Effects of Interventions in Pregnancy on Maternal Weight and Obstetric Outcomes - Assignment Example

NURSING RESEARCH CRITIQUE Nursing Research Critique Introduction The aim of this case study is to critique research papers related to nursing practice. The paper aims at finding strengths and weaknesses and also analyse knowledge in three selected researches that have been carried out within United Kingdom. Research papers to be critiqued in this case study are Effects of Interventions in Pregnancy on Maternal Weight and Obstetric Outcomes: Meta-Analysis of Randomised Evidence carried out by Thangaratinam et al., Antenatal lifestyle advice for ladies or women who are overweight or obese: LIMIT randomised trial by Dodd et al. and Exploration and confirmation of factors associated with pregnancy that is uncomplicated in nulliparous women: prospective cohort study by Chappbell and colleagues. The three research papers have been selected for critiquing. Questions will be formulated from a consultant-client session, where by a ‘PICO’ question format will be employed. A rationale for the question will also be formulated. Answers to the questions will be sought using the Carper’s (1978, p. 10) frame work that he developed for consultation in a nurse-patient scenario. Associated ideas learnt in class will also be included in the case study. The original framework developed by Carpers will be utilized. It will comprise of the following sections: empirical, personal, aesthetic, socio political and ethical sections (Carper, 1978, p. 11) The empirical section will comprise of a review of three research papers. A description of strategies used to search for literature and rationale for the choices made will be included in this section. A critical appraisal of the papers and empirical evidence for the research will also be documented in this section. At the end of the section, a summary of findings from the literature search will be included. The ethical section of the case study will seek to demonstrate that ethical principles are applicable as shown in clinical decisions and evidence presented during appraisal of the research papers. Personal, social political and aesthetic sections will also be presented. Parts of the paper to be critiqued include: data analysis and sampling methods. Recommendation and conclusion section will explore the research papers in a view to clarify and also question certain practices used in the research paper. Future research in the various fields of the research papers will be highlighted (Petry, 2014, p. 35). Clients involved in this study comprised of women in various stages of pregnancy and with varying weight related issues. The clients were seeking for information on how to manage weigh gaining during their pregnancy term. The consultation aimed to establish the conditions under which the women carry the pregnancy. Weight of the women was the most significant characteristic as it is associated with a myriad of problems in carrying a pregnancy to full term. Over weight in pregnant women is associated with bone fractures while being underweight is associated with increased rate of miscarriages. Questions arising from the consultation are: Question no. 1: ‘In pregnant women, is being overweight, as compared to having normal body weight, associated with bone problems?’ Rationale of the question: overweight in pregnant women increases the occurrence of bone fractures and back pains. Therefore, the question aim to establish the category of women at a higher risk of weight related problems between overweight and normal weight women. PICO analysis: P Population/ patient = patient with weight problems during pregnancy I Intervention/ indicator = being overweight C Control = women of normal weight O Outcome = increase in weight associated back pain and bone fractures Question no. 2: ‘In pregnant women between 15 to 20 weeks of gestation, is there an increase in factors associated with complicated pregnancy, compared to other stages of pregnancy?’ Rationale of the question: gestation period between the 15th to 20 weeks is associated with a rise in pregnancy complications. Therefore, there is a need to establish the varying degree of pregnancy complications during the gestation period. P Patient = patients in the 15th to 20th week of gestation. I Intervention = C Control = rest of pregnancy term. O Outcome = increase in pregnancy complications. Question no. 3: ‘In pregnant women with weight problems, do lifestyle interventions and antenatal dietary, compared to normal prenatal dietary interventions, reduced obesity rate? Rationale for the question: lifestyle and dietary interventions play an important role or function in reducing chances of pregnant women from developing obesity. Therefore, there is need to investigate whether, lifestyle and dietary interventions are effective in reducing obesity as compared to the normal prenatal dietary interventions. P Patient = pregnant women with weight problems I Intervention = lifestyle and antenatal dietary interventions C Control = normal prenatal dietary interventions O Outcome = reduced obesity rate Critique of ‘Antenatal Lifestyle Advice for Women Who Are Overweight or Obese: Limit Randomised Trial’ By Jodie M. Doddand and Colleagues This paper was edited and published in the British Medical Journal on 10th February 2014. To critique the study, first, it