Objective: Avoidable perinatal brain injury, including preventable hypoxic ischaemic encephalopathy (HIE), remains a major global challenge for maternity care. In the UK, progress is hindered by weaknesses in infrastructure of routinely collected perinatal data. We sought to develop a strategy to support improvement in data relating to potentially avoidable HIE. Design: Online survey of UK-based professionals, structured discussions with a multidisciplinary advisory group, and three workshops with patient/family representatives. Setting: United Kingdom. Main outcome measures: Co-created recommendations for improving the consistency, comprehensiveness, linkage, quality, and practical use of routinely collected UK maternity and neonatal data related to potentially avoidable HIE. Results: Between 85-98% of survey participants (N=411) rated most of the data items proposed as characterising avoidable brain injury as important. They also identified data gaps, particularly for intrapartum risk factors. Participants wanted accessible, unit level feedback and capability building for interpreting data, while cautioning against sharing data with families without context. The advisory group (n=35) and patient/family representatives (n=9) converged on 15 recommendations covering: definitions; a core item catalogue and shared data dictionary; electronic patient record interoperability; workflow integrated data capture; secure individual level linkage with longer term follow up; strengthened audit and feedback; and improved capture and sharing of data relevant to families. Conclusions: The recommendations offer a roadmap for developing an integrated data source that builds on existing datasets of routinely collected maternity and neonatal data. Even a basic version of this data source would already help promote actionable use of data and guide investments in digital infrastructure that enables continuous improvement cycles. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement The Avoiding Brain Injury in Childbirth programme (Department of Health and Social Care, UK) supported this work. THIS Institute is funded by the Health Foundation, Grant/Award Number: RHZF/001 - RG88620. The Health Foundation is an independent charity committed to bringing about better health and health care for people in the UK. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Ethical approval for the survey was given by the University of Cambridge Psychology Research Ethics Committee (PRE.2024.087, see https://www.bio.cam.ac.uk/psyres for further information). I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes The data that support the findings of this evaluation are available on request from the corresponding author. Access to fully anonymized data may be granted to bona fide researchers under a data sharing agreement. The data are not publicly available because of privacy or ethical restrictions.

OBJECTIVE:To assess the measurement properties of the International Consultation on Incontinence-Perinatal Pelvic Health Self-Assessment Questionnaire (ICIQ-PPHSAQ) and to identify symptom subscales for scoring. DESIGN, SETTING AND POPULATION:Two cohorts of perinatal women (antenatal and postnatal) at nine NHS trusts in England completed ICIQ-PPHSAQ at baseline (16-19 weeks' gestation for the antenatal cohort and 6-9 weeks postnatal for the postnatal cohort) and at up to three further timepoints, with follow-up extending to 9 months postnatal. METHODS:Descriptive analyses and exploratory factor analyses (EFAs) identified symptom subscales from which subscale scores were calculated. Internal consistency was evaluated using Cronbach's alpha (α). Test-retest reliability was assessed using an interval of 1 week after baseline, using weighted Kappa (κ) for individual ordinal items and the intraclass correlation coefficient (ICC) for subscale scores. Construct validity and known-groups validity were assessed by comparison with the Patient Global Impression of Severity (PGI-S). Responsiveness was assessed by examining the mean differences between baseline and each timepoint. RESULTS:A total of 162 antenatal women who were 16-19 weeks gestation, and 173 women 6-9 weeks postnatal were recruited. Almost all the items performed acceptably in the test-retest analyses and completion rates were high in all the scored items (< 5% missing data). EFAs derived nine symptom subscales; seven of which had acceptable overall reliability indicators, except the vaginal symptom and vaginal changes subscales. Known-groups validity was demonstrated for all nine subscales, and six out of nine showed responsiveness to change (p < 0.05) over the study time-period. CONCLUSION:The study provides evidence supporting the validity and reliability of ICIQ-PPHSAQ, with responsiveness demonstrated across several domains. The instrument can be used to assess perinatal pelvic floor dysfunction risk factors and symptoms in English perinatal pelvic health services.

