Development of a survey instrument to evaluate women's experiences of their maternity care.

BACKGROUND: The process of developing a survey instrument to evaluate women's experiences of their maternity care is complex given that maternity care encapsulates various contexts, services, professions and professionals across the antenatal, intranatal and postnatal periods. AIM: To identify and prioritise items for inclusion in the National Maternity Experience Survey, a survey instrument to evaluate women's experiences of their maternity care in the Republic of Ireland. METHODS: This study used an adapted two-phase exploratory sequential mixed methods design. Phase one identified items for possible inclusion and developed an exhaustive item pool through a systematic review, focus groups and one to one interviews, and a gap analysis. Phase two prioritised the items for inclusion in the final item bank through a Delphi study and consensus review. FINDINGS: Following iterative consultation with key stakeholder groups, a bank of 95 items have been prioritised and grouped within eight distinct care sections; care during your pregnancy, care during your labour and birth, care in hospital after the birth of your baby, specialised care for your baby, feeding your baby, care at home after the birth of your baby, overall care and you and your household. CONCLUSION: Robust and rigorous methods have been used to develop a bank of 95 suitable items for inclusion in the National Maternity Experience Survey.

Current State of Transgender Medical Education in the United States and Canada: Update to a Scoping Review.

BACKGROUND: The published literature on education about transgender health within health professions curricula was previously found to be sporadic and fragmented. Recently, more inclusive and holistic approaches have been adopted. We summarize advances in transgender health education. METHODS: A 5-stage scoping review framework was followed, including a literature search for articles relevant to transgender health care interventions in 5 databases (Education Source, LGBT Source, MedEd Portal, PsycInfo, PubMed) from January 2017 to September 2019. Search results were screened to include original articles reporting outcomes of educational interventions with a transgender health component that included MD/DO students in the United States and Canada. A gray literature search identified continuing medical education (CME) courses from 12 health professional associations with significant transgender-related content. RESULTS: Our literature search identified 966 unique publications published in the 2 years since our prior review, of which 10 met inclusion criteria. Novel educational formats included interdisciplinary interventions, post-residency training including CME courses, and online web modules, all of which were effective in improving competencies related to transgender health care. Gray literature search resulted 15 CME courses with learning objectives appropriate to the 7 professional organizations who published them. CONCLUSIONS: Current transgender health curricula include an expanding variety of educational intervention formats driven by their respective educational context, learning objectives, and placement in the health professional curriculum. Notable limitations include paucity of objective educational intervention outcomes measurements, absence of long-term follow-up data, and varied nature of intervention types. A clear best practice for transgender curricular development has not yet been identified in the literature.

Measuring women's experiences of maternity care: protocol for a systematic review of self-report survey instruments.

BACKGROUND: The use of survey instruments to measure women's experiences of their maternity care is regarded internationally as an indicator of the quality of care received. To ensure the credibility of the data arising from these instruments, the methodological quality of development must be high. This paper reports the protocol for a systematic review of self-report instruments used to measure women's experiences of their maternity care. METHODS: Citation databases CINAHL, Ovid MEDLINE and EMBASE will be searched from 2002 to 2018 using keywords including women, experience, maternity care, questionnaires, surveys, and self-report. Citations will be screened by two reviewers, in two rounds, for inclusion as per predetermined inclusion and exclusion criteria. Data extraction forms will be populated with data, extracted from each study, to evaluate the methodological quality of each survey instrument and the criteria for good measurement properties using quality criteria. Data will also be extracted to categorise the items included in each survey instrument. A combination of a structured narrative synthesis and quantitate summaries in tabular format will allow for recommendations to be made on the use, adaptation and development of future survey instruments. DISCUSSION: The value of survey instruments that evaluate women's experiences of their maternity care, as a marker of quality care, has been recognised internationally with many countries employing the use of such instruments to inform policy and practice. The development of these instruments must be methodologically sound and the instrument itself fit for the purpose and context in which it is used. This protocol describes the methods that will be used to complete a systematic review that will serve as a guide for choosing the most appropriate existing instruments to use or adapt so that they are fit for purpose, in addition to informing the development of new instruments. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42018105325.

Women's experiences of their maternity care: A principle- based concept analysis.