is important to find out whether the study carried out clearly targeted a focused issue. The research was carried out in three maternity hospitals owned by the government across South Australia. A total of 2212 women at a gestation period of 10+0 and 20+0 weeks were recruited for the research. Only the healthy women were involved in this study and were required to have a singleton pregnancy. A telephone randomised server that used computer generated schedule was used (Petry, 2014, p. 43). The health issue studied was the role of lifestyle and dietary interventions played in determining the outcome in obese pregnant women. The measure of the study main outcome was the incidence of infants born with a birth weight of ≥ 90th centile for sex and gestation. Secondary outcomes were already pre-specified and comprised of hypertension, birth weight exceeding 4000g, pre-eclampsia and gestational diabetes. Analysis carried out utilised intention in treating principles (Dodd, J., Turnbull, D., McPhee, A., Deusse, A., Rosalie, M. and Crowther, C. 2014, p. 2). The research is a multicentre randomised trial whereby the researchers utilised a central randomisation telephone server that utilised schedules that were computer generated and the body mass index of the participants was recorded. The trial is appropriate to determine the effects of lifestyle and dietary intervention in the health outcomes in overweight and obese women. In the trial, the authors involve 2212 women as they provide a substantial pool of participants whose results can be compared. Participants recruited for the trial comprise of women from three metropolitan area hospitals. These areas are comprised of women who have a high rate of developing obesity during pregnancy. Eligible recruits were required to have singleton pregnancy and a BMI of ≥25 and in the 10+0 to 20+0 week gestation period. This category of women are characterised by little addition of weight as compared to those with twin birth. Hence it is possible for the researchers to follow up the participants as they are expected to exhibit linear weight addition (Dodd, et al., 2014, p. 4). 2212 participants from 3 maternity hospitals were selected. 1108 of the women were put through lifestyle and dietary interventions while the control group comprised of 1104 women who were put under standard care according to guidelines in the local guidelines. The sample used by the researchers is not a proper representative of the national population of Australia. To fully represent the population of the country, the researchers should have expanded their research to a bigger proportion of the population. The findings of the research are therefore not representative of metropolitan areas of South Australia and Adelaide. However, decision by the researchers to include singleton pregnancies only rather than twin pregnancies make the finding credible. This is because as biasness associated with high addition of weight exhibited by women carrying twins is eliminated (Dodd, et al., 2014, p. 5). The researchers do well to eliminate biasness associated with measurement and classification. Measures taken to eliminate the biasness were implemented from the first day of the trial. The height and BMI of the participants were calculated during the initial antenatal appointment. Eligible women were randomised by calling a central randomisation service before receiving standard care or lifestyle advice. This measure ensured that the biasness in recruitment was eliminated. The researchers adopted objective measures throughout the research whereby, balanced variable blocks in the ratio of 1:1 were utilised by the computer generated randomised schedule. An official not involved in the trial was involved in the randomisation exercise in order to eliminate biasness that would arise. To reduce biasness in the exercise further, officials involved in assessing outcomes were blinded to the allocated treatment groups. The measures applied by the researchers are standard in most clinical trials. Measures applied are validated as they are internationally recognised as the best practices in managing pregnant women through out the gestation period (Dodd, et al., 2014, p. 3). The research paper has not explicitly outlined how data was collected from the field. The researchers have included the outcomes without including a proper data collection method in the report. The initial pages of the report have however informed us that the data was collected from the participants though direct measurement of weight and height. These records were preserved in order to track weight changes in the participants. Most of the data also seems to have been collected through interviews and questionnaires for example demographic data. There is no further indication of any other method to have been applied by the researches in the report (Dodd, et al., 2014, p. 4). The participants recruited for the trial are not sufficient for a nation study. They are not a representative sample of the Australian population as the study focuses on only three metropolitan areas. Further more, the researchers have not included any power calculation of how they came up with a sample of 2202 people out of all the pregnant women in the three maternity facilities. Therefore, the participants of this research are not sufficient to make any informed decisions or