The impact of motivational interviewing on participation in childbirth preparation classes and having a natural delivery: a randomised trial

Factors associated with spontaneous vaginal birth in nulliparous women: A descriptive systematic review

PROBLEM

Spontaneous vaginal birth (SVB) rates for nulliparous women are declining internationally.

BACKGROUND

There is inadequate understanding of factors affecting this trend overall and limited large-scale responses to improve women's opportunity to birth spontaneously.

AIM

To undertake a descriptive systematic review identifying factors associated with spontaneous vaginal birth at term, in nulliparous women with a singleton pregnancy.

METHODS

Quantitative studies of all designs, of nulliparous women with a singleton pregnancy and cephalic presentation, who experienced a SVB at term were included. Nine databases were searched (inception to October 2022). Two reviewers undertook quality appraisal; Randomised Controlled Trials (RCTs) with high risk of bias (ROB 2.0) and other designs with (QATSDD) scoring ≤ 50% were excluded.

FINDINGS

Data were abstracted from 90 studies (32 RCTs, 39 cohort, 9 cross-sectional, 4 prevalence, 5 case control, 1 quasi-experimental). SVB rates varied (13%-99%). Modifiable factors associated with SVB included addressing fear of childbirth, low impact antenatal exercise, maternal positioning during second-stage labour and midwifery led care. Complexities arising during pregnancy and regional analgesia were shown to decrease SVB and other interventions, such as routine induction of labour were equivocal.

DISCUSSION

Antenatal preparation (low impact exercise, childbirth education, addressing fear of childbirth) may increase SVB, as does midwifery continuity-of-care. Intrapartum strategies to optimise labour progression emerged as promising areas for further research.

CONCLUSION

Declining SVB rates may be improved through multi-factorial approaches inclusive of maternal, fetal and clinical care domains. However, the variability of SVB rates testifies to the complexity of the issue.

Outcomes from a pilot genetic counseling intervention using motivational interviewing and the extended parallel process model to increase cascade cholesterol screening

Familial hypercholesterolemia (FH) is an inherited condition resulting in increased risk of premature cardiovascular disease. This risk can be reduced with early diagnosis and treatment, but it can be challenging to identify individuals with FH. Cascade screening, the most efficient and cost-effective identification method, requires FH patients to communicate with their at-risk family and encourage them to pursue screening. Beyond FH, patients with conditions increasing disease risk to family members report barriers to the communication process such as insufficient knowledge of the condition and discomfort informing relatives. We conducted a pilot study of a genetic counseling intervention incorporating behavior-change principles from motivational interviewing (MI) and the extended parallel process model (EPPM) to help parents of children with FH overcome these barriers and improve cascade screening rates for FH. Of the 13 participants who completed the intervention and post-intervention surveys, 6 reported contacting and/or screening additional relatives. A large effect size in increasing communication and screening was observed (η²  = 0.20), with the mean percent of at-risk relatives contacted rising from 33% to 45%, and the mean percent screened rising from 32% to 42%. On average, 2.23 new relatives were contacted and 2.46 were screened, per participant, by the end of the study. Direct content analysis revealed that despite the open-ended nature of the goal-setting process, participant goals fell into two categories including those who set goals focused on communicating with and screening family members (n = 9) and those who set goals only focused on managing FH (n = 4). Overall, the communication and screening rates reported after the intervention were higher than previous observations in adult FH populations. These results suggest this EPPM/MI genetic counseling intervention could be a useful tool for increasing communication and cascade screening for FH. With further research on goal-setting techniques, the intervention could be refined and replicated to identify more individuals affected by FH or modified for use with other actionable genetic conditions.

Reducing emergency cesarean delivery and improving the primiparous experience: Findings of the RECIPE study

OBJECTIVE

The ability to predict the need for emergency Cesarean delivery holds the potential to facilitate birth choices. The objective of the RECIPE study (Reducing Emergency Cesarean delivery and Improving the Primiparous Experience) was to externally validate a Cesarean delivery risk prediction model. This model, developed by the Genesis study, identified five key predictive factors for emergency Cesarean delivery: maternal age, maternal height, BMI, fetal head circumference (HC) and fetal abdominal circumference (AC).

