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Press releases Saturday 29 September 2007
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(1) Are midwife led maternity units safe?
(2) Occupational therapy is an effective way of improving the daily life of stroke patients
(3) Vulnerable groups are not at higher risk of physician assisted death
(4) Smoking ban has improved both air and music quality in Irish pubs
(1) Are midwife led maternity units safe?
(Head to Head: Do we have enough evidence to judge whether midwife led maternity units safe?) http://www.bmj.com/cgi/full/335/7621/642No http://www.bmj.com/cgi/full/335/7621/643
The UK government claims it is trying to give women more choice by converting local maternity units to midwife led services. But are they safe? Two experts debate the issue in this week's BMJ.
Lesley Page, visiting professor in midwifery at King's College London, believes that such units improve the birth experience.
The move to have all women give birth in hospital was one of the biggest uncontrolled medical and social experiments of the 20th century, she writes. From 1954 to the 1980s in the UK the percentage of births at home fell from about 35% to 1% in the belief that this would increase safety and reduce the inequalities of care. But this was never evaluated and has never been proved, she says.
The shift has also resulted in a tendency to dehumanisation, particularly in large hospitals, and difficulty in providing personal care appropriate to individual needs.
She believes that birth centres not only provide a further choice for women but also clinical environments where midwives can fully use their skills and provide support for normal birth avoiding necessary intervention.
A one size fits all approach to maternity care is neither advisable nor sustainable, she says. A network of services is required so that women may be referred and transferred when necessary and cared for by the appropriate professional.
Consultant obstetricians have valuable skills that need to be concentrated on the care of women with complicated pregnancies. Safer maternity services are those that recognise and respond to the effects of inequalities and ethnicity, recognise the risk of unnecessary interventions, and support all professionals to play their full part in care, she concludes.
But James Drife, professor of obstetrics and gynaecology at the University of Leeds, remains worried about the risks of delivering outside hospital.
The NHS, which has a near monopoly of childbirth, is promoting midwife units as a way of offering choice and is advising women that they are safe for low risk pregnancies, he writes. But this advice is not based on evidence.
Maternal complications during childbirth are no less frequent than they were in the past, he says, but prompt treatment saves lives every day across the UK, and national maternal mortality is low because emergencies are managed effectively.
However, evidence on safety of midwife led units is lacking. Two reviews suggested trends towards higher perinatal death and, although not statistically significant, they should worry those who want to change patterns of care, he warns. Even in hospitals that have a consultant unit and a midwife led unit in the same building, the evidence is not entirely reassuring.
It is disturbing that in an era of evidence based medicine, midwife led units are being promoted before their safety has been established, he says. The attractions of a relaxed environment and non-intervention are easy to understand, but most women put the highest premium on safety for their baby.
Last year the National Perinatal Epidemiology Unit began an evaluation of alternative locations for labour and birth. Further changes should await reliable evidence on safety and must not be driven by political expediency, he concludes.
Contacts:
Lesley Page, Visiting Professor in Midwifery, Florence Nightingale School of Nursing and Midwifery, King's College London, UK
Email: lesley.page{at}kcl.ac.uk
James Drife, Professor of Obstetrics and Gynaecology, University of Leeds, UK
Email: j.o.drife{at}leeds.ac.uk
(2) Occupational therapy is an effective way of improving the daily life of stroke patients
(Occupational therapy for patients with problems in personal activities of daily living after stroke: systematic review of randomised trials)
BMJ Online First
Occupational therapy can improve the lives of patients who have suffered a stroke and lessen their chances of deteriorating, according to a study published on bmj.com today.
Stroke is the second leading cause of death in the world and the leading cause of serious, long-term disability in adults. Six months after a stroke approximately half of survivors are dependent on others to help them carry out everyday tasks such as eating, dressing and going to the toilet. We already know that rehabilitation is important after a stroke, but don't know enough about the effectiveness of the separate components of the rehabilitation package.
Occupational therapy is defined as the use of purposeful activity designed to achieve outcomes which promote health, prevent injury or disability and which develop, improve or restore the highest possible level of independence. But it has many different components. This study reviewed trials comparing an occupational therapy intervention which focussed on the activities of daily living with a control group where there was no routine intervention.
Researchers looked at nine randomised controlled trials with a total group size of 1258 people. The mean age ranged from 55 to 87.5 years. They found that patients who had undergone occupational therapy after a stroke were significantly more independent and able to carry out everyday tasks. This may not seem surprising, but the study also found that the odds of a poor outcome such as dependency on others and deterioration were also significantly lower.
Lynn Legg and colleagues conclude: "Occupational therapy after stroke "works" in that it improves outcome in terms of ability in personal activities of daily living."
