Association between intrapartum fetal pulse oximetry and adverse perinatal and long-term outcomes: a systematic review and meta-analysis protocol

Background

Current methods of intrapartum fetal monitoring based on heart rate, increase the rates of operative delivery but do not prevent or accurately detect fetal hypoxic brain injury. There is a need for more accurate methods of intrapartum fetal surveillance that will decrease the incidence of adverse perinatal and long-term neurodevelopmental outcomes while maintaining the lowest possible rate of obstetric intervention. Fetal pulse oximetry (FPO) is a technology that may contribute to improved intrapartum fetal wellbeing evaluation by providing a non-invasive measurement of fetal oxygenation status.

Objective

This systematic review and meta-analysis aims to synthesise the evidence examining the association between intrapartum fetal oxygen saturation levels and adverse perinatal and long-term outcomes in the offspring.

Methods

We will include randomised control trials (RCTs), cohort, cross-sectional and case-control studies which examine the use of FPO during labour as a means of measuring intrapartum fetal oxygen saturation and assess its effectiveness at detecting adverse perinatal and long-term outcomes compared to existing intrapartum surveillance methods. A detailed systematic search of PubMed, EMBASE, CINAHL, The Cochrane Library, Web of Science, ClinicalTrials.Gov and WHO ICTRP will be conducted following a detailed search strategy until February 2024. Three authors will independently review titles, abstracts and full text of articles. Two reviewers will independently extract data using a pre-defined data extraction form and assess the quality of included studies using the Risk of Bias tool for RCTs and Newcastle-Ottawa Scale for observational studies. The grading of recommendations, assessment, development, and evaluation (GRADE) approach will be used to evaluate the certainty of the evidence. We will use random-effects meta-analysis for each exposure-outcome association to calculate pooled estimates using the generic variance method. This systematic review will follow the Preferred Reporting Items for Systematic reviews and Meta-analyses and MOOSE guidelines.

PROSPERO registration

CRD42023457368 (04/09/2023).

A systematic review of standardised tools used in perinatal death review programmes

INTRODUCTION

Reducing preventable perinatal deaths is the focus of perinatal death surveillance and response programmes. Standardised review tools can help identify modifiable factors in perinatal deaths.

AIM

This systematic review aimed to identify, compare, and appraise perinatal mortality review tools (PMRTs) in upper-middle to high-income countries.

METHODS

Four major scientific databases were searched for publications relating to perinatal death reviews. There were no restrictions on date, study, or publication type. Professional websites for each country were searched for relevant material. The Appraisal of Guidelines Research and Evaluation Health Systems (AGREE-HS) checklist was used for quality appraisal of each tool. A narrative synthesis was used to describe and compare tools.

FINDINGS

Ten PMRTs were included. Five PMRTs were from high-income countries, four from upper-middle income countries and one was designed for use in a global context. The structure, content, and quality of each PMRT varied. Each tool collected information about the antepartum, intrapartum, and neonatal periods and a section to classify perinatal deaths using a standardised classification system. All tools reviewed the care provided. Five tools included recommendation development for changes to clinical care. Four tools mentioned parent involvement in the review process. For quality appraisal, one review tool scored "high quality", six scored "moderate quality" and two scored "poor quality".

CONCLUSION

There is little standardisation when it comes to PMRTs. Guidance on structuring PMRTs in a standardised way is needed. Recommendation development from a review is important to highlight changes to care required to reduce preventable perinatal deaths.

A national survey of surgical training in gynaecology: 2014-2021

OBJECTIVES

Over the last decade barriers to surgical training have been identified, including reducing access to theatre lists, reducing numbers of major surgical procedures being performed, increasing numbers of trainees and reduction in working hours since the introduction of the European Work Time Directive (EWTD). We aimed to assess the impact of these challenges on training in gynaecology over time.

STUDY DESIGN

We designed a study which aimed to assess both trainers and trainees perception of gynaecological surgical training in Ireland. The purpose of this was to identify confidence levels and challenges and to highlight potential areas for future improvement of surgical training in gynaecology. A a cross-sectional survey was distributed to all trainees and trainers registered with the Royal College of Physicians of Ireland Obstetrics and Gynaecology higher specialist training programme in 2014, 2017 and again in 2021.

RESULTS

During the study period trainees' confidence that the training programme prepared them to perform gynaecological surgery fell significantly. This fall in confidence was most evident for trainees' ability to perform abdominal hysterectomy (40.9% vs 15.2%, χ2 = 4.61, p =.03) and vaginal hysterectomy (31.8% vs 12.1%, χ2 = 4.58, p =.03) when comparing 2014 with 2021. All trainees reporteded that gynaecology was not given adequate time in the training programme to prepare them to practice independently as consultants. Themes identified by participants to improve training included dedicated access to theatre time with a named trainer, increased simulation training and subspecialisation at later stages of training.

CONCLUSION

Our findings show an overall decrease in trainees' and trainers' confidence in the surgical training available in gynaecology over an eight-year period.. This is particularly true for major gynaecology procedures. Efforts must be made to ensure trainees have improved access to surgical training in gynaecology. Potential solutions include improving access to simulation and incorporation of subspecialist training into later stages of training.

