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Ayers S, Coates R, Sinesi A, Cheyne H, Maxwell M, Best C, McNicol S, Williams LR, Uddin N, Hutton U, Howard G, Shakespeare J, Walker JJ, Alderdice F, Jomeen J. Assessment of perinatal anxiety: diagnostic accuracy of five measures. Br J Psychiatry 2024; 224:132-138. [PMID: 38270148 PMCID: PMC10933560 DOI: 10.1192/bjp.2023.174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 11/16/2023] [Accepted: 11/17/2023] [Indexed: 01/26/2024]
Abstract
BACKGROUND Anxiety in pregnancy and after giving birth (the perinatal period) is highly prevalent but under-recognised. Robust methods of assessing perinatal anxiety are essential for services to identify and treat women appropriately. AIMS To determine which assessment measures are most psychometrically robust and effective at identifying women with perinatal anxiety (primary objective) and depression (secondary objective). METHOD We conducted a prospective longitudinal cohort study of 2243 women who completed five measures of anxiety and depression (Generalized Anxiety Disorder scale (GAD) two- and seven-item versions; Whooley questions; Clinical Outcomes in Routine Evaluation (CORE-10); and Stirling Antenatal Anxiety Scale (SAAS)) during pregnancy (15 weeks, 22 weeks and 31 weeks) and after birth (6 weeks). To assess diagnostic accuracy a sample of 403 participants completed modules of the Mini-International Neuropsychiatric Interview (MINI). RESULTS The best diagnostic accuracy for anxiety was shown by the CORE-10 and SAAS. The best diagnostic accuracy for depression was shown by the CORE-10, SAAS and Whooley questions, although the SAAS had lower specificity. The same cut-off scores for each measure were optimal for identifying anxiety or depression (SAAS ≥9; CORE-10 ≥9; Whooley ≥1). All measures were psychometrically robust, with good internal consistency, convergent validity and unidimensional factor structure. CONCLUSIONS This study identified robust and effective methods of assessing perinatal anxiety and depression. We recommend using the CORE-10 or SAAS to assess perinatal anxiety and the CORE-10 or Whooley questions to assess depression. The GAD-2 and GAD-7 did not perform as well as other measures and optimal cut-offs were lower than currently recommended.
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Affiliation(s)
- Susan Ayers
- Centre for Maternal and Child Health Research, School of Health and Psychological Sciences, City University of London, UK
| | - Rose Coates
- Centre for Maternal and Child Health Research, School of Health and Psychological Sciences, City University of London, UK
| | - Andrea Sinesi
- Nursing, Midwifery and Allied Health Professions Research Unit, University of Stirling, UK
| | - Helen Cheyne
- Nursing, Midwifery and Allied Health Professions Research Unit, University of Stirling, UK
| | - Margaret Maxwell
- Nursing, Midwifery and Allied Health Professions Research Unit, University of Stirling, UK
| | - Catherine Best
- Nursing, Midwifery and Allied Health Professions Research Unit, University of Stirling, UK
| | - Stacey McNicol
- Nursing, Midwifery and Allied Health Professions Research Unit, University of Stirling, UK
| | - Louise R. Williams
- Centre for Maternal and Child Health Research, School of Health and Psychological Sciences, City University of London, UK
| | - Nazihah Uddin
- Centre for Maternal and Child Health Research, School of Health and Psychological Sciences, City University of London, UK
| | - Una Hutton
- Centre for Maternal and Child Health Research, School of Health and Psychological Sciences, City University of London, UK
| | | | | | - James J. Walker
- Faculty of Medicine and Health, St James's University Hospital, University of Leeds, UK
| | - Fiona Alderdice
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, UK; and School of Nursing and Midwifery, Queen's University Belfast, UK
| | - Julie Jomeen
- Faculty of Health, Southern Cross University, Australia
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Ayers S, Sinesi A, Coates R, Cheyne H, Maxwell M, Best C, McNicol S, Williams LR, Uddin N, Shakespeare J, Alderdice F. When is the best time to screen for perinatal anxiety? A longitudinal cohort study. J Anxiety Disord 2024; 103:102841. [PMID: 38367480 DOI: 10.1016/j.janxdis.2024.102841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 01/02/2024] [Accepted: 01/29/2024] [Indexed: 02/19/2024]
Abstract
BACKGROUND For screening for anxiety during pregnancy and after birth to be efficient and effective it is important to know the optimal time to screen in order to identify women who might benefit from treatment. AIMS To determine the optimal time to screen for perinatal anxiety to identify women with anxiety disorders and those who want treatment. A secondary aim was to examine the stability and course of perinatal anxiety over time. METHODS Prospective longitudinal cohort study of 2243 women who completed five screening questionnaires of anxiety and mental health symptoms in early pregnancy (11 weeks), mid-pregnancy (23 weeks), late pregnancy (32 weeks) and postnatally (8 weeks). Anxiety and mental health questionnaires were the GAD7, GAD2, SAAS, CORE-10 and Whooley questions. To establish presence of anxiety disorders diagnostic interviews were conducted with a subsample of 403 participants. RESULTS Early pregnancy was the optimal time to screen for anxiety to identify women with anxiety disorders and women wanting treatment at any time during pregnancy or postnatally. These findings were consistent across all five questionnaires of anxiety and mental health. Receiving treatment for perinatal mental health problems was most strongly associated with late pregnancy and/or postnatal assessments. Anxiety symptoms were highest in early pregnancy and decreased over time. CONCLUSION Findings show that screening in early pregnancy is optimal for identifying women who have, or develop, anxiety disorders and who want treatment. This has clear implications for practice and policy for anxiety screening during the perinatal period.
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Affiliation(s)
- Susan Ayers
- Centre for Maternal and Child Health Research, School of Health and Psychological Sciences, City, University of London, Northampton Square, London, UK.
