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Background High-quality antenatal care is important for ensuring optimal birth outcomes and reducing risks of maternal and fetal mortality and morbidity. The COVID-19 pandemic disrupted the usual provision of antenatal care, with much care shifting to remote forms of provision. We aimed to characterise what quality would look like for remote antenatal care from the perspectives of those who use, provide and organise it. Methods This UK- wide study involved interviews and an online survey inviting free- text responses with: those who were or had been pregnant since March 2020; maternity professionals and managers of maternity services and system- level stakeholders. Recruitment used network-based approaches, professional and community networks and purposively selected hospitals. Analysis of interview transcripts was based on the constant comparative method. Free-text survey responses were analysed using a coding framework developed by researchers. Findings Participants included 106 pregnant women and 105 healthcare professionals and managers/ stakeholders. Analysis enabled generation of a framework of the domains of quality that appear to be most relevant to stakeholders in remote antenatal care: efficiency and timeliness; effectiveness; safety; accessibility; equity and inclusion; person- centredness and choice and continuity. Participants reported that remote care was not straightforwardly positive or negative across these domains. Care that was more transactional in nature was identified as more suitable for remote modalities, but remote care was also seen as having potential to undermine important aspects of trusting relationships and continuity, to amplify or create new forms of structural inequality and to create possible risks to safety. Conclusions This study offers a provisional framework that can help in structuring thinking, policy and practice. By outlining the range of domains relevant to remote antenatal care, this framework is likely to be of value in guiding policy, practice and research. [ABSTRACT FROM AUTHOR]

Background Problems in intrapartum electronic fetal monitoring with cardiotocography (CTG) remain a major area of preventable harm. Poor understanding of the range of influences on safety may have hindered improvement. Taking an interdisciplinary perspective, we sought to characterise the everyday practice of CTG monitoring and the work systems within which it takes place, with the goal of identifying potential sources of risk. Methods Human factors/ergonomics (HF/E) experts and social scientists conducted 325 hours of observations and 23 interviews in three maternity units in the UK, focusing on how CTG tasks were undertaken, the influences on this work and the cultural and organisational features of work settings. HF/E analysis was based on the Systems Engineering Initiative for Patient Safety 2.0 model. Social science analysis was based on the constant comparative method. Results CTG monitoring can be understood as a complex sociotechnical activity, with tasks, people, tools and technology, and organisational and external factors all combining to affect safety. Fetal heart rate patterns need to be recorded and interpreted correctly. Systems are also required for seeking the opinions of others, determining whether the situation warrants concern, escalating concerns and mobilising response. These processes may be inadequately designed or function suboptimally, and may be further complicated by staffing issues, equipment and ergonomics issues, and competing and frequently changing clinical guidelines. Practice may also be affected by variable standards and workflows, variations in clinical competence, teamwork and situation awareness, and the ability to communicate concerns freely. Conclusions CTG monitoring is an inherently collective and sociotechnical practice. Improving it will require accounting for complex system interdependencies, rather than focusing solely on discrete factors such as individual technical proficiency in interpreting traces. [ABSTRACT FROM AUTHOR]

Clinical tools for use in practice--such as medicine reconciliation charts, diagnosis support tools and track- and- trigger charts--are endemic in healthcare, but relatively little attention is given to how to optimise their design. User- centred design approaches and co- design principles offer potential for improving usability and acceptability of clinical tools, but limited practical guidance is currently available. We propose a framework (FRamework for co- dESign of Clinical practice tOols or 'FRESCO') offering practical guidance based on user- centred methods and co- design principles, organised in five steps: (1) establish a multidisciplinary advisory group; (2) develop initial drafts of the prototype; (3) conduct think- aloud usability evaluations; (4) test in clinical simulations; (5) generate a final prototype informed by workshops. We applied the framework in a case study to support co- design of a prototype track- and- trigger chart for detecting and responding to possible fetal deterioration during labour. This started with establishing an advisory group of 22 members with varied expertise. Two initial draft prototypes were developed--one based on a version produced by national bodies, and the other with similar content but designed using human factors principles. Think- aloud usability evaluations of these prototypes were conducted with 15 professionals, and the findings used to inform co-design of an improved draft prototype. This was tested with 52 maternity professionals from five maternity units through clinical simulations. Analysis of these simulations and six workshops were used to co-design the final prototype to the point of readiness for large- scale testing. By codifying existing methods and principles into a single framework, FRESCO supported mobilisation of the expertise and ingenuity of diverse stakeholders to co- design a prototype track- and- trigger chart in an area of pressing service need. Subject to further evaluation, the framework has potential for application beyond the area of clinical practice in which it was applied. [ABSTRACT FROM AUTHOR]

