Attitudes of women with gestational diabetes toward diet and exercise: a qualitative study

OBJECTIVE

Gestational diabetes (GDM) refers to glucose intolerance of varying severity first occurring in pregnancy. Following a diagnosis of GDM, exercise and dietary modification has a positive effect on improving glycemic control. Lifestyle changes affected in pregnancies affected by GDM have beneficial effects on long-term health if continued following birth. In addition, the psychological impact of a diagnosis of GDM should not be overlooked. Reports of maternal stress, anxiety, and fear are commonly reported issues in the literature. Support, both socially and from health care professionals, is also linked with higher rates of success in GDM management. Research to date had focused on women's reaction to a diagnosis of GDM, their mood and quality of life following a diagnosis, and their knowledge or opinions on the management of GDM. This qualitative study explored the attitudes of women with GDM toward these lifestyle changes, specifically diet and exercise. Women were also asked to identify advice that would be useful for other women newly diagnosed with GDM.

METHODS

With ethical approval a qualitative study was conducted using semi-structured interviews which were examined using Thematic Analysis. Patients were invited to participate and gave written consent after a discussion with a study researcher. The question plan for semi-structured interviews was designed with the advice of patient advocates. Recurrent themes were developed until the saturation of data.

RESULTS

Thirty-two women took part in the study. Time, convenience, and lack of educational awareness were common barriers to healthy eating and physical activity plans. Enablers for change included meal planning and organization. Women regarded their diets pre-diagnosis as healthy, with small "tweaks" (such as portion control) required to comply with recommendations. Another significant facilitator to change was support from the woman's partner. This also set a benchmark for plans of diet maintenance within the family structure after pregnancy. Unlike dietary changes, a consistent theme was that exercise was considered a "chore" in managing GDM and was unlikely to be continued in the long term. Practical advice offered by participants for other women with GDM included organization, realistic approaches, and lack of self-blame.

CONCLUSION

Women reported that changes in diet would be more achievable in the long term than changes in exercise patterns. Partners and the clinical team were significant sources of support. Women's views are crucial to providing clinicians with a comprehensive and holistic understanding of disease management. Involving women in self-care decisions and empowering women to manage their own health are key contributors to long-term behavior change as well as service provision and policy implementation.

Validation of a questionnaire exploring patient attitudes towards bedside teaching

BACKGROUND

Bedside teaching (BST) facilitates medical education and has reduced in practice, often due to patient-related concerns. This study aimed to validate a questionnaire exploring patients attitudes towards BST.

METHODS

International guidelines for questionnaire development were followed. Seven steps were included: literature review, patient interviews, development of clear and understandable items, expert validation, cognitive interviewing and pilot testing. Statistical analyses included exploratory factor analysis, internal consistency, investigation of demographic influences and discriminant validity across subscales.

RESULTS

Following the literature review, 32 interviews were conducted. Potential items were developed, reviewed and adapted. Experts in medical education and statistics reviewed the draft questionnaire. Fifteen patients consented to cognitive testing and 401 consenting patients completed the final version. The median age of participants was 35 years of age (range: 18 to 70 years). Participants included women attending for antenatal (40%), postnatal (32%) and gynaecology issues (28%). Just under one third (29%) had taken part in medical student teaching previously. Statistical analyses found a two-factor solution, consisting of Educate medical professionals and Conditions for participation subscales with good internal consistency; responses did not vary by age or education. Participants who had opted-in for teaching in the ward and bedside endorsed higher levels of Educate medical professionals, suggesting discriminant validity. A majority of patients (> 92%) reported that they were happy to be involved in BST. Patients believed that they should not be asked to participate in BST should they feel stressed or unwell (68.2%).

CONCLUSION

This study shows extensive patient support for BST, independent of age or education. The desire to educate is a strong motivating factor. This strong support by patients for BST is an area that medical schools and universities can potentially develop. Future versions of this questionnaire may include virtual bedside teaching, in the context of social distancing.

