Browsing by Author "Harris, Tina"

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    Adverse pregnancy outcomes attributable to socio economic and ethnic inequalities in England: a national cohort study
    (2022-03-09) Jardine, J.; Walker, T.; Gurol-Urganci, I.; Webster, K.; Muller, P.; Hawdon, J.; Khalil, A.; van der Meulen, J.; Harris, Tina
    Adverse pregnancy outcomes attributable to socioeconomic and ethnic inequalities in England: a national cohort study Background Socioeconomic deprivation and an ethnic minority background are known risk factors for adverse pregnancy outcomes. However, there is a lack of evidence on the strength of these risk factors and on the scale of their impact. Aims/objectives We quantified the magnitude of adverse pregnancy outcomes attributable to socioeconomic and ethnic inequalities at population level in England Methods (including research design, sample, analysis and ethical approval) We used administrative hospital data to evaluate stillbirth (SB), preterm birth (PTB) and fetal growth restriction (FGR) in England between 1/4/15-31/3/17 by socioeconomic deprivation quintiles and ethnic group. Attributable fractions (AF) for the entire population and specific groups compared to least deprived and/or White women were calculated without and with adjustment for smoking and body mass index (BMI). This study was exempt from ethical review as we used routinely collected data; personal data used without individual consent was approved by the NHS Health Research Authority. Findings 1 155 981 women with a singleton birth were included. There were 4505 stillbirths (0·4%). Of liveborn babies, 69175 (6·0%) were PTBs and 22 679 (2·0%) births with FGR. 24% of SBs, 19% of PTBs, and 31% of FGR could be attributed to socioeconomic inequality. These population AFs were substantially reduced with adjustment for ethnic group, smoking and BMI (12%, 10% and 17%, respectively). 12% of SBs, 1.2% of PTBs and 17% of FGR could be attributed to ethnic inequality. Adjustment for socioeconomic deprivation, smoking and BMI had only a small impact on these ethnic group AFs (13%, 2.6% and 19%, respectively). Group-specific AFs were especially high in the most socioeconomically deprived South-Asian women and Black women for SB (54% and 64%, respectively) and FGR (72% and 55%, respectively). Conclusions. Reducing FGR, SB and PTB rates can only realistically be achieved with midwives, obstetricians, public health professionals and politicians working together to reduce such inequalities in outcome for the most vulnerable.
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    Adverse pregnancy outcomes attributable to socioeconomic and ethnic inequalities in England: a national cohort study
    (Elsevier, 2021-11-01) Jardine, J.; Gurol-Urganci, I.; Webster, K.; Muller, P.; Hawdon, J.; Khalil, A.; Harris, Tina; van der Meulen, J.
    Background Socioeconomic deprivation and an ethnic minority background are known risk factors for adverse pregnancy outcomes. We quantified the magnitude of these socioeconomic and ethnic inequalities at population level in England. Methods We evaluated stillbirth, preterm birth (< 37 weeks gestation), and fetal growth restriction (FGR; liveborn with birthweight <3rd centile) in England between 1st April 2015 and 31st March 2017 by socioeconomic deprivation quintiles and ethnic group. Attributable fractions (AF) for the entire population and specific groups compared to least deprived and/or White women were calculated without and with adjustment for smoking and body mass index (BMI). Findings 1 155 981 women with a singleton birth were included. 4 494 births were stillbirths (0·4%). Of the 1 151 487 liveborn babies, 71 398 (6·2%) were preterm births and 23 526 (2·0%) births with FGR. 24% of stillbirths, 19% of preterm births, and 31% of FGR could be attributed to socioeconomic inequality. These population AFs were substantially reduced with adjustment for ethnic group, smoking and BMI (8%, 13% and 19%, respectively). 12% of stillbirths, 1% of preterm births and 17% of FGR could be attributed to ethnic inequality. Adjustment for socioeconomic deprivation, smoking and BMI only had a small impact on these ethnic group AFs (13%, 3% and 19%, respectively). Group-specific AFs were especially high in the most socioeconomically deprived South-Asian women and Black women for stillbirth (54% and 64%, respectively) and FGR (72% and 55%, respectively). Interpretation Socioeconomic inequalities account for a quarter of stillbirths, a fifth of preterm births, and a third of births with FGR. The largest inequalities were seen in the most deprived Black and South-Asian women. Prevention should target the entire population as well as particular high-risk ethnic minority groups, addressing specific risk factors and the wider determinants of health.