STUDY DESIGN

This prospective, observational study was conducted in two tertiary referral perinatal centers. Inclusion criteria were as follows: primiparous women with a singleton, cephalic presentation fetus in the absence of fetal growth restriction (FGR), oligohydramnios, pre-eclampsia, pre-existing diabetes mellitus or an indication for planned Cesarean delivery. Between 38 + 0 and 40 + 6 weeks' gestational age, participants attended for prenatal assessment that enabled the determination of an individualized risk calculation for emergency Cesarean delivery during labour based on maternal height, BMI, fetal HC and AC, with crucially both participants and care providers being blinded to the resultant risk prediction score. Labor, delivery and postnatal outcomes were ascertained. Calibration and receiver operator curves were generated to determine the predictive capacity for emergency Cesarean delivery of the Genesis risk prediction model in this cohort.

RESULTS

559 primiparous participants were enrolled from May 2017 to April 2019, of whom 142 (25 %) had an emergency Cesarean delivery during labour. Participants with a low predicted risk score (<10 %) had a mean predicted rate of 8% (+/- standard deviation of 2%) and a similarly low actual observed rate of Cesarean delivery (8%). Participants with a high predicted risk (>50 %) had a mean predicted Cesarean delivery rate of 64 % (+/- standard deviation of 9%) and also had a high actual observed Cesarean delivery rate (62 %). The calibration curve and receiver operating characteristic curve demonstrated that this validation study had comparable discriminatory power for emergency Cesarean delivery to that described in the original Genesis study. The Area Under the Curve (AUC) in Genesis was 0.69, whereas the AUC in RECIPE was 0.72, which reflects good predictive capacity of the risk prediction model.

CONCLUSION

The accuracy of the Genesis Cesarean delivery prediction tool is supported by this validation study.

The RECIPE study: reducing emergency Caesareans and improving the Primiparous experience: a blinded, prospective, observational study

Background

The RECIPE study aims to validate a risk prediction model for intrapartum caesarean delivery which has been developed by our group. The Genesis study was a prospective observational study carried out by the Perinatal Ireland Research Consortium across 7 clinical centres in Ireland between October 2012 and June 2015. Genesis investigated a range of maternal and fetal parameters in a prospective blinded study of 2336 singleton pregnancies between 39 + 0–41 + 0 weeks’ gestational age. This resulted in the development of a risk prediction model for Caesarean Delivery in nulliparous women at term. The RECIPE study now proposes to provide external validation of this risk prediction tool.

Methods

In order to externally validate the model, we aim to include a centre which was not involved in the original study. We propose a trial of risk-assignment for intrapartum caesarean amongst nulliparous women with a singleton pregnancy between 38 + 0 and 40 + 6 weeks’ gestational age who are planning a vaginal birth. Results of the risk prediction tool will be concealed from participants and from midwives and doctors providing labour care.. Participants will be invited for an ultrasound scan and delivery details will be collated postnatally. The principal aim of this study is to externally validate the risk prediction model. This prediction model holds the potential to accurately identify nulliparous women who are likely to achieve an uncomplicated vaginal birth and those at high prospect of requiring an unplanned caesarean delivery.

Discussion

Validation of the Genesis prediction model would enable more accurate counselling for women in the antenatal setting regarding their own likelihood of requiring an intrapartum Caesarean section. It would also provide valuable personalised information to women about the anticipated course of their own labour. We believe that this is an issue of national relevance that will impact positively on obstetric practice, and will positively empower women to make considered, personalised choices surrounding labour and delivery.

Perspective of pregnant women regarding antenatal preparation: A qualitative study

BACKGROUND

Antenatal Education programs have been recommended for pregnant women to help them during gestation, childbirth and development of parenthood. Evidence on the perspectives and expectations of pregnant women regarding antenatal education in hospital settings, specifically in developing countries is still scarce. In-depth understanding is a key issue to organize interventions.

AIM

Identify experiences, needs and expectations of a group of pregnant women regarding antenatal education.

METHODS

A qualitative study was conducted. Data were collected through semi-structured interviews at the antenatal clinic of a public maternity teaching hospital in the southeastern region of Brazil. The interviews were recorded, transcribed verbatim and thematic analysis was performed. Twenty-two pregnant women were recruited following the logic of purposive sampling.