Providers’ experience of abortion care: A scoping review protocol. (Preprint)

Background

Despite being one of the most common gynecological procedures in the world, abortion care remains highly stigmatized. Internationally, providers have noted negative impacts related to their involvement in the services, and abortion care has been described as “dirty work.” Though much of the existing research focuses on the challenges of providing, many have also highlighted the positive aspects of working in abortion care. Despite the steadily increasing interest in this area over the past decade, however, no one has sought to systematically review the literature to date.

Objective

The aim of this review is to systematically explore published studies on the experiences of abortion care providers to create a narrative review on the lived experience of providing abortion care, reflecting on what is already known and what areas require further exploration.

Methods

This review will be conducted according to the framework outlined by Levac et al, which expanded on the popular Arksey and O’Malley framework. We will systematically search for peer-reviewed articles in 6 electronic databases: CINAHL, the Cochrane Library, EMBASE, PsycInfo, PubMed, and Web of Science. Following a pilot exercise, we devised a search strategy to identify relevant studies. In this protocol, we outline how citations will be assessed for eligibility and what information will be extracted from the included articles. We also highlight how this information will be combined in the review.

Results

As of December 2021, at the time of writing, we have searched for articles in the electronic databases and identified 6624 unique citations. We intend to fully assess these citations for eligibility by the end of January 2022, chart and analyze data from the eligible citations by the end of March 2022, and submit a journal article for peer review by late spring 2022.

Conclusions

The findings of this review will provide a comprehensive overview on the known experiences of providing abortion care. We also anticipate that the findings will identify aspects of care and experiences that are not reflected in the available literature. We will disseminate the results via a publication in a peer-reviewed academic journal and by presenting the findings at conferences in the areas of abortion care, obstetrics, and midwifery. As this review is a secondary analysis of published articles, ethical approval was not required.

International Registered Report Identifier (IRRID)

DERR1-10.2196/35481

Antenatal prediction of fetal macrosomia in pregnancies affected by maternal pre-gestational diabetes

AIMS

Higher rates of fetal macrosomia may occur in infants of women with pre-gestational diabetes compared with non-diabetic controls. Antenatal predication of fetal macrosomia remains challenging. Ultrasound over-estimated fetal weight could result in over-classification of fetuses as macrosomic with corresponding inappropriate clinical interventions. Previously we had studied a measurement - the anterior abdominal wall measurement (AAW) - to predict fetal macrosomia in fetal estimation of weight. The purpose of the study was to study whether specific third trimester ultrasound measurements with measures of glycaemic control (HbA1c) predicted macrosomia in babies born to women with pre-gestational diabetes. In particular, a new variant of this measurement (fetal anterior abdominal wall thickness (AAW), abdominal circumference (AC) ratio: AAW:AC) was investigated.

METHODS

This was a prospective cohort study in a tertiary referral maternity hospital. Serial growth scans including measurement of AAW and AC: AAW ratio was performed at 30, 33- and 36-weeks' gestation. Birth-weight data was collected, and macrosomia was defined as >90th centile based on gestational age and gender of the baby. Serial HbA1c as measured at the first antenatal visit, 14, 20- and 36-weeks' gestation were reported for this study.

RESULTS

Of the 416 pregnancies analyzed, mean maternal age was 33.3 years. One in five women were primigravida's. The mean birthweight was 3548 g (+/- 581 g), of which 142 (34%) babies were classified as macrosomic. The median gestational age at delivery was 38³ weeks (31⁴ - 40² weeks). There were 37 (9%) babies born preterm at <37 weeks' gestation. Mean AC measurements in fetuses that would be born with macrosomia compared with those with a non-macrosomic birth weight were 282 mm vs. 266 mm at 30 weeks, 318.3 mm vs. 297 mm at 33 weeks and 350 mm vs. 325 mm at 36 weeks' gestation (all p < .001). Mean AAW measurements in macrosomic fetuses compared with normal size fetuses were 3.7 mm vs. 3.3 mm at 30 weeks, 4.9 mm vs 4.3 mm at 33 weeks and 5.9 mm vs. 5.3 mm at 36 weeks' gestation (all p < .001). The mean AC: AAW was 0.01 for both normal and macrosomic fetuses at 30 weeks. There was no clinical or statistical difference in AC:AAW ratios between non-macrosomic and macrosomic infants. Binary logistic regression showed that AC at 36 weeks was most predictive of macrosomia (76.5%), followed by AAW at 30 weeks (68.5%). Using a combination of HbA1c booking, 14, 20, 36 weeks and AAW 30, 33, 36 weeks and AC 30, 33, 36 weeks predicted macrosomia in 80.9%. The ratio of AC: AAW did not act as a useful antenatal clinical predictor of macrosomia at birth.

