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Representations of our external environment and of our internal memories together guide our awareness and actions. While large numbers of features and objects from the boundless external environment compete for sensory processing, working memory capacity is highly limited. Though extracting and integrating features into relevant objects are major objectives of perception, feature integration and well separated object representations may be basic characteristics of working memory. As discussed in Chapter 1, attentional selection of both external and internal content is pivotal, but its workings may differ according to the distinct representational formats. This thesis investigates how attention prioritises feature information in working memory to guide future actions. To test my hypotheses, I design and conduct behavioural studies, analyse neurophysiological recordings, and apply computational modelling. My empirical findings describe two main ways through which feature representations in working memory can be modulated: through goal-related prioritisation and through interacting with lingering sensory history. Chapters 2 and 4 describe tasks in which internally maintained information can be prioritised based on task demands. They demonstrate prioritisation of items and feature dimensions during working-memory delays, as well as the ability to protect and update features during maintenance. Chapter 4 also outlines how stimulus history modulates sensory processing and interacts with goal-based influences. Sensory content from same-trial or previous-trial information exerts opposing systematic performance biases. Applying neural decoding methods that I develop in Chapter 3, I reveal in Chapter 4 that both same-trial and previous-trial sensory history generates a repulsive neural bias at encoding, modulated by task relevance of previous stimuli. The findings suggest that other biases at post-perceptual stages may also contribute to the final opposing biases in performance. Taken together, the studies in the thesis extend our understanding of how visual feature information in working memory can be modulated and prioritised to serve future behaviour adaptively.

The file attached to this record is the author's final peer reviewed version. The Publisher's final version can be found by following the DOI link. ABSTRACT Objectives – To assess the association between hospital-level rates of induction of labour and emergency caesarean section, as measures of “practice style”, and rates of adverse perinatal outcomes. Design – National study using electronic maternity records. Setting – English National Health Service. Participants – Hospitals providing maternity care to women between April 2015 and March 2017. Main outcome measures – Stillbirth, admission to a neonatal unit, and babies receiving mechanical ventilation. Results – Among singleton term births, the risk of stillbirth was 0.15%; of admission to a neonatal unit 5.4%; and of mechanical ventilation 0.54%. There was considerable between-hospital variation in the induction of labour rate (minimum 17.5%, maximum 40.7%) and the emergency caesarean section rate (minimum 5.6%, maximum 17.1%). Women who gave birth in hospitals with a higher induction of labour rate had better perinatal outcomes. For each 5%-point increase in induction, there was a decrease in the risk of term stillbirth by 9% (OR 0.91; 95% CI 0.85 to 0.97) and mechanical ventilation by 14% (OR 0.86; 95% CI 0.79 to 0.94). There was no significant association between hospital-level induction of labour rates and neonatal unit admission at term (p>0.05). There was no significant association between hospital-level emergency caesarean section rates and adverse perinatal outcomes (p always >0.05). Conclusions – There is considerable between-hospital variation in the use of induction of labour and emergency caesarean section. Hospitals with a higher induction rate had a lower risk of adverse birth outcomes. A similar association was not found for caesarean section.

