Methods to induce labour: a systematic review, network meta-analysis and cost-effectiveness analysis.

OBJECTIVES: To compare the clinical effectiveness and cost-effectiveness of labour induction methods. METHODS: We conducted a systematic review of randomised trials comparing interventions for third-trimester labour induction (search date: March 2014). Network meta-analysis was possible for six of nine prespecified key outcomes: vaginal delivery within 24 hours (VD24), caesarean section, uterine hyperstimulation, neonatal intensive care unit (NICU) admissions, instrumental delivery and infant Apgar scores. We developed a decision-tree model from a UK NHS perspective and calculated incremental cost-effectiveness ratios, expected costs, utilities and net benefit, and cost-effectiveness acceptability curves. MAIN RESULTS: In all, 611 studies comparing 31 active interventions were included. Intravenous oxytocin with amniotomy and vaginal misoprostol (≥50 µg) were most likely to achieve VD24. Titrated low-dose oral misoprostol achieved the lowest odds of caesarean section, but there was considerable uncertainty in ranking estimates. Vaginal (≥50 µg) and buccal/sublingual misoprostol were most likely to increase uterine hyperstimulation with high uncertainty in ranking estimates. Compared with placebo, extra-amniotic prostaglandin E2 reduced NICU admissions. There were insufficient data to conduct analyses for maternal and neonatal mortality and serious morbidity or maternal satisfaction. Conclusions were robust after exclusion of studies at high risk of bias. Due to poor reporting of VD24, the cost-effectiveness analysis compared a subset of 20 interventions. There was considerable uncertainty in estimates, but buccal/sublingual and titrated (low-dose) misoprostol showed the highest probability of being most cost-effective. CONCLUSIONS: Future trials should be designed and powered to detect a method that is more cost-effective than low-dose titrated oral misoprostol. TWEETABLE ABSTRACT: New study ranks methods to induce labour in pregnant women on effectiveness and cost.

A review of the literature on women's views on their maternity care in the community in the UK.

OBJECTIVES: to review the UK literature relating to women's views on community-based maternity care between 1970 and 1998. DESIGN: UK research studies examining community-based maternity care were identified by searching several electronic databases using defined search terms. Data extraction was carried out by two or more independent reviewers using a pro-forma. Findings are summarised in this paper. FINDINGS: a total of 624 papers were retrieved and 241 met inclusion criteria. Only 40 papers included some form of comparison group. Examples from more recent and relevant papers focusing on women's views of their maternity care are described and discussed. Women expressed high levels of satisfaction with care. However, there are serious gaps in the research evidence. CONCLUSION AND POLICY IMPLICATIONS: most of the papers included in the review were descriptive and few studies were of a size and quality to enable findings to be generalised to other groups and settings. More information is needed on the care process. There is a need for research studies to examine consumer views where different groups of women experience different care processes.

A review of the literature on the midwife and community-based maternity care.

OBJECTIVE: to review the UK literature relating to community-based maternity care. DESIGN: all UK research studies published between 1970 and 1998 relating to community-based maternity care were included. Searches were made via a number of electronic databases using defined search terms. All papers included were independently reviewed by a minimum of two researchers. Study findings were tabulated using a pro-forma. Findings are summarised in this paper. FINDINGS: a total of 241 papers were deemed to meet all inclusion criteria. The majority of studies used descriptive methods with only 11 papers reporting findings from randomised controlled trials. Findings are reported relating to clinical outcomes, the care process and the views of women and health professionals. CONCLUSION AND POLICY IMPLICATIONS: the overall quality of the evidence in the papers reviewed was very mixed. What limited evidence there is suggests that, for the majority of women, care in community settings is as safe and as acceptable to women as care provided in hospital. Despite a large volume of literature, the amount that is known about midwives' contribution to care, and what women think about it, is limited. There is a need for controlled studies to compare outcomes for different patterns of care and for well-designed observational studies to provide information on the care process.

Adjusting stroke patients' poor position: an observational study.

Although nurses' role in rehabilitation has been generally ill-defined and consistently undervalued, of all professional groups, nurses working with stroke patients have potentially the greatest contribution to make. Stroke patients are believed to benefit from good posture yet they can spend long periods in inappropriate positions. This study examined the positioning, handling and mobilizing of stroke patients in hospital. Non-participant observation was used to gather data on stroke patients' position and nurses' activities. This paper addresses two basic questions--what causes the adjustment of patients from poor to good position and who is involved in achieving this adjustment. Poor position was observed to end 158 times in 380 'patient hours' of observation. The most frequent causes of positional improvement were activities whose primary intention was unrelated to position correction. The deliberate adjustment of patients' position by nurses was a rare event which occupied a small part of nurses' time. The potential for a more considered and consistent nursing approach appears to be great.