CONCLUSIONS

Abdominal circumference at 36 weeks was the single best predictor of fetal macrosomia. A combined model of HbA1c, AC and AAW was the best antenatal predictor of macrosomia, with intriguing clinical possibilities in the possible prevention of maternal and fetal complications of macrosomia.

Factors affecting confidence and competence of doctors in performing operative vaginal births: A qualitative study

OBJECTIVES

Operative vaginal birth (OVB) is an important skill for obstetricians. It is the most common emergency intervention in obstetrics and requires a high degree of skill. While there is a lot of data available on technical and non-technical factors affecting the outcome of OVBs little work has been done to investigate the factors that make obstetricians feel confident and competent when performing such a procedure. The objective of this study was therefore to identify the common factors that affect confidence and competence of obstetricians in operative vaginal births (OVB). Our hypothesis was that a qualitative research method would provide a rich approach where themes would be developed that the participants themselves identify as important.

STUDY DESIGN

Qualitative research within two University Hospitals and one District Hospital in Ireland. Participants interviewed ranged from first year trainees to consultant obstetricians. Interviews using open ended questions. Interviews were recorded on audio and later transcribed. Thematic analysis was performed until saturation.

RESULTS

35 obstetricians were interviewed. The median number of years of experience was 5 years (range 3-20 years). The median number of OVB was 200 (range 20-1000+). Vacuum was the preferred choice amongst junior trainees. Preference shifted to forceps with increasing clinical experience. Seven clear themes emerged. Three themes were common to all participants: firstly, that all clinicians reported respect for the primiparous OVB in anticipation of possible complications, secondly the wish for senior midwifery support and finally the importance of clinical experience and exposure. Four themes were common to trainees only. Female clinicians in training reported significant self-doubt in their ability to perform an OVB and had concerns about causing harm. Clinicians in training wished to be trained by consultants during their first year on the labour ward. Experience was important. The final theme was a wish for more training in forceps OVB by clinicians in training.

CONCLUSION

This qualitative study identified factors that can be used to design education and training in OVB in order to support trainees and ultimately improve care for the woman and baby.

The Profile of Women Attending the National Maternity Hospital Emergency Out Of Hours Service – Two Decades On. A Retrospective Review

Introduction This study aimed to review the profile of women attending an out of hours emergency service (OHS) in a maternity hospital and compare it to a previous study. Methods Retrospective study. Demographic information was recorded including timing of presentation, reason and outcome. Results In 2017, 9,020 women attended the OHS, a 334% increase since 1993. On detailed review of 2,143 charts, most (84.7%, n=1,815) were antenatal. The most common reason for presenting to the OHS then was first trimester bleeding. In 2017, over half of antenatal women (51%, n=1,092) presented with “other” reasons, such as vomiting, hypertension or suspected pre-eclampsia. Admission rates significantly decreased from 1993 (38% (n=1,053) in 1993 vs. 16% (n=338) in 2017; p<0.05). Discussion Numbers attending for emergency maternity care have increased in both numbers and variety of presentations. It is important that women are seen and cared for in a compassionate, kind and evidence based manner.

Familiarisation to and reproducibility of cycling at 110% peak power output

AIM

This study investigated the familiarisation to and test re-test reproducibility of constant load cycling at 110% peak power output (WPEAK).

METHODS

Eleven healthy, but not cycle trained, males performed a graded incremental exercise test to ascertain WPEAK followed by three trials (T1, T2 and T3) at 110% WPEAK to exhaustion. Trials were separated by ~7 days.

