BACKGROUND:To better understand reported COVID-19 pandemic effects on pregnancy, we examined temporal trends in pregnancy outcomes in a diverse population from South London, United Kingdom. METHODS:We included 31,411 singleton pregnancies with complete registration and birth outcomes across pre-pandemic (May 1, 2019-March 22, 2020, 24.5%), pandemic lockdowns (March 23, 2020-July 17, 2021, 32.3%), and pandemic without lockdown epochs (July 18, 2021-April 22, 2023, 43.2%). Multivariable regression was employed to evaluate outcomes by study epoch, adjusting for potential confounders (e.g., ethnicity, deprivation, site), followed by generalized additive modelling to visualise monthly trends. RESULTS:Here we show that of 17 outcomes: six have stable trends (e.g., preterm birth, stillbirth); eight show linear trends, either decreasing (e.g., gestational age at birth, vaginal tears) or increasing (e.g., Caesareans, postpartum haemorrhage); and three show quadratic (complex) trends (e.g., secondary mental health services, labour induction). CONCLUSIONS:Overall, most outcomes during the pandemic mirror pre-pandemic trends, with fluctuations observed likely due to site-specific responses. Our findings highlight the need for temporal analysis of pregnancy outcomes.

Introduction Health-system shocks, such as the COVID-19 pandemic, significantly disrupted routine maternity care. This study explored the lived experiences of accessing maternity care during such a shock, with a focus on marginalised populations and those with social or medical complexity.Methods Semi-structured interviews (n=55) were conducted with 40 women and 15 partners across the UK who accessed maternity care during the pandemic. Data were analysed using Template Analysis, guided by an extended Candidacy framework, which explores how healthcare eligibility is negotiated between individuals and health systems.Results At the individual level, limited information and disrupted relationships made it harder for individuals to assert their claim to candidacy, when seeking care. At the system level, services became harder to use due to new barriers associated with virtual care delivery and restrictions on partners. Judgements were made by professionals on cultural differences, birth plans and women’s opinions being disrespected. At the joint individual-system level, navigating the system was harder due to ever-changing restrictions. Service users resisted offers of care that did not align with their needs. Local conditions such as media messaging and heavy strain on the National Health Service workforce further exacerbated negative experiences of care. These barriers were exacerbated for those belonging to marginalised groups.Conclusions Barriers to seeking maternity care during health-system shocks are layered across individual, system and joint levels, and disproportionately affect those facing social or medical disadvantage. Responsive policies and service designs must address these intersecting challenges to improve equity in access and care during future disruptions.

Background: Mental disorders affect 27% of UK women during the perinatal period (pregnancy and the first postpartum year) and are associated with increased risk of adverse maternal and child outcomes. Despite the societal burden, access to mental health services remains inconsistent, particularly for certain ethnic groups. The aim of this study was to characterise pregnant women, from an ethnically and socioeconomically diverse UK antenatal urban population, with identified risk of mental disorders in the perinatal period, and to evaluate the proportion in contact with mental health services We also explore potential inequity and barriers to access, as measured by referral and engagement with care. Methods: This study utilised linked maternity and mental health records from the eLIXIR Born in South London database, comprising 67,308 pregnancies from 2018 to 2023. These records provided information about: antenatal mental health assessments through three areas of enquiry: Whooley (depression screening) questions, 2) self-reported mental health conditions, 3) family history of severe mental illness, as well as referrals to, and engagement with mental health services during pregnancy. Findings: Among those in contact with mental health services, 38.39%, 24.73%, and 6.14% had been identified by one, two, or three areas of antenatal mental health enquiry, respectively. A positive relationship was observed between the number of questions endorsed and referral to and engagement with treatment. However, ethnic disparities were evident: Asian and Asian British women had lower odds of referral to mental health service (OR=0.51, 95% CI [0.42, 0.61]) and engagement (OR = 0.73, 95% CI [.59, .91]), compared to White women, while Black, African, Caribbean, and Black British women had higher odds of referral (OR=1.45, 95% CI [1.32, 1.60]), but lower odds of engagement (OR=0.73, 95% CI [0.59, 0.91]). Women requiring an interpreter had lower odds of referral (OR = 0.69, 95% CI [0.56, 0.82]). Interpretation: The study highlights significant disparities in identification and treatment of mental disorders in the perinatal period, perinatal mental disorders. Improved referral and care pathways, and culturally sensitive assessments are indicated to redress these disparities.

