Organised and non-organised activities contribute to overall physical activity levels in adolescents and young adults with Down syndrome: a cross-sectional study.

BACKGROUND: Participation in organised and non-organised physical activities among adolescents and young adults with Down syndrome is underexplored. This study aimed to examine differences between organised and non-organised physical activities among adolescents and young adults with Down syndrome. METHODS: Forty participants with Down syndrome (27 woman; mean age 21.4 ± 4.9 years) were recruited. Data on physical activity participation were collected by self- or proxy-reported questionnaires about attendance, involvement and type of physical activity. RESULTS: Adolescents and young adults with Down syndrome participated in more organised than non-organised activities (P < 0.05), more often (P < 0.05), but there was no difference in the total time spent participating in these activities overall. Participants spent more time in vigorous physical activity during organised activities (P < 0.05) and spent more time in light physical activity during non-organised physical activities (P < 0.05). Dancing (organised activity) and walking (non-organised activity) were the most reported activities. CONCLUSIONS: Participation in both organised and non-organised physical activities is important to increase overall physical activity levels of adolescents and young adults with Down syndrome. Future research exploring physical activity preferences may help guide the planning and adaption of community programmes for this group.

A 12-week exercise programme has a positive effect on everyday executive function in young people with Down syndrome: a pilot non-randomised controlled trial.

BACKGROUND: Exercise has the potential to reduce cognitive decline in people with Down syndrome by maximising their cognitive function. The aim of the study was to determine the effect of regular exercise on cognitive functioning in young people with Down syndrome. METHOD: People with Down syndrome were eligible if aged between 13 and 35 years and enrolled to participate in an exercise programme (called FitSkills). The intervention was a 12-week community-based exercise programme completed with a student mentor. Outcomes were assessed before (week 0) and immediately after (week 13) the intervention. Executive functioning (planning, response inhibition, attention shifting) was assessed using Tower of London, Sustained Attention to Response Task, CANTAB Intra-extra Dimensional Set Shift Test, Cognitive Scale for Down Syndrome, and Behaviour Rating Inventory of Executive Function (BRIEF). Working memory was assessed using the CANTAB Paired Associates Learning task, and information processing speed was assessed using the Motor Screening Task. Outcomes were analysed using ANCOVA with the baseline measure as the covariate. RESULTS: Twenty participants (9 women; mean age 23.6 ± 6.6 years) enrolled. Between-group differences, in favour of the experimental group, were found for the global executive composite score of the BRIEF (mean difference -4.77 units, 95% CI -9.30 to -0.25). There were no between group differences for any other outcome measured. CONCLUSION: Participation in a 12-week exercise programme was effective in improving everyday executive functions in young people with Down syndrome. These preliminary findings need to be confirmed in future randomised controlled trials of community-based exercise with larger sample sizes.

Many physiotherapists lack preparedness to prescribe physical activity and exercise to people with musculoskeletal pain: A multi-national survey.

OBJECTIVES: Determine physiotherapists' (i) awareness of physical activity, and exercise prescription guidelines; (ii) perceived role, knowledge, confidence, skills and training in prescribing and progressing aerobic exercise and resistance training to people with musculoskeletal pain; (iii) professional development preferences; and (iv) perceived influences of external factors on exercise prescription for people with musculoskeletal pain. DESIGN: Multi-national cross-sectional survey. METHODS: An open online survey was developed specifically for this study. RESULTS: 1,352 physiotherapists from 56 countries participated. The majority of respondents correctly stated physical activity guidelines for adults (60%) and children (53%), but only 37% correctly stated guidelines for older adults. Eleven percent and 16% could name an accepted guideline for aerobic exercise and resistance training, respectively. Most agreed their role included prescribing aerobic exercise (75%) and resistance training (89%). Fewer reported they had the confidence, training or skills to prescribe aerobic exercise (38-50%) and resistance training (49-70%). Workshops were the most preferred (44%) professional development option. Most respondents believed appointment scheduling and access to equipment and professional development (62-79%) affected their ability to prescribe effective exercise. CONCLUSION: Many physiotherapists lack knowledge and training to provide physical activity advice, and to prescribe aerobic exercise and resistance training to people with musculoskeletal pain.

A rare complication of accidental dural puncture during epidural insertion for labour analgesia.