Plain language summary: Over one‐quarter of women in the UK have a caesarean birth (CB). More than one in 20 of these births occurs near the end of labour, when the cervix is fully dilated (second stage). In these circumstances, and when labour has been prolonged, the baby's head can become lodged deep in the maternal pelvis making it challenging to deliver the baby. During the caesarean birth, difficulty in delivery of the baby's head may result – this emergency is known as impacted fetal head (IFH). These are technically challenging births that pose significant risks to both the woman and baby. Complications for the woman include tears in the womb, serious bleeding and longer hospital stay. Babies are at increased risk of injury including damage to the head and face, lack of oxygen to the brain, nerve damage, and in rare cases, the baby may die from these complications. Maternity staff are increasingly encountering IFH at CB, and reports of associated injuries have risen dramatically in recent years. The latest UK studies suggest that IFH may complicate as many as one in 10 unplanned CBs (1.5% of all births) and that two in 100 babies affected by IFH die or are seriously injured. Moreover, there has been a sharp increase in reports of babies having brain injuries when their birth was complicated by IFH. When an IFH occurs, the maternity team can use different approaches to help deliver the baby's head at CB. These include: an assistant (another obstetrician or midwife) pushing the head up from the vagina; delivering the baby feet first; using a specially designed inflatable balloon device to elevate the baby's head and/or giving the mother a medicine to relax the womb. However, there is currently no consensus for how best to manage these births. This has resulted in a lack of confidence among maternity staff, variable practice and potentially avoidable harm in some circumstances. This paper reviews the current evidence regarding the prediction, prevention and management of IFH at CB, integrating findings from a systematic review commissioned from the National Guideline Alliance. [ABSTRACT FROM AUTHOR]

The PROMPT Maternity Foundation aims to reduce preventable harm to mothers and babies in maternity care by making effective multi-professional training as widely available as possible [ABSTRACT FROM AUTHOR]

