Andrew Symon

Postnatal quality of life assessment: validation of the Mother-Generated Index

Quality of life is multifactorial, but may not be adequately assessed using existing validated health measures. The Mother‐Generated Index, a subjective tool to measure postnatal quality of life, was assessed in a study of 102 women in Tayside, Scotland. They specified the most important areas of their lives having had a baby, and scored these. The Index showed good correlation with established measures of physical and psychological wellbeing, and accurately tracked attitudes towards the baby and the partner. Face, criterion and construct validity were all demonstrated. As both content and scoring are subjectively determined, the Index encourages a holistic assessment.

Evaluating the reliability, validity, acceptability, and practicality of SMS text messaging as a tool to collect research data: results from the Feeding Your Baby project.

OBJECTIVE To test the reliability, validity, acceptability, and practicality of short message service (SMS) messaging for collection of research data. MATERIALS AND METHODS The studies were carried out in a cohort of recently delivered women in Tayside, Scotland, UK, who were asked about their current infant feeding method and future feeding plans. Reliability was assessed by comparison of their responses to two SMS messages sent 1 day apart. Validity was assessed by comparison of their responses to text questions and the same question administered by phone 1 day later, by comparison with the same data collected from other sources, and by correlation with other related measures. Acceptability was evaluated using quantitative and qualitative questions, and practicality by analysis of a researcher log. RESULTS Reliability of the factual SMS message gave perfect agreement. Reliabilities for the numerical question were reasonable, with κ between 0.76 (95% CI 0.56 to 0.96) and 0.80 (95% CI 0.59 to 1.00). Validity for data compared with that collected by phone within 24 h (κ =0.92 (95% CI 0.84 to 1.00)) and with health visitor data (κ =0.85 (95% CI 0.73 to 0.97)) was excellent. Correlation validity between the text responses and other related demographic and clinical measures was as expected. Participants found the method a convenient and acceptable way of providing data. For researchers, SMS text messaging provided an easy and functional method of gathering a large volume of data. CONCLUSION In this sample and for these questions, SMS was a reliable and valid method for capturing research data.

A randomized, controlled trial of computerized physiologic trend monitoring in an intensive care unit

OBJECTIVE To assess whether the provision of computerized physiologic trend data could improve outcome in newborn infants requiring intensive care. DESIGN Randomized, controlled trial, with subsidiary questionnaire studies. SETTING Tertiary neonatal intensive care unit with 12 intensive care cots. PATIENTS All infants admitted between January 1991 and September 1993 who were < or =32 wks gestation or >32 wks gestation, and ventilated for >4 hrs or asphyxiated. INTERVENTIONS Randomization to one of four groups for first 7 days of life: A) no display of trend data; B) continuous display of trend data; C1) alternating 24-hr display of trend data, starting with display in first 24 hrs; and C2) alternating 24-hr display of trend data, starting with no display in first 24 hrs. MEASUREMENTS AND MAIN RESULTS The short-term effects of monitoring on patient outcome was judged by volume of colloid given, number of blood gases taken, and by measurement taken from cranial Doppler ultrasound. Medium-term measures included time ventilated, time given supplemental oxygen, death, time to death or discharge, and cranial ultrasound at discharge. Long-term outcome was assessed by neurodevelopmental status at age 1 to 4 yrs of age. Staff and parent questionnaires assessed their respective attitudes to the introduction of this technology. None of the patient outcome measures, short-, medium-, or long-term, demonstrated any significant benefit from the provision of computerized physiologic trend monitoring. Staff questionnaires demonstrated an acceptance of the system and an improved understanding of neonatal physiology as a result of computerized physiologic trends. Parent questionnaires demonstrated increased anxiety caused by the system in 11% of parents, although only 1% of parents continued to have concerns if the system were able to help their child. CONCLUSIONS A randomized, controlled trial was unable to demonstrate any benefit to patients resulting from the introduction of a computerized physiologic trend monitoring system. Benefits of the system have been recognized, however, in subsidiary studies, staff education, and research studies.

