Linked article: This is a mini commentary on Bray et al., pp. 61–70 in this issue. To view this article, visit https://doi.org/10.1111/1471-0528.18266.
Linked article: This is a mini commentary on Bray et al., pp. 61–70 in this issue. To view this article, visit https://doi.org/10.1111/1471-0528.18266.
Lord Darzi, in his recent report, concludes that ‘too many women, babies and families are being let down’ by UK maternity services [1]. Complex underlying factors have put UK maternity units under significant pressure with repeated reports of poor work cultures, over-stressed staff leaving the NHS, stories of birth trauma and calls for a national maternity inquiry. Whilst maternal and perinatal outcomes are significantly better than those in the United States [2], they lag behind those in many comparator countries in Scandinavia and the rest of Europe [3]. Whilst the proportion of obstetric related negligence claims sits at around 10% of the total, the costs of maternity negligence payments are soaring and at £1.1 billion per year are over a third of the total UK maternity budget [4]. The perception might be that standards have fallen and that outcomes are worsening. But despite decreasing births rates, whole time equivalent doctors and midwives have been increasing for many years [5], and term stillbirth and neonatal mortality and morbidity rates are steadily improving [6]. Judging by the most commonly used important outcome, perinatal mortality, you could argue that the standard of care has never been better. So, why does UK maternity care appear to be in crisis?
First, there is increasing medicalisation of birth caused by multiple interrelated factors (Figure 1). Pregnant women in the UK are becoming older, increasingly overweight, have more complex medical problems—all risk factors for adverse outcomes. The increased ability of fetal medicine to detect fetal abnormalities and identify women as ‘high risk’ mean that more parents are approaching birth with anxieties about the outcome. Meanwhile, recent studies have found that induction of labour can reduce many adverse medical outcomes, not least by preventing stillbirths [7-9]. Combining this with the national ambition around maternity safety [10] and the legal requirement to inform women of all options that can reduce stillbirth [11], means that many practitioners and women feel pressurised into labour induction. The increase in induction rates (to 33% nationally [12]) has led to delays [13] and poor experience, resulting in more women opting for a caesarean birth instead. The NHS maternity staffing and estate, designed to support high numbers of ‘low risk’ births, has yet to fully adapt to the increased numbers on ‘high risk’ care pathways, further exacerbating the problem.
Second, there is a shift in who controls birth. Traditionally, providers have adopted a very medical model in which the doctor was in charge, and this remains the case in societies with marked social hierarchies or in specialisms that deal with acute specialist pathologies such as oncology or general surgery. But society has moved on. The information revolution means
In a high-risk pregnant population with singleton pregnancies, the primary objective was to evaluate the association between anxiety and arterial stiffness (AS) and the secondary objective was to investigate whether anxiety is associated with the incidence of preeclampsia.
Secondary analysis of a prospective cohort study (2012–2016).
Two tertiary care antenatal clinics in Montreal, Canada.
High-risk pregnant individuals with pre-existing hypertension, diabetes, renal dysfunction, previous preeclampsia, or age ≥ 35 years were included. Exclusion criteria were excessive alcohol or drug use and cardiovascular disease. People with pregnancy loss, incomplete questionnaires and loss to follow-up were excluded from analysis.
Participants were enrolled before 14-weeks' gestation, with follow-up assessments of AS every 4 weeks until delivery. Anxiety symptoms were assessed every trimester by the Beck Anxiety Inventory and by self-reported history of emotional disorders (anxiety/depression).
AS and wave reflection parameters, primarily carotid-femoral pulse wave velocity and preeclampsia diagnosis.
Of 235 individuals recruited, 161 were included in this secondary analysis. Baseline anxiety symptoms were present in 35.4% of participants. Anxiety was associated with a significant increase in carotid-femoral pulse wave velocity across gestation, which persisted after adjustments for relevant confounders, in a combined mixed-effects model (B = 0.27, 95% confidence interval [CI] = 0.008–0.530, p = 0.04). A severity-response relationship was observed, where greater anxiety severity correlated with higher AS. Twelve participants (7.5%) developed preeclampsia. The association between anxiety and preeclampsia risk showed a non-significant trend (odds ratio [OR] = 2.77, 95% CI = 0.84–9.18). However, a history of emotional disorders significantly elevated preeclampsia risk (OR = 3.91, 95% CI = 1.14–13.40), independent of other
To determine the efficacy of an animated educational video combined with traditional counselling to reduce anxiety levels among pregnant women seeking outpatient medical abortion.
Randomised controlled trial with two parallel groups.
Single centre in Bangkok, Thailand.
60 pregnant women seeking outpatient medical abortion.
Participants received either an animated educational video combined with traditional counselling (n = 30) or traditional counselling alone (n = 30).
Postintervention anxiety levels were assessed by the Spielberger State–Trait Anxiety Inventory (STAI), and satisfaction levels were measured by a 5-point Likert-type scale.
There were no significant differences in demographic characteristics between groups. The postintervention STAI scores were significantly lower in the video group compared to the non-video group (32.70 ± 4.96 vs. 41.47 ± 8.57, p < 0.01). The odds of moderate to severe anxiety were significantly lower in the video group (OR 10.29, 95% CI 2.56–41.37). Patient satisfaction levels were similarly high in both groups (4.92 ± 0.27 vs. 4.85 ± 0.36, p = 0.42).
Incorporating an animated educational video into traditional counselling effectively reduced anxiety in pregnant women seeking outpatient medical abortion while maintaining high levels of satisfaction with the medical service provided.
To compare the frequency and timing of postpartum haemorrhage (PPH) treatment initiation between hospitals implementing the MOTIVE treatment bundle (which consisted of uterine Massage, Oxytocic drugs, Tranexamic acid, IntraVenous fluids and Examination) and those following usual care.
Nested prospective observational study.
Hospitals in Nigeria, Kenya, Tanzania and South Africa participating in the E-MOTIVE trial.
Healthcare workers treating PPH.
Between June and December 2022, we observed healthcare workers for 1–2 weeks in 39 E-MOTIVE and 39 usual care hospitals across Nigeria, Kenya, Tanzania, and South Africa managing vaginal birth and treating PPH. We descriptively compared the frequency and timing from PPH detection to treatment initiation of individual treatments and the MOTIVE bundle, between E-MOTIVE care and usual care.
Among 2578 observations in E-MOTIVE care hospitals, 295 (11%) PPHs were treated, and among 2834 observations in usual care hospitals, 219 (8%) PPHs were treated. In E-MOTIVE care hospitals, 97% (286/295) of women with PPH received the MOTIVE bundle, compared to 36% (79/219) in usual care. Median initiation times for the first component were similar (0 vs. 1 min), but E-MOTIVE care hospitals achieved faster initiation of all components (13 min, IQR 6–18) compared to usual care (18 min, IQR 10–25). In total, 79% (233/295) of women in E-MOTIVE care had all components initiated within 20 min, compared to 22% (48/219) in usual care.
Timely and comprehensive management of PPH using the MOTIVE bundle, particularly initiating all components within 15–20 min, was commonly observed in the E-MOTIVE care hospitals. Scaling up E-MOTIVE care should emphasise timely bundle initiation to strengthen PPH treatment and improve maternal health outcomes in low-and-middle-income countries.
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