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    Associations between ethnicity and admission to intensive care among women giving birth: a cohort study
    (Wiley, 2021) Jardine, J; Gurol-Urganci, I; Harris, Tina; Hawdon, J; Pasupathy, D; van der Meulen, J; Walker, K
    Abstract Objective: To determine the association between ethnic group and likelihood of admission to intensive care in pregnancy and the postnatal period. Design: Cohort study. Setting: Maternity and intensive care units in England and Wales. Population or Sample: 631 851 women who had a record of a registerable birth between 1st April 2015 and 31st March 2016 in a database used for national audit. Methods: Logistic regression analyses of linked maternity and intensive care records, with multiple imputation to account for missing data. Main Outcome Measures: Admission to intensive care in pregnancy or postnatal period to six weeks after birth. Results: 2.24 per 1000 maternities were associated with intensive care admission. Black women were more than twice as likely as women from other ethnic groups to be admitted (OR 2.21 (1.82, 2.68). This association was only partially explained by demographic, lifestyle, pregnancy and birth factors (adjOR 1.69 (95% CI 1.37, 2.09)). A higher proportion of intensive care admissions in Black women were for obstetric haemorrhage than in women from other ethnic groups. Conclusions: Black women have an increased risk of intensive care admission which cannot be explained by demographic, health, lifestyle, pregnancy and birth factors. Clinical and policy intervention should focus on the early identification and management of severe illness, particularly obstetric haemorrhage, in Black women, in order to reduce inequalities in intensive care admission. Funding: This study was funded by a programme grant from the Healthcare Quality Improvement Partnership.
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    Authors Reply to "Induction of labour and emergency caesarean section in English maternity services: examining outcomes is needed before recommending changes in practice".
    (Wiley, 2022-12-27) Gurol-Urganci, Ipek; Jardine, Jennifer; Harris, Tina; Khalil, Asma; van der Meulen, Jan
    We thank Anna Seijmonsbergen-Schermers and colleagues for their interest in our paper in which we describe that there is considerable between-hospital variation in the use of induction of labour and emergency caesarean section in singleton term births that took place in the English National Health Service between April 2015 and March 2017.1 More importantly, we also show that hospitals with a higher rate of induction had slightly lower risks of adverse perinatal outcomes, whilst a similar association was not found for emergency caesarean section. In our paper, we suggest that the between-hospital variation observed in the induction of labour and emergency caesarean section rates may reflect differences in the ‘practice style’ of hospitals providing maternity services. Admittedly at the risk of over-interpreting our results, we conclude that a more proactive practice style with an increased use of induction of labour, rather than an increased use of caesarean section in emergency situations, seems to be linked to safer childbirth. Seijmonsbergen-Schermers and colleagues raise two issues. First, they argue that the range of outcome measures we use, i.e., antenatal and intrapartum stillbirth, neonatal unit admission, and mechanical ventilation, is too narrow. They argue that perinatal mortality should have been used instead of stillbirth, because induction of labour may in some cases only change the timing of birth without preventing a baby dying in utero or at a later stage. We could not agree more. Indeed, the ideal study would have used perinatal mortality. However, it is important to note that in our paper we also show associations of induction of labour with better postnatal outcomes, e.g., lower neonatal admission and mechanical ventilation, which are fully in line with the associations that we report for stillbirth. Second, Seijmonsbergen-Schermers and colleagues contrast our results with a population-based follow-up study they carried out using linked data reporting a range of outcomes in healthy women giving birth to a singleton term baby with and without induction of labour between 2000 and 2016 in New South Wales, Australia.2 They conclude that their results show that induction of labour for non-medical reasons was associated with more adverse perinatal outcomes. Here, we need to point out the fundamental difference between this study and the one that we report in our paper: we answer a different question with a different study design. We compare outcomes in hospitals with higher and lower rates of