FINDINGS

All the participants reported they would like to receive guidance on non-pharmacological techniques for pain management during labor. The participants reported barriers to performed physical exercise; however, they also said that if they were encouraged by healthcare professionals they would exercise. According to the majority, the exercises should be of low intensity, and the improvement of general wellbeing was the most commented benefit. Also participants said that antenatal education meetings should be linked to antenatal consultations to facilitate participation. According to some participants, knowledge about antenatal education was acquired in conversations with other women, from lay media, and some reported a lack of guidance during antenatal consultation.

CONCLUSION

The participants of our study reported they would like to participate in antenatal education groups to receive guidance on non-pharmacological techniques to use during labor and childbirth.

Telehealth Interventions Designed for Women: an Evidence Map

BACKGROUND

Telehealth employs technology to connect patients to the right healthcare resources at the right time. Women are high utilizers of healthcare with gender-specific health issues that may benefit from the convenience and personalization of telehealth. Thus, we produced an evidence map describing the quantity, distribution, and characteristics of evidence assessing the effectiveness of telehealth services designed for women.

METHODS

We searched MEDLINE^® (via PubMed^®) and Embase^® from inception through March 20, 2018. We screened systematic reviews (SRs), randomized trials, and quasi-experimental studies using predetermined eligibility criteria. Articles meeting inclusion criteria were identified for data abstraction. To assess emerging trends, we also conducted a targeted search of ClinicalTrials.gov .

RESULTS

Two hundred thirty-four primary studies and three SRs were eligible for abstraction. We grouped studies into focused areas of research: maternal health (n = 96), prevention (n = 46), disease management (n = 63), family planning (n = 9), high-risk breast cancer assessment (n = 10), intimate partner violence (n = 7), and mental health (n = 3). Most interventions focused on phone as the primary telehealth modality and featured healthcare team-to-patient communication and were limited in duration (e.g., < 12 weeks). Few interventions were conducted with older women (≥ 60 years) or in racially/ethnically diverse populations. There are few SRs in this area and limited evidence regarding newer telehealth modalities such as mobile-based applications or short message service/texting. Targeted search of clinical.trials.gov yielded 73 ongoing studies that show a shift in the use of non-telephone modalities.

DISCUSSION

Our systematic evidence map highlights gaps in the existing literature, such as a lack of studies in key women's health areas (intimate partner violence, mental health), and a dearth of relevant SRs. With few existing SRs in this literature, there is an opportunity for examining effects, efficiency, and acceptability across studies to inform efforts at implementing telehealth for women.

Pre-hypertension and the risk of diabetes mellitus incidence using a marginal structural model in an Iranian prospective cohort study

OBJECTIVES

The aim of this study was to evaluate the effect of pre-hypertension and its sub-classification on the development of diabetes.

METHODS

In this cohort study, 2,941 people 40 to 64 years old without hypertension or diabetes were followed from 2009 through 2014. According to the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC)-7 criteria, we classified participants into normal and pre-hypertension groups. The effect of pre-hypertension on the 5-year incidence rate of diabetes was studied using inverse probability of treatment weighting. We modeled the exposure and censored cases given confounding factors such as age, sex, body mass index, smoking, economic status, and education.

RESULTS

The 5-year incidence rate of diabetes among people with pre-hypertension and those with normal blood pressure (BP) was 12.7 and 9.7%, respectively. The risk ratio (RR) for people with pre-hypertension was estimated to be 1.13 (95% confidence interval [CI], 0.90 to 1.41). The RRs among people with normal BP and high-normal BP, according to the JNC-6 criteria, compared to those with optimal BP were 0.96 (95% CI, 0.73 to 1.25) and 1.31 (95% CI, 1.01 to 1.72), respectively.

CONCLUSIONS

Our results showed that participants who had higher levels of BP (high-normal compared to optimal BP) had a higher risk of diabetes development. With regard to the quantitative nature of BP, using the specifically distinguishing of stage 1 hypertension or high-normal BP may be a more meaningful categorization for diabetes risk assessment than the JNC-7 classification.