Continuous quality improvement and metabolic screening during pregnancy at primary health centres attended by Aboriginal and Torres Strait Islander women

Objective: To investigate associations between the provision of routine metabolic screening and follow-up in pregnancy and participation by primary health care centres in a large-scale continuous quality improvement (CQI) initiative.Design: Longitudinal analysis of 2592 audited maternal health records.Setting and participants: Seventy-six community-controlled or government-operated primary health care centres serving predominantly Aboriginal and Torres Strait Islander communities, in urban, regional or remote locations in five Australian states and territories.Intervention: Up to four CQI cycles supported by the Audit and Best Practice for Chronic Disease Research Partnership.Main outcomes measures:Screening and follow-up for body mass index (BMI), blood pressure and diabetes in pregnancy.Results: Overall, 87.9% of women attending the participating health centres were Aboriginal or Torres Strait Islander. Women attending a health centre after it had conducted one or more CQI cycles were more likely to receive BMI, blood pressure and diabetes screening. For example, the proportion of women receiving diabetes screening at baseline (before the first CQI cycle) was 56.1%; after cycle 1 it was 63.7% (odds ratio [OR], 1.3; 95% CI, 1.0–1.6), after cycle 2, 61.6% (OR, 1.2; 95% CI, 0.9–1.7), after cycle 3, 63.7% (OR, 1.7; 95% CI, 1.1–2.6), and after cycle 4, 75.5% (OR, 3.4; 95% CI, 1.9–5.9). Diabetes screening was associated with higher self-ratings of overall organisational systems (P = 0.03), self-management support (P = 0.04) and organisational influence and integration (P = 0.01).Conclusion: These findings support the value of CQI approaches that focus on systems-level issues in primary care to improve the provision of recommended pregnancy care at primary health care centres in predominantly Aboriginal and Torres Strait Islander communities

Depression and diabetes distress in adults with type 2 diabetes: results from the Australian National Diabetes Audit (ANDA) 2016

This study explores the prevalence of, and factors associated with, likely depression and diabetes distress in adults with type 2 diabetes in a large, national sample. Australian National Diabetes Audit data were analysed from adults with type 2 diabetes attending 50 diabetes centres. The Brief Case find for Depression and Diabetes Distress Score 17 were administered to screen for likely depression and diabetes-related distress, respectively. A total of 2,552 adults with type 2 diabetes participated: (mean ± SD) age was 63 ± 13 years, diabetes duration was 12 ± 10 years, and HbA1c was 8 ± 2%. Twenty-nine percent of patients had likely depression, 7% had high diabetes distress, and 5% had both. Difficulty following dietary recommendations, smoking, forgetting medications, and diabetes distress were all associated with greater odds of depression whereas higher own health rating was associated with lower odds (all p < 0.02). Female gender, increasing HbA1c, insulin use, difficulty following dietary recommendations and depression were all associated with greater odds of diabetes distress & older age, higher own health rating and monitoring blood glucose levels as recommended were associated with lower odds (all p < 0.04). Depression was associated with sub-optimal self-care, while diabetes distress was associated with higher HbA1c and sub-optimal self-care

Systematic review and meta-analysis : the prevalence of mental illness in child and adolescent refugees and asylum seekers

Objective Over half of the world’s refugee population are under the age of 18 years. This systematic review aims to summarise the current body of evidence for the prevalence of mental illness in child and adolescent refugee populations. Method Eight electronic databases, grey literature, and Google Scholar were searched for articles from 1 January 2003 to 5 February 2018. Strict inclusion criteria regarding the diagnosis of mental illness were imposed. Study quality was assessed using a template according to study design, and study heterogeneity using I2 statistic. Random effects meta-analyses results were presented given heterogeneity among studies. The protocol for this systematic review was registered with PROSPERO (CRD42016046349). Results Eight studies were eligible, involving 779 child and adolescent refugees and asylum seekers, with studies conducted in five countries. The overall prevalence of post-traumatic stress disorder (PTSD) was 22.71% (95% CI 12.79-32.64), depression 13.81% (95% CI 5.96-21.67), and anxiety disorders 15.77% (95% CI 8.04-23.50). Attention-deficit/hyperactivity disorder (ADHD) was 8.6% (1.08-16.12) and oppositional defiant disorder (ODD) was 1.69% (95% CI -0.78 – 4.16). Due to high heterogeneity, further subgroup analyses were conducted. Conclusion Refugee and asylum seeker children have high rates of PTSD, depression, and anxiety. Without the serious commitment by health and resettlement services to provide early support to promote mental health, these findings suggest a high proportion of refugee children are at risk of educational disadvantage and poor social integration in host communities, potentially affecting their life course

