The Real Birth Online Workshop: addressing the barriers to effective antenatal education (#3043)

Idea Description
Supplementary Information
Innovation 'Elevator Pitch':
Our online workshop helps women from all backgrounds in all demographic areas to access positive, factual information to support their birth choices using evidence-based information that can be updated as and when new guidance is released.
Overview of Innovation:
The Real Birth Company’s mission statements are ‘to provide relevant, up to date, evidence based antenatal information that is delivered with a positive attitude’ and ‘to impart our knowledge with confidence to empower women and their birth partners at this very special time’.

We have achieved this with our RCM accredited antenatal education training programme that has been developed into an online e-learning antenatal resource for women birthing in the UK & is available in several languages. This e-learning resource is a birth physiology workshop full of important information that supports UK practice & enables women to understand the reasons behind their care, whilst supporting them to make informed choices in labour.

Antenatal education is essential to helping women form opinions & make choices in regard to their pregnancy & birth. There are various types of antenatal education. Hospital accessible antenatal education is dependant on resources, demographics & availability of staff to name a few. Lots of these classes use traditional methods of teaching with limited time to discuss at length the physiology.

The Real Birth online workshop is easily updated & uses evidence-based information from NICE, WHO, RCM, RCOG & others. It is holistic, culturally sensitive & can be accessed from anywhere by computer, tablet or mobile phone.

The innovation of creating a multi-lingual online e-learning workshop came from the positive birth results that were consistent with women & their partners who had attended a specifically designed positive birth workshop.

The workshop was created using techniques that help graduate students revise for exams, this learning technique has been integrated into the imparting of positive birth physiology. The use of non-threatening language & positive birth information helps to normalise birth & reduce fear. When fear is reduced in labour the benefits for both mother & baby are both psychological & physiological.

Barriers to effective antenatal education can include:
  • time pressures for antenatal classes
  • finding midwives who feel comfortable giving antenatal education
  • update & training costs
  • availability of classes
  • limited spaces for face to face classes
  • cost of interpreting services/availability of interpreters
  • birth terminology used
  • women being unable to attend for social or demographic reasons
Our online workshop works to address these barriers to help women from all backgrounds in all demographic areas to access positive, factual information.

Stage of Development:
Market ready and adopted - Fully proven, commercially deployable, market ready and already adopted in some areas (in a different region or sector)
Similar Content3
Overview summary:
There is a wide disparity between the emphasis on breastfeeding in culture and the support for mothers attempting to breastfeed for the first time.
Funding for Health Visitor run baby groups & drop-ins throughout the UK have been cut in past 2 years due to budget constraints, leading to increasing social isolation of new mothers.
Young mothers in particular may not have ever encountered another breastfeeding mother, given that the last generation was largely encouraged to bottle-feed.
Challenge identified and actions taken :
Our target - Mothers who may not have access to current research and/or may be unduly influenced by cultural barriers to breastfeeding.
c 700,000 newborn babies born in UK each year. A high proportion will be to new mothers with no experience or understanding of breastfeeding.
Funded by ACE from 2017-18, ‘Holding Time’ a series of photographic portraits of mothers breastfeeding was shown at Fabrica Gallery, ONCA Gallery and Royal Brompton Hospital in London, in print, video and installation formats, accompanied by talks and workshops. ONCA featured a Breastfeeding Hub where comfortable seating encouraged mothers to stay longer and talk with other mothers.