To assess the range and frequency of additional congenital malformations identified among children born alive with CL/P. Analysis of patient-level data from a national registry of cleft births linked to national administrative data of hospital admissions. National Health Service, England. Children born between 2000 and 2012 receiving cleft care in English NHS hospitals. The proportion of children with ICD-10 codes for additional congenital malformations, according to cleft type. The study included 9403 children. Of these 2114 (22.5%) had CL±A, 4509 (48.0%) had CP, 1896 (20.2%) had UCLP, and 884 (9.4%) had BCLP. A total of 3653 (38.8%) children had additional congenital malformations documented in their hospital admission records. The prevalence of additional congenital malformations was greatest among children with CP (53.0%), followed by those with BCLP (33.5%), UCLP (26.3%), and then CL±A (22.2%) (P

OBJECTIVE: To compare the incidence of systemic conditions between women who had surgical treatment for stress incontinence with mesh and without mesh. DESIGN: National cohort study. SETTING: English National Health Service. POPULATION: Women with no previous record of systemic disease who had first-time urinary incontinence surgery between 1 January 2006 and 31 December 2013, followed up to the earliest of 10 years or 31 March 2019. METHODS: Competing-risks regression was used to estimate hazard ratios (HR), adjusted for patient characteristics, with HR > 1 indicating increased incidence following mesh surgery. MAIN OUTCOME MEASURES: First postoperative admission with a record of autoimmune disease, fibromyalgia or myalgic encephalomyelitis up to 10 years following the first incontinence procedure. RESULTS: The cohort included 88 947 women who had mesh surgery and 3389 women who had non-mesh surgery. Both treatment groups were similar with respect to age, socio-economic deprivation, comorbidity and ethnicity. The 10-year cumulative incidence of autoimmune disease, fibromyalgia or myalgic encephalomyelitis was 8.1% (95% CI 7.9-8.3%) in the mesh group and 9.0% (95% CI 8.0-10.1%) in the non-mesh group (adjusted HR 0.89, 95% CI 0.79-1.01; P = 0.07). A sensitivity analysis including only autoimmune diseases as an outcome returned a similar result. CONCLUSIONS: These findings do not support claims that synthetic mesh slings cause systemic disease. TWEETABLE ABSTRACT: No evidence of increased risk of systemic conditions after stress incontinence treatment with a mesh sling.

Adverse pregnancy outcomes attributable to socioeconomic and ethnic inequalities in England: a national cohort study Background Socioeconomic deprivation and an ethnic minority background are known risk factors for adverse pregnancy outcomes. However, there is a lack of evidence on the strength of these risk factors and on the scale of their impact. Aims/objectives We quantified the magnitude of adverse pregnancy outcomes attributable to socioeconomic and ethnic inequalities at population level in England Methods (including research design, sample, analysis and ethical approval) We used administrative hospital data to evaluate stillbirth (SB), preterm birth (PTB) and fetal growth restriction (FGR) in England between 1/4/15-31/3/17 by socioeconomic deprivation quintiles and ethnic group. Attributable fractions (AF) for the entire population and specific groups compared to least deprived and/or White women were calculated without and with adjustment for smoking and body mass index (BMI). This study was exempt from ethical review as we used routinely collected data; personal data used without individual consent was approved by the NHS Health Research Authority. Findings 1 155 981 women with a singleton birth were included. There were 4505 stillbirths (0·4%). Of liveborn babies, 69175 (6·0%) were PTBs and 22 679 (2·0%) births with FGR. 24% of SBs, 19% of PTBs, and 31% of FGR could be attributed to socioeconomic inequality. These population AFs were substantially reduced with adjustment for ethnic group, smoking and BMI (12%, 10% and 17%, respectively). 12% of SBs, 1.2% of PTBs and 17% of FGR could be attributed to ethnic inequality. Adjustment for socioeconomic deprivation, smoking and BMI had only a small impact on these ethnic group AFs (13%, 2.6% and 19%, respectively). Group-specific AFs were especially high in the most socioeconomically deprived South-Asian women and Black women for SB (54% and 64%, respectively) and FGR (72% and 55%, respectively). Conclusions. Reducing FGR, SB and PTB rates can only realistically be achieved with midwives, obstetricians, public health professionals and politicians working together to reduce such inequalities in outcome for the most vulnerable.

