Today we received an end-of-year good-news message from ResearchGate telling us that 700 people had ‘read’ our book Midwifery, Childbirth and the Media . Lee Wright, Senior Lecturer in the School of Nursing and Midwifery at Birmingham City University wrote in his review of our edited volume: “…our media image and digital foot print are rapidly becoming the most important window into our profession. In a rapidly changing environment this book provides an up to date and informative insight into how our profession is affected by the media and how our profession can inform and influence the image of midwifery. This area is going to become even more important in the future universities and trusts increasingly use broadcast and social media to manage information and inform our clients of the services we provide. This book will be the important first text in a new growth area. It brings together an internationally recognised group of authors who are experts in this field. I wholeheartedly recommend it to you.”
This edited collection was published by Palgrave Macmillan in 2017 and it is part of a larger body of Bournemouth University research on the topic [2-6].
Professor Edwin van Teijlingen, Professor Vanora Hundley and Associate Professor Ann Luce
- Luce, A., Hundley, V., van Teijlingen, E. (Eds.) (2017) Midwifery, Childbirth and the Media, London: Palgrave Macmillan [ISBN: 978-3-319-63512-5].
- Luce, A., Cash, M., Hundley, V., Cheyne, H., van Teijlingen, E., Angell, C. (2016) “Is it realistic?” the portrayal of pregnancy and childbirth in the media BMC Pregnancy & Childbirth 16: 40 http://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-016-0827-x
- Angell, C. (2017) An Everyday Trauma: How the Media Portrays Infant Feeding, In: Luce, A. et al. (Eds.) Midwifery, Childbirth and the Media, London: Palgrave Macmillan pp: 45-59.
- Hundley, V., Luce, A., van Teijlingen, E., Edlund, S. (2019) Changing the narrative around childbirth: whose responsibility is it? Evidence-based Midwifery 17(2): 47-52.
- Hundley, V., Duff, E., Dewberry, J., Luce, A., van Teijlingen, E. (2014) Fear in childbirth: are the media responsible? MIDIRS Midwifery Digest 24(4): 444-447.
- Hundley, V., Luce, A., van Teijlingen, E. (2015) Do midwives need to be more media savvy? MIDIRS Midwifery Digest 25(1):5-10.
Today the European Journal of Midwifery published our paper ‘Midwives’ views towards women using mHealth and eHealth to self-monitor their pregnancy: A systematic review of the literature’. There are many apps to help women to monitor aspects of their own pregnancy and maternal health. This literature review aims to understand midwives’ perspectives on women self-monitoring their pregnancy using eHealth and mHealth, and establish gaps in research. mHealth (mobile health) is the use of mobile devices, digital technologies for health, health analytics, or tele-health, whilst eHealth (electronic health) is the health care supported by electronic processes.
It established that midwives generally hold ambivalent views towards the use of eHealth and mHealth technologies in antenatal care. Often, midwives acknowledged the potential benefits of such technologies, such as their ability to modernise antenatal care and to help women make more informed decisions about their pregnancy. However, midwives were quick to point out the risks and limitations of these, such as the accuracy of conveyed information, and negative impacts on the patient-professional relationship. The authors conclude that with COVID-19 making face-to-face maternity service provision more complicated and with technology is continuously developing, there is a compelling need for studies that investigate the role of eHealth and mHealth in self-monitoring pregnancy, and the consequences this has for pregnant women, health professionals and organisations, as well as midwifery curricula.
Prof. Edwin van Teijlingen
Centre for Midwifery, Maternal & Perinatal Health (CMMPH)
- Vickery, M., Way, S., Hundley, V., Smith, G., van Teijlingen, E., Westwood G. (2020) Midwives’ views women’s use of mHealth and eHealth to self-monitor their pregnancy: A systematic review of the literature, European Journal of Midwifery 4: 36 DOI: https://doi.org/10.18332/ejm/126625
This week Dr. Preeti Mahato in the Centre for Midwifery, Maternal & Perinatal Health (CMMPH) appeared in several newspapers and new website in Nepal. The media reported both in Nepali [1-4] and in English, the latter in South Asia Time  on her recently published paper on birthing centres in Nepal. This latest paper from her PhD was published in the scientific journal PLoS ONE . The paper is co-authored by CMMPH’s Dr.Catherene Angell, Prof.Edwin van Teijlingen and Prof. Vanora Hundley as well as BU Visiting Professor Padam Simkhada (Associate Dean International at the School of Human and Health Sciences, University of Huddersfield.
