text:
The country’s newest COVID-19 patient is an Antiguan and Barbudan national. That is all the information we have at this time.
This information was shared in the Cabinet notes, which were distributed Thursday morning.
Here is the information:
The Minister of Health reported on the state of the Covid-19 pandemic in Antigua and Barbuda. Up until the start of C
abinet, no cases of Covid-19 were being treated in Antigua and Barbuda. The protocols established by the Cabinet and the advice rendered by the medical professionals have resulted in the superb management of the disease in the island-state.
The Minister stressed the need to remain vigilant and encouraged adherence to the wearing of masks, the frequent washing of hands, to social distancing and proper etiquette when sneezing, coughing and speaking to others. He credited the absence of domestic spread and of community spread in Antigua and Barbuda to the adherence of the population to the rules established in the law and in the regulations.
In the post-Cabinet period, the Minister announced on radio that one case of Covid-19 has been confirmed from tests submitted to CARPHA. So that there is one Antigua and Barbuda national who is currently being treated for the disease.
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Antenatal care trial interventions: a systematic scoping review and taxonomy development of care models
BMC Pregnancy and Childbirth volume 17, Article number: 8 (2017)
Antenatal care models vary widely around the world, reflecting local contexts, drivers and resources. Randomised controlled trials (RCTs) have tested the impact of multi-component antenatal care interventions on service delivery and outcomes in many countries since the 1980s. Some have applied entirely new schemes, while others have modified existing care delivery approaches. Systematic reviews (SRs) indicate that some specific antenatal interventions are more effective than others; however the causal mechanisms leading to better outcomes are poorly understood, limiting implementation and future research. As a first step in identifying what might be making the difference we conducted a scoping review of interventions tested in RCTs in order to establish a taxonomy of antenatal care models.
A protocol-driven systematic search was undertaken of databases for RCTs and SRs reporting antenatal care interventions. Results were unrestricted by time or locality, but limited to English language. Key characteristics of both experimental and control interventions in the included trials were mapped using SPIO (Study design; Population; Intervention; Outcomes) criteria and the intervention and principal outcome measures were described. Commonalities and differences between the components that were being tested in each study were identified by consensus, resulting in a comprehensive description of emergent models for antenatal care interventions.
Of 13,050 articles retrieved, we identified 153 eligible articles including 130 RCTs in 34 countries. The interventions tested in these trials varied from the number of visits to the location of care provision, and from the content of care to the professional/lay group providing that care. In most studies neither intervention nor control arm was well described. Our analysis of the identified trials of antenatal care interventions produced the following taxonomy: Universal provision model (for all women irrespective of health state or complications); Restricted ‘lower-risk’-based provision model (midwifery-led or reduced/flexible visit approach for healthy women); Augmented provision model (antenatal care as in Universal provision above but augmented by clinical, educational or behavioural intervention); Targeted ‘higher-risk’-based provision model (for woman with defined clinical or socio-demographic risk factors). The first category was most commonly tested in low-income countries (i.e. resource-poor settings), particularly in Asia. The other categories were tested around the world. The trials included a range of care providers, including midwives, nurses, doctors, and lay workers.
Interventions can be defined and described in many ways. The intended antenatal care population group proved the simplest and most clinically relevant way of distinguishing trials which might otherwise be categorised together. Since our review excluded non-trial interventions, the taxonomy does not represent antenatal care provision worldwide. It offers a stable and reproducible approach to describing the purpose and content of models of antenatal care which have been tested in a trial. It highlights a lack of reported detail of trial interventions and usual care processes. It provides a baseline for future work to examine and test the salient characteristics of the most effective models, and could also help decision-makers and service planners in planning implementation.
In an attempt to establish an evidence base for improving pregnancy outcomes over recent decades, a range of antenatal care interventions, reflecting local contexts, political drivers and financial considerations, have been the subject of randomised controlled trials (RCTs). These RCTs have ranged from applying an intervention that is an entirely new form of antenatal care provision (usually where existing provision was scanty or there was a desire to introduce a fundamentally different approach), to modifying the care delivery when existing services were already sophisticated, e.g. additional clinics for specific groups of women.
Within many high-income countries the increasing acceptance of women’s rights regarding choice and autonomy in maternity care has led to a more woman-centred approach to antenatal care. For example, United Kingdom (UK) maternity care has been driven by policies to empower service users , with evaluations of women’s experiences [2–4]. Similar drivers have been noted in Australia  and New Zealand . Several RCTs have reflected the increasing focus on woman-centred care by incorporating continuity of care elements [7, 8], often involving team or caseload midwifery. Team midwifery is defined as a group of midwives providing care and taking shared responsibility for women from the antenatal period, through labour and on to postnatal care . In caseloading, a midwife is responsible for the continuum of care throughout pregnancy, birth and the postnatal period for a small identified number of women . The impetus to provide high standards in maternity care is not limited to high-income countries, as intervention trials have occurred around the world. The Lancet Series on Midwifery produced the global evidence-based Quality Maternal and Newborn Care (QMNC) Framework  which emphasises this desire to provide all women with high quality maternity care. Such care has long been recognised as providing a sound foundation for the health of future generations , although the resources needed to provide such care are not evenly distributed round the world. The World Health Organisation (WHO) antenatal care standards have just been updated , and now recommend eight visits. At the time of our review the recommendation was for a minimum of four visits to a skilled birth attendant with specific activities to be undertaken for each visit.
Cochrane reviews have found that adverse outcomes, including preterm birth, could be reduced by ‘midwife-led continuity of care’ provision [7, 8], while a matched cohort study of women accessing an independent midwife (IM) in the UK and women receiving ‘standard’ National Health Service (NHS) care found a significantly reduced preterm birth rate in the IM group . Independent midwives provide care on a contractual basis outside of routine state-funded provision. A review  of ‘non-standard’ maternity care models in the United States (US), UK and Australia found an association with increased attendance for antenatal care, fewer preterm births, and increased breastfeeding initiation. Although concerns have been expressed about methodological limitations of its evaluations, the CenteringPregnancy™ (CP) group-based model of antenatal care and education has been evaluated positively, demonstrating both clinical benefits and improved social outcomes . The question of the cost-effectiveness of different models of care is also important , especially in relation to outcomes with long-term sequelae such as preterm birth , although some economic analyses do not distinguish birth centre and continuity models. A Cochrane review  of group-based antenatal care found no improvements in clinical outcomes, although the four included trials were quite heterogeneous.
In order to clarify the various interventions that have been attempted and achieved, and to categorise similar approaches so that a taxonomy of models can be produced, we initiated a systematic scoping review of RCTs and systematic reviews (SRs) of RCTs. In this article we use the term ‘intervention’ when referring to particular trials, and ‘model’ when referring to the resulting taxonomy. Because the term ‘model’ is frequently used when referring to an individual approach which might be the subject of a trial, we also used this as a search term (see below). The review was started in 2014 under the auspices of the multi-disciplinary and multi-institution McTempo research collaboration (Models of Care: The Effects on Maternal & Perinatal Outcomes). This research is timely because of the recent focus on global midwifery and what good quality maternal and newborn care should encompass . The overall aim of the McTempo research collaboration is to examine the association between and possible mechanisms within different models of antenatal care and a range of clinical, psychosocial and organisational outcomes. This scoping review was undertaken as an initial step towards this aim.
Taxonomies (Greek: ‘arrangement method’) were historically used as classification systems within biology, but have also been used in other disciplines . As a basis for future work in this area, the specific aim of this study was to develop a taxonomy of antenatal care interventions that have been tested in RCTs.
A study protocol was developed and search strategies were implemented accordingly. Primary searches were conducted by the York Health Economics Consortium during July-August 2014. The search architecture comprised three concepts: antenatal care; models linked to carers – non-midwife specific; models linked to midwives. These concepts were combined as follows: (Antenatal care AND Models linked to carer – non-midwife specific) OR Models linked to midwives. The strategy also included additional focused stand-alone searches on potentially relevant antenatal model terms (‘antenatal’ and synonyms; model; group/individual/team/caseload/shared/integrated/multidisciplinary). Table 1 shows inclusion and exclusion criteria, and the databases searched. The search was restricted to SRs and RCTs, without a date restriction.
The titles and abstracts of the articles obtained through this process were screened independently by paired members of the team; those identified as suitable for full text review were then screened using SPIO criteria (Study design, Population, Intervention, Outcome). For this purpose of producing a taxonomy of models we did not perform a formal quality assessment of all the identified papers. We have done so for specific sub-groups in order to achieve other goals within the project team’s remit . We made the primary study the main focus of this taxonomy. We have distinguished primary and sibling papers reporting empirical studies, as well as the systematic reviews which included such studies.
Scrutiny and evaluation of the intervention was carried out by the McTempo team who classified the relevant trials according to the target group, type of intervention offered, who was involved in its delivery, how it was organised, and where these interventions typically took place. As this was a scoping review this was an iterative process. Commonalities and differences were identified through group discussion, resulting in eventual consensus. While we broadly followed the Arksey and O’Malley  methodological framework for scoping reviews we did not adjust our inclusion and exclusion criteria post hoc; in addition, we restricted ourselves to higher levels of research evidence, namely RCTs and systematic reviews of RCTs.
The searches found 13,046 papers and four papers were subsequently identified from reference lists. Following screening of titles and abstracts, 322 papers were identified for full text screening. Of those, 134 papers were excluded at this stage, and 12 papers were unobtainable (largely due to length of time since publication). There was one missed duplicate identified at the full text stage. This process is detailed in the PRISMA flow chart in Fig. 1.
As Fig. 1 indicates, 153 articles reporting 130 interventions involving antenatal care were identified for full review, as were 22 associated SRs. These papers related to clinical care and/or organisational delivery, and could contain educational or lifestyle elements. All interventions covered the antenatal period; some also included intrapartum and postnatal care (Table 2). While some papers provided information about the trial’s intervention arm, this was often scanty (cf. ). Similarly, the control arms were rarely described in any detail. Despite relevant authors being contacted, 12 papers were unobtainable, ten dating from 1985 to 98.