A project website (, and YouTube channel promoted 5 min Podcast interviews with participating mothers from the photographic series. A BLOG written by Dr Newell explored issues surrounding the cultural barriers to breastfeeding. Facebook promotions and postcard campaigns at GP surgeries drew visitors to the website and exhibitions.
Impacts / outcomes: 
Findings / Outcomes:
  1. Exhibition audience was more mixed in gender and age than anticipated
  2. Workshops and talks were attended by many academic, medical and health researchers/practitioners
  3. The ‘Holding Time’ slideshow drew audience to the Youtube channel
  4. YouTube recommendations helped to attract many thousands of visitors to the channel.
  5. The Breastfeeding Hub resulted in longer visits to exhibition
  6. Interviews/talks/workshops revealed structural barriers within health practice where policy and practice are not meeting.
Exhibitions x 10 days/ 435 visitors
Website: 1,000 users/ +67%
Talks x 2: 70 attendees
Facebook fans 303 posts/+91 fans/ +695 engagement
YouTube Analytics: 36,400 Views/ +6,710/60 Likes/+179 Subscribers
Which local or national clinical or policy priorities does this innovation address:
Public Health England - Health matters: giving every child the best start in life; Public Health England Commissioning Infant Feeding Guidance; NHS Start4Life; UNICEF; Every child matters
Supporting quote for the innovation from key stakeholders:
National Strategy:
Include actions to promote, protect and support breastfeeding in all policy areas where breastfeeding has an impact. This includes: obesity, diabetes and cancer reduction; emotional attachment and subsequent school readiness; improved maternal and child mental health; wellbeing in the workplace; and environmental sustainability.

Good practice guidance identifies that breast milk is considered the physiological norm of nutrition for infants and can provide wider benefits to further promote the bond between mother and baby. Some of the key evidence based benefits of breastfeeding are summarised below:

• Children who are breastfed for longer periods have lower infectious morbidity (including diarrhoea and vomiting) and lower risk of infant mortality
• Less risk of constipation
• Reduced likelihood of becoming obese or developing type 2 diabetes or other obesity related conditions later in life

• Reduced risk of developing breast and ovarian cancer
• Reduced risk of diabetes
• Develops stronger relationship bonds through skin touch between mother and baby
• It is a free resource and readily available
To gain the maximum benefits of breastfeeding the World Health Organization recommends an exclusive breastfeeding period for the first six months of life and continuing to breastfeed for at least two years.

West Midlands
• Breastfeeding initiation is significantly lower in the West Midlands compared to the England averages between 2010 and 2015
• Initiation rates between Local Authorities within West Midlands range from 48% to 77% out of all maternities during 2014/15

Key risks of lower breastfeeding uptake:
• Younger age of mother with those aged under 20 years the least likely to breastfeed.
• Mothers who are from a white ethnic background.
• Mothers who have never worked or employed in a routine or manual occupation (classified as lower socio-economic status).
• Younger age left full time education with mothers who left at or before 16 years least likely to breastfeed.
• Mothers in the most deprived quintile of society (classified as being in quintile 1 of the Index of Multiple Deprivation IMD calculation).

Patterns and associations of breastfeeding prevalence:
• Breastfeeding prevalence rates in England in 2010 were higher for each risk factor group compared to 2005 data for each reported period from time of birth to nine months.
• Breastfeeding prevalence dropped at an increased rate after two weeks from birth for all key risk indicator groups. At six months, roughly one third of mothers were still breastfeeding.
• The largest difference in breastfeeding prevalence is associated with age of the mother followed by age the mother left full time education and then socio-economic status and deprivation respectively.

Awareness of health benefits of breastfeeding:
• An inverse association is demonstrated between awareness of the health benefits of breastfeeding and younger age of mother, mothers classified as Asian or black, those in a lower socio-economic status and mothers who were intending to only formula feed or who had not yet made a decision.
• Mothers from a white ethnic background reported the most awareness but are the highest ethnic risk group to not breastfeed.

Information sharing:
• The groups least likely to receive information about the health benefits of breastfeeding include mothers aged under 20 years and those who have never worked.
• There is no significant difference between ethnicity and receipt of breastfeeding information.
• For all groups there are a low proportion of women who reported attending antenatal classes where infant feeding was discussed.

