Pregnant people's views and knowledge on prenatal screening for fetal trisomy in the absence of a national screening program.

Multiple non-invasive prenatal tests (NIPT) are available to screen for risk of fetal trisomy, however, there is no national prenatal screening program in Republic of Ireland. This study aimed to analyze pregnant people's opinions on availability, cost, and knowledge of NIPT for fetal aneuploidy. An anonymous questionnaire on prenatal screening tests and termination of pregnancy was distributed to patients attending antenatal clinics at a tertiary hospital. Descriptive analyses and chi-squared tests were completed. Among respondents, 62% (200/321) understood the scope of prenatal screening tests, with 77% (251/326) and 76% (245/323) correctly interpreting low- and high-risk test results, respectively. Only 26% (83/319) of participants had heard of NIPT. Chi-square tests showed a higher proportion of these people were ≥40 years old (p-value, <0.001), had post-graduate education (p-value, <0.001), or attended private clinics (p-value <0.001). Over 91% (303/331) of participants said every pregnant person should be offered prenatal screening tests for aneuploidy and 88% (263/299) believed these should be free. While pregnant Irish individuals have reasonable understanding of screening test interpretation, most were unaware of screening options. Additionally, participants' views on availability and associated cost of tests show the need for a national prenatal screening program, including education on fetal aneuploidy. These findings have relevance for countries without screening policies and are pertinent for broader maternity services.

Follow-up and outcomes of patients with a pregnancy of unknown location: A comparison of two prediction models.

BACKGROUND: The time period while delineating the final diagnosis following presentation with a pregnancy of unknown location (PUL) can be an anxious time, as well as being time and resource intensive. Prediction models have been utilised in order to tailor counselling, frame expectations and plan care. OBJECTIVES: We aimed to review diagnoses of PUL in our population and assess the value of two prediction models. STUDY DESIGN: We reviewed all 394 PUL diagnoses over a three year period in a tertiary level maternity hospital. We then retrospectively applied the M1 and M6NP models to assess their accuracy when compared to the final diagnosis. RESULTS: PUL comprises of 2.9% (394/13401) of attendances in our unit, requiring 752 scans and 1613 separate blood tests. Just under one in ten women (9.9%, n = 39) presenting with a PUL had a viable pregnancy at discharge, however of the remainder, only 18.0% (n = 83) required medical or surgical treatment for a PUL. The M1 model was more successful at predicting an ectopic pregnancy than the M6NP, with the latter over-predicting viable pregnancies (33.4%, n = 77). CONCLUSIONS: We demonstrate that the management of women with a PUL could be stratified through the application of outcome prediction models, having positive results for framing expectations and potentially reducing this resource-intensive diagnosis.

Reply to: "The partner-an underutilized facilitator to support healthy gestational weight gain".

Facilitators and barriers influencing weight management behaviours were identified in our meta-synthesis of qualitative research entitled "Facilitators and barriers influencing weight management behaviours during pregnancy: a meta-synthesis of qualitative research". This manuscript is in response to the letter submitted by Sparks et al. regarding that work. The authors highlight the importance of including partners into intervention design when addressing weight management behaviours. We agree with the authors that it is important to include partners into intervention design and further research is granted to identify facilitators and barriers affecting their influence over women. As per our findings, the influence of the social context goes beyond the partner and we suggest that future interventions should address other relevant people in women's contexts such as parents, other relatives, and close friends.

A systematic review of behaviour change techniques used in the context of stillbirth prevention.