OBJECTIVES:In the UK, an estimated two million migrants are irregular or subject to No Recourse to Public Funds (NRPF) visa conditions, restricting welfare access and often requiring payment for NHS maternity care. The impact on maternity and perinatal service use remains poorly quantified. STUDY DESIGN:Retrospective cross-sectional study. METHODS:We used linked electronic health records from maternity, neonatal, and mental health services in South London (eLIXIR-BiSL cohort). The sample included 56,690 women with 67,308 pregnancies (Oct 2018-Oct 2023). Migration status was categorised as UK-born, migrants with recourse to public funds, NRPF, or unknown visa status. Adjusted risk ratios (aRRs) were estimated using generalised linear models, controlling for sociodemographic and clinical characteristics. RESULTS:Compared with UK-born women, migrants, particularly those with NRPF, had lower engagement with services. Women with NRPF were less likely to access early antenatal care (aRR 0.36 [0.33-0.38]), attend maternity triage (0.89 [0.82-0.96]), or birth in midwife-led settings (0.51 [0.36-0.71]). They were more likely to access care late (3.61 [3.33-3.92]), receive inadequate antenatal care (1.41 [1.30-1.53]), transfer providers (1.54 [1.36-1.74]), and experience prolonged postnatal stays (1.38 [1.21-1.57]). Women with NRPF had lower mental health care contact before (0.05 [0.03-0.08]) and during pregnancy (0.51 [0.37-0.69]), and reduced engagement with social care (0.36 [0.17-0.70]) and the criminal justice system (0.30 [0.19-0.44]). CONCLUSIONS:Migrants with NRPF or unknown visa status face persistent barriers to maternity and mental health care. Inclusive reforms are needed to address inequity.

OBJECTIVE:Addressing inequalities in maternal and newborn health is a UK public health priority. Evidence on effective multi-interventional strategies is urgently needed. This study evaluated the impact of community-based midwife continuity of care (CBMCOC) models for women and babies in ethnically diverse and socially disadvantaged areas of South London. DESIGN:We conducted a prospective cohort study using the eLIXIR, Born in South London, maternity-child data linkage. SETTING:United Kingdom. POPULATION:Pregnant women exposed to CBMCOC and standard care between 2018 and 2020. METHODS:Propensity score matching (1:4) was used to account for differences between CBMCOC and standard care cohorts and control for confounding bias. Conditional logistic regression estimated risk ratios. Subgroup analysis included women of Black, Asian and other ethnic minority groups, and those living in highly deprived areas. OUTCOMES:The primary outcome was preterm birth (< 37 weeks' gestation). Secondary outcomes included other relevant maternal, perinatal, process and clinical variables. RESULTS:Before matching, 12 386 women were exposed to standard care and 1338 to CBMCOC; after matching, 5352 and 1338 were included, respectively. The risk of preterm birth was lower among women exposed to CBMCOC (unmatched: 4.6% vs. 10.3%, RR = 0.50, 95% CI: 0.38-0.64; matched: 4.6% vs. 8.4%, RR = 0.54, 95% CI: 0.40-0.70). Subgroup analyses showed reduced preterm birth rates among ethnic minority women and those in deprived areas when exposed to CBMCOC. CONCLUSIONS:In this diverse population with a range of risk factors, locality-based interventions integrating community-based care and midwife continuity may reduce maternal and newborn health inequalities. Further trials of such models should be conducted.

