Obstetrics & Gynaecology - Doctoral Theses
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Item Digitalisation in healthcare: the future of surgical training(University College Cork, 2023) Galvin, Daniel; O'Reilly, Barry A.Introduction The impact of digital technology and artificial intelligence (AI) has a daily impact on our lives. Healthcare as an industry is at the forefront of technological innovation. The application of novel technology to aid performance and enhance training in surgery is key. Challenges in surgical training owing to an increase in trainee numbers, a reduction in working hours, increase in complexity and variety of surgeries performed have become major issues in surgical education. The COVID-19 pandemic further compounded these concerns between 2020 and 2022 where there was significant disruption and reduction in elective surgical activity. Methods Five studies examining the challenges in surgical training in gynaecology and their potential solutions were designed. These comprised of a national cross-sectional trainee and trainer survey on the current challenges of surgical training in gynaecology and in training during the COVID-19 pandemic. Potential solutions examined were a trial of the application of artificial intelligence to the grading of surgical performance and two randomised controlled trails of the application of transcranial direct current stimulation (tDCS) to enhance surgical performance in laparoscopic and robotic surgery. Results Our results showed significant challenges in surgical training over the last decade with a significant reduction in trainee confidence and experience in operative gynaecology. The COVID-19 pandemic had a significant impact on operative volumes of both trainees and trainers. Trainees failed to increase their self-reported confidence in performing common gynaecology procedures over the pandemic period. AI grading of operative performance was shown to be a potential means of enhancing trainee feedback and reducing workload for trainers. tDCS was shown to decrease rates of excessive velocity events during novice laparoscopic training setting it out as a potential solution to maximise training opportunities. tDCS was not shown to enhance robotic surgical performance. Conclusion While the current training environment is challenging in operative gynaecology, potential solutions to augment and accelerate training exist. Further study is required to assess the best means of implementing these solutions to ensure continued access to high quality surgical training.Item Infertility and recurrent miscarriage: an examination of pregnancy outcomes, services and patient experience(University College Cork, 2024) Linehan, Laura Aoife; O'Donoghue, Keelin; Hennessy, MaritaBackground Miscarriage and infertility are distinct reproductive health conditions which profoundly impact the lives of women and men affected. Although miscarriage is the most common complication of pregnancy affecting an estimated 23 million women globally a year, it remains poorly understood (1). There is a limited evidence base for investigation and treatments for miscarriage or recurrent miscarriage (RM), and approximately half of women/couples will have unexplained RM (2). Similarly, up to one in six couples are affected by infertility, this is an estimated 48.5 million people, with 30% having unexplained infertility (2,3). Miscarriage and infertility share a number of risk factors and are reciprocally associated, in addition to being associated with adverse pregnancy outcomes. The impacts of RM and infertility are also in parallel, with both experiences bearing psychological sequelae, economic burdens and isolation as a consequence of stigmatisation. Despite these commonalities, the dual experience of RM and infertility is not widely described in the literature or clinical practice guidelines and the optimal management of women/couples is unclear. RM and infertility are separately receiving greater attention from policy makers, nationally and internationally, therefore greater evidence is needed to inform policy and practice. Thus, the overall objective of this thesis is to examine the dual experience of RM and infertility and to add to the knowledge base on the current care issues, reproductive outcomes and lived experiences to inform improvements in care. Methods To meet this objective, a number of quantitative and qualitative studies were conducted. A narrative review of the literature was undertaken to determine what is known of the dual experience of RM and infertility and to identify the knowledge gaps (Chapter 2). A National Clinical Guideline was developed to provide evidence-based guidance for the management of RM in the Republic of Ireland (Chapter 3). A retrospective cohort study of women with three consecutive first-trimester miscarriages was undertaken to examine reproductive outcomes after RM, including women with a history of RM and infertility (Chapter 4). For this study descriptive and inferential statistics were utilised. A national service evaluation was conducted using key performance indicators (KPIs) for RM to establish how care for women/couples with RM and infertility compares to international recommendations (Chapter 5). These KPIs were also employed in an audit of RM and infertility care in a tertiary referral maternity hospital to examine how care compared to international recommendations (chapter 6). A qualitative semi-structured interview study of women with lived experience of RM and infertility and healthcare professionals working in these areas was also undertaken, utilising reflexive thematic analysis (Chapter 8). Results The narrative review (Chapter 2) demonstrated that women with RM and infertility are not well studied in the wider literature and feature predominantly within sub-groups of investigations or treatments, and their experiences are underexplored within qualitative studies. These findings are reflected in the exclusion of women with RM and infertility in international Clinical Practice Guidelines, thus it is unclear how best to manage and support this complex cohort. The National Clinical Practice Guideline for the management of RM (Chapter 3) sets out evidence-based recommendations for the structure of care, supportive care, investigation and treatment of RM, including subsequent pregnancy management. The retrospective cohort study of 748 women with RM (Chapter 4) found a subsequent pregnancy rate of 77%, with a cumulative live-birth rate of 63%. The multinomial regression analysis demonstrated that maternal age, smoking and parental karyotype were associated with reproductive outcomes. Additionally, there was a lower live-birth rate in women age over 40 years (44%) or with a history of infertility (54%). The national service evaluation (Chapter 5) found that while care is largely in line with international clinical practice guidelines, there is variation in counselling, imaging and surgical treatments offered. Areas for education identified included fertility counselling and resources for information provision and supportive care. Importantly, clinical outcomes were seldom audited. The audit of care for 128 women with RM and infertility (Chapter 6) found that alongside good clinical practice there are several areas for improvement: Counselling regarding risk factors and treatments, availability of genetic counselling, access to ultrasound and cytogenetic investigation should be improved. The subsequent pregnancy rate was 70% with a live-birth rate of 63% and a preterm birth rate of 11%, with 36% of women conceiving with assisted reproductive technologies. For the qualitative study (Chapter 7), 33 individuals were interviewed: 17 women with lived experience of RM and infertility and 16 healthcare professionals. Four themes were actively generated: “exploring all avenues”, “exhausting all resources”, “separateness” and “no woman is an island”, which captured this complex experience. The themes encompassed the challenges in seeking care and the many personal burdens of RM and infertility, which were compounded by stigmatisation, a lack of knowledge and awareness, the divisions within the healthcare system and the limited availability of supports. Conclusions This doctoral work has examined the dual experience of RM and infertility in the ROI and has provided meaningful insights into the difficulties within current service provision and the management of RM and infertility. This work has also provided guidance for evidence-based management for the care of women/couples with RM. It has made an important contribution to the literature in describing the reproductive outcomes for women following RM and RM and infertility. This thesis has also distinctly depicted the lived experiences of women with RM and infertility and also of relevant healthcare professionals. Through analysis of these findings, this thesis identified three overarching themes: 1) the dual experience of RM and infertility needs greater recognition; 2) there is a need for equity and balance in the care provided to women with RM and infertility; 3) information is central to improving care. Several recommendations for practice and policy are made. There is a need for greater education and training for healthcare professionals regarding reproductive health, which must be supplemented by increased availability of high-quality and accessible information resources for women and their families. Improvements in knowledge and awareness of RM and infertility must be accompanied by improved data collection to inform and develop services, identify inequities in care and better direct resources to improve access to RM and fertility care. There must be increased investment in supportive care for women/couples experiencing RM and infertility, with better acknowledgement of the life impacts of this experience on both partners. Recommendations from the Clinical Practice Guidelines for RM and for fertility must be appropriately resourced and implemented to facilitate standardisation of care, alongside implementation of the Assisted Human Reproduction legislation to ensure better regulation within fertility services. Future research must prioritise the inclusion of