In addition to the inherent limitations of satisfaction studies found in the literature, problems may arise if such surveys are used uncritically to shape the future provision of maternity services, because service users tend to value the status quo over innovations of which they have no experience. Therefore, although satisfaction surveys have a role to play, we argue that they should only be used with caution, and preferably as part of an array of tools.

The pilot raised a number of fundamental issues related to the process of conducting a large-scale survey, including the method of distributing the questionnaire, gaining access to patients, and reliance on 'gatekeepers'. This paper highlights the lessons learned as well as the balancing act of using research methods in the most optimal way under the combined pressure of time, ethical considerations and the influences of stakeholders. Reporting the kinds of practical issues that occur during pilot studies might help others avoid similar pitfalls and mistakes.

Objective To explore prospectively women's decision making regarding mode of delivery after a previous caesarean section.Main outcome measures The evolution of decision making, women's participation in decision making, and factors affecting decision making.Design and methods A qualitative study using diaries, observations and semi-structured interviews. Data were analysed thematically from both a longitudinal and a cross-sectional perspective.Setting An antenatal unit in a large teaching hospital in Scotland and participants' homes.Sample Twenty-six women who had previously had a caesarean section for a nonrecurrent cause.Results Women were influenced by their own previous experiences and expectations, and the final decision on mode of delivery often developed during the course of the pregnancy. Most acknowledged that any decision was provisional and might change if circumstances necessitated. Despite a universal desire to be involved in the process, many women did not participate actively and were uncomfortable with having responsibility for decision making. Feelings about the amount and quality of the information received regarding delivery options varied greatly, with many women wishing for information to be tailored to their individual clinical circumstances and needs. In contrast to the impression created in the media, there was no evidence of clear preferences or strong demands for elective caesarean section. ConclusionWomen who have had a previous caesarean section do not usually have firm ideas about mode of delivery. They look for targeted information and guidance from medical personnel based on their individual circumstances, and some are unhappy with the responsibility of deciding how to deliver in the current pregnancy.

The discrete choice experiment appears to be a useful tool in assessing the strength of women's preferences for different aspects of maternity care. Future research should include a qualitative approach to explore in greater depth the processes involved in shaping women's preferences.

Objective To compare the effectiveness of an algorithm for diagnosis of active labour in primiparous women with standard care in terms of maternal and neonatal outcomes.Design Cluster randomised trial.Setting Maternity units in Scotland with at least 800 annual births.Participants 4503 women giving birth for the first time, in 14 maternity units. Seven experimental clusters collected data from a baseline sample of 1029 women and a post-implementation sample of 896 women. The seven control clusters had a baseline sample of 1291 women and a post-implementation sample of 1287 women.Intervention Use of an algorithm by midwives to assist their diagnosis of active labour, compared with standard care.Main outcomes Primary outcome: use of oxytocin for augmentation of labour. Secondary outcomes: medical interventions in labour, admission management, and birth outcome.Results No significant difference was found between groups in percentage use of oxytocin for augmentation of labour (experimental minus control, difference=0.3, 95% confidence interval −9.2 to 9.8; P=0.9) or in the use of medical interventions in labour. Women in the algorithm group were more likely to be discharged from the labour suite after their first labour assessment (difference=−19.2, −29.9 to −8.6; P=0.002) and to have more pre-labour admissions (0.29, 0.04 to 0.55; P=0.03).Conclusions Use of an algorithm to assist midwives with the diagnosis of active labour in primiparous women did not result in a reduction in oxytocin use or in medical intervention in spontaneous labour. Significantly more women in the experimental group were discharged home after their first labour ward assessment.Trial registration Current Controlled Trials ISRCTN00522952.