recommendations that are expected to affect the national population as aimed by the research paper (Dodd, et al., 2014, p. 6). The results have been presented as proportions of women who were first to be contacted by the researchers. This figure has been broken down into smaller proportions in a table, highlighting in percentages the number of women who consented to taking part in the trial. Using a flowchart like diagram, the proportion of randomised women who took part in lifestyle advice and standard care has been presented. The results have also been presented as measurements such a median to show median BMI of the participating group. The presented results are effective in summing up the outcomes of the research (Dodd, et al., 2014, p. 17). Data analysis in the report is sufficiently rigorous as the researchers have described the analysis process in details. Log binomial regression was applied to analyse binary outcomes with Fisher’s exact tests used to express treatment effects. To analyse continuous outcome, linear and Poisson regression were used. Data presented include: birth weight in relation to outcomes of maternal age, maternal smoking and social economic status of the parents. Data on maternal age at the time of giving birth is also correlated to the birth weight. The data is sufficient to support the findings that there is no difference in birth outcomes and maternal pregnancy between the two treatment groups (Dodd, et al., 2014, p. 1). The findings are explicit in that lifestyle and dietary advice to pregnant overweight women do not reduce risk of giving birth to large infants for their gestational age but is associated to a significant reduction of infant weight above 4,000g. The researchers also adequately discuss the strengths and limitations of the randomised trial. The credibility of their findings being pegged on the robust methods used as compared to previous research. The original research question is adequately answered by the findings (Dodd, et al., 2014, p. 9). The results of the study can be applied to the local population but with varying degree of success. This is due to various challenges that have also been appreciated by the researchers such as economic cost to be incurred in providing the unique needs to every woman and the additional prenatal clinic attendances that they are required to fulfil. The researchers have sufficiently compare the results of the study with existing literature. Institute of Medicine guidelines show that 42% of the participants gained excess weight. The findings are consistent with the report of Sebire and colleagues who carried out their research using the UK population and found out that infants were likely to have more weight if born to obese mothers (Dodd, et al., 2014, p. 24). Critique of ‘Exploration and Confirmation of Factors Associated With Uncomplicated Pregnancy in Nulliparous Women: Prospective Cohort Study’ By: Lucy C. Chappell and Colleagues This research paper was published in British Medical Journal on 21st November 2013. The paper seeks to find out the factor associated with uncomplicated pregnancy during the 15th to 20th gestation week. The mother may pose risks to the pregnancy from her lifestyle habits during this gestation time. These include smoking, drug abuse and alcohol abuse. The population studied comprised of nulliporous women carrying a single baby from Adelaide, Australia, Auckland, New Zealand, Leeds and Manchester all in UK and Cork in Ireland. Data bases containing reproductive information of 5628 women from the location identified were accessed by the researchers for analysis (Cha, L., Seed, P., Myers, J., Taylor, R., Kenny, L. and Dekker, G. 2013, p. 1). The researchers carried out an observational multicentre cohort study spread all over UK and Australia. A cohort study is the most appropriate approach for such a study as the participants were geographically distributed. The study question of this clinical study is efficiently answered by following life histories of the population segments of interest in order to establish factors behind uncomplicated pregnancy. Furthermore, the population segments targeted in these countries are not infected by any disease and therefore, their reproductive data from hospital data bases is sufficient to answer the study question (Cha, et al., 2013, p. 5). 5628 participants were recruited for the study and were from Australia, Ireland and the United Kingdom. Observational multicentre places in the various cities were able to recruit women for the study. This sample population is representative of pregnant women in their 15th to 20th week of gestation. Hence, results from this study are applicable to all women in the four countries between their 15th to 20th weeks of gestation. The sample population is thus a sufficient representation of the target population. However, if the sample population is meant to be representative of the total population of these three countries, it would be insufficient since the samples are taken from several cities such as Adelaide, Auckland, Leeds, Manchester and Cork. Thus, the sampled population should be increased to cover most parts of the three countries for its results to be representative (Cha, et al., 2013, p. 3). Measures used by the researchers in this study are objective. This study’s main outcome measure was the group of women with