Jennifer E. Lutomski

Increasing trends in atonic postpartum haemorrhage in Ireland: an 11‐year population‐based cohort study

Please cite this paper as: Lutomski J, Byrne B, Devane D, Greene R. Increasing trends in atonic postpartum haemorrhage in Ireland: an 11‐year population‐based cohort study. BJOG 2011; DOI: 10.1111/j.1471‐0528.2011.03198.x

The development of the Older Persons and Informal Caregivers Survey Minimum DataSet (TOPICS-MDS): A large-scale data sharing initiative

Introduction In 2008, the Ministry of Health, Welfare and Sport commissioned the National Care for the Elderly Programme. While numerous research projects in older persons’ health care were to be conducted under this national agenda, the Programme further advocated the development of The Older Persons and Informal Caregivers Survey Minimum DataSet (TOPICS-MDS) which would be integrated into all funded research protocols. In this context, we describe TOPICS data sharing initiative (www.topics-mds.eu). Materials and Methods A working group drafted TOPICS-MDS prototype, which was subsequently approved by a multidisciplinary panel. Using instruments validated for older populations, information was collected on demographics, morbidity, quality of life, functional limitations, mental health, social functioning and health service utilisation. For informal caregivers, information was collected on demographics, hours of informal care and quality of life (including subjective care-related burden). Results Between 2010 and 2013, a total of 41 research projects contributed data to TOPICS-MDS, resulting in preliminary data available for 32,310 older persons and 3,940 informal caregivers. The majority of studies sampled were from primary care settings and inclusion criteria differed across studies. Discussion TOPICS-MDS is a public data repository which contains essential data to better understand health challenges experienced by older persons and informal caregivers. Such findings are relevant for countries where increasing health-related expenditure has necessitated the evaluation of contemporary health care delivery. Although open sharing of data can be difficult to achieve in practice, proactively addressing issues of data protection, conflicting data analysis requests and funding limitations during TOPICS-MDS developmental phase has fostered a data sharing culture. To date, TOPICS-MDS has been successfully incorporated into 41 research projects, thus supporting the feasibility of constructing a large (>30,000 observations), standardised dataset pooled from various study protocols with different sampling frameworks. This unique implementation strategy improves efficiency and facilitates individual-level data meta-analysis.

Living longer and feeling better: healthy lifestyle, self-rated health, obesity and depression in Ireland.

BACKGROUND The combination of four protective lifestyle behaviours (being physically active, a non-smoker, a moderate alcohol consumer and having adequate fruit and vegetable intake) has been estimated to increase life expectancy by 14 years. However, the effect of adopting these lifestyle behaviours on general health, obesity and mental health is less defined. We examined the combined effect of these behaviours on self-rated health, overweight/obesity and depression. METHODS Using data from the Survey of Lifestyle Attitudes and Nutrition (SLAN) 2007 (), a protective lifestyle behaviour (PLB) score was constructed for 10,364 men and women (>18 years), and representative of the Republic of Ireland adult population (response rate 62%). Respondents scored a maximum of four points, one point each for being physically active, consuming five or more fruit and vegetable servings daily, a non-smoker and a moderate drinker. RESULTS One-fifth of respondents (20%) adopted four PLBs, 35% adopted three, 29% two, 13% one and 2% adopted none. Compared to those with zero PLBs, those with four were seven times more likely to rate their general health as excellent/very good [OR 6.8 95% CI (3.64-12.82)] and four times more likely to have better mental health [OR 4.4 95% CI (2.34-8.22)]. CONCLUSIONS Adoption of core protective lifestyle factors known to increase life expectancy is associated with positive self-rated health, healthier weight and better mental health. These lifestyles have the potential to add quality and quantity to life.

Temporal trends in misclassification patterns of measured and self-report based body mass index categories--findings from three population surveys in Ireland.

BackgroundAs the use of self-reported data to classify obesity continues, the temporal change in the accuracy of self-report measurement when compared to clinical measurement remains unclear. The objective of this study was to examine temporal trends in misclassification patterns, as well as sensitivity and specificity, of clinically measured versus self-report based body mass index (BMI) from three national lifestyle surveys over a 10-year period.MethodsThe Surveys of Lifestyle Attitudes and Nutrition (SLÁN) were interview based cross-sectional survey/measurements involving nationally representative samples in 1998, 2002 and 2007. Data from a subsample of both self-reported and measured height and weight were available from 66 men and 142 women in 1998, 147 men and 184 women in 2002 and 909 men and 1128 women in 2007. Respondents were classified into the BMI categories normal (< 25 kg m-2), overweight (25- < 30 kg m-2) and obese (≥ 30 kg m-2).ResultsUnderreporting of BMI increased across the three surveys (14%→21%→24%; p = 0.002). Sensitivity scores for the normal category exceeded 94% in all three surveys but decreased for the overweight (75%→68%→66%) and obese categories (80%→64%→53%). Simultaneously, specificity levels remained high.ConclusionsBMI values based on self-reported determinations of height and weight in population samples are underestimating the true prevalence of the obesity epidemic and this underestimation is increasing with time. The decreased sensitivity and consistently high specificity scores in the obese category across time, highlights the limitation of self-report based BMI classifications and the need for simple, readily comprehensible indicators of obesity.

