Reproductive outsourcing: an empirical ethics account of cross-border reproductive care in Canada.

Cross-border reproductive care (CBRC) can be defined as the movement from one jurisdiction to another for medically assisted reproduction (MAR). CBRC raises many ethical concerns that have been addressed extensively. However, the conclusions are still based on scarce evidence even considering the global scale of CBRC. Empirical ethics appears as a way to foster this ethical reflection on CBRC while attuning it with the experiences of its main actors. To better understand the 'in and out' situation of CBRC in Canada, we conducted an ethnographic study taking a 'critically applied ethics' approach. This article presents a part of the findings of this research, obtained by data triangulation from qualitative analysis of pertinent literature, participant observation in two Canadian fertility clinics and 40 semidirected interviews. Based on participants' perceptions, four themes emerged: (1) inconsistencies of the Canadian legal framework; (2) autonomy and the necessity to resort to CBRC; (3) safety and the management of CBRC individual risks; and (4) justice and solidarity. The interaction between these four themes highlights the problematic of 'reproductive outsourcing' that characterised the Canadian situation, a system where the controversial aspects of MAR are knowingly pushed outside the borders.

Less-tight versus tight control of hypertension in pregnancy.

BACKGROUND: The effects of less-tight versus tight control of hypertension on pregnancy complications are unclear. METHODS: We performed an open, international, multicenter trial involving women at 14 weeks 0 days to 33 weeks 6 days of gestation who had nonproteinuric preexisting or gestational hypertension, office diastolic blood pressure of 90 to 105 mm Hg (or 85 to 105 mm Hg if the woman was taking antihypertensive medications), and a live fetus. Women were randomly assigned to less-tight control (target diastolic blood pressure, 100 mm Hg) or tight control (target diastolic blood pressure, 85 mm Hg). The composite primary outcome was pregnancy loss or high-level neonatal care for more than 48 hours during the first 28 postnatal days. The secondary outcome was serious maternal complications occurring up to 6 weeks post partum or until hospital discharge, whichever was later. RESULTS: Included in the analysis were 987 women; 74.6% had preexisting hypertension. The primary-outcome rates were similar among 493 women assigned to less-tight control and 488 women assigned to tight control (31.4% and 30.7%, respectively; adjusted odds ratio, 1.02; 95% confidence interval [CI], 0.77 to 1.35), as were the rates of serious maternal complications (3.7% and 2.0%, respectively; adjusted odds ratio, 1.74; 95% CI, 0.79 to 3.84), despite a mean diastolic blood pressure that was higher in the less-tight-control group by 4.6 mm Hg (95% CI, 3.7 to 5.4). Severe hypertension (≥160/110 mm Hg) developed in 40.6% of the women in the less-tight-control group and 27.5% of the women in the tight-control group (P<0.001). CONCLUSIONS: We found no significant between-group differences in the risk of pregnancy loss, high-level neonatal care, or overall maternal complications, although less-tight control was associated with a significantly higher frequency of severe maternal hypertension. (Funded by the Canadian Institutes of Health Research; CHIPS Current Controlled Trials number, ISRCTN71416914; ClinicalTrials.gov number, NCT01192412.).

Sustained impact of a computer-assisted antimicrobial stewardship intervention on antimicrobial use and length of stay.

Objectives: : Prospective audit and feedback interventions are the core components of an antimicrobial stewardship programme. Herein, we describe the sustained impact of an antimicrobial stewardship programme, based on a novel clinical decision-support system (Antimicrobial Prescription Surveillance System; APSS), on antimicrobial use and costs, hospital length of stay (LOS) in days and the proportion of inappropriate antimicrobial prescriptions. Methods: A quasi-experimental, retrospective study was conducted using interrupted time series between 2008 and 2013. Data on all hospitalized adults receiving antimicrobials were extracted from the data warehouse of a 677 bed academic centre. The intervention started in August 2010. Prospective audit and feedback interventions, led by a pharmacist, were triggered by APSS based on deviations from published and local guidelines. Changes in outcomes before and after the intervention were compared using segmented regression analysis. Results: APSS reviewed 40 605 hospitalizations for 35 778 patients who received antimicrobials. The intervention was associated with a decrease in the average LOS (level change -0.92, P < 0.01; trend -0.08, P < 0.01; intercept 11.4 days), antimicrobial consumption in DDDs/1000 inpatient days (level change -32.4, P < 0.01; trend -1.12, P < 0.02; intercept 243 DDDs per 1000 days of hospitalization), antimicrobial spending in Canadian dollars (level change -19 649, P = 0.01; trend -1881, P < 0.01; intercept $74 683) and proportion of non-concordance with local guidelines for prescribing antimicrobials (level change -2.3, P = 0.04; intercept 41%). Conclusions: The implementation of the APSS-initiated strategy was associated with a positive impact on antimicrobial use and spending, LOS and inappropriate prescriptions. The high rate of accepted interventions may have contributed to these results.