BACKGROUND: Stillbirth is one of the most devastating pregnancy outcomes that families can experience. Previous research has associated a wide range of risk factors with stillbirth, including maternal behaviours such as substance use, sleep position and attendance and engagement with antenatal care. Hence, some preventive efforts have been focused on tackling the behavioural risk factors for stillbirth. This study aimed to identify the Behaviour Change Techniques (BCTs) used in behaviour change interventions tacking behavioural risk factors for stillbirth such as substance use, sleep position, unattendance to antenatal care and weight management. STUDY DESIGN: A systematic review of the literature was conducted in June 2021 and updated in November 2022 in five databases: CINHAL, Psyhinfo, SociIndex, PubMed and Web of Science. Studies published in high-income countries describing interventions designed in the context of stillbirth prevention, reporting stillbirth rates and changes in behaviour were eligible for inclusion. BCTs were identified using the Behaviour Change Technique Taxonomy v1. RESULTS: Nine interventions were included in this review identified in 16 different publications. Of these, 4 interventions focused on more than one behaviour (smoking, monitoring fetal movements, sleep position, care-seeking behaviours), one focused on smoking, three on monitoring fetal movements and one on sleep position. Twenty-seven BCTs were identified across all interventions. The most commonly used was "Information about health consequences" (n = 7/9) followed by "Adding objects to the environment" (n = 6/9). One of the interventions included in this review has not been assessed for efficacy yet, of the remaining eight, three showed results in the reduction of stillbirth rates. and four interventions produced behaviour change (smoking reductions, increased knowledge, reduced supine sleeping time). CONCLUSIONS: Our findings suggest that interventions designed to date have limited effects on the rates of stillbirth and utilise a limited number of BCTs which are mostly focused on information provision. Further research is necessary to design evidence base behaviour change interventions with a greater focus to tackle all the other factors influencing behaviour change during pregnancy (e.g.: social influence, environmental barriers).

Exploring first-time mothers' experiences and knowledge about behavioural risk factors for stillbirth.

BACKGROUND: Modifiable factors such as substance use, lack of attendance at antenatal care, overweight or obesity and sleeping position are associated with a higher risk of stillbirth. This qualitative study aimed to explore women's experiences of modifiable factors during pregnancy and their awareness of stillbirth. METHODS: Purposive sampling was implemented by hospital staff in a large tertiary maternity hospital in Ireland between November 2020 and March 2021. Women were approached during their stay in the hospital and were invited to participate in a semistructured interview 3-5 months later. Eligible women were primiparous, >18 years of age and had an uncomplicated pregnancy and delivery. Eighteen women who consented to be followed up were interviewed at 3-5 months postpartum. Thematic analysis was used to analyse the data. RESULTS: Four themes were identified: attitudes towards behaviour change, awareness regarding stillbirth and risk factors, the silence around stillbirth and risks, and attitudes towards receiving information about stillbirth. Women spoke about behaviour change in terms of outcomes, and most changes (e.g., ceasing alcohol consumption) were perceived as easy to manage. Awareness of stillbirth was limited among the women interviewed, and the association between risk behaviours and stillbirth was not known by any woman. Results suggest that there is a silence around stillbirth, including in antenatal care, which hinders information provision. However, most women highlighted the value of receiving information and extra education about modifiable risk factors and stillbirth. CONCLUSION: There is a general lack of understanding of the link between behavioural risk factors and potential pregnancy outcomes such as stillbirth. Providing further information to women about stillbirth and providing additional support with behaviour change might contribute to enhancing preventive efforts. PATIENT OR PUBLIC CONTRIBUTION: Patients were involved in this study by providing their experiences of antenatal care which were used as primary data.

Critical discourse analysis on the influence of media commentary on fatal fetal anomaly in Ireland.

Fatal Fetal Anomaly (FFA) has generated international media attention as termination of pregnancy (TOP) for FFA was legislated for, for the first time in Ireland. Media offers an insight into what health-related information is available to the public and how it is presented to them. The aim of this study was to examine how information related to FFA, TOP for FFA and perinatal palliative care (PPC) were framed in Irish published media. A critical discourse analysis, which examines the relations between discourse and social and cultural phenomena was implemented. Habermasian's framework facilitated an objective analysis of the text, to facilitate interpretation and understanding of socially produced meanings. A broadsheet and journal were chosen. Dated from 2012 to 2017, 129 articles were identified. Themes of personification of the unborn, human rights and power and politics were embedded in the discourse, creating political influence to sway perceptions and views. Terminology were chosen by different ideological perspectives to create varying contexts and support arguments. PPC was suppressed within the published media. This study highlights misrepresentations in the information delivered to the public and suggests the need for healthcare professionals to expand their media literacy and develop these skills with their patients.