BACKGROUND:Evidence on how poverty and social determinants influence adverse maternal and perinatal outcomes in the UK is limited. While ethnicity and area-level deprivation are well described, fewer studies examine the cumulative impact of poverty-related factors such as low income, employment insecurity, housing, and access to social support. METHODS:We analysed 67,308 pregnancies from the eLIXIR cohort using linked NHS records. Social determinants were defined using the WHO framework as structural (ethnicity, migration status, area deprivation) and intermediary (housing, employment, financial hardship, social support, barriers to care). The primary outcome was a composite adverse perinatal outcome. Binary logistic regression models with random intercepts accounted for repeated pregnancies, and adjusted risk ratios (aRRs) were estimated controlling for key sociodemographic and clinical factors. RESULTS:Structural poverty-related social determinants of health were associated with increased risk of adverse perinatal outcomes, including Black (aRR 1.50, 95% CI 1.42-1.59), Asian (aRR 1.49, 95% CI 1.39-1.59), and other minoritised ethnic backgrounds (aRR 1.50, 95% CI 1.42-1.59), residence in the most deprived areas (aRR 1.10, 95% CI 1.01-1.20), non-UK birth (aRR 1.20, 95% CI 1.15-1.25), and recent migration (aRR 1.32, 95% CI 1.14-1.53). Intermediary poverty-related social determinants of health were independently associated with increased risk beyond ethnicity and deprivation, including lack of social support (aRR 1.21, 95% CI 1.02-1.42), unemployment (aRR 1.16, 95% CI 1.10-1.23), financial hardship (aRR 1.17, 95% CI 1.01-1.35), living in social housing (aRR 1.16, 95% CI 1.09-1.24), transfer of care between hospitals (aRR 1.27, 95% CI 1.18-1.37), missed appointments (aRR 1.19, 95% CI 1.04-1.37), and unscheduled maternity care use (aRR 1.21, 95% CI 1.14-1.29). Women exposed to multiple overlapping poverty-related social determinants of health had a substantially higher likelihood of adverse perinatal outcomes (aRR 1.23, 95% CI 1.12-1.35). CONCLUSIONS:Structural and intermediary social determinants related to poverty have a substantial and cumulative impact on maternal and perinatal outcomes, independent of individual clinical risk. Addressing these inequities requires integrated, cross-sector strategies that extend beyond healthcare to the wider social conditions influencing maternal and child health. CLINICAL TRIAL NUMBER:Not applicable.

Objective Explore the prevalence of mental disorders, health risk factors, and access to mental health services before and during the perinatal period in women with a history of social care involvement prior to pregnancy. Method Longitudinal cohort study using a data linkage between primary, maternity, and mental health records in the London borough of Lambeth held within the Early Life Cross-Linkage in Research (eLIXIR) Partnership database and Lambeth DataNet. We compared women with a singleton pregnancy leading to a live birth between January 2018 and December 2021 with a history of social care involvement before pregnancy (n = 289; 5.2%) to those without (n = 5254; 94.8%) on the prevalence of mental disorders, preconception risk factors, and health service or social care contact during the perinatal period. Results There are large inconsistencies of recordings of social care involvement between primary care and maternity care. Women with social care involvement before pregnancy experience had increased levels of mental disorders, preconception risk factors, mental health (adj OR 2.55; 95% CI (1.82-3.57), p < 0.001) and social care service referrals (adj OR 7.29; 95% CI (4.83-10.99), p < 0.001), and antidepressant use (adj OR 2.08; 95% CI (1.31-3.33), p < 0.001) during the perinatal period. Conclusions There is a need for better data integration and agency working between social care and healthcare to support women with complex social factors during the perinatal period. Healthcare and social care staff should adopt a trauma-informed approach, aiming to build therapeutic relationship with women. Services need to consider the wider reproductive health needs of women accessing their services.

Background Healthcare professionals (HCPs) and policymakers had to reorganise and adapt to maternity services rapidly during the pandemic, and as a result, women's care-seeking and experience within maternity services were affected.Aims This study aims to explore HCPs' and policymakers' perspectives of maternity care-seeking and experiences, with a particular focus on marginalised groups. We take a future-focused approach to informing policy to rebuild UK maternity services which remain beleaguered.Method Semi-structured in-depth interviews were undertaken with 21 HCPs and 20 policymakers across the four nations of the UK to discuss their perception of maternity care-seeking and experiences during the pandemic. Data were analysed using Template Analysis, based on an extended version of the Candidacy framework.Results HCPs struggled to navigate reconfiguration of services and implement changes. It was challenging to strike a balance between the need to protect women from the virus while maintaining high-quality care. The transition to virtual care hindered HCPs' ability to identify patients' claim to candidacy, affecting the ability to deliver safe and high-quality care. The standardisation of self-monitoring and virtual care, although beneficial for some, adversely affected those with medical and social complexity. Policy had failed to address inequalities prior to service reconfiguration, making it harder for HCPs to engage with marginalised groups. This included service users with social complexity: lack of social support, mental health problems or belonging to a minority group relating to sexual orientation or gender identity; or medical complexity: those who had to perform self-monitoring of symptoms during pregnancy for any complication, including hypertension, gestational diabetes, additional scans for predisposition to genetic complications, or previous pregnancy loss. A lack of ethnic diversity within leadership roles meant guidelines failed to consider the needs of minority groups who subsequently received substandard maternity care.Conclusions This study affirms the negative effects the pandemic had on maternity care-seeking and experience, while highlighting the need for policy to prioritise marginalised groups, patient-centredness and the well-being of HCPs and policymakers to rebuild a resilient maternity service.