Association of antenatal diet and physical activity–based interventions with gestational weight gain and pregnancy outcomes : a systematic review and meta-analysis

Importance: Excessive gestational weight gain (GWG) is common and associated with adverse pregnancy outcomes. Antenatal lifestyle interventions limit GWG; yet benefits of different intervention types and specific maternal and neonatal outcomes are unclear. Objective: To evaluate the association of different types of diet and physical activity–based antenatal lifestyle interventions with GWG and maternal and neonatal outcomes. Data Sources: A 2-stage systematic literature search of MEDLINE, Embase, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, Cochrane Central Register of Controlled Trials, and Health Technology Assessment Database was conducted from February 1, 2017, to May 31, 2020. Search results from the present study were integrated with those from a previous systematic review from 1990 to February 2017. Study Selection: Randomized trials reporting GWG and maternal and neonatal outcomes. Data Extraction and Synthesis: Data were extracted for random-effects meta-analyses to calculate the summary effect estimates and 95% CIs. Main Outcomes and Measures: Outcomes were clinically prioritized, with mean GWG as the primary outcome. Secondary outcomes included gestational diabetes, hypertensive disorders of pregnancy, cesarean section, preterm delivery, large or small for gestational age neonates, neonatal intensive care unit admission, or fetal death. Results: A total of 117 randomized clinical trials of antenatal lifestyle interventions (involving 34 546 women) were included. Overall lifestyle intervention was associated with reduced GWG (−1.15 kg; 95% CI, −1.40 to −0.91), risk of gestational diabetes (odds ratio [OR], 0.79; 95% CI, 0.70-0.89), and total adverse maternal outcomes (OR, 0.89; 95% CI, 0.84-0.94) vs routine care. Compared with routine care, diet was associated with less GWG (−2.63 kg; 95% CI, −3.87 to −1.40) than physical activity (−1.04 kg; 95% CI, −1.33 to −0.74) or mixed interventions (eg, unstructured lifestyle support, written information with weight monitoring, or behavioral support alone) (−0.74 kg; 95% CI, −1.06 to −0.43). Diet was associated with reduced risk of gestational diabetes (OR, 0.61; 95% CI, 0.45-0.82), preterm delivery (OR, 0.43; 95% CI, 0.22-0.84), large for gestational age neonate (OR, 0.19; 95% CI, 0.08-0.47), neonatal intensive care admission (OR, 0.68; 95% CI, 0.48-0.95), and total adverse maternal (OR, 0.75; 95% CI, 0.61-0.92) and neonatal outcomes (OR, 0.44; 95% CI, 0.26-0.72). Physical activity was associated with reduced GWG and reduced risk of gestational diabetes (OR, 0.60; 95% CI, 0.47-0.75), hypertensive disorders (OR, 0.66; 95% CI, 0.48-0.90), cesarean section (OR, 0.85; 95% CI, 0.75-0.95), and total adverse maternal outcomes (OR, 0.78; 95% CI, 0.71-0.86). Diet with physical activity was associated with reduced GWG (−1.35 kg; 95% CI, −1.95 to −0.75) and reduced risk of gestational diabetes (OR, 0.72; 95% CI, 0.54-0.96) and total adverse maternal outcomes (OR, 0.81; 95% CI, 0.69-0.95). Mixed interventions were associated with reduced GWG only. Conclusions and Relevance: This systematic review and meta-analysis found level 1 evidence that antenatal structured diet and physical activity–based lifestyle interventions were associated with reduced GWG and lower risk of adverse maternal and neonatal outcomes. The findings support the implementation of such interventions in routine antenatal care and policy around the world

Contraception use and pregnancy outcomes in women with polycystic ovary syndrome: Data from the Australian longitudinal study on women's health