Over one‐quarter of women in the UK have a caesarean birth (CB). More than one in 20 of these caesarean births occurs near the end of labour, when the cervix is fully dilated (second stage). In these circumstances, and when labour has been prolonged, the baby's head can become lodged deep in the maternal pelvis making it challenging to deliver the baby. During the CB, difficulty in delivery of the baby's head may result—this emergency is known as impacted fetal head (IFH). These are technically challenging births that pose significant risks to both the woman and baby. Complications for the woman include tears in the womb, serious bleeding and longer hospital stays. Babies are at increased risk of injury including damage to the head and face, lack of oxygen to the brain, nerve damage, and in rare cases, the baby may die from these complications. Maternity staff are increasingly encountering IFH at CB, and reports of associated injuries have risen dramatically in recent years. The latest UK studies suggest that IFH may complicate as many as one in 10 unplanned caesarean births (1.5% of all births) and that two in 100 babies affected by IFH die or are seriously injured. Moreover, there has been a sharp increase in reports of babies having brain injuries when their birth was complicated by IFH. When an IFH occurs, the maternity team can use different approaches to help deliver the baby's head at CB. These include: an assistant (another obstetrician or midwife) pushing the head up from the vagina; delivering the baby's feet first; using a specially designed inflatable balloon device to elevate the baby's head and/or giving the mother a medicine to relax the womb. There has been a lack of consensus for how best to manage these births. [Correction added on 11 November 2025, after first online publication: The preceding sentence has been added in this version.] This has resulted in a lack of confidence among maternity staff, variable practice and potentially avoidable harm in some circumstances. This paper reviews the current evidence regarding the prediction, prevention and management of IFH at CB, integrating findings from a systematic review commissioned from the Avoiding Brain Injury in Childbirth (ABC) programme.

Objective In the UK and worldwide, there are substantial ethnic inequalities in maternal and perinatal care and outcomes. We aim to assess the impact of the unprecedented change in care provision during the COVID-19 pandemic on inequalities in adverse maternity outcomes.Design Retrospective cohort study using structured electronic health record data.Setting English hospital trusts providing maternity care.Participants Women giving birth and babies born in the National Health Service (NHS) in England between 1 April 2018 and 31 March 2021, in three time groups: prepandemic, the first pandemic wave (26 March 2020 to 30 June 2020) and second pandemic wave (1 July 2020 to 31 March 2021). Self-reported ethnicity was grouped into White, South-Asian, Black, Mixed and Other.Main outcome measures Composite and component measures of maternal (emergency caesarean section, obstetric anal sphincter injury, hysterectomy, sepsis, anaesthetic complications and prolonged hospital stay) and perinatal (stillbirth, neonatal death, preterm birth, brain injury, small for gestational age and prolonged hospital stay). Poisson regression was used to compare relative risks between different ethnic groups.Findings 1.54 million maternal and 1.43 million neonatal records were included. The overall incidence of adverse outcomes per 1000 births initially decreased maternal: from 308.0 (95% CI 307.0 to 309.0) to 291.0 (95% CI 311.4 to 314.9) (p<0.001); perinatal: from 133.0 (95% CI 132.3 to 133.7) to 111.9 (95% CI 110.1 to 113.7) (p<0.001)), but then increased in the second pandemic period (maternal: 313.2 (95% CI 311.4 to 314.9) (p<0.001); perinatal 118.9 (95% CI 117.7 to 120.0) (p<0.001)). The risk of adverse outcomes was higher in women and babies from all ethnic minority groups compared with White women in both pandemic periods. Black and South-Asian women and babies were approximately 25% more likely to sustain adverse outcomes. While similar overall changes in adverse outcomes were seen in all groups, existing inequalities were sustained throughout the pandemic periods.Interpretation Existing inequalities in adverse maternal and perinatal/neonatal outcomes were maintained, not tempered, during the pandemic, despite substantial changes to maternity services and care. Further research on possible interventions to reduce inequality is needed.