Introduction In the last decade, UK maternal death surveillance data have shown that among the women who died during pregnancy and the year after birth (the perinatal period), the proportion of women with Children’s Social Care (CSC) involvement nearly doubled. Parental non-engagement in the context of CSC involvement has been described as a particular professional concern.Objective To explore organisational and system barriers when accessing and engaging with healthcare services experienced by women with CSC involvement who subsequently died during the perinatal period.Methods MBRRACE-UK national surveillance data were used to identify women who died during or in the year after pregnancy in the UK between 2014 and 2021 and who had CSC involvement. A confidential enquiry of healthcare records of a random sample of women with CSC involvement during pregnancy or in the year after the end of pregnancy and who subsequently died (n=47) was undertaken to explore barriers to care.Results We identified four themes to describe the barriers faced by women with CSC involvement when accessing and engaging with healthcare services in the perinatal period: (1) burden of care, (2) disruption of care, (3) follow-up of non-attendance and (4) bias in care. Our findings highlighted the additional challenges that women had to contend with, while already facing multiple adversities in their daily lives.Conclusion Our confidential enquiry found that the existing narrative of non-engagement among women with CSC involvement is unfounded for most women. Care for women with CSC involvement needs to be made trauma-informed, accessible and minimally disruptive.

OBJECTIVE:To examine ethnic disparities in perinatal outcomes and the role of migration factors. DESIGN:Retrospective cohort. SETTING:Two maternity services in South London, UK. POPULATION OR SAMPLE:Women birthing singleton infants between 24 and 43 weeks' gestation (2018-2023). METHODS:Linked electronic health records were analysed using generalised linear mixed models (GLMMs) with Poisson distribution to estimate adjusted risk ratios (aRR) and 95% confidence intervals (CI) by ethnicity, migration, interpreter need, and country-of-origin income, adjusting for socioeconomic deprivation and medical risk. MAIN OUTCOME MEASURES:Emergency caesarean, haemorrhage, preterm birth, low birthweight, low Apgar score, stillbirth or neonatal death. RESULTS:Among 44 634 births, compared with White women, emergency caesarean risk was higher for Asian (aRR 1.22, 95% CI 1.14-1.30, p < 0.001) and Black women (1.16, 1.10-1.23, p < 0.001). Haemorrhage was higher for Asian women (1.12, 1.02-1.23, p = 0.021), those needing interpretation (1.16, 1.06-1.27, p < 0.001), and lower for Mixed ethnicity women (0.86, 0.74-0.99, p = 0.038). Infants of Black women had elevated risks of preterm birth (1.23, 1.13-1.34, p < 0.001), low birthweight (1.74, 1.60-1.89, p < 0.001), low Apgar (2.06, 1.71-2.48, p < 0.001), and stillbirth/neonatal death (1.57, 1.21-2.05, p < 0.001). Asian infants had increased risks of preterm birth (1.19, 1.07-1.33, p = 0.002) and low birthweight (1.69, 1.52-1.87, p < 0.001). Foreign-born women had lower risks of low birthweight (0.71, 0.62-0.81, p < 0.001) but higher risks of low Apgar (1.24, 1.06-1.46, p = 0.009) and stillbirth/neonatal death (1.33, 1.07-1.65, p = 0.011). Risks were highest for ethnic minority, foreign-born women, though effect sizes were modest. CONCLUSIONS:Ethnic minority and foreign-born women, particularly from LMICs or needing interpreters, face elevated risks with modest clinical impact.

