Laura Oakley

Health promotion for adolescents in primary care: randomised controlled trial

Abstract Objectives: To evaluate the effectiveness of inviting teenagers to general practice consultations to discuss health behaviour concerns and appropriate follow up care. Design: Randomised controlled trial, with participants randomised to a consultation (intervention) or usual care (control). Questionnaires completed at baseline, 3 months, and 12 months. Setting: Eight general practices in Hertfordshire, England. Participants: 1516 teenagers aged 14-15 years. Intervention: Consultations with practice nurses to discuss health concerns and develop plans for healthier lifestyles. Main outcome measures: Mental and physical health, “stage of change” for health related behaviour, and use of health services. Results: At baseline 970 teenagers completed questionnaires; 23% smoked, 35% had been drunk in the previous three months, 64% considered they ate unhealthily, 39% took little exercise, and 36% had possible depression. 41% (304) of teenagers invited attended for a consultation; over one third (112) were offered follow up care. More intervention group teenagers reported positive movement in stage of change for diet and exercise and in at least one of four behaviours (diet, exercise, smoking, drinking alcohol) at 3 months (41% v 31%, P<0.01), but this did not persist at 12 months. There was marginally more positive change in actual behaviour by intervention teenagers at 3 months (16% v 12%, P=0.06). Recognition of possible depression resulted in improved mental health outcomes at 3 and 12 months. 97% of attenders said they would recommend the intervention to a friend. Conclusions: Change in behaviour was slight but encouraging, and the intervention was well received and relatively cheap.

Factors associated with breastfeeding in England: an analysis by primary care trust.

Objectives To identify the sociodemographic factors associated with variation in area-based breastfeeding in England; to calculate the predicted breastfeeding rates adjusted for sociodemographic variations. Design Ecological analysis of routine data using random effects logistic regression. Setting All 151 primary care trusts (PCTs) in England 2010–2011. Outcome measures PCT level data on breastfeeding: initiation, any and exclusive breastfeeding at 6–8 weeks. Results There was considerable variation in breastfeeding across PCTs (breastfeeding initiation mean 72%, range 39–93%; any breastfeeding at 6–8 weeks mean 45%, range 19–83%; exclusive breastfeeding at 6–8 weeks mean 32%, range 14–58%), with London PCTs reporting markedly higher rates. Maternal age was strongly associated with area-based breastfeeding, with a 4–6% increase in odds of breastfeeding associated with a unit increase in the percentage of older mothers. Outside London, the proportion of the local population from a Black and Minority Ethnic (BME) background, compared with those from a White British background, was associated with higher breastfeeding (1–3% increase in odds per unit increase in the proportion from a BME background). Area-based deprivation was associated with reduced odds of breastfeeding (21–32% reduced odds comparing most deprived quintile to least deprived quintile). Weaker associations were observed between sociodemographic factors and breastfeeding in London PCTs. Very few PCTs reported breastfeeding figures substantially above or below the national average, having adjusted for variations in sociodemographic factors. Conclusions Our results show striking associations between sociodemographic factors and breastfeeding at the area level, with much of the variation in breastfeeding rates explained by the sociodemographic profile. The sociodemographic context of breastfeeding is clearly important at the area level as well as the individual level. Our findings can be used to inform decision-making relating to local priorities and service provision.

Association between congenital toxoplasmosis and preterm birth, low birthweight and small for gestational age birth

Objective  To determine the association between congenital toxoplasmosis and preterm birth, low birthweight and small for gestational age birth.

Smoking cessation programmes in pregnancy: Systematically addressing development, implementation, women's concerns and effectiveness

Objectives To increase a reviews relevance to practitioners and service users and identify the implications for systematic review methodology. Methods A systematic review of the effects of smoking cessation programmes implemented during pregnancy integrated process indicators and the views of maternity service users and health promotion specialists. Additional qualitative data were extracted systematically from included randomised control trials (RCTs) to determine whether the design of interventions and conclusions arising from their evaluation related to the views of service users. On completing the review we reflected on the types of observational and qualitative research it drew on, where this research was incorporated into the review, and its added value. Results Incorporating process indicators into the review revealed: 1) problems with implementation and transplantation of some interventions and 2) studies with more stringent quality criteria and process evaluations demonstrated greater impact (weighted mean difference in smoking). Pregnant smokers were rarely involved in the design or evaluation of the interventions. Prior observational and qualitative studies and small scale consultations influenced the criteria by which the effectiveness of the interventions were judged, and revealed to what extent these criteria are adopted in practice. Conclusions Systematically abstracting data about the development and delivery of interventions revealed gaps that might be filled by the active involvement of service users.

