The effect of culturally-adapted health education interventions among culturally and linguistically diverse (CALD) patients with a chronic illness: A meta-analysis and descriptive systematic review.

OBJECTIVE: To review the effectiveness of health education interventions adapted for culturally and linguistically diverse (CALD) populations with a chronic illness. METHODS: A systematic review and meta-analysis were conducted. Eligible studies were identified across six databases. Data were extracted and intervention effect was summarized using standardized mean difference. If there were insufficient data for meta-analysis, a descriptive summary was included. Modifying effects of intervention format, length, intensity, provider, self-management skills taught, and behavioral change techniques (BCTs) utilized were examined. RESULTS: 58 studies were reviewed and data were extracted for 36 outcomes. Most interventions used multiple modes of delivery and were facilitated by bilingual health care professionals (HCPs). On average, interventions included 5.19 self-management skills and 4.82 BCTs. Interventions were effective in reducing BMI, cholesterol, triglycerides, blood glucose, HbA1C, and depression, and in increasing knowledge. Effectiveness was influenced partly by provider, with HCPs favored over lay providers or paraprofessionals in increasing knowledge; however, the opposite was noted for HbA1c. CONCLUSIONS: Health education interventions are effective among CALD populations, particularly at improving objective, distal outcomes (e.g., anthropometric measures). These interventions may be equally effective in improving proximal patient-reported outcomes (PROs); however, diversity in PROs limited analyses. PRACTICE IMPLICATIONS: Core outcome sets (COS) are needed to further investigate and compare health education intervention effectiveness on PROs.

Barriers and facilitators to birth without epidural in a tertiary obstetric referral center: Perspectives of health care professionals and patients.

BACKGROUND: Epidural rates are high in tertiary obstetric referral centers, even though many patients in tertiary settings might not want or need epidural analgesia. Epidural rates are influenced by factors including labor support and routine medical intervention. This study aimed to identify barriers and facilitators to birth without epidural in a Canadian tertiary center, from the perspectives of doctors, nurses, and patients. METHODS: In this qualitative exploratory study, individual, semi-structured interviews were conducted in 2016 with 5 doctors, 5 nurses, and 4 patients who intended to birth without epidural. Interviews were audio-recorded, transcribed, and analyzed using inductive qualitative thematic analysis. RESULTS: Several contextual factors in the tertiary center facilitated or were barriers to birth without epidural. The following themes emerged: (1) differing perceptions of pain, (2) being ready for things to go wrong, (3) labor support is more labor intensive, and (4) having insufficient resources for birth without epidural. CONCLUSIONS: Reconciling patient birth goals with staff focus on patient safety is challenging in the tertiary context. Discrepancies between health care professional and patient attitudes about childbirth pain may influence decision-making about epidural use. Maintaining labor support skills is challenging for health care professionals who have limited exposure to birth without epidural. There is a need to allocate dedicated resources to better support birth without epidural. Specifically, support could be improved through the implementation of guidelines for assessment and management of labor pain, provision of a variety of pain management options, and labor support training for health care professionals.

Depression screening and patient outcomes in pregnancy or postpartum: a systematic review.

OBJECTIVE: Clinical practice guidelines disagree on whether health care professionals should screen women for depression during pregnancy or postpartum. The objective of this systematic review was to determine whether depression screening improves depression outcomes among women during pregnancy or the postpartum period. METHODS: Searches included the CINAHL, EMBASE, ISI, MEDLINE, and PsycINFO databases through April 1, 2013; manual journal searches; reference list reviews; citation tracking of included articles; and trial registry reviews. RCTs in any language that compared depression outcomes between women during pregnancy or postpartum randomized to undergo depression screening versus women not screened were eligible. RESULTS: There were 9,242 unique titles/abstracts and 15 full-text articles reviewed. Only 1 RCT of screening postpartum was included, but none during pregnancy. The eligible postpartum study evaluated screening in mothers in Hong Kong with 2-month-old babies (N=462) and reported a standardized mean difference for symptoms of depression at 6 months postpartum of 0.34 (95% confidence interval=0.15 to 0.52, P<0.001). Standardized mean difference per 44 additional women treated in the intervention trial arm compared to the non-screening arm was approximately 1.8. Risk of bias was high, however, because the status of outcome measures was changed post-hoc and because the reported effect size per woman treated was 6-7 times the effect sizes reported in comparable depression care interventions. CONCLUSION: There is currently no evidence from any well-designed and conducted RCT that screening for depression would benefit women in pregnancy or postpartum. Existing guidelines that recommend depression screening during pregnancy or postpartum should be re-considered.