We acknowledge that classifying interventions is complex and open to debate, in part because of the language/terms used. For example, an intervention based on ‘continuity’ or ‘midwife-led’ care could also be classified as a group-based intervention; an augmented care approach could contain elements of continuity of care and also adopt a group-based approach, etc. Our rationale for distinguishing the interventions relates principally to their target population, but also takes into account other contextual factors. Inevitably, there is a degree of overlap between some of the interventions, and the distinctions we have drawn in order to produce this taxonomy are open to debate. There is some overlap in terms of service provision between the Universal provision and the Restricted ‘lower risk’-based models, for example. All the interventions were covered by a mix of public and/or private financing, with or without an insurance element. Following the initial classification of the studies, the results were reviewed by the McTempo team. Minor subsequent adjustments resulted in an agreed classification taxonomy (Table 2). We emphasise that our review concerned interventions which have been tested in trials; we did not review all maternity care models worldwide.
Our taxonomy identified four classifications of antenatal care models:
Universal provision model. In this model the full spectrum of antenatal care was available to all women. We have used the term ‘midwifery-led’ rather than ‘midwife-led’ because the care provided in some studies reported here, while constituting midwifery, involved non-midwives whose practice and scope was not covered by the standard international definition of a midwife .
Restricted ‘lower risk’-based provision model. This model had some components in common with the ‘Universal provision’, but eligibility was restricted to women considered to be ‘low risk’. The definition of ‘low risk’ varied across trials/settings. In the Discussion we consider the potential pitfalls of using the term ‘risk’ within this taxonomy.
Augmented provision model. These trials were not restrictive in terms of eligibility, but comprised standard antenatal care augmented by additional clinical or educational input, or specific behavioural interventions. A sub-set of this category included trials which featured lifestyle interventions where the primary outcome was not pregnancy-related but focussed on lifestyle issues (e.g. smoking, nutrition, exercise).
Targeted ‘higher risk’-based provision model. These trials included woman deemed to have ‘higher risk’ status (whether for clinical, psychosocial or socio-demographic reasons), and provided care tailored to that specific risk status.
A range of types of care went to make up each model. Tables 3, 4, 5 and 6 describe these categories’ population groups and the focus of the relevant interventions, and cite the primary paper from each trial. It indicates the country in which that trial took place, and if the trial had any sibling papers or was included in any associated systematic reviews. It also specifies each category’s reference list.
Universal provision model
Trials in this model fell into four main categories, with an additional ‘multiple focus’ category for a related systematic review. The interventions were community-based or midwifery-led, or involved reduced or flexible visits or group-based care. See reference lists T3-1 to T3-5 (Additional file 1).
Community delivered interventions
These 14 ‘community delivered’ interventions were mainly provided in low resource settings with limited existing antenatal service provision; there was one associated SR  which included one study not retrieved by our search. These interventions are a relatively recent innovation: the cited papers range from 2004 to 2013.
Interventions typically involved regular community group meetings for women of child-bearing age. Two interventions reported positive outcomes relating to the inclusion of husbands/partners in interventions [26, 27]. Across the other studies in this group, there were outcome commonalities of infant/maternal morbidity and mortality; indeed Prost et al.’s meta-analysis  found that such interventions have the potential to improve maternal and infant mortality, and reduce stillbirth rates in low resource settings.
The earliest of these five studies was published in 1995 , with the most recent being the Tracy and Walker studies in 2013. As noted above, we have deliberately used the term ‘midwifery-led’, and in this we are drawing on some of the discussion in The Lancet Series on Midwifery which contextualised the varied settings around the world in which midwifery care is provided. For example, Walker et al.’s Mexican study  employed obstetric nurses as well as midwives to provide rural practice care. Wu et al.’s study in China  was carried out in areas where there had previously been no organised systematic antenatal care, and against a backdrop of political and socio-economic change. It was the only study in this category not to claim some benefit from the intervention. Both Walker et al. and Wu et al. focussed more on task-based work than on continuity of care. By contrast the other studies in this category occurred in the UK and Australia where there is a strong tradition of both systematic antenatal care and of midwifery practice, and all involved continuity of care: team midwifery  and caseload midwifery [31, 32]. Other midwifery-led interventions did have eligibility criteria based on specific risk factors, and are considered under the Restricted ‘lower risk’-based model section below.
Reduced or flexible visit interventions
There were four studies within this category; we note that several other similar studies did apply eligibility criteria based on risk, and these are considered under ‘Restricted lower-risk-based provision’. Two Zimbabwean studies addressed efficient use of limited resources. Majoko et al.  compared five visits to the standard 13. Clement et al.  – the oldest study - reported on an intervention where the reduction was from 13 to seven visits. Villar et al.’s  multinational study concluded that a reduced visit schedule could be implemented without adversely affecting clinical outcomes, although maternal satisfaction was reduced. We note, incidentally, that the new WHO guidelines on antenatal care, based on Vogel et al.’s secondary analysis , have increased the minimum number of recommended visits from four to eight .
There were two recent studies in this category, both comparing ‘group antenatal care’ with individual care. Jafari et al.  reported positive clinical outcomes such as the reduced likelihood of caesarean delivery and time to diagnosis for hypertension and urinary/vaginal infections. Satisfaction levels were significantly improved in the intervention group. Comparable clinical outcomes were not reported by Andersson et al. ; in their paper satisfaction with group care was reported in terms of there being “fewer deficiencies”.
Homer et al.’s associated SR  included two additional group care trials ([40, 41]) which we classified by their target group (adolescents and ‘women in the military/military wives’) rather than by the intervention type (see Table 6).
We identified one systematic review which examined a range of interventions intended to reduce one specific outcome (stillbirth) . These interventions included reduced visit schedules.
Restricted ‘lower risk’-based model
We have distinguished certain types of intervention which were shared between our Universal and Restricted ‘lower risk’-based provision models (Table 4). However, while the format of the intervention was similar the target population was different. The Restricted ‘lower risk’-based studies comprised midwifery-led trials and reduced or flexible visit interventions. See reference lists T4-1 to T4-3 (Additional file 1).
Twenty papers reported 12 ‘midwifery-led’ studies, mostly in Australia (5) and the UK (3), which placed risk eligibility criteria on potential participants (Table 3). In terms of timeframe they range from Flint’s 1989 study  to the new millennium. We have distinguished these from the midwifery-led interventions in the ‘Universal provision’ model because while the care given was often comparable, there was a crucial restriction on eligibility. Risk assessment in clinical practice now covers not just clinical (physical and/or psychological) factors, but social factors too, making it increasingly difficult for a pregnant woman to avoid being labelled as ‘not low risk’.
The Chinese study  took place in an environment without a strong tradition of midwifery care, differing, for example, from Australia and the UK. There was one economic analysis of a ‘midwife-led’ hospital antenatal clinic (); the others all evaluated continuity intervention. Turnbull et al. () and McLachlan et al. () adopted a caseload approach; the remainder used a team midwifery approach.
There were five associated SRs, three of which also covered the ‘Universal provision’ midwifery-led interventions discussed above. As with the ‘midwifery-led’ category these covered studies in both our Universal and Restricted ‘lower risk’-based provision models.
Reduced or flexible visit interventions
As above in the Universal provision section, these six trials (four UK-based; two US-based) also investigated women’s satisfaction in addition to clinical outcomes. Chronologically, they were quite close together (published 1996–2000). Women’s satisfaction levels were lower in three studies ([48–50]). Only one study showed a slight increase in satisfaction (), although the sample size was very small (n = 43 intervention, n = 38 control). In Sikorski et al.’s study , dissatisfaction was assumed if the women would have preferred more visits in the intervention arm, or fewer visits in the control arm. It should be noted that reduced visit schemes have different connotations worldwide. The previous reduced visit model suggested by the WHO of at least four visits , for example, was usually only applied in low-income countries. The studies reported here were all in high-income countries, where the model tends to have a baseline for all women with increased visits for those with complications. The early trials in the 1990s started from a base of a higher number of antenatal visits (often up to 14); what was termed ‘reduced’ visits (ranging from six for multiparous women  to eleven ) is now close to the norm in high-income countries.
Three of the four SRs ([54–56]) agreed that reduced visits did not result in detrimental clinical outcomes. Dowswell et al.  cautioned that if implemented in settings with limited resources, and where the number of visits was already low, further reductions might have a negative impact on perinatal mortality.
As with the Universal Provision model, one SR examined a range of interventions aimed at reducing stillbirth, including one community-based midwifery-led intervention .
Augmented provision model
Interventions in Table 5 were ‘universal’ as they did not restrict eligibility based on risk, but standard antenatal care was augmented by additional/specific clinical, educational or behavioural interventions. We distinguish these from behavioural interventions that were targeted at ‘higher risk’ groups (such as obese women, or smokers), which fit our Targeted ‘higher risk’-based model.
Additional care interventions
These 13 trials mainly involved the intervention of an educational element of care, and focussed on diverse outcomes, such as epidural use (), low birth weight (), perceived breast feeding advice and support (), infant feeding practices (), general attitudes and behaviour () and health service use in the year after birth (). There were therefore no intervention and outcome commonalities for comparison. One SR concluded that telephone support may assist in reducing low birth weight, postnatal depressive symptoms and smoking relapse, as well as increasing breastfeeding duration (). However, the authors caution that there was diversity in the nature of the interventions in the small number of studies available for comparison. In chronological terms Elbourne’s 1987 study () was an outlier: all others were published between 2005 and 2013.
These seven studies covered diverse interventions, including measures to address issues such as gestational weight gain (), anaemia , and self-hypnosis  to improve the childbirth experience. The oldest date from 2009 [65, 66]. The interventions were integrated into the core care package, and available to all women, not only those with a specific need. For example, the two studies by Barakat et al. [66, 68] recruited healthy pregnant women to an exercise programme. The exercise programme trials by Stafne et al.  and Barakat et al.  also reported on gestational diabetes mellitus, but were not able to influence this outcome positively.
