M Williams’s research while affiliated with Perinatal Institute and other places

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Publications (22)


VP53.01: Reduction of stillbirths in England according to uptake of the Growth Assessment Protocol 2008–2017
  • Article

October 2020

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9 Reads

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3 Citations

Ultrasound in Obstetrics and Gynecology

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M. Williams

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Reduction of stillbirths in England according to uptake of the Growth Assessment Protocol, 2008‐2017: 10 year population based cohort study
  • Article
  • Full-text available

August 2020

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27 Reads

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20 Citations

Ultrasound in Obstetrics and Gynecology

Objective: Antenatal detection of small for gestational age (SGA) can significantly reduce the risk of stillbirth. The Growth Assessment Protocol (GAP) was developed to address the problem that most SGA fetuses are missed antenatally. We set out to analyse the effect that the GAP program had on stillbirth rates in England. Methods: We analysed data from 2008 (before GAP roll-out) to 2017 (latest ONS unit based data). The program consisted of 5 elements (training, evidence based guidelines, customised charts, recording of process and outcome indicators, missed case audit). All maternity units in England were categorised into one of three groups: 1. not in the GAP program; 2. GAP partially implemented (incomplete adoption of protocol, no monitoring and audit) and 3. GAP completely implemented. A subset of the 'complete' group was a cohort of the 20 units with the highest SGA detection rates. Unit level livebirth and stillbirth data were obtained from the Office of National Statistics (ONS) for each of these categories. Results: Stillbirth rates declined across all groups, and significantly more so in units where GAP was completely implemented (P <0.05). The steepest decline was in the units with the 20 best SGA detection rates, showing a 24% lower stillbirth rate (P<0.01) compared to units not using GAP. This remained significant after mixed effect logistic regression of potential confounding including social deprivation (RR 0.76, CI 0.64-0.90). Examination of the nine Bradford Hill causality criteria and associated characteristics suggests that the association between implementation of GAP and reduction of stillbirth rate was causal. Conclusion: There has been an overall reduction in stillbirth rates in England which is likely to be a result of increased awareness and guidelines on the importance of antenatal detection of SGA as a key risk factor for stillbirth. The decline in stillbirth rates was significantly greater in maternity units that had fully implemented the GAP program, and was most pronounced in units with the highest antenatal SGA detection rates. This article is protected by copyright. All rights reserved.

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Figure 2 Quarterly stillbirth rate in Scotland from 2007 to 2018. Rephased median rate (horizontal lines) from 2014 onwards was 3.92 per 1000 births, demonstrating 22.6% sustained improvement. Figure adapted from Healthcare Improvement Scotland 13 .
The Growth Assessment Protocol: a major cause of declining stillbirth rates in the UK

June 2020

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277 Reads

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2 Citations

Ultrasound in Obstetrics and Gynecology


Maternal Cardiac Function in Women at High Risk for Pre-eclampsia Treated With 150 mg Aspirin or Placebo: An Observational Study

January 2020

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25 Reads

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3 Citations

Obstetric Anesthesia Digest

( BJOG . 2020;127:1018–1025) The Aspirin for Prevention of Preterm Pre-eclampsia (ASPRE) trial recently reported that aspirin (150 mg/d) may reduce the risk of preterm and early pre-eclampsia (PE) by 60% and 90%, respectively, in pregnant women screened in their first trimester. Although commonly used for the prevention and treatment of heart attacks or strokes in the general population, aspirin has also been shown to cause high blood pressure and exacerbate pre-existing heart failure. This may be explained in part by the inhibition of PGI 2 , a compensatory vasodilatory prostacyclin which results in vasoconstriction. In pregnant women at high risk for preterm PE, aspirin could lead to unfavorable cardiac outcomes. The aim of this study was to compare the hemodynamic effect of aspirin versus placebo in women at high-risk for preterm PE and to compare this effect in women at low risk versus high risk for developing this condition.