A protocol for a systematic review of standardised tools used in perinatal death review programmes

Introduction: Perinatal mortality encompasses stillbirths and early neonatal deaths. A perinatal death surveillance and response cycle has been recommended by the World Health Organization for use in the review of perinatal deaths. The main components of the cycle include identifying and reporting perinatal deaths, and reviewing the deaths, including potentially modifiable factors, in order to measure and improve quality of care provided to women and infants. There is no consensus on the best way to design, implement and conduct perinatal death reviews. This systematic review aims to identify standardised tools that are used to review perinatal deaths.  Objectives: The primary aim of this protocol is to describe methodology for a systematic search of the literature to identify standardised tools that are used to review perinatal deaths in upper-middle to high-income countries. Review tools may include standardised checklists, forms, frameworks or other structured documents used to review perinatal deaths. Review tools will be appraised to see if they incorporate the identification of modifiable factors in perinatal deaths and establish recommendations for improvements to quality of care provided. Methods: A systematic review of the literature will be performed to identify peer-reviewed publications and grey literature describing the use of perinatal mortality review tools without date restrictions. The eligibility of review tools for inclusion will be based on inclusion and exclusion criteria applied to the SPIDER framework. Data will be extracted based on the structure and content of included review tools, and the tools will be appraised using the Appraisal of Guidelines Research and Evaluation Health Systems (AGREE-HS) instrument. Conclusion: This systematic review protocol for identifying and appraising standardised perinatal mortality review tools may help to establish the optimal way to structure a standardised review process for perinatal mortality in middle- to high-income countries. PROSPERO registration: CRD42022326877.

A protocol for a systematic review of standardised tools used in perinatal death review programmes

Introduction: Perinatal mortality encompasses stillbirths and early neonatal deaths. A perinatal death surveillance and response cycle has been recommended by the World Health Organization for use in the review of perinatal deaths. The main components of the cycle include identifying and reporting perinatal deaths, and reviewing the deaths, including potentially modifiable factors, in order to measure and improve quality of care provided to women and infants. There is no consensus on the best way to design, implement and conduct perinatal death reviews. This systematic review aims to identify standardised tools that are used to review perinatal deaths.  Objectives: The primary aim of this protocol is to describe methodology for a systematic search of the literature to identify standardised tools that are used to review perinatal deaths in upper-middle to high-income countries. Review tools may include standardised checklists, forms, frameworks or other structured documents used to review perinatal deaths. Review tools will be appraised to see if they incorporate the identification of modifiable factors in perinatal deaths and establish recommendations for improvements to quality of care provided. Methods: A systematic review of the literature will be performed to identify peer-reviewed publications and grey literature describing the use of perinatal mortality review tools without date restrictions. The eligibility of review tools for inclusion will be based on inclusion and exclusion criteria applied to the SPIDER framework. Data will be extracted based on the structure and content of included review tools, and the tools will be appraised using the Appraisal of Guidelines Research and Evaluation Health Systems (AGREE-HS) instrument. Conclusion: This systematic review protocol for identifying and appraising standardised perinatal mortality review tools may help to establish the optimal way to structure a standardised review process for perinatal mortality in middle- to high-income countries. PROSPERO registration: CRD42022326877.

Patient reported outcome measures in childbirth and postpartum maternal quality of life: a protocol for systematic review of measurement properties

Background: Patient centred healthcare is the corner stone to many healthcare strategies. Patient specific health needs should be at the fore of healthcare improvements and quality measurements.  Patient reported outcome measures (PROM) that support real world clinical effectiveness assessments are increasingly being used to highlight domains where there is the greatest scope for change. Objectives: This systematic review aims to identify and evaluate existing patient reported assessment measures/tool(s) that can be used in developing a PROM for postpartum women. We will assess and evaluate their measurement properties in a transparent and structured way in accordance with the COSMIN guidelines. Methods: Methodological guidelines for systematic reviews of PROMs have been developed by the COSMIN initiative and will be followed for this systematic review. A systematic literature review will be performed using PubMed, CINAHL and EMBASE from inception to the present day. Two reviewers independently will judge eligibility, conduct data extraction and assess the methodological quality of each study as per COSMIN guidelines. Inclusion criteria: studies should concern PROM with an aim to evaluate measurement properties in the development or the evaluation of a PROM of interest. Included PROM will focus upon postpartum women assessing morbidity and quality of care. All peer reviewed studies with an assessment tool designed for patient completion will be considered. Exclusion criteria; abstract, letters and non-peer reviewed publications. Studies will be graded on measurement properties and quality of evidence as laid out by COSMIN. All studies and characteristics eligible for inclusion will be summarised and a recommendation to the most suitable measurement tool(s) will be given. Discussion: We will provide a comprehensive description of all available patient reported assessment tools available for childbirth and postpartum quality of life and recommend based on COSMIN guidelines the most suitable instrument(s) available for use.

Perinatal mortality audits and reporting of perinatal deaths: systematic review of outcomes and barriers

BACKGROUND

Perinatal deaths are a devastating experience for all families and healthcare professionals involved. Audit of perinatal mortality (PNM) is essential to better understand the factors associated with perinatal death, to identify key deficiencies in healthcare provision and should be utilised to improve the quality of perinatal care. However, barriers exist to successful audit implementation and few countries have implemented national perinatal audit programs.

CONTENT

We searched the PubMed, EMBASE and EBSCO host, including Medline, Academic Search Complete and CINAHL Plus databases for articles that were published from 1st January 2000. Articles evaluating perinatal mortality audits or audit implementation, identifying risk or care factors of perinatal mortality through audits, in middle and/or high-income countries were considered for inclusion in this review. Twenty articles met inclusion criteria. Incomplete datasets, nonstandard audit methods and classifications, and inadequate staff training were highlighted as barriers to PNM reporting and audit implementation. Failure in timely detection and management of antenatal maternal and fetal conditions and late presentation or failure to escalate care were the most common substandard care factors identified through audit. Overall, recommendations for perinatal audit focused on standardised audit tools and training of staff. Overall, the implementation of audit recommendations remains unclear.

SUMMARY

This review highlights barriers to audit practices and emphasises the need for adequately trained staff to participate in regular audit that is standardised and thorough. To achieve the goal of reducing PNM, it is crucial that the audit cycle is completed with continuous re-evaluation of recommended changes.

