Beyond maternal death: improving the quality of maternal care through national studies of ‘near-miss’ maternal morbidity

Knight M, Acosta C, Brocklehurst P, Cheshire A, Fitzpatrick K, Hinton L, Jokinen M, Kemp B, Kurinczuk JJ, Lewis G, Lindquist A, Locock L, Nair M, Patel N, Quigley M, Ridge D, Rivero-Arias O, Sellers S, Shah A on behalf of the UKNeS coapplicant group. Background Studies of maternal mortality have been shown to result in important improvements to women’s health. It is now recognised that in countries such as the UK, where maternal deaths are rare, the study of near-miss severe maternal morbidity provides additional information to aid disease prevention, treatment and service provision. Objectives To (1) estimate the incidence of specific near-miss morbidities; (2) assess the contribution of existing risk factors to incidence; (3) describe different interventions and their impact on outcomes and costs; (4) identify any groups in which outcomes differ; (5) investigate factors associated with maternal death; (6) compare an external confidential enquiry or a local review approach for investigating quality of care for affected women; and (7) assess the longer-term impacts. Methods Mixed quantitative and qualitative methods including primary national observational studies, database analyses, surveys and case studies overseen by a user advisory group. Setting Maternity units in all four countries of the UK. Participants Women with near-miss maternal morbidities, their partners and comparison women without severe morbidity. Main outcome measures The incidence, risk factors, management and outcomes of uterine rupture, placenta accreta, haemolysis, elevated liver enzymes and low platelets (HELLP) syndrome, severe sepsis, amniotic fluid embolism and pregnancy at advanced maternal age (≥ 48 years at completion of pregnancy); factors associated with progression from severe morbidity to death; associations between severe maternal morbidity and ethnicity and socioeconomic status; lessons for care identified by local and external review; economic evaluation of interventions for management of postpartum haemorrhage (PPH); women’s experiences of near-miss maternal morbidity; long-term outcomes; and models of maternity care commissioned through experience-led and standard approaches. Results Women and their partners reported long-term impacts of near-miss maternal morbidities on their physical and mental health. Older maternal age and caesarean delivery are associated with severe maternal morbidity in both current and future pregnancies. Antibiotic prescription for pregnant or postpartum women with suspected infection does not necessarily prevent progression to severe sepsis, which may be rapidly progressive. Delay in delivery, of up to 48 hours, may be safely undertaken in women with HELLP syndrome in whom there is no fetal compromise. Uterine compression sutures are a cost-effective second-line therapy for PPH. Medical comorbidities are associated with a fivefold increase in the odds of maternal death from direct pregnancy complications. External reviews identified more specific clinical messages for care than local reviews. Experience-led commissioning may be used as a way to commission maternity services. Limitations This programme used observational studies, some with limited sample size, and the possibility of uncontrolled confounding cannot be excluded. Conclusions Implementation of the findings of this research could prevent both future severe pregnancy complications as well as improving the outcome of pregnancy for women. One of the clearest findings relates to the population of women with other medical and mental health problems in pregnancy and their risk of severe morbidity. Further research into models of pre-pregnancy, pregnancy and postnatal care is clearly needed.

The Roles of ‘Conventional’ and Demand-Responsive Bus Services

Purpose - The roles of ‘conventional’ (fixed-route and fixed-timetable) bus services is examined and compared to demand-responsive services, taking rural areas in England as the basis for comparison. It adopts a ‘rural’ definition of settlements under a population of 10,000. Design/methodology/approach - Evidence from the National Travel Survey, technical press reports and academic work is brought together to examine the overall picture. Findings - Inter-urban services between towns can provide a cost-effective way of serving rural areas where smaller settlements are suitably located. The cost structures of both fixed-route and demand-responsive services indicate that staff time and cost associated with vehicle provision are the main elements. Demand-responsive services may enable larger areas to be covered, to meet planning objectives of ensuring a minimum of level of service, but experience often shows high unit cost and public expenditure per passenger trip. Economic evaluation indicates user benefits per passenger trip of similar magnitude to existing average public expenditure per trip on fixed-route services. Considerable scope exists for improvements to conventional services through better marketing and service reliability. Practical implications - The main issue in England is the level of funding for rural services in general, and the importance attached to serving those without access to cars in such areas. Social implications - The boundary between fixed-route and demand-responsive operation may lie at relatively low population densities. Originality/value - The chapter uses statistical data, academic research and operator experience of enhanced conventional bus services to provide a synthesis of outcomes in rural areas.