induction and emergency caesarean section; Our study does not directly compare a group of women who had induction of labour with a group of women who did not. Therefore, the studies are not directly comparable. Our study design, comparing perinatal outcomes according to hospital-level intervention rates, is likely to be less strongly affected by confounding by clinical indication than the population-based follow-up study by Seijmonsbergen-Schermers. Most importantly, we wholeheartedly support Seijmonsbergen-Schermers’ final plea: projects aiming to get a better understanding of how we can make childbirth safer should include a range of measures and indicators, ideally covering both maternal and neonatal outcomes beyond the intrapartum period.3 References 1. Seijmonsbergen-Schermers A, Peters LL, Downe S, Dahlen H, de Jonge A. Induction of labour and emergency caesarean section in English maternity services: Examining outcomes is needed be fore recommending changes in practice. BJOG. 2022. https://doi. org/10.1111/1471-0528.17359 2. Gurol-Urganci I, Jardine J, Carroll F, et al. Use of induction of labour and emergency caesarean section and perinatal outcomes in English maternity services: a national hospital-level study. BJOG. Vol 129, 11:1899-1906 3. Dahlen HG, Thornton C, Downe S, et al. Intrapartum interventions and outcomes for women and children following induction of labour at term in uncomplicated pregnancies: a 16-year population-based linked data study. BMJ Open. 2021;11(6):e047040. 4. NMPA Project Team. National Maternity and Perinatal Audit: Clinical Report 2022. Based on births in NHS maternity services in England and Wales between 1 April 2018 and 31 March 2019. London: RCOG;2022.
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    Barriers to nursing job motivation.
    (Research Journal of Biological Sciences, 2008) Oshvandi, Khodaya; Zamanzadeh, V; Ahmadi, F; Fathi-Azar, E; Anthony, Denis Martin; Harris, Tina
    Nurses are the largest professional group within hospitals. The lack of Nursing Job Motivation (NJM) has a negative effect on the health and safety of clients. There are issues in work disinterestedness and job dissatisfaction among nurses. This research presents the findings of a study exploring the barriers to NJM among Iranian nurses. This study was situated within the grounded theory method. Participants were 19 Iranian registered nurses working in some hospitals in Tabriz and Hamadan in Iran. Through data analysis, several main themes emerged to describe the factors that hindered NJM. Nurses in this study identified job difficulty, powerlessness and lack of authority, low income, harassment and violence to them, lack of support for nurses, centralized management, physician-centred culture in hospitals, lack of facilities and lack of a clear nursing job description. Job motivation is essential for enhancing nurses` role, strengthening the professional image, improving the healthcare system, increasing the quality of caring and the individual and community health. To maximize primary health care effectiveness, health workers especially nurses must be motivated. It can be facilitated by eliminating barriers to job motivation.
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    Care in the third stage of labour
    (Bailliere Tindall, 2011) Harris, Tina
    This chapter describes the physiology of third stage of labour, differentiates between expectant and active management, explores the debate between expectant and active management and the implications for midwifery practice. The chapter also includes how to eaxmine the term placenta and membranes
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    Care in the third stage of labour
    (Elsevier, 2016-06-26) Harris, Tina
    After reading this chapter you will be able to: Describe the physiology of the third stage of labour Differentiate between expectant and active management Identify variations in management of the third stage of labour and their potential benefits and limitations Explore the debate between expectant and active management and the implications for midwifery practice Identify how to examine the term placenta and membranes
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    Care in the third stage of labour
    (Bailliere Tindall, 2004) Harris, Tina
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    Clinical Report 2021: Based on births in NHS maternity services in England, Scotland and Wales between 1 April 2017 and 31 March 2018
    (Royal College of Obstetricians and Gynaecologists, 2021-09-30) Carroll, F.; Coe, M.; Dunn, G.; Fremeaux, A.; Gurol-Urganci, I.; Harris, Tina; Hawdon, J.; Heighway, E.; Karia, A.; Khalil, A.; Muller, P.; Thomas, L.; Waite, L.; Webster, K.; van der Meulen, J.
