Women's experience of transfer from midwifery unit to hospital obstetric unit during labour: a qualitative interview study.

Acknowledgements RER was funded by a Researcher Development Award from the National Institute for Health Research (NIHR) (RDA/03/07/066). The views expressed in this paper are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health. The authors would like to thank the midwives and voluntary organisations who helped with recruitment and, in particular, all the women who took part in the study.Peer reviewedPublisher PD

Perinatal outcomes after maternal 2009/H1N1 infection: national cohort study

Objectives To follow up a UK national cohort of women admitted to hospital with confirmed 2009/H1N1 influenza in pregnancy in order to obtain a complete picture of pregnancy outcomes and estimate the risks of adverse fetal and infant outcomes

Incidence and risk factors for placenta accreta/increta/percreta in the UK: a national case-control study.

Placenta accreta/increta/percreta is associated with major pregnancy complications and is thought to be becoming more common. The aims of this study were to estimate the incidence of placenta accreta/increta/percreta in the UK and to investigate and quantify the associated risk factors

Facility-based stillbirth review processes used in different countries across the world: a systematic review

Background: Facility-based stillbirth review provides opportunities to estimate incidence, evaluate causes and risk factors for stillbirths, and identify any issues related to the quality of pregnancy and childbirth care which require improvement. Our aim was to systematically review all types and methods of facility-based stillbirth review processes used in different countries across the world, to examine how stillbirth reviews in facility settings are being conducted worldwide and to identify the outcomes of implementing the reviews. Moreover, to identify facilitators and barriers influencing the implementation of the identified facility-based stillbirth reviews processes by conducting subgroup analyses. Methods: A systematic review of published literature was conducted by searching MEDLINE (OvidSP) [1946-present], EMBASE (OvidSP) [1974-present], WHO Global Index Medicus (globalindexmedicus.net), Global Health (OvidSP) [1973–2022 Week 8] and CINAHL (EBSCOHost) [1982-present] from their inception until 11 January, 2023. For unpublished or grey literature, the WHO databases, Google Scholar and ProQuest Dissertations & Theses Global were searched, as well as hand searching the reference lists of included studies. MESH terms encompassing “∗Clinical Audit”, “∗Perinatal Mortality”, “Pregnancy Complications”, and “Stillbirth” were used with Boolean operators. Studies that used a facility-based review process or any approach to evaluate care prior to stillbirth, and explained the methods used were included. Reviews and editorials were excluded. Three authors (YYB, UGA, and DBT) independently screened and extracted data, and assessed the risk of bias using an adapted JBI's Checklist for Case Series. A logic model was used to inform the narrative synthesis. The review protocol was registered with PROSPERO, CRD42022304239. Findings: A total of 68 studies from 17 high-income (HICs) and 22 low-and-middle-income countries (LMICs) met the inclusion criteria from a total of 7258 identified records. These were stillbirth reviews conducted at different levels: district, state, national, and international. Three types were identified: audit, review, and confidential enquiry, but not all desired components were included in most processes, which led to a mismatch between the description of the type and the actual method used. Routine data from hospital records was the most common data source for identifying stillbirths, and case assessment was based on stillbirth definition in 48 out of 68 studies. Hospital notes were the most common source of information about care received and causes/risk factors for stillbirth. Short-term and medium-term outcomes were reported in 14 studies, but impact of the review process on reducing stillbirth, which is more difficult to establish, was not reported in any study. Facilitators and barriers in implementing a successful stillbirth review process identified from 14 studies focused on three main themes: resources, expertise, and commitment. Interpretation: This systematic review's findings identified that there is a need for clear guidelines on how to measure the impact of implementation of changes based on outputs of stillbirth reviews and methods to enable effective dissemination of learning points in the future and promoting them through training platforms. In addition, there is a need to develop and adopt a universal definition of stillbirth to facilitate meaningful comparison of stillbirth rates between regions. The key limitation of this review is that while using a logic model for narrative synthesis was deemed most appropriate for this study, sequence of implementing a stillbirth review in the real world is not linear, and assumptions are often not met. Therefore, the logic model proposed in this study should be interpreted with flexibility when designing a stillbirth review process. The generated learnings from the stillbirth review processes inform the action plans and allow facilities to consider where the changes should happen to improve the quality of care in the facilities, enabling positive short-term and medium-term outcomes. Funding: Kellogg College, University of Oxford, Clarendon Fund, University of Oxford, Nuffield Department of Population Health, University of Oxford and Medical Research Council (MRC)