We are very grateful to BU’s Dr. Nirmal Aryal for engaging with all his media contacts in Nepal to achieve this great coverage.
- Mahato, P., van Teijlingen, E., Simkhada, P., Angell, C., Hundley, V. (2020), Evaluation of a health promotion intervention associated with birthing centres in rural Nepal PLoS One 15(5): e0233607. https://doi.org/10.1371/journal.pone.0233607
Last week the Regional Office for South East Asia of the WHO (World Health Organization) published its strategy for strengthening midwifery . The report highlights how Bangladesh, India and Nepal have recently introduced midwifery education. They joined DPR Korea, Myanmar, Sri Lanka and TimorLeste in establishing midwives as an independent cadre of the health workforce.
This report cited our 2015 paper on midwifery developments in Nepal which appeared in the Journal of Asian Midwives . The lead author Jillian Ireland is a Visiting Faculty in the Centre for Midwifery, Maternal & Perinatal Health (CMMPH) and Professional Midwifery Advocate at Poole Hospital NHS Foundation Trust, my other co-author, Joy Kemp, is Global Professional Adviser at the Royal College of Midwives (RCM). The paper reflects on the RCM Global Midwifery Twinning Project in Nepal. The paper argues that the presence of a strong professional association of midwives in a country yields double benefits. On one side, the association provides inputs into framing policies and developing standards of care, and on the other, it ensures quality services by continuously updating its members with information and evidence for practice.
Bournemouth University’s work in Nepal is ongoing with a project run by CMMPH helping to develop midwifery education and training the trainers funded by the German aid organisation GIZ (Deutsche Gesellschaft für Internationale Zusammenarbeit).
- World Health Organization. Regional Office for South-East Asia (2020) Regional Strategic Directions for strengthening Midwifery in the South-East Asia Region 2020–2024, Delhi: World Health Organization. Regional Office for South-East Asia.
- Ireland, J., van Teijlingen, E, Kemp J. (2015) Twinning in Nepal: the Royal College of Midwives UK and the Midwifery Society of Nepal working in partnership, Journal of Asian Midwives 2 (1): 26-33. http://ecommons.aku.edu/jam/vol2/iss1/5/
This week the journal BMC Pregnancy & Childbirth accepted a new paper written by three Bournemouth University Psychologists. The paper ‘Be Quiet and Man Up: A Qualitative Questionnaire Study into Men Who Experienced Birth Trauma’ is written by Emily Daniels, Emily Arden-Close and Andrew Mayers  . The paper, using online questionnaires, argues that fathers reported that witnessing their partner’s traumatic birth affected them. They felt this affected their mental health and relationships long into the postnatal period. However, there is no nationally recognised support in place for fathers to use as a result of their experiences. The participants attributed this to being perceived as less important than women in the postnatal period, and maternity services’ perceptions of the father more generally. Implications include ensuring support is available for mother and father following a traumatic birth, with additional staff training geared towards the father’s role.
This paper adds to the growing pool of publications by Bournemouth University staff on men and maternity care. Earlier research work has been published in The Conversation  and the Journal of Neonatal Nursing [3-4].
Prof. Edwin van Teijlingen
Centre for Midwifery, Maternal & Perinatal health (CMMPH) and Associate Editor BMC Pregnancy & Childbirth
- Daniels, E., Arden-Close, E., Mayers, A. (2020) Be Quiet and Man Up: A Qualitative Questionnaire Study into Men Who Experienced Birth Trauma, BMC Pregnancy & Childbirth (accepted).
- Mayers, A. (2017) Postnatal depression: men get it too, The Conversation, 20 November https://theconversation.com/postnatal-depression-men-get-it-too-87567
- Ireland, J., Khashu, M., Cescutti-Butler, L., van Teijlingen, E., Hewitt-Taylor, J. (2016) Experiences of fathers with babies admitted to neonatal care units: A review of the literature, Journal of Neonatal Nursing 22(4): 171–176.
