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293 Investigation into the implementation of shared decision-making to support pregnant women with hypertension plan childbirth
  1. Rebecca Whybrow,
  2. Louise Webster,
  3. Jane Sandall
  1. Methodologies Department, King’s College London, London, UK

Abstract

Introduction Hypertension in pregnancy is one of the leading causes of maternal mortality worldwide1 and although mortality is declining in the UK,2 women can still experience substantial morbidity from complications such as eclampsia.3 Additionally, perinatal mortality remains high, with the UK population-attributable risk of stillbirth from chronic hypertension at 14%4 and around half of all neonates born to mothers who have had severe hypertension in pregnancy being admitted to the neonatal unit.5 There is a lack of evidence regarding optimal timing of birth in women who have hypertension in pregnancy. Early term birth reduces the likelihood of the woman developing pre- eclampsia and the occurance of stillbirth, but is not itself without risk (risk of fetal neurodevelopmental delay, admission to neonatal unit and caesarean section). National guidance recommends planning birth based on maternal and fetal indications using the principles of shared decision-making (SDM).

Methods We used a multiple method multisite approach to establish implementation of SDM to support timing and mode of birth decision-making. To assess implementation we used a national survey of healthcare professionals (n=97), case notes review (n=55), structured observations (n=42) and semi-structured qualitative interviews with healthcare professionals (n=13) and pregnant women (n=18).

Results Analysis is ongoing and will be available prior to the ISDM conference. Early findings: most women were offered delivery before 40 weeks gestation and half of women had a caesarean section. SDM was not implemented with fidelity in many cases. Sub-optimal implementation of SDM impacted women’s experience of antenatal care. Healthcare professionals report the absence of evidence about optimal timing of birth, lack of training in SDM and absence of SDM tools as barriers to implementation.

Conclusion SDM interventions are required to support professional, and women with hypertension, plan timing and mode of birth.

References

  1. Bramham K, Parnell B, Nelson-Piercy C, et al. Chronic hypertension and pregnancy outcomes: systematic review and meta-analysis. BMJ: British Medical Journal 2014;348:g2301. doi: 10.1136/bmj.g2301

  2. Knight MNM, Tuffnell D, Kenyon S, Shakespeare J, Brocklehurst P, Kurinczuk JJ (Eds.) on behalf of MBRRACE-UK. . Saving Lives, Improving Mothers’ Care − Surveillance of maternal deaths in the UK 2012−14 and lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009;14:2016.

  3. Magee LA, von Dadelszen P, Rey E, et al. Less-tight versus tight control of hypertension in pregnancy. N Engl J Med 2015;372(5):407–17. doi: 10.1056/NEJMoa1404595 [published Online First: 2015/01/30]

  4. Flenady V, Koopmans L, Middleton P, et al. Major risk factors for stillbirth in high-income countries: a systematic review and meta-analysis. Lancet 2011;377(9774):1331–40. doi: 10.1016/S0140-6736(10)62233-7 [published Online First: 2011/04/19]

  5. Magee LA, von Dadelszen P, Singer J, et al. The CHIPS Randomized Controlled Trial (Control of Hypertension in Pregnancy Study): Is Severe Hypertension Just an Elevated Blood Pressure? Hypertension 2016;68(5):1153–59. doi: 10.1161/HYPERTENSIONAHA.116.07862 [published Online First: 2016/09/14]

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