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Place K, Rahkonen L, Tekay A, Väyrynen K, Orden M, Vääräsmäki M, Uotila J, Tihtonen K, Rinne K, Mäkikallio K, Heinonen S, Kruit H. Labor induction at 41 +0 gestational weeks or expectant management for the nulliparous woman: The Finnish randomized controlled multicenter trial. Acta Obstet Gynecol Scand 2024; 103:505-511. [PMID: 38112629 PMCID: PMC10867371 DOI: 10.1111/aogs.14755] [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] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 11/18/2023] [Accepted: 12/01/2023] [Indexed: 12/21/2023]
Abstract
INTRODUCTION Neonatal and maternal risks increase in term pregnancy as gestational age advances and become increasingly evident post-term. Management practices of late- and post-term pregnancies vary, and the optimal time point for intervention by labor induction is yet to be determined. MATERIAL AND METHODS This randomized controlled trial of 381 nulliparous women with unripe cervices compared labor induction at 41+0 gestational weeks (early induction) with expectant management and labor induction at 41+5 to 42+1 gestational weeks (expectant management). This multicenter study included all five university hospitals and the largest central hospital in Finland. The study period was 2018-2022. Participants were randomized to either early induction (48.8%, n = 186) or expectant management (51.2%, n = 195) with equal randomization ratios of 1:1. This was a superiority trial, and the primary outcomes were rates of cesarean section (CS) and composite of adverse neonatal outcomes. The trial was registered at the ISRCTN registry (ISRCTN83219789, https://doi.org/10.1186/ISRCTN83219789). RESULTS The rates of CS (16.7% [n = 31] vs. 24.1% [n = 47], RR 0.7 [95% CI: 0.5-1.0], p = 0.07) and a composite of adverse neonatal outcomes (9.7% [n = 18] vs. 14.4% [n = 28], RR 0.7 [95% CI: 0.4-1.2] p = 0.16) did not significantly differ between the groups, but the operative delivery rate was lower in the early induction group than in the expectant management group (30.6% [n = 57] vs. 45.6% [n = 89], p = 0.003). The rates of hemorrhage ≥1000 mL and neonatal weight ≥4000 g were also lower in the early induction group, as was the vacuum extraction rate in women with vaginal delivery. Of the women with expectant management, 45.6% (n = 89) had spontaneous onset of labor. No perinatal deaths occurred, but one case of eclampsia appeared in the expectant management group. CONCLUSIONS Offering labor induction to nulliparous women at 41+0 gestational weeks may decrease the probability of operative delivery, postpartum hemorrhage, and neonatal weight ≥4000 g. However, this study was underpowered to affirm the trends of rising rates of CS and adverse neonatal outcomes in the expectant management group. Thus, expectant management could remain an option for some, as one in two women with expectant management had a spontaneous onset of labor.
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Affiliation(s)
- Katariina Place
- Department of Obstetrics and GynecologyHelsinki University Hospital and University of HelsinkiHelsinkiFinland
| | - Leena Rahkonen
- Department of Obstetrics and GynecologyHelsinki University Hospital and University of HelsinkiHelsinkiFinland
| | - Aydin Tekay
- Department of Obstetrics and GynecologyHelsinki University Hospital and University of HelsinkiHelsinkiFinland
| | - Kirsi Väyrynen
- Department of Obstetrics and GynecologyCentral Finland Central HospitalJyväskyläFinland
| | - Maija‐Riitta Orden
- Department of Obstetrics and GynecologyKuopio University Hospital and University of Eastern FinlandKuopioFinland
| | - Marja Vääräsmäki
- Clinical Medicine Research Unit, Department of Obstetrics and Gynecology, Medical Research Center OuluOulu University Hospital and University of OuluOuluFinland
| | - Jukka Uotila
- Department of Obstetrics and GynecologyTampere University Hospital and Tampere UniversityTampereFinland
| | - Kati Tihtonen
- Department of Obstetrics and GynecologyTampere University Hospital and Tampere UniversityTampereFinland
| | - Kirsi Rinne
- Department of Obstetrics and GynecologyTurku University Hospital and University of TurkuTurkuFinland
| | - Kaarin Mäkikallio
- Department of Obstetrics and GynecologyTurku University Hospital and University of TurkuTurkuFinland