RESULTS

Although there was no difference in time to exhaustion (TLIM) between T1 and T2 (P=0.100) and T2 and T3 (P=0.095) respectively, a difference was observed between T1 and T3 (P=0.046). Correlation coefficients, coefficients of determination, limits of agreement (LoA) and within-subject coefficient of variation (CV) improved across trials demonstrating T2 and T3 had the strongest relationship (T1 vs. T3: r=0.73; r2=0.53; Bias=40 s; CV=14%; T1 vs. T2: r=0.66; r2=0.43; Bias=24 s; CV=10%; T2 vs. T3: r=0.97; r2=0.95; Bias=16 s; CV=7%). There was no difference across trials for HR (P=0.12), BLa (P=0.76), RER (P=0.52), VE, (P=0.32), VO2, (P=0.33), local RPE (RPEL; P=1) and overall RPE (RPEO; P=0.91) at exhaustion or BLa (P=0.76) and pH (P=0.47) 5-minutes post-exercise.

CONCLUSION

Constant load cycling at 110% WPEAK is a reliable protocol when assessing supramaximal exercise performance after completion of two familiarisation trials.

The effects of elevated levels of sodium bicarbonate (NaHCO₃) on the acute power output and time to fatigue of maximally stimulated mouse soleus and EDL muscles

This study examined the effects of elevated buffer capacity [~32 mM HCO₃(-)] through administration of sodium bicarbonate (NaHCO₃) on maximally stimulated isolated mouse soleus (SOL) and extensor digitorum longus (EDL) muscles undergoing cyclical length changes at 37 °C. The elevated buffering capacity was of an equivalent level to that achieved in humans with acute oral supplementation. We evaluated the acute effects of elevated [HCO₃(-)] on (1) maximal acute power output (PO) and (2) time to fatigue to 60 % of maximum control PO (TLIM60), the level of decline in muscle PO observed in humans undertaking similar exercise, using the work loop technique. Acute PO was on average 7.0 ± 4.8 % greater for NaHCO₃-treated EDL muscles (P < 0.001; ES = 2.0) and 3.6 ± 1.8 % greater for NaHCO₃-treated SOL muscles (P < 0.001; ES = 2.3) compared to CON. Increases in PO were likely due to greater force production throughout shortening. The acute effects of NaHCO₃ on EDL were significantly greater (P < 0.001; ES = 0.9) than on SOL. Treatment of EDL (P = 0.22; ES = 0.6) and SOL (P = 0.19; ES = 0.9) with NaHCO₃ did not alter the pattern of fatigue. Although significant differences were not observed in whole group data, the fatigability of muscle performance was variable, suggesting that there might be inter-individual differences in response to NaHCO₃ supplementation. These results present the best indication to date that NaHCO₃ has direct peripheral effects on mammalian skeletal muscle resulting in increased acute power output.

Quality management in mental health. II. Managing risk of dangerousness

In 1995 R. L. Coleman and D. E. K. Hunter described a quality management approach that produced measurable improvements in quality of care in a state-operated psychiatric hospital. Continued evolution of this approach has subsequently enabled the development and implementation of effective processes for managing risk of dangerousness among patients throughout the hospital. Supported by management principles that promote hospital-wide quality improvement, clinicians and managers produced an environment that was conducive to promoting quality. The hospital-wide quality improvement context involved integrating multiple activities designed to promote quality of care, including significant collaborations with other health care organizations. The hospital's mission as an acute care psychiatric facility has required that it focus on assessing and managing risk of dangerousness in a systematic manner. This was done through developing and utilizing a predictive risk assessment instrument and indicators for managerial oversight. This was accomplished in these steps. First, clinical leaders rated potential criteria according to estimates of their ability to predict dangerousness behavior and reviewed their estimates in relation to clinical findings. Second (and concurrently), clinicians and managers implemented procedures to monitor clinical risk and performance. Finally, outcome data were reviewed. They suggested that this approach was effective in reducing risk of dangerous behavior among patients on all psychiatric wards.