Community midwifery care and social care pathways

March 2015

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938 Reads

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3 Citations

Evidence Based Midwifery

Background. Social issues are an important aspect of maternity care. In 2008, Birmingham Health and Wellbeing Partnership commissioned the West Midlands Perinatal Institute to conduct a regional confidential enquiry into perinatal deaths. As the majority of pregnancy care takes place in the community, a questionnaire accompanied the enquiry in order to give background information concerning workload as well as perceived confidence and competence of community midwives (CMWs) in giving care. Aim. To investigate how well CMWs considered themselves able to deal with social issues and care. Method. A retrospective total population semi-structured postal questionnaire about community midwifery was developed, incorporating workload and provision of care, as well as specific questions about social issues and confidence in making referrals or providing care. All community midwives (n=278) working in six large inner city maternity hospitals in the West Midlands between 2008 and 2009 were sent a questionnaire. As part of a confidential enquiry into perinatal deaths in the West Midlands, ethical approval was not deemed to be necessary. Findings. A total of 213 (77%) of the questionnaires were returned. The majority of the respondents were experienced midwives; 153 (72%) had been qualified for over 10 years, although 71 (33%) had been working within community for less than five years. There was wide variation in knowledge of social care pathways, and in the confidence and compliance of their use. Pathways where CMWs had the highest knowledge were child protection, mental health issues, drugs and alcohol, smoking and teenage pregnancy. All of these areas had high rates of referrals. There was, however, a lack of knowledge of social care pathways for women with physical and learning difficulties, new migrants and asylum-seekers, and those claiming benefit and with housing issues. These areas had low referral rates, and referrals were not consistent with available care pathways. Conclusion. There appeared to be a large disparity in social care offered by CMWs across the trusts surveyed. Many CMWs considered that they were not able to appropriately manage women with specific social needs, most notably new migrants or asylum-seekers and women with learning or physical disabilities. The study highlights the need for clear, standardised social care pathways, as well as training and ongoing support to improve quality and equity of care both within and across trusts. This may also increase CMWs' confidence and competence to appropriately identify and support vulnerable women.


Citations (10)


... Endothelial damage associated with placental dysfunction and a maternal high-risk factor profile contributes to BP elevation, perpetuation of widespread vascular damage, and increased peripheral resistance. In the United Kingdom cohort of the ASPRE (Combined Multimarker Screening and Randomized Patient Treatment with Aspirin for Evidence-Based Preeclampsia Prevention) trial, women underwent hemodynamic evaluation by a bioreactance system, and the cardiac output, stroke volume, and peripheral resistance were registered during different pregnancy stages [23]. Women at low risk of hypertensive complications ineligible for consequent randomization to aspirin or placebo participated in hemodynamic measures evaluation. ...

Reference:

Management of hypertensive disorders in pregnancy: a Position Statement of the European Society of Hypertension Working Group 'Hypertension in Women'
Maternal Cardiac Function in Women at High Risk for Pre-eclampsia Treated With 150 mg Aspirin or Placebo: An Observational Study
  • Citing Article
  • January 2020

Obstetric Anesthesia Digest

... A recent observational study of GAP implementation across the UK also described variation in implementation using nonstandardised outcomes. Their analysis demonstrated a greater reduction of stillbirth rates in maternity units that had completely implemented GAP (defined by reporting the birthweight and outcomes of more than 75% of births via the GAP online tool) compared with those that did not implement GAP [34]. A third of maternity units (31%; n = 29/94) implementing GAP achieved only partial implementation. ...

VP53.01: Reduction of stillbirths in England according to uptake of the Growth Assessment Protocol 2008–2017
  • Citing Article
  • October 2020

Ultrasound in Obstetrics and Gynecology

... Existen además curvas de crecimiento personalizadas, cuyas fórmulas incluyen características maternas y fetales como la talla, peso pregestacional, paridad y sexo fetal. Varios estudios han justificado su uso (8)(9)(10) , pero otros no están de acuerdo con estas consideraciones (11,12) . Por tanto, existe discrepancia entre los médicos sobre cuál de las curvas se deben usar para clasificar el crecimiento fetal (13) . ...

