Impact of a quality improvement project to reduce the rate of obstetric anal sphincter injury: a multicentre study with a stepped-wedge design.

OBJECTIVE: To evaluate the impact of a care bundle (antenatal information to women, manual perineal protection and mediolateral episiotomy when indicated) on obstetric anal sphincter injury (OASI) rates. DESIGN: Multicentre stepped-wedge cluster design. SETTING: Sixteen maternity units located in four regions across England, Scotland and Wales. POPULATION: Women with singleton live births between October 2016 and March 2018. METHODS: Stepwise region by region roll-out every 3 months starting January 2017. The four maternity units in a region started at the same time. Multi-level logistic regression was used to estimate the impact of the care bundle, adjusting for time trend and case-mix factors (age, ethnicity, body mass index, parity, birthweight and mode of birth). MAIN OUTCOME MEASURES: Obstetric anal sphincter injury in singleton live vaginal births. RESULTS: A total of 55 060 singleton live vaginal births were included (79% spontaneous and 21% operative). Median maternal age was 30 years (interquartile range 26-34 years) and 46% of women were primiparous. The OASI rate decreased from 3.3% before to 3.0% after care bundle implementation (adjusted odds ratio 0.80, 95% CI 0.65-0.98, P = 0.03). There was no evidence that the effect of the care bundle differed according to parity (P = 0.77) or mode of birth (P = 0.31). There were no significant changes in caesarean section (P = 0.19) or episiotomy rates (P = 0.16) during the study period. CONCLUSIONS: The implementation of this care bundle reduced OASI rates without affecting caesarean section rates or episiotomy use. These findings demonstrate its potential for reducing perineal trauma during childbirth. TWEETABLE ABSTRACT: OASI Care Bundle reduced severe perineal tear rates without affecting caesarean section rates or episiotomy use.

Perinatal and maternal outcomes in planned home and obstetric unit births in women at 'higher risk' of complications: secondary analysis of the Birthplace national prospective cohort study.

OBJECTIVE: To explore and compare perinatal and maternal outcomes in women at 'higher risk' of complications planning home versus obstetric unit (OU) birth. DESIGN: Prospective cohort study. SETTING: OUs and planned home births in England. POPULATION: 8180 'higher risk' women in the Birthplace cohort. METHODS: We used Poisson regression to calculate relative risks adjusted for maternal characteristics. Sensitivity analyses explored possible effects of differences in risk between groups and alternative outcome measures. MAIN OUTCOME MEASURES: Composite perinatal outcome measure encompassing 'intrapartum related mortality and morbidity' (intrapartum stillbirth, early neonatal death, neonatal encephalopathy, meconium aspiration syndrome, brachial plexus injury, fractured humerus or clavicle) and neonatal admission within 48 hours for more than 48 hours. Two composite maternal outcome measures capturing intrapartum interventions/adverse maternal outcomes and straightforward birth. RESULTS: The risk of 'intrapartum related mortality and morbidity' or neonatal admission for more than 48 hours was lower in planned home births than planned OU births [adjusted relative risks (RR) 0.50, 95% CI 0.31-0.81]. Adjustment for clinical risk factors did not materially affect this finding. The direction of effect was reversed for the more restricted outcome measure 'intrapartum related mortality and morbidity' (RR adjusted for parity 1.92, 95% CI 0.97-3.80). Maternal interventions were lower in planned home births. CONCLUSIONS: The babies of 'higher risk' women who plan birth in an OU appear more likely to be admitted to neonatal care than those whose mothers plan birth at home, but it is unclear if this reflects a real difference in morbidity. Rates of intrapartum related morbidity and mortality did not differ statistically significantly between settings at the 5% level but a larger study would be required to rule out a clinically important difference between the groups.

High social class and suicide in persons at risk for schizophrenia.

OBJECTIVE: The relationship between suicide and social class has been equivocal. While some authors have reported that higher social class is related to higher rates of suicide, most other studies report that lower social class is associated with higher rates of suicide. Our study attempted to resolve these inconsistencies by using a High Risk for schizophrenia method. METHOD: Children of women with severe schizophrenia were assessed in 1962. In 2005, when subjects were a mean age of 58 years, we identified those who had committed suicide. RESULTS: A higher rate of suicide was associated with risk for schizophrenia in the High-Risk sample. Higher social class origin was associated with suicide in persons at risk for mental illness. CONCLUSION: Higher social class origin was associated with suicide in subjects at genetic risk for schizophrenia (but not those without risk).