BACKGROUND: Despite many countries employing the use of national and large scale regional surveys to explore women's experiences of their maternity care, with the results informing national maternity policy and practice, the concept itself is ambiguous and ill-defined having not been subject of a structured concept development endeavour. AIM: The aim of this review is to report on an in-depth analysis conducted on the concept of 'women's experiences of their maternity care'. METHODS: Using the principle-based method of concept analysis by Penrod and Hupcey (2005), the concept of 'women's experiences of their maternity care' was analysed under the epistemological, pragmatic, linguistic and logical principles. The final dataset included 87 items of literature published between 1990 and 2017 retrieved from a systematic search of the MEDLINE, CINAHL, EMBASE and PSYCinfo databases. FINDINGS: The epistemological principle identified that a theoretical definition of the concept is elusive with a variety of implicit meanings. The pragmatic principle supports the utility of the concept in scientific literature, however the lack of a theoretical definition has led to inconsistent use of the concept, as highlighted by the linguistic principle. Furthermore, the logical principle highlighted that as the concept lacks definition blurring is identifiable when theoretically positioned with related concepts. CONCLUSION: The outcome of this concept analysis is a theoretical definition of a previously undefined concept. This definition highlights the subjective nature of the concept, its dependency upon a woman's individual needs, expectations and circumstances and the influence of the organisation and delivery of maternity care.

Concept development in Nursing and Midwifery: An overview of methodological approaches.

BACKGROUND: Over the past four decades, there has been a growing focus on the resolution of conceptual problems through the process of concept development. As the focus on this area has grown, so too has the number of debates in the literature on methodological aspects of concept development. AIM: To provide an overview of the essential methodological considerations of concept development. DESIGN: Discussion paper. An overview is presented of the methodological considerations of commonly used concept development strategies and methods within nursing and midwifery. DATA SOURCES: Literature dating from the inception of concept development in nursing and midwifery. IMPLICATIONS FOR NURSING AND MIDWIFERY: The robust development of concepts is a vital component in advancing the knowledge base of nursing and midwifery theory and practice. However, the complexity of the concept development literature may serve to exacerbate the challenges of developing a given concept, in particular for the novice researcher. CONCLUSION: The methodological considerations discussed provides guidance in determining the most appropriate strategy and method of concept development.

What do women want? Valuing women's preferences and estimating demand for alternative models of maternity care using a discrete choice experiment.

In many countries, there has been a considerable shift towards providing a more woman-centred maternity service, which affords greater consumer choice. Maternity service provision in Ireland is set to follow this trend with policymakers committed to improving maternal choice at hospital level. However, women's preferences for maternity care are unknown, as is the expected demand for new services. In this paper, we used a discrete choice experiment (DCE) to (1) investigate women's strengths of preference for different features of maternity care; (2) predict market uptake for consultant- and midwifery-led care, and a hybrid model of care called the Domiciliary In and Out of Hospital Care scheme; and (3) calculate the welfare change arising from the provision of these services. Women attending antenatal care across two teaching hospitals in Ireland were invited to participate in the study. Women's preferred model of care resembled the hybrid model of care, with considerably more women expected to utilise this service than either consultant- or midwifery-led care. The benefit of providing all three services proved considerably greater than the benefit of providing two or fewer services. From a priority setting perspective, pursuing all three models of care would generate a considerable welfare gain, although the cost-effectiveness of such an approach needs to be considered.

A Cost-Benefit Analysis of Two Alternative Models of Maternity Care in Ireland.