Outcomes for births booked under an independent midwife and births in NHS maternity units: matched comparison study

Objective To compare clinical outcomes between women employing an independent midwife and comparable pregnant women using NHS services. Design Anonymised matched cohort analysis. Cases from the database of the Independent Midwives’ Association (IMA) matched up to 1:5 with Scottish National Health Service (NHS) records for age, parity, year of birth, and socioeconomic status. Multivariable logistic regression models used to explore the relation between explanatory variables and outcomes; analyses controlled for potential confounding factors and adjusted for stratification. Setting UK databases 2002-5. Participants Anonymised records for 8676 women (7214 NHS; 1462 IMA). Main outcome measures Unassisted vertex delivery, live birth, perinatal death, onset of labour, gestation, use of analgesia, duration of labour, perineal trauma, Apgar scores, admission to neonatal intensive care, infant feeding. Results IMA cohort mothers were significantly more likely to achieve an unassisted vertex delivery than NHS cohort mothers (77.9% (1139) v 54.3% (3918); odds ratio 3.49, 95% confidence interval 2.99 to 4.07) but also significantly more likely to experience a stillbirth or a neonatal death (1.7% (25) v 0.6% (46); 5.91, 3.27 to 10.7). All odds ratios are adjusted for confounding factors. Exclusion of “high risk” cases from both cohorts showed a non-significant difference (0.5% (5) v 0.3% (18); 2.73, 0.87 to 8.55); the “low risk” IMA perinatal mortality rate is comparable with other studies of low risk births. Women in the IMA cohort had a higher incidence of pre-existing medical conditions (1.5% (22) v 1.0% (72) in the NHS cohort) and previous obstetric complications (21.0% (307) v 17.8% (1284)). The incidence of twin pregnancy was also higher (3.4% (50) v 3.1% (224)). In the IMA cohort, 66.0% of mothers (965/1462) had home births, compared with only 0.4% of NHS cohort mothers (27/7214). Spontaneous onset of labour was more common in the IMA group (96.6% (1405) v 74.5% (5365); 10.43, 7.74 to 14.0), and fewer mothers used pharmacological analgesia (40.2% (588) v 60.6% (4370); 0.42, 0.38 to 0.47). Mothers in the IMA cohort were much more likely to breast feed (88.0% (1286) v 64.0% (2759); 3.46, 2.84 to 4.20). Prematurity (4.3% (63) v 6.9% (498); 0.49, 0.35 to 0.69), low birth weight (4.0% (60) v 7.1%) (523); 0.93, 0.62 to 1.38), and rate of admission to neonatal intensive care (4.4% (65) v 9.3% (667); 0.43, 0.32 to 0.59) were all higher in the NHS dataset. Conclusions Healthcare policy tries to direct patient choice towards clinically appropriate and practicable options; nevertheless, pregnant women are free to make decisions about birth preferences, including place of delivery and staff in attendance. While clinical outcomes across a range of variables were significantly better for women accessing an independent midwife, the significantly higher perinatal mortality rates for high risk cases in this group indicate an urgent need for a review of these cases. The significantly higher prematurity and admission rates to intensive care in the NHS cohort also indicate an urgent need for review.

Prediction of initiation and cessation of breastfeeding from late pregnancy to 16 weeks: the Feeding Your Baby (FYB) cohort study.