3D Cohort Study: The Integrated Research Network in Perinatology of Quebec and Eastern Ontario.

BACKGROUND: The 3D Cohort Study (Design, Develop, Discover) was established to help bridge knowledge gaps about the links between various adverse exposures during pregnancy with birth outcomes and later health outcomes in children. METHODS: Pregnant women and their partners were recruited during the first trimester from nine sites in Quebec and followed along with their children through to 2 years of age. Questionnaires were administered during pregnancy and post-delivery to collect information on demographics, mental health and life style, medical history, psychosocial measures, diet, infant growth, and neurodevelopment. Information on the delivery and newborn outcomes were abstracted from medical charts. Biological specimens were collected from mothers during each trimester, fathers (once during the pregnancy), and infants (at delivery and 2 years of age) for storage in a biological specimen bank. RESULTS: Of the 9864 women screened, 6348 met the eligibility criteria and 2366 women participated in the study (37% of eligible women). Among women in the 3D cohort, 1721 of their partners (1704 biological fathers) agreed to participate (73%). Two thousand two hundred and nineteen participants had a live singleton birth (94%). Prenatal blood and urine samples as well as vaginal secretions were collected for ≥98% of participants, cord blood for 81% of livebirths, and placental tissue for 89% of livebirths. CONCLUSIONS: The 3D Cohort Study combines a rich bank of multiple biological specimens with extensive clinical, life style, and psychosocial data. This data set is a valuable resource for studying the developmental etiology of birth and early childhood neurodevelopmental outcomes.

Can adverse maternal and perinatal outcomes be predicted when blood pressure becomes elevated? Secondary analyses from the CHIPS (Control of Hypertension In Pregnancy Study) randomized controlled trial.

INTRODUCTION: For women with chronic or gestational hypertension in CHIPS (Control of Hypertension In Pregnancy Study, NCT01192412), we aimed to examine whether clinical predictors collected at randomization could predict adverse outcomes. MATERIAL AND METHODS: This was a planned, secondary analysis of data from the 987 women in the CHIPS Trial. Logistic regression was used to examine the impact of 19 candidate predictors on the probability of adverse perinatal (pregnancy loss or high level neonatal care for >48 h, or birthweight <10th percentile) or maternal outcomes (severe hypertension, preeclampsia, or delivery at <34 or <37 weeks). A model containing all candidate predictors was used to start the stepwise regression process based on goodness of fit as measured by the Akaike information criterion. For face validity, these variables were forced into the model: treatment group ("less tight" or "tight" control), antihypertensive type at randomization, and blood pressure within 1 week before randomization. Continuous variables were represented continuously or dichotomized based on the smaller p-value in univariate analyses. An area-under-the-receiver-operating-curve (AUC ROC) of ≥0.70 was taken to reflect a potentially useful model. RESULTS: Point estimates for AUC ROC were <0.70 for all but severe hypertension (0.70, 95% CI 0.67-0.74) and delivery at <34 weeks (0.71, 95% CI 0.66-0.75). Therefore, no model warranted further assessment of performance. CONCLUSIONS: CHIPS data suggest that when women with chronic hypertension develop an elevated blood pressure in pregnancy, or formerly normotensive women develop new gestational hypertension, maternal and current pregnancy clinical characteristics cannot predict adverse outcomes in the index pregnancy.

