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.

Analysis of maternal and child health policies in Malawi: The methodological perspective

The question of why most health policies do not achieve their intended results continues to receive a considerable attention in the literature. This is in the light of the recognized gap between policy as intent and policy as practice, which calls for substantial research work to understand the factors that improve policy implementation. Although there is substantial work that explains the reasons why policies achieve or fail to achieve their intended outcomes, there are limited case studies that illustrate how to analyze policies from the methodological perspective. In this article, we report and discuss how a mixed qualitative research method was applied for analyzing maternal and child health policies in Malawi. For the purposes of this article, we do not report research findings; instead we focus our dicussion on the methodology of the study and draw lessons for policy analysis research work. We base our disusssion on our experiences from a study in which we analyzed maternal and child health policies in Malawi over the period from 1964 to 2008. Noting the multifaceted nature of maternal and child health policies, we adopted a mixed qualitative research method, whereby a number of data collection methods were employed. This approach allowed for the capturing of different perspectives of maternal and child health policies in Malawi and for strengthening of the weaknesses of each method, especially in terms of data validity. This research suggested that the multidimensional nature of maternal and child health policies, like other health policies, calls for a combination of research designs as well as a variety of methods of data collection and analysis. In addition, we suggest that, as an emerging research field, health policy analysis will benefit more from case study designs because they provide rich experiences in the actual policy context.

Business Process Redesign in Information Technology Incident Management: A teaching case

This paper consists of a detailed case narrative on how a leading Australian Finance organisation has utilised contemporary Business Process Management (BPM) concepts for improving the IT incident management processes within the whole organisation. The target audience includes practitioners who are interested in BPM case studies and Academics who may be seeking case studies for innovative teaching practices.

IT service desk process improvement : a narrative style case study

This paper is a detailed case narrative on how a Faculty of a leading Australian University conducted a rigorous process improvement project, applying fundamental Business Process Management (BPM) concepts. The key goal was to increase the efficiency of the faculty’s service desk. The decrease of available funds due to reducing student numbers and the ever increasing costs associated with service desk prompted this project. The outcomes of the project presented a set of recommendations which leads to organizational innovation having information technology as an enabler for change. The target audience includes general BPM practitioners or academics who are interested in BPM related case studies, and specific organisations who might be interested in conducting BPM within their service desk processes.

Who or what decides how stakeholders are optimally engaged by governance networks delivering public outcomes?

As the problems involving infrastructure delivery have become more complex and contentious, there has been an acknowledgement that these problems cannot be resolved by any one body working alone. This understanding has driven multi-sectoral collaboration and has led to an expansion of the set of actors, including stakeholders, who are now involved in delivery of infrastructure projects and services. However, more needs to be understood about how to include stakeholders in these processes and the optimal ways of developing the requisite combination of stakeholders to achieve effective outcomes. This thesis draws on stakeholder theory and governance network theory to obtain insights into how three networks delivering public outcomes within the Roads Alliance in Queensland engage with stakeholders in the delivery of complex and sensitive infrastructure services and projects. New knowledge about stakeholders will be obtained by testing a model of Stakeholder Salience and Engagement which combines and extends the stakeholder identification and salience theory (Mitchell, Agle, and Wood, 1997), ladder of stakeholder management and engagement (Friedman and Miles, 2006) and the model of stakeholder engagement and moral treatment of stakeholders (Greenwood, 2007). By applying this model, the broad research question: “Who or what decides how stakeholders are optimally engaged by governance networks delivering public outcomes?” will be addressed. The case studies will test a theoretical model of stakeholder salience and engagement which links strategic management decisions about stakeholder salience with the quality and quantity of engagement strategies for engaging different types of stakeholders. The outcomes of this research will contribute to and extend stakeholder theory by showing how stakeholder salience impacts on decisions about the types of engagement processes implemented. Governance network theory will be extended by showing how governance networks interact with stakeholders through the concepts of stakeholder salience and engagement. From a practical perspective this research will provide governance networks with an indication of how to optimise engagement with different types of stakeholders.