Objective To derive prediction models for both initiation and cessation of breastfeeding using demographic, psychological and obstetric variables. Design A prospective cohort study. Setting Women delivering at Ninewells Hospital, Dundee, UK. Data sources Demographic data and psychological measures were obtained during pregnancy by questionnaire. Birth details, feeding method at birth and at hospital discharge were obtained from the Ninewells hospital database, Dundee, UK. Breastfeeding women were followed up by text messages every 2 weeks until 16 weeks or until breastfeeding was discontinued to ascertain feeding method and feeding intentions. Participants Pregnant women over 30 weeks gestation aged 16 years and above, living in Dundee, booked to deliver at Ninewells Hospital, Dundee, and able to speak English. Main outcome measure Initiation and cessation of breastfeeding. Results From the total cohort of women at delivery (n=344) 68% (95% CI 63% to 73%) of women had started breastfeeding at discharge. Significant predictors of initiating breastfeeding were older age, parity, greater intention to breastfeed from a Theory of Planned Behaviour (TPB)-based questionnaire, higher Iowa Infant Feeding Assessment Scale (IIFAS) score as well as living with a husband or partner. For the final model, the AUROC was 0.967. For those who initiated breastfeeding (n=233), the strongest predictors of stopping were low intention to breastfeed from TPB, low IIFAS score and non-managerial/professional occupations. Conclusions The findings from this study will be used to inform the protocol for an intervention study to encourage and support prolonged breastfeeding as intentions appear to be a key intervention focus for initiation. The predictive models could be used to identify women at high risk of not initiating and also women at high risk of stopping for interventions to improve the longevity of breastfeeding.

Infant feeding in Eastern Scotland: A longitudinal mixed methods evaluation of antenatal intentions and postnatal satisfaction—The Feeding Your Baby study

BACKGROUND breast-feeding initiation rates have improved in Scotland, but exclusive and partial breast-feeding rates fall rapidly for several reasons. We aimed to examine whether antenatal feeding intention was associated with satisfaction with infant feeding method; and to explore the similarities and differences in infant feeding experience of women with different antenatal feeding intention scores. METHOD(S) antenatal questionnaire assessment of infant feeding intentions, based on the theory of planned behaviour; two-weekly postnatal follow-up of infant feeding practice by text messaging; final telephone interview to determine reasons for and satisfaction with infant feeding practice. RESULTS 355 women in eastern Scotland were recruited antenatally; 292 completed postnatal follow up. Antenatal feeding intentions broadly predicted postnatal practice. The highest satisfaction scores were seen in mothers with no breast-feeding intention who formula fed from birth, and those with high breast-feeding intention who breastfed for more than 8 weeks. The lowest satisfaction scores were seen in those with high intention scores who only managed to breast feed for less than 3 weeks. This suggests that satisfaction with infant feeding is associated with achieving feeding goals, whether artificial milk or breast feeding. Reasons for stopping breast feeding were broadly similar over time (too demanding, pain, latching, perception of amount of milk, lack of professional support, sibling jealousy). Perseverance appeared to mark out those women who managed to breast feed for longer; this was seen across the socio-economic spectrum. Societal and professional pressure to breast feed was commonly experienced. CONCLUSIONS satisfaction with actual infant feeding practice is associated with antenatal intention; levels are higher for those meeting their goals, whether formula feeding from birth or breast feeding for longer periods. Perceived pressure to breast feed raises questions about informed decision making. Identifying those who will benefit most from targeted infant feeding support is crucial.

Cross‐cultural adaptation and translation of a quality of life tool for new mothers: a methodological and experiential account from six countries

AIM To examine the challenges and solutions encountered in the translation and cross-cultural adaptation of an English language quality of life tool in India, China, Iran, Portugal, Brazil, and Poland. BACKGROUND Those embarking on research involving translation and cross-cultural adaptation must address certain practical and conceptual issues. These include instrument choice, linguistic factors, and cultural or philosophical differences, which may render an instrument inappropriate, even when expertly translated. Publication bias arises when studies encountering difficulties do not admit to these, or are not published at all. As an educative guide to the potential pitfalls involved in the cross-cultural adaptation process, this article reports the conceptual, linguistic, and methodological experiences of researchers in six countries, who translated and adapted the Mother-Generated Index, a quality of life tool originally developed in English. DATA SOURCES Principal investigator experience from six stand-alone studies (two published) ranging from postgraduate research to citywide surveys. DISCUSSION/IMPLICATIONS FOR NURSING: This analysis of a series of stand-alone cross-cultural studies provides lessons about how conceptual issues, such as the uniqueness of perceived quality of life and the experience of new motherhood, can be addressed. This original international approach highlights practical lessons relating to instrument choice, and the resources available to researchers with different levels of experience. Although researchers may be confident of effective translation, conceptual and practical difficulties may be more problematic. CONCLUSION Instrument choice is crucial. Researchers must negotiate adequate resources for cross-cultural research, including time, translation facilities, and expert advice about conceptual issues.