High quality data is important to understanding epidemiology and supporting improvement efforts in perinatal brain injury. It is not clear which data items relevant to brain injury are captured across UK sources of routinely collected data, nor what needs to be done to ensure that those sources are fit for purpose in improving care. We reviewed data dictionaries of four main UK perinatal data sources and consulted a multi-professional group (N = 27) with expertise in neonatal/maternity care, statistics, and clinical negligence. None of the data sources we reviewed currently captures, on its own, the range of items relevant to brain injury. Data items lack common definitions and ongoing linkage across the different sources. Our consultation identified the need for standardising the definition of avoidable perinatal brain injury, resolving inconsistencies in capturing data, improving linkage of data across existing data sources, and co-designing a strategy for meaningful use of data. Limited standardisation and linkage across UK data sources are key problems in using data to guide improvement efforts aimed at reducing risk of avoidable perinatal brain injury. A programme involving co-design with healthcare professionals and families to improve capture and use of data is now needed.

Assisted vaginal birth rates are falling globally with rising cesarean delivery rates. Cesarean delivery is not without consequence, particularly when carried out in the second stage of labor. Cesarean delivery in the second stage is not entirely protective against pelvic floor morbidity and can lead to serious complications in a subsequent pregnancy. It should be acknowledged that the likelihood of morbidity for mother and baby associated with cesarean delivery increases with advancing labor and is greater than spontaneous vaginal birth, irrespective of the method of operative birth in the second stage of labor. In this article, we argue that assisted vaginal birth is a skilled and safe option that should always be considered and be available as an option for women who need assistance in the second stage of labor. Selecting the most appropriate mode of birth at full dilatation requires accurate clinical assessment, supported decision-making, and personalized care with consideration for the woman's preferences. Achieving vaginal birth with the primary instrument is more likely with forceps than with vacuum extraction (risk ratio, 0.58; 95% confidence interval, 0.39-0.88). Midcavity forceps are associated with a greater incidence of obstetric anal sphincter injury (odds ratio, 1.83; 95% confidence interval, 1.32-2.55) but no difference in neonatal Apgar score or umbilical artery pH. The risk for adverse outcomes is minimized when the procedure is conducted by a skilled accoucheur who selects the most appropriate instrument likely to achieve vaginal birth with the primary instrument. Anticipation of potential complications and dynamic decision-making are just as important as the technique for safe instrument use. Good communication with the woman and the birthing partner is vital and there are various recommendations on how to achieve this. There have been recent developments (such as OdonAssist) in device innovation, training, and strategies for implementation at a scale that can provide opportunities for both improved outcomes and reinvigoration of an essential skill that can save mothers' and babies' lives across the world.

BACKGROUND: The first feasibility study of the OdonAssist inflatable device for use in clinically indicated assisted vaginal birth reported a success rate of 48% with no significant safety concerns. Additional studies exploring the device performance in other clinical settings are warranted before definitive conclusions can be drawn about its safety and efficacy in current practice. OBJECTIVE: This study aimed to investigate the safety and efficacy of the OdonAssist before conducting a randomized controlled trial. STUDY DESIGN: This was an open-label, nonrandomized study of 104 women with a clinically indicated assisted vaginal birth using the OdonAssist at the Besancon University Hospital, France. Data, including those of a nested cohort group of women who had an assisted vaginal birth using vacuum or spatulas because a trained OdonAssist device operator was not available at the time of delivery, were collected. The primary outcome measure was the proportion of successful assisted vaginal births using the OdonAssist. Neonatal outcome data were reviewed at days 1 and 28, and maternal outcomes were investigated up to day 90. RESULTS: Between December 2019 and May 2021, 2191 pregnant women were approached, and 83% (1636/1973) of them consented to participate in the study. Among them, 10.7% (176/1636) required an assisted vaginal birth owing to a vertex presentation atthorn1 and below. The OdonAssist was used in 59% of births (104/176), and 41.1% (72/176) of the participants were included in the nested cohort group. The rate of successful assisted vaginal births using the OdonAssist was 88.5% (92/104). No emergency cesarean deliveries were performed in the OdonAssist group. There were no serious adverse maternal or neonatal reactions related to the use of the device. The rate of third- and fourth-degree perineal tears with the OdonAssist was 3.8% (4/104). The maternal perception ratings of the birth experience with the OdonAssist (collected on days 1, 7, and 28 using a 15-point scale) were high. In addition, the operators reported a positive perception of the device, with ease of use across the different steps of the procedure. One single technique was used for all vertex fetal head positions. CONCLUSION: The OdonAssist is a safe and effective alternative to other current devices for assisted vaginal births. The high acceptance rate (83%) among pregnant women and the high rate of successful assisted vaginal births using the OdonAssist confirm the feasibility of a future randomized controlled trial.

