Health economic analysis of a cluster-randomised trial (OptiBIRTH) designed to increase rates of vaginal birth after caesarean section.

OBJECTIVE: To perform a health economic analysis of an intervention designed to increase rates of vaginal birth after caesarean, compared with usual care. DESIGN: Economic analysis alongside the cluster-randomised OptiBIRTH trial (Optimising childbirth by increasing vaginal birth after caesarean section (VBAC) through enhanced women-centred care). SETTING: Fifteen maternity units in three European countries - Germany (five), Ireland (five), and Italy (five) - with relatively low VBAC rates. POPULATION: Pregnant women with a history of one previous lower-segment caesarean section; sites were randomised (3:2) to intervention or control. METHODS: A cost-utility analysis from both societal and health-services perspectives, using a decision tree. MAIN OUTCOME MEASURES: Costs and resource use per woman and infant were compared between the control and intervention group by country, from pregnancy recognition until 3 months postpartum. Based on the caesarean section rates, and maternal and neonatal morbidities and mortality, the incremental cost-utility ratios were calculated per country. RESULTS: The mean difference in costs per quality-adjusted life years (QALYs) gained from a societal perspective between the intervention and the control group, using a probabilistic sensitivity analysis, was: €263 (95% CI €258-268) and 0.008 QALYs (95% CI 0.008-0.009 QALYs) for Germany, €456 (95% CI €448-464) and 0.052 QALYs (95% CI 0.051-0.053 QALYs) for Ireland, and €1174 (95% CI €1170-1178) and 0.006 QALYs (95% CI 0.005-0.007 QALYs) for Italy. The incremental cost-utility ratios were €33,741/QALY for Germany, €8785/QALY for Ireland, and €214,318/QALY for Italy, with a 51% probability of being cost-effective for Germany, 92% for Ireland, and 15% for Italy. CONCLUSION: The OptiBIRTH intervention was likely to be cost-effective in Ireland and Germany. TWEETABLE ABSTRACT: The OptiBIRTH intervention (to increase VBAC rates) is likely to be cost-effective in Germany and Ireland.

Care in subsequent pregnancies following stillbirth: an international survey of parents.

OBJECTIVE: To assess the frequency of additional care, and parents' perceptions of quality, respectful care, in pregnancies subsequent to stillbirth. DESIGN: Multi-language web-based survey. SETTING: International. POPULATION: A total of 2716 parents, from 40 high- and middle-income countries. METHODS: Data were obtained from a broader survey of parents' experiences following stillbirth. Data were analysed using descriptive statistics and stratified by geographic region. Subgroup analyses explored variation in additional care by gestational age at index stillbirth. MAIN OUTCOME MEASURES: Frequency of additional care, and perceptions of quality, respectful care. RESULTS: The majority (66%) of parents conceived their subsequent pregnancy within 1 year of stillbirth. Additional antenatal care visits and ultrasound scans were provided for 67% and 70% of all parents, respectively, although there was wide variation across geographic regions. Care addressing psychosocial needs was less frequently provided, such as additional visits to a bereavement counsellor (10%) and access to named care provider's phone number (27%). Compared with parents whose stillbirth occurred at ≤ 29 weeks of gestation, parents whose stillbirth occurred at ≥ 30 weeks of gestation were more likely to receive various forms of additional care, particularly the option for early delivery after 37 weeks. Around half (47-63%) of all parents felt that elements of quality, respectful care were consistently applied, such as spending enough time with parents and involving parents in decision-making. CONCLUSIONS: Greater attention is required to providing thoughtful, empathic and collaborative care in all pregnancies following stillbirth. Specific education and training for health professionals is needed. TWEETABLE ABSTRACT: More support for providing quality care in pregnancies after stillbirth is needed. PLAIN LANGUAGE SUMMARY: Study rationale and design More than two million babies are stillborn every year. Most parents will conceive again soon after having a stillborn baby. These parents are more likely to have another stillborn baby in the next pregnancy than parents who have not had a stillborn baby before. The next pregnancy after stillbirth is often an extremely anxious time for parents, as they worry about whether their baby will survive. In this study we asked 2716 parents from 40 countries about the care they received during their first pregnancy after stillbirth. Parents were recruited mainly through the International Stillbirth Alliance and completed on online survey that was available in six languages. Findings Parents often had extra antenatal visits and extra ultrasound scans in the next pregnancy, but they rarely had extra emotional support. Also, many parents felt their care providers did not always listen to them and spend enough time with them, involve them in decisions, and take their concerns seriously. Parents were more likely to receive various forms of extra care in the next pregnancy if their baby had died later in pregnancy compared to earlier in pregnancy. Limitations In this study we only have information from parents who were able and willing to complete an online survey. Most of the parents were involved in charity and support groups and most parents lived in developed countries. We do not know how well the findings relate to other parents. Finally, our study does not include parents who may have tried for another pregnancy but were not able to conceive. Potential impact This study can help to improve care through the development of best practice guidelines for pregnancies following stillbirth. The results suggest that parents need better emotional support in these pregnancies, and more opportunities to participate actively in decisions about care. Extra support should be available no matter how far along in pregnancy the previous stillborn baby died.