A 33-year-old multiparous term parturient requested an epidural for labour analgesia. An accidental dural puncture was noted at the time of epidural needle insertion and an intrathecal catheter was placed. The intrathecal catheter was removed 10 h later and was noted to be intact. The following day, there was a significant leak of clear fluid from the catheter insertion site. Cerebrospinal fluid was detected using beta-trace protein testing. The patient remained asymptomatic and we deduced the cause could be a cutaneous fistula. Similar published reports have suggested the causes of similar presentations could include leakage of interstitial oedema, local anaesthetic or cerebrospinal fluid. It is important to consider the diagnosis of clear fluid leakage following an accidental dural puncture and the management of a cerebrospinal fluid-cutaneous fistula in the absence of neurological symptoms.

Effectiveness of interventions to increase physical activity in individuals with intellectual disabilities: a systematic review of randomised controlled trials.

BACKGROUND: People with intellectual disabilities (ID) often do not meet recommended guidelines for physical activity. The aim of this study was to systematically review available evidence that evaluated the effectiveness of interventions to increase physical activity in individuals with ID. METHOD: Five electronic databases (MEDLINE, CINAHL, EMBASE, SPORTDiscus and Cochrane Central Register of Controlled Trials) were searched from inception of the database to July 2017 to identify randomised controlled trials that evaluated the effectiveness of interventions to improve physical activity among people with ID. Trials were included if they measured at least one objective measure of physical activity. Quality appraisal was completed by two independent reviewers using the Cochrane Risk of Bias Tool. The magnitude of treatment effect was estimated for each intervention by calculating the standardised mean difference (SMD) and associated 95% confidence interval. RESULTS: Nine randomised controlled trials (976 participants, 501 women, age range 9 months to 83 years) were included. Four trials evaluated unimodal interventions and five trials evaluated multimodal health promotion programmes based on using supportive environments to enable sustained behavioural changes in physical activity. None of the trials were rated as low risk of bias as all had at least one item on the Cochrane Risk of Bias Tool that was considered to be high risk. No trials were able to implement participant blinding. Three trials found statistically significant beneficial effects of interventions for increasing physical activity. Results showed that a 10-week progressive resistance training programme led to maintenance of physical activity levels at 24 weeks in adolescents with Down syndrome (SMD 0.78, 95% CI 0.17 to 1.40). Additionally, a 12- to 16-month multicomponent diet and physical activity programme produced improvement in physical activity at programme completion in adults with ID (reported effect size of 0.29). Finally, an 8-month physical activity and fitness programme increased physical activity at 8 months in adults with ID (SMD 0.91, 95% CI 0.20 to 1.60). Findings regarding other interventions were inconclusive with small effects that were not statistically significant. CONCLUSIONS: There is inconsistent evidence of the effects of interventions for improving physical activity levels in individuals with ID. A progressive resistance training programme was found to maintain physical activity levels in adolescents with Down syndrome, while a multicomponent diet and physical activity programme and a physical activity and fitness programme were found to improve physical activity levels in adults with ID. Future trials using rigorous research designs are required to confirm these findings and establish whether other interventions designed to increase physical activity in people with ID are effective.

Progressive resistance training did not improve walking but can improve muscle performance, quality of life and fatigue in adults with multiple sclerosis: a randomized controlled trial.

BACKGROUND: Few high-quality trials have examined the effects of progressive resistance training (PRT) on people with multiple sclerosis (MS). OBJECTIVE: To determine the effectiveness of PRT for people with MS, focusing on improving the gait deficits common in this population. METHODS: Using a single blind randomized controlled trial, people with relapsing-remitting MS were randomly allocated to either a PRT program targeting the lower limb muscles twice a week for 10 weeks (n = 36), or usual care plus an attention and social program conducted once a week for 10 weeks (n = 35). Outcomes were recorded at baseline, week 10 and week 22. RESULTS: Participants attended 92% of training sessions, with no serious adverse events. At 10 weeks, no differences were detected in walking performance. However, compared with the comparison group PRT demonstrated increased leg press strength (16.8%, SD 4.5), increased reverse leg press strength (29.8%, SD 12.7), and increased muscle endurance of the reverse leg press (38.7%, SD 32.8). Improvements in favor of PRT were also found for physical fatigue (Mean difference -3.9 units, 95%CI -6.6 to -1.3), and the physical health domain of quality of life (Mean difference 1.5 units, 95%CI 0.1 to 2.9). At week 22 almost no between-group differences remained. CONCLUSION: PRT is a relatively safe intervention that can have short-term effects on reducing physical fatigue, increasing muscle endurance and can lead to small improvements in muscle strength and quality of life in people with relapsing-remitting MS. However, no improvements in walking performance were observed and benefits do not appear to persist if training is completely stopped.