Planning for a cohort study to investigate the impact and management of influenza in pregnancy in a future pandemic

Background: Evidence from the 2009 A/H1N1 influenza pandemic demonstrated that pregnant women are particularly vulnerable to infection and at an increased risk of death. Active data collection through the UK Obstetric Surveillance System (UKOSS) about women admitted to hospital during the 2009 A/H1N1 pandemic was used to inform ongoing clinical guidance regarding the use of antiviral treatment for pregnant women and demonstrated that, in addition to an increased risk of maternal morbidity, influenza infection in pregnancy is associated with poor perinatal outcomes, including an increased risk of stillbirth and preterm birth. This evidence influenced the decision to offer routine influenza immunisation to pregnant women. Even in a non-epidemic period, pregnant women continue to die from influenza. Objective: To establish, and then to put into hibernation, the study mechanisms needed to mount a rapid investigation of the impact of pandemic influenza in pregnancy in the event of a newly emerging pandemic strain. Design: A new UKOSS cohort study was designed, based on the 2009–10 study, and following consultation with the Pandemic Flu Planning Group at the Royal College of Obstetricians and Gynaecologists and the UKOSS Steering Committee, to identify potential previously unanswered questions. Setting: UK maternity units. Participants: All pregnant women admitted to hospital with influenza in a future pandemic. Main outcome measures: Management of pregnant women with influenza infection, intervention rates, treatment and pregnancy outcome for both the mother and fetus. Results: The study was designed and approved by the UKOSS Steering Committee and then placed into hibernation for activation in the event of an influenza pandemic. Conclusions: Pregnant women, as a result of their changed immunological status, appear to be particularly susceptible to infection, including from influenza. The existence of the UKOSS enabled us to rapidly mount a study of pregnant women who were hospitalised with 2009 A/H1N1 influenza. Minor modifications to incorporate previously unanswered questions and our previous study enabled us to design, and then put into hibernation, a new study ready to investigate the impact and management of influenza in pregnancy, which is poised for activation in the event of a newly emerging pandemic strain. This will enable real-time data to be available on which to base rapid changes in clinical management as the as-yet-unforeseen pandemic unfolds. In the event of an influenza pandemic the study will be available to be immediately activated following expedited regulatory approvals. Trial registration: Current Controlled Trials ISRCTN44137563. Funding: The National Institute for Health Research Health Services and Delivery Research programme

Parents' Active Role and ENgagement in The review of their Stillbirth/perinatal death 2 (PARENTS 2) study: a mixed-methods study of implementation.

OBJECTIVE: When a formal review of care takes places after the death of a baby, parents are largely unaware it takes place and are often not meaningfully involved in the review process. Parent engagement in the process is likely to be essential for a successful review and to improve patient safety. This study aimed to evaluate an intervention process of parental engagement in perinatal mortality review (PNMR) and to identify barriers and facilitators to its implementation. DESIGN: Mixed-methods study of parents' engagement in PNMR. SETTING: Single tertiary maternity unit in the UK. PARTICIPANTS: Bereaved parents and healthcare professionals (HCPs). INTERVENTIONS: Parent engagement in the PNMR (intervention) was based on principles derived through national consensus and qualitative research with parents, HCPs and stakeholders in the UK. OUTCOMES: Recruitment rates, bereaved parents and HCPs' perceptions. RESULTS: Eighty-one per cent of bereaved parents approached (13/16) agreed to participate in the study. Two focus groups with bereaved parents (n=11) and HCP (n=7) were carried out postimplementation to investigate their perceptions of the process.Overarching findings were improved dialogue and continuity of care with parents, and improvements in the PNMR process and patient safety. Bereaved parents agreed that engagement in the PNMR process was invaluable and helped them in their grieving. HCP perceived that parent involvement improved the review process and lessons learnt from the deaths; information to understand the impact of aspects of care on the baby's death were often only found in the parents' recollections. CONCLUSIONS: Parental engagement in the PNMR process is achievable and useful for parents and HCP alike, and critically can improve patient safety and future care for mothers and babies. To learn and prevent perinatal deaths effectively, all hospitals should give parents the option to engage with the review of their baby's death

