Methods for combining ancillary data in stochastic compartment models of cancer mortality: Generalization of heterogeneity models∗

In analyzing mortality data there may be available information from survey and other sources that describe the marginal distribution of risk factors. We present a mortality model where nationally representative survey data on risk factor distributions are combined with data on cohort mortality rates to increase information, i.e., a fixed marginal risk factor distribution is combined with a cohort model representing unobserved individual risk heterogeneity. The model is applied to lung cancer mortality in nine U.S. white male cohorts aged 30 to 70 in 1950 and followed 38 years. Estimates of the cohort specific proportions of smokers were made from the National Health Interview Survey. Comparisons are made for models with different patterns of changes with age of individual heterogeneity.     

A dynamic multistate model of robustness and frailty

Dynamic multistate models can show realistic population dynamics over time, model complex cycles, and encompass the life history of a cohort. This paper uses a recently developed approach to obtain the analytic solution of a time‐dependent multidimensional differential equation. The illustrative robust/frail model presented shows that the assumption of fixed individual frailty can be abandoned in a two living state model that allows transitions between health statuses and nonproportional hazards of death.     

Understanding pathways leading to stillbirth: The role of care-seeking and care received during pregnancy and childbirth in Kabul province,Afghanistan

BackgroundThe underlying pathways leading to stillbirth in low- and middle-income countries are not well understood. Context-specific understanding of how and why stillbirths occur is needed to prioritise interventions and identify barriers to their effective implementation and uptake.AimTo explore the contribution of contextual, individual, household-level and health system factors to stillbirth in Afghanistan.MethodsUsing a qualitative approach, we conducted semi-structured in-depth interviews with women and men that experienced stillbirth, female elders, community health workers, healthcare providers, and government officials in Kabul province, Afghanistan between October-November 2017. We used thematic analysis to identify contributing factors and developed a conceptual map describing possible pathways to stillbirth.FindingsWe found that low utilisation and access to healthcare was a key contributing factor, as were unmanaged conditions in pregnancy that increased women’s risk of complications and stillbirth. Sociocultural factors related to the treatment of women and perceptions about medical interventions deprived women of interventions that could potentially prevent stillbirth. The quality of care from public and private providers during pregnancy and childbirth was a recurring concern exacerbated by health system constraints that led to unnecessary delays; while environmental factors linked to the ongoing conflict were also perceived to contribute to stillbirth. These pathways were underscored by social, cultural, economic factors and individual perceptions that contributed to the three-delays.DiscussionEfforts are needed at the community-level to facilitate care-seeking and raise awareness of stillbirth risk factors and the facility-level to strengthen antenatal and childbirth care quality, ensure culturally appropriate and respectful care, and reduce treatment delays.     

The multistate life table with duration‐dependence

A method for generalizing the multistate, or increment‐decrement, life table to include rates which depend upon duration of exposure to risk, as well as upon age, is proposed. The method is built upon the linear approximation, called the linear integration hypothesis, developed mainly by Rogers and his colleagues. Although the use of rates indexed by duration categories leads to a substantial increase in the state space of the model, it is possible to arrange the rates in such a way that matrices to be inverted are no larger than those encountered in the usual multistate life table. In the more general approach it is possible to derive several new summary indices of the life‐table cohort's history, such as the mean and median time in current status, at any age. The method is illustrated using a simple four‐state marital‐status model which has appeared often in the literature; here, rates of divorce and widowhood vary by duration of marriage as well as age.     

Family matters: the role of the family in immigrants' destination language acquisition

Studies of immigrants' destination language acquisition to date have focused on the individual. In contrast, this paper is concerned with the relationships among family members in the determinants of destination language proficiency among immigrants. A model of immigrant language proficiency is augmented to include dynamics among family members. It is tested using data on a sample of recent immigrants. Children are shown to have a negative effect on their mother's language proficiency, but no effect on their father's. There is a substantial positive correlation between the language skills of spouses. This is due to the correlation between spouses in both the measured and the unmeasured determinants of destination language skills, even when country of origin fixed effects are held constant.

Heterogeneity,dependence among causes of death and Gompertz

Heterogeneity in a population with respect to mortality, or variation in “frailty”; among members of that population, which has been discussed extensively in the literature over the last decade and a half is essential to any realistic model of dependence among causes of death. The main problem then is the development of a mortality model incorporating heterogeneity and cause of death which is both realistic and of manageable proportions.