Financial media, globalisation, and China’s economic integration: comparing narrative construction of the Economist and Caijing

In June 2015, legal frameworks of the Asian Infrastructural Investment Bank were signed by its 57 founding members. Proposed and initiated by China, this multilateral development bank is considered to be an Asian counterpart to break the monopoly of the World Bank and the International Monetary Fund. In October 2015, China’s Central Bank announced a benchmark interest rate cut to combat the economic slowdown. The easing policy coincides with the European Central Bank’s announcement of doubts over US Fed’s commitment to raise interest rates. Global stock markets responded positively to China’s move, with the exception of the indexes from Wall Street (Bland, 2015; Elliott, 2015). In the meantime, China’s ‘One Belt, One Road’ (or New Silk Road Economic Belt) became atopic of discourse in relation to its growing global economy, as China pledged $40 billion to trade and infrastructure projects (Bermingham, 2015). The foreign policy aims to reinforce the economic belt from western China through Central Asia towards Europe, as well as to construct maritime trading routes from coastal China through the South China Sea (Summers, 2015). In 2012, The Economist launched a new China section, to reveal the complexity of the‘meteoric rise’ of China. John Micklethwait, who was then the chief editor of the magazine, said that China’s emergence as a global power justified giving it a section of its own(Roush, 2012). In July 2015, Hu Shuli, the former chief editor of Caijing, announced the launch of a think tank and financial data service division called Caixin Insight Group, which encompasses the new Caixin China Purchasing Managers Index (PMI). Incooperation with with Markit Group, a principal global provider of PMI, the index soon became a widely cited economic indicator. One anecdote from November’s Caixin shows how much has changed: in a high-profile dialogue between Hu Shuli and Kevin Rudd, Hu insisted on asking questions in English; interestingly, the former Prime Minister of Australia insisted on replying in Chinese. These recent developments point to one thing: the economic ascent of China and its increasing influence on the power play between economics and politics in world markets. China has begun to take a more active role in rule making and enforcement under neoliberal frameworks. However, due to the country’s size and the scale of its economy in comparison to other countries, China’s version of globalisation has unique characteristics. The ‘Capitalist-socialist’ paradox is vital to China’s market-oriented transformation. In order to comprehend how such unique features are articulated and understood, there are several questions worth investigating in the realms of media and communication studies,such as how China’s neoliberal restructuring is portrayed and perceived by different types of interested parties, and how these portrayals are de-contextualised and re-contextualised in global or Anglo-American narratives. Therefore, based on a combination of the themes of globalisation, financial media and China’s economic integration, this thesis attempts to explore how financial media construct the narratives of China’s economic globalisation through the deployment of comparative and multi-disciplinary approaches. Two outstanding elite financial magazines, Britain’s The Economist, which has a global readership and influence, and Caijing, China’s leading financial magazine, are chosen as case studies to exemplify differing media discourses, representing, respectively, Anglo-American and Chinese socio-economic and political backgrounds, as well as their own journalistic cultures. This thesis tries to answer the questions of how and why China’s neoliberal restructuring is constructed from a globally-oriented perspective. The construction primarily involves people who are influential in business and policymaking. Hence, the analysis falls into the paradigm of elite-elite communication, which is an important but relatively less developed perspective in studying China and its globalisation. The comparing of characteristics of narrative construction are the result of the textual analysis of articles published over a ten-year period (mid-1998 to mid-2008). The corpus of samples come from the two media outlets’ coverage of three selected events:China becoming a member of the World Trade Organization, its outward direct investment, and the listing of stocks of Chinese companies in overseas exchanges, which are mutually exclusive in sample collection and collectively exhaustive in the inclusion of articles regarding China’s economic globalisation. The findings help to understand that, despite language, socio-economic and political differences, elite financial media with globally-oriented readerships share similar methods of and approaches to agenda setting, the evaluation of news prominence, the selection of frame, and the advocacy of deeply rooted neoliberal ideas. The comparison of their distinctive features reflects the different phases of building up the sense of identity in their readers as global elites, as well as the different economic interests that are aligned with the corresponding readerships. However, textual analysis is only relevant in terms of exploring how the narratives are constructed and the elements they include; textual analysis alone prevents us from seeing the obstacles and the constrains of the journalistic practices of construction. Therefore, this thesis provides a brief discussion of interviews with practitioners from the two media, in order to understand how similar or different narratives are manifested and perceived, how the concept of neoliberalism deviates from and is justified in the Chinese context, and how and for what purpose deviations arise from Western to Chinese contexts. The thesis also contributes to defining financial media in the domain of elite communication. The relevant and closely interlocking concepts of globalisation, elitism and neoliberalism are discussed, and are used as a theoretical bedrock in the analysis of texts and contexts. It is important to address the agenda-setting and ideological role of elite financial media, because of its narrative formula of infusing business facts with opinions,which is important in constructing the global elite identity as well as influencing neoliberal policy-making. On the other hand, ‘journalistic professionalism’ has been redefined, in that the elite identity is shared by the content producer, reader and the actors in the news stories emerging from the much-compressed news cycle. The professionalism of elite financial media requires a dual definition, that of being professional in the understanding of business facts and statistics, and that of being professional in the making sense of stories by deploying economic logic.

Evaluation for Participation and Sustainability in Planning

‘Evaluation for Participation and Sustainability in Planning’ is the title of a new book edited by Johan Woltjer and his colleagues Angela Hull, Ernest Alexander, and Abdul Khakee. The book addresses the evaluation of planning interventions from several perspectives (social, economic, environmental). Specifically, the attention is focused on: - how evaluation is used in planning practice, including the choice of indicators or the criteria to evaluate participation; - the introduction of new kinds of information, such as measuring the cumulative effects or bringing criteria on capability and well-being into play; - alternative ways of collecting and presenting information, through using GIS or focusing on strategic environmental awareness and ‘hotspots’; and - understanding how strategic planning objectives are implemented in local practice.