| | - Andrea Sinesi
- Nursing, Midwifery and Allied Health Professions Research Unit, Pathfoot Building, University of Stirling, Stirling, UK
| | - Rose Coates
- Centre for Maternal and Child Health Research, School of Health and Psychological Sciences, City, University of London, Northampton Square, London, UK
| | - Helen Cheyne
- Nursing, Midwifery and Allied Health Professions Research Unit, Pathfoot Building, University of Stirling, Stirling, UK
| | - Margaret Maxwell
- Nursing, Midwifery and Allied Health Professions Research Unit, Pathfoot Building, University of Stirling, Stirling, UK
| | - Catherine Best
- Nursing, Midwifery and Allied Health Professions Research Unit, Pathfoot Building, University of Stirling, Stirling, UK
| | - Stacey McNicol
- Nursing, Midwifery and Allied Health Professions Research Unit, Pathfoot Building, University of Stirling, Stirling, UK
| | - Louise R Williams
- Centre for Maternal and Child Health Research, School of Health and Psychological Sciences, City, University of London, Northampton Square, London, UK
| | - Nazihah Uddin
- Centre for Maternal and Child Health Research, School of Health and Psychological Sciences, City, University of London, Northampton Square, London, UK
| | | | - Fiona Alderdice
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, UK
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Webb R, Ford E, Shakespeare J, Easter A, Alderdice F, Holly J, Coates R, Hogg S, Cheyne H, McMullen S, Gilbody S, Salmon D, Ayers S. Conceptual framework on barriers and facilitators to implementing perinatal mental health care and treatment for women: the MATRIx evidence synthesis. Health Soc Care Deliv Res 2024; 12:1-187. [PMID: 38317290 DOI: 10.3310/kqfe0107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
Background Perinatal mental health difficulties can occur during pregnancy or after birth and mental illness is a leading cause of maternal death. It is therefore important to identify the barriers and facilitators to implementing and accessing perinatal mental health care. Objectives Our research objective was to develop a conceptual framework of barriers and facilitators to perinatal mental health care (defined as identification, assessment, care and treatment) to inform perinatal mental health services. Methods Two systematic reviews were conducted to synthesise the evidence on: Review 1 barriers and facilitators to implementing perinatal mental health care; and Review 2 barriers to women accessing perinatal mental health care. Results were used to develop a conceptual framework which was then refined through consultations with stakeholders. Data sources Pre-planned searches were conducted on MEDLINE, EMBASE, PsychInfo and CINAHL. Review 2 also included Scopus and the Cochrane Database of Systematic Reviews. Review methods In Review 1, studies were included if they examined barriers or facilitators to implementing perinatal mental health care. In Review 2, systematic reviews were included if they examined barriers and facilitators to women seeking help, accessing help and engaging in perinatal mental health care; and they used systematic search strategies. Only qualitative papers were identified from the searches. Results were analysed using thematic synthesis and themes were mapped on to a theoretically informed multi-level model then grouped to reflect different stages of the care pathway. Results Review 1 included 46 studies. Most were carried out in higher income countries and evaluated as good quality with low risk of bias. Review 2 included 32 systematic reviews. Most were carried out in higher income countries and evaluated as having low confidence in the results. Barriers and facilitators to perinatal mental health care were identified at seven levels: Individual (e.g. beliefs about mental illness); Health professional (e.g. confidence addressing perinatal mental illness); Interpersonal (e.g. relationship between women and health professionals); Organisational (e.g. continuity of carer); Commissioner (e.g. referral pathways); Political (e.g. women's economic status); and Societal (e.g. stigma). These factors impacted on perinatal mental health care at different stages of the care pathway. Results from reviews were synthesised to develop two MATRIx conceptual frameworks of the (1) barriers and (2) facilitators to perinatal mental health care. These provide pictorial representations of 66 barriers and 39 facilitators that intersect across the care pathway and at different levels. Limitations In Review 1 only 10% of abstracts were double screened and 10% of included papers methodologically appraised by two reviewers. The majority of reviews included in Review 2 were evaluated as having low (n = 14) or critically low (n = 5) confidence in their results. Both reviews only included papers published in academic journals and written in English. Conclusions The MATRIx frameworks highlight the complex interplay of individual and system level factors across different stages of the care pathway that influence women accessing perinatal mental health care and effective implementation of perinatal mental health services. Recommendations for health policy and practice These include using the conceptual frameworks to inform comprehensive, strategic and evidence-based approaches to perinatal mental health care; ensuring care is easy to access and flexible; providing culturally sensitive care; adequate funding of services; and quality training for health professionals with protected time to do it. Future work Further research is needed to examine access to perinatal mental health care for specific groups, such as fathers, immigrants or those in lower income countries. Trial registration This trial is registered as PROSPERO: (R1) CRD42019142854; (R2) CRD42020193107. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR 128068) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 2. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Rebecca Webb
- Centre for Maternal and Child Health Research, School of Health Sciences, City, University of London, London, UK
| | - Elizabeth Ford
- Department of Primary Care and Public Health, Brighton & Sussex Medical School, Falmer, UK
| | | | - Abigail Easter
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
- Section of Women's Mental Health, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Fiona Alderdice
- Oxford Population Health, National Perinatal Epidemiology Unit (NPEU), Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | | | - Rose Coates
- Centre for Maternal and Child Health Research, School of Health Sciences, City, University of London, London, UK
| | - Sally Hogg
- The Parent-Infant Foundation, London, UK
| | - Helen Cheyne
- Nursing, Midwifery and Allied Health Professions Research Unit, University of Stirling, Stirling, UK
| | | | - Simon Gilbody
- Mental Health and Addictions Research Group, University of York, York, UK
| | - Debra Salmon
- Centre for Maternal and Child Health Research, School of Health Sciences, City, University of London, London, UK
| | - Susan Ayers
- Centre for Maternal and Child Health Research, School of Health Sciences, City, University of London, London, UK
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Webb R, Uddin N, Constantinou G, Ford E, Easter A, Shakespeare J, Hann A, Roberts N, Alderdice F, Sinesi A, Coates R, Hogg S, Ayers S. Meta-review of the barriers and facilitators to women accessing perinatal mental healthcare. BMJ Open 2023; 13:e066703. [PMID: 37474171 PMCID: PMC10360426 DOI: 10.1136/bmjopen-2022-066703] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/22/2023] Open
Abstract
Perinatal mental health (PMH) problems are common and can have an adverse impact on women and their families. However, research suggests that a substantial proportion of women with PMH problems do not access care. OBJECTIVES To synthesise the results from previous systematic reviews of barriers and facilitators to women to seeking help, accessing help, and engaging in PMH care, and to suggest recommendations for clinical practice and policy. DESIGN A meta-review of systematic reviews. REVIEW METHODS Seven databases were searched and reviewed using a Preferred Reporting Items for Systematic Reviews and Meta Analyses search strategy. Studies that focused on the views of women seeking help and accessing PMH care were included. Data were analysed using thematic synthesis. Assessing the Methodological Quality of Systematic Reviews-2 was used to assess review methodology. To improve validity of results, a qualitative sensitivity analysis was conducted to assess whether themes remained consistent across all reviews, regardless of their quality rating. RESULTS A total of 32 reviews were included. A wide range of barriers and facilitators to women accessing PMH care were identified. These mapped across a multilevel model of influential factors (individual, healthcare professional, interpersonal, organisational, political and societal) and across the care pathway (from decision to consult to receiving care). Evidence-based recommendations to support the design and delivery of PMH care were produced based on identified barriers and facilitators. CONCLUSION The identified barriers and facilitators point to a complex interplay of many factors, highlighting the need for an international effort to increase awareness of PMH problems, reduce mental health stigma, and provide woman-centred, flexible care, delivered by well trained and culturally sensitive primary care, maternity, and psychiatric health professionals. PROSPERO REGISTRATION NUMBER CRD42019142854.
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Affiliation(s)
- Rebecca Webb
- Centre for Maternal and Child Health Research, City University, London, UK
| | - Nazihah Uddin
- Centre for Maternal and Child Health Research, City University, London, UK
| | | | - Elizabeth Ford
- Department of Primary Care and Public Health, Brighton and Sussex Medical School, Brighton, UK
| | - Abigail Easter
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
- Section of Women's Mental Health, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | | | | | - Nia Roberts
- Bodleian Health Care Libraries, University of Oxford, Oxford, UK
| | - Fiona Alderdice
- Nuffield Department of Population Health, National Perinatal Epidemiology Unit, Oxford, UK
| | - Andrea Sinesi
- Nursing, Midwifery and Allied Health Professions Research Unit (NMAHP RU), University of Stirling, Stirling, UK
| | - Rose Coates
- Centre for Maternal and Child Health Research, City University, London, UK
| | - Sally Hogg
- Faculty of Education, University of Cambridge, Cambridge, UK
| | - Susan Ayers
- Centre for Maternal and Child Health Research, City University, London, UK
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Webb R, Ford E, Easter A, Shakespeare J, Holly J, Hogg S, Coates R, Ayers S. Conceptual frameworks of barriers and facilitators to perinatal mental healthcare: the MATRIx models. BJPsych Open 2023; 9:e127. [PMID: 37439097 PMCID: PMC10375902 DOI: 10.1192/bjo.2023.510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/14/2023] Open
Abstract
BACKGROUND Perinatal mental health (PMH) problems are a leading cause of maternal death and increase the risk of poor outcomes for women and their families. It is therefore important to identify the barriers and facilitators to implementing and accessing PMH care. AIMS To develop a conceptual framework of barriers and facilitators to PMH care to inform PMH services. METHOD Relevant literature was systematically identified, categorised and mapped onto the framework. The framework was then validated through evaluating confidence with the evidence base and feedback from stakeholders (women and families, health professionals, commissioners and policy makers). RESULTS Barriers and facilitators to PMH care were identified at seven levels: individual (e.g. beliefs about mental illness), health professional (e.g. confidence addressing perinatal mental illness), interpersonal (e.g. relationship between women and health professionals), organisational (e.g. continuity of carer), commissioner (e.g. referral pathways), political (e.g. women's economic status) and societal (e.g. stigma). The MATRIx conceptual frameworks provide pictorial representations of 66 barriers and 39 facilitators to PMH care. CONCLUSIONS The MATRIx frameworks highlight the complex interplay of individual and system-level factors across different stages of the care pathway that influence women accessing PMH care and effective implementation of PMH services. Recommendations are made for health policy and practice. These include using the conceptual frameworks to inform comprehensive, strategic and evidence-based approaches to PMH care; ensuring care is easy to access and flexible; providing culturally sensitive care; adequate funding of services and quality training for health professionals, with protected time to complete it.
