First and second trimester ultrasound in pregnancy: A systematic review and metasynthesis of the views and experiences of pregnant women, partners, and health workers

BackgroundThe World Health Organization (WHO) recommends one ultrasound scan before 24 weeks gestation as part of routine antenatal care (WHO 2016). We explored influences on provision and uptake through views and experiences of pregnant women, partners, and health workers.MethodsWe undertook a systematic review (PROSPERO CRD42021230926). We derived summaries of findings and overarching themes using metasynthesis methods. We searched MEDLINE, CINAHL, PsycINFO, SocIndex, LILACS, and AIM (Nov 25th 2020) for qualitative studies reporting views and experiences of routine ultrasound provision to 24 weeks gestation, with no language or date restriction. After quality assessment, data were logged and analysed in Excel. We assessed confidence in the findings using Grade-CERQual.FindingsFrom 7076 hits, we included 80 papers (1994–2020, 23 countries, 16 LICs/MICs, over 1500 participants). We identified 17 review findings, (moderate or high confidence: 14/17), and four themes: sociocultural influences and expectations; the power of visual technology; joy and devastation: consequences of ultrasound findings; the significance of relationship in the ultrasound encounter. Providing or receiving ultrasound was positive for most, reportedly increasing parental-fetal engagement. However, abnormal findings were often shocking. Some reported changing future reproductive decisions after equivocal results, even when the eventual diagnosis was positive. Attitudes and behaviours of sonographers influenced service user experience. Ultrasound providers expressed concern about making mistakes, recognising their need for education, training, and adequate time with women. Ultrasound sex determination influenced female feticide in some contexts, in others, termination was not socially acceptable. Overuse was noted to reduce clinical antenatal skills as well as the use and uptake of other forms of antenatal care. These factors influenced utility and equity of ultrasound in some settings.ConclusionThough antenatal ultrasound was largely seen as positive, long-term adverse psychological and reproductive consequences were reported for some. Gender inequity may be reinforced by female feticide following ultrasound in some contexts. Provider attitudes and behaviours, time to engage fully with service users, social norms, access to follow up, and the potential for overuse all need to be considered

First and second trimester ultrasound in pregnancy: A systematic review and metasynthesis of the views and experiences of pregnant women, partners, and health workers

BackgroundThe World Health Organization (WHO) recommends one ultrasound scan before 24 weeks gestation as part of routine antenatal care (WHO 2016). We explored influences on provision and uptake through views and experiences of pregnant women, partners, and health workers.MethodsWe undertook a systematic review (PROSPERO CRD42021230926). We derived summaries of findings and overarching themes using metasynthesis methods. We searched MEDLINE, CINAHL, PsycINFO, SocIndex, LILACS, and AIM (Nov 25th 2020) for qualitative studies reporting views and experiences of routine ultrasound provision to 24 weeks gestation, with no language or date restriction. After quality assessment, data were logged and analysed in Excel. We assessed confidence in the findings using Grade-CERQual.FindingsFrom 7076 hits, we included 80 papers (1994–2020, 23 countries, 16 LICs/MICs, over 1500 participants). We identified 17 review findings, (moderate or high confidence: 14/17), and four themes: sociocultural influences and expectations; the power of visual technology; joy and devastation: consequences of ultrasound findings; the significance of relationship in the ultrasound encounter. Providing or receiving ultrasound was positive for most, reportedly increasing parental-fetal engagement. However, abnormal findings were often shocking. Some reported changing future reproductive decisions after equivocal results, even when the eventual diagnosis was positive. Attitudes and behaviours of sonographers influenced service user experience. Ultrasound providers expressed concern about making mistakes, recognising their need for education, training, and adequate time with women. Ultrasound sex determination influenced female feticide in some contexts, in others, termination was not socially acceptable. Overuse was noted to reduce clinical antenatal skills as well as the use and uptake of other forms of antenatal care. These factors influenced utility and equity of ultrasound in some settings.ConclusionThough antenatal ultrasound was largely seen as positive, long-term adverse psychological and reproductive consequences were reported for some. Gender inequity may be reinforced by female feticide following ultrasound in some contexts. Provider attitudes and behaviours, time to engage fully with service users, social norms, access to follow up, and the potential for overuse all need to be considered

