Alcohol consumption, cigarette smoking and fetal outcome in Victoria, 1985

The aims of this study were to document the extent of cigarette smoking and alcohol consumption by Victorian women during pregnancy and relate the use of cigarettes and alcohol to various measures of pregnancy outcome. The study found that 24 per cent of women smoked during pregnancy and smoking was more common amongst younger women; 99.5 per cent of women drank, on average, less than two standard drinks per day and older women were more likely to be drinkers than younger women; 3.6 per cent of women reported at least one episode of binge drinking during pregnancy. There was an increasing trend in the proportion of low birthweight (less than 2500 g) infants with increasing use of tobacco and a dose-dependent reduction in mean birthweight. Drinkers were less likely to have a pre-term or low birthweight infant than abstainers and babies born to drinkers had a higher mean birthweight than babies born to abstainers. The results of our study did not suggest that drinkers were at increased risk of delivering an infant with a congenital malformation, however heavy drinking was very uncommon in the studied population.

Brief antenatal cognitive behaviour therapy group intervention for the prevention of postnatal depression and anxiety: a randomised controlled trial

BACKGROUND

The majority of randomised controlled trials examining the effectiveness of antenatal group interventions at preventing postnatal depression in "at risk" women have used a "psychoeducational" intervention. The aim of the present study is to evaluate the effectiveness of an antenatal cognitive behavioural group intervention in a primary care setting for pregnant women identified with mild to moderate symptoms in pregnancy and/or at risk of developing depression or anxiety in the perinatal period.

METHOD

Subjects were randomised to a CBT group intervention or control condition (information booklet) and administered the EPDS and STAI at pre (Time 1) and post intervention (Time 2), and at 2 months (Time 3) and 4 months postpartum (Time 4). MINIs were administered at Times 1, 3 and 4.

RESULTS

Of the 774 women approached, 277 accepted and were suitable; thus 191 were randomised to the CBT intervention and 86 to the control condition. The subsequent 52% drop-out left 89 women "completing" the CBT groups and 43 in the control group; these two groups were well matched on demographic variables. Intention to treat analyses revealed relatively low mean baseline EPDS scores (means 6.88 -8.16) with no reduction in EPDS scores in either group from Time 1 to Time 4. MINI depression criteria were fulfilled by 19% of all participants at Time 1 but there was no reduction in depression in either group; in contrast those with MINI anxiety diagnoses reduced from 28% in late pregnancy to 16% at four months postpartum in the CBT group with similar reductions in the control group. Analyses on the 132 "completers" showed significant symptomatic improvement over time for both the CBT group and control condition. Depression scores in the most symptomatic women (EPDS>12; N=19) decreased steadily by over 50% over the total time course but there were no differences in improvement between the CBT and control groups.

LIMITATIONS

A number of methodological factors may have obscured our results including a tendency to natural remission in mildly symptomatic subjects and the possibility that our control condition was therapeutic in itself.

CONCLUSION

While a modest reduction in depression scores was noted in study "completers", both the CBT group intervention control condition were equally beneficial. The reasons for this finding include the low symptom level at baseline; the potential effectiveness of the control condition; and the brevity of the intervention.

Precancerous changes in the cervix and risk of subsequent preterm birth

OBJECTIVE

The aims of this study were (i) to examine whether women referred for assessment of precancerous changes in the cervix had higher rates of preterm birth compared with those in the general population and (ii) to compare preterm birth rates for treated and untreated women adjusting for possible confounding factors.

DESIGN

Retrospective cohort design.

SETTING

Teaching hospital.

POPULATION

All women referred to the Royal Women's Hospital, Melbourne (1982-2000), who subsequently had a birth recorded on the Victorian Perinatal Data Collection system (n = 5548).

METHODS

Record linkage of hospital dysplasia clinic records and population-based birth records.

MAIN OUTCOME MEASURES

Total preterm delivery (<37 weeks of gestation) and subtypes.

RESULTS

Both treated and untreated women were at a significantly increased risk for preterm birth compared with those in the general population: treated--standardised prevalence ratio (SPR) 2.0, 95% CI 1.8-2.3 and untreated--SPR 1.5, 95% CI 1.4-1.7. Within the cohort, the treated women were significantly more likely to give birth preterm (adjusted OR 1.23, 95% CI 1.01-1.51). An increased risk of preterm birth was also associated with a history of induced or spontaneous abortions, illicit drug use during pregnancy or a major maternal medical condition. Cone biopsy, loop electrosurgical excision procedure and diathermy were associated with preterm birth. After adjusting for possible confounding factors, only diathermy remained significant (adjusted OR 1.72, 95% CI 1.36-2.17). Women treated using laser ablation were not at an increased risk for preterm birth (adjusted OR 1.1, 95% CI 0.8-1.4).

CONCLUSIONS

Diagnosis of precancerous changes in the cervix (regardless of the treatment) was associated with an increased risk of preterm birth. Consideration should be given to the preferential use of ablative treatments.