[This corrects the article DOI: 10.1371/journal.pone.0305738.].

BACKGROUND:The COVID-19 pandemic resulted in major reconfiguration of maternity services, particularly an increase in virtual antenatal care. OBJECTIVE:We explored associations between virtual antenatal care trajectories and pregnancy outcomes. STUDY DESIGN:Pregnancy and birth outcome data were obtained from a multiethnic and socioeconomically deprived UK inner-city population before and during the pandemic (with and without lockdown). Data were collected using a health record data linkage from the Born in South London cohort. Antenatal care was characterized by the number of outpatient contacts during 6 gestational windows: 0 to 14+6, 15 to 20+6, 21 to 27+6, 28 to 32+6, 33 to 36+6, and ≥37 weeks' gestation. In each window, the proportion of virtual antenatal care was grouped into quartiles, and group-based trajectory modeling was used to extract virtual antenatal care trajectories. Associations between these trajectories and pregnancy outcomes were explored using adjusted multinominal logistic regression. RESULTS:The analysis included 34,114 mother-child dyads (October 2018-July 2023). Group-based trajectory modeling suggested 4 trajectories of virtual antenatal care contacts: low and stable virtual care throughout pregnancy (Trajectory 0; n=27,751 pregnancies, 81.3%), high first trimester virtual care (Trajectory 1; n=832, 2.4%), high second trimester virtual care (Trajectory 2; n=2,410, 7.1%), and high third trimester virtual care (Trajectory 3; n=3,121, 9.2%). Following adjustment, compared with the low and stable group (Trajectory 0), high second trimester virtual care was associated with less gestational hypertension (adjusted relative risk ratio, 0.84; 95% confidence interval, 0.74-0.96) and assisted vaginal birth (0.87 [0.76-1.00]), and more premature births (<37 weeks, 1.21 [1.02-1.44]), labor induction (1.13; 1.02-1.25), breech presentation (1.92; 1.02-3.62), and postpartum hemorrhage (1.14; 1.00-1.30). Similarly, compared to the low and stable group (Trajectory 0), high third trimester virtual care had less gestational hypertension (0.84 [0.73, 0.96]), more premature births (<37 weeks; 1.35; 1.16-1.58) and elective (1.54; 1.38-1.72) or emergency (1.21; 1.01-1.34) cesarean sections, and neonatal intensive care admissions (1.28; 1.09-1.50); fewer third-degree/fourth-degree vaginal tears (0.82; 0.75-0.90); and less early infant skin-to-skin contact (0.82; 0.73-0.92) and breastfeeding (0.90; 0.81-0.99). CONCLUSION:A higher proportion of virtual care contacts in antenatal care in the second or third trimesters was associated with a greater risk of adverse pregnancy outcomes.

Maternal outcomes for ethnic minority women facing social disadvantage are significantly poorer compared to those in more advantageous social positions. This disparity may be linked to fewer healthcare visits and increased barriers, such as discrimination. This study investigates the differences in everyday discrimination experienced by women at risk of preterm birth, from diverse ethnic backgrounds and levels of social deprivation and examines its impact on birth outcomes. This secondary analysis utilised data from the POPPIE study, which included 333 participants from a diverse inner London sample. 1) assess the impact of ethnicity and social deprivation on women’s experiences of discrimination during pregnancy; and 2) explore the relationship between discrimination and birth outcomes. The Everyday Discrimination Scale was employed. Propensity score matching was used to create comparable groups based on sociodemographic characteristics. The mean maternal age was 32 years (SD 5.4), with 38.1% identifying as non-White and 5.4% not fluent in English. Despite 45.6% holding high educational qualifications and 69% being in paid employment, 17% had a household income below £250 per week, primarily from areas of high social deprivation (69.3%). Significant differences in everyday discrimination scores were observed across ethnic groups, particularly among individuals from Black and Other ethnic backgrounds. Notably, race (p = 0.001) and skin colour (p = 0.013) were the primary reasons for reported discrimination, with over 70% of women from these groups experiencing considerable perceived discrimination. This analysis highlights the intersection of deprivation, ethnicity, and experiences of discrimination. While no significant differences in maternal outcomes were found across ethnicities, the findings underscore the necessity for targeted healthcare services and information for ethnic minority pregnant women from lower socio-economic backgrounds. Further research is essential to explore these dynamics in larger samples and to incorporate routinely collected data on discrimination and stigma in maternal health research.

