Evaluation of the CARES Skills Framework as a Peer Support Model in the Paramedic Undergraduate Curriculum: Facilitating Challenging Discussions in a Safe Environment.

OBJECTIVE: Infant or child death is reported as being the most distressing type of case paramedics attend. Student paramedics also identify supporting bereaved families as an area associated with low confidence. This study evaluated the CARES skills framework (Connect to emotion, Attention training, Reflective listening, Empathy, Support help seeking) as a peer support model to encourage student paramedics to talk about grief and death related to infants and children. METHOD: A convenience sample of first-year paramedic students (target n = 154) was recruited from a single Australian regional university. A modified nominal group technique method was used following a student debriefing session designed to identify problems, generate solutions, and make decisions regarding the efficacy of the CARES skills framework. RESULTS: Of 154 eligible participants, 141 participated (92% response rate). Peer social support normalized students' emotions related to death and dying. Although naming emotions was challenging, students reported that the CARES model facilitated a safe environment to talk about death and dying. Students reported feeling heard and connected to their peers during the exercise and an enhanced sense of belonging after the exercise. CONCLUSIONS: Findings contribute to evidence that suggests the CARES model is a useful mechanism to enhance peer social support in paramedic students.

The impact of an autonomous nurse-led high-flow nasal cannula oxygen protocol on clinical outcomes of infants with bronchiolitis.

OBJECTIVE: To investigate the relationship of the implementation of a nurse-led high-flow nasal cannula oxygen protocol on the clinical outcomes of infants with bronchiolitis in a regional paediatric unit. BACKGROUND: Bronchiolitis is a common lower respiratory illness and is the leading cause for hospitalisation of infants globally. Standard care involves the provision of supportive measures. Historically, supplemental oxygen was provided by low-flow nasal cannula. High-flow nasal cannula oxygen has been increasingly adopted despite limited evidence of its efficacy. METHODS: This study employed non-equivalent, post-implementation only design to explore clinical outcomes of infants with bronchiolitis admitted for high-flow nasal cannula oxygen therapy. The study compared infants in the 24 months before and after the initiation of a high-flow nasal cannula protocol. The primary clinical outcome was length of stay, secondary outcomes included time on high flow, weaning time, escalation of care and time outside of physiological parameters. Implementation strategy evaluation was measured by compliance with applying the protocol, reported as episodes of variance, and duration of variance. The StaRI checklist was selected as the most appropriate reporting guideline. RESULTS: A total of 80 patients were admitted with bronchiolitis and received high-flow nasal cannula oxygen therapy during a 48-month period; 37 patients were prior, and 43 after, the introduction of a nurse-led high-flow nasal cannula protocol. Length of stay was significantly reduced in the post-implementation group compared to the historical control group (83.8 vs. 61.3 h). Time on high flow and weaning time was decreased in the post-implementation group compared to the control group (33.5 vs. 26.7 h and 26 vs.12.25 h, respectively); however, these did not reach statistical significance. There was varied application of the HFNC protocol. CONCLUSIONS: The implementation of a nurse-led high-flow nasal cannula protocol was associated with a reduced length of stay. RELEVANCE TO CLINICAL PRACTICE: This study demonstrated that infants with bronchiolitis that were treated with a nurse-led high-flow nasal cannula (HFNC) therapy protocol had positive effects on clinical outcomes including a shorter length of stay than compared with those with physician-directed care in a regional paediatric unit. A weight-based (2 L/kg) HFNC therapy was safely administered to infants with bronchiolitis in a regional hospital paediatric ward with no paediatric intensive care unit (PICU).

Effect of infusion set replacement intervals on catheter-related bloodstream infections (RSVP): a randomised, controlled, equivalence (central venous access device)-non-inferiority (peripheral arterial catheter) trial.