Critically ill parturient women and admission to intensive care: a 5-year review

Thirty-nine parturient women were admitted to a general intensive care unit (ICU) from April 1989 to March 1994 and of these four were readmitted (total 43 admissions). Twelve women were admitted to the obstetric unit from peripheral hospitals in different regions, but no requirement for intensive care was perceived on referral. Six women were transfered directly into the intensive care unit from different hospitals in the region. The incidence of obstetric patients requiring ICU admission, excluding direct transfers, was 0.64%. The majority (85%) were postpartum, and 64% were primiparous. Morbidity was caused primarily by hypertensive disorders (33%) and haemorrhage (33%). The remainder included medical disorders (21%)[ sepsis (13%) and surgical problems (5%). Associated major complications were acute renal failure, coagulopathies and adult respiratory distress syndrome. A multidisciplinary approach to management is practised and specialist interventions included haemofiltration and haemodialysis (18%) and radiological arterial embolisation (10%). Ventilatory and inotropic support were given in 38% and 41% of patients respectively. Only one patient died on the intensive care unit, this was from multiorgan failure secondary to sepsis.

Interventions for promoting smoking cessation during pregnancy

BACKGROUND

Smoking remains one of the few potentially preventable factors associated with low birthweight, preterm birth and perinatal death.

OBJECTIVES

To assess the effects of smoking cessation programs implemented during pregnancy on the health of the fetus, infant, mother, and family.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group trials register and the Cochrane Tobacco Addiction Group trials register (July 2003), MEDLINE (January 2002 to July 2003), EMBASE (January 2002 to July 2003), PsychLIT (January 2002 to July 2003), CINAHL (January 2002 to July 2003), and AUSTHEALTH (January 2002 to 2003). We contacted trial authors to locate additional unpublished data. We handsearched references of identified trials and recent obstetric journals.

SELECTION CRITERIA

Randomised and quasi-randomised trials of smoking cessation programs implemented during pregnancy.

DATA COLLECTION AND ANALYSIS

Four reviewers assessed trial quality and extracted data independently.

MAIN RESULTS

This review included 64 trials. Fifty-one randomised controlled trials (20,931 women) and six cluster-randomised trials (over 7500 women) provided data on smoking cessation and/or perinatal outcomes. Despite substantial variation in the intensity of the intervention and the extent of reminders and reinforcement through pregnancy, there was an increase in the median intensity of both 'usual care' and interventions over time. There was a significant reduction in smoking in the intervention groups of the 48 trials included: (relative risk (RR) 0.94, 95% confidence interval (CI) 0.93 to 0.95), an absolute difference of six in 100 women continuing to smoke. The 36 trials with validated smoking cessation had a similar reduction (RR 0.94, 95% CI 0.92 to 0.95). Smoking cessation interventions reduced low birthweight (RR 0.81, 95% CI 0.70 to 0.94) and preterm birth (RR 0.84, 95% CI 0.72 to 0.98), and there was a 33 g (95% CI 11 g to 55 g) increase in mean birthweight. There were no statistically significant differences in very low birthweight, stillbirths, perinatal or neonatal mortality but these analyses had very limited power. One intervention strategy, rewards plus social support (two trials), resulted in a significantly greater smoking reduction than other strategies (RR 0.77, 95% CI 0.72 to 0.82). Five trials of smoking relapse prevention (over 800 women) showed no statistically significant reduction in relapse.

REVIEWERS' CONCLUSIONS

Smoking cessation programs in pregnancy reduce the proportion of women who continue to smoke, and reduce low birthweight and preterm birth. The pooled trials have inadequate power to detect reductions in perinatal mortality or very low birthweight.

How useful is the concept of somatization in cross-cultural studies of maternal depression? A contribution from the Mothers in a New Country (MINC) study

Somatization of depression symptoms has been assumed to characterize particular cultural groups, yet evidence for this has often been anecdotal. The Mothers in a New Country (MINC) study aimed to explore cultural assumptions about somatization in three groups of immigrant women who had recently given birth in Melbourne, Australia. Physical health (SF-36 physical health dimensions and a symptom list) and depression (EPDS, SF-36 mental health dimension and self assessment) data from personal interviews with Vietnamese (n = 104), Turkish (n = 107) and Filipino (n = 107) women, conducted in women's language of choice, six to nine months after childbirth were analyzed. Comparisons with data from a statewide postal survey of Victorian women are also made. Contrary to the study hypothesis that Turkish and Vietnamese women in particular would exhibit a high degree of somatization (leading to low depression scores on the standard measures and greater reporting of somatic symptoms), Turkish women were in fact most likely of the three groups to be assessed as depressed on the two psychological measures and by self-assessment, to report high levels of somatic symptoms, and Vietnamese and Filipino women had a low prevalence of depression on all measures and relatively lower levels of somatic symptom reporting. The MINC study findings thus call into question some common cultural assumptions about depression and demonstrate the importance of designing studies which can put hypothesized cultural differences to the test.