Please see
A film made by rb&hArts – the Charitable trust an partner at Royal Brompton Hospital.
Plans for the future:
A three year campaign of exhibitions/web content creation/printed book to stimulate and curate conversations around breastfeeding between the public and medical professions addressing the discrepancy between research and practice in order to inform research communities and the general public.

  • 10 new exhibitions of Holding Time at community, health and art centres, birthing units and hospitals across the country.
  • 10 x Postcard campaigns of 1000- 1500 (e.g. 25 cards x 50 surgeries per exhibition) leading public to online content
  • 20 mother stories Podcasts
  • Expansion of Mother Stories section of website
  • Transcripts/closed caption subtitles for all Podcasts
  • 20 guest BLOG posts: Academics/medical researchers to write on subjects raised by women in workshops and interviews e.g. the struggle to feed in the early stages, the establishment of lactation, post partum care, expressing, breastfeeding in public, looking at how current research can help parents make informed choices in these areas.
  • 10 Podcasts with Academics/medical researchers/health professionals
  •  Facebook Q&A sessions with guest researchers/practitioners and participating mothers
  • Breastfeeding Hubs/workshops/talks where possible/appropriate delivered by Dr Lucila Newell and Lisa Creagh
  • Facebook/Instagram channels to promote the above.
A limited edition book featuring Holding Time with an introduction by Dr Debra Bick, essay by Ruth Stirton/Lucila Newell/Erin Barnett. Schilt publishers have confirmed they will produce and distribute this book across Europe and North America using their existing channels.
Tips for adoption:
Any Community health space can host the exhibition, promote the exhibition using the tested method of GPs surgeries locally and linking to the online content. They can also suggest researchers and mothers to interview or write BLOG posts. I have applied to Wellcome for a budget to cover ten exhibitions in areas with low breastfeeding rates nationally.
Contact for further information:
For more information please contact Lisa Creagh
Project Web:
Artist site:
Tel: 07816 577140
See additional 'Links' document attached
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Innovation 'Elevator Pitch':
We have successfully designed, implemented and evaluated a standardised triage system for use within maternity care.  It is currently used in eight maternity units, with more planned.
Overview of Innovation:
Triage systems are designed to ensure the patient receives the level and quality of care appropriate to their clinical needs and resources available. Triage involves establishing the presenting problem, undertaking a standardised physiological assessment including vital signs and results in a score being assigned based on predictors of urgency which determines the priority of on-going care.
The physiological changes associated with pregnancy mean the standard triage tools may not be applicable. In addition, the underlying good health of the maternity population, which may mask the severity of maternal illness, and no assessment of the condition of the unborn baby reinforce the need for a specific maternity tool. While some informal triaging takes place within maternity care, a national survey showed that women currently wait to be seen in the order in which they arrive and that current prioritisation systems do not use clinical determinants.
Birmingham Symptom specific Obstetric Triage System (BSOTS)
The system was co-produced by clinicians and researchers in Birmingham to prioritise care for women presenting with pregnancy related complications or concerns.  
The BSOTS bundle includes:
  • Completion of a standard clinical triage assessment by a midwife within 15 minutes of the woman’s attendance.  This includes taking a brief maternal history, completion of baseline maternal observations, assessment of pain levels, abdominal palpation and auscultation of the fetal heart rate .
  • This assessment is used to define a category of clinical urgency using a 4-category scale, which guides timing of subsequent assessment and immediate care (by an obstetrician if required) using algorithms.
  • Standardised symptom-specific algorithms are used for allocation of clinical priority and the immediate care and further investigations of the eight commonest reasons for attendance (abdominal pain, antenatal bleeding, hypertension, suspected labour, ruptured membranes, reduced foetal movements, unwell/other, and postnatal concerns). 
  • Documentation is provided to support and standardise completion of the clinical tasks required.
Implementation of BSOTS requires multidisciplinary training of clinicians which takes approximately three hours. The BSOTS training has also been developed and elevated by the team
