Award Title: Listen2Baby - Improving monitoring of the baby during uncomplicated labour: a study using experience-based co-design
Funder: Department of Health and Social Care

Abstract: Background
UK guidance recommends that women without medical or obstetric risk factors, up to 45% of women, are looked after by midwives during labour and birth, and fetal wellbeing is assessed using regular ‘intermittent auscultation’ (IA) of the baby’s heart rate. There is clear national guidance about the timing and frequency of IA during labour, but successive national enquiries have identified that IA is often not carried out as recommended and that this contributes to death or severe health problems in babies. There is little or no evidence about the best IA device, timing, frequency or counting techniques; midwives’ practical experience of IA; women’s or partners’ experience; or IA training. In the absence of evidence, the barriers to conducting IA in line with national guidance are poorly understood.
Aims and objectives
The aim of this study is to improve the quality and safety of fetal monitoring in uncomplicated labours through (a) improved understanding of the organisational context and practice of IA, and (b) development and evaluation of a range of solutions, a 'toolkit' to improve IA practice; and to produce evidence to inform practice change and service development in midwifery and maternity care more broadly.
Objectives:
i.	Describe the range of IA devices, counting methods, and training used
ii.	Describe the practice of IA and identify the facilitators of and challenges to midwives following national guidance
iii.	Explore and describe women’s and partners’ experience of IA
iv.	Develop a toolkit to improve IA practice based on findings of i-iii
v.	Test the feasibility and acceptability of the toolkit, develop a systematic, theory-driven plan for implementation, and evaluate effectiveness.
Methods
We will use experience-based co-design (EBCD) to develop a practical toolkit to improve IA practice and an implementation plan which we will evaluate for feasibility, acceptability and effectiveness.
I.	We will carry out a survey of practice in all 220 UK midwifery units, and in the 35 UK obstetric units without a linked midwifery unit, to describe the range of IA devices, methods, IA training and details of IA audits.
II.	We will use observational fieldwork, structured conversation and semi-structured interviews in a purposive sample of at least eight NHS settings to capture aspects of tacit IA practice, and explore and understand midwives’ perspectives on IA practice.
III.	We will convene, and carry out focus groups with, a lived-experience user group to explore and describe women’s and partners’ experiences of IA.
IV.	Using the research evidence generated in components I-III, we will work with midwives, service users, and key policy and practice stakeholders to co-design a toolkit to improve the practice of IA.
V.	We will used mixed methods including qualitative interviews and field notes, and an uncontrolled before and after study to test feasibility and acceptability and evaluate effectiveness in our research sites.
Outputs, dissemination and impact
In addition to academic publications and presentations, the primary output will be an evidence-based co-designed toolkit for IA, including practical guidance for implementation, which can be embedded in and disseminated through national maternity safety initiatives. We anticipate benefit in terms of midwives’ increased confidence in IA skills and knowledge, improved quality of IA, translating into improved safety for babies, within 4-6 years of the start of the project.

Lay Abstract: What we know
For women experiencing an uncomplicated labour, UK guidance recommends that midwives monitor the baby’s heart rate using a hand-held fetal stethoscope or ultrasound device. This is known as ‘intermittent auscultation’ (IA), which means ‘listening at regular intervals’, and is used in the labours of up to 300,000 women every year in the UK. 
National guidance says that midwives should listen to the baby’s heart rate straight after a contraction for at least one minute, and that they should do this and record the baby’s heart rate every fifteen minutes during the first stage of labour, and every five minutes in the second (pushing) stage.
Several national investigations have found issues with the way IA is carried out in practice that have contributed to death or severe injury in babies. Problems include IA not being carried out at the right time or often enough; the baby’s heart rate not being recorded properly; and midwives not recognising or acting on concerns about the baby’s heart rate.
What we want to find out
There is no research evidence about the best way to do IA in practice, including what is the best device or counting method to use, and we don’t know why IA is not always carried out in line with national guidance. Most research so far has focused on continuous electronic monitoring (where the woman has a belt around her tummy, producing an electronic or paper trace of the baby’s heart rate), which is used for women with pregnancy complications.
Our research will find out how midwives do IA in practice, what devices and counting methods they prefer to use and why, and what problems they have in following national guidance about IA. We will also find out what IA is like for women and their partners. We will work with midwives, women and their partners, and other national experts, to use this information to design and test a practical ‘toolkit’ to help midwives do IA in the best way to ensure safety for babies.
How we will do this research
We will carry out a survey of all UK NHS organisations to find out what IA devices, counting methods and training packages midwives use. We will watch midwives using IA in different units across the UK and talk to them about what doing IA is like from their point of view. We will also speak to women with different experiences of having their baby’s heart rate monitored using IA. We will collect the key points from all this information.
Together with midwives, women and other experts we will then use ‘experience-based co-design’ (EBCD) to design a practical ‘toolkit’ to improve the practice of IA. This means holding meetings to feed back the research results to midwives, women and partners, and others with an interest or expertise in IA. We will discuss the results together, agree what to work on and form small co-design groups to design solutions. Together these solutions will form our toolkit, which we will then test in a small number of units to see whether and how it works. Finally, we will get everyone involved together to share the final toolkit. We don’t know what the toolkit will look like yet because it will come out of the EBCD process, but it could include a website, videos, posters or prompt cards. 
Throughout the project, we will work closely with women, midwives, and senior NHS and government policy colleagues to make sure that the results of this research, and the toolkit we produce, will lead to changes in practice to improve the way that IA is carried out.

Research Activity Codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health Categories: REPRODUCTIVE HEALTH AND CHILDBIRTH