A qualitative review of challenges in recruitment and retention in obstetrics and gynecology in Ireland: The consultants' solution based perspective.

AIM: Recruitment and retention remains a concern in obstetrics and gynecology, with consultants having a unique perspective on the daily challenges. We aimed to examine these and examine their solutions to future-proofing the workforce. METHODS: Primary data were collected from consultant obstetrician-gynecologists in the Republic of Ireland. Using a qualitative methodology, semi-structured interviews were conducted with 17 participants recruited through purposive sampling. Following transcription, deductive content analysis was conducted to identify themes and categories with respect to challenges and solutions in the specialty. RESULTS: Findings revealed four superordinate themes of professional and personal factors, opinions of the specialty and the role of the consultant. Respondents expressed fear about low morale in the specialty, but also threats posed by resource availability and training limitations, in addition to medico-legal and media challenges. Solutions centered around re-evaluating training pathways and implementing improved advocacy and support structures for the specialty and for those working within it. CONCLUSIONS: This study provides a unique standpoint from which to explore an international in obstetrics and gynecology. Its solution-based outlook provides the framework to implement changes to protect and retain the current workforce as well as future-proofing recruitment to secure the specialty.

Induction of labor: reviewing the past to improve the future.

BACKGROUND: Women undergoing induction of labor should be empowered with accurate information. OBJECTIVE: This study aimed to examine the characteristics of and indications for induction of labor and delivery outcomes to help inform practice and counseling. STUDY DESIGN: We conducted a retrospective cohort study of all singleton pregnancies undergoing induction of labor over a 3-month period in a tertiary-level hospital in the Republic of Ireland. Data were obtained from paper and electronic registries. Descriptive and inferential statistics were performed on data collected. RESULTS: There were 1084 women delivered, with an induction rate of 46.0% (n=499). Primiparous women were more likely to be induced compared with multiparous women (51.4%; n=254/494 vs 41.5%; n=245/590; P<.001), and were more likely to be induced for postmaturity (30.7%; n=78/254 vs 23.6%; 58/245; P≤.001). More than half (50.3%; 251/399) were induced before 40 weeks' gestation, irrespective of parity. Multiparous women and those induced for maternal medical indications had a shorter overall time to delivery interval (21.7 hours [standard deviation, 13.0] vs 13.8 hours [standard deviation, 11.2]; P<.001 and 18.3 hours [standard deviation, 12.7] vs 14.7 hours [standard deviation, 12.4]; P<.01). CONCLUSION: Information on induction of labor can aid in the guidance and education of women undergoing the process, educate clinicians for appropriate counseling, and facilitate shared decision-making.

Facilitators and barriers to seeking and engaging with antenatal care in high-income countries: A meta-synthesis of qualitative research.

Inadequate attendance to antenatal care has been associated with negative maternal and fetal outcomes, including stillbirth. This study aimed to identify facilitators and barriers to antenatal care attendance. A systematic search was conducted in March 2019 and updated in January 2021. Qualitative studies involving pregnant or post-partum women up to 12 months from high-income countries that provided data about facilitators and barriers to antenatal care attendance were sought. Meta-ethnography was used to inform this meta-synthesis. Fifteen studies were included in the analysis. Findings indicate that inadequate antenatal care attendance is influenced at different levels. Aspects like sociodemographic factors, difficulties navigating the health system, administrative delays, lack of flexibility and tailored care, constant change of carer and communication issues also act as barriers. These issues affect women's access to knowledge and the formation of women's beliefs and feelings towards seeking care. On the contrary, having a positive attitude towards the pregnancy, encountering empathetic healthcare professionals and availing of social support acted as facilitators. The reasons why women seek or delay attending antenatal care are multifactorial and can be explained using the Social Determinants of Health Framework. Any response needs to be taken across all levels of influence and not just focused on the individual. A better understanding of the barriers and facilitators to antenatal care might contribute to informing intervention or policy development addressing this issue.

