Reem Malouf

Prognostic Factors for Poor Cognitive Development in Children Born Very Preterm or With Very Low Birth Weight: A Systematic Review.

IMPORTANCE Cognitive delay is the most common form of impairment among children born very preterm (VPT) at 32 weeks or less or with very low birth weight (VLBW) of 1250 g or less. It is important to identify factors that are robust predictors of long-term outcome because the ability to predict future prognosis will assist in health care and educational service planning and provision. OBJECTIVE To identify prognostic factors for poor cognitive development in children born VPT or with VLBW. EVIDENCE REVIEW A systematic review was conducted using MEDLINE, EMBASE, and PyscINFO databases to identify studies published between January 1, 1990, and June 1, 2014, reporting multivariable prediction models for neurodevelopment in VPT or VLBW children. Thirty-one studies comprising 98 risk factor models for cognitive outcome were identified. Two independent reviewers extracted key information on study design, outcome definition, risk factor selection, model development, and reporting and conducted a risk-of-bias assessment. FINDINGS There was evidence that male sex, nonwhite race/ethnicity, lower level of parental education, and lower birth weight were predictive of global cognitive impairment in children younger than 5 years. In older children, only the influence of parental education was sustained. Male sex was also predictive of language impairment in early infancy, but not in middle childhood. Gestational age was a poor predictor of cognitive outcome, probably because of a reduced discriminatory power in cohorts restricted to a narrow gestational age range. The prognostic value of neonatal brain injury was unclear; however, studies adopted mixed strategies for managing children with physical or neurosensory disability. CONCLUSIONS AND RELEVANCE The influence of perinatal risk factors on cognitive development of VPT or VLBW children appears to diminish over time as environmental factors become more important. It is difficult to isolate cognitive outcomes from motor and neurosensory impairment, and the strategy for dealing with untestable children has implications for risk prediction.

Cochrane review on 'Statins for the treatment of dementia'

This review aimed to assess the clinical efficacy and tolerability of statins in the treatment of dementia.

Women with disability: the experience of maternity care during pregnancy, labour and birth and the postnatal period.

BackgroundIt has been estimated that 9.4% of women giving birth in the United Kingdom have one or more limiting longstanding illness which may cause disability, affecting pregnancy, birth and early parenting. No large scale studies on a nationally representative population have been carried out on the maternity experiences of disabled women to our knowledge.MethodSecondary analysis of data from a survey of women in 2010 by English National Health Service Trusts on behalf of the Care Quality Commission was undertaken. 144 trusts in England took part in the postal survey.Women self-identified with disability and were excluded if less than 16 years of age or if their baby had died. The 12 page structured questionnaire with sections on antenatal, labour and birth and postnatal care covered access, information, communication and choice. Descriptive and adjusted analyses compared disabled and non-disabled groups. Comparisons were made separately for five disability subgroups: physical disability, sensory impairment, mental health conditions, learning disability and women with more than one type of disability.ResultsDisabled women comprised 6.14% (1,482) of the total sample (24,155) and appeared to use maternity services more than non-disabled women. Most were positive about their care and reported sufficient access and involvement, but were less likely to breastfeed. The experience of women with different types of disability varied: physically disabled women used antenatal and postnatal services more, but had less choice about labour and birth; the experience of those with a sensory impairment differed little from the non-disabled women, but they were more likely to have met staff before labour; women with mental health disabilities also used services more, but were more critical of communication and support; women with a learning disability and those with multiple disabilities were least likely to report a positive experience of maternity care.ConclusionThis national study describes disabled women’s experiences of pregnancy, child birth and postnatal care in comparison with non-disabled women. While in many areas there were no differences, there was evidence of specific groups appropriately receiving more care. Areas for improvement included infant feeding and better communication in the context of individualised care.

Prognostic factors for cerebral palsy and motor impairment in children born very preterm or very low birthweight: a systematic review

There is a large literature reporting risk factor analyses for poor neurodevelopment in children born very preterm (VPT: ≤32wks) or very low birthweight (VLBW: ≤1250g), which to date has not been formally summarized. The aim of this paper was to identify prognostic factors for cerebral palsy (CP) and motor impairment in children born VPT/VLBW.

Risk Factor Models for Neurodevelopmental Outcomes in Children Born Very Preterm or With Very Low Birth Weight: A Systematic Review of Methodology and Reporting.

