One size fits all? The role of social determinants of health on AI-driven CTG intrapartum decision-support tools in term babies

Key objectives: to analyse the interaction between ethnicity and other social determinants of health and adverse outcomes during labour in term babies; to use ethnicity data and other social determinants of health in AI-driven CTG intrapartum decision-support tools to predict perinatal adverse events; to understand the experience of women from underrepresented backgrounds and clinicians using AI-driven decision aid tool for intrapartum risk assessment. Clinical need: Hypoxia, before or during labour remains a significant challenge to clinical teams, from its origin, detection, prevention, and treatment. Moreover, labour presents several challenges to mother and fetus. The long-lasting physical and mental challenge has often been compared to a marathon and the effort required giving rise to its name, 'labour'. Physiologically, contractions compress blood vessels that lead to an intermittent myometrial hypoxia. However, if this hypoxia is prolonged, will contribute to dysfunctional (slow to progress) labours. Hypoxia in labour is still unknown, and is responsible for adverse perinatal outcomes in women and babies and unplanned surgical interventions (Wray et al. 2021). Intrapartum hypoxic ischaemic injury is a major contributor to stillbirths, neonatal encephalopathy and mortality, and long term neurodevelopmental sequelae worldwide (Lovers et al. 2022). Furthermore, evidence shows that women from the poorest backgrounds and mothers from Black, Asian and Minority Ethnic groups are at higher risk of their baby dying in the womb or soon after birth (Draper et al. 2018). Consequently, these adverse perinatal outcomes have not only a detrimental impact on women's, infants and families' lives but also have an effect on human, material and economic resources. Hence, the prevention of hypoxia is a major public health issue and a significant health priority.The use of cardiotocography (CTG) has become a standard technique to monitor the state of the fetus during labour; however, the major problems with fetal heart rate (FHR) monitoring relate to the reading and interpretation of the CTG tracings (Schiermeier et al. 2008). Controversies around routine CTG monitoring exist nowadays due to the their high false-positive rate and increment in clinical interventions without improving neonatal outcomes (Alfirevic et al. 2013). Nevertheless intrapartum CTG is currently the only method of surveillance approved by national societies (Georgieva et al. 2014), particularly for high risk pregnant women ( Ayres-de-Campos et al. 2015). The need for tackling this public health issue has been acknowledged through the development of several national campaigns and reports, such as Saving Babies Lives, the NHS Long Term Plan and the Ockenden report. The Oxford Labour Monitoring (University of Oxford) is a specialist team developing data-driven cardiotocography (CTG) systems/software to continuously assess fetal wellbeing at the onset of and during term labour. The OxSys, an AI-driven decision support tool in labour serves as a screening test to identify high risk or unfit babies at the onset of labour. This tool is based on a statistical prognostic model that takes into consideration antenatal and intrapartum risk factors as well as using computerized CTG to predict the risk of experiencing perinatal adverse outcomes.

Impact on Health and Care
The CDT primarily addresses the most pressing needs of nations such as the UK - namely the growth of expenditure on long term health conditions. These conditions (e.g. diabetes, depression, arthritis) cost the NHS over £70Bn a year (~70% of its budget). As our populations continue to age these illnesses threaten the nation's health and its finances.

Digital technologies transforming our world - from transport to relationships, from entertainment to finance - and there is consensus that digital solutions will have a huge role to play in health and care. Through the CDT's emphasis on multidisciplinarity, teamwork, design and responsible innovation, it will produce future leaders positioned to seize that opportunity.

Impact on the Economy
The UK has Europe's 2nd largest medical technology industry and a hugely strong track record in health, technology and societal research. It is very well-placed to develop digital health and care solutions that meet the needs of society through the creation of new businesses.

Achieving economic impact is more than a matter of technology. The CDT has therefore been designed to ensure that its graduates are team players with deep understanding of health and social care systems, good design and the social context within which a new technology is introduced.

Many multinationals have been keen to engage the CDT (e.g. Microsoft, AstraZeneca, Lilly, Biogen, Arm, Huawei ) and part of the Director's role will be to position the UK as a destination for inwards investment in Digital Health. CDT partners collectively employ nearly 1,000,000 people worldwide and are easily in a position to create thousands of jobs in the UK.

The connection to CDT research will strongly benefit UK enterprises such as System C and Babylon, along with smaller companies such as Ayuda Heuristics and Evolyst.

Impact on the Public
When new technologies are proposed to collect and analyse highly personal health data, and are potentially involved in life or death decisions, it is vital that the public are given a voice. The team's experience is that listening to the public makes research better, however involving a full spectrum of the community in research also has benefits to those communities; it can be empowering, it can support the personal development of individuals within communities who may have little awareness of higher education and it can catalyse community groups to come together around key health and care issues.

Policy Makers
From the team's conversations with the senior leadership of the NHS, local leaders of health and social care transformation (see letters from NHS and Bristol City Council) and national reports, it is very apparent that digital solutions are seen as vital to the delivery of health and care. The research of the CDT can inform policy makers about the likely impact of new technology on future services.

Partner organisation Care & Repair will disseminate research findings around independent living and have a track record of translating academic research into changes in practice and policy.

Carers UK represent the role of informal carers, such as family members, in health and social care. They have a strong voice in policy development in the UK and are well-placed to disseminate the CDTs research to policy makers.

STEM Education
It has been shown that outreach for school age children around STEM topics can improve engagement in STEM topics at school. However female entry into STEM at University level remains dramatically lower than males; the reverse being true for health and life sciences. The CDT outreach leverages this fact to focus STEM outreach activities on digital health and care, which can encourage young women into computer science and impact on the next generation of women in higher education.

For academic impact see "Academic Beneficiaries" section.