Strengths and pitfalls of Canadian gamete and embryo donor registries: searching for beneficent solutions.

For the gamete and embryo donation community, it is well recognized that the implementation of a gamete and embryo donor registry (GEDR) represents a good initiative to ensure the best possible health conditions for donor-conceived individuals. Be they national, institutional or independent, GEDR can play a major role in the transmission of health-related genetic and medical information. However, from a bioethical analysis standpoint, GEDR raise many questions regarding the extent of their beneficent nature. Based on the recent Canadian GEDR aborted attempt, this article will focus on bioethical issues and paradoxes that can impact the wellbeing of donor-conceived individuals, half-siblings, donors and parents. On one hand, the implementation of a GEDR can be ethically justified as a beneficent action towards lessening harm associated with the transmission of hereditary disease and increasing the effectiveness of preventive and therapeutic approaches. On the other hand, examined through the concept of nonpaternalistic beneficence, GEDR challenge us to recognize beneficiaries' free agency, as well as the importance to transmit reliable and pertinent information. Ultimately, beyond an individualistic application of the principle of beneficence, socioethics invite us to consider consistency with societal values as a prerequisite for achieving a common good. Because the issue of whether or not to protect the donor's anonymity occupies the forefront of the discussion surrounding gamete and embryo donation, there is less interest in other initiatives, which may be implemented to ensure the best possible medical and psychosocial conditions for donor-conceived individuals. In this article, we propose a bioethical analysis of the use of gamete and embryo donor registries (GEDR) from the angle of the principle of beneficence. More specifically, we will concentrate on the Canadian situation regarding GEDR. We will look at the strengths and pitfalls of this mechanism and suggest a solution to maximize the benefits of a GEDR. Many have suggested that such an initiative could have a beneficial impact on the wellbeing of donor-conceived individuals, half-siblings, donors and parents, by ensuring the constant flow of health-related medical and genetic information. As self-evident as the social acceptability of a GEDR may seem, we wish to show the limitations of the benefits that a registry is supposed to provide. We argue that a GEDR has to do more than simply transmit health-related information between parties. It also has to be based on pertinent and reliable data, be useful for health promotion and recognize beneficiaries' free agency. Ultimately, the implementation of a GEDR has to take into consideration wider social values.

Interrelations between four antepartum obstetric interventions and cesarean delivery in women at low risk: a systematic review and modeling of the cascade of interventions.

OBJECTIVES: To critically appraise the literature on the relations between four intrapartum obstetric interventions-electronic fetal monitoring (EFM), epidural analgesia, labor induction, and labor acceleration; and two types of delivery-instrumental (forceps and vacuum) and cesarean section. METHODS: This review included meta-analyses published between January 2000 and April 2012 including at least one randomized clinical trial published after 1995 and presenting results on low-risk pregnancies between 37 and 42 weeks of gestation, searched in the databases Medline, Cochrane Library, and EMBASE with no language restriction. RESULTS: Of 306 documents identified, 8 fulfilled the inclusion criteria and presented results on women at low risk. EFM at admission (vs intermittent auscultation) was associated with cesarean delivery (odds ratio [OR] = 1.20, 95% confidence interval [CI] 1.00-1.44) and epidural analgesia (OR = 1.25, 95% CI 1.09-1.43). Epidural on request was associated with cesarean delivery (OR = 1.60, 95% CI 1.18-2.18), instrumental delivery (OR = 1.21, 95% CI 1.03-1.44), and oxytocin use (OR = 1.20, 95% CI 1.01-1.43) when compared with epidural on request plus nonpharmacological labor pain control methods such as one-to-one support, breathing techniques, and relaxation. Induction and acceleration of labor showed heterogeneous patterns of associations with cesarean delivery and instrumental delivery. CONCLUSIONS: Complex patterns of associations between obstetric interventions and modes of delivery were illustrated in an empirical model. Intermittent auscultation and nonpharmacological labor pain control interventions, such as one-to-one support during labor, have the potential for substantially reducing cesarean deliveries.

Nonpharmacologic approaches for pain management during labor compared with usual care: a meta-analysis.