[German Version of the Childbirth Self-Efficacy Inventory and its Short Form]. / Deutsche Version des Childbirth Self-Efficacy Inventory und dessen Kurzform - ein Fragebogen zur Selbstwirksamkeit.

BACKGROUND: The Childbirth Self-Efficacy Inventory (CBSEI) is an instrument that measures women's perceived self-efficacy towards labour. It is used in 9 countries, a 32-item short form (CBSEI-C32) in 4 countries. German versions of the CBSEI and the CBSEI-C32 have not been developed thus far. METHODS: A forward-backward translation was performed, followed by administration of both instruments to a sample of 155 participants of antenatal classes. Pregnant women answered questions regarding their medical history and user-friendliness of the instruments. 80 respondents completed the CBSEI, 75 the CBSEI-C32. Reliability via Cronbach alpha was calculated for the 4 subscales of the CBSEI and the 2 subscales of the short form. Validity was only assessed for the 2 scales of the CBSEI-C32 because all women (n=155) completed this instrument. RESULTS: 2 Cronbach alpha values were greater than 0.74 (adequate), the others greater than 0.80 (good). Most of the factors of the CBSEI-C32 (75%) were above ≥0.5. Calculation of the item-to-total-correlations revealed that the exclusion of 3 items might be indicated for the German version. The short form showed a significant association between level of education and perceived self-efficacy (p=0.01). RESULTS in the area of user-friendliness were more encouraging for the CBSEI-C32 than for the CBSEI. CONCLUSION: The German version of the CBSEI is a useful instrument which may improve advice and counselling during prenatal care in Germany.

Redesigning German Maternity Records: Results from a Pilot study.

PURPOSE: The German maternity record (GMR, "Mutterpass") is the most important document for pregnant women and their health care providers during antenatal care. While the serological and ultrasound sections have been updated regularly, the document's catalogue of pre-existing factors has remained unaltered since 1986. We investigated whether a health-focused revision of the GMR would serve the needs of pregnant women and their care providers. METHODS: A revised version of the Mutterpass was developed by a multidisciplinary panel of experts, focusing on health and salutogenesis. The new document highlights the uncomplicated pregnancy, and gives pregnant women the opportunity to make their own notes and to choose an appropriate place of birth after consultation with the doctor or midwife. These changes were developed within the requirements of the latest version of the German maternity guidelines (GMG) mandatory during the revision process. To test for user-friendliness and acceptance, 23 persons--8 consultants, 7 midwives and 8 pregnant women--were asked to evaluate the revised GMR. Comments could be entered in the GMR itself and in an electronic survey. Notes in the GMR (n=296 comments) were assigned to one of 7 categories (e. g. general comments, structural aspects) by 2 reviewers. After 6 weeks one of the reviewers repeated her evaluation. RESULTS: 20 of the 23 persons approached wrote comments in the document, 19 participated in the electronic survey. Consultants and midwives predominantly stated that they would prefer to work with the revised GMR (92%). Pregnant women appreciated the space for their own notes (83%). Most respondents (90%) had a good general impression. Inter-observer agreement was kappa=0.43, intra-observer agreement kappa=0.55. CONCLUSIONS: This health-focused version of the German maternity record is a first step towards optimising maternity records in Germany. Future investigations should consider revisions going beyond the content of the mandatory guidelines.