BACKGROUND: The optimal duration of infusion set use to prevent life-threatening catheter-related bloodstream infection (CRBSI) is unclear. We aimed to compare the effectiveness and costs of 7-day (intervention) versus 4-day (control) infusion set replacement to prevent CRBSI in patients with central venous access devices (tunnelled cuffed, non-tunnelled, peripherally inserted, and totally implanted) and peripheral arterial catheters. METHODS: We did a randomised, controlled, assessor-masked trial at ten Australian hospitals. Our hypothesis was CRBSI equivalence for central venous access devices and non-inferiority for peripheral arterial catheters (both 2% margin). Adults and children with expected greater than 24 h central venous access device-peripheral arterial catheter use were randomly assigned (1:1; stratified by hospital, catheter type, and intensive care unit or ward) by a centralised, web-based service (concealed before allocation) to infusion set replacement every 7 days, or 4 days. This included crystalloids, non-lipid parenteral nutrition, and medication infusions. Patients and clinicians were not masked, but the primary outcome (CRBSI) was adjudicated by masked infectious diseases physicians. The analysis was modified intention to treat (mITT). This study is registered with the Australian New Zealand Clinical Trials Registry ACTRN12610000505000 and is complete. FINDINGS: Between May 30, 2011, and Dec, 9, 2016, from 6007 patients assessed, we assigned 2944 patients to 7-day (n=1463) or 4-day (n=1481) infusion set replacement, with 2941 in the mITT analysis. For central venous access devices, 20 (1·78%) of 1124 patients (7-day group) and 16 (1·46%) of 1097 patients (4-day group) had CRBSI (absolute risk difference [ARD] 0·32%, 95% CI -0·73 to 1·37). For peripheral arterial catheters, one (0·28%) of 357 patients in the 7-day group and none of 363 patients in the 4-day group had CRBSI (ARD 0·28%, -0·27% to 0·83%). There were no treatment-related adverse events. INTERPRETATION: Infusion set use can be safely extended to 7 days with resultant cost and workload reductions. FUNDING: Australian National Health and Medical Research Council.

Interventions for interpersonal communication about end of life care between health practitioners and affected people.

BACKGROUND: Communication about end of life (EoL) and EoL care is critically important for providing quality care as people approach death. Such communication is often complex and involves many people (patients, family members, carers, health professionals). How best to communicate with people in the period approaching death is not known, but is an important question for quality of care at EoL worldwide. This review fills a gap in the evidence on interpersonal communication (between people and health professionals) in the last year of life, focusing on interventions to improve interpersonal communication and patient, family member and carer outcomes. OBJECTIVES: To assess the effects of interventions designed to improve verbal interpersonal communication about EoL care between health practitioners and people affected by EoL. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, PsycINFO, and CINAHL from inception to July 2018, without language or date restrictions. We contacted authors of included studies and experts and searched reference lists to identify relevant papers. We searched grey literature sources, conference proceedings, and clinical trials registries in September 2019. Database searches were re-run in June 2021 and potentially relevant studies listed as awaiting classification or ongoing. SELECTION CRITERIA: This review assessed the effects of interventions, evaluated in randomised and quasi-randomised trials, intended to enhance interpersonal communication about EoL care between patients expected to die within 12 months, their family members and carers, and health practitioners involved in their care. Patients of any age from birth, in any setting or care context (e.g. acute catastrophic injury, chronic illness), and all health professionals involved in their care were eligible. All communication interventions were eligible, as long as they included interpersonal interaction(s) between patients and family members or carers and health professionals. Interventions could be simple or complex, with one or more communication aims (e.g. to inform, skill, engage, support). Effects were sought on outcomes for patients, family and carers, health professionals and health systems, including adverse (unintended) effects. To ensure this review's focus was maintained on interpersonal communication in the last 12 months of life,  we excluded studies that addressed specific decisions, shared or otherwise, and the tools involved in such decision-making. We also excluded studies focused on advance care planning (ACP) reporting ACP uptake or completion as the primary outcome. Finally, we excluded studies of communication skills training for health professionals unless patient outcomes were reported as primary outcomes. DATA COLLECTION AND ANALYSIS: Standard Cochrane methods were used, including dual review author study selection, data extraction and quality assessment of the included studies. MAIN RESULTS: Eight trials were included. All assessed intervention effects compared with usual care. Certainty of the evidence was low or very low. All outcomes were downgraded for indirectness based on the review's purpose, and many were downgraded for imprecision and/or inconsistency. Certainty was not commonly downgraded for methodological limitations. A summary of the review's findings is as follows. Knowledge and understanding (four studies, low-certainty evidence; one study without usable data): interventions to improve communication (e.g. question prompt list, with or without patient and physician training) may have little or no effect on knowledge of illness and prognosis, or information needs and preferences, although studies were small and measures used varied across trials.  Evaluation of the communication (six studies measuring several constructs (communication quality, patient-centredness, involvement preferences, doctor-patient relationship, satisfaction with consultation), most low-certainty evidence): across constructs there may be minimal or no effects of interventions to improve EoL communication, and there is uncertainty about effects of interventions such as a patient-specific feedback sheet on quality of communication.  Discussions of EoL or EoL care (six studies measuring selected outcomes, low- or very low-certainty evidence): a family conference intervention may increase duration of EoL discussions in an intensive care unit (ICU) setting, while use of a structured serious illness conversation guide may lead to earlier discussions of EoL and EoL care (each assessed by one study). We are uncertain about effects on occurrence of discussions and question asking in consultations, and there may be little or no effect on content of communication in consultations.  Adverse outcomes or unintended effects (limited evidence): there is insufficient evidence to determine whether there are adverse outcomes associated with communication interventions  (e.g. question prompt list, family conference, structured discussions) for EoL and EoL care. Patient and/or carer anxiety was reported by three studies, but judged as confounded. No other unintended consequences, or worsening of desired outcomes, were reported. Patient/carer quality of life (four studies, low-certainty evidence; two without useable data): interventions to improve communication may have little or no effect on quality of life.  Health practitioner outcomes (three studies, low-certainty evidence; two without usable data): interventions to improve communication may have little or no effect on health practitioner outcomes (satisfaction with communication during consultation; one study); effects on other outcomes (knowledge, preparedness to communicate) are unknown. Health systems impacts: communication interventions (e.g. structured EoL conversations) may have little or no effect on carer or clinician ratings of quality of EoL care (satisfaction with care, symptom management, comfort assessment, quality of care) (three studies, low-certainty evidence), or on patients' self-rated care and illness, or numbers of care goals met (one study, low-certainty evidence). Communication interventions (e.g. question prompt list alone or with nurse-led communication skills training) may slightly increase mean consultation length (two studies), but other health service impacts (e.g. hospital admissions) are unclear. AUTHORS' CONCLUSIONS: Findings of this review are inconclusive for practice. Future research might contribute meaningfully by seeking to fill gaps for populations not yet studied in trials; and to develop responsive outcome measures with which to better assess the effects of communication on the range of people involved in EoL communication episodes. Mixed methods and/or qualitative research may contribute usefully to better understand the complex interplay between different parties involved in communication, and to inform development of more effective interventions and appropriate outcome measures. Co-design of such interventions and outcomes, involving the full range of people affected by EoL communication and care, should be a key underpinning principle for future research in this area.