Management and implications of severe COVID-19 in pregnancy in the UK: data from the UK Obstetric Surveillance System national cohort

INTRODUCTION: There is a lack of population level data on risk factors and impact of severe COVID-19 in pregnancy. The aims of this study were to determine the characteristics, and maternal and perinatal outcomes associated with severe COVID-19 in pregnancy compared with those with mild and moderate COVID-19 and to explore the impact of timing of birth. MATERIAL AND METHODS: This was a secondary analysis of a national, prospective cohort study. All pregnant women admitted to hospital in the UK with symptomatic SARS-CoV-2 from March 1, 2020 to October 31, 2021 were included. The severity of maternal infection (need for high flow or invasive ventilation, intensive care admission or died), pregnancy and perinatal outcomes, and the impact of timing of birth were analyzed using multivariable logistic regression. RESULTS: Of 4436 pregnant women, 13.9% (n = 616) had severe infection. Women with severe infection were more likely to be aged ≥30 years (adjusted odds ratio [aOR] aged 30-39 1.48, 95% confidence interval [CI] 1.20-1.83), be overweight or obese (aOR 1.73, 95% CI 1.34-2.25 and aOR 2.52 95% CI 1.97-3.23, respectively), be of mixed ethnicity (aOR 1.93, 95% CI 1.17-3.21) or have gestational diabetes (aOR 1.43, 95% CI 1.09-1.87) compared with those with mild or moderate infection. Women with severe infection were more likely to have a pre-labor cesarean birth (aOR 8.84, 95% CI 6.61-11.83), a very or extreme preterm birth (28-31+ weeks' gestation, aOR 18.97, 95% CI 7.78-14.85; <28 weeks' gestation, aOR 12.35, 95% CI 6.34-24.05) and their babies were more likely to be stillborn (aOR 2.51, 95% CI 1.35-4.66) or admitted to a neonatal unit (aOR 11.61, 95% CI 9.28-14.52). Of 112 women with severe infection who were discharged and gave birth at a later admission, the majority gave birth ≥36 weeks (85.7%), noting that three women in this group (2.7%) had a stillbirth. CONCLUSIONS: Severe COVID-19 in pregnancy increases the risk of adverse outcomes. Information to promote uptake of vaccination should specifically target those at greatest risk of severe outcomes. Decisions about timing of birth should be informed by multidisciplinary team discussion; however, our data suggest that women with severe infection who do not require early delivery have mostly good outcomes but that those with severe infection at term may warrant rapid delivery

Severity of maternal infection and perinatal outcomes during periods of SARS-CoV-2 wildtype, alpha, and delta variant dominance in the UK: prospective cohort study

