Does continuity of carer matter to women from minority ethnic groups?

OBJECTIVE: To explore the maternity care views and experiences of minority ethnic women who did not respond to a postal survey of mothers' responses to care and to assess whether the concept of continuity mattered to them. DESIGN: A semi-structured narrative interview, at about six months following birth, designed to encourage women to describe their experiences of pregnancy, birth and maternity care in their own words and according to their own perspectives. SETTING: Maternity care in a London NHS Trust with two teaching hospital units, where women in a specific neighbourhood received caseload midwifery care as part of a pilot scheme and other women received conventional (normally 'shared') maternity care. PARTICIPANTS: 20 women, half receiving caseload midwifery care and half conventional maternity care. MEASUREMENTS AND FINDINGS: The interviews were transcribed in full and the texts analysed by open coding and grouping into conceptual areas and linking themes. Key findings related to continuity of carer are highlighted in this paper but related concepts, such as that of control will be reported in more detail elsewhere. Although detailed views and requirements were specific to these women, underlying values and priorities were similar to those reported widely in consumer research in maternity care. The women valued concepts such as communication, support, and control highly but those receiving conventional care were disappointed with their care, particularly in hospital settings and did not feel it was focused on them as a person. Women receiving caseload midwifery care held more positive views and emphasised the role of having 'their own' midwife in supporting such concepts. They showed greater trust and confidence in the professionals and in the personal transition of giving birth. KEY CONCLUSIONS: This small study adds to an existing body of evidence that minority ethnic women do not receive a high quality of maternity care in conventional services and suggests that this is related to the institutional organisation of care. It does not support the assumption that the principles of Changing Childbirth, in particular that of continuity of carer, do not matter to them. Conversely, this group of women shared similar fundamental values and hopes of the service with the wider population of which they are a part but experience a greater dissonance between expectations and experience. IMPLICATIONS FOR PRACTICE: Organisation of maternity care should make caseload midwifery available as a choice for such women to facilitate more woman-centred care.     

Cesarean delivery technique: evidence or tradition? A review of the evidence-based cesarean delivery

Cesarean delivery is the most common surgical procedure performed in the United States, yet the techniques used during this procedure often vary significantly among providers. The purpose of this review was to evaluate and outline current evidence behind the cesarean delivery technique. A search of the PubMed database was conducted using the terms cesarean section and cesarean delivery and the technique of interest, for example, cesarean section prophylactic antibiotics. Few aspects of the cesarean delivery were found to have high-quality consistent evidence to support use of a particular technique. Because many aspects of the procedure are based on limited or no data, more studies on specific cesarean delivery techniques are clearly needed. Providers should be aware of which components of the cesarean delivery are evidence-based versus not when performing this procedure.     

Are birth kits a good idea? A systematic review of the evidence

Objective

to identify the current state of knowledge regarding the effects of births kits on clean birth practices and on newborn and maternal outcomes.

Design

the scoping review was informed through a systematic literature review; a call for information distributed to experts in maternal and child health, relevant research centres and specialist libraries; and a search of the web sites of groups working in the area of maternal and child health. Data were synthesised to produce a summary of the state of knowledge regarding birth kits. Meta-analysis was not attempted because of the varied study designs and the heterogeneous nature of the interventions.

Participants

births kit use was identified in 51 low resource countries, but evaluations were scarce, with only nine studies reporting effects of intervention packages including births kits.

Findings

the quality of evidence for inferring causality was weak, with only one randomised controlled trial. In two studies, births kit use along with co-interventions resulted in a statistically significant increase in the likelihood of the attendant having clean hands. The impact on other aspects of cleanliness was less clear. Intervention packages which include births kits were associated with reduced newborn mortality (three studies), omphalitis (four studies), and puerperal sepsis (three studies). The one study that considered maternal mortality was not large enough to estimate relative reduction with much precision. None of the studies reported any adverse effects; however, none explicitly described looking for negative consequences.

Conclusion

providing birth kits to facilitate clean practices seems commonsense, but there is no evidence to indicate effects, positive or negative, separate from those achieved by a broader intervention package. More robust methods and knowledge systems are needed to understand the contextual factors and share relevant implementation lessons.     

Post-discharge nutrition: what does the evidence support?