In a recent paper (J. H. Pollard, 1991), it has been shown that many life table results are remarkably insensitive to the strict shape of the mortality curve, at least for more developed populations, and that accurate approximations can in many cases be obtained knowing only the mortality rates at two representative ages (e.g. 50 and 70). These results and the Gompertz “law”; of mortality can be used to develop manageable approximate formulae for the expectation of life under heterogeneity and correlation among the causes of death. The formulae are confirmed by simulation.

Numerical results indicate, somewhat surprisingly, that the effects of correlation among causes of death, even at quite high levels, on expectation of life and changes on expectation of life when particular causes of death are reduced or eliminated are relatively minor.     

Marketing and Quality of Life: A Model for Improving Perinatal Health Status

Introduction: A marketing/business model using non-traditional Quality of Life measures was developed to assess perinatal health status on a micro-geographic level. This perinatal health status needs assessment study for Georgia South Central Region was conducted for the years 1994–1999. The model may be applied to any geographic unit in the U.S. – from a block group level to a state or a region. Methodology: An Infant Health Risk Score was created for each county and census tract by calculating the Z-scores of various Medical, Lifestyle, and Access variables so as to construct a Quality of Life Index. The scores identified the areas in the region that were at high risk for certain medical, lifestyle, and access variables (i.e., high risk for preterm births, low education levels, and poor access to perinatal services). A marketing tool, Claritas PRIZM Clusters, was used to identify a specific cluster and associated marketing information for each census tract within the region. Results: The Infant Health Quality of Life Risk Scores were linked with the PRIZM cluster marketing data to target areas in the region that exhibit high risk medical, lifestyle, and access scores. Health promotion and disease prevention strategies were developed using a marketing/business model. Specifically, media usage and consumer behavior purchasing patterns were identified and processed for every high risk area in the region. The categories for media usage were television, radio, and magazines and the categories for consumer behavior included restaurants, food items, and shopping locations. Discussion: The Perinatal Region is developing strategies to implement the media usage and consumer behavior marketing information to focus their prevention efforts to the high risk areas in the region based on the Quality of Life Measurements. Linking marketing business tools with a Quality of Life health status needs assessment has significant potential for improving the planning, the evaluation, and the focus of prevention efforts.     

An empirical model to predict arsenic pollution affected life expectancy

A robust, globally implementable and simple empirical model to predict the arsenic pollution affected life expectancy using a stepwise regression was developed. Life expectancy calculated using a life table technique requires crude death rates data that are not available for small administrative units, complex calculations and does not consider socioeconomic parameters. Hence, a model was needed to forecast the impact of arsenic pollution and socioeconomic parameters on life expectancy for locations with limited data availability. A linear multiple regression technique was used to develop an empirical model to predict arsenic pollution affected life expectancy at birth. The model was calibrated using nine arsenic polluted administrative blocks of district Murshidabad, West Bengal, India and tested independently for three other arsenic polluted blocks of the same district. The R ² values for the plot of actual versus predicted life expectancy at birth were 0.98 for calibration, testing and independent validation. The model is complementary to the life table technique and offers a means to assist planning by public health engineers and health policy makers to mitigate arsenic pollution on a community priority basis.     

Does the way maternity care is provided affect maternal and neonatal outcomes for young women? A review of the research literature

BackgroundYoung pregnant women who continue a pregnancy are primarily from a socioeconomically deprived background. The risk factors associated with low socio-economic status may independently affect perinatal and neonatal morbidity to a greater extent than the young age of the woman. Young pregnant women are frequently sceptical about health care providers who they can perceive to be judgemental. This may lead to late booking for pregnancy care, attending few appointments, or not attending the health service for any antenatal care.QuestionDoes the way maternity care is provided affect maternal and neonatal outcomes for young women?MethodA systematic search of the major health databases.ResultsNine research articles met the eligibility criteria: one randomised controlled trial, three prospective cohort studies, two comparative studies with concurrent controls, two comparative studies with historical controls, and one case series.DiscussionProviding young women with a non-standard model of maternity care has some beneficial and no known detrimental effects on childbirth outcomes. While there is a dearth of evidence on the effectiveness of a Midwifery Group Practice model of care for young women, there is strong evidence to suggest that a Group Antenatal Care model increases antenatal visit attendance and breastfeeding initiation, and decreases the risk of preterm birth. There is research to indicate that a Young Women's Clinic model may also increase antenatal visit attendance and decrease the incidence of preterm birth.ConclusionMore well-designed and resourced midwifery models of care for young women should be implemented and rigorously researched.     

