A qualitative study of partner engagement in HIV testing in Malawi and Kenya.

In low-income settings, partner engagement in HIV testing during pregnancy is well recognised, but uptake remains low. To understand why men fail to engage, 76 in-depth, individual interviews were conducted with women (n = 23), men (n = 36) and community stakeholders (n = 17) in Malawi and Kenya. Transcribed data were analysed thematically. Male engagement was verbally supported. However, definitions of 'engagement' varied; women wanted a shared experience, whereas men wanted to offer practical and financial support. Women and stakeholders supported couples-testing, but some men thought separate testing was preferable. Barriers to couples-testing were strongly linked to barriers to antenatal engagement, with some direct fear of HIV-testing itself. The major themes identified included diverse definitions of male engagement, cultural norms, poor communication and environmental discomfort - all of which were underpinned by hegemonic masculinity. Couples-testing will only increase when strategies to improve reproductive health care are implemented and men's health is given proper consideration within the process. As social norms constitute a barrier, community-based interventions are likely to be most effective. A multi-pronged approach could include advocacy through social media and community forums, the provision of tailored information, the presence of positive role models and a welcoming environment.

Identification of women at risk of depression in pregnancy: using women's accounts to understand the poor specificity of the Whooley and Arroll case finding questions in clinical practice.

Antenatal mental health assessment is increasingly common in high-income countries. Despite lacking evidence on validation or acceptability, the Whooley questions (modified PHQ-2) and Arroll 'help' question are used in the UK at booking (the first formal antenatal appointment) to identify possible cases of depression. This study investigated validation of the questions and women's views on assessment. Women (n = 191) booking at an inner-city hospital completed the Whooley and Arroll questions as part of their routine clinical care then completed a research questionnaire containing the Edinburgh postnatal depression scale (EPDS). A purposive subsample (n = 22) were subsequently interviewed. The Whooley questions 'missed' half the possible cases identified using the EPDS (EPDS threshold ≥ 10: sensitivity 45.7 %, specificity 92.1 %; ≥ 13: sensitivity 47.8 %, specificity 86.1 %), worsening to nine in ten when adopting the Arroll item (EPDS ≥ 10: sensitivity 9.1 %, specificity 98.2 %; ≥ 13: sensitivity 9.5 %, specificity 97.1 %). Women's accounts indicated that under-disclosure relates to the context of assessment and perceived relevance of depression to maternity services. Depression symptoms are under-identified in current local practice. While validated tools are needed that can be readily applied in routine maternity care, psychometric properties will be influenced by the context of disclosure when implemented in practice.

The New Nigerian Mental Health Act: A Huge Leap Before Looking Closely?

A new Mental Health law was recently enacted in Nigeria to replace the Lunacy Ordinance of 1958. The passage of the new law was a major leap from the old. It was received with excitement because the former law was not only outdated but failed to address core issues such as the promotion of mental health and the protection of the rights of the mentally ill. Though the new law adequately makes provisions for these, it has considerable flaws that may hinder implementation. Parts of it lack clarity and other parts are somewhat overzealous in safeguarding the mentally ill, thus potentially defeating its purpose. It appears that certain aspects were not well thought out, or there was no 'looking well' before leaping to legislate. This paper aims to critically review flawed aspects of the new law and make recommendations on the way forward.

The timing of elective caesarean delivery between 2000 and 2009 in England.