- Fisher, D., Khashu, M, Adama, E, Feeley, N, Garfield, C, Ireland, J, Koliouli F, Lindberg, B., Noergaard, B., Provenzi, L., Thomson-Salo, F., van Teijlingen, E (2018) Fathers in neonatal units: Improving infant health by supporting the baby-father bond & mother-father co-parenting Journal of Neonatal Nursing 24(6): 306-312 https://doi.org/10.1016/j.jnn.2018.08.007
Congratulations to Dr. Rachel Arnold in the Centre for Midwifery, Maternal & Perinatal Health who had her first paper accepted since she started working at BU two months ago. Her paper ‘Villains or victims? An ethnography of Afghan maternity staff and the challenge of high quality respectful care’ is co-authored with her former PhD supervisors Professor Kath Ryan (BU Visiting Faculy), Professor Emerita Immy Holloway and CMMPH’s Professor Edwin van Teijlingen . The paper is Open Access funded by Bournemouth University’s Open Access Fund which will help promote the visibility of the paper before REF 2021.
I was tempted to head this blog ‘Dr. Arnold only two months at BU and first paper published’, but I decide this would perhaps send the wrong message to other new BU staff. Rachel completed her PhD in CMMPH and this is paper is the third publication from her thesis. The other academic publications by Dr. Arnold on Afghanistan have been in BJOG and Social Science & Medicine [2-3].
- Arnold, R., van Teijlingen, E., Ryan, K., Holloway, I. (2019) Villains or victims? An ethnography of Afghan maternity staff and the challenge of high quality respectful care , BMC Pregnancy and Childbirth (accepted).
- Arnold R., van Teijlingen E, Ryan K., Holloway I. (2015) Understanding Afghan health care providers: Qualitative study of culture of care in Kabul maternity hospital, BJOG 122: 260-267.
- Arnold, R., van Teijlingen, E., Ryan, K., Holloway, I. (2018) Parallel worlds: an ethnography of care in an Afghan maternity hospital, Social Science & Medicine 126:33-40.
The month saw the publication of the latest collaborative paper between FHSS academics, BU Visiting Faculty and NHS clinicians. Our paper ‘Design errors in vital sign charts used in consultant-led maternity units in the United Kingdom’  is available for a free download from Elsevier until August 28, 2019. Till then no sign up, registration or fees are required, click here.
The authors, as part of the Modified Obstetric Warning Score (MObs) Research Group, lead by BU Visiting Faculty Richard Isaac, argue that obstetric observation charts in the UK contain poor design features. These charts have common errors such as an inappropriate use of colour, poor alignment and axes labelling. Consequently, these design errors render charts difficult to use and could compromise patient safety. The article calls for an evidence-based, standardised obstetric observation chart, which should integrate ‘human factors’ and user experience.
This research team, earlier published ‘Vital signs and other observations used to detect deterioration in pregnant women: Analysis of vital sign charts in consultant-led maternity units’. 
- Isaacs, R., Smith, G., Gale-Andrews, L., Wee, M., van Teijlingen, E., Bick, D.E., Hundley, V. on behalf of the Modified Obstetric Warning Score (MObs) Research Group. (2019) Design errors in vital sign charts used in consultant-led maternity units in the United Kingdom, International Journal of Obstetric Anesthesia 39:60-67.
- Smith, G., Isaacs, R., Gale-Andrews, L., Wee, M., van Teijlingen, E., Bick, D., Hundley, V. (2017) Vital signs and other observations used to detect deterioration in pregnant women: Analysis of vital sign charts in consultant-led maternity units. International Journal of Obstetric Anesthesia 30: 44-51.
FHSS PhD student Alice Ladur has been awarded a small but very competitive grant by FfWG, the Funds for Women Graduates. FfWG is the trading name of the BFWG Charitable Foundation and the BFWG (British Federation of Women Graduates), which is affiliated to the International Federation of University Women.
Alice is based in the Centre for Midwifery, Maternal & Perinatal Health (CMMPH). Her PhD research in Uganda is supervised by Prof. Vanora Hundley and Prof. Edwin van Teijlingen. Her thesis research has already resulted in an academic paper published in the international journal BMC Pregnancy & Childbirth, which Open Access.
This week saw the publication of ‘Perceived barriers to accessing Female Community Health Volunteers’ (FCHV) services among ethnic minority women in Nepal: A qualitative study’ . This article in the Open Access journal PLoS ONE highlights the key role volunteers play in delivering health services to minorities/the poorest people, especially in low-income countries like Nepal.