The Ruifrok et al. SR  included the earlier of the Barakat studies and Phelan et al. , as well as studies we list under Targeted ‘higher risk’-based provision. The Domenjoz et al. SR  covered 16 studies, only three of which we had identified. This discrepancy occurred because many of their included studies were separate from and not additional to antenatal care, and therefore did not report any pregnancy outcomes. They were thus not eligible for our review. One associated systematic review  (since updated) did not cover any of our identified papers, an anomaly explained by the eclectic nature of behavioural interventions and the inclusion criteria for meta-analyses. Sibley et al.  included Azad et al.  which we listed under ‘Community delivered interventions’ (see Table 3).
Targeted ‘higher risk’-based model
The review identified 67 trials that detailed risk-assessed targeted interventions. By ‘targeted’ here we mean that particular populations were targeted on the basis of some ‘higher risk’ calculation, not that particular outcomes were sought. This is a complex group of interventions, involving many different categories; what they have in common is that a particular risk-based factor was the principal criterion for trial eligibility. These trials are detailed in Table 6. See reference lists T6-1 to T6-7 (Additional file 1).
Population sub-groups with defined clinical, psychosocial and/or socio-demographic risk factors were the focus of these interventions, which ranged from managing anxiety and mental health issues, to reducing tobacco and alcohol consumption. Such a broad category defies easy classification, but it was noticeable that some sub-groups had temporal associations. For example, all but one of the ten studies aimed at trying to prevent preterm birth were published from 1990 to 2000, whereas the five studies focussing on obesity were all published after 2010.
We appreciate that pregnant women may have multiple risk factors and/or be at risk of more than one poor outcome; where possible we used the primary outcome identified by the authors, but in nine cases we had to label this group as ‘multiple risks’; there were three SRs associated with ‘multiple risks’. Other named risk factors ranged from risk of preterm labour or having a low birthweight baby to smoking, mental health issues, being overweight or being at risk of abuse.
Socio-demographic risk groups included adolescents, women on low income and women in or with partners in the armed forces.
In this scoping review we have identified many different trials of antenatal care which have been attempted around the world. Synthesising the evidence from such diverse studies is inevitably difficult: the context around the world varies widely, and has itself shifted over time within particular locations. Our taxonomy of Universal, Restricted ‘lower risk’-based, Augmented and Targeted ‘higher risk’-based provision models summarises the nature and intention of the various trials of antenatal care that have been conducted since the 1980s. It is therefore of assistance in answering questions about who is included in trials, the nature of the intervention, and what outcomes the trial hopes to achieve. It is possible that this taxonomy misses certain crucial characteristics that could differentiate models of antenatal care. However, our taxonomy allows us to present the data in a systematic way, and to highlight the range of foci behind these interventions, something we believe will be of interest to service designers and those planning further antenatal care model research. As noted in the introduction, this project has been the first step of a planned programme of research exploring the effects of different care models on pregnancy outcomes. We acknowledge that by focussing only on RCTs and SRs of RCTs, we have not included studies using other methodologies. Scoping studies may choose to select a broad range of research and non-research evidence - they are not limited to a single approach [76, 77]. Our decision to include only RCTs and SRs of RCTs means that our taxonomy is of models with existing evidence of effectiveness. We also wish to emphasise that while we would have preferred to use an alternative concept to ‘risk’ in our taxonomy this was inescapable given the approach adopted by many of the studies we analysed. We are aware of the dangers of reifying a risk-based approach with such terminology, and suggest that wherever possible future trials also test Universal models.
We acknowledge that the study and analysis of Universal models is large, as they are eclectic. Many of the recent examples were community-based models in low resource settings, reflecting the desire of health care providers in such countries to provide broad coverage for pregnant women. It might be argued that countries with more developed maternity care systems are able to provide a range of models, and that the Universal model is particularly suited to countries at a particular stage in their development. However, the fact that some countries with a long-standing history of midwifery care (UK, Australia, Sweden) also trialled Universal midwifery-led models suggests that the broad scope of Universal models could work globally. The same three high income countries – as well as several others – predominated in the Restricted ‘lower risk’-based model. Despite being well evaluated, extending or replicating such models is problematic, not least because the inherent causal mechanisms have not been identified. Nevertheless, exploring such models may offer the opportunity to identify these mechanisms. This is work in which the McTempo collaboration is currently engaged.
Any maternity care system must be flexible, and the proliferation of lifestyle-related morbidity such as obesity or diabetes means that augmented and targeted models will also be required. We have distinguished these models on the basis of their intended audience, but as we conceded earlier, there are inevitably areas of overlap within our taxonomy.
Descriptions of the trials
The process of categorisation of these studies revealed an important limitation. While many of the reports described the intervention involved (i.e. how it was organised), they rarely detailed exactly what was done. It may be that their authors took it for granted that readers would understand what is involved in clinical care, but many did not discuss details of assessment and screening, or mention how the workforce was organised, or their philosophy of care – i.e. woman-centred, avoiding unnecessary interventions, optimising physiological processes, etc. Hoffman et al.  note that “the quality of description of interventions in publications… is remarkably poor” (page 1). In particular, the interaction between practitioner and pregnant woman - the human element - was rarely described. There is research indicating that women value how clinical procedures are carried out , and this is an area for future research. Authors may also have considered that readers would know what ‘routine care’ meant (i.e. the care given to the control arm in the trial), but as ‘routine care’ varies around the world and has changed over time this lack of information makes it difficult to know exactly what was different about the intervention. Also missing in many reports is a consideration of the underpinning values and philosophy of the intervention (noted by Hoffman et al. ), again perhaps because the authors assumed this was understood. This gap in the evidence makes replicating interventions more difficult, a significant hindrance when trying to evaluate and implement best evidence.
Distinguishing and comparing the models
Establishing a taxonomy from 130 very different trials which all had multiple features entailed detailed discussion within the McTempo group. Our decision to use the trials’ intended population rather than their type of intervention as the principal (but not sole) means of categorising them was the most efficient way of teasing out divergent trials which might otherwise be categorised together.
There was considerable overlap between our categories in terms of the kind of intervention that was introduced: ‘midwifery-led’ and ‘reduced/flexible visit’ studies were at times universally available, and at times restricted. As their target population was different we felt it important to distinguish them since risk assessment clearly plays a significant role within health care. This is considered further below. This was most obviously seen in the Targeted ‘higher risk’-based provision model, where the interventions focused on those with identified risk criteria.
Some interventions could be of benefit in more than one model. For example, we placed trials designed to reduce the risk of gestational diabetes in the Targeted ‘higher risk’-based model as there was a specific pregnancy-focussed aim to these studies. However, there were similarities with some of the ‘Behavioural Intervention’ studies which focused on lifestyle issues such as weight reduction. Our review found that the combined effects of lifestyle programmes, when incorporated as part of routine antenatal care, may help to reduce gestational diabetes, gestational weight gain, and unplanned caesarean sections. There is scope for investigating such interventions further.
Group interventions may offer more peer support opportunities, as well as improving clinical outcomes, and are therefore worth investigating further as a means of delivering antenatal care, perhaps in conjunction with reduced individual visits. The ‘social’ element within such interventions sets them apart from traditional ‘one-to-one’ care as experienced in many high-income countries; if the claimed improvements in outcomes are repeated in further robust evaluations then this element is worthy of serious consideration. An example of this approach is the CenteringPregnancy™ Group Prenatal Care Model, evaluations of which suggest that outcomes are significantly improved even in populations which usually have poorer than average outcomes, such as teenage mothers and those from deprived backgrounds [79, 80]. The multicentre RCT by Ickovics et al.  was published too late for inclusion in our search, and we are aware of another recently commenced RCT evaluating CenteringPregnancy™ in the USA. Other group antenatal care schemes have also been evaluated [19, 82].
The heterogeneity of the studies included in this review is also reflected in the broad range of primary outcome measures. Even within the studies examining midwifery-led care, the primary outcomes ranged from the process of care (continuity of caregiver, number of intrapartum caregivers, known caregiver at birth, overall clinic salary costs) to health-related outcomes (preterm birth, various indices of morbidity, psychological well-being) and patient preference-related outcomes (satisfaction with care). Certain outcomes (e.g. satisfaction) were often measured using study-specific questionnaires, making comparisons problematic. Indeed, the heterogeneity of the studies we identified means that systematic review and meta-analysis is often not possible across a range of outcomes. Nevertheless, we did identify scope to conduct a meta-analysis of neonatal outcomes.
While interventions in the Universal provision model offered care that was meant to be available to everyone, interventions in the Restricted ‘lower risk’-based model were limited to women deemed low risk. However, the definition of ‘low risk’ varied between studies, which makes comparisons much harder. Indeed, the whole notion of risk labelling is problematic , and the practice may at times even be counter-productive , not least because risk assessment has evolved and grown. As noted above it includes social factors too, so it is harder for a woman to avoid the label ‘not low risk’. McCourt et al.’s  exploration of women’s views about research priorities found that this focus on risk identification was causing concern. As long ago as 1989, in the first edition of Effective Care in Pregnancy and Childbirth, concerns were being raised that the over-use of risk labels could predispose pregnant women to poorer outcomes . Renfrew et al.  suggest that, rather than concentrating on risk identification and management, the primary focus of both care and research should be on optimising biological, psychological, social and cultural processes, and tailoring care to the needs of individual women and infants, thereby avoiding viewing pregnancy and childbirth through a ‘risk lens’. They offer the QMNC framework as a means of examining the factors underpinning these processes, an approach that could be used in planning antenatal care interventions. The paper proposes a distinction between ‘what all women and babies need’ and ‘what some women and babies also need’, and suggests using the terms ‘healthy women and babies’ and ‘women and babies with complications’ rather than referring to high and low risk criteria. While the use of the term ‘risk’ proved inescapable within this taxonomy of studies to date, we would advocate that future interventions and models resist the high-versus-low risk dichotomy, and instead use the terminology proposed by Renfrew et al. – e.g. “skilled supportive and preventive care for all, promotion of normal reproductive processes, first-line management of complications, and skilled emergency care” .