ABSTRACT Impacted fetal head (IFH) is a complication that occurs in 10% of cesarean deliveries (CDs). Disimpacting the fetal head can have significant maternal risks, including trauma to the uterus, vagina, cervix, and bladder, postpartum hemorrhage, as well as neonatal risks, including skull fracture, intracranial hemorrhage, head and face trauma, low oxygen levels, admission to the neonatal intensive care unit, and death. Perinatal head injury due to IFH has resulted in increased litigation, with IFH identified as a contributing factor in nearly 10% of the most expensive maternity claims in the United Kingdom in 2018. International consensus on the most effective and safe management of IFH is lacking. Moreover, recent surveys of maternity professionals in the United Kingdom have reported a scarcity of training, lack of confidence, and underused techniques for IFH. Understanding how maternity professionals view the management of IFH during CD is helpful to improve care, training, and research. The aim of this study was to assess the views, understanding and practices to manage IFH during CD. This was a survey of health care professionals who provide maternity care or work in policy, research, or other areas of maternity care, using a secure online collaborative platform called Thiscovery. Participants included Thiscovery subscribers and members of clinical practice societies, such as the Royal College of Midwives, Royal College of Obstetricians and Gynecologists, and Royal College of Anesthetists. The survey analyzed responses for open-ended questions, with free-text entries, and closed-ended questions. A total of 419 participants were included in the analysis, including 144 midwives, 216 obstetricians, and 59 other maternity professionals. A high level of agreement was found among 79% of obstetricians who preferred a definition of IFH at CD that included “additional maneuvers and/or tocolysis to disimpact and deliver the fetal head.” About a third of free-text responses from 17 respondents noted a need to incorporate the difficulty or inability to get a hand below the fetal head for delivery. Approximately 95% of participants agreed or strongly agreed that management of IFH at CD requires a multiprofessional approach. When asked about communicating an IFH emergency, 55% preferred using the declaration, “This is an impacted fetal head.” Free-text responses from 57 participants emphasized the importance of clear communication and awareness of the emergency across all team members before and during the management of IFH as well as with the woman and birth partner. More than 70% found that a change of operator, manual cephalic extraction, tocolysis, operating changing hand, reserve breech extraction, Fetal Pillow, head-down tilt, and vaginal disimpaction were safe and effective techniques and adjunctive measures for managing IFH at CD. However, free-text responses from 56 participants found mixed views on the use of tocolysis, noting the risk of complications such as postpartum hemorrhage. The use of Fetal Pillow was positively accepted by 71 participants. Comparing obstetricians with midwives, approximately three quarters of obstetricians considered vaginal disimpaction before CD acceptable (72% preincision and 76% postincision). Fewer midwives favored this technique (25% preincision and 52% postincision), with 88% reporting that knowing the position of the fetal head would be helpful to know before undertaking vaginal disimpaction. Training in vaginal disimpaction was considered essential by 85% of midwives and obstetricians. Yet only 81% of midwives and 57% of obstetricians had received such training. The preferred method of training was hands-on training in simulation (91%), followed by animated video illustrating disimpaction techniques (73%) and small-group teaching (55%). Free text responses form 159 participants demonstrated a need and appetite for more training. The most frequent suggestions to improve care for IFH at CD included holding briefings and debriefings before and after the emergency and having robust plans for escalation and calling for help. This study identified high agreement among United Kingdom maternity professionals to define IFH at CD. The study authors suggested a standard definition as “a cesarean birth where the obstetrician is unable to deliver the fetal head with their usual delivering hand, and additional maneuvers and/or tocolysis are required to disimpact and deliver the fetal head.” In addition, using unambiguous language in the emergency, such as declaring “This is an impacted fetal head,” facilitates teamwork and collaboration and improves care.

