In 2020, I wrote an editorial in this Journal on social determinants of health, defined by the WHO as “The conditions in which people are born, grow, live, work and age” (BJOG. 2020;127(4):431–2). Therefore, I am really pleased that in this issue we are able to give our readers a highly relevant Scientific Impact Paper on precisely this subject. It aims to inform all of us about the relationship between social determinants of health and the risk of maternal death. The paper is written on behalf of the Royal College of Obstetricians and Gynaecologists and for this reason it has a UK focus, but anyone who reads it will see that the extensive literature review and recommendations are of relevance everywhere. Social determinants have a strong influence on a person's health and it is crucial to understand and appreciate that this remains the case even within a public health system such as the UK National Health Service (NHS), where reproductive and maternity services are provided for free.

The COVID pandemic clearly meets the criteria and definition of an important Social Determinant of Health. In this issue, Davies and colleagues (1133–1139) present data on the effects of the pandemic on the diagnosis of cervical cancer, from six major cancer centres in the North of England. They observed a reduction in cancer diagnoses (by 25%) when comparing data from May to October 2020 to a similar period in 2019. Sadly, these data do not suggest a reduction in cancer: rather they are due to early disease that has gone undetected during the pandemic.

Forecasts of the likely impact of COVID on expected cases of cervical cancer in addition to the normal background diagnostic rates over three periods, assuming no additional treatment capacity is provided.

The authors use these observations to develop forecasts, also taking into account the temporary cessation in screening during the pandemic; these projections suggest there will be a significant increase in cervical cancer cases presenting over the next 3 years. Usefully, the authors also suggest what changes are required (including increases in surgical capacity) to deal with this increase, and demonstrate that associated morbidity or mortality could be mitigated. The associated mini-commentary by Leslie Massad (1140) brilliantly explains how the pandemic is likely to disrupt cervical cancer prevention efforts well into the future and highlights the need for health systems to implement interventions to compensate for not just for these later-diagnosed cancers, but also for missed cervical cancer prevention opportunities.

Directly relevant to this issue is the report by Jacquelyn Dillon and colleagues on 1104–1111. Unlike the universal care provided by NHS in the United Kingdom, the United States Medicaid system is a federal and state funded programme that provides health insurance coverage to those individuals that have limited income. This is a significant proportion: Medicaid covers almost a quarter of the US population. The authors took advantage of data available from the Medicaid system to examine cervical screening practices, and in particular to assess adherence to evidence-based screening recommendations. As this is a more vulnerable population I was pleased to see that there was no suggestion of under-screening. In contrast, average-risk women with Medicaid are frequently “over-screened”, with one–third undergoing repeat screening above the recommended 3-year minimum screening interval. The authors explain the balance between screening that reduces the burden of cervical cancer, and the potential negative effects of overuse of screening. Importantly, these are population-based data, and as clinicians we should always be aware of individuals that may be particularly vulnerable or avoid screening.

The authors of the Scientific Impact Paper highlight that many current models of care often fail those living in adverse social circumstances with risk factors, including those with pre-existing health problems. One such (rare) condition is a maternal cerebrovascular malformation such as an arterial venous malformation (AVM) or a cavernoma. Matthew Cauldwell and colleagues (page 1151–1157) pooled data from six specialist centres in London in order to examine the impact on maternal, obstetric and neonatal outcomes. No maternal deaths occurred in the 83 pregnancies (63 women) and almost three quarters of women had a vaginal delivery. There were seven cerebral bleeds (six women – one women suffered a cerebral bleed in two pregnancies) and none occurred in the peripartum period. Read how these favourable outcomes were achieved by multidisciplinary care teams at specialist centres.

Finally, I would like to highlight the study by Timothy Wen and colleagues, who examined 73 million delivery hospitalisations in the United States to look at trends, risk factors and outcomes related to hypertensive disorders of pregnancy (HDP). This doubled from 6% of births in 2000 to 12% in 2018, and the proportion of births with risk factors for HDP went from 1 in 10 to almost 1 in 4 over the same time-frame. The incidence of stroke decreased for women with HDP after 2013, possibly as a result of relevant ACOG recommendations, but there were increases in adverse renal and liver effects. In her linked minicommentary on p 1061 Miriam F. van Oostwaard explains that these rising figures are not only due to changes in definitions, and reviews opportunities for prevention.

It is clear that at least some hypertensive conditions are aetiologically linked to placental dysfunction, highlighting the need for research in this area. I wanted to close by highlighting a Priority Setting Partnership (PSP) for placental pathology. The team at BJOG is passionate about supporting research in all possible ways, so we are happy to invite our readers to participate in this project; identifying the top research priorities through priority setting exercises has the potential to accelerate research and clinical improvements, also by demonstrating the importance of research topics to funders. I would invite those interested to visit the study website using this QR code.