Antenatal screening for postnatal depression: a systematic review

OBJECTIVE

To describe the screening properties of the antenatal tools which have been developed to predict depression after birth and to summarize the implications of the findings for antenatal screening.

METHOD

Systematic review and secondary analysis of published papers.

RESULTS

Sixteen studies including sufficient data for the calculation of screening properties were identified. The majority developed a study-specific screening instrument. Outcome assessments used the Edinburgh Postnatal Depression Scale or standardized diagnostic psychiatric interviews, or both. In the two largest population-based studies, the proportion of women screening as positive ('at risk' of postnatal depression) was 16 and 52%, respectively, and of these only 35 and 8% actually developed depression after birth.

CONCLUSION

No screening instrument(s) met the criteria for routine application in the antenatal period. Factors that may have affected poor sensitivity and positive predictive values include the exclusion of key domains in predicting risk, particularly personality, a past history of abuse and postnatal events, the contribution of which may be being under-estimated in studies evaluating antenatal risk prediction tools.

What interventions may reduce postpartum depression

Postnatal depression is a major public health problem affecting about one in seven women after childbirth. Depression is also common during pregnancy and throughout the perinatal period it is associated with symptoms of anxiety. Apart from the adverse consequences for women themselves becoming depressed when they are going through demanding physical and social changes, there are additional concerns. There is the possible negative impact of maternal depression on the relationship between mother and child and on the child's emotional, behavioural and cognitive development. Primary prevention and early intervention/secondary prevention strategies are potentially important in view of the frequent contact pregnant women, new mothers and infants have with health services, but the effectiveness of these strategies needs to be tested. In the past year there have been five new studies of antenatal screening for postnatal depression. These studies are consistent with nine earlier studies in showing that there is no evidence to support routine antenatal screening for postnatal depression. Seven new primary prevention/early intervention trials add evidence on a wide range of interventions ranging from practical support to individual interpersonal therapy, but without identifying significant differences in depression as an outcome. Two new trials of secondary prevention, one involving interpersonal therapy and the other including partners in a series of psychoeducational visits, show promise but neither is large enough to form a basis for practice change. Novel interventions, or promising findings, with a strong basis in theory need to be tested in trials which are appropriately sized and which comply with internationally accepted design and reporting guidelines.

Modelling the potential impact of population-wide periconceptional folate/multivitamin supplementation on multiple births

OBJECTIVE

To develop a model of the impact of population-wide periconceptional folate supplementation on neural tube defects and twin births.

DESIGN

A hypothetical cohort of 100,000 pregnancies > or =20 weeks, plus terminations of pregnancy after prenatal diagnosis before 20 weeks.

METHODS

Application of pooled data on the relative risks for neural tube defects and twins following periconceptional folate from meta-analysis of the randomised trials.

MAIN OUTCOME MEASURES

1. Pregnancies with a neural tube defect (i.e. terminations of pregnancy, perinatal deaths, and surviving infants); 2. twin births (i.e. preterm births, perinatal deaths, postneonatal deaths, birth defects, cerebral palsy); 3. numbers needed to treat.

RESULTS

The change in neural tube defects would be 75 fewer terminations (95% CI -47, -90), 30 fewer perinatal deaths (95% CI 18, -35), and 13 fewer surviving infants with a neural tube defect (95% CI -8, -16). The change in twinning would be an additional 572 twin confinements (95% CI -100, +1587), among whom there would be 63 very preterm twin confinements (95% CI -11, +174), 54 perinatal and postneonatal deaths (95% CI -9, +149), 48 surviving twins with a birth defect (95% CI -8, +133), and nine with cerebral palsy (95% CI -2, +26). The numbers needed to treat for the prevention of one pregnancy with a neural tube defect is 847, for the birth of one additional set of twins is 175, for the birth of one additional set of very preterm twins is 1587, and for the birth of an additional twin with any of the following outcomes (perinatal death, postneonatal death, survival with a birth defect, or survival with cerebral palsy) is 901.

CONCLUSIONS

Monitoring rates of neural tube defects and twinning is essential as supplementation or fortification with folate is implemented.

Randomised controlled trial of midwife led debriefing to reduce maternal depression after operative childbirth

OBJECTIVE

To assess the effectiveness of a midwife led debriefing session during the postpartum hospital stay in reducing the prevalence of maternal depression at six months postpartum among women giving birth by caesarean section, forceps, or vacuum extraction.

DESIGN

Randomised controlled trial.

SETTING

Large maternity teaching hospital in Melbourne, Australia.

PARTICIPANTS

1041 women who had given birth by caesarean section (n= 624) or with the use of forceps (n= 353) or vacuum extraction (n= 64).

MAIN OUTCOME MEASURES

Maternal depression (score >/=13 on the Edinburgh postnatal depression scale) and overall health status (comparison of mean scores on SF-36 subscales) measured by postal questionnaire at six months postpartum.