Reduction of stillbirths in England according to uptake of the Growth Assessment Protocol, 2008‐2017: 10 year population based cohort study

Ultrasound in Obstetrics and Gynecology

... A report based on data from Scotland claimed that stillbirths there declined already before GAP was implemented [48]. However the study was demonstrably flawed [49]: although the information was available well before their analysis was undertaken, the authors failed to include data from the following years where the stillbirth rate rose again, showing that the pre GAP drop was temporary and probably associated with a concurrent research study with higher scanning rates being rolled out in Scottish units [50]. Following subsequent GAP implementation, the stillbirth rate showed a sustained decline, in line with trends observed in English regions [49]. ...

The Growth Assessment Protocol: a major cause of declining stillbirth rates in the UK

Ultrasound in Obstetrics and Gynecology

... Community midwifery interventions focus on health education, support, screening, surveillance, and promoting a culture of respectful maternity care [36,37]. These findings align with other studies and policy actions that have investigated the scope of midwifery practice in community care [37][38][39]. In a community health context, these public health interventions primarily aim to address social determinants of health (SDOH) in maternity care to reduce health inequalities and disparities and improve pregnancy and childbirth outcomes [40]. ...

Community midwifery care and social care pathways

Evidence Based Midwifery

... 12 In 2013, the Perinatal Institute of the UK introduced the growth assessment protocol (GAP), which is a care bundle that includes the use of customized centile charts for fundal height and estimated fetal weight (EFW) measurements (gestation-related optimal weight [GROW] charts), evidence-based protocols and risk assessment, training and accreditation of clinical staff, a rolling audit program and benchmarking of performance. 13 Following its recommendation by the Royal College of Obstetricians and Gynecologist guidelines, the uptake of GROW charts or GAP increased between 2008 and 2017 in the UK, with a concomitant 22% reduction of stillbirth rates in regions of high uptake. 14 However, a study reported a more pronounced decline in stillbirths in Scotland (where the GAP uptake is very low) than in England and Wales, suggesting that the reductions in stillbirth rates were coincidental rather than causal. ...

The Growth Assessment Protocol: a national programme toimprove patient safety in maternity care
  • Citing Article
  • January 2013

... There is increasing evidence that TNF-α is also linked to other pro-inflammatory conditions of pregnancy, such as villitis of unknown etiology (VUE) [11][12][13][14], preeclampsia [15,16] and recurrent pregnancy loss [17]. The important role of TNF-α in placental inflammation is supported by data from animal studies. ...

Preventing stillbirths through improved antenatal recognition of pregnancies at risk due to fetal growth restriction
  • Citing Article
  • August 2014

Public Health

... 21 From discussion with our colleagues in the UK, we learned that standardized reviews of adverse perinatal outcomes helped to identify underlying preventable causes, and they have underpinned significant reductions in stillbirths in the West Midlands of England. 22 Recent evaluation of a pilot of the SCOR application in 17 maternity units in the United Kingdom found it to be a useful tool for assessing and learning lessons from adverse outcomes. 22,23 One of the challenges of testing this tool was that there was no accepted standard for comparison. ...

PPO.35 The SCOR programme for perinatal death reviews: results of pilot and user survey
  • Citing Article
  • June 2014

Archives of Disease in Childhood - Fetal and Neonatal Edition

... A West Midlands audit of 'current practice' in scan regimes afforded to pregnancies with a past history of SGA birth -a clinically undisputed indication for serial scans in subsequent pregnanciesfound that the median number of scans performed was between 2 and 3 only, and 21% of these high-risk pregnancies had no third trimester scan at all. 9 The audit highlighted the importance of scan frequency: a one scan policy (usually at 32 weeks) or two scans (usually at 28 and 34 weeks) resulted in a detection rate of around 30%, which was little better than doing no scans at all. ...

PFM.70 Effect of serial scan frequency on antenatal detection of fetal growth restriction
  • Citing Article
  • June 2014

Archives of Disease in Childhood - Fetal and Neonatal Edition

... Midwife's workforce is suspected to be heavy because needed professional ability that demanding concentration and skills. 2 Midwifery care had a important role in the reduction of maternal and newborn mortality and morbidity. 3 Mortality becomes one of the condition that causes stress and anxiety in the midwifery practice in developing countries. ...

Community midwife caseloads and their effect on stress and performance

Archives of Disease in Childhood - Fetal and Neonatal Edition