Marketing and Quality of Life: A Model for Improving Perinatal Health Status

Introduction: A marketing/business model using non-traditional Quality of Life measures was developed to assess perinatal health status on a micro-geographic level. This perinatal health status needs assessment study for Georgia South Central Region was conducted for the years 1994–1999. The model may be applied to any geographic unit in the U.S. – from a block group level to a state or a region. Methodology: An Infant Health Risk Score was created for each county and census tract by calculating the Z-scores of various Medical, Lifestyle, and Access variables so as to construct a Quality of Life Index. The scores identified the areas in the region that were at high risk for certain medical, lifestyle, and access variables (i.e., high risk for preterm births, low education levels, and poor access to perinatal services). A marketing tool, Claritas PRIZM Clusters, was used to identify a specific cluster and associated marketing information for each census tract within the region. Results: The Infant Health Quality of Life Risk Scores were linked with the PRIZM cluster marketing data to target areas in the region that exhibit high risk medical, lifestyle, and access scores. Health promotion and disease prevention strategies were developed using a marketing/business model. Specifically, media usage and consumer behavior purchasing patterns were identified and processed for every high risk area in the region. The categories for media usage were television, radio, and magazines and the categories for consumer behavior included restaurants, food items, and shopping locations. Discussion: The Perinatal Region is developing strategies to implement the media usage and consumer behavior marketing information to focus their prevention efforts to the high risk areas in the region based on the Quality of Life Measurements. Linking marketing business tools with a Quality of Life health status needs assessment has significant potential for improving the planning, the evaluation, and the focus of prevention efforts.     

Survival of related individuals: An extension of some fundamental results of heterogeneity analysis

Many ideas in the analysis of heterogeneous mortality are based on the relationship between individual and observed hazard rates. This connection is established with the help of conditional averaging procedure: The observed risk of death at age x is calculated among those who survive this age. The analogy of this result for bivariate survival model with correlated individual hazards is derived. In the case of correlated frailty model the parametric specification of the mean, variance and correlation coefficient of the bivariate frailty distribution among survivors is obtained. The relationship between local association measure and the characteristics of the bivariate frailty distribution among survivors is established.     

Salutogenic qualities of midwifery care: A best-fit framework synthesis

BackgroundAlthough midwifery care is wellness-based and promotes normal physiology, it exists within a medical model that focuses on risk aversion and disease prevention. Salutogenic theory could provide an alternative approach to midwifery care, supporting health-promoting factors, rather than solely avoiding adverse events.AimsThe aim of this study was to explore women’s experiences of their midwifery care and identify salutogenic aspects of midwifery care.MethodsBest-fit framework synthesis was used to analyse 349 quotes about women’s experiences of midwifery care from 31 qualitative studies in ten high-income countries. Key salutogenic concepts of comprehensibility, manageability and meaningfulness were used as the basis for coding, and thematic analysis was used to expand and clarify the framework to best fit the data.FindingsDefinitions for the salutogenic aspects of midwifery care were developed. Comprehensibility (cognitive aspects of health): ways that midwives help women increase predictability and preparation during childbearing through apredictable caregiver, a predictable system and preparation for an unpredictable experience. Manageability (behavioural aspects of health): ways that midwives enhance and support a woman’s internal resilience, adding extra support when needed, and strengthen women’s external resources through connections to family, community and specialist care. Meaningfulness (emotional/spiritual aspects of health): ways that midwives encourage the commitment and engagement of childbearing women by providing care through a personalised relationship, by cultivating a woman’s autonomy.ConclusionFindings of this study may be used to further research into ways that salutogenic theory can bring a health and wellness-focused agenda to midwifery policy and practice.     

Aboriginal women in rural Australia; a small study of infant feeding behaviour

BackgroundAboriginal women in rural areas have lower rates of breastfeeding than Australian averages. The reasons for this are poorly understood. Aboriginal people experience higher morbidity and increased rates of chronic disease throughout the life cycle. The protective effects of sustained breastfeeding could benefit rural Aboriginal communities.ObjectiveTo explore the factors impacting upon infant feeding choices in a rural Aboriginal Community.MethodsSemi-structured interviews were conducted with eight Aboriginal rural dwelling first time mothers. These women received a continuity of midwife and Aboriginal Health Worker model of care. Interviews were also undertaken with five Aboriginal Health Workers and two Aboriginal community breastfeeding champions. The analysis was integrated with a conventional literature review and was further developed and illustrated with historical literature. Indigenist methodology guided the study design, analysis and the dissemination of results.ResultsThree key themes were identified. These were “I’m doing the best thing for…” which encompasses the motivations underpinning infant feeding decisions; “this is what I know…” which explores individual and community knowledge regarding infant feeding; and “a safe place to feed” identifying the barriers that negative societal messages pose for women as they make infant feeding decisions. It appears loss of family and community breastfeeding knowledge resulting from colonisation still influences the Aboriginal women of today.DiscussionAboriginal women value and trust knowledge which is passed to them from extended family members and women within their Community. Cultural, historical and socioeconomic factors all strongly influence the infant feeding decisions of individuals in this study.ConclusionsEfforts to normalise breastfeeding in the culture of rural dwelling Aboriginal women and their supporting community appear to be necessary and may promote breastfeeding more effectively than optimal professional care of individuals can do.     