Identifying the barriers and facilitators to participation in physical activity for children with Down syndrome.

BACKGROUND: Many children with Down syndrome do not undertake the recommended amount of daily physical activity. The aim of this study was to explore the barriers and facilitators to physical activity for this group. METHODS: Eighteen in-depth interviews were conducted with 20 parents (16 mothers, 4 fathers) of children with Down syndrome aged between 2 and 17 years to examine what factors facilitate physical activity and what factors are barriers to activity for their children. The participants were recruited through a community disability organisation that advocates for people with Down syndrome and their families. Interviews were recorded, transcribed and independently coded and analysed by two researchers using thematic analysis. RESULTS: Four themes on facilitators of physical activity were identified: (1) the positive role of the family; (2) opportunity for social interaction with peers; (3) structured accessible programmes that make adaptations for children with Down syndrome; and (4) children who were determined to succeed and physically skilled. Four themes on the barriers to physical activity were also identified: (1) characteristics commonly associated with Down syndrome; (2) competing family responsibilities; (3) reduced physical or behavioural skills; and (4) a lack of accessible programmes. CONCLUSIONS: The results highlight the important role of families in determining how much physical activity children with Down syndrome undertake and the effect that common characteristics associated with Down syndrome can have on maintaining an active lifestyle. Future research needs to concentrate on successful methods of encouraging physical activity, such as ensuring social interaction is part of the activity, and eliminating barriers to physical activity such as the a lack of appropriate programmes for children with Down syndrome. Implementing these strategies may encourage children with Down syndrome to participate more frequently in a physically active lifestyle.

Identifying facilitators and barriers to physical activity for adults with Down syndrome.

BACKGROUND: Adults with Down syndrome are typically sedentary, and many do not participate in the recommended levels of physical activity per week. The aim of this study was to identify the facilitators and barriers to physical activity for this group. METHOD: Semi-structured interviews were conducted to elicit the views of adults with Down syndrome and their support people about what factors facilitate physical activity and what factors are barriers to activity. A sample of 18 participants (3 men, 15 women) was recruited through two agencies providing services for adults with disabilities; six participants were adults with Down syndrome and 12 participants were support people (four were parents of adults with Down syndrome and eight participants were employed by day programmes attended by the adults with Down syndrome). The interviews were recorded, transcribed verbatim and independently coded by two researchers. RESULTS: Three themes around facilitators to physical activity were identified: (1) support from others; (2) that the physical activity was fun or had an interesting purpose; and (3) routine and familiarity. Three themes around barriers were also identified: (1) lack of support; (2) not wanting to engage in physical activity; and (3) medical and physiological factors. CONCLUSIONS: The results suggest that support people play a key role, both as facilitators and barriers, in the participation by adults with Down syndrome in physical activity. Many of the barriers and facilitators of activity for adults with Down syndrome indentified are similar to those reported for adults without impairment. Our findings are also consistent with established theories in the field of health behaviour change.

School children's use of computers and teachers' education in computer ergonomics.

A national survey to investigate the education of teachers in computer-related ergonomics was carried out by postal questionnaire. The use of computers by primary school children (age 4-12 years) was also investigated. Data were collected from a random sample of 25% (n = 830) of primary schools in the Republic of Ireland. Questionnaires (n = 1863) were returned from 416 schools giving a response rate of 50.1%. Almost all schools (99.7%) had computers for children's use. The computers were most often (69.8%) used in the classroom. The majority (56.3%) of children worked in pairs. Most teachers (89.6%) had received computer training, but few (17.6%) had received ergonomics information during the training. Respondents were not satisfied with their current knowledge of ergonomics. Over 90% stated that they would like to receive further information by printed format or during a training course, rather than by computer (web or CD-ROM).

Upper extremity peripheral venous pressure measurements accurately reflect pulmonary artery pressures in patients with cavopulmonary or Fontan connections.

