Okay. Can you start by saying your name and your position?
So I'm Maria Knight and I'm professor of maternal and child population health in the Nuffield Department of Population Health.
Lovely. Thank you. And without telling me your entire life story, can you just take me through the key steps in your career to date?
And I mean, starting with how you got interested in science and medicine at all.
So I'm medically trained and I started with an interest in pregnancy.
So initially I moved into training as an obstetrician.
I did a PhD at that point, a dphil in the university and realised that actually research for me.
So I did land based research then, but that wasn't close enough to making a difference to patients for me.
So I. So working in the lab wasn't close enough.
The research didn't lead to a change for patients quick enough for me, whereas I got some exposure to to epidemiological research and clinical trials.
So I realised that actually I wanted to get the epidemiology training and the route to do that was through training in public health.
So what are the epidemiological questions in terms of maternal and neonatal health?
What was I mean, I think what I'm. What was the big question that really drove you to say so?
My my research in the lab was around understanding the causes, the basic causes of pre-eclampsia.
But actually, you know, that's something that happens quite a long time before the poor outcomes.
You know, we still lose mums, we still lose babies from pre-eclampsia because of the treatment they need around the time,
you know, around the end of pregnancy, around the time of giving birth. So just to fill in quickly, what is pre-eclampsia?
It's a pre-eclampsia is high blood pressure in pregnancy.
So actually, when you're talking on a global basis, still one of the leading causes that we we lose mums and babies and yet you know,
what we need to know is well what do we need to treat them with at the time we've made the diagnosis as opposed to my lab work,
which was almost the how do we prevent this stage and to to, to find out how to treat them.
We need an observational studies where we just look at what women are being treated with and who seems to do better, but also clinical trials.
And through a very big clinical trial that was done around about the time that I was doing my PhD, not by me.
We found that aspirin, simple aspirin was good at preventing baby deaths in women with pre-eclampsia.
So seeing the power of that was what really drove me into public health.
The added appeal of public health for me is that I can see that actually many things are driven by inequalities,
by much more wider determinants of health and people will be familiar with,
you know, things are much worse if you live in a deprived area, if you you're less educated,
if you are unemployed, all of which relates to wider determinants of health.
And the advantage of of working through public health is that I'm able to think about those wider prevention elements as well.
So it's for me, a big a big motivated to to be able to link the two together and make a more immediate
difference to preventing severe illness and death in pregnant women and their babies.
So has that that I interrupted you as you would go through your career steps.
Have you stayed in Oxford ever since? Not intentionally, but yes, I'm I stayed in Oxford ever since.
Well, I as I say, I was I was doing my dphil here and then went back into training in obstetrics but realised I wanted to move into public health.
And the huge advantage in Oxford is that we have the unit where I am now, which is the National Perinatal Epidemiology Unit,
which does exactly the kind of research that I knew I was interested in.
And an added benefit was that while training as a registrar in public health, I was able to come here to do some of my training.
So because that was in Oxford and there's no other place like it, it was the reason to stay in Oxford.
So and I've never left.
So you've talked about pre-eclampsia and you've talked about some of the social factors.
What is it possible to put a figure on how risky pregnancy and birth are today for a woman in the UK?
Sorry, that's a terribly broad question and depends on those different things.
But how is a problem? So so I can give you exact answers to that said.
Part one of my current roles that I've been doing for about ten years now is that I lead the national
investigations into all maternal deaths during pregnancy or up to a year after the end of pregnancy.
This is the UK obstetric surveillance. No, this is this is the what is called the confidential inquiries into maternal deaths.
All right. I like to, but not the same as the UK obstetric surveillance system.
So the, the, the confidential inquiries is a program that's been going for 70 years in in the UK investigate.
Maternal deaths. So every time a mother dies in pregnancy or shortly after, every time a mother dies in pregnancy,
or shortly after we find out about it and then investigate her care to identify ways of improving care to prevent women from dying in the future.
So on the basis of that, I can give you exact numbers around about one in every 10,000 women giving birth
will die either during pregnancy or six weeks after the end of pregnancy.
So it's not common. And sadly for babies, that's that's much more common.
So about five in every thousand babies who are born either die or are either
stillborn or die in the neonatal periods or die in the first month of life.
And so, I mean, in summary, pregnancy is very safe in the UK, but then there are a lot of women who have severe complications.
