Exploring the sustainable impacts of a clinical healthcare research scholarship programme.

BACKGROUND: The NHS is the first public body globally to commit to net zero. AIM: This study aimed to explore the environmental sustainability impact of a hospital scholarship programme. METHOD: A sustainable quality improvement value framework was used to measure the programme's environmental, social and financial effects. RESULTS: The social impact through face-to-face contact was most valued by scholars; there were also savings in carbon emissions and costs. DISCUSSION: Training in sustainability is essential for the workforce but little infrastructure and expertise are available within organisations to support staff to provide sustainable healthcare in day-to-day practice. CONCLUSION: Sustainable healthcare should be supported by education and national guidance and implementation plans should be drawn up to this end. The social impact of the framework used is often seen as less important than its environmental and financial components; however, as its value to scholars illustrates, the components are intertwined and should be considered of equal importance.

Development of a standardized peer review and oversight process in cases of suspected child physical abuse.

Peer review of medical opinions provided in cases of suspected child physical abuse is generally considered to be best practice for pediatricians engaged in this field. However, there are no published standardized guidelines on how pediatricians should undertake physical abuse peer review including case selection and process. Due to the high-stakes nature in the field of child abuse pediatrics, rigorous quality assurance practices and oversight mechanisms are essential to safeguard children, families, health care providers, and intersecting systems. The Suspected Child Abuse and Neglect program at The Hospital for Sick Children, Toronto, Canada developed a structured peer review process for cases of suspected physical abuse. Included in the process is an approach for the evaluation of institutional complaints received related to a child abuse pediatrician's medical opinion. This quality assurance process is presented so that other child abuse pediatricians and programs may replicate or adapt the protocol for their own local context.

IPV Routine Enquiry in Antenatal Care: Perspectives of Women and Healthcare Professionals-A Qualitative Study.

Despite one in three women experiencing abuse by an intimate partner in their lifetime, intimate partner violence (IPV) is under-reported. Globally, IPV routine enquiry is used as part of healthcare response to addressing IPV. This paper presents the views of pregnant women (n = 40) and providers (n = 30) of IPV routine enquiry as part of antenatal care policy in Ireland. Respondents supported IPV routine enquiry as part of usual antenatal care, and while immediate disclosure was recognized as important, it was not a primary expectation. Routine enquiry was seen as a woman's right and a providers' duty to provide holistic, empowered, women centered and safe care and where provision of information and education on IPV is as fundamental as the disclosure of abuse.

[Maternal mortality in France, 2016-2018, frequency, causes and women's profile]. / Mortalité maternelle en France, 2016­2018, fréquence, causes et profil des femmes.

OBJECTIVE: To describe, for the 2016-2018 period, the frequency, causes and risk factors of maternal deaths in France. METHOD: Data from the National Confidential Enquiry into Maternal Deaths for 2016-2018. RESULTS: For 2016-2018, 272 maternal deaths occurred in France up to 1 year after the end of pregnancy, i.e a maternal mortality ratio of 11.8 per 100,000 live births (95 % CI 10.4-13.3), and 8.5 (IC 95 % 7.4-9.8) for maternal mortality up to 42 days. Compared to women aged 20-24, the risk of maternal death is multiplied by 2.6 for women aged 35-39, by 5 for women aged 40 and over. Obese women are twice as frequent among maternal deaths (26 %) than in the general population of parturients (11 %). There are territorial disparities -the maternal mortality ratio in the French overseas departments is 2 times higher than in metropolitan France (significant difference but smaller than in 2013-2015)-, and social disparities -the mortality of migrant women remains higher than that of women born in France, particularly for women born in sub-Saharan Africa whose risk is 3 times higher than that of native women. One in three women who died (34 %) had socio-economic vulnerability versus 22 % in the overall population of parturients. Among causes of maternal deaths, the predominant role of psychiatric conditions (mostly suicides) is confirmed for the period 2016-2018, leading cause of maternal mortality considered up to 1 year (17 %), MMR of 1.9/100,000 NV. i.e. approximately one death from psychiatric causes every 3 weeks. Cardiovascular diseases are the second leading cause of maternal mortality up to one year (14 %) and the leading cause up to 42 days (16 %), with 1.3 deaths per 100,000 NV. Amniotic fluid embolism ranks as the third cause (8 %) (2nd cause, 11 %, for MM limited to 42 days), i.e. MMR of 0.9 per 100,000 NV. After a regular decline over the last decade, maternal mortality from obstetric hemorrhage is at a stable level compared to the previous triennium 2013-2015, MMR of 0.9/100,000 NV, i.e 5th cause of MM up to one year (7 %) and 4th cause of MM up to 42 days. CONCLUSION: The overall national maternal mortality ratio does not show a downward trend, even with constant surveillance method. Territorial inequalities persist but change in their magnitude and in the regions concerned. The profile of the causes of maternal mortality up to one year of the pregnancy end shows the leading role of suicides and cardiovascular diseases, which illustrates that the health of pregnant women or those who have recently given birth is not limited to the obstetric domain, and highlights the importance of multidisciplinarity in the management and organization of care for women in this period.