They say further work is needed to define which individuals are most likely to benefit from occupational therapy and which specific interventions are the most effective.
Contact:
Lynn Legg, Research Therapist, University of Glasgow, Scotland, UK
Email: step{at}clinmed.gla.ac.uk
(3) Vulnerable groups are not at higher risk of physician assisted death
(Physician assisted death in vulnerable populations)
http://www.bmj.com/cgi/full/335/7621/625
Claims that vulnerable groups, such as the elderly and people with physical or mental disabilities, are at an increased risk of physician assisted death are not supported by evidence, says an expert in this week's BMJ.
Physician assisted death (both voluntary active euthanasia and physician assisted suicide) has been openly practiced in the Netherlands for more than 25 years and was formally legalised in 2002. Physician assisted suicide was also legalised in Oregon in 1997, writes Professor Timothy Quill of the University of Rochester, USA.
Many concerns still surround the practice, but evidence now exists to answer questions about the risks and benefits of legalisation.
For example, a study published in this week's Journal of Medical Ethics analysed data from Oregon and the Netherlands and found no increased incidence of physician assisted death in elderly people, women, people with low socioeconomic status, minors, people with physical disabilities or mental illness.
These findings call into question the claim that the risks associated with legalisation will fall most heavily on potentially vulnerable populations, says Quill.
Further evidence dispels the concern that these practices become more common over time. In Oregon, physician assisted death accounts for around one in 1000 deaths each year, with no significant change in frequency over nine years. The Dutch practices of physician assisted death have also remained stable over the duration of four studies, and hospice and palliative care have become more prevalent in recent years.
Evidence from the US also shows higher rates of assisted death in areas where these practices are prohibited than in Oregon after legalisation. Although the data are not directly comparable, none the less, it raises the possibility that legalisation and regulation with safeguards may protect rather than facilitate the practice, says Quill.
The argument that legalisation is a slippery slope is also not supported by the evidence, he adds. A recent study found that four out of six Western European countries where assisted death is illegal had a much higher incidence of unreported cases than is seen in the Netherlands.
Finally, limited data suggests that the practice of terminal sedation, which has been legal in the US since 1997, accounts for up to 44% of deaths, while in the Netherlands, it accounted for 5.6% of deaths in 2001 and 7.1% in 2005.
These days, patients who are dying are faced with a wide array of uncertainties and choices, and the physical and psychological challenges they experience are more complex, says Quill.
Studies help clarify the risks and benefits of controversial practices like physician assisted death or terminal sedation and suggest that outcomes are more favourable when practitioners work together with patients and families in an open and accountable environment.
Patients who are dying and their families need us to be as objective and honest as possible in these deliberations, he concludes.
Contact:
Timothy Quill, Professor of Medicine, Psychiatry and Medical Humanities, University of Rochester School of Medicine, Rochester, NY, USA
Email: timothy_quill{at}urmc.rochester.edu
(4) Smoking ban has improved both air and music quality in Irish pubs
(Confessions of an accordion cleaner)
http://www.bmj.com/cgi/full/335/7621/630-b
The smoking ban has not only improved air quality in Irish pubs but also appears to have improved the quality of the music, according to doctors in a letter to this week's BMJ.
The pub session (or seisiún in Gaelic), where musicians gather to play traditional music together, is commonplace throughout bars in Ireland, write John Garvey and colleagues. Instruments include the accordion, concertina, melodeon and Uilleann (or Irish) bagpipes, all of which are bellows-driven instruments.
There is, they say, anecdotal evidence that the interiors of accordions played regularly in smoke-filled environments are dirtied as a result of the trapping of contaminant particles circulating in the air as it filters through the instrument.
So they conducted a telephone survey of all workers involved in the cleaning, repair, maintenance, and renovation of accordions in the Republic of Ireland. They managed to contact six out of seven such workers.
All participants pointed out that a strong smell of cigarette smoke emanated from accordions played in a smoke-filled environment when they are opened. Soot-like dirt is also deposited throughout the instrument but particularly where air enters the bellows through the air inlet valve and on the reeds.
One repairer commented that the deposition of dirt could be substantial enough to affect the pitch of the reed. Two others claimed that if a musician tended to play in a particular key, that this could be determined from the distribution of dirt around particular reeds.
All who were questioned stated categorically that these signs had definitely improved in accordions they had worked on since the introduction of the smoking ban in Ireland.
The authors conclude: "Our results provide further evidence that the smoking ban has improved air quality in Irish bars and its implementation in the face of initial opposition has been music to the ears of the people of Ireland."
Contact:
John Garvey, Specialist Registrar, Pulmonary and Sleep Disorders Unit, St Vincent's University Hospital, Dublin, Republic of Ireland
Email: john.garvey{at}ucd.ie
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