STUDY QUESTION: Do contraception use, pregnancy outcome and number of children differ in women with and without polycystic ovary syndrome (PCOS)? SUMMARY ANSWER: Women with PCOS were less likely to report use of contraception and more likely to report a miscarriage, whilst number of children was similar between groups. WHAT IS KNOWN ALREADY: The oral contraceptive pill is used in the management of PCOS, but the patterns of contraception use in women with PCOS is not known. In women with PCOS who undergo assisted reproduction, the risk of pregnancy loss appears higher, yet pregnancy loss and family size among community-based women with PCOS is not known. STUDY DESIGN, SIZE AND DURATION: This is a cross-sectional analysis of a longitudinal cohort study. Mailed survey data were collected at five time points (years 1996, 2000, 2003, 2006 and 2009). Data from respondents to Survey 4 (2006), aged 28-33 (n = 9145, 62% of the original cohort aged 18-23 years) were analysed. PARTICIPANTS/MATERIALS, SETTING, METHODS: This study was conducted in a general community setting. Data from participants who responded to the questions on PCOS, contraception and pregnancy outcome were analysed. The main outcome measures were self-reported PCOS, body mass index (BMI), contraception use, pregnancy loss and number of children. MAIN RESULTS AND THE ROLE OF CHANCE: In women aged 28-33 years, women with PCOS were less likely to be using contraception (61 versus 79%, P < 0.001) and more likely to be trying to conceive (56 versus 45%, P < 0.001), compared with women not reporting PCOS. A greater proportion of women with PCOS reported pregnancy loss (20 versus 15%, P = 0.003). PCOS was not independently associated with pregnancy loss; however, BMI was independently associated with pregnancy loss in the overweight and obese groups (OR 1.2, 95% CI 1.04-1.4, P = 0.02 and OR 1.4, 95% CI 1.1-1.6, P = 0.001, respectively). Fertility treatment use was also independently associated with pregnancy loss (adjusted OR 3.2, 95% CI 2.4-4.2, P < 0.001). There was no significant difference in number of children between women with and without PCOS. LIMITATIONS, REASON FOR CAUTION: PCOS, contraception use and pregnancy outcome data were self-reported. Attrition occurred, but is reasonable compared with similar longitudinal cohort studies. WIDER IMPLICATIONS OF THE FINDINGS: This community-based cohort aged 28-33 years provides insights into the contraceptive use, pregnancy loss and family size of a large cohort of unselected women. Women reporting PCOS had lower rates of contraception use and were more likely to be currently trying to conceive, suggesting that they may be aware of potential fertility challenges, yet in those not planning to conceive, contraceptive use was low and further education may be required. Despite prior reports of higher rates of pregnancy loss in PCOS, usually from infertility services, in this community-based population, PCOS was not independently associated with pregnancy loss, yet independent risk factors for pregnancy loss included higher BMI, were higher in PCOS. The number of children per woman was similar in the both groups, albeit with more infertility treatment in PCOS. This may reassure women with PCOS that with access to fertility treatment, family sizes appear similar to women not reporting PCOS.A.E. Joham, J.A. Boyle, S. Ranasinha, S. Zoungas, H.J. Teed

A continuous quality improvement initiative:improving the provision of pregnancy care for Aboriginal and Torres Strait Islander women

Background: Australian Aboriginal and Torres Strait Islander (Indigenous) women are at greater risk of adverse pregnancy outcomes than non-Indigenous women. Pregnancy care has a key role in identifying and addressing modifiable risk factors that contribute to adverse outcomes. We investigated whether participation in a continuous quality improvement (CQI) initiative was associated with increases in provision of recommended pregnancy care by primary health care centers (PHCs) in predominantly Indigenous communities, and whether provision of care was associated with organizational systems or characteristics. Methods: Longitudinal analysis of 2220 pregnancy care records from 50 PHCs involved in up to four cycles of CQI in Australia between 2007 and 2012. Linear and logistic regression analyses investigated associations between documented provision of pregnancy care and each CQI cycle, and self-ratings of organizational systems. Main outcome measures included screening and counselling for lifestyle-related risk factors. Results: Women attending PHCs after ≥1 CQI cycles were more likely to receive each pregnancy care measure than women attending before PHCs had completed one cycle e.g. screening for cigarette use: baseline = 73 % (reference), cycle one = 90 % [odds ratio (OR):3.0, 95 % confidence interval (CI):2.2-4.1], two = 91 % (OR:5.1, 95 % CI:3.3-7.8), three = 93 % (OR:6.3, 95 % CI:3.1-13), four = 95 % (OR:11, 95 % CI:4.3-29). Greater self-ratings of overall organizational systems were significantly associated with greater screening for alcohol use (β = 6.8, 95 % CI:0.25-13), nutrition counselling (β = 8.3, 95 % CI:3.1-13), and folate prescription (β = 7.9, 95 % CI:2.6-13). Conclusion: Participation in a CQI initiative by PHCs in Indigenous communities is associated with greater provision of pregnancy care regarding lifestyle-related risk factors. More broadly, these findings support incorporation of CQI activities addressing systems level issues into primary care settings to improve the quality of pregnancy care.Melanie E. Gibson-Helm, Alice R. Rumbold, Helena J. Teede, Sanjeeva Ranasinha, Ross S. Bailie and Jacqueline A. Boyl