Title Obstetric interventions and pregnancy outcomes during the COVID-19 pandemic in England: a nationwide cohort study 300 words excluding title and headings No references Background The COVID-19 pandemic has disrupted maternity services worldwide and imposed restrictions on societal behaviours. The ‘indirect’ effects of these changes on maternal and neonatal outcomes are likely to be larger than the direct effects of COVID-19 infection. Aims and objective/s Comparing obstetric intervention rates and pregnancy outcomes in England during the pandemic/prepandemic periods To assess if the differences in rates varied according to ethnic and socioeconomic background. Method (must include research design, sample, analysis and ethical approval) National study of singleton births in English NHS hospitals. Births during the COVID-19 pandemic period (23/03/20-22/2/21) compared with births during the corresponding calendar period one year earlier. Hospital Episode Statistics provided data about maternal characteristics, obstetric inventions and maternal and neonatal outcomes. Multi-level logistic regression models were used with all models adjusted for maternal characteristics and COVID-19 status at birth. This study was exempt from ethical review as we used routinely collected data; personal data used without individual consent was approved by the NHS Health Research Authority. Findings: Of 948,020 singleton births 451,727 occurred during the defined pandemic period. Maternal characteristics were similar in the pre-pandemic and pandemic periods. Compared to the pre-pandemic period, stillbirth rates remained similar (0.36% versus 0.37% p-value 0.16),preterm birth and SGA birth rates were slightly lower (6.0% versus 6.1% and 6% versus 5.8% respectively, both p

Background\ud \ud There is a debate about the safety and effectiveness of surgical treatments for stress urinary incontinence. Controversy about the use of synthetic mesh sling insertion has led to an increased uptake of retropubic colposuspension and autologous sling procedures. Comparative evidence on the long-term outcomes from these procedures is needed.\ud \ud \ud \ud Objective\ud \ud To compare the risk of reoperation at 10 years after operation between women treated for stress urinary incontinence with retropubic colposuspension, mesh sling insertion, and autologous sling procedures.\ud \ud \ud \ud Study Design\ud \ud The records of admissions to National Health Service hosptials were used to identify women who had first-time stress incontinence surgery between 2006 and 2013 in England. The first incidence of the following outcomes was assessed: further stress incontinence surgery, surgery for a complication (either mesh removal, prolapse repair, or incisional hernia repair), and any reoperation (either further stress incontinence surgery, mesh removal, prolapse repair, or incisional hernia repair). The cumulative incidence of each of these outcomes up to 10 years after surgery was calculated, considering death as a competing event. Multivariable modeling was then used to estimate the reoperation hazard ratios for the different initial surgery types with adjustments for patient characteristics and concurrent prolapse surgery or hysterectomy.\ud \ud \ud \ud Results\ud \ud The analysis included 2262 women treated with retropubic colposuspension, 92,524 treated with mesh sling insertion, and 1234 treated with autologous sling. The cumulative incidence of any first reoperation at 10 years was 21.3% (95% confidence interval, 19.5–23.0) after retropubic colposuspension, 10.9% (10.7–11.1) after mesh sling insertion, and 12.0% (10.2–13.9) after autologous sling procedures. The women who had a retropubic colposuspension were significantly more likely to have a reoperation than women who had an autologous sling (adjusted hazard ratio for any reoperation: 1.79 [1.47–2.17]; for further stress incontinence surgery: 1.64 [1.19–2.26]; for surgery for complications: 1.89 [1.49–2.40]), whereas the women who had mesh slings had a similar hazard (for any reoperation: 0.90 [0.76–1.07]; for further stress incontinence surgery: 0.75 [0.57–0.99]; for surgery for complications: 1.11 [0.89–1.36]). A sensitivity analysis excluding the women who had concurrent prolapse surgery or hysterectomy produced similar results.\ud \ud \ud \ud Conclusion\ud \ud Retropubic colposuspension is associated with higher risk of reoperation at 10 years after surgery than mesh sling insertion or autologous sling procedures, with 1 in 5 women requiring reoperation.

To determine the association between ethnic group and risk of postpartum haemorrhage in women giving birth.Cohort study.Maternity units in England.A total of 981 801 records of births between 1 April 2015 and 31 March 2017 in a national clinical database.Multivariable logistic regression analyses with multiple imputation to account for missing data and robust standard errors to account for clustering within hospitals.Postpartum haemorrhage of ≥1500 ml (PPH).A total of 28 268 (2.9%) births were complicated by PPH. Risks were higher in women from black (3.9%) and other (3.5%) ethnic backgrounds. Following adjustment for maternal and fetal characteristics, and care at birth, there was evidence of an increased risk of PPH in women from all ethnic minority groups, with the largest increase seen in black women (adjusted OR 1.54, 95% CI 1.45-1.63). The increase in risk was robust to sensitivity analyses, which included changing the outcome to PPH of ≥3000 ml.In England, women from ethnic minority backgrounds have an increased risk of PPH, when maternal, fetal and birth characteristics are taken into account. Factors contributing to this increased risk need further investigation. Perinatal care for women from ethnic minority backgrounds should focus on preventative measures to optimise maternal outcomes.Women with an ethnic minority background giving birth in England have an increased risk of postpartum haemorrhage, even when characteristics of the mother, the baby and the care received are taken into account.

