Tokophobia and fear of birth: a workshop consensus statement on current issues and recommendations for future research Abstract Objective: The workshop aimed to discuss and develop a statement on the current state of the evidence and opinion in the field of Fear of Childbirth (FoC) and Tokophobia (Tocophobia), and to provide some recommendations for research. Background: A group of international researchers, clinicians and a service user met in 2019 to discuss the state of clinical and academic knowledge relating to FoC/Tokophobia. Five key areas were identified and agreed as the focus of discussion at the meeting. Methods: 12 clinicians and researchers, invited for their known expertise in this or a closely related area (e.g. PTSD) met in Hull, UK to discuss their understanding of the evidence for FoC/ Tokophobia and current practice. The meeting focused on identifying areas of uncertainty, key areas of knowledge, emerging research and possible future research within the field. The consensus described in this paper constitutes the expression of the general opinion of the participants and does not necessarily imply unanimity Keys points for discussion: Whilst there is a body of work in the field of FoC, work specifically focussed on tokophobia is more recent. It was agreed that there remains a wide range of issues, for which we need further evidence, which were addressed in the workshop including complexity in defining prevalence, a theoretical lack of understanding of tokophobia, which gives rise to challenges for robust assessment and the identification of risk factors. An improved understanding of the aetiological and developmental aspects of tokophobia is required to underpin appropriate, effective and evidencebased interventions. The development and evaluation of pathways of care and the interventions these might incorporate, should be a focus of future research to explore the potential for positive outcomes. Conclusion: Significant gaps remain within the FoC/tokophobia knowledge base. Further research continues to be needed across all areas identified.

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NHS England, the Institute for Healthcare Improvement, Picker and NHS Improvement started the work described in this article to strengthen how patients, carers and staff working together in co-design and co-production can make a real difference in improving experience of care. Always Events®, which is an improvement methodology for the co-design and consistent implementation of those aspects of patient experience that matter most to patients in a health care setting, was chosen. The approach has been to first test the methodology with three organizations then to spread to a substantial proportion of acute health care providers, with concurrent scale-up within organizations that were early adopters in single settings, and then spread to other providers including care homes, primary care and integrated care systems. For organizations to be successful in embedding and sustaining Always Events, and to have a significant impact on improving experience, we learnt that health organizations should: a) co-produce with patients/service users from the very start and throughout every phase, b) integrate quality improvement, patient experience and person-centered care, c) identify an Executive Leader champion who can support the team to gain momentum from the beginning, d) keep an open mind and not be tempted to predetermine what changes need to be made; patients/service users & staff know the challenges and have the best, simplest and most affordable ideas for improvement and finally, e) involving point of care staff from the beginning and co-designing the Always Event with them will support engagement and reduce resistance to change.

Objective: To evaluate empirically the degree of content overlap between four self-report measures of fear of childbirth (FoC) identified as 'best in class' by a recent review.Background: FoC and tokophobia is an area of increasing clinical concern and has been linked to poor maternal and neonatal outcomes. Clinical pathways have been established to improve care and interventionsfor FoC however, ambiguity and inconsistency remain regarding the most appropriate assessment measures.Method: A multi-rater and consensus content analysis was undertaken to determine the degree of overlap between four 'best in class' measures of FoC/tokophobia. Results:The Slade-Pais expectations of childbirth scale (SPECS) was found to be the preferred measure in terms of symptom overlap of the tools evaluated, however, the overall level of overlap among these measures was weak. Conclusion:Limitations inherent to the current battery of preferred measures of FoC suggests both the desirability and urgency to develop a theoretically-grounded, psychometrically robust and accurate FoC assessment measure. Current measures of FoC are not interchangeable.

(1) Background: Women with personality disorder are at risk of social and emotional problems which impact deleteriously on everyday functioning. Moreover, a personality disorder diagnosis has been established to have an adverse impact upon pregnancy outcomes and child health. Understanding this impact is critical to improving both maternal and child outcomes. This systematic review and meta-analysis will evaluate the contemporary evidence regarding these relationships. (2) Methods: Prospero and Cochrane were searched for any systematic reviews already completed on this topic. Academic Search Premier, CINAHL Complete, MEDLINE, PsycARTICLES, PsycINFO via the EBSCO host, and the Web of Science Core Collection were searched to include research articles published between 1980 and 2019. A total of 158 records were identified; 105 records were screened by reviewing the abstract; 99 records were excluded; 6 full text articles were assessed for eligibility; 5 records were included in the review. (3) Results: All the included studies reported on preterm birth. The meta-analysis indicates significant risk of preterm birth in women with personality disorder (overall odds ratio (OR) 2.62; CI 2.24–3.06; p < 0.01). Three studies reported on low birth weight, with the meta-analysis indicating a raised risk of low birth weight of the babies born to women with personality disorder (overall OR 2.00 CI 1.12–3.57 (p = 0.02)). Three studies reported on appearance, pulse, grimace, activity, and respiration (APGAR) score, with the meta-analysis of OR’s indicating a risk of low APGAR score in women with personality disorder (overall OR 2.31; CI 1.17–4.55; p = 0.02). (4) Conclusions: The infants of women with personality disorder are at elevated risk of preterm birth, low birth weight and low APGAR score.