Women's use of non-conventional herbal uterotonic in pregnancy and labour: evidence from birth attendants.

BACKGROUND: Over the years, governments and stakeholders have implemented various policies/programmes to improve maternal health outcomes in low-middle-income countries. In Ghana, Community Health Officers were trained as midwives to increase access to skilled maternal healthcare. The government subsequently banned traditional birth attendants from providing direct maternal healthcare in 2000. Despite these, there is an unprecedented utilisation of TBAs' services, including herbal uterotonics. This has attempted to defeat stakeholders' campaigns to improve maternal health outcomes. Thus, we explored and highlighted herbal uterotonic consumption in pregnancy and birth and the implications on maternal and newborn health outcomes in North-Western Ghana. METHODS: This was an exploratory qualitative study that investigated traditional birth attendants (n = 17) and healthcare providers' (n = 26) perspectives on the intake of herbal uterotonics in pregnancy and childbirth in rural Ghana, using in-depth interviews. A combination of convenience, purposive and snowball sampling procedures were employed in selecting participants. RESULTS: Findings were captured in two domains: (1) perceived rationale for herbal uterotonic intake, and (2) potential adverse impacts of herbal uterotonic intake in pregnancy and labour, and nine topics: (i) confidence in unskilled attendance at birth, (ii) cost and a shortage of essential medicines, (iii) herbal uterotonics as a remedy for obstetric problems, (iv) herbal uterotonics facilitate birth, (v) attraction of home birth for cultural reasons, (vi) affordability of herbal uterotonics, (vii) unintended consequences and adverse outcomes, (viii) risks using herbal uterotonics to manage fertility and (ix) risks using herbal uterotonics to facilitate home birth. CONCLUSION: The findings have suggested that the intake of non-conventional herbal uterotonic is widespread in the study area, although the constituents of the herb are unknown. However, complex and multiple factors of healthcare cost, desire for homebirth, unawareness of the negative effects of such substances, perceived way of addressing obstetric problems and cultural undertones, among others, accounted for herbal uterotonics consumption. We also encourage research into the constituents of 'mansugo' and the potential benefits and adverse effects. We recommend qualitative studies involving previous users of this herbal uterotonic to inform policy and healthcare provision.

Integrated review of the knowledge, attitudes, and practices of maternity health care professionals concerning umbilical cord clamping.