2020 年，我在本期刊上写了一篇关于健康的社会决定因素的社论，世卫组织将其定义为“人们出生、成长、生活、工作和年龄的条件”（BJOG . 2020;127(4):431– 2）。因此，我很高兴在本期中，我们能够为我们的读者提供高度相关的科学影响论文正是在这个主题上。它旨在让我们所有人了解健康的社会决定因素与孕产妇死亡风险之间的关系。该论文是代表英国皇家妇产科学院撰写的，因此它以英国为重点，但任何阅读它的人都会发现，广泛的文献回顾和建议在任何地方都具有相关性。社

COVID大流行显然符合健康的重要社会决定因素的标准和定义。在本期中，Davies 及其同事 (1133–1139) 提供了来自英格兰北部六个主要癌症中心的关于大流行对宫颈癌诊断影响的数据。在将 2020 年 5 月至 2020 年 10 月的数据与 2019 年同期的数据进行比较时，他们观察到癌症诊断减少了（减少了 25%）。遗憾的是，这些数据并未表明癌症的减少：而是由于早期疾病未被发现疫情期间。

假设没有提供额外的治疗能力，预测除了三个时期的正常背景诊断率外，COVID 对预期宫颈癌病例的可能影响。

作者利用这些观察结果进行预测，同时考虑到大流行期间暂时停止筛查；这些预测表明，未来 3 年出现的宫颈癌病例将显着增加。有用的是，作者还提出了需要进行哪些改变（包括提高手术能力）来应对这种增加，并证明可以减轻相关的发病率或死亡率。莱斯利·马萨德 (Leslie Massad) (1140) 的相关迷你评论精彩地解释了大流行如何在未来很长时间内破坏宫颈癌的预防工作，并强调卫生系统需要实施干预措施，以补偿这些后来诊断出的癌症，也为错过了预防宫颈癌的机会。

与此问题直接相关的是 Jacquelyn Dillon 及其同事在 1104-1111 上的报告。与英国 NHS 提供的全民医疗保健不同，美国医疗补助系统是一项由联邦和州资助的计划，为收入有限的个人提供健康保险。这是一个很大的比例：医疗补助覆盖了近四分之一的美国人口。作者利用医疗补助系统提供的数据来检查宫颈筛查实践，特别是评估对循证筛查建议的遵守情况。由于这是一个更脆弱的人群，我很高兴看到没有任何筛查不足的迹象。相比之下，拥有 Medicaid 的平均风险女性经常被“过度筛查”，三分之一的人接受超过建议的 3 年最短筛查间隔的重复筛查。作者解释了减少宫颈癌负担的筛查与过度使用筛查的潜在负面影响之间的平衡。重要的是，这些是基于人群的数据，作为临床医生，我们应该始终了解可能特别脆弱或避免筛查的个体。

科学影响论文的作者强调许多当前的护理模式常常使那些生活在具有风险因素的不利社会环境中的人失败，包括那些已经存在健康问题的人。一种这样的（罕见）病症是母体脑血管畸形，例如动静脉畸形（AVM）或海绵状血管瘤。Matthew Cauldwell 及其同事（第 1151-1157 页）汇总了伦敦六个专科中心的数据，以检查对孕产妇、产科和新生儿结局的影响。83 次怀孕（63 名妇女）中没有发生孕产妇死亡，几乎四分之三的妇女进行了阴道分娩。有 7 例脑出血（6 名女性 - 1 名女性在 2 次妊娠中发生脑出血），围产期没有发生。阅读专家中心的多学科护理团队如何取得这些有利的结果。

最后，我想强调一下 Timothy Wen 及其同事的研究，他们检查了美国 7300 万分娩住院病例，以了解与妊娠期高血压疾病 (HDP) 相关的趋势、风险因素和结果。这一比例从 2000 年的 6% 增长到 2018 年的 12%，在同一时间段内，具有 HDP 危险因素的出生比例从十分之一上升到几乎四分之一。2013 年后 HDP 女性的卒中发生率下降，这可能是由于 ACOG 的相关建议，但对肾脏和肝脏的不良反应有所增加。Miriam F. van Oostwaard 在第 1061 页的相关迷你评论中解释说，这些上升的数字不仅是由于定义的变化，而且还回顾了预防的机会。

很明显，至少有一些高血压疾病在病因学上与胎盘功能障碍有关，突出了该领域研究的必要性。最后，我想强调胎盘病理学的优先设置伙伴关系 (PSP)。BJOG 团队热衷于以各种可能的方式支持研究，因此我们很高兴邀请我们的读者参与这个项目；通过优先级设置活动确定最重要的研究优先事项有可能加速研究和临床改进，同时也通过向资助者展示研究主题的重要性。我会邀请有兴趣的人使用这个二维码访问研究网站。