Search

Background: Pregnant women who have previously had a caesarean birth and who have no contraindication for vaginal birth after caesarean (VBAC) may need to decide whether to choose between a repeat caesarean birth or to commence labour with the intention of achieving a VBAC. Women need information about their options and interventions designed to support decision-making may be helpful. Decision support interventions can be implemented independently, or shared with health professionals during clinical encounters or used in mediated social encounters with others, such as telephone decision coaching services. Decision support interventions can include decision aids, one-on-one counselling, group information or support sessions and decision protocols or algorithms. This review considers any decision support intervention for pregnant women making birth choices after a previous caesarean birth., Objectives: To examine the effectiveness of interventions to support decision-making about vaginal birth after a caesarean birth.Secondary objectives are to identify issues related to the acceptability of any interventions to parents and the feasibility of their implementation., Search Methods: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 June 2013), Current Controlled Trials (22 July 2013), the WHO International Clinical Trials Registry Platform Search Portal (ICTRP) (22 July 2013) and reference lists of retrieved articles. We also conducted citation searches of included studies to identify possible concurrent qualitative studies., Selection Criteria: All published, unpublished, and ongoing randomised controlled trials (RCTs) and quasi-randomised trials with reported data of any intervention designed to support pregnant women who have previously had a caesarean birth make decisions about their options for birth. Studies using a cluster-randomised design were eligible for inclusion but none were identified. Studies using a cross-over design were not eligible for inclusion. Studies published in abstract form only would have been eligible for inclusion if data were able to be extracted., Data Collection and Analysis: Two review authors independently applied the selection criteria and carried out data extraction and quality assessment of studies. Data were checked for accuracy. We contacted authors of included trials for additional information. All included interventions were classified as independent, shared or mediated decision supports. Consensus was obtained for classifications. Verification of the final list of included studies was undertaken by three review authors., Main Results: Three randomised controlled trials involving 2270 women from high-income countries were eligible for inclusion in the review. Outcomes were reported for 1280 infants in one study. The interventions assessed in the trials were designed to be used either independently by women or mediated through the involvement of independent support. No studies looked at shared decision supports, that is, interventions designed to facilitate shared decision-making with health professionals during clinical encounters.We found no difference in planned mode of birth: VBAC (risk ratio (RR) 1.03, 95% confidence interval (CI) 0.97 to 1.10; I² = 0%) or caesarean birth (RR 0.96, 95% CI 0.84 to 1.10; I² = 0%). The proportion of women unsure about preference did not change (RR 0.87, 95% CI 0.62 to 1.20; I² = 0%).There was no difference in adverse outcomes reported between intervention and control groups (one trial, 1275 women/1280 babies): permanent (RR 0.66, 95% CI 0.32 to 1.36); severe (RR 1.02, 95% CI 0.77 to 1.36); unclear (0.66, 95% CI 0.27, 1.61). Overall, 64.8% of those indicating preference for VBAC achieved it, while 97.1% of those planning caesarean birth achieved this mode of birth. We found no difference in the proportion of women achieving congruence between preferred and actual mode of birth (RR 1.02, 95% CI 0.96 to 1.07) (three trials, 1921 women).More women had caesarean births (57.3%), including 535 women where it was unplanned (42.6% all caesarean deliveries and 24.4% all births). We found no difference in actual mode of birth between groups, (average RR 0.97, 95% CI 0.89 to 1.06) (three trials, 2190 women).Decisional conflict about preferred mode of birth was lower (less uncertainty) for women with decisional support (standardised mean difference (SMD) -0.25, 95% CI -0.47 to -0.02; two trials, 787 women; I² = 48%). There was also a significant increase in knowledge among women with decision support compared with those in the control group (SMD 0.74, 95% CI 0.46 to 1.03; two trials, 787 women; I² = 65%). However, there was considerable heterogeneity between the two studies contributing to this outcome ( I² = 65%) and attrition was greater than 15 per cent and the evidence for this outcome is considered to be moderate quality only. There was no difference in satisfaction between women with decision support and those without it (SMD 0.06, 95% CI -0.09 to 0.20; two trials, 797 women; I² = 0%). No study assessed decisional regret or whether women's information needs were met.Qualitative data gathered in interviews with women and health professionals provided information about acceptability of the decision support and its feasibility of implementation. While women liked the decision support there was concern among health professionals about their impact on their time and workload., Authors' Conclusions: Evidence is limited to independent and mediated decision supports. Research is needed on shared decision support interventions for women considering mode of birth in a pregnancy after a caesarean birth to use with their care providers.

