Evaluating parental perceptions of written handbooks provided during shared decision making with parents anticipating extremely preterm birth

The standard of care in Canada for infants born < 22 weeks gestational age (GA) is palliative care (PC) while for infants > 26 weeks GA, it is early intensive care (EIC). However, between 22 + 0 and 25 + 6 weeks GA, there is a “gray zone” where both PC and EIC are reasonable options. A shared decision-making (SDM) approach for these difficult decisions is recommended. SDM results in informed decisions based on evidence and family values, in the best interests of the infant. We use a parent handbook, which complements the prenatal counseling session. However, parents of extremely preterm infants have not evaluated the current version of our handbook. Our objective was to answer the research question: how do parents of extremely preterm infants perceive a parent handbook provided during the antenatal counseling process? This qualitative, descriptive study was conducted at a Level III center. We recruited a prospective sample of parents, who were facing anticipated birth at extreme prematurity. An in-person interview was conducted within 48 hours, using a semi-structured interview guide. Interviews were transcribed verbatim and analyzed manually, using constant comparative analysis. Timing: The handbook was given following a neonatal consult, which was described as ideal. Ease of use: The handbook was easy to understand, clearly written and straightforward. Layout and format: The appearance was felt to be inconsequential given the situation. All parents preferred a paper copy to an electronic one. Imagery: Reactions to the photos used were varied; some parents felt frightened, while others felt a sense of comfort. Graphs and tables: Parents unanimously expressed appreciation for a visual representation of data. Content: There was criticism regarding missing imperative data and comparison to the tool used during the antenatal counseling session. The parental perceptions of using a handbook on EPI can be divided into 6 main themes: timing, ease of use, layout/format, imagery, graphs/tables and content. Overall, parents felt the handbook was a useful resource for reputable information. They also felt it was a tool which aided in decision-making. Some parents were satisfied with simple information, which helped them feel less overwhelmed, while others felt the depth of information was insufficient.

To explore whether the information content, process and social interaction of the antenatal consultation satisfies the informational needs of women admitted to hospital in preterm and threatened preterm labour. Fifty women with pregnancies of gestational ages of between 25 and 32 weeks were admitted to a tertiary care perinatal referral centre and provided with an antenatal consultation about the medical risks and treatments relative to their potentially premature infant. Within 48 h following the consultation, patients were asked to respond to a questionnaire to assess their recall of the information provided, their information expectations and their anxiety level. The majority of respondents (92%) thought that the antenatal consultation increased their knowledge and understanding of what might happen if their infant was born preterm. Although the mean state anxiety score was high, 78% agreed that the consultation relieved some of their worry and anxiety about their baby. In rank order, respondents wanted information about chances of survival, likely medical problems and the risk for disability, followed by medical treatments and breastfeeding. They consistently recalled receiving information about chances of survival, likely medical problems and medical treatments. Following the antenatal consultation, respondents were generally satisfied with the information provided but remained highly anxious. Recall of the discussion about disability was inconsistent. They reported needing an opportunity to express their feelings, and to talk about their baby and their anticipated interaction with their baby. Recognizing these aspects can help to improve physician-patient communication.

Decision-Making for Extremely Preterm Infants: A Qualitative Systematic Review

امروزه اینترنت در همۀ امور به کار گرفته می شود و هر فردی با توجه به نیاز و توانمندی خود، از آن بهره می برد. این فناوری بر جوانان و دانشجویان و به خصوص، دانشجویان خوابگاهی که احساس غربت و دوری از خانواده را شدیدتر تجربه می کنند، تأثیرگذارتر است. هدف از مطالعۀ حاضر، بررسی تجارب دختران دانشجوی خوابگاهی از اینترنت و سایت های اینترنتی است. این پژوهش به شیوۀ پژوهش کیفی پدیدار شناسی و با استفاده از مصاحبه های عمیق و نیمه ساختار یافته و نمونه گیری مبتنی بر هدف، انجام شده است. افراد مورد مصاحبه، دیدگاه ها و تجارب خود را پیرامون اینترنت و محتوای سایت هایی که بازدید می شود، به بحث گذاشتند. مکالمات ضبط و سپس دست نویسی شد و با استفاده از روش درون مایه ای براون و کلارک تجزیه و تحلیل شد. طی این پژوهش، پنج درون مایۀ اصلی که هرکدام حاوی تعدادی درون مایۀ فرعی هستند، استخراج شد. درون مایه ها عبارت اند از: دلایل کارآمدی، عوامل ترغیب کننده، سواد اطلاعاتی، پیامد، محدودیت ها. نتایج این پژوهش می تواند برای خود فرد، خانواده ها و مسؤولین سودمند باشد. مسألۀ مهم در این پژوهش، لزوم آموزش دانشجویان جهت آشنایی با جنبه های کاربردی مثبت و همچنین، پیامدهای منفی اینترنت برای گزینش آگاهانۀ منابع و اطلاعات، است.

