Janet Tucker

CRIB II: an update of the clinical risk index for babies score

The clinical risk index for babies (CRIB) score is a risk-adjustment instrument widely used in neonatal intensive care. Its appropriateness with contemporary data has been questioned. We have examined these questions, developed a new five-item CRIB II score with data from a UK-wide sample of infants admitted to neonatal intensive care in 1998-99, and shown how mortality after neonatal intensive care has fallen in the past 12 years. CRIB II provides a recalibrated and simplified scoring system that avoids the potential problems of early treatment bias. A valid and simple method of risk-adjustment for neonatal intensive care is important to ensure accurate assessment of quality of care. Such assessments should be done in tandem with national audit systems for neonatal intensive care, incorporating measures of morbidity as well as mortality.

Using willingness to pay to value alternative models of antenatal care

Recent years have seen the development of different models of antenatal care, especially for low risk women. More specifically, there has been a move for more general practitioner and midwifery involvement in such care. Given the current changes that are taking place in the provision of antenatal care, it is becoming increasingly important to carry out economic evaluations of alternative models of care. This paper applies the economic instrument of willingness to pay to assess the benefits of two alternative forms of antenatal care: general practitioner/midwife routine led care versus obstetrician led care. The results suggest a willingness to pay of pounds 2500 for antenatal care, with no significant difference between the types of care provided. It is concluded that before firm policy conclusions can be reached, further studies should be undertaken to address methodological issues around the willingness to pay technique.

Models of intrapartum care and women’s trade‐offs in remote and rural Scotland: a mixed‐methods study

Objective  To explore women’s preferences for, and trade‐offs between, key attributes of intrapartum care models.

Characteristics of Effective Interventions in Improving Young People's Sexual Health: A Review of Reviews.

The purpose of this paper is to conduct a review of reviews to identify characteristics of effective sex and relationship education (SRE) interventions and/or programmes in young people to improve sexual health and identify barriers and facilitators for implementation. Six bibliographic databases were searched from 1986 to 2006 for systematic reviews that assessed SRE interventions or programmes in participants between 10 and 18 years old and their partners. All outcomes of improvement in sexual health were assessed and 30 systematic reviews were included. Effective interventions and/or programmes tended to be those targeting younger age groups before they become sexually active, focused interventions tailored to the physical and biological development stages, theory based, and abstinence education programmes that incorporate values of relationships and provide skills training and links to contraceptive services. Adequate training of personnel delivering the interventions and culturally sensitive programmes were identified as important facilitators of effectiveness. Future research should explore the appropriate age for initiating sex education and investigate targeting specific behaviour compared with multiple-outcome targeting. Research exploring the reasons for interventions focusing on specific populations (i.e. African and Hispanic origins), even if they were conducted in countries dominated by Caucasians, is warranted.

“Choice” and place of delivery: a qualitative study of women in remote and rural Scotland

Objective: To explore women’s perceptions of “choice” of place of delivery in remote and rural areas where different models of maternity services are available. Setting and methods: Remote and rural areas of the North of Scotland. A qualitative study design involved focus groups with women who had recent experience of maternity services. Results: Women had varying experiences and perceptions of choice regarding place of delivery. Most women had, or perceived they had, no choice, though some felt they had a genuine choice. When comparing different places of birth, women based their decisions primarily on their perceptions of safety. Consultant-led care was associated with covering every eventuality, while midwife-led care was associated with greater quality in terms of psycho-social support. Women engaged differently in the choice process, ranging from “acceptors” to “active choosers.” The presentation of choice by health professionals, pregnancy complications, geographical accessibility and the implications of alternative places of delivery in terms of demands on social networks were also influential in “choice.” Conclusions: Provision of different models of maternity services may not be sufficient to convince women they have “choice.” The paper raises fundamental questions about the meaning of “choice” within current policy developments and calls for a more critical approach to the use of choice as a service development and analytical concept.

Sustainable maternity services in remote and rural Scotland? A qualitative survey of staff views on required skills, competencies and training

Objectives: To explore staff views on their roles, skills and training to deliver high quality and local intrapartum services in remote and rural settings against national recommendations. Design: Interview and postal survey. Setting: A stratified representative sample of remote and rural maternity units in Scotland (December 2002 to May 2003). Participants: Staff proportionally representative of professional groups involved in maternity care. Results: Staff interviews took place at 11 units (response rate 93%). A subsequent postal survey included the interview sample and staff in a further 11 units (response rate 78%). Medical specialisation, workforce issues, and proposed regulatory evaluation of competencies linked to throughput raised concerns about the sustainability and safety of services, particularly for “generalists” in rural maternity care teams and for medical cover in small district general hospitals with large rural catchments. Risk assessment and decision making to transfer were seen as central for effective rural practice and these were influenced by rural context. Staff self-reported competence and confidence varied according to procedure, but noted service change appeared to be underway ahead of their preparedness. Self-reported competence in managing obstetric emergencies was surprisingly high, with the caveat that they were not independently assessed in this study. Staff with access to video conference technology reported low actual use although there was enthusiasm about its potential use. Conclusions: Considerable uncertainties remain around staffing models and training to maintain maternity care team skills and competencies. Further research is required to test how this will impact on safety, appropriateness, and access and acceptability to rural communities.

The costs of alternative types of routine antenatal care for low-risk women: shared care vs care by general practitioners and community midwives.