INTRODUCTION:Despite increasing incidence of impacted fetal head at cesarean birth and associated injury, it is unclear which techniques are most effective for prevention and management. A high quality evidence review in accordance with international reporting standards is currently lacking. To address this gap, we aimed to identify, assess, and synthesize studies comparing techniques to prevent or manage impacted fetal head at cesarean birth prior to or at full cervical dilatation. MATERIAL AND METHODS:We searched MEDLINE, Emcare, Embase and Cochrane databases up to 1 January 2023 (PROSPERO: CRD420212750016). Included were randomized controlled trials (any size) and non-randomized comparative studies (n ≥ 30 in each arm) comparing techniques or adjunctive measures to prevent or manage impacted fetal head at cesarean birth. Following screening and data extraction, we assessed risk of bias for individual studies using RoB2 and ROBINS-I, and certainty of evidence using GRADE. We synthesized data using meta-analysis where appropriate, including sensitivity analyses excluding data published in potential predatory journals or at risk of retraction. RESULTS:We identified 24 eligible studies (11 randomized and 13 non-randomized) including 3558 women, that compared vaginal disimpaction, reverse breech extraction, the Patwardhan method and/or the Fetal Pillow®. GRADE certainty of evidence was low or very low for all 96 outcomes across seven reported comparisons. Pooled analysis mostly showed no or equivocal differences in outcomes across comparisons of techniques. Although some maternal outcomes suggested differences between techniques (eg risk ratio of 3.41 [95% CI: 2.50-4.66] for uterine incision extension with vaginal disimpaction vs. reverse breech extraction), these were based on unreliable pooled estimates given very low GRADE certainty and, in some cases, additional risk of bias introduced by data published in potential predatory journals or at risk of retraction. CONCLUSIONS:The current weaknesses in the evidence base mean that no firm recommendations can be made about the superiority of any one impacted fetal head technique over another, indicating that high quality training is needed across the range of techniques. Future studies to improve the evidence base are urgently required, using a standard definition of impacted fetal head, agreed maternal and neonatal outcome sets for impacted fetal head, and internationally recommended reporting standards.

BackgroundLarge-scale improvement programmes are a frequent response to quality and safety problems in health systems globally, but have mixed impact. The extent to which they meet criteria for programme quality, particularly in relation to transparency of reporting and evaluation, is unclear.AimTo identify large-scale improvement programmes focused on intrapartum care implemented in English National Health Service maternity services in the period 2010–2023, and to conduct a structured quality assessment.MethodsWe drew on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidance to inform the design and reporting of our study. We identified relevant programmes using multiple search strategies of grey literature, research databases and other sources. Programmes that met a prespecified definition of improvement programme, that focused on intrapartum care and that had a retrievable evaluation report were subject to structured assessment using selected features of programme quality.ResultsWe identified 1434 records via databases and other sources. 14 major initiatives in English maternity services could not be quality assessed due to lack of a retrievable evaluation report. Quality assessment of the 15 improvement programmes meeting our criteria for assessment found highly variable quality and reporting. Programme specification was variable and mostly low quality. Only eight reported the evidence base for their interventions. Description of implementation support was poor and none reported customisation for challenged services. None reported reduction of inequalities as an explicit goal. Only seven made use of explicit patient and public involvement practices, and only six explicitly used published theories/models/frameworks to guide implementation. Programmes varied in their reporting of the planning, scope and design of evaluation, with weak designs evident.ConclusionsPoor transparency of reporting and weak or absent evaluation undermine large-scale improvement programmes by limiting learning and accountability. This review indicates important targets for improving quality in large-scale programmes.