Comparing Electronic Health Record Domains' Utility to Identify Transgender Patients

Purpose

Earlier literature has reported on the utility of diagnostic codes and demographic information for identifying transgender patients. We aim to assess which method identifies the most transgender patients utilizing readily available tools from within the electronic health record (EHR).

Methods

A de-identified patient database from a single EHR that allows for searching any discrete data point in the EHR was used to query International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10) diagnostic codes and demographic data specific to transgender patients from January 2011 to April 2019.

Results

Demographic data and ICD-10 codes yielded 1494 individual EHRs with transgender-specific data domains. ICD-10 diagnostic codes alone identified 942 (63.05%) unique EHRs. Demographics alone identified 218 (14.59%) unique EHRs. A total of 334 (22.36%) unique EHRs had both ICD-10 and demographic identifiers. Of those identified by transgender-specific demographic data (552), 294 (53.26%) were trans masculine, 215 (38.95%) were trans feminine, and 43 (7.79%) were nonbinary. Of the 552 demographic-identified transgender patients, 141 (25.86%) were identified by a two-part gender identity demographic question.

Conclusions

ICD-10 diagnostic codes, not demographic data, identified the most transgender patient records, but neither diagnostic codes alone nor demographic data captured the full population. Only 26.36% of the charts identified as transgender patients had both ICD-10 codes and demographic data. We recommend that when identifying transgender populations through EHR domains, a combination of diagnostic codes and demographic data be used. Furthermore, research is needed to optimize disclosure and collection of demographic information for gender minority populations.

Patient reported outcome measures in childbirth and postpartum maternal quality of life: a protocol for systematic review of measurement properties

Background: Patient centred healthcare is the corner stone to many healthcare strategies. Patient specific health needs should be at the fore of healthcare improvements and quality measurements.  Patient reported outcome measures (PROM) that support real world clinical effectiveness assessments are increasingly being used to highlight domains where there is the greatest scope for change. Objectives: This systematic review aims to identify and evaluate existing patient reported assessment measures/tool(s) that can be used in developing a PROM for postpartum women. We will assess and evaluate their measurement properties in a transparent and structured way in accordance with the COSMIN guidelines. Methods: Methodological guidelines for systematic reviews of PROMs have been developed by the COSMIN initiative and will be followed for this systematic review. A systematic literature review will be performed using PubMed and EMBASE from inception to the present day. Two reviewers independently will judge eligibility, conduct data extraction and assess the methodological quality of each study as per COSMIN guidelines. Inclusion criteria: studies should concern PROM with an aim to evaluate measurement properties in the development or the evaluation of a PROM of interest. Included PROMS will focus upon postpartum women assessing morbidity and quality of care. All peer reviewed studies with an assessment tool designed for patient completion will be considered. Exclusion criteria; abstract, letters and non-peer reviewed publications. Studies will be graded on measurement properties and quality of evidence as laid out by COSMIN. All studies and characteristics eligible for inclusion will be summarised and a recommendation to the most suitable measurement tool(s) will be given. Discussion: We will provide a comprehensive description of all available patient reported assessment tools available for childbirth and postpartum quality of life and recommend based on COSMIN guidelines the most suitable instrument(s) available for use.

National perinatal mortality audits and resultant initiatives in four countries

BACKGROUND

It is important to examine perinatal deaths as part of a national mortality audit to identify risk factors. Implementing and re-evaluating recommendations from perinatal mortality audits completes the audit cycle, preventing similar deaths in the future. Lack of implementation results in recommendations recurring.

OBJECTIVES

In this study we examine national perinatal mortality audits' methodology in four high-income countries (United Kingdom, New Zealand, Ireland, Netherlands) to highlight different approaches taken. We compare the recommendations made in these audits' reports over the last five years, as well as review national initiatives and programmes addressing them.

STUDY DESIGN

This study is an integrative review where two comprehensive literature searches were completed: on established national perinatal mortality audits in high-income countries; and on national initiatives addressing recommendations from these audits. Content analysis of the audits' recommendations was performed organising them into themes according to topics these focused on.

RESULTS

Though the methodology of the national perinatal mortality audits varied, all four were state-funded and had standardised online data collection forms to report deaths. The recommendations themes included: Raising public awareness of perinatal mortality risk factors, Detection of fetal growth restriction, Prevention of preterm birth, Resources for data collection and review. Only the UK had various initiatives addressing perinatal mortality risk factors directly. New Zealand included stakeholders in the audit recommendations' development and provided updates on their implementation. The Netherlands developed a programme for audit recommendation implementation. Ireland created a group which is progressing some recommendations from the audit.

CONCLUSIONS

National perinatal mortality audits are important in identifying contributory factors and making recommendations to address these. Recurring recommendations suggest a failure to resolve the identified issues. This study shows how some challenges are common to high-income countries' audits, highlighting the need for shared learning of successful initiatives.

Governance of maternity services: Effects on the management of perinatal deaths and bereavement services

BACKGROUND

External inquiries are carried out following adverse maternal/perinatal events, to examine the care provided and make recommendations to improve it. Clinical governance ensures that organisations promote high-quality care and are accountable for the care they provide, thus contributing to its improvement.

OBJECTIVE

This study examined how Irish perinatal bereavement services and the management of perinatal deaths (including events leading up to the deaths) were affected by developments in maternity services governance as described in ten Irish enquiry reports published over 14 years (2005-18).

METHODS

Two clinicians collected data from the ten enquiry reports by using a specifically designed review tool. Thematic analysis was carried out, following the steps of familiarising, coding, identifying, grouping and revising themes.