Objectives: To compare the costs to the health service, women and their families of routine antenatal care provided by either traditional obstetrician-led shared care or general practitioner (GP)/community midwife care. Method: A multicentre randomized controlled trial in 51 general practices linked to nine maternity hospitals in Scotland: 1667 low-risk pregnant women provided information on costs to the health service. 704 of these women provided information on non-health service costs. Results: GP/midwife antenatal care was found to cost statistically significantly less than shared care. This was the case for investigations carried out at routine antenatal visits (GP/midwife = £87.25, shared care = £91.15, P = 0.05), staffing costs at routine antenatal visits (GP/midwife = £127.76, shared care = £131.09, P = 0.001), and non-health service costs incurred by women and their companions (GP/midwife = £118.53, shared care = £133.49, P = 0.001). While non-routine care in the GP/midwife arm of the trial costs less than in the shared care arm, the difference was not statistically significant (GP/midwife = £83.74, shared care = £94.43, P = 0.46). The total societal cost of antenatal care was £417.28 per woman in the GP/midwife arm of the trial and £450.19 in the shared care arm of the trial. This difference was statistically significant (P < 0.001). The application of sensitivity analysis did not change these results. Conclusions: GP/midwife antenatal care is a satisfactory option for low-risk pregnant women in Scotland provided that clinical outcomes and womens satisfaction are at least the same as those of women with shared care.

Moderately premature infants at Kaiser Permanente Medical Care Program in California are discharged home earlier than their peers in Massachusetts and the United Kingdom

Objective: To compare gestational age at discharge between infants born at 30–34+6 weeks gestational age who were admitted to neonatal intensive care units (NICUs) in California, Massachusetts, and the United Kingdom. Design: Prospective observational cohort study. Setting: Fifty four United Kingdom, five California, and five Massachusetts NICUs. Subjects: A total of 4359 infants who survived to discharge home after admission to an NICU. Main outcome measures: Gestational age at discharge home. Results: The mean (SD) postmenstrual age at discharge of the infants in California, Massachusetts, and the United Kingdom were 35.9 (1.3), 36.3 (1.3), and 36.3 (1.9) weeks respectively (p  =  0.001). Compared with the United Kingdom, adjusted discharge of infants occurred 3.9 (95% confidence interval (CI) 1.4 to 6.5) days earlier in California, and 0.9 (95% CI −1.2 to 3.0) days earlier in Massachusetts. Conclusions: Infants of 30–34+6 weeks gestation at birth admitted and cared for in hospitals in California have a shorter length of stay than those in the United Kingdom. Certain characteristics of the integrated healthcare approach pursued by the health maintenance organisation of the NICUs in California may foster earlier discharge. The California system may provide opportunities for identifying practices for reducing the length of stay of moderately premature infants.

Risk assessment and decision making about in-labour transfer from rural maternity care: a social judgment and signal detection analysis

BackgroundThe importance of respecting women’s wishes to give birth close to their local community is supported by policy in many developed countries. However, persistent concerns about the quality and safety of maternity care in rural communities have been expressed. Safe childbirth in rural communities depends on good risk assessment and decision making as to whether and when the transfer of a woman in labour to an obstetric led unit is required. This is a difficult decision. Wide variation in transfer rates between rural maternity units have been reported suggesting different decision making criteria may be involved; furthermore, rural midwives and family doctors report feeling isolated in making these decisions and that staff in urban centres do not understand the difficulties they face. In order to develop more evidence based decision making strategies greater understanding of the way in which maternity care providers currently make decisions is required. This study aimed to examine how midwives working in urban and rural settings and obstetricians make intrapartum transfer decisions, and describe sources of variation in decision making.MethodsThe study was conducted in three stages. 1. 20 midwives and four obstetricians described factors influencing transfer decisions. 2. Vignettes depicting an intrapartum scenario were developed based on stage one data. 3. Vignettes were presented to 122 midwives and 12 obstetricians who were asked to assess the level of risk in each case and decide whether to transfer or not. Social judgment analysis was used to identify the factors and factor weights used in assessment. Signal detection analysis was used to identify participants’ ability to distinguish high and low risk cases and personal decision thresholds.ResultsWhen reviewing the same case information in vignettes midwives in different settings and obstetricians made very similar risk assessments. Despite this, a wide range of transfer decisions were still made, suggesting that the main source of variation in decision making and transfer rates is not in the assessment but the personal decision thresholds of clinicians.ConclusionsCurrently health care practice focuses on supporting or improving decision making through skills training and clinical guidelines. However, these methods alone are unlikely to be effective in improving consistency of decision making.

UK neonatal intensive care services in 1996

A census of activity and staff levels in 1996 was conducted in UK neonatal units and achieved a 100% response from 246 units. Among the 186 neonatal intensive care units, the median (interquartile range) number of total cots was 18(14−22); level 1 intensive care cots 4(2−6); total admissions 318(262−405); very low birthweight admissions 40(28−68); and the number ventilated or given CPAP by endotracheal tube 52(32−83). Forty six (25%) intensive care units lacked the recommended minimum of one consultant with prime responsibility for neonatal medicine. As a conservative estimate 79% of intensive care units had a lower nursing provision than that recommended in previously published guidelines. There was substantial variation in activity and staffing levels among units.