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Background: Around 1 in 150 babies are stillborn or die in the first month of life in the UK. Most women conceive again, and subsequent pregnancies are often characterised by feelings of stress and anxiety, persisting beyond the birth. Psychological distress increases the risk of poor pregnancy outcomes and longer-term parenting difficulties. Appropriate emotional support in subsequent pregnancies is key to ensure the wellbeing of women and families. Substantial variability in existing care has been reported, including fragmentation and poor communication. A new care package improving midwifery continuity and access to emotional support during subsequent pregnancy could improve outcomes. However, no study has assessed the feasibility of a full-scale trial to test effectiveness in improving outcomes and cost-effectiveness for the National Health Service (NHS).Methods: A prospective, mixed-methods pre-and post-cohort study, in two Northwest England Maternity Units. Thirty-eight women, (≤ 20 weeks' gestation, with a previous stillbirth, or neonatal death) were offered the study intervention (allocation of a named midwife care coordinator and access to group and online support). Sixteen women receiving usual care were recruited in the 6 months preceding implementation of the intervention. Outcome data were collected at 2 antenatal and 1 postnatal visit(s). Qualitative interviews captured experiences of care and research processes with women (n = 20), partners (n = 5), and midwives (n = 8).Results: Overall recruitment was 90% of target, and 77% of women completed the study. A diverse sample reflected the local population, but non-English speaking was a barrier to participation. Study processes and data collection methods were acceptable. Those who received increased midwifery continuity valued the relationship with the care coordinator and perceived positive impacts on pregnancy experiences. However, the anticipated increase in antenatal continuity for direct midwife contacts was not observed for the intervention group. Take-up of in-person support groups was also limited.Conclusions: Women and partners welcomed the opportunity to participate in research. Continuity of midwifery care was supported as a beneficial strategy to improve care and support in pregnancy after the death of a baby by both parents and professionals. Important barriers to implementation included changes in leadership, service pressures and competing priorities.Trial Registration: ISRCTN17447733 first registration 13/02/2018. [ABSTRACT FROM AUTHOR]

Real-world judgements and decisions often require choosing from an open-ended set of options which cannot be exhaustively considered before a choice is made. Recent work has found that the options people do consider tend to have particular features, such as high historical value. Here, we pursue the idea that option generation during decision making may reflect a more general mechanism for calling things to mind, by which relevant features in a context-appropriate representational space guide what comes to mind. In this paper, we evaluate this proposal primarily based on what comes to mind in different familiar categories. We first introduce an empirical approach for deriving the space of features that people use to represent items in a particular category and for locating the category members that come to mind within that space. We show that in both familiar and ad hoc categories, a category member's location along certain dimensions of the derived feature space predicts its likelihood of coming to mind. Next, we show that category members from these feature space locations come to mind by default in a way that is somewhat impervious to conscious control. We then demonstrate that the extent to which a given dimension is a predictor of what comes to mind within a category is related to how relevant that feature is for representing the category in question, using a novel measure of general feature relevance. Finally, we illustrate the usefulness of this framework in the context of a decision making task. We close with the proposal that people call category members to mind according to their location in representational space, specifically based on the predicted usefulness of considering category members with particular features. [ABSTRACT FROM AUTHOR]

Background Guidelines from the National Institute for Health and Care Excellence recommend that telemetry is offered to any woman who needs continuous cardiotocography in labour. Methods An online survey of 168 maternity units in the UK was undertaken between November 2013 and February 2014 to determine how many units in the UK offered telemetry to women in labour and in what circumstances it was used. Findings The response rate was 62% (n=104). Some 63% (n=65) of responding units had at least one cardiotocography machine that could monitor the fetal heart via telemetry. Telemetry was used most often for women who had experienced a previous caesarean section and respondents felt that mobility and satisfaction with labour experience were most likely to be positively influenced by telemetry. Conclusion The survey gives an indication of how often and for whom telemetry is being used in the UK and describes the benefits that maternity units see for women using telemetry, such as increased choice and control. [ABSTRACT FROM AUTHOR]