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Affiliation(s)
- Rebecca Webb
- Centre for Maternal and Child Health Research, School of Health Sciences, City, University of London, UK
| | - Elizabeth Ford
- Department of Primary Care and Public Health, Brighton & Sussex Medical School, UK
| | - Abigail Easter
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, UK; and Section of Women's Mental Health, Institute of Psychiatry, Psychology & Neuroscience, King's College London, UK
| | | | - Jennifer Holly
- Section of Women's Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK
| | - Sally Hogg
- Faculty of Education, University of Cambridge, UK
| | - Rose Coates
- Centre for Maternal and Child Health Research, School of Health Sciences, City, University of London, UK
| | - Susan Ayers
- Centre for Maternal and Child Health Research, School of Health Sciences, City, University of London, UK
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Shakespeare J, Dixon S, Marwaha S. Primary care and bipolar disorder. Br J Gen Pract 2023; 73:104-105. [PMID: 36823056 PMCID: PMC9976825 DOI: 10.3399/bjgp23x732057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023] Open
Affiliation(s)
| | - Sharon Dixon
- Nuffield Department of Primary Care Health Sciences, University of Oxford; GP Partner, Donnington Medical Partnership, Oxford
| | - Steven Marwaha
- Bipolar UK Commissioner; Professor of Psychiatry, Institute for Mental Health, University of Birmingham; Consultant Psychiatrist, Specialist Mood Disorders Clinic and Solihull Mental Health Trust, Birmingham
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Webb R, Ayers S, Shakespeare J. Improving accessing to perinatal mental health care. J Reprod Infant Psychol 2022; 40:435-438. [PMID: 36285387 DOI: 10.1080/02646838.2022.2121993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Affiliation(s)
- Rebecca Webb
- Centre for Maternal and Child Health, School of Health Sciences, City, University of London, London, UK
| | - Susan Ayers
- Centre for Maternal and Child Health, School of Health Sciences, City, University of London, London, UK
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Mortimer H, Habash-Bailey H, Cooper M, Ayers S, Cooke J, Shakespeare J, Aslanyan D, Ford E. An exploratory qualitative study exploring GPs' and psychiatrists' perceptions of post-traumatic stress disorder in postnatal women using a fictional case vignette. Stress Health 2022; 38:544-555. [PMID: 34775683 DOI: 10.1002/smi.3114] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 10/06/2021] [Accepted: 11/01/2021] [Indexed: 11/09/2022]
Abstract
Postnatal post-traumatic stress disorder (PTSD) affects 3%-4% of women who give birth. It is underdiagnosed and undertreated. Thus far, no studies have investigated doctors' perceptions of PTSD in postnatal women. We investigated whether GPs and psychiatrists perceive PTSD symptoms after birth to indicate pathology and what diagnosis and management they would offer. Semi-structured interviews were conducted with six GPs and seven psychiatrists using a fictional vignette featuring a woman experiencing PTSD following a traumatic birth. A framework analysis approach was used. Despite half the GPs recognizing trauma-related features in the vignette their most common diagnosis was postnatal depression whereas six of the seven psychiatrists identified PTSD. Management plans reflected this. Both GPs and psychiatrists lacked trust in timeliness of referrals to psychological services. Both suggested referral to specialist perinatal mental health teams. Results suggest women are unlikely to get a PTSD diagnosis during initial GP consultations, however the woman-centred care proposed by GPs means that a trauma-focussed diagnosis later in the care pathway was not ruled out. Further research is needed to confirm these findings, which suggest that an evidence base around best management for women with postnatal PTSD is sorely needed, especially to inform GP training.
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Affiliation(s)
- Harriet Mortimer
- Department of Primary Care and Public Health, Brighton and Sussex Medical School, Watson Building, Falmer Campus, Brighton, UK
| | - Haniah Habash-Bailey
- Department of Primary Care and Public Health, Brighton and Sussex Medical School, Watson Building, Falmer Campus, Brighton, UK
| | - Maxwell Cooper
- Department of Primary Care and Public Health, Brighton and Sussex Medical School, Watson Building, Falmer Campus, Brighton, UK
| | - Susan Ayers
- Centre for Maternal and Child Health Research, School of Health Sciences, City University of London, Northampton Square, London, UK
| | - Jennifer Cooke
- Sussex Partnership Specialist Perinatal Mental Health Service, Sussex Partnership NHS Foundation Trust, Worthing, West Sussex, UK
| | | | - Daron Aslanyan
- Department of Primary Care and Public Health, Brighton and Sussex Medical School, Watson Building, Falmer Campus, Brighton, UK
| | - Elizabeth Ford
- Department of Primary Care and Public Health, Brighton and Sussex Medical School, Watson Building, Falmer Campus, Brighton, UK
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Knight M, Bunch K, Vousden N, Banerjee A, Cox P, Cross-Sudworth F, Dhanjal MK, Douglas J, Girling J, Kenyon S, Kotnis R, Patel R, Shakespeare J, Tuffnell D, Wilkinson M, Kurinczuk JJ. A national cohort study and confidential enquiry to investigate ethnic disparities in maternal mortality. EClinicalMedicine 2022; 43:101237. [PMID: 34977514 PMCID: PMC8683666 DOI: 10.1016/j.eclinm.2021.101237] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 11/25/2021] [Accepted: 11/25/2021] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Ethnic disparities in maternal mortality were first documented in the UK in the early 2000s but are known to be widening. This project aimed to describe the women who died in the UK during or up to a year after the end of pregnancy, to compare the quality of care received by women from different aggregated ethnic groups, and to identify any structural or cultural biases or discrimination affecting their care. METHODS National surveillance data was used to identify all 1894 women who died during or up to a year after the end of pregnancy between 2009 and 18 in the UK. Their characteristics and causes of death were described. A Confidential Enquiry was undertaken to describe the quality of care women received. The care of a stratified random sample of 54 women who died during or up to a year after the end of pregnancy between 2009 and 18, (18 from the aggregated group of Black women, 19 from the Asian aggregated group and 17 from the White aggregated group) was re-examined specifically to describe any structural or cultural biases or discrimination identified. FINDINGS There were no major differences causes of death between women from different aggregated ethnic groups, with cardiovascular disease the leading cause of death in all groups. Multiple areas of bias were identified in the care women received, including lack of nuanced care (notable amongst women from Black aggregated ethnic groups who died), microaggressions (most prominent in the care of women from Asian aggregated ethnic groups who died) and clinical, social and cultural complexity (evident across all ethnic groups). INTERPRETATION This confidential enquiry suggests that multiple structural and other biases exist in UK maternity care. Further research on the role of microaggressions is warranted. FUNDING This research is funded by the National Institute for Health Research (NIHR) Policy Research Programme, conducted through the Policy Research Unit in Maternal and Neonatal Health and Care, PR-PRU-1217-21,202. MK is an NIHR Senior Investigator. SK is part funded and FCS fully funded by the National Institute for Health Research (NIHR) Applied Research Centre (ARC) West Midlands. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.