BACKGROUND: Umbilical cord clamp timing has implications for newborn health, which include increased iron stores up to 6 months of age. National and International cord clamping guidelines differ as do health professionals' practices. The rationale for differences in cord clamping practice is unclear. AIMS AND OBJECTIVE: Studies on the knowledge, attitudes, and practices of maternity health care professionals about cord clamp timing were synthesized. Similarities and differences between professional groups and understanding of the optimal timing of cord clamp timing for term newborns were compared. METHODS: An integrative review was undertaken. PubMed, Scopus, MIDIRS, CINAHL, and Google Scholar were searched. Publication date limits were set between January 2007 and December 2020. Quality appraisal was undertaken using the Critical Appraisal Skills Program (CASP) tools. RESULTS: Eighteen studies met inclusion criteria, as they included primary research studies that investigated maternity health care professionals' knowledge, attitudes, and practices about umbilical cord clamping, and were written in English. Four main subject areas were identified: a) knowledge of optimal cord clamp timing; b) attitudes and perceptions of early vs deferred cord clamping; c) cord clamping practice; and d) rationale for cord clamping practice. CONCLUSIONS: Different attitudes and practices were identified between midwifery and medical professionals in relation to cord clamp timing together with health professional knowledge and practice gaps pertaining to optimal cord clamp timing. Contemporary evidence should inform guidelines for clinical practice and be embedded into maternity health professional curricula and professional development programs.

Challenges parents encounter when implementing infant safe sleep advice.

AIM: To understand which safe sleep recommendations parents find most challenging to implement, identifying common barriers encountered; and investigate whether challenges are associated with practices employed. METHODS: A cross-sectional survey of 3341 Australian families with young infants who birthed a live baby during April-May 2017. Caregivers were asked about infant care practices and family characteristics. Qualitative free-text items explored challenges faced with current safe sleep recommendations. RESULTS: Nearly one-third (n = 1033, 31%) of caregivers reported difficulty with at least one safe sleep recommendation. Infant sleep position and avoiding bed-sharing were identified as the most challenging recommendations. Caregivers described barriers which influenced consistency in uptake of advice. Families who described difficulty with a recommendation were significantly less likely to consistently employ that advice compared to those who did not report difficulty (sleep position: 198/473,42% vs 2548/2837,90% [p < 0.0001]; own sleep space: (269/344,78% vs 1331/2884,46% [p < 0.0001]). When families encountered challenges, they often proposed alternate strategies with an inference their substitute action compensated potential increased risk. CONCLUSION: Many families encounter difficulties implementing safe sleep advice; these challenges negatively impact care practices. Effective interventions meeting individual family needs, to provide safe sleep environments consistently, are necessary to improve sleep-related infant care and further reduce infant mortality.

Priority setting: Consensus for Australia's infant safe sleeping public health promotion programme.

AIM: To develop focused priorities to inform the revision of Australia's Sudden Unexpected Death in Infancy (SUDI) risk reduction public health programme. METHODS: A content expert consensus research activity was designed using two consensus techniques. The two-phase study employed a Delphi process (phase 1) and a Nominal Group workshop technique (phase 2). The Delphi invited 56 national and international content experts. The Nominal Group comprised 17 Australasian experts and stakeholders to ensure priority setting was relevant to the Australian context. RESULTS: Phase 1 established a ranked thematic list of 10 key SUDI risk reduction themes. Phase 2 addressed three nominal questions producing prioritised lists for: key-message wording; contextual information and strategies to support caregiver implementation of key messages; and considerations in redesigning and dissemination of a safe sleep campaign. The top four priority themes were: sleep position, sleep space, smoking and surface-sharing. CONCLUSION: This two-phase priority setting was successful in establishing clearly defined infant safe sleep priorities. International content expert participation in phase 1 strengthened priority setting outcomes while phase 2 ensured final outcomes provided a strong national focus reflective of identified needs of Australian families. Findings provide a foundation from which important components can be considered when revising and developing future SUDI risk reduction programmes.

An evaluation of pathologists' application of the diagnostic criteria from the San Diego definition of SIDS and unclassified sudden infant death.