Facilitators and barriers influencing weight management behaviours during pregnancy: a meta-synthesis of qualitative research.

BACKGROUND: Obesity and overweight are considered risk factors for a range of adverse outcomes, including stillbirth. This study aims to identify factors reported by women influencing weight management behaviours during pregnancy. METHODS: A systematic search was conducted in five databases from inception to 2019 and updated in 2021. Qualitative studies involving pregnant or post-partum women, from high-income countries, examining women's experiences of weight management during pregnancy were included. Meta-ethnography was used to facilitate the meta-synthesis of 17 studies. RESULTS: Three themes were identified during the analysis: (1) Awareness and beliefs about weight gain and weight management, which included level of awareness and knowledge about dietary and exercise recommendations, risk perception and decision balance, perceived control over health and weight gain and personal insecurities. (2) Antenatal healthcare, women's experiences of their interactions with healthcare professionals during the antenatal period and the quality of the education received had an effect on women's behaviour. Further, our findings highlight the need for clear and direct information, and improved interactions with healthcare professionals, to better support women's weight management behaviours. (3) Social and environmental influence, the social judgement and stigmatization associated with overweight and obesity also acted as a negative influence in womens' engagement in weight management behaviours. CONCLUSION: Interventions developed to promote and maintain weight management behaviours during pregnancy should consider all levels of influence over women's behaviours, including women's level of awareness and beliefs, experiences in antenatal care, education provision and social influence.

How we define recurrent miscarriage matters: A qualitative exploration of the views of people with professional or lived experience.

BACKGROUND: Recurrent miscarriage (RM) affects 1%-3% of women/couples of reproductive age depending on the definition used, for example, whether 2 or ≥3 miscarriages. Stakeholders' views of how RM is defined have received limited attention to date. A definition reflects the medical evidence and values of a society at the time, and thus warrants ongoing review. AIM: We aimed to explore the views of women and men with lived experience of RM, and those involved in the delivery/management of services and supports, on how RM is and/or should be defined. METHODS: We adopted a qualitative study design, incorporating semi-structured interviews. We used purposive sampling to recruit participants in the Republic of Ireland, ensuring diverse perspectives were included. Women and men with lived experience of ≥2 consecutive first-trimester miscarriages were recruited via health professionals and social media; other participants via the research team's networks. Interviews were audio-recorded, transcribed, pseudo-anonymized and analysed using reflexive thematic analysis. FINDINGS: We conducted interviews with 42 health professionals/service providers and 13 women and 7 men with lived experience of RM (June 2020 to February 2021). We generated three interrelated themes from the data: (i) The need for a standardized definition of recurrent miscarriage-Finding a balance between research evidence, individual needs and healthcare resources, (ii) The definition is a route to finding an answer and/or validating women/couples' experience of loss and (iii) Working around the definition-Advocacy and impacts. CONCLUSION: A nuanced approach to defining RM is warranted, one which is evidence-informed recognizes the individual needs of women/couples, and considers healthcare resources. PATIENT OR PUBLIC CONTRIBUTION: Members of the multidisciplinary RE:CURRENT (REcurrent miscarriage: evaluating CURRENT services) Project Research Advisory Group (including four parent advocates, two of whom are co-authors on this article) were actively involved throughout the study, including the generation of topic guides and the refining of themes.

Developing guideline-based key performance indicators for recurrent miscarriage care: lessons from a multi-stage consensus process with a diverse stakeholder group.