BackgroundHigh-quality antenatal care is important for ensuring optimal birth outcomes and reducing risks of maternal and fetal mortality and morbidity. The COVID-19 pandemic disrupted the usual provision of antenatal care, with much care shifting to remote forms of provision. We aimed to characterise what quality would look like for remote antenatal care from the perspectives of those who use, provide and organise it.MethodsThis UK-wide study involved interviews and an online survey inviting free-text responses with: those who were or had been pregnant since March 2020; maternity professionals and managers of maternity services and system-level stakeholders. Recruitment used network-based approaches, professional and community networks and purposively selected hospitals. Analysis of interview transcripts was based on the constant comparative method. Free-text survey responses were analysed using a coding framework developed by researchers.FindingsParticipants included 106 pregnant women and 105 healthcare professionals and managers/stakeholders. Analysis enabled generation of a framework of the domains of quality that appear to be most relevant to stakeholders in remote antenatal care: efficiency and timeliness; effectiveness; safety; accessibility; equity and inclusion; person-centredness and choice and continuity. Participants reported that remote care was not straightforwardly positive or negative across these domains. Care that was more transactional in nature was identified as more suitable for remote modalities, but remote care was also seen as having potential to undermine important aspects of trusting relationships and continuity, to amplify or create new forms of structural inequality and to create possible risks to safety.ConclusionsThis study offers a provisional framework that can help in structuring thinking, policy and practice. By outlining the range of domains relevant to remote antenatal care, this framework is likely to be of value in guiding policy, practice and research.

Objectives: During the COVID-19 pandemic, rapid and heterogeneous changes were made to maternity care. Identification of changes that may reduce maternal health inequalities is a national priority. The aim of this project was to use data collected about care and outcomes to identify NHS Trusts in the UK where inequalities in outcomes reduced during the pandemic and explore through interviews how the changes that occurred may have led to a reduction in inequalities. Methods: A Women's Reference Group of public advisors guided the project. Analysis of Hospital Episode Statistics Admitted Patient Care data of 128 organisations in England identified "positive deviant" organisations that reduced inequalities, using maternal and perinatal composite adverse outcome indicators. Positive deviant organisations were identified for investigation, alongside comparators. Senior clinicians, heads of midwifery and representatives of women giving birth were interviewed. Reflexive thematic analysis was employed. Results: The change in the inequality gap for the maternal indicator ranged from a reduction of -0.24 to an increase of 0.30 per 1000 births between the pre-pandemic and pandemic period. For the perinatal composite indicator, the change in inequality gap ranged from -0.47 to 0.67 per 1000 births. Nine Trusts were identified as positive deviants and 10 as comparators. We conducted 20 interviews from six positive deviant and four comparator organisations. Positive deviants reported that necessary shifts in roles led to productive and novel use of expert staff; comparators reported senior staff 'stepping in' where needed and no benefits of this. They reported proactivity and quick reactions, increased team working, and rapid implementation of new ideas. Comparators found constant changes overwhelming, and no increase in team working. No specific differences in care processes were identified. Conclusions: Harnessing proactivity, flexibility, staffing resource, and increased team working proves vital in reducing health inequalities.

Clinical tools for use in practice-such as medicine reconciliation charts, diagnosis support tools and track-and-trigger charts-are endemic in healthcare, but relatively little attention is given to how to optimise their design. User-centred design approaches and co-design principles offer potential for improving usability and acceptability of clinical tools, but limited practical guidance is currently available. We propose a framework (FRamework for co-dESign of Clinical practice tOols or 'FRESCO') offering practical guidance based on user-centred methods and co-design principles, organised in five steps: (1) establish a multidisciplinary advisory group; (2) develop initial drafts of the prototype; (3) conduct think-aloud usability evaluations; (4) test in clinical simulations; (5) generate a final prototype informed by workshops. We applied the framework in a case study to support co-design of a prototype track-and-trigger chart for detecting and responding to possible fetal deterioration during labour. This started with establishing an advisory group of 22 members with varied expertise. Two initial draft prototypes were developed-one based on a version produced by national bodies, and the other with similar content but designed using human factors principles. Think-aloud usability evaluations of these prototypes were conducted with 15 professionals, and the findings used to inform co-design of an improved draft prototype. This was tested with 52 maternity professionals from five maternity units through clinical simulations. Analysis of these simulations and six workshops were used to co-design the final prototype to the point of readiness for large-scale testing. By codifying existing methods and principles into a single framework, FRESCO supported mobilisation of the expertise and ingenuity of diverse stakeholders to co-design a prototype track-and-trigger chart in an area of pressing service need. Subject to further evaluation, the framework has potential for application beyond the area of clinical practice in which it was applied.