uncomplicated birth. These were designated to be those with normotensive pregnancy usually delivered at or after 37 weeks of gestation. The birth results in a liveborn who is not small as per the gestation age. The comparison group consist of women who had complicated pregnancy. This measure applied by the researchers is sufficient to answer the study question as comparison of the two groups of women will yield sufficient outcome needed to identify factors that result in an uncomplicated birth in women (Cha, et al., 2013, p. 7). Data collection methods applied focused on collecting data about the participants from primary health care givers from the participating countries. The researchers diversified the areas from which to recruit the participants in order for the findings to be representative of a bigger population. The researchers have also made it clear that primary data was extracted from the participants through primary health care givers such as obstetricians, laboratory technicians, nurses and doctors. Afterward, the mined data was fed to a data base through the internet for it to be shared with the researchers. The researchers have not justified the reasons behind setting up a database rather than being on the ground. However, the researchers have explicitly explained how the primary health care givers collected data from the participants and fed it to the common data base. They were also required to recheck the data entered to minimise errors entered. More so, participants with missing data were required to be followed up by the recruited primary health care givers (Cha, et al., 2013, p. 6). The researchers recruited a total of 5628 from the three countries selected. There is no formula included in the report to show how the researchers arrived at this number of participants. However, the researchers have shown how they have broken down the sample population to individual sample groups each from the participating countries. They chose to use a random selection at arriving at the number of women to recruit from each country. Through this method, they arrived at 3196 from Australia and New Zealand while the remaining 2432 were recruited from Republic of Ireland and United Kingdom (Cha, et al., 2013, p. 4). The results are presented as proportions where by 61.3% of the women had uncomplicated pregnancy while the rest had complicated pregnancy. Tables have been employed throughout the report to present the proportions of various outcomes. The proportions are invaluable in concluding that Ireland and United Kingdom had lower level of complicated pregnancies at 58.6% as compared to Australia and New Zealand at 63.5%. Tables have also been used to present the reasons and factors as to why pregnancy may be categorised as being complicated while another as being uncomplicated. The results are therefore applicable to the populations of the participating countries as they have clearly identified factors responsible for uncomplicated pregnancies (Cha, et al., 2013, p. 5). Data analysis in this report have been deeply described to the extent that the researchers have divided the datasets of the sample population of 5628 women into participants to be recruited from all the four countries. 86 variables were identified based on whether questions were asked directly or were derived. The participants were grouped depending on family circumstances for example ethnicity and maternal history. The rest of the groups were categorised on the basis of medical risks, general risks and their obstetric history as well as diet. Stata software version 11.2 was use to conduct data analysis whereby, binomial regression was used to estimate risk ratios. There is enough data presented by the researchers to support their finding that factors responsible for complicated pregnancy are: body mass index, drugs misuse in the 1st trimester and an average blood pressure (Cha, et al., 2013, p. 5). The findings are explicit in the report as the factors responsible for complicated birth have been identified as body mass index, drugs misuse in the 1st trimester and an average blood pressure. Beneficial practices likely to result in uncomplicated pregnancy are increased intake of fruits before getting pregnant, family history and being in a paying employment. The researchers have also discussed in details the strengths and weaknesses of the research. The main strength identified is the research has an international set up. The main weakness is that the list of identified variables is not all inclusive and not applicable to other populations of women. Credibility of the research arises from the fact that its findings are comparable with other studies (Cha, et al., 2013, p. 6). The results are generally inapplicable in the local setting as the subjects covered in the research are women who have no medical problems. Such a requirement can not be applied in a normal population as pregnant women can be healthy or sick. More so, in the local settings, multiparous women are part of the population. For the results to be applicable, such a research should be carried out without segregating multiparous women and those with medical problems. The researchers have also reported that no other research have been carried out using the same approach as they have. Hence, they recommend for further research to be carried out in the same approach as theirs. This