What we often talk about is near misses or well, I really like the South African system.
We call them the Great Saves. So with my other hats on which she started to introduce,
I set up the UK obstetric surveillance system to look at those severe complications in pregnancy.
Because they're severe, they're relatively uncommon.
So it's not something as a as a clinician working in a hospital, you would see on a day to day basis,
probably it's the kind of thing you might see once a year for the rarer complications, maybe once in your lifetime.
So it's very difficult to build up the knowledge to know how we treat women as an individual, as obstetricians yet.
But because we collect information on a national basis from all the hospitals with maternity units,
we can bring all that together to then provide information on how women can and how we should be managing these women with these complications.
But can you give a couple of examples of the kinds of complications? Yeah.
So one of the complications, for example, is and is so sometimes that the placenta can grow deeper into the womb than normal.
It's a condition called placenta accreta or abnormally invasive placenta placenta
accreta spectrum often associated with having had a previous caesarian birth.
So as you can imagine, we've got higher caesarean birth rates now.
So the rates of placenta accreta are increasing.
But a simple question is, well, I thought if I know that this woman I'm caring for has got this condition, how do I how do I deliver her baby?
And then what do I do about the placenta?
Because the risk to her is a very, very severe bleeding.
And so by collecting that information nationally, we can show we did show that the best thing to do is is leave the placenta alone.
Don't touch the placenta. Don't try and remove the placenta and then go straight to actually do a hysterectomy for
for something which obviously certainly means that woman will no longer be fertile,
but she will be alive and so will her baby. And say what?
Her baby. Exactly. Yeah.
So yeah, but but obviously we can't if we're if we're only managing to three women like that every year as an individual clinician,
we wouldn't have all of the information to be able to to look at the difference.
Hmm. And we're going to get to COVID. But what about infectious disease?
What about things like flu and what what data was there available on how that affected pregnancy?
So a very pertinent question and we'll come on to COVID.
So because we have this national system, when the the swine flu pandemic came along, which I think is a distant memory for most people.
2009 was a 2009. Yeah, that's right.
One one of the questions was, well, was this going to.
Did this affect pregnant women more than it affected affected non-pregnant women?
So we were able to collect information very rapidly through the obstetric surveillance system,
although it's not as rapidly as we would have would have wanted because the pandemic hit in.
So I think it was about April 2009. So there was a small wave of flu infection sort of over the summer in the UK, but relatively small.
We we because we hadn't planned the study at that point, we didn't collect data during that wave but it.
Whereas we we were able to collect it in the winter wave, which was much bigger in the UK.
And we were able to show that women who got treated with antivirals within two days
of the symptoms starting had about a 90% lower risk of needing intensive care.
So and at that time, the the guidance, again, I don't know if you remember,
but there was a phone line that you could phone up to get antivirals at Tamiflu, I think it was.
Now, I won't go into the the subsequent research around Tamiflu,
but if you were not pregnant, you could phone up that line and you could just go collect it.
And you didn't have to go to your doctor. But if you were pregnant, you had to go to your doctor.
So there was there were more barriers to actually getting treated when you were pregnant.
So obviously, by having that information to say, well, actually,
it's even more important that pregnant women get treated quickly, it means you then thinking thinking a system level.
Right. We've got to remove these barriers. So actually that the barriers were believed so that when pregnant women were able to
get antivirals through the thing helpline and were they more vulnerable in pregnancy,
does that increase your vulnerability to severe? It does so increases your vulnerability to severe flu.
So so they were they were pregnant women who were having to go on heart bypass machines because of the severity of their flu.
So, yes, it is undoubtedly makes your flu more severe.
And, you know, that's an interesting question that we never quite know,
so that there are some infections which whether you're pregnant or not, it's no difference in the severity.
And there are others where we know that pregnant women are more severely affected.
And that's a question that we will always need to answer if a new infection comes along.
And yet, surprisingly not recognised that we will always need to answer that question.
And so so yeah, very pertinent when it comes to COVID.
Well, I think we have come to cope with I think that it was a very good background introduction.
So I'm asking everybody this. Can you remember when you first became aware that something was going on in China
and that actually it looked as if it was going to become a global pandemic?
So I can't remember whether it was the end of December or beginning of January, but I became aware because there's a within the within the department,
there's quite a lot of work goes on with with China and they actually have a large birth cohort.
And in fact the year before, in fact actually it might even have been December, it was December 2019.