The prediction of long-term outcomes in surviving infants born very preterm (VPT) or with very low birth weight (VLBW) is necessary to guide clinical management, provide information to parents, and help target and evaluate interventions. There is a large body of literature describing risk factor models for neurodevelopmental outcomes in VPT/VLBW children, yet few, if any, have been developed for use in routine clinical practice or adopted for use in research studies or policy evaluation. We sought to systematically review the methods and reporting of studies that have developed a multivariable risk factor model for neurodevelopment in surviving VPT/VLBW children. We searched the MEDLINE, Embase, and PsycINFO databases from January 1, 1990, to June 1, 2014, and identified 78 studies reporting 222 risk factor models. Most studies presented risk factor analyses that were not intended to be used for prediction, confirming that there is a dearth of specifically designed prognostic modeling studies for long-term outcomes in surviving VPT/VLBW children. We highlight the strengths and weaknesses of the research methodology and reporting to date, and provide recommendations for the design and analysis of future studies seeking to analyze risk prediction or develop prognostic models for VPT/VLBW children.

Prognostic Factors for Behavioral Problems and Psychiatric Disorders in Children Born Very Preterm or Very Low Birth Weight: A Systematic Review.

Objective: Risk factors associated with adverse behavioral outcomes in very preterm (VPT) or very low birth weight (VLBW) infants are poorly understood. The aim of this article is to identify prognostic factors for behavioral problems and psychiatric disorders in children born ⩽32 weeks gestational age or with birth weight ⩽1250 g. Method: A systematic review was conducted using MEDLINE, Embase, and Pyscinfo databases to identify studies published between January 1, 1990 and June 1, 2014 reporting multivariable prediction models for behavioral problems or psychiatric disorders in VPT/VLBW children. Fifteen studies were identified and 2 independent reviewers extracted key information on study design, outcome definition, risk factor selection, model development, reporting, and conducted a risk of bias assessment. Results: The 15 studies included reported risk factor analyses for the following domains: general behavioral problems (n = 8), any psychiatric disorder (n = 2), autism spectrum symptoms/disorders (n = 5), and attention deficit/hyperactivity disorder (n = 1). Findings were inconclusive because of the following: small number of studies in each domain, heterogeneity in outcome measures, lack of overlap in the risk factors examined, and differences in strategies for dealing with children with neurological impairments. Conclusion: There is a lack of evidence concerning risk factors for behavior problems and psychiatric disorders among VPT/VLBW survivors. This review has identified the need for further research examining the etiology of disorders of psychological development in the VPT/VLBW population to refine risk prediction and identify targets for intervention. Large well-conducted studies that use standard diagnostic evaluations to assess psychiatric disorders throughout childhood and adolescence are required.

What influences birth place preferences, choices and decision-making amongst healthy women with straightforward pregnancies in the UK? A qualitative evidence synthesis using a ‘best fit’ framework approach

BackgroundEnglish maternity care policy has supported offering women choice of birth setting for over twenty years, but only 13% of women in England currently give birth in settings other than obstetric units (OUs). It is unclear why uptake of non-OU settings for birth remains relatively low. This paper presents a synthesis of qualitative evidence which explores influences on women’s experiences of birth place choice, preference and decision-making from the perspectives of women using maternity services.MethodsQualitative evidence synthesis of UK research published January 1992-March 2015, using a ‘best-fit’ framework approach. Searches were run in seven electronic data bases applying a comprehensive search strategy. Thematic framework analysis was used to synthesise extracted data from included studies.ResultsTwenty-four papers drawing on twenty studies met the inclusion criteria. The synthesis identified support for the key framework themes. Women’s experiences of choosing or deciding where to give birth were influenced by whether they received information about available options and about the right to choose, women’s preferences for different services and their attributes, previous birth experiences, views of family, friends and health care professionals and women’s beliefs about risk and safety. The synthesis additionally identified that women’s access to choice of place of birth during the antenatal period varied. Planning to give birth in OU was straightforward, but although women considering birth in a setting other than hospital OU were sometimes well-supported, they also encountered obstacles and described needing to ‘counter the negativity’ surrounding home birth or birth in midwife-led settings.ConclusionsOver the period covered by the review, it was straightforward for low risk women to opt for hospital birth in the UK. Accessing home birth was more complex and contested. The evidence on freestanding midwifery units (FMUs) is more limited, but suggests that women wanting to opt for an FMU birth experienced similar barriers. The extent to which women experienced similar problems accessing alongside midwifery units (AMUs) is unclear.Women’s preferences for different birth options, particularly for ‘hospital’ vs non-hospital settings, are shaped by their pre-existing values, beliefs and experience, and not all women are open to all birth settings.