RESULTS

917 (88%) of the women recruited responded to the outcome questionnaire. More women allocated to debriefing scored as depressed six months after birth than women allocated to usual postpartum care (81 (17%) v 65 (14%)), although this difference was not significant (odds ratio=1.24, 95% confidence interval 0.87 to 1.77). They were also more likely to report that depression had been a problem for them since the birth, but the difference was not significant (123 (28%) v 94 (22%); odds ratio=1. 37, 1.00 to 1.86). Women allocated to debriefing had poorer health status on seven of the eight SF-36 subscales, although the difference was significant only for role functioning (emotional): mean scores 73.32 v 78.98, t= -2.31, 95% confidence interval -10.48 to -0.84).

CONCLUSIONS

Midwife led debriefing after operative birth is ineffective in reducing maternal morbidity at six months postpartum. The possibility that debriefing contributed to emotional health problems for some women cannot be excluded.

Vaginal births after Caesarean (VBAC): a population study

This paper describes delivery outcomes for women from Victoria, Australia, who gave birth in 1995 and whose immediately previous (penultimate) delivery, within a 5-year search period, was a Caesarean section. Because of the large numbers of records involved, dedicated computer software for record linkage was used to identify the previous delivery and link it with the woman's current birth in 1995. Overall, 79% of the records from multiparous women were linked successfully. Approximately 15% were not linked because the previous birth was before the search period or was an abortion that would not have been reported to the Perinatal Data Collection Unit. Reasons for not being able to link the last 6% of the records include the previous pregnancy being overseas or interstate. Women who had a vaginal birth as the penultimate birth or a multiple birth at either event were excluded, resulting in a study population of 4663 linked records. More women (68%) had a repeat Caesarean than went into labour and, of the remaining women who laboured, 56% delivered vaginally. Overall, 18% of the women delivered vaginally. For the women who went into labour, the reported number experiencing a uterine rupture was two per 1000 births. Uterine rupture was not reported in the two-thirds who did not labour but had a repeat Caesarean. A review of the perinatal deaths identified only two deaths, one baby being born by elective Caesarean and one by a vaginal birth after a previous Caesarean (VBAC) where the choice of delivery methods may have contributed to the death. This large study is one of the few in the literature to provide population-based information on vaginal births after a previous Caesarean and related outcomes.

Physical health problems after childbirth and maternal depression at six to seven months postpartum

OBJECTIVE

To investigate the relationship between maternal physical and emotional health problems six to nine months after childbirth.

DESIGN

Statewide postal survey, incorporating the Edinburgh Postnatal Depression Scale, distributed to women six to seven months after childbirth, with telephone interview follow up of a sub-sample of participants at seven to nine months postpartum.

PARTICIPANTS

The postal survey was distributed to all women who gave birth in a two-week period in Victoria, Australia in September 1993, except those who had a stillbirth or known neonatal death. Follow up interviews were conducted with respondents to the postal survey who provided contact details and expressed interest in participating in further research selected to recruit three groups of equivalent size according to scores on the Edinburgh Postnatal Depression Scale: a low scoring group (< 9); a borderline group (9-12); and a group with scores indicating probable depression (> or = 13).

RESULTS

The response rate to the postal survey was 62.5% (n = 1,336). Respondents were representative of the total sample in terms of mode of delivery, parity and infant birthweight; young women, single women and women of non-English speaking background were under-represented. The participation rate in telephone follow up interviews was: 89.1% (n = 204), comprising 66 women with an Edinburgh Postnatal Depression Scale score of < 9; 72 women scoring 9-12; and 66 scoring > or =13. The point prevalence of depression at six to seven months postpartum was 16.9% (225/1,331, 95% CI 14.9-18.9%). Physical and related health problems associated with significantly increased odds of depression at six to seven months were: tiredness (OR 3.42 [2.2-5.3]); urinary incontinence (OR 2.23 [1.5-3.4]); back pain (OR 2.20 [1.6-3.0]); sexual problems (OR 2.16 [1.6-3.0]); more coughs, colds and minor illnesses than usual (OR 2.78 [1.9-4.1]); bowel problems (OR 1.93 [1.3-2.9]) and relationship difficulties (OR 3.88 [2.8-5.4]). At follow up, three physical health factors were associated with statistically significant linear trends with poorer levels of emotional wellbeing. These were: tiredness (chi2 for linear trend = 12.38, P < 0.001); urinary incontinence (chi2 for linear trend = 5.63, P = 0.02); and more minor illnesses than usual (chi2 for linear trend = 7.94, P = 0.005).

CONCLUSION

The study confirms a link between maternal emotional wellbeing and physical health and recovery in the postnatal period and has important implications for clinical practice. Strategies for encouraging greater disclosure of physical and emotional health problems, assessment of the physical health of recent mothers presenting with depression, and emotional health of recent mothers presenting with other morbidity should be high priorities for all health professionals in contact with mothers in the year following childbirth.