Aim: Evidence on effective communication in antenatal consultations between midwives and pregnant women is lacking. In a study, antenatal consultations implementation outcomes were evaluated. From the data, relevant aspects emerged concerning communication during consultations. This paper presents selected results and proposes a theoretical foundation for antenatal consultations. Design: A qualitative design. Methods: Semi-structured interviews were conducted with ten midwives, eight pregnant women, eight managers, and eight physicians in two hospitals. The interviews were audiotaped, transcribed, and analyzed with framework analysis using the following steps: 1) Familiarization; 2) Coding: first, inductive coding (open coding to identify new themes), followed by deductive coding (by theory-predefined codes); 3) Development and application of an analytic framework; 4) Data-charting in a matrix; and 5) Interpretation. Results: Amongst others, the following findings emerged from the data: communication about childbirth is influenced by the perceptions and conceptions of the midwife and the pregnant woman herself; pregnant women&#8217;s degree of participation in the consultation process depends to a significant extent on the attitude of the midwife. Conclusion: To assure the success of consultations, we propose a consultation model comprising the following elements: the life world of the woman and midwife, the construction of a social reality, and the mediation of mutual goals, expectations, intentions, wishes, and beliefs.

Critical decisions regarding infants at risk of being born at the limits of viability are primarily discussed during the antenatal consultation with a Neonatologist. These decisions are emotionally unthinkable; choosing between intensive care to support survival or palliative care. One the one hand, we don't know whether the baby will survive, and if it survives, will the baby be significantly handicapped; on the other hand, certain death. Each participant of the antenatal consultation, the parents and the neonatologist, carry their own values to define the best interest of the infant that will support the final decision. Even though shared decision-making is promoted by professional societies, the parents might not participate as they expect. Moreover, the neonatologist might inaccurately estimate the parents desire to participate or limit the parents' authority to make decision. In those circumstances, open communication between the parents and the neonatologist is essential. However, the most effective strategies for communication and encouragement of parent participation are unknown. The goals of this study are to explore the communication between the parents and the neonatologist and to describe the factors that promote parent satisfaction in their participation in the decision-making process. We conducted a qualitative study based on ethno-methodology to analyze videotapes of the interactions between parents and neonatologists during the antenatal consultation. Post-antenatal consultation interviews were used to define parent satisfaction scores for their participation during interaction. Five system – infant at risk including 10 parents and six neonatologists participated in the study. Results highlight key factors such as sharing ‘weighted’ information, offering choices, allowing time to think and building trustworthy parent-doctor relationships through communication promote the opportunity for parents to participate. Important communication behaviours including empathy, support and listening, taking turns as “expert” facilitate parent participation in the decision making process. The key factors were integrated in a model to facilitate parents' participation in the decision making to their satisfaction (Figure). From this model we identified specific communication strategies examples useful to the neonatologist that will support parents in their participation in a true shared decision-making process

To assess the impact on maternal anxiety of a multidisciplinary approach in prenatal management of fetal surgical anomalies. A case-control study was undertaken: Group A (cases) consisted of 16 couples receiving a prenatal multidisciplinary counselling, Group B (controls) was represented by 16 couples, who received diagnosis of the fetal anomaly and the relevant counselling by an obstetrician only. The fetuses were affected by the following gastrointestinal anomalies: gastroschisis, omphalocele, intestinal atresia. The Italian version of the Spielberger State-Trait Anxiety Inventory was utilized to assess maternal anxiety. In Group A maternal anxiety level was assessed after the first antenatal counselling and at birth, whereas in Group B only at birth. At birth, Group A presented STAI-S scores significantly lower than after the first antenatal consultation with the team (Mean +/- SD = 39.87 +/- 6.46 versus 68.93 +/- 5.81; p < 0.01). At the end of the first day spent with the baby in the Neonatal Surgery Unit, Group A presented STAI-S scores significantly lower than Group B (Mean +/- SD = 39.87 +/- 6.46 versus 70.62 +/- 4.12; p < 0.01). This study provides evidence of the positive impact on maternal anxiety of a multidisciplinary approach in prenatal management of fetal surgical anomalies.