women with a dual experience of RM and infertility in investigations, treatments, and outcome studies, thereby enriching the evidence base for management. Moreover, there is a need to explore factors contributing to delayed childbearing in Irish society and develop strategies to enhance and disseminate reproductive health knowledge effectively. Facilitators and barriers to accessing fertility and RM care across all levels of society must be examined to address the current inequities in care. Further patient and public involvement in research are also necessary to identify the optimal supportive care and resources for women/couples with RM and infertility. Addressing these issues can promote a more compassionate, informed, and equitable approach to reproductive healthcare for individuals dealing with RM and infertility in the Republic of Ireland.Item Axis of placental ageing in adverse pregnancy outcomes(University College Cork, 2023) Manna, Samprikta; McCarthy, Fergus; McCarthy, Cathal; European Chiropractors' UnionBackground: Pre-eclampsia (PE), an adverse pregnancy outcome affects 2-5% pregnancies worldwide and significantly adversely impacts both maternal and fetal outcomes. Intrauterine growth restriction (IUGR) is defined as the inability of the fetus to reach normal growth potential within the uterus as a result of various genetic, environmental, or placental factors. Premature ageing of the placenta in pregnancy outcomes such as PE and IUGR is associated with the persistent presence of oxidative stress and placental insufficiency reducing its functional capacity. Placental proteomics has been instrumental in improving our understanding of molecular mechanisms involved in the pathophysiology of placental insufficiency as well as identifying biomarkers to predict and diagnose pregnancy outcomes. In this study, we investigated cellular senescence phenotypes of PE and IUGR pregnancies by simultaneously measuring several biomarkers of senescence, as well as the proteomic signature of the placenta in healthy and adverse pregnancy outcomes PE and IUGR. Method: Maternal plasma and placental samples were collected at term (>37 weeks) and preterm (<37 weeks) gestation from nulliparous women undergoing prelabour elective Caesarean section with PE without intrauterine growth restriction (PE; n=5), PE associated with intrauterine growth restriction (n=8), intrauterine growth restriction (IUGR <10th centile) (n=6) and age-matched controls (n=20) from Cork University Maternity Hospital, Cork, Ireland. To assess cellular senescence absolute telomere length (aTL) and senescence associated genes in the placentas was performed by RTqPCR. Cyclin-dependent kinase inhibitors (p21 and p16) expression were determined by Western blotting. Senescence Associated Secretory Phenotype (SASP) were evaluated in maternal plasma by multiplex ELISA assay. Proteomic analysis of placental samples dissected into 3 sub-anatomical regions (maternal, middle, fetal) taken from 3 nulliparous healthy placentas was performed by mass-spectrometry and pathway analysis was conducted. Based on the differentially expressed proteins (DEPs), a placenta specific disease map using NaviCenta focusing on functional analysis to include the placenta specific context for healthy (n=4) compared to PE affected (n=4) and IUGR affected (n=4) placentas. Results: Placental expression of senescence associated genes CHEK1, PCNA, PTEN, CDKN2A, CCNB-1 was significantly upregulated in PE, while TBX-2, PCNA, ATM and CCNB-1 expression were significantly decreased in IUGR compared to controls. Moreover, placental p16 protein expression was significantly decreased in PE only when compared to controls placentas. We also observed that IL-6 was significantly increased in maternal circulation in PE when compared to controls; while IFN-γ was significantly increased in maternal circulation in women affected with IUGR when compared to controls. Proteomic profiling of healthy placentas divided into three sub-anatomical regions identified 1081, 1086, and 1101 proteins in maternal, middle, and fetal sub-anatomical regions respectively. Depending on sample site location and sub-anatomical regions, 374 differentially expressed proteins (DEP) were identified. When we investigated the proteomic variations between PE and IUGR placentas when compared to controls we observed 314, 391, and 378 proteins in healthy control, PE, and IUGR placenta, respectively. We performed functional analysis by combining ClusterCompare and NaviCenta to analyse a placenta-centric context, and observed regulatory elements predominantly involved in the immune regulation, complement cascade and antioxidant activities in PE and IUGR compared to control placentas. Conclusion: This thesis provides evidence of premature senescence in IUGR, while in PE, evidence of activated cell cycle checkpoint regulators is suggestive of cellular repair and proliferation rather than progression to cellular senescence. The heterogeneity within senescence molecular markers of these phenotypes highlights the complexity and disparity between pathophysiological insults