North West England Research Articles

5-Axis Machining Skills at the Heart of Burnley College’s Curriculum

A partnership in the North-West of England between employers, academia and an advanced manufacturing OEM is offering a blueprint for solving the skills crisis

Early intervention for children and young people with neurodevelopmental conditions and intellectual disability: “The Getting Help” offer for Northwest England

Purpose The purpose of this paper is to outline what early support should be offered to children and young people with neurodevelopmental conditions including those who are autistic or have intellectual disability. A review of all child and adolescent mental health services (CAMHS) services in the Northwest completed by NHS England and Improvement (Doyle and Ryan, 2021) found that there was no clear Tier 2 offer (for mild to moderate mental health issues) for autistic children and young people or for those with intellectual disability. Following this review, a project group that had developed a model for mental health services for autistic children and young people and for those with intellectual disability (Wee et al., 2021) was tasked with articulating the “Getting Help” offer for children and young people with neurodevelopmental conditions, including intellectual disability. Design/methodology/approach A working group was created consisting of professionals from mental health, education and local authority and lived experience representatives of coproduction partners. A brief review of the background literature was also conducted. Six meetings were held to create a framework for the “Getting Help” offer and to discuss what the offer should be based on professional expertise and lived experience. Findings Recommendations for the Getting Help multi-agency offer included pre- and post-assessment support as part of a single attention deficit hyperactivity disorder/autism/neurodevelopmental pathway, community support for children with intellectual disability, access to adapted mental health support and the need for early recognition and support for avoidant and restrictive food intake disorder. Key themes from working group discussions included the reduction in the quality of services experienced by children and families due to silo working, which increased the risk of falling between multi-agency services and led to early signs of neurodevelopmental needs, or mental health issues being missed. Another theme was aiming for equity of access and outcomes. Originality/value This work is a response to a coproduced review of CAMHS in the Northwest and incorporates the lived experience of young people and families. It also adopts a holistic multi-agency neurodevelopmental approach rather than focusing on a single diagnosis or service.

Hemp Cultivation and Processing in North-West England

Although by the 1830s–40s it is unlikely that any of the 150 fields named ‘Hempland’ or similar in the tithe surveys for the counties of Lancashire, Westmorland and Cumberland, were actually then growing hemp, nevertheless these field-names are a useful source for a study of its cultivation in the region. This paper shows that although such cultivation is found back to the early medieval period, it expanded in the early modern period, moving in some places beyond cultivation for consumption on the farm where it was grown, to commercial growth for the rope-making and sail-cloth industries, before losing out in the eighteenth century to imports from the Baltic. The distribution of ‘Hemp…’ field-names, and information from other sources, reveals that cultivation was restricted to the lowlands of the region, notably in proximity to the mosslands, and almost entirely avoiding the Lake District and hilly regions to the east. Where grown for household use, the fields were generally small, often half an acre or less, and were often directly attached to the homestead: while documentary evidence shows it was mainly female household members who were responsible for the cultivation and processing of the hemp, and for turning it into cloth and cord.

Postoperative opioids administered to inpatients with major or orthopaedic surgery: A retrospective cohort study using data from hospital electronic prescribing systems.

Opioids administered in hospital during the immediate postoperative period are likely to influence post-surgical outcomes, but inpatient prescribing during the admission is challenging to access. Modified-release(MR) preparations have been especially associated with harm, whilst certain populations such as the elderly or those with renal impairment may be vulnerable to complications. This study aimed to assess postoperative opioid utilisation patterns during hospital stay for people admitted for major/orthopaedic surgery. Patients admitted to a teaching hospital in the North-West of England between 2010-2021 for major/orthopaedic surgery with an admission for ≥1 day were included. We examined opioid administrations in the first seven days post-surgery in hospital, and "first 48 hours" were defined as the initial period. Proportions of MR opioids, initial immediate-release(IR) oxycodone and initial morphine milligram equivalents (MME)/day were calculated and summarised by calendar year. We also assessed the proportion of patients prescribed an opioid at discharge. Among patients admitted for major/orthopaedic surgery, 71.1% of patients administered opioids during their hospitalisation. In total 50,496 patients with 60,167 hospital admissions were evaluated. Between 2010-2017 MR opioids increased from 8.7% to 16.1% and dropped to 11.6% in 2021. Initial use of oxycodone IR among younger patients (≤70 years) rose from 8.3% to 25.5% (2010-2017) and dropped to 17.2% in 2021. The proportion of patients on ≥50MME/day ranged from 13% (2021) to 22.9% (2010). Of the patients administered an opioid in hospital, 26,920 (53.3%) patients were discharged on an opioid. In patients hospitalised with major/orthopaedic surgery, 4 in 6 patients were administered an opioid. We observed a high frequency of administered MR opioids in adult patients and initial oxycodone IR in the ≤70 age group. Patients prescribed with ≥50MME/day ranged between 13-22.9%. This is the first published study evaluating UK inpatient opioid use, which highlights opportunities for improving safer prescribing in line with latest recommendations.