Despite being widely used, few studies have assessed the utility of the San Diego definition of sudden infant death syndrome (SIDS). The purpose of this study was to evaluate pathologists' application of the San Diego definition in all cases of sudden unexpected death in infancy (SUDI) that occurred in Queensland, Australia, between 2010 and 2014. Key coronial documents of 228 cases of SUDI were reviewed independently by three reviewers and classified according to the San Diego definition. Clear guidance regarding the evidentiary threshold for classification and interpretation of the San Diego definition was provided. All reviewers classified cases identically in 202 cases (88.6%). Consensus was achieved on the classification of the remaining 26 deaths following case discussion. After review, 79 cases were classified as SIDS, a one third reduction compared with the original classification, mainly due to a high probability of accidental asphyxia. The number of cases classified as undetermined (USID) almost doubled (75/228, 32.9%), and there was more than a fivefold increase in cases classified as asphyxia (43/228, 18.9%). Natural conditions decreased by approximately one third (21/228, 9.2%). This study demonstrates that with clear guidelines for interpretation, the San Diego definition can be applied reliably, with discrepancies resolved through a process of peer review.

Maternity health professionals' perspectives of cord clamp timing, cord blood banking and cord blood donation: a qualitative study.

BACKGROUND: Parents today have several options for the management of their infant's cord blood during the third stage of labour. Parents can choose to have their infant's cord clamped early or to have deferred cord clamping. If the cord is clamped early, cord blood can be collected for private cord blood banking or public cord blood donation for use later if needed. If cord clamping is deferred, the placental blood physiologically transfuses to the neonate and there are physiological advantages to this. These benefits include a smoother cardiovascular transition and increased haemoglobin levels while not interfering with the practice of collecting cord blood for gases if needed. The aim of this study is to explore Australian maternity health professionals' perspectives towards cord clamp timing, cord blood banking and cord blood donation. METHODS: Fourteen maternity health professionals (midwives and obstetricians) from both private and public practice settings in Australia participated in semi-structured interviews either in person or by telephone. Interviews were transcribed and data analysed using thematic analysis. RESULTS: Overall there was strong support for deferred cord clamping, and this was seen as important and routinely discussed with parents as part of antenatal care. However, support did not extend to the options of cord blood banking and donation and to routinely informing parents of these options even when these were available at their birthing location. CONCLUSION: Formalised education for maternity health professionals is needed about the benefits and implications of cord blood banking and cord blood donation so that they have the confidence to openly discuss all options of cord clamp timing, cord blood banking and cord blood donation to facilitate informed decision-making by parents.

Infant care practices and parent uptake of safe sleep messages: a cross-sectional survey in Queensland, Australia.

BACKGROUND: Globally, the incidence of sleep-related infant mortality declined dramatically following the first public health campaigns seen internationally in the 1990s to reduce the risks of sudden infant death. However, Australian Sudden Unexpected Death in Infancy (SUDI) rates have plateaued with little change in incidence since 2004 despite two further public health safe sleep campaigns. This study aims to describe contemporary infant care practices employed by families related to the current public health SUDI prevention program. METHODS: A cross-sectional survey of 3341 Queensland primary caregivers with infants approximately 3-months of age was conducted using the Queensland Registry of Births, Deaths and Marriages as a sampling frame. Surveys were returned either via reply-paid mail or online. Questionnaires explored prevalence of infant care practices and awareness of safe sleep recommendations. Univariable analysis was used to generate descriptive statistics for key variables. RESULTS: Overall, only 13% of families routinely practised all six 'Safe Sleeping' program messages. More than one third (1118, 34%) of infants had slept in a non-supine sleep position at some time. Potentially hazardous sleep environments were common, with 38% of infants sleeping with soft items or bulky bedding, or on soft surfaces. Nearly half, for either day- or night-time sleeps, were routinely placed in a sleep environment that was not designed or recommended for safe infant sleep (i.e. a bouncer, pram, beanbag). Most babies (84%) were reportedly smoke free before and after birth. Sleeping in the same room as their caregiver for night-time sleeps was usual practice for 75% of babies. Half (1600, 50%) of all babies shared a sleep surface in the last two-weeks. At 8-weeks, 17% of infants were no longer receiving any breastmilk. CONCLUSIONS: The prevalence rates of infant care practices among this Australian population demonstrate many families continue to employ suboptimal practices despite Australia's current safe sleep campaign. Strategic approaches together with informed decisions about pertinent messages to feature within future public health campaigns and government policies are required so targeted support can be provided to families with young infants to aid the translation of safe sleep evidence into safe sleeping practices.

Prevalence of risk factors for sudden infant death among Indigenous and non-Indigenous people in Australia.

