Outcome of planned home births in an inner city practice.

OBJECTIVE--To assess the outcome of pregnancy for women booking for home births in an inner London practice between 1977 and 1989. DESIGN--Retrospective review of practice obstetric records. SETTING--A general practice in London. SUBJECTS--285 women registered with the practice or referred by neighbouring general practitioners or local community midwives. MAIN OUTCOME MEASURES--Place of birth and number of cases transferred to specialist care before, during, and after labour. RESULTS--Of 285 women who booked for home births, eight left the practice area before the onset of labour, giving a study population of 277 women. Six had spontaneous abortions, 26 were transferred to specialist care during pregnancy, another 26 were transferred during labour, and four were transferred in the postpartum period. 215 women (77.6%, 95% confidence interval 72.7 to 82.5) had normal births at home without needing specialist help. Transfer to specialist care during pregnancy was not significantly related to parity, but nulliparous women were significantly more likely to require transfer during labour (p = 0.00002). Postnatal complications requiring specialist attention were uncommon among mothers delivered at home (four cases) and rare among their babies (three cases). CONCLUSIONS--Birth at home is practical and safe for a self selected population of multiparous women, but nulliparous women are more likely to require transfer to hospital during labour because of delay in labour. Close cooperation between the general practitioner and both community midwives and hospital obstetricians is important in minimising the risks of trial of labour at home.     

Preventing iron deficiency in preschool children by implementing an educational and screening programme in an inner city practice.

OBJECTIVE--To assess the feasibility and acceptability of screening young children for iron deficiency in a deprived inner city practice and to assess the effects of a programme of dietary education. DESIGN--Prospective study of children in general practice, comparison with historical controls. SETTING--A deprived inner city practice. PATIENTS--127 Children aged 13-24 months. Findings were compared with those in 110 children of the same age studied previously. INTERVENTIONS--All mothers received dietary education antenatally and in the first year after giving birth. Screening for iron deficiency (defined as mean cell volume less than 75 fl and haemoglobin concentration less than 105 g/l) and haemoglobinopathy (when appropriate) was offered for all children attending for immunisation against measles, mumps, and rubella over 12 months; capillary blood samples were taken after immunisation. MAIN OUTCOME MEASURES--Uptake of the screening programme expressed as the percentage of all children eligible for immunisation who were screened, and the effectiveness of the dietary education as shown by the prevalence of iron deficiency in the two groups. RESULTS--Altogether, 122 of the 127 (96%) children who attended for immunisation had their haemoglobin concentration and mean cell volume measured; 90% of all children aged 13-24 months in the practice were screened. Dietary education, clinical procedures, and counselling were incorporated successfully into the clinic''s work. Ten children (8%) were iron deficient, all of whom responded to iron supplements, and eight had a haemoglobinopathy trait. In the previous study 110 children (70%) had been screened and 28 children (25%) had been iron deficient. The two groups were similar in terms of sex, social class, and ethnic group. CONCLUSIONS--Screening young children for iron deficiency, sickle cell disease, and thalassaemia when they attended for immunisation was acceptable and successful in a socially deprived inner city practice. Dietary education may have accounted for some of the reduction in the prevalence of iron deficiency that occurred over the two years.     

Mobile patients in an inner London practice.

In an area with the most highly mobile population in Britain 10% of the consultations in one practice were with temporary residents and a further 10% with newly registered patients. We analysed data gathered in 1980 about these two groups and about established patients that included demographic characteristics, the diagnoses made, and the actions taken by the doctors. Temporary residents caused a considerable amount of administration, but they were relatively straightforward to deal with medically and the practice received compensation for the work; with new patients problems were more time consuming, both clinically and administratively, and there was no financial compensation. A practice with a high turnover of its registered patients is at a considerable disadvantage compared with one in a more settled area.     

Cervical screening in an inner city area: response to a call system in general practice.

To determine whether a cervical screening call system based in general practice in a deprived inner city area would increase the numbers of women who came forward for cervical smears the response to letters of invitation for screening was monitored for one year in one general practice in the Paddington and North Kensington district of London. Women aged 20-64 were identified from the computerised age-sex register. Only 16% of these women had had a smear test. A total of 750 call letters was sent out. Initially the response was poor (57 women; 22%), and 85 (32%) letters were returned marked "address unknown." After the age-sex register was updated the response to call was 330 women (44%). The response of women aged over 35 was better than the response of women aged 35 and under (229 (53%) v 101 (32%)). In the year of the study the number of women aged 20-64 on the revised register who had been screened rose by 330 (14%). A general practice based call system can improve uptake of cervical screening even in a highly mobile, socially underprivileged population.     

First year of an inner city general practitioner community hospital.