Effects of interventions for women and their partners to reduce or prevent stress and anxiety: A systematic review

BackgroundThe period from conception to two years postpartum (the first 1000 days) represents a normative transitional period, which can be potentially stressful for some parents. Parental stress and anxiety adversely impacts psychological and physical health for parents and children.AimThe aim of this review is to systematically examine effects of interventions for women and their partners to reduce or prevent stress and/or anxiety during the first 1000 days.MethodsMEDLINE, Embase, CINAHL, PsychINFO, and Maternity and Infant Care were searched from inception to March 2019. Randomised controlled trials examining intervention effects on parental stress and/or anxiety during first 1000 days were eligible for inclusion. Data were independently extracted by two reviewers and narratively synthesised.FindingsFifteen interventions, reported in 16 studies, met inclusion criteria (n = 1911 participants). Overall, findings were inconsistent and the majority of trials demonstrated high risk of bias. Interventions were predominantly delivered to women during pregnancy and only two studies included fathers. There was some evidence that adapting interventions to the pre and postnatal periods provided benefits for stress and anxiety reduction, however there was limited evidence for individual intervention types or approaches.ConclusionsThere is currently inconsistent evidence of what interventions are most effective for women during the first 1000 days and there is insufficient evidence for any interventions for male partners during this period. There is a clear need for rigorous development and examination of interventions developed specifically to reduce or prevent stress and/or anxiety across the first 1000 days.     

Gestational weight gain in obese women by class of obesity and select maternal/newborn outcomes: A systematic review

BackgroundObesity and gestational weight gain impact maternal and fetal risks. Gestational weight gain guidelines are not stratified by severity of obesity.AimConduct a systematic review of original research with sufficient information about gestational weight gain in obese women stratified by obesity class that could be compared to current Institute of Medicine guidelines. Evaluate variance in risk for selected outcomes of pregnancy with differing gestational weight gain in obese women by class of obesity.MethodsA keyword advanced search was conducted of English-language, peer-reviewed journal articles using 3 electronic databases, article reference lists and table of content notifications through January 2015. Data were synthesized to show changes in risk by prevalence.FindingsTen articles met inclusion criteria. Outcomes assessed were large for gestational age, small for gestational age, and cesarean delivery. Results represent nearly 740,000 obese women from four different countries. Findings consistently demonstrated gestational weight gain varies by obesity class and most obese women gain more than recommended by Institute of Medicine guidelines. Obese women are at low risk for small for gestational age and high risk for large for gestational age and risk varies with class of obesity and gestational weight gain. Research suggests the lowest combined risk of selected outcomes with weight gain of 5–9 kg in women with class I obesity, 1 to less than 5 kg for class II obesity and no gestational weight gain for women with class III obesity.ConclusionsGestational weight gain guidelines may need modification for severity of obesity.     

An analysis of media reporting on the closure of freestanding midwifery units in England

ProblemDespite clinical guidelines and policy promoting choice of place of birth, 14 Freestanding Midwifery Units were closed between 2008 and 2015, closures reported in the media as justified by low use and financial constraints.BackgroundThe Birthplace in England Programme found that freestanding midwifery units provided the most cost-effective birthplace for women at low risk of complications. Women planning birth in a freestanding unit were less likely to experience interventions and serious morbidity than those planning obstetric unit birth, with no difference in outcomes for babies.MethodsThis paper uses an interpretative technique developed for policy analysis to explore the representation of these closures in 191 news articles, to explore the public climate in which they occurred.Findings and discussionThe articles focussed on underuse by women and financial constraints on services. Despite the inclusion of service user voices, the power of framing was held by service managers and commissioners. The analysis exposed how neoliberalist and austerity policies have privileged representation of individual consumer choice and market-driven provision as drivers of changes in health services. This normative framing presents the reasons given for closure as hard to refute and cultural norms persist that birth is safest in an obstetric setting, despite evidence to the contrary.ConclusionThe rise of neoliberalism and austerity in contemporary Britain has influenced the reform of maternity services, in particular the closure of midwifery units. Justifications given for closure silence other narratives, predominantly from service users, that attempt to present women’s choice in terms of rights and a social model of care.     