Assessing safe and personalised maternity and neonatal care through a pandemic: a case study of outcomes and experiences in two trusts in England using the ASPIRE COVID-19 framework

Background: The COVID-19 pandemic has resulted in profound and far-reaching impacts on maternal and newborn care and outcomes. As part of the ASPIRE COVID-19 project, we describe processes and outcome measures relating to safe and personalised maternity care in England which we map against a pre-developed ASPIRE framework to establish the potential impact of the COVID-19 pandemic for two UK trusts. Methods: We undertook a mixed-methods system-wide case study using quantitative routinely collected data and qualitative data from two Trusts and their service users from 2019 to 2021 (start and completion dates varied by available data). We mapped findings to our prior ASPIRE conceptual framework that explains pathways for the impact of COVID-19 on safe and personalised care. Results: The ASPIRE framework enabled us to develop a comprehensive, systems-level understanding of the impact of the pandemic on service delivery, user experience and staff wellbeing, and place it within the context of pre-existing challenges. Maternity services experienced some impacts on core service coverage, though not on Trust level clinical health outcomes (with the possible exception of readmissions in one Trust). Both users and staff found some pandemic-driven changes challenging such as remote or reduced antenatal and community postnatal contacts, and restrictions on companionship. Other key changes included an increased need for mental health support, changes in the availability and uptake of home birth services and changes in induction procedures. Many emergency adaptations persisted at the end of data collection. Differences between the trusts indicate complex change pathways. Staff reported some removal of bureaucracy, which allowed greater flexibility. During the first wave of COVID-19 staffing numbers increased, resolving some pre-pandemic shortages: however, by October 2021 they declined markedly. Trying to maintain the quality and availability of services had marked negative consequences for personnel. Timely routine clinical and staffing data were not always available and personalised care and user and staff experiences were poorly captured. Conclusions: The COVID-19 crisis magnified pre-pandemic problems and in particular, poor staffing levels. Maintaining services took a significant toll on staff wellbeing. There is some evidence that these pressures are continuing. There was marked variation in Trust responses. Lack of accessible and timely data at Trust and national levels hampered rapid insights. The ASPIRE COVID-19 framework could be useful for modelling the impact of future crises on routine care

Swiss public health measures associated with reduced SARS-CoV-2 transmission using genome data

Genome sequences from evolving infectious pathogens allow quantification of case introductions and local transmission dynamics. We sequenced 11,357 severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) genomes from Switzerland in 2020 - the sixth largest effort globally. Using a representative subset of these data, we estimated viral introductions to Switzerland and their persistence over the course of 2020. We contrasted these estimates with simple null models representing the absence of certain public health measures. We show that Switzerland's border closures de-coupled case introductions from incidence in neighboring countries. Under a simple model, we estimate an 86-98% reduction in introductions during Switzerland's strictest border closures. Furthermore, the Swiss 2020 partial lockdown roughly halved the time for sampled introductions to die out. Last, we quantified local transmission dynamics once introductions into Switzerland occurred, using a phylodynamic model. We found that transmission slowed 35-63% upon outbreak detection in summer 2020, but not in fall. This finding may indicate successful contact tracing over summer before overburdening in fall. The study highlights the added value of genome sequencing data for understanding transmission dynamics

‘There's only so much you can be pushed’: Magnification of the maternity staffing crisis by the 2020/21 COVID‐19 pandemic