OBJECTIVES: To assess the effects of nonpharmacologic approaches to pain relief during labor, according to their endogenous mechanism of action, on obstetric interventions, maternal, and neonatal outcomes. DATA SOURCE: Cochrane library, Medline, Embase, CINAHL and the MRCT databases were used to screen studies from January 1990 to December 2012. STUDY SELECTION: According to Cochrane criteria, we selected randomized controlled trials that compared nonpharmacologic approaches for pain relief during labor to usual care, using intention-to-treat method. RESULTS: Nonpharmacologic approaches, based on Gate Control (water immersion, massage, ambulation, positions) and Diffuse Noxious Inhibitory Control (acupressure, acupuncture, electrical stimulation, water injections), are associated with a reduction in epidural analgesia and a higher maternal satisfaction with childbirth. When compared with nonpharmacologic approaches based on Central Nervous System Control (education, attention deviation, support), usual care is associated with increased odds of epidural OR 1.13 (95% CI 1.05-1.23), cesarean delivery OR 1.60 (95% CI 1.18-2.18), instrumental delivery OR 1.21 (95% CI 1.03-1.44), use of oxytocin OR 1.20 (95% CI 1.01-1.43), labor duration (29.7 min, 95% CI 4.5-54.8), and a lesser satisfaction with childbirth. Tailored nonpharmacologic approaches, based on continuous support, were the most effective for reducing obstetric interventions. CONCLUSION: Nonpharmacologic approaches to relieve pain during labor, when used as a part of hospital pain relief strategies, provide significant benefits to women and their infants without causing additional harm.

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 %.

Prediction of adverse maternal outcomes in pre-eclampsia: development and validation of the fullPIERS model.

BACKGROUND: Pre-eclampsia is a leading cause of maternal deaths. These deaths mainly result from eclampsia, uncontrolled hypertension, or systemic inflammation. We developed and validated the fullPIERS model with the aim of identifying the risk of fatal or life-threatening complications in women with pre-eclampsia within 48 h of hospital admission for the disorder. METHODS: We developed and internally validated the fullPIERS model in a prospective, multicentre study in women who were admitted to tertiary obstetric centres with pre-eclampsia or who developed pre-eclampsia after admission. The outcome of interest was maternal mortality or other serious complications of pre-eclampsia. Routinely reported and informative variables were included in a stepwise backward elimination regression model to predict the adverse maternal outcome. We assessed performance using the area under the curve (AUC) of the receiver operating characteristic (ROC). Standard bootstrapping techniques were used to assess potential overfitting. FINDINGS: 261 of 2023 women with pre-eclampsia had adverse outcomes at any time after hospital admission (106 [5%] within 48 h of admission). Predictors of adverse maternal outcome included gestational age, chest pain or dyspnoea, oxygen saturation, platelet count, and creatinine and aspartate transaminase concentrations. The fullPIERS model predicted adverse maternal outcomes within 48 h of study eligibility (AUC ROC 0·88, 95% CI 0·84-0·92). There was no significant overfitting. fullPIERS performed well (AUC ROC >0·7) up to 7 days after eligibility. INTERPRETATION: The fullPIERS model identifies women at increased risk of adverse outcomes up to 7 days before complications arise and can thereby modify direct patient care (eg, timing of delivery, place of care), improve the design of clinical trials, and inform biomedical investigations related to pre-eclampsia. FUNDING: Canadian Institutes of Health Research; UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development, and Research Training in Human Reproduction; Preeclampsia Foundation; International Federation of Obstetricians and Gynecologists; Michael Smith Foundation for Health Research; and Child and Family Research Institute.

Suture restriction of the temporal bone as a risk factor for acute otitis media in children: cohort study.