Background: Maternal obesity is a frequent obstetric risk factor, linked with short- and long-term consequences for mother and child, including foetal overgrowth, growth restriction and stillbirth. The mechanisms underlying these pathologies remain unknown but likely involve the placenta. Aims: To study placental cell turnover in relation to maternal body mass index (BMI). Methods: Term placental villous tissue was randomly sampled from 24 pregnancies, with a range of maternal BMI of 19.5-49.6. Immunohistochemistry was performed for human chorionic gonadotropin, Ki67 and M30 and image analysis used to calculate syncytiotrophoblast area and proliferative and apoptotic indices. Results were compared categorically between women of BMI 18.5-24.9 (normal), BMI 30.0-39.9 (obese classes 1and 2) and BMI 40+ (obese class 3) and continuously against BMI; p < 0.05 by the Kruskal-Wallis test or linear regression was considered statistically significant. Results: Increased maternal BMI was associated with categorical (normal versus obese class 3 and obese classes 1 and 2 versus obese class 3, both p < 0.05) and continuous ( r2 = 0.24, p = 0.016) reductions in the proliferative index and a continuous reduction ( r2 = 0.17, p = 0.047) in the apoptotic index. Discussion: Maternal obesity is associated with a dose-dependent reduction in placental villous proliferation and apoptosis which may increase susceptibility to adverse pregnancy outcomes. [ABSTRACT FROM AUTHOR]

Abstract: Background: There is a global trend, in high resource countries, for delayed childbearing beyond the age of 35. Women of advanced maternal age are considered to be at higher risk of poor maternal and neonatal outcomes. Women''s views and experiences of delayed childbearing are relatively unexplored. Objectives: To gain an understanding of factors influencing women''s decisions to delay childbearing and explore their experiences and perceptions of associated risks. Design: A qualitative phenomenological study. Setting: Greater Manchester, United Kingdom. Participants: Purposive sample of 18 women aged 35 and over in three groups; six women with no children who were not pregnant, six women pregnant with their first child and six women with no children attending a fertility clinic. Methods: Data were collected by in depth semi-structured interviews, managed manually and subjected to thematic analysis. Results: Three main themes were identified; the chapters of life, the need to know, and childbearing being within or beyond women''s control. Women focussed on the need for a stable relationship, being “ready” to have a baby, and acquisition of life experience. Their experiences reflected a lack of awareness of many of the risks associated with pregnancy over age 35 and disbelief that age alone necessarily increased the likelihood of poor outcomes. Women perceived a lack of choice in the timing of when to start a family. Women suggested that although they may have reached a juncture in their lives, at which they felt ready to have a baby, the circumstances in which they found themselves may not support this; factors such as relationship, financial stability, health and fertility, were often outside of their control. Conclusions: Women do not perceive that they have ultimate control when it comes to the timing of childbearing. Health professionals and the media should be aware of the complex interplay of factors surrounding women''s reasons for delaying childbearing. Sensitive information and support should be provided allowing for varying perceptions of risk status. Women may benefit from pre-conception education. [Copyright &y& Elsevier]

Objectives: To identify what factors affect women's' decisions to delay childbearing, and to explore women's' experiences and their perceptions of associated risks. Design: Systematic procedures were used for search strategy, study selection, data extraction and analysis. Findings were synthesised using an approach developed from meta-ethnography. Data sources: We included qualitative papers, not confined to geographical area (1980–2009). Databases included CINAHL, MEDLINE, EMBASE, PsycInfo, ASSIA, MIDIRS, British Nursing Index and the National Research Register. We selected qualitative empirical studies exploring the views and experiences of women of advanced maternal age who were childless or primigravidae with a singleton pregnancy or primiparous. Review methods: Twelve papers fulfilled the selection criteria and were included for synthesis. Results: Women appear to face an issue of ‘informed and uninformed decision making’; those who believe they are informed but may not be, those who are not informed and find out they are at risk once pregnant, and those who are well informed but choose to delay pregnancy anyway. Maternity services could provide information to enable informed choice regarding timing of childbearing. Conclusions: Health professionals need to be mindful of the fact that women delay childbearing for various reasons. A strategy of pre-conception education may be beneficial in informing childbearing decisions. Obstetricians and midwives should be sensitive to the fact that women may not be aware of all the risks associated with delayed childbearing. [Copyright &y& Elsevier]

Abstract: Control of vascular resistance and blood flow in the fetoplacental circulation is incompletely understood. Reactive oxygen species (ROS), physiological and pathophysiological regulators of vascular tone, are elevated in preeclampsia (PE), a disease of pregnancy characterized by increased fetoplacental vascular resistance. We tested the hypothesis that ROS modulate vascular reactivity in placental chorionic plate arteries. Wire myography was used to examine (1) the effects of acute exposure to ROS on arterial function in normal pregnancy and (2) the effects of maternal antioxidant supplementation on arterial reactivity in women at high risk for PE participating in the Vitamins in Pre-eclampsia (VIP) trial. ROS generated by xanthine plus xanthine oxidase enhanced basal tension, vasoconstriction in response to the thromboxane mimetic U46619, and relaxation in response to sodium nitroprusside. Hydrogen peroxide and peroxynitrite increased basal tone and relaxed preconstricted arteries (U44619), respectively. In women at risk for PE, chorionic plate artery constriction in response to U46619 was greater in the women receiving placebo compared to the women supplemented with the antioxidant vitamins C and E. ROS may regulate fetoplacental vascular resistance and blood flow in the short term, and chronic exposure to raised ROS could contribute to elevated fetoplacental vascular resistance in PE and fetal growth restriction (FGR). [Copyright &y& Elsevier]