BACKGROUND: Standardised care pathways tailored to women/couples who experience recurrent miscarriage are needed; however, clinical practice is inconsistent and poorly organised. In this paper, we outline our processes and experiences of developing guideline-based key performance indicators (KPIs) for recurrent miscarriage care with a diverse stakeholder group which will be used to evaluate national services. To date, such exercises have generally only involved clinicians, with the need for greater stakeholder involvement highlighted. METHODS: Our study involved six stages: (i) identification and synthesis of recommendations for recurrent miscarriage care through a systematic review of clinical practice guidelines; (ii) a two-round modified e-Delphi survey with stakeholders to develop consensus on recommendations and outcomes; (iii) four virtual meetings to develop this consensus further; (iv) development of a list of candidate KPIs; (v) survey to achieve consensus on the final suite of KPIs and a (vi) virtual meeting to agree on the final set of KPIs. Through participatory methods, participants provided feedback on the process of KPI development. RESULTS: From an initial list of 373 recommendations and 14 outcomes, 110 indicators were prioritised for inclusion in the final suite of KPIs: (i) structure of care (n = 20); (ii) counselling and supportive care (n = 7); (iii) investigations (n = 30); treatment (n = 34); outcomes (n = 19). Participants' feedback on the process comprised three main themes: accessibility, richness in diversity, streamlining the development process. CONCLUSIONS: It is important and feasible to develop guideline-based KPIs with a diverse stakeholder group. One hundred and ten KPIs were prioritised for inclusion in a suite of guideline-based KPIs for recurrent miscarriage care. Insights into our experiences may help others undertaking similar projects, particularly those undertaken in the absence of a clinical guideline and/or involving a range of stakeholders.

Women/couples who have recurrent/repeated miscarriages should receive care that meets their needs, through agreed care pathways. This is often not the case. Key performance indicators (KPIs) are measures of specific elements of care (structures, processes and/or outcomes), which can help us to judge the quality of care given. In this paper, we describe how we worked with women and men with lived experience, doctors, nurses, managers, and others, to develop and agree on a list KPIs for recurrent miscarriage care in Ireland. We will use these to check what services are doing across the country and what could be done better. Participants filled out surveys and took part in meetings to vote on and agree on what KPIs were important to include. They also shared their views and experiences of taking part in this work. Together, we developed 110 KPIs for recurrent miscarriage care. These include measures of how care is structured, counselling and supports, investigations and treatments provided, and health-related outcomes. Participants' valued the different views that people brought to discussions and what they learned. They suggested ways that the process could be made more participant-friendly. For example, being up-front about the time it would take, explaining medical terms more, and cutting down on the number of items to be rated in surveys. It is important and possible to develop KPIs with different groups, particularly those with lived experience. Learning from our study may help others who want to do similar projects, such as develop KPIs or guidelines for care.

The impact of COVID-19 on pregnant womens' experiences and perceptions of antenatal maternity care, social support, and stress-reduction strategies.

BACKGROUND: The COVID-19 pandemic has impacted on maternity care, supports and women's mental health. AIM: The aim of this study was to assess pregnant women's satisfaction with antenatal care and social support and to examine stress-reduction strategies women used during the pandemic. METHODS: An online survey was conducted between June and July 2020. Pregnant women, aged over 18 years were recruited. The survey included closed and open-ended questions to assess women's perceptions and satisfaction with their antenatal care, social support, and stress-reduction strategies. Descriptive statistics and multivariate analysis were used for quantitative analyses; qualitative content analysis was used for open-ended questions. FINDINGS: 573 pregnant women completed the survey. Women reported low levels of social support which was predicted by women's mental health and demographic factors and was related to public health and maternity service restrictions. Women reported that restrictions implemented in the maternity services limited their face-to face interactions with healthcare professionals and meant their partners could not attend antenatal appointments or support them in the postpartum period in the maternity setting. The lack of information on COVID-19 and pregnancy meant women had greater uncertainty about pregnancy and birth. DISCUSSION: Our findings indicate how the lack of access to antenatal care and reduced perceived social support as a result of the restrictions implemented in response to the COVID-19 pandemic, potentially intensifies pregnancy specific stress. CONCLUSIONS: There is a need for the provision of supportive care, both formally and informally, particularly with women who may be more vulnerable during a pandemic.

Facilitators and barriers to substance-free pregnancies in high-income countries: A meta-synthesis of qualitative research.

