Antidepressants for mothers: what are we prescribing?

Prescribing in the perinatal period is based on a risk-benefit analysis, in the context of a limited evidence base, composed primarily of case series and reports. Mothers with depressive illness often present first in the community and effective treatment is paramount for the wellbeing of both mother and child. We aimed at investigating current prescribing practices among general practitioners (GPs) of antidepressants to mothers presenting in first trimester of pregnancy and during breastfeeding. This qualitative study was conducted by way of postal survey to 78 GPs within South Central Edinburgh catchment area. All responses were anonymous and confidential. We discovered inconsistent prescribing patterns among GPs to both pregnant and breastfeeding mothers. Only one GP suggested consulting clinical guidelines when making prescribing choices. There was no mention of the continuation of an antidepressant from pregnancy into breastfeeding as a reason of choice. Inconsistent prescribing patterns among GPs could have implications for the wellbeing of mother and child, and may be reflective of an underlying educational need among GPs.     

Evaluation of the mandatory child abuse course for physicians: do we need to repeat it?

INTRODUCTION: Child abuse is one of the most common disorders affecting children of all ages. The objective of this study was to measure and assess the effectiveness of the mandated New York State child abuse and maltreatment course, and to identify and define the need for a refresher course. METHODS: This study was conducted in two parts. Part 1 consisted of a web-based survey among the paediatric members of 'Physicians Online' in New York State, and Part 2 consisted of an anonymous questionnaire survey using conventional US mail among the registered physicians in New York State who took the mandatory 'Recognition of Child Abuse and Maltreatment Course' between January 1988 and December 1998. The questionnaire included demographic information, test questions, and opinions of the physicians regarding the need for a refresher course. RESULTS: The web survey yielded 239/664 (36%) responses in 1 week. Approximately 45% of the respondents agreed that participation in the course produced a significant difference in their knowledge base and recommended that the course should be repeated every 5 years. The response rate for the mail survey was 56% (424/756). Among the respondents, 88% agreed that participation in the course produced an increased source of knowledge and practice (mean score of 3.2 +/- 1.2 using a scale of 1-5; where 1 = disagree and 5 = agree). The time since the course was taken (1-5 years vs >5 years ago) did not significantly influence their responses. Although 84% of the respondents answered the test questions correctly, significant differences were noted across practice specialty (P<0.05). In response to the question regarding the necessity for a refresher course, the mean score was 2.55 +/- 1.6 using a linear scale of 0-5 (where 0 = strongly disagree and 5 = strongly agree). CONCLUSIONS: These data suggest that practice specialty, not the time since the course was taken, made a significant difference in the knowledge of recognition and reporting of child abuse.     

Prioritizing investments in health technology assessment. Can we assess potential value for money?

OBJECTIVE: The objective was to develop an economic prioritization model to assist those involved in the selection and prioritization of health technology assessment topics and commissioning of HTA projects. METHODS: The model used decision analytic techniques to estimate the expected costs and benefits of the health care interventions that were the focus of the HTA question(s) considered by the NHS Health Technology Assessment Programme in England. Initial estimation of the value for money of HTA was conducted for several topics considered in 1997 and 1998. RESULTS: The results indicate that, using information routinely available in the literature and from the vignettes, it was not possible to estimate the absolute value of HTA with any certainty for this stage of the prioritization process. Overall, the results were uncertain for 65% of the HTA questions or topics analyzed. The relative costs of the interventions or technologies compared to existing costs of care and likely levels of utilization were critical factors in most of the analyses. The probability that the technology was effective with the HTA and the impact of the HTA on utilization rates were also key determinants of expected costs and benefits. CONCLUSIONS: The main conclusion was that it is feasible to conduct ex ante assessments of the value for money of HTA for specific topics. However, substantial work is required to ensure that the methods used are valid, reliable, consistent, and an efficient use of valuable research time.     

Baby friendly hospitals: are we failing mothers who formula feed their babies?

The UNICEF Baby Friendly Hospital Initiative (BFHI) has identified steps to promote breast-feeding in maternity hospitals worldwide. However, in the UK it is customary for women to make informed choices about their method of infant feeding and surveys show that a substantial number choose formula feeding either initially or after a few weeks. While upholding the benefits of breast-feeding, health professionals have a duty of care to ensure that mothers who choose to formula feed are taught to do so safely and appropriately with correct and up-to-date information, e.g. on allergy prevention. Many midwives are under the mistaken impression that the BFHI's "ten steps" to successful breast-feeding forbid discussion with mothers about formulae and the practicalities of formula feeding, including demonstration of sterilisation of equipment and preparation of feeds. In fact the BFHI clearly includes what is required for safe and appropriate formula feeding. Yet it is not easy for midwives to obtain the information they need on formula feeding, especially as many maternity units in the UK appear to have stopped manufacturers' representatives from meeting with managers or clinical midwives to give factual information on infant formula. As a result of these factors, a serious discrepancy has opened up between the stated goals of the BFHI and its interpretation in practice, and some mothers and their babies are being badly served.     

The European health potential: what can we learn from each other?