unique to each obstetric complication. Proteomic profiling of sub-anatomical placental regions highlighted the variabilities between regions particularly providing evidence of senescence in these regions. Placental proteomic mapping of healthy placentas compared to adverse pregnancy outcomes PE and IUGR revealed the importance of complement system, inflammatory response, and antioxidant activity in placental function in PE placentas. The identification of novel targets such as transcription factor activity and synergistic miRNAs elements within the core regulatory network, might enlighten future placental research within adverse pregnancy outcomes.Item Rethinking stillbirth through behaviour change(University College Cork, 2022) Escañuela Sánchez, Tamara; O'Donoghue, Keelin; Matvienko-Sikar, Karen; Meaney, Sarah; Byrne, Molly; Science Foundation IrelandBackground Worldwide, two million babies are stillborn every year. While the majority of stillbirths occur in low and middle-income countries, stillbirth is still one of the most common adverse pregnancy outcomes in high-income countries. In Ireland, the latest National Perinatal Mortality Clinical Audit report states a stillbirth rate of 4.20 per 1000 births for the year 2020, showing an increase compared to previous years. The belief that reduced stillbirth rates in high-income countries cannot be achieved is refuted by differences in stillbirth rates across different countries. Although not all stillbirths are preventable, there has been a call made in high-income countries to focus on risk factors for stillbirth, in order to reduce stillbirth rates. These risk factors include sociodemographic factors, medical factors, obstetric history-related factors, placental and fetal-related factors as well as behavioural and lifestyle-related factors. Some of these factors are modifiable through medical management or through behaviour change modification. This Thesis focuses on risk factors that have the potential to be modified through maternal behaviour change interventions: substance use (smoking, alcohol, and illicit drug use), high BMI, sleep position, and attendance at antenatal care. Strategies have been successfully implemented internationally to reduce stillbirth rates by designing and implementing care bundles that, amongst other elements, take into consideration the modifiable/behavioural risk factors for stillbirth. However, in Ireland, no such initiatives have been developed, although recommendations have been made that support their development. For behaviour change interventions or public health initiatives to have the best possible success in reducing the rates of stillbirth, they need to be designed with a solid evidence base. Hence, the overall objective of this Thesis was to build the evidence base to enhance the understanding of the modifiable behavioural risk factors for stillbirth and pregnancy. Further, this evidence base is needed to inform the future development of a behaviour change intervention that could be part of a care bundle with the objective of reducing stillbirth rates in Ireland. Methodology To address the Thesis´s aims, both qualitative and quantitative methods were utilised. Applying multiple methods to explore a phenomenon provides flexibility to analyse different aspects of it in the different studies. Initially, a non-systematic review of the literature was conducted to identify the target behavioural risk factors that this project was going to focus on (Chapter 2). A website quantitative content analysis was conducted to assess the availability of information related to stillbirth and behavioural risk factors for stillbirth in Irish and UK websites (Chapter 3). For this study, descriptive and inferential statistics were utilised. Further, three systematic qualitative meta-synthesis were conducted to identify facilitators and barriers to modify identified behavioural risk factors according to the pregnant women’s experience (Chapters 4-6). A meta-ethnographic approach as described by Noblit and Hare was adopted to conduct these qualitative meta-syntheses. Reflexive Thematic Analysis as described by Braun and Clarke, with a constructivist approach, was used to conduct a qualitative semi-structured interview study with postpartum women about their experiences of stillbirth information provision and behaviour change during their antenatal care (Chapter 7). Finally, a systematic review of interventions designed in the context of stillbirth prevention that targeted behavioural risk factors was conducted (Chapter 8). This systematic review had the objective of identifying which behaviour change techniques (BCTs) have been used to date. Results The findings of the literature review (Chapter 2) showed that the modifiable behavioural risk factors with the strongest evidence of associations with stillbirth were substance use, smoking, heavy drinking and illicit drug use, lack of attendance and compliance with antenatal care, weight-related risks, and sleep position. The quantitative content analysis of websites (Chapter 3) revealed that information about stillbirth and