Comparing Internet-Based Cognitive Behavioral Therapy With Standard Care for Women With Fear of Birth: Randomized Controlled Trial.

BACKGROUND: Although many pregnant women report fear related to the approaching birth, no consensus exists on how fear of birth should be handled in clinical care. OBJECTIVE: This randomized controlled trial aimed to compare the efficacy of a guided internet-based self-help program based on cognitive behavioral therapy (guided ICBT) with standard care on the levels of fear of birth in a sample of pregnant women reporting fear of birth. METHODS: This nonblinded, multicenter randomized controlled trial with a parallel design was conducted at three study centers (hospitals) in Sweden. Recruitment commenced at the ultrasound screening examination during gestational weeks 17-20. The therapist-guided ICBT intervention was inspired by the Unified protocol for transdiagnostic treatment of emotional disorders and consisted of 8 treatment modules and 1 module for postpartum follow-up. The aim was to help participants observe and understand their fear of birth and find new ways of coping with difficult thoughts and emotions. Standard care was offered in the three different study regions. The primary outcome was self-assessed levels of fear of birth, measured using the Fear of Birth Scale. RESULTS: We included 258 pregnant women reporting clinically significant levels of fear of birth (guided ICBT group, 127; standard care group, 131). Of the 127 women randomized to the guided ICBT group, 103 (81%) commenced treatment, 60 (47%) moved on to the second module, and only 13 (10%) finished ≥4 modules. The levels of fear of birth did not differ between the intervention groups postintervention. At 1-year postpartum follow-up, participants in the guided ICBT group exhibited significantly lower levels of fear of birth (U=3674.00, z=-1.97, P=.049, Cohen d=0.28, 95% CI -0.01 to 0.57). Using the linear mixed models analysis, an overall decrease in the levels of fear of birth over time was found (P≤ .001), along with a significant interaction between time and intervention, showing a larger reduction in fear of birth in the guided ICBT group over time (F1,192.538=4.96, P=.03). CONCLUSIONS: Fear of birth decreased over time in both intervention groups; while the decrease was slightly larger in the guided ICBT group, the main effect of time alone, regardless of treatment allocation, was most evident. Poor treatment adherence to guided ICBT implies low feasibility and acceptance of this treatment. TRIAL REGISTRATION: ClinicalTrials.gov NCT02306434; https://clinicaltrials.gov/ct2/show/NCT02306434 (Archived by WebCite at http://www.webcitation.org/70sj83qat).

Prevalence and management of diabetes in residential aged care facilities in north-east Victoria, Australia.

BACKGROUND: Managing diabetes in residential aged care facilities (RACFs) presents challenges to general practitioners (GPs) as the incidence of the disease increases. OBJECTIVE: The objective of this article is to describe the prevalence and management of diabetes in RACFs in north-east Victoria. METHODS: The method used for this study was a cross-sectional audit of medical files. RESULTS: Ten RACFs were invited and agreed to participate, giving a sample of 593 residents. Diabetes prevalence was 18.2% (n = 108). Half of the residents with diabetes had received a glycated haemoglobin (HbA1c) test in the previous six months. Of these residents, half had an HbA1c result of 8%. The frequency of hypoglycaemic events was found to be 10%. Hyperglycaemic episodes (HbA1C >10%) occurred in 69% of residents with diabetes; 21% had hyperglycaemic episodes when defined by levels greater than those set by the resident's GP. Diabetes-related unscheduled hospitalisations was found to be 6.5%, while diabetes-related general practice visits was 23%. DISCUSSION: The prevalence of diabetes in the RACFs was higher than previously reported in rural Victoria. Practice variance from evidence-based guidelines may be contributing to unplanned hospitalisations and increased acute general practice visits.

Continuity of midwifery care for rural women through caseload group practice: Delivering for almost 20 years.

OBJECTIVE: To describe the clinical outcomes and sustainability factors of a long-standing midwifery led caseload model of rural maternity care. DESIGN: Retrospective clinical audit from 1998 to 2011 and autoethnographic narrative of the midwifery program told by the longest serving midwives under three key themes relating to sustainable practice. SETTING: Regional Health Service with annual birth rate of 500. Maternity care is provided by either public antenatal clinic/GP shared care or midwife-led care. PARTICIPANTS: Women attending a rural caseload midwifery group practice between the period 1998-2011 and midwives working in the same group practice during that period. MAIN OUTCOME MEASURES: Antenatal attendance, maternal mortality, infant morbidity and mortality, mode of birth, known midwife at birth, initiation of breastfeeding. RESULTS: There were 1674 births between 1998 and 2011. Clinical outcomes for women and infants closely reflected national maternity indicator data. The group practice midwives attribute sustainability of the program to the enjoyment of flexibility in their working environment, to establishing trust amongst themselves, the women they care for, and with the obstetricians, GPs and health service executives. The rigorous application of midwifery principles including robust clinical governance have been hallmarks of success. CONCLUSION: This caseload midwifery group practice is a safe, satisfying and sustainable model of maternity care in a rural setting. Clinical outcomes are similar to standard care. Success can be attributed to strong leadership across all levels of policy, health service management and, most importantly, the rural midwives providing the service.

The role of women's attitudinal profiles in satisfaction with the quality of their antenatal and intrapartum care.