Objectives To investigate maternal mortality in the context of children's social care (CSC) involvement, and to explore the quality of maternity care that women with CSC involvement received.Design National cohort study and confidential enquiry.Setting MBRRACE-UK (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK) national surveillance dataset for deaths that occurred during pregnancy or up to a year after pregnancy, UK, 2014-22.Participants 1451 women who died during or in the year after pregnancy in the UK; 420 women (28.9%) had CSC involvement. 47 women's healthcare records were included in the confidential enquiry to describe the care of a random sample of women who died during the perinatal period who had CSC involvement.Main outcome measures Rates and causes of maternal deaths by CSC involvement and quality of care.Results A third (420/1451, 28.9%) of the women who died during or in the year after pregnancy had CSC involvement for their (unborn) baby. Women with CSC involvement were more likely to be aged ≤20 years (rate ratio 1.85, 95% confidence interval 1.27 to 2.63, compared with those aged 21-29 years), living in the most deprived areas (rate ratio 2.19, 1.42 to 3.50, compared with those least deprived), and less likely to be from black (rate ratio 0.56, 0.35 to 0.84) or Asian ethnic backgrounds (rate ratio 0.26, 0.14 to 0.44, compared with white women) than women who died with no known CSC involvement. Deaths occurred predominantly between six weeks and the year after pregnancy (75%), and higher proportions of deaths were caused by suicide, other psychiatric causes, including substance overdose, and homicide. A confidential enquiry identified that risk assessment and recognition, medication management, coordination of care, and staff competencies were essential components in providing personalised, holistic, and trauma-informed care when dealing with medical and social complexity. Multiple individual and systemic barriers hindered access and engagement with healthcare.Conclusions Women with CSC involvement who died during or in the year after pregnancy encountered multiple inequalities and were at an increased risk of maternal mortality from psychiatric causes and homicide. A critical review of current care pathways and policy changes is urgently needed to tailor care to the needs of this group of women and to look at the inequalities that disproportionately affect them.

Binge eating is one of the most prevalent eating disorder behaviours in pregnancy, its risk factors and association with pregnancy-related outcomes has sparsely researched in this population. This study aimed to investigate: (hypothesis 1) the effectiveness of a lifestyle intervention in reducing binge eating; (hypothesis 2) the association between depressive symptoms and binge eating behaviours throughout the perinatal period; and (hypothesis 3) the association between binge eating, gestational weight gain and birthweight in a cohort of pregnant women with obesity. This is a planned secondary analysis of the UK Pregnancies Better Eating and Activity Trial (UPBEAT) randomized controlled trial. Exposures were trial arms (hypothesis 1); depressive symptoms (hypothesis 2); and number of weekly binge eating episodes and binge eating behaviours (hypothesis 3). Outcomes were number of weekly binge eating episodes and binge eating behaviours and cognitions (hypotheses 1 and 2), gestational weight gain and child's birthweight (hypothesis 3). There was no evidence that the UPBEAT intervention was effective in reducing number of weekly binge eating behaviours (IRR .942; 95%CI .756, 1.174) or binge eating behaviours (IRR 1.005; 95%CI .861, 1.174). Increased levels of depressive symptoms were associated with a higher number of binge eating behaviours (IRR 1.031; 95%CI 1.015, 1.048) and its associated features (IRR 1.030; 95%CI 1.019, 1.041). There was evidence that more frequent binge eating behaviours lead to greater increase in gestational weight gain. (coefficient = .614; 95%CI .264, .964). There is a need for holistic interventions that promote maternal mental health and address binge eating behaviours. More work is required in the field to understand which interventions would prove efficacious.