BACKGROUND: Previous studies have associated substance use (alcohol, illicit drugs and smoking) to negative pregnancy outcomes, including higher risk of stillbirth. AIM: This study aims to identify facilitators and barriers reported by women to remain substance free during pregnancy. METHODS: A systematic search was conducted in six databases from inception to March 2019 and updated in November 2020. Qualitative studies involving pregnant or post-partum women, from high-income countries, examining women's experiences of substance use during pregnancy were eligible. Meta-ethnography was used to facilitate this meta-synthesis. FINDINGS: Twenty-two studies were included for analysis. Internal barriers included the perceived emotional and social benefits of using substances such as stress coping, and the associated feelings of shame and guilt. Finding insensitive professionals, the lack of information and discussion about risks, and lack of social support were identified as external barriers. Furthermore, the social stigma and fear of prosecution associated with substance use led some women to conceal their use. Facilitators included awareness of the health risks of substance use, having intrinsic incentives and finding support in family, friends and professionals. DISCUSSION: Perceived benefits, knowledge, experiences in health care settings, and social factors all play important roles in women's behaviours. These factors can co-occur and must be considered together to be able to understand the complexity of prenatal substance use. CONCLUSION: Increased clinical and community awareness of the modifiable risk factors associated with substance use during pregnancy presented in this study, is necessary to inform future prevention efforts.

Prenatal stress, health, and health behaviours during the COVID-19 pandemic: An international survey.

BACKGROUND: Pregnant women's stress, mental and physical health, and health behaviours can have important implications for maternal and child health outcomes. AIM: To examine pregnant women's levels of stress, mental and physical health, and health behaviours during the COVID-19 pandemic. METHODS: A cross-sectional survey was conducted online, with recruitment and data collection occurring between 16/6/20 and 17/7/20. Participants were pregnant women recruited via online pregnancy/parenting communities. Participants self-reported their levels of general stress, pregnancy-specific stress and COVID-19 related stress, mental and physical health, general health behaviours, and COVID-19 related health behaviours. FINDINGS: 573 pregnant women participated in the survey. Participants were most commonly resident in the United States (42.6%, n=243), Ireland (41.2%, n=235) or the United Kingdom (10%, n=57). The majority (80.0%, n=457) were married and educated to degree level or above (79.3, n=453). Pregnant women reported high levels of pregnancy-specific and COVID-19-related stress, and low levels of mental and physical health, during the pandemic. Encouragingly, pregnant women in this study generally reported high levels of adherence to public health advice and pregnancy health behaviours. Stress and general mental health outcomes were best predicted by well-being factors (including stress and social support). Health impairing behaviours (e.g. poor diet) were predicted by both well-being and demographic factors. DISCUSSION: Interventions targeting pregnancy- and pandemic-specific stress at the population level will be essential to support mental health and minimise adverse outcomes for women and children during the pandemic.

Assessing the concordance and accuracy between hospital discharge data, electronic health records, and register books for diagnosis of inpatient admissions of miscarriage: A retrospective linked data study.

BACKGROUND: Despite the high prevalence of miscarriage, there are few studies which assess the concordance of a diagnosis of miscarriage in routinely collected health databases. OBJECTIVES: To determine agreement and accuracy for the diagnosis of miscarriage between electronic health records (EHR), the Hospital Inpatient-Enquiry (HIPE) system, and hospital register books in Ireland. METHODS: This is a retrospective study comparing agreement of diagnosis of miscarriage between three hospital data sources from January to June 2017. All inpatient admissions for miscarriage were reviewed from a single, tertiary maternity hospital in Ireland. Kappa, sensitivity, specificity, positive and negative predictive value were calculated. RESULTS: In this retrospective concordance study, EHR records confirmed 96.2% diagnosis of miscarriage of HIPE records, and 95.1% of register books records. A total of 95 records were not recorded in the register books but were recorded in HIPE and EHR. This study found a considerable variability when comparing definitions of type of miscarriage (i.e., missed miscarriage, incomplete, and complete) between the three data sources. CONCLUSION: Although this study found a high concordance in inpatient admissions for miscarriage between EHR, HIPE, and register books, a considerable discrepancy was found when classifying miscarriage between the three data sources.