[National confidential enquiry into maternal deaths in France, a 25-year enhanced surveillance system, essential for the reliable characterization of maternal deaths]. / Enquête Nationale Confidentielle sur les Morts Maternelles en France, un système de surveillance améliorée depuis 25 ans, indispensable pour la caractérisation fiable des décès maternels.

Although maternal mortality is rare in wealthy countries, it remains a fundamental indicator of maternal health. It is considered to be a "sentinel event", the occurrence of which indicates dysfunctions, often cumulative, in the healthcare system. In addition to the classic epidemiological surveillance findings - number of deaths, maternal mortality ratio, distribution of medical causes, sub-groups of women at risk - its study, through a precise analysis of the history of each woman who died, enables to highlight areas for improvement in the content or organisation of care, the correction of which will make it possible to prevent not only deaths but also upstream morbid events involving the same mechanisms. To achieve this dual epidemiological and clinical audit objective, an ad hoc "enhanced" system is needed. France has had such a system since 1996, the Enquête Nationale Confidentielle sur la Mortalité Maternelle (ENCMM), under the joint supervision of Santé Publique France and Inserm. The ENCMM method aims to identify maternal deaths exhaustively and reliably up to 1 year after the end of pregnancy, and to document each death as fully as possible. The 1st step is the multi-source identification (direct declaration, death certificates, linkage with birth certificates, hospital stay database) of women who died during pregnancy or in the year following its end. The 2nd step is the collection of detailed information for each death by a pair of clinical assessors. The 3rd step is the review of these anonymised documents by the National Expert Committee on Maternal Mortality, which establishes the maternal nature of the death (causal link with pregnancy) and, with a stated aim of improvement rather than judgement, assesses the adequacy of care and the preventability of the death. The summary of the information gathered for maternal deaths in the 2016-2018 period is presented in the other articles of this special issue.

[Maternal mortality, adequation of care and preventability, France 2016-2018]. / Mortalité maternelle, adéquation des soins et évitabilité, France 2016­2018.

OBJECTIVE: To describe, for the 2016-2018 period, the adequacy of care provided to women who died of maternal death in France, as well as the possible preventability of these deaths. METHOD: National data from the Enquête Nationale Confidentielle sur les Morts Maternelles for 2016-2018. For each maternal death identified, the National Expert Committee on Maternal Mortality (CNEMM) assesses the adequacy of the care provided and whether the death was probably, possibly or not preventable. RESULTS: For 2016-2018, 272 maternal deaths (considered up to 1 year after the end of pregnancy) occurred in France. Of these, 265 had sufficient information collected by the confidential survey and could be assessed by the CNEMM. In total, care was judged to be "sub-optimal" for 66% of deaths assessed for all causes, a proportion similar to that for previous periods. In addition to the obstetric and anaesthetic care provided at the time of the acute complication, which was judged to be sub-optimal for 45% (obstetric care) and 38% (anaesthetic care) of maternal deaths, this report highlights the scope for improvement in other types of care, more related to prevention and screening: "sub-optimal" preconception care for 51% of the women who died for whom it was justified, particularly notable for deaths linked to a preexisting condition (52%) and for suicides (67%); prenatal surveillance judged to be "sub-optimal" in 30% of cases, a sub-optimality also more frequent among deaths linked to a preexisting condition (35%) and suicides (34%). In all, 59.7% of maternal deaths assessed were judged to be "probably" (17%) or "possibly" (42.7%) preventable, a profile that remained stable. Suicide and other psychiatric causes, the leading cause of maternal death, were considered to be potentially preventable in 79% of cases. Deaths from haemorrhage remained largely preventable (95%, the highest proportion by cause). The factor most often implicated was inadequate care, and preventability linked to this factor was identified in 53% of deaths, all causes combined. Gap in organization of care was a preventability factor identified in 24% of deaths, and poor interaction between the woman and the healthcare system in 22% of deaths. CONCLUSION: This proportion of more than half of potentially preventable maternal deaths shows that a reduction in maternal mortality in France is still possible and must be achieved, the objective being to prevent all preventable deaths. Analysis of the factors involved, overall and by cause of death, suggests areas for improvement.

