Transport to Place of Care

Availability of emergency transport is taken for granted in high-income countries. The debate in such countries relates to such matters as the marginal advantages of helicopters over vehicle ambulances, and what to do when the emergency team arrives at the scene of an accident. But in low- or low-middle-income countries, the situation is very different – in Malawi, for example, there is no pretence that a comprehensive ambulance system exists. The subject of transport does not seem to get attention commensurate with its importance. Researchers love to study the easy stuff – role of particulates in lung disease; prevalence of diabetes in urban vs. rural areas; effectiveness of vaccines. But study selection should not depend solely on tractability – the scientific spotlight should also encompass topics that are more difficult to pin down, but which are critically important. Transport of critically ill patients falls into this category.[1]

Time is of the essence for many conditions. Maternity care is an archetypal example,[2] where delayed treatment in conditions such as placental abruption, eclampsia, ruptured uterus, and obstructed labour can be fatal for mother and child. The same applies to acute infections (most notably meningococcal meningitis) and trauma where time is critical (even if there is no abrupt cut-off following the so called ‘golden hour’).[3] The outcome for many surgical conditions is affected by delay during which, by way of example, an infected viscus may rupture, an incarcerated hernia may become gangrenous, or a patient with a ruptured tubal pregnancy might exsanguinate. However, in many low-income countries less than one patient in fifty has access to an ambulance service.[4] What is to be done?

The subject has been reviewed by Wilson and colleagues in a maternity care context.[5] Their review revealed a number of papers based on qualitative research. They find the theory that one might have anticipated – long delays, lack of infrastructure, and so on. They also make some less intuitive findings. People think that having an emergency vehicle at the ready could bring bad luck, and that it is shameful to expose oneself when experiencing vaginal bleeding.

Quite a lot of work has been done on the use of satellites to develop isochrones based on distances,[6] gradients, and road provision. But working out how long it should take to reach a hospital does not say much about how long it takes in the absence of a service for the transport of acutely sick patients.

We start from the premise that, for the time being at least, a fully-fledged ambulance service is beyond the affordability threshold for many low-income countries. However, we note that many people make it to hospital in an emergency even when no ambulance is available. This finding makes one think of ‘grass-roots’ solutions; finding ways to release the capacity inherent in communities in order to provide more rapid transfers. An interesting finding in Wilson’s paper is that few people, even very poor people, could not find the money for transfer to a place of care in a dire emergency. However, this does not square with work on acutely ill children in Malawi (Nicola Desmond, personal communication), nor work done by CLAHRC WM researchers showing the large effects that user fees have in supressing demand, especially for children, in the Neno province of Malawi.[7] In any event, a grass roots solution should be sought, pending the day when all injured or acutely ill people have access to an ambulance. Possible solutions include community risk-sharing schemes, incentives to promote local enterprises to transport sick people, and automatic credit transfer arrangements to reimburse those who provide emergency transport.

I am leading a work package for the NIHR Global Surgery Unit, based at the University of Birmingham, concerned with access to care. We will describe current practice across purposively sampled countries, work with local people to design a ‘solution’, conduct geographical and cost-benefit analyses, and then work with decision-makers to implement affordable and acceptable improvement programmes. These are likely to involve a system of local risk-sharing (community insurance), IT facilitated transfer of funds, promotion of local transport enterprises, community engagement, and awareness raising. We are very keen to collaborate with others who may be planning work on this important topic.

— Richard Lilford, CLAHRC WM Director

References:

1. United Nations. The Millennium Development Goals Report 2007. New York: United Nations; 2007.
2. Forster G, Simfukew V, Barber C. Use of intermediate mode of transport for patient transport: a literature review contrasted with the findings of Transaid Bicycle Ambulance project in Eastern Zambia. London: Transaid; 2009.
3. Lord JM, Midwinter MJ, Chen Y-F, Belli A, Brohi K, Kovacs EJ, Koenderman L, Kubes P, Lilford RJ. The systemic immune response to trauma: an overview of pathophysiology and treatment. Lancet. 2014; 384(9952): 1455-65.
4. Nyamandi V, Zibengwa E. Mobility and Health. 2007. In: Wilson A, Hillman S, Rosato M, Costello A, Hussein J, MacArthur C, Coomarasamy A. A systematic review and thematic synthesis of qualitative studies on maternal emergency transport in low- and middle-income countries. Int J Gynaecol Obstet. 2013; 122(3): 192-201.
5. Wilson A, Hillman S, Rosato M, Skelton J, Costello A, Hussein J, MacArthur C, Coomarasamy A. A systematic review and thematic synthesis of qualitative studies on maternal emergency transport in low- and middle-income countries. Int J Gynaecol Obstet. 2013; 122(3): 192-201.
6. Frew R, Higgs G, Harding J, Langford M. Investigating geospatial data usability from a health geography perspective using sensitivity analysis: The example of potential accessibility to primary healthcare. J Transp Health 2017 (In Press).
7. Watson SI, Wroe EB, Dunbar EL, Mukherjee J, Squire SB, Nazimera L, Dullie L, Lilford RJ. The impact of user fees on health services utilization and infectious disease diagnoses in Neno District, Malawi: a longitudinal, quasi-experimental study. BMC Health Serv Res. 2016; 16(1): 595.