This paper studies community health workers in Nepal, who are known as Female Community Health Volunteers (FCHVs). To address this issue, we conducted a qualitative study to explore perceived barriers to accessing maternal and child healthcare services among ethnic minority groups in two different parts of Nepal with varying degrees of access to local healthcare centres. Semi-structured interviews were conducted with twenty FCHVs, 26 women service users and 11 paid local health workers. In addition, 15 FCHVs participated in four focus group discussions.
A thematic analysis of the data identified five major themes underlying barriers to accessing available maternal and child healthcare services by ethnic minority groups. These themes include: a) lack of knowledge among service users; b) lack of trust in volunteers; c) traditional beliefs and healthcare practices; d) low decision-making power of women; and e) perceived indignities experienced when using health centres. The paper concluded that community health programmes should focus on increasing awareness of healthcare services among ethnic minority groups, and the programmes should involve family members (husband and mothers-in-law) and traditional health practitioners. Both the FCHVs and local healthcare providers should be trained to communicate effectively in order to deliver respectful care among ethnic minorities if we want to achieve universal healthcare coverage for maternal and child health in low- and -middle income countries.
The paper is based on the PhD research conducted by Dr. Sarita Panday in ScHARR at the University of Sheffield. Dr. Panday is currently affiliated with the Walter H. Shorenstein Asia-Pacific Research Centre (APARC) at Stanford University in the USA. Her co-authors are Prof. Paul Bissell at the University of Huddersfield, FHSS’s Visiting Prof. Padam Simkhada at the Liverpool John Moores University and BU Prof. Edwin van Teijlingen. This is the second paper from Dr. Panday’s excellent thesis, the first paper was also published in an Open Access journal BMC Health Services Research .
- Panday S, Bissell P, van Teijlingen E, Simkhada P (2019) Perceived barriers to accessing Female Community Health Volunteers’ (FCHV) services among ethnic minority women in Nepal: A qualitative study. PLoS ONE 14(6): e0217070.
- Panday S, Bissell P, van Teijlingen E, Simkhada P (2017) The contribution of female community health volunteers (FCHVs) to maternity care in Nepal: a qualitative study. BMC Health Services Research 17(1):623.
BU’s Dr. Bibha Simkhada’s paper ‘Factors affecting the utilisation of antenatal care in developing countries: a systematic review of the literature’  is currently the 27th most cited paper in the Journal of Advanced Nursing. This is great achievement considering that the journal has published nearly ten thousand articles since its inception (to be precise 9,847). The Journal of Advanced Nursing (published by Wiley) is one of the prestigious journals in the nursing field. This extremely well-cited paper was part of Bibha’s Ph.D. study at the University of Aberdeen. Dr. Bibha Simkhada is Lecturer in Adult Nursing in the Department of Nursing and Clinical Sciences. One of her co-authors also works at BU, Prof. Edwin van Teijlingen and a second co-author, Prof. Padam Simkhada from Liverpool John Moores University is Visiting Professor in the Faculty of Health & Social Sciences. The third co-author Dr. Maureen Porter retired a few years ago.
- Simkhada, B., van Teijlingen E., Porter, M., Simkhada, P. (2008) Factors affecting the utilisation of antenatal care in developing countries: a systematic review of the literature, Journal of Advanced Nursing 61(3): 244-260.
Congratulations to Denyse King, who is currently attending the Future Technologies Conference, FTC 2018; Vancouver, BC; Canada (15-16 November). Her conference paper ‘NoObesity apps – From approach to finished app’ has been published in Advances in Intelligent Systems and Computing . Denyse is part of the Centre for Midwifery, Maternal & Perinatal Health (CMMHP) where she is a Lecturer (Academic) in Midwifery based at BU’s campus in Portsmouth ,
Obesity is still a growing public health problem in the UK and many healthcare workers find it challenging to have a discussion with service users about this sensitive topic. They also feel they are not competent to provide the relevant heath advice and are seeking easily accessible, evidence-based, mobile health learning (mHealth). mHealth applications (apps) such as the Professional NoObesity and Family NoObesity (due for release late 2018), have been designed to: support families with making sustainable positive behaviour changes to their health and well-being, ease pressure on practitioners’ overweight and obesity care related workloads, as well as to support the education of professionals, students and service users. This paper describes the process of designing the apps from the inception of the idea, through the stages of research, app builds and testing. The processes of collaborative working to design and develop the apps to meet the needs of both service users and health professionals will also be reflected upon. Childhood obesity is an complex problem and whilst it is recognised that the NoObesity apps cannot singlehandedly resolve this health crisis, it is proposed that they can support families to identify and reduce the barriers that prevent them from living healthier, happier lives.