Routine Sensitive Enquiry of Adult Interpersonal Trauma in Community Mental Health Teams: An Audit of the Initial Assessment Tool.

This audit aimed to evaluate the utility of the Initial Assessment Tool (IAT) in documenting routine sensitive enquiry of adult interpersonal trauma within three Community Mental Health Teams (CMHTs) in North-East Glasgow. In addition, it sought to evaluate if disclosures informed patient risk assessments and if patients were signposted to additional support services. 57% of 90 IATs had evidence of routine sensitive enquiry. Of 51 casefiles with evidence of routine sensitive enquiry, 61% had evidence of the information informing their risk assessments and 14% had documented recommendations of support organisations. The IAT appeared able to assist clinicians with routine sensitive enquiry in adulthood. However, there may be advantage in supporting staff understanding of how to ask questions to specific populations and to use this information to inform treatment planning. Given the prevalence of adult interpersonal trauma experienced by patients presenting to CMHTs, trauma-informed approaches to care should be implemented.

Bruises in Premobile Infants: A Contested Area of Research, Policy and Practice.

This paper provides an analysis of the procedures adopted by statutory safeguarding partners throughout England in response to finding bruising in premobile infants. Against the backdrop of empirical research, we begin by challenging the view that bruising in premobile infants can be considered rare and thus suggestive of physical abuse. Then, within the procedure themselves, we point to differences in the definitions of what constitutes a premobile child, differences in the interpretation of research into bruising, and differences in how local authorities require social workers to act. We then discuss the risks involved with over-reaction to bruising in premobile children. Finally, we suggest changes to procedures that would support the appropriate use of discretion by social workers and health staff in this difficult area of practise.

The ongoing importance of the routine enquiry into trauma and abuse and trauma-informed care within mental health trusts in England.

WHAT IS KNOWN ON THE SUBJECT?: A significant number of people with mental health diagnoses have also experienced some form of trauma. In 2008, it was recommended that MHTs in England provide training to MHPs to support them in how to ask their service users about trauma and abuse. It has been identified that staff are not consistently enquiring about trauma and abuse in mental health services. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: A description of how many MHTs in England are providing training for staff to ensure that they enquire about trauma and abuse. The current gaps in the resources available for mental health practitioners and staff. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Much more work and development of trauma-informed care and accessibility of training is needed for MHPs working in MHTs. Most MHTs still need to take the first step of implementing training in trauma-informed care. This should involve ways to ask about trauma and abuse and advice on how to respond to any disclosures made. ABSTRACT: INTRODUCTION: Trauma, abuse and adversities are extremely prevalent for those who access secondary mental health services. Health policy guidance recommends that mental health professionals (MHPs) should routinely enquire about trauma and abuse. Staff training is required to adopt trauma-informed approaches, as research has identified a clear gap in practice. This study provides a baseline measure of the current provision of trauma-informed training in English mental health trusts (MHTs). QUESTION: What trauma-informed training is currently available for MHPs in England? METHOD: A freedom of information request was submitted to 52 MHTs in England to explore the current training available for MHPs in trauma-informed care, routine enquiry into abuse and responding to disclosures. RESULTS: The results showed 70% of respondents reported no available training in trauma-informed care. DISCUSSION: Many MHTs in England do not provide any trauma-informed training (despite existing recommendations from 2008). Does this contribute to the re-traumatisation of patients? IMPLICATIONS FOR PRACTICE: MHTs in England require a responsible and active approach to training MHPs in sensitive routine enquiry into trauma and abuse as a first step to becoming trauma responsive.

