The United Kingdom and the Netherlands maternity care responses to COVID-19: A comparative study

BACKGROUND

The national health care response to coronavirus (COVID-19) has varied between countries. The United Kingdom (UK) and the Netherlands (NL) have comparable maternity and neonatal care systems, and experienced similar numbers of COVID-19 infections, but had different organisational responses to the pandemic. Understanding why and how similarities and differences occurred in these two contexts could inform optimal care in normal circumstances, and during future crises.

AIM

To compare the UK and Dutch COVID-19 maternity and neonatal care responses in three key domains: choice of birthplace, companionship, and families in vulnerable situations.

METHOD

A multi-method study, including documentary analysis of national organisation policy and guidance on COVID-19, and interviews with national and regional stakeholders.

FINDINGS

Both countries had an infection control focus, with less emphasis on the impact of restrictions, especially for families in vulnerable situations. Differences included care providers' fear of contracting COVID-19; the extent to which community- and personalised care was embedded in the care system before the pandemic; and how far multidisciplinary collaboration and service-user involvement were prioritised.

CONCLUSION

We recommend that countries should 1) make a systematic plan for crisis decision-making before a serious event occurs, and that this must include authentic service-user involvement, multidisciplinary collaboration, and protection of staff wellbeing 2) integrate women's and families' values into the maternity and neonatal care system, ensuring equitable inclusion of the most vulnerable and 3) strengthen community provision to ensure system wide resilience to future shocks from pandemics, or other unexpected large-scale events.

‘Moving towards understanding’, acceptability of investigations following stillbirth in sub‐Saharan Africa: a grounded theory study

OBJECTIVE

To explore the views of women, partners, families, health workers and community leaders of potential investigations to determine the cause(s) of stillbirth, in Malawi, Tanzania and Zambia.

DESIGN

Grounded theory.

SETTING

Tertiary facilities and community settings in Blantyre, Malawi, Mwanza, Tanzania and Mansa, Zambia.

SAMPLE

Purposive and theoretical sampling was used to recruit 124 participants: 33 women, 18 partners, 19 family members, 29 health workers and 25 community leaders, across three countries.

METHODS

Semi-structured interviews were conducted using a topic guide for focus. Analysis was completed using constant comparative analysis. Sampling ceased at data saturation.

RESULTS

Women wanted to know the cause of stillbirth, but this was tempered by their fear of the implications of this knowledge; in particular, the potential for them to be blamed for the death of their baby. There were also concerns about the potential consequences of denying tradition and culture. Non-invasive investigations were most likely to be accepted on the basis of causing less 'harm' to the baby. Parents' decision-making was influenced by type of investigation, family and cultural influences and financial cost.

CONCLUSIONS

Parents want to understand the cause of death, but face emotional, cultural and economic barriers to this. Offering investigations will require these barriers to be addressed, services to be available and a no-blame culture developed to improve outcomes. Community awareness, education and support for parents in making decisions are vital prior to implementing investigations in these settings.

Prediction of stillbirth: an umbrella review of evaluation of prognostic variables

BACKGROUND

Stillbirth accounts for over 2 million deaths a year worldwide and rates remains stubbornly high. Multivariable prediction models may be key to individualised monitoring, intervention or early birth in pregnancy to prevent stillbirth.

OBJECTIVES

To collate and evaluate systematic reviews of factors associated with stillbirth in order to identify variables relevant to prediction model development.

SEARCH STRATEGY

MEDLINE, Embase, DARE and Cochrane Library databases and reference lists were searched up to November 2019.

SELECTION CRITERIA

We included systematic reviews of association of individual variables with stillbirth without language restriction.

DATA COLLECTION AND ANALYSIS

Abstract screening and data extraction were conducted in duplicate. Methodological quality was assessed using AMSTAR and QUIPS criteria. The evidence supporting association with each variable was graded.

RESULTS

The search identified 1198 citations. Sixty-nine systematic reviews reporting 64 variables were included. The most frequently reported were maternal age (n = 5), body mass index (n = 6) and maternal diabetes (n = 5). Uterine artery Doppler appeared to have the best performance of any single test for stillbirth. The strongest evidence of association was for nulliparity and pre-existing hypertension.

