Healthcare professionals' views on two computer-based decision aids for women choosing mode of delivery after previous caesarean section: a qualitative study.

OBJECTIVE: To explore healthcare professionals' views about decision aids, developed by the DiAMOND study group, for women choosing mode of delivery after a previous caesarean section. DESIGN/METHODS: A qualitative focus group study. Data were analysed thematically. SETTING: Two city maternity units, surrounding community midwife units and general practitioner (GP) practices in southwest England. SAMPLE: Twenty-eight healthcare professionals, comprising obstetricians, hospital and community midwives and GPs, who participated in six focus groups. RESULTS: Participants were generally positive about the decision aids. Most thought they should be implemented during early pregnancy in the community, but should be accessible throughout pregnancy, with any arising questions discussed with an obstetrician nearer to term. Perceived barriers to implementation included service issues (e.g. time pressure, cost and access), computer issues (e.g. computer literacy) and people issues (e.g. women's prior delivery preferences and clinician preference). Facilitators to implementation included access to more standardised and reliable information and empowerment of the user. Self-accessing the aids, increased awareness of decision aids among healthcare professionals and incorporation of aids into usual care were suggested as possible ways to improve implementation success. CONCLUSIONS: This study gives insight into healthcare professionals' views on the role of decision aids for women choosing a mode of delivery after a prior caesarean section. It highlights potential obstacles to their implementation and ways to address these. Such aids could be a useful adjunct to current antenatal care.

Women's experience of decision making about mode of delivery after a previous caesarean section: the role of health professionals and information about health risks.

OBJECTIVE: To explore women's experiences of decision making about mode of delivery after previous caesarean section. DESIGN: A qualitative interview study. SETTING: Two city maternity units in southwest England and Eastern Scotland. SAMPLE: Twenty-one women who had recently delivered a baby and whose previous child was delivered by caesarean section. METHODS: Semi-structured interviews analysed using the framework approach. MAIN OUTCOME MEASURES: Women's views on the influence of uncertainty on decision making, issues concerning information provision and decision-making roles. RESULTS: Experiences of decision making varied considerably. Some women were certain about choosing either vaginal birth after caesarean or repeat elective caesarean section, others were very uncertain and for some this uncertainty persisted after the birth. Information was most commonly provided by hospital doctors (mainly consultants) and more often related to procedural issues rather than possible health risks and benefits. Women felt they had to actively seek information rather than it being provided routinely. Most women were able to make their own decision about mode of delivery. Health professionals generally took a supportive role whichever mode of delivery was chosen. Although many women were comfortable with this approach, some felt they would have liked more guidance. CONCLUSION: On the whole, women experienced having control over the decision about planned mode of delivery. For many, making this decision was difficult and for some it was the cause of prolonged anxiety. Women were often making the decision without being provided with comprehensive and specific information about possible health risks and benefits. We are currently conducting a randomised controlled trial to investigate whether access to a decision aid is beneficial to women in this situation.

European Nicotinamide Diabetes Intervention Trial (ENDIT): a randomised controlled trial of intervention before the onset of type 1 diabetes.

BACKGROUND: Results of studies in animals and human beings suggest that type 1 diabetes is preventable. Nicotinamide prevents autoimmune diabetes in animal models, possibly through inhibition of the DNA repair enzyme poly-ADP-ribose polymerase and prevention of beta-cell NAD depletion. We aimed to assess whether high dose nicotinamide prevents or delays clinical onset of diabetes in people with a first-degree family history of type 1 diabetes. METHOD: We did a randomised double-blind placebo-controlled trial of nicotinamide in 552 relatives with confirmed islet cell antibody (ICA) levels of 20 Juvenile Diabetes Federation (JDF) units or more, and a non-diabetic oral glucose tolerance test. Participants were recruited from 18 European countries, Canada, and the USA, and were randomly allocated oral modified release nicotinamide (1.2 g/m2) or placebo for 5 years. Random allocation was done with a pseudorandom number generator and we used size balanced blocks of four and stratified by age and national group. Primary outcome was development of diabetes, as defined by WHO criteria. Analysis was done on an intention-to-treat basis. FINDINGS: There was no difference in the development of diabetes between the treatment groups. Of 159 participants who developed diabetes in the course of the trial, 82 were taking nicotinamide and 77 were on placebo. The unadjusted hazard ratio for development of diabetes was 1.07 (95% CI 0.78-1.45; p=0.69), and the hazard ratio adjusted for age-at-entry, baseline glucose tolerance, and number of islet autoantibodies detected was 1.01 (0.73-1.38; p=0.97). Of 168 (30.4%) participants who withdrew from the trial, 83 were on placebo. The number of serious adverse events did not differ between treatment groups. Nicotinamide treatment did not affect growth in children or first-phase insulin secretion. INTERPRETATION: Large-scale controlled trials of interventions designed to prevent the onset of type 1 diabetes are feasible, but nicotinamide was ineffective at the dose we used.