INTRODUCTION:We aimed to explore the conceptualization and perception of self-monitoring amongst women, partners, healthcare professionals (HCPs), and policymakers, with particular interest in those living with social/medical complexity. MATERIAL AND METHODS:Across the United Kingdom, 96 semi-structured in-depth qualitative interviews were conducted with 40 women, 15 partners, 21 HCPs, and 20 policymakers to discuss their lived experience of utilizing, delivering, or developing policy for self-monitoring during the COVID-19 pandemic. A thematic framework analysis was undertaken to develop themes, considered by participant type, ethnicity, geographical region, personal experience of self-monitoring, and social complexity, and a content analysis was used to explore how self-monitoring was conceptualized. RESULTS:Two themes (and ten sub-themes) were derived from the Thematic Framework Analysis: "Organizational logistics" (reported by up to 10% participants; sub-themes: useful resources and infrastructure, lack of instructions and information provided, communication between HCPs and service users, logistical issues, legitimate concerns about clinical practice, and personalization of care) and "Agency and responsibility over care" (reported by up to 6% participants; sub-themes: anxiety and overwhelm, control over care, avoiding hospitals, and disengaged users). A post hoc Qualitative Content Analysis was conducted in a deviation from the protocol which showed women and partners conceptualized self-monitoring as a general awareness of one's body and monitoring for specific clinical signs, whereas HCPs and policymakers understood self-monitoring as the use of a device for self-measurement. CONCLUSIONS:Marked differences exist in how self-monitoring is conceptualized by service users and service providers, which could influence how service users engage with the practice. Outstanding concerns about implementation include instructions for service users, communication between service users and service providers, HCP workload, safety and quality of care, and the management of disengaged users when self-monitoring is used to replace care delivered face to face.

Background: The "healthy migrant effect" suggests migrants experience better health than local populations despite socioeconomic disadvantage. Its relevance to maternal and child health is uncertain. This systematic review and meta-analysis examined outcomes among migrant women and children in high-income countries (HICs), and the impact of restrictive healthcare policies. Methods: Studies published between 2014 and 2024 comparing outcomes for foreign-born migrant women and children (up to five years) with local-born populations were included. Quality was assessed using the NewcastleOttawa Scale. Pooled odds ratios (ORs) were calculated using random-effects meta-analyses. Findings: Fifty-one moderate- or high-quality studies (67,471,879 participants across 16 HICs) were included. Migrant women were more likely to be from minority ethnic groups, have lower educational and socioeconomic status, and be older and multiparous. Migrants had higher odds of emergency caesarean birth (OR=1.24, 95% CI=1.16-1.33), food insecurity (OR=2.49, 95%CI=1.24-5.96), perinatal depression/anxiety (OR=1.67, 95% CI=1.10-2.54), intimate partner violence (OR=2.20, 95%CI=1.31-3.72), and low Apgar scores (OR=1.37, 95% CI=1.19-1.56). Odds of low birth weight were slightly lower (OR=0.95, 95%CI=0.90-1.00). Associations persisted under restrictive healthcare policies. No significant differences were found in maternal mortality, severe maternal morbidity, preterm birth, fetal loss, neonatal intensive care use, or vaccination coverage. There is a notable lack of evidence on longer-term child health outcomes. Interpretation: The "healthy migrant effect" may not apply during the perinatal period. Migrant women face significant health inequities, exacerbated by exclusionary policies. Further research, particularly into long-term child outcomes and in inclusive healthcare settings, is needed to inform equitable policy and practice.

