatal care settings. Although midwives provide routine screening for substance use and referral for treatment in pregnancy, little is known about the barriers and facilitators they experience.AimThe study explored barriers and facilitators experienced by midwives in antenatal settings to screening and referral of pregnant women who use alcohol or other drugs.Design/settingA semi-structured interview was adopted to explore barriers and facilitators experienced by midwives in screening and referring pregnant women for alcohol or other drugs specialised services. Eighteen midwives were recruited from urban, regional and rural antenatal settings in Victoria. Interviews were tape recorded and transcribed verbatim. Themes were generated by thematic analysis, the process of identifying patterns within the data.FindingsOf the seven themes identified under barriers, five could be categorised as “institution and provider-related”, namely: (i) lack of validated screening tool, (ii) inadequate support and training, (iii) discomfort in screening, (iv) lack of multidisciplinary team and specialised treatment in regional and rural areas, and (v) workload and limited consultation time. Conversely, two themes could be classified as ‘client-related’, namely (i) non- or partial-disclosure of substance use, and (ii) reluctance and non-adherence to referrals. All five themes under facilitators were “institution and provider-related.” They are (i) a woman-centred philosophy of care, (ii) evidence of harms from substance use on neonates, (iii) experience and training, (iv) continuity of care, and (v) availability of multidisciplinary team and funding.Key conclusions and implications for practiceTo the best of our knowledge, this is the first study of its kind conducted in Victoria. This study not only adds to the limited body of knowledge on barriers experienced by midwives but also identifies facilitators in antenatal settings that promote screening and referral of pregnant women who use substance. Most of the barriers and facilitators are interrelated. Despite midwives’ willingness to screen all pregnant women for substance use and provision of referral, they often felt limited in their capacity. Availability and accessibility to validated screening tool(s), in addition to regular, ongoing training for all midwives to maintain clinical competence and provide effective communication are imperative. Availability of a multidisciplinary team, funds and specialised care facilities such as detoxification and mental health services, especially in regional and rural areas, are necessary to effectively support at-risk pregnant women.     

Awareness,Beliefs and Perspectives Regarding Weight Retention and Weight Gain among Postpartum Women in India: A Thematic Analysis of Focus Group Discussions and In-Depth Interviews

Background and AimsThe pregnancy weight is usually retained in the form of abdominal fat during the postpartum period. The willingness to lose weight is influenced by knowledge, attitude, beliefs and practices. This study aims to comprehend the awareness, beliefs and perspectives of postpartum women regarding their perceived factors, barriers and facilitators associated with post-pregnancy weight status.MethodsOverweight and obese postpartum women aged between 20 and 40 years and had delivered an infant in the last 2 years were recruited via convenience and purposive sampling techniques. The final sample comprised 27 participants with a mean age of 29.96 ± 4.50 years. Four focus group discussions and eight in-depth interviews carried out were audio-recorded and transcribed verbatim. Codes, sub-themes and themes were generated using Atlas.ti 9 software.ResultsMajor themes identified were perceived factors causing postpartum weight retention/weight gain including social and cultural beliefs related to diet and exercise specifically associated with this period, perceived motivators and deterrents of weight loss including eagerness to lose weight and perceived facilitators and barriers to weight loss including intrinsic and extrinsic factors such as time, energy, evidence-based knowledge about diet and physical activity, family support and obligation to family’s advice.ConclusionThe unique challenges and barriers associated with postpartum weight loss efforts should be taken into consideration by healthcare professionals and public health policy-makers to design strategies specific to postpartum women.Supplementary InformationThe online version contains supplementary material available at 10.1007/s13224-022-01644-9.     