AIM: To examine differences in the prevalence of risk factors for sudden unexpected death in infancy (SUDI) between Aboriginal and Torres Strait Islander and non-Indigenous infants. METHODS: A retrospective cohort study of SUDI in Queensland during 2010-2014 examined exposure to SUDI risk factors, to identify factors accounting for higher SUDI mortality among Indigenous infants. A multistage algorithm was applied to linked data to determine Indigenous status. RESULTS: There were 228 SUDI, of which Indigenous infants comprised 26.8%. The Indigenous SUDI rate was 2.13/1000 live births compared to 0.72/1000 for non-Indigenous. The disparity between Indigenous and non-Indigenous SUDI was accounted for by surface sharing (OR = 2.93 95% CI = 1.41, 6.07), smoking (OR = 2.49, 95% CI = 1.13, 5.52), and a combination of background antenatal and sociodemographic factors (inadequate antenatal care [OR = 6.93, 95% CI = 2.20, 21.86], young maternal age at first birth [OR = 4.02, 95% CI = 1.49, 10.80] and outer regional [OR = 3.03, 95% CI = 1.37, 6.72] and remote locations [OR = 11.31, 95% CI = 3.47, 36.83]). CONCLUSION: Culturally responsive prevention efforts, including wrap-around maternity care and strategies that reduce maternal smoking and promote safer yet culturally acceptable ways of surface sharing, may reduce Indigenous SUDI mortality.

The use of post-mortem lividity to determine sleep position in sudden unexpected deaths in infancy.

AIM: To compare parental reports of position found in sudden unexpected deaths in infancy (SUDI) to autopsy reports of lividity and to more accurately classify infant sleep position. METHODS: Cases of SUDI in Queensland between 2010 and 2014 were reviewed to determine the position in which infants were reported to have been placed and found. This was compared to the distribution of post-mortem lividity at autopsy. Evidence of lividity present during early death scene investigation was also recorded. RESULTS: There was a discordance between the position an infant was reported to have been found and the position of lividity at autopsy in 22/228 SUDI (9.6%). All infants had anterior lividity despite 13 reportedly found supine, three on their side and six in an unknown position. Using anterior lividity at autopsy to change the position found increased the proportion of prone infants from 37.7% to 47.4%. In 47.8% cases, anterior or lateral lividity reported at the scene was no longer present at autopsy. CONCLUSION: Previously published odds ratios may have underestimated the risk of sudden infant death associated with prone sleep position. SUDI death scene investigation protocols should require photographic documentation of lividity prior to transporting an infant.

Narratives on why pregnant women delay seeking maternal health care during delivery and obstetric complications in rural Ghana.

BACKGROUND: Despite the many maternal healthcare policy programmes in Ghana such as free the antenatal care (ANC) and the fee-exemption policy under the National Health Insurance Scheme, among others, the country has yet to make substantial improvements in addressing low skilled care utilisation in pregnancy and delivery. From previous studies, maternal mortality has been linked to women's healthcare decision-making power at the household level in many low and middle-income countries. Thus, a pregnant women's ability to choose a healthcare provider, act on her preferences, and to be sufficiently financially empowered to take the lead in deciding on reproductive and pregnancy care has significant effects on service utilisation outcomes. Therefore, we explored rural community-level barriers to seeking care related to obstetric complications and delivery from the perspectives of mothers, youth, opinion leaders and healthcare providers in Nadowli-Kaleo and Daffiama-Bussie-Issa districts in the Upper West Region of Ghana. METHODS: This exploratory qualitative study was based on the narratives of women, health providers and community stakeholders regarding the expectant women's autonomy to decide and utilise maternal care. To achieve maximal diversity of responses, purposive sampling procedures were followed in selecting 16 health professionals, three traditional birth attendants and 240 community members (opinion leaders, youth and non-pregnant women) who participated in individual depth interviews and focus group discussions. RESULTS: Women's lack of autonomy to seek care without prior permission, perceived quality care of traditional birth attendants, stigmatisation of unplanned pregnancies and cultural beliefs associated with late disclosure of childbirth labour all delayed mothers timely use of skilled care in the study communities. These barriers compounded problems arising from communities that are geographically isolated from hospital care. CONCLUSIONS: Decisions about seeking maternal care were usually made by the expectant woman's husband and family without providing adequate support to pregnant women during the latter stages of pregnancy and delivery. We conclude that this is primarily a cultural issue. The study recommends a change in the approach to community-level health education campaigns for maximum impacts through the increased involvement of men and families in health service delivery and utilisation.

How reliable is parental/carer assessment of infant health status?