behavioural risk factors for stillbirths was scarce on websites directed at the pregnant population, with only one website containing all the information sought. Five main areas of concern were identified across the three meta-synthesis of qualitative research of facilitators and barriers influencing women’s prenatal health behaviours (Chapters 4-6), regardless of the behaviour explored: 1) health literacy, awareness of risks and benefits; 2) insufficient and overwhelming sources of information; 3) lack of opportunities and healthcare professionals attitudes interfering with communication & discussion; 4) social influence of environment, and 5) social judgement, stigmatisation of women and silence around stillbirth. Further, the qualitative study with postpartum women (Chapter 7) revealed that women perceived behaviour change during pregnancy as easy and natural, as they were focused on obtaining the best outcomes for their babies. Although women had high levels of awareness regarding health advice, their awareness about stillbirth was very limited. Women reported a lack of discussion about stillbirth and behavioural risk factors during their antenatal care; however, most women showed a positive disposition towards receiving this information because “knowledge is key”, as long as it is done in a “sensible manner”. The systematic review of interventions designed in the context of stillbirth prevention identified nine relevant interventions. From the BCT coding, it was established that the most common BCT used was “information about health consequences”, followed by “adding objects to the environment” (Chapter 8). Conclusion This research makes a valuable contribution to the understanding of the maternal behaviours associated with an increased risk of stillbirth, and it provides a necessary evidence-base to inform future prevention strategies to reduce rates of stillbirth in Ireland and in similar healthcare settings. This research sought to incorporate women’s voices and use research methods to produce high-quality results that meet the research objectives. The findings from the studies in this Thesis support four overarching topics and highlight issues related to 1) health literacy and sources of information, 2) relationships with healthcare professionals (HCPs), 3) healthcare systems and structural barriers, and 4) interpersonal, social and structural factors. In response to the research findings, several recommendations are made in relation to policy, practice and research which are grounded on women’s experiences during pregnancy. Regarding policy, these recommendations include improving education and information sources for women and HCPs, providing pregnancy-specific supports, utilising community services to support women with behaviour change, and developing a care bundle to tackle the behavioural risk factors for stillbirth. Furthermore, the work practice recommendations made include developing clinical guidelines to support HCPs in providing care to pregnant women, and prioritising health promotion during antenatal care. These priorities might also serve to help funders and researchers to design and conduct policy-relevant research. The key future research areas identified by this Thesis are in relation to the involvement of PPI representatives, the assessment of the quality of the available sources of information and the further exploration of potential facilitators and barriers to modifying pregnant women’s sleeping position from a qualitative perspective. In addition, this Thesis proposes a detailed process to continue building on the work set out in the different studies to develop a pregnancy-specific behaviour change intervention for the modifiable behavioural risk factors for stillbirth in the future.Item Data quality in the evolving digitised health service(University College Cork, 2021) McKernan, Joye; Greene, Richard A.; Corcoran, PaulBackground/Objective: The research undertaken for this thesis focussed on data quality in the evolving digitised health service. In Ireland we all need to have our details on an electronic healthcare record. We need to have fully integrated systems documenting our health information across our whole life. We as patients need to be central to our care and have access to our data. EHRs can change healthcare by saving money, improving communication, and reducing errors. The introduction of an EHR is a substantial change management project that needs to include all stakeholders to ensure success. It requires vision, dedication, time, and patience. The power and importance of data cannot be overemphasised; we need to analyse what is required from data, using robust standard approaches, and ensure data is of high quality so that it can be used to improve patient outcomes and improve staff working conditions. The aim of this research project was to focus on aspects of digitisation that go towards achieving a high-quality data repository. We aimed to investigate the development and use of an EHR in the Irish healthcare system with specific consideration to the elements that impact data quality. We examined