A Systematic Review of Barriers to Vaccination During Pregnancy in the Canadian Context

ObjectiveAlthough vaccination in pregnancy has the potential to affect maternal and infant morbidity and mortality dramatically, uptake of recommended vaccinations in pregnancy remains low. The objective of this study was to identify barriers and facilitators of vaccination during pregnancy in Canada.MethodsThe Medline database and the tables of contents of four relevant Canadian journals were screened to identify all studies that considered barriers and/or facilitators to vaccination during pregnancy, specifically in Canadian settings. Citations were screened, and a narrative synthesis of findings was undertaken given the heterogeneity of study design.ResultsIn total, 17 studies met inclusion criteria, most with a focus on the seasonal and pandemic influenza vaccines. Facilitators and barriers were identified at the level of the patient and the provider. At both levels, knowledge was an important facilitator of vaccine acceptance during pregnancy and was notably improved in studies following the 2009 pandemic H1N1 influenza outbreak compared with earlier studies. Vaccine endorsement by a prenatal care provider and clear messages of safety for the fetus emerged as key motivators. Few studies addressed system-level barriers or interventions for improving vaccine uptake during pregnancy in the Canadian setting.ConclusionCommon themes have emerged from the Canadian literature addressing barriers and facilitators of vaccination during pregnancy. However, there is a paucity of literature to suggest strategies to improve the uptake of vaccination during pregnancy in Canadian settings. Further research is urgently needed given the expanding role of vaccination during routine prenatal care.     

Newborn care and safety: the black box of obstetric practices and residency training

Certain causes of newborn mortality such as sudden unexpected infant death, which includes sleep-related infant death and sudden unexplained infant death syndrome, are potentially preventable. Obstetricians are uniquely positioned to counsel new parents about safe practices regarding newborn sleep, feeding, and transportation. Patients often do not develop a relationship with their pediatricians until the neonate has been discharged, and the newborn period is a time of particular vulnerability. Newborn safety should be routinely taught in obstetric curricula, and the American College/Congress of Obstetricians and Gynecologists and the American Academy of Pediatrics (AAP) should partner to disseminate updated literature and guidelines to health care providers regarding newborn safety. Current guidelines from the Academy of Pediatrics Task Force on Sudden Infant Syndrome are summarized in this article.     

Assessing mental health during pregnancy: An exploratory qualitative study of midwives’ perceptions

BackgroundMental health disorders are estimated to affect between 10% and 20% of women who access maternity services and can be defined as a public health issue due to the potential consequences for women, children and families. Detecting problems early in pregnancy can significantly improve outcomes for women and their families. However, mental health problems are not being consistently identified in routine midwifery practice and little is known from current literature about midwives’ practice in relation to current national guidelines or the impact models of care have on assessing maternal mental health.ObjectiveTo identify midwives’ views about barriers and facilitators to screening for mental health in pregnancy using current UK guidelines.DesignNine community midwives from a single district general hospital in the south of England were recruited to take part in focus groups. Thematic analysis was used to extract key themes from the data.FindingsThree key themes were identified from the focus groups and included system factors, social factors and trust. Barriers and facilitators to screening maternal mental health were associated with the initial ‘booking’ appointment’ and differences in models of care. Barriers to screening were defined as high workload, poor continuity, and a lack of trust between women and midwives.ConclusionsThis study highlights key barriers and facilitators associated with mental health screening during pregnancy, including issues of trust and uncertainty about women's willingness to disclose mental health conditions. Further research is required to evaluate the relationship between women and midwives in contemporary practice and the influence this may have on maternal mental health.     

Reflections on an educational intervention to encourage midwives to work in a continuity of care model – exploration and potential solutions

ObjectiveTo explore barriers and facilitators for midwives working in a midwifery continuity of carer model, and to assess if an educational intervention could help address some of these barriers, designed to help achieve NHS England's target of majority of women receiving midwifery continuity of carer by March 2021.DesignTwo-day workshops were co-designed by experienced continuity midwives, service managers and midwifery educators using implementation theory delivered to maternity staff, with barriers assessed prior to training and re-assessed at the end.Setting and participants1407 maternity healthcare professionals from 62 different National Health Service trusts across England attended 56 different workshops.FindingsPerceived barriers to working in this model were reported more frequently than facilitators. Reported facilitators prior to training included perceived benefits to the midwife and to women. Reported barriers included personal and professional concerns, fear, issues with the national agenda and institutional and/or organisational issues. The educational intervention was able to address the majority of barriers raised. The training was well evaluated, with an average rating of 4.2 on a five-point Likert scale.Key conclusionsWhile this specific educational intervention appears to have been useful in addressing concerns with working in a continuity model, further work is needed to identify barriers to change. This will aid more local designed interventions.Implications for practiceIf policy targets related to continuity of carer are to be achieved then working in this way needs to be sustainable and appeal to the current midwifery workforce.     