Stage of Development:
Market ready and adopted - Fully proven, commercially deployable, market ready and already adopted in some areas (in a different region or sector)
WMAHSN priorities and themes addressed: 
Innovation and adoption
Benefit to NHS:
The benefits to the NHS of a dedicated maternity triage system are centred on improving safety for women and their babies by reducing the interval from their attendance to their initial review by a midwife and prioritising urgent care. BSOTS is supported by Royal College of Obstetrics and Gynaecology and Royal College of Midwives for national implementation.
Implementation of BSOTS as the system improves management of the triage department by enabling staff to:
  • See how many women are waiting who have not yet had their initial triage assessment to determine level of clinical urgency
  • See how many women who have had the initial assessment and the level of clinical urgency is known for each women
  • Know when further assessments are due for women in the Department
  • In circumstances where women attend who require urgent treatment it allows women with less clinical urgency to be safely moved out to the waiting area and escalation to occur
  • Facilitate easy handover of the department between shifts using SBAR
  • Use a shared language between clinicians to communicate clinical priority
BSOTS  provides a standardised process to manage emergency attendances and reduces staff safety concerns in maternity triage whilst increasing their resilience and improving handover and communication.
Initial evaluation at BWCNFT demonstrated  that the use of BSOTS increased the numbers of women seen within 15minutes of attendance from 39% to 54% [Relative risk (RR) 1.4 (1.2, 1.7 (95% confidence interval (CI)] and reduced the time to medical review for those who require it. Thus providing a robust pathway for rapid assessment and urgent medical care if required, improving outcomes for mothers and their babies.
Good reliability and validity of the BSOTS bundle were found on the basis of the numbers of women who re-attended and investigation of predefined maternal and neonatal morbidities.  All the midwives reported that BSOTS training had improved their knowledge and confidence and that implementation of the system improved safety for mothers and babies and reduced stress amongst the clinicians.
Intra-rator reliability was excellent both at BWCNFT initially with an Intracluster Correlation Coefficient (ICC) of 0.961 (95% CI 0.91-0.99), and in the additional maternity units where the ICC was 0.971 (0.915-0.996). There was no apparent difference between midwifery band level and amount of triage experience. Showing that the BSOTS tools are reliable and consistent for use amongst varied midwifery staff.
Initial Review Rating
4.60 (2 ratings)
Benefit to WM population:
The West Midlands remains a national outlier for poor rates of perinatal and infant mortality and is committed to the national ambition to halve the number of stillbirths, neonatal and maternal deaths and brain injuries by 2025.
In line with the National Maternity Review (published in February 2016) which set out a clear vision for maternity services across England to become safer and to promote good practice for safer care; the Birmingham Symptom specific Obstetric Triage System (BSOTs) improves the process and clinical prioritisation of care for women presenting with pregnancy related complications or concerns. BSOTs has also been shown to prioritise urgent care for those women who are most unwell or requiring more rapid access to obstetric intervention and emergency treatment.
With increasing use of the Birmingham Symptom specific Obstetric Triage System (BSOTs) across the maternity units within the West Midlands region, women can expect continuity of process and care when they present to units with urgent concerns and that care is standardised across the region. Standardisation of the maternity triage pathway also provides an opportunity to ensure that the midwifery and medical workforce in maternity are able to be trained with the right skills to implement appropriately timed and clinically relevant prioritised of care within all maternity triage departments in which they may work.
Current and planned activity: 
The Birmingham Symptom specific Obstetric Triage System (BSOTs) is currently used in seven units nationally; including half of all maternity units within West Midlands.
A further twelve maternity units have received training for their implementation teams and are due to launch the BSOTs programme in the next six months.
Bespoke training courses for maternity teams are held in Birmingham every two months. This training includes specific training the trainers materials, the BSOTS© maternity algorithms, Triage Assessment Cards and Patient information posters and tips for implementation from other units.