Predicting the impact of in vitro fertilisation and other forms of assisted conception on perinatal and infant mortality in England and Wales: examining the role of multiplicity.

The increased risk of perinatal and infant mortality observed among in vitro fertilisation (IVF) births and other assisted conception births is thought to be largely attributable to multiplicity. Using mortality statistics and estimates of the proportion of births following infertility treatment, we predicted the excess stillbirths and infant deaths associated with twins and higher order births resulting from assisted conception in England and Wales. According to our results, approximately 73 deaths could have been avoided in 2001 if all IVF infants had been born as singletons or as naturally occurring monozygotic twins, equating to a population attributable risk fraction of around 1% for perinatal and infant deaths. If we include all types of assisted conception, this figure was estimated to be around 4% of deaths—more than 220 perinatal and infant deaths in 2001. We confirm the public health importance of multiple births associated with assisted conception.

Association between breastfeeding support and breastfeeding rates in the UK: a comparison of late preterm and term infants.

Objective To explore the association between breastfeeding support and breastfeeding among late preterm (gestation 34–36 weeks) and term (gestation ≥37 weeks) infants. Methods Secondary analysis of the UK 2010 Infant Feeding Survey. Logistic regression was used to determine the association of breastfeeding support with breastfeeding at 10 days and 6 weeks in late preterm and term infants. Results The study included 14 525 term and 579 late preterm infants. A total of 11 729 infants initiated breastfeeding (11 292 (81.1%) term, 437 (79.4%) late preterm infants, p=0.425). Of these, 9230 (84.3%) term and 365 (85.6%) late preterm infants were breastfeeding at 10 days (p=0.586); of these 7547 (82.0%) term and 281 (75.4%) late preterm infants were still breastfeeding at 6 weeks (p=0.012). Mothers who reported receiving contact details for breastfeeding support groups had a higher likelihood of breastfeeding late preterm (adjusted ORs, aOR 3.14, 95% CI 1.40 to 7.04) and term infants (aOR 2.24, 95% CI 1.86 to 2.68) at 10 days and term infants at 6 weeks (aOR 1.83, 95% CI 1.51 to 2.22). Those who reported that they did not receive enough help with breastfeeding in hospital had a lower likelihood of breastfeeding late preterm at 10 days and term infants at 10 days and 6 weeks, compared to those who reported having enough help. Conclusions Receiving sufficient help with breastfeeding in hospital and the contact details for breastfeeding support groups is associated with breastfeeding term infants up to 6 weeks and late preterm infants at 10 days.

Ethnic variation in stillbirth risk and the role of maternal obesity: analysis of routine data from a London maternity unit.

BackgroundApproximately 5 in 1,000 deliveries in England and Wales result in stillbirth, with little improvement in figures over the last few decades. The aim of this study was to investigate the association between clinical and socio-demographic factors and stillbirth, with a particular focus on ethnicity and obesity.MethodsAnalysis of routine maternity data on 53,293 singleton births occurring in a large London teaching hospital between 2004 and 2012. Logistic regression was used to investigate risk factors for stillbirth and to explore potential effect modification.Results53,293 deliveries occurred during the time period, of which 329 resulted in a stillbirth (6.2 per 1,000 births). Compared to White women, non-White ethnicity was associated with a doubling of the odds of stillbirth (aOR for Black women 2.15, 95% CI 1.56-2.97; aOR for South Asian women 2.33, 95% CI 1.42-3.83). Obese women had a trend towards higher odds of stillbirth compared to women of recommended BMI (aOR 1.38, 95% CI 0.98-1.96), though this was not significant (p 0.07). Both higher parity (≥2 compared to para 1) and hypertension were associated with a higher odds of stillbirth (parity ≥2 aOR 1.65, 95% CI 1.13-2.39; hypertension aOR 1.84, 95% CI 1.22-2.78) but there was no evidence that area deprivation or maternal age were independently associated with stillbirth in this population. There was some evidence of effect modification between ethnicity and obesity (p value for interaction 0.06), with obesity a particularly strong risk factor for stillbirth in South Asian women (aOR 4.64, 95% CI 1.84-11.70).ConclusionsThere was a high prevalence of stillbirth in this multi-ethnic urban population. The increased risk of stillbirth observed in non-White women remains after adjusting for other factors. Our finding of possible effect modification between ethnicity and obesity suggests that further research should be conducted in order to improve understanding of the interplay between ethnicity, obesity and stillbirth.