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Affiliation(s)
- Marian Knight
- Policy Research Unit in Maternal and Neonatal Health and Care, National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, United Kingdom
- Corresponding author at: Policy Research Unit in Maternal and Neonatal Health and Care, National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Oxford, OX3 7LF, United Kingdom.
| | - Kathryn Bunch
- Policy Research Unit in Maternal and Neonatal Health and Care, National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, United Kingdom
| | - Nicola Vousden
- Policy Research Unit in Maternal and Neonatal Health and Care, National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, United Kingdom
| | - Anita Banerjee
- Guys and St Thomas’ Hospitals NHS Foundation Trust, London, United Kingdom
| | - Philippa Cox
- Homerton University Hospital NHS Foundation Trust, London, United Kingdom
| | | | - Mandish K. Dhanjal
- Queen Charlotte's and Chelsea Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Jenny Douglas
- School of Health, Wellbeing and Social Care, Faculty of Wellbeing, Education and Language Studies, The Open University, United Kingdom
| | - Joanna Girling
- Chelsea and Westminster Hospital NHS FT, London, United Kingdom
| | - Sara Kenyon
- Institute of Applied Health Research, University of Birmingham, United Kingdom
| | | | - Roshni Patel
- Chelsea and Westminster Hospital NHS FT, London, United Kingdom
| | - Judy Shakespeare
- Policy Research Unit in Maternal and Neonatal Health and Care, National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, United Kingdom
- Retired GP, Oxford, United Kingdom
| | - Derek Tuffnell
- Bradford Hospitals NHS Foundation Trust, Bradford, United Kingdom
| | - Meg Wilkinson
- University College London Hospitals, London, United Kingdom
| | - Jennifer J. Kurinczuk
- Policy Research Unit in Maternal and Neonatal Health and Care, National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, United Kingdom
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Webb R, Uddin N, Ford E, Easter A, Shakespeare J, Roberts N, Alderdice F, Coates R, Hogg S, Cheyne H, Ayers S. Barriers and facilitators to implementing perinatal mental health care in health and social care settings: a systematic review. Lancet Psychiatry 2021; 8:521-534. [PMID: 33838118 DOI: 10.1016/s2215-0366(20)30467-3] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 10/14/2020] [Accepted: 10/16/2020] [Indexed: 02/06/2023]
Abstract
The improvement of perinatal mental health formed part of WHO's Millennium Development Goals. Research suggests that the implementation of perinatal mental health care is variable. To ensure successful implementation, barriers and facilitators to implementing perinatal mental health services need to be identified. Therefore, we aimed to identify the barriers and facilitators to implementing assessment, care, referral, and treatment for perinatal mental health into health and social care services. In this systematic review, we searched CINAHL, Embase, MEDLINE, and PsycINFO with no language restrictions for primary research articles published between database inception and Dec 11, 2019. Forward and backward searches of included studies were completed by March 31, 2020. Studies were eligible if they made statements about factors that either facilitated or impeded the implementation of perinatal mental health assessment, care, referral, or treatment. Partial (10%) dual screening was done. Data were extracted with EPPI-Reviewer 4 and analysed by use of a thematic synthesis. The protocol is registered on PROSPERO, CRD42019142854. Database searching identified 21 535 citations, of which 46 studies were included. Implementation occurred in a wide range of settings and was affected by individual (eg, an inability to attend treatment), health-care professional (eg, training), interpersonal (eg, trusting relationships), organisational (eg, clear referral pathways), political (eg, funding), and societal factors (eg, stigma and culture). A complex range of barriers and facilitators affect the implementation of perinatal mental health policy and practice. Perinatal mental health services should be flexible and women-centred, and delivered by well trained health-care professionals working within a structure that facilitates continuity of carer. Strategies that can be used to improve implementation include, but are not limited to, co-production of services, implementation team meetings, funding, and coalition building. Future research should focus on implementation barriers and facilitators dependent on illness severity, the health-care setting, and inpatient care.
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Affiliation(s)
- Rebecca Webb
- Centre for Maternal and Child Health, City, University of London, London, UK.
| | - Nazihah Uddin
- Centre for Maternal and Child Health, City, University of London, London, UK
| | - Elizabeth Ford
- Department of Primary Care and Public Health, Brighton & Sussex Medical School, Falmer, UK
| | - Abigail Easter
- Section of Women's Mental Health, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | | | - Nia Roberts
- Nuffield Department of Population Health, Bodleian Health Care Libraries, Oxford, UK
| | - Fiona Alderdice
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
| | - Rose Coates
- Centre for Maternal and Child Health, City, University of London, London, UK
| | | | - Helen Cheyne
- NMAHP Research Unit, Faculty of Health Sciences and Sport, University of Stirling, Stirling, UK
| | - Susan Ayers
- Centre for Maternal and Child Health, City, University of London, London, UK
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Jomeen J, Martin CR, Jones C, Marshall C, Ayers S, Burt K, Frodsham L, Horsch A, Midwinter D, O'Connell M, Shakespeare J, Sheen K, Thomson G. Tokophobia and fear of birth: a workshop consensus statement on current issues and recommendations for future research. J Reprod Infant Psychol 2020; 39:2-15. [PMID: 33206580 DOI: 10.1080/02646838.2020.1843908] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Objective: To discuss and develop a statement on the current state of the evidence and opinion in Fear of Childbirth (FoC) and Tokophobia (Tocophobia), and to provide recommendations. Background: A group met in 2019 to discuss the state of clinical and academic knowledge relating to FoC/Tokophobia. Five key areas were agreed as the focus of the meeting. Methods: 12 internationally acknowledged experts, in this or a closely related area (e.g. PTSD) met to discuss their understanding of the evidence for FoC/ Tokophobia and current practice. The consensus described in this paper constitutes the expression of the general opinion of the participants and does not necessarily imply unanimity. Keys points: Work focussed on tokophobia is recent and there remains a wide range of issues, which were addressed in the workshop including complexity in defining prevalence, a theoretical lack of understanding, which creates challenge for robust assessment and the identification of risk factors. An improved aetiological and developmental understanding of the tokophobia is required to underpin appropriate, effective and evidence-based interventions. Evaluation of pathways of care and relevant interventions, should be a focus of future research. Conclusion: Significant gaps remain within the FoC/tokophobia knowledge base. Further research is necessary.
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Affiliation(s)
- J Jomeen
- School of Health & Human Sciences, Southern Cross University , Bilinga, Australia.,Institute for Clinical and Applied Health Research (ICAHR), University of Hull , Hull, UK
| | - C R Martin
- School of Health & Human Sciences, Southern Cross University , Bilinga, Australia.,Institute for Clinical and Applied Health Research (ICAHR), University of Hull , Hull, UK.,School of Nursing and Allied Health, Buckinghamshire New University , High Wycombe, UK
| | - C Jones
- Institute for Clinical and Applied Health Research (ICAHR), University of Hull , Hull, UK
| | - C Marshall
- Perinatal Mental Health Team, Humber Teaching NHS Foundation Trust , Hull, UK
| | - S Ayers
- Centre for Maternal and Child Health Research, School of Health Sciences, City, University of London , London, UK
| | - K Burt
- Expert by Experience , UK
| | - L Frodsham
- Obstetric Medicine, Guy's and St Thomas' NHS Foundation Trust , London, UK
| | - A Horsch
- Institute of Higher Education and Research in Healthcare (IUFRS), University of Lausanne , Lausanne, Switzerland.,Department Woman-Mother-Child, University Hospital , Lausanne, Switzerland
| | - D Midwinter
- Maternity and Midwifery Services, North Lincolnshire and Goole NHS Foundation Trust , Scunthorpe, UK
| | - M O'Connell
- School of Nursing and Midwifery, Royal College of Surgeons Ireland in Bahrain , Adliya, Bahrain
| | | | - K Sheen
- School of Psychology, Faculty of Health, Liverpool John Moores University , Liverpool, UK
| | - G Thomson
- Maternal and Infant Nutrition & Nurture Unit, School of Community Health & Midwifery, University of Central Lancashire , Lancashire, UK.,School of Education, Health and Social Studies, Dalarna University , Falun, Sweden
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Affiliation(s)
- Claire A Wilson
- Section of Women's Mental Health, King's College London, London SE5 8AF, UK
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Emily Finch
- South London and Maudsley NHS Foundation Trust, London, UK
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Affiliation(s)
| | | | | | | | | | - Judith Stephenson
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK
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14
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Affiliation(s)
- Debra Bick
- Warwick Clinical Trials Unit, University of Warwick, United Kingdom.