    Executive summary Introduction Maternity and perinatal services in the UK are currently subject to a number of maternity and neonatal review programmes, including quality monitoring and improvement initiatives. These programmes focus attention on the quality of care provided by maternity services in the UK at both a national level and the individual trust or board level.1–3 In parallel to the improvement initiatives for clinical care, there are ongoing improvements in the collation and processing of maternity and neonatal data, including improved capture of detailed information about demographics of birthing people and care episodes occurring along the maternity continuum of care. These data are critical to enable evaluation and implementation of improvement strategies. The National Maternity and Perinatal Audit (NMPA) uses these data to produce information that can support the improvement of maternity and perinatal care. In this report, for the first time, the NMPA is using a new centralised data source (MSDS v1.5) for births in England, while continuing to use the established centralised maternity datasets in Scotland and Wales. This report presents measures of maternity and perinatal care based on births in English, Scottish and Welsh NHS services between 1 April 2017 and 31 March 2018. The report also provides contextual information describing the characteristics of women and babies cared for during this time period and whose data have been included in this report. The limitations of MSDS mean that for births in England the key findings and recommendations made in this report are specific to data quality only. There are insufficient data to draw clinical conclusions. For births in Scotland and Wales, the consistency of the data sources used means that clinical key findings are possible in this report. However, clinical recommendations are avoided for all countries in this report. This is because the NMPA’s next clinical report for births in 2018/19 is expected to be published in early 2022 and will use MSDS data with improved completeness; as a result, it will be able to provide a more comprehensive picture of variation of care across the three countries. Throughout this document we use the term ‘birthing people’ as well as ‘women’. It is important to acknowledge that it is not only people who identify as women who access maternity and gynaecology services. Methods The analysis in this report is based on 304 518 births in NHS maternity services in England, Scotland and Wales between 1 April 2017 and 31 March 2018.* The report is estimated to have captured 41.5% of eligible births in this time period (34% of births in England, 97% of births in Wales and 100% of births in Scotland). The NMPA makes use of data collected electronically through healthcare information systems and national datasets. Data for births in England are provided by NHS Digital’s Maternity Services Data Set version 1.5 (MSDS v1.5) as well as by Hospital Episode Statistics (HES) records. * The time lag between the period covered by this report and its publication is due to the delayed receipt of the MSDS dataset for England. National Maternity and Perinatal Audit: Clinical Report 2021 xi Data for births in Scotland are provided by Public Health Scotland Data and Intelligence (formerly the Information Services Division, ISD), based on data from the Scottish Birth Record and Scottish Morbidity Records (SMR-01 and SMR-02). Linkages to records from the National Records of Scotland (NRS) are also made for births, deaths and stillbirths. Data for births in Wales are provided by the Maternity Indicators dataset (MIds), a dataset managed by the NHS Wales Informatics Service (NWIS), as well as Admitted Patient Care (APC) records from the Patient Episode Database for Wales (PEDW), and some fields from the National Community Child Health Database (NCCHD). In order to compare like with like, the majority of measures are restricted to singleton term births. As a general principle, the denominator for each measure is restricted to women or babies to whom the outcome or intervention of interest is applicable; for example, third or fourth degree tears are only measured among women who have experienced a vaginal birth. Rates of measures are also adjusted for risk factors that are beyond the control of the maternity service, such as age, parity, previous caesarean birth and clinical risk factors that may explain variation in results between organisations. The NHS trusts and boards included in the audit provided intrapartum maternity care at one or more sites. Where possible, site-level results are available on the NMPA website.