Pilot study: Quality of life assessment of postnatal fatigue and other physical morbidity

Postnatal morbidity is increasingly recognized, but standard assessments may not capture what is most important to the woman with such morbidity in terms of her quality of life. The Mother-Generated Index (MGI) is a proposed postnatal quality-of-life instrument which allows the mother to determine both content and scoring. In this pilot study we found that although a degree of psychological and physical morbidity (including tiredness) is common, and may be very significant, for most women these factors are low-grade, and other aspects of their lives are more important. A quality-of-life approach allows the mother to determine her own postnatal assessment, and encourages practitioners to view her more holistically.

Nocebo and the potential harm of ‘high risk’ labelling: a scoping review

AIMS A discussion of the existence, prevalence and characteristics of the nocebo effect in health care. BACKGROUND There is increasing but inconsistent evidence for nocebo effects (the opposite of placebo). Causal mechanisms are believed to be similar to placebo (negative effects result from suggestions of negative clinical outcomes). Risk screening in health care may produce this unintended effect through labelling some patients as high risk. Given health cares almost universal coverage this potentially affects many people. DESIGN Discussion paper following a scoping review of the existence and frequency of nocebo. DATA SOURCES Literature databases (PsycINFO, MEDLINE, CCTR, CINAHL and EMBASE) searched from inception dates to 2013. IMPLICATIONS FOR NURSING Significant empirical evidence indicates that negative beliefs may impact on health outcomes (incidence estimates range from 3-27%). The nocebo effect, rooted in the complex interplay between physiological functioning and social factors, appears significantly more common among women and where prior negative knowledge or expectations exist. Pre-existing psychological characteristics (anxiety, neuroses, panic disorder or pessimism) exacerbate it. CONCLUSION While the placebo effect is well documented, there has been no systematic attempt to synthesize primary empirical research on the role of nocebo. It is possible that nocebo outcomes may be preventable through careful consideration of information provision and the prior identification of potentially high risk individuals. This paper summarizes the scale and importance of the nocebo effect, its distribution according to a range of social and clinical variables and its known relation to psychological precursors. It identifies important gaps in the research literature.

Maternal quality of life assessment: the feasibility of antenatal–postnatal follow‐up using the Mother‐Generated Index

Introduction. The Mother‐Generated Index (MGI) is a quantitative/qualitative postnatal quality‐of‐life tool. This study examined the feasibility of assessing changes in quality of life from late pregnancy to the postnatal period. Design. Attempted 6‐week postnatal follow‐up of 35 women who had completed the MGI and General Health Questionnaire antenatally. Quality of life comments were assessed thematically. Quantitative data were analysed in Excel and SPSS. Stepwise regression assessed the feasibility of identifying factors predictive of postnatal MGI score. Findings. Nineteen participants responded postnatally (56%). Quality of life scores rose for some and fell for others. Whereas 38% of comments antenatally had been positive, this rose to 51% postnatally. During pregnancy, ‘Tiredness’, ‘Looking forward to baby’, ‘Aches and pains’ and ‘Work’ predominated; postnatally, this changed to ‘Feelings about baby’, ‘Sense of self’, ‘Relationship with partner’, and ‘Adaptation to new role’. The regression analysis suggested that antenatal MGI, parity and degree of perineal trauma may be predictive of postnatal MGI score. Conclusions . This small exploratory study suggests that postnatal follow‐up using the MGI is feasible. This approach contributes towards a more holistic understanding of the pregnant woman/mother and her unique and evolving situation.