The effect of the national demonstration project Healthy Respect on teenage sexual health behaviour.

BACKGROUND: As part of the independent evaluation of Healthy Respect (a national demonstration project to improve teenage sexual health in Scotland) this study examined the effect of the school-based sexual health education intervention comprising multiprofessional classroom delivery and alongside drop-in clinics on teenage sexual behaviour outcomes. METHODS: Before-and-after cross-sectional surveys of secondary school pupils (average age 14 years and 6 months) were used in 10 Healthy Respect intervention schools in Lothian region and 5 comparison schools without intervention in Grampian region (2001 and 2003). RESULTS: By 2003, the proportion of pupils in Lothian feeling confident about getting condoms and using condoms properly significantly increased, more Lothian pupils (particularly boys) showed improved knowledge about condoms being protective against sexually transmitted infections. No further evidence of improved knowledge, attitudes, or intentions was evident after the intervention. Pupils in Lothian remained more likely to think using a condom would be embarrassing (especially girls), would reduce sexual enjoyment (especially boys), and intentions about condom use (as closer predictors of actual behaviour change) showed no significant improvement. More Lothian ( approximately 24%) than Grampian ( approximately 19%) pupils report having had sexual intercourse at age <16 years, both before and after the intervention, with no evidence of a significant reduction in Lothian by 2003. Overall differences in attitudes to condom use by gender were noted. Findings remain consistent in both unadjusted and adjusted comparisons. CONCLUSION: These findings demonstrate limited impact on sexual health behaviour outcomes, and raise questions about the likely and achievable sexual health gains for teenagers from school-based interventions.

Terminology in early pregnancy loss: what women hear and what clinicians write.

OBJECTIVE: The Royal College of Obstetricians and Gynaecologists recommends that patient-focused terminology be used in early pregnancy care. The objective of the study was to evaluate whether inappropriate terminology is continuing to be used in Scottish gynaecology services. METHODS: A case note review (1259 records) and a patient survey (648 replies) assessed usage of four inappropriate terms ('abortion', 'blighted ovum', 'incompetent cervix' and 'pregnancy failure') in 18 Scottish hospitals providing secondary care to women with early pregnancy loss. RESULTS: Women reported hearing 'abortion' in 4.2% of hospital episodes (95% CI 2.9-6.0), but the term was used in 9.9% (95% CI 8.4-11.7) of hospital records. CONCLUSION: In order to meet national recommendations on terminology for early pregnancy loss, clinicians should not only say 'miscarriage' but also write it.

The acceptability of home medical abortion to women in UK settings.

OBJECTIVE: To assess the acceptability of home medical abortion to women in UK settings. DESIGN: Questionnaire survey. SETTING: Four NHS gynaecology units in England and Scotland. SUBJECTS: Women undergoing conventional, hospital-based, medical abortion up to nine weeks of gestation. METHODS: A self-complete questionnaire explored the acceptability of abortion in hospital (including pain and bleeding experienced) and at home. Comparisons were made between centres (English and Scottish). MAIN OUTCOME MEASURE: Women's views on home administration of misoprostol for medical abortion; perceived acceptability and perceived ability to cope with the process at home. RESULTS: Sixty-six percent (366/553) of the questionnaires were returned: Edinburgh, 204 (56%); London, 92 (25%); Hull, 43 (12%); and Glasgow, 27 (7%). Individual questionnaire items were answered by varying numbers of women: 228/320 (71%; 95% CI: 66-76%) said there was nothing that happened during abortion in the hospital that they would have been unable to cope with at home; 123/342 (36%; 95% CI: 31-41%) said they would have opted to have home abortion, had that choice been available. However, 219/342 (64%; 95% CI: 59-69%) indicated that they would prefer to have abortion in the hospital. The majority of women said they would have coped at home with bleeding (280/355, 79%; 95% CI: 74-83%) and with pain if given analgesia (203/268, 76%; 95% CI: 70-81%). CONCLUSION: This study suggests that most women would welcome being offered the choice of having medical abortion at home or in hospital. The development of home abortion must be seen as complementary, not an alternative, to hospital services.

Are national recommendations regarding examination and disposal of products of miscarriage being followed? A need for revised guidelines?

