Judith T. Fullerton

Recruitment of hard-to-reach population subgroups via adaptations of the snowball sampling strategy.

Nurse researchers and educators often engage in outreach to narrowly defined populations. This article offers examples of how variations on the snowball sampling recruitment strategy can be applied in the creation of culturally appropriate, community-based information dissemination efforts related to recruitment to health education programs and research studies. Examples from the primary authors program of research are provided to demonstrate how adaptations of snowball sampling can be used effectively in the recruitment of members of traditionally underserved or vulnerable populations. The adaptation of snowball sampling techniques, as described in this article, helped the authors to gain access to each of the more-vulnerable population groups of interest. The use of culturally sensitive recruitment strategies is both appropriate and effective in enlisting the involvement of members of vulnerable populations. Adaptations of snowball sampling strategies should be considered when recruiting participants for education programs or for research studies when the recruitment of a population-based sample is not essential.

Research Article: Recruitment of hard‐to‐reach population subgroups via adaptations of the snowball sampling strategy

Nurse researchers and educators often engage in outreach to narrowly defined populations. This article offers examples of how variations on the snowball sampling recruitment strategy can be applied in the creation of culturally appropriate, community-based information dissemination efforts related to recruitment to health education programs and research studies. Examples from the primary authors program of research are provided to demonstrate how adaptations of snowball sampling can be used effectively in the recruitment of members of traditionally underserved or vulnerable populations. The adaptation of snowball sampling techniques, as described in this article, helped the authors to gain access to each of the more-vulnerable population groups of interest. The use of culturally sensitive recruitment strategies is both appropriate and effective in enlisting the involvement of members of vulnerable populations. Adaptations of snowball sampling strategies should be considered when recruiting participants for education programs or for research studies when the recruitment of a population-based sample is not essential.

Outcomes, Safety, and Resource Utilization in a Collaborative Care Birth Center Program Compared With Traditional Physician-Based Perinatal Care

OBJECTIVE We compared outcomes, safety, and resource utilization in a collaborative management birth center model of perinatal care versus traditional physician-based care. METHODS We studied 2957 low-risk, low-income women: 1808 receiving collaborative care and 1149 receiving traditional care. RESULTS Major antepartum (adjusted risk difference [RD] = -0.5%; 95% confidence interval [CI] = -2.5, 1.5), intrapartum (adjusted RD = 0.8%; 95% CI = -2.4, 4.0), and neonatal (adjusted RD = -1.8%; 95% CI = -3.8, 0.1) complications were similar, as were neonatal intensive care unit admissions (adjusted RD = -1.3%; 95% CI = -3.8, 1.1). Collaborative care had a greater number of normal spontaneous vaginal deliveries (adjusted RD = 14.9%; 95% CI = 11.5, 18.3) and less use of epidural anesthesia (adjusted RD = -35.7%; 95% CI = -39.5, -31.8). CONCLUSIONS For low-risk women, both scenarios result in safe outcomes for mothers and babies. However, fewer operative deliveries and medical resources were used in collaborative care.

Effective in-service training design and delivery: evidence from an integrative literature review.