In this paper global differences in health between the 12 countries of the European Union are compared and related to variations in so-called determinants of health, especially socio-economic and life style factors and characteristics of the health care system in each country. This leads to two main conclusions. The first conclusion is that the health differences that exist within the European Union can only be partially explained by variations in determinants of health. Still, the comparison offers intriguing clues for improving health, containing cost and further research in the European Union. The second conclusion is that considerable data on health and determinants of health are collected in each country, but that international comparability is still limited. The ongoing activities in the standardization of European data collection need our full support.     

Mandatory notification of child abuse: when to report?

Case histories are based on actual medical negligence claims, however certain facts have been omitted or changed by the author to ensure the anonymity of the parties involved. In all Australian states and territories, except Western Australia, general practitioners are required by law to report cases of child abuse to the appropriate child protection service. This article outlines the GP's duty to report cases of child abuse, including the legislative requirements in each state and territory.     

Sunlight exposure assessment: can we accurately assess vitamin D exposure from sunlight questionnaires?

The purpose of this review is to summarize the peer-reviewed literature in relation to sunlight exposure assessment and the validity of using sunlight exposure questionnaires to quantify vitamin D status. There is greater variability in personal ultraviolet (UV) light exposure as the result of personal behavior than as the result of ambient UV light exposure. Although statistically significant, the correlation coefficients for the relation between personal report of sun exposure and ambient UV light measured by dosimetry (assessment of radiation dose) are relatively low. Moreover, the few studies to assess the relation between sunlight measures and serum 25-hydroxyvitamin D show low correlations. These low correlations may not be surprising given that personal factors like melanin content in skin and age also influence cutaneous synthesis of vitamin D. In summary, sunlight exposure questionnaires currently provide imprecise estimates of vitamin D status. Research should be directed to develop more objective, nonintrusive, and economical measures of sunlight exposure to quantify personal vitamin D status.     

Jocelin: a best-case scenario for a young child with disabilities who experienced abuse?

Cross-system collaborations are central to the provision of services for young children with disabilities who have experienced abuse. While multiple position papers and policy briefs emphasize and encourage these cross-system collaborations between the Early Intervention and Child Welfare systems, very limited empirical research has examined these collaborations. This intrinsic case study examines Jocelin, a young child who experienced abuse, her family, and the EI and CW professionals who support her and her family. We share three case study ‘patches’ to examine the approach to, as well as the quality and quantity of EI and CW services provided to Jocelin and her family. Implications for future research are discussed.     

Sick child care options: what do working mothers prefer?

More than half of all mothers with children under age 6 are in the labor force. Working mothers must take off anywhere from 5.6 days to 28.8 days per employee per year to care for their sick children. In a survey of 134 working mothers with children in day care centers, 70% expressed an interest in sick child care options outside the home, especially a sick room at the child's regular day care center or an infirmary at the parent's workplace. Mothers who chose "out-of home care" were more likely to: be minority (p less than 0.01); be single parents (p = 0.06); earn less than $10,000 annually (p = 0.03); want their children with temperatures of 100-100.9 F to remain in school until the end of the day (p less than 0.01). Communities and day care centers serving especially lower income, minority or single-parent working mothers should consider investigating these out-of-home sick child care options; the savings to employers could be $2 to $12 billion per year, not to speak of the personal savings to the mothers themselves.     

Healthy mothers, healthy children: does maternal demand for antenatal care matter for child health in Nepal?

Nepal's Safe Motherhood Programme has failed to deliver expected gains in maternal and child health. Nepalese mothers and their children continue to dispense with (or be denied) antenatal care, experience high maternal mortality rates and suffer chronic malnutrition. We address the correlates and consequences of antenatal care utilization in Nepal by applying two-stage least squares, binomial logit and Heckman selection bias estimates to data drawn from the Nepal Health and Demographic Surveys of 1996 and 2001. Results indicate that maternal education, even at low levels, significantly increases the use of antenatal care; paternal education plays a more important role in the use of routine antenatal care than the conventional wisdom suggests; and when mothers use routine professional antenatal care and maintain good health their children tend to stay healthy through infancy and early childhood. Since health-seeking behaviour is circumscribed by patriarchal gender norms in Nepal, health policies should not only focus on female education and women's status, but also involve husbands in the process of maternal care utilization.     

Combined endpoints: can we use them?

Analysing specific non-fatal events in isolation may lead to spurious conclusions about efficacy unless the events considered are combined with all-cause mortality. The use of combined endpoints has therefore become widespread, at least in cardiovascular disease trials. Combining all-cause mortality with selected non-fatal events is useful because event-free survival, an important criterion in therapy evaluation, is addressed in this manner. In many clinical trials, symptoms, signs or paraclinical measures (for example, blood pressure, exercise duration, quality of life scores) are used as endpoints. If the patient died before the endpoint was measured, or it was otherwise not possible to perform follow-up assessments as planned, the effect of treatment on these endpoints may be distorted if the patients concerned are ignored in the analysis. Examples are given of how distortion can be avoided by including all patients randomized in an analysis that uses a ranked combined endpoint based both on clinical events and on paraclinical measures. A distinction is made between a pseudo intention-to-treat analysis that disregards study medication status at the time of endpoint assessment but is confined to patients with data, and a true intention-to-treat analysis that takes into account all patients randomized based on a ranked combined endpoint.