the experiences of the development team, patients, staff, service culture and the data collected. Methods: We used both quantitative and qualitative methods; this mixed method approach allowed for a deeper understanding of the issues. A document analysis of the closure report of the implementation of the EHR (MN-CMS) from the national project team was supported with discussions with team members. Patients at antenatal booking visits in an Irish maternity unit were invited to participate and complete a survey with respect to digitization of their health data. The survey was divided into three distinctive sections; participant information, regarding the staff encounters on their visits and questions about the new system. To engage with staff a pre- EHR implementation survey, a post EHR implementation survey and a post-implementation EHR documentation audit was carried out. A four-step approach was required when applying a national framework to a national data set. The four steps included a literature review, using elements of a data quality framework to develop the planning of an audit tool, data quality assessment of the Major Obstetric Haemorrhage (MOH) audit dataset. The fourth step assessed the data quality using the five dimensions of quality: (1) relevance, (2) accuracy and reliability, (3) timeliness and punctuality, (4) coherence and comparability, and (5) accessibility and clarity. To explore data quality in an EHR two phases were used; initially we examined the data from year 1 (2018); following analysis of the data set we found data quality issues. We then enacted an intervention and assessed the effect of a new data quality process. The intervention was to introduce a data quality resource to assess the datapoints within 1-2 days after documentation of the care by the healthcare professional. We assessed clinical data extracted from the MN-CMS national database for missing data and then examined the significance of the data issues. An ethnographic study approach was used to explore service culture around shift clinical handover, the process was divided into three components: an observational study, a short staff survey and a cause-and-effect assessment. Results: This project showed that several factors, need to be explored to fully understand data quality in healthcare. There is a growing need for high quality clinical ‘Big Data’ to measure, enhance and evaluate healthcare; clinical data systems need to be producing high quality complete and accurate data for primary and secondary use. Patients want to have access to their records and want to engage with healthcare professionals in their care. This engagement will lead to patients having more control over their health outcomes. EHRs are now becoming more and more widespread globally; in Ireland the Maternal & Newborn Clinical Management System (MN-CMS) has been implemented for four maternity units and is a pathfinder EHR project. It is a clinically led, patient centred EHR. Staff engagement is required for the implementation phase; they are a vital component to ensure a successful implementation. Staff may require additional training to ensure their documentation positively impacts data quality. There is a requirement to standardise terminology in relation to data quality and use data quality frameworks to assess the dimension of data quality. It is meaningful and useful to apply national data quality frameworks to data sets to investigate where improvements may be made. Capturing and ensuring quality data from an EHR takes time and resources; the data needs to be examined for accuracy and completeness. Resources in the form of staff are required to achieve this impact on data quality. They can improve data directly and more importantly they can engage with staff regarding their documentation, identify need for further training, technical solution changes and indeed review of data points and the value of recording them. Following the implementation of an EHR, workflows and practices might not change when they should have; it is important to explore why these changes may not occur and address the issues to identify the barriers and allow enablers to achieve appropriate change, engaging with staff in the process. Conclusion: This project aimed to explore the impacts of digitizing healthcare documentation on the quality of that data, examining the impact through patients, staff, and processes. This thesis has shown a need to move towards standardised terminology and methodologies to achieve these goals and the projects involved took a practical solutions approach. We have shown the importance of staff members and their role in the success of the project implementation. We have highlighted the importance of the use of frameworks to robustly assess data quality. There is growing literature regarding EHRs and data quality with the rapid expansion in digitization of healthcare data. This thesis adds to that literature, but significantly more work is needed in the areas of standardisation of data quality frameworks, the importance of staff in data quality, and co-designed patient portals.