Who is at risk of burnout? A cross-sectional survey of midwives in a tertiary maternity hospital in Melbourne,Australia

BackgroundBurnout is an occupational phenomenon with the potential to affect a person’s physical and mental health, job satisfaction and quality of work. There is evidence of burnout occurring in the midwifery profession, but inadequate data on the prevalence of, and the factors associated with, burnout.AimIdentify the prevalence of burnout in a population of midwives and explore what individual and workforce characteristics, and what occupational stressors, were associated with burnout.MethodsA cross-sectional survey of permanently employed midwives was conducted in a tertiary maternity service in Melbourne, Australia in 2017. Data collected included individual and workforce-related characteristics and occupational stressors. Burnout was explored using the Copenhagen Burnout Inventory. Univariate and multivariate analyses were conducted to ascertain associations between respondents’ characteristics, stressors, and burnout levels.FindingsA total of 257/266 midwives (97%) responded. There were significant levels of exhaustion and fatigue among respondents; 68% of midwives were experiencing personal burnout, 51% work-related burnout, and 10% were experiencing client-related burnout. Being aged ≤ 35 years, and/or having inadequate support was associated with personal and work-related burnout. Having inadequate acknowledgement was associated with client-related burnout.ConclusionHealth services need to understand the risk factors for burnout among midwives, identify and support groups that are most vulnerable, and address areas that are amenable to intervention. In our context this means ensuring midwives receive adequate acknowledgement and support, particularly younger midwives. These findings need to be tested in other settings to help inform a broader understanding and ensure the sustainability of the midwifery profession.     

Predictors of postpartum depression service use: A theory-informed,integrative systematic review

ProblemPostpartum depression affects many women globally, yet rates of treatment use are low. A comprehensive view of factors associated with treatment use, from women’s and providers’ perspectives, based on a theoretical model is lacking.BackgroundSeveral studies examined various factors associated with postpartum depression service use; however, each study focused on a small number of factors.AimThis study describes a systematic literature review based on the Behavioral Model of Health Service Use. The purpose of this article is to review and synthesize the available literature regarding factors associated with women’s mental health service use for postpartum depression from women’s and healthcare providers’ perspectives, and provide a comprehensive integrative view of the subject.MethodsThree electronic databases were searched, and 35 studies published up to 2018 in English language journals met inclusion criteria for review. Factors associated with postpartum depression service use were classified according to the Behavioral Model of Health Service Use’s constructs.FindingsService use for postpartum depression is a function of a woman’s predisposition to use mental health services; individual, familial, and communal factors which enable or pose barriers to use of mental health services; and the woman’s perceived or evaluated need for treatment. In addition, societal determinants impact the woman’s decision to seek help directly or through impacting the health and mental health care service system’s resources and organization.ConclusionThis review illustrates key factors for researchers and practitioners to consider when treating postpartum women and developing interventions to enhance postpartum depression treatment use.     

The experiences of privately practising midwives in Australia who have been reported to the Australian Health Practitioner Regulation Agency: A qualitative study

BackgroundIn Australia the majority of homebirths are attended by privately practising midwives (PPMs). In recent years PPMs have been increasingly reported to the Australian Health Practitioner Regulation Agency (AHPRA) mostly by other health professionals.Purposeto explore the experiences of PPMs in Australia who have been reported to the AHPRA.MethodsA qualitative interpretive approach, employing in-depth interviews with eight PPMs was undertaken and analysed using thematic analysis. A feminist theoretical framework was used to underpin the research.ResultsThe majority of reports made to AHPRA occurred when midwives supported women who chose care considered outside the recommended Australian College of Midwives (ACM) Consultation and Referral Guidelines. During data analysis an overarching theme emerged, “Caught between women and the system”, which described the participants’ feelings of working as a PPM in Australia. There were six themes and several sub-themes: The suppression of midwifery, A flawed system, Lack of support, Devastation on so many levels, Making changes in the aftermath and Walking a tight rope forever. The findings from this study reveal that midwives who are under investigation suffer from emotional and psychological distress. Understanding the effects of the process of investigation is important to improve the quality of professional and personal support available to PPMs who are reported to AHPRA and to streamline processes.ConclusionIt is becoming increasingly difficult for PPMs to support the wishes and needs of individual women and also meet the requirements of the regulators, as well as the increasingly risk averse health service.