After the bidirectional cavopulmonary or Fontan operation, the physiologic consequence is passive flow of the systemic venous return to the pulmonary arteries. Knowledge of pulmonary artery pressure (PA) is valuable in the management of these patients, and obtaining this information without the need for a central line or cardiac catheterization would be advantageous. The aim of this study was to evaluate the correlation between upper extremity peripheral venous (PV) pressures and PA or superior vena cava (SVC) pressures in patients who have undergone cavopulmonary or Fontan connections. During cardiac catheterization, 19 patients with complex cyanotic heart disease who had undergone a cavopulmonary shunt or Fontan procedure were studied. Simultaneous pressure measurements were obtained from the peripheral intravenous line placed prior to the procedure and the SVC or PA. The mean pressures were compared. The mean PV pressure was 17.5 +/- 5.6 mmHg. The mean SVC or PA pressure was 16.1 +/- 5.4 mmHg. The mean difference was 1.5 +/- 1.5 mmHg ( p < 0.001). The correlation coefficient PV to SVC or PA pressure was 0.97 ( p < 0.001). PV pressure measurements taken from an upper extremity accurately reflect PA pressures in patients who have undergone a cavopulmonary shunt or Fontan procedure.

Client and staff views on facilities and services, before and after the convergence of sexual, reproductive and women's services.

OBJECTIVE: To evaluate client and staff views on existing facilities and services, before and after the convergence of sexual, reproductive and women's services. METHODS: Evaluation involved questionnaire survey of clients and staff, one-to-one interviews with staff and review of routinely collected clinical activity data. RESULTS: The integration of the three services led to a reduction in stigma associated with attending sexual health services. Despite some staff concerns, the number of men attending the services did not decrease. There was increased satisfaction with the new service, especially the quality of facilities. There were increased numbers of referrals between clinical services in the Sandyford Initiative. CONCLUSIONS: Sexual, reproductive and women's services can be integrated to provide improved facilities for clients.

Development and application of a quality control procedure for short-wave diathermy units.

Short-wave diathermy (SWD) is a form of radiofrequency (RF) radiation, operating at 27.12 MHz, that is used therapeutically by physiotherapists. Although this form of therapy is widely available, the management of the equipment is not often addressed by either physiotherapists or by medical physics/clinical engineering. A quality control protocol for SWD units, examining power output and electrical and mechanical condition, was developed and applied to 20 units used in clinical practice. In addition, an environmental assessment of where the units were used was also included. Results showed that the power output was generally stable (coefficient of variation range 0-8.8%) and reproducible (coefficient of variation range 0-6.8%). When the outputs from 12 similar units were compared, it was found that the relationship between the units' intensity settings and power output measurements was non-linear. Two units with mechanical timers were found to have inaccuracies that could contribute, under a 'worst-case' scenario, to a dosage error of up to 45%. Environmental analysis found that all treatment plinths in use contained metal parts, which could constitute a fire hazard, and no department examined was equipped with an RF screened room, a facility that would ensure that other persons in the vicinity were not exposed to excessive stray radiation.

Current practice patterns in the treatment of Charcot foot.

Treatment of Charcot foot osteoarthropathy has emerged as a major component of the American Orthopaedic Foot and Ankle Society (AOFAS) Diabetes 2000 Initiative. A two-part survey described treatment patterns and current footwear use of patients with Charcot osteoarthropathy of the foot and ankle. In the first part, 94 consecutive patients with a history of Charcot foot and ankle presenting for care were questioned on their foot-specific treatment and current footwear use. A history of diabetic foot ulcer was given by 39 (41%) patients, and an infection had been present in a foot of 20 (21%) patients. The initial treatment of the Charcot foot and ankle had been a total contact cast in 46 (49%) patients, and a pre-fabricated walking boot in 19 (20%). Charcot related surgery had consisted of 76 procedures in 46 (49%) patients. Sixty-three (67%) patients were currently using accommodative footwear (depth-inlay shoes in 46 [49%], custom shoes in 10 [11%], and CROW in 7 [7%] patients), and 72 (77%) were currently using custom accommodative foot orthoses. The second part of this study consisted of a questionnaire completed by 37 orthopaedic surgeons (members of AOFAS) interested in forming a Charcot Study Group. They treated an average of 11.8 patients having Charcot foot or ankle per month. Thirty (81%) used the Semmes-Weinstein 5.07 monofilament as a screening tool for peripheral neuropathy. For treatment of Eichenholtz Stage I, 29 (78%) used a total contact cast and 15 (41%) allowed weightbearing; for Stage II, 30 (81%) physicians used a total contact cast and 18 (49%) allowed weightbearing. Although the literature contains uniform recommendations for immobilization and non-weightbearing as treatment for the initial phases of Charcot arthropathy, the results of this benchmarking study reveal that currenl treatment is varied.