The first inner city general practitioner community hospital opened on 4 January 1982. This paper describes the operation of the hospital over the first 12 months. There were 316 admissions, with an average length of stay of 13 days. The average age of the patients was 73 and the most common reason for admission was disease of the respiratory system. Thirty five per cent of patients were admitted because of an acute illness and 37% were admitted on the same day as the request for admission. The policies of intermittent or phased care allowed for the admission of patients at regular intervals to relieve carers, and the assessment of the home circumstances of all patients allowed for planning the patient''s return home.     

Acceptability of an oral contraceptive that reduces the frequency of menstruation: the tri-cycle pill regimen.

The frequency of menstruation was reduced to once every three months in 196 women by the continuous administration of the oral contraceptive pill, Minilyn, for 84 days (tri-cycle regimen). No pregnancies occurred. One hundred and sixty-one women (82%) welcomed the reduction in the number of periods with the associated freedom from menstrual and premenstrual symptoms, and many found the tri-cycle regimen easier to follow. Weight gain of more than 2 kg, irregular cycle control, especially in the first three months, breast tenderness, and headaches were the main side effects. Menstrual loss was unchanged or reduced in all but seven women. The doctors and nurses on the clinic staff were less enthusiastic about this regimen than the volunteers themselves.     

Psychiatric morbidity in a general practice in an Indian city.

Psychiatric morbidity in an Indian general practice was studied using the 12 item version of the General Health Questionnaire to screen 882 patients who represented 9000 consecutive adult patients attending the practice. The questionnaire was valid with a cutting score of 1/2 when compared with section 1 of the standardised Indian Psychiatric Survey Schedule. The probable prevalence of psychiatric morbidity was 35.9%. The general practitioner identified only about 25% of patients. Five of the 12 questions on the General Health Questionnaire had a higher discriminatory capacity, and the performance of the patients on these five questions was valid when compared to section 1 of the Indian Psychiatric Survey Schedule.     

Evaluation of the cervical cytology screening programme in an inner city health district.

District health authorities have been instructed to operate a cervical cytology call and recall screening programme using the age-sex registers held by family practitioner committees. A detailed evaluation of implementation in an inner London district showed that 477 out of 687 (69%) invitation letters sent to women by the family practitioner committee were either inaccurate or inappropriate: almost half of the recorded addresses were incorrect and a further fifth of the women were not eligible for a test. Overall, 90 women had a smear, which is only 13% of the total but 43% of those found to be eligible. The findings did not differ significantly with age. The findings have major implications not only for the effectiveness of call and recall for screening for cervical cancer but also for the future development of screening for breast cancer in such areas.     

Factors associated with home visiting in an inner London general practice.

We decided to examine the services provided by doctors in an inner London practice for domiciliary care. It was expected that the study would highlight the most relevant questions and variables related to access and uptake of this service; it would thus contribute to the design of an accurate procedure for auditing the pattern of delivery of home care to be conducted in the practice in the future. During the study period, 1976-81, there were 90 500 doctor-patient contacts. For patients up to the age of 10 years the proportion of home visits was 9.2%, falling to 2.2% in the age group 20 to 29; then there is a quasi plateau till the age of 60. After 60 the proportion of home visits doubles in each of the following 10 year age groups, reaching 54% in the over 80s. The proportion of home visits (standardised by age) rises from social class II (8.0%) to social class V (10.0%), but is higher in social class I (11.7%). The proportion of home visits according to distance from the practice rises from 8.2% near the health centre to 9.6% at a distance of 0.25 to 0.50 mile, and drops to 8.8% beyond 0.75 mile. The distance effect is not consistent when the social class dimension is added: social classes I and II have higher proportions of home visits in certain age and distance groups. Single people have the lowest proportion of home visits (6.8%); there are large differences between men and women among widowed (14.1% and 8.6% respectively) and divorced or separated (7.0% and 10.7% respectively) patients. There are important variations in the proportions of home visits made by the doctors in the practice, the trainees carrying out proportionally many more home visits. Data collected in the practice can be used to define specific issues for future audit exercises. Furthermore, sociodemographic characteristics of patients have been shown to be associated with use and access to medical services.     

Quality of care and contraceptive pill discontinuation in rural Egypt

Indicators of family planning service access and quality were generated using the Egypt DHS-I (1988) and the Egypt Service Availability Survey (1989), and linked to episodes of contraceptive pill use. Multilevel analysis was used to ascertain whether or not these access and quality indicators influence the continuation of pill use, net of women's socioeconomic, demographic and motivational characteristics. A model with random components at the cluster and women levels was fitted for all reasons of discontinuation, except desire for pregnancy, at 24 months of use. Net of women's background characteristics, the results show that facilities with smaller numbers of health personnel trained in family planning, a lack of access to facilities with female doctors and a lack of range of available methods are associated with a high risk of discontinuation of pill use for all reasons except desire for pregnancy.