BackgroundStudies of maternal mortality have been shown to result in important improvements to women’s health. It is now recognised that in countries such as the UK, where maternal deaths are rare, the study of near-miss severe maternal morbidity provides additional information to aid disease prevention, treatment and service provision.ObjectivesTo (1) estimate the incidence of specific near-miss morbidities; (2) assess the contribution of existing risk factors to incidence; (3) describe different interventions and their impact on outcomes and costs; (4) identify any groups in which outcomes differ; (5) investigate factors associated with maternal death; (6) compare an external confidential enquiry or a local review approach for investigating quality of care for affected women; and (7) assess the longer-term impacts.MethodsMixed quantitative and qualitative methods including primary national observational studies, database analyses, surveys and case studies overseen by a user advisory group.SettingMaternity units in all four countries of the UK.ParticipantsWomen with near-miss maternal morbidities, their partners and comparison women without severe morbidity.Main outcome measuresThe incidence, risk factors, management and outcomes of uterine rupture, placenta accreta, haemolysis, elevated liver enzymes and low platelets (HELLP) syndrome, severe sepsis, amniotic fluid embolism and pregnancy at advanced maternal age (≥ 48 years at completion of pregnancy); factors associated with progression from severe morbidity to death; associations between severe maternal morbidity and ethnicity and socioeconomic status; lessons for care identified by local and external review; economic evaluation of interventions for management of postpartum haemorrhage (PPH); women’s experiences of near-miss maternal morbidity; long-term outcomes; and models of maternity care commissioned through experience-led and standard approaches.ResultsWomen and their partners reported long-term impacts of near-miss maternal morbidities on their physical and mental health. Older maternal age and caesarean delivery are associated with severe maternal morbidity in both current and future pregnancies. Antibiotic prescription for pregnant or postpartum women with suspected infection does not necessarily prevent progression to severe sepsis, which may be rapidly progressive. Delay in delivery, of up to 48 hours, may be safely undertaken in women with HELLP syndrome in whom there is no fetal compromise. Uterine compression sutures are a cost-effective second-line therapy for PPH. Medical comorbidities are associated with a fivefold increase in the odds of maternal death from direct pregnancy complications. External reviews identified more specific clinical messages for care than local reviews. Experience-led commissioning may be used as a way to commission maternity services.LimitationsThis programme used observational studies, some with limited sample size, and the possibility of uncontrolled confounding cannot be excluded.ConclusionsImplementation of the findings of this research could prevent both future severe pregnancy complications as well as improving the outcome of pregnancy for women. One of the clearest findings relates to the population of women with other medical and mental health problems in pregnancy and their risk of severe morbidity. Further research into models of pre-pregnancy, pregnancy and postnatal care is clearly needed.FundingThe National Institute for Health Research Programme Grants for Applied Research programme.
Background‘Neoliberal’ work policies, austerity, NHS restructuring, and increased GP consultation rates provide the backdrop against increasing reports of GP burnout and an impending shortage of GPs.AimTo explore GPs’ experiences of workplace challenges and stresses, and their coping strategies, particularly focusing on understanding the impact of recent NHS workplace change.Design and settingStudy design was qualitative, with data collected from two focus groups and seven one-to-one telephone interviews.MethodFocus groups and one-to-one telephone interviews explored the experiences of GPs currently practising in England, recruited through convenience sampling. Data were collected using a semi-structured interview approach and analysed using thematic analysis.ResultsThere were 22 GP participants recruited: focus groups (n = 15) and interviews (n = 7). Interviewees understood GPs to be under intense and historically unprecedented pressures, which were tied to the contexts in which they work, with important moral implications for ‘good’ doctoring. Many reported that being a full-time GP was too stressful: work-related stress led to mood changes, sleep disruption, increases in anxiety, and tensions with loved ones. Some had subsequently sought ways to downsize their clinical workload. Workplace change resulted in little time for the things that helped GP resilience: a good work–life balance and better contact with colleagues. Although some GPs were coping better than others, GPs acknowledged that there was only so much an individual GP could do to manage their stress, given the external work issues they faced.ConclusionGPs experience their emotional lives and stresses as being meaningfully shaped by NHS factors. To support GPs to provide effective care, resilience building should move beyond the individual to include systemic work issues.
These results suggest caring for a child with CP may put parents at risk from poor psychosocial well-being. Interventions to improve parental well-being are urgently needed.
Little is known about the proportion of mothers of children with cerebral palsy (CP) who experience distress, particularly in terms of depressed and anxious moods. The present study aimed to address this issue by examining the level of maternal anxious and depressed moods. The associations between maternal psychological well-being and self-efficacy and perception of children's eating, sleeping and mobility were also examined. The sample comprised 78 mothers (mean age, 37 years; standard deviation, 7.91) of children with CP aged < 16 years of age. Data were collected by selfadministered questionnaires based on standard measures of anxious and depressed moods that were mailed to mothers. Results showed 29.8%, 26% and 11.7% of mothers were at low, moderate, and high risk of clinically anxious mood compared with population female norms of 23%, 13%, and 3%, respectively. A total of 22.1% and 19.5% of mothers were at low and moderate risk of clinically depressed mood compared with norms of 9% and 4%, respectively. Anxious and depressed moods were inversely associated with generalised self-efficacy (p = 0.001) and anxious mood was inversely associated with children's sleeping difficulties. In conclusion, levels of maternal psychological wellbeing are a cause for concern and warrant exploration of interventions that will reduce maternal distress, and increase self-efficacy.
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