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Geary RS, Gurol-Urganci I, Kiran A, Cromwell DA, Bansi-Matharu L, Shakespeare J, Mahmood T, van der Meulen J. Factors associated with receiving surgical treatment for menorrhagia in England and Wales: findings from a cohort study of the National Heavy Menstrual Bleeding Audit. BMJ Open 2019; 9:e024260. [PMID: 30782899 PMCID: PMC6377553 DOI: 10.1136/bmjopen-2018-024260] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To examine the factors associated with receiving surgery for heavy menstrual bleeding (HMB) in England and Wales. DESIGN National cohort study. SETTING National Health Service hospitals. PARTICIPANTS Women with HMB aged 18-60 who had a new referral to secondary care. METHODS Patient-reported data linked to administrative hospital data. Risk ratios (RR) estimated using multivariable Poisson regression. PRIMARY OUTCOME MEASURE Surgery within 1 year of first outpatient clinic visit. RESULTS 14 545 women were included. At their first clinic visit, mean age was 42 years, mean symptom severity score was 62 (scale ranging from 0 (least) to 100 (most severe)), 73.9% of women reported having symptoms for >1 year and 30.4% reported no prior treatment in primary care. One year later, 42.6% had received surgery. Of these, 57.8% had endometrial ablation and 37.2% hysterectomy. Women with more severe symptoms were more likely to have received surgery (most vs least severe quintile, 33.1% vs 56.0%; RR 1.6, 95% CI 1.5 to 1.7). Surgery was more likely among those who reported prior primary care treatment compared with those who did not (48.0% vs 31.1%; RR 1.5, 95% CI 1.4 to 1.6). Surgery was less likely among Asian and more likely among black women, compared with white women. Surgery was not associated with socioeconomic deprivation. CONCLUSIONS Receipt of surgery for HMB depends on symptom severity and prior treatment in primary care. Referral pathways should be locally audited to ensure women with HMB receive care that addresses their individual needs and preferences, especially for those who do not receive treatment in primary care.
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Affiliation(s)
- Rebecca Sally Geary
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
- Lindsay Stewart Centre for Audit and Clinical Informatics, Royal College of Obstetricians and Gynaecologists, London, UK
| | - Ipek Gurol-Urganci
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
- Lindsay Stewart Centre for Audit and Clinical Informatics, Royal College of Obstetricians and Gynaecologists, London, UK
| | - Amit Kiran
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
- Lindsay Stewart Centre for Audit and Clinical Informatics, Royal College of Obstetricians and Gynaecologists, London, UK
| | - David A Cromwell
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
- Lindsay Stewart Centre for Audit and Clinical Informatics, Royal College of Obstetricians and Gynaecologists, London, UK
| | | | | | - Tahir Mahmood
- Lindsay Stewart Centre for Audit and Clinical Informatics, Royal College of Obstetricians and Gynaecologists, London, UK
| | - Jan van der Meulen
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
- Lindsay Stewart Centre for Audit and Clinical Informatics, Royal College of Obstetricians and Gynaecologists, London, UK
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Kiran A, Geary RS, Gurol-Urganci I, Cromwell DA, Bansi-Matharu L, Shakespeare J, Mahmood T, van der Meulen J. Sociodemographic differences in symptom severity and duration among women referred to secondary care for menorrhagia in England and Wales: a cohort study from the National Heavy Menstrual Bleeding Audit. BMJ Open 2018; 8:e018444. [PMID: 29420229 PMCID: PMC5829848 DOI: 10.1136/bmjopen-2017-018444] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To examine symptom severity and duration at time of referral to secondary care for heavy menstrual bleeding (HMB) by socioeconomic deprivation, age and ethnicity DESIGN: Cohort analysis of data from the National HMB Audit linked to Hospital Episode Statistics data. SETTING English and Welsh National Health Services (secondary care): February 2011 to January 2012. PARTICIPANTS 15 325 women aged 18-60 years in England and Wales who had a new referral for HMB to a gynaecology outpatient department METHODS: Multivariable linear regression to calculate adjusted differences in mean symptom severity and quality of life scores at first outpatient visit. Multivariable logistic regression to calculate adjusted ORs. Adjustment for body mass index, parity and comorbidities. PRIMARY OUTCOME MEASURES Mean symptom severity score (0=best, 100=worst), mean condition-specific quality of life score (0=worst, 100=best) and symptom duration (≥1 year). RESULTS Women were on average 42 years old and 12% reported minority ethnic backgrounds. Mean symptom severity and condition-specific quality of life scores were 61.8 and 34.7. Almost three-quarters of women (74%) reported having had symptoms for ≥1 year. Women from more deprived areas had more severe symptoms at their first outpatient visit (difference -6.1; 95% CI-7.2 to -4.9, between least and most deprived quintiles) and worse condition-specific quality of life (difference 6.3; 95% CI 5.1 to 7.5). Symptom severity declined with age while quality of life improved. CONCLUSIONS Women living in more deprived areas reported more severe HMB symptoms and poorer quality of life at the start of treatment in secondary care. Providers should examine referral practices to explore if these differences reflect women's health-seeking behaviour or how providers decide whether or not to refer.
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Affiliation(s)
- Amit Kiran
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
- Lindsay Stewart Centre for Audit and Clinical Informatics, Royal College of Obstetricians and Gynaecologists, London, UK
| | - Rebecca Sally Geary
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
- Lindsay Stewart Centre for Audit and Clinical Informatics, Royal College of Obstetricians and Gynaecologists, London, UK
| | - Ipek Gurol-Urganci
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
- Lindsay Stewart Centre for Audit and Clinical Informatics, Royal College of Obstetricians and Gynaecologists, London, UK
| | - David A Cromwell
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
- Lindsay Stewart Centre for Audit and Clinical Informatics, Royal College of Obstetricians and Gynaecologists, London, UK
| | | | | | - Tahir Mahmood
- Lindsay Stewart Centre for Audit and Clinical Informatics, Royal College of Obstetricians and Gynaecologists, London, UK
| | - Jan van der Meulen
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
- Lindsay Stewart Centre for Audit and Clinical Informatics, Royal College of Obstetricians and Gynaecologists, London, UK
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Prior M, Bagness C, Brewin J, Coomarasamy A, Easthope L, Hepworth-Jones B, Hinshaw K, O'Toole E, Orford J, Regan L, Raine-Fenning N, Shakespeare J, Small R, Thornton J, Metcalf L. Priorities for research in miscarriage: a priority setting partnership between people affected by miscarriage and professionals following the James Lind Alliance methodology. BMJ Open 2017; 7:e016571. [PMID: 28838896 PMCID: PMC5629698 DOI: 10.1136/bmjopen-2017-016571] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES To identify and prioritise important research questions for miscarriage. DESIGN A priority setting partnership using prospective surveys and consensus meetings following methods advocated by the James Lind Alliance. SETTING UK. PARTICIPANTS Women and those affected by miscarriage working alongside healthcare professionals. RESULTS In the initial survey, 1093 participants (932 women who have experienced miscarriage, 8 partners, 17 family members, friends or colleagues, 104 healthcare professionals and eight charitable organisations) submitted 3279 questions. A review of existing literature identified a further 64. Non-questions were removed, and the remaining questions were categorised and summarised into 58 questions. In an interim electronic survey, 2122 respondents chose their top 10 priorities from the 58 summary questions. The 25 highest ranked in the survey were prioritised at a final face-to-face workshop. In summary, the top 10 priorities were ranked as follows: research into preventative treatment, emotional aspects in general, investigation, relevance of pre-existing medical conditions, emotional support as a treatment, importance of lifestyle factors, importance of genetic and chromosomal causes, preconception tests, investigation after different numbers of miscarriage and male causal factors. CONCLUSIONS These results should be the focus of future miscarriage research. Presently, studies are being conducted to address the top priority; however, many other priorities, especially psychological and emotional support, are less well researched areas. We hope our results will encourage both researchers and funders to focus on these priorities.