| | - Seppo Heinonen
- Department of Obstetrics and GynecologyHelsinki University Hospital and University of HelsinkiHelsinkiFinland
| | - Heidi Kruit
- Department of Obstetrics and GynecologyHelsinki University Hospital and University of HelsinkiHelsinkiFinland
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Väyrynen K, Chen A, Leskelä RL, Raussi-Lehto E, Klemetti R, Heinonen S, Torkki P, Tekay A. Introducing standard patient-reported measures (PRMs) into routine maternity care: A pre-implementation qualitative study on women's perspectives in Finland. BMC Health Serv Res 2023; 23:845. [PMID: 37563587 PMCID: PMC10413725 DOI: 10.1186/s12913-023-09818-5] [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] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 07/16/2023] [Indexed: 08/12/2023] Open
Abstract
BACKGROUND Systematically using standard patient-reported measures (PRMs) in clinical routines is trending. The International Consortium for Health Outcomes Measurement (ICHOM) has developed condition-specific standard sets of patient-centred measures, one of which is the Pregnancy and Childbirth Standard (PCB) set, where standard PRMs are included. There is limited knowledge on the use of ICHOM PCB set-included PRMs (ICHOM-PCB-PRMs) in routine care. This study investigates women's perspectives on the future implementation of standard ICHOM-PCB-PRMs in routine maternity care in Finland. METHODS Semi-structured interviews were conducted. Pregnant and postpartum women were asked to evaluate each ICHOM-PCB-PRM in several dimensions, e.g., importance and quality of questions, and to provide their views on future implementation in terms of benefits, difficulties, and practices. With the predefined topics and themes, deductive analysis was applied. Ethical committee approval (HUS 220/880/2015) and research permissions were obtained. RESULTS 22 women participated. Participants felt that most of the ICHOM-PCB-PRMs were important, relevant, understandable, and appropriately designed, and agreed that some changes in ICHOM-PCB-PRMs were needed, e.g., adding other important measures, changing the wording, and adding open-ended questions. Women would be hesitant to answer questions honestly if follow-up actions were unclear. Most "outcome" measures could be asked repeatedly as maternal health status changes over time, and "experience" measures could be asked separately for different service providers. Disagreements regarding data collection at birth were observed. PRMs were regarded as a way for women to express their thoughts and feelings. Our participants were concerned about the possible consequences of negatively answering the PREMs questions and the availability of follow-up care. Participants expected that they could answer short and easy questions digitally before appointments, and that instructions and follow-up actions based on their answers should be available. CONCLUSION ICHOM-PCB-PRMs could be applicable in Finnish maternity care, but some modifications may be required. Careful consideration is needed regarding how and when PRMs questions are asked for eliciting more accurate and honest answers and minimizing women feeling judged, embarrassed, or offended. Follow-ups should be available according to women's responses and needs. This study provides insights on the adoption and implementation of standard PRMs in routine maternity care.
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Affiliation(s)
- Kirsi Väyrynen
- Department of Public Health, Faculty of Medicine, University of Helsinki, Biomedicum 1, Helsinki, 00290, Finland
- Department of Obstetrics and Gynaecology, Central Finland Central Hospital, Hoitajantie 3, Jyväskylä, 40620, Finland
| | - An Chen
- Department of Obstetrics and Gynaecology, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 2, Helsinki, 00290, Finland.
- Institute of Healthcare Engineering, Management and Architecture (HEMA), Department of Industrial Engineering and Management, Aalto University, Maarintie 8, P.O. Box 15500, Aalto, FI-00076, Finland.
- Nordic Healthcare Group Oy, Vattuniemenranta 2, Helsinki, 00210, Finland.
- School of Public Health, Zhejiang Chinese Medical University, No. 548 Binwen Road, Binjiang District, Hangzhou, Zhejiang Province, 310053, China.
