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.

Transplanting diglossia: attitudes towards Standard and Cypriot Greek among London’s Greek Cypriot community

The linguistic situation in Greek-speaking Cyprus has been traditionally described as a textbook case of diglossia à la Ferguson (1959) with Standard Modern Greek (SModGr) being labelled as the High variety and Cypriot Greek (CypGr), the regional ModGr variety of Cyprus, being labelled the Low variety (Arvaniti, 2011; Moschonas, 1996). More recently, however, it has been proposed that the linguistic repertoire available to speakers features an array of forms of CypGr, which is best described as a continuum ranging from basilectal to acrolectal varieties (Katsoyannou et al., 2006; Tsiplakou et al., 2006). The basilectal end encompasses low prestige varieties predominantly spoken in rural areas. The acrolectal end is occupied by the version of SModGr used in the public domain in Cyprus (Arvaniti, 2006/2010). SModGr is known to carry high prestige in Cyprus. Speakers of CypGr describe speakers of the standard as more attractive, more intelligent, more interesting and more educated than speakers of the Cypriot dialect (Papapavlou, 1998). In this paper, I explore the relation between SModGr and CypGr in a diasporic setting, namely, the Greek Cypriot community of London. The United Kingdom is home to a sizeable Greek Cypriot community, whose population is presently estimated to fall between 200,000 and 300,000 individuals (Christodoulou-Pipis, 1991; National Federation of Cypriots in the UK). Similarly to the Cyprus homeland, the members of the Greek Cypriot parikia (‘community’) share a rich linguistic repertoire, which, in addition to varieties of Greek, crucially includes English. As is often the case with diasporas, the parikia does not form a homogeneous speech community in that not all of its members have an equally good command of Greek or even English. Rather, different types of monolingual and bilingual speakers are found including a large number of heritage speakers in the sense of Benmamoun et al. (2013), Montrul (2008, 2015) and Polinsky & Kagan (2007). Twenty British-born heritage speakers of CypGr were interviewed on their attitudes towards the different varieties of Greek. Results indicate that the prestige relation between SModGr and CypGr that holds in Cyprus has been transplanted to the parikia. SModGr is widely perceived as the prestigious variety and is described in positive terms (‘correct’, ‘proper’). The use of CypGr, on the other hand, enjoys covert prestige: it is perceived as an index of solidarity and in-group membership but at the same time is also viewed by heritage speakers as reminiscent of the hardship and lack of education of the generation that brought CypGr to the UK. In certain cases, the use of CypGr by heritage speakers is actively discouraged by the first generation not only in the public domain but also in private domains such as the home. Active discouragement targets both lexical and grammatical variants that are traditionally associated with basilectal varieties of CypGr, and heritage language features, especially the adoption of morphologically adapted loanwords from English. References Arvaniti, Amalia. 2006/2010. Linguistic practices in Cyprus and the emergence of Cypriot Standard Greek. Mediterranean Language Review 17, 15–45. Benmamoun, Elabbas, Silvina Montrul & Maria Polinsky. 2013. Heritage languages and their speakers: opportunities and challenges for linguists. Theoretical Linguistics 39(3/4), 129–181. Christodoulou-Pipis, Irina. 1991. Greek Outside Greece: Language Use by Greek-Cypriots in Britain. Nicosia: Diaspora Books. Ferguson, Charles A. 1959. Diglossia. Word 15(2), 325–340. Katsoyannou, Marianna, Andreas Papapavlou, Pavlos Pavlou & Stavroula Tsiplakou. 2006. Didialektikes koinotites kai glossiko syneches: i periptosi tis kypriakis [Bidialectal communities and linguistic continuum: the case of Cypriot Greek]. In Mark Janse, Brian D. Joseph & Angela Ralli (eds.), Proceedings of the 2nd International Conference of Modern Greek Dialects and Linguistic Theory, Mytilene, Greece, 30 September – 3 October 2004, 156–171. Patras: University of Patras. Montrul, Silvina A. 2008. Incomplete Acquisition in Bilingualism: Re-examining the Age Factor. Amsterdam/Philadelphia: John Benjamins. Montrul, Silvina. 2015. The Acquisition of Heritage Languages. Cambridge: Cambridge University Press. Moschonas, Spiros. 1996. I glossiki dimorfia stin Kypro [Diglossia in Cyprus]. In “Ischyres” – “Astheneis” Glosses stin Evropaiki Enosi: Opseis tou glossikou igemonismou [“Strong” – “Weak” Languages in the European Union: Aspects of Linguistic Imperialism], 121–128. Thessaloniki: Kentro Ellinikis Glossas. Polinsky, Maria & Olga Kagan. 2007. Heritage languages: in the ‘wild’ and in the classroom. Languages and Linguistics Compass 1(5), 368–395. Tsiplakou, Stavroula, Andreas Papapavlou, Pavlos Pavlou & Marianna Katsoyannou. 2006. Levelling, koineization and their implications for bidialectism. In Frans L. Hinskens (Eds.), Language Variation – European Perspectives: Selected Papers from the Third International Conference on Language Variation in Europe (ICLaVE 3), Amsterdam, June 2005, 265–279. Amsterdam/Philadelphia: John Benjamins.