The total adherence score, a numerical value for each participant, reflected the adherence to the contents of the statewide perinatal guidelines. Scoring encompassed preconception counselling, antenatal care (clinical assessment and investigations), foetal wellbeing assessments, planned risk stratification, mode of delivery and labour recommendations as per guidelines [20]. A scoring system was devised that measured adherence variables used in this study were equally weighted, giving a maximum score of forty to measure adherence. Positive documentation of the guidelines, regardless of the entry point, achieved a score. A minimum score of acceptable guideline adherence was determined after comparing the two cardiac groups mean, and median adherence scores with expert review of selected cases identifying the minimum expected care. From this analysis, a score of 35 (for the ‘preexistent’) and 17 (for the ‘newly acquired’) cardiac conditions were deemed acceptable guideline adherence.

The data collected from the retrospective clinical audit of medical records identified pregnancy complications for mother and baby, including morbidities, outcomes, the expected clinical investigations and interventions. Therefore, the string data required coding and categorisation. Likewise, variables utilised in the statistical analysis were categorised into three groups, namely: maternal cardiac (n = 17), obstetric (n = 17) and neonatal (n = 20) see S3 Table. Explicitly, the clinical variables for both primary and secondary clinical outcomes, investigations, and interventions during pregnancy could alter the trajectory for mother and baby, thus influencing the uptake of guidelines and acute complications related to poor guideline adherence [19].

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