Women’s birth place preferences in the United Kingdom: a systematic review and narrative synthesis of the quantitative literature

BackgroundCurrent clinical guidelines and national policy in England support offering ‘low risk’ women a choice of birth setting, but despite an increase in provison of midwifery units in England the vast majority of women still give birth in obstetric units and there is uncertainty around how best to configure services. There is therefore a need to better understand women’s birth place preferences. The aim of this review was to summarise the recent quantitative evidence on UK women’s birth place preferences with a focus on identifying the service attributes that ‘low risk’ women prefer and on identifying which attributes women prioritise when choosing their intended maternity unit or birth setting.MethodsWe searched Medline, Embase, PsycINFO, Science Citation Index, Social Science Index, CINAHL and ASSIA to identify quantitative studies published in scientific journals since 1992 and designed to describe and explore women’s preferences in relation to place of birth. We included experimental stated preference studies, surveys and mixed-methods studies containing relevant quantitative data, where participants were ‘low risk’ or ‘unselected’ groups of women with experience of UK maternity services.ResultsWe included five experimental stated preference studies and four observational surveys, including a total of 4201 respondents. Most studies were old with only three conducted since 2000. Methodological quality was generally poor. The attributes and preferences most commonly explored related to pain relief, continuity of midwife, involvement/availability of medical staff, ‘homely’ environment/atmosphere, decision-making style, distance/travel time and need for transfer. Service attributes that were almost universally valued by women included local services, being attended by a known midwife and a preference for a degree of control and involvement in decision-making. A substantial proportion of women had a strong preference for care in a hospital setting where medical staff are not necessarily involved in their care, but are readily available.ConclusionsThe majority of women appear to value some service attributes while preferences differ for others. Policy makers, commissioners and service providers might usefully consider how to extend the availability of services that most women value while offering a choice of options that enable women to access services that best fit their needs and preferences.

Systematic review of heath care interventions to improve outcomes for women with disability and their family during pregnancy, birth and postnatal period.

BackgroundHealth care providers are often unfamiliar with the needs of women with disability. Moreover maternity and postnatal services may not be specifically tailored to the needs of women with disability and their families. We conducted a systematic review to determine the effectiveness of healthcare interventions to improve outcomes for pregnant and postnatal women with disability and for their families.MethodsStudies on pregnant and postnatal women with disability and their families which evaluated the effectiveness of an intervention using a design that met the criteria used by the Cochrane Effective Practice and Organization of Care group were eligible for inclusion in this review. A comprehensive search strategy was carried using eleven electronic databases. No restriction on date or language was applied. Included studies were assessed for quality and their results summarized and tabulated.ResultsOnly three studies fully met the inclusion criteria. All were published after 1990, and conducted as small single-centre randomized controlled trials. The studies were heterogeneous and not comparable. Therefore the main finding of this review was the lack of published research on the effectiveness of healthcare interventions to improve outcomes for pregnant women with disability and their families.ConclusionsMore research is required to evaluate healthcare interventions to improve outcomes for pregnant women with disability and their families.

Access and quality of maternity care for disabled women during pregnancy, birth and the postnatal period in England: data from a national survey

Objectives More disabled women are becoming mothers, and yet, their care is rarely the focus of quantitative research. This study aimed to investigate access and quality of maternity care for women with differing disabilities. Design Secondary analysis was conducted on data from a 2015 national survey of womens experience of maternity care. Descriptive and adjusted analyses were undertaken for five disability groups: physical disability, sensory impairment, mental health disability, learning disability and multiple disability, and comparisons were made with the responses of non-disabled women. Setting Survey data were collected on womens experience of primary and secondary care in all trusts providing maternity care in England. Participants Women who had given birth three months previously, among whom were groups self-identifying with different types of disability. Exclusions were limited to women whose baby had died and those who were younger than 16 years at the time of the recent birth. Results Overall, 20,094 women completed and returned the survey; 1958 women (9.5%) self-identified as having a disability. The findings indicate some gaps in maternity care provision for these women relating to interpersonal aspects of care: communication, feeling listened to and supported, involvement in decision making, having a trusted and respected relationship with clinical staff. Women from all disability groups wanted more postnatal contacts and help with infant feeding. Conclusion While access to care was generally satisfactory for disabled women, womens emotional well-being and support during pregnancy and beyond is an area that is in need of improvement. Specific areas identified included disseminating information effectively, ensuring appropriate communication and understanding, and supporting womens sense of control to build trusting relationships with healthcare providers.