| | - Riikka-Leena Leskelä
- Department of Public Health, Faculty of Medicine, University of Helsinki, Biomedicum 1, Helsinki, 00290, Finland
- Nordic Healthcare Group Oy, Vattuniemenranta 2, Helsinki, 00210, Finland
| | - Eija Raussi-Lehto
- Customer-oriented Wellbeing and Health Hub, Metropolia University of Applied Sciences, Myllypurontie 1, Helsinki, 00920, Finland
- Department of Neuroscience and Biomedical Engineering, Aalto University, Otakaari 3, Espoo, 02150, Finland
| | - Reija Klemetti
- Finnish National Institute for Health and Welfare, Mannerheimintie 166, Helsinki, 00300, Finland
| | - Seppo Heinonen
- Department of Obstetrics and Gynaecology, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 2, Helsinki, 00290, Finland
| | - Paulus Torkki
- Department of Public Health, Faculty of Medicine, University of Helsinki, Biomedicum 1, Helsinki, 00290, Finland
| | - Aydin Tekay
- Department of Obstetrics and Gynaecology, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 2, Helsinki, 00290, Finland
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Chen A, Väyrynen K, Leskelä R, Torkki P, Heinonen S, Tekay A, Acharya G. The acceptability of implementing patient-reported measures in routine maternity care: A systematic review. Acta Obstet Gynecol Scand 2023; 102:406-419. [PMID: 36647292 PMCID: PMC10008272 DOI: 10.1111/aogs.14506] [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] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 12/10/2022] [Accepted: 12/18/2022] [Indexed: 01/18/2023]
Abstract
INTRODUCTION Patient-reported measures (PRMs) are becoming popular as they might influence clinical decisions, help to deliver patient-centered care, and improve health care quality. However, the limited knowledge and consensus about the acceptability of implementing PRMs in maternity care hinder their widespread use in clinical practice, and evidence-based recommendations are lacking. This systematic review aims to synthesize available evidence on the acceptability of implementing PRMs in routine maternity care. MATERIAL AND METHODS Literature on the implementation of PRMs in maternity care was electronically searched in six databases (PsycARTICLES, PubMed, Scopus, Web of Science, Cochrane Database of Systematic Reviews, and CINAHL), screened and selected for the topic of "acceptability". Theoretical Framework of Acceptability was used as the basic framework guiding data analysis and synthesis. Evidence was thematically analyzed and synthesized. Mixed Method Appraisal Tool and GRADE-CERQual approach were used to assess the quality of studies and evaluate the confidence in the review findings. RESULTS Overall, 4971 articles were screened. From 24 studies, we identified five themes regarding the acceptability of implementing PRMs in routine maternity care: (1) user's action and behavior, (2) stakeholders' attitudes, (3) perceived benefits, (4) perceived challenges and risks, and (5) stakeholders' preferences and suggestions on implementation. While pregnant and postpartum women, health professionals and other stakeholders involved in maternity care were generally positive about the implementation of PRMs in routine care and recognized the potential benefits (eg health improvement, women empowerment, care and services improvement and healthcare system advancement), they pointed out possible challenges and risks in answering PRMs questions, responding to answers, and setting up integrated information systems as well as suggested solutions in the aspects of PRMs data collection, follow-up care, and system-level management. The confidence in the review findings was moderate due to methodological limitations of included studies. CONCLUSIONS Available empirical evidence suggested that the use of PRMs in routine maternity care is acceptable among stakeholders involved in maternity care and the potential benefits of its integration in routine clinical practice to healthcare improvement has been recognized. However, possible challenges in data collection, follow-up care arrangement and system-level integration should be appropriately addressed.
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Affiliation(s)
- An Chen
- Institute of Healthcare Engineering, Management and Architecture (HEMA), Department of Industrial Engineering and ManagementAalto UniversityEspooFinland
- Department of Obstetrics and GynecologyHelsinki University Hospital and University of HelsinkiHelsinkiFinland
- Nordic Healthcare Group OyHelsinkiFinland
| | - Kirsi Väyrynen
- Department of Obstetrics and GynecologyCentral Finland Central HospitaJyväskyläFinland
| | | | - Paulus Torkki
- Institute of Healthcare Engineering, Management and Architecture (HEMA), Department of Industrial Engineering and ManagementAalto UniversityEspooFinland
- Nordic Healthcare Group OyHelsinkiFinland
- Department of Public Health, Faculty of MedicineHelsinki UniversityHelsinkiFinland
| | - Seppo Heinonen
- Department of Obstetrics and GynecologyHelsinki University Hospital and University of HelsinkiHelsinkiFinland
| | - Aydin Tekay
- Department of Obstetrics and GynecologyHelsinki University Hospital and University of HelsinkiHelsinkiFinland
| | - Ganesh Acharya
- Division of Obstetrics & Gynecology, Department of Clinical Science, Intervention and Technology (CLINTEC)Karolinska InstitutetStockholmSweden
- Women`s Health and Perinatology Research grroup, Department of Clinical MedicineUiT The Arctic University of NorwayTromsøNorway
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Chen A, Väyrynen K, Schmidt A, Leskelä R, Torkki P, Heinonen S, Tekay A, Acharya G. The impact of implementing patient-reported measures in routine maternity care: a systematic review. Acta Obstet Gynecol Scand 2022; 101:1184-1196. [PMID: 36065150 PMCID: PMC9812106 DOI: 10.1111/aogs.14446] [Citation(s) in RCA: 4] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 08/04/2022] [Accepted: 08/09/2022] [Indexed: 01/07/2023]
Abstract