Child care responsibilities and participation in continuing education and training: issues relating to motivation, funding and domestic roles.

Changes in the organization and funding of health services and in the education and training of NHS staff have placed increased influence in the hands of employers and individual students as users of continuing professional development. Against this policy context an interview study was carried out with students participating in a range of continuing professional development activities. The sample included 89 participants attending a range of courses. Approximately half of the sample had children. Many of the participants were attending courses in their own rather than in their employers' time and several were self-funding. The influence of domestic responsibilities on motivations, along with the impact of course participation on home and family life, were examined. Results revealed that those with children were less likely to perceive continuing education in a positive light compared to those without. The impact of course participation on home and family life was invariably negative and for some the consequences were serious. The policy implications of findings are discussed.

Antenatal home blood pressure monitoring: a pilot randomised controlled trial.

OBJECTIVE: To measure recruitment to, compliance with, and the acceptability of a trial designed to test whether a reduced schedule of antenatal visits combined with training in self-measurement of blood pressure at home may improve hypertension screening and save money. To test the specific hypothesis that even after taking into account extra unscheduled visits, the reduced schedule with ambulatory monitoring reduces total visits. DESIGN: A pilot randomised controlled trial. SETTING: Four urban and four rural general practices in Yorkshire and Lancashire. POPULATION: One hundred and five low risk women in the third trimester of pregnancy. Eighty women participated. INTERVENTION: Women were invited to participate at 24-28 weeks. Those who accepted were allocated either to a standard nine subsequent visit schedule (30, 32, 34, 36, 37, 38, 39, 40, 41 weeks) or to a reduced schedule (34, 38, 41 weeks). Those in the latter group measured their blood pressure weekly using a portable sphygmomanometer at home. MAIN OUTCOME MEASURES: Recruitment, total number of clinic visits, frequency of blood pressure measurement, schedule preference, and anxiety. RESULTS: Although there were more unscheduled visits in the home monitoring group, this did not outweigh the reduction in scheduled visits, (total visits reduced from 7 x 4 to 4 x 5, P < 0 x 001), and blood pressure was measured during more weeks (9 vs 7 weeks, P < 0 x 001) in the experimental group. Most women expressed a preference for the reduced schedule both when the idea was first suggested, and after they had experienced it, and there were no significant differences in anxiety. CONCLUSION: Replacement of antenatal screening visits with home blood pressure monitoring is acceptable to women. The reduction in clinic visits is not compensated by an increase in visits for other reasons and overall blood pressure measurement is omitted less often. Whether it reduces adverse outcomes or has any rare side effects will require a larger trial, but this pilot study indicates that it is likely to be safe, and that such a large trial would be feasible.

Investigating recovery from stroke: a qualitative study.

A recent randomized controlled trial evaluated the effects of specialist nurses providing information, advice and support to caregivers and patients at home during the first year after a stroke. Reported here are the results of a complementary study which used qualitative methods to examine the experience of patients and caregivers during the year of recovery after a stroke. We used semi-structured interviews with a purposively selected sample of 30 patients and 15 caregivers at the end of a randomized controlled trial (13-16 months post-stroke). Patients and caregivers provided vivid descriptions of the recovery process. Recovery was perceived in terms of the degree of congruence patients identified between their lives before, and after, stroke. Patients therefore had individual and personal yardsticks for measuring their recovery. In conclusion, further research and interventions must consider the diverse, complex, dynamic and highly personal character of stroke recovery. Traditional outcome measures are too simplistic to capture patients' and caregivers' experiences. There do not appear to be single or simple solutions to the problems of facilitating psycho-social adjustment.

Enrolled nurse conversion: trapped into training.

The introduction of Project 2000 in the late 1980s aimed to replace the existing two levels of nurse training with a single level of entry. This entailed phasing out training for enrolled nurses (ENs) and 'conversion' courses were introduced to allow ENs to upgrade their qualification. As part of a larger study of continuing education and training in the National Health Service (NHS), a cohort of ENs taking part in an open-learning conversion course were interviewed. Sixteen nurses described their motives for undertaking the course and the impact of the course on their work and home lives. Data collected in interviews were analysed using qualitative methods and revealed that all of these nurses felt under pressure to take part in the course. Participation in the course was associated with changes in home and work life. The findings of the study have implications in terms of study leave policy.

