Systematic exploration of local reviews of the care of maternal deaths in the UK and Ireland between 2012 and 2014: A case note review study

Objectives Local reviews of the care of women who die in pregnancy and post-birth should be undertaken. We investigated the quantity and quality of hospital reviews. DesignAnonymised case notes review. Participants All 233 women in the UK and Ireland who died during or up to 6 weeks after pregnancy from any cause related to or aggravated by pregnancy or its management in 2012-2014. Main outcome measures The number of local reviews undertaken. Quality was assessed by the composition of the review panel, whether root causes were systematically assessed and actions detailed. Results The care of 177/233 (76%) women who died was reviewed locally. The care of women who died in early pregnancy and after 28 days post-birth was less likely to be reviewed as was the care of women who died outside maternity services and who died from mental health-related causes. 140 local reviews were available for assessment. Multidisciplinary review was undertaken for 65% (91/140). External involvement in review occurred in 12% (17/140) and of the family in 14% (19/140). The root causes of deaths were systematically assessed according to national guidance in 13% (18/140). In 88% (123/140) actions were recommended to improve future care, with a timeline and person responsible identified in 55% (77/140). Audit to monitor implementation of changes was recommended in 14% (19/140). Conclusions This systematic assessment of local reviews of care demonstrated that not all hospitals undertake a review of care of women who die during or after pregnancy and in the majority quality is lacking. The care of these women should be reviewed using a standardised robust process including root cause analysis to maximise learning and undertaken by an appropriate multidisciplinary team who are given training, support and adequate time

Systematic exploration of local reviews of the care of maternal deaths in the UK and Ireland between 2012 and 2014:a case note review study

ObjectivesLocal reviews of the care of women who die in pregnancy and post-birth should be undertaken. We investigated the quantity and quality of hospital reviews.DesignAnonymised case notes review.ParticipantsAll 233 women in the UK and Ireland who died during or up to 6 weeks after pregnancy from any cause related to or aggravated by pregnancy or its management in 2012–2014.Main outcome measuresThe number of local reviews undertaken. Quality was assessed by the composition of the review panel, whether root causes were systematically assessed and actions detailed.ResultsThe care of 177/233 (76%) women who died was reviewed locally. The care of women who died in early pregnancy and after 28 days post-birth was less likely to be reviewed as was the care of women who died outside maternity services and who died from mental health-related causes. 140 local reviews were available for assessment. Multidisciplinary review was undertaken for 65% (91/140). External involvement in review occurred in 12% (17/140) and of the family in 14% (19/140). The root causes of deaths were systematically assessed according to national guidance in 13% (18/140). In 88% (123/140) actions were recommended to improve future care, with a timeline and person responsible identified in 55% (77/140). Audit to monitor implementation of changes was recommended in 14% (19/140).ConclusionsThis systematic assessment of local reviews of care demonstrated that not all hospitals undertake a review of care of women who die during or after pregnancy and in the majority quality is lacking. The care of these women should be reviewed using a standardised robust process including root cause analysis to maximise learning and undertaken by an appropriate multidisciplinary team who are given training, support and adequate time

Midwives’ perspectives of continuity based working in the UK: A cross-sectional survey

Objective: UK policy is advocating continuity of midwife throughout the antenatal, intrapartum and postnatal period in order to improve outcomes. We explored the working patterns that midwives are willing and able to adopt, barriers to change, and what would help midwives to work in continuity models of care.Design: A cross-sectional survey.Setting: 27 English maternity providers in the seven geographically-based ‘Early Adopter’ sites, which have been chosen to fast-track national policy implementation. Participants: All midwives working in the ‘Early Adopter’ sites were eligible to take part.Method: Anonymous online survey disseminated by local and national leaders, and social media, in October 2017. Descriptive statistics were calculated for quantitative survey responses. Qualitative free text responses were analysed thematically.Findings: 798 midwives participated (estimated response rate 20% calculated using local and national NHS workforce headcount data for participating sites). Being willing or able to work in a continuity model (caseloading and/or team)was lowest where this included intrapartum care in both hospital and home settings (35%, n = 279). Willingness to work in a continuity model of care increased as the range of intrapartum care settings covered decreased (home births only 45%, n = 359; no intrapartum care at all 54%, n = 426). A need to work on the same day each week was reported by 24% (n = 188). 31% (n = 246) were currently working 12 h shifts only, while 37% (n = 295) reported being unable to work any on-calls and/or nights. Qualitative analysis revealed multiple barriers to working in continuity models: the most prominent was caring responsibilities for children and others. Midwives suggested a range of approaches to facilitate working differently including concessions in the way midwife roles are organised, such as greater autonomy and choice in working patterns.Conclusions: Findings suggest that many midwives are not currently able or willing to work in continuity models, which includes care across antenatal, intrapartum and postnatal periods as recommended by UK policy.Implications for Practice: A range of approaches to providing continuity models should be explored as the implementation of ‘Better Births’ takes place across England. This should include studies of the impact of the different models on women, babies and midwives, along with their practical scalability and cost

P-glycoprotein-9 and macrocyclic lactone resistance status in selected strains of the ovine gastrointestinal nematode, Teladorsagia circumcincta