Problem In Zimbabwe, many health facilities are not able to manage serious obstetric complications. Staff most commonly identified inadequate training as the greatest barrier to preventing avoidable maternal deaths. Approach We established an onsite obstetric emergencies training programme for maternity staff in the Mpilo Central Hospital. We trained 12 local staff to become trainers and provided them with the equipment and resources needed for the course. The trainers held one-day courses for 299 staff at the hospital. Local setting Maternal mortality in Zimbabwe has increased from 555 to 960 per 100000 pregnant women from 2006 to 2011 and 47% of the deaths are believed to be avoidable. Most obstetric emergencies trainings are held off-site, away from the clinical area, for a limited number of staff. Relevant changes Following an in-hospital train-the-trainers course, 90% (138/153) of maternity staff were trained locally within the first year, with 299 hospital staff trained to date. Local system changes Included: the Introduction of a labour ward board, emergency boxes, colour-coded early warning observation charts and a maternity dashboard. In this hospital, these changes have been associated with a 34% reduction in hospital maternal mortality from 67 maternal deaths per 9078 births (0.74%) in 2011 compared with 48 maternal deaths per 9884 births (0.49%) in 2014. Lessons learnt Introducing obstetric emergencies training and tools was feasible onsite, improved clinical practice, was sustained by local staff and associated with improved clinical outcomes. Further work to study the implementation and effect of this intervention at scale is required. Probleme Au Zimbabwe, de nombreux etablissements de sante ne sont pas en mesure de gerer les complications obstetricales graves. Selon les personnels de sante, c'est une formation inadaptee qui est le plus souvent identifiee comme le principal obstacle pour prevenir les deces maternels evitables. Approche Nous avons concu un programme local de formation aux urgences obstetricales, destine au personnel de la maternite de l'Hopital Central Mpilo. Nous avons forme 12 membres du personnel local pour assumer le role de formateurs et nous leur avons fourni tout le materiel et les ressources necessaires pourorganiser des formations. Ces formateurs ont dispense des cours de formation d'une journee a 299 membres du personnel de l'hopital. Environnement local Au Zimbabwe, entre 2006 et 2011, la mortalite maternelle est passee de 555 a 960 deces pour 100 000 femmes enceintes. 47 % de ces deces sont consideres comme evitables. Pour la plupart, les cours de formation aux urgences obstetricales sont dispenses en externe, hors de l'etablissement de sante, et ils ne concernent qu'un nombre limite de membres du personnel. Changements significatifs Consecutivement au cours de formation des formateurs organise au sein meme de l'hopital, 90 % du personnel de la maternite (138 personnes sur 153) a ete forme localement, des la premiere annee, et a ce jour, 299 membres du personnel de l'hopital ont ete formes. Parmi les changements constates localement, nous pouvons citer l'introduction de divers outils : tableau de planification pour les salles de travail, kits d'urgences, tableaux d'observation et d'alerte anticipee avec code couleur et tableau de bord de la maternite. Dans cet hopital, ces changements ont permis une baisse de 34 % de la mortalite maternelle hospitaliere : de 67 deces maternels pour 9 078 naissances (0,74 %) en 2011, l'hopital est passe a 48 deces maternels pour 9 884 naissances (0,49 %) en 2014. Lecons tirees L'introduction de cette formation aux urgences obstetricales et de divers outils a pu etre mise en pratique sur le terrain, elle a permis d'ameliorer les pratiques cliniques, elle a ete soutenue par le personnel local et elle a conduit aune amelioration des resultats cliniques. Des travaux complementaires doiventaujourd'hui etre menes pour etudier la mise en oeuvre et les effets de ce programme a d'autres echelles. Situacion En Zimbabwe, muchos centros de salud no pueden gestionar las complicaciones obstetricas graves. Segun el personal, la formacion inadecuada es el mayor obstaculo para la prevencion de muertes maternas evitables. Enfoque Se establecio un programa de formacion en emergencias obstetricas in situ para personal de maternidad en el Hospital Central de Mpilo. Se formo a 12 miembros del personal local para convertirlos en instructores y se les proporciono el equipo y los recursos necesarios para el curso. Los instructores realizaron cursos de un dia para 299 miembros del personal del hospital. Marco regional La mortalidad materna en Zimbabwe ha aumentado de 555 a 960 por 100.000 mujeres embarazadas de 2006 a 2011 y se cree que el 47% de las muertes son evitables. La mayoria de formaciones en emergencias obstetricas tienen lugar fuera del emplazamiento, lejos de la zona clinica, para un numero limitado de miembros del personal. Cambios importantes Tras un curso para formar a los instructores realizado en el hospital, se formo localmente al 90% (138/153) del personal de maternidad durante el primer ano, con 299 trabajadores del hospital formados hasta la fecha. Los cambios en el sistema local incluyeron: la introduccion de una cama en la sala de partos, cajas de emergencia, historiales de observacion de alerta temprana con codigos de color y un panel de maternidad. En este hospital, estos cambios se han relacionado con una reduccion del 34% en la mortalidad materna en el hospital, de 67 muertes maternas por 9.078 nacimientos (0,74%) en 2011 se paso a 48 muertes maternas por 9.884 nacimientos (0,49%) en 2014. Lecciones aprendidas La introduccion de herramientas y formacion en emergencias obstetricas fue posible in situ, mejoro la practica clinica, recibio el apoyo del personal local y se relaciono con resultados clinicos mejorados. Se requiere mas trabajo para estudiar la implementacion y el efecto de esta intervencion a escala., Introduction Improving maternity care is a global priority, yet many health facilities in low-income countries are not able to manage obstetric complications adequately. (1) Staff most commonly identified inadequate training [...]