Decision - Support Software Tool Handbook

The road and transport industry in Australia and overseas has come a long way to understanding the impact of road traffic noise on the urban environment. Most road authorities now have guidelines to help assess and manage the impact of road traffic noise on noise-sensitive areas and development. While several economic studies across Australia and overseas have tried to value the impact of noise on property prices, decision-makers investing in road traffic noise management strategies have relatively limited historic data and case studies to go on. The perceived success of a noise management strategy currently relies largely on community expectations at a given time, and is not necessarily based on the analysis of the costs and benefits, or the long-term viability and value to the community of the proposed treatment options. With changing trends in urban design, it is essential that the 'whole-of-life' costs and benefits of noise ameliorative treatment options and strategies be identified and made available for decisionmakers in future investment considerations. For this reason, CRC for Construction Innovation Australia funded a research project, Noise Management in Urban Environments to help decision-makers with future road traffic noise management investment decisions. RMIT University and the Queensland Department of Main Roads (QDMR) have conducted the research work, in collaboration with the Queensland Department of Public Works, ARUP Pty Ltd, and the Queensland University of Technology. The research has formed the basis for the development of a decision-support software tool, and helped collate technical and costing data for known noise amelioration treatment options. We intend that the decision support software tool (DST) should help an investment decision-maker to be better informed of suitable noise ameliorative treatment options on a project-by-project basis and identify likely costs and benefits associated with each of those options. This handbook has been prepared as a procedural guide for conducting a comparative assessment of noise ameliorative options. The handbook outlines the methodology and assumptions adopted in the decision-support framework for the investment decision-maker and user of the DST. The DST has been developed to provide an integrated user-friendly interface between road traffic noise modelling software, the relevant assessment criteria and the options analysis process. A user guide for the DST is incorporated in this handbook.

Case study of collaborative learning in two contexts : what do English language learners gain?

This chapter describes the use of collaborative learning as an approach to enhance English language learning by students from non-English speaking backgrounds. Communicative Language Teaching (CLT) principles were applied to two case studies, one comprising of undergraduate English as Foreign Language Learners in Turkey and the other involved English as Second Language learners in Australia. Social constructivism inspired communicative language teaching using collaborative learning activities such as team work, interactive peer-based learning, and iterative stages of learning matrix were incorporated to enhance students' learning outcomes. Data collected after the CLT intervention was made up of field notes, reflective logs and focus group interviews which revealed complementarities, as well as subtle differences between the two cases. The findings were summarized as learning dispositions; speaking fluency and confidence; learning diagnostics and completion deficiencies; task engagement, flow theory and higher order thinking skills; in addition to self efficacy and development of student identity. CLT has the potential to provide a more inclusive and dynamic education for diverse learners through vital outcomes and benefits which resonate with the real world.

Maltreated children in the early years : international perspectives on the teacher’s role

Child abuse and neglect is a significant health and social problem with serious consequences for children, families and communities. This chapter provides students, early childhood teachers, and administrators with an evidence base for understanding their role in relation to child abuse and neglect. The chapter draws from international and interdisciplinary research to address four key areas of responsibility: i) recognising signs of child abuse and neglect; ii) reporting child abuse and neglect; iii) supporting children in the classroom; and iv) teaching children to protect themselves (Watts, 1997).

Psychological treatment dropout among pathological gamblers

Premature dropout from treatments for pathological gambling is potentially of significant importance, if it occurs before substantial progress has been made in addressing the problem. A systematic review of current research on dropout from psychological treatments for pathological gambling identified 12 studies from five countries. Dropout ranged from 14% to 50%, with a median of dropout 26%. Overall, 31% of the participants dropped out of treatment. Few studies distinguish between dropouts at different stages of participation. The evidence on specific variables that predict dropout is limited or inconsistent, and is characterised by a lack of a coherent, gambling-specific model and by methodological problems. Two studies that attempted to apply motivational and compliance-enhancing techniques were found. Both showed promising effects on reduction of dropout and improvement of short-term impact of treatment, but inconsistent results on longer-term outcomes were obtained. The review highlighted a need for more rigorous investigation of the extent of dropout and of variables associated with dropout from pathological gambling treatment programs. Further research on interventions to enhance retention and reduce dropout from psychological treatment is also required.

An intervention for substance abuse in schizophrenia

Describes a cognitive-behavioral intervention for alcohol and cannabis abuse with schizophrenic patients. The intervention integrates substance abuse treatment with other aspects of psychosis management, including assessment, use of anti-psychotic medication, and training in coping skills.