BACKGROUND: In 2004, the National Institute for Clinical Excellence (NICE) recommended that an elective caesarean section for an uncomplicated pregnancy should not be carried out before 39 completed weeks due to increased risk of respiratory morbidity in newborns. We describe the trends and variation across 63 English NHS trusts in the timing of elective caesarean section (CS) for low-risk singleton deliveries. METHODS: We identified elective CS deliveries between 1st April 2000 and 28th February 2009 in English NHS trusts using the Hospital Episode Statistics. We selected women with uncomplicated pregnancies who had an elective CS delivery after 34 completed weeks of gestation, and analysed the trends and the trust-level variation in the timing of elective CS. The impact of the NICE guidance on the monthly rate of elective CS deliveries performed after 39 weeks was estimated using an interrupted time-series design with autoregressive integrated moving average (ARIMA). RESULTS: There were 118,456 elective CS deliveries at the 63 NHS trusts. The overall proportion of elective CS deliveries done after 39 completed weeks steadily increased from 39% in 2000/01 to 63% in 2008/09. The proportions rose from 43% to 67% for women with breech presentation and from 35% to 62% for women with a previous CS. There was significant variation across NHS trusts in each year; in 2008/09, with the proportions of elective CS done after 39 weeks ranging from 28% to 89% (Inter-quartile range limits: 54% to 72%). We found a small but statistically significant increase in the proportion immediately after the publication of the NICE guidance, but its rate of growth rate declined slightly thereafter. CONCLUSIONS: NHS trusts in our study have responded to the new evidence on the benefits of delaying elective CS to after 39 weeks gestation. However, substantial differences between NHS trusts remain, which indicates there is room for further improvement. We suggest that maternity services and commissioners adopt the "timing of elective caesarean" as a quality indicator to support clinical practice.

Risk of placenta previa in second birth after first birth cesarean section: a population-based study and meta-analysis.

OBJECTIVE: To compare the risk of placenta previa at second birth among women who had a cesarean section (CS) at first birth with women who delivered vaginally. METHODS: Retrospective cohort study of 399,674 women who gave birth to a singleton first and second baby between April 2000 and February 2009 in England. Multiple logistic regression was used to adjust the estimates for maternal age, ethnicity, deprivation, placenta previa at first birth, inter-birth interval and pregnancy complications. In addition, we conducted a meta-analysis of the reported results in peer-reviewed articles since 1980. RESULTS: The rate of placenta previa at second birth for women with vaginal first births was 4.4 per 1000 births, compared to 8.7 per 1000 births for women with CS at first birth. After adjustment, CS at first birth remained associated with an increased risk of placenta previa (odds ratio = 1.60; 95% CI 1.44 to 1.76). In the meta-analysis of 37 previously published studies from 21 countries, the overall pooled random effects odds ratio was 2.20 (95% CI 1.96-2.46). Our results from the current study is consistent with those of the meta-analysis as the pooled odds ratio for the six population-based cohort studies that analyzed second births only was 1.51 (95% CI 1.39-1.65). CONCLUSIONS: There is an increased risk of placenta previa in the subsequent pregnancy after CS delivery at first birth, but the risk is lower than previously estimated. Given the placenta previa rate in England and the adjusted effect of previous CS, 359 deliveries by CS at first birth would result in one additional case of placenta previa in the next pregnancy.

Non-surgical management of ectopic pregnancy: appropriate risk management must be in place.

INTRODUCTION: Advances in technology have facilitated early diagnosis of ectopic pregnancy, which in turn has increased the scope for non-surgical treatment. Unfortunately risks associated with such management, including maternal death, are coming to the fore. This paper highlights the risks and how they could be avoided. FINDINGS: The risks include rupture of ectopic pregnancy during treatment with methotrexate or during expectant management, inadvertent administration of methotrexate to viable early intrauterine pregnancy, methotrexate embryopathy, allergic reaction to methotrexate, development of methotrexate pneumonitis and fatal administration of methotrexate to a woman with a concurrent medical problem. CONCLUSION: There is an urgent need for appropriate risk management procedures to be applied in units where non-surgical (i.e. expectant or medical) management of ectopic pregnancy is offered. Risk management should address organisational issues such as safe handling of the chemotherapeutic agent, prescription and supply, consent (informed choice), documentation and adequacy of follow-up arrangements. Women undergoing non-surgical management should have ready access (for example by telephone) to professional advice and to surgical intervention in the event of an emergency.

Risk management in gynaecology: principles and practice.

The majority of gynaecology patients are fit women receiving relatively straightforward care. However, human error is inevitable. Furthermore, new treatments and technologies are constantly emerging, today's trainees are less experienced than their predecessors, and the need for team work is greater than ever. These and other factors pose threats to patient safety. Patient safety can be improved through risk management. This review describes risk management principles and tools applicable to gynaecology and highlights common sources of patient safety incidents in gynaecology clinics, wards and operating theatres. It provides an overview of communication, consent, staff training and supervision, and use of clinical practice guidance. Underlying theoretical principles are amply illustrated by practical examples.