BACKGROUND: Eustachian tube (ET) dysfunction plays an important role in the pathogenesis of acute otitis media (AOM). Unfortunately, there is a lack of knowledge about the exact role of the ET's bony support, the temporal bone, on occurrence of AOM. This study investigates whether severe suture restriction of the temporal bone is a risk factor for development of AOM in young children. METHODS: Using a prospective cohort design, 64 children aged 6 to 18 months without prior history of AOM were followed during the cold season (September 2009 to April 2010). Temporal bone status (categorized as with or without severe suture restriction) was evaluated using palpation and a cranial bone mobility test. Information about potential baseline confounders and risk factors for AOM (gender, age, birth weight, gestational age, use of pacifier, daycare attendance, presence of siblings, low socioeconomic status, breastfeeding ≥ 6 months, parental smoking and history of upper respiratory tract infection) were also collected. Occurrence of AOM diagnosed by physicians blinded to temporal bone status was the main outcome. Data were analyzed using hierarchical linear and nonlinear (multilevel) models. RESULTS: Severe suture restriction of the temporal bone was identified in 23 children (35.9%). At least one AOM episode was diagnosed in 14 (48.3%) of the ears associated with temporal bones previously identified as having severe suture restriction and in 28 (28.3%) of those without severe suture restriction. Higher risk for AOM was explained by severe suture restriction of the temporal bone (adjusted relative risk (RR), 2.26, 95% CI 1.43 to 2.91, p<.01), pacifier use (RR, 2.59, 95% CI 1.51 to 3.22, p<.01) and younger age (RR, 0.22, 95% CI 0.10 to 0.52, p=.001). CONCLUSIONS: The study results indicate that severe suture restriction of the temporal bone is a risk factor for AOM in young children. Subsequent intervention studies are needed to determine if this mechanical risk factor can be modified in young children.

The impact of perceived maternal stress and other psychosocial risk factors on pregnancy complications.

OBJECTIVE: The aim of this study was to ascertain the contribution of perceived maternal stress and other components of a psychosocial profile to the occurrence of complications of pregnancy. METHODS: We conducted a prospective cohort study of pregnant women in a tertiary perinatal centre in Eastern Townships, Quebec. Psychosocial profile was assessed between 10 and 20 weeks' gestation and 25 and 30 weeks' gestation using six validated self-administered questionnaires. After delivery, data related to maternal, perinatal, and neonatal outcomes were collected. Descriptive, bivariate, and ANOVA repeated measures were performed. RESULTS: Among 303 consenting women, 81 (26.7%) had at least one pregnancy complication. Biomedical risk factors were evenly distributed in both groups (with or without complications). Women with complications had higher mean perceived stress at 10 to 20 weeks than those with uneventful term pregnancies (32.6 ± 11.7 vs. 29.3 ± 10.3; P < 0.05). Among those with complications, women with preterm birth perceived even more stress at 10 to 20 weeks (34.4 ± 11.5 vs. 29.3 ± 10.3; P < 0.05) than those with term pregnancies. Peer social support at 25 to 30 weeks, in women with a complication, was reported to be less than in women with an uneventful term pregnancy (51.0 ± 16.6 vs. 55.5 ± 13.8; P < 0.05). Other psychosocial dimensions were similar in both groups. CONCLUSION: Maternally perceived stress before 20 weeks' gestation is associated with complications of pregnancy and especially with preterm birth.

An international trial of antioxidants in the prevention of preeclampsia (INTAPP).

OBJECTIVE: We sought to investigate whether prenatal vitamin C and E supplementation reduces the incidence of gestational hypertension (GH) and its adverse conditions among high- and low-risk women. STUDY DESIGN: In a multicenter randomized controlled trial, women were stratified by the risk status and assigned to daily treatment (1 g vitamin C and 400 IU vitamin E) or placebo. The primary outcome was GH and its adverse conditions. RESULTS: Of the 2647 women randomized, 2363 were included in the analysis. There was no difference in the risk of GH and its adverse conditions between groups (relative risk, 0.99; 95% confidence interval, 0.78-1.26). However, vitamins C and E increased the risk of fetal loss or perinatal death (nonprespecified) as well as preterm prelabor rupture of membranes. CONCLUSION: Vitamin C and E supplementation did not reduce the rate of preeclampsia or GH, but increased the risk of fetal loss or perinatal death and preterm prelabor rupture of membranes.

Is sleep disturbed in pregnancy?