In vivo practice for needle phobia : report on two cases

Describes case studies of 2 males (aged 28 and 30 yrs) in which in vivo practice was applied to needle phobia and associated vasovagal fainting. In vivo practice combines skill acquisition with an opportunity to disconfirm negative expectations. Substantial improvements in self-efficacy, anxiety, and performance were obtained. Treatment gains generalized to other settings and were maintained at 3–6 mo follow-up. In vivo practice is recommended for further research into needle phobias.

High quality/high equity systems of education: Curriculum, teachers and reform in the search for equitable outcomes for all students

The issue of what an effective high quality / high equity education system might look like remains contested. Indeed there is more educational commentary on those systems that do not achieve this goal (see for example Luke & Woods, 2009 for a detailed review of the No Child Left Behind policy initiatives put forward in the United States under the Bush Administration) than there is detailed consideration of what such a system might enact and represent. A long held critique of socio cultural and critical perspectives in education has been their focus on deconstruction to the supposed detriment of reconstructive work. This critique is less warranted in recent times based on work in the field, especially the plethora of qualitative research focusing on case studies of ‘best practice’. However it certainly remains the case that there is more work to be done in investigating the characteristics of a socially just system. This issue of Point and Counterpoint aims to progress such a discussion. Several of the authors call for a reconfiguration of the use of large scale comparative assessment measures and all suggest new ways of thinking about quality and equity for school systems. Each of the papers tackles different aspects of the problematic of how to achieve high equity without compromising quality within a large education system. They each take a reconstructive focus, highlighting ways forward for education systems in Australia and beyond. While each paper investigates different aspects of the issue, the clearly stated objective of seeking to delineate and articulate characteristics of socially just education is consistent throughout the issue.

Girl in the Shadows and resilience and coping strategies in contemporary young adult fiction

The novel manuscript Girl in the Shadows tells the story of two teenage girls whose friendship, safety and sanity are pushed to the limits when an unexplained phenomenon invades their lives. Sixteen-year-old Tash has everything a teenage girl could want: good looks, brains and freedom from her busy parents. But when she looks into her mirror, a stranger’s face stares back at her. Her best friend Mal believes it’s an evil spirit and enters the world of the supernatural to find answers. But spell books and ouija boards cannot fix a problem that comes from deep within the soul. It will take a journey to the edge of madness for Tash to face the truth inside her heart and see the evil that lurks in her home. And Mal’s love and courage to pull her back into life. The exegesis examines resilience and coping strategies in adolescence, in particular, the relationship of trauma to brain development in children and teenagers. It draws on recent discoveries in neuroscience and psychology to provide a framework to examine the role of coping strategies in building resilience. Within this broader context, it analyses two works of contemporary young adult fiction, Freaky Green Eyes by Joyce Carol Oates and Sonya Hartnett’s Surrender, their use of the split persona as a coping mechanism within young adult fiction and the potential of young adult literature as a tool to help build resilience in teen readers.

An evaluation framework for educational reform projects for teacher quality improvements in developing countries : a case study of Egyptian education reform

The role of the evaluation for Official Development Assistance (ODA) enterprises including educational development has become critical after increasing “aid fatigue” experienced by the international community in the 1990s. To date, however, monitoring and evaluating outcomes of the projects has been limited to the project life. Consequently these have been mainly through the international aid agencies. Furthermore, the monitoring and evaluation led by international aid agencies have paid little attention to aspects of the sustainability of technical cooperation in educational development. To sustain the impact of technical cooperation, the reinforcement of evaluation has drawn increasing attention in light of the emerging modalities in international development. Therefore this research was inspired to investigate alternative evaluation frameworks for an educational reform project for teacher quality improvement that may increase possibilities for long term sustainability. Importantly, the new modalities in international development and educational issues provide new options. In addition, the research reviewed theoretical and practical issues surrounding evaluation in general, and highlighted the evaluation of education reform projects. The research reported explored via case studies, the evaluation processes employed by the Egyptian education reform projects implemented by the Japan International Cooperation Agency (JICA) and the United Nations Children’s Fund (UNICEF). The case studies used three data sources (archival and relevant documents, a survey questionnaire and interviews) to illuminate the contextually-embedded evaluation processes. The research found that process evaluation is a potential alternative method since it is likely to be locally institutionalised, which may yield long-term sustainability of the projects.