Although there are no official recommendations for specific nutrient intakes in premature infants after hospital discharge, it is agreed that the goal should be to achieve the body composition and rate of growth of that of a normal fetus of the same postmenstrual age during the entire first year of life. A general recommendation to use the special formulas designed for preterm infants after hospital discharge in place of the formulas for term infants cannot be made from the available evidence at this time. Infants fed human milk after discharge are of the greatest concern as human milk does not in theory meet the requirements for growth in these infants. Such infants should remain on supplemental vitamins and Fe while breastfeeding, and growth as well as serum levels of phosphorus and alkaline phosphatase should be carefully monitored. The increased risk of preterm infants for obesity and the metabolic syndrome secondary to the metabolic/nutritional events early in life (programming) is likely to be small compared with the contribution of other risk factors, such as parental size, weight as an adolescent, and various lifestyle factors such as physical activity.     

Uterine artery occlusion: what is the evidence?

Symptomatic uterine fibroids are a relatively common gynecologic condition. In the past, fibroids were exclusively treated by myomectomy and/or hysterectomy. With the advent of uterine artery embolization or uterine artery occlusion, there now exist minimally invasive approaches to fibroid therapy especially for women in whom surgery is contraindicated or for those who wish to retain their uterus and possibly fertility. Fertility and pregnancy outcomes after these minimally invasive therapies are currently being evaluated.     

Does the mode of delivery predispose women to anal incontinence in the first year postpartum? A comparative systematic review

Objectives  To assess if mode of delivery is associated with increased symptoms of anal incontinence following childbirth.
Design  Systematic review of all relevant studies in English.
Data sources  Medline, Embase, Cochrane Library, bibliographies of retrieved primary articles and consultation with experts.
Study selection and data extraction  Data were extracted on study characteristics, quality and results. Exposure to risk factors was compared between women with and without anal incontinence. Categorical data in 2 × 2 contingency tables were used to generate odds ratios.
Results  Eighteen studies met the inclusion criteria with 12 237 participants. Women having any type of vaginal delivery compared with a caesarean section have an increased risk of developing symptoms of solid, liquid or flatus anal incontinence. The risk varies with the mode of delivery ranging from a doubled risk with a forceps delivery (OR 2.01, 95% CI 1.47–2.74, P < 0.0001) to a third increased risk for a spontaneous vaginal delivery (OR 1.32, 95% CI 1.04–1.68, P = 0.02). Instrumental deliveries also resulted in more symptoms of anal incontinence when compared with spontaneous vaginal delivery (OR 1.47, 95% CI 1.22–1.78). This was statistically significant for forceps deliveries alone (OR 1.5, 95% CI 1.19–1.89, P = 0.0006) but not for ventouse deliveries (OR 1.31, 95% CI 0.97–1.77, P = 0.08). When symptoms of solid and liquid anal incontinence alone were assessed, these trends persisted but were no longer statistically significant.
Conclusion  Symptoms of anal incontinence in the first year postpartum are associated with mode of delivery.     

Hysterectomy: what do women need and want to know?

OBJECTIVE: The purpose of this article is to describe women's experiences of hysterectomy and to identify their fears, concerns, and met as well as unmet health care needs. DESIGN: Narrative data of women's hysterectomy experiences were collected via a written survey. SETTING: Data were collected from women living in southeastern Wisconsin. PARTICIPANTS: Participants were 102 women who had undergone hysterectomy within the previous 2 years. The mean age of the women was 43 and mean time since hysterectomy was 13 months. Eighty percent of the women had undergone both hysterectomy and oophorectomy, and 78% were taking hormone replacement therapy. MAIN OUTCOME MEASURES: A questionnaire of women's hysterectomy needs and a demographic questionnaire were used to collect data via mail. The data from three open-ended questions were content analyzed. RESULTS: Seven themes about women's experiences of hysterectomy were identified: (a) positive aspects, (b) hormone replacement therapy, (c) insufficient information, (d) changes in sexual feelings and functioning, (e) emotional support, (f) psychologic sequelae, and (g) feelings of loss. CONCLUSIONS: Women wanted treatment choices, a part in decision-making, accurate and useful information at an appropriate time, provider support, and access to professional and lay support systems. The essentials for hysterectomy care are outlined and include the characteristics of care that women desire, the informational content that women want, health care systems that support patient satisfaction, and the outcomes women want.     

Pelvic floor muscle training in the prevention and treatment of urinary incontinence in women - what is the evidence?