FINDINGS

Seven main themes were identified: workforce, leadership, management of risk, work environment, hospital oversight, national documents, data collection. Eight reports noted shortcomings in staffing levels, with a workforce that was under-resourced, and at times carried excessive workloads. The absence of 24/7 midwifery-shift leaders in maternity units resulted in problems with care at times not being escalated appropriately. The absence of a widely-owned, understood strategic plan for the management of the maternity services was mentioned in the reports from 2013. Conclusions and implications for practice The National Bereavement Care Standards were published in 2016 to address deficiencies identified in the enquiry reports and to standardise perinatal bereavement care across Irish maternity units. Though the first Irish Maternity Strategy (2016-26) was published in 2016, its implementation is incomplete. Inconsistencies remain in the definition and collection of national perinatal data, as well as concerns regarding the lack of local audit activities on pregnancy outcomes. Greater focus on hospital oversight, implementation of national documents and reliable data collection is required. To be effective and initiate positive changes in clinical services, documents such as incident reviews, national strategies and national reports including inquiries, need to include realistic recommendations with clear timelines and responsibilities for implementation.

Telemedicine Training in the COVID Era: Revamping a Routine OSCE to Prepare Medicine Residents for Virtual Care

BACKGROUND

During the rapid onset of the pandemic, clinicians transitioned from traditional outpatient practice to virtual modalities for providing routine care to patient panels. Like training programs nationwide, telemedicine training and assessment had not been systematically incorporated into our residency. In response, a scheduled Internal Medicine (IM) Objective Structured Clinical Examination (OSCE) was adapted to a remote modality to become virtual care-focused learning experience for trainees and to provide valuable feedback to educators.

METHODS

Standardized Patients (SPs) rated residents on their communication (including information gathering, relationship development and patient education), patient activation and satisfaction, and telemedicine skills. Analyses included a comparison of domain scores for residents who participated in both the 2020 remote and 2019 in-person OSCEs, and a review of written resident comments about the virtual OSCE.

RESULTS

During 2020's video visit OSCE (VOSCE), residents (n = 23) excelled at nonverbal communication but struggled with virtual physical exams and information gathering. In debrief, residents expressed substantial interest in more opportunity to practice virtual visit skills going forward. In comparing scores of the virtual care (2020) OSCE with the in-person (2019) version, the small subset of residents who participated in both assessments (n = 9) performed similarly on communication skills, patient satisfaction and activation. Patient education scores were significantly lower during the virtual care OSCE (P = .008).

CONCLUSION

Our reformulated OSCE accomplished 3 goals including; (1) physically distancing residents from SPs per COVID regulations, (2) providing residents with the opportunity to practice critical virtual visit skills, and (3) alerting our educators to curricular improvement areas. Our methods are useful for other institutions and have applications to the larger medical education community.

Impact of bereavement care and pregnancy loss services on families: Findings and recommendations from Irish inquiry reports

BACKGROUND

Pregnancy loss and the death of their baby can be overwhelming for families, especially when the loss is unexpected. The standard of bereavement care families receive around the time of pregnancy or early infant loss can have a significant impact on their psychological recovery. At times external inquiries are carried out to identify issues in the maternity care provided and make recommendations to improve its' standard.

OBJECTIVE

This study aims to describe the impact of bereavement care provided to families around the time of pregnancy and/or early infant loss as stated in ten published inquiry reports related to Irish maternity services.

METHODS

Using thematic analysis, issues with care encountered by bereaved parents as outlined in the reports were identified. These focussed around five main themes (communication, healthcare staff skills, maternity unit environment, post-mortem/coronial process, local incident reviews).

FINDINGS

Bereavement care, as described by families in the ten reports, was not consistently individualised or respectful, resulting in additional feelings of anger and upset. Problems with clear communication of complex issues, in a manner that is understandable to bereaved families, were identified in several reports. Recommendations from the inquiry reports included that experienced and skilled staff should always be available to provide immediate support to bereaved families as appropriate, and assist families in understanding and processing information around the time of their loss.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Consistent, individualised bereavement care facilitates a seamless transition for bereaved families from diagnosis through the hospital stay to discharge and follow-up, allowing them to focus on their baby, their bereavement and their family's wellbeing. The process of consent for a perinatal post-mortem and associated concerns have evolved over the timeframe of the ten inquiries. We reflect further on this and the impacts of the other issues highlighted, as well as discussing possible improvements to address them as described in the scientific literature.

Measuring women's experiences of maternity care: A systematic review of self-report survey instruments

BACKGROUND

Recognition of the measurement of women's experiences of their maternity care as a critical component of care quality evaluation has led to a proliferation of instruments to measure this concept. However, the suboptimal methodological and psychometric quality of these instruments, or the lack of reporting of same, hinders the credibility and efficient use of the arising results, which often serve as an indicator for the direction of limited resources within maternity services.

AIM

To review systematically and critically appraise self-report survey instruments measuring women's experiences of their maternity care.

METHODS

A systematic review was conducted using comprehensive searches of the CINAHL, OVID MEDLINE and EMBASE citation databases. Inclusion and exclusion criteria were applied, and a stepped approach employed to facilitate evaluation of the methodological and psychometric quality of included instruments.

FINDINGS

4905 records were obtained from database searches. Additional records were obtained via reference checking and by expert suggestion. Following stepped screening, 40 papers related to 20 instruments are included in this review. Findings indicate that evidence of the methodological and psychometric quality have not been reported for many included instruments.

CONCLUSIONS

Published evidence of the methodological and psychometric quality of self-report survey instruments to evaluate women's experiences of their maternity care is lacking. The conduct and reporting of future development processes of such instruments can be improved. Systematic review PROSPERO registration: CRD42018105325.