Pregnancies in liver and kidney transplant recipients: a review of the current literature and recommendation.

In this article, we focus on the biggest groups of organ transplant recipients, patients with a kidney or liver graft. Among these patients, about one sixth included women of childbearing potential. Therefore, the wish of getting pregnant is frequent in these peculiar patients, and careful planning and management of the pregnancies requires the expertise of obstetricians, midwives and transplant experts. Altogether, the outcome of the pregnancies in these women is acceptable. About 75% off all pregnancies ended successfully with live births, and this is comparable if not superior to pregnancies in healthy women. This success might be caused not only by the special and intensive care provided to these high-risk pregnancies by the transplant centres but also by the low rate of unplanned pregnancies. The risk of rejections and organ loss after delivery is about 10%, and it is slightly enhanced in liver transplant recipients (LTRs) in comparison to kidney graft recipients (KTRs) but the number of organ losses in direct association with a pregnancy is rare. However, there is not only a higher frequency of pregnancy-associated disorders such as pre-eclampsia and preterm delivery but also an acceleration of hypertension, new-onset diabetes mellitus and newly arising infections also favoured by the maintained immunosuppressive therapy. This implies a specialized 'control system' for these pregnant women that comprises ultrasound and Doppler investigation for risk assessment, infection screening, suitable therapy and the choice of non-teratogenic immunosuppressives. Antihypertensive treatment must be well balanced and adjusted to the possible growth-retarding effect on the foetus as well as on the co-morbidity of the mother. Finally, supplementation of vitamin D and iron is much more important in these transplanted women than in healthy pregnant women as vitamin D deficiency and anaemia are discussed to have an impact on pre-eclampsia and preterm delivery. These claims are widely discussed. Furthermore, the current literature is systematically reviewed by Scopus analysis.

Oncogenic B-Raf signaling in melanoma cells controls a network of microRNAs with combinatorial functions.

Over two-thirds of melanomas have activating mutations in B-Raf, leading to constitutive activation of the B-Raf/MKK/ERK signaling pathway. The most prevalent mutation, B-RafV600E, promotes cancer cell behavior through mechanisms that are still incompletely defined. Here, we used a sensitive microarray profiling platform to compare microRNA (miRNA) expression levels between primary melanocytes and B-RafV600E-positive melanoma cell lines, and between melanoma cells treated in the presence and absence of an MKK1/2 inhibitor. We identified a network of >20 miRNAs deregulated by B-Raf/MKK/ERK in melanoma cells, the majority of which modulate the expression of key cancer regulatory genes and functions. Importantly, miRNAs within the network converge on protein regulation and cancer phenotypes, suggesting that these miRNAs might function combinatorially. We show that miRNAs augment effects on protein repression and cell invasion when co-expressed, and gene-specific latency and interference effects between miRNAs were also observed. Thus, B-Raf/MKK/ERK controls key aspects of cancer cell behavior and gene expression by modulating a network of miRNAs with cross-regulatory functions. The findings highlight the potential for complex interactions between coordinately regulated miRNAs within a network.

[History of the German antenatal record ("mutterpass") and its need for updating]. / Zur Historie des Mutterpasses und seines Aktualisierungsbedarfs.

BACKGROUND: The German antenatal record, the "Mutterpass", is the most important document in German antenatal care. Following its introduction in 1968, subsequent editions were adapted to take account of successive revisions of the German maternity guidelines ("Mutterschaftsrichtlinien"). Before 1995, however, no details giving evidence for or explaining the reasons for the modifications to the maternity guidelines were included. While the maternity guidelines have been regularly updated, particularly with regard to serological findings and ultrasound examinations, the risk catalogue included in the "Mutterpass" has not, but has remained unchanged since 1986. Just one risk factor out of the 52 items listed suffices to define a pregnant woman as being at high risk during childbirth. DISCUSSION AND CONCLUSION: The history of the risk catalogue shows that its revision is essential to meet current health science requirements. Likewise, arguments for an evidence-based revision of the items of the risk catalogue are to be found in current literature.

[Midwife attendance during labour and its relation to interventions and outcome of birth]. / Zusammenhänge zwischen Anwesenheit der Hebamme, Interventionen und dem Outcome der Geburt.