BACKGROUND: The Irish government has committed to expand midwifery-led care alongside consultant-led care nationally, although very little is known about the potential net benefits of this reconfiguration. OBJECTIVES: To formally compare the costs and benefits of the major models of care in Ireland, with a view to informing priority setting using the contingent valuation technique and cost-benefit analysis. METHODS: A marginal payment scale willingness-to-pay question was adopted from an ex ante perspective. 450 pregnant women were invited to participate in the study. Cost estimates were collected primarily, describing the average cost of a package of care. Net benefit estimates were calculated over a 1-year cycle using a third-party payer perspective. RESULTS: To avoid midwifery-led care, women were willing to pay €821.13 (95% CI 761.66-1150.41); to avoid consultant-led care, women were willing to pay €795.06 (95% CI 695.51-921.15). The average cost of a package of consultant- and midwifery-led care was €1,762.12 (95% CI 1496.73-2027.51) and €1018.47 (95% CI 916.61-1120.33), respectively. Midwifery-led care ranked as the best use of resources, generating a net benefit of €1491.22 (95% CI 989.35-1991.93), compared with €123.23 (95% CI -376.58 to 621.42) for consultant-led care. CONCLUSIONS: While both models of care are cost-beneficial, the decision to provide both alternatives may be constrained by resource issues. If only one alternative can be implemented then midwifery-led care should be undertaken for low-risk women, leaving consultant-led care for high-risk women. However, pursuing one alternative contradicts a key objective of government policy, which seeks to improve maternal choice. Ideally, multiple alternatives should be pursued.

What women want: Exploring pregnant women's preferences for alternative models of maternity care.

Depending on obstetric risk, maternity care may be provided in one of two locations at hospital level: a consultant-led unit (CLU) or a midwifery-led unit (MLU). Care in a MLU is sparsely provided in Ireland, comprising as few as two units out of a total 21 maternity units. Given its potential for greater efficiencies of care and cost-savings for the state, there has been an increased interest to expand MLUs in Ireland. Yet, very little is known about women's preferences for midwifery-led care, and whether they would utilise this service when presented with the choice of delivering in a CLU or MLU. This study seeks to involve women in the future planning of maternity care by investigating their preferences for care and subsequent motivations when choosing place of birth. Qualitative research is undertaken to explore maternal preferences for these different models of care. Women only revealed a preference for the MLU when co-located with a CLU due to its close proximity to medical services. However, the results suggest women do not have a clear preference for either model of care, but rather a hybrid model of care which encompasses features of both consultant- and midwifery-led care.

Quantum critical scaling at the edge of Fermi liquid stability in a cuprate superconductor.

In the high-temperature cuprate superconductors, the pervasiveness of anomalous electronic transport properties suggests that violation of conventional Fermi liquid behavior is closely tied to superconductivity. In other classes of unconventional superconductors, atypical transport is well correlated with proximity to a quantum critical point, but the relative importance of quantum criticality in the cuprates remains uncertain. Here, we identify quantum critical scaling in the electron-doped cuprate material La(2-x)Ce(x)CuO(4) with a line of quantum critical points that surrounds the superconducting phase as a function of magnetic field and charge doping. This zero-temperature phase boundary, which delineates a metallic Fermi liquid regime from an extended non-Fermi liquid ground state, closely follows the upper critical field of the overdoped superconducting phase and gives rise to an expanse of distinct non-Fermi liquid behavior at finite temperatures. Together with signatures of two distinct flavors of quantum fluctuations, these facts suggest that quantum criticality plays a significant role in shaping the anomalous properties of the cuprate phase diagram.

Comparative toxicity of eight oil dispersants, Louisiana sweet crude oil (LSC), and chemically dispersed LSC to two aquatic test species.

The present study describes the acute toxicity of eight commercial oil dispersants, South Louisiana sweet crude oil (LSC), and chemically dispersed LSC. The approach used consistent test methodologies within a single laboratory in assessing the relative acute toxicity of the eight dispersants, including Corexit 9500A, the predominant dispersant applied during the DeepWater Horizon spill in the Gulf of Mexico. Static acute toxicity tests were performed using two Gulf of Mexico estuarine test species, the mysid shrimp (Americamysis bahia) and the inland silversides (Menidia beryllina). Dispersant-only test solutions were prepared with high-energy mixing, whereas water-accommodated fractions of LSC and chemically dispersed LSC were prepared with moderate energy followed by settling and testing of the aqueous phase. The median lethal concentration (LC50) values for the dispersant-only tests were calculated using nominal concentrations, whereas tests conducted with LSC alone and dispersed LSC were based on measured total petroleum hydrocarbon (TPH) concentrations. For all eight dispersants in both test species, the dispersants alone were less toxic (LC50s: 2.9 to >5,600 µl/L) than the dispersant-LSC mixtures (0.4-13 mg TPH/L). Louisiana sweet crude oil alone had generally similar toxicity to A. bahia (LC50: 2.7 mg TPH/L) and M. beryllina (LC50: 3.5 mg TPH/L) as the dispersant-LSC mixtures. The results of the present study indicate that Corexit 9500A had generally similar toxicity to other available dispersants when tested alone but was generally less toxic as a mixture with LSC.