A Cluster RCT of an Internet-Based Programme to Promote Activity and Reduce Postpartum Calorie Intake in Poor Hispanic Women

When I read the introduction and methods section of a research paper I often try to guess the result before I read on. In the case of the paper above [1] I guessed a null result. I guessed wrong. In this cluster RCT (12 clusters, 371 patients), a carefully designed and piloted internet-based intervention to nudge women to healthy living reduced mean mass by a statistically significant 2.3kg compared to standard care. There was no effect on exercise as assessed by a pedometer. The authors express surprise that there was ‘no’ reduction in calorie intake, but they over-interpret this finding. The variance in measured calories was very wide and the p-value was 0.06. They make the mistake of reifying the 95% limits on the confidence interval.

The 2.3kg mean intervention effect may strike some as nugatory. However, a relatively small reduction in mass can have a worthwhile metabolic and health effect, as we showed in a study of liver function tests.[2] Postpartum weight loss is important because it is associated with long-term obesity, is largely truncal, and increases risk in any subsequent pregnancy. Dr Ponnusamy Saravanan from CLAHRC WM is collaborating with Prof Kamlesh Khunti (Director of CLAHRC East Midlands) in tackling the problem.

— Richard Lilford, CLAHRC WM Director

References:

1. Phelan S, Hagobian T, Brannen A, et al. Effect of an Internet-Based Program on Weight Loss for Low-Income Postpartum Women: A Randomized Clinical Trial. JAMA. 2017; 312(23): 2381-91.
2. Lilford RJ, Bentham L, Girling A, et al. Birmingham and Lambeth Liver Evaluation Testing Strategies (BALLETS): a prospective cohort study. Health Technol Assess. 2013; 17(28): 1-307.

Using Real-Time Simulation to Improve the Dialogue when Discussing Women’s Options for Place of Birth

CLAHRC WM Theme 1, Maternity and Child Health, has been involved in carrying out some simulation training with midwives as part of their ‘place of birth’ study. This study has explored midwives’ views of their discussions with women about their options for where to give birth and followed on from the 2011 Birthplace study,[1] which found that for low risk, multiparous women, there was no significant difference in composite perinatal outcomes between women who gave birth in obstetric units, in maternity led units, or at home. Despite this, many women are not offered the full range of birth place options by their midwife and are often unaware that they have a choice about where they can choose to give birth, instead viewing hospital as the ‘default’ option.[2] The ‘place of birth’ study aimed to help promote choice of place of birth in midwives’ discussions with women. This involved a co-production approach, with midwives being involved in the study process and design. Findings from the literature, focus groups with midwives and a preliminary midwifery workshop resulted in identification of the need for a pragmatic, standardised ‘place of birth’ dialogue, that midwives could use as a tool for use in their discussions with women about where to give birth. A provisional draft of this dialogue was put together by midwives working at BWNFT (with input and guidance from the CLAHRC team) and covered aspects relating to the safety and practicalities of giving birth at home, in the Birth Centre and in Delivery Suite. It aimed to use appropriate language and openers so that women would consider all three of the birth place options available to them.

We decided to use role players in a second midwifery and PPI workshop to simulate the interactions between a midwife and a woman when using the dialogue. This was to explore how well the dialogue worked in ‘real’ practice and whether it sounded right or needed amending. At the workshop, two female role players acted out the dialogue (one playing a midwife and one a pregnant woman) and workshop attendees had the opportunity to modify the dialogue based on what sounded and felt right and what didn’t, until a finalised dialogue for multiparous women was agreed on. This process was repeated again, but for nulliparous women, resulting in the formation of two slightly different dialogues, due to differences in safety and risk meaning that slightly different information needed to be conveyed.

The role playing and subsequent discussions were audio recorded to allow any changes to the dialogue which were agreed on to be saved and transcribed. This ensured that a precise final dialogue could be written up by the CLAHRC team, which accurately detailed what was agreed on by the midwives and PPI during the workshop session. This finalised dialogue is intended as a prompt and a supportive tool to convey the sort of information midwives should be giving to women when talking to them about their place of birth options, rather than a script which midwives have to rigidly stick to. However, the final dialogue should convey a true reflection of what works in practice, to provide a useful resource to midwives when thinking about how to approach these discussions.