Background: Childhood vaccination (also described as immunisation) is an important and effective way to reduce childhood illness and death. However, there are many children who do not receive the recommended vaccines because their parents do not know why vaccination is important, do not understand how, where or when to get their children vaccinated, disagree with vaccination as a public health measure, or have concerns about vaccine safety.Face to face interventions to inform or educate parents about routine childhood vaccination may improve vaccination rates and parental knowledge or understanding of vaccination. Such interventions may describe or explain the practical and logistical factors associated with vaccination, and enable parents to understand the meaning and relevance of vaccination for their family or community., Objectives: To assess the effects of face to face interventions for informing or educating parents about early childhood vaccination on immunisation uptake and parental knowledge., Search Methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 7); MEDLINE (OvidSP) (1946 to July 2012); EMBASE + Embase Classic (OvidSP) (1947 to July 2012); CINAHL (EbscoHOST) (1981 to July 2012); PsycINFO (OvidSP) (1806 to July 2012); Global Health (CAB) (1910 to July 2012); Global Health Library (WHO) (searched July 2012); Google Scholar (searched September 2012), ISI Web of Science (searched September 2012) and reference lists of relevant articles. We searched for ongoing trials in The International Clinical Trials Registry Platform (ICTRP) (searched August 2012) and for grey literature in The Grey Literature Report and OpenGrey (searched August 2012). We also contacted authors of included studies and experts in the field. There were no language or date restrictions., Selection Criteria: Randomised controlled trials (RCTs) and cluster RCTs evaluating the effects of face to face interventions delivered to individual parents or groups of parents to inform or educate about early childhood vaccination, compared with control or with another face to face intervention. Early childhood vaccines are all recommended routine childhood vaccines outlined by the World Health Organization, with the exception of human papillomavirus vaccine (HPV) which is delivered to adolescents., Data Collection and Analysis: Two authors independently reviewed database search results for inclusion. Grey literature searches were conducted and reviewed by a single author. Two authors independently extracted data and assessed the risk of bias of included studies. We contacted study authors for additional information., Main Results: We included six RCTs and one cluster RCT involving a total of 2978 participants. Three studies were conducted in low- or middle-income countries and four were conducted in high-income countries. The cluster RCT did not contribute usable data to the review. The interventions comprised a mix of single-session and multi-session strategies. The quality of the evidence for each outcome was low to very low and the studies were at moderate risk of bias overall. All these trials compared face to face interventions directed to individual parents with control.The three studies assessing the effect of a single-session intervention on immunisation status could not be pooled due to high heterogeneity. The overall result is uncertain because the individual study results ranged from no evidence of effect to a significant increase in immunisation.Two studies assessed the effect of a multi-session intervention on immunisation status. These studies were also not pooled due to heterogeneity and the result was very uncertain, ranging from a non-significant decrease in immunisation to no evidence of effect.The two studies assessing the effect of a face to face intervention on knowledge or understanding of vaccination were very uncertain and were not pooled as data from one study were skewed. However, neither study showed evidence of an effect on knowledge scores in the intervention group. Only one study measured the cost of a case management intervention. The estimated additional cost per fully immunised child for the intervention was approximately eight times higher than usual care.The review also considered the following secondary outcomes: intention to vaccinate child, parent experience of intervention, and adverse effects. No adverse effects related to the intervention were measured by any of the included studies, and there were no data on the other outcomes of interest., Authors' Conclusions: The limited evidence available is low quality and suggests that face to face interventions to inform or educate parents about childhood vaccination have little to no impact on immunisation status, or knowledge or understanding of vaccination. There is insufficient evidence to comment on the cost of implementing the intervention, parent intention to vaccinate, parent experience of the intervention, or adverse effects. Given the apparently limited effect of such interventions, it may be feasible and appropriate to incorporate communication about vaccination into a healthcare encounter, rather than conduct it as a separate activity.

Aim: To examine the general practitioner (GP) consultation patterns for primary health-care services provided in residential aged care facilities (RACFs) by consultation type., Method: Analyses of service provision and RACF population data for the period 1998-2011. All Medicare-subsidised services provided by GPs across Australia in RACFs were included and categorised by consultation type and by time of service delivery (business or after-hours)., Results: Overall service delivery increased from 12 118 per 1000 residents in financial year (FY) 1998-99 to 17 079 per 1000 residents in FY2010-11, a 41% increase. Since FY2007-08, the rate of brief consultations has grown by an average of 20% each year. Delivery of after-hours consultations also increased., Conclusions: The pattern of GP services provided in RACFs has changed substantially over time. To some extent these changes reflect regulatory adjustments; however, the pattern is at odds with the ever-increasing dependence levels of residents., (© 2012 The Authors. Australasian Journal on Ageing © 2012 ACOTA.)

