Modelling: one tool in the decision-making toolkit

Editorial comment on the Viewpoint - Should prioritising health interventions be informed by modelling studies? The case of cancer control in Aotearoa New Zealand, published by Wilson. N, et al VIEWPOINT Vol 134 No 1531: 12 March 202

Crude and adjusted ORs (with <i>p</i>-value) for all outcomes comparing medical-led to midwife-led care.

<p>Crude and adjusted ORs (with <i>p</i>-value) for all outcomes comparing medical-led to midwife-led care.</p

Numbers and incidence rates of perinatal outcomes by 1,000 total and live births.

<p>Numbers and incidence rates of perinatal outcomes by 1,000 total and live births.</p

Characteristics of the overall cohort and the midwife-led and medical-led groups.

<p>Characteristics of the overall cohort and the midwife-led and medical-led groups.</p

A Comparison of Midwife-Led and Medical-Led Models of Care and Their Relationship to Adverse Fetal and Neonatal Outcomes: A Retrospective Cohort Study in New Zealand

<div><p>Background</p><p>Internationally, a typical model of maternity care is a medically led system with varying levels of midwifery input. New Zealand has a midwife-led model of care, and there are movements in other countries to adopt such a system. There is a paucity of systemic evaluation that formally investigates safety-related outcomes in relationship to midwife-led care within an entire maternity service. The main objective of this study was to compare major adverse perinatal outcomes between midwife-led and medical-led maternity care in New Zealand.</p><p>Methods and Findings</p><p>This was a population-based retrospective cohort study. Participants were mother/baby pairs for all 244,047 singleton, term deliveries occurring between 1 January 2008 and 31 December 2012 in New Zealand in which no major fetal, neonatal, chromosomal or metabolic abnormality was identified and the mother was first registered with a midwife, obstetrician, or general practitioner as lead maternity carer. Main outcome measures were low Apgar score at five min, intrauterine hypoxia, birth-related asphyxia, neonatal encephalopathy, small for gestational age (as a negative control), and mortality outcomes (perinatal related mortality, stillbirth, and neonatal mortality). Logistic regression models were fitted, with crude and adjusted odds ratios (ORs) generated for each outcome for midwife-led versus medical-led care (based on lead maternity carer at first registration) with 95% confidence intervals. Fully adjusted models included age, ethnicity, deprivation, trimester of registration, parity, smoking, body mass index (BMI), and pre-existing diabetes and/or hypertension in the model. Of the 244,047 pregnancies included in the study, 223,385 (91.5%) were first registered with a midwife lead maternity carer, and 20,662 (8.5%) with a medical lead maternity carer. Adjusted ORs showed that medical-led births were associated with lower odds of an Apgar score of less than seven at 5 min (OR 0.52; 95% confidence interval 0.43–0.64), intrauterine hypoxia (OR 0.79; 0.62–1.02), birth-related asphyxia (OR 0.45; 0.32–0.62), and neonatal encephalopathy (OR 0.61; 0.38–0.97). No association was found between lead carer at first registration and being small for gestational age (SGA), which was included as a negative control (OR 1.00; 0.95–1.05). It was not possible to definitively determine whether one model of care was associated with fewer infant deaths, with ORs for the medical-led model compared with the midwife-led model being 0.80 (0.54–1.19) for perinatal related mortality, 0.86 (0.55–1.34) for stillbirth, and 0.62 (0.25–1.53) for neonatal mortality. Major limitations were related to the use of routine data in which some variables lacked detail; for example, we were unable to differentiate the midwife-led group into those who had received medical input during pregnancy and those who had not.</p><p>Conclusions</p><p>There is an unexplained excess of adverse events in midwife-led deliveries in New Zealand where midwives practice autonomously. The findings are of concern and demonstrate a need for further research that specifically investigates the reasons for the apparent excess of adverse outcomes in mothers with midwife-led care. These findings should be interpreted in the context of New Zealand’s internationally comparable birth outcomes and in the context of research that supports the many benefits of midwife-led care, such as greater patient satisfaction and lower intervention rates.</p></div

Adjusted ORs of low Apgar and small for gestational age in relation to maternal characteristics.

<p>Adjusted ORs of low Apgar and small for gestational age in relation to maternal characteristics.</p

Adjusted ORs of PRM and birth asphyxia/hypoxia/neonatal encephalopathy in relation to maternal characteristics.

<p>Adjusted ORs of PRM and birth asphyxia/hypoxia/neonatal encephalopathy in relation to maternal characteristics.</p

Additional file 1: Figure S1. of Ethnic inequalities in cancer incidence and mortality: census-linked cohort studies with 87 million years of person-time follow-up

Hazardous alcohol consumption by ethnicity as measured by the AUDIT tool, score ≥8 for 15+ year olds in the New Zealand Health Survey. Figure S2. Seroprevalence data indicating H. pylori prevalence by birth cohort (McDonald et al., 2015) in New Zealand. Figure S3. Mortality rates by ethnicity for all-cause and specific causes of mortality, from national census-linked data in New Zealand males and females 1–74 years old 1981–2011. Figure S4. Cancer mortality by ethnicity, age standardised, from the national census-linked data in New Zealand males and females 1–74 years old 1981–2011. Figure S5. Absolute ethnic inequalities (age standardised rate differences) in cancer incidence, from national census-linked data in New Zealand males and females 1–74 years old 1981–2011. Figure S6. Absolute ethnic inequalities (age standardised rate differences) in cancer mortality, from national census-linked data in New Zealand males and females 1–74 years old 1981–2011. Figure S7. Decomposition of absolute ethnic inequalities in cancer mortality (top) and incidence (bottom) by major contributing cancer types, comparing Māori and Pacific peoples with European/Other in males and females aged 1–74 years in New Zealand. Table S1. SAS output only showing the statistically significant rate differences used to select cancer incidences for presenting in this paper. (DOCX 840 kb

Additional file 1: of Physical activity and risk of testicular cancer: a systematic review

Table S1. Papers included in meta-analysis of association between physical activity and testicular cancer risk, with study meta-data. Table S2. Extracted data relating to high vs. low physical activity. Table S3. Extracted data relating to high vs. low recreational physical activity at adolescence/early adulthood. Table S4. PICOS (Patient/Participant, Intervention, Comparator, Outcome, Study design) criteria for inclusion of studies. Table S5. List of excluded papers with reason for exclusion. Table S6. Assessment of study quality against Newcastle-Ottawa criteria for case-control studies. Table S7. Assessment of study quality against Newcastle-Ottawa criteria for cohort studies. (DOCX 134 kb

Additional file 2: of BetaMe: impact of a comprehensive digital health programme on HbA1c and weight at 12 months for people with diabetes and pre-diabetes: study protocol for a randomised controlled trial

Health literacy modules. (DOCX 14 kb