Title: How can NICE intrapartum guidelines recommendations on place of birth for women with uncomplicated pregnancies be implemented in practice?
Funder: Department of Health and Social Care

Abstract: Background: There is a growing interest in developing theoretically informed strategies for implementing research evidence into practice. Poor theoretical underpinning makes it difficult to understand and explain how, when, for whom and why implementation succeeds or fails. The use of theoretical approaches offers the potential of increasing the predictability of successful implementation. Within maternity service, the community is facing the challenge of implementing NICE intrapartum guidelines for women with uncomplicated pregnancies. Despite the NICE recommendations to commissioners and providers to ensure that all four birth settings (home, alongside and freestanding midwifery unit and obstetric unit) are available to healthy women at low risk of complications, to date the majority of births in England are assisted in hospital. Many NHS services still offer obstetric unit (OU) as the mainstream option and midwifery-led birth settings as an alternative. Aims: This Fellowship aims to develop a theoretically informed knowledge implementation pathway to guide and support commissioners and service providers in implementing evidence into the NHS services, using maternity services as a case study. The primary aim of the research project will be to explore whether the development and implementation of Midwifery-led Birth Settings Pathway (The Pathway) can have an impact on the number of births outside OUs. The secondary, but equally important aim, will be to enhance understanding of how to effectively implement evidence-based service organisation and delivery type changes in complex NHS settings, in order to apply the lessons learnt to other settings and areas of healthcare. Research question: How can NICE intrapartum guidelines recommendations on place of birth for women with uncomplicated pregnancies be implemented in practice? Plan of investigation: I will conduct a Participatory Action Research (PAR) project, in four sites that form part of the same NHS Trust, each with a different history and operational management. PAR consists of a family of research methodologies, which aim to implement change with the active engagement of the co-participants. Change is implemented and evaluated at the same time in a cyclical way following a PAR-cycle (Plan, Act, Observe, Reflect). The Promoting Action on Research Implementation In Health Services (PARIHS) approach offers a theoretically informed framework to guide implementation design and evaluation. A modified version of the PARIHS will be nested and tested within a PAR project to implement and evaluate the impact of The Pathway aimed at translating NICE recommendations on place of birth for women with uncomplicated pregnancies into an actionable local plan for increasing the number of births outside OUs.Methods: Data collection will include qualitative and quantitative methods. Qualitative methods: focus groups; interviews; non-participant observation; analysis of local documents and guidelines. Qualitative data will be analysed using thematic analysis. Quantitative methods: time-series analysis of rates of births at home and in midwifery units as well as key clinical outcomes in these settings, local audits and service users surveys as part of routine service evaluation. Potential Benefits: Successful development of a theoretically informed framework could offer not only direct benefits to service users and the NHS but also lessons to be applied more widely within the field of implementation science. Service users would benefit by having access to evidence-based care, which is safe and engenders positive experiences. The NHS will benefit by providing cost-effective care, which values its staff and offers job satisfaction, as highlighted by the literature. There could be several cost savings associated with increasing birth outside OUs: direct cost savings related to the reduction of costly birth interventions, birth complications, need for medical care and length of hospital admission; longer term cost savings due to the reduction in maternal morbidity.

Lay abstract: Background: Robust evidence suggests that midwifery-led birth settings, such as midwifery units in hospital or community as well as home birth can reduce intervention such as instrumental and cesarean births while offering safe care for the mother and her baby. Midwifery-led birth settings are also less expensive than obstetric units (OU). For this reason the NICE Intrapartum Guidelines published in 2014 recommended clinicians to advise healthy women with uncomplicated pregnancies to consider planning their births in midwifery-led settings. Despite the recommendations to commissioners and providers to ensure that all four birth settings (home, AMU, FMU, OU) are available, in London to date there are only three FMUs and the majority of women give birth in hospital. Many NHS services still offer OU as the mainstream option and midwifery-led birth settings as an alternative. In 2013, planned out-of-hospital birth only accounted for 3% of all births and in London number of births in midwifery-led birth settings varies from 3% to 25%. This subject therefore provides an ideal case to study and address the challenge of implementation of research knowledge into NHS settings. Studies of knowledge implementation have highlighted that strategies for change should focus on context, culture and systems in the NHS as well as practices and should use more active and inter-disciplinary approaches to sharing and learning. The Promoting Action on Research Implementation In Health Services (PARIHS) approach offers a framework to guide implementation design and evaluation. A modified version of PARIHS will be nested and tested within a Participatory Action Research (PAR) project to implement and evaluate the impact of a Midwifery-led Birth Settings Pathway (The Pathway) aimed at translating NICE recommendations on place of birth for women with uncomplicated pregnancies into an actionable local plan for increasing the number of births outside OUs.This Fellowship builds on the previous work conducted by Dr Coxon, a former NIHR Knowledge Mobilisation Fellow, NICE intrapartum guidelines tools and the tools produced by the London Maternity Strategic Clinical Networks. The proposed work focuses on service providers and commissioners, since unless services are confident and competent to provide these care options, choices for women will remain limited. A strong collaboration is proposed with key professional and service users' organisations and they are listed in the collaborations' section of the application.The aims of this Fellowship are: To explore whether the development and implementation of The Pathway can have an impact on the number of births outside OUs and assess the impact on service users and frontline staff. To contribute to the development of knowledge mobilisation (KM) theory and research methodologies. To improve the knowledge implementation of NIHR and other evidence, policy and NICE guidelines into practice within the NHS. To help developing a culture of active participation of service users and frontline staff in research and planning service delivery. To further develop my knowledge and skills in KM and implementation research Design and methods: I will conduct the PAR in four sites that form part of the same NHS Trust, each with a different history and different operational management. This will include the development, implementation and evaluation of The Pathway. PAR consists of a family of research methodologies, which aim to implement change with the engagement of the co-participants. Change is implemented and evaluated at the same time in a cyclical way following a PAR-cycle (Plan, Act, Observe, Reflect). Data collection will include qualitative and quantitative methods. Qualitative: focus groups; interviews; workshops; analysis of local documents and guidelines, analysed using thematic analysis. Quantitative: analysis of routinely collected data; local audits and service user surveys as part of routine service evaluation. Parents and Public Involvement: Six service users have been involved in identifying the topic as well as writing this proposal. PPI members will be active partners at every step of the project including dissemination. Dissemination: I will include academic and non-academic dissemination via a range of outputs including articles and presentations, dissemination via the London Collaborations for Leadership in Applied Health Research and Care (CLAHRCs) and functioning as a knowledge broker crossing boundaries between the SCNs, NHS England, professional and user organisations. I am a senior clinician and academic with a strong interest in implementation of evidence-based practice within the NHS. I have a strong track record of developing new evidence-based women-centred services in the NHS. This Fellowship would give me the opportunity to further develop my knowledge and skills in KM enhancing the impact of my work, with likely direct benefits for the NHS and service users.

Research activity codes: 8.4 RESEARCH DESIGN AND METHODOLOGIES (HEALTH SERVICES);8.3 POLICY, ETHICS AND RESEARCH GOVERNANCE
Health categories: REPRODUCTIVE HEALTH AND CHILDBIRTH