Testing a Theory of Change Model for Evaluating the Impact of Action Learning Programs

This paper reports findings from an evaluation of an executive leadership development program in a large global healthcare organization. The paper offers a rethinking of evaluation from a transfer of learning model to a more open-ended, developmental approach based on a theory of change when learning is action-oriented, emergent, informal and incidental. Included in this paper are data from the evaluation illustrating learning increases in individual, group and system capacities to effectively engage with the demands placed on leaders and organizations in a complex, global context

Performance of screening for aneuploidies by cell-free DNA analysis of maternal blood in twin pregnancies

Objectives To report clinical implementation of cell‐free DNA (cfDNA) analysis of maternal blood in screening for trisomies 21, 18 and 13 in twin pregnancies and examine variables that could influence the failure rate of the test. Methods cfDNA testing was performed in 515 twin pregnancies at 10–28 weeks' gestation. The failure rate of the test to provide results was compared with that in 1847 singleton pregnancies, and logistic regression analysis was used to determine which factors among maternal and pregnancy characteristics were significant predictors of test failure. Results Failure rate of the cfDNA test at first sampling was 1.7% in singletons and 5.6% in twins. Of those with a test result, the median fetal fraction in twins was 8.7% (range, 4.1–30.0%), which was lower than that in singletons (11.7% (range, 4.0–38.9%)). Multivariable regression analysis demonstrated that twin pregnancy, higher maternal weight and conception by in‐vitro fertilization provided significant independent prediction of test failure. Follow‐up was available in 351 (68.2%) of the twin pregnancies and comprised 334 with euploid fetuses, 12 discordant for trisomy 21 and five discordant for trisomy 18. In all 323 euploid cases with a result, the risk score for each trisomy was < 1:10 000. In 11 of the 12 cases with trisomy 21 and in the five with trisomy 18, the cfDNA test gave a high‐risk result, but in one case of trisomy 21, the score was < 1:10 000. Conclusion In twin pregnancies screening by cfDNA testing is feasible, but the failure rate is higher and detection rate may be lower than in singletons

Routine assessment of cerebroplacental ratio at 35-37 weeks' gestation in the prediction of adverse perinatal outcome

Background: Third trimester studies in selected high-risk pregnancies have reported that low cerebroplacental ratio (CPR), due to high pulsatility index (PI) in the umbilical artery (UA), and or decreased PI in the fetal middle cerebral artery (MCA), is associated with increased risk of adverse perinatal outcomes. Objective: To investigate the predictive performance of screening for adverse perinatal outcome by the cerebroplacental ratio (CPR) measured routinely at 35+6 - 36+6 weeks’ gestation. Methods: This was a prospective observational study in 47,211 women with singleton pregnancies undergoing routine ultrasound examination at 35+6 - 36+6 weeks’ gestation, including measurement of UA-PI and MCA-PI. The measured UA-PI and MCA-PI and their ratio were converted to multiples of the median (MoM) after adjustment for gestational age. Multivariable logistic regression analysis was used to determine whether CPR improved the prediction of adverse perinatal outcome that was provided by maternal characteristics, medical history and obstetric factors. The following outcome measures were considered: first, adverse perinatal outcome consisting of stillbirth, neonatal death or hypoxic ischemic encephalopathy grades 2 and 3, second, presence of surrogate markers of perinatal hypoxia consisting of umbilical arterial or venous cord blood pH ≤7 and ≤7.1, respectively, 5-minute Apgar score 24 hours, third, cesarean section for presumed fetal distress in labor, and fourth, neonatal birthweight <3rd percentile for gestational age. Results: Low CPR was associated with increased risk of adverse perinatal outcome, presence of surrogate markers of perinatal hypoxia, cesarean section for presumed fetal distress in labor and birth of neonates with birthweight <3rd percentile. However, multivariable regression analysis demonstrated that the prediction of these adverse outcomes by maternal demographic characteristics and medical history was only marginally improved by the addition of CPR. The performance of low CPR in the prediction of each adverse outcome was poor, with detection rates of 13–26% and false positive rate of about 10%. In appropriate for gestational age (AGA) neonates with birthweight ≥10th percentile the predictive accuracy of CPR was low with positive and negative likelihood ratios (LRs) ranging from 1.21 to 1.82, and 0.92 to 0.98, respectively; although the accuracy was better in small for gestational age (SGA) neonates this was also low with positive LRs of 1.31 to 2.26 and negative LRs of 0.69 to 0.92. Similar values were obtained in fetuses classified as SGA and AGA according to the estimated fetal weight. In the prediction of adverse outcomes within two weeks, rather than at any stage, after assessment the detection rate was higher but this was achieved at higher false positive rate and therefore similar positive and negative LRs. Conclusion: In pregnancies undergoing routine antenatal assessment at 35+0 - 36+6 weeks’ gestation measurement of CPR provides poor prediction of adverse perinatal outcome in both SGA and AGA fetuses. Consequently, there is no justification in a shift of the focus of prenatal care from identification of pregnancies with low estimated fetal weight to that of pregnancies with low CPR

