BackgroundStudies of daily variations in the numbers of births in England and Wales since the 1970s have found a pronounced weekly cycle, with numbers of daily births being highest from Tuesdays to Fridays and lowest at weekends and on public holidays. Mortality appeared to be higher at weekends. As time of birth was not included in national data systems until 2005, there have been no previous analyses by time of day.ObjectivesTo link data from birth registration and birth notification to data about care during birth and any subsequent hospital admissions and to quality assure the linkage. To use the linked data to analyse births and their outcomes by time of day, day of the week and year of birth.DesignA retrospective birth cohort analysis of linked routine data.SettingEngland and Wales.Outcome measuresMortality of babies and mothers, and morbidity recorded at birth and any subsequent hospital admission.Population and data sourcesBirth registration and notification records of 7,013,804 births in 2005–14, already linked to subsequent death registration records for babies, children and women who died within 1 year of giving birth, were provided by the Office for National Statistics. Stillbirths and neonatal deaths data from confidential enquiries for 2005–9 were linked to the registration records. Data for England were linked to Hospital Episode Statistics (HES) and data for Wales were linked to the Patient Episode Database for Wales and the National Community Child Health Database.ResultsCross-sectional analysis of all births in England and Wales showed a regular weekly cycle. Numbers of births each day increased from Mondays to Fridays. Numbers were lowest at weekends and on public holidays. Overall, numbers of births peaked between 09.00 and 12.00, followed by a much smaller peak in the early afternoon and a decrease after 17.00. Numbers then increased from 20.00, peaking at around 03.00–05.00, before falling again after 06.00. Singleton births after spontaneous onset and birth, including births in freestanding midwifery units and at home, were most likely to occur between midnight and 06.00, peaking at 04.00–06.00. Elective caesarean births were concentrated in weekday mornings. Births after induced labours were more likely to occur at hours around midnight on Tuesdays to Saturdays, irrespective of the mode of birth.LimitationsThe project was delayed by data access and information technology infrastructure problems. Data from confidential enquiries were available only for 2005–9 and some HES variables were incomplete. There was insufficient time to analyse the mortality and morbidity outcomes.ConclusionsThe timing of birth varies by place of birth, onset of labour and mode of birth. These patterns have implications for midwifery and medical staffing.Future workAn application has now been submitted for funding to analyse the mortality outcomes and further funding will be sought to undertake the other outstanding analyses.FundingThis project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full inHealth Services and Delivery Research; Vol. 7, No. 18. See the NIHR Journals Library website for further project information.

ObjectiveTo identify factors influencing the provision, utilisation and sustainability of midwifery units (MUs) in England.DesignCase studies, using individual interviews and focus groups, in six National Health Service (NHS) Trust maternity services in England.Setting and participantsNHS maternity services in different geographical areas of England Maternity care staff and service users from six NHS Trusts: two Trusts where more than 20% of all women gave birth in MUs, two Trusts where less than 10% of all women gave birth in MUs and two Trusts without MUs. Obstetric, midwifery and neonatal clinical leaders, managers, service user representatives and commissioners were individually interviewed (n=57). Twenty-six focus groups were undertaken with midwives (n=60) and service users (n=52).Main outcome measuresFactors influencing MU use.FindingsThe study findings identify several barriers to the uptake of MUs. Within a context of a history of obstetric-led provision and lack of decision-maker awareness of the clinical and economic evidence, most Trust managers and clinicians do not regard their MU provision as being as important as their obstetric unit (OU) provision. Therefore, it does not get embedded as an equal and parallel component in the Trust’s overall maternity package of care. The analysis illuminates how implementation of complex interventions in health services is influenced by a range of factors including the medicalisation of childbirth, perceived financial constraints, adequate leadership and institutional norms protecting the status quo.ConclusionsThere are significant obstacles to MUs reaching their full potential, especially free-standing midwifery units. These include the lack of commitment by providers to embed MUs as an essential service provision alongside their OUs, an absence of leadership to drive through these changes and the capacity and willingness of providers to address women’s information needs. If these remain unaddressed, childbearing women’s access to MUs will continue to be restricted.