Understanding barriers and facilitators to palliative and end-of-life care research: a mixed method study of generalist and specialist health, social care, and research professionals

BackgroundPalliative care provision should be driven by high quality research evidence. However, there are barriers to conducting research. Most research attention focuses on potential patient barriers; staff and organisational issues that affect research involvement are underexplored. The aim of this research is to understand professional and organisational facilitators and barriers to conducting palliative care research.MethodsA mixed methods study, using an open cross-sectional online survey, followed by working groups using nominal group techniques. Participants were professionals interested in palliative care research, working as generalist/specialist palliative care providers, or palliative care research staff across areas of North West England. Recruitment was via local health organisations, personal networks, and social media in 2022. Data were examined using descriptive statistics and content analysis.ResultsParticipants (survey n = 293, working groups n = 20) were mainly from clinical settings (71%) with 45% nurses and 45% working more than 10 years in palliative care. 75% were not active in research but 73% indicated a desire to increase research involvement. Key barriers included lack of organisational research culture and capacity (including prioritisation and available time); research knowledge (including skills/expertise and funding opportunities); research infrastructure (including collaborative opportunities across multiple organisations and governance challenges); and patient and public perceptions of research (including vulnerabilities and burdens). Key facilitators included dedicated research staff, and active research groups, collaborations, and networking opportunities.ConclusionsProfessionals working in palliative care are keen to be research active, but lack time, skills, and support to build research capabilities and collaborations. A shift in organisational culture is needed to enhance palliative care research capacity and collaborative opportunities across clinical and research settings.

Seeking ambidexterity through hyperautomation: What next for GBA logistics in their evolution from local labour entrepreneurs to global players in logistics

Based in the Northwest of England, GBA Logistics (GBA) is a global logistics provider focussing on the transportation of goods. Founded in 1987 as GBA Services, this family firm has transformed from being a provider of labour for local companies, to a major player within the national and international logistics sector, now ranking in the top 50 operators in the UK. Starting as a sole trader, GBA became a limited company in 2000 and now employs around 400 staff across 16 locations in the UK and Europe. Working in a highly competitive, dynamic environment, the company constantly faces the challenge of optimising its existing services whilst needing to explore new opportunities to meet the changing demands of its clients. Balancing these two opposing requirements is known as organisational ambidexterity. Part of GBA’s strategic response to this challenge, is to explore how it can employ advanced technologies such as artificial intelligence and robotic process automation to enhance its efficiency and effectiveness, whilst identifying novel ways to adapt to market conditions. The application of these emerging technologies to automate and optimise operations is known as hyperautomation. For GBA, striking a balance between offering standardisation versus a customised service to customers is increasingly crucial to its success. However, this family firm’s underlying culture of entrepreneurial spirit and adaptability together with its commitment to remain relevant and competitive in logistical services means it is keen to explore how it can exploit hyperautomation to achieve its aim of organisational ambidexterity.

Move Well, Feel Good: Feasibility and acceptability of a school-based motor competence intervention to promote positive mental health.