Multiple regression models for hindcasting and forecasting midsummer hypoxia in the Gulf of Mexico.

A new suite of multiple regression models was developed that describes relationships between the area of bottom water hypoxia along the northern Gulf of Mexico and Mississippi-Atchafalaya River nitrate concentration, total phosphorus (TP) concentration, and discharge. Model input variables were derived from two load estimation methods, the adjusted maximum likelihood estimation (AMLE) and the composite (COMP) method, developed by the U.S. Geological Survey. Variability in midsummer hypoxic area was described by models that incorporated May discharge, May nitrate, and February TP concentrations or their spring (discharge and nitrate) and winter (TP) averages. The regression models predicted the observed hypoxic area within +/-30%, yet model residuals showed an increasing trend with time. An additional model variable, Epoch, which allowed post-1993 observations to have a different intercept than earlier observations, suggested that hypoxic area has been 6450 km2 greater per unit discharge and nutrients since 1993. Model forecasts predicted that a dual 45% reduction in nitrate and TP concentration would likely reduce hypoxic area to approximately 5000 km2, the coastal goal established by the Mississippi River/Gulf of Mexico Watershed Nutrient Task Force. However, the COMP load estimation method, which is more accurate than the AMLE method, resulted in a smaller predicted hypoxia response to any given nutrient reduction than models based on the AMLE method. Monte Carlo simulations predicted that five years after an instantaneous 50% nitrate reduction or dual 45% nitrate and TP reduction it would be possible to resolve a significant reduction in hypoxic area. However, if nutrient reduction targets were achieved gradually (e.g., over 10 years), much more than a decade would be required before a significant downward trend in both nutrient concentrations and hypoxic area could be resolved against the large background of interannual variability. The multiple regression models and statistical approaches applied provide improved capabilities for evaluating dual nutrient management strategies to address Gulf hypoxia and a clearer perspective on the strengths and limitations of approaching the problem using regression models.

Reduced hypoxic ventilatory response with preserved blood oxygenation in yoga trainees and Himalayan Buddhist monks at altitude: evidence of a different adaptive strategy?

Yoga induces long-term changes in respiratory function and control. We tested whether it represents a successful strategy for high-altitude adaptation. We compared ventilatory, cardiovascular and hematological parameters in: 12 Caucasian yoga trainees and 12 control sea-level residents, at baseline and after 2-week exposure to high altitude (Pyramid Laboratory, Nepal, 5,050 m), 38 active lifestyle high-altitude natives (Sherpas) and 13 contemplative lifestyle high-altitude natives with practice of yoga-like respiratory exercises (Buddhist monks) studied at 5,050 m. At baseline, hypoxic ventilatory response (HVR), red blood cell count and hematocrit were lower in Caucasian yoga trainees than in controls. After 14 days at altitude, yoga trainees showed similar oxygen saturation, blood pressure, RR interval compared to controls, but lower HVR (-0.44 +/- 0.08 vs. -0.98 +/- 0.21 l/min/m/%SaO(2), P < 0.05), minute ventilation (8.3 +/- 0.9 vs. 10.8 +/- 1.6 l/min, P < 0.05), breathing rate (indicating higher ventilatory efficiency), and lower red blood cell count, hemoglobin, hematocrit, albumin, erythropoietin and soluble transferrin receptors. Hypoxic ventilatory response in monks was lower than in Sherpas (-0.23 +/- 0.05 vs. -0.63 +/- 0.09 l/min/m/%SaO(2), P < 0.05); values were similar to baseline data of yoga trainees and Caucasian controls, respectively. Red blood cell count and hematocrit were lower in monks as compared to Sherpas. In conclusion, Caucasian subjects practicing yoga maintain a satisfactory oxygen transport at high altitude, with minimal increase in ventilation and with reduced hematological changes, resembling Himalayan natives. Respiratory adaptations induced by the practice of yoga may represent an efficient strategy to cope with altitude-induced hypoxia.