To evaluate the impact of the meningococcal A (MenA) vaccine introduction in Mali through mass campaigns on the routine immunization program and the wider health system. We used a mixed-methods case-study design, combining semi-structured interviews with 31 key informants, a survey among 18 health facilities, and analysis of routine health facility data on number of routine vaccinations and antenatal consultations before, during, and after the MenA vaccine campaign in December 2010. Survey and interview data were collected at the national level and in 2 regions in July and August 2011, with additional interviews in January 2012. Many health system functions were not affected-either positively or negatively-by the MenA vaccine introduction. The majority of effects were felt on the immunization program. Benefits included strengthened communication and social mobilization, surveillance, and provider skills. Drawbacks included the interruption of routine vaccination services in the majority of health facilities surveyed (67%). The average daily number of children receiving routine vaccinations was 79% to 87% lower during the 10-day campaign period than during other periods of the month. Antenatal care consultations were also reduced during the campaign period by 10% to 15%. Key informants argued that, with an average of 14 campaigns per year, mass campaigns would have a substantial cumulative negative effect on routine health services. Many also argued that the MenA campaign missed potential opportunities for health systems strengthening because integration with other health services was lacking. The MenA vaccine introduction interrupted routine vaccination and other health services. When introducing a new vaccine through a campaign, coverage of routine health services should be monitored alongside campaign vaccine coverage to highlight where and how long services are disrupted and to mitigate risks to routine services.

Care practices during neonatal transition can significantly impact both short- and long-term neonatal outcomes. The Evidence-based Practice for Improving Quality (EPIQ) II study was initiated in 2009 with the goal of improving neonatal outcomes (results in CMAJ 2014, 186:E485–94). As part of the study, the EPIQ Golden Hour Committee focused on transitional care (TC) practices in the first hour after birth, including use of the 2010 NRP recommendations for immediate management of preterm infants. Determine the current management practices during the Golden Hour for infants of <32 weeks GA in Canadian NICUs. A survey was emailed to all EPIQ II site investigators and/or co-ordinators in August 2014 with two monthly reminders. The survey included questions on unit characteristics, antenatal management, composition of the TC team, and management in the first hour after birth. The responses to the questions were categorized into four GA groups: 230/7–236/7 wks, 240/7–256/7 wks, 260/7–276/7 wks, and 280/7–316/7 wks. Of the 23 EPIQ II NICUs that were perinatal centers, 13 (56%) completed the survey. Eight sites had >15 level III NICU beds. Antenatal counseling was provided >75% of the time by 92% and 77% of units for GA <28 and 28 to 316/7 wks, respectively. A neonatal fellow or neonatologist/paediatrican was mostly responsible for counseling. 92% did not have a structured template for counseling although one-half used decision aids. The TC team consisted of three or more individuals for stabilization of infants of <28 wks GA and neonatologists were present in 92% of the units, this varied according to the time of the day. 77% of units practiced DCC, 100% used thermal wrap to maintain temperature, the initial FiO2 ranged from 21–40%, and 100% followed the NRP recommended oxygen saturation guide. In spontaneously breathing infants, CPAP was the initial mode of ventilatory support. Prophylactic surfactant was administered by 31% of units for <26 wk GA infants. Infants of <24 wks GA were most likely to be intubated and ventilated. Umbilical venous and arterial catheters were used by 92% for infants of 24 wks GA. Most units did not measure sound levels or offer skin-to-skin contact in the delivery room. Most Canadian NICUs practice NRP recommendations for preterm infants. DCC, thermal wrap, non-invasive ventilation, and FiO2 of <40% are used during the first hour after birth.

BackgroundIn this study, we assessed the communication strategies used by neonatologists in antenatal consultations which may influence decision-making when determining whether to provide resuscitation or comfort measures only in the care of periviable neonates.MethodsThis study employed a qualitative study design using inductive thematic discourse analysis of ‘naturally occurring data’ in the form of antenatal conversations around resuscitation decisions at the grey zone of viability. The study occurred between February 2017 and June 2018 on a labor and delivery unit within a large Midwestern tertiary care hospital. Participants included 25 mothers who were admitted to the study hospital with anticipated delivery in the grey zone of viability and practicing neonatologists or neonatology fellows who partnered in antenatal consultation. We used a two-stage inductive analytic process to focus on how neonatologists’ discourses constructed SDM in antenatal consultations. First, we used a thematic discourse analysis to interpret the recurring patterns of meaning within the transcribed antenatal consultations, and second, we theorized the subsequent effects of these discourses on shaping the context of SDM in antenatal encounters.ResultsIn this qualitative study, that included discourse analysis of real-time audio conversations in 25 antenatal consults, neonatologists used language that creates projected autonomy through (i) descriptions of fetal physiology (ii) development of the fetus’s presence, and (iii) fetal role in decision-making.ConclusionDiscourse analysis of real-time audio conversations in antenatal consultations was revelatory of how various discursive patterns brought the fetus into decision-making, thus changing who is considered the key actor in SDM.