Objective: To quantify the incidence of intrapartum risk factors in labours with an adverse outcome, and compare them with the incidence of the same indicators in a series of consecutive labours without adverse outcome. Design: Case–control study. Setting: Twenty‐six maternity units in the UK. Population or sample: Sixty‐nine labours with an adverse outcome and 198 labours without adverse outcome. Methods: Observational study. Main outcome measures: Incidence of risk factors in hourly assessments for 7 hours before birth in the two groups. Results: A risk score combining suspected fetal growth restriction, tachysystole, meconium in the amniotic fluid and fetal heart rate abnormalities (baseline rate and variability, presence of decelerations) gave the best indication of likely outcome group. Conclusions: Accurate risk assessment in labour requires fetal heart rate abnormalities to be considered in context with additional intrapartum risk factors. [ABSTRACT FROM AUTHOR]

Introduction: Impacted fetal head (IFH) is a challenging complication of cesarean section (CS) associated with significant morbidity. Training opportunities for IFH have been reported as inconsistent and inadequate. This study assessed the validity of a novel birth simulator for IFH at cesarean section. Material and methods: Obstetricians and midwives collaborated with model‐making company, Limbs & Things (UK), to modify the original PROMPT Flex® simulator and develop a new "Enhanced CS Module" for IFH at cesarean section. Changes included addition of a retractable uterus and restricted pelvic inlet, and the fetal mannequin was modified to allow accurate limb articulation and flexion at the waist. Obstetricians and midwives from three maternity units in Southwest England were individually recorded, each undertaking three simulated scenarios of IFH at cesarean section. Obstetricians were asked to deliver the fetal head and midwives, to perform a vaginal push‐up. Participants completed a questionnaire on realism (face validity) and usefulness for training (content validity) with five‐point Likert scale responses. Construct validity was assessed by testing an a priori hypothesis that "experts" (consultant obstetricians with >7 years' experience) would be more likely to achieve delivery than "novices" (registrars with <7 years' experience). Performance variables were compared between groups using Chi‐square and Mann–Whitney U‐tests. Results: In all, 105 simulated scenarios were undertaken by 35 obstetricians and midwives. A range of techniques were employed to deliver the IFH including change of hand, vaginal disimpaction and reverse breech extraction. Overall, 86% (30/35) described the model as fairly (4)/very realistic (5) (median = 4, interquartile range [IQR] = 4–5). The model was considered fairly (4)/very useful (5) for training by 97% (34/35; median = 5; IQR = 5–5). Experts delivered the fetal head in all simulations (36/36) and novices delivered the head in 76.9% (30/39) (p = 0.002). Experts delivered the fetal head 58% quicker than novices (median = 66.8 s, IQR = 53–86 vs median = 104 s, IQR = 67.7–137). Conclusions: This novel birth trainer realistically simulates IFH at cesarean section and allows rehearsal of all disimpaction techniques. It was reported to be very useful for training and distinguishes between novice and expert obstetricians. Techniques for IFH are difficult to learn experientially. Simulation is likely to provide an effective and safe form of training. [ABSTRACT FROM AUTHOR]

Background Considering the public health importance of stillbirth, this study quantified the trends in stillbirths over eight decades in England and Wales. Methods This longitudinal study utilized the publicly available aggregated data from the Office for National Statistics that captured maternity information for babies delivered in England and Wales from 1940 to 2019. We computed the trends in stillbirth with the associated incidence risk difference, incidence risk ratio, and extra lives saved per decade. Results From 1940-2019, 56 906 273 births were reported. The stillbirth rate declined (85%) drastically up to the early 1980s. In the initial five decades, the estimated number of deaths per decade further decreased by 67 765 (9.49/1000 births) in 1940-1949, 2569 (0.08/1000 births) in 1950-1959, 9121 (3.50/1000 births) in 1960-1969, 15 262 (2.31/1000 births) in 1970-1979, and 10 284 (1.57/1000 births) in 1980-1989. However, the stillbirth rate increased by an additional 3850 (0.58/1000 births) stillbirths in 1990-1999 and 693 (0.11/1000 births) stillbirths in 2000-2009. The stillbirth rate declined again during 2010- 2019, with 3714 fewer stillbirths (0.54/1000 births). The incidence of maternal age <20 years reduced over time, but pregnancy among older women (>35 years) increased. Conclusions The stillbirth rate declined drastically, but the rate of decline slowed in the last three decades. Though teenage pregnancy (<20 years) had reduced, the prevalence of women with a higher risk of stillbirth may have risen due to an increase in advanced maternal age. Improved, more personalised care is required to reduce the stillbirth rate further. [ABSTRACT FROM AUTHOR]