Objective: To determine whether delivery mode influences placental chorionic plate arterial and venous vascular reactivity. Methods: Normal term placentas were obtained after vaginal delivery or cesarean section. Chorionic plate arterial and venous function was assessed by wire myography. Results: Sodium nitroprusside-induced arterial relaxation increased post cesarean section at 20% oxygen. Decreased U46619-induced venous contraction was observed in vaginal deliveries at 7% oxygen. Sodium nitroprusside-induced relaxation increased in vaginal delivery at 20% oxygen. Conclusion: Delivery mode does not alter chorionic plate arterial vascular reactivity under physiological conditions, however venous reactivity was modified, a factor for consideration when interpreting functional experimental data. [ABSTRACT FROM AUTHOR]

Background: The grief associated with the death of a baby is enduring, however most women embark on another pregnancy, many in less than a year following their loss. Symptoms of anxiety and depression are reported to be increased in pregnancies after perinatal death, although effect on maternal stress is less clear. Variation between individual studies may result from differences in gestation at sampling, the questionnaire used and the type of antecedent perinatal death. We aimed to describe quantitative measures of anxiety, depression, stress and quality of life at different timepoints in pregnancies after perinatal death and in the early postnatal period.Methods: Women recruited from three sites in the North-West of England. Women were asked to participate if a previous pregnancy had ended in a perinatal death. Participants completed validated measures of psychological state (Cambridge Worry Score, Edinburgh Postnatal Depression Score (EPDS), Generalized Anxiety Disorder 7-item score) and health status (EQ-5D-5L™ and EQ5D-Visual Analogue Scale) at three time points, approximately 15 weeks' and 32 weeks' gestation and 6 weeks postnatally. A sample of hair was taken at approximately 36 weeks' gestation for measurement of hair cortisol in a subgroup of women. The hair sample was divided into samples from each trimester and cortisol measured by ELISA.Results: In total 112 women participated in the study. Measures of anxiety and depressive symptoms decreased from the highest levels at 15 weeks' gestation to 6-weeks postnatal (for example mean GAD-7: 15 weeks 8.2 ± 5.5, 6 weeks postnatal 4.4 ± 5.0, p<0.001). Hair cortisol levels fell in a similar profile to anxiety and depression symptoms (p<0.05). In contrast, the median EQ-5D index, measuring health status was 0.768 at 15 weeks' gestation (Interquartile range (IQR) 0.684-0.879), 0.696 at 32 weeks' (IQR 0.637-0.768) and 0.89 (0.760-1.00) at 6 weeks postnatal. There was a negative relationship between EPDS and perceived health status.Conclusions: This study demonstrated heightened anxiety and depressive symptoms and elevated cortisol levels in women in pregnancies after a stillbirth or neonatal death which decrease as pregnancy progresses. Further studies are needed to determine optimal care for women to address these negative psychological consequences. [ABSTRACT FROM AUTHOR]

Background: Stillbirth and (obstetric) fistula are traumatic life events, commonly experienced together following an obstructed labour in low‐ and middle‐income countries with limited access to maternity care. Few studies have explored women's experiences of the combined trauma of stillbirth and fistula. Aim: To explore the lived experiences of women following stillbirth and fistula. Methods: Qualitative, guided by Heideggerian phenomenology. Twenty women who had experienced a stillbirth were interviewed while attending a specialist Hospital fistula service in urban Kenya. Data were analysed following Van Manen's reflexive approach. Results: Three main themes summarised participants' experiences: 'Treated like an alien' reflected the isolation and stigma felt by women. The additive and multiplying impacts of stillbirth and fistula and the ways in which women coped with their situations were summarised in 'Shattered dreams'. The impact of beliefs and practices of women and those around them were encapsulated in 'It was not written on my forehead'. Conclusion: The distress women experienced following the death of a baby was intensified by the development of a fistula. Health professionals lacked an understanding of the pathophysiology and identification of fistula and its association with stillbirth. Women were isolated as they were stigmatised and blamed for both conditions. Difficulty accessing follow‐up care meant that women suffered for long periods while living with a constant reminder of their baby's death. Cultural beliefs, faith and family support affected women's resilience, mental health and recovery. Specialist services, staff training and inclusive policies are needed to improve knowledge and awareness and enhance women's experiences. Patient or Public Contribution: A Community Engagement and Involvement group of bereaved mothers with lived experience of stillbirth and neonatal death assisted with the review of the study protocol, participant‐facing materials and confirmation of findings. [ABSTRACT FROM AUTHOR]