BackgroundIn-service training represents a significant financial investment for supporting continued competence of the health care workforce. An integrative review of the education and training literature was conducted to identify effective training approaches for health worker continuing professional education (CPE) and what evidence exists of outcomes derived from CPE.MethodsA literature review was conducted from multiple databases including PubMed, the Cochrane Library and Cumulative Index to Nursing and Allied Health Literature (CINAHL) between May and June 2011. The initial review of titles and abstracts produced 244 results. Articles selected for analysis after two quality reviews consisted of systematic reviews, randomized controlled trials (RCTs) and programme evaluations published in peer-reviewed journals from 2000 to 2011 in the English language. The articles analysed included 37 systematic reviews and 32 RCTs. The research questions focused on the evidence supporting educational techniques, frequency, setting and media used to deliver instruction for continuing health professional education.ResultsThe evidence suggests the use of multiple techniques that allow for interaction and enable learners to process and apply information. Case-based learning, clinical simulations, practice and feedback are identified as effective educational techniques. Didactic techniques that involve passive instruction, such as reading or lecture, have been found to have little or no impact on learning outcomes. Repetitive interventions, rather than single interventions, were shown to be superior for learning outcomes. Settings similar to the workplace improved skill acquisition and performance. Computer-based learning can be equally or more effective than live instruction and more cost efficient if effective techniques are used. Effective techniques can lead to improvements in knowledge and skill outcomes and clinical practice behaviours, but there is less evidence directly linking CPE to improved clinical outcomes. Very limited quality data are available from low- to middle-income countries.ConclusionsEducational techniques are critical to learning outcomes. Targeted, repetitive interventions can result in better learning outcomes. Setting should be selected to support relevant and realistic practice and increase efficiency. Media should be selected based on the potential to support effective educational techniques and efficiency of instruction. CPE can lead to improved learning outcomes if effective techniques are used. Limited data indicate that there may also be an effect on improving clinical practice behaviours. The research agenda calls for well-constructed evaluations of culturally appropriate combinations of technique, setting, frequency and media, developed for and tested among all levels of health workers in low- and middle-income countries.

Misoprostol for postpartum hemorrhage prevention at home birth: an integrative review of global implementation experience to date

BackgroundHemorrhage continues to be a leading cause of maternal death in developing countries. The 2012 World Health Organization guidelines for the prevention and management of postpartum hemorrhage (PPH) recommend oral administration of misoprostol by community health workers (CHWs). However, there are several outstanding questions about distribution of misoprostol for PPH prevention at home births.MethodsWe conducted an integrative review of published research studies and evaluation reports from programs that distributed misoprostol at the community level for prevention of PPH at home births. We reviewed methods and cadres involved in education of end-users, drug administration, distribution, and coverage, correct and incorrect usage, and serious adverse events.ResultsEighteen programs were identified; only seven reported all data of interest. Programs utilized a range of strategies and timings for distributing misoprostol. Distribution rates were higher when misoprostol was distributed at a home visit during late pregnancy (54.5-96.9%) or at birth (22.5-83.6%), compared to antenatal care (ANC) distribution at any ANC visit (22.5-49.1%) or late ANC visit (21.0-26.7%). Coverage rates were highest when CHWs and traditional birth attendants distributed misoprostol and lower when health workers/ANC providers distributed the medication. The highest distribution and coverage rates were achieved by programs that allowed self-administration. Seven women took misoprostol prior to delivery out of more than 12,000 women who were followed-up. Facility birth rates increased in the three programs for which this information was available. Fifty-one (51) maternal deaths were reported among 86,732 women taking misoprostol: 24 were attributed to perceived PPH; none were directly attributed to use of misoprostol. Even if all deaths were attributable to PPH, the equivalent ratio (59 maternal deaths/100,000 live births) is substantially lower than the reported maternal mortality ratio in any of these countries.ConclusionsCommunity-based programs for prevention of PPH at home birth using misoprostol can achieve high distribution and use of the medication, using diverse program strategies. Coverage was greatest when misoprostol was distributed by community health agents at home visits. Programs appear to be safe, with an extremely low rate of ante- or intrapartum administration of the medication.

CONCEPTIONS OF PRENATAL CARE AMONG SOMALI WOMEN IN SAN DIEGO

Studies have shown that culturally sensitive prenatal care improves access to and utilization of that care. Focus groups were used to explore the beliefs and attitudes toward prenatal care among Somali women in San Diego, particularly in regard to their perinatal experiences following immigration. The women were very well informed about healthy prenatal practices, including nutrition and exercise, and very compliant in following such practices, having found ways and means to accommodate these practices into their new American lifestyle. The women were generally pleased with the care that they have received in San Diego and tolerant of most diagnostic and therapeutic interventions. The women preferred to be seen by a female doctor/health care practitioner who is informed about the female circumcision practiced in Somalia and who is conservative in the decision to perform cesarean section deliveries.