American Orthopaedic Foot and Ankle Society shoe survey of diabetic patients.

A one-page written survey was completed by 402 randomly selected patients with diabetes in five cities during a scheduled visit to their endocrinologist. Patients averaged 61.5 years of age and had been diagnosed with diabetes for 27.3 years. This study suggests that approximately 25% of adults with diabetes are at risk for developing foot ulcers, the precursor to deep infection leading to lower limb amputation. The goal at the inception of this project was to obtain benchmark data on the current level of prophylactic foot care being provided to adult patients with diabetes. The results of this survey suggest that most individuals with diabetes and their physicians are aware of potential diabetic foot morbidity, yet very few take advantage of prophylactic protective footware. Even fewer are presently taking advantage of benefits established through the Medicare Therapeutic Foot Bill. This survey highlights a substantial opportunity for improvement in the long-term care of individuals with diabetes.

Subjective appraisal of problem severity and the ASI: secondary data or second opinion? Addiction Severity Index.

The Addiction Severity Index is a popular research and clinical tool for the characterization of individuals grappling with substance abuse problems. For research, use of the seven objectively calculated composite scores of problem severity is recommended. In contrast, clinical use of the instrument relies more upon its subjectively derived interviewer and client severity rating scores. However, little systematic research has looked at the comparability of these two sources of client data. This study compared the objective and subjective scores of the ASI of male (n=141) and female (n=58) clients entering substance abuse treatment. In addition, clients' narratives about their most worrisome problems were recorded and put to content analyses. While significant correlations were found among the various subjective indices, little relationship could be discerned between the objective composite scores and any of the subjective indices derived from either the ASI or the clients' narratives. As the focus of outcome research shifts from objective client and treatment characteristics to a better understanding of the process of intervention, empirical characterization of substance abuse treatment outcome may be enriched by the inclusion of subjective data that taps into the client's own perceptions of problems and treatment efficacy in addition to more objective sources of data.

Development of a community nurse-led continence service.

Extrapolations from prevalence studies suggest that on average 56,000 adults experience urinary incontinence in Glasgow, a third of whom will have been incontinent during the last week. A review by a multidisciplinary health gain commissioning team concluded that existing continence services in Glasgow had developed opportunistically and that problems exist, e.g. prescription of products without full assessment of continence problems. In response to this situation, a new community nurse-led continence service was introduced in 1995. This article describes the development and evaluation of this new service. For the past 3 years the service has employed five staff nurses and a physiotherapist. The team is solely employed to promote continence. It carries out assessments both in nursing and residential homes and community clinics. The planned evaluation will assess the effectiveness of this team in promoting continence and the future demand for continence nurse-led services.

The incidence and characteristics of violent men in substance abuse treatment.

Linkage between marital violence and substance abuse has been noted in men seeking treatment for substance-use disorders. The present study examined (1) the incidence of family violence in men admitted into substance abuse treatment; (2) the psychosocial characteristics associated with marital violence; and (3) the comparability of violent substance abusers to their treatment cohorts. Fifty-nine men in substance abuse treatment involved in a significant relationship in the past year were assessed for substance abuse, family violence, psychosocial functioning, and personality attributes. Fifty-eight percent of men reported at least one incident of physical familial violence in the past year, while 100% of the men reported having engaged in psychological abuse in the past year. Additionally, greater violence was associated with interpersonal insensitivity, hostile outbursts, and poorer overall functioning independent of substance abuse. Finally, violent male substance abusers reported significantly more hostility, suspiciousness, projection of blame, and interpersonal inadequacy than did the less violent substance abusers. These findings suggest that, in drug-treatment settings, systematic objective screening for family violence is routinely called for.

Testing and evaluation for astronaut extravehicular activity (EVA) operability.