Geographical and historical considerations
Including only English-language articles may have missed some interventions from non-Anglophone countries. However, in addition to countries in which English is the predominant language or at least widely used (Australia, Canada, India, Ireland, Kenya, Malawi, Pakistan, South Africa, UK, USA, Zambia, Zimbabwe) we identified studies from Asia (China, Bangladesh, Indonesia, Nepal, Thailand, Vietnam), Francophone Africa (Benin), the near East (Iran, Saudi Arabia), Latin America and the Caribbean (Argentina, Cuba, Chile, Guatemala, Mexico), and across Europe (Denmark, Finland, France, Germany, the Netherlands, Norway, Spain, Sweden). The countries listed here also indicate that while the research infrastructure required to conduct and report robust RCTs in widely-available journals may be a source of bias for researchers in some developing countries, this is by no means an inevitable obstacle. The community-delivered interventions (Table 3) were almost exclusively in low-income countries. Our review agrees with Persson et al.  and Prost et al.  that community interventions show promise for outcome benefits in areas with limited resources (e.g. rural Asia). Lassi et al.’s  recent Cochrane review found that such schemes reduce neonatal mortality and morbidity as well as maternal morbidity.
It was noticeable that of the 67 trials in the Targeted ‘higher risk’-based model, 37 were based in the USA. Midwifery does not have a long tradition there (indeed, in some parts it is still unknown). Much of the focus of US research has been on reducing the likelihood of poor outcomes (notably low birth weight or preterm birth) within specific populations; those on low incomes, African Americans and Native Americans featured prominently.
The taxonomy also allows us to review historical trends. The Restricted ‘lower risk’-based model spans the longest period, from the 1980s to very recently, and these studies were predominantly from Australia and the UK. This reflects the particular place of midwifery within these countries, as well as historical concerns in the 1980s and 1990s about over-medicalisation of care and the role of choice and continuity of care within the maternity services. Offering ‘continuity models’, including team and caseload midwifery, was an attempt to improve both clinical outcomes and maternal satisfaction. However, what is striking about the interventions we have reviewed here is both how trends change over time, and how different countries apply different interventions. While the ‘midwifery-led’ interventions were a feature of the 1980s and 1990s in Australia and the UK, in more recent years they have featured in countries which have not had the same strong midwifery tradition, such as China and Mexico. The interventions tested there bore little resemblance to midwifery as experienced, for example, in the UK.
On the basis of this review, we propose that policy makers who are intending to amend current antenatal care, or to introduce it for the first time, should consider what type of care is most appropriate for their population, based on the findings from this study. We also propose that there is a need for a programme of research that examines different models of care from the perspective of what is known to constitute good quality care. This includes making explicit the philosophical underpinnings of proposed and existing models, and should also comprise stakeholder involvement in the development of a core outcomes data set so that comparative and observational studies in this area can be more easily compared.
This comprehensive taxonomy provides an explanation of 130 antenatal care intervention trials from around the world over a period of 30 years. The trials were diverse in terms of purpose and scope, but we believe that clarifying this picture will help to inform thinking on future interventions. We can conclude that different antenatal care trials have claimed a range of improved clinical, psychosocial and organisational outcomes, but as yet the causal mechanisms are not understood, and this is an area that must be addressed if best evidence is to be replicated and extended. Our taxonomy of ‘Universal’ provision, ‘Restricted ‘lower-risk’-based’ provision, ‘Augmented’ provision and ‘Targeted ‘higher-risk’-based’ provision models may also help decision makers, service planners and policy makers in planning new strategies, although, as we have noted, we suggest that the focus is on inclusiveness rather than being focussed on inconsistent notions of risk. The focus on the intended target for an intervention is, we believe, the clearest way of explaining how and why trials in this field have been conducted. However, the field is dynamic, and since our search further trials have been initiated. We recommend that both policy makers and researchers in this area should use the findings of this review as a basis for decision making in this area in future.
Human Immunodeficiency Virus
Models of care: the effects on maternal & perinatal outcomes
National Health Service
Preferred Reporting Items for Systematic Reviews and Meta-analyses
Quality maternal and newborn care
Randomised controlled trials
Study design, population, intervention, outcomes
World Health Organisation
Department of Health. Maternity matters: choice, access and continuity of care in a safe service. London: HMSO; 2007.
Maternity Services Action Group. A refreshed framework for maternity services. Edinburgh: Scottish Government; 2011.
Redshaw M, Henderson J. Safely delivered: a national survey of women’s experience of maternity care. Oxford: NPEU; 2014.
Care Quality Commission. Maternity services survey 2015. London: CQC; 2015.
Newnham E. Midwifery directions: the Australian Maternity Services Review. Health Sociol Rev. 2010;19(2):245–59.
Ministry of Health [NZ]. New Zealand Maternity Standards: a set of standards to guide the planning, funding and monitoring or maternity services by the Ministry of Health and District Health Boards. Ministry of Health, editor. Wellington; 2011.
Sandall J, Soltani H, Gates S, Shennan A, Devane D. Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database Syst Rev. 2013;8:CD004667.
Sandall J, Soltani H, Gates S, Shennan A, Devane D. Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database Syst Rev. 2015;9:CD004667.
National Childbirth Trust. NCT policy briefing: NICE Intrapartum Care Guideline: care of healthy women and their babies during childbirth. London: NCT; 2007.
Hartz DL, Foureur M, Tracy SK. Australian caseload midwifery: the exception or the rule. Women Birth. 2012;25(1):39–46.
Renfrew MJ, McFadden A, Bastos MH, Campbell J, Channon AA, Cheung NF, Audebert Delage Silva DR, Downe S, Kennedy HP, Malata A, et al. Midwifery and quality care: findings from a new evidence-informed framework for maternal and newborn care. Lancet. 2014;384(9948):1129–45.
World Health Organisation. Report of the Director General, March 1992. Geneva: WHO; 1992.
World Health Organisation. WHO recommendations on antenatal care for a positive pregnancy experience. Geneva: WHO; 2016.
Symon A, Winter C, Inkster M, Donnan PT. Outcomes for births booked under an independent midwife and births in NHS maternity units: matched comparison study. BMJ. 2009;338:b2060.
Allen J, Gamble J, Stapleton H, Kildea S. Does the way maternity care is provided affect maternal and neonatal outcomes for young women? A review of the research literature. Women Birth. 2012;25(2):54–63.
McNeill JA, Reiger KM. Rethinking prenatal care within a social model of health: an exploratory study in Northern Ireland. Health Care Women Int. 2015;36(1):5–25.
Ryan P, Revill P, Devane D, Normand C. An assessment of the cost-effectiveness of midwife-led care in the United Kingdom. Midwifery. 2013;29(4):368–76.
Mangham LJ, Petrou S, Doyle LW, Draper ES, Marlow N. The cost of preterm birth throughout childhood in England and Wales. Pediatrics. 2009;123:e312–27.
Catling C, Medley A, Foureur M, Ryan C, Leap N, Teate A, Homer C. Group versus conventional antenatal care for pregnant women. In: Cochrane Database Syst Rev. 2015.
Michie S, Richardson M, Johnston M, Abraham C, Francis J, Hardeman W, Eccles MP, Cane J, Wood CE. The behavior change technique taxonomy (v1) of 93 hierarchically clustered techniques: building an international consensus for the reporting of behavior change interventions. Ann Behav Med. 2013;46(1):81–95.
Symon A, Pringle J, Cheyne H, Downe S, Hundley V, Lee E, Lynn F, McFadden A, McNeill J, Renfrew MJ, et al. Midwifery-led antenatal care models: mapping a systematic review to an evidence-based quality framework to identify key components and characteristics of care. BMC Pregnancy Childbirth. 2016;16:168.
Arksey H, O'Malley L. Scoping studies: towards a methodological framework. Int J Soc Res Methodol. 2005;8(1):19–32.
Hoffman T, Glasziou P, Boutron I, Milne R, Perera R, Moher D, Altman D, Barbour V, Macdonald H, Johnston M, et al. Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide. BMJ. 2014;348:g1687.
ICM International Definition of the Midwife. http://www.internationalmidwives.org/assets/uploads/documents/Definition%20of%20the%20Midwife%20-%202011.pdf. Accessed 9 Dec 2016.
Prost A, Colbourn T, Seward N, Azad K, Coomarasamy A, Copas A, Houweling T, Fottrell E, Kuddus A, Lewycka S, et al. Women’s groups practising participatory learning and action to improve maternal and newborn health in low-resource settings: a systematic review and meta-analysis. Lancet. 2013;381:1736–46.
Mullany BC, Becker S, Hindin MJ. The impact of including husbands in antenatal health education services on maternal health practices in urban Nepal: results from a randomized controlled trial. Health Educ Res. 2007;22(2):166–76.
Midhet F, Becker S. Impact of community-based interventions on maternal and neonatal health indicators: Results from a community randomized trial in rural Balochistan, Pakistan. Reprod Health. 2010;7:30.
Rowley MJ, Hensley MJ, Brinsmead MW, Wlodarczyk JH. Continuity of care by a midwife team versus routine care during pregnancy and birth: a randomised trial. Med J Aust. 1995;163(6):289–93.
Walker D, DeMaria L, Gonzalez-Hernandez D, Padron-Salas A, Romero-Alvarez M, Suarez L. Are all skilled birth attendants created equal? A cluster randomised controlled study of non-physician based obstetric care in primary health care clinics in Mexico. Midwifery. 2013;29(10):1199–205.
Wu Z, Viisainen K, Wang Y, Hemminki E. Evaluation of a community-based randomized controlled prenatal care trial in rural China. BMC Health Serv Res. 2011;11:92.
North Staffordshire Changing Childbirth Research Team. A randomised study of midwifery caseload care and traditional ‘shared-care’. Midwifery. 2000;16(4):295–302.
Tracy SK, Hartz DL, Tracy MB, Allen J, Forti A, Hall B, White J, Lainchbury A, Stapleton H, Beckmann M, et al. Caseload midwifery care versus standard maternity care for women of any risk: M@NGO, a randomised controlled trial. Lancet. 2013;382(9906):1723–32.