A comparative study of two immunoassays of maternal placental growth factor.

Circulating maternal levels of placental growth factor correlates well with placental function and numerous studies advocate its role to help rule-out preterm pre-eclampsia. A number of automated immunoassay platforms to quantify placental growth factors are currently available. The aim of this study was to highlight the importance of developing and validating appropriate reference ranges and clinical cut-offs for immunoassays, by comparing the results obtained from two different immunoassays of placental growth factor; the Quantikine® ELISA and the automated Triage® test. This was a secondary subgroup analysis of samples collected as part of a prospective cross-sectional study of placental growth factors in twin pregnancy. Consenting pregnant women with a twin pregnancy, across a variety of gestations, had a single blood sample taken at a one-time point only during their pregnancy. The plasma was initially biobanked and then later analysed in batches using both immunoassays. Although the placental growth factor values of the two immunoassays correlated well (r = 0.88, n = 178, p < .001), the actual results obtained were significantly different (mean difference 238.1 pg/ml). Poor concordance between the two immunoassays was also present, with the Triage® test recording 36 cases as <100 pg/ml whereas the Quantikine® ELISA identified only 4 as <100 pg/ml. Biomarker levels may vary significantly between different immunoassay platforms, highlighting the importance of developing validated clinical cut-offs for any automated immunoassay before its clinical application. These differences need to be understood to facilitate clinical utility given that placental growth factor testing is likely to be introduced into widespread clinical practice.

Clinical practice guidelines for recurrent miscarriage in high-income countries: a systematic review.

Recurrent miscarriage affects 1-2% of women of reproductive age, depending on the definition used. A systematic review was conducted to identify, appraise and describe clinical practice guidelines (CPG) published since 2000 for the investigation, management, and/or follow-up of recurrent miscarriage within high-income countries. Six major databases, eight guideline repositories and the websites of 11 professional organizations were searched to identify potentially eligible studies. The quality of eligible CPG was assessed using the Appraisal of Guidelines for Research and Evaluation (AGREE II) Tool. A narrative synthesis was conducted to describe, compare and contrast the CPG and recommendations therein. Thirty-two CPG were included, from which 373 recommendations concerning first-trimester recurrent miscarriage were identified across four sub-categories: structure of care (42 recommendations, nine CPG), investigations (134 recommendations, 23 CPG), treatment (153 recommendations, 24 CPG), and counselling and supportive care (46 recommendations, nine CPG). Most CPG scored 'poor' on applicability (84%) and editorial independence (69%); and to a lesser extent stakeholder involvement (38%) and rigour of development (31%). Varying levels of consensus were found across CPG, with some conflicting recommendations. Greater efforts are required to improve the quality of evidence underpinning CPG, the rigour of their development and the inclusion of multi-disciplinary perspectives, including those with lived experience of recurrent miscarriage.

Experiences of Volunteers Supporting Parents Following a Fatal Fetal Anomaly Diagnosis.

Ireland has had a reliance on voluntary groups to provide peer-to-peer bereavement support. The aim of this study was to explore volunteers', within these voluntary groups, experiences of supporting parents following a fatal fetal anomaly diagnosis. Purposive sampling was used to recruit volunteers (n = 17) and face-to-face interviews undertaken. NVivo12 was utilized to assist in the thematic analysis of the data. Five themes; "motivation for altruistic acts," "being challenged," "value of education and training," "supporting volunteers to support others," and "it is not a sprint, it is a marathon" were identified. Volunteers felt comfortable in their peer-support role but found the lack of knowledge regarding newly implemented termination of pregnancy (TOP) services challenging. The importance of education/training was identified, emphasizing the need for collaboration with health care professionals and other voluntary organizations for support. The findings illustrate the need for collaborative working between health care professionals and volunteers to assist them in supporting bereaved parents.