Sharing obstetric care: barriers to integrated systems of care

OBJECTIVES

To map the provision of shared obstetric care in Victoria, and investigate the views of care providers about the ways in which current practice could be improved.

METHOD

All Victorian public hospitals with > or = 300 births per annum and a purposive sample of hospitals with < 300 births per annum were mailed a questionnaire seeking information about current practice. Interviews with key informants (n = 32) were conducted at four case study sites.

RESULTS

The response rate to the hospital survey was 98% (42/43). Fourteen different models of shared care were identified. Two-thirds of hospitals with > or = 300 births per annum (16/28) had three or more different models of shared care. Six hospitals (15%) had written guidelines for all models of shared care offered; 13 (32%) had written guidelines covering some models. Practice varied considerably in relation to: exclusion criteria, recommended schedule of visits and use of patient-held records. There was little consensus about the content of visits and responsibility for covering particular aspects of care. Few hospitals (6/42) had written information for women about shared care. Care providers expressed divergent views regarding the question of where ultimate responsibility lies for individual patient care and for the overall management of shared care.

CONCLUSIONS

Current funding arrangements provide strong incentives to expand enrollment in shared obstetric care. Expansion of shared care has occurred without the development of formal, consultative and agreed arrangements between providers, or adequate provision for monitoring, evaluation and review. The variety, complexity and fluidity of models of shared care and lack of agreed procedures contribute to difficulties experienced by both providers and women participating in shared care.

IMPLICATIONS

Detailed evidence-based agreed guidelines developed in consultation with hospital and community providers, and provision of improved information to women about what to expect in shared care arrangements are urgently required.

Disaster medicine: an emerging specialty

The diverse nature of natural and man-made disasters demands a wide range of medical skills and resources from any attendant clinician. Working in a hostile environment may also require armed protection. This article considers the types of disasters, their medical requirements and the training of doctors wishing to be involved in this field of medicine. It includes a description of the Diploma in the Medical Care of Catastrophes.

Interventions for promoting smoking cessation during pregnancy

BACKGROUND

Smoking remains one of the few potentially preventable factors associated with low birthweight, very preterm birth and perinatal death.

OBJECTIVES

The objective of this review was to assess the effects of smoking cessation programs implemented during pregnancy on the health of the fetus and infant, on the mother and on the family.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group trials register and the Cochrane Tobacco Addiction Group trials register.

SELECTION CRITERIA

Randomised and quasi-randomised trials of smoking cessation programs implemented during pregnancy.

DATA COLLECTION AND ANALYSIS

Trial quality was assessed and data were extracted independently by two reviewers.

MAIN RESULTS

Forty-four trials were identified: 37 trials including 16,916 women provided data on smoking cessation and/or perinatal outcomes, as did one cluster-randomised trial including 3000 women. Over 800 women were included in trials of smoking relapse prevention. There was substantial variation in the intensity of the intervention and the extent of reminders and reinforcement through pregnancy. Based on 34 trials there was a significant reduction in smoking in the intervention groups (odds ratio 0.53, 95% confidence interval 0. 47 to 0.60), an absolute difference of 6.4% women continuing to smoke. The eight trials with validated smoking cessation, a high intensity intervention and a high quality score had an odds ratio of 0.53, 95% confidence interval 0.44 to 0.63 and an absolute difference in continued smoking of 8.1%. The subset of trials with information on fetal outcome revealed a reduction in low birthweight (odds ratio 0.80, 95% confidence interval 0.67 to 0.95), a reduction in preterm birth (odds ratio 0.83, 95% confidence interval 0.69 to 0. 99) and an increase in mean birthweight of 28g (95% confidence interval 9 to 49). There were no differences in very low birthweight or perinatal mortality. Five trials of smoking relapse prevention showed no significant difference. The single large cluster-randomised trial showed no evidence of a decrease in continued smoking or adjusted mean birthweight.

REVIEWER'S CONCLUSIONS

Smoking cessation programs in pregnancy appear to reduce smoking, low birthweight and preterm birth, but no effect was detected for very low birthweight or perinatal mortality.

Periconceptional supplementation with folate and/or multivitamins for preventing neural tube defects

BACKGROUND

Neural tube defects arise during the development of the brain and spinal cord.

OBJECTIVES

The objective of this review was to assess the effects of increased consumption of multivitamins or folate on the prevalence of neural tube defects before pregnancy and in the first two months of pregnancy (periconceptionally).

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group trials register.

SELECTION CRITERIA

Randomised and quasi-randomised trials comparing periconceptional supplementation by multivitamins with placebo, folate with placebo, or multivitamins with folate; different dosages of multivitamins or folate; prepregnancy dietary advice and counselling in primary care settings to increase the consumption of folate-rich foods, or folate-fortified foods, with standard care; increased intensity of information provision with standard public health dissemination.

DATA COLLECTION AND ANALYSIS

Two reviewers assessed trial quality and extracted data.