I had been over to visit the one here in China where they have this large birth cohort,
which they recruit pregnant women, they have some blood tests, and then they follow them and their babies.
And when the the the the COVID concern came up, as it were, as it was actually, we thought, well,
this this cohort is it would be a great way of finding out whether it's adversely affecting pregnant women or not.
So we actually applied for a grant to do that study that wasn't successful, but in actual fact was rapidly overtaken by events.
And sadly, because that we had many, many more infections here,
difference in public health control measures and actually collecting data in the UK became very much more pertinent.
And so, yes, so my second part of that question is usually when,
when did you realise that this was something that you were going to have to get involved with?
But it sounded like, well, I'm going to take you I'm going to take you back to flu.
Yes. Because what what was brilliant, I think about the UK I knew would have to be we have to be positive about the bits that were positive.
So after the experience of the swine flu pandemic where we recognised that there were quite there
were a number of research studies that would need to be done in the event of another pandemic.
Actually, the National Institute for Health Research, as it was then,
and I actually put out a call for studies to be set up and then what it called hibernated ready for a future pandemic.
So in in 2011, I applied for one of those which we we were successful.
Funded in 2012. So I had a hibernated what was we thought would be for another pandemic, flu pandemic.
I had a hibernated study set up ready to run through the UK obstetrics the first time I've heard about hibernated studies.
Okay. So I think there's no there were nine hibernated studies on the portfolio of of which I think eight were activated.
And why it's important is because because I had everything ready to go.
We tested it twice alone along the way.
So effectively we knew things were still still.
Right. It meant that I was very quickly able to adapt it to, to cave it in February,
get the get the ethics permissions so that it meant that on March the 18th,
when I was asked to activate it and I was able to get things going on March the 22nd.
So you'll hear all about the nine days of the nine days of recovery from from start to activating.
But we were even quicker. To be fair, we had been funded nine years beforehand.
So, uh, and, and for me that's,
I guess one of my concerns is that I think those portfolio studies were really
successful and why are we not getting ready now for when we need those again?
And what and what did the study actually do?
I'd say and talk to you about the UK obstetric surveillance systems.
We have hospitals in every maternity unit in the country participates and so we used across the UK obstetric
surveillance system to collect information about all pregnant women with COVID who were hospitalised.
We anticipated we'd have a study, a 500 week, up to 20,000 by the time we stopped at and obviously was a huge,
hugely down to the efforts of clinicians in all of the hospitals,
but particularly the network of research midwives who were also pivoted to help with that and and they were absolutely amazing.
But so I was doing that. So I have to staff and myself.
And so I would I was analysing those data on a weekly basis for the for the Royal Colleges to inform their guidance,
but also for the Departments of health. So that so that A, we could see what was happening to numbers.
But importantly, those questions about, well, if I get it, what happens to my baby?
Is it worse for pregnant women? Which pregnant women is it worse for?
And, you know, again,
looking back to me and my public health background and in that the so we did the first analysis that we released at the end of May slightly earlier,
obviously to NHS England and Department of Health, which showed that 56% of women admitted with COVID in pregnancy were from ethnic minority groups.
That's on a background of normally about about 18% of the population of pregnant women as a whole are from ethnic minority groups.
So clearly that group were particularly at very high risk of severe outcomes and
the there was an instant response from NHS England and a number of hospitals.
He put in place different actions to to ensure a lower threshold of, of, of concern of women from black and ethnic minority groups.
Some did some some brilliant daily telephone calls to that because obviously we would
we were being told to stay at home and and isolate if if we'd got an infection.
But they were. So then there's a concern that you stay at home too long when you're too sick before you come in.
So some hospitals were then instituting daily phone calls to to check in with women so that they knew that they could advise them to come in early.
So so some really, really good responses by having the direct communication through and with,
as I say, with the colleges, but also with the NHS and Department of Health.
So, you know, as a researcher, incredibly satisfying is the wrong.
But you know, you feel that actually your skills,
what you're doing is really making a difference and going back to the beginning of this conversation.
But you know that that is why I didn't carry on with love research.
It was it was to enable this kind of research.
And then we we carried on obviously collecting information as because then the next question, oh, well, we've now got a new variant.
Have things changed? What is the impact of vaccination?
And we we showed that the the Delta variant was very, very much worse for for pregnant women.