Objective To investigate the effect of service provision on consumer preferences, in particular, whether women who have access to systems of care which offer particular attributes (such as continuity of carer) value these attributes more highly than women for whom the attributes are not a realistic option. Design Simple rating scales and a discrete choice experiment were used to assess the importance to women of different aspects of intrapartum care. Sample and setting The sample consisted of 301 women at low obstetric risk, identified from three geographical areas, each with a different system of maternity care provision. Methods Midwives gave an anonymous, self-completed questionnaire to the women at the booking visit.Categorical data from the rating scales were analysed using the m 2 test. Analysis of the discrete choice experiment was conducted using random effect probit regression. Main outcome measures Women's preference for different attributes of intrapartum care.Results From the rating scales, it appeared that women in the area with least continuity rated this aspect of care significantly lower than women in other areas (P ¼ 0.007). Although the discrete choice experiment appeared to confirm this, the difference was not statistically significant. Conclusions The findings from this study suggest that the systems of care on offer do influence women's preferences for aspects of intrapartum care. Women in areas where continuity of carer was a realistic option appeared to value this aspect of care more highly. The tendency for preferences to be influenced not only by previous experience of a service but also by knowledge of its availability has important implications for the inclusion of consumers' values in deciding whether to introduce innovations in care. It has been suggested that greater consumer involvement may be a useful means of challenging the accepted view of what is important in health services and of facilitating change. However, the findings from this study suggest that consumer views may have the opposite effect. If consumers do prefer what they know, then a policy of tailoring health services to local preferences will simply reinforce current provision of services, reinforcing existing inequalities in the provision of care.

SummaryThe Confidential Enquiries into Maternal Deaths in the UK have recommended obstetric early warning systems for early identification of clinical deterioration to reduce maternal morbidity and mortality. This survey explored early warning systems currently used by maternity units in the UK. An electronic questionnaire was sent to all 205 lead obstetric anaesthetists under the auspices of the Obstetric Anaesthetists' Association, generating 130 (63%) responses. All respondents reported use of an obstetric early warning system, compared with 19% in a similar survey in 2007. Respondents agreed that the six most important physiological parameters to record were respiratory rate, heart rate, temperature, systolic and diastolic blood pressure and oxygen saturation. One hundred and eighteen (91%) lead anaesthetists agreed that early warning systems helped to prevent obstetric morbidity. Staffing pressures were perceived as the greatest barrier to their use, and improved audit, education and training for healthcare professionals were identified as priority areas.

Background Using misoprostol to prevent postpartum haemorrhage (PPH) in home-birth settings remains controversial.Objectives To review the safety and effectiveness of oral misoprostol in preventing PPH in home-birth settings.Search strategy The Cochrane Library, PubMed, and POPLINE were searched for articles published until 31 March 2012.Selection criteria Studies, conducted in low-resource countries, comparing oral misoprostol with a placebo or no treatment in a home-birth setting. Studies of misoprostol administered by other routes were excluded.Data collection and analysis Data were extracted by two reviewers and independently checked for accuracy by a third. The quality of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. Data were sythesised and meta-analysis was performed where appropriate.Main results Ten papers describing two randomised and four non randomised trials. Administration of misoprostol was associated with a significant reduction in the incidence of PPH (RR 0.58, 95% CI 0.38-0.87), additional uterotonics (RR 0.34, 95% CI 0.16-0.73), and referral for PPH (RR 0.49, 95% CI 0.37-0.66). None of the studies was large enough to detect a difference in maternal mortality, and none reported neonatal mortality. Shivering and pyrexia were the most common side effects.Author's conclusions The finding that the distribution of oral misoprostol through frontline health workers is effective in reducing the incidence of PPH could be a significant step forwards in reducing maternal deaths in low-resource countries. However, given the limited number of high-quality studies in this review, further randomised controlled trials are required to confirm the association, particularly in different implementation settings. Adverse effects have not been systematically captured, and there has been limited consideration of the potential for inappropriate or inadvertent use of misoprostol. Further evidence is needed to inform the development of implementation and safety guidelines on the routine availability of misoprostol.