INTRODUCTION While there is growing interest in applying patient-reported measures (PRMs) in clinical routine, limited collective evidence of the impact of PRMs hinder their widespread use in specific contexts, such as maternity care. Our objective was to synthesize existing emperical evidence on the impact of implementing PRMs in routine maternity care. MATERIAL AND METHODS We followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines (version 2020). We electronically searched six databases for the literature on the implementation of PRMs in maternity care. A multi-level (woman, clinical, organizational, national and societal) analytic framework for analyzing and synthesizing emperically proven impacts of PRMs was developed. Quality was assessed using the Mixed Method Appraisal Tool. The GRADE-CERQual approach was used to assess the confidence in the review findings and arguments. The protocol was registered in PROSPERO (CRD42021234501). RESULTS Overall, 4971 articles were screened. The emperical evidence, collected from 11 relevant studies, showed that the use of PRMs in routine maternity care could produce positive effects on clinical process (assessment and detection of health problems, clinical visit preparation, resource use, woman-professional communication, decision-making, woman-professional relationship, and care quality), and health behavior and outcomes (women's health and wellbeing, quality of life, health behavior, experiences and satisfaction with healthcare services), awareness, engagement and self-management of own health, and disclosure of health issues. The confidence in the review findings was low to moderate due to a limited number of studies, inadequate data and methodological limitations of included studies. CONCLUSIONS The limited emperical evidence available suggested that the use of PRMs may have positive effects at the individual health level and clinical process level. However, the evidence was not strong enough to provide policy recommendations on the use of PRMs in routine maternity care. This review revealed limitations of currently available research, such as lack of generalizability and narrow scopes in investigating impact. Efforts are needed to improve the quality of research on the use of PRMs in routine maternity care by widening the study population, including different types of PRMs, and considering the effects of PRMs at different levels and domains of healthcare.
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Affiliation(s)
- An Chen
- Department of Industrial Engineering and ManagementInstitute of Healthcare Engineering, Management and Architecture (HEMA), Aalto UniversityEspooFinland,Department of Obstetrics and GynecologyHelsinki University Hospital and University of HelsinkiHelsinkiFinland,Nordic Healthcare Group OyHelsinkiFinland
| | - Kirsi Väyrynen
- Department of Obstetrics and GynecologyCentral Finland Central HospitaJyväskyläFinland
| | | | - Riikka‐Leena Leskelä
- Nordic Healthcare Group OyHelsinkiFinland,Department of Public Health, Faculty of MedicineHelsinki UniversityHelsinkiFinland
| | - Paulus Torkki
- Department of Industrial Engineering and ManagementInstitute of Healthcare Engineering, Management and Architecture (HEMA), Aalto UniversityEspooFinland,Nordic Healthcare Group OyHelsinkiFinland,Department of Public Health, Faculty of MedicineHelsinki UniversityHelsinkiFinland
| | - Seppo Heinonen
- Department of Obstetrics and GynecologyHelsinki University Hospital and University of HelsinkiHelsinkiFinland
| | - Aydin Tekay
- Department of Obstetrics and GynecologyHelsinki University Hospital and University of HelsinkiHelsinkiFinland
| | - Ganesh Acharya
- Division of Obstetrics & Gynecology, Department of Clinical ScienceIntervention and Technology (CLINTEC), Karolinska InstitutetStockholmSweden,Women's Health and Perinatology Research Group, Department of Clinical MedicineUiT ‐ The Arctic University of NorwayTromsøNorway
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Chen A, Väyrynen K, Leskelä RL, Heinonen S, Lillrank P, Tekay A, Torkki P. A qualitative study on professionals' attitudes and views towards the introduction of patient reported measures into public maternity care pathway. BMC Health Serv Res 2021; 21:645. [PMID: 34217284 PMCID: PMC8254939 DOI: 10.1186/s12913-021-06658-z] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 06/16/2021] [Indexed: 11/10/2022] Open
Abstract
Background The importance and potential benefits of introducing patient reported measures (PRMs) into health care service have been widely acknowledged, yet the experience regarding their implementation into practice is limited. There is a considerable paucity of research in adopting PRMs in maternity care routine. This study, which utilizes the PRMs included in Pregnancy and Childbirth (PCB) outcome set developed by International Consortium for Health Outcomes Measurement (ICHOM) as sample measures, aims to elicit Finnish professionals’ views on PRMs and to explore the applicability of PRMs in Finnish public maternity care. Methods This qualitative study, applying semi-structured interviews, described the local professionals’ views towards the application of PRMs in Finnish public maternity care. Professionals were asked to assess the PRMs defined in ICHOM PCB set and provide their expectations and concerns on the implementation of PRMs in Finnish public maternity service. Results Twenty professionals participated in the interviews. Participants agreed on the importance and relevance of the PRMs questions included in ICHOM PCB set for delivering and developing maternity care in Finland. However, they criticized the number and length of questions as well as the recommended time points of data collection. In addition, for a successful implementation, various steps like developing suitable questions, redesigning service pathway and protocols, and motivating women to respond to PRMs questions were considered to be important. Also, some potential obstacles, difficulties and risks associated with the implementation were underlined. Conclusion This study indicates that the implementation of PRMs into Finnish public maternity service is possible, highly relevant and important. However, the adoption of PRMs into routine practice may be challenging and will require a series of efforts. This study shows viewpoints from Finnish professionals who have not participated in developing the ICHOM PCB standard set and provides important insights on the development and implementation of PRMs. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06658-z.