Further development of the Birmingham Symptom specific Obstetric Triage System (BSOTs) with Clevemed systems to transfer the paper based system into an electronic tool with contemporaneous patient record is on-going; due to complete by May 2019. This will enable maternity units currently using the Badgernet Maternity electronic system to use BSOTs digitally and further improve availability.
What is the intellectual property status of your innovation?:
Use is currently protected by signing a Licensing agreement provided by UoB and MidTech.
The schedule within the licensing agreement includes the Birmingham Symptom specific Obstetric Triage System (BSOTs) package for Training and Implementation and is intended to ensure the package is used as intended and that training has been given before implementation
The package is intended to support local training, implementation and on-going use of the (BSOTs) system, in the maternity unit assessing women who attend with unscheduled pregnancy related concerns. This package is set out during the face to face training course, it includes specific training the trainers materials, local training materials, the BSOTS© maternity algorithms, BSOTS© Triage Assessment Cards and BSOTS© Patient information posters. The components of the triage system should be adopted in its entirety, rather than separately.
Return on Investment (£ Value): 
Return on Investment (Timescale): 
0-6 mon
Ease of scalability: 
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Innovation 'Elevator Pitch':
Good quality maternity information is essential to provide safe care. We will evaluate the Mother’s Information Application (MiApp), a personalised electronic, fully interoperable version of the Perinatal Institute’s hand-held notes. 
Overview of Innovation:
Currently hand-held paper notes are the primary record for maternity. The Perinatal Institute’s maternity notes have become the standard, used in approx 60% of pregnancies in England -

The Perinatal Institute have been successful in combining the utility of a standardised, evidence based record for clinicians, with details on the care the mother should expect at the various stages of pregnancy, outlining her choices as well as essential information and key messages to ensure best possible maternal engagement in her care.

The hand-held notes are the master record allowing complete inter-operability with all care providers, but require double or triple entry of data to ensure electronic systems are up to date. With increasing development of information systems, electronic records are starting to become the principal maternity record, which takes information and control away from the mother. Instead they carry either:
  • Print outs of certain aspects of care (being paper heavy and complicated to navigate) or
  • Minimal information in the form of a summary ‘co-op card’ or appointment card.
This results in a lack of routine pregnancy information being given to women, an absence of specific information available to the mother about her own pregnancy, and a lack of inter- operability between the systems used at different facilities meaning other care providers do not have access to the mother’s record if required.
The Mother’s Information Application (MiApp) is a personalised, electronic, fully interoperable version of the Perinatal Institute’s hand-held notes available on smart phones, tablets or desktop computers. It returns control of the health record to the mother, and allows her to make her maternity healthcare record available to her designated care providers, directly or through integration with local information systems.
MiApp is able to:
  • Provide expectant and new mothers with relevant information about their pregnancy, explaining what to expect at each stage and listing options to allow informed choices.
  • Act as the master document for recording and updating details about the care received,
    including results of screening tests, investigations, risk assessments, referrals, and management plans.
Stage of Development:
Close to market - Prototype near completion and final form may require additional validation/evaluation and all CE marking and regulatory requirements are in place
WMAHSN priorities and themes addressed: 
Long term conditions: a whole system, person-centred approach / Wellness and prevention of illness / Digital health / Innovation and adoption / Patient and medicines safety / Person centred care
Benefit to NHS:
MiApp is able to:
  • Provide expectant and new mothers with relevant information about their pregnancy, explaining what to expect at each stage and listing options to allow informed choices.
  • Act as the master document for recording and updating details about the care received, including results of screening tests, investigations, risk assessments, referrals, and management plans.
  • Give mothers control over their data with complete national inter-operability (using industry standard HL7 messaging) allowing her various care providers to access details and include additional information as appropriate.
  • Avoid the need for double entry of data, reducing the administrative burden on clinicians and administrators and thus increasing time for clinical care.
  • Provide high quality data for clinical care as well as for secondary uses, and support evidence based commissioning, service planning and performance monitoring.
  • Increased cost savings because of reduced double entry of data, reduced clinical coding time, reduced litigation costs and reduced clinical time spent on record keeping (a separate cost benefit analysis will be provided).
  • Integrated messaging system between patients and clinicians as well as between clinicians, which reduces unnecessary appointments and enhances quality of care.
Online Discussion Rating
5.86 (7 ratings)
Initial Review Rating
3.80 (1 ratings)
Benefit to WM population:
There are a number of health and weatlth benefits to the West Midlands population, including:
  • Good quality data produced from MiApp will support commissioners to tailor services according to local needs.
  • Individual NHS Trusts can use the data produced to benchmark their services and therefore recognise areas for further improvement. 
  • Clinical risks are greatly recuded through the interoperability, as the West Midlands population will be able to move between healthcare providers with a fully accessible, complete healthcare record.
  • In recognition of the diverse West Midlands population, the record incorporates translation into 18 languages along with information in video format. The aim is that families from all backgrounds and of all capabilities have access to information that they can understand and use appropriately to improve their health.
  • MiApp enables access to the wider health and social care system by highlighting services that are available to all, empoweing women to take control of their own health.
  • Promotes standardised care for the West Midlands population in line with national guidelines.