Background: Stillbirth remains one of the least understood areas of infant death and accurate data on the causes of stillbirth are the cornerstone of stillbirth prevention. An autopsy examination remains the gold standard post-mortem investigation for stillbirth. However, decisions about post-mortem investigations, particularly autopsy are difficult. The purpose of this review is to examine the effectiveness of methods to help parents who have experienced a stillbirth decide whether to have post-mortem investigations, including whether to have an autopsy performed., Objectives: The primary objectives were a) to examine the effectiveness of interventions to support parents' decisions about autopsy consent after a stillbirth on outcomes for parents, and b) to determine autopsy rates. Secondary objectives were to identify issues related to the acceptability of any interventions to parents and the feasibility of their implementation., Search Methods: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (29 October 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 10), MEDLINE (1966 to 24 July 2012) and EMBASE (1980 to 24 July 2012), Current Controlled Trials metaRegister (mRCT) (18 September 2012) and the WHO International Clinical Trials Registry Platform Search Portal (ICTRP) (18 September 2012). We also searched the websites of the Stillbirth and Neonatal Death Charity (SANDS) and International Stillbirth Alliance (ISA) (18 September 2012) and then subsequently searched the websites of all the ISA member organisations., Selection Criteria: Randomised controlled trials (RCTs) of interventions designed specifically to support parents who have experienced a stillbirth make decisions about their options for post-mortem investigations including all investigations after stillbirth compared with usual care., Data Collection and Analysis: Two review authors independently screened citations against the selection criteria. , Main Results: No studies meeting the review inclusion criteria were identified. A search of 40 websites associated with supporting parents who experience stillbirth also found little reference to, or information about autopsy or other post-mortem examinations., Authors' Conclusions: Support for parents making decisions about autopsy or other post-mortem examinations after stillbirth must rely on the ad hoc knowledge and experience of those involved at the time.

This paper examines the value of facilitated telephone and online support groups for palliative care. Telephone interviews were conducted with twenty people living with advanced cancer who had participated in either a telephone or online support group facilitated by the Cancer Council Victoria, Melbourne, Australia. Two dominant participant narratives emerged: a focus on dying with dignity or an interest in deferring discussion of death and dying to focus on the present. Despite the different approaches, participants found the technology-based support groups to be accessible and safe environments in which to discuss difficult topics in privacy. Technology-based strategies provide opportunities for health professionals to provide social and emotional care to more people by moving beyond individualised care and facilitate peer-to-peer support at the end of life, especially to those with specific needs. Such options are feasible for palliative care services to set up and acceptable to a group of clients, especially for younger clients or those socially or geographically isolated.

Objective: To determine changes in the pattern of use of standard general practice consultations, and the degree to which any changes are offset by the use of special Medicare Benefits Schedule (MBS) items., Design, Participants and Setting: Population-based retrospective analysis of age- and sex-standardised Medicare claims data (1994-2009) on the utilisation of general practice standard consultations (Levels A, B, C and D) alone and in combination with health assessments and care plans and other special MBS items., Results: Utilisation rates of Level C and D (long) consultations increased consistently from 1994 to 2004, but by 2009 a considerable decline had occurred. A reverse of this pattern was observed for Level A (short) consultations. When utilisation rates for special items and long consultations were combined, the combined utilisation rate followed an upward trend until 2007, but also declined in 2008 and 2009., Conclusions: The decline in the use of Level C and D consultations in recent years has been dramatic and accompanied by an increase in use of Level A consultations. While the use of special items has offset the decline in long consultations, this compensating effect has weakened in the past 2 years. This pattern is at odds with health policy objectives that rely on long consultations to provide preventive care and chronic disease management. Given the current situation, the recently introduced Medicare reforms (May 2010), including changes to Levels B, C and D consultation item descriptors, may not be sufficient to change consultation patterns.

Health decisions involve sharing information and making choices-even if the choice is to leave the decision to others. The way that information is delivered and understood by consumers across their cancer journey in turn influences the health decisions they take. A public health approach to the cancer journey considers the information needs of individuals and the structures and systems that facilitate the provision of credible and timely information. This paper examines emerging research that takes a public health approach to promote information-sharing and health decisions, identifies information-sharing mechanisms used by providers to facilitate shared decisions and evaluates decision support processes designed to improve information-sharing and self-care events. Evidence is presented to guide future research directions.