Towards safe practice in instrumental vaginal delivery.

Approximately one in ten deliveries in the Western world is an instrumental vaginal delivery. Like other surgical operations, instrumental vaginal delivery has its complications, and the operator is obliged to critically appraise the indication for the procedure and the background risk factors, and communicate effectively with the woman. Also, it calls for team work. The safe approach to instrumental delivery should therefore be similar to that adopted for other surgical operations in terms of preoperative assessment, intraoperative precautions and postoperative care. Safe practice in instrumental delivery addresses the various types of error that may occur, and places a strong premium on operator skills, competence, and familiarity with the particular instrument. This chapter reviews good practice in the conduct of instrumental delivery, highlights what could go wrong, and outlines interventions that could reduce the incidence of harm. Issues relating to communication and consent as well as training and documentation are discussed. Indications for abandonment are outlined, and the importance of situational awareness is emphasized. Safe practice tips are amply provided.

Situational awareness and its application in the delivery suite.

The delivery suite is a high-risk environment. Transitions between low-risk and high-risk can be swift, and sentinel events can occur without warning. The prevention of accidents in this environment rests on the vigilance of the individual practitioner at the frontline. It is, therefore, important that the individual practitioner should develop and maintain the cognitive skills to anticipate, recognize, and intercept unfolding error chains. This commentary gives an overview of a nontechnical skill that is essential for safe practice in a delivery suite: situational awareness. A basic description of situational awareness is provided, using examples of loss of situational awareness in the delivery suite and examples of simple interventions that could promote situational awareness. Involuntary automaticity readily creeps in during performance of routine tasks, and cognitive overload could deplete attentional resources that are, by nature, limited. Strategies and tactics for maintaining situational awareness include proactively seeking and managing information on unfolding events, continually updating individual and team mental models, mindful use of checklists and scoreboards, and avoidance of attentional blindness. These simple interventions require minimal financial resources but could immensely enhance clinical performance and patient safety. Situational awareness should be included in the training of obstetrician-gynecologists and other staff working in a delivery suite.

Antenatal mental health referrals: review of local clinical practice and pregnant women's experiences in England.

OBJECTIVE: to investigate (i) the consistency and completeness of mental health assessment documented at hospital booking; (ii) the subsequent management of pregnant women identified as experiencing, or at risk of, mental health problems; and (iii) women's experiences of the mental health referral process. DESIGN: mixed methods cohort study SETTING: large, inner-city hospital in the north of England PARTICIPANTS: women (n=191) booking at their first formal antenatal appointment; mean gestational age at booking 13 weeks. METHODS: women self-completed the routine mental health assessment in the clinical handheld maternity notes, followed by a research pack. Documentation of mental health assessment (including assessment of depression symptoms using the Whooley and Arroll questions, and mental health history), mental health referrals and their management were obtained from women's health records following birth. Longitudinal semi-structured interviews were conducted with a purposive sub-sample of 22 women during and after pregnancy. FINDINGS: documentation of responses to the Whooley and Arroll questions was limited to the handheld notes and symptoms were not routinely monitored using these questions, even for women identified as possible cases of depression. The common focus of referrals was on the women's previous mental health history rather than current depression symptoms, assessed using the Whooley questions. Women referred to a Mental Health Specialist Midwife for further support were triaged based on the written referral and few met eligibility criteria. Although some women initially viewed the referral as offering a 'safety net', analysis of health records and subsequent interviews with women both indicated that communication regarding the management of referrals was inadequate and women tended not to hear back about the outcome of their referral. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: mental health assessment was introduced without ensuring that identified needs would be managed consistently. Care pathways and practices need to encompass identification, subsequent referral and management of mental ill-health, and ensure effective communication with patients and between health professionals.

Surrogacy in modern obstetric practice.