Diagnosis of fetal defects in twin pregnancies at routine 11-13-week ultrasound examination

Objective: To examine the performance of the routine 11-13 weeks scan in detecting fetal defects in twin pregnancies and to examine if in pregnancies with fetal defects, compared to those with normal fetuses, there is increased incidence of nuchal translucency (NT) thickness ≥95th and ≥99th percentiles or intertwin discordance in crown-rump length (CRL) ≥10% and ≥15%. Methods: This was a retrospective analysis of prospectively collected data in twin pregnancies undergoing routine ultrasound examination for fetal anatomy, according to standardized protocols, at 11-13 weeks’ gestation between 2002 and 2019. Pregnancies with known chromosomal abnormalities were excluded. The final diagnosis of fetal defects was based on the results of postnatal examination in the case of livebirths and on the findings of the last ultrasound examination in the cases of pregnancy termination, miscarriage or stillbirth. The performance of the 11-13 weeks scan in the detection of fetal defects was determined. Results: The study population of 6,366 twin pregnancies with two live fetuses at 11-13 weeks’ gestation, included 4,979 (78.2%) dichorionic (DC) and 1,387 (21.8%) monochorionic (MC) twin pregnancies. The main findings were: first, the overall incidence of fetal defects was higher in MC than DC twins (2.8% vs. 1.3%); second, the proportion of defects diagnosed in the first-trimester was higher in MC than in DC twins (52.6% vs. 27.1%); third, the pattern of defects in relation to detectability at the 11-13 weeks scan, always detectable, sometimes detectable and never detectable, was similar to that previously reported in singleton pregnancies; fourth, always detectable defects included acrania, alobar holoprosencephaly, encephalocele, pentalogy of Cantrell, exomphalos, body stalk anomaly, TRAP sequence and conjoined twins; fifth, the incidence of fetal NT ≥95th percentile was higher in those with than without defects (16.5% vs. 4.5% in DC twins and 19.2% vs. 5.9% in MC twins) and this was also true for NT >99th percentile (8.3% vs. 1.0% in DC twins and 15.4% vs. 2.0% in MC twins); and sixth, the incidence of CRL discordance ≥10% was higher in those with than without defects (20.2% vs. 7.9% in DC twins and 33.8% vs. 9.3% in MC twins) and this was also true for CRL discordance ≥15% (10.1% vs. 1.9% in DC twins and 28.2% vs. 2.8% in MC twins). Conclusions: First, fetal defects are more common in MC than in DC twin pregnancies, second, first-trimester detection of fetal defects in DC twin pregnancies is similar to that in singleton pregnancies, third, detectability of defects in MC twins is higher than in DC twins, fourth, in twin pregnancies with fetal defects there is a higher intertwin discordance in CRL and incidence of high NT, but the predictive performance of screening by these markers is poor

Cervical length at 23 weeks' gestation - relation to demographic characteristics and previous obstetric history in South African women

Objectives. To determine the distribution of cervical length in a routine population of singleton  pregnancies; to examine the relationship between cervical length, demographic characteristics, and previous obstetric history; and to compare these data with data from a similar study undertaken in the UK.Patients and methods. The study was conducted among women attending routine antenatal clinics at  Coronation, Johannesburg General and Chris Hani Baragwanath hospitals. Cervical length was measured by means of transvaginal ultrasound at 23 weeks' gestation in women with singleton pregnancies attending these clinics, as part of a multicentre randomised trial investigating the value of cerclage in a short cervix. The distribution of cervical length was determined and the significance of differences in median cervical lengths between subgroups was calculated according to maternal age, ethnic origin, maternal body mass index (BMI), cigarette smoking, alcohol intake, and previous obstetric history.Results. Cervical screening was offered to women (N = 2 173) attending clinics for a 23-week scan during the study period (July 1999- September 2002). Most women (N = 1 920) accepted, while 253 declined. Complete outcomes (date and mode of delivery; gestation at delivery, birth weight, Apgar scores,  maternal blood loss, whether the patient was cerclaged or not, and any complications) were obtained for 1 603 women who accepted screening. Cervical length was measured successfully in all cases. Median cervical length was 33.7 mm and in 64 cases (3.3%) the length was 15 mm or less. Significantly shorter cervical lengths were found in those with a history of previous miscarriage, preterm delivery, those aged less than 20 years and those with an abnormal BMI. Cervical length was not significantly shorter in black women than in coloured and white women.Conclusions. At 23 weeks' gestation the median cervical length in a South African population was 33.2 mm. In 3.3% of the population the length was 15 mm. There was an association between cervical length, demographic characteristics and previous obstetric history