BACKGROUND: Continuity of midwifery care during labour is beneficial. We investigated the relationship between midwife presence, interventions and outcome. PATIENTS AND METHODS: From the overall sample of singleton pregnancies in cephalic presentation (n=4 438) we selected 541 prospectively documented hospital-based birth processes occurring at term without antenatal risks and spontaneous mode of birth. Univariate and multivariate analyses were performed. RESULTS: Midwives were present for up to six hours in 66% of 247 births to primiparae, and for up to three hours in 61% of 294 births to multiparae. Midwives were present for more than 75% of the overall labour duration in 62% of all births in nulliparae and 63% in multiparae. Midwife presence for more than 75% of the total birth duration correlated positively to immersion in water (p<0.02), up to two CTG tracings (p<0.001), and up to three vaginal examinations (p<0.04). Midwives working in hospitals which contributed more than 50% of their eligible births were present for longer during labour than midwives in units with a lower participation rate (p<0.002). Multivariate regression revealed that up to two CTG tracings (p<0.001) and a participation rate of more than 50% (p<0.002) were significantly related to midwife presence. DISCUSSION: Intensive intrapartum midwife presence during spontaneous birth was associated neither with fetal outcome nor with interventions, except for up to two CTG tracings. This might be due to shorter labour or the later commencement of care. CONCLUSIONS: Intrapartum midwife presence covers a large portion of the birth process, but continues to be poorly understood.

[Out-of-hospital births in Germany--a comparison of "large", "medium", and "small" free-standing birth centres]. / Ausserklinische Geburtshilfe in Deutschland--Perinataldaten "grosser", "mittlerer" und "kleiner" Geburtshäuser im Vergleich.

BACKGROUND: How do maternal and foetal outcomes in out-of-hospital births vary in relation to birth centre size? PATIENTS AND METHODS: Routine perinatal data from out-of-hospital births in 80 birth centres in Germany between 1999 and 2002 were analysed. Birth centres were grouped according to their annual mean birth rate into small (< or = 70 births per year), medium (71 - 155 births per year), and large (> 155 births per year) units. Breech births (n = 43) and twins (n = 14) were excluded from the analysis (level of significance p < 0.01). RESULTS: Pregnancy and perinatal risks, foetal and maternal morbidity and mortality, perineal lacerations and transfer of newborns to NICU did not differ between the three groups which comprised a total of 14,629 births. Less episotomies were performed in large birth centres compared to small or medium-sized birth centres. Significantly less women were transferred from medium-sized birth centres to hospital following delivery. Five minute Apgar scores < or = 7 were significantly more frequent in birth centres with the highest birth rates. During labour significantly less women were transferred to hospital from medium-sized birth centres than from small or large centres. The transfer rate difference between nulliparae and multiparae was 4 : 1. CONCLUSION: Perinatal parameters appear to differ in some aspects according to how the birth centres were labelled. Nevertheless, these differences have only little clinical significance and may be explained by the demographic characteristics of the population. These results do not allow the general conclusion that the quality of out-of-hospital care in Germany differs in relation to the annual birth rates of the birth centres.

[Scientific evidence on labor duration from systematic reviews]. / Wissenschaftliche Evidenz aus systematischen Ubersichtsarbeiten zum Gebären.

OBJECTIVE: We examined the evidence of systematic reviews in the Cochrane Library on interventions that influence the duration of labor. MATERIAL AND METHODS: Of the 208 Cochrane Pregnancy and Childbirth systematic reviews, 69 deal with labor and birth of which 20 address the effect of intrapartum interventions. We analyzed the reviews with respect to those interventions that affected the duration of birth. RESULTS: Six reviews, related to 5 interventions (amniotomy, epidural analgesia, continuous support, amnioinfusion, and maternal position), reported a significant effect on the duration of labor. Six found no significant effect on labor duration. The remaining eight reviews did not assess the effect of the intervention on labor duration. DISCUSSION: Interventions that have a significant influence on labor duration may interact with each other. Therefore, perinatal databases should ascertain not only if but also when an intervention has been performed.

[The five stages of labour]. / Die fünf Geburtszeiten.