Majoko F, Munjanja SP, Nystrom L, Mason E, Lindmark G. Randomised controlled trial of two antenatal care models in rural Zimbabwe. BJOG. 2007;114(7):802–10.
Clement S, Sikorski J, Wilson J, Das S, Smeeton N. Women’s satisfaction with traditional and reduced antenatal visit schedules. Midwifery. 1996;12(3):120–8.
Villar J. WHO antenatal care randomised trial for the evaluation of a new model of routine antenatal care (vol 357, pg 1551, 2001). Lancet. 2001;358(9292):1556.
Vogel J, Habib N, Souza J, Gülmezoglu A, Dowswell T, Carroli G, Baaqeel H, Lumbiganon P, Piaggio G, Oladapo O. Antenatal care packages with reduced visits and perinatal mortality: a secondary analysis of the WHO Antenatal Care Trial. Reprod Health. 2013;10:19.
Jafari F, Eftekhar H, Mohammad K, Fotouhi A. Does group prenatal care affect satisfaction and prenatal care utilization in Iranian pregnant women? Iran J Public Health. 2010;39(2):52–62.
Andersson E, Christensson K, Hildingsson I. Mothers’ satisfaction with group antenatal care versus individual antenatal care - a clinical trial. Sex Reprod Healthc. 2013;4(3):113–20.
Homer CSE, Ryan C, Leap N, Foureur M, Teate A, Catling-Paull CJ. Group versus conventional antenatal care for women. Cochrane Database Syst Rev. 2012;11:CD007622.
Ickovics JR, Kershaw TS, Westdahl C, Magriples U, Massey Z, Reynolds H, Rising SS. Group prenatal care and perinatal outcomes: a randomized controlled trial.[Erratum appears in Obstet Gynecol. 2007 Oct;110(4):937]. Obstet Gynecol. 2007;110(2 Pt 1):330–9.
Kennedy H, Farrell T, Paden R, Hill S, Jolivet R, Cooper B, Rising S. A randomized clinical trial of group prenatal care in two military settings. Mil Med. 2011;176(10):1169–77.
Yakoob MY, Menezes EV, Soomro T, Haws RA, Darmstadt GL, Bhutta ZA. Reducing stillbirths: behavioural and nutritional interventions before and during pregnancy. BMC Pregnancy Childbirth. 2009;9:S3.
Flint C, Poulengeris P, Grant A. The ‘Know Your Midwife’ scheme–a randomised trial of continuity of care by a team of midwives. Midwifery. 1989;5(1):11–6.
Gu C, Wu X, Ding Y, Zhu X, Zhang Z. The effectiveness of a Chinese midwives’ antenatal clinic service on childbirth outcomes for primiparae: a randomised controlled trial. Int J Nurs Stud. 2013;50(12):1689–97.
Giles W, Collins J, Ong F, MacDonald R. Antenatal care of low risk obstetric patients by midwives. A randomised controlled trial. Med J Aust. 1992;157(3):158–61.
Turnbull D, Holmes A, Shields N, Cheyne H, Twaddle S, Gilmour WH, McGinley M, Reid M, Johnstone I, Geer I, et al. Randomised, controlled trial of efficacy of midwife-managed care. Lancet. 1996;348(9022):213–8.
McLachlan HL, Forster DA, Davey MA, Farrell T, Gold L, Biro MA, Albers L, Flood M, Oats J, Waldenstrom U. Effects of continuity of care by a primary midwife (caseload midwifery) on caesarean section rates in women of low obstetric risk: the COSMOS randomised controlled trial. BJOG. 2012;119(12):1483–92.
Sikorski J, Wilson J, Clement S, Das S, Smeeton N. A randomised controlled trial comparing two schedules of antenatal visits: the antenatal care project. BMJ. 1996;312(7030):546–53.
Henderson J, Roberts T, Sikorski J, Wilson J, Clement S. An economic evaluation comparing two schedules of antenatal visits. J Health Serv Res Policy. 2000;5(2):69–75.
Jewell D, Sharp D, Sanders J, Peters TJ. A randomised controlled trial of flexibility in routine antenatal care. Br J Obstet Gynaecol. 2000;107(10):1241–7.
Walker DS, KoniakGriffin D. Evaluation of a reduced-frequency prenatal visit schedule for low-risk women at a free-standing birthing center. J Nurse Midwifery. 1997;42(4):295–303.
World Health Organisation. Standards for maternal and newborn care: provision of effective antenatal care. Geneva: WHO; 2006.
Tucker JS, Hall MH, Howie PW, Reid ME, Barbour RS, Florey CD, McIlwaine GM. Should obstetricians see women with normal pregnancies? A multicentre randomised controlled trial of routine antenatal care by general practitioners and midwives compared with shared care led by obstetricians. BMJ. 1996;312(7030):554–9.
Khan-Neelofur D, Gulmezoglu M, Villar J, Grp WHOACTR. Who should provide routine antenatal care for low-risk women, and how often? A systematic review of randomised controlled trials. Paediatr Perinat Epidemiol. 1998;12:7–26.
Carroli G, Villar J, Piaggio G, Khan-Neelofur D, Gulmezoglu M, Mugford M, Lumbiganon P, Farnot U, Bersgjo P, Grp WHOACTR. WHO systematic review of randomised controlled trials of routine antenatal care. Lancet. 2001;357(9268):1565–70.
Villar J, Carroli G, Zavaleta N, Donner A, Wojdyla D, Faundes A, Velazco A, Bataglia V, Langer A, Narvaez A, et al. Maternal and neonatal individual risks and benefits associated with caesarean delivery: multicentre prospective study. BMJ. 2007;335(7628):1025–9.
Dowswell T, Carroli G, Duley L, Gates S, Gulmezoglu AM, Khan-Neelofur D, Piaggio GG. Alternative versus standard packages of antenatal care for low-risk pregnancy. Cochrane Database Syst Rev. 2010;10:CD000934.
Bergstrom M, Kieler H, Waldenstrom U. Effects of natural childbirth preparation versus standard antenatal education on epidural rates, experience of childbirth and parental stress in mothers and fathers: a randomised controlled multicentre trial. BJOG. 2009;116(9):1167–76.
Ekhtiari YS, Majlessi F, Foroushani AR, Shakibazadeh E. Effect of a self-care educational program based on the health belief model on reducing low birth weight among pregnant Iranian women. Int J Prev Med. 2014;5(1):76–82.
Ekstrom A, Widstrom AM, Nissen E. Does continuity of care by well-trained breastfeeding counselors improve a mother’s perception of support? Birth-Issue Perinat Care. 2006;33(2):123–30.
Wen LM, Baur LA, Simpson JM, Rissel C, Flood VM. Effectiveness of an early intervention on infant feeding practices and “tummy time”: a randomized controlled trial. Arch Pediatr Adolesc Med. 2011;165(8):701–7.
Elbourne D, Richardson M, Chalmers I, Waterhouse I, Holt E. The Newbury Maternity Care Study - a randomised controlled trial to assess a policy of women holding their own obstetric records. Br J Obstet Gynaecol. 1987;94(7):612–9.
Au F, Shiell A, van der Pol M, Johnston DW, Tough S. Does supplementary prenatal nursing and home visitation reduce healthcare costs in the year after childbirth? J Adv Nurs. 2006;56(6):657–68.
Dennis C-L, Kingston D. A systematic review of telephone support for women during pregnancy and the early postpartum period. J Obstet Gynecol Neonatal Nurs. 2008;37(3):301–14.
Asbee SM, Jenkins TR, Butler JR, White J, Elliot M, Rutledge A. Preventing excessive weight gain during pregnancy through dietary and lifestyle counseling: a randomized controlled trial. Obstet Gynecol. 2009;113(2 Pt 1):305–12.
Barakat R, Ruiz JR, Lucia A. Exercise during pregnancy and risk of maternal anaemia: a randomised controlled trial. Br J Sports Med. 2009;12:954–6.
Werner A, Uldbjerg N, Zachariae R, Wu CS, Nohr EA. Antenatal hypnosis training and childbirth experience: a randomized controlled trial. Birth-Issue Perinat Care. 2013;40(4):272–80.
Barakat R, Pelaez M, Lopez C, Lucia A, Ruiz JR. Exercise during pregnancy and gestational diabetes-related adverse effects: a randomised controlled trial. Br J Sports Med. 2013;47:630–6.
Stafne S, Salvesen K, Romundstad P, Eggebo T, Carlsen S, Morkved S. Regular exercise during pregnancy to prevent gestational diabetes. Obstet Gynecol. 2012;119(1):29–36.
Ruifrok AE, Van Poppel MNM, Van Wely M, Rogozinska E, Khan KS, De Groot CJM, Thangaratinam S, Mol BW. Association between weight gain during pregnancy and pregnancy outcomes after dietary and lifestyle interventions: a meta-analysis. Am J Perinatol. 2014;31(5):353–64.
Phelan S, Phipps MG, Abrams B, Darroch F, Schaffner A, Wing RR. Randomized trial of a behavioral intervention to prevent excessive gestational weight gain: the fit for delivery study. Am J Clin Nutr. 2011;93(4):772–9.
Domenjoz I, Kayser B, Boulvain M. Effect of physical activity during pregnancy on mode of delivery. Am J Obstet Gynecol. 2014;401:e1–e11.
Ota E, Tobe-Gai R, Mori R, Farrar D. Antenatal dietary advice and supplementation to increase energy and protein intake. Cochrane Database Syst Rev. 2012;9:CD000032.
Sibley Lynn M, Sipe Theresa A, Barry D. Traditional birth attendant training for improving health behaviours and pregnancy outcomes. In: Cochrane Database Syst Rev. John Wiley & Sons, Ltd; 2012
Azad K, Barnett S, Banerjee B, Shaha S, Khan K, Rego AR, Barua S, Flatman D, Pagel C, Prost A, et al. Effect of scaling up women’s groups on birth outcomes in three rural districts in Bangladesh: a cluster-randomised controlled trial. Lancet. 2010;375(9721):1193–202.