Preventable obstetrical interventions: how many caesarean sections can be prevented in Canada?

Public health authorities have been alarmed by the progressive rise in rates of Caesarean section in Canada, approaching one birth in three in several provinces. We aimed therefore to consider what were preventable obstetrical interventions in women with a low-risk pregnancy and to propose an analytic framework for the reduction of the rate of CS. We obtained statistical variations of CS rates over time, across regions, and within professional practices from MED-ÉCHO, the Quebec hospitalization database, from 1969 to 2009. Data were extracted from a recent systematic review of the cascade of obstetrical interventions to calculate the population-attributable fractions for each intervention associated with an increased probability of CS. We thereby identified expectant management (as an alternative to labour induction) and planned vaginal birth after CS as the leading strategies for potentially reducing rates of CS in women at low risk. For vaginal birth after CS, an increase to its 1995 level could lower the current CS rate of 23.2% (2009 to 2010) to 21.0%. Other alternatives to obstetrical interventions with a potential for lowering CS rates included non-pharmacological pain control methods (such as continuous support during childbirth) in addition to usual care, intermittent auscultation of the fetal heart (instead of electronic fetal monitoring), and multidisciplinary internal quality assessment audits. We believe, therefore, that the concept of preventable CS is supported by empirical evidence, and we identified realistic strategies to maintain a CS rate in Quebec near 20%.

Les autorités en matière de santé publique ont été alarmées par la hausse graduelle des taux de césarienne (CS) au Canada (près d'une naissance sur trois dans plusieurs provinces). Nous avons donc cherché à identifier les interventions obstétricales qui pouvaient être évitées chez les femmes qui connaissent une grossesse les exposant à de faibles risques, ainsi qu'à proposer un cadre analytique pour la réduction du taux de CS. Les variations statistiques, entre 1969 et 2009, des taux de CS avec le temps, d'une région à l'autre et en fonction des pratiques professionnelles ont été tirées de MED-ÉCHO (la base de données sur l'hospitalisation au Québec). Des données ont été tirées d'une récente analyse systématique de la cascade d'interventions obstétricales en vue de calculer les fractions étiologiques du risque pour chacune des interventions associées à une probabilité accrue de CS. Nous avons ainsi identifié la prise en charge non interventionniste (à titre de solution de rechange au déclenchement du travail) et l'accouchement vaginal planifié après CS comme étant les principales stratégies pouvant permettre la réduction des taux de CS chez les femmes exposées à de faibles risques. Pour ce qui est de l'accouchement vaginal après CS, une hausse jusqu'à son niveau de 1995 pourrait faire passer le taux actuel de CS de 23,2 % (de 2009 à 2010) à 21,0 %. Parmi les solutions de rechange aux interventions obstétricales qui présentent le potentiel d'abaisser les taux de CS, on trouvait les méthodes non pharmacologiques de maîtrise de la douleur (comme l'offre d'un soutien continu pendant l'accouchement) s'ajoutant aux soins habituels, l'auscultation intermittente du cœur fœtal (plutôt que le monitorage électronique du fœtus) et les audits internes multidisciplinaires de la qualité. Nous estimons donc que le concept de la CS évitable est soutenu par des données empiriques et nous avons identifié des stratégies réalistes permettant d'assurer le maintien, au Québec, d'un taux de CS se situant près de 20 %.

Women's experience of an emergency caesarean birth.

AIMS: To explore women's experience of an emergency caesarean birth to gain a better understanding of their thoughts, and feelings throughout the birth process. BACKGROUND: Women who experience an emergency caesarean birth have an increased risk of psychological distress, however, little is known about the nature of this experience from their perspective. Given the sudden and unexpected nature of this type of birth and the increased risk of psychological distress for these women, it is important for nurses to understand the experience of women who have had an emergency caesarean birth. DESIGN: A qualitative descriptive study was conducted. METHOD: Nine Canadian women who had healthy infants were interviewed a few days after having an emergency caesarean birth. Thematic analysis of interview data was conducted concurrent with the data collection. RESULTS: Seven themes were identified describing the women's experience: (1) It was for the best, (2) I did not have control, (3) Everything was going to be okay, (4) I was so disappointed, (5) I was so scared, (6) I could not believe it and (7) I was excited. CONCLUSION: A key finding was that women felt out of control during this event and used reassuring thoughts to minimise their distress. RELEVANCE TO CLINICAL PRACTICE: Nurses should aim to enhance women's perception of control during the emergency caesarean birth, encourage open expression of their thoughts and feelings about the birth experience, and support the use of positive reframing to cope with this event.