MAIN RESULTS

Four trials involving 6425 women were included. The trials all addressed the question of supplementation and they were of variable quality. No dissemination trials were identified. Periconceptional folate supplementation reduced the incidence of neural tube defects (odds ratio 0.28, 95% confidence interval 0.15 to 0.53). Folate supplementation did not significantly increase spontaneous abortion, ectopic pregnancy or stillbirth, although there was a possible increase in multiple gestation. Multivitamins alone were not associated with prevention of neural tube defects and did not produce preventive effects when given with folate.

REVIEWER'S CONCLUSIONS

Periconceptional folate supplementation has a strong protective effect against neural tube defects. Information about folate should be made more widely available throughout the health and education systems. Women whose fetuses or babies have neural tube defects should be offered continuing folate supplementation. The benefits and risks of fortifying basic food stuffs, such as flour, with added folate remain unresolved.

Cross-cultural research: trying to do it better. 2. Enhancing data quality

OBJECTIVE

To describe the dilemmas for cross-cultural research in translating study instruments and implementing quality assurance methods, drawing on strategies utilised in the Mothers in a New Country (MINC) Study.

METHOD

To translation of study instruments in the MINC Study included: forward and back translations, a bilingual group review process, consultation with bilingual content experts, piloting of different versions of translations, a process for exploring unresolved difficulties and caution in interpreting unusual study findings. Interview quality was assessed by: 1. An ongoing review of interviewer-prepared English coding schedules to ensure completeness of data and identify problems with interview administration. 2. Analysis of fully translated transcripts of six randomly selected early interviews to assess the accuracy and consistency with which questions were asked. 3. A comparison of data sources for 45 randomly selected interviews (original language interview schedules, English coding schedules and translated interview transcripts) to determine the rate and nature of discrepancies.

RESULTS

Translation strategies that went beyond simple forward and back translations achieved more reliable and appropriate translations. The complexity of language and cultural differences sometimes still meant less than satisfactory results. Interview tapes played an important quality assurance role, enabling feedback to the interviewers and providing a basis of comparison for identification of data discrepancies.

IMPLICATIONS

Ensuring good data quality in cross-cultural research is both critically important and difficult. Open discussion of the problems and concerted efforts to deal with them would benefit future research.

Cross-cultural research: trying to do it better. 1. Issues in study design

OBJECTIVE

To discuss a range of strategies to address the methodological and practical challenges in designing cross-cultural public health studies.

METHOD

The Mothers in a New Country (MINC) Study was an interview study of 318 Vietnamese, Turkish and Filipino recent mothers exploring their views of maternity care and the early months of motherhood. It was carried out in Melbourne between 1994 and 1997. Sampling, recruitment, retention and representativeness all pose problems for studies involving non-English-speaking background immigrant populations, as do selection, training and support processes for bicultural interviewers. These issues are discussed with reference to the strategies undertaken to tackle them in the MINC Study.

RESULTS

In the MINC Study, a systematic approach to sampling and recruitment, combined with a flexible and sensitive study protocol were largely successful both in achieving in adequate sample size and a largely representative study sample. Similarly, paying significant attention to the selection, training and ongoing support of the biocultural interviewers employed on the study contributed greatly to its successful completion and enhanced confidence in the study findings.

IMPLICATIONS

Both researchers and funders need to take seriously the implications of the many methodological and practical issues involved in designing sound cross-cultural public health studies. In particular, there are major implications for study costs and timelines. However, the benefits to be gained are significant.

Long-term effects on women of assisted reproduction

The long-term health sequelae for women from assisted reproductive technology (ART) have not been studied extensively. There are a number of reasons that women's health may be compromised after ART procedures, including the consequences of the increased incidence of multiple births, operative deliveries, and preterm infants, the possible adverse effects of the drug regimens used for ovarian stimulation, and the instrumentation involved in ART procedures. In this paper we review the existing literature in these areas. It emphasizes the effects of the drugs used for ovarian stimulation, and in particular the incidence of cancer among women who have undergone ART. The review indicates that there is cause for concern about the long-term effects on women from ART treatments. It highlights the lack of research undertaken in almost all areas related to women's long-term health after ART. In the area of ART and cancer, it draws attention to the lack of conclusive evidence in relation to the posited association between fertility treatments and cancer, resulting from the limited number of very large studies and the need for longer follow-up periods. We make a number of recommendations regarding further research that is needed to address the current shortcomings in the published literature.

Mothers in a new country: the role of culture and communication in Vietnamese, Turkish and Filipino women's experiences of giving birth in Australia

There are few population based studies which explore the views immigrant women have of the maternity care they receive in their new homelands. Three hundred and eighteen Vietnamese, Turkish and Filipino women who gave birth in three major city hospitals in Melbourne, Australia were interviewed about their experiences of maternity care. Outcomes and experiences for women with different levels of English fluency were studied, as were women's needs and preferences for assistance with interpreting. Observance of traditional cultural practices surrounding birth and the impact of not being able to observe such practices on women's experiences of care were also explored. Women in the study not fluent in English experienced problems in communicating with their caregivers and these were reflected in less positive experiences of care. Women were less concerned that caregivers knew little about their cultural practices than they were about care they experienced as unkind, rushed, and unsupportive. Maternity care for immigrant women is only likely to improve when barriers to effective communication are addressed and attention is paid to raising standards of care.