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    Evaluating the care we provide: the role of the National Maternity and Perinatal Audit
    (Association of Radical Midwives, 2017) Harris, Tina; Blotkamp, A.
    The Healthcare Quality Improvement Partnership (HQIP) have commissioned the Royal College of Obstetrics and Gynaecology, (in collaboration with the Royal College of Midwives, the Royal College of Paediatrics and Child Health and the London School of Hygiene and Tropical Medicine) to undertake a National Maternity and Perinatal Audit across England, Scotland and Wales. Funded for 3 years, the audit will encompass the care of healthy women and babies as well as those with complex conditions or circumstances. This paper discusses the value of auditing maternity services to explore variation in care delivery and how the audit will undertake this project. Aiming to evaluate a broad range of care pathways and outcomes, the NMPA will map the care journey from the beginning of pregnancy, during the antenatal, intrapartum and postnatal period across England, Scotland and Wales. This includes the care of healthy women and babies and those with more complex health and social care needs, across midwifery-led and obstetric units, at home and in the community.
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    Giving birth in water in England; a National retrospective cohort study of factors associated with its use in 50,482 women
    (Royal College of Obstetricians and Gynaecologists, 2019-06-17) Aughey, Harriet; Jardine, Jen; Moitt, Natalie; Blotkamp, Andrea; Pasupathy, Dharmintra; Harris, Tina; The NMPA Project Team
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    Grounded theory
    (Nursing Standard, 2015-04-29) Harris, Tina
    Grounded theory is a popular research approach in health care and the social sciences. This article provides a description of grounded theory methodology and its key components, using examples from published studies to demonstrate practical application. It aims to demystify grounded theory for novice nurse researchers, by explaining what it is, when to use it, why they would want to use it and how to use it. It should enable nurse researchers to decide if grounded theory is an appropriate approach for their research, and to determine the quality of any grounded theory research they read.
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    A grounded theory study of midwives experiences of supporting women to have a lotus birth
    (2014) Mulheron, G.; Harris, Tina
    This grounded theory study was devised to explore with midwives their experience of supporting women who have chosen to have a Lotus Birth (LB), in order to inform midwifery practice in the future when supporting women in their birth choices. STUDY OBJECTIVES: 1) To gain information about the nature of Lotus Birth. 2) To gain insight into how to support women who would like to have a Lotus Birth experience. 3) To inform midwifery practice about caring for women who choose to have a Lotus Birth. 4) To look at the risk if any posed to babies from the practice of Lotus Birth and to discuss if they do or do not fit any of the recognised parameters of child abuse as defined by the NSPCC(2012). 5) To explore from the midwives perspective their experience of Lotus Birth and to generate theory to explain their experiences. Ethical approval was granted and project designed following national Research ethical standards and codes of conduct (RCN 2009, DH 2005). Midwives with experience of LB were recruited via advertisements placed in journals and websites. Semi structured interviews took place with thirteen midwives who worked in either the NHS or independent midwives. Interviews were analysed using the principles of grounded theory. Midwives described their experiences of LB in detail, expressed their views on whether the practice was harmful to babies, and discussed why women chose it and how women who did, viewed the placenta and its role. The grounded theory which emerged was based on the Core concept that ‘Autonomous Practitioners are better able to support women’s choice’ and ‘the empowerment of women, empowers midwives who in turn, are able to empower women; a ‘cycle of empowerment’. Substantive categories were: women’s choice, power and control, supervision, constraints on practice, past experience and beliefs and philosophy.