Women's perceptions of maternity carers.

OBJECTIVE: To investigate women's perceptions about the roles of different types of staff providing maternity care. DESIGN: A descriptive study using screening questionnaires and semi-structured interviews. SETTING: Two hospitals in the north of England, one in a predominantly urban, inner-city area and the other in a mixed urban-rural area. PARTICIPANTS: 537 women between 16 and 24 weeks' gestation from two hospitals serving urban and rural areas completed screen questionnaires, and 247 (46%) were interviewed in their homes. In this paper we report on the findings of the interview study. FINDINGS: The majority of women were clear about the role of the midwife in the maternity care of all women. Obstetricians were primarily perceived as being there to provide specialist or emergency care. Many women were uncertain about the specific role of their GP in maternity care. There was variation in women's views about whether different types of staff are qualified to perform particular tasks. IMPLICATIONS FOR PRACTICE: Women need information about the roles and functions of maternity carers in order to make choices about their care.

Motivational forces affecting participation in post-registration degree courses and effects on home and work life: a qualitative study.

Over the past decade, pre- and post-registration education for nurses and midwives in the United Kingdom has undergone major change, creating an atmosphere where continuing professional development is a matter of priority for individual health care staff. Against this context of change, and as part of a larger study of continuing education and training in the National Health Service, a cohort of participants in a part-time health studies degree course were interviewed using a semi-structured schedule. Twenty-nine nurses, midwives and allied professional staff described their motives for participation in the course and its effects on their professional and personal lives. Data collected in interviews were analysed using qualitative methods and revealed that participation was encouraged by both professional and personal factors. For many staff participation was prompted by negative feelings about themselves and their professional status. Participation in the course was associated with (largely negative) changes in home and family life and most participants faced additional financial burdens. The findings of the study have implications for policy relating to the funding of continual professional education for nurses and other health care staff. Health care staff are receiving mixed messages about continuing education from policy makers and employers. Dependence on willingness and ability to pay for post-registration degree-level studies is unlikely to be an efficient or equitable means of ensuring lifelong learning for healthcare staff.

Short postnatal hospital stay: implications for women and service providers.

BACKGROUND: In a bid to increase consumer satisfaction, recent government reports have encouraged maternity services providers to offer women more choice about their care. At the same time, there has been considerable pressure on hospital managers and clinicians to drive down health service costs. Women need information about the likely effects of different service patterns on their wellbeing, and service providers about the implications of allowing women choice. METHODS: This paper reports on a descriptive study in six districts in the Yorkshire Region and focuses on the implications of variation in length of stay. The aim of the study was to describe variation in the care process and to explore associations between care process variables, consumer satisfaction and maternal psychological wellbeing. One hundred and twenty randomly selected women in each district delivering in a specified four-week period were asked to complete postal survey questionnaires in the postnatal period. RESULTS: There were significant differences between districts in terms of the length of postnatal hospital stay for women experiencing normal deliveries. Those women who thought that their postnatal length of stay was too short had significantly higher depression scores. CONCLUSIONS: Variation in length of postnatal hospital stay may have implications for consumer satisfaction, maternal psychological outcomes and resource use.

Preventing childhood unintentional injuries--what works? A literature review.

AIM: The aim of this paper is to report on a systematic review of the world literature to provide information about the most effective forms of health promotion interventions to reduce childhood (0-14 years) unintentional injuries. The findings are of relevance to policy makers at a local or national level, to practitioners and researchers. METHODS: The relevant literature has been identified through the use of electronic databases, hand searching of journals, scanning reference lists, and consultation with key informants. RESULTS: Examples of interventions that have been effective in reducing injury include: bicycle helmet legislation, area wide traffic calming measures, child safety restraint legislation, child resistant containers to prevent poisoning, and window bars to prevent falls. Interventions effective in changing behaviour include bicycle helmet education and legislation, child restraint legislation, child restraint loan schemes, child restraint educational campaigns, pedestrian education aimed at the child/parent, provision of smoke detectors, and parent education on home hazard reduction. For the community based campaigns, the key to success has been the sustained use of surveillance systems, the commitment of interagency cooperation and the time needed to develop networks and implement a range of interventions. Education, environmental modification and legislation all have a part to play and their effect in combination is important. CONCLUSION: The design of evaluations in injury prevention needs to be improved so that more reliable evidence can be obtained. Better information is needed on process, so that successful strategies can be replicated elsewhere. There is also a need for literature reviews on effectiveness to be updated regularly and for their findings to be widely disseminated to policy makers, researchers, and practitioners.