Davis K, Drey N, Gould D. What are scoping studies? A review of the nursing literature. Int J Nurs Stud. 2009;46:1368–400.
Levac D, Colquhoun H, O'Brien KK. Scoping studies: advancing the methodology. Scoping studies: advancing the methodology. 2010;5:69–77.
Dowswell T, Renfrew M, Hewison J, Gregson B. A review of the literature on the midwife and community-based maternity care. Midwifery Matters. 2001;17:194–202.
Klima C, Norr K, Vonderheid S, Handler A. Introduction of centering pregnancy in a public health clinic. J Midwifery Women Health. 2009;54(1):27–34.
Dellos L, Marshall K. Reducing preterm birth in Iowa with centering pregnancy. Proceedings in Obstetrics and Gynecology. 2011;2(2):11.
Ickovics J, Earnshaw V, Lewis J, Kershaw T, Magriples U, Stasko E, Rising S, Cassells A, Cunningham S, Bernstein P, et al. Cluster randomized controlled trial of group prenatal care: perinatal outcomes among adolescents in New York city health centers. Am J Public Health. 2016;106(2):359–65.
Craswell A, Kearney L, Reed R. Expecting and Connecting’ group pregnancy care: evaluation of a collaborative clinic. Women Birth. 2016;29(5):416–22.
Lee S, Ayers S, Holden D. Risk perception of women during high risk pregnancy: a systematic review. Health, Risk and Society. 2012;14(6):511–31.
Cheyne H, McCourt C, Semple K. Mother knows best: developing an evidence informed, consumer led, agenda for maternity care. Midwifery. 2013;29(6):705–12.
McCourt C, Cheyne H, Semple K. Mothers involved in research agenda setting: report of the MIRAS project. Stirling: NMAHP; 2012.
Alexander S, Keirse MJNC. Formal risk scoring during pregnancy. In: Chalmers I, Enkin M, Keirse MJNC, editors. Effective care in pregnancy and childbirth. Volume 1. Oxford: Oxford Medical Publications; 1989.
Persson LA, Nga NT, Malqvist M, Dinh Thi Phuong H, Eriksson L, Wallin L, Selling K, Huy TQ, Duc DM, Tiep TV, et al. Effect of facilitation of local maternal-and-newborn stakeholder groups on neonatal mortality: cluster-randomized controlled trial. Plos Medicine. 2013;10(5):e1001445.
Prost A, Colbourn T, Seward T. Women’s groups practising participatory learning and action to improve maternal and newborn health in low-resource settings: a systematic review and meta-analysis (vol 381, pg 1736, 2013). Lancet. 2014;383(9931):1806.
Lassi ZS, Bhutta ZA. Community-based intervention packages for reducing maternal and neonatal morbidity and mortality and improving neonatal outcomes. Cochrane Database Syst Rev. 2015;3:CD007754.
We would like to thank Jane Sandall, Professor of Social Science and Women's Health, King’s College, London, and Helen Cheyne, Professor of Midwifery, University of Stirling, for their contribution to the development of this project; and to Dr Mick Arber and Dr Julie Glanville of the York Health Economics Consortium for their detailed work in conducting the original search of the literature.
This project was undertaken as part of a programme grant from the Scottish Government Chief Nurse’s Office to the SMART (Scottish Midwives Advancing Research Together) collaboration. The views expressed are those of the authors and not of the Scottish Government Chief Nurse’s Office.
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All articles retrieved though standard university searches or direct contact with named author.
All authors except JP conceived of the study. AS, JP, VH, EL, AM, MRD, EvT and HW carried out data extraction. All authors (AS, JP, SD, VH, EL, FL, AM, JM, MR, MRD, EvT, HW, FA) were instrumental in the study’s development, in reviewing successive drafts of the paper, and in approval of the final manuscript.
The authors declare that they have no competing interests.
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Symon, A., Pringle, J., Downe, S. et al. Antenatal care trial interventions: a systematic scoping review and taxonomy development of care models. BMC Pregnancy Childbirth 17, 8 (2017). https://doi.org/10.1186/s12884-016-1186-3

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#WeAreDyingHere is a short film that looks at gender-based violence and femicide in South Africa; the award-winning short film has a powerful message.
South Africa (15 October 2021) – #WeAreDyingHere is a powerful short film created by writer and performer Siphokazi Jonas. Originally a stage performance, the important message is being taken to a larger audience, including being showcased at international film festivals.
#WeAreDyingHere was adapted from critically acclaimed stage performance of the same name. It features Siphokazi Jonas who directed the original stage production as well as poet Hope Netshivhambe and musician Zimbini Makwetu who helped co-write the performance. Both ladies reprised their roles in the film adaption too.
The stage performance was streamed online during the height of the South African lockdown and TimeOut New York called it “one of the best productions to stream during the lockdown”.
Springbok rugby captain and global ambassador for the United Nations Spotlight Initiative, Siya Kolisi together with his wife Rachel Kolisi are the Executive Producers of the short film.
“One of the most beautiful results of this film is that it causes people to stop, think and more so encourages men and women to have conversations. Like the title, it gets straight to the point” explained Rachel.
“There are many things that need to be unpacked in this film, and there is a lot that can be explained” Siya added.“The narrative of the film also teaches you that Gender-Based Violence doesn’t start with the violence, but the whole thought process; the film encompasses a lot of educational learnings for us as men.”
#WeAreDyingHere chronicles the journey of three soldiers forced to survive a war that they did not choose. In this war against women’s bodies, they attempt to find solace by telling their stories under the constant watch of a relentless enemy. #WeAreDyingHere is an intimate reflection on the impact of violence, harassment, abuse, rape and femicide on everyday life. While the film never depicts any violence, the psychological and emotional trauma on these soldiers is evident. It is a necessary insight into the experience of living in South Africa where names of missing or murdered women trend frequently.
The film was sent in to the Female Filmmakers Film Festival Berlin, where it won the title for Best Short Film and title of Female for Change.
“Did someone say AWARD-WINNING FILM?? #WeAreDyingHere takes two. We need a proper celebration, this online business won’t do. Thank you to Female Filmmakers Film Festival Berlin and congratulations to fellow winners! This is yet another example of why I am such a believer in collaboration.” – Siphokazi Jonas
Although the film title is, #WeAreDyingHere, the producers want the film to leave everyone with an overwhelming sense of how much women want to live: to thrive, fearlessly, and as freely as possible.
Take a look at the trailer below. Stay tuned to their social media here to find out where you can view this short film.


The LG Wing is the latest consumer handheld device that can be used to test the limits of people’s will not to click back and forth when opening or panning. With two screens, a pop-up camera, and plenty of screen space, there will be some durability questions and the company is trying to answer those in a new video with performative CGI.
The first problem that is resolved in the video by extremely close shots of gears, pistons and cables is the durability of the wing-like pivot mechanism of the wing between the base case and the display as well as the upper display. It includes a holster spring and double track guide to keep things in place while moving, as well as a hydraulic piston to cushion shocks by limiting.
LG assures its customers that it has put the mechanism through a 200,000 cycle test. Samsung did the same for its original Galaxy Fold with a flexible display, but that didn’t stop reviewers from damaging it that easily. More answers are needed for further questions.
The company also addresses questions about the weight of the wing and its overall thickness. The official mass listed on the data sheet is 260 grams, which is 22 grams below the Samsung Galaxy Z Fold2. LG achieves its optimizations by using lighter plastic OLED displays, the perforation of its metal housing and presumably the assembly of its displays under a single controller chip. At least that’s what we conclude from the line “Two displays to one”.
However, it gets its accreditation with a MIL-STD-810G rating against drops from 120cm away at 26 different angles, which doesn’t mean you can’t break the wing with a drop. As with servo cameras on some other phones, it retracts when the wing detects a dive. LG also says it put a hydrophobic coating on the inner parts and a polyacetal film on the touchscreens, but there are no official IP ratings here for dust and water resistance. So take these for what you want.
We’ll stay seated for a while before AT&T and Verizon pick up the wing later this fall. So expect more of this marketing to show up.


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WHAT WE DO
We offer a variety of different services, these include:
Intergenerational Music Projects for schools, colleges and universities
Interactive and educational intergenerational music programmes for children and the elderly by bringing local communities together. Each carefully designed project brings together at least two or three different age groups who might not normally come into regular contact, with focus on fun musical interaction. We are incredibly passionate about what we do and are seeing huge benefits in sharing music across the generations.
Skill enhancement training aims to work with healthcare professionals in care settings and carers in the community to have the confidence and skills to use person-centred music with older adults, particularly people living with dementia. We provide one day training for healthcare professionals to learn how to use person-centred music activities particularly personalised playlists with people living with dementia, and we provide ongoing support to help the care homes embed personalised music into their care provision.
Intergenerational Care Home Choirs
Our choir project aims to connect and empower residents and carers through music. We pride ourselves on the fact that our services are much more than ‘entertainment’; our work is underpinned by research in music sociology and our clients value our expert knowledge.
We provide high quality, research-based services; building strong relationships with our clients and beneficiaries, and their needs are at the heart of everything we do.
Music Workshops and Performances
High quality music workshops and performances for older adults in care settings. Our workshops are interactive, and reminiscence based, using a variety of percussion instruments and resources to spark reminiscence discussions, promoting social interaction, self-confidence and stimulating the brain all led by Music Therapists.
We are passionate about creating a positive and sustainable impact on all our participants.
All our services aim to benefit all communities within the health and education sector as the work: shares cultural and musical understanding, increases the access to music-making, encourages informal music-making at homes, promotes sustainability by including volunteering and/or staff development and lastly raises self-confidence and self-esteem of participants.

domain: artistic


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A dog is a man’s best friend. They are loyal, adorable and they make the best companions. But with so many different breeds in the world, which one is the right fit for you?
Here are some of the top tiny dog breeds for sale:
The Chihuahua is a small breed of dog that originated in Mexico. They were named after the state of Chihuahua where they were first found. The name Chihuahua comes from an Aztec dialect meaning “deer-like”. The Chihuahua has been around since ancient times, but it wasn’t until 1892 that they were first recognized by the American Kennel Club. Today, they are one of the most popular breeds in America!