OBJECTIVE: To assess features of sleep among pregnant women. METHODS: We conducted a prospective cohort study of low-risk pregnant women in a tertiary perinatal centre (CHUS) in Eastern Townships, Quebec. Sleep was assessed during the second trimester (mean gestational age 16.1 +/- 3.0 weeks) (T2) and third trimester (mean gestational age 27.5 +/- 1.8 weeks) (T3) using a validated self-administered questionnaire, the Pittsburgh Sleep Quality Index (PSQI). Scores in this index range from 0 to 21, representing the cumulative scoring of seven sleep components. Subjects with a score > 5 were identified as "poor sleepers." Descriptive, bivariate, and regression analyses were performed. RESULTS: Among 260 consenting women, 192 (73.6%) had a term delivery without any adverse outcome. There were no differences in sleep parameters between pregnancies with adverse outcome and without adverse outcome. Mean overall PSQI scores showed evidence of deterioration in sleep quality from T2 (5.26 +/- 3.16) to T3 (6.73 +/- 4.02; P < 0.01). This deterioration was displayed in five of seven sleep components (P < 0.01). Scores in the "poor sleeper" range were recorded by 36% of women in T2 and 56%, of women in T3 (P < 0.01). "Poor sleep" in T2 and T3 was associated with low or high weight gain (P < 0.01), annual family income < $40,000 (P = 0.03), and single motherhood (P < 0.01). There was a trend for a seasonal influence on sleep scores (P = 0.08). The only predictor of poor sleep using multivariate analysis was single motherhood (P < 0.01). CONCLUSION: Sleep is disturbed in early pregnancy and is worse in the third trimester. Interventions to improve sleep should be sought to optimize quality of life for pregnant women.

Determinants of clinical information system post-adoption success.

The diffusion of information technology (IT) in healthcare systems to support clinical processes makes the evaluation of physician and nurse post-adoption an important challenge for clinical information systems (CIS). This paper examines the relationships between the determinants of success of a CIS based on an expectation-confirmation paradigm in a cross-sectional survey performed at the Sherbrooke University Hospital (CHUS). 32.2% (161) of physicians and 27.1% (352) of nurses responded to the survey questionnaires. Results suggested that physician and nurse satisfaction is determined differently according to post-adoption expectations: compatibility, confirmation of expectations, usefulness, ease of use, and support. The best predictor of physician satisfaction was perceived usefulness (r=.25, p=.0003) whereas for nurses it was ease of use (r=.18, p=.0003). Confirmation of expectations was strongly associated with each post-adoption expectation and positions its importance in CIS design and redesign. This study draws attention to the differences between physician and nurse perceptions of information technology and emphasizes post-adoption evaluation to measure CIS success. Physicians and nurses post-adoption expectations were key factors to warn again potential discontinuance.

Low-dose ASA response using the PFA-100 in women with high-risk pregnancy.

OBJECTIVES: To study the platelet function response to low-dose ASA with the Platelet Function Analyzer (PFA-100) in pregnant women and to identify maternal characteristics associated with non-responsiveness. METHODS: We conducted a prospective cohort study involving 87 pregnant women on ASA. The platelet function response to ASA was measured as the closure time obtained with epinephrine cartridges (CT-EPI) by the PFA-100. Non-response to ASA was defined as a CT-EPI < or =150 seconds after four weeks of therapy. Non-responders were given an escalating dose of ASA and their CT-EPI was tested again. RESULTS: After four weeks of enteric-coated ASA 81 mg daily, 25/87 women (28.7%) were non-responders (95% CI 16.1 to 41.4). Among these women, a CT-EPI < or =150 seconds was found in 8/24 women (33.3%) after another four weeks of alternating ASA 81 mg and 162 mg daily. After a further four-week course of ASA 162 mg daily, a CT-EPI < or =150 seconds was found in 3/6 women (50.0%). Among the women who initially responded and who were reassessed at 24-32 weeks of pregnancy, the CT-EPI was < or =150 seconds in 9/36 (25.0%). There was no statistical difference in maternal characteristics between ASA responders and non-responders. CONCLUSION: A significant number of pregnant women showed a lack of platelet function response to ASA 81 mg that was in most cases overcome with higher dosing. Furthermore, the prevalence of non-responsiveness increased with advancing pregnancy.

Biopsychosocial determinants of pregnancy length and fetal growth.

