Title: Opportunity-Led Research Proposal: National Survey of Women's Experiences of Maternity Care
Funder: Health and Social Care Research and Development Division (HSC R&D) of Public Health Agency, Northern Ireland

Abstract: The context. As maternity services change over time it is critical to document the views of women with recent experience of maternity care, at national and local level. Following on from a survey carried out a decade earlier the last national survey of recent mothers was carried out three years ago in 2006 , followed by the Healthcare Commission Maternity Service Review which showed substantial variation between trusts and regions in the services provided and women’s experience of care. The policy document ‘Maternity Matters’, has laid out a practical framework for individualised care in which choice, access and continuity of care within a safe service are a priority. It recognised that maternity care is the earliest intervention which underpins the later care described in ‘Every Child Matters: Every Child Matters: Change for Children in Health Services’ and the ‘National Service Framework for Children, Young People and Maternity Services’. The kind of service described and the goals that have been set make it timely to undertake another national survey as maternity services are evolving, with a range of innovations planned and being introduced. The information from this study will provide a benchmark of current practice and a baseline for measuring change over the period during which the NSF has been implemented. It will also enable comparison between women’s experience and care in different regions of England. Such a study will inform policy in maternity care, support implementation and change and provide a further point of comparison for local surveys of user views and experiences in individual trusts. Other policy documents such as ‘Saving Mothers’ Lives 2003-2005’ and the series of NICE Guidelines on antnatal, intrapartum and postnatal care with provide an important context for maternal health and care. A number of broad themes emerge from all these policy documents. These include making the user perspective and experience central to service design, delivery and outcome evaluation, and supporting people in making better choices for their health and the health of their families.Contemporary NHS maternity care aims for ”Women to have easy access to supportive, high quality maternity services, designed around their individual needs and those of their babies” (Standard 11 of the NSF ). Underpinning this is the principle that the best care is defined by the health and social needs of the woman and her family. As services change over time it is critical to document the views of women with recent experience of maternity care, at national and local level. Obtaining information about women's views and experiences is important for several reasons: • All health care is about more than the technical aspects of treatment. Good care meets the needs of people as individuals, including their needs for choice, encouragement, information and reassurance. • Women’s reactions to care around the time of birth can affect they way they care for themselves and their baby and influence the contact they go on to have with care-givers. It is also a window of opportunity for intervention, with many women and their partners being in touch with services. Whether women and their partners feel they have had a good or bad experience is partly affected by clinical events, but the explanations and support they get from staff can also be important to them for a long time. When things go well, women may feel more confident with the new baby and happier to ask for help and advice from care-givers. When things go badly, women may dwell on their experiences and may be very anxious about another pregnancy. • Some aspects of care can be assessed only by asking women, or are more practical to get this way. For example, if a trust aims to provide women with information about local maternity services and choices, then it is important to ask whether women actually received this information. Women need to be the ones to say whether they got enough information, whether they were able to understand what was said to them, whether they were treated kindly, and whether qualities of the services and facilities were good. Women are also best able to say whether they knew the care-givers who looked after them at different stages. The 2010 survey. This 2010 survey of recent mothers will follow a similar format to that used in 2006 by NPEU. The questionnaire will allow women to describe the care they have received, to express their views about it in structured questions and to make some written response if they wish. Some of the results will be about clinical aspects of care; this will be useful in giving a background to women’s experiences and also because national statistics about maternity care do not cover all topics of interest. Method. The same procedures will be followed as for the 2006 NPEU survey. 1. Ethical approval MREC approval for the study will be sought at the earliest opportunity. 