Current obstetric and midwifery textbooks subdivide childbirth in three distinct phases commonly referred to as the first, second and third stage of labour. This differs from older textbooks in the 19 th century, which recognized five phases. The first one referred to the period between the onset of labour-like activity and the start of progressive cervical dilatation, the second to the phase of progressive cervical dilatation, and the third to the descent of the fetal head to the pelvic floor. The fourth period then reflected the active expulsion of the baby, while the fifth referred to what is now commonly known as the third stage of labour, i. e. the period between birth and delivery of the placenta. This difference in subdividing childbirth is to some extent reflected in the subdivision between latent and active first stage labour that emerged in the mid-20 th century. It is also reflected in subdividing the second stage of labour into the periods before and after the start of maternal expulsive efforts. The review thus indicates that the history of subdividing childbirth in different stages or phases cannot be seen in isolation from the prevailing research and clinical interests at the time. It also suggests that the old subdivision in five periods is more helpful in the understanding and appropriate documentation of the dynamic process of birth than the current delineation of first, second, and third stage labour.

[German-speaking midwifes prefer vaginal mode of delivery to elective Caesarean]. / Hebammen präferieren vaginale Geburt statt Wunschsektio1.

Increasing ceasarean section rates are a world wide concern in obstetrics. One of the latest contributing factors is the elective caesarean section in uncomplicated singleton pregnancy at term. The preference for this mode of delivery was primarily brought forward by obstetric practitioners (Al Mufty, McCarthy, Fisk 1996). A questionnaire, which mainly aimed to ask germanspeaking midwifes in Austria, Germany and Switzerland about their personal choice of delivery mode, was included in one of the issues of the German-language midwifery journal "Die Hebamme". This questionnaire contained 5 half-closed/half open questions describing specific obstetric occurrences. The midwifes were asked to express their preferred mode of delivery and describe their reason for choosing. 446 questionnaires (12 %) were returned. The majority (100 %) of the german speaking midwifes preferred a normal vaginal delivery in an uncomplicated singleton pregnancy at term with a child in cephalic presentation. The rating was about the same (97 %) in the presence of general risk factors which don't indicate a primary caesarean section. Breech presentation and macrosomia are a matter of concern to the midwifes. Midwifes arguing for a first child in breech presentation or with macrosomia > 4.5 kg vote highly significantly more frequently for elective caesarean section than midwifes arguing for at least the second child. The first-rate reasons for the preference of vaginal delivery concern the natural and physiological way of delivery, the personal experience of delivery, the higher risks of caesarean section and the possibility of a later caesarean section in case of fetal distress during first or second stage of labour. Concerns are expressed about the maintenance of competence amongst practitioners, thus influencing the choice of mode of delivery in obstetrics.

Effects of functional ability and training on chair-rise biomechanics in older adults.

BACKGROUND: Difficulty in rising from a chair is common in older adults and may be assessed by examining the biomechanics of the rise. The purposes of this study were (i) to analyze the biomechanics of rise performance during chair-rise tasks with varying task demand in older adults with varying rise ability and (ii) to determine whether a strength-training program might improve chair-rise success and alter chair-rise biomechanics, particularly under situations of increased task demand. METHODS: A training group (n = 16; mean age, 82 years) completed a 12-week strength-training regimen while a control group (n = 14; mean age, 84 years) participated in a seated flexibility program. Outcomes included the ability to complete seven chair-rise tasks, and, if the chair-rise tasks were successful, the biomechanics of these rises. Chair-rise task demand was increased by lowering the seat height, restricting the use of hands, increasing rise speed, and limiting foot support. RESULTS: At baseline, increased chair-rise task demand generally required increased task completion time, increased anterior center of pressure (COP) placement, increased momentum, increased hip flexion, and increased hip and knee torque output. Those unable to rise at 100% knee height without the use of their hands (task NH-100), compared with those able to rise during task NH-100, followed this pattern in requiring increased time, more anterior placement of the COP, and increased hip flexion to rise in the least demanding tasks allowing the use of hands. However, the unable subjects generated less momentum and knee torque in these tasks. At 12 weeks, and compared with baseline and controls, the training group demonstrated changes in chair-rise biomechanics but no significant changes in rise success. The training subjects, as compared with the controls, maintained a more posterior COP, increased their vertical and horizontal momentum, maintained their knees in greater extension, and maintained their knee-torque output. CONCLUSIONS: These data demonstrate that subtle yet significant changes can be demonstrated in chair-rise performance as a result of a controlled resistance-training program. These biomechanical changes may represent a shift away from impairment in chair-rise ability, and, although the changes are small, they represent how training may reduce rise difficulty.