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    Making comparisons
    (Midwives, 2017-12) Blotkamp, A.; Harris, Tina
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    Maternal and perinatal outcomes of pregnant women with SARS-CoV-2 infection at the time of birth in England: national cohort study
    (American Journal of Obstetrics and Gynaecology, 2021-05-19) Gurol-Urganci, I.; Jardine, J.; Carroll, F.; Draycott, T.; Dunn, G.; Fremeaux, A.; Harris, Tina; Hawdon, J.; Morris, E.; Muller, P.; Waite, L.; Webster, K.; van der Meulen, J.; Khalil, A.
    ABSTRACT Objective: The aim of this study was to determine the association between SARS-CoV-2 26 infection at the time of birth and maternal and perinatal outcomes. 27 28 Methods: This is a population-based cohort study in England. The inclusion criteria were women with a recorded singleton birth between 29th May 2020 and 31st 29 January 2021 in a 30 national database of hospital admissions. Maternal and perinatal outcomes were compared 31 between pregnant women with a laboratory-confirmed SARS-CoV-2 infection recorded in the 32 birth episode and those without. Study outcomes were fetal death at or beyond 24 weeks’ 33 gestation (stillbirth), preterm birth (<37 weeks gestation), small for gestational age infant (SGA; birthweight <10th centile), preeclampsia/eclampsia, induction of labor, mode of birth, specialist neonatal care, composite neonatal adverse outcome indicator, maternal and neonatal length of hospital stay following birth (3 days or more), 28-day neonatal and 42-day maternal hospital readmission. Adjusted odds ratios (aOR) and their 95% confidence interval (CI) for the association between SARS-CoV-2 infection status and outcomes were calculated using logistic regression, adjusting for maternal age, ethnicity, parity, pre-existing diabetes, pre-existing hypertension and socioeconomic deprivation measured using Index of Multiple Deprivation 2019. Models were fitted with robust standard errors to account for hospital-level clustering. The analysis of the neonatal outcomes was repeated for those born at term (≥ 37 weeks’ gestation) since preterm birth has been reported to be more common in pregnant women with SARS-CoV-2 infection. Results The analysis included 342,080 women, of whom 3,527 had laboratory-confirmed SARS-CoV-2 infection. Laboratory-confirmed SARS-CoV-2 infection was more common in women who were younger, of non-white ethnicity, primiparous, residing in the most deprived areas, or had comorbidities. Fetal death (aOR, 2.21, 95% CI 1.58-3.11; P<0.001) and preterm birth (aOR 2.17, 95% CI 1.96-2.42; P<0.001) occurred more frequently in women with SARS-CoV-2 infection than those without. Risk of preeclampsia/eclampsia (aOR 1.55, 95% CI 1.29-1.85; P<0.001), birth by emergency Cesarean delivery (aOR 1.63, 95% CI 1.51-1.76; P<0.001) and prolonged admission following birth (aOR 1.57, 95%CI 1.44-1.72; P<0.001) were significantly higher for women with SARS-CoV-2 infection than those without. There were no significant differences in the rate of other maternal outcomes. Risk of neonatal adverse outcome (aOR 1.45, 95% CI 1.27-1.66; P<0.001), need for specialist neonatal care (aOR 1.24, 95% CI 1.02-1.51; P=0.03), and prolonged neonatal admission following birth (aOR 1.61, 95% CI 1.49-1.75; P<0.001) were all significantly higher for infants with mothers with laboratory-confirmed SARS-CoV-2 infection. When the analysis was restricted to pregnancies delivered at term (≥37 weeks), there were no significant differences in neonatal adverse outcome (P=0.78), need for specialist neonatal care after birth (P=0.22) or neonatal readmission within four weeks of birth (P=0.05). Neonates born at term to mothers with laboratory-confirmed SARS-CoV-2 infection were more likely to have prolonged admission following birth (21.1% compared to 14.6%, aOR 1.61, 95% CI 1.49-1.75; P<0.001). Conclusions SARS-CoV-2 infection at the time of birth is associated with higher rates of fetal death, preterm birth, preeclampsia and emergency Cesarean delivery. There were no additional adverse neonatal outcomes, other than those related to preterm delivery. Pregnant women should be counseled regarding risks of SARS-COV-2 infection and should be considered a priority for vaccination.