Concerns about the impact of staffing shortages and burnout in the maternity workforce on safe and respectful care are long-standing, in the UK and internationally.1, 2 The COVID-19 pandemic has further reduced workforce availability worldwide.3 We explored the impact of the pandemic on maternity staff experience.We thematically analysed in-depth interviews (November 2020–October 2021) with 28 frontline maternity staff and 28 heads of service from seven geographically and demographically diverse NHS Trusts in England, as part of the ASPIRE COVID-19 study.The pandemic magnified existing problems within maternity care. Well established challenges such as short staffing, organisational demands, and barriers to providing relational care were exacerbated by the pandemic, leaving staff emotionally exhausted and unable to carry on. While the service is usually maintained through the goodwill of its workers, this is not sustainable in the long-term or through crisis situations. We identified three sub-themes (Figure 1) that capture changing experiences as the pandemic progressed.A sudden influx of staff and resources early in the pandemic, combined with a sense of camaraderie, public support and professional pride, led to an unexpectedly positive work environment. Despite fears for their own health and worries about taking home the virus to their families, many reported that making huge personal sacrifices was part of being involved in something bigger than themselves.However, these protective factors did not last. Experiences later in the pandemic included poor staff recruitment and retention, deteriorating physical and psychological wellbeing, insufficient staffing and unmanageable workloads. Some described unsafe working practices such as an inability to provide one-to-one care in labour, and excessively long working hours. Many described the emotional distress of working intensively to maintain standards of care but feeling only able to do the ‘bare minimum’. For some, the dissonance between the safe and personalised care they wanted to provide, and the experience of dangerously low levels of staffing, was associated with accounts of significant moral injury and distress.Those interviewed later in 2021 reported increasingly critical staffing shortages. Respondents described compassion fatigue, both towards their colleagues and for those in their care. ‘Exhausted’, ‘broken’, ‘unable to carry on’ or similar terms were used by a majority of participants. Serious concerns were raised about a rising incidence of burnout and breakdown, leading to an exodus of experienced and expert staff. One obstetrician warned of the ‘the biggest midwifery crisis of all time’.Our findings indicate that the COVID-19 pandemic has magnified the existing and escalating maternity staffing crisis in England, impacting on the ability to provide both safe and personalised care. International evidence suggests that maternity services globally face similar challenges.3 Coping mechanisms that usually enabled staff to go ‘above and beyond’ to plug service gaps were breaking down towards the end of the data collection period, reducing the sustainability of all but basic care, and risking the psychological, emotional and physical health of respondents.The impact of sub-optimal staffing on service user safety is increasingly highlighted in maternity safety reviews, which have also recognised that although staff are frequently intensely concerned about staffing ratios, these concerns have been dismissed.4, 5 Addressing insufficient staffing in maternity is a central recommendation of these reviews and can no longer be ignored.There is a unique opportunity for a post-pandemic rebuild of maternity services. This should begin by examining protective factors and organisational and political drivers that sustain psychological and physical staff wellbeing, and optimal service user outcomes and experiences. These include explicit organisational commitment to safe and sustainable staffing, flexible, autonomous practice, and protected time to provide person-centred, relational care. Getting these factors right, may promote sustainable recruitment and retention of professional maternity care staff, both for care under normal circumstances and for future crises

‘There's only so much you can be pushed’: Magnification of the maternity staffing crisis by the 2020/21 COVID‐19 pandemic