Surrogacy is rising in profile and prevalence, which means that perinatal care providers face an increasing likelihood of encountering a case in their clinical practice. Rapidly expanding scientific knowledge (for example, fetal programming) and technological advances (for example, prenatal screening and diagnosis) pose challenges in the management of the surrogate mother; in particular, they could exacerbate conflict between the interests of the baby, the surrogate mother, and the intending parent(s). Navigating these often-tranquil-but-sometimes-stormy waters is facilitated if perinatal care providers are aware of the relevant ethical, legal, and service delivery issues. This paper describes the ethical and legal context of surrogacy, and outlines key clinical practice issues in management of the surrogate mother.

Mapping the patient safety footprint: The RADICAL framework.

Numerous interventions to promote patient safety have been proposed. For these to produce demonstrable and positive change, appropriate metrics should be available. Measurements must, however, be comprehensive enough to cover all domains of patient safety. In this paper, I introduce the term 'patient safety footprint' to encapsulate the totality of attributes and domains that define or describe the degree of protection accorded to patient safety by a healthcare provider (individual or organisation). A framework, identified by the acronym RADICAL, is presented. It specifies and captures all domains required for mapping the patient safety footprint: (R)aise (A)wareness, (D)esign for safety, (I)nvolve users, (C)ollect and (A)nalyse patient safety data, and (L)earn from patient safety incidents. In addition to providing a schema, the RADICAL framework describes a worldview of the concept of patient safety. Examples are given of its application in obstetrics and gynaecology.

The bionomic approach to patient safety and its application in gynaecological surgery.

In the past 2 decades, a gradual shift has taken place from the 'person approach' to patient safety (in which the individual clinician at the sharp end is blamed for any accident) to a 'systems approach' (in which causation of accidents is attributed to loopholes in the organisational defences). Increasingly, however, concern has been expressed that the systems approach risks absolving individuals from responsibility for patient safety, and a balance between the systems and person approaches has been sought. In this paper, resolution of the tension between the person and the systems approaches is advocated through the use of a paradigm that places more emphasis on the relationships between the individual at the sharp end and other components of the system. This paradigm, which is adapted from ecosystems, has been labelled the 'bionomic approach'. A bionomic approach to patient safety incorporates principles and concepts of human ecology and applies them to the healthcare system, situating the individual as an intrinsic component of the system rather than an adjunct. It builds on the notion that 'people create safety' and on the recognition that, in some clinical areas, particularly surgery, the individual is the primary defence against patient safety incidents. Skills required for 'error wisdom' are described, and the principles of the bionomic approach are applied to gynaecological surgery, using an illustrative case study.

Not-patient and not-visitor: a metasynthesis fathers' encounters with pregnancy, birth and maternity care.

INTRODUCTION: the active engagement of fathers in maternity care is associated with long-term health and social benefits for the mother, baby and family. The maternity care expectations and experiences of expectant and new fathers have received little attention to date. AIM: to identify and synthesise good quality qualitative research that explores the views and experiences of fathers who have encountered maternity care in high resource settings. METHODS: based on a pre-determined search strategy, relevant databases were searched for papers published between January 1999 and January 2010. Backchaining of the reference lists in included papers was undertaken. INCLUSION CRITERIA: good quality qualitative research studies exploring fathers' involvement in maternity care through pregnancy, birth, and up to 6 months postnatally, that were undertaken in high resource countries. No language restrictions were imposed. ANALYTIC STRATEGY: the analysis was based on the metaethnographic techniques of Noblit and Hare (1988) as amended by Downe et al. (2007). FINDINGS: from 856 hits 23 papers were included. The emerging themes were as follows: risk and uncertainty, exclusion, fear and frustration, the ideal and the reality, issues of support and experiencing transition. SYNTHESIS: fathers feel themselves to be 'partner and parent' but their experience of maternity care services is as 'not-patient and not-visitor'. This situates them in an interstitial and undefined space (both emotionally and physically) with the consequence that many feel excluded and fearful. CONCLUSIONS: fathers cannot support their partner effectively in achieving the ideal of transition to a successful pregnancy, joyful birth and positive parenthood experience unless they are themselves supported, included, and prepared for the reality of risk and uncertainty in pregnancy, labour and parenthood and for their role in this context.