OBJECTIVE: To compare perceptions of antenatal and intrapartum care in women categorized into three profiles based on attitudes and fear. DESIGN: Prospective longitudinal cohort study using self-report questionnaires. Profiles were constructed from responses to the Birth Attitudes Profile Scale and the Fear of Birth Scale at pregnancy weeks 18 to 20. Perception of the quality of care was measured using the Quality from Patient's Perspective index at 34 to 36 weeks pregnancy and 2 months after birth. SETTING: Two hospitals in Sweden and Australia. PARTICIPANTS: Five hundred and five (505) pregnant women from one hospital in Västernorrland, Sweden (n = 386) and one in northeast Victoria, Australia (n = 123). RESULTS: Women were categorized into three profiles: self-determiners, take it as it comes, and fearful. The self-determiners reported the best outcomes, whereas the fearful were most likely to perceive deficient care. Antenatally the fearful were more likely to indicate deficiencies in medical care, emotional care, support received from nurse-midwives or doctors and nurse-midwives'/doctors' understanding of the woman's situation. They also reported deficiencies in two aspects of intrapartum care: support during birth and control during birth. CONCLUSIONS: Attitudinal profiling of women during pregnancy may assist clinicians to deliver the style and content of antenatal and intrapartum care to match what women value and need. An awareness of a woman's fear of birth provides an opportunity to offer comprehensive emotional support with the aim of promoting a positive birth experience.

Thrombolysis for acute ST elevation myocardial infarction: a pilot study comparing results from GP led small rural health emergency departments with results from a physician led sub-regional emergency department.

INTRODUCTION: Urgent angiogram is best treatment for patients presenting with ST elevation myocardial infarction (STEMI) in the first 90 min after contacting medical help. For Australian residents of inner and outer regional areas and remote or very remote areas, quick access to angiograms is not available. Numerous approaches have been developed to maximize reperfusion but delays due to systematic and patient factors persist. Diminishing confidence of some GPs in small rural health services to administer thrombolytics was one barrier to timely reperfusion identified in northeast Victoria, Australia. The aim of this study was to compare the frequency and outcomes of STEMI patients treated with thrombolysis by GPs in small rural emergency departments (EDs) with the outcomes from thrombolysis for STEMI in the physician-led, sub-regional ED in northeast Victoria. METHODS: Data were gathered by a medical file audit. Outcome measures were the frequency of STEMI, symptom to presentation times, mode of transport to hospital, ambulance call to presentation at ED times, door to needle (DTN) times, subsequent percutanous intervention (PCI) or coronary artery bypass grafts (CABG), physician follow up and death. RESULTS: In total 68 cases were audited. Univariate analysis showed no significant differences between the GP-led or physician-led EDs in time from onset of symptoms to presentation, DTN times, thrombolysis related complications or subsequent access to PCI or CABG. Follow-up care was similar in both groups. Transport to hospital differed between the groups with only half of all cases arriving at the ED by ambulance, almost all of which went to the sub-regional hospital. CONCLUSIONS: Thrombolysis for STEMI in the small GP-led EDs had similar results to thrombolysis administered by the physician-led ED. There is substantial time benefit to be gained by encouraging GP-led EDs to provide thrombolysis treatment, thereby improving patient prognosis and survival.

The influence of women's fear, attitudes and beliefs of childbirth on mode and experience of birth.

BACKGROUND: Women's fears and attitudes to childbirth may influence the maternity care they receive and the outcomes of birth. This study aimed to develop profiles of women according to their attitudes regarding birth and their levels of childbirth related fear. The association of these profiles with mode and outcomes of birth was explored. METHODS: Prospective longitudinal cohort design with self report questionnaires containing a set of attitudinal statements regarding birth (Birth Attitudes Profile Scale) and a fear of birth scale (FOBS). Pregnant women responded at 18-20 weeks gestation and two months after birth from a regional area of Sweden (n = 386) and a regional area of Australia (n = 123). Cluster analysis was used to identify a set of profiles. Odds ratios (95% CI) were calculated, comparing cluster membership for country of care, pregnancy characteristics, birth experience and outcomes. RESULTS: Three clusters were identified - 'Self determiners' (clear attitudes about birth including seeing it as a natural process and no childbirth fear), 'Take it as it comes' (no fear of birth and low levels of agreement with any of the attitude statements) and 'Fearful' (afraid of birth, with concerns for the personal impact of birth including pain and control, safety concerns and low levels of agreement with attitudes relating to women's freedom of choice or birth as a natural process). At 18 -20 weeks gestation, when compared to the 'Self determiners', women in the 'Fearful' cluster were more likely to: prefer a caesarean (OR = 3.3 CI: 1.6-6.8), hold less than positive feelings about being pregnant (OR = 3.6 CI: 1.4-9.0), report less than positive feelings about the approaching birth (OR = 7.2 CI: 4.4-12.0) and less than positive feelings about the first weeks with a newborn (OR = 2.0 CI 1.2-3.6). At two months post partum the 'Fearful' cluster had a greater likelihood of having had an elective caesarean (OR = 5.4 CI 2.1-14.2); they were more likely to have had an epidural if they laboured (OR = 1.9 CI 1.1-3.2) and to experience their labour pain as more intense than women in the other clusters. The 'Fearful' cluster were more likely to report a negative experience of birth (OR = 1.7 CI 1.02- 2.9). The 'Take it as it comes' cluster had a higher likelihood of an elective caesarean (OR 3.0 CI 1.1-8.0). CONCLUSIONS: In this study three clusters of women were identified. Belonging to the 'Fearful' cluster had a negative effect on women's emotional health during pregnancy and increased the likelihood of a negative birth experience. Both women in the 'Take it as it comes' and the 'Fearful' cluster had higher odds of having an elective caesarean compared to women in the 'Self determiners'. Understanding women's attitudes and level of fear may help midwives and doctors to tailor their interactions with women.