Concerns about the impact of staffing shortages and burnout in the maternity workforce on safe and respectful care are long-standing, in the UK and internationally.1, 2 The COVID-19 pandemic has further reduced workforce availability worldwide.3 We explored the impact of the pandemic on maternity staff experience.We thematically analysed in-depth interviews (November 2020–October 2021) with 28 frontline maternity staff and 28 heads of service from seven geographically and demographically diverse NHS Trusts in England, as part of the ASPIRE COVID-19 study.The pandemic magnified existing problems within maternity care. Well established challenges such as short staffing, organisational demands, and barriers to providing relational care were exacerbated by the pandemic, leaving staff emotionally exhausted and unable to carry on. While the service is usually maintained through the goodwill of its workers, this is not sustainable in the long-term or through crisis situations. We identified three sub-themes (Figure 1) that capture changing experiences as the pandemic progressed.A sudden influx of staff and resources early in the pandemic, combined with a sense of camaraderie, public support and professional pride, led to an unexpectedly positive work environment. Despite fears for their own health and worries about taking home the virus to their families, many reported that making huge personal sacrifices was part of being involved in something bigger than themselves.However, these protective factors did not last. Experiences later in the pandemic included poor staff recruitment and retention, deteriorating physical and psychological wellbeing, insufficient staffing and unmanageable workloads. Some described unsafe working practices such as an inability to provide one-to-one care in labour, and excessively long working hours. Many described the emotional distress of working intensively to maintain standards of care but feeling only able to do the ‘bare minimum’. For some, the dissonance between the safe and personalised care they wanted to provide, and the experience of dangerously low levels of staffing, was associated with accounts of significant moral injury and distress.Those interviewed later in 2021 reported increasingly critical staffing shortages. Respondents described compassion fatigue, both towards their colleagues and for those in their care. ‘Exhausted’, ‘broken’, ‘unable to carry on’ or similar terms were used by a majority of participants. Serious concerns were raised about a rising incidence of burnout and breakdown, leading to an exodus of experienced and expert staff. One obstetrician warned of the ‘the biggest midwifery crisis of all time’.Our findings indicate that the COVID-19 pandemic has magnified the existing and escalating maternity staffing crisis in England, impacting on the ability to provide both safe and personalised care. International evidence suggests that maternity services globally face similar challenges.3 Coping mechanisms that usually enabled staff to go ‘above and beyond’ to plug service gaps were breaking down towards the end of the data collection period, reducing the sustainability of all but basic care, and risking the psychological, emotional and physical health of respondents.The impact of sub-optimal staffing on service user safety is increasingly highlighted in maternity safety reviews, which have also recognised that although staff are frequently intensely concerned about staffing ratios, these concerns have been dismissed.4, 5 Addressing insufficient staffing in maternity is a central recommendation of these reviews and can no longer be ignored.There is a unique opportunity for a post-pandemic rebuild of maternity services. This should begin by examining protective factors and organisational and political drivers that sustain psychological and physical staff wellbeing, and optimal service user outcomes and experiences. These include explicit organisational commitment to safe and sustainable staffing, flexible, autonomous practice, and protected time to provide person-centred, relational care. Getting these factors right, may promote sustainable recruitment and retention of professional maternity care staff, both for care under normal circumstances and for future crises

Factors that influence the uptake of postnatal care from the perspective of fathers, partners and other family members: a qualitative evidence synthesis

Background Postnatal care (PNC) is a key component of maternity provision and presents opportunities for healthcare providers to optimise the health and well-being of women and newborns. However, PNC is often undervalued by parents, family members and healthcare providers. As part of a larger qualitative review exploring the factors that influence PNC uptake by relevant stakeholders, we examined a subset of studies highlighting the views of fathers, partners and family members of postpartum women. Methods We undertook a qualitative evidence synthesis using a framework synthesis approach. We searched multiple databases and included studies with extractable qualitative data focusing on PNC utilisation. We identified and labelled a subset of articles reflecting the views of fathers, partners and other family members. Data abstraction and quality assessment were carried out using a bespoke data extraction form and established quality assessment tools. The framework was developed a priori based on previous research on the topic and adapted accordingly. Findings were assessed for confidence using the GRADE-CERQual approach and are presented by country income group. Results Of 12 678 papers identified from the original search, 109 were tagged as ‘family members views’ and, of these, 30 were eligible for this review. Twenty-nine incorporated fathers’ views, 7 included the views of grandmothers or mothers-in-law, 4 incorporated other family member views and 1 included comothers. Four themes emerged: access and availability; adapting to fatherhood; sociocultural influences and experiences of care. These findings highlight the significant role played by fathers and family members on the uptake of PNC by women as well as the distinct concerns and needs of fathers during the early postnatal period. Conclusion To optimise access to postnatal care, health providers should adopt a more inclusive approach incorporating flexible contact opportunities, the availability of more ‘family-friendly’ information and access to psychosocial support services for both parents

