Breastfeeding, pregnancy, medicines, neurodevelopment, and population databases: the information desert.

BACKGROUND: The pharmacoepidemiology of the long-term benefits and harms of medicines in pregnancy and breastfeeding has received little attention. The impact of maternal medicines on children is increasingly recognised as a source of avoidable harm. The focus of attention has expanded from congenital anomalies to include less visible, but equally important, outcomes, including cognition, neurodevelopmental disorders, educational performance, and childhood ill-health. Breastfeeding, whether as a source of medicine exposure, a mitigator of adverse effects or as an outcome, has been all but ignored in pharmacoepidemiology and pharmacovigilance: a significant 'blind spot'. WHOLE-POPULATION DATA ON BREASTFEEDING: WHY WE NEED THEM: Optimal child development and maternal health necessitate breastfeeding, yet little information exists to guide families regarding the safety of medicine use during lactation. Breastfeeding initiation or success may be altered by medicine use, and breastfeeding may obscure the true relationship between medicine exposure during pregnancy and developmental outcomes. Absent or poorly standardised recording of breastfeeding in most population databases hampers analysis and understanding of the complex relationships between medicine, pregnancy, breastfeeding and infant and maternal health. The purpose of this paper is to present the arguments for breastfeeding to be included alongside medicine use and neurodevelopmental outcomes in whole-population database investigations of the harms and benefits of medicines during pregnancy, the puerperium and postnatal period. We review: 1) the current situation, 2) how these complexities might be accommodated in pharmacoepidemiological models, using antidepressants and antiepileptics as examples; 3) the challenges in obtaining comprehensive data. CONCLUSIONS: The scarcity of whole-population data and the complexities of the inter-relationships between breastfeeding, medicines, co-exposures and infant outcomes are significant barriers to full characterisation of the benefits and harms of medicines during pregnancy and breastfeeding. This makes it difficult to answer the questions: 'is it safe to breastfeed whilst taking this medicine', and 'will this medicine interfere with breastfeeding and/ or infants' development'?

Managing long-term worklessness in primary care: a focus group study.

BACKGROUND: Evidence suggests that overall the benefits of work are greater than the harmful effects of long-term unemployment and prolonged sickness absence. General practitioners (GPs) often feel that work and health-related issues extend beyond their role. There is a paucity of research that focuses on GPs' attitudes to the management of long-term worklessness. AIMS: To explore GPs' perceptions of the management of individuals in receipt of long-term incapacity benefits and their attitudes to UK government funded return to work programmes such as the Want2Work scheme in Wales. METHODS: A qualitative study set in South Wales. Focus groups were conducted with GPs and explored the role of primary care and the challenges that GPs face when managing long-term worklessness and how the Want2Work programme might benefit GP practice. Data were analysed using the framework method of analysis. RESULTS: The main themes that emerged from the GP focus groups were role boundaries, responsibilities, negotiation and knowledge. A key finding was that many of the participants felt that their role in managing long-term worklessness was limited to providing support and management of health-related issues only. The perceived risk to their own personal safety in addressing these issues with some patients also impacted on GPs' decision making CONCLUSIONS: There seems to be a clear divide between managing patients' health concerns and their work-related activities. Some GPs recognized that patients became 'lost' in their system once receiving long-term benefits.

Exploring the perceptions of out-of-hours training for GP registrars in Wales.

This paper explores the perceptions of GP registrars about the quality of the training that they receive within out-of-hours (OOH) settings. Focus groups with trainers, clinical supervisors and GP registrars revealed three areas of interest: supervision, educational experience and system factors. Implications for OOH training are discussed.