The Teladorsagia circumcincta P-glycoprotein-9 (Tci-pgp-9) gene has previously been implicated in multiple-anthelmintic resistance in this parasite. Here we further characterise genetic diversity in Tci-pgp-9 and its possible role in ivermectin (IVM) and multi-drug resistance using two UK field isolates of T. circumcincta, one susceptible to anthelmintics (MTci2) and the other resistant to most available anthelmintics including IVM (MTci5). A comparison of full-length Tci-pgp-9 cDNA transcripts from the MTci2 and MTci5 isolates (∼3.8 kb in both cases) indicated that they shared 95.6% and 99.5% identity at the nucleotide and amino acid levels, respectively. Nine non-synonymous SNPs were found in the MTci5 sequences relative to their MTci2 counterparts. Twelve genomic sequence variants of the first internucleotide binding domain of Tci-pgp-9 were identified and up to 10 of these were present in some individual worms, strongly supporting previous evidence that amplification of this gene has occurred in T. circumcincta. On average, fewer distinct sequence variants of Tci-pgp-9 were present in individual worms of the MTci5 isolate than in those of the MTci2 isolate. A further reduction in the number of sequence variants was observed in individuals derived from an IVM-treated sub-population of MTci5. These findings suggest that Tci-pgp-9 was under purifying selection in the face of IVM treatment in T. circumcincta, with some sequence variants being selected against

Community postnatal care delivery in England since Covid-19 : a qualitative study of midwifery leaders' perspectives and strategies.

COVID-19 impacted negatively on maternity care experiences of women and staff. Understanding the emergency response is key to inform future plans. Before the COVID-19 pandemic, experts highlighted concerns about UK community postnatal care, and its impact on long-term health, wellbeing, and inequalities. These appear to have been exacerbated by the pandemic. To explore community postnatal care provision during and since the pandemic across a large diverse UK region. A descriptive qualitative approach. Virtual semi-structured interviews conducted November 2022-February 2023. All regional midwifery community postnatal care leaders were invited to participate. 11/13 midwifery leaders participated. Three main themes were identified: Changes to postnatal care (strategic response, care on the ground); Impact of postnatal care changes (staff and women's experiences); and Drivers of postnatal care changes in (COVID-19, workforce issues). Changes to postnatal care during the pandemic included introduction of virtual care, increased role of Maternity Support Workers, and moving away from home visits to clinic appointments. This has largely continued without evaluation. The number of care episodes provided for low and high-risk families appears to have changed little. Those requiring additional support but not deemed highest risk appear to have been most impacted. Staffing levels influenced amount and type of care provided. There was little inter-organisation collaboration in the postnatal pandemic response. Changes to postnatal care provision introduced more efficient working practices. However, evaluation is needed to ensure ongoing safe, equitable and individualised care provision post pandemic within limited resources

Fitness costs of parasites explain multiple life history tradeoffs in a wild mammal

Reproduction in wild animals can divert limited resources away from immune defence, resulting in increased parasite burdens. A longstanding prediction of life history theory states that these parasites can harm the individual, reducing the organism's subsequent fitness and producing reproduction-fitness tradeoffs. Here, we examined associations among reproductive allocation, immunity, parasitism, and subsequent fitness in a wild population of individually identified red deer ( Cervus elaphus ). Using path analysis, we investigated whether costs of lactation for downstream survival and fecundity were mediated by changes in strongyle nematode count and mucosal antibody levels. Lactating females exhibited increased parasite counts, which were in turn associated with substantially decreased fitness in the following year in terms of overwinter survival, fecundity, subsequent calf weight, and parturition date. This study offers observational evidence for parasite regulation of multiple life history tradeoffs, supporting the role of parasites as an important mediating factor in wild mammal populations.The anonymised data files are present in the `DataList.rds` object; the scripts will run the path analysis and generate the figures, using these datasets. Funding provided by: Natural Environment Research CouncilCrossref Funder Registry ID: http://dx.doi.org/10.13039/501100000270Award Number: NE/L00688X/1Funding provided by: Natural Environment Research CouncilCrossref Funder Registry ID: http://dx.doi.org/10.13039/501100000270Award Number: NE/L002558/1Noninvasive faecal collection from the Isle of Rum red dee

Investigating the perceived versus actual gastrointestinal nematode challenge on extensive sheep farms

Extensive farming systems form an integral part of sheep production systems across Europe. However, with innate production handicaps, declining sheep numbers and narrow economic margins, production is becoming increasingly challenging threatening the future sustainability of the industry. Gastrointestinal nematodes (GINs) are a significant cause of production losses to the global sheep industry, with well-established resistance to the major anthelmintic groups. Traditionally, extensive farming systems are not thought to have a significant parasite challenge compared with intensive farms, but there is a need to identify the scale and importance of GINs on extensive farms to inform the need for sustainable control strategies. In this study, a questionnaire of extensive farmers (n=34) was conducted and parasitological data were collected from nine study farms to investigate the perceived versus actual GIN and anthelmintic resistance challenge faced by extensive farms. The results showed a production-limiting challenge on most farms, with a higher GIN challenge observed on improved pastures. Furthermore, over half of the extensive farmers perceived anthelmintic resistance to be a greater problem for intensive farmers, with only 20% of respondents reporting known anthelmintic resistance. However, all study farms had evidence of resistance to at least one group of anthelmintics. Consequently, this study has demonstrated that despite the traditional perception of parasitism on extensive farms, there is a need to increasingly consider its impact and take a proactive approach to sustainable control, with solutions tailored to their unique management