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Affiliation(s)
- An Chen
- Department of Industrial Engineering and Management, Institute of Healthcare Engineering, Management and Architecture (HEMA), Aalto University, Maarintie 8, P.O. Box 15500, FI-00076 AALTO, 02150, Espoo, Finland. .,Nordic Healthcare Group Oy, Vattuniemenranta 2, 00210, Helsinki, Finland.
| | - Kirsi Väyrynen
- Department of Obstetrics and Gynaecology, Central Finland Central Hospital, Keskussairaalantie 19, 40620, Jyväskylä, Finland
| | | | - Seppo Heinonen
- Department of Obstetrics and Gynaecology, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 2, 00290, Helsinki, Finland
| | - Paul Lillrank
- Department of Industrial Engineering and Management, Institute of Healthcare Engineering, Management and Architecture (HEMA), Aalto University, Maarintie 8, P.O. Box 15500, FI-00076 AALTO, 02150, Espoo, Finland
| | - Aydin Tekay
- Department of Obstetrics and Gynaecology, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 2, 00290, Helsinki, Finland
| | - Paulus Torkki
- Department of Industrial Engineering and Management, Institute of Healthcare Engineering, Management and Architecture (HEMA), Aalto University, Maarintie 8, P.O. Box 15500, FI-00076 AALTO, 02150, Espoo, Finland.,Nordic Healthcare Group Oy, Vattuniemenranta 2, 00210, Helsinki, Finland.,Department of Public Health, Faculty of Medicine, Helsinki University, Biomedicum 1, 00290, Helsinki, Finland
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Hartikainen KM, Sun L, Polvivaara M, Brause M, Lehtimäki K, Haapasalo J, Möttönen T, Väyrynen K, Ogawa KH, Öhman J, Peltola J. Immediate effects of deep brain stimulation of anterior thalamic nuclei on executive functions and emotion-attention interaction in humans. J Clin Exp Neuropsychol 2014; 36:540-50. [PMID: 24839985 PMCID: PMC4066928 DOI: 10.1080/13803395.2014.913554] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [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] [Indexed: 11/06/2022]
Abstract
Background Deep brain stimulation (DBS) of anterior thalamic nuclei (ANT) is a novel promising therapeutic method for treating refractory epilepsy. Despite reports of subjective memory impairments and mood disturbances in patients with ANT-DBS, little is known of its effects on cognitive and affective processes. Hypothesis The anterior thalamus has connections to prefrontal and limbic networks important for cognitive control and emotional reactivity. More specifically, anterior cingulate cortex (ACC), linked with ANT, has been assigned roles related to response inhibition and attention allocation to threat. Thus, we hypothesized ANT-DBS to influence executive functions, particularly response inhibition, and modulate emotional reactivity to threat. Method Twelve patients having undergone ANT-DBS for intractable epilepsy participated in the study. Patients performed a computer-based executive reaction time (RT) test—that is, a go/ no-go visual discrimination task with threat-related emotional distractors and rule switching, while the DBS was switched ON (5/5 mA constant current) and OFF every few minutes. Results ANT-DBS increased the amount of commission errors—that is, errors where subjects failed to withhold from responding. Furthermore, ANT-DBS slowed RTs in context of threat-related distractors. When stimulation was turned off, threat-related distractors had no distinct effect on RTs. Conclusion We found immediate objective effects of ANT-DBS on human cognitive control and emotion-attention interaction. We suggest that ANT-DBS compromised response inhibition and enhanced attention allocation to threat due to altered functioning of neural networks that involve the DBS-target, ANT, and the regions connected to it such as ACC. The results highlight the need to consider affective and cognitive side-effects in addition to the therapeutic effect when adjusting stimulation parameters. Furthermore, this study introduces a novel window into cognitive and affective processes by modulating the associative and limbic networks with direct stimulation of key nodes in the thalamus.
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Affiliation(s)
- Kaisa M Hartikainen
- a Behavioral Neurology Research Unit, Tampere University Hospital , Tampere , Finland
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