Objective To explore pregnant women’s preferences for birth setting in England. Design Labelled discrete choice experiment (DCE). Setting Online survey. Sample Pregnant women recruited through social media and an online panel. Methods We developed a DCE to assess women’s preferences for four hypothetical birth settings based on seven attributes: reputation, continuity of care, distance from home, time to see a doctor, partner able to stay overnight, chance of straightforward birth and safety for baby. We used a mixed logit model, with setting modelled as an alternative-specific constant, and conducted a scenario analysis to evaluate the impact of changes in attribute levels on uptake of birth settings. Main outcome measures Women’s preferences for birth setting. Results 257 pregnant women completed the DCE. All birth setting attributes, except ‘time to see doctor’, were significant in women’s choice (p<0.05). There was significant heterogeneity in preferences for some attributes. Changes to levels for ‘safety for the baby’ and ‘partner able to stay overnight’ were associated with larger changes from baseline uptake of birth setting. If the preferences identified were translated into the real-world context up to a third of those who reported planning birth in an obstetric unit might choose a midwifery unit assuming universal access to all settings, and knowledge of the differences between settings. Conclusions We found that ‘safety for the baby’, ‘chance of a straightforward birth’ and ‘can the woman’s partner stay overnight following birth’ were particularly important in women’s preferences for hypothetical birth setting. If all birth settings were available to women and they were aware of the differences between them, it is likely that more low risk women who currently plan birth in OUs might choose a midwifery unit.

IntroductionWe report on service user participation in ‘Births and their Outcomes’, a population-based, retrospective, birth cohort, data linkage study to analyse the daily, weekly and yearly cycles of births and their implications for the NHS. Although Public Involvement and Engagement (PI&E), also referred to here as Patient and Public Involvement (PPI), has a long history in maternity services, PI&E in maternity data linkage studies is new. We have reported using the GRIPP2 short form. ObjectivesWe aimed to involve and engage a wide range of maternity service users and their representatives to ensure that our use of routinely collected maternity and birth records was acceptable and that our research analyses using linked data were relevant to their expressed safety and quality of care needs.  MethodsA three-tiered approach to PPI was used. Having both PPI co-investigators and PPI members of the Study Advisory Group ensured service user involvement was part of the strategic development of the project. A larger constituency of maternity service users was engaged through four workshops held throughout England. ResultsTwo co-investigators with experience of PPI in maternity research were involved from design stage to dissemination. Four PPI study advisors contributed service user perspectives. Engagement workshops attracted around 100 attendees, recruited largely from Maternity Services Liaison Committees and a community engagement group. They supported use of the data, believing the study had potential to improve safety and quality of maternity services. They contributed their experiences and concerns which will assist with interpretation of the analyses. ConclusionUse of PPI ‘knowledge intermediaries’ successfully bridged the gap between data intensive research and lived experience, but more inclusivity in involvement and engagement is required. The concerns and questions of service users provide social legitimacy and a relevance framework for researchers carrying out analyses.

Problem: Despite clinical guidelines and policy promoting choice of place of birth, 14 Freestanding Midwifery Units were closed between 2008 and 2015, closures justified in the media by low use and financial constraints. Background: The Birthplace in England Programme found that freestanding midwifery units provided the most cost-effective birthplace for women at low risk of complications. Women planning birth in a freestanding unit were less likely to experience interventions and serious morbidity than than those planning obstetric unit birth, with no difference in outcomes for babies. Methods: This paper uses an interpretative technique developed for policy analysis to explore the representation of these closures in 191 news articles, to explore the public climate in which they occurred. Findings and discussion: The articles focussed on underuse by women and financial constraints on services. Despite the inclusion of service user voices, the power of framing was held by service managers and commissioners. The analysis exposed how neoliberalist and austerity policies have privileged representation of individual consumer choice and market-driven provision as drivers of changes in health services. This normative framing presents the reasons given for closure as hard to refute and cultural norms persist that birth is safest in an obstetric setting, despite evidence to the contrary. Conclusion: The rise of neoliberalism and austerity in contemporary Britain has influenced the reform of maternity services, in particular the closure of midwifery units. Justifications given for closure silence other narratives, predominantly from service users, that attempt to present women's choice in terms of rights and a social model of care.