Binational confidential enquiry of maternal deaths due to postpartum hemorrhage in France and the Netherlands: Lessons learned through the perspective of a different context of care.

OBJECTIVE: To learn lessons for maternity care by scrutinizing postpartum hemorrhage management (PPH) in cases of PPH-related maternal deaths in France and the Netherlands. METHODS: In this binational Confidential Enquiry into Maternal Deaths (CEMD), 14 PPH-related maternal deaths were reviewed by six experts from the French and Dutch national maternal death review committees regarding cause and preventability of death, clinical care and healthcare organization. Improvable care factors and lessons learned were identified. CEMD practices and PPH guidelines in France and the Netherlands were compared in the process. RESULTS: For France, new insights were primarily related to organization of healthcare, with lessons learned focusing on medical leadership and implementation of (surgical) checklists. For the Netherlands, insights were mainly related to clinical care, emphasizing hemostatic surgery earlier in the course of PPH and reducing the third stage of labor by prompter manual removal of the placenta. Experts recommended extending PPH guidelines with specific guidance for women refusing blood products and systematic evaluation of risk factors. The quality of CEMD was presumed to benefit from enhanced case finding, also through non-obstetric sources, and electronic reporting of maternal deaths to reduce the administrative burden. CONCLUSION: A binational CEMD revealed opportunities for improvement of care beyond lessons learned at the national level.

Evidencing Enquiry Based Learning: An Innovative Approach to Educating Children and Young People's Nursing Students.

This discussion paper gives an overview of an innovative online distance learning pre-registration BSc (Hons) Children and Young People's nursing program underpinned by Enquiry-Based Learning pedagogy. Whilst the program is delivered to all four fields of practice (Adult, Children and Young People, Learning Disability, and Mental Health), in all four nations of the UK (England, Scotland, Wales, and Northern Ireland), the focus here is Children and Young People's nursing. Nurse education programs are delivered in accordance with the Standards for Nurse Education developed by the professional nursing body in the UK. This online distance learning curriculum uses a life-course perspective for all fields of nursing. Students develop the general knowledge and skills to care for all people across the life course but as the program progresses, they learn how to care for people within their own field of practice in greater depth. The educational context of the Children and Young People's nursing program highlights that the use of Enquiry-Based Learning can help address some of the challenges faced by Children and Young People's nursing students. A critical evaluation of Enquiry-Based Learning and its use within the curriculum concludes that Enquiry-Based Learning provides Children and Young People's nursing students with the graduate attributes of being able to communicate with infants, children, young people, and their families, adopt critical thinking to clinical settings and have an ability to find, generate, or synthesize their own knowledge in order to lead and manage evidence-based quality care for infants, children, young people, and their families in a variety of care settings and within interprofessional teams.

Identifying victimisation profiles in people with psychosis and a history of childhood trauma: a latent class analysis.

Background: People with psychosis experience higher rates of childhood victimisation compared to the general population, which may impact on mental health and recovery. This study aimed to identify childhood victimisation profiles in a clinical sample to inform recommendations for routine care. Methods: Participants were 146 adults (ages 19-65 years; M = 42.2) with schizophrenia-spectrum diagnoses reporting trauma. Childhood trauma was assessed using two retrospective measures, and a latent class analysis (LCA) was performed on four trauma types (sexual abuse, emotional abuse, physical abuse and neglect). Multinomial logistic regression investigated demographic differences between the classes. Results: Four distinct childhood trauma classes were identified: Emotional abuse/neglect (n = 29); physical abuse (n = 14); sexual abuse (n = 19); and poly-victimisation (n = 84). There were no differences between the classes in terms of age, ethnicity, relationship status, education or current employment (relative risk (RR) = 0.85-1.27, p > 0.05). Participants in the poly-victimisation class were significantly more likely to be female (RR = 0.22-0.28, p < 0.04). Discussion: Adults with psychosis, particularly females, are likely to report poly-victimisation in childhood. This highlights the need to comprehensively but concisely assess experiences of abuse and neglect in clinical care, in line with trauma-informed approaches.