Assessing safe and personalised maternity and neonatal care through a pandemic: a case study of outcomes and experiences in two trusts in England using the ASPIRE COVID-19 framework

BackgroundThe COVID-19 pandemic has resulted in profound and far-reaching impacts on maternal and newborn care and outcomes. As part of the ASPIRE COVID-19 project, we describe processes and outcome measures relating to safe and personalised maternity care in England which we map against a pre-developed ASPIRE framework to establish the potential impact of the COVID-19 pandemic for two UK trusts.MethodsWe undertook a mixed-methods system-wide case study using quantitative routinely collected data and qualitative data from two Trusts and their service users from 2019 to 2021 (start and completion dates varied by available data). We mapped findings to our prior ASPIRE conceptual framework that explains pathways for the impact of COVID-19 on safe and personalised care.ResultsThe ASPIRE framework enabled us to develop a comprehensive, systems-level understanding of the impact of the pandemic on service delivery, user experience and staff wellbeing, and place it within the context of pre-existing challenges.Maternity services experienced some impacts on core service coverage, though not on Trust level clinical health outcomes (with the possible exception of readmissions in one Trust). Both users and staff found some pandemic-driven changes challenging such as remote or reduced antenatal and community postnatal contacts, and restrictions on companionship. Other key changes included an increased need for mental health support, changes in the availability and uptake of home birth services and changes in induction procedures. Many emergency adaptations persisted at the end of data collection. Differences between the trusts indicate complex change pathways. Staff reported some removal of bureaucracy, which allowed greater flexibility.During the first wave of COVID-19 staffing numbers increased, resolving some pre-pandemic shortages: however, by October 2021 they declined markedly. Trying to maintain the quality and availability of services had marked negative consequences for personnel. Timely routine clinical and staffing data were not always available and personalised care and user and staff experiences were poorly captured.ConclusionsThe COVID-19 crisis magnified pre-pandemic problems and in particular, poor staffing levels. Maintaining services took a significant toll on staff wellbeing. There is some evidence that these pressures are continuing. There was marked variation in Trust responses. Lack of accessible and timely data at Trust and national levels hampered rapid insights. The ASPIRE COVID-19 framework could be useful for modelling the impact of future crises on routine care

SARS-CoV-2 Evolution among Oncological Population: In-Depth Virological Analysis of a Clinical Cohort

Background: Oncological patients have a higher risk of prolonged SARS-CoV-2 shedding, which, in turn, can lead to evolutionary mutations and emergence of novel viral variants. The aim of this study was to analyze biological samples of a cohort of oncological patients by deep sequencing to detect any significant viral mutations. Methods: High-throughput sequencing was performed on selected samples from a SARS-CoV-2-positive oncological patient cohort. Analysis of variants and minority variants was performed using a validated bioinformatics pipeline. Results: Among 54 oncological patients, we analyzed 12 samples of 6 patients, either serial nasopharyngeal swab samples or samples from the upper and lower respiratory tracts, by high-throughput sequencing. We identified amino acid changes D614G and P4715L as well as mutations at nucleotide positions 241 and 3037 in all samples. There were no other significant mutations, but we observed intra-host evolution in some minority variants, mainly in the ORF1ab gene. There was no significant mutation identified in the spike region and no minority variants common to several hosts. Conclusions: There was no major and rapid evolution of viral strains in this oncological patient cohort, but there was minority variant evolution, reflecting a dynamic pattern of quasi-species replication.</p