The Pomeranian is a breed of dog that originated in Germany over 400 years ago. Their name comes from Pomerania which was an area in Germany and Poland with a large population of Pommeranian shepherds. These dogs were used as shepherd dogs because they had short hair, making them easy to care for during cold weather months when sheep would need extra warmth while out on pasture at night time. The Pommeranian was officially recognized by
Small dog breeds are the perfect choice for people who live in apartments, townhouses or homes with small yards. They don’t require a lot of exercise and their small size makes them easy to care for and transport. Some of these tiny dogs even qualify as lap dogs.
Tiny Dog Breeds For Sale
If you’re looking for a new puppy, here are some of the smallest dog breeds available for sale:
Tiny dog breeds are small dogs that weigh less than 10 pounds. They are perfect for apartment living and can easily fit in your purse.
Tiny dog breeds make great pets because they are fun and entertaining to watch, but they also require a lot of attention. If you want a dog that will be happy spending most of its day by your side, then a tiny dog breed is for you.
If you’re looking for a tiny dog breed to adopt or purchase, take a look at our list of some of the best tiny dog breeds available today:1
- Yorkshire Terrier
- Shih Tzu
If you are looking for a tiny dog breed that is close to your heart, here is a list of some of the most popular small dog breeds.
- Japanese Chin
- Yorkshire Terrier
There are thousands of dog breeds to choose from, but only a few of them make good pets for people with small apartments and limited space. These tiny dog breeds are small enough to be carried around in your purse or stowed away in a closet when they’re not needed.
The most popular small dogs include the Yorkshire Terrier, Chihuahua, Pomeranian and Maltese. These breeds have been popular for centuries because they’re easy to train, clean and carry around. They can also make great companions for children because they’re easy to manage, even if they get a little rambunctious at times.
Here’s a closer look at some of the most popular tiny dog breeds:

domain: pet


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Choroidal Malignant Melanoma:
58-year-old female with pigmented retinal lesion and exudative retinal detachment
July 8, 2014
Chief Complaint: Incidental pigmented lesion identified on dilated exam
History of Present Illness: A 58-year-old female was referred by her optometrist for the evaluation of a pigmented lesion in her right eye (OD) found incidentally on dilated exam. The last dilated exam was performed 3 years prior and was reportedly normal at that time. The patient denied change in vision, flashes, floaters, and pain.
Past Ocular History: Myopia and presbyopia
Past Medical History: Hypertension, no known primary malignancies
Best corrected visual acuity: 20/20 OD, 20/20 -2 left eye (OS)
Applanation tonometry: 15 mmHg OD, 15 mmHg OS
Confrontation visual fields: Total superotemporal deficiency OD, full OS
Motility/Alignment: Full, orthophoric
Slit lamp exam: no sentinel vessels, anterior chamber deep and quiet, normal iris without rubeosis, 1+ nuclear sclerotic cataract in both eyes (OU); 1+ pigmented anterior vitreous cell OD, no vitreous cell OS.
Fundus Exam OD:
Figure 1: (click image for higher resolution)
Elevated, peripapillary, moderately pigmented collar button shaped choroidal mass with mild overlying RPE metaplasia inferonasal to the optic disc. The mass measures 14 x 11 x 6 mm and overhangs the disc.
There is an exudative retinal detachment of the inferior 20% of retina when the patient sits upright.
Figure 2: (click image for higher resolution)
Close-up of lesion showing disruption of Bruch's membrane and nodular tumor eruption in a "collar button" shape.
Fundus Exam OS:
Figure 3: (click image for higher resolution)
There are a few small hard drusen in the macula. The fundus is otherwise unremarkable.
Figure 4: (click image for higher resolution)
B-scan ultrasonography revealed an irregular, peaked choroidal mass 6 mm in height x 13 mm at its base. It had low to medium reflectivity and 2+ internal vascularity. An exudative retinal detachment is appreciated inferior to the mass.
Figure 5: (click image for higher resolution)
A-scan ultrasonography demonstrated low to medium internal reflectivity.
Figure 6: (click image for higher resolution)
OCT showed a choroidal mass with disruption the RPE and Bruch's membrane and associated subretinal fluid.
Based on the clinical appearance and echographic findings, the patient was diagnosed with a medium-sized peripapillary choroidal melanoma with secondary exudative retinal detachment inferiorly OD. The patient underwent metastatic workup for tumor staging. The outside complete blood count (CBC), basic metabolic panel (BMP), liver function tests (LFTs), chest x-ray, and abdominal ultrasound were negative for evidence of metastasis. The patient was counseled on management options including brachytherapy, charged particle radiation, enucleation, observation, and alternative therapies. The likely development of profound vision loss due to radiation optic neuropathy following radiation treatment was also discussed. The patient elected to have an enucleation with prosthesis.
Enucleation was performed by oculoplastic surgeons at the University of Iowa. Pathologic evaluation of the globe confirmed the mass was a mixed cell choroidal melanoma with >10% epithelioid cells and <90% spindle cells. The mass was positive for invasion of Bruch's membrane, perineural invasion of choroidal nerve twigs, and minimal tumor infiltrating lymphocytes. No vascular, ciliary body, or extraocular invasion was noted and the optic nerve margins were free of tumor. It was classified as American Joint Committee on Cancer (AJCC) stage pT3a and grade pG2.
The patient tolerated surgery well and later received an ocular prosthesis. Due to the clear margins and lack of evidence indicating distant metastasis, no further treatment for choroidal melanoma was necessary. The patient was counseled to undergo yearly eye exams with annual tumor surveillance, consisting of a physical exam, liver function studies, and imaging of the liver with ultrasonography or MRI with contrast.
Figure 7: (click image for higher resolution)
Gross specimen of the globe after enucleation showing posterior choroidal mass with adjacent retinal detachment.
Figure 8: (click image for higher resolution)
Histolopathology demonstrating the choroidal melanoma which disrupts Bruch's membrane forming a "collar button" appearance. An exudative retinal detachment is present adjacent to the tumor anteriorly. Hematoxylin and eosin, original magnification 10x
Clinical diagnosis and treatment
Uveal melanoma is the most common primary intraocular malignancy in adults. It arises from the neuroectodermal melanocytes within the uveal tract, most commonly involving the choroid (85%) (1). Choroidal melanoma presentation peaks at the age of 60 years with a higher incidence in Caucasians. Tumors can be asymptomatic and detected incidentally on fundus exam or symptomatic with decreased visual acuity, blurring, metamorphopsia, flashes, floaters or visual field loss (2).
It is important to be able to distinguish between melanoma and pseudomelanomas, like choroidal nevus, choroidal metastasis, melanocytoma, or hyperplasia of the retinal pigmented epithelium (RPE). Physical appearance of the lesion on fundus exam can help differentiate the lesion. Nevi are usually flat, <6 mm in diameter, and may have overlying drusen. Choroidal metastases are typically amelanotic, lobulated, and associated with more subretinal fluid than melanomas of a similar size. Melanocytomas are black, often extend onto the optic nerve and invade the nerve fiber layer, giving a feathered appearance. Congenital hyperplasia of the RPE (CHRPE) is typically a sharply demarcated pigmented lesion with scalloped margins (3).
There are several clinical elements that suggest choroidal melanoma on exam:
- Solid dark brown to amelanotic in color with well-defined borders
- Biconvex shape with lenticular cross section
- Overlying clumps of orange lipofuscin pigment
- Lack of overlying drusen
- Secondary subretinal fluid / exudative retinal detachment
- Penetration of Bruch's membrane and nodular eruption beneath the retina forming a "collar button" or "mushroom" shape
A useful mnemonic can be used to help remember these features,
"To Find Small Ocular Melanoma" (TFSOM) (4). This corresponds to:
- Thickness >2 mm
- Fluid (subretinal)
- Orange pigment
- Margins within 3 mm of the optic disc
Figure 9 : (click image for higher resolution)
A different patient presenting with visual symptoms and a pigmented choroidal mass highly suspicious for choroidal melanoma. (A) Biconvex shape with orange pigment overlying the mass and subretinal fluid inferonasal to the lesion. (B) OCT shows subretinal fluid adjacent to the lesion.
Echography is the most useful ancillary test for supporting the clinical diagnosis of choroidal melanoma. The A-scan assesses internal reflectivity, vascularity, and elevation. Melanomas characteristically display low internal reflectivity and a solid tumor pattern. Tumors that have erupted through Bruch's membrane show high amplitude internal reflectivity corresponding to the outer cap followed by low amplitude internal reflectivity corresponding to the basal region. The B-scan demonstrates the size, position, and thickness of the lesion, and can detect extrascleral extension. Most choroidal melanomas present with an exudative retinal detachment that can be imaged on B-scan (5).
Management is dependent on the tumor size, location, and effect on the patient's vision. Conservative therapy that aims to salvage the globe is first-line. There is a wide variety of treatment options for choroidal melanoma, including (6):
- Observation – Indicated when differentiation between melanoma and nevus cannot be made definitively, for some monocular patients, and for patients with significant co-existing life-threatening conditions.
- Brachytherapy – A radioactive episcleral plaque is implanted exterior to the tumor for 3-5 days. This is usually first-line treatment for tumors with basal diameter <20 mm because it can be vision sparing and effective.
- Proton beam radiation – Irradiation with charged particles. This modality has less lateral spread of radiation, which may be useful for tumors close to the optic disc or macula, or for large tumors.
- Transpupillary thermotherapy – Laser beam induces cell death by hyperthermia. Useful adjunct to radiotherapy, and sometimes used as a primary therapy for small tumors.
- Trans-scleral choroidectomy – Difficult procedure with high complication rate. Usually combined with radiation.
- Enucleation – Excision of the globe. Used for large tumors, optic nerve invasion, significant extrascleral extension, or blind, painful eyes. Occasionally, patients choose enucleation even when globe sparing options are viable.