Many women suffer from urinary incontinence (UI). During and after pregnancy, women are advised to perform pelvic floor muscle training (PFMT) to prevent the development of UI. In established UI, PFMT is prescribed routinely as first-line treatment. Published studies are small, underpowered and of uneven methodological quality. Variations in study populations, intervention types and outcome measures make comparisons difficult. While further studies are needed, the available evidence suggests a lack of long-term efficacy of peripartum PFMT. In established UI, there seems to be a modest immediate response to PFMT. Based on the available evidence, we believe that a critical reappraisal of PFMT is needed, and judgments on the place of PFMT in current clinical practice should be reserved until further evidence, including cost-benefit analyses, has unequivocally demonstrated a clinically relevant efficacy.     

Predictive factors of perinatal mortality in transfused fetuses due to maternal alloimmunization: what really matters?

Introduction: Alloimmunization is the main cause of fetal anemia. There are not many consistent analyses associating antenatal parameters to perinatal mortality in transfused fetuses due to maternal alloimmunization. The study aimed to determine the prognostic variables related to perinatal death. Material and Methods: A cohort study analyzed 128 fetuses treated with intrauterine transfusion (IUT), until the early neonatal period. Perinatal mortality was associated with prognostic conditions related to prematurity, severity of fetal anemia and IUT procedure by univariated logistic regression. Multiple logistic regression was used to compute the odds ratio (OR) for adjusting the hemoglobin deficit at the last IUT, gestational age at birth, complications of IUT, antenatal corticosteroid and hydrops. Results: Perinatal mortality rate found in this study was 18.1%. The hemoglobin deficit at the last IUT (OR: 1.26, 95% CI: 1.04–1.53), gestational age at birth (OR: 0.53, 95% CI: 0.38–0.74) and the presence of transfusional complications (OR: 5.43, 95% CI: 142–20.76) were significant in predicting fetal death. Conclusion: Perinatal mortality prediction in transfused fetuses is not associated only to severity of anemia, but also to the risks of IUT and prematurity.     

Neonatal hypoxia of the second twin after vaginal delivery of the first twin: what matters?*

Objective: Optimal management of twin deliveries is controversial. We aimed to assess potential risk factors correlated to the development of hypoxia in the second twin after vaginal delivery of the first twin.

Study design: This is a retrospective observational study including diamniotic twin pregnancies delivering at our Institution at 35 weeks of gestational age or more, weighing ≥1800?g. Hypoxia was defined as at least one of the following: Apgar score <5 at 10 minute, neonatal resuscitation for >10 minutes, neonatal acidosis (pH ≤7 and/or BE ≥12?mmol/L).

Results: A number of 275 diamniotic twin pregnancies met the inclusion criteria and were divided within the following groups: (1) second twin not developing neonatal hypoxia (n?=?265); and (2) second twin developing neonatal hypoxia (n?=?10). The rate of second twins with neonatal hypoxia during the study period was 3.6% (10/275). Abnormal cardiotocography during the intertwin delivery interval, defined as ACOG category III, was significantly correlated to second twin hypoxia. Of interest, there was no significant difference in the intertwin delivery interval between the study groups. In addition, breech presentation of the second twin did not show to be a risk factor for neonatal hypoxia. None of the second twins developing neonatal hypoxia was reported to have encephalopathy (follow up of at least 24 months). At multivariate analysis, only abnormal cardiotocography was an independent risk factor for second twin hypoxia (OR 17.8, 95% CI 4.1–77.2).

Conclusions: In our study, neonatal hypoxia was significantly correlated to abnormal cardiotocography, while intertwin delivery interval was not correlated to the development of this adverse neonatal outcome.     

Predicting women's perceptions of domestic violence and sexual assault agency helpfulness: what matters to program clients?

Study goals were to assess if community agency interactions, the characteristics of services provided by staff, and the combinations of services received can predict women's perceptions of victim service helpfulness around domestic violence and sexual assault. Data were collected from agency representatives in 26 communities, and both women who used services and others living in the community (n = 1,509 women). Women found nonprofit victim services more helpful based on staff behavior in those agencies and the extent to which women felt control when working with staff; helpfulness of services was enhanced when agencies interacted with the legal system and other community agencies.     

Clinical evaluation of women with PMB. Is it always necessary an endometrial biopsy to be performed? A review of the literature

Background  

Endometrial carcinoma is the most distressing cause of abnormal vaginal bleeding. The intention of clinical management in the case of postmenopausal bleeding is to achieve an accurate diagnosis without overinvestigation.