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Affiliation(s)
- Matthew Prior
- Department of Child Health Obstetrics and Gynaecology, University of Nottingham, Nottingham, UK
| | | | | | - Arri Coomarasamy
- School of Clinical and Experimental Medicine, University of Birmingham, Edgbaston, UK
| | - Lucy Easthope
- University of Lincoln Law School, Lincoln, Lincolnshire, UK
| | | | - Kim Hinshaw
- Department of Obstetrician and Gynaecologist, Sunderland Royal Hospital, Sunderland, UK
| | - Emily O'Toole
- Royal College of Obstetricians and Gynaecologists Women's Voices Involvement Panel, London, UK
| | - Julie Orford
- Royal College of Obstetricians and Gynaecologists Women's Voices Involvement Panel, London, UK
| | - Lesley Regan
- Royal College of Obstetricians and Gynaecologists, London, UK
| | - Nick Raine-Fenning
- Division of Obstetrics & Gynaecology, School of Clinical Sciences, University of Nottingham, Nottingham, Nottinghamshire, UK
| | | | - Rachel Small
- Department of Gynaecology, Heart of England NHS Foundation Trust, Birmingham, UK
| | | | - Leanne Metcalf
- The James Lind Alliance, National Institute for Health Research Evaluation, Trials and Studies Coordinating Centre, Southampton, UK
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Abstract
BACKGROUND Perinatal anxiety and depression are widespread, with up to 20% of women affected during pregnancy and after birth. In the UK, management of perinatal mental health falls under the remit of general practitioners (GPs). We reviewed the literature on GPs' routine recognition, diagnosis and management of anxiety and depression in the perinatal period. METHOD A systematic search of Embase, Medline, PsycInfo, Pubmed, Scopus and Web of Science was conducted. Studies were eligible if they reported quantitative measures of GPs' or Family Physicians' assessment, recognition and management of anxiety or depression in pregnancy or post-partum. RESULTS Thirteen papers, reporting 10 studies, were identified from the United States, Australia, UK, Netherlands and Canada. All reported on depression; two included anxiety disorders. Reported awareness and ability to diagnose perinatal depression among GPs was high. GPs knew about and used screening tools in the UK but less so in US settings. Antidepressants were the first line of treatment, with various SSRIs considered safest. Counseling by GPs and referrals to specialists were common in the post-natal period, less so in pregnancy. Treatment choices were determined by resources, attitudes, knowledge and training. CONCLUSIONS Data on GPs' awareness and management of perinatal depression were sparse and unlikely to be generalizable. Future directions for research are proposed; such as exploring the management of anxiety disorders which are largely missing from the literature, and understanding more about barriers to disclosure and recognition in primary care. More standardized training could help to improve recognition and management practices.
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Affiliation(s)
- Elizabeth Ford
- Division of Primary Care and Public Health, Brighton and Sussex Medical School, Brighton, UK
| | - Judy Shakespeare
- Royal College of General Practitioners, 30 Euston Square, London NW1 2FB, UK
| | - Fatin Elias
- Centre for Maternal and Child Health Research, School of Health Sciences, City, University of London, London, UK
| | - Susan Ayers
- Centre for Maternal and Child Health Research, School of Health Sciences, City, University of London, London, UK
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Saratzis A, Thatcher A, Bath MF, Sidloff DA, Bown MJ, Shakespeare J, Sayers RD, Imray C. Reporting individual surgeon outcomes does not lead to risk aversion in abdominal aortic aneurysm surgery. Ann R Coll Surg Engl 2017; 99:161-165. [PMID: 28071950 DOI: 10.1308/rcsann.2017.0005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Reporting surgeons' outcomes has recently been introduced in the UK. This has the potential to result in surgeons becoming risk averse. The aim of this study was to investigate whether reporting outcomes for abdominal aortic aneurysm (AAA) surgery impacts on the number and risk profile (level of fitness) of patients offered elective treatment. METHODS Publically available National Vascular Registry data were used to compare the number of AAAs treated in those centres across the UK that reported outcomes for the periods 2008-2012, 2009-2013 and 2010-2014. Furthermore, the number and characteristics of patients referred for consideration of elective AAA repair at a single tertiary unit were analysed yearly between 2010 and 2014. Clinic, casualty and theatre event codes were searched to obtain all AAAs treated. The results of cardiopulmonary exercise testing (CPET) were assessed. RESULTS For the 85 centres that reported outcomes in all three five-year periods, the median number of AAAs treated per unit increased between the periods 2008-2012 and 2010-2014 from 192 to 214 per year (p=0.006). In the single centre cohort study, the proportion of patients offered elective AAA repair increased from 74% in 2009-2010 to 81% in 2013-2014, with a maximum of 84% in 2012-2013. The age, aneurysm size and CPET results (anaerobic threshold levels) for those eventually offered elective treatment did not differ significantly between 2010 and 2014. CONCLUSIONS The results do not support the assumption that reporting individual surgeon outcomes is associated with a risk averse strategy regarding patient selection in aneurysm surgery at present.
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Affiliation(s)
| | | | | | | | | | - J Shakespeare
- University Hospitals Coventry and Warwickshire NHS Trust , UK
| | | | - C Imray
- University Hospitals Coventry and Warwickshire NHS Trust , UK
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Knight M, Nair M, Brocklehurst P, Kenyon S, Neilson J, Shakespeare J, Tuffnell D, Kurinczuk JJ. Examining the impact of introducing ICD-MM on observed trends in maternal mortality rates in the UK 2003-13. BMC Pregnancy Childbirth 2016; 16:178. [PMID: 27440079 PMCID: PMC4955124 DOI: 10.1186/s12884-016-0959-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Accepted: 07/12/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The causes of maternal death are now classified internationally according to ICD-MM. One significant change with the introduction of ICD-MM in 2012 was the reclassification of maternal suicide from the indirect group to the direct group. This has led to concerns about the impact of this reclassification on calculated mortality rates. The aim of this analysis was to examine the trends in maternal deaths in the UK over the past 10 years, and to investigate the impact of reclassification using ICD-MM on the observed rates. METHODS Data about all maternal deaths between 2003-13 in the UK were included in this analysis. Data about maternal deaths occurring prior to 2009 were obtained from previously published reports. The deaths of women from 2009-13 during or after pregnancy were identified through the MBRRACE-UK Confidential Enquiry into Maternal Deaths. The underlying causes of maternal death were reclassified from a disease-based system to ICD-MM. Maternal mortality rates with 95 % confidence intervals were calculated using national data on the number of maternities as the denominator. Rate ratios with 95 % CI were calculated to compare the change in rates of maternal death as per ICD-MM relative to the old classification system. RESULTS There was a decrease in the maternal death rate between 2003-05 and 2011-13 (rate ratio (RR) 0.65; 95 % CI 0.54-0.77 comparing 2003-5 with 2011-13; p = 0.005 for trend over time). The direct maternal death rate calculated using the old classification decreased with a RR of 0.47 (95 % CI 0.34-0.63) when comparing 2011-13 with 2003-05; p = 0.005 for trend over time. Reclassification using ICD-MM made little material difference to the observed trend in direct maternal death rates, RR = 0.51 (95 % CI 0.39-0.68) when comparing 2003-5 with 2011-13; p = 0.005 for trend over time. CONCLUSIONS The impact of reclassifying maternal deaths according to ICD-MM in the UK was minimal. However, such reclassification raises awareness of maternal suicides and hence is the first step to actions to prevent women dying by suicide in the future. Recognising and acknowledging these women's deaths is more important than concerns over the impact reclassification using ICD-MM might have on reported maternal death rates.