Endoscopic placental laser coagulation in dichorionic and monochorionic triplet pregnancies

Objective: To report outcome of monochorionic (MC) and dichorionic (DC) triamniotic (TA) triplet pregnancies treated with endoscopic laser coagulation of communicating placental vessels for severe fetofetal transfusion syndrome (FFTS) and selective fetal growth restriction (sFGR). Methods: Laser surgery was performed at 18 (15-24) weeks gestation in 11 MCTA and 33 DCTA pregnancies complicated by FFTS and 14 DCTA pregnancies complicated by sFGR. Data from our study and previous reports were pooled using meta-analytic techniques. Results: Survival of at least one baby and survival among all fetuses was 97.0% and 72.7% in DCTA pregnancies with FFTS, 78.6% and 52.4% in DCTA pregnancies with sFGR and 81.8% and 39.4% in MCTA pregnancies with FFTS. In the combined data from our study and previous reports, the pooled survival rates in 132 DCTA pregnancies with FFTS were 94.4% and 76.1% and in 29 MCTA pregnancies with FFTS were 80.6% and 57.5%. Conclusions: Survival after laser surgery is higher in DC triplets with FFTS than those with sFGR and in DC than MC triplets with FFTS

Prediction of stillbirth from placental growth factor at 19-24 weeks

Objectives: To investigate whether measurement of maternal serum placental growth factor (PLGF) at 19-24 weeks’ gestation improves the performance of screening for stillbirths that is achieved by a combination of maternal factors, fetal biometry and uterine artery pulsatility index (UT-PI) and evaluate the performance of screening of this model for all stillbirths and those due to impaired placentation and unexplained or other causes. Methods: This was a prospective screening study of 70,003 singleton pregnancies including 268 stillbirths, carried out in two phases. The first phase, which included prospective measurements of UT-PI and fetal biometry were available in all cases. The second phase included prospective measurements of maternal serum PLGF which were available for 9,870 live births and 86 antepartum stillbirths. The values of PLGF obtained from this screening study were simulated in the remaining cases based on bivariate Gaussian distributions, defined by the mean and standard deviations. Multivariate logistic regression analysis was used to determine whether the addition of maternal serum PLGF improved the performance of screening that was achieved by a combination of maternal factors, fetal biometry and UT-PI. Results: Significant contribution to the prediction of stillbirths was provided by maternal factor derived a priori risk, MoM values of PLGF, UT-PI and fetal biometry Z-scores. A model combining these variables predicted 58% of all stillbirths and 84% of those due to impaired placentation, at false positive rate of 10%; within the impaired placentation group the detection rate of stillbirth at 37 weeks (97% vs 61%; p<0.01). Conclusions: A high proportion of stillbirths due to impaired placentation can be effectively identified in the second trimester of pregnancy

Effective stakeholder management for medical practitioners

The importance of organizational-stakeholder relationships is highlighted in most organizational studies literature. This article investigates the relationship between medical practices and their stakeholders and has been developed to provide guidance on stakeholder engagement and communication. It is intended to provide a useful reference point for all medical practices concerning stakeholder engagement activities. Direction is provided on how to identify and ultimately engage with stakeholders. It should hopefully further develop the effectiveness of engagement efforts that are undertaken between a medical practice and its stakeholders. The ability of a medical practice to cultivate and sustain strong relationships with its prominent stakeholder groups greatly enhances the likelihood that the relationship will endure. Medical practitioners in South Africa are generally in urgent need of pursuing new ways of delivering quality health care through developing new service models that have been developed with the help of relevant stakeholders. Since stakeholder relationship management is critical for corporate sustainability, medical practice management should seek strategic direction by investigating the relative competitive threat and relative supportive value of each stakeholder and then classify them accordingly