The role playing was very well received by the midwives and PPI representatives and encouraged interaction, discussion and debate as to the best way to approach place of birth discussions with women. Having the role players present at the workshop meant that any suggested changes to the dialogue could be incorporated and re-enacted by the role players, until a version of the dialogue emerged that had been developed and refined by the midwives who will be using the dialogue in their everyday practice.

The CLAHRC team are continuing to work with midwives at BWNFT to think about the best ways of successfully implementing the place of birth dialogue into midwives everyday practice. We have utilised the COM-B framework [3] to identify a variety of behaviour change techniques that might be useful mechanisms to help embed the dialogue in the short and longer term. We are currently finalising a protocol to support the implementation of the place of birth dialogue in clinical practice and to evaluate how successful it has been in changing the way that midwives talk to women about their options for where to give birth.

— Catherine Shneerson, Research Fellow, CLAHRC WM Theme 1

References

1. Birthplace in England Collaborative Group. Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study. BMJ 2011; 343: d7400
2. Coxon K, Sandall J, Fulop N J. To what extent are women free to choose where to give birth? How discourses of risk, blame and responsibility influence birth place decisions. Health, Risk & Society. 2014; 16(1): 52-67.
3. Michie S, van Stralen M, West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci. 2011; 6: 42.

So Does Breastfeeding Increase Children’s IQ?

News Blog readers will have seen a short report on the Lancet article from Brazil associating breastfeeding with improved IQ.[1] Alas, probably not correct: at least any effect must be very small, according to a recent article that greatly improves on the Lancet paper.[2] First, the authors cite a thorough systematic review published in BMJ Open [3] and conclude that “Any observed associations are best explained by residual confounding.” Second, they conduct an observational analysis of nearly 12,000 children from the Twins Early Development Study. They find that breastfed girls, but not boys, have a significant, but very small, increase in IQ at age 2. They also find that the slope of the increase in IQ beyond age 2 is unaffected by whether or not the child was breastfed. They conclude that, while science cannot exclude tiny effects, the evidence for an effect of breastfeeding on IQ is very weak. Most studies show that the effect goes away or rapidly attenuates as adjustments are made for known confounders. These results are consistent with various experimental studies of nutritional supplements in early life, where null results contrast with positive results from social and educational interventions.

— Richard Lilford, CLAHRC WM Director

References:

1. Victoria CG, et al. Association between breastfeeding and intelligence, educational attainment, and income at 30 years of age: a prospective birth cohort study from Brazil. Lancet Glob Health. 2015; 3(4): e199-205.
2. von Stumm S & Plomin R. Breastfeeding and IQ Growth from Toddlerhood through Adolescence. PLoS One. 2015. [ePub].
3. Walfisch A, Sermer C, Cressman A, Koren G. Breast milk and cognitive development – the role of confounders: a systematic review. BMJ Open 2013; 3: e003259.

Unpaid Work in the Home

It has long been argued that the cost of environmental degradation should be included in National Accounts and subtracted from Gross National Product. China’s growth postings would be less spectacular if the consequences of air pollution were taken into account, as would Indonesia’s growth rate estimates if deforestation was included. A recent article argues for also taking into account the value of unpaid work bringing up children and caring for the elderly.[1] Women increasingly participate in the labour market with little or no compensating reduction in domestic duties. This results in stress and reduced quality of life. Rai and colleagues suggest that not only should this work be valued and included in the National Accounts, but women should be compensated for the stress that arises. In high-income countries parents are provided with paid parental leave. The motivation here may be largely driven by a desire to increase fertility rather than to improve parents’ wellbeing. It is possible that the economic benefits of improving the dependency ratio, along with those of reducing stress, more than compensate for the upfront costs of the transfers that make this possible. The negative economic consequences of a high-dependency ratio have been discussed in previous blogs.[2] [3] In low-income countries return on investment from supporting parents of young children may be yet greater. The global partner to CLAHRC WM is working with the Africa Population Health Research Center (APHRC) to evaluate the benefit of schemes that promote breastfeeding at work. Here, the benefits include improved outcomes for both mother and child. It is strange how health economics tends to ignore societal effects of interventions on productivity and national wealth.