In response to the adverse impacts of the COVID-19 lockdown measures Move Well, Feel Good (MWFG) was developed as a school intervention using improvement of motor competence as a mechanism for promoting positive mental health. Study objectives were to evaluate the feasibility and acceptability of MWFG and to describe changes in child-level outcomes. Five northwest England primary schools were recruited. MWFG was delivered over 10-weeks through physical education (PE) lessons, which were supplemented by optional class-time, break-time, and home activities. The intervention focused on development of 9-10 year-old children's motor competence in locomotor, object control, and stability skills, and psychosocial skills. Feasibility was evaluated against nine pre-defined criteria using surveys, interviews (teachers), and focus groups (children). Pre- and post-intervention assessments of motor competence, mental health, prosocial behaviour, wellbeing, and 24-hour movement behaviours were also completed. The five recruited schools represented 83% of the target number, 108 children consented (54% of target) with teachers recruited in all schools (100% of target). Intervention dose was reflected by 76% of the 45 scheduled PE lessons being delivered, and adherence was strong (>85% of children attending ≥75% of lessons). Positive indicators of acceptability were provided by 86% of children, 83% of PE teachers, and 90% of class teachers. Data collection methods were deemed acceptable by 91% of children and 80% of class teachers, and children spoke positively about participating in the data collection. Child-level outcome data collection was completed by 65%-97% of children, with a 3%-35% attrition rate at post-intervention, depending on measure. Favourable changes in motor competence (+13.7%), mental health difficulties (-8.8%), and prosocial behaviour (+7.6%) were observed. MWFG is an acceptable and feasible motor competence intervention to promote positive mental health. Content and delivery modifications could inform progression to a pilot trial with a more robust design.

Investigating adherence to tyrosine kinase inhibitors in renal cancer.

Tyrosine kinase inhibitors (TKIs) have been used as the first-line treatment for many patients with renal cell carcinoma (RCC), the seventh most common cancer in the United Kingdom. However, suboptimal adherence to TKIs can result in poor clinical prognosis. This study quantified RCC patients' adherence to TKIs and explored factors associated with suboptimal adherence. This retrospective cohort study was conducted at a specialist oncology tertiary hospital in Northwest England, using pharmacy dispensing records between November 2021 and March 2022. TKI prescriptions dispensed to patients with RCC were extracted to calculate the persistency gaps (≥7 or ≥14 days) and medication possession ratio (MPR). Multilevel regression analysis was conducted to associate MPR and persistency gaps with specific patient-related and TKI-related factors. This study did not require ethics approval. Of the 2225 prescriptions dispensed to 109 patients, 469 (23.4%) and 274 (13.7%) persistency gaps of ≥7 and ≥14 days were identified. About 75% and 92% of patients had a persistency gap of ≥7 days within the first 90 days and 180 days. The length of time since the first TKI prescription (p < 0.001) and the use of sunitinib(p = 0.003) were significantly associated with the number of prescription gaps of ≥7 days. Moreover, the median MPR was 95.6% (interquartile range: 90.7%, 100.1%). Similarly, the length of time since the first TKI prescription was dispensed (p < 0.001) and the use of sunitinib (p = 0.034) were significantly associated with MPR. This single-centre study found that patients with RCC generally adhere to TKIs (MPR > 90%), but many patients experienced a persistency gap. The crucial window to mitigate TKI utilisation is within 180 days after the initial dispensing of TKIs. Further large-scale studies are required to comprehensively investigate other factors associated with adherence to TKIs and develop interventions to improve adherence and medication use problems.

Cardiovascular risk and physical activity in Syrians living in England compared with the population of North West England: a cross-sectional study

ObjectiveThis study aims to assess the 10-year cardiovascular risk and physical activity among Syrians residing in England and compare them with the North West England population.DesignCross-sectional study.SettingBilingual online questionnaire distributed...

Simulated Learning for Psychotherapy: A Focus Group Study of Psychiatry Core Trainees in the North West of England

Simulated Learning for Psychotherapy: A Focus Group Study of Psychiatry Core Trainees in the North West of England

Fidelity to and utility of a home blood pressure self-monitoring regime in people with pre-hypertension: results from the REVERSE study.

Around 40% of adults have pre-hypertension (120-139/80-89mmHg) increasing their risk of developing hypertension and associated cardiovascular conditions. Guidance on pre-hypertension management focuses on improving lifestyle. Self-monitoring may improve awareness and understanding of blood pressure (BP) for people with pre-hypertension, allowing them to modify their lifestyle risks. To determine the fidelity to and utility of a home BP self-monitoring regime in people with pre-hypertension. This sub-study is part of a larger prospective, non-randomised feasibility study. Individuals with pre-hypertension were identified via GP records and pharmacy NHS Health Checks in Northwest England. Participants received training for home BP self-monitoring. They were asked to complete two readings (leaving a 5-minute interval) on the first three days of the month for six months, colour-code their readings and take action using a simple algorithm, then send them to the research team within 7 days. Eighty participants (aged 40-79, mean=59) enrolled. The majority were female (n=45, 56%), White British (n=79, 99%), and had not previously monitored their BP (n=55, 69%). Seventy-five (94%) participants completed the training. Sixty-one (81%) received online training and 14 (19%) opted for a face-to-face session. Sixty-one (81%) completed all six months of readings, 51 (68%) also returned them on time. All in-person training participants completed all six months of readings on time. Reasons for non-compliance to the protocol included battery issues, forgetting, and struggling to find a consistent time for readings. Home BP self-monitoring can be feasible and easily implementable for people with pre-hypertension - however, some barriers were identified.