Current and planned activity: 
The Perinatal Institute is a national not-for-profit organisation set up to enhance the safety and quality of maternity care. It is a qualified provider of
maternity support services, including education and training in standardised maternity records, fetal growth assessment and perinatal audit.

The Perinatal Institute has won numerous national awards including most recently the 2016 Queens Award for Enterprise, the 2015 BMJ Award for clinical leaership and the 2015 Patient Safety Award for IT and Technology

The conduct of a quantitative and qualitative evaluation of the MiApp system in comparison to current systems.
What is the intellectual property status of your innovation?:
The intellectual property belongs to the Perinatal Institute
Return on Investment (£ Value): 
Return on Investment (Timescale): 
1 year
Ease of scalability: 
Regional Scalability:
The service can be scaled rapidly and efficiently across the region. Our business case means it is likely to be cost-efficent in a very short space of time making it an attractive proposition for commissioners.
A robust evaluation of MiApp will establish the feasibility of using this type of solution and provide a measure of it’s transferability to maternity care across the region and ultimately the UK. 

The project will consist of a quantitative and qualitative evaluation of the MiApp system in comparison to current systems. This evaluation includes a:
  1. Structured survey and semi-structured interviews to explore existing maternity systems with expectant mothers and clinicians.
  2. Structured survey and semi-structured interviews to explore the experience of expectant mothers and clinicians using MiApp. This will include using the principles of user testing to evaluate the mother’s ability to retain and assimilate information held on MiApp.
  3. Economic evaluation of MiApp in relation to time spent on administration in comparison to current systems
Key Deliverables
  • Report on current range of systems available in the West Midlands and their perceived effectiveness in providing mothers and clinicians the information needed for safe maternity care
  • Qualitative and quantitative assessment of user experience of current systems and MiApp.
  • Cost benefit analysis with implications for service delivery in the West Midlands and nationally
  • MiApp is in the process of being rolled out at two sites in the UK but to date there has been no formal evaluation of the effectiveness of MiApp for clinicians and mothers.
  • Proposed outcome measures for women include:
  • Satisfaction with care
  • Retention and assimilation of information
  • Engagement in pregnancy
Inclusion criteria
A number of characteristics can influence the ability to find and understand information in an IT application (including age, educational attainment, inability to speak/read English and deprivation). To help ensure that our cohort reflects this range of characteristics, we will purposively select women from a variety of backgrounds and ensuring the survey is available in multiple languages. 
Adoption target:
The conduct of an evaluation is predicated on the adoption of the device within selected settings. This would be the the first stage of a controlled roll-out, one where we will precisely measure the benefits it provides to encourage its adoption across the region and beyond. 
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