"Worn out": Coping strategies for managing antiretroviral treatment fatigue among urban people of color living with HIV who were recently disengaged from outpatient HIV care

Antiretroviral-related treatment fatigue is inconsistently defined in the literature on barriers to ART adherence. Research suggests that treatment fatigue is a salient challenge for people struggling with antiretroviral therapy adherence, but little is known about how people living with HIV attempt to manage this fatigue. Twenty-seven semi-structured interviews were conducted with low-income people of color living with HIV in NYC that were currently, or recently, disengaged from HIV care. The findings from this exploratory study suggest that treatment fatigue was common and that participants devised personal strategies to overcome it. These strategies included using reminder programs, requesting weekly rather than monthly pill quantities, and taking "pill holidays". The varied nature- and varying levels of effectiveness- of these strategies highlight the need for specific programming to provide tailored support. Future research should examine treatment fatigue as a specific subtype of adherence challenge, and aim to define pill fatigue clearly.

Perinatal mortality audits and reviews: Past, present and the way forward

Perinatal deaths are devastating for families and staff involved. Failure to examine perinatal deaths for substandard care prevents learning and may lead to recurrence of events, as well as prolonged morbidity in bereaved families and hospital staff. Perinatal mortality reviews can identify factors contributing to suboptimal care. An integrative literature review was carried out to study the different types of perinatal mortality reviews currently being done internationally, establishing a comparison and examining promising new developments. We start by outlining issues with the classification of perinatal deaths and the different types of perinatal mortality reviews carried out in high-income countries. We reflect on the challenges that are encountered in the current processes and we then comment on how these may be overcome. Current literature shows that differences in classifications of perinatal deaths continue to impede important international comparisons. National perinatal mortality audits can provide reliable high-quality data to facilitate national and international benchmarking. Confidential enquiries give expert assessment on anonymised information to initiate system-wide improvements, but to provide local information on perinatal deaths unit-based multi-disciplinary team reviews are required. Additionally, there is a need to shift from a blame-culture to a focus on achieving best practice by learning from mistakes. Review tools and processes have been implemented in some countries to standardize perinatal mortality reviews, but there is still more work to be done. Involving the bereaved parents in the perinatal mortality review process is important and ways to achieve this are progressing. A structured approach to the perinatal mortality review process should be developed to facilitate sharing of experiences and challenges at national (or international) level. To achieve a reduction in the number of stillbirths and neonatal deaths, it is crucial to ensure that the perinatal mortality audit and review cycle is completed with implementation and re-evaluation of recommended changes in maternity services.

Irish Inquiry Reports Relating to Perinatal Deaths and Pregnancy Loss Services

Aims External inquiries are carried out following specific adverse events in healthcare, many in maternity care; to identify issues and make recommendations to improve standards of care. Methods Ten publically-available national inquiry reports published between 2005-2018 relating to pregnancy loss services, were reviewed by 2 clinicians, separately, examining the content and recommendations from each report. Results A total of 258 recommendations were made in 9 reports (90%). Five inquiries (50%) clearly stated that affected families were involved and four (40%) involved affected clinical staff. In 9 reports (90%) recommendations included: increase workforce staffing and/or training, strengthen clinical governance, enhance adverse incident management and comprehensive data collection e.g. maternity outcomes. Only two inquiry reports (20%) stated that feedback was sought from key stakeholders prior to publication. Conclusion A collaborative and standardised inquiry process involving and supporting all persons affected as well as key stakeholders would ensure that all relevant issues are identified, recommendations are implemented and essential lessons are learned.

Measuring women's experiences of maternity care: protocol for a systematic review of self-report survey instruments

BACKGROUND

The use of survey instruments to measure women's experiences of their maternity care is regarded internationally as an indicator of the quality of care received. To ensure the credibility of the data arising from these instruments, the methodological quality of development must be high. This paper reports the protocol for a systematic review of self-report instruments used to measure women's experiences of their maternity care.

METHODS

Citation databases CINAHL, Ovid MEDLINE and EMBASE will be searched from 2002 to 2018 using keywords including women, experience, maternity care, questionnaires, surveys, and self-report. Citations will be screened by two reviewers, in two rounds, for inclusion as per predetermined inclusion and exclusion criteria. Data extraction forms will be populated with data, extracted from each study, to evaluate the methodological quality of each survey instrument and the criteria for good measurement properties using quality criteria. Data will also be extracted to categorise the items included in each survey instrument. A combination of a structured narrative synthesis and quantitate summaries in tabular format will allow for recommendations to be made on the use, adaptation and development of future survey instruments.

DISCUSSION

The value of survey instruments that evaluate women's experiences of their maternity care, as a marker of quality care, has been recognised internationally with many countries employing the use of such instruments to inform policy and practice. The development of these instruments must be methodologically sound and the instrument itself fit for the purpose and context in which it is used. This protocol describes the methods that will be used to complete a systematic review that will serve as a guide for choosing the most appropriate existing instruments to use or adapt so that they are fit for purpose, in addition to informing the development of new instruments.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018105325.

Parental opinion of consent in neonatal research

BACKGROUND

Neonatal research, particularly neonatal emergency research is a challenging area, notably in relation to obtaining valid prospective informed consent. The aim of this study is to determine parental perceptions of the consent process involved in performing research in newborn care, to explore methods used to obtain consent and their acceptability to parents.

METHODS

A parental questionnaire was developed that examined attitudes towards research and hypothetical research studies, in which the acceptability of various methods of consent was examined (informed, waived, deferred). These research scenarios were of varying time sensitivity and perceived risk level. The study setting was an Irish maternity hospital.

