Associations between social and behavioural factors and the risk of late stillbirth - findings from the Midland and North of England Stillbirth case-control study.

OBJECTIVE: To investigate behavioural and social characteristics of women who experienced a late stillbirth compared with women with ongoing live pregnancies at similar gestation. DESIGN: Case-control study. SETTING: 41 maternity units in the UK. POPULATION: Women who had a stillbirth ≥28 weeks' gestation (n = 287) and women with an ongoing pregnancy at the time of interview (n = 714). METHODS: Data were collected using an interviewer-administered questionnaire which included questions regarding women's behaviours (e.g. alcohol intake and household smoke exposure) and social characteristics (e.g. ethnicity, employment, housing). Stress was measured by the 10-item Perceived Stress Scale. MAIN OUTCOME MEASURE: Late stillbirth. RESULTS: Multivariable analysis adjusting for co-existing social and behavioural factors showed women living in the most deprived quintile had an increased risk of stillbirth compared with the least deprived quintile (adjusted odds ratio [aOR] 3.16; 95% CI 1.47-6.77). There was an increased risk of late stillbirth associated with unemployment (aOR 2.32; 95% CI 1.00-5.38) and women who declined to answer the question about domestic abuse (aOR 4.12; 95% CI 2.49-6.81). A greater number of antenatal visits than recommended was associated with a reduction in stillbirth (aOR 0.26; 95% CI 0.16-0.42). CONCLUSIONS: This study demonstrates associations between late stillbirth and socio-economic deprivation, perceived stress and domestic abuse, highlighting the need for strategies to prevent stillbirth to extend beyond maternity care. Enhanced antenatal care may be able to mitigate some of the increased risk of stillbirth. TWEETABLE ABSTRACT: Deprivation, unemployment, social stress & declining to answer about domestic abuse increase risk of #stillbirth after 28 weeks' gestation.

Parents' experiences of care following the loss of a baby at the margins between miscarriage, stillbirth and neonatal death: a UK qualitative study.

OBJECTIVE: To explore the healthcare experiences of parents whose baby died either before, during or shortly after birth between 20+0 and 23+6  weeks of gestation in order to identify practical ways to improve healthcare provision. DESIGN: Qualitative interview study. SETTING: England through two parent support organisations and four NHS Trusts. SAMPLE: A purposive sample of parents. METHODS: Thematic analysis of semi-structured in-depth narrative interviews. MAIN OUTCOME MEASURES: Parents' healthcare experiences. RESULTS: The key overarching theme to emerge from interviews with 38 parents was the importance of the terminology used to refer to the death of their baby. Parents who were told they were 'losing a baby' rather than 'having a miscarriage' were more prepared for the realities of labour, the birth experience and for making decisions around seeing and holding their baby. Appropriate terminology validated their loss, and impacted on parents' health and wellbeing immediately following bereavement and in the longer term. CONCLUSION: For parents experiencing the death of their baby at the margins between miscarriage, stillbirth and neonatal death, ensuring the use of appropriate terminology that reflects parents' preferences is vital. This helps to validate their loss and prepare them for the experiences of labour and birth. Reflecting parents' language preferences combined with compassionate bereavement care is likely to have a positive impact on parents' experiences and improve longer-term outcomes. TWEETABLE ABSTRACT: Describing baby loss shortly before 24 weeks of gestation as a 'miscarriage' does not prepare parents for labour and birth, seeing their baby and making memories.

Economic costs associated with moderate and late preterm birth: a prospective population-based study.