Grade-focused interactions in higher education: has the pursuit for good grades replaced learning?

Undergraduate science students face immense pressure, both internally and externally, to achieve certain grades. Grade-focused interactions between students and instructors have anecdotally been reported to be increasing. However, no empirical study has yet evaluated students' grade perceptions or the prevalence of these interactions. If we want to change students' grade fixation, we first need to understand it. The purpose of this research study was to investigate the prevalence of and factors that contribute to students' grade-focused interactions. Using a mixed-methods approach via surveys and a quasi-experimental intervention with focus groups and audio recordings of student-instructor interactions, we found that students' perceptions of grades are relatively fixed. Furthermore, although >25% of our respondents reported negotiating a grade, there were no significant perceptual differences or academic values held between students who self-reported engaging in grade-focused interactions and those who did not. Our findings suggest that unless institutional and professional program requirements change, the pressure faced by students and their preoccupation with grades will not change either.NEW & NOTEWORTHY Undergraduate science students face immense pressure to perform academically; this pressure may be linked to grade-focused interactions, which have been anecdotally reported among educators. This study evaluated the prevalence of and motivations underlying this behavior. One-quarter of our study participants self-reported negotiating a grade. The vast majority of respondents perceived that they lost grades (rather than earned them); an intervention to change this "grade loss" mentality failed to have any impact on students' behavior.

'Things we are expected to just do and deal with': Using the medical humanities to encourage reflection on vulnerability and nurture clinical skills, collegiality, compassion, and self-care.

The Vulnerability in Medicine (ViM) program was developed to provide protected time and psychologically safe spaces for third-year medical students to consider challenges in the doctor-patient relationship and the clinical workplace. A suite of discussion-prompts presented in a small-group learning environment provides a springboard for students to reflect on their development as clinicians, understand the personhood of their patients, explore the therapeutic relationship, and consider emotional responses and personal, cultural, and social assumptions that impact on care. The program supports students to recognise vulnerability in themselves, the patient, their tutors, and the wider clinical team, as they face the challenge of aligning the clinician they want to become with ideals of professionalism and the imperfect clinical workplace. This 6­week program focuses on the vulnerability of patients, students, and doctors in a weekly tutorial interposed with clinical placements primarily in geriatric, rehabilitation, or palliative medicine. The tutorials draw from the medical humanities and use experiential, reflective, and narrative learning techniques. They are facilitated by generalist clinicians who model their own vulnerability, humanity, and reflective practice by sharing tutorial tasks equally with students. Students report feeling supported, and appreciate the opportunity to discuss ethical, psychosocial, and emotional aspects of medicine whilst reflecting on what medical practice means to them. Tutors experience a deeper appreciation of student journeys and their own vocations as clinicians and teachers. The sharing of vulnerability exposes the humanity of patients, students, and clinicians, and sustains our whole-person approach to the care of patients, students, and ourselves.

A synthesis of clinical and health system bottlenecks to implementing new WHO postpartum hemorrhage recommendations: Secondary data analysis of the Kenya Confidential Enquiry into Maternal Deaths 2014-2017.