Because it is the human component that defines space mission success, careful planning is required to ensure that hardware can be operated and maintained by crews on-orbit. Several methods exist to allow researchers and designers to better predict how hardware designs will behave under the harsh environment of low Earth orbit, and whether designs incorporate the necessary features for Extra Vehicular Activity (EVA) operability. Testing under conditions of simulated microgravity can occur during the design concept phase when verifying design operability, during mission training, or concurrently with on-orbit mission operations. The bulk of testing is focused on normal operations, but also includes evaluation of credible mission contingencies or "what would happen if" planning. The astronauts and cosmonauts who fly these space missions are well prepared and trained to survive and be productive in Earth's orbit. The engineers, designers, and training crews involved in space missions subject themselves to Earth based simulation techniques that also expose them to extreme environments. Aircraft falling ten thousand feet, alternating g-loads, underwater testing at 45 foot depth, enclosure in a vacuum chamber and subject to thermal extremes, each carries with it inherent risks to the humans preparing for space missions.

Satisfaction with midwife-managed care in different time periods: a randomised controlled trial of 1299 women.

OBJECTIVE: To compare women's satisfaction with midwife-managed care with 'shared care' over three different time periods. DESIGN: Randomised controlled trial. SETTING: Glasgow Royal Maternity Hospital, Glasgow, UK. PARTICIPANTS: 1299 women experiencing normal pregnancy (consent rate: 82%). Six hundred and forty-eight women were randomised to midwife-managed care and 651 to 'shared care'. METHODS: Three self-report questionnaires were sent to women's homes. The questionnaires examined: satisfaction with antenatal care at 34-35 weeks' gestation, and satisfaction with intrapartum, hospital- and home-based postnatal care at seven weeks postnatally. The third questionnaire reviewed satisfaction with intrapartum care seven months after delivery. FINDINGS: Women in both groups were satisfied. However, women in the midwife-managed group were more highly satisfied in relation to the dimensions examined: relationships with staff, information transfer, choices and decisions, and social support. The differences between the two groups were evident for all time periods (i.e. antenatal, intrapartum and postnatal periods) and were sustained at seven-month follow-up. This is illustrated in the mean scores for relationships with staff, as measured at 34-35 weeks' gestation (possible range -2; very negative attitudes to 2; very positive attitudes). Women in the midwife-managed group scored a mean of 1.22 compared to 0.74 for the 'shared care' group (mean diff: 0.48; 95% CI: 0.42 to 0.55). While women in both groups were more likely to make positive rather than negative comments in open-ended questions, the midwife-managed group were more likely to make positive comments whereas the 'shared care' group were more likely to make negative comments. CONCLUSION: Midwife-managed care for healthy pregnant women which is integrated into existing services improves satisfaction with antenatal, intrapartum and postnatal care.

Randomised, controlled trial of efficacy of midwife-managed care.

BACKGROUND: Midwife-managed programmes of care are being widely implemented although there has been little investigation of their efficacy. We have compared midwife-managed care with shared care (ie, care divided among midwives, hospital doctors, and general practitioners) in terms of clinical efficacy and women's satisfaction. METHODS: We carried out a randomised controlled trial of 1299 pregnant women who had no adverse characteristics at booking (consent rate 81.9%). 648 women were assigned midwife-managed care and 651 shared care. The research hypothesis was that compared with shared care, midwife-managed care would produce fewer interventions, similar (or more favourable) outcomes, similar complications, and greater satisfaction with care. Data were collected by retrospective review of case records and self-report questionnaires. Analysis was by intention to treat. FINDINGS: Interventions were similar in the two groups or lower with midwife-managed care. For example, women in the midwife-managed group were less likely than women in shared care to have induction of labour (146 [23.9%] vs 199 [33.3%]; 95% CI for difference 4.4-14.5). Women in the midwife-managed group were more likely to have an intact perineum and less likely to have had an episiotomy (p = 0.02), with no significant difference in perineal tears. Complication rates were similar. Overall, 32.8% of women were permanently transferred from midwife-managed care (28.7% for clinical reasons, 3.7% for non-clinical reasons). Women in both groups reported satisfaction with their care but the midwife-managed group were significantly more satisfied with their antenatal (difference in mean scores 0.48 [95% CI 0.41-0.55]), intrapartum (0.28 [0.18-0.37]), hospital-based postnatal care (0.57 [0.45-0.70]), and home-based postnatal care (0.33 [0.25-0.42]). INTERPRETATION: We conclude that midwife-managed care for healthy women, integrated within existing services, is clinically effective and enhances women's satisfaction with maternity care.