OBJECTIVE: We sought to determine the economic costs associated with moderate and late preterm birth. DESIGN: An economic study was nested within a prospective cohort study. SAMPLE: Infants born between 32(+0) and 36(+6)  weeks of gestation in the East Midlands of England. A sample of infants born at ≥37 weeks of gestation acted as controls. METHODS: Data on resource use, estimated from a National Health Service (NHS) and personal social services perspective, and separately from a societal perspective, were collected between birth and 24 months corrected age (or death), and valued in pounds sterling, at 2010-11 prices. Descriptive statistics and multivariable analyses were used to estimate the relationship between gestational age at birth and economic costs. MAIN OUTCOME MEASURES: Cumulative resource use and economic costs over the first two years of life. RESULTS: Of all eligible births, 1146 (83%) preterm and 1258 (79%) term infants were recruited. Mean (standard error) total societal costs from birth to 24 months were £12 037 (£1114) and £5823 (£1232) for children born moderately preterm (32(+0) -33(+6)  weeks of gestation) and late preterm (34(+0) -36(+6)  weeks of gestation), respectively, compared with £2056 (£132) for children born at term. The mean societal cost difference between moderate and late preterm and term infants was £4657 (bootstrap 95% confidence interval, 95% CI £2513-6803; P < 0.001). Multivariable regressions revealed that, after controlling for clinical and sociodemographic characteristics, moderate and late preterm birth increased societal costs by £7583 (£874) and £1963 (£337), respectively, compared with birth at full term. CONCLUSIONS: Moderate and late preterm birth is associated with significantly increased economic costs over the first 2 years of life. Our economic estimates can be used to inform budgetary and service planning by clinical decision-makers, and economic evaluations of interventions aimed at preventing moderate and late preterm birth or alleviating its adverse consequences. TWEETABLE ABSTRACT: Moderate and late preterm birth is associated with increased economic costs over the first 2 years of life.

Post-operative blood salvage with autologous retransfusion in primary total hip replacement.

Clinical, haematological or economic benefits of post-operative blood salvage with autologous blood re-transfusion have yet to be clearly demonstrated for primary total hip replacement. We performed a prospective randomised study to analyse differences in postoperative haemoglobin levels and homologous blood requirements in two groups of patients undergoing primary total hip replacement. A series of 158 patients was studied. In one group two vacuum drains were used and in the other the ABTrans autologous retransfusion system. A total of 58 patients (76%) in the re-transfusion group received autologous blood. There was no significant difference in the mean post-operative haemoglobin levels in the two groups. There were, however, significantly fewer patients with post-operative haemoglobin values less than 9.0 g/dl and significantly fewer patients who required transfusion of homologous blood in the re-transfusion group. There was also a small overall cost saving in this group.

Socioeconomic inequalities in very preterm birth rates.

AIMS: To investigate the extent of socioeconomic inequalities in the incidence of very preterm birth over the past decade. METHODS: Ecological study of all 549 618 births in the former Trent health region, UK, from 1 January 1994 to 31 December 2003. All singleton births of 22(+0) to 32(+6) weeks gestation (7 185 births) were identified from population surveys of neonatal services and stillbirths. Poisson regression was used to calculate incidence of very preterm birth (22-32 weeks) and extremely preterm birth (22-28 weeks) by year of birth and decile of deprivation (child poverty section of the Index of Multiple Deprivation). RESULTS: Incidence of very preterm singleton birth rose from 11.9 per 1000 births in 1994 to 13.7 per 1000 births in 2003. Those from the most deprived decile were at nearly twice the risk of very preterm birth compared with those from the least deprived decile, with 16.4 per 1000 births in the most deprived decile compared with 8.5 per 1000 births in the least deprived decile (incidence rate ratio 1.94; 95% CI (1.73 to 2.17)). This deprivation gap remained unchanged throughout the 10-year period. The magnitude of socio-economic inequalities was the same for extremely preterm births (22-28 weeks incidence rate ratio 1.94; 95% CI (1.62 to 2.32)). CONCLUSIONS: This large, unique dataset of very preterm births shows wide socio-economic inequalities that persist over time. These findings are likely to have consequences on the burden of long-term morbidity. Our research can assist future healthcare planning, the monitoring of socio-economic inequalities and the targeting of interventions in order to reduce this persistent deprivation gap.

Emergency admissions of older people to hospital: a link with material deprivation.