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Affiliation(s)
- Marian Knight
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Headington, Oxford, OX3 7LF, UK.
| | - Manisha Nair
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Headington, Oxford, OX3 7LF, UK
| | - Peter Brocklehurst
- Institute for Women's Health UCL, Medical School Building, 74 Huntley Street, London, WC1E 6AU, UK
| | - Sara Kenyon
- School of Health and Population Sciences, Edgbaston Campus, University of Birmingham, Edgbaston, B15 2TT, UK
| | - James Neilson
- Department of Women's & Children's Health, Institute of Translational Medicine, University of Liverpool and Centre for Women's Health Research, Liverpool Women's Hospital, Crown Street, Liverpool, L8 7SS, UK
| | - Judy Shakespeare
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Headington, Oxford, OX3 7LF, UK
| | - Derek Tuffnell
- Bradford Teaching Hospitals NHS Foundation Trust, Duckworth Lane, Bradford, BD9 6RJ, UK
| | - Jennifer J Kurinczuk
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Headington, Oxford, OX3 7LF, UK
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Shakespeare J. Norman Philip Watson. Assoc Med J 2016. [DOI: 10.1136/bmj.i2072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Kurinczuk JJ, Draper ES, Field DJ, Bevan C, Brocklehurst P, Gray R, Kenyon S, Manktelow BN, Neilson JP, Redshaw M, Scott J, Shakespeare J, Smith LK, Knight M. Experiences with maternal and perinatal death reviews in the UK--the MBRRACE-UK programme. BJOG 2014; 121 Suppl 4:41-6. [PMID: 25236632 DOI: 10.1111/1471-0528.12820] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2014] [Indexed: 11/28/2022]
Abstract
Established in 1952, the programme of surveillance and Confidential Enquiries into Maternal Deaths in the UK is the longest running such programme worldwide. Although more recently instituted, surveillance and confidential enquiries into perinatal deaths are also now well established nationally. Recent changes to funding and commissioning of the Enquiries have enabled both a reinvigoration of the processes and improvements to the methodology with an increased frequency of future reporting. Close engagement with stakeholders and a regulator requirement for doctors to participate have both supported the impetus for involvement of all professionals leading to greater potential for improved quality of care for women and babies.
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Affiliation(s)
- J J Kurinczuk
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
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Affiliation(s)
- Ian Jones
- National Centre for Mental Health, MRC Centre for Neuropsychiatric Genetics and Genomics, Cardiff University, UK
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Shakespeare J. Fragmentation of basic and nursing care may be to blame for unsafe wards. BMJ 2013; 346:f1949. [PMID: 23550070 DOI: 10.1136/bmj.f1949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Fielding R, Gelder C, Shakespeare J. P27 QUIPP Achievement Associated with the Creation of an Accurate Home Oxygen Register and Removal of Inappropriate Short Burst Oxygen Therapy. Thorax 2012. [DOI: 10.1136/thoraxjnl-2012-202678.168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Shakespeare J. John "Derrick" Holdsworth. Assoc Med J 2012. [DOI: 10.1136/bmj.e4667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Cantwell R, Clutton-Brock T, Cooper G, Dawson A, Drife J, Garrod D, Harper A, Hulbert D, Lucas S, McClure J, Millward-Sadler H, Neilson J, Nelson-Piercy C, Norman J, O'Herlihy C, Oates M, Shakespeare J, de Swiet M, Williamson C, Beale V, Knight M, Lennox C, Miller A, Parmar D, Rogers J, Springett A. Saving Mothers' Lives: Reviewing maternal deaths to make motherhood safer: 2006-2008. The Eighth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. BJOG 2011; 118 Suppl 1:1-203. [PMID: 21356004 DOI: 10.1111/j.1471-0528.2010.02847.x] [Citation(s) in RCA: 624] [Impact Index Per Article: 48.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
In the triennium 2006-2008, 261 women in the UK died directly or indirectly related to pregnancy. The overall maternal mortality rate was 11.39 per 100,000 maternities. Direct deaths decreased from 6.24 per 100,000 maternities in 2003-2005 to 4.67 per 100,000 maternities in 2006–2008 (p = 0.02). This decline is predominantly due to the reduction in deaths from thromboembolism and, to a lesser extent, haemorrhage. For the first time there has been a reduction in the inequalities gap, with a significant decrease in maternal mortality rates among those living in the most deprived areas and those in the lowest socio-economic group. Despite a decline in the overall UK maternal mortality rate, there has been an increase in deaths related to genital tract sepsis, particularly from community acquired Group A streptococcal disease. The mortality rate related to sepsis increased from 0.85 deaths per 100,000 maternities in 2003-2005 to 1.13 deaths in 2006-2008, and sepsis is now the most common cause of Direct maternal death. Cardiac disease is the most common cause of Indirect death; the Indirect maternal mortality rate has not changed significantly since 2003-2005. This Confidential Enquiry identified substandard care in 70% of Direct deaths and 55% of Indirect deaths. Many of the identified avoidable factors remain the same as those identified in previous Enquiries. Recommendations for improving care have been developed and are highlighted in this report. Implementing the Top ten recommendations should be prioritised in order to ensure the overall UK maternal mortality rate continues to decline.
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Gibson J, McKenzie-McHarg K, Shakespeare J, Price J, Gray R. A systematic review of studies validating the Edinburgh Postnatal Depression Scale in antepartum and postpartum women. Acta Psychiatr Scand 2009; 119:350-64. [PMID: 19298573 DOI: 10.1111/j.1600-0447.2009.01363.x] [Citation(s) in RCA: 666] [Impact Index Per Article: 44.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The Edinburgh Postnatal Depression Scale (EPDS) is the most widely used screening tool for postpartum depression (PPD). We systematically reviewed the published evidence on its validity in detecting PPD and antepartum depression (APD) up to July 2008. METHOD Systematic review of validation studies of the EPDS included 1987-2008. Cut-off points of 9/10 for possible PPD, 12/13 for probable PPD and 14/15 for APD were used. RESULTS Thirty-seven studies met the inclusion criteria. Sensitivity and specificity of cut-off points showed marked heterogeneity between different studies. Sensitivity results ranged from 34 to 100% and specificity from 44 to 100%. Positive likelihood ratios ranged from 1.61 to 78. CONCLUSION Heterogeneity among study findings may be due to differences in study methodology, language and diagnostic interview/criteria used. Therefore, the results of different studies may not be directly comparable and the EPDS may not be an equally valid screening tool across all settings and contexts.
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Affiliation(s)
- J Gibson
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK.
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Newall C, McCauley TM, Shakespeare J, Cooper BG. Is it necessary to use a noseclip in the performance of spirometry using a wedge bellows device? Chron Respir Dis 2007; 4:53-7. [PMID: 17416154 DOI: 10.1177/1479972306072889] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
There is no current consensus among published guidelines on whether noseclips are required during spirometry testing. This study investigated the effect of noseclips on spirometric measurements in patients with a range of disease. Fifty-two patients (30 male; mean age 58.0 years, range 19-78; mean FEV1 82.6% predicted, range 23.8-128.3%) performed measurements of VC, FVC and FEV1 according to ARTP/BTS guidelines (1994) using a wedge bellows spirometer (Vitalograph Model S, Bucks, U.K.). All patients performed two sets of measurements (with and without noseclips) in random order (Group 1 = noseclips first; n=30; Group 2 (without noseclips first, n=22). Tests were conducted by qualified physiologists. Measurements obtained with and without the use of noseclips were similar (mean differences FEV1 -0.030 L SD 0.210 and -0.005 L SD 0.093 for Groups 1 and 2 respectively; FVC -0.007 L SD 0.109 and -0.040 L SD 0.117; VC 0.036L SD 0.137 and -0.040 L SD 0.150) and were not dependent on patient group or previous test experience. Four patients had differences outside the 95% confidence limits for each parameter. There were no significant correlations between the differences with and without noseclips and severity of lung disease, age, smoking history, BMI or lung volume (all P > 0.100). The within patient coefficient of variation did not depend on the testing method. Use of noseclips during spirometry does not systematically affect the results obtained or the within-subject repeatability. Marked individual differences highlight the importance of maintaining consistency in the method adopted for a particular patient.