And Omicron looks much similar to to the first variant as it was the wild type.
What was that? And this is where I, I still get cross frustrated.
Cross cross is a mild word for it. Pregnant women were excluded from all the initial via vaccine trials.
Now, I had a question about that. Let's let's just explore that in a bit more detail.
So. Yeah.
I've got a question about, say, how they fit together.
Oh, do you? But. But, yes. So let's just go back a bit of background.
When people do trials of new kinds of treatments, how common is it for pregnant women to be included?
Very rare. Yeah. And the reason for that is so the default is always exclusion because of fear of damaging the baby.
As a fear of damaging the baby. Yes. So safe.
It is. It is. So if you're if you're a pharmaceutical company, why would you include pregnant women in your research?
It's it's risky. It means you are putting yourself theoretically, you might be putting yourself at risk.
It'll be a much more bigger insurance. And it's a small market.
You know, there is no motivation to include pregnant women in your in your trial,
even if it is clearly a disease that affects pregnant women as well as others.
The potential for benefit for pregnant women is as great, if not greater than than for others.
And in many cases, there are similar drugs or that drugs have been used in pregnancy in in previous times.
So you've got you've got evidence to suggest that there's not going to be a problem in pregnancy.
But that benefit I, I always now talk about benefits before risks.
So that benefit risk analysis is never done.
And there is not there's no there's no incentive from regulators.
So there's no you know, it's not it's not linked to your licensing approvals that you need to make sure that
you're including pregnant women or at least justify why you're excluding them.
But even more basic is that there's no real requirement to do to collect that
information afterwards when we are using the medications in pregnant women.
Because what happens is that the obstetricians and the doctors,
physicians end up having to use medications in pregnancy because their assessment is this is the new woman I need.
This is this is going to be of benefit. You know, I'm doing the the estimation in my head.
And I think there is much greater potential for benefit than there is for any potential for harm.
So they're having to do that on a daily basis. And I'd recommend to women that they take drugs.
But even then, we've got no robust system for collecting the information about when those drugs are used and what happens to pregnant women,
which, you know, a bit akin to what we do in the UK obstetric surveillance system could give us
at least information for women to be able to base decisions on in the future.
So going back to the COVID vaccine, I mean, as we all know,
one of those vaccines was developed right here in Oxford in a building not too far away from where the one where you sit.
Were you at all involved in conversations about how those trials were set up initially?
No, I did I did send a message to the to the trial team at one point.
But but I was told that somebody else was was talking to the company.
And I don't think that the company wanted to take the risk and put, you know, pretty quotes around taking the risk.
But obviously, nobody had the data that I was seeing about that to be able to make that benefit risk assessment.
We've got very clear ethical guidance that pre-dates the pandemic plan for exactly the situation.
And that quite clearly states that, you know, ethically,
we should not be denying pregnant women the potential to benefit when when we're enabling it for other people.
And I don't want it to come across that I am in any way going to be forcing pregnant women to take part in clinical trials.
The position that I want to get to, the position where we are at least offering pregnant women the choice to participate in a.
While that may be to their benefit.
And and we do know that when we do enable pregnant women to take part, the pregnant women will choose to take part.
And we did for recovery. So for recovery, we saw recovery.
This was a trial of treatments in hospice. So this was a trial for treatment?
Yes. So so obviously, we knew pregnant women were getting very sick.
And but so so we enabled pregnant women to to participate.
And because we enable pregnant women to participate, when the results of that trial came out,
you could see pregnant women were included in this trial.
Therefore, we can include them in the guidance. But you need to treat them with dexamethasone or in this case, steroids.
But yeah, so so again,
it was a direct you could see very quickly how the results of the trial were adopted into guidance for treatment
for pregnant women and what was the consequence of their not having been included in the trials for vaccination.
So I mentioned to you back at the beginning that one of one of my roles is to, um, count and investigate the care of all women who die in pregnancy.
So obviously some women died during that.
The 2020 when we didn't have vaccine, more women, three times as many women died in 2021, in 2021 winter, when everybody was eligible for vaccination,
and then the end of 20 at the end of 2021 and almost exclusively they were unvaccinated
because the the lack of evidence and the the a lot of a lot of the misinformation about risk.
Misinformation. Absolutely, misinformation. Talking about risk not not ever thinking about benefit and not even not even no real conceptualisation
of what that potential risk that they were talking about might be meant that that yeah.