King D., Rahman E., Potter A., van Teijlingen E. (2019) NoObesity Apps – From Approach to Finished App. In: Arai K., Bhatia R., Kapoor S. (eds) Proceedings of the Future Technologies Conference (FTC) 2018. FTC 2018. Advances in Intelligent Systems and Computing, vol 881. Springer, Cham, pp. 1145-1157.
Congratulations to Lesley Milne, senior lecturer in midwifery, on the acceptance of her latest paper on maternity care in Nepal. This new paper ‘Gender inequalities and childbearing: A qualitative study of two maternity units in Nepal’ will appear soon in the Open Access publication: Journal of Asian Midwives . This is the second publication from a qualitative research study undertaken in two birthing facilities in Kathmandu Valley to examine barriers to women accessing these services from the perspective of hospital staff .
The study received financial support from Wellbeing of Women and the RCM (Royal College of Midwives) as Lesley won their first International Fellowship Award. The study was a collaboration led by Lesley in the Centre for Midwifery, Maternal & Perinatal Health (CMMPH) with two of FHSS’s Visiting Faculty, namely Prof. Padam Simkhada who is based at Liverpool John Moores University and Jillian Ireland, Professional Midwifery Advocate based at Poole NHS Hospitals Foundation Trust.
Profs. Vanora Hundley & Edwin van Teijlingen
- Milne, L., Ireland, J., van Teijlingen, E., Hundley, V., Simkhada, P.P. (2018) Gender inequalities and childbearing: A qualitative study of two maternity units in Nepal, Journal of Asian Midwives (accepted).
- Milne, L., van Teijlingen, E., Hundley, V., Simkhada, P., Ireland, J. (2015) Staff perspectives of barriers to women accessing birthing services in Nepal: A qualitative study BMC Pregnancy & Childbirth 15:142 www.biomedcentral.com/1471-2393/15/142 .
This week 8-12 October is both Mental Health Week and Library Week, and both are celebrated widely at Bournemouth University. On Thursday Prof. Edwin van Teijlingen will present on research on mental health and maternity care in the Centre for Midwifery, Maternal and Perinatal Health (CMMPH) as part of in the BU Library Week celebrations.
The presentation includes some of the findings from out recently completed THET-funded study on a maternal mental health intervention in southern Nepal as well as some reflections on working and researching in the country. The slides for tomorrow’s presentation can be found at LinkedIn, click here!
Last week I attended and presented e-poster at the RCOG (Royal College of Obstetrics & Gynaecology) World Congress 2018 in Singapore. The main congress programme run 22 to 24 March. RCOG president Professor Lesley Regan told in her opening speech that this Congress had more than 2,800 delegates and 150 speakers from 82 countries. Prof Regan also said that the Congress focused on the need for all to work in the field of obstetrics and gynaecology and to act as advocates for women’s health. Furthermore, she stressed that it is necessary to look beyond clinical aspects and provide safe, high-quality care to speak for the needs of the women, many of whom have no choice of their own.
The e-poster I presented ‘Study of rural maternity and childbirth care in a southern district of Nepal’ is part of my PhD study on maternity care in Nepal.
My poster was displayed on the morning of 22nd March (8:08– 8:16 AM) under the topic ‘early pregnancy and acute gynaecology’. Over the three days programme schedule, I also attended several plenary sessions, oral presentations and viewed many e-posters. Although there were many topics specific to clinical aspects of obstetrics and gynaecology, I was mostly interested in presentations related to contraception and fertility control, abortion, gender equality, reproductive and sexual health of marginalised communities, female genital mutilation, breastfeeding and so on. Overall, it was a great experience to learn about research in women’s health and maternity care and an opportunity to do networking with researchers with similar interests.
Finally, I would like to thank Santander Awards to provide me fund to cover my expenses to attend this congress and my supervisors for motivating me to apply for this conference.