An investigation of social inequalities in help-seeking and use of health services for fertility problems in a population-based sample of UK women.

Although infertility is an important public health problem, treatment can be expensive and resources are increasingly scarce. This study investigates possible inequalities in the use of medical services for fertility problems. We analysed data from a population-based survey for associations between socio-economic characteristics and help-seeking or use of services, to establish whether inequalities existed. More women of higher social status and education reported fertility problems, but there was no clear trend in help-seeking, investigations or treatments for infertility by social status and education level. New work is planned to investigate these issues more fully, particularly the role of family income.

Risk of Adverse Obstetric and Neonatal Outcomes by Maternal Age: Quantifying Individual and Population Level Risk Using Routine UK Maternity Data

Objective The objective of this study was to investigate whether moderately increased maternal age is associated with obstetric and neonatal outcome in a contemporary population, and to consider the possible role of co-morbidities in explaining any increased risk. Study Design Secondary analysis of routinely collected data from a large maternity unit in London, UK. Data were available on 51,225 singleton deliveries (≥22 weeks) occurring to women aged ≥20 between 2004 and 2012. Modified Poisson regression was used to estimate risk ratios for the association between maternal age and obstetric and neonatal outcome (delivery type, postpartum haemorrhage, stillbirth, low birthweight, preterm birth, small for gestational age, neonatal unit admission), using the reference group 20–24 years. Population attributable fractions were calculated to quantify the population impact. Results We found an association between increasing maternal age and major postpartum haemorrhage (≥1000ml blood loss) (RR 1.36 95% CI 1.18–1.57 for age 25–29 rising to 2.41 95% CI 2.02–2.88 for age ≥40). Similar trends were observed for caesarean delivery, most notably for elective caesareans (RR 1.64 95% CI 1.36–1.96 for age 25–29 rising to 4.94 95% CI 4.09–5.96 for age ≥40). There was evidence that parity modified this association, with a higher prevalence of elective caesarean delivery in older nulliparous women. Women aged ≥35 were at increased risk of low birthweight and preterm birth. We found no evidence that the risk of stillbirth, small for gestational age, or neonatal unit admission differed by maternal age. Conclusions Our results suggest a gradual increase in the risk of caesarean delivery and postpartum haemorrhage from age 25, persisting after taking into account maternal BMI, hypertension and diabetes. The risk of low birthweight and preterm birth was elevated in women over 35. Further research is needed to understand the reasons behind the high prevalence of elective caesarean delivery in nulliparous older mothers.

Breastfeeding in England: time trends 2005-2006 to 2012-2013 and inequalities by area profile.

Breastfeeding rates in England have risen steadily since the 1970s, but rates remain low and little is known about area-based trends. We report an ecological analysis of time trends in area breastfeeding rates in England using annual data on breastfeeding initiation (2005-2006 to 2012-2013) and any breastfeeding at 6-8 weeks (2008-2009 to 2012-2013) for 151 primary care trusts (PCTs). Overall, breastfeeding initiation rose from 65.5% in 2005-2006 to 72.4% in 2012-2013 (average annual absolute increase 0.9%). There was a statistically significantly higher (interaction P < 0.001) annual increase in initiation in PCTs in the most deprived (1.2%) compared with the least deprived tertile (0.7%), and in PCTs with low baseline breastfeeding initiation (2005-2006; 1.4%) compared with high baseline initiation (0.6%). Similar trends were observed when PCTs were stratified by the proportion of teenage mothers and maternal smoking, but not when stratified by ethnicity. Although breastfeeding prevalence at 6-8 weeks also increased significantly over the observed time period (41.2% in 2008-2009, 43.7% in 2012-2013; annual increase 0.7%), there was no difference in the average increase by deprivation profile, ethnicity, teenage mothers and maternal smoking. However, PCTs with low baseline prevalence in 2008-2009 saw a significantly larger annual increase (0.8%) compared with PCTs with high baseline prevalence (0.07%). In conclusion, breastfeeding initiation and prevalence have seen higher increases in areas with low initial breastfeeding, and for initiation, more disadvantaged areas. Although these results suggest that inequalities in breastfeeding have narrowed, rates have plateaued since 2010-2011. Sustained efforts are needed to address breastfeeding inequalities.