Scoping Review of Postpartum Discharge Education Provided by Nurses

ObjectiveTo determine what is known about postpartum education provided by nurses to women before discharge from the hospital after birth and whether current nursing practices are effective to prepare women to identify warning signs of complications, perform self-care (physical and emotional), prepare for parenting a newborn, and establish infant feeding.Data SourcesWe conducted a systematic search of CINAHL Plus and MEDLINE for relevant sources, including peer-reviewed articles, conference presentations, and guidelines from professional organizations, that were published in English from January 2010 through November 30, 2020.Study SelectionWe included sources if participants were women who had given birth to a healthy, liveborn, term infant and were receiving education in whole or in part by a nurse during the maternity hospitalization. We excluded sources with samples of high-risk women or those who gave birth to high-risk infants (preterm, congenital anomalies, neonatal abstinence syndrome). Forty-six of the sources met the inclusion criteria.Data ExtractionWe extracted citation, type of document, country of origin, context (prenatal/postpartum or both and inpatient/outpatient or both), aim, participants (mother/father or both, sample characteristics), content of education and who provided it, outcomes or key themes, and main results.Data SynthesisInfant topics included breastfeeding and safe sleep, and maternal topics included breastfeeding, postpartum mood, and self-care after birth. Nurses prioritized safety, including safe sleep; preventing infant falls; decreasing infection; screening for postpartum depression; and avoiding adverse outcomes after discharge. Women focused on self-care, pain management, infant care, and parenting. Women and nurses prioritized breastfeeding. Authors of the included sources measured effectiveness by patient satisfaction, chart audit, pre- and posttests of nurses’ knowledge, and breastfeeding duration. Women reported barriers to postpartum education such as limited nursing time or conflicting information.ConclusionPostpartum education is a priority, but its effectiveness is not well studied. Few maternal or infant health–centered outcomes have been measured beyond breastfeeding duration. Nursing care and nurse expertise are not easily quantified or measured. Research is needed to inform best practices for postpartum education.     

Parents’ Experiences With a Model of Integrated Maternity and Neonatal Care Designed to Empower Parents

ObjectiveTo explore the experiences of parents with an integrated maternity and neonatal ward designed to empower parents by providing family-integrated care (FICare) to mother–newborn couplets in single-family rooms.DesignA qualitative analysis with a contextual constructivist approach.SettingAn integrated maternity and neonatal level 2 ward designed to empower parents in a teaching hospital in Amsterdam, the Netherlands. Maternity and neonatal care, up to and including highly complex care, is provided to mother–newborn couplets in single-family rooms according to the principles of FICare.ParticipantsTwenty-seven mothers and nine fathers of newborns who were hospitalized for at least 7 days.MethodsWe held four focus group discussions and eight semistructured interviews 1 to 3 months after discharge of the newborn to explore which experiences (mechanisms) facilitated or impeded aspects of parent empowerment (outcomes) under which specific conditions of the integrated infrastructure (contexts). We used the realist evaluation model to analyze the data.ResultsOur analysis revealed five themes of parent empowerment (outcomes): Feeling Respected, Gaining Self-Management Tools, Insights Into the Newborn’s Condition, Perceived Control, and Self-Efficacy. For each theme, participants reported facilitating and impeding experiences (mechanisms) that were initiated and influenced by the combination of single-family rooms, couplet care, rooming-in, and FICare (contexts). Unrestricted physical proximity to their newborns, 24 hours per day, in a safe private environment offered parents intensive learning experiences through active participation in care. It helped them to achieve independent parenthood at the time of discharge, but it also generated challenges such as power conflicts with the staff; prioritizing care for themselves, siblings, or the newborn; feelings of isolation; and lack of sleep.ConclusionProviding FICare to mother–newborn couplets in single-family rooms offers parents an intensive learning context for independent parenthood at the time of discharge. Health care professionals should be aware of the challenges and facilitators experienced by parents in the context of close physical proximity to their newborns 24 hours per day in single-family rooms. This awareness will allow them to better support parents in their empowerment process toward independent parenthood at the time of discharge.     