BACKGROUND: National guidance documents advise that tissue obtained from treatment of miscarriage should be submitted for histological examination to exclude trophoblastic disease and ectopic pregnancy, and require sensitive disposal of human tissue. The aim of this study was to determine the extent to which health professionals have adopted these recommendations. METHODS AND RESULTS: Fifteen Scottish Obstetric and Gynaecology services participated in an audit of early pregnancy loss care. Three audit tools were used. In a case note review, 484 women completed medical or surgical treatment for miscarriage. 71% of records contained evidence of histological examination of tissue. Documentation of discussion of disposal of tissue with the woman was found in 29% of records. In a patient survey, 648 women with threatened or confirmed miscarriage returned questionnaires. Active treatment occurred in 134 cases. Only 55%, 50.9% and 47.4% reported being 'informed', 'consented' and 'involved', respectively, with decisions about tissue disposal. In a staff survey, a postal questionnaire was administered to 224 gynaecologists, with 144 replies. Self reported practice as 'seldom' or 'occasional' for sending tissue for histological examination was 34% for surgical evacuation and 57% for medical management. Reporting of 'seldom' or 'occasional' discussion of disposal of tissue with the woman was 42% and 49% for surgical and medical treatment, respectively. CONCLUSIONS: National guidance on these issues was found to be contentious and implementation was variable. Wide consultation with stakeholders is needed prior to the publication of revised guidance.

The impact of guidelines on mild hypertension in pregnancy: time series analysis.

OBJECTIVE: To determine the impact of a national strategy to promote implementation of a guideline on the management of mild, non-proteinuric hypertension in pregnancy. DESIGN: Simple, interrupted time series analysis. SETTING: Four maternity units in Scotland. POPULATION: Women delivering a live or stillborn baby. METHODS: Dissemination of the guideline under the auspices of a national clinical effectiveness programme, supported by a national launch meeting and feedback from a survey of obstetricians highlighting aspects of care that could be improved. MAIN OUTCOME MEASURES: Appropriateness of initial investigation and subsequent clinical management, and costs of guideline development and implementation activities. DATA COLLECTION: Twenty-four months pre-intervention and 12 months post-intervention data were abstracted from a random sample of case notes. RESULTS: Initial investigation was consistent with recommendations for 59.9% out of 1263 women and subsequent clinical management for 67.6% out of 1081 in whom a diagnosis could be made from available data. There were no significant changes in the appropriateness of initial investigation (10.6%; 95% confidence interval [CI] -0.1% to 19.3%; decreasing by 1.2% per month post-implementation, 95% CI -2.5% to 0.1%) or clinical management (-0.3%; 95% CI -8.7% to 11.2%). Guideline development and implementation cost an estimated pound 2784 per maternity unit in Scotland. CONCLUSIONS: Clinical care of mild hypertension in pregnancy remains highly inconsistent. The lack of the intervention effect may be related to the complexity of the guideline recommendations and the nature of the implementation strategy.

Outcomes of pregnancies in women with type 1 diabetes in Scotland: a national population-based study.

OBJECTIVE: To determine the outcomes of pregnancies in women with pre-existing, type 1 diabetes. DESIGN: Prospective, population-based cohort. SETTING: Scotland. POPULATION: All 273 women with type 1 diabetes with a pregnancy ending (in miscarriage, abortion or delivery) during the 12 months (from April 1, 1998 to March 31, 1999). METHODS: Pregnancies identified prospectively by clinicians in each hospital; outcome data collected from case records and from Scottish national data sets. MAIN OUTCOME MEASURES: Perinatal and infant mortality, congenital anomaly and birthweight. RESULTS: Of the 273 pregnancies, 40 (14.7%) ended in miscarriage, 20 (7.3%) in abortion and 213 (78%) in delivery. Three deliveries were twin births, thus 216 babies were born. Stillbirth rate (4/216): 18.5 (95% CI 5.1-46.8) per 1000 total births; perinatal mortality rate (6/216): 27.8 (95% CI 10.2-59.4) per 1000 births. There were 13 verified congenital anomalies (in six abortions and seven live births), anomaly rate: 60 (95% CI 32-101) per 1000 total births. Among 208 singleton, live born infants, the mean birthweight was 3427 g. Standardised birthweight scores, relative to a reference population, showed a unimodal distribution, shifted to the right (mean, 1.57 SD). CONCLUSIONS: In an unselected population, adverse outcomes remain more common among the infants of mothers with type 1 diabetes than in the general population. The targets of the St Vincent Declaration of 1989 have not been met. Improvements may be gained by increases in provision of prepregnancy care and in the proportion of pregnancies that are planned. However, further research is needed to clarify the root causes of adverse outcomes in the pregnancies of women with diabetes.