Problems often arise in cases of lethal inflicted injury in infants and children in determining the chronology of events. However, on occasion it may be assumed that a parent's statement that the child appeared normal at a particular time is correct. It is then inferred that the lethal injury occurred after this time. In a study of infants from Queensland, Australia a significant number of cases occurred where a parent/carer did not actually recognise that an infant was deceased or in extremis despite handling of the infants, some of whom had established rigor mortis. Assessment of their infant's health status was quite flawed, presumably due to inattention, fatigue, or confirmatory bias (seeing what is expected). This could also apply to infants with head injuries who may manifest quite non-specific signs such as lethargy, somnolence or alteration in conscious state, manifestations that could easily be confused with normal drowsiness or sleep. Thus, the evaluation of parent/carer statements must be tempered by the knowledge that their opinions may not always (for completely understandable reasons) be reliable, and should not be uncritically accepted as a basis for deciding the time course for a lethal process.

Parents' knowledge, awareness and attitudes of cord blood donation and banking options: an integrative review.

BACKGROUND: For over 25 years cord blood has been used as an alternative to bone marrow for therapeutic use in conditions of the blood, immune system and metabolic disorders. Parents can decide if they would like to privately store their infant's cord blood for later use if needed or to publicly donate it. Parents need to be aware of the options that exist for their infant's cord blood and have access to the relevant information to inform their choice. The aim of this paper is to identify parent's knowledge and awareness of cord blood donation, private banking options and stem cell use, and parent sources and preferred sources of this information. METHODS: An integrative review was conducted using several electronic databases to identify papers on parents' knowledge, attitudes and attitudes towards umbilical cord blood donation and banking. The CASP tool was used to determine validity and quality of the studies included in the review. RESULTS: The search of the international literature identified 25 papers which met review inclusion criteria. This integrative review identified parents' knowledge of cord banking and/or donation as low, with awareness of cord blood banking options greater than knowledge. Parents were found to have positive attitudes towards cord blood donation including awareness of the value of cord blood and its uses, with the option considered to be an ethical and altruistic choice. Knowledge on cord blood use were mixed; many studies' participants did not correctly identify uses. Information sources for parents on cord blood was found to be varied, fragmented and inconsistent. Health professionals were identified as the preferred source of information on cord blood banking for parents. CONCLUSIONS: This integrative review has identified that further research should focus on identifying information that expectant parents require to assist them to make informed choices around cord blood banking; and identifying barriers present for health professionals providing evidence based information on cord blood use and banking options.

Identifying the risk: a prospective cohort study examining postpartum haemorrhage in a regional Australian health service.

BACKGROUND: In industrialised countries the incidence of postpartum haemorrhage (PPH) is increasing, for which exact etiology is not well understood. Studies have relied upon retrospective data with estimated blood loss as the primary outcome, known to be underestimated by clinicians. This study aimed to explore variables associated with PPH in a cohort of women birthing vaginally in coastal Queensland, Australia, using the gravimetric method to measure blood loss. METHODS: Women were prospectively recruited to participate using an opt-out consent process. Maternal demographics; pregnancy history; model of care; mode of birth; third stage management practices; antenatal, intrapartum and immediate postpartum complications; gravimetric and estimated blood loss; and haematological laboratory data, were collected via a pre-designed data collection instrument. Descriptive statistics were used for demographic, intrapartum and birthing practices. A General Linear Model was used for multivariate analysis to examine relationship between gravimetric blood loss and demographic, birthing practices and intrapartum variables. The primary outcome was a postpartum haemorrhage (blood loss > 500 ml). RESULTS: 522 singleton births were included in the analysis. Maternal mean age was 29 years; 58% were multiparous. Most participants received active (291, 55.7%) or modified active management of third stage (191, 36.6%). Of 451 births with valid gravimetric blood loss recorded, 35% (n = 159) recorded a loss of 500 ml or more and 111 (70%) of these were recorded as PPH. Gravimetric blood loss was strongly correlated with estimated blood loss (r = 0.88; p < 0.001). On average, the estimated blood loss was lower than the gravimetric blood loss, about 78% of the measured value. High neonatal weight, perineal injury, complications during labour, separation of mother and baby, and observation of a gush of blood were associated with PPH. Nulliparity, labour induction and augmentation, syntocinon use were not associated with PPH. CONCLUSIONS: In contrast to previous study findings, nulliparity, labour induction and augmentation were not associated with PPH. Estimation of blood loss was relatively accurate in comparison to gravimetric assessment; raising questions about routine gravimetric assessment of blood loss following uncomplicated births. Further research is required to investigate type and speed of blood loss associated with PPH.

Attitudes to lesbian, gay, bisexual and transgender parents seeking health care for their children in two early parenting services in Australia.