CONCLUSION

We have identified variables relevant to the development of prediction models for stillbirth. Age, parity and prior adverse pregnancy outcomes had a more convincing association than the best performing tests, which were PAPP-A, PlGF and UtAD. The evidence was limited by high heterogeneity and lack of data on intervention bias.

TWEETABLE ABSTRACT

Review shows key predictors for use in developing models predicting stillbirth include age, prior pregnancy outcome and PAPP-A, PLGF and Uterine artery Doppler.

Adverse pregnancy outcomes and subsequent development of connective tissue disease in the UK: an epidemiological study

OBJECTIVE

This study assessed prevalence of connective tissue disease (CTDs), systemic lupus erythematosus (SLE), antiphospholipid syndrome (APS) and antiphospholipid antibodies (aPL) in women with previous adverse pregnancy outcome compared with uncomplicated livebirths.

DESIGN

Retrospective case-control study.

SETTING

UK Primary Care.

POPULATION OR SAMPLE

Records of women, 18 years and older, within the Clinical Practice Research Datalink (CPRD) (1 January 2000-31 December 2013).

METHODS

Clinical Practice Research Datalink was searched for pregnancy terms to identify adverse pregnancy outcome. Each identified case was matched to five livebirths.

MAIN OUTCOME MEASURES

Diagnosis of SLE, CTD, APS or autoimmune antibodies. Poisson regression was performed to calculate relative risk ratios (RR), comparing adverse pregnancy outcome with livebirth cohorts.

RESULTS

Clinical Practice Research Datalink identified 20 123 adverse pregnancy outcomes matched to 97 323 livebirths, with a total of 875 590 person-years follow up. Median follow up from study entry was 7.29 years (SD 4.39). Compared with women with an uncomplicated livebirth, women with adverse pregnancy outcome had an increased risk of developing CTD or autoimmune antibodies (RR 3.20, 95% CI 2.90-3.51). Risk was greatest following a stillbirth (RR 5.82, 95% CI 4.97-6.81). For CTD and SLE, the risk was greatest within the first 5 years of adverse pregnancy outcome. Risk for aPL and APS diagnosis was highest ≥5 years from adverse pregnancy outcome.

CONCLUSIONS

Adverse pregnancy outcome is associated with increased risk of developing maternal CTD, including SLE. Either immunological factors predispose women to adverse pregnancy outcome and subsequent CTD diagnosis or, alternatively, adverse pregnancy outcome initiates autoimmune events which culminate in CTD in later life.

TWEETABLE ABSTRACT

Stillbirth is associated with increased maternal risk of developing systemic lupus erythematosus (SLE).

Impact of consultant obstetric presence on serious incidents

Purpose

Many organisations, including the Royal College of Obstetricians and Gynaecologists, have recommended increasing the number of hours of consultant obstetric presence in UK National Health Service maternity units to improve patient care. St Mary’s Hospital, Manchester implemented 24-7 consultant presence in September 2014. The paper aims to discuss these issues.

Design/methodology/approach

To assess the impact of 24-7 consultant presence upon women and babies, a retrospective review of all serious clinical intrapartum incidents occurring between September 2011 and September 2017 was carried out by two independent reviewers; disagreements in classification were reviewed by a senior Obstetrician. The impact of consultant presence was classified in a structure agreed a priori.

Findings

A total of 72 incidents were reviewed. Consultants were directly involved in the care of 75.6 per cent of cases before 24-7 consultant presence compared to 96.8 per cent afterwards. Negative impact due to a lack of consultant presence fell from 22 per cent of the incidents before 24-7 consultant presence to 9.7 per cent after implementation. In contrast, positive impact of consultant presence increased from 14.6 to 32.3 per cent following the introduction of 24-7 consultant presence.

Practical implications

Introduction of 24-7 consultant presence reduced the negative impact caused by a lack of, or delay in, consultant presence as identified by serious untoward incident (SUI) reviews. Consultant presence was more likely to have a positive influence on care delivery.

Originality/value

This is the first assessment of the impact of 24-7 consultant presence on the SUIs in obstetrics.