Dietitians’ perspectives on clinical pathways and practice in relation to the dietary management of irritable bowel syndrome in the UK: A qualitative study

Irritable bowel syndrome (IBS) is a chronic and relapsing gastrointestinal condition which negatively impacts quality of life(1). Dietary triggers are common and dietary management is central to the IBS treatment pathway with dietitians being the main education providers for patients(2). The aim of this study was to explore the perceptions of dietitians towards current practices in IBS services in clinical settings across the UK.Qualitative semi-structured interviews were undertaken to explore current practices, barriers, and facilitators to dietetic practice and expected treatment outcomes. Eligible participants were dietitians specialising in IBS and working in the National Health System (NHS) in the UK. Interviews were held virtually. Audio was recorded and transcribed following intelligent transcription. Data were analysed using template analysis (3).Thirteen dietitians (n=12 female) specialising in gastroenterology consented to participate in the study. Dietitians were working in various NHS Trusts across the country (Southeast England n=3; Southwest England n=3; Northwest England n=2; Northeast England n=1; West Midlands n=1; Southwest Wales n=1 and Southcentral Scotland n=2). Ten out of 13 dietitians had more than five years of experience in IBS management. Three main themes emerged: 1) Dietetic services as part of IBS referral pathways; 2) Practices in relation to dietetic services and 3) Implications of services on patients’ expectations and feelings. Each main theme had subthemes to facilitate the description and interpretation of data. The increasing number of IBS referrals to dietitians and the need for accurate and timely IBS diagnosis and specialist IBS dietitians was reported, alongside the use of digital innovation to facilitate practice and access to dietetic care. The use of Internet as a source of (mis)information by patients and the limited time available for educating patients were identified as potential barriers to dietetic practice. Dietitians follow a patient-centred approach to dietary counselling and recognise the negative implications of perceived IBS-related stigma by patients on their feelings and treatment expectations.The study identified areas and practices which can facilitate access to dietetic services and patient- centred care in IBS management as outlined in guidelines (4).

"Finding my voice again" - women's experiences of psychological therapy in perinatal secondary care settings: a qualitative study.

Although women often experience mental health comorbidities in the perinatal period, the evidence-base for psychological therapy across diagnostic boundaries in the perinatal period remains limited. As there is a need to understand experiences of therapy, irrespective of diagnosis, to inform intervention provision, the aims of this study were to explore women's experiences of psychological therapy for perinatal mental health difficulties and to identify the mechanisms that women attributed to the most significant therapeutic change for themselves and/or the mother-infant relationship. Semi-structured interviews were conducted with 16 women who received therapy within specialist perinatal community mental health settings in the Northwest of England, the UK. Interview data were analysed using reflexive thematic analysis. One overarching theme entitled participant life stories were at the heart of therapy was identified alongside three other main themes: 1.) We're in this together - therapeutic bond and establishing a coherent sense of self, 2.) Surfing the urge to 'fix' feelings - Sitting with emotions improved regulation and 3.) Seeing myself in a new light - Shifting self-blame to self-compassion enhanced self-efficacy. Theme 1 consisted of three subthemes. Participants described the quality of the therapeutic relationship as the fundamental foundation to (re)connecting with their needs, values and boundaries, which improved their sense of agency, self-esteem, therapeutic engagement and self-understanding. Shifting emotional avoidance to emotional engagement improved their self-regulation. Considering alternative factors that could have contributed to their experiences helped them to defuse self-blame and enhance self-compassion. Finally, changes in their mental health led to positive relational changes in their relationship with their infant and improved communication with partners. Sensitivity, engagement and responsivity experienced in the therapist-woman relationship was reported to be mirrored in the mother-infant relationship. Developing a coherent sense of self and self-regulation skills both appeared to heighten women's self-compassion and empathy for their infants, which also seemed to improve their ability to tolerate uncertainty and mixed emotions within themselves and their infants. The mechanisms of change in the perinatal period are important to consider at a stakeholder, therapist and service management level to parsimoniously and best meet the needs of women and the mother-infant relationship.