The vast majority of patients (98%) with choroidal melanoma have no detectable metastatic disease, but a metastatic workup should be completed for every suspected diagnosis including a complete physical exam, CBC, LFTs, chest x-ray, and imaging of abdominal organs (usually ultrasonography for routine monitoring) (7). Metastatic disease is spread hematogenously with preferential spread to the liver, and occasional involvement of the lungs, bone, skin, or brain. Despite advancements in melanoma detection and treatment, prognosis has remained relatively stable. Five year all-cause survival from diagnosis is 90% for small melanomas, 70% for medium, and 50% for large. Disseminated melanoma at the time of diagnosis is usually fatal within one year (8).
Adverse clinical prognostic factors:
- Size of >15 mm maximal linear dimension
- Tumor growth
- Ciliary body involvement
- Anterior location
- Juxtapapillary location
- Extrascleral tumor extension
- Older age at diagnosis
- Regrowth after globe-conserving therapy
Melanomas are classified based on histopathology as per the Modified Callender Classification, with a strong correlation between microscopic features and prognosis. Lesions can contain spindles cells, epitheloid cells, or both. Spindle cell melanomas have the best prognosis, epithelioid cell melanomas have the least favorable prognosis, and mixed-cell melanomas have an intermediate prognosis (9). Tumors made entirely of spindle A cells are nevi.
Figure 10: (click image for higher resolution)
Spindle A cells
Melanin bleach, original magnification 300x
Elongated cells with slender nuclei and indistinct nucleoli.
A longitudinal fold may be present in the nuclei.
Spindle B cells
Hematoxylin and eosin, original magnification 300x
Ellipsoid cells with a more plump nucleus, coarser chromatin, and more prominent nucleoli compared to spindle A cells
There is a higher nuclear:cytoplasm ratio than spindle A cells.
Hematoxylin and eosin, original magnification 300x
Pleomorphic polyhedral cells with eosinophilic cytoplasm and a larger, rounder nucleus than spindle cells.
The nuclei have distinct, irregular nuclear membranes with large, eosinophilic nucleoli.
These cells are often discohesive, and some may be bizarre or multinucleated.
Epithelioid cells usually have greater mitotic activity than spindle-type cells.
Other histopathologic features can also be associated with poor prognosis and metastasis including (10,11):
- Presence of complex vascular patterns (fibrovascular networks have worst prognosis)
- High mitotic index
- Mean of 10 largest nuclei
- Tumor-infiltrating lymphocytes
- Cytogenic abnormalities (monosomy 3, trisomy 8)
- Gene expression profiling (class 2 worse than class 1)
Figure 11: (click image for higher resolution)
Histopathology demonstrating choroidal melanoma vascular patterns. Vascular patterns can range from silent (no vessels) to networks that consist of at least 3 back-to-back vascular loops. More complicated vascular patterns carry a poorer prognosis. (A-top image) Parallel-oriented straight vessels. (B-bottom image) Complex vascular pattern with a large fibrovascular network. Melanin bleach and Periodic Acid Schiff without hematoxylin, original magnification 100x
Choroidal melanoma has a typical pattern of spread as the tumor enlarges. It begins as a brown dome-shaped lesion that causes early exudative subretinal detachment. It can expand to disrupt Bruch's membrane and herniate into the posterior chamber, forming the classic "collar button" or "mushroom" configuration. Invasion of scleral vasculature allows orbital spread. Distant metastatic disease occurs hematogenously by penetration into the vortex veins. Optic nerve invasion rarely occurs, usually only with large peripapillary melanomas.
Diagnosis: Choroidal melanoma
Clinical features associated with poorer prognosis:
Pathologic features (associated with poorer prognosis):
American Joint Committee on Cancer TNM Staging (www.mmmp.org)
Differential Diagnosis: Pigmented Retinal Lesion
- Choroidal nevus
- Congenital hypertrophy of retinal pigmented epithelium (CHRPE)
- Retinal pigmented epithelium hyperplasia
- Choroidal metastasis
- Subretinal or suprachoroidal hemorrhage
- Choroidal granuloma
- Posterior scleritis
- Elevated disciform scar
- Prominent vortex vein ampulla
- Margo CE. The collaborative ocular melanoma study: an overview. Cancer Control. 2004; 11(5):304–309.
- Kansaki J. Signs in Ophthalmology: Causes and Differential Diagnosis. St Louis: Mosby/Elsevier. 2010; pp 310-318.
- Khurana AK. Comprehensive Ophthalmology. New Delhi: New Age International Publishers. 2007; pp 162-163. Available online at http://site.ebrary.com/lib/uiowa/Doc?id=10323376.
- Shields CL, Furuta M, Berman E, Zahler J, Hoberman D, Mashayekhi, Shields J. Arch Ophthalmol. 2009;127(8):981-987.
- Section 8.2 Uveal Melanoma. In:Yanoff M., Duker J. Ophthalmology, 4th ed.St. Louis: Mosby/Elsevier. 2014; pp 801-809.
- Kanski J., Bowling B. Clinical Ophthalmology: A Systematic Approach, 7th ed. New York: Elsevier/Saunders. 2011; pp 501-504.
- Rankin SJA, Johnston .B. Metastatic disease from untreated choroidal and ciliary body melanomas. Int Ophthalmol. 1991;1 5:75-78.
- Basic and Clinical Science Course: Section 12. Retina and vitreous. San Francisco: American Academy of Ophthalmology. 2006-2007.
- McLean IW, Foster WD, Zimmerman LE, Gamel JW. Modifications of Callender's classification of uveal melanoma at the Armed Forces Institute of Pathology. Am J Ophthalmol. 1983; 96:502-509.
- Gamel JW, McCurdy JB, McLean IW. A comparison of prognostic covariates for uveal melanoma. Invest Ophthalmol Vis Sci. 1992; 33:1919-1922.
- Folberg R, Rummelt V, Parys-Van Ginderdeuren R, et al. The prognostic value of tumor blood vessel morphology in primary uveal melanoma. Ophthalmology 1993; 100:1389-1398.
- Gallagher, RP, Elwood, JM, Rootman, J, et al. Risk factors for ocular melanoma: Western Canada Melanoma Study. J Natl Cancer Inst 1985; 74(4):775-778.
Suggested Citation Format:
Mullaney S, Vislisel J, Maltry A, Boldt HC. Choroidal Malignant Melanoma: 58-year-old female with pigmented retinal lesion and exudative retinal detachment. EyeRounds.org. July 8, 2014; available from http://EyeRounds.org/cases/190-choroidal-malignant-Melanoma.htm


Distance modulus and the inverse square lawWatch
and then further research I discover about standard candles and more specifically cepheid variables and type 1a supernovae. As far as I understand we use this standard candles of known luminosity, then measure the apparent magnitude and then use the inverse square law to work out the distance. My question is, is using the inverse square law different to using the distance modulus or is the distance modulus just an expression of the inverse square law? So when using standard candles do you use the known luminosity to work out absolute magnitude, then measure the apparent magnitude and then work out the distance using the distance modulus?


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Find out about our inaugural Zoom makeup competition, with top industry judges. All you need to to know is here.
World Bodypainting Festival came back bigger and better for 2021, with a hybrid version that combined online with a live category. Check out the incredible images.
We look at the Beauty For A Better World global digital project that encourages all creatives to share their vision of beauty and show how you can get involved.
We announce the winner of our Spring #TheProsChallenge makeup competition – find out the winning and highly commended entries.
Our first Warpaint Challenge for 2021 offers a prize packed with goodies from a diverse collection of UK pro makeup artists – glitters, brushes and books packed into a Get-Set-Go bag.


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Plan to tax fast food and promote good farming hits hurdle
A RADICAL idea for dealing with a global obesity epidemic by the World Health Organisation to crack down on fast food and promote farmers' produce is already hitting hurdles here despite Australia's increasing waistlines.
In a Monday missive from Geneva, Switzerland, WHO backed findings by American and Irish researchers, which called for financial incentives for farmers to "sell health foods and fresh food items" and sanctions on "ultra-processed" or fast foods and soft drinks through a tax.
Of the 25 countries considered by researchers, Australia had the sharpest rise in fast-food sales second only to Canada.
In these westernised nations, people have been eating an average of 3430 calories a day despite men and women needing no more than 2500 per day.
Farming groups and the peak body for fast-food outlets are opposing the recommendations.
A spokesman for the Queensland Farmers Federation said it would be "unusual, unwelcome and unlikely" for any government policy to determine how farmers sell their produce.
A spokesman for the Australian Grocery and Food Council - the lobby group for fast-food outlets - did not discuss the WHO report directly, but said plenty was already being done by the industry to improve health habits.
He said the industry was trying to reduce fat, energy and salt while increasing fibre, wholegrain, fruit and vegetables in "commonly eaten foods".

domain: food


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But to the man on whose land Abu Hussein shall run into a hole such as is this hole, I will give not dollars, but a most unmeasurable beating
The heavy beating
sound was evidently just behind us, and ever and again a bright green vapour drove up like a veil across our peephole.
and all at once I stopped, sat up in dismay and, bending over apprehensively, began to listen with a beating
The sound of a clear, high voice in a monotonous singsong now rang out behind him and came across the water with a distinctness that pierced and subdued all other sounds, even the beating
of the ripples in his ears.
A heavy tropical shower was beating
down upon them.
Anne went in with cheeks of flame and her heart beating
to her fingertips.
What we cannot make you understand over here is that every Japanese soldier who crept across the bare plains or lay stretched in the trenches, who loaded his rifle and shot and killed and waited for death,--every man felt something beating
in his heart which those others did not feel.
This time they could hear the sound of an engine beating
away in the boat-house on the other side of the Hall.
I saw the Hairless One, out in the open space, beating
his chest and bristling, but afraid to come forward.
The owner went up after him and quickly drove him down, beating
him severely with a thick wooden cudgel.
A CHIEF of Police who had seen an Officer beating
a Thug was very indignant, and said he must not do so any more on pain of dismissal.
A sound as of the beating
of distant drums--a murmur of swarming voices, a sharp, far cry signing all to silence, and Halpin Frayser dreamed that he was dead.

domain: literature