OBJECTIVE: To compare the severity of maternal infection and perinatal outcomes during periods in which wildtype, alpha variant, and delta variant of SARS-CoV-2 were dominant in the UK. DESIGN: Prospective cohort study. SETTING: 194 obstetric units across the UK, during the following periods: between 1 March and 30 November 2020 (wildtype dominance), between 1 December 2020 and 15 May 2021 (alpha variant dominance), and between 16 May and 31 October 2021 (delta variant dominance). PARTICIPANTS: 4436 pregnant women admitted to hospital with covid-19 related symptoms. MAIN OUTCOME MEASURES: Moderate to severe maternal SARS-CoV-2 infection (indicated by any of the following: oxygen saturation <95% on admission, need for oxygen treatment, evidence of pneumonia on imaging, admission to intensive care, or maternal death), and pregnancy and perinatal outcomes (including mode and gestation of birth, stillbirth, live birth, admission to neonatal intensive care, and neonatal death). RESULTS: 1387, 1613, and 1436 pregnant women were admitted to hospital with covid-19 related symptoms during the wildtype, alpha, and delta dominance periods, respectively; of these women, 340, 585, and 614 had moderate to severe infection, respectively. The proportion of pregnant women admitted with moderate to severe infection increased during the subsequent alpha and delta dominance periods, compared with the wildtype dominance period (wildtype 24.5% v alpha 36.2% (adjusted odds ratio 1.98, 95% confidence interval 1.66% to 2.37%); wildtype 24.5% v delta 42.8% (2.66, 2.21 to 3.20)). Compared with the wildtype dominance period, women admitted during the alpha dominance period were significantly more likely to have pneumonia, require respiratory support, and be admitted to intensive care; these three risks were even greater during the delta dominance period (wildtype v delta: pneumonia, adjusted odds ratio 2.52, 95% confidence interval 2.06 to 3.09; respiratory support, 1.90, 1.52 to 2.37; and intensive care, 2.71, 2.06 to 3.56). Of 1761 women whose vaccination status was known, 38 (2.2%) had one dose and 16 (1%) had two doses before their diagnosis (of whom 14 (88%) had mild infection). The proportion of women receiving drug treatment for SARS-CoV-2 management was low, but did increase between the wildtype dominance period and the alpha and delta dominance periods (10.4% wildtype v 14.9% alpha (2.74, 2.08 to 3.60); 10.4% wildtype v 13.6% delta (2.54, 1.90 to 3.38)). CONCLUSIONS: While limited by the absence of variant sequencing data, these findings suggest that during the periods when the alpha and delta variants of SARS-CoV-2 were dominant, covid-19 was associated with more severe maternal infection and worse pregnancy outcomes than during the wildtype dominance period. Most women admitted with SARS-CoV-2 related symptoms were unvaccinated. Urgent action to prioritise vaccine uptake in pregnancy is essential. STUDY REGISTRATION: ISRCTN40092247

Severity of maternal SARS-CoV-2 infection and perinatal outcomes of women admitted to hospital during the omicron variant dominant period using UK Obstetric Surveillance System data: prospective, national cohort study.

OBJECTIVES: To describe the severity of maternal infection when the omicron SARS-CoV-2 variant (B.1.1.529) was dominant (15 December 2021 to 14 March 2022) and describe outcomes by symptoms and vaccination status. DESIGN: Prospective, national cohort study using the UK Obstetric Surveillance System. SETTING: 94 hospitals in the UK with a consultant led maternity unit. PARTICIPANTS: Pregnant women admitted to hospital for any cause with a positive SARS-CoV-2 test. MAIN OUTCOME MEASURES: Symptomatic or asymptomatic infection, vaccination status by doses before admission, and severity of maternal infection (moderate or severe infection according to modified World Health Organization's criteria). RESULTS: Of 3699 women who were admitted to hospital, 986 (26.7%, 95% confidence interval 25.3% to 28.1%) had symptoms; of these, 144 (14.6%, 12.5% to 17.0%) had a moderate to severe infection, 99 (10.4%, 8.6% to 12.5%) of 953 received respiratory support, and 30 (3.0%, 2.1% to 4.3%) were admitted to an intensive care unit. Covid-19 specific drug treatment was given to 13 (43.3%) of the 30 women in intensive care. Four women with symptoms died (0.4%, 0.1% to 1.1%). Vaccination status was known for 845 (85.6%) women with symptoms; 489 (58.9%) were unvaccinated and only 55 (6.5%) had three doses. Moderate to severe infection was reported for 93 (19.0%) of 489 unvaccinated women with symptoms, decreasing to three (5.5%) of 55 after three doses. Among the 30 women with symptoms who were admitted to intensive care, 23 (76.7%) were unvaccinated and none had received three doses. CONCLUSION: Most women with severe covid-19 disease were unvaccinated and vaccine coverage among pregnant women admitted to hospital with SARS-CoV-2 was low. Ongoing action to prioritise and advocate for vaccine uptake in pregnancy is essential. A better understanding of the persistent low use of drug treatments is an urgent priority. TRIAL REGISTRATION: ISRCTN 40092247

National active surveillance to understand and inform neonatal care in COVID-19.

The novel coronavirus severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes COVID-19 and has spread rapidly. COVID-19 was declared a pandemic by the WHO on 12 March 2020. Robust, population-based data describing COVID-19 during pregnancy and the neonatal period are critical to understand and manage this global threat in these groups