Background: When a woman has had a previous caesarean birth, there are two options for her care in a subsequent pregnancy: planned elective repeat caesarean or planned vaginal birth. While there are risks and benefits for both planned elective repeat caesarean birth and planned vaginal birth after caesarean, current sources of information are limited to non-randomised cohort studies. Studies designed in this way have significant potential for bias and consequently conclusions based on these results are limited in their reliability and should be interpreted with caution., Objectives: To assess, using the best available evidence, the benefits and harms of a policy of planned elective repeat caesarean section with a policy of planned vaginal birth after caesarean section for women with a previous caesarean birth., Search Strategy: We searched the Cochrane Pregnancy and Childbirth Group trials register (24 June 2004), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 1, 2004), and PubMed (1966 to 24 June 2004)., Selection Criteria: Randomised controlled trials with reported data that compared outcomes in mothers and babies who planned a repeat elective caesarean section with outcomes in women who planned a vaginal birth, where a previous birth had been by caesarean., Data Collection and Analysis: Two reviewers independently assessed trial quality and extracted data., Main Results: There were no randomised controlled trials identified., Reviewers' Conclusions: Planned elective repeat caesarean section and planned vaginal birth after caesarean section for women with a prior caesarean birth are both associated with benefits and harms. Evidence for these care practices is drawn from non-randomised studies, associated with potential bias. Any results and conclusions must therefore be interpreted with caution. Randomised controlled trials are required to provide the most reliable evidence regarding the benefits and harms of both planned elective repeat caesarean section and planned vaginal birth for women with a previous caesarean birth.

Background: Information is routinely given to pregnant women, but information about caesarean birth may be inadequate., Objectives: To examine the effectiveness of information about caesarean birth., Search Strategy: We searched the Cochrane Pregnancy and Childbirth register, CENTRAL (26 November 2002), MEDLINE [online via PubMed 1966-] and the Web of Science citation database [1995-] (20 September 2002), and reference lists of relevant articles., Selection Criteria: Randomised controlled trials, non-randomised clinical trials and controlled before-and-after studies of information given to pregnant women about caesarean birth., Data Collection and Analysis: Two reviewers independently assessed trial quality and extracted data. Missing and further data were sought from trial authors unsuccessfully. Analyses were based on 'intention to treat'. Relative risk and confidence intervals were calculated and reported. Consumer reviewers commented on adequacy of information reported in each study., Main Results: Two randomised controlled trials involving 1451 women met the inclusion criteria. Both studies aimed to reduce caesarean births by encouraging women to attempt vaginal delivery. One used a program of prenatal education and support, and the other cognitive therapy to reduce fear. Results were not combined because of differences in the study populations. Non-clinical outcomes were ascertained in both studies through questionnaires, but were subject to rates of loss to follow-up exceeding 10%.A number of important outcomes cannot be reported: knowledge or understanding; decisional conflict; and women's perceptions: of their ability to discuss care with clinicians or family/friends, of whether information needs were met, and of satisfaction with decision-making. Neither study assessed women's perception of participation in decision-making about caesarean birth, but Fraser 1997, who examined the effect of study participation on decision making, found that women in the intervention group were more likely to consider that attempting vaginal birth was easier (51% compared to 28% in control group), or more difficult (10% compared to 6%). These results could be affected by the attrition rate of 11%, and are possibly subject to bias. Neither intervention used in these trials made any difference to clinical outcomes. About 70% or more women attempted vaginal delivery in both trials, yet caesarean delivery rates exceeded 40%, at least 10% higher than was hoped. There was no significant difference between control and intervention groups for any of the outcomes measured: vaginal birth, elective/scheduled caesarean, and attempted vaginal delivery. Outcome data, although similar for both groups, were not sufficient to compare maternal and neonatal morbidity or neonatal mortality. There was no difference in the psychological outcomes for the intervention and control groups reported by either of the included trials. Consumer reviewers said information for women considering a vaginal birth after caesarean (VBAC) should include: risks of VBAC and elective caesarean; warning signs in labour; philosophy and policies of hospital and staff; strategies to improve chances of success; and information about probability of success with specific care givers., Reviewer's Conclusions: Research has focussed on encouraging women to attempt vaginal delivery. Trials of interventions to encourage women to attempt vaginal birth showed no effect, but shortcomings in study design mean that the evidence is inconclusive. Further research on this topic is urgently needed.