BackgroundProblems in intrapartum electronic fetal monitoring with cardiotocography (CTG) remain a major area of preventable harm. Poor understanding of the range of influences on safety may have hindered improvement. Taking an interdisciplinary perspective, we sought to characterise the everyday practice of CTG monitoring and the work systems within which it takes place, with the goal of identifying potential sources of risk.MethodsHuman factors/ergonomics (HF/E) experts and social scientists conducted 325 hours of observations and 23 interviews in three maternity units in the UK, focusing on how CTG tasks were undertaken, the influences on this work and the cultural and organisational features of work settings. HF/E analysis was based on the Systems Engineering Initiative for Patient Safety 2.0 model. Social science analysis was based on the constant comparative method.ResultsCTG monitoring can be understood as a complex sociotechnical activity, with tasks, people, tools and technology, and organisational and external factors all combining to affect safety. Fetal heart rate patterns need to be recorded and interpreted correctly. Systems are also required for seeking the opinions of others, determining whether the situation warrants concern, escalating concerns and mobilising response. These processes may be inadequately designed or function suboptimally, and may be further complicated by staffing issues, equipment and ergonomics issues, and competing and frequently changing clinical guidelines. Practice may also be affected by variable standards and workflows, variations in clinical competence, teamwork and situation awareness, and the ability to communicate concerns freely.ConclusionsCTG monitoring is an inherently collective and sociotechnical practice. Improving it will require accounting for complex system interdependencies, rather than focusing solely on discrete factors such as individual technical proficiency in interpreting traces.

Access to emergency obstetric care, including assisted vaginal birth and caesarean birth, is crucial for improving maternal and childbirth outcomes. However, although the proportion of births by caesarean section has increased during the last few decades, the use of assisted vaginal birth has declined. This is particularly the case in low- and middle-income countries, despite an assisted vaginal birth often being less risky than caesarean birth. We therefore conducted a three-step process to identify a research agenda necessary to increase the use of, or reintroduce, assisted vaginal birth: after conducting an evidence synthesis, which informed a consultation with technical experts who proposed an initial research agenda, we sought and incorporated the views of women's representatives of this agenda. This process has allowed us to identify a comprehensive research agenda, with topics categorized as: (i) the need to understand women's perceptions of assisted vaginal birth, and provide appropriate and reliable information; (ii) the importance of training health-care providers in clinical skills but also in respectful care, effective communication, shared decision-making and informed consent; and (iii) the barriers to and facilitators of implementation and sustainability. From women's feedback, we learned of the urgent need to recognize labour, childbirth and postpartum experiences as inherently physiological and dignified human processes, in which interventions should only be implemented if necessary. The promotion and/or reintroduction of assisted vaginal birth in low-resource settings requires governments, policy-makers and hospital administrators to support skilled health-care providers who can, in turn, respectfully support women in labour and childbirth.

Objective We aimed to explore the experiences and perspectives of pregnant women, antenatal healthcare professionals, and system leaders to understand the impact of the implementation of remote provision of antenatal care during the COVID-19 pandemic and beyond. Methods We conducted a qualitative study involving semi-structured interviews with 93 participants, including 45 individuals who had been pregnant during the study period, 34 health care professionals, and 14 managers and system-level stakeholders. Analysis was based on the constant comparative method and used the theoretical framework of candidacy. Results We found that remote antenatal care had far-reaching effects on access when understood through the lens of candidacy. It altered women’s own identification of themselves and their babies as eligible for antenatal care. Navigating services became more challenging, often requiring considerable digital literacy and sociocultural capital. Services became less permeable, meaning that they were more difficult to use and demanding of the personal and social resources of users. Remote consultations were seen as more transactional in character and were limited by lack of face-to-face contact and safe spaces, making it more difficult for women to make their needs – both clinical and social – known, and for professionals to assess them. Operational and institutional challenges, including problems in sharing of antenatal records, were consequential. There were suggestions that a shift to remote provision of antenatal care might increase risks of inequities in access to care in relation to every feature of candidacy we characterised. Conclusion It is important to recognise the implications for access to antenatal care of a shift to remote delivery. It is not a simple swap: it restructures many aspects of candidacy for care in ways that pose risks of amplifying existing intersectional inequalities that lead to poorer outcomes. Addressing these challenges through policy and practice action is needed to tackle these risks.