The causes and mechanisms related to preterm delivery and intrauterine growth restriction are poorly understood. Our objective was to assess the direct and indirect effects of psychosocial and biomedical factors on the duration of pregnancy and fetal growth. A self-administered questionnaire was distributed to pregnant women attending prenatal ultrasound clinics in nine hospitals in the Montérégie region in the province of Quebec, Canada, from November 1997 to May 1998. Prenatal questionnaires were linked with birth certificates. Theoretical models explaining pregnancy length and fetal growth were developed and tested, using path analysis. In order to reduce the number of variables from the questionnaire, a principal component analysis was performed, and the three most important new dimensions were retained as explanatory variables in the final models. Data were available for 1602 singleton pregnancies. The biophysical score, covering both maternal age and the pre-pregnancy body mass index, was the only variable statistically associated with pregnancy length. Smoking, obstetric history, maternal health and biophysical indices were direct predictors of fetal growth. Perceived stress, social support and self-esteem were not directly related to pregnancy outcomes, but were determinants of smoking and the above-mentioned biomedical variables. More studies are needed to identify the mechanisms by which adverse psychosocial factors are translated into adverse biological effects.

Validation of a screening tool to identify the nutritionally at-risk pregnancy.

OBJECTIVE: To assess the efficacy of a screening tool to be used by nurses to determine which economically disadvantaged pregnant women are most likely to benefit from a dietitian's intensive intervention. METHODS: The 26-variable screening tool was used by 53 nurses in 17 Montreal primary care facilities at first contact with 300 subjects who were eligible for prenatal programs for low-income women. Among these, 259 subjects were subsequently interviewed by a Montreal Diet Dispensary (MDD) dietitian using the Higgins Method, established as the gold standard for the detection of a nutritionally at-risk pregnancy. Comparisons of the results obtained by dietitians using the Higgins Method with scores obtained by nurses using the screening tool to determine risk levels and individual variables were analyzed using the Pearson correlation coefficient, receiver operating characteristic (ROC) curves, and predictive indices such as sensitivity, specificity, and predictive values. RESULTS: Because of low agreement between the findings of MDD dietitians and nurses using the screening tool, 10 variables were excluded. The resulting 16-variable tool showed a correlation coefficient of 0.70. The ROC cut-off for this simplified tool was 8, meaning that a woman would be considered at nutritional risk if her score was 8 or more. This score optimized sensitivity (85%) with rather low specificity (50%), but retained a positive predictive value of 87% and a negative predictive value of 55%. CONCLUSION: Revisions of the screening tool to identify nutritionally at-risk pregnant women led to the development of a simplified screening tool with an acceptable measure of nutritional risk in pregnancy. Hence, the use of this tool by any health professional will identify the majority of the nutritionally at-risk pregnant women most likely to benefit from a dietitian's intensive intervention.

[The factors facilitating and constraining the continuation of breastfeeding in women in Estrie (Quebec)]. / Les facteurs facilitant et contraignant l'allaitement maternel en Estrie (Québec).

OBJECTIVE: To document breastfeeding rates from birth to six months as well as the factors facilitating and constraining the continuation of breastfeeding in women in the Eastern Townships of Quebec and to compare these to the results obtained in 1999. METHOD: Postal questionnaire sent to 374 mothers who had breastfed and analysis of archival data. RESULTS: Breastfeeding rates were 86.3% at birth and 75% at discharge from hospital in all mothers who gave birth to a child in 2004-2005. Breastfeeding rates in the 272 mothers who answered the questionnaire were reported to be 67.3% and 47.4% at three and six months respectively. Results indicate that 8.9% of infants were still receiving breast milk exclusively after the third month. However, 27.9% of the mothers had stopped breastfeeding during the infant's first week. Support from the nurses was the primary factor facilitating breastfeeding. The main reasons the mothers gave for stopping breastfeeding were problems with breastfeeding and fatigue. CONCLUSION: Breastfeeding rates in this area of Quebec have increased significantly in the past five years and are comparable with those in the rest of Canada. Breastfeeding exclusively up to six months is rare, and initiatives to support breastfeeding mothers in the hospital and in the community are having success.