RESULTS

There were 600 responses to the questionnaire. In 93% of cases, parents felt that their involvement in the consent process was essential. In emergency situations, 52% felt full prospective informed consent was necessary; however, almost 28% of parents would feel pressure to consent. Most (75%) parents would prefer to be approached to discuss neonatal research studies antenatally, irrespective of study type and 40% of parents felt that neonates involved in research studies received overall better care. Acceptability of deferred consent was greater than waived, and was highest for the more emergency-based scenarios presented.

DISCUSSION

Parents feel that they should play a central role in research involving their children. There were differences in the acceptability of various consent methods with strongest agreement for informed consent and lowest agreement for waived consent. Parents were more willing to accede to deferred consent in the cardiopulmonary resuscitation scenario study. These findings provide useful insights to consent strategies in future newborn research studies.

1296. Potential use of Sexually Transmitted Infection (STI) Testing for Expanding HIV Pre-Exposure Prophylaxis (PrEP) at an Urban Hospital Center

Background

Despite the high efficacy of PrEP, it continues to be underutilized. We examined the extent to which patients with a documented positive test for STIs were provided PrEP at an urban municipal medical center.

Methods

We reviewed data of all patients seen between January 1, 2014 and July 30, 2017 who were > 18 years old and had an initial HIV negative test and ≥1 positive test for Chlamydia, Gonorrhea, or Syphilis. We examined PrEP prescription data by gender, race/ethnicity, and clinic location. Differences between groups were compared using Chi-squared analysis and logistic regression.

Results

Of 1,142 initially HIV− patients who were identified as having a positive STI result, 52% were female, 89% either Black or Hispanic, with a median age of 40 years (quartiles 30, 47). 58% had Medicare/Medicaid and 34% were self-pay or uninsured (Table 1). Only 25 (2.1%) of 1,142 patients who had ≥1 STI test positive were prescribed PrEP. No women received PrEP. Whites (aOR: 21.7 [95% CI:4.4, 107, P < 0.001] and Hispanics (aOR:6.64 [95% CI:1.35, 32.8, P = 0.02] were both more likely to receive PrEP than Blacks, after adjusting for age, sex, marital status, and insurance. All PrEP prescriptions originated from the Medicine, Emergency, or HIV specialty clinics although most STI testing was obtained in Emergency and Obstetrical/Gynecological clinics (Table 2).

Conclusion

There were significant missed opportunities for HIV prevention among patients with STIs within the medical center, particularly among Hispanic and Black patients. Enrichment programs to educate providers and increase PrEP prescriptions may have a major impact on expanding HIV prevention, especially for women.

Disclosures

All authors: No reported disclosures.

Realizing the promise of The Partnership for Maternal, Newborn and Child Health

Reflecting on Storeng and Béhague ("Lives in the balance": the politics of integration in the Partnership for Maternal, Newborn and Child Health. Health Policy and Planning Storeng and Béhague (2016).) historical ethnography of the Partnership for Maternal, Newborn and Child Health (PMNCH), this commentary provides a more current account of PMNCH's trajectory since its inception in 2005. It highlights PMNCH's distinct characteristics and how it is positioned to play an instrumental role in the current global health landscape.

Un pionnier de la bibliothéconomie au Canada français Auguste-Marie Morisset, OMI

Cette esquisse biographique célèbre la mémoire du père Auguste-Marie Morisset, OMI, bibliothécaire en chef de l’Université d’Ottawa durant quelque 25 ans. L’Université lui a rendu hommage en donnant son nom au pavillon qui loge sa bibliothèque des arts et des sciences. On ne trouvera ici ni réquisitoire ni plaidoyer, mais un portrait du père Morisset tel qu’il apparaît à travers les sources et les témoignages, avec ses qualités et ses défauts, ses ombres et ses lumières, ses réalisations et ses échecs. Les auteurs ont voulu suivre toutes les étapes de sa vie, mais en insistant particulièrement sur sa carrière dans le milieu des bibliothèques, comme professeur, directeur de bibliothèque, fondateur d’une école de bibliothéconomie, conférencier et homme d’associations.

Placenta accreta and maternal morbidity in the Republic of Ireland, 2005-2010

OBJECTIVE

To describe the nationwide prevalence of placenta accreta and to quantify its impact on maternal morbidity.

METHODS

Using discharge data for public hospitals in Ireland, years 2005-2010, deliveries with placenta accreta were identified using ICD-10-AM code for morbidly adherent placenta and compared with deliveries without the condition. Adjusted odds ratios (aOR) and 95% confidence intervals (CI) were estimated using logistic regression.

RESULTS

Placenta accreta prevalence increased 34% from 2005 to 2010 (7.9/10 000 deliveries versus 10.6/10 000 deliveries). This condition was associated with a substantial increased risk of hemorrhage (aOR: 16.6, 95% CI: 13.4-20.5), hysterectomy (aOR: 950.6, 95% CI: 632.9-1427.9), procedures to reduce uterine blood flow (aOR: 72.4, 95% CI: 35.1-149.4), transfusion (aOR: 41.8, 95% CI: 33.4-52.2), anemia (aOR 15.1, 95% CI: 10.8-21.0), abdominal organ injury (aOR: 8.2, 95% CI: 5.2-13.1), bladder surgery (aOR: 38.5, 95% CI: 21.8-68.1), mechanical ventilation (aOR: 63.2, 95% CI: 28.4-140.6), intensive care unit admission (aOR: 41.3, 95% CI: 30.0-56.9), and co-existing placenta previa (aOR: 23.2, 95% CI: 16.8-31.8) as well as increased risk of cesarean section, longer hospitalization and stillbirth.

CONCLUSIONS

To our knowledge, this is the first study to use a comparison group of deliveries without placenta accreta and quantitatively illustrate with odds ratios the profound adverse health effects of this condition on the mother.