Intrapartum fetal heart rate monitoring: do Swiss midwives implement evidence into practice?

OBJECTIVE: Evidence Based Medicine has shown that the results of continuous electronic fetal heart rate (FHR) monitoring are equivalent to those of intermittent auscultation. We were interested in the method midwives preferred to use to monitor FHR during labour and the factors which influenced their choice of method. STUDY DESIGN: A questionnaire with Likert scaled questions was sent to 500 German speaking Swiss midwives. Data analysis was performed by using SPSS for Windows. RESULTS: The majority of the midwives were confident monitoring FHR using intermittent auscultation as their main method during low risk delivery. The essential factors influencing the choice of method of FHR monitoring were their own personal experience and hospital guidelines. Less important were factors such as risk category, litigation, the mother's preferences, research results, time and staffing levels. CONCLUSIONS: Although the skills necessary to implement evidence into obstetrical practice are still available, evidence based research results do not seem to be of great importance, when midwives decide which method to use for intrapartum FHR monitoring. Hospital policies and the professional training received were more important factors. Programs designed to implement evidence in care should reflect the identification and use of these factors in order to facilitate the process of realisation.

Locomotor advantages of Neandertal skeletal morphology at the knee and ankle.

We quantified Neandertal knee extensor and ankle plantarflexor moments to determine whether differences between Neandertal and recent human skeletal morphology represent important functional differences. Neandertal skeletal differences in the patella, tibial tuberosity, and calcaneus were used to modify a computer model of recent humans to calculate the moment arms and moments of Neandertal knee extensor and ankle plantarflexor muscles. We also conducted sensitivity studies on the effect of musculotendon parameters on the Neandertal moments. As expected, we found that Neandertal moment arms were greater than recent humans at the ankle (122-141%); however, the magnitude of the increase was not well-predicted from measurements of size differences between Neandertal and recent human skeletons. At the knee, Neandertal moment arms were greater than those of recent humans in the locomotor range (108%) but less so at more flexed knee angles (102%). Not all Neandertal skeletal adaptations at the knee contributed to increased moment arm. Knee extensor moments were enhanced in the Neandertal models in the locomotor range (111%), regardless of musculotendon parameters. At the ankle, however, Neandertal plantarflexor moment was greater than that of recent humans (149-200%) at all joint angles only if muscle fiber length increased proportionately with moment arm. Our results demonstrate that Neandertal skeletal morphology, compared to that of recent humans, generated greater moments at both the knee and ankle in the locomotor range but not at higher angles of knee flexion or ankle plantarflexion.

A comparison of three-dimensional and two-dimensional analyses of facial motion.

The purpose of this study was to compare the amplitude of facial motion obtained using three-dimensional (3-D) and two-dimensional (2-D) methods. The amplitude of motion of fifteen facial landmarks during five maximal animations (smile, lip-purse, grimace, eye closure, and cheek-puff) was quantified in 3-D and 2-D using a video-based system. Results showed that the 3-D amplitudes were significantly larger than the 2-D amplitudes, especially for landmarks on the lower face during the smile animation. In the latter instance, the 2-D amplitudes underestimated the 3-D amplitudes by as much as 43%. The difference between 3-D and 2-D amplitudes was greater for 2-D amplitudes obtained from one camera rather than from multiple cameras. The results suggest that a 2-D analysis may not be adequate to assess facial motion during maximal animations, and that a 3-D analysis may be more appropriate for detecting clinical differences in facial function.

Reliability of a three-dimensional method for measuring facial animation: a case report.

Reliable methods of quantifying functional impairment of the craniofacial region are sorely lacking. The purpose of this study was to test the reliability of a three-dimensional method for assessing the functional repertoire of the face. Subjects were instructed to perform repeated sequences of five maximal facial animations. Facial motions were captured by three 60-Hz video cameras, and three-dimensional maximum motion amplitudes were calculated. Student's t-test and Pearson product-moment correlation coefficients were used to test for significant differences between repetitions. The results show moderate to excellent reliability of the amplitude of motion for the landmarks over all animations. For each specific animation, certain landmarks demonstrated excellent reliability of motion.