PARENTS 2 study: consensus report for parental engagement in the perinatal mortality review process

OBJECTIVE

The PARENTS 1 study (Parents' Active Role and ENgagement in The review of their Stillbirth/perinatal death) found that parents would endorse the opportunity to give feedback into the perinatal mortality review (PNMR) process. In subsequent focus groups, healthcare professionals were positive about parental engagement, although they considered that there may be significant challenges. The objective of this study was to develop core principles and recommendations for parental engagement in PNMR in the UK.

METHODS

A two-round Delphi technique was followed to reach consensus on core principles for parental engagement in the PNMR process; Round 1 included a national consensus workshop and Round 2 an online questionnaire. The consensus meeting was attended by a national panel of stakeholders (clinical and academic experts, parent advocates, managers and commissioners) in stillbirth and neonatal and bereavement care. To develop recommendations for parental engagement, participants discussed four key areas comprising: communication with parents, including receiving feedback; the format of the PNMR meeting; the parental engagement pathway; and challenging aspects of engaging with parents in reviews. Content analysis was conducted to generate recommendations from the meeting for a subsequent anonymous web-based survey. Attendees of the consensus workshop and members of the PARENTS 2 Project Advisory Board were asked to rank recommendations using a 9-point Likert scale from 1 (not important) to 9 (critically important). It had been agreed a priori, in compliance with established Grading of Recommendations, Assessment, Development and Evaluation (GRADE) criteria, that 'consensus' would be achieved if over 70% of participants scored the principle as 'critical' (score of 7-9) and fewer than 15% scored the principle as 'not important' (score of 1-3). Principles for which consensus was achieved were included in the core recommendations.

RESULTS

Of the 29 invited stakeholders, 22 participated in the consensus meeting and 25 (86% response rate) in the subsequent online questionnaire in June 2017. Consensus was agreed on 12 core principles. Of the 25 participants, 96% agreed that a face-to-face explanation of the PNMR process was of critical importance, 72% considered that parents should be offered the opportunity to nominate a suitable advocate, 92% believed that responses to parents' comments should be formally documented, 96% indicated that it was vital for action plans to be translated into lessons learnt and that this process should be monitored, and 100% of stakeholders voted that a plain-English summary should be produced for the parents following the meeting. There was good agreement on a further seven principles.

CONCLUSIONS

Key national stakeholders were unanimously supportive of parental engagement in the PNMR process and agreed on core principles to make this process feasible, meaningful and robust. A 6-month pilot of parental engagement in the PNMR process (PARENTS 2 study) in two UK units took place after the consensus on core principles. In collaboration with the National Perinatal Epidemiology Unit, the findings will inform the national standardized PNMR tool. © 2018 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.

The structure and utility of the placental pathology report

The placenta is one of the most exciting organs. It is dynamic; its morphology and function continuously develop and adjust over its brief life span. It mediates the physiology of two distinct yet highly interconnected individuals. The pathology that develops in the placenta, and the adaptations the placenta undergoes to mitigate this pathology, may influence the later life health of the mother and baby (Circ Res, 116, 2015, 715; Hum Reprod Update, 17, 2011, 397; Nutr Rev 71, 2013, S88; Placenta, 36, 2015, S20). Pathological placenta examination may reveal macroscopic and microscopic patterns that provide valuable information to the obstetricians, neonatologists, and pediatricians caring for the family. The placenta often plays a key role in understanding adverse fetal outcomes such as hypoxic brain injury, cerebral palsy, fetal growth restriction, stillbirth, and neonatal death (Placenta, 35, 2014, 552; Placenta, 52, 2017, 58; Placenta, 30, 2009, 700; Obstet Gynecol, 114, 2009, 809; Clin Perinatol, 33, 2006, 503; Pediatr Dev Pathol, 11, 2008, 456; Arch Pathol Lab Med, 124, 2000, 1785). Moreover, it may help to understand the pathophysiology of pregnancy, improve management of subsequent pregnancies, and assist in medicolegal assessment. Placental pathologic examination may even provide evidence of susceptibility to adult-onset diseases such as diabetes (Pediatr Dev Pathol, 6, 2003, 54; Diabetes Metab, 36, 2010, 682; BJOG, 113, 2006, 1126; Int J Gynaecol Obstet, 104, 2009, S25; Zentralbl Gynakol, 97, 1975, 875). Pathologic examination of the placenta may thus be of tremendous value, particularly for those women experiencing an adverse pregnancy outcome. However, this potential utility may be entirely wasted, if the findings are not communicated in an effective manner to the appropriate clinicians. An optimized, readily understandable report of pathological findings is essential for clinical utility.