Epidemiological approaches to infertility

There are a number of reasons why epidemiological approaches to infertility have not made a major contribution to research in Australia. They include the success of generic treatments, the high public profile of infertility and the consequent polarization of discussion over treatment versus prevention, some reluctance to draw attention to possible aetiologic factors which may be perceived negatively in public debates, and the lack of graduate training in reproductive and perinatal epidemiology. Voluntary infertility is now common for most of the fertile life span in developed countries, and intended family size is small. Many important conditions cannot be diagnosed without the use of invasive procedures or complex investigations, and the more widespread use of less invasive procedures has shown other conditions to be relatively common in healthy populations. If epidemiological approaches are to make a greater contribution towards an increased understanding and control of infertility, research should focus on retrospective and prospective cohort studies of the incidence and prevalence of infertility, nested case-control studies of occupational and environmental exposures, and an extension of the developing use of record-linkage across routinely collected data systems and registers.

The role of the general practitioner in postnatal care: a survey from Australian general practice

BACKGROUND

Despite the practice of routine postnatal check-ups, many women experience problems in the months after childbirth. General practitioners (GPs) are involved in routine postnatal care, yet little research has been undertaken to explore this role.

AIM

To report the views of Australian GPs as to what physical examination and discussion should take place at the routine six week postnatal check-up and to determine the influence of gender on the approach to the check-up.

METHOD

Postal survey of 1104 Australian GPs, yielding an eligible sample of 1022.

RESULTS

A total of 715/1022 (70%) usable surveys returned. Over 65% of GPs recommend routine examination of the abdomen, blood pressure, perineum, vagina, pelvic floor, and breasts at the six week check-up. Fewer than a half the sample believed that physical problems (urine and bowel symptoms, back problems), sexual issues, relationship and parenting issues should be routinely discussed. After controlling for age, practice location, obstetric practice, and qualifications, the sex of the GP remains an important factor influencing the GP's approach to postnatal care. Female GPs are three times more likely to believe that maternal feelings should be discussed routinely and about twice as likely to believe that infant sleeping/behaviour, maternal sleeping/diet/tiredness, coping with other children, relationship with partner, and household work should form part of the routine discussion with all recent mothers.

CONCLUSIONS

Sex of practitioner and older age (60 years or more) are the two most important influences on a GP's approach to postnatal care. This study indicates a need for GPs to shift their focus from routine examination to indicated examination to allow more time to discuss common postnatal problems.

Does an early postnatal check-up improve maternal health: results from a randomised trial in Australian general practice

OBJECTIVES

To investigate whether a visit to a general practitioner one week after discharge results in less depression, increased breastfeeding rates, improved patient wellbeing, fewer physical problems and greater satisfaction with general practice care than the traditional six week postnatal check-up.

DESIGN

A randomised controlled trial.

SETTING

Rural and metropolitan Victoria, Australia. Population Women giving birth at one rural and one metropolitan hospital between February and December 1995 inclusive.

METHODS

All women received a letter and appointment date to see a general practitioner for a check-up: the intervention group for one week after hospital discharge, the control group for six weeks after birth. A mail-out survey was conducted at three and six months after birth, including Edinburgh Postnatal Depression Scale and Short Form 36.

RESULTS

1017/1407 (72.3%) women giving birth at participating hospitals were eligible for the trial: 683 (67.2%) gave informed consent. The average response rate to postal follow up at three and six months was 67.5%. No significant differences were found between the groups in: Edinburgh Postnatal Depression and Short Form 36 scores; number of problems; breastfeeding rates; or satisfaction with general practitioner care. Women in the intervention group were less likely to attend for their check-up (76.4% vs 88.4%; P = 0.001), more likely to discuss labour and birth at their check-up (OR= 1.77, 95% CI 1.17-2.68), less likely to have a vaginal examination (OR = 0.51; 95%, CI 0.34-0.77) or pap smear (OR = 0.34; 95% CI = 0.22-0.52) at their check; more likely to report difficulties with low milk supply (OR= 1.72; 95% CI = 1.12-2.66) and adjusting to the demands of a new baby (OR = 1.76; 95% CI 1.13 2.74), more likely to talk to a general practitioner about their baby (68.2% vs 58.0%; P=0.02) and less likely to consult a hospital doctor about their baby (7.3% vs 14.0%, P = 0.02).

CONCLUSIONS

To make clinically important improvements in maternal health more is required than early postnatal review.

Support, sensitivity, satisfaction: Filipino, Turkish and Vietnamese women's experiences of postnatal hospital stay

OBJECTIVE

To assess Filipino, Turkish and Vietnamese women's views about their care during the postnatal hospital stay.