Effects of voluntary wheel running on LPS-induced sickness behavior in aged mice

Peripheral stimulation of the innate immune system with LPS causes exaggerated neuroinflammation and prolonged sickness behavior in aged mice. Regular moderate intensity exercise has been shown to exert anti-inflammatory effects that may protect against inappropriate neuroinflammation and sickness in aged mice. The purpose of this study was to test the hypothesis that voluntary wheel running would attenuate LPS-induced sickness behavior and proinflammatory cytokine gene expression in ~22-month-old C57BL/6J mice. Mice were housed with a running wheel (VWR), locked-wheel (Locked), or no wheel (Standard) for 10 weeks, after which they were intraperitoneally injected with LPS across a range of doses (0.02, 0.08, 0.16, 0.33 mg/kg). VWR mice ran on average 3.5 km/day and lost significantly more body weight and body fat, and increased their forced exercise tolerance compared to Locked and Shoebox mice. VWR had no effect on LPS-induced anorexia, adipsia, weight-loss, or reductions in locomotor activity at any LPS dose when compared to Locked and Shoebox groups. LPS induced sickness behavior in a dose-dependent fashion (0.33>0.02 mg/kg). Twenty-four hours post-injection (0.33 mg/kg LPS or Saline) we found a LPS-induced upregulation of whole brain TNFα, IL-1β, and IL-10 mRNA, and increased IL-1β and IL-6 in the spleen and liver; these effects were not attenuated by VWR. We conclude that VWR does not reduce LPS-induced exaggerated or prolonged sickness behavior in aged animals, or 24h post-injection (0.33 mg/kg LPS or Saline) brain and peripheral proinflammatory cytokine gene expression. The necessity of the sickness response is critical for survival and may outweigh the subtle benefits of exercise training in aged animals.

Monitoring the tidal Delaware River for ambient toxicity

This study assessed ambient waters in an urbanized area of the Delaware River, to determine whether river water samples exhibited chronic lethal or sublethal toxicity when measured in laboratory experiments. Toxicity was assessed at 16 fixed stations in the main-stem river and 29 stations in tributaries of the tidal Delaware River with salinities from 0 to 15 parts per 1000 (ppt) using Pimephales promelas, Americamysis bahia, Menidia beryllina, and Ceriodaphnia dubia in 7-d tests; Pseudokirchneriella subcapitata in a 96-h test; and Hyalella azteca in a 10-d water-only test. The toxicity tests measured organism survival, growth, and reproduction. Results from testing water samples collected in 4 different y indicated that the samples from sites tested in the main-stem of the Delaware River and from the majority of its tributaries did not produce chronic toxicity. The surveys identified tributaries that warrant further assessment for toxicity.

Effects of Healthy Families New York on the promotion of maternal parenting competencies and the prevention of harsh parenting

OBJECTIVES

This paper examines the effectiveness of the Healthy Families New York (HFNY) home visiting program in promoting parenting competencies and preventing maladaptive parenting behaviors in mothers at risk for child abuse and neglect.

METHODS

The study used microlevel observational assessments of mother-child interactions in the third wave of a randomized controlled trial to evaluate whether mothers who received home visiting services were more likely to exhibit positive parenting and less likely to display negative parenting behaviors than those who did not receive these services. Women were randomly assigned during pregnancy or shortly after the birth of the target child to an intervention group that was offered home visiting services or a control group that was given referrals to other services. At Year 3, 522 mother and child pairs were systematically observed while they interacted in semistructured tasks presenting varied parenting challenges. The study also sought to replicate a finding from Year 2, which revealed that program effects on harsh parenting were stronger among young, first-time mothers who were randomly assigned during pregnancy (the High Prevention Opportunity subgroup) than among the other mothers (the Limited Prevention Opportunity subgroup).

RESULTS

Results indicate that HFNY was effective in fostering positive parenting, such as maternal responsivity and cognitive engagement. With respect to negative parenting, HFNY mothers in the High Prevention Opportunity subgroup were less likely than their counterparts in the control group to use harsh parenting, while no differences were detected for the Limited Prevention Opportunity subgroup.

CONCLUSION

HFNY was successful in promoting positive parenting among mothers at risk for child abuse and neglect, which may reflect the program's strength-based approach. The replication of the High Prevention Opportunity subgroup as a moderator of program effects on harsh parenting further suggests that HFNY may be more useful for preventing the initiation rather than the recurrence of child abuse and neglect.

PRACTICE IMPLICATIONS

To optimize service delivery, HFNY should continue to focus on enhancing parent-child interactions, prioritize HFNY services for young, first-time mothers who are offered the program during pregnancy, and investigate effective strategies to reduce negative parenting practices among the Limited Prevention Opportunity subgroup.

Differences in the control of breathing between Andean highlanders and lowlanders after 10 days acclimatization at 3850 m