Background Understanding potential barriers to implementation of public health policy is important to ensure well-informed decisions, and stakeholders play critical roles in implementation. Stakeholder analysis is expected to shed light on Ghana’s progress with the implementation of the National Action Plan on Antimicrobial Resistance since the completion of the Global Health Security Agenda’s Joint External Evaluation. The outcome of stakeholder analysis can improve understanding of their roles and institutional capacity to promote prudent use of antibiotics in populations at the community level. Methods Eight semi-structured in-depth interviews were conducted with participants of the Joint External Evaluation process, including personnel from the policy, research, and practice programs in Ghana’s public health sector. In-person interviews were conducted between September and October 2018 in the Greater Accra and Upper West regions. Results The analysis revealed four main themes: national burden of disease and antibiotic resistance, policy development, implementation barriers, and strategies. Ghana’s national antimicrobial policy and action plans to enhance public education and awareness align with the objectives of the Global Action Plan on Antimicrobial Resistance. All respondents expressed concern about the increasing proliferation of antibiotic-resistant bacteria, which they attribute in part to the inappropriate use of antibiotics in local communities. Although Ghana has laws to regulate the sale of antibiotics, enforcement has been a major challenge. Inadequate funding for monitoring compliance comprises the greatest challenge. Stakeholders also acknowledged the importance of strengthening cross-sectoral collaboration, and the need to leverage resources from the animal and environmental sectors through a One Health approach to ensure successful implementation of the national action plan. Conclusions This study identified several opportunities for effective implementation of the Ghana’s National Action Plan on Antimicrobial Resistance. Stakeholders were enthusiastic about the effectiveness of the One Health approach, and there is strong political will to promote multisectoral partnership to advance implementation efforts.

BackgroundInformal carers play an increasingly vital role in supporting the older population and the sustainability of health care systems. Care Companion is a theory-based and coproduced Web-based intervention to help support informal carers’ resilience. It aims to provide personalized access to information and resources that are responsive to individuals’ caring needs and responsibilities and thereby reduce the burdens associated with caregiving roles. Following the development of a prototype, it was necessary to undertake user acceptability testing to assess its suitability for wider implementation.ObjectiveThis study aimed to undertake user acceptance testing to investigate the perceived usefulness and ease of use of Care Companion. The key objectives were to (1) explore how potential and actual users perceived its usefulness, (2) explore the barriers and facilitators to its uptake and use and (3) gather suggestions to inform plans for an area-wide implementation.MethodsWe conducted user acceptance testing underpinned by principles of rapid appraisal using a qualitative descriptive approach. Focus groups, observations, and semistructured interviews were used in two phases of data collection. Participants were adult carers who were recruited through local support groups. Within the first phase, think-aloud interviews and observations were undertaken while the carers familiarized themselves with and navigated through the platform. In the second phase, focus group discussions were undertaken. Interested participants were then invited to trial Care Companion for up to 4 weeks and were followed up through semistructured telephone interviews exploring their experiences of using the platform. Thematic analysis was applied to the data, and a coding framework was developed iteratively with each phase of the study, informing subsequent phases of data collection and analysis.ResultsOverall, Care Companion was perceived to be a useful tool to support caregiving activities. The key themes were related to its appearance and ease of use, the profile setup and log-in process, concerns related to the safety and confidentiality of personal information, potential barriers to use and uptake and suggestions for overcoming them, and suggestions for improving Care Companion. More specifically, these related to the need for personalized resources aimed specifically at the carers (instead of care recipients), the benefits of incorporating a Web-based journal, the importance of providing transparency about security and data usage, minimizing barriers to initial registration, offering demonstrations to support uptake by people with low technological literacy, and the need to develop a culturally sensitive approach.ConclusionsThe findings identified ways of improving the ease of use and usefulness of Care Companion and demonstrated the importance of undertaking detailed user acceptance testing when developing an intervention for a diverse population, such as informal carers of older people. These findings have informed the further refinement of Care Companion and the strategy for its full implementation.