Sociodemographic, lifestyle, mental health and dietary factors associated with direction of misreporting of energy intake.

OBJECTIVE To estimate the extent of under- and over-reporting, to examine associations with misreporting and sociodemographic and lifestyle characteristics and mental health status and to identify differential reporting in micro- and macronutrient intake and quality of diet. DESIGN A health and lifestyle questionnaire and a semi-quantitative FFQ were completed as part of the 2007 Survey of Lifestyle, Attitudes and Nutrition. Energy intake (EI) and intake of micro- and macronutrients were determined by applying locally adapted conversion software. A dietary score was constructed to identify healthier diets. Accuracy of reported EI was estimated using the Goldberg method. ANOVA, χ2 tests and logistic regression were used to examine associations. SETTING Residential households in Ireland. SUBJECTS A nationally representative sample of 7521 adults aged 18 years or older. RESULTS Overall, 33·2 % of participants were under-reporters while 11·9 % were over-reporters. After adjustment, there was an increased odds of under-reporting among obese men (OR = 2·01, 95 % CI 1·46, 2·77) and women (OR = 1·68, 95 % CI 1·23, 2·30) compared to participants with a healthy BMI. Older age, low socio-economic status and overweight/obesity reduced the odds of over-reporting. Among under-reporters, the percentage of EI from fat was lower and overall diet was healthier compared to accurate and over-reporters. The reported usage of salt, fried food consumption and snacking varied significantly by levels of misreporting. CONCLUSIONS Patterns in differential reporting were evident across sociodemographic, lifestyle and mental health factors and diet quality. Consideration should be given to how misreporting affects nutrient analysis to ensure sound nutritional policy.

Caesarean Delivery and Subsequent Stillbirth or Miscarriage: Systematic Review and Meta-Analysis

Objective To compare the risk of stillbirth and miscarriage in a subsequent pregnancy in women with a previous Caesarean or vaginal delivery. Design Systematic review of the published literature including seven databases: CINAHL; the Cochrane library; Embase; Medline; PubMed; SCOPUS and Web of Knowledge from 1945 until November 11th 2011, using a detailed search-strategy and cross-checking of reference lists. Study Selection Cohort, case-control and cross-sectional studies examining the association between previous Caesarean section and subsequent stillbirth or miscarriage risk. Two assessors screened titles to identify eligible studies, using a standardised data abstraction form and assessed study quality. Data synthesis 11 articles were included for stillbirth, totalling 1,961,829 pregnancies and 7,308 events. Eight eligible articles were included for miscarriage, totalling 147,017 pregnancies and 12,682 events. Pooled estimates across the stillbirth studies were obtained using random-effect models. Among women with a previous Caesarean an increase in odds of 1.23 [95% CI 1.08, 1.40] for stillbirth was yielded. Subgroup analyses including unexplained stillbirths yielded an OR of 1.47 [95% CI 1.20, 1.80], an OR of 2.11 [95% CI 1.16, 3.84] for explained stillbirths and an OR of 1.27 [95% CI 0.95, 1.70] for antepartum stillbirths. Only one study reported adjusted estimates in the miscarriage review, therefore results are presented individually. Conclusions Given the recent revision of the National Institute for Health and Clinical Excellence guidelines (NICE), providing women the right to request a Caesarean, it is essential to establish whether mode of delivery has an association with subsequent risk of stillbirth or miscarriage. Overall, compared to vaginal delivery, the pooled estimates suggest that Caesarean delivery may increase the risk of stillbirth by 23%. Results for the miscarriage review were inconsistent and lack of adjustment for confounding was a major limitation. Higher methodological quality research is required to reliably assess the risk of miscarriage in subsequent pregnancies.