Findings From the Analysis of the American College of Nurse‐Midwives' Membership Surveys: 2000–2003

Findings from the American College of Nurse-Midwives (ACNM) membership data provide descriptive information about selected characteristics of certified nurse-midwives (CNMs), certified midwives (CMs), and students enrolled in ACNM-accredited programs who are members of the organization. This article presents findings from the analysis of membership data for the years 2000 to 2003. Members remain predominantly white and female, with their age averaging in the mid-40s. Similarly, student demographics reflect little change from those reported in prior years. Students are primarily white, female, and in the mid-30s. Proportionately, there has been little increase in the diversity of members. The proportion of CNMs/CMs with a bachelors degree continues to rise, as does the proportion of CNMs/CMs holding doctoral degrees. The majority of CNMs/CMs identified a broad domain of clinical midwifery practice as their primary responsibility in their primary employment, and hospitals remain the largest employer of responding midwives. The salaries of employed midwives appear to be increasing, although the modal salary (60,000 US dollars to 69,000 US dollars ) is unchanged from prior years. The profile of the membership has remained fairly constant, with small changes in the trend over time noted for age, employment patterns, and attendance at birth sites for the 4 years analyzed.

Measuring Outcomes of Midwifery Care: Development of An Instrument To Assess Optimality

Research on the outcomes of midwifery care is hampered by the lack of appropriate instruments that measure both process and outcomes of care in lower risk women. This article describes an effort to adapt an existing measurement instrument focused on the optimal outcomes of care (The Optimality Index-US) to reflect the contemporary style of U.S.-based nurse-midwifery practice. Evidence for content validity of the instrument was derived from literature reports of randomized clinical trials, synthetic reviews, and the clinical consensus of professional reviewers. Eleven perinatal health professionals and consumers, representing disciplines of obstetrics and gynecology, midwifery, epidemiology, and neonatology reviewed the instrument. The instrument was then applied to an existing data set of women who intended to give birth at home (N = 1,286 women) to determine its utility in measuring events in the process and outcome of perinatal health care as managed by nurse-midwives. Results suggest that the tool holds promise for use in outcomes studies of U.S. perinatal care. Further testing of the instrument among diverse multicultural population groups, with various providers, and in diverse birth settings is warranted.

Competency-based education: The essential basis of pre-service education for the professional midwifery workforce

BACKGROUND many articles published in the decade since promulgation of the Millennium Development Goals have acknowledged the distinct advantages to maternal and newborn health outcomes that can be achieved as a result of expanding access to skilled birth attendant (including midwifery) services. However, these advantages are often predicated on the assumption that the midwifery workforce shares a common definition and identity. Regrettably, a clear delineation of midwifery competencies is rarely addressed. A core set of midwifery competencies is essential to providing the high quality services that lead to the desirable health outcomes described in that body of research. Attribution of improved outcomes to access to midwifery cannot be made without a common understanding of a defined set of services provided to standard by the midwifery workforce across the inter-conceptional and childbearing time frame. The International Confederation of Midwives (ICM) has developed a clear list of competencies that delineate the domains of practice for the fully qualified, professional midwife. These domains frame the educational outcomes that must be conveyed within competency-based education programmes. PURPOSE this article explores the concept of competency-based education for midwives; first exploring the concept of competency itself, then providing examples of what is already known about competency-based approaches to curriculum design, teacher preparation, teacher support and assessment of student learning. These concepts are linked to the ICM competencies as the unifying construct for education of individuals who share a common definition and identity as midwives.

Outcomes of a community- and home-based intervention for safe motherhood and newborn care.

Mothers and their home birth attendants residing in rural Uttar Pradesh (UP), India, were taught to recognize and take action to resolve selected maternal and neonatal life-threatening problems. Community mobilization efforts were designed to reduce delays in transport to emergency obstetric care (EOC) referral units and to increase use of family planning. Retention of knowledge and skills for recognition and intervention for maternal bleeding and newborn sepsis was enhanced when pictorial depictions of the problem or take action message or both were used as memory aids. Advocacy efforts for use of EOC facilities were less successful. The community health promotion and home-based life-saving skills education efforts tested are recommended for replication.