Background Telehealth has gained popularity, particularly in the COVID-19 era. The use of telehealth is now being applied to preoperative evaluation clinics in an effort to overcome barriers to antenatal anesthesia assessment of high-risk obstetrical patients. Objectives The objective of this study is to determine if the quality of antenatal anesthesia telehealth consults of high-risk obstetric patients is comparable to in-person encounters. This is determined by assessing if telehealth consults are feasible and meet the standards of care, as well as the level of patient satisfaction and ease of use as reported by providers. Study design This retrospective study assessed patients prior to delivery who completed a video-telehealth anesthesia consultation (51 cases) from November 1st, 2019 to November 30th, 2020 and all of those for patients receiving an in-person anesthesia consultation (171 controls) from November 2017 through October 2019. Our primary hypothesis was that telehealth and in-person consultations would not result in different standards of care. The primary outcome was an indicator of meeting the standard of care, and the difference in proportions between the telehealth and in-person consultation was tested by Fisher's exact test. Our secondary hypotheses were that patients reported high levels of satisfaction and could use telehealth easily and providers could use the platform easily. Secondary outcomes were assessed by using the Consultation and Relational Empathy (CARE) and the Telehealth Usability Questionnaire (TUQ) surveys, respectively. Results For the primary outcome, 94.1% (48/51) of telehealth and 89.5% (153/171) of in-person visits met the standard of care, indicating no significant difference between groups (p-value = .4204). The CARE score was 46 [41,50] {median [interquartile range]}, (p-value < .0001), indicating patient satisfaction with telehealth. The use-average scores on the TUQ for the patient and provider were 6.67 [6.33, 7] and 6 [5.33, 7] respectively, indicating great system usability. Conclusion This study demonstrates no significant difference in the standard of care between in-person and telehealth visits. Furthermore, telehealth consultation was feasible and associated with high patient satisfaction and platform usability. Preoperative consultation of high-risk obstetric patients using telehealth visits should be routinely considered in clinical practice. Condensation: There is no significant difference in the standard of care between in-person and telehealth antenatal anesthesia consultations, and patients report high satisfaction and platform usability. Telehealth is gaining popularity, but its role in antenatal anesthesia consultation of high risk obstetrical patients has not yet been defined with respect to standard of care, patient satisfaction, and platform usability. There was no significant difference in standard of care between in-person and telehealth antenatal anesthesia consultations, and patients reported high satisfaction and platform usability. Telehealth should be considered as an alternative to in-person antenatal anesthesia consultation of high risk obstetrical patients. It is a particularly attractive alternative to in-person consultation due to cost-savings, increased patient accessibility, and ease of use.

Aims: to assess the nutritional knowledge of pregnant women attending antenatal consultation at Wamy health center of the health district of Tillabéri. Study Design: This is a cross-sectional study. Place and Duration of Study: Wamy Health Center, Health District of Tillabéri, Niger republic, from August to September 2022. Methodology: We randomly selected 60 pregnant women admitted for antenatal consultation. Semi-structured questionnaire that was developed for the purpose have permitted to collect information concerning the sociodemographic characteristics and nutrition knowledge of admitted pregnant women. Results: The results showed that majority of the mothers (96.7%) were unaware of the nutritional requirements during pregnancy which include knowledge about food sources of macronutrients and micronutrients. Most of them were recorded to be aware of the benefits of maternal diets during pregnancy (85%) and on the growth and development of fetus (80%). Conclusion: Findings highlight the knowledge gap on nutrition that exists in antenatal mothers attending Wamy health center of the health district of Tillabéri. Therefore, nutrition advice as an integral part of the antenatal nutritional counseling should be reinforced and intensified within the maternity unit of the health center in order to effectively address this issue.

To assess whether antenatal decisions regarding the neonatal care at birth for extremely preterm infants are more likely to be made when using shared decision-making (SDM)-style consultations compared to standard consultations. In 2015, we implemented a clinical practice guideline promoting SDM use within antenatal consultations in our single-centre university-based perinatal unit. We conducted a prospective cohort study with a retrospective chart review based on data collected from all pregnant women presenting to obstetrical triage between 22 + 0 and 25 + 6 weeks gestation between September 2015 and June 2018. Two-hundred-and-seventeen cases presented; 137 received antenatal consultations with 82 (60%) being SDM-style. Decisions were frequently made (88%; 120/137) after the consultations, with no significant difference between consultation style (RR 1.08, 95% CI [0.95-1.26], p = 0.28). The provision of either an SDM-style or a standard antenatal consultation seemed to comparably facilitate the reaching of a care decision.