AIMS AND OBJECTIVES: To examine the attitudes to and knowledge and beliefs about homosexuality of nurses and allied professionals in two early parenting services in Australia. BACKGROUND: Early parenting services employ nurses and allied professionals. Access and inclusion policies are important in community health and early childhood service settings. However, little is known about the perceptions of professionals who work within early parenting services in relation to lesbian, gay, bisexual and transgender families. DESIGN: This is the final in a series of studies and was undertaken in two early parenting services in two states in Australia using a cross-sectional design with quantitative and qualitative approaches. METHODS: Validated questionnaires were completed by 51 nurses and allied professionals and tested with chi-squared test of independence (or Fisher's exact test), Mann-Whitney U-test, Kruskal-Wallis one-way analysis of variance or Spearman's rank correlation. Thematic analysis examined qualitative data collected in a box for free comments. RESULTS: Of the constructs measured by the questionnaires, no significant relationships were found in knowledge, attitude and gay affirmative practice scores by sociodemographic variables or professional group. However, attitude scores towards lesbians and gay men were significantly negatively affected by conservative political affiliation (p = 0·038), held religious beliefs (p = 0·011) and frequency of praying (p = 0·018). Six overall themes were found as follows: respect, parenting role, implications for the child, management, disclosure, resources and training. CONCLUSIONS: The study provided an in-depth analysis of the attitudes, knowledge and beliefs of professionals in two early parenting services, showing that work is needed to promote acceptance of diversity and the inclusion of lesbian, gay, bisexual and transgender families in planning, developing, evaluating and accessing early parenting services. RELEVANCE TO CLINICAL PRACTICE: Access and inclusion plans for lesbian, gay, bisexual and transgender families are crucial in early parenting services in Australia and should be included in professional development programmes.

New Frameworks for Understanding Sudden Unexpected Deaths in Infancy (SUDI) in Socially Vulnerable Families.

THEORETICAL PRINCIPLES: Sociological frameworks may enhance understanding of the complex and multidimensional nature of disadvantage, which is prevalent among families who experience Sudden Unexpected Death in Infancy (SUDI). PHENOMENA ADDRESSED: SUDI is the largest category of postneonatal death and largely associated with the social determinants of health. The highly successful 'Back to Sleep' campaign has resulted in a more than 85% decrease in SUDI. However, social inequalities have accompanied this decrease, and the burden of SUDI now lies with the most disadvantaged and socially vulnerable families. A considerable body of research on the phenomena of SUDI and disadvantage has been published over the last decade, demonstrating the widening social gradient in SUDI, and the importance in recognising structural factors and the multifactorial nature of disadvantage. Gaps in understanding of risk factors and scepticism about the received wisdom of health professionals have emerged as central themes in understanding why socially vulnerable families may adopt unsafe infant care practices. The direct impact of social disadvantage on infant care has also been recognised. RESEARCH LINKAGES: The translation of epidemiological findings regarding SUDI risk into public health recommendations for health professionals and families alike has to date focused on eliminating individual level risk behaviours. Unfortunately, such a model largely ignores the broader social, cultural, and structural contexts in which such behaviours occur. Translating the new knowledge offered by sociological frameworks and the principles of behavioural economics into evidence based interventions may assist in the reduction of SUDI mortality in our most socially vulnerable families.

Barriers to Addressing Social Determinants of Health in Pediatric Nursing Practice: An Integrative Review.

PROBLEM: Despite a substantial body of knowledge regarding the importance of the social determinants of health, recognizing and responding to the psychosocial circumstances of seriously and chronically ill children and their families is not well established in routine pediatric nursing care. ELIGIBILITY CRITERIA: The search process focused on psychological and social determinants and care in the healthcare setting. Searches were limited to research and review publications written in the English language. The quality of evidence was graded using the National Health and Medical Research Council evidence hierarchy. RESULTS: Thirteen publications were identified for inclusion. Healthcare providers do recognize emotional distress experienced by patients, but feel unable to address psychosocial issues due to the lack of time, a lack of confidence in their own communication skills, and the perception that patients and their families prioritize physical care over psychosocial care. For patients and their families the main issue was that the healthcare system was focused on physical care with little opportunity to talk about psychosocial concerns. CONCLUSIONS: The greatest barrier to addressing the social determinants of health in the pediatric context is the dominance of the 'medical model' of care. Also, many healthcare providers believe that they lack the communication skills necessary to talk about psychosocial issues. IMPLICATIONS: The way forward will be to empower nurses through the sharing of knowledge of the social determinants of health, the development of skills in relationship building and therapeutic communication, and the mentorship of compassionate family-centered care.