Barriers to and facilitators for newborn resuscitation in Malawi, Africa

Newborn resuscitation is a key component of efforts to reduce neonatal morbidity and mortality. This article reports the findings of focus groups conducted to explore the barriers and facilitators present for obstetric nurse providers in a central urban hospital in Malawi regarding the training and provision of neonatal resuscitation. All obstetric nurse providers in this setting participated in focus groups; these groups identified 4 themes: 1) confidence in their skills in assessing newborns and recognizing the need for resuscitation, 2) a lack of resources, 3) facilitators who would enable them to introduce resuscitation, and 4) solutions to the current problems. Resource shortages and barriers to providing care included availability of staff, equipment, and supplies; labor ward geography; ethical dilemmas; and the lack of standard protocols regarding newborn resuscitation. Facilitators were professional experience and the critical load of deliveries performed. Solutions to barriers included small resource additions as well as long-term policy changes. With standard policy and protocols, experienced, confident nurses could overcome the barriers to providing newborn resuscitation. This group identified ways to change systems to decrease infant mortality, thereby improving the health and quality of life of women receiving care in Malawi.     

Staff perspectives regarding the implementation of a yoga intervention with chronic pain self-management in a clinical setting

Chronic pain affects millions of Americans and can be addressed through multiple modalities, interventions, and strategies. Yoga and self-management have been proven effective in treating chronic pain, but little research has been conducted on the feasibility and implementation barriers related to these alternative intervention forms. In our qualitative study, we examined staff perceptions regarding the feasibility of implementing yoga along with established self-management at a pain management clinic in Colorado. We utilized the Implementation Drivers of Competency, Organizational, and Leadership, and our added Hypothetical Driver to explore barriers and facilitators related to project implementation. Our findings suggest that positive staff and patient attitudes were crucial for successful implementation. We also identified physical space, transportation, and supportive leadership as necessary components of project implementation. Further research is needed to examine barriers such as funding to ensure intervention sustainability and the need for adequate staffing.     

Patients' and professionals' barriers and facilitators to external cephalic version for breech presentation at term,a qualitative analysis in the Netherlands

Objectiveexternal cephalic version (ECV) is a relatively simple and safe manoeuvre and a proven effective approach in the reduction of breech presentation at term. There is professional consensus that ECV should be offered to all women with a fetus in breech presentation, but only up to 70% of women eligible for ECV undergo an ECV attempt. The aim of the study was to identify barriers and facilitators for ECV among professionals and women with a breech presentation at term.Designqualitative study with semi-structured interviews.SettingDutch hospitals.Participantspregnant women with a breech presentation who had decided on ECV, and midwives and gynaecologists treating women with a breech presentation.Measurementson the basis of national guidelines and expert opinions, we developed topic lists to guide the interviews and discuss barriers and facilitators in order to decide on ECV (pregnant women) or advice on ECV (midwives and gynaecologists).Findingsamong pregnant women the main barriers were fear, the preference to have a planned caesarean section (CS), incomplete information and having witnessed birth complications within the family or among friends. The main facilitators were the wish for a home birth, the wish for a vaginal delivery and confidence of the safety of ECV. Among professionals the main barriers were a lack of knowledge to fully inform and counsel patients on ECV, and the inability to counsel women who preferred a primary CS. The main facilitator was an unambiguous policy on (counselling for) ECV within the region.Conclusionwe identified several barriers and facilitators possibly explaining the suboptimal implementation of ECV for breech presentation in the Netherlands.This knowledge should be taken into account in designing implementation strategies for ECV to improve the uptake of ECV by professionals and patients.