Crime and the schizophrenia spectrum: a diathesis-stress model.

Previous studies support a relationship between schizophrenia and antisocial behavior. In the present study, offspring of schizophrenics showed a greater degree of antisocial behavior than did offspring of parents without psychopathology. The present study clarifies the interplay between risk for schizophrenia and developmental factors in determining antisocial behavior. Those variables which distinguished high-risk criminal behavior from high-risk non-criminal behavior were irritability and shortened attention span in infancy, paternal absence during ages 15 to 17, lower WAIS Verbal IQ, impoverished neighborhood, family discord and negative attitude towards father. In a multiple regression analysis, paternal absence in adolescence, shortness of attention span, and low Verbal IQ each contributed a unique portion of the variance in antisocial behavior. A block of interaction terms (Stressor X Risk) did not contribute a significant portion of the variance in antisocial behavior, suggesting that those factors which predict antisocial behavior in the high-risk group are the same factors which predict antisocial behavior in the low-risk group. In addition, a significant portion of the variance in phenotypic outcome (criminal vs. schizophrenic) was accounted for by passivity in infancy (predictive of schizophrenia) and low Verbal IQ (more common in high-risk criminals). Shortened attention spans in infancy were found to precede both criminal behavior and schizophrenia in this sample. This feature may therefore indicate a genetic vulnerability to schizophrenia.

Motor impairment and antisocial behavior in adolescent males at high risk for schizophrenia.

A familial link between schizophrenia and antisocial behavior has been established (e.g., Silverton, 1985). This study examined this relationship in a Danish cohort. The subjects were 36 high-risk males (offspring of a schizophrenic parent) and 36 low-risk males (offspring of parents without psychopathology). This high-risk subjects exhibited more antisocial behavior than the low-risk subjects. We tested the hypothesis of a correlation between neurointegrative deficits, as defined by motor impairment, and antisocial behavior, rated at ages 10-13, in subjects at genetic risk for schizophrenia. Path analyses were conducted from motor impairment at 1 year and motor impairment at 10-13 years to antisocial behavior separately for high-risk and low-risk subjects. Adolescent motor impairment was a significant predictor of antisocial behavior for high-risk subjects. Motor impairment at 1 year was also associated with antisocial behavior for these subjects, although the association was partly due to the indirect effects of motor impairment at 1 year on motor impairment at 10-13 years, which, in turn, was associated with changes in antisocial behavior. As predicted, none of the path coefficients nor the effect coefficient was significant for low-risk subjects.

Class drift and schizophrenia.

This study is part of an ongoing analysis of 207 children with schizophrenic mothers (high-risk subjects) and 104 low-risk controls begun in 1962 by Mednick & Schulsinger. The purpose of this study was to examine class mobility in schizophrenics, using a prospective paradigm. In the present study, 14 high-risk schizophrenics were matched with 14 high-risk non-schizophrenics and 14 low-risk non-schizophrenics on age, sex and social class origin. Groups were compared on highest class attainment and socio-economic status in 1972. Results indicated that while high-risk non-schizophrenics were comparable in class attainment to low-risk non-schizophrenics, the high-risk schizophrenics were downwardly mobile in comparison to their non-schizophrenic high-risk counterparts. The class drift hypothesis was thus supported.

Cerebral ventricular size in the offspring of schizophrenic mothers. A preliminary study.

Within a prospective, longitudinal study of offspring of schizophrenic mothers, computed tomographic scan-derived measurements of ventricular size were evaluated for a subsample consisting of schizophrenics, borderline schizophrenics (DSM-III schizotypal), and mentally healthy individuals. Schizophrenics exhibited larger ventricular sizes and borderline schizophrenics smaller ventricular sizes than mentally healthy individuals. Ventricular size correlated with premorbidly obtained obstetric data. These results are interpreted as being consistent with the hypothesis that neurological insult may decompensate schizotypal individuals toward florid schizophrenia.

Impaired speed of visual information processing in marijuana intoxication.

The authors conducted a double-blind crossover study to investigate the effects of marijuana on visual information processing. The authors used a tachistoscopic paradigm, and the results show no marijuana effect on the critical stimulus duration, a measure of stimulus intake. The visual backward masking data are compatible with a marijuana-induced slowness of information processing from labile unconscious iconic memory to more permanent memory processes. These results are discussed in relation to reports of marijuana's effects on perception and early information processing.