OBJECTIVE: To describe maternal deaths from postpartum hemorrhage (PPH) in Kenya by secondary analysis of the Kenya Confidential Enquiry into Maternal Deaths (CEMD) database and clinical audit of a sample of those deaths, and to identify the perceived challenges to implementing country-specific PPH guidelines. METHODS: A retrospective descriptive study using the Kenyan CEMD database and anonymized maternal death records from 2014-2017. Eight standards from the Kenya National Guidelines for Quality Obstetric and Perinatal Care were selected to perform clinical audit. The process of supporting eight Sub-Saharan African countries to develop country-specific PPH guidelines was described and perceived challenges implementing these were identified. RESULTS: In total, 725 women died from PPH. Most women attended at least one antenatal care visit (67.2%) and most did not receive iron and folate supplementation (35.7%). Only 39.0% of women received prophylactic uterotonics in the third stage of labor. Factors significantly associated with receiving prophylactic uterotonics were place of delivery (χ2  = 43.666, df = 4; P < 0.001), being reviewed by a medical doctor (χ2  = 16.905, df = 1; P < 0.001), and being reviewed by a specialist (χ2  = 49.244, df = 1; P < 0.001). Only three of eight standards had a greater percentage of met cases in comparison to unmet cases. Key concerns about implementation of the new WHO PPH guidance included use of misoprostol by unskilled health personnel, availability of misoprostol and tranexamic acid (TXA) at primary healthcare level, lack of availability of heat-stable carbetocin (HSC) due to cost, lack of awareness and education about HSC and TXA, and lack of systems to ensure quality oxytocin is available at point of care. CONCLUSION: There is a need for improved quality of care for women to minimize the risk of mortality from PPH, by implementing updated clinical guidelines combined with focused health system interventions.

Nationwide confidential enquiries into maternal deaths because of obstetric hemorrhage in the Netherlands between 2006 and 2019.

INTRODUCTION: Obstetric hemorrhage-related deaths are rare in high income countries. Yet, with increasing incidences of obstetric hemorrhage in these countries, it is of utmost importance to learn lessons from each obstetric hemorrhage-related death to improve maternity care. Our objective was to calculate the obstetric hemorrhage-related maternal mortality ratio (MMR), assess causes of obstetric hemorrhage-related deaths, and identify lessons learned. MATERIAL AND METHODS: Nationwide mixed-methods prospective case-series with confidential enquiries into maternal deaths due to obstetric hemorrhage in the Netherlands from January 1, 2006 to December 31, 2019. RESULTS: The obstetric hemorrhage-related MMR in the Netherlands in 2006-2019 was 0.7 per 100 000 livebirths and was not statistically significantly different compared with the previous MMR of 1.0 per 100 000 livebirths in 1993-2005 (odds ratio 0.70, 95% confidence interval 0.38-1.30). Leading underlying cause of hemorrhage was retained placenta. Early recognition of persistent bleeding, prompt involvement of a senior clinician and timely management tailored to the cause of hemorrhage with attention to coagulopathy were prominent lessons learned. Also, timely recourse to surgical interventions, including hysterectomy, in case other management options fail to stop bleeding came up as an important lesson in several obstetric hemorrhage-related deaths. CONCLUSIONS: The obstetric hemorrhage-related MMR in the Netherlands in 2006-2019 has not substantially changed compared to the MMR of the previous enquiry in 1993-2005. Although obstetric hemorrhage is commonly encountered by maternity care professionals, it is important to remain vigilant for possible adverse maternal outcomes and act upon an ongoing bleeding following birth in a more timely and adequate manner. Our confidential enquiries still led to important lessons learned with clinical advice to professionals as how to improve maternity care and avoid maternal deaths. Drawing lessons from maternal deaths should remain a qualitative and moral imperative.

Effect of Recombinant Human Brain Natriuretic Peptide on Acute Carbon Monoxide Poisoning Complicated with Heart Failure with Reduced Ejection Fraction.

This paper aims to observe the effect of recombinant human brain natriuretic peptide (rhBNP) on treatment of acute carbon monoxide poisoning (ACMP) complicated with heart failure with reduced ejection fraction (HFREF).A total of 103 patients with ACMP complicated with HFREF admitted to our department from October 2016 to March 2020 were observed. Patients were divided into control group (50 cases) and experimental group (53 cases). The control group was given diuretic, vasodilator, and digitalis treatment, and the experimental group was supplemented with rhBNP treatment based on the control group. Patients' general information was collected. The levels of myocardial injury-associated indicators of patients were detected at and after admission.No significant differences were observed in the general data of patients compared with control group. The acute physiology and chronic health enquiry II score of patients was positively correlated with left ventricular ejection fraction (LVEF). At admission, the levels of myocardial injury indicators, N-terminal B-type brain natriuretic peptide, and cardiac ultrasound indexes had no significant difference between the control group and experimental group. However, after admission, the LVEF and stroke output levels were elevated, while the other indicators were all decreased compared with the control group.The rhBNP exerts a protective effect on ACMP-induced cardiomyocyte injury to improve cardiac function, shorten the length of hospital stay, and reduce the incidence and mortality of delayed encephalopathy after carbon monoxide poisoning.