BACKGROUND: The aim was to investigate whether variations in emergency admission to hospital amongst older people in Leicestershire vary with the level of material deprivation of the area in which they live. METHODS: Data were extracted from the Trent Patient Information System for patients aged 65 and over, admitted as an emergency medical admission to Leicestershire's acute and community hospitals on at least one occasion during the period October 1993-September 1994. The 1991 Census was used to examine the nature of the areas from which these emergency admissions were drawn and variations in emergency admission rates across Leicestershire. The relationship between emergency medical admissions and age, sex and material deprivation as measured by the Townsend deprivation score was examined. RESULTS: There were 13,305 people aged 65 or over with at least one emergency medical admission out of an estimated population (65 and over) in 1994 of 134,608 (9.9 per cent). Unconditional logistic regression showed that the risk of emergency admission increased with age and was also higher for men than for women. Emergency admissions increased significantly with increasing deprivation for each age group. This was most notable in the 65-74 years age group, yielding an odds ratio of 2.06 [95 per cent confidence interval (1.86, 2.29)], when comparing those from the most deprived areas with those from the least deprived areas. CONCLUSIONS: The increased risk of emergency medical admission to hospital, which is associated with residence in areas characterized as deprived by Census-based indicators, suggests there are enduring inequalities in health or health care amongst older people. Inequalities noted for all ages persist into old age, although in the 'oldest' age groups, the effect is weaker. Material deprivation may also be a proxy for other factors, such as differences in social support and the type of care received.

Cost and time savings following introduction of rejection criteria for clinical specimens.

We have evaluated the yield of several tests and have instituted specimen rejection criteria to reduce costs and save time. For a 12-month period, we recorded the reduction of these tests and calculated the resultant cost and time savings. Seven changes were analyzed: not performing fungal or mycobacterial (acid-fast bacillus) cultures on cerebrospinal fluid (CSF) specimens from patients without known immunosuppression when chemistry and cell count are normal; not performing routine stool culture or ovum and parasite examination on specimens from patients in the hospital for > 3 days; not culturing endotracheal suction aspirates when no organisms or > 10 squamous epithelial cells are present; discontinuing broth cultures on all specimens except for tissue, continuous ambulatory peritoneal dialysis fluid, and CSF from patients with shunts; and eliminating bacterial antigen tests. For each test, the number not performed (n), reagent savings, and technologist time saved, respectively, were as follows: CSF fungal culture, 267, $999, and 67 h; CSF acid-fast bacillus culture, 275, $1,662, and 124 h; stool cultures, 320, $2,991, and 98 h; ovum and parasite examinations, 216, $525, and 108 h; endotracheal suction aspirate cultures, 1,505, $4,447, and 306 h; broth cultures, 5,218, $4,931, and 80 h; and bacterial antigen tests, 2,598, $2,293, and 299 h. Overall, 5,181 tests were rejected and 5,218 broth cultures were omitted. Achievable savings were $28,000 in reagent costs and 1,082 h of technologist time. In conclusion, rejecting specimens of proven low yield saves reagent costs and, more importantly, saves technologist time. This time can be spent on specimens having greater diagnostic utility.

Children's vision screening: impact on inequalities in central England.

STUDY OBJECTIVE: To investigate the relationship between age at presentation of amblyopia and social deprivation before and after the introduction of changes to a vision screening service. DESIGN: Two cohorts of children treated for amblyopia in 1983 and 1992. SETTING: THe orthoptic department of Leicester Royal Infirmary. PARTICIPANTS: The 209 patients treated for amblyopia who first attended the orthoptic department in 1983, and 203 who first attended in 1992. MEASUREMENTS: Age at presentation to the orthoptic department was the main outcome measure. Social deprivation was measured by Townsend deprivation score for the electoral ward in which the child lived, using 1981 and 1991 census data. MAIN RESULTS: After the introduction of changes in the screening programme, the mean at presentation of amblyopia associated with microtropia or no strabismus was reduced from 6.6 years to 5.0 years. In 1983 there was a significant relationship between deprivation and age at presentation (p = 0.0001), with those from more deprived areas presenting later. No similar association was found in children referred in 1992 (p = 0.17). There was no change in mean age of presentation of amblyopia associated with a large angle of strabismus (3.3 years in 1983 and 1992) and no relationship between deprivation and age at presentation 1983 or 1992 (p = 0.24 and p = 0.39 respectively). CONCLUSION: Since the introduction of changes to vision screening, the relationship between social deprivation and the age of presentation of asymptomatic amblyopia seems to have disappeared. Children are now referred earlier and those from deprived areas are not being overlooked.

Mexican-American views of Anglo medical and dietetic practices.

Institutions involved in health care delivery and foodservice to a population with large ethnic communities might increase their effectiveness if they knew the possible influences of the folklore or local customs of these groups on the attitudes of their patients. The observations and survey of Spanish-speaking patients by the Department of Food Services at the University of Arizona Health Science Center should be a stimulus for further study of ethnic groups by health professionals.