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    Maternity admissions to intensive care in England, Wales and Scotland in 2015/16: A report from the National Maternity and Perinatal Audit.
    (Royal College of Obstetricians and Gynaecologists, 2019) Jardine, Jen; Aughey, Harriet; Blotkamp, Andrea; Carroll, Fran; Gurol-Urganci, Ipek; Harris, Tina; Hawdon, Jane; Knight, Hannah; Mamza, Lindsey; Moitt, Natalie; Pasupathy, Dharmintra; van der Meulen, Jan
    The National Maternity and Perinatal Audit (NMPA) is a national audit of the NHS maternity services across England, Scotland and Wales, commissioned in July 2016 by the Healthcare Quality Improvement Partnership (HQIP) on behalf of NHS England, the Welsh Government and the Health Department of the Scottish Government. The NMPA is led by the Royal College of Obstetricians and Gynaecologists (RCOG) in partnership with the Royal College of Midwives (RCM), the Royal College of Paediatrics and Child Health (RCPCH) and the London School of Hygiene & Tropical Medicine (LSHTM). The overarching objective of the NMPA is to produce high-quality information about NHS maternity and neonatal services that can be used by providers, commissioners and users of the services to benchmark against national standards and recommendations where these exist, and to identify good practice and areas for improvement in the care of women and babies. This report focuses on maternal admissions to intensive care in England, Wales and Scotland. The NMPA, and the data it holds, offers a unique opportunity to link maternity data, which contain information about the mother, her pregnancy and her baby, to data from national data sets for intensive care admissions. The purpose of this report is to describe the feasibility of linking the NMPA’s maternity data to intensive care data and to evaluate the suitability of rates of maternal admission to intensive care as an indicator of care quality. It also describes the demographics of women admitted to intensive care and the reasons for admission.
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    The maternity map
    (Royal College of Midwives, 2017-09) Blotkamp, A.; Harris, Tina
    As the first organisational report of the NMPA is published, Andrea Blotkamp and Tina Harris reveal the picture that has emerged. The NMPA is led by the RCOG in partnership with the RCM, the RCPCH and the London School of Hygeine and Tropical Medicine.
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    Midwifery practice in the third stage of labour.
    (De Montfort University, 2005) Harris, Tina
    This thesis investigated practice variation among midwives during the third stage of labour. The study aimed to identify and explain the variety of ways midwives managed the third stage and to see if it was possible to identify midwife characteristics associated with different third stage management practices. Initially emphasis was placed on models of midwifery care in labour and the mechanism by which midwives developed expertise in third stage management. A qualitative approach was used based upon the principles of grounded theory with the constant comparative method utilised to collect and analyse multiple types of data simultaneously. Fifty one midwives employed in two NHS trusts were interviewed with the practice of a further seven midwives observed. An analysis of computer records also took place together with analysis of twenty eight editions of two midwifery textbooks published throughout the 20th century. Multiple types of third stage management were described with inter and intra practice variation revealed among midwives. The complexity of third stage care was exposed through the identification of 22 aspects to third stage practice with between two and five care options available for each aspect. A theory of contingent decision making for the third stage of labour was revealed which explained how midwives adopted different forms of care through a complex decision making process which was contingent on the learning opportunities midwives were exposed to, the context in which practice decisions were made and the philosophical underpinnings of midwifery care. Practice variation was explained within this multi-factorial framework. The thesis highlights the difficulties in standardising midwifery practice and questions the validity of doing so. In this study practice variation in third stage care was a reflection of the individuality of midwives and the way midwives chose to individualise the care of women. In light of this a reappraisal of comparative studies in third stage management is needed together with an evaluation of the role of practice guidelines which attempt to standardise practice.