Our BU briefing papers are designed to make our research outputs accessible and easily digestible so that our research findings can quickly be applied – whether to society, culture, public policy, services, the environment or to improve quality of life. They have been created to highlight research findings and their potential impact within their field.
This paper focuses on the perspectives of Afghan healthcare providers on their roles, experiences, values and motivations, and the impact this has on the quality of care for perinatal women and their newborn babies. To understand their perspectives , the researchers undertook a six-week observation – including interviews and focus groups – to analyse the culture of a maternity hospital in Kabul, Afghanistan.
This research study offers multiple insights into Afghan healthcare provider behaviour and reveals complex interrelated issues that affect care in this setting. It is one of few international studies that explore care from the perspective of healthcare providers in their cultural and social environment. It reveals that understanding the context of healthcare is crucial to understanding behaviour and the underlying problems to quality of care.
Click here to read the briefing paper.
To find out how your research output could be turned into a BU Briefing, contact email@example.com.
Yesterday the Scottish Government has published its national maternity review ‘The Best Start – A Five Year Forward Plan for Maternity and Neonatal Care in Scotland’. The report has been widely welcomed and gained, among others, the full support from the Royal College of Midwives (RCM). Mary Ross-Davie, RCM Director for Scotland noted: “This is a defining moment for maternity services in Scotland and will be a seismic shift for our maternity services. The plan has the potential to revolutionise maternity care, to deliver safer and better services for women, babies and their families, and to improve the health of our population.”
The Best Start recognises that maternity and neonatal services matter to the health and wellbeing of Scotland’s people. The report’s underpinning is more of a social model of childbirth as it observes that “The health, development, social, and economic consequences of childbirth and the early weeks of life are profound, and the impact, both positive and negative, is felt by individual families and communities as well as across the whole of society.”
Having lived for 25 years in Scotland I am happy to have made a small contribution to this import report.
Prof. Edwin van Teijlingen
Centre for Midwifery, Maternal & Perinatal Health
Yesterday saw the publication of the paper ‘Antenatal care trial interventions: a systematic scoping review and taxonomy development of care models’, which is the first paper this year for the Centre for Midwifery, Maternal & Perinatal Health (CMMPH) . The paper is based on a cross-UK collaboration led by Dr. Andrew Symon from the University of Dundee which is published in the Open Access journal BMC Pregnancy & Childbirth. This is the second paper from this collaboration, the first one ‘Midwifery-led antenatal care models: Mapping a systematic review to an evidence-based quality framework to identify key components & characteristics of care ‘ was published last year .
The latest BMC Pregnancy & Childbirth paper is a first step in establishing a taxonomy of antenatal care models. The article concludes that interventions can be defined and described in many ways. The intended antenatal care population group proved the simplest and most clinically relevant way of distinguishing trials which might otherwise be categorised together. Since our review excluded non-trial interventions, the taxonomy does not represent antenatal care provision worldwide. It offers a stable and reproducible approach to describing the purpose and content of models of antenatal care which have been tested in a trial. perhaps key is that the paper highlights a lack of reported detail of trial interventions and usual care processes.
Our paper provides a baseline for future work to examine and test the salient characteristics of the most effective models, and could also help decision-makers and service planners in planning implementation.
Moreover we look forward to conducting more research as part of this exciting collaboration in midwifery and maternity care.
Prof. Edwin van Teijlingen & Prof. Vanora Hundley
- Symon, A., Pringle, J., Downe, S., Hundley, V., Lee, E., Lynn, F., McFadden, A., McNeill, J., Renfrew, M., Ross-Davie, M., van Teijlingen, E., Whitford, H., Alderdice, F. (2017) Antenatal care trial interventions: a systematic scoping review and taxonomy development of care models BMC Pregnancy & Childbirth 17:8 http://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-016-1186-3
- Symon, A., Pringle, J., Cheyne, H., Downe, S., Hundley, V., Lee, E., Lynn, F., McFadden, A., McNeill, J., Renfrew, M., Ross-Davie, M., van Teijlingen, E., Whitford, H, Alderdice, F. (2016) Midwifery-led antenatal care models: Mapping a systematic review to an evidence-based quality framework to identify key components & characteristics of care, BMC Pregnancy & Childbirth 16: 168 http://www.biomedcentral.com/1471-2393/16/168