Confidential enquiry into maternal deaths in the Netherlands, 2006-2018.

INTRODUCTION: To calculate the maternal mortality ratio (MMR) for 2006-2018 in the Netherlands and compare this with 1993-2005, and to describe women's characteristics, causes of death and improvable factors. MATERIAL AND METHODS: We performed a nationwide, cohort study of all maternal deaths between January 1, 2006 and December 31, 2018 reported to the Audit Committee Maternal Mortality and Morbidity. Main outcome measures were the national MMR and causes of death. RESULTS: Overall MMR was 6.2 per 100 000 live births, a decrease from 12.1 in 1993-2005 (risk ratio [RR] 0.5). Women with a non-western ethnic background had an increased MMR compared with Dutch women (MMR 6.5 vs. 5.0, RR 1.3). The MMR was increased among women with a background from Surinam/Dutch Antilles (MMR 14.7, RR 2.9). Half of all women had an uncomplicated medical history (79/161, 49.1%). Of 171 pregnancy-related deaths within 1 year postpartum, 102 (60%) had a direct and 69 (40%) an indirect cause of death. Leading causes within 42 days postpartum were cardiac disease (n = 21, 14.9%), hypertensive disorders (n = 20, 14.2%) and thrombosis (n = 19, 13.5%). Up to 1 year postpartum, the most common cause of death was cardiac disease (n = 32, 18.7%). Improvable care factors were identified in 76 (47.5%) of all deaths. CONCLUSIONS: Maternal mortality halved in 2006-2018 compared with 1993-2005. Cardiac disease became the main cause. In almost half of all deaths, improvable factors were identified and women with a background from Surinam/Dutch Antilles had a threefold increased risk of death compared with Dutch women without a background of migration.

Exploring nursing students' learning experiences and attitudes toward older persons in a gerontological nursing course using self-regulated online enquiry-based learning during the COVID-19 pandemic: A mixed-methods study.

BACKGROUND: During the COVID-19 pandemic, universities adopted online teaching as the primary teaching and learning method. Most of the online teaching, however, has been limited to the broadcasting of asynchronous lectures and sharing of teaching materials. OBJECTIVES: To explore undergraduate nursing students' self-regulated learning experiences, satisfaction, and attitudes toward older persons in a gerontological nursing course using online self-regulated enquiry-based learning (EBL) during the COVID-19 pandemic. DESIGN: A mixed-methods design was adopted. SETTING: A university in Hong Kong providing pre-registration nursing programmes. PARTICIPANTS: 155 students studying in the fourth year in a five-year Bachelor of Nursing programme participated in the quantitative study in which 18 joined the focus groups (4 groups with group size of 4-5). METHODS: Five video-based scenarios along with two interactive online workshops, a mind-map development exercise, gamified assessments, reading materials, group discussions, and presentations were adopted in a gerontological nursing course offered in 2019-2020 to enhance the students' learning, driven by a process of enquiry. Attitudes toward older people were measured at baseline and one week after the course (post-test). Information on self-regulated learning experiences, satisfaction, and confidence were collected at post-test only. Paired t-tests and descriptive statistics were used to analyse the data. Focus groups were conducted through semi-structured interviews and transcribed verbatim for inductive content analysis. RESULTS: A significant improvement was demonstrated in the students' attitude toward older people. The students appreciated the opportunities provided by the online EBL to apply key concepts of gerontology in the teaching and learning activities and to enhance their critical thinking skills. Three major themes were revealed from the focus group: Perception of the teaching pedagogy, Improvement of cognitive skills, and Positive and negative aspects of the learning experience. CONCLUSIONS: The online self-regulated EBL improved the students' online learning experience in a gerontological nursing course during the pandemic and improved their attitudes toward older people.