PARENTS 2 study protocol: pilot of Parents' Active Role and ENgagement in the review of Their Stillbirth/perinatal death

BACKGROUND

The perinatal mortality review meeting that takes place within the hospital following a stillbirth or neonatal death enables clinicians to learn vital lessons to improve care for women and their families for the future. Recent evidence suggests that parents are unaware that a formal review following the death of their baby takes place. Many would welcome the opportunity to feedback into the meeting itself. Parental involvement in the perinatal mortality review meeting has the potential to improve patient satisfaction, drive improvements in patient safety and promote an open culture within healthcare. Yet evidence on the feasibility of involving bereaved parents in the review process is lacking. This paper describes the protocol for the Parents' Active Role and Engangement iN the review of their Stillbirth/perinatal death study (PARENTS 2) , whereby healthcare professionals' and stakeholders' perceptions of parental involvement will be investigated, and parental involvement in the perinatal mortality review will be piloted and evaluated at two hospitals.

METHODS AND ANALYSIS

We will investigate perceptions of parental involvement in the perinatal mortality review process by conducting four focus groups. A three-round modified Delphi technique will be employed to gain a consensus on principles of parental involvement in the perinatal mortality review process. We will use three sequential rounds, including a national consensus meeting workshop with experts in stillbirth, neonatal death and bereavement care, and a two-stage anonymous online questionnaire. We will pilot a new perinatal mortality review process with parental involvement over a 6-month study period. The impact of the new process will be evaluated by assessing parents' experiences of their care and parents' and staff perceptions of their involvement in the process by conducting further focus groups and using a Parent Generated Index questionnaire.

ETHICS AND DISSEMINATION

This study has ethical approval from the UK Health Research Authority. We will disseminate the findings through national and international conferences and international peer-reviewed journals.

Systematic review to understand and improve care after stillbirth: a review of parents' and healthcare professionals' experiences

Background

2.7 million babies were stillborn in 2015 worldwide; behind these statistics lie the experiences of bereaved parents. The first Lancet series on stillbirth in 2011 described stillbirth as one of the “most shamefully neglected” areas of public health, recommended improving interaction between families and frontline caregivers and made a plea for increased investment in relevant research.

Methods

A systematic review of qualitative, quantitative and mixed-method studies researching parents and healthcare professionals experiences of care after stillbirth in high-income westernised countries (Europe, North America, Australia and South Africa) was conducted. The review was designed to inform research, training and improve care for parents who experience stillbirth.

Results

Four thousand four hundred eighty eight abstracts were identified; 52 studies were eligible for inclusion. Synthesis and quantitative aggregation (meta-summary) was used to extract findings and calculate frequency effect sizes (FES%) for each theme (shown in italics), a measure of the prevalence of that finding in the included studies.

Researchers’ areas of interest may influence reporting of findings in the literature and result in higher FES sizes, such as; support memory making (53 %) and fathers have different needs (18 %). Other parental findings were more unexpected; Parents want increased public awareness (20 %) and for stillbirth care to be prioritised (5 %).

Parental findings highlighted lessons for staff; prepare parents for vaginal birth (23 %), discuss concerns (13 %), give options & time (20 %), privacy not abandonment (30 %), tailored post-mortem discussions (20 %) and post-natal information (30 %).

Parental and staff findings were often related; behaviours and actions of staff have a memorable impact on parents (53 %) whilst staff described emotional, knowledge and system-based barriers to providing effective care (100 %). Parents reported distress being caused by midwives hiding behind ‘doing’ and ritualising guidelines whilst staff described distancing themselves from parents and focusing on tasks as coping strategies.