Executive summary Introduction The purpose of this report is to describe inequalities in maternity and perinatal care for women and their babies in England, Scotland and Wales during the period 1 April 2015 to 31 March 2018. Using routinely collected data, care and outcomes experienced by women and babies using NHS maternity services are measured and stratified by ethnicity and by Index of Multiple Deprivation (IMD), a proxy for socio-economic deprivation. This report focuses on the following maternal measures: ● caesarean birth (presented as elective, emergency and both combined) ● birth without intervention ● major postpartum haemorrhage (1500 ml or more) and the following perinatal measures: ● an Apgar score of less than 7 at 5 minutes ● breast milk at first feed ● neonatal unit admission at term. Methods This report uses existing NMPA linked datasets. Ethnicity is coded using the Office for National Statistics (ONS) 2001 census categorisation of 16+1 codes for ethnicity,2 grouped into white, South Asian, Black and Other (comprising ‘Mixed’ and ‘Other’ combined). Socio-economic deprivation is measured using the Index of Multiple Deprivation (IMD), an area-based measurement of multiple deprivation calculated for each lower-layer super output area (LSOA) in England and Wales, and data zone in Scotland.3 IMD is based on residential postcode and grouped into quintiles of national distribution (quintile 1 = least deprived to quintile 5 = most deprived) for analysis. Results for each maternal and perinatal measure are reported by the mother’s ethnic group and IMD quintile. The results presented in this report are crude and therefore descriptive. The results do not take into account the interactions that contributory factors, such as parity, age, pre-existing co-morbidities, ethnicity and deprivation may have on each other, the complexities of which are not easily interpreted in an audit report such as this. An advisory group comprising professionals and a diverse range of service user representatives with experience of accessing maternity care was involved in the sprint audit. The advisory group was involved in the choice of measures for inclusion in this report, interpretation of results, identifying key messages, and reviewing the draft report and recommendations. Key findings Our results demonstrate differences in outcomes of maternity and perinatal care among women and birthing people, and their babies, via comparisons between those living in the most deprived and the least deprived areas in Great Britain, and in those from ethnic minority groups versus white ethnic groups. Women from South Asian and Black ethnic groups and those from the most deprived areas had higher rates of hypertension and diabetes when compared with women from white ethnic groups and those in the least deprived areas. Smoking was considerably higher among women and birthing people from white ethnic groups and those in the most deprived quintile. Women from Black ethnic groups had a higher rate of experiencing a birth without intervention. While this may be desirable in many situations, it may also represent circumstances where interventions are desired or indicated but do not occur. Rates of caesarean birth (both elective and emergency combined) and rates of emergency caesarean birth were highest for women from Black ethnic groups and higher for women from South Asian groups when compared with those from white ethnic groups. Women and birthing people from Black ethnic groups had higher rates of major postpartum haemorrhage (1500 ml or more) when compared with women and birthing people from white ethnic groups. In contrast to the usual association of increased deprivation with increased morbidity, a decreasing trend for major postpartum haemorrhage (1500 ml or more) was observed from the least to most deprived. Babies born to women from South Asian ethnic groups were less likely to have an Apgar score of less than 7 at 5 minutes but were more likely to be admitted to a neonatal unit at term when compared with babies born to women from white ethnic groups. Babies born to women from Black ethnic groups were more likely to be assessed as having an Apgar score of less than 7 at 5 minutes and were more likely to be admitted to a neonatal unit at term when compared with babies born to women from white ethnic groups. Rates of receiving breast milk at their first feed were significantly lower for babies born to white women and to those living in the most deprived areas. We also found areas of concern with regard to data completeness and rates of missing data by ethnic group and IMD. Our results show 1 in 10 women and birthing people in Great Britain (1 in 5 in Scotland) did not have their ethnic group recorded, and IMD was missing for 6%. Recommendations R1 Target efforts for a life-course approach to improve the health of people, addressing the wider social determinants of health as well as specific health-related risk factors. Offer individualised preconception and antenatal information tailored to their circumstances, including BMI, smoking, pre-existing comorbidities (hypertension and type 2 diabetes) and whether this is their first birth or they have previously had a caesarean birth. (Audience: Healthcare professionals working in maternity services, maternity services providers, general practitioners, primary care providers, public health policy