A Cluster Randomised Controlled Trial of a Targeted Distributed Toothpaste and Toothbrushing Programme.

The aim was to assess the effectiveness of a distributed, targeted toothbrush and toothpaste programme on referrals for tooth extraction under Dental General Anaesthetic (DGA), in children of high-risk families compared to usual care. A recruiter and assessor-blinded, clustered parallel randomised control trial (RCT). Families with one or more children aged between 3 and 10 years having undergone a DGA operation for extraction of carious teeth, were approached within hospitals in the North West of England. Families were randomised at the cluster level in a 1:1 ratio. All eligible children within the family consented to the study. The primary outcome was participant referral for a DGA 6-24-month post-randomisation. A total of 961 families (1,671 children) were randomised, 482 families (832 children) to the intervention, and 479 families (839 children) to the control group. Families (1,662 children, 955 families) were included in the final analysis (825 intervention, 837 control). Marginal regression models (generalised estimating equation approach) taking into account cluster membership were used to model the effectiveness of the intervention at 24 and 48 month follow-up, including the variables, age, sex, and IMD quintile. Seventy-six children (9.2%) in the intervention group had a DGA referral within 2 years compared to 57 children (6.8%) in the control group. The study found no effect of a clinically meaningful difference between the intervention group and usual care (risk ratio 1.36, 95% CI: 0.98-1.89) in reducing referral for DGA for a targeted postal toothpaste/toothbrush program in a contemporary, population with previous family experience of DGA residing in an area of high deprivation. The target of the intervention (families of children with a DGA) was the correct focus given the referrals observed over 2 and 4 years. The study can aid policymakers, local authorities and commissioners to understand repeat DGA within families and further need for intervention.

Compound mortality impacts from extreme temperatures and the COVID-19 pandemic

Extreme weather and coronavirus-type pandemics are both leading global health concerns. Until now, no study has quantified the compound health consequences of the co-occurrence of them. We estimate the mortality attributable to extreme heat and cold events, which dominate the UK health burden from weather hazards, in England and Wales in the period 2020-2022, during which the COVID-19 pandemic peaked in terms of mortality. We show that temperature-related mortality exceeded COVID-19 mortality by 8% in South West England. Combined, extreme temperatures and COVID-19 led to 19 (95% confidence interval: 16–22 in North West England) to 24 (95% confidence interval: 20–29 in Wales) excess deaths per 100,000 population during heatwaves, and 80 (95% confidence interval: 75–86 in Yorkshire and the Humber) to 127 (95% confidence interval: 123–132 in East of England) excess deaths per 100,000 population during cold snaps. These numbers are at least ~2 times higher than the previous decade. Society must increase preparedness for compound health crises such as extreme weather coinciding with pandemics.

Patient experiences of their current asthma care and their views toward providing support for patients with asthma in community pharmacy: A Qualitative study

BackgroundAn estimated 300 million people live with asthma globally. In England, a significant percentage live with poorly controlled asthma symptoms. Community pharmacists might be able to play a role in filling gaps in asthma care as they have the expertise and are in regular contact with patients with long term conditions. This study described patients' experiences of the management of their asthma in the general physician (GP) practice and community pharmacy settings and explored patients' views on providing support for them in community pharmacy. MethodThis is a descriptive qualitative study. Thirteen adult asthma patients were recruited from a GP practice in the Northwest of England. Semi-structured qualitative interviews were conducted face-to-face or by telephone. The interviews were recorded, transcribed and analysed using a thematic analysis approach. Ethics approval was obtained before the study commenced and all participants gave informed written consent to participate. ResultsWe identified challenges in the current asthma care provided to patients with asthma including lack of continuity of care, inability to book an appointment and other experienced differences in the quality of asthma care provided to them and/or access to annual asthma reviews across different GP practices. Additionally, there is lack of awareness of services provided in community pharmacy. These challenges along with having comorbidities alongside asthma may negatively affect asthma patients' engagement with their asthma appointments and their behaviour toward their asthma. ConclusionsPatients showed trust in community pharmacists same as other HCPs to support them with their asthma care. Patients thought that being provided with regular asthma care including reviews in community pharmacy might be a suitable approach to respond to patients' needs and preferences in terms of their asthma management because of ease of access to community pharmacy. Pharmacists could be involved in the provision of community pharmacy-based asthma interventions that involve more than inhaler technique education. Further research should focus on developing structured approaches for asthma patient education that can be implemented consistently in the context of community pharmacy in England.