Parents and staff both identified the need for improved training (parents 25 % & staff 57 %); continuity of care (parents 15 % & staff 36 %); supportive systems & structures (parents 50 %); and clear care pathways (parents 5 %).

Conclusions

Parents’ and healthcare workers’ experiences of stillbirth can inform training, improve the provision of care and highlight areas for future research.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-016-0806-2) contains supplementary material, which is available to authorized users.

Auscultation of the fetal heart in early pregnancy

INTRODUCTION

Auscultation of the fetal heart is a common event in antenatal care, in early pregnancy it may be associated with false negative results, which require ultrasound scan to confirm fetal viability.

METHODS

We studied 197 women in early pregnancy to determine the gestational age at which the fetal heart can be reliably identified and the factors which determined the accuracy of the test.

RESULTS

The proportion of successful auscultations increased with advancing gestation (p < 0.001). There was no effect of maternal body mass index or the level of midwifery experience.

CONCLUSION

For a sensitivity of 90%, the fetal heart should be auscultated after 13 week gestation. If a sensitivity of 80% is acceptable the fetal heart can be auscultated after 12 + 1 week gestation.

Detection and management of decreased fetal movements in Australia and New Zealand: a survey of obstetric practice

BACKGROUND

Decreased fetal movement (DFM) is associated with increased risk of adverse pregnancy outcome. However, there is limited research to inform practice in the detection and management of DFM.

AIMS

To identify current practices and views of obstetricians in Australia and New Zealand regarding DFM.

METHODS

A postal survey of Fellows and Members, and obstetric trainees of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists.

RESULTS

Of the 1700 surveys distributed, 1066 (63%) were returned, of these, 805 (76% of responders) were currently practising and included in the analysis. The majority considered that asking women about fetal movement should be a part of routine care. Sixty per cent reported maternal perception of DFM for 12 h was sufficient evidence of DFM and 77% DFM for 24 h. KICK charts were used routinely by 39%, increasing to 66% following an episode of DFM. Alarm limits varied, the most commonly reported was < 10 movements in 12 h (74%). Only 6% agreed with the internationally recommended definition of < 10 movements in two hours. Interventions for DFM varied, while 81% would routinely undertake a cardiotocograph, 20% would routinely perform ultrasound and 20% more frequent antenatal visits.

CONCLUSIONS

While monitoring fetal movement is an important part of antenatal care in Australia and New Zealand, variation in obstetric practice for DFM is evident. Large-scale randomised controlled trials are required to identify optimal screening and management options. In the interim, high quality clinical practice guidelines using the best available advice are needed to enhance consistency in practice including advice provided to women.

Endometrioid adenocarcinoma presenting in a patient 18 years after hysterectomy: a potential hazard of unopposed oestrogen therapy

We present a case of endometrioid adenocarcinoma arising from extragonadal endometriosis 18 years after total abdominal hysterectomy with bilateral salpingo-oophorectomy. After the primary surgery the patient received 11 years of unopposed oestrogen hormone replacement therapy. She presented with symptoms of urinary retention and pelvic mass. Following resection, histopathology identified the mass as an endometrioid adenocarcinoma. The association between persistent endometriosis and the development of endometrial cancer are discussed here together with the risks of unopposed oestrogen in the development of such lesions.

Acupressure for the in-patient treatment of nausea and vomiting in early pregnancy: a randomized control trial

OBJECTIVE

The purpose of this study was to evaluate the efficacy of acupressure at the P6 point for the in-patient treatment of severe nausea and vomiting in early pregnancy.

STUDY DESIGN

This was a prospective single-blind randomized control trial that involved 80 patients with nausea and vomiting plus ketonuria before 14 weeks of gestation.

RESULTS

There was no difference between length of stay, amount of medication, or fluid required between the acupressure and placebo groups, although acupressure reduced the number of patients who stayed > or =4 nights in the hospital. Acupressure was well tolerated and not associated with an increase in perinatal morbidity or death.

CONCLUSION

The use of acupressure at the P6 point does not reduce the amount of antiemetic medication that is required, the requirement for intravenous fluid, and median duration of in-patient stay more than the use of placebo. A small reduction was seen in the number of women who required > or =4 days in the hospital.