— Richard Lilford, CLAHRC WM Director

References:

1. Rai SM, Hoskyns C, Thomas D. Depletion: the cost of social reproduction. Int Fem J Polit. 2014; 16(1): 86-105.
2. Lilford R. Is Low Fertility a Problem for High-Income Countries, but a Boon For Low-Income Countries? CLAHRC WM News Blog. December 12 2014.
3. Lilford R. Improving Hospital Care: Not Easy When Budgets are Pressed. CLAHRC WM News Blog. January 23 2015.

When is a False Positive Not a False Positive?

Readers will know that analysis of foetal DNA circulating in maternal blood yields a very accurate (sensitive and specific) test for Down’s syndrome and other trisomies (where there are extra copies of one of the chromosomes in the normal pair). But some false positives arise. A recent report identifies two cases where the extra chromosome arose not from the foetus, but from an error in cell division propagated in a clone of metastatic cells from a previously undiagnosed cancer.[1]

Years ago, I tried to find foetal trisomies by harvesting foetal cells from blood, and my friend and colleague, Peter Selby, tried to diagnose metastasising cancer by harvesting cancer cells from the circulation. We were both looking in the wrong place – we should have been going directly for free circulating DNA, not cells containing DNA.

— Richard Lilford, CLAHRC WM Director

Reference:

1. Romero R, Mahoney MJ. Noninvasive Prenatal Testing and Detection of Maternal Cancer. JAMA. 2015; 314(2): 131-3.

Care that is Not Just Unskilled but Abusive

Maternal care is disrespectful to the point of abuse in many of the countries of the world.[1] How can it be that members of the caring professions can so abuse their position of trust? This short editorial argues that a culture of poor care can develop among perfectly ordinary people – indeed, we know this from the iconic experiments of Zimbardo [2] and Milgram.[3] As the Good Samaritan experiment shows,[4] people are exquisitely sensitive to their environment, especially their social environment.[5] So, here is my model for how an abusive culture develops:

— Richard Lilford, CLAHRC WM Director

References:

1. The Lancet. Achieving respectful care for women and babies. Lancet. 2015. 385:1366.
2. Haney C, Banks C, Zimbardo P. A Study of Prisoners and Guards in a Simulated Prison. Washington, D.C.: Office of Naval Research. 1973.
3. Milgram S. Behavioral Study of Obedience. J Abnorm Psychol. 1963; 67(4):371-8.
4. Darley JM, Batson D. “From Jerusalem to Jericho”: A Study of Situational and Dispositional Variables in Helping Behavior. J Pers Soc Psychol. 1973; 27(1): 100-8.
5. Bandura A, Ross D, Ross SA. Transmission of aggression through imitation of aggressive models. J Abnorm Soc Psychol. 1961; 63: 575-82.

Really Important Papers on Child Development

Our CLAHRC has recently conducted an individually randomised trial of the effect of perinatal (before and after birth) support from lay health workers for women at high social risk. The results have been submitted for publication, but in the meantime the BMJ has reported a 2×2 factorial RCT of an integrated early child development intervention, consisting of micronutrient supplementation and weekly stimulation through local women. The study was conducted across 96 communities in Columbia.[1] While the supplementation yielded a null result, the additional psychosocial stimulation produced marked improvements in cognition and language over an 18 month intervention period. The results partly corroborate a similar recent study reported in the Lancet.[2] This study was also a 2×2 factorial design, again of nutrition (including micronutrients) and stimulation. This study involved 80 communities in Pakistan. They replicated the findings regarding stimulation, but also recorded a positive, albeit smaller, cognitive benefits from the nutritional intervention. Babies and toddlers are little learning machines who love to interact, and benefit themselves and others by doing so. The effect of nutrition may be more context dependent.[3] Our CLAHRC is considering conducting an overview, combining studies that examine antenatal and postnatal interventions, or both, and that compare interventions targeted mainly at the mother, versus those where the infant is the primary focus of attention. In the meantime, here are two excellent cluster factorial designs of similar interventions in two different continents, serendipitously published within weeks of one another.

— Richard Lilford, CLAHRC WM Director

References:

1. Attanasio OP, Fernandez C, Fitzsimons EO, Grantham-McGregor SM, Meghir C, Rubio-Codina M. Using the infrastructure of a conditional cash transfer program to deliver a scalable integrated early child development program in Colombia: cluster randomized controlled trial. BMJ. 2014; 349: g5785.
2. Yousafzai AK, Rasheed MA, Rizvi A, Armstrong R, Bhutta ZA. Effect of integrated responsive stimulation and nutrition interventions in the Lady Health Worker programme in Pakistan on child development, growth, and health outcomes: a cluster-randomised factorial effectiveness trial. Lancet. 2014; 384: 1282-93.
3. Black MM & Hurley KM. Investment in early childhood development. Lancet. 2014; 384: 1244-5.