makers) R2 Target efforts to reduce smoking. Audit rates of carbon monoxide testing and referrals for smoking cessation for women during pregnancy, and audit compliance with monitoring for fetal growth restriction. (Audience: Healthcare professionals working in maternity services, maternity services providers, general practitioners, primary care providers, stop smoking services, public health policy makers) R3 Support research and investigation into why women from ethnic minority groups and more deprived areas have higher rates of stillbirth, taking into consideration differences in care, specific risk factors and the wider determinants of health. (Audience: National Institute for Health Research, Health and Care Research Wales and NHS Research Scotland in consultation with the Royal College of Obstetricians and Gynaecologists and policy makers, service planners/commissioners, service managers and healthcare professionals working for maternity services) R4 Improve availability and quality of information about choices during pregnancy and labour, with particular attention to the development of evidence-based shared decision-making tools for place, mode and timing of birth and pain relief options. Consider using the IDECIDE tool (when available). (Audience: Healthcare professionals working in maternity services, maternity services providers, NHS England, NHS Scotland, NHS Wales) R5 Avoid term admissions to a neonatal unit through improving transitional care provision, by establishing facilities where they are not currently available; or in hospitals that do have transitional care facilities, by expanding cot space availability and increasing numbers of appropriately trained staff. (Audience: Maternity and neonatal services providers) R6 Offer all women breastfeeding information and support, and target support in specific areas where breastfeeding rates are lowest (see also Priority 4c, intervention 3 of the Equity and Equality: Guidance for Local Maternity Systems). (Audience: Healthcare professionals working in maternity services, health visitors, primary care providers, maternity care services) R7 Review equality and diversity training provision and update to include the risks associated with deprivation, and how to recognise and avoid unconscious bias (see also Priority 4d, intervention 1 of the Equity and Equality: Guidance for Local Maternity Systems). (Audience: Local trusts and health boards, medical Royal Colleges, Royal Colleges of Nursing and Midwifery, General Medical Council, Nursing and Midwifery Council, Health and Care Professions Council, higher education institutions) R8 Ethnicity should be asked of and accurately recorded for all pregnant people using agreed ethnic group coding systems that should be updated regularly in accordance with the most current census groups. Consideration should be given to methods for self-reporting of ethnicity whenever possible (see also Priority 3, intervention 1 of the Equity and Equality: Guidance for Local Maternity Systems). (Audience: Healthcare professionals working in maternity services, maternity service providers, general practitioners, primary care providers, NHS England, NHS Scotland, NHS Wales) R9 Review the ethnic diversity and rates of socio-economic deprivation in the local area of each NHS trust or board and consider ways to reduce inequalities in healthcare outcomes (see also Priority 4, intervention 1 of the Equity and Equality: Guidance for Local Maternity Systems). (Audience: Local trusts and health boards, primary care providers, public health bodies, local government) R10 Prioritise further research in NHS maternity and perinatal care that could improve outcomes for women, and their babies, from ethnic minority groups and those in the most deprived areas. Undertaking quantitative analysis to investigate ethnic and socio-economic inequalities and report on the mediating factors and causal pathways; along with qualitative research to include exploring the experiences of people accessing maternity care. (Audience: National Institute for Health Research, UK Research and Innovation, Health and Care Research Wales and NHS Research Scotland in consultation with the Royal College of Obstetricians and Gynaecologists and policy makers, service planners/commissioners, service managers and healthcare professionals working for maternity services

Executive summary Introduction Maternity and perinatal services in the UK are currently subject to a number of maternity and neonatal review programmes, including quality monitoring and improvement initiatives. These programmes focus attention on the quality of care provided by maternity services in the UK at both a national level and the individual trust or board level.1–3 In parallel to the improvement initiatives for clinical care, there are ongoing improvements in the collation and processing of maternity and neonatal data, including improved capture of detailed information about demographics of birthing people and care episodes occurring along the maternity continuum of care. These data are critical to enable evaluation and implementation of improvement strategies. The National Maternity and Perinatal Audit (NMPA) uses these data to produce information that can support the improvement of maternity and perinatal care. In this report, for the first time, the NMPA is using a new centralised data source (MSDS v1.5) for