would make it possible for comparisons to be made between different populations all over the world (Cha, et al., 2013, p. 5). Critique of ‘Weight and Obstetric Outcomes: Meta-Analysis of Randomised Evidence’ By S. Thangaratinam and Colleagues This research paper was published in the British Medical Journal on 17th May 2012. The researchers sought to investigate how lifestyle and dietary interventions influence both foetal and maternal weight. They also aimed at quantifyng the relationship between the interventions and obstetric outcomes. The population studied comprise of 2212 women sourced from database maintained by Medline, BIOSIS, Embase, Science Citation Index, LILACS, Database of Systemic Reviews (CDSR), Cochrane Central Register of Controlled Trials (CENTRAL), Health Technology Assessment Database (HTA), Database of Abstracts of Reviews of Effects (DARE) and PsychInfo (Thangaratinam, S., Rogozińska, E., Jolly, K., Glinkowski, S., Roseboom, T. & Tomlinson, J. 2012. p. 5). This is an observational study and is appropriate to answer the study question of the research. This research investigates the effects of lifestyle and dietary intervention during the gestation period. Pregnancy being a characteristic of a particular group of the population makes the research an ideal example of an ideal descriptive study. Information about the participants is accessed from databases maintained by major health organisations. Such information has been collected over a period of time and enables the researchers interact with the participants’ health information (Thangaratinam, et al., 2012. p. 7). 2212 women were recruited for the study from 215 research papers extracted or retrieved from databases. A review of the literature and analysis was able to come up with the category of women who during their pregnancy reported back the effects of lifestyle and dietary interventions. The researchers were also able to classify the intervention depending on whether they are based on physical activity, diet, or an application of mixed approach between physical activity and diet. Researchers have not indicated the origin of the participants in order to establish if they represent a definite population. Hence, it is not possible to decipher if the sample population is appropriate for the study (Thangaratinam, et al., 2012. p. 7). Measurements of the study comprise of three groups of women based on the intervention they reported to observe. The first group observe diet intervention while the second observe physical activity intervention. The third group observed a mixed approach of interventions comprising of both physical and dietary measures. The three measurements are appropriate for this study as the study question will be appropriately answered. Results from the three groups of pregnant women were compared and contradicted by the researchers in order to come up with findings that are applicable in other populations (Thangaratinam, et al., 2012. p. 9). Data about the subjects of the study was collected from databases maintained by Medline, BIOSIS, Embase, Science Citation Index, LILACS, Database of Systemic Reviews (CDSR), Cochrane Central Register of Controlled Trials (CENTRAL), Health Technology Assessment Database (HTA), Database of Abstracts of Reviews of Effects (DARE) and PsychInfo (Mahmood and Arulkumaran, S. 2012, p. 68). Retrieving such large amounts of data from databases is a cheap and effective method to carry out a study rather than being on the ground collecting information. The researchers have not justified why they chose to review research papers from databases rather than carry out the research while on the ground. There is no explicit method of data collection such as interviews that the researchers used to collect data (Thangaratinam, et al., 2012. p. 2). The results of the study indicate that 44 control trials from the databases composed of women who reported about using three intervention measures through out the gestation period. From the results, the researchers have concluded that mothers who observed lifestyle and dietary intervention gave birth to babies with an average reduction of 1.42 kg in weight as compared to bays born to mothers who did not observe intervention measures. The researchers have not included any formula to explain how they came up with a population sample of 2212 women (Thangaratinam, et al., 2012. p. 3). The results are presented in tables whereby the proportions of women observing lifestyle and dietary intervention are shown in percentages. Bar graphs have also been extensively used to present the characteristics of the participants recruited for the study and also the intervention they took to throughout the pregnancy period (Branca, Nikogosian and Lobstein, 2007, p. 34). The mean difference of weight gained during the gestation period in women observing intervention measures has also been presented as a table. These results are meaningful in that they enable us make conclusions on the research problem being investigated (Thangaratinam, et al., 2012. p. 7). Data analysis performed on data collected is rigorous enough as the researchers have dedicated it a large section of the report. The researchers have performed an analysis of variance on individual subgroups of the women using intervention measures. The effectiveness of these intervention measures has also been analysed so