The very high levels of hesitancy in pregnancy and you know the system barriers in place at the beginning which
didn't help either in that again you know we could all go to a mass vaccination centre to get our vaccine,
but if you were pregnant, you had to get extra signatures or they refused to give you a vaccine,
even though they were able to give you, you know, so they were there were challenges.
So it wasn't just the the women who were hesitant that the clinical system itself had hesitancy within it about treating the exact.
Yes, yes. Yeah. And so it was left to individual clinicians, nurses who had to say whether it was safe or not.
Exactly. Yeah, yeah, it was.
It was, um, and if you want to, you know, if you want to enable pregnant women to get vaccinated, you do it when they're going for a routine check.
But because I mean, because of some of the issues around storage and things of the of the Pfizer vaccine in particular,
they were only available in certain places.
They didn't have them in hospital clinics in a short, short shelf life out of the extreme deep freeze and that that kind of thing.
So there were lots of barriers that made it harder, coupled with a lot of misinformation.
Um, and again, you know, there could be other solutions.
So we started talking about flu. You know, pregnant women have been having flu vaccine so that there are,
there are old vaccine technologies that pregnant women are being been being vaccinated with with with vaccines for a long time.
And, you know, we could have made sure that we were we were enabling one of the old vaccine technologies.
So, you know, killed virus, for example, which we would have new concerns over safety and pregnancy.
So at least that was a vaccine that pregnant women could have had without any theoretical concerns over them or any vaccines,
which that there are no real concerns about it or any vaccine.
We obviously now have information about millions of women who have been vaccinated.
Pregnancy with no concerns at all.
But even when we started vaccinating in the UK and pregnant women were being vaccinated, that information was not being collected.
So again, we had to delay it.
Even when we were recommending the vaccine to pregnant women, we had to delay in enabling them to have information to make an informed choice.
So all of these things, I really just want to make sure that they're not going to happen again.
There's still some big delays to actually getting information out.
Mm hmm. And that I mean, what can you say?
Is that a system failure? Or can you point the finger at who was the what was the of bill putting up the barriers?
It was so, so clearly I female I spend my life working on my own pregnancy research.
I have three daughters. So everything, everything in my world, life revolves around women, pregnancy.
It's it's just a no brainer for me. You have to be thinking about pregnant women.
I'm just not sure, you know, in those groups that were advising it the first time is was there anybody who even have that thinking?
I suspect not. They kind of thought I mean, if I thought they were having, as you suggested earlier,
with all around the threat of compensation if babies died and that kind of thing.
Yeah, yeah, yeah. Um, some of the lessons to be learned.
Well, so we're about to go into a, well, pregnant women because I was counting so many dying last winter,
the JCB changed their guidance and put pregnant women into a higher risk group so they are now eligible for the booster doses.
But I still am not clear that anybody will be collecting systematically and
publishing in a timely manner information about women who've had the booster dose
in pregnancy to be be reassured that the booster dose is effective and to give
that reassuring information about women for women who are getting immunised.
And to counter all of the misinformation that's on social media, I'm not convinced that that's going to happen in a timely manner yet.
I'm still hopeful, but I'm not convinced. Mm hmm.
I meant to do this in a different order, but never mind. It is sort of slightly back to front.
But what? What?
Why are pregnant women at heightened risk from the infection itself?
So good question. To which I'm not sure I can give you a straight answer because I do kind of work at the lab level.
But we do know that your immune system changes when you're pregnant because effectively you are the baby is genetically different from you.
So you have to become more immune tolerant, a bit like, you know, if you if you have a transplant, you have to you have to become b immunosuppressed.
So you do reject the transplant. So we have there are immune changes in pregnancy.
And obviously, depending on which bits of your immune system are tackling,
which infection that that whether that the changes of pregnancy mean that you're effectively a little bit more immunosuppressed,
therefore you might get a worse infection.
And there are probably you know, there's likely to be other genetic things involved.
The mean particular groups of pregnant women might be more at risk, but we don't know any of those.
And is that just a physiological thing about having a very large abdomen?
Well, so so, yes.
I mean, there is there's no doubt that that severe COVID is much worse in the in the third trimester of pregnancy.
So so obviously, the physical and lung capacity is part of an issue, partly an issue that but yes, but but yeah, that's not the sole explanation.
But yeah, yeah. And, and then there's the that kind of social side of it.