births in England, while continuing to use the established centralised maternity datasets in Scotland and Wales. This report presents measures of maternity and perinatal care based on births in English, Scottish and Welsh NHS services between 1 April 2017 and 31 March 2018. The report also provides contextual information describing the characteristics of women and babies cared for during this time period and whose data have been included in this report. The limitations of MSDS mean that for births in England the key findings and recommendations made in this report are specific to data quality only. There are insufficient data to draw clinical conclusions. For births in Scotland and Wales, the consistency of the data sources used means that clinical key findings are possible in this report. However, clinical recommendations are avoided for all countries in this report. This is because the NMPA’s next clinical report for births in 2018/19 is expected to be published in early 2022 and will use MSDS data with improved completeness; as a result, it will be able to provide a more comprehensive picture of variation of care across the three countries. Throughout this document we use the term ‘birthing people’ as well as ‘women’. It is important to acknowledge that it is not only people who identify as women who access maternity and gynaecology services. Methods The analysis in this report is based on 304 518 births in NHS maternity services in England, Scotland and Wales between 1 April 2017 and 31 March 2018.* The report is estimated to have captured 41.5% of eligible births in this time period (34% of births in England, 97% of births in Wales and 100% of births in Scotland). The NMPA makes use of data collected electronically through healthcare information systems and national datasets. Data for births in England are provided by NHS Digital’s Maternity Services Data Set version 1.5 (MSDS v1.5) as well as by Hospital Episode Statistics (HES) records. * The time lag between the period covered by this report and its publication is due to the delayed receipt of the MSDS dataset for England. National Maternity and Perinatal Audit: Clinical Report 2021 xi Data for births in Scotland are provided by Public Health Scotland Data and Intelligence (formerly the Information Services Division, ISD), based on data from the Scottish Birth Record and Scottish Morbidity Records (SMR-01 and SMR-02). Linkages to records from the National Records of Scotland (NRS) are also made for births, deaths and stillbirths. Data for births in Wales are provided by the Maternity Indicators dataset (MIds), a dataset managed by the NHS Wales Informatics Service (NWIS), as well as Admitted Patient Care (APC) records from the Patient Episode Database for Wales (PEDW), and some fields from the National Community Child Health Database (NCCHD). In order to compare like with like, the majority of measures are restricted to singleton term births. As a general principle, the denominator for each measure is restricted to women or babies to whom the outcome or intervention of interest is applicable; for example, third or fourth degree tears are only measured among women who have experienced a vaginal birth. Rates of measures are also adjusted for risk factors that are beyond the control of the maternity service, such as age, parity, previous caesarean birth and clinical risk factors that may explain variation in results between organisations. The NHS trusts and boards included in the audit provided intrapartum maternity care at one or more sites. Where possible, site-level results are available on the NMPA website.

OBJECTIVE: To determine the association between ethnic group and likelihood of admission to intensive care in pregnancy and the postnatal period. DESIGN: Cohort study. SETTING: Maternity and intensive care units in England and Wales. POPULATION OR SAMPLE: A total of 631 851 women who had a record of a registerable birth between 1 April 2015 and 31 March 2016 in a database used for national audit. METHODS: Logistic regression analyses of linked maternity and intensive care records, with multiple imputation to account for missing data. MAIN OUTCOME MEASURES: Admission to intensive care in pregnancy or postnatal period to 6 weeks after birth. RESULTS: In all, 2.24 per 1000 maternities were associated with intensive care admission. Black women were more than twice as likely as women from other ethnic groups to be admitted (odds ratio [OR] 2.21, 95% CI 1.82-2.68). This association was only partially explained by demographic, lifestyle, pregnancy and birth factors (adjusted OR 1.69, 95% CI 1.37-2.09). A higher proportion of intensive care admissions in Black women were for obstetric haemorrhage than in women from other ethnic groups. CONCLUSIONS: Black women have an increased risk of intensive care admission that cannot be explained by demographic, health, lifestyle, pregnancy and birth factors. Clinical and policy intervention should focus on the early identification and management of severe illness, particularly obstetric haemorrhage, in Black women, in order to reduce inequalities in intensive care admission. TWEETABLE ABSTRACT: Black women are almost twice as likely as White women to be admitted to intensive care during pregnancy and the postpartum period; this risk remains after accounting for demographic, health, lifestyle, pregnancy and birth factors.