In Pursuit of Equanimity: Managing Change and Adversity in Early Modern English Households, c.1570–c.1670

Abstract This article establishes equanimity as an important emotional ideal in the late sixteenth and seventeenth centuries. In showing how equanimity served to strengthen positive emotions and temper disruptive states, it promotes a more positive view of the era’s emotional landscape. The article employs the pursuit of equanimity as an intimate analytical device for uncovering the agency of ordinary people, and thus offers historians a new perspective on momentous change and adversity in the early modern period. It charts personal experiences of adversity—from physical and spiritual threats to familial disputes, uncertain patriarchal power and economic precarity—alongside individual management of religious, social and political change following the English Reformations and during the Civil War. Where other scholars have examined how different social groups reactively negotiated new realities, this microhistorical study of one gentry family in the North West of England urges historians to refocus their attention on the proactive courses that people took. Through a detailed examination of 541 manuscript letters, domestic decorative schemes, and archaeological evidence of ritual practices of protection, the article uncovers how the Moretons of Little Moreton Hall in Cheshire managed change and mitigated disaster. It discusses instances where equanimity played a persistent role in motivating the family’s actions and behaviours in daily life, and argues that practices designed to promote emotional harmony were crucial for preserving kinship networks and managing personal well-being, as well as gender relations within households, in early modern England.

ASSESSING RISK FACTORS FOR OSTEOPOROSIS AND FRACTURES AT DIFFERENT SITES: LUMBAR VERTEBRAE VERSUS NECK OF FEMURS IN A LARGE COHORT. A CROSS-SECTIONAL STUDY

Osteoporosis can cause significant disability and cost to health services globally. We aim to compare risk fractures for both osteoporosis and fractures at the L1-L4 vertebrae (LV) and the neck of femurs (NOFs) in patients referred for DEXA scan in the North-West of England.Data was obtained from 31546 patients referred for DEXA scan in the North-West of England between 2004 and 2011. Demographic data was retrospectively analysed using STATA, utilising chi-squared and t-tests. Logistical models were used to report odds ratios for risk factors included in the FRAX tool looking for differences between osteoporosis and fracture risk at the LV and NOFs.In a study involving 2530 cases of LV fractures and 1363 of NOF fractures, age was significantly linked to fractures and osteoporosis at both sites, with a higher risk of osteoporosis at NOFs compared to LV. Height provided protection against fractures and osteoporosis at both sites, with a more pronounced protective effect against osteoporosis at NOFs. Weight was more protective for NOF fractures, while smoking increased osteoporosis risk with no site-specific difference. Steroids were unexpectedly protective for fractures at both sites, with no significant difference, while alcohol consumption was protective against osteoporosis at both sites and associated with increased LV fracture risk. Rheumatoid arthritis increased osteoporosis risk in NOFs and implied a higher fracture risk, though not statistically significant compared to LV. Results summarised in Table 1.Our study reveals that established osteoporosis and fracture risk factors impact distinct bony sites differently. Age and rheumatoid arthritis increase osteoporosis risk more at NOFs than LV, while height and steroids provide greater protection at NOFs. Height significantly protects LV fractures, with alcohol predicting them. Further research is needed to explore risk factors’ impact on additional bony sites and understand the observed differences’ pathophysiology.For any figures or tables, please contact the authors directly.

6281706 Anaesthetic management of women with booking body-mass index > 40 kg ·m−2 for Caesarean. A retrospective analysis from the north-west of England

6281706 Anaesthetic management of women with booking body-mass index > 40 kg ·m−2 for Caesarean. A retrospective analysis from the north-west of England

6301635 Anaesthesia for 360 women with a booking body mass index > 40 kg.m-2 for elective caesarean birth in nine maternity units in the north-west of England

6301635 Anaesthesia for 360 women with a booking body mass index > 40 kg.m-2 for elective caesarean birth in nine maternity units in the north-west of England