DESIGN

Interviews were conducted with recent mothers in the language of the women's choice, 6-9 months after birth, by three bilingual interviewers.

PARTICIPANTS

Three hundred and eighteen women born in the Philippines (107), Turkey (107) and Vietnam (104) who had migrated to Australia.

SETTING

Women were recruited from the postnatal wards of three maternity teaching hospitals in Melbourne, Australia, and interviewed at home.

FINDINGS

Overall satisfaction with care was low, and one in three women left hospital feeling that they required more support and assistance with both baby care and their own personal needs. The method of baby feeding varied between the groups, with women giving some insight into the reason for their choice. A significant minority wanted more help with feeding, irrespective of the method. The need for rest was a recurrent theme, with women stating that staff's attitudes to individual preferences, coupled with lack of assistance, made this difficult. The majority of comments women made regarding their postnatal stay focused on the attitude and behaviour of staff and about routine aspects of care. Issues related to culture and cultural practices were not of primary concern to women.

CONCLUSION

Maternity services need to consider ways in which care can focus on the individual needs and preferences of women.

Involvement of Victorian general practitioners in obstetric and postnatal care

OBJECTIVE

To assess the current nature and extent of general practice (obstetric) involvement and the effect of gender on the provision of maternity care in Victoria.

METHOD

A postal survey to a community derived sample of 1104 Victorian general practitioners (with oversampling of female GPs) in August 1994 with hierarchical data analysis techniques used to account for the clustered (divisional) nature of the sampling frame.

RESULTS

A 70% response rate was achieved (715 out of an eligible sample of 1022). Three hundred and sixty-two (45.6%) GPs were providing shared care, 127 (17.7%) intrapartum care and 656 (92%) were involved in seeing women for their routine 6 week postnatal checkup. Male and female GPs were equally qualified and as likely to be vocationally registered (90% vs 92%). Female GPs were less likely than male GPs (11% vs 25%) to be involved in intrapartum care (OR = 0.4, 95% CI = 0.3-.06). Female GPs were more likely than male GPs (50% vs 41%) to be involved in shared care (OR = 1.4, 95% CI = 1.01-2.0), and postnatal care (OR = 3.7, 95% CI = 2.5-5.4). Provincial city (population > 15,000) GPs were more likely to provide shared care than other GPs. Fifty-two per cent of GPs providing shared care held a Diploma of Obstetrics. After accounting for the gender differences associated with practice location, rural GPs were more likely to provide intrapartum care (OR = 10.6, 95% CI = 3.5-32.4).

CONCLUSION

General practitioners play an important role in all facets of maternity care. Female and male GPs differ in their type of obstetric practice. If GPs are to maintain an intrapartum role, prompt action is required to increase the number of GPs involved in intrapartum care. The training requirements for shared care should be reviewed and a more suitable postnatal care curriculum should be developed.

Is baby too warm? The use of infant clothing, bedding and home heating in Victoria, Australia

Overheating of infants has been associated with a raised risk for sudden infant death syndrome (SIDS). Data on the use of heating, bedding and clothing and other measures affecting the thermal environment of 4 week old infants were collected at a home interview for infants of women born in Australia (Anglo-Celtic background), in Southern Europe, in Asia and of women who had a planned out-of-hospital birth. These groups have different risks of SIDS not explained by the classic social and perinatal risk factors nor associated with the currently promoted 'new' risk factors. Thermal insulation of the infant's bedding and clothing and excess thermal insulation (for any observed room temperature) were calculated. Bed sharing differed significantly between the groups as did the use of a sheepskin, tucking in firmly, the closing of doors and windows and the use of heating in the infant's room. After stratifying by bed sharing practice and season of interview, it was found that bed sharing infants had more thermal insulation than those sleeping alone irrespective of season of interview. Infants sleeping alone in the Asian-born and Southern European-born groups were kept warmer than infants in the other two groups. Cultural factors appear to affect the thermal environment in which infants are raised. Some bed sharing infants in all four groups were inappropriately warm, particularly in colder weather, but this was more likely in the Asian-born (low risk) group than in the home birth (high risk) group. These results do not explain the differences in SIDS incidence between the groups.

Are cuts to health expenditure in Victoria compromising quality of care?

Separate state-wide surveys of women who had recently given birth in Victoria were conducted in 1989 and 1993. The first survey was conducted in conjunction with the Victorian Ministerial Review of Birthing Services. The second survey occurred three years after the release of the Review's final report and three months after the introduction of casemix funding. It coincided with a period of substantial cutbacks to expenditure on Victorian public hospitals. In both studies, surveys were mailed to women 6 to 9 months after the birth. Response rates were 71.4% (n = 790) in 1989 and 62.5% (n = 1336) in 1993. Between the two surveys, the proportion of women giving critical feedback about caregivers, more than doubled. The survey findings suggest that standards of care are being compromised in the current economic and policy environment.