Aim: Pregnancy after the death of a baby is associated with numerous, varied psychological challenges for pregnant women. This study aimed to explore women's experiences of pregnancy whilst attending a specialist antenatal service for pregnancies after a perinatal death.Methods: Semi-structured interviews with twenty women in a subsequent pregnancy after a perinatal death were conducted and analyzed taking an inductive thematic analysis approach.Results: All women expressed a heightened "awareness of risk". Two subthemes demonstrated how increased awareness of risk affected their experience and their desire regarding antenatal and postnatal support. Women talked about stillbirth being a "quiet, unspoken subject" causing them internal conflict as they had an awareness of pregnancy complications that other people did not. Navigating subsequent pregnancies relied on them "expecting the worst and hoping for the best" in terms of pregnancy outcomes. Women viewed specialist antenatal care in pregnancy after perinatal loss favorably, as it enabled them to receive tailored care that met their needs stemming from their increased awareness of and personal expectations of risk.Conclusion: Women's experiences can be used to develop models of care but further studies are required to determine to identify which components are most valued. [ABSTRACT FROM AUTHOR]

Background: Stillbirth is an extremely traumatic and distressing experience for parents, with profound and long-lasting negative impacts. Cultural beliefs and practices surrounding death vary considerably across different contexts and groups, and are a key influence on individual experiences, impacting grief, adjustment, and support needs. Few studies have explored cultural influences surrounding stillbirth in an African context. This study explored the influence of cultural beliefs and practices on the experiences of bereaved parents and health workers after stillbirth in urban and rural settings in Kenya and Uganda.Methods: A qualitative descriptive study design was employed. Face to face interviews were conducted with parents (N = 134) who experienced a stillbirth (≤ 1 year) and health workers (N = 61) at five facilities in Uganda and Kenya. Interviews were conducted in English or the participants' local language, audio-recorded and transcribed verbatim. Analysis was conducted using descriptive thematic analysis.Results: Commonalities in cultural beliefs and practices existed across the two countries. Three main themes were identified: 1) Gathering round, describes the collective support parents received from family and friends after stillbirth. 2)'It is against our custom' addresses cultural constraints and prohibitions impacting parents' behaviour and coping in the immediate aftermath of the baby's death. 3) 'Maybe it's God's plan or witchcraft' summarises spiritual, supernatural, and social beliefs surrounding the causes of stillbirth.Conclusions: Kinship and social support helped parents to cope with the loss and grief. However, other practices and beliefs surrounding stillbirth were sometimes a source of stress, fear, stigma and anxiety especially to the women. Conforming to cultural practices meant that parents were prevented from: holding and seeing their baby, openly discussing the death, memory-making and attending the burial. The conflict between addressing their own needs and complying with community norms hindered parents' grief and adjustment. There is an urgent need to develop culturally sensitive community programmes geared towards demystifying stillbirths and providing an avenue for parents to grieve in their own way. [ABSTRACT FROM AUTHOR]

Objective: To develop global consensus on a set of evidence-based core principles for bereavement care after stillbirth.Methods: A modified policy-Delphi methodology was used to consult international stakeholders and healthcare workers with experience in stillbirth between September 2017 and October 2018. Five sequential rounds involved two expert stakeholder meetings and three internet-based surveys, including a global internet-based survey targeted at healthcare workers in a wide range of settings.Results: Initially, 23 expert stakeholders considered 43 evidence-based themes derived from systematic reviews, identifying 10 core principles. The global survey received 236 responses from participants in 26 countries, after which nine principles met a priori criteria for inclusion. The final stakeholder meeting and internet-based survey of all participants confirmed consensus on eight core principles. Highest quality bereavement care should be enabled through training of healthcare staff to reduce stigma and establish respectful care, including acknowledgement and support for grief responses, and provision for physical and psychologic needs. Women and families should be supported to make informed choices, including those concerning their future reproductive health.Conclusion: Consensus was established for eight principles for stillbirth bereavement care. Further work should explore implementation and involve the voices of women and families globally. [ABSTRACT FROM AUTHOR]