So how did the pandemic impact the experience of being a pregnant woman in society?
Yeah. So again, when you look back and you think, well, why did nobody realise?
So obviously the pandemic hit lockdown, dramatic change in NHS services, you know, clinics stopped, everything went online.
But lots of, you know, surgeons who've been doing routine operations with pivoted to COVID care and in whatever shape it took.
But hang on, you know, pregnant women who are still pregnant and will carry on giving birth, they'll carry on having the same complications.
They will need the same level of care. And yet it was highly variable in some places.
They they took the took away the the consultant obstetricians to COVID care.
In other places, it was the other way round that kept the consultant obstetricians and took away the juniors too,
which at least meant that you were left with your experts.
But, you know, the the Royal College of Obstetricians and Gynaecologists had to intervene and say, look, don't take away the senior stuff,
which you'd have thought was just common sense, but all of those, you know,
so the other aspects to pregnant women you know that the do we don't we shield.
So they were recommended to shield because we had no idea about whether it was going to be more severe in pregnancy.
They couldn't take their partners with them to appointments.
They some of the obviously more appointments had to be online, but mental health wise, big impacts.
I mean, mental health is of concern during and after pregnancy as it is, but hugely more potentially impacts.
And if you can't even have the support of about that,
when you when you're going through various appointments, it's obviously going to make it even worse.
And then even when we began, can't come out of it.
You know, pregnant women didn't know, well, should I still be shielding?
What should I do now? And then when?
Vaccination began to come in. It's like, well, do I get vaccinated?
Don't I get vaccinated? And if I don't, do I then shield.
And so very difficult messaging for for pregnant women and a huge change in their care.
And there's no doubt we saw some impacts of of more remote care,
particularly for for more vulnerable women or where language was was more of a problem.
Because you can imagine having having a remote consultation where your English understanding is is okay.
But but but not, you know, not not not native speaking.
It can be can be very easy to to nod through things and actually not be able to express your concerns.
And some of those things which which would come out in a face to face consultation or with an interpreter.
And so there were there were undoubtedly changes that that impacted on maternity care.
And what about birth itself? Were partners forbidden to attend to?
So partners were allowed to in most places. It was only when the woman was in established labour.
So there were there were quite a lot of people reporting their experiences of,
of a sick waiting in the car park in the car for when they were told that they could go in and partners missing the event because
they were still out in the car park in the car and labour starting you know is that it's it's a bit uncertain as to you know,
when labour when you're in established labour or not so and that I mean,
particularly for your first birth is an incredibly uncertain time for you as a woman.
And to be completely unsupported at that time makes it really so hard.
So hard. And is that something you've been able to follow up?
So it's a there are there's quite a number of studies that have picked up on women's experiences, not know that that I've done.
And there are obviously and were looking at whether there were changes in outcomes over the pandemic.
I the mental health in particular is a big concern to me.
So I know that, that, that there definitely been changes in mental health that that were very negative.
But yeah and, and what I noticed you've got a study just a but there was a paper about the protocol for the study.
So I don't know how far you've got with it yet, but looking out to two years, babies when they get to two years old.
Yeah. Whether or not there's any effect of the mother having been infected.
Yes. So if you've basically described it so, you know, we where we are looking at babies and mums who've been infected,
but also babies of mums who haven't been infected to see whether there's any changes in their developmental outcomes.
A Two years because we, we simply don't know.
So it's a completely open question. Exactly. Yes, it's an interesting you one of the one of the challenges that's always thrown back
by the the the the the misinformation brigade when you're talking about vaccine,
well, what's the long term outcomes of the baby?
Well, you know, we can't answer that because we're only two years from the beginning of the
pandemic and only a year and a half from when we first started giving vaccines.
So so it's an immediate way of being able to just put them on the back foot, because you can't answer that.
But though I suppose what you can always say is that you do know that the outcomes of
babies whose mothers were not vaccinated and who got severely ill with COVID exactly.
Are pretty bad. Yeah. Yeah.
So did did you I mean, how supported did you feel by your research community?
I mean, you clearly the big differences between people within the field in which you work and other areas of medicine.
But was there a sense of a community pulling together in the subject that you're of?
Very definitely. I mean, you mentioned. Earlier the than the network of of research midwives and the the reporting conditions for you costs
none of whom were paid to to to collect the information that they did was was was incredible.