as to determine the most effective measure. Findings of the research are explicit in that they have answered the study question. The researchers found out that lifestyle and dietary interventions during pregnancy effectively reduced gestational weight and no adverse effect on babies being small for their gestational age (Thangaratinam, et al., 2012. p. 1). The researchers have outlined the strengths and weaknesses of their research. They have identified the strength of their research to be in their ability to carry out a review that was comprehensive in its search and scope. Their main weakness and failure lies in their inability to identify optimal changes in weight after interventions meant to minimise both foetal and maternal complications. The findings of the research are applicable in my local settings as the groups of women covered by the research are in similar conditions as my local settings (Thangaratinam, et al., 2012. p. 3). Overview Summary The essay critiques three research papers with clinical findings. The studies were done or carried out in the United Kingdom, Ireland and Australia and focuses on the health and wellbeing of both pregnant women and their babies. The papers were published in the British Medical Journal. The structure of the critique essay is first discusses whether the study clearly addresses a focussed issue (Branca, et al., 2007, p. 36). To answer the question, the population being studied is analysed with a view to establish it characteristics and the size of the sample population. The health measures studied are also explored with a view to establish the risk factors that the researchers took into account, the expected outcomes and preventive behaviour that the researchers expect to meet (OLeary, 2009, p. 34). The method used by the researchers to answer the study question is also reviewed. To critique this section, the project design is identified whether it’s a cross-sectional or descriptive study making it possible to determine whether the study question has been appropriately addressed. Method used by the researchers to recruit the subjects is also questioned. Is it an acceptable way? The aim is to find a selection bias in the recruitment of the subjects and if the results have been compromised. The sample size is examined to establish whether it is representative of the population and whether anyone else should have been included as a subject in the research (Sokol and ‎Sokol, 2007, p. 76). The measurements used in the research are also reviewed with an aim to establish whether the sample population has been divided into the appropriate groups in order to answer the study question. Data collection methods are also reviewed with an aim to establish whether the methods used were justified. The review also aims at establishing whether other explicit data collection methods such as interviews and surveys were used. The number of participants is also reviewed in order to establish whether they are enough for the study. Any power formulas used by the researchers to come up with a sample population are noted (Bogaerts, 2013, p. 65). Presentation methods of the results are also critiqued so as to establish whether they are effective. The review aims at establishing if the results are presented as proportions or measurement. Graph, table and statistical tools used are also noted down. Data analysis methods employed and their effectiveness is also critiqued. This aims at establishing whether the depth of data analysis employed is sufficient to support the research findings. The critique essay also aims finding out if the research has its findings explicitly presented. Their credibility and any relationship to other published papers are noted down. In conclusion, the critique essay aims explores whether the published finding are in any way applicable to the local settings (Petry, 2014, p. 45). References Bogaerts, A. 2013. Obesity and Pregnancy. Brussels: Maklu Publishers. Branca, F., Nikogosian, H. &‎ Lobstein, T. 2007.The Challenge of Obesity in the WHO European Region and the Stratergies for Response. Geneva: World Health Organization. Carper, B. A. 1978. Fundamental Patterns of Knowing In Nursing. Advances in Nursing Science, 1(1), 13-23. Cha, L., Seed, P., Myers, J., Taylor, R., Kenny, L. & Dekker, G. 2013. Exploration and confirmation of factors associated with uncomplicated pregnancy in nulliparous women: prospective cohort study. British Medical Journal, 347 (f6398). Dodd, J., Turnbull, D., McPhee, A., Deusse, A., Rosalie, M. & Crowther, C. 2014. Antenatal lifestyle advice for women who are overweight or obese: limit randomised trial. British Medical Journal, 348 (g1285). Mahmood, ‎T. & Arulkumaran, S. 2012. Obesity: A ticking time bomb for reproductive health. London: Newnes Publishers. OLeary, J. 2009. Shoulder Dystocia and Birth Injury: Prevention and Treatment. New York: Springer. Petry, C. 2014. Gestational Diabetes: Origins, Complications, and Treatment. New York: CRC Press. Sokol, A. & ‎Sokol, E. 2007. General Gynecology: The Requisites in Obstetrics and Gynecology. New York: Elsevier Health Sciences. Thangaratinam, S., Rogozińska, E., Jolly, K., Glinkowski, S., Roseboom, T. & Tomlinson, J. 2012. Effects of interventions in pregnancy on maternal weight and obstetric outcomes: meta-analysis of randomised evidence. British Medical Journal, 344 (2088). Read More