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Affiliation(s)
- C Newall
- PAREXEL International, Northwick Park Hospital, Harrow, UK.
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Shakespeare J, Blake F, Garcia J. How do women with postnatal depression experience listening visits in primary care? A qualitative interview study. J Reprod Infant Psychol 2006. [DOI: 10.1080/02646830600643866] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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Shakespeare J, Blake F, Garcia J. Breast-feeding difficulties experienced by women taking part in a qualitative interview study of postnatal depression. Midwifery 2004; 20:251-60. [PMID: 15337281 DOI: 10.1016/j.midw.2003.12.011] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2003] [Revised: 10/01/2003] [Accepted: 12/22/2003] [Indexed: 11/28/2022]
Abstract
OBJECTIVE to explore how women experience breast-feeding difficulties. This theme emerged unexpectedly during a study of women's experiences of screening with the Edinburgh postnatal depression scale (EPDS) and subsequent care from primary health-care professionals. DESIGN qualitative in-depth interview study. SETTING postnatal women of 22 general practices within Oxford City Primary Care Group area. PARTICIPANTS 39 postnatal women from a purposeful sample were interviewed at an average of 15 months postnatal. They were chosen from different general practices and with a range of emotional difficulties after birth, judged using EPDS results at eight weeks and eight months postnatal, and whether they received 'listening visits' from health visitors. MEASUREMENTS AND FINDINGS a qualitative thematic analysis was used, including searches for anticipated and emergent themes. Fifteen women had breast-feeding difficulties. Five themes emerged which explore the difficulties. Firstly, commitment to breast feeding and high expectations of success; secondly, unexpected difficulties; thirdly, seeking professional support for difficulties; fourthly, finding a way to cope; and fifthly, guilt. KEY CONCLUSIONS in this study breast-feeding difficulties were common, caused emotional distress and interactions with professionals could be difficult. Current breast-feeding policy, such as the 'Baby Friendly Initiative', may be a contributing factor. This needs to be explored in a further study.
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Taket A, Nurse J, Smith K, Watson J, Shakespeare J, Lavis V, Cosgrove K, Mulley K, Feder G. Routinely asking women about domestic violence in health settings. BMJ 2003; 327:673-6. [PMID: 14500444 PMCID: PMC196400 DOI: 10.1136/bmj.327.7416.673] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/14/2003] [Indexed: 11/04/2022]
Abstract
Health professionals are ideally placed to identify domestic violence but cannot do so without training on raising the issue and knowledge of advice and support services
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Affiliation(s)
- Ann Taket
- Faculty of Health and Social Care, London South Bank University, London SE1 0AA.
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Shakespeare J, Blake F, Garcia J. A qualitative study of the acceptability of routine screening of postnatal women using the Edinburgh Postnatal Depression Scale. Br J Gen Pract 2003; 53:614-9. [PMID: 14601337 PMCID: PMC1314675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/27/2023] Open
Abstract
BACKGROUND Screening for postnatal depression using the Edinburgh Postnatal Depression Scale (EPDS) has been widely recommended and implemented in primary care, although little is known about how acceptable it is to women. AIM To explore the acceptability to women of postnatal screening by health visitors with the EPDS. DESIGN OF STUDY Qualitative interview study. SETTING Postnatal patients from 22 general practices within the area of Oxford City Primary Care Group. METHOD Thirty-nine postnatal women from a purposive sample were interviewed, chosen on the basis of different general practices, EPDS results at eight weeks and eight months postnatal, and whether 'listening visits' were received. The interviews were analysed using the constant comparative method. RESULTS Just over half of the women interviewed found screening with the EPDS less than acceptable, whatever their postnatal emotional health. The main themes identified were problems with the process of screening and, in particular, the venue, the personal intrusion of screening and stigma. The women interviewed had a clear preference for talking about how they felt, rather than filling out a questionnaire. CONCLUSION For this sample, routine screening with the EPDS was less than acceptable for the majority of women. This is of concern, as universal screening with the EPDS for the detection of postnatal depression is already recommended and widespread in primary care.
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Affiliation(s)
- A Harnden
- Department of Primary Health Care, Institute of Health Sciences, Oxford OX3 7LF.
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Sherrard J, Shakespeare J. Sexually transmitted infections in primary care: a need for education. Br J Gen Pract 2001; 51:585. [PMID: 11462331 PMCID: PMC1314063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2023] Open
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Cann K, Withnell S, Shakespeare J, Doll H, Thomas J. Domestic violence: a comparative survey of levels of detection, knowledge, and attitudes in healthcare workers. Public Health 2001; 115:89-95. [PMID: 11406772 DOI: 10.1038/sj.ph.1900749] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/24/2000] [Indexed: 11/08/2022]
Abstract
The objective of this study was to compare the knowledge, attitudes, responses and levels of detection of domestic violence among a variety of healthcare workers in different specialities.Self-administered questionnaires were sent to community and hospital based healthcare workers in Oxfordshire working in primary care, obstetrics and gynaecology, mental health and accident and emergency. These comprised all principal general practitioners and general practitioner registrars, 50% of practice/district nurses and health visitors in each practice, and all healthcare workers in obstetrics and gynaecology, community mental health teams and accident and emergency in one trust. The amount of domestic violence detected in different healthcare settings was far less than indicated by anonymous surveys and crime figures. Knowledge about many of the issues surrounding domestic violence was inconsistent and there were fundamental deficiencies. The attitudes of healthcare workers to domestic violence were generally sympathetic and supportive. Women, nurses and community mental health workers reported significantly better knowledge and more positive attitudes than other respondents. Gender, role and speciality were independently associated with more positive attitudes and the latter two were independently associated with good knowledge. The response that healthcare workers make when they uncover domestic violence is confused and often inappropriate. In conclusion, most healthcare workers accept that domestic violence is a healthcare issue but lack fundamental knowledge about the issues surrounding domestic violence itself and appropriate agencies that can offer help. They also lack skills in identifying and discussing this issue with patients/clients. A large, unfulfilled training need has been identified.
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Affiliation(s)
- K Cann
- Department of Public Health and Health Policy, Oxfordshire Health Authority, The Richards Building, Old Road, Headington, Oxford, OX3 7LG, UK
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Affiliation(s)
- J Shakespeare
- Summertown Health Centre, 160 Banbury Road, Oxford OX2 7BS.
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Shakespeare J, Evans J. The future for non-principal general practitioners: lost doctors--lost to whom? Br J Gen Pract 1999; 49:868-9. [PMID: 10818649 PMCID: PMC1313554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023] Open
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Shakespeare J, Anderson J. Huntington's disease--falling through the net. Health Trends 1992; 25:19-23. [PMID: 10125696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
A survey was undertaken in Leicestershire of 25 carers of patients suffering from Huntington's Disease. The needs of families suffering from a late onset hereditary disease cross many service boundaries, thus providing a challenge for service providers. The results of the survey show that the service provision for people caring for patients with this disease are poor, particularly the availability and difficulty in access of some services. Two of the carers' most basic needs were for better residential care for their relatives and access to a source of long-term follow-up.
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Shakespeare J. Loss control cuts accidents and costs. Occup Health (Lond) 1972; 24:357-61. [PMID: 4484915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Holland P, Parkes D, Shakespeare J. Proceedings: Concentrations of the oxime 2-hydroxyiminomethyl pyridinium methyl methane sulphonate (P2S) after intramuscular injections in humans. Br J Pharmacol 1972; 44:368P. [PMID: 4358414 PMCID: PMC1666038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
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