2. Questionnaire development Objective: To develop a postal questionnaire to measure women’s experiences and views of their maternity care, based on the instrument developed for the NPEU survey carried out in 2006. The questionnaire developed for the 2006 national survey of recent mothers will form the basis of the 2006 survey, however, it will be further developed to ensure that it reflects current issues of interest, such as: • Planned pregnancy • Choice in accessing maternity care • Midwife as first point of antenatal contact • Father engagement • Place of birth • Postnatal support and care after discharge home • Compliance with recommendations made in the NICE guidelines on antenatal, intra-partum and postnatal care. The over-arching research questions this survey will help to address are: i) What is current clinical practice in provision of maternity care in the UK? This will include aspects of the clinical care provided, but also the service provision and organisation around that care. ii) What are the key areas of concern for women receiving contemporary maternity care in the UK? iii) Have women’s experiences and perceptions of care changed over the last three years? iv) What regional differences are there in women’s experience of care? These questions will be addressed with reference to a number of overarching topics within maternity care including access, choice, communication and attitudes. The changes to the instrument will be agreed and it will be tested with a small number of women in cognitive interviews to ensure that the additional questions can be understood and women’s understanding of the questionnaire can be explored. These women will be recruited for the cognitive interviews from community and NCT groups to ensure that women from a wide range of social and ethnic backgrounds are included. No pilot study is planned as the survey will use the modified 2006 survey instrument. 2. Identification of sample. Women will be randomly selected from birth registration by the Office for National Statistics. A national random sample of 9700 women is proposed aged 16 years and over who had their baby in a two week period in England. These women will be contacted 3 months after the birth of their baby, providing that the NHS Central Register has not been notified about the death of the baby. 3. Data collection. A questionnaire will be sent to each woman by the Office for National Statistics (with an invitation letter from the Registrar General or their representative, an information leaflet and a sheet with different languages and a free phone contact number). Once completed, the questionnaires, each identifiable only by a unique reference number, will be returned to NPEU and then to the contractor for data entry. ONS will be informed about which questionnaires have been returned to prevent inappropriate reminders being sent. The planned mail out is for September 2009. Two reminders will be sent to non-responders. The first will be a letter sent two weeks after the initial questionnaire reminding the woman that a questionnaire was sent and asking for its completion and return. The second reminder, sent two weeks after the first reminder, will include a letter and a copy of the questionnaire. If no response is obtained, no further contact will be made. ONS will be asked to produce simple aggregate statistics of the women who fail to respond, such as their age distribution, socio-economic classification etc, to enable the responders to be compared with the non-responders, which will allow the results of the survey to be interpreted appropriately. Data will be stored indefinitely in accordance with the data archiving policy at the National Perinatal Epidemiology Unit. NPEU will seek appropriate guidance with the intention of placing the archive dataset with the UK Data Archive at Essex University. 4. Analysis. Data analysis. Descriptive statistics, such as means and proportions with 95% confidence intervals, will be estimated. Proportions will be compared using analysis of variance or Chi-squared tests as appropriate. Multiple regression techniques, such as logistic regression, will be used for comparisons as appropriate. Sample size. The total sample size for the survey is 9700 women. This allows for a response rate of 60% (in 2006 this was 63%), giving a projected sample size of 5820. Justification for proposed sample size. As an example, in the 2006 survey 86% of women made their first contact with a health professional before 12 weeks gestation. The proposed sample size will enable us to estimate this proportion with 95% confidence intervals from 85% to 87%. When comparing the 2006 and 2010 surveys, the proposed sample size would have in excess of 90% power to detect an absolute difference in the outcome of 2%, i.e. if 88% of women in the 2010 survey state that they first contacted a health professional before 12 weeks of pregnancy, we can be certain that this reflects a true difference. In the 2006 survey 86% of women made their first contact with a health professional before 12 weeks gestation. We have assumed an improvement in the light of the PSA target to 90% overall. This sample size will enable us to identify if the SHA with the smallest population falls 7% or greater below the assumed 90% population rate of women making their first contact with a health professional (North East England) and 3% or greater in the largest SHA (London). The sampling frame used only allows sampling from all SHAs as a whole and therefore in order to make sure there are sufficient numbers of respondents in the SHA with the smallest numbers of birth for the analyses required, the sample size is greater than that used in the 2006 survey. Project management. Maggie Redshaw will be the lead for the project, with statistical, administrative and management support. A project management group consisting of representatives of DH and NPEU will bet set up to agree content changes and review progress against objectives. Outputs. A detailed technical report and executive summary will be prepared for the Department of Health. Papers will be prepared for publication in appropriate peer reviewed scientific journals and presentation at selected conferences. With the permission of the DH, the technical report will also be posted on the NPEU website, and made available to relevant stakeholders, particularly consumer organisations. Copies of the technical report and relevant publications will be forwarded to the relevant Royal Colleges, such as the Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives.


Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: REPRODUCTIVE HEALTH AND CHILDBIRTH