Multidisciplinary care for pregnant women with cardiac disease: A mixed methods evaluation

Background: Cardiac disease is associated with adverse outcomes in pregnancy and is the leading cause of indirect maternal death in the United Kingdom (UK) and internationally. National and international guidelines recommend women should receive care from multidisciplinary teams; however evidence is lacking to inform how they should be operationalised. Objectives: To describe the composition and processes of multidisciplinary care between maternity and cardiac services before, during and after pregnancy for women with cardiac disease, and explore clinicians' (cardiologists, obstetricians, nurses, midwives) and women's experiences of delivering/receiving care within these models. Design: Mixed-methods comprising case-note audit, interviews and observation. Setting: Two inner-city National Health Service (NHS) maternity units in the south of England serving similar obstetric populations, selected to represent different models of multidisciplinary team care. Participants: Women with significant cardiac disease (either arrhythmic or structural, e.g. tetralogy of fallot) who gave birth between June 1 st 2014 and 31 st May 2015 (audit/interviews), or attended an multidisciplinary team clinic (obstetric/cardiac) during April 2016 (observation). Methods: A two-phase sequential explanatory design was undertaken. A retrospective case-note audit of maternity and medical records (n = 42 women) followed by interviews with a sub-sample (n = 7 women). Interviews were conducted with clinicians (n = 7) and observation of a multidisciplinary team clinic in one site (n = 8 women, n = 4 clinicians). Results: The interests and expertise of individual clinicians employed by the hospital trusts influenced the degree of integration between cardiac and maternity care. Integration between cardiac and maternity services varied from an ad-hoc 'collaborative' model at Site B to an 'interdisciplinary' approach at Site A. In both sites there was limited documented evidence of individualised postnatal care plans in line with national guidance. Unlike pathways for risk assessment, referral and joined care in pregnancy for women with congenital cardiac disease, pathways for women with acquired conditions lacked clarity. Midwives at both sites were often responsible for performing the initial maternal cardiac risk assessment despite minimal training in this. Clinicians and women's perceptions of 'normality' in pregnancy/birth, and its relationship to 'safe' maternity care were at odds. Conclusion: The limited evidence and guidance to support multidisciplinary team working for pregnancy in women with cardiac disease particularly those with acquired conditions has resulted in variable models and pathways of care. Evidence-based guidance regarding the operationalisation of integrated care between maternity and cardiac services including pathways between local and specialist centres for all women with cardiac disease in pregnancy is urgently required.