So absolutely within the pregnancy care community huge huge support for because they
recognised the need for and the importance of the information for for them and for women.
So, so really. Absolutely amazing.
Mm hmm. And what about internationally? I mean, you you do have international links.
Yes. So so we have an international collaboration of of countries who have systems similar to to to and the UK obstetrics surveillance system.
And actually they adopted similar protocol and and data were collected across several of the European countries as well.
And, and in fact, now the the the w the W.H.O. are trying to also put in place something that means we're not going to be here,
that the data collection will be enabled across a range of low and middle income country settings in the event of another pandemic,
and have been using the UK centric surveillance system as a model to to think about what we should set in place now for the future.
So, you know, again, satisfaction is the wrong word.
But but I, I certainly feel that by, by at least doing a small bit,
but showing what might work and that the fact that it could then be adopted globally is, is.
Yeah. And the pandemic, I mean, it's a sort of silver lining story, isn't it?
And obviously the pandemic was awful,
but if it puts in place something that could be beneficial with other diseases and other conditions, then that's at least something to.
And I will absolutely continue to advocate for for pregnant women.
So if nothing, you know, if if we can actually change the conversation and let's let's think about benefits as well as risks
when we're talking about any research question or let's just make sure we're collecting the data.
So so like you say that there are there are definite silver linings that the that we can hopefully ensure are put in place for next time.
So so that the last part of this, I just want to ask you about how the pandemic and what went on in the pandemic impacted on you personally.
Yes. So how did they. I mean, first of all, there was lockdown. How did that impact on what you were able to do or what what what was your sense so.
Well, it was it was fascinating. Fascinating.
On how I was frantically busy, the busiest I've ever been in my life.
Within the four walls of study. This is the thing I said to you.
I've got three daughters, two of whom were at university, but obviously with the university shop.
So they. So we we were all locked in at home.
And the youngest one was still at school, but she was still at school. Yes.
Yes. So the youngest was doing A-level, doing well in the sixth form.
So, yes, we we we were all locked in.
And, you know, all of those from from the the kids about, you know, missing the these university experiences they would never have again.
And so so obviously having to be a mum as well and and try and support them in what was a particularly challenging time for them.
You may have seen in an opinion piece. So I think I said to you, I'll have the the study is activated on the Friday the 18th or the Friday the 19th.
But anyway, Friday, Saturday, Sunday, the Sunday, my dad was admitted to hospital with COVID.
We opened the study on the Monday he died two weeks later in hospital couldn't go and.
So very personal and and yet I almost fell for him I had to keep going to get the information.
So sorry. I'm I'm not surprised.
That sounds extraordinarily tough. And did you yourself feel personally threatened by the possibility of catching the virus?
I was never really particularly worried about, you know, I'm youngish, relatively fit, female.
And I kind of assumed if I got over, it would be okay.
I volunteered for one of the trials, so I was a participant in one of the trials.
Um, do you know whether you would, you would receive, but you were in a group that, and, and, but, but no, I was not particularly worried.
I, I stick to the rules of the, you know, so we, we stuck to the rule.
You know, there was again, there was some, you know, nice family experiences that you would never.
So we would all but every morning, all five of us would do some exercises in the back garden, you know.
So there was some family experiences we wouldn't otherwise have had.
So you've got to you've got to positively on know on those kind of things.
But, and yeah, so it was, it was the, the challenge of, of having to do so much oneself in in yeah it,
it just was bizarre being frantically busy, sat in a chair in a very small room.
We had to do a bit of rearranging so that the conservatory became my husband's office and the children with, uh, with me arranged to meet me.
So there were places where they could work, but. Yeah. And do you think.
I think you've already answered this really. But do you think that the fact that you were working on something that was so
important helped to support your own wellbeing through those difficult times?
Yeah, I think you're right. And, and actually I, I so I did feel valued because there's no doubt.
And in interacting directly with, with people like Eddie Morris, who was the president of the Royal College of Obstetricians and Gynaecologists.
And so knowing that the information that I was collating, analysing was going directly to make a difference.
It does, as you say, it motivates you to keep going.
And and. Yeah, don't.
Don't have time to think or worry. Mm hmm. And what about your wider team?
Did they have pressures that you needed to take time to pay attention to, to help them keep going?
I mean, it was challenging for the wider team. So, um, my programme manager was herself pregnant at the time, so, and,
and the registrar I worked most closely with actually went through two pregnancies in the course of the.