Objective: The PARENTS 1 study (Parents' Active Role and ENgagement in The review of their Stillbirth/perinatal death) found that parents would endorse the opportunity to give feedback into the perinatal mortality review (PNMR) process. In subsequent focus groups, healthcare professionals were positive about parental engagement, although they considered that there may be significant challenges. The objective of this study was to develop core principles and recommendations for parental engagement in PNMR in the UK.Methods: A two-round Delphi technique was followed to reach consensus on core principles for parental engagement in the PNMR process; Round 1 included a national consensus workshop and Round 2 an online questionnaire. The consensus meeting was attended by a national panel of stakeholders (clinical and academic experts, parent advocates, managers and commissioners) in stillbirth and neonatal and bereavement care. To develop recommendations for parental engagement, participants discussed four key areas comprising: communication with parents, including receiving feedback; the format of the PNMR meeting; the parental engagement pathway; and challenging aspects of engaging with parents in reviews. Content analysis was conducted to generate recommendations from the meeting for a subsequent anonymous web-based survey. Attendees of the consensus workshop and members of the PARENTS 2 Project Advisory Board were asked to rank recommendations using a 9-point Likert scale from 1 (not important) to 9 (critically important). It had been agreed a priori, in compliance with established Grading of Recommendations, Assessment, Development and Evaluation (GRADE) criteria, that 'consensus' would be achieved if over 70% of participants scored the principle as 'critical' (score of 7-9) and fewer than 15% scored the principle as 'not important' (score of 1-3). Principles for which consensus was achieved were included in the core recommendations.Results: Of the 29 invited stakeholders, 22 participated in the consensus meeting and 25 (86% response rate) in the subsequent online questionnaire in June 2017. Consensus was agreed on 12 core principles. Of the 25 participants, 96% agreed that a face-to-face explanation of the PNMR process was of critical importance, 72% considered that parents should be offered the opportunity to nominate a suitable advocate, 92% believed that responses to parents' comments should be formally documented, 96% indicated that it was vital for action plans to be translated into lessons learnt and that this process should be monitored, and 100% of stakeholders voted that a plain-English summary should be produced for the parents following the meeting. There was good agreement on a further seven principles.Conclusions: Key national stakeholders were unanimously supportive of parental engagement in the PNMR process and agreed on core principles to make this process feasible, meaningful and robust. A 6-month pilot of parental engagement in the PNMR process (PARENTS 2 study) in two UK units took place after the consensus on core principles. In collaboration with the National Perinatal Epidemiology Unit, the findings will inform the national standardized PNMR tool. © 2018 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology. [ABSTRACT FROM AUTHOR]

Background: Recent decades have witnessed an increase in mean maternal age at childbirth in most high-resourced countries. Advanced maternal age has been associated with several adverse maternal and perinatal outcomes. Although there are many studies on this topic, data from large contemporary population-based cohorts that controls for demographic variables known to influence perinatal outcomes is limited. Methods: We performed a population-based cohort study using data on all singleton births in 2004–2008 from the North Western Perinatal Survey based at The University of Manchester, UK. We compared pregnancy outcomes in women aged 30–34, 35–39 and ≥40 years with women aged 20–29 years using log-linear binomial regression. Models were adjusted for parity, ethnicity, social deprivation score and body mass index. Results: The final study cohort consisted of 215,344 births; 122,307 mothers (54.19%) were aged 20–29 years, 62,371(27.63%) were aged 30–34 years, 33,966(15.05%) were aged 35–39 years and 7,066(3.13%) were aged ≥40 years. Women aged 40+ at delivery were at increased risk of stillbirth (RR = 1.83, [95% CI 1.37–2.43]), pre-term (RR = 1.25, [95% CI: 1.14–1.36]) and very pre-term birth (RR = 1.29, [95% CI:1.08–1.55]), Macrosomia (RR = 1.31, [95% CI: 1.12–1.54]), extremely large for gestational age (RR = 1.40, [95% CI: 1.25–1.58]) and Caesarean delivery (RR = 1.83, [95% CI: 1.77–1.90]). Conclusions: Advanced maternal age is associated with a range of adverse pregnancy outcomes. These risks are independent of parity and remain after adjusting for the ameliorating effects of higher socioeconomic status. The data from this large contemporary cohort will be of interest to healthcare providers and women and will facilitate evidence based counselling of older expectant mothers. [ABSTRACT FROM AUTHOR]