Background:During the COVID-19 pandemic, significant reconfigurations were made to maternity care, to deliver this essential service while minimising the risk of infection for pregnant/post partum women and their infants, initially considered to be more vulnerable. Design:This mixed-methods study had three work packages. Work package 1 used quantitative methods to analyse pregnancy outcomes over time, considering service reconfiguration and inequalities, using routinely collected maternity and offspring data from three diverse South London trusts. Work package 2 involved in-depth interviews with a diverse sample of pregnant/post partum women, partners, healthcare professionals and policy-makers, and used thematic framework analysis. Systematic reviews were undertaken of women's experiences of receiving maternity care during the pandemic, and healthcare professionals' experiences of providing that care. Questionnaires (October-December 2021 and August-September 2022) were administered nationally via the King's College London COVID Symptom Study Biobank, to evaluate vaccine uptake among women who were planning pregnancy, pregnant or post partum. Work package 3 engaged stakeholders within maternity systems through regional Listening Events and a national Policy Lab. Results:Among women of reproductive age (8 December 2020-15 February 2021), older age, white ethnicity and a lack of social deprivation were associated with higher vaccine uptake, although ethnicity exerted the strongest effect (Office for National Statistics data). Across pre-pandemic, pandemic with and pandemic without lockdowns, pregnancy outcomes, over time, largely followed pre-pandemic trends (record linkage, South London). However, virtual antenatal care in the second and third trimesters was associated with an excess of adverse pregnancy outcomes (and increased costs). Work package 2:Our systematic reviews of experiences of receiving (by women) or delivering (by healthcare professionals) maternity care during the pandemic identified the need for personalised care adapted to service users and communities, including those who are marginalised, and including provision of information; and co-design and coproduction of services with service users and staff, to reflect their collective lived experiences. This has the potential to improve workplace well-being for maternity care staff and facilitate inclusive and equitable care for service users. Interviews about COVID-19 vaccination in pregnancy identified a legacy of mistrust, lack of information, and confusing guidance that contributed to vaccine hesitancy for pregnant women during the pandemic. In our national survey, women of reproductive age (including pregnant/post partum women) reported being promptly vaccinated, but with angst and despite having received misinformation and discouragement from some healthcare professionals. Work package 3:Our programme's findings, published literature and Listening Event discussions led us to focus our Policy Lab on how coproduction can be used in local health systems to substantially improve maternity care over the next 2 years. Participants identified barriers to success, set out their vision for what could be achieved and suggested possible actions to progress improvement at a local level. Study limitations:In our analysis of data for women of reproductive age (from the Office for National Statistics), we lacked data on other potential determinants of vaccination (such as previous COVID-19 or comorbidities). For analysis of pregnancy outcomes (work package 1), limitations include that our study population was only from South London, however diverse, and we did not adjust fully for multiple analyses; however, we consider that our results reflect a coherent pattern of the main processes operating. For our trajectories of virtual antenatal care analysis, a limitation is that those women assigned to the same trajectory are assumed to follow the same pattern of virtual antenatal care. Also, we defined virtual antenatal care as an appointment that was missing blood pressure, dipstick proteinuria and fetal heart rate (after 16 weeks'), without mention of self-monitoring of these parameters at home; however, if blood pressure had been recorded in the observations as part of 'at-home' monitoring during the COVID-19 pandemic, we will have underestimated the prevalence of virtual antenatal care. For our national survey, our participants were not diverse, reflecting the general demographic of ZOE (ZOE Limited, London, UK) app users, limiting generalisability of our findings. For our systematic reviews, we included only English-language papers, but our focus was on studies of the United Kingdom population which are highly likely to be published in English; regardless, no studies for this review were excluded based on language. Future work:Maternity care is currently in crisis in the United Kingdom. Adopting a maternity system through partnership between those receiving and delivering maternity care could provide solutions necessary to 'build back better', for now and for future health system shocks. Conclusions:Our findings suggest that maternity care provision, although altered substantially, largely preserved pregnancy outcomes, although experiences of care receipt and delivery were poorer. Costs may have been lower because less care was sought, although virtual (vs. face-to-face) care was more expensive. There is evidence to suggest that the current context of maternity care is of a demoralised and depleted workforce. Implementing a coproduction learning health system could offer needed solutions to improve maternity care delivery, experiences of care and workplace culture, building resilience to withstand future health system shocks. Funding:This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme as award number NIHR134293.

In the last decade, rates of children with child protection agency involvement have increased in many high-income countries, including the UK. Disparities in both maternal and child health outcomes as well as child welfare referrals have been widely evidenced, yet no previous research has investigated contact with child protection agencies in the UK (Children’s Social Care, CSC) during pregnancy using linked maternity and mental health records. The aim of this study was to investigate characteristics of pregnant women when child protection agencies are involved and investigate what risk factors are associated with child protection agency contact during pregnancy. We conducted a retrospective cross-sectional study using linked electronic health records from maternity, neonatal, and mental health services in South London (eLIXIR-BiSL cohort). A cohort of singleton pregnancy records was created (October 2018 – April 2023). We used descriptive statistics to investigate sociodemographic and clinical characteristics, and binomial regression to explore risk factors and characteristics associated with CSC contact during pregnancy. A cohort of 36,322 singleton pregnancy records was studied, with CSC contact identified in 2,206 records (6