So so for them, you know, absolutely incredibly, you know, really close to the personal for them as well.
And again, you know, they they worked so much over and above, you know, within within the unit here.
We obviously had clinical trials and other studies ongoing and people were working off their ironing boards.
And, you know, the I mean so the team in that that the rapidly pivoting to try and get laptops to as many people as possible
and set up all the remote access that they did do an amazing job to to enable us all to keep going.
And so. Yeah. And when did you feel satisfied with the way the university or the department or
between them handled the and meeting the regulations for for not coming in to work,
not mixing at work or and when things began to reopen and so on.
So, so I guess, I mean, the, the, I was fortunate.
I had the laptop, I already had remote access anyway.
So I was relatively able to, to, to get on with things.
But, you know, and obviously the department here was was leading the recovery trial as well.
So so I think that the support they were very well aware of people who had kind of critical positions,
but also kept it going for most of the most of the people as well and recognised where there was a need for you know,
there were there were people who, whose home arrangements were really difficult to enable to, to work.
So we were very good at putting in the protective and you know,
been doing twice weekly testing and lots of protective aspects to for people who had come into the office or needed to come into the office.
Um, I in fact ended up coming back to work into the,
in the office earlier than many people for my mental health basically because it was you know that the that that frantically busy within
the same four walls never getting out was really I suppose that was about it must have been what it must've been about a year in.
Yeah. So after, after about a year I just, I needed to go back into the office and, but felt very safe when I was, it was just like Glen.
So, you know, I wasn't having to sit on a bus or anything.
And as a department they certainly recognised, you know, where that they were.
Challenges. I think now we're at a more difficult stage where there are people who have enjoyed remote working and there are definitely benefits.
You know, there were meetings that we used to do in person that were much better done remotely now.
Um, and I think we're at a delicate balance between, between coming back or coming back as we were before or a more flexible stage.
And I think I think the jury's out department to list with whether we've hit the right balance yet.
But it's it's impossible to to gauge at the moment.
We're still you know, what we know can be cases are going up a bit at the moment and we're only really getting
back into the business as usual kind of research and NHS is still under strain.
So I think it's, I think it's a bit of what this space and you do,
I mean you still have some questions to answer to ask about COVID like this was study.
Yes, exactly. And we will have an while to come to know that will.
Exactly. There will still be boosters, you know, I mean, sorry, there will still be variants and you know, will we will we will will.
It's, as most people seem to think, turn into a flu being you know, it being a winter a winter kind of disease, a bit like flu.
Yeah. So has the experience changed your attitude or your approach to your work?
And how would you like to see things change in the future?
So it's definitely made me more outspoken.
People laugh when they hear me say this. But I'm not I'm not a terribly outspoken person, usually.
But some of what is still happening in terms of exclusion of pregnant women is just so wrong.
I am getting more and more vocal. I think people probably think I'm now just that's all I ever talk about.
Don't use social media. I didn't ask. So I will.
Good question. So I'm very, very I tend to use social media for disseminating things.
I don't I don't tend to express a lot of opinions on social media.
And I, I've written 2 to 2 opinion articles for the BMJ where I expressed some of it, but I don't, I, I don't tend to mouth off on social media, but.
But I, I, I am trying and trying to advocate in the forums where it's for where it's and where there might be an ear of relevant people in power.
Mm hmm. Mm hmm. And how sanguine are you that some things might change as a result of the experience of the pandemic?
I'm I'm worried that they they don't seem to be moving.
We I mean, we learnt so many lessons.
You know, I could and I think there are many of us that could write down a list now of what we need to have in place research wise,
research platform wise, studies in hibernation for the next time.
But that doesn't seem to be happening. I and I'm not entirely sure why.
Possibly because everybody's still concentrating on getting back to normal.
And and, you know, maybe we're not going to be rapidly going into that next pandemic.
I mean, at one point, monkeypox looks like it might be, but that does seem to be settling down.
Well, I mean, and fortunately, a vaccine that was an off the shelf, readily available to to help.
And there's a new pandemic preparedness institute.
I wondered whether that might have a maternity strand in it.
Good question. To which I don't know the answer.
I know nothing at all about what's happening in the Pandemic Preparedness Institute, but many things at Oxford are totally opaque.
But is an 800 year old institution? Yeah.
Thank you very much.