Sociodemographic, health and lifestyle predictors of poor diets

OBJECTIVE Poor-quality diet, regarded as an important contributor to health inequalities, is linked to adverse health outcomes. We investigated sociodemographic and lifestyle predictors of poor-quality diet in a population sample. DESIGN A cross-sectional analysis of the Survey of Lifestyle, Attitudes and Nutrition (SLÁN). Diet was assessed using an FFQ (n 9223, response rate = 89%), from which a dietary score (the DASH (Dietary Approaches to Stop Hypertension) score) was constructed. SETTING General population of the Republic of Ireland. SUBJECTS The SLÁN survey is a two-stage clustered sample of 10,364 individuals aged 18 years. RESULTS Adjusting for age and gender, a number of sociodemographic, lifestyle and health-related variables were associated with poor-quality diet: social class, education, marital status, social support, food poverty (FP), smoking status, alcohol consumption, underweight and self-perceived general health. These associations persisted when adjusted for age, gender and social class. They were not significantly altered in the multivariate analysis, although the association with social support was attenuated and that with FP was borderline significant (OR = 1·2, 95% CI 1·03, 1·45). A classical U-shaped relationship between alcohol consumption and dietary quality was observed. Dietary quality was associated with social class, educational attainment, FP and related core determinants of health. CONCLUSIONS The extent to which social inequalities in health can be explained by socially determined differences in dietary intake is probably underestimated. The use of composite dietary quality scores such as the DASH score to address the issue of confounding by diet in the relationship between alcohol consumption and health merits further study.

Hyperemesis gravidarum: current perspectives.

Hyperemesis gravidarum is a complex condition with a multifactorial etiology characterized by severe intractable nausea and vomiting. Despite a high prevalence, studies exploring underlying etiology and treatments are limited. We performed a literature review, focusing on articles published over the last 10 years, to examine current perspectives and recent developments in hyperemesis gravidarum.

At what price? a cost-effectiveness analysis comparing trial of labour after previous caesarean versus elective repeat caesarean delivery

Background Elective repeat caesarean delivery (ERCD) rates have been increasing worldwide, thus prompting obstetric discourse on the risks and benefits for the mother and infant. Yet, these increasing rates also have major economic implications for the health care system. Given the dearth of information on the cost-effectiveness related to mode of delivery, the aim of this paper was to perform an economic evaluation on the costs and short-term maternal health consequences associated with a trial of labour after one previous caesarean delivery compared with ERCD for low risk women in Ireland. Methods Using a decision analytic model, a cost-effectiveness analysis (CEA) was performed where the measure of health gain was quality-adjusted life years (QALYs) over a six-week time horizon. A review of international literature was conducted to derive representative estimates of adverse maternal health outcomes following a trial of labour after caesarean (TOLAC) and ERCD. Delivery/procedure costs derived from primary data collection and combined both “bottom-up” and “top-down” costing estimations. Results Maternal morbidities emerged in twice as many cases in the TOLAC group than the ERCD group. However, a TOLAC was found to be the most-effective method of delivery because it was substantially less expensive than ERCD (€1,835.06 versus €4,039.87 per women, respectively), and QALYs were modestly higher (0.84 versus 0.70). Our findings were supported by probabilistic sensitivity analysis. Conclusions Clinicians need to be well informed of the benefits and risks of TOLAC among low risk women. Ideally, clinician-patient discourse would address differences in length of hospital stay and postpartum recovery time. While it is premature advocate a policy of TOLAC across maternity units, the results of the study prompt further analysis and repeat iterations, encouraging future studies to synthesis previous research and new and relevant evidence under a single comprehensive decision model.

Private health care coverage and increased risk of obstetric intervention

BackgroundWhen clinically indicated, common obstetric interventions can greatly improve maternal and neonatal outcomes. However, variation in intervention rates suggests that obstetric practice may not be solely driven by case criteria.MethodsDifferences in obstetric intervention rates by private and public status in Ireland were examined using nationally representative hospital discharge data. A retrospective cohort study was performed on childbirth hospitalisations occurring between 2005 and 2010. Multivariate logistic regression analysis with correction for the relative risk was conducted to determine the risk of obstetric intervention (caesarean delivery, operative vaginal delivery, induction of labour or episiotomy) by private or public status while adjusting for obstetric risk factors.Results403,642 childbirth hospitalisations were reviewed; approximately one-third of maternities (30.2%) were booked privately. After controlling for relevant obstetric risk factors, women with private coverage were more likely to have an elective caesarean delivery (RR: 1.48; 95% CI: 1.45-1.51), an emergency caesarean delivery (RR: 1.13; 95% CI: 1.12-1.16) and an operative vaginal delivery (RR: 1.25; 95% CI: 1.22-1.27). Compared to women with public coverage who had a vaginal delivery, women with private coverage were 40% more likely to have an episiotomy (RR: 1.40; 95% CI: 1.38-1.43).ConclusionsIrrespective of obstetric risk factors, women who opted for private maternity care were significantly more likely to have an obstetric intervention. To better understand both clinical and non-clinical dynamics, future studies of examining health care coverage status and obstetric intervention would ideally apply mixed-method techniques.