We used Duffin's isoxic hyperoxic ( mmHg) and hypoxic ( mmHg) rebreathing tests to compare the control of breathing in eight (7 male) Andean highlanders and six (4 male) acclimatizing Caucasian lowlanders after 10 days at 3850 m. Compared to lowlanders, highlanders had an increased non-chemoreflex drive to breathe, characterized by higher basal ventilation at both hyperoxia (10.5 +/- 0.7 vs. 4.9 +/- 0.5 l min(1), P = 0.002) and hypoxia (13.8 +/- 1.4 vs. 5.7 +/- 0.9 l min(1), P < 0.001). Highlanders had a single ventilatory sensitivity to CO(2) that was lower than that of the lowlanders (P < 0.001), whose response was characterized by two ventilatory sensitivities (VeS1 and VeS2) separated by a patterning threshold. There was no difference in ventilatory recruitment thresholds (VRTs) between populations (P = 0.209). Hypoxia decreased VRT within both populations (highlanders: 36.4 +/- 1.3 to 31.7 +/- 0.7 mmHg, P < 0.001; lowlanders: 35.3 +/- 1.3 to 28.8 +/- 0.9 mmHg, P < 0.001), but it had no effect on basal ventilation (P = 0.12) or on ventilatory sensitivities in either population (P = 0.684). Within lowlanders, VeS2 was substantially greater than VeS1 at both isoxic tensions (hyperoxic: 9.9 +/- 1.7 vs. 2.8 +/- 0.2, P = 0.005; hypoxic: 13.2 +/- 1.9 vs. 2.8 +/- 0.5, P < 0.001), although hypoxia had no effect on either of the sensitivities (P = 0.192). We conclude that the control of breathing in Andean highlanders is different from that in acclimatizing lowlanders, although there are some similarities. Specifically, acclimatizing lowlanders have relatively lower non-chemoreflex drives to breathe, increased ventilatory sensitivities to CO(2), and an altered pattern of ventilatory response to CO(2) with two ventilatory sensitivities separated by a patterning threshold. Similar to highlanders and unlike lowlanders at sea-level, acclimatizing lowlanders respond to hypobaric hypoxia by decreasing their VRT instead of changing their ventilatory sensitivity to CO(2).

Differences in the control of breathing between Himalayan and sea-level residents

We compared the control of breathing of 12 male Himalayan highlanders with that of 21 male sea-level Caucasian lowlanders using isoxic hyperoxic ( = 150 mmHg) and hypoxic ( = 50 mmHg) Duffin's rebreathing tests. Highlanders had lower mean +/- s.e.m. ventilatory sensitivities to CO(2) than lowlanders at both isoxic tensions (hyperoxic: 2.3 +/- 0.3 vs. 4.2 +/- 0.3 l min(1) mmHg(1), P = 0.021; hypoxic: 2.8 +/- 0.3 vs. 7.1 +/- 0.6 l min(1) mmHg(1), P < 0.001), and the usual increase in ventilatory sensitivity to CO(2) induced by hypoxia in lowlanders was absent in highlanders (P = 0.361). Furthermore, the ventilatory recruitment threshold (VRT) CO(2) tensions in highlanders were lower than in lowlanders (hyperoxic: 33.8 +/- 0.9 vs. 48.9 +/- 0.7 mmHg, P < 0.001; hypoxic: 31.2 +/- 1.1 vs. 44.7 +/- 0.7 mmHg, P < 0.001). Both groups had reduced ventilatory recruitment thresholds with hypoxia (P < 0.001) and there were no differences in the sub-threshold ventilations (non-chemoreflex drives to breathe) between lowlanders and highlanders at both isoxic tensions (P = 0.982), with a trend for higher basal ventilation during hypoxia (P = 0.052). We conclude that control of breathing in Himalayan highlanders is distinctly different from that of sea-level lowlanders. Specifically, Himalayan highlanders have decreased central and absent peripheral sensitivities to CO(2). Their response to hypoxia was heterogeneous, with the majority decreasing their VRT indicating either a CO(2)-independent increase in activity of peripheral chemoreceptor or hypoxia-induced increase in [H(+)] at the central chemoreceptor. In some highlanders, the decrease in VRT was accompanied by an increase in sensitivity to CO(2), while in others VRT remained unchanged and their sub-threshold ventilations increased, although these were not statistically significant.

Tolerability of ongoing phase II study of concomitant radiation and docetaxel followed by docetaxel in prostate cancer patients with a persistent or rising PSA after radical prostatectomy

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Background: Patients with a detectable PSA after radical prostatectomy (RRP) have persistent disease and inevitably succumb to disease as progression ensues. Radiation has been used in the salvage setting, but has only been found to cure less than half of these patients. SWOG 8794 has recently reported a significant increase in metastasis free survival in 15 years with adjuvant radiation for patients with high risk findings after RRP. It is of particular interest if adjuvant chemoradiation (CRT) can improve the rate of reaching a PSA nadir of zero after RRP in men with persistent or rising PSA. This ongoing IRB approved trial has thus far evaluated the tolerability of CRT utilizing the radiosensitizing agent Docetaxel (DX) for 7 weeks after RRP followed by adjuvant full dose DX (75mg/m2). Methods: Patients: Chemotherapy/hormone naïve, status post RRP, post-op PSA > 0.2 ng/mL on two separate occasions, ECOG ≤ 2; treated with taxane-based chemotherapy (DX 20mg/m2 weekly) concurrent with standard dose radiation for 7 weeks, and post-radiation chemotherapy DX (75mg/ m2) given every 21 days for 4 cycles with premedication intravenous dexamethasone. Primary endpoint: Rate of PSA decline; Number of subjects reaching PSA nadir of zero. Secondary endpoints: Progression Free Survival (PFS) based on PSA progression, toxicity graded via Common Terminology Criteria for Adverse Events Version 3.0 (CTCAE), and overall survival (OS). Results: From 5/07 to 12/08, 16 pts with detectable PSA after RRP were treated; Median age 65 [48–74]; 16/16 completed CRT; 11/16 completed CRT and adjuvant DX; 3/16 dropped out due to adverse events after CRT; Toxicity: 19% (3/16) patients experienced Grade 3 toxicity during CRT and adjuvant DX; 29% (4/14) patients had Grade 3 toxicity during adjuvant DX; no Grade 4 toxicities. See Table . Conclusions: DX in combination with standard radiation appears to be well tolerated in patients with persistent PSA after RRP. [Table: see text]

No significant financial relationships to disclose.