The main emphasis of Professor Christine MacArthur’s research over the last 30 years has been on aspects of women’s childbirth-health. This has comprised generation of hypotheses in large observational studies and investigation of related interventions in randomised controlled trials.
Postnatal urinary and faecal incontinence:
This work, over the last 15 years, is based around a large cohort study (ProLong) with colleagues in Aberdeen and New Zealand. The ProLong Study is just about to contact women at 20+years:
Christine’s earlier work on incontinence was part of a study of health problems up to 9 years after birth among 11701 women based on questionnaires and obstetric case notes. It was published as a book, ‘Health After Childbirth’, by HMSO in 1991. The current cohort study is following an initial group of 7879 women who gave birth in 1993/4 to investigate persistence and risk factors of incontinence and prolapse. It is currently the largest long-tem postpartum cohort study on the topic. The latest paper (BJOG 2011) showed that Caesarean section, relative to vaginal birth is not associated with a reduction in stress incontinence unless all a woman’s deliveries are by Caesarean. And even exclusive Caesarean delivery is not associated with less faecal incontinence: whilst just one forceps delivery will increase the risk. A linked RCT (PINT) of pelvic floor muscle exercise for women with symptoms at 3 months postpartum showed improvement at 1 year but not at 6 years (both BMJ). A current linked RCT (PREVPROL) is on exercise to prevent prolapse, funded in UK centres by RCOG charity Wellbeing. Christine also collaborates on a postpartum cohort study with colleagues at University of Melbourne.
Evaluation of maternity health services
Current research is on lay/peer health workers, an area with little evidence of effectiveness yet widespread service use. As the main focus of the maternity theme of NIHR BBC CLAHRC programme the theme group are conducting an RCT (ELSIPS) to evaluate a pregnancy outreach worker service. The service is provided by Birmingham PCTs to improve birth outcomes in women identified by midwives as having social risk. Recruitment is underway and expected to finish at end of 2011, with follow-up to 3 months after birth.
Breastfeeding services are an area where peer workers are recommended by DoH but with inadequate evidence. A peer support worker service to increase breastfeeding initiation and continuation in Heart of Birmingham PCT was evaluated in a cluster RCT (HoBBIT). The findings showed no benefit of the service in increasing initiation (in BMJ) or continuation to 6 months postpartum. Two systematic reviews by the team further examine evidence on breastfeeding peer support.
Arising from her earlier studies on childbirth-related health, Christine led an RCT of re-designed midwifery-led postnatal care. Care was extended to 28 days postpartum, needs based by systematically identifying health problems and with evidence-based guidelines (produced for midwives by team) to manage these. Findings (Lancet 2001) showed improvement in psychological health and reduction in postnatal depression; these informed the maternity NSF. The guidelines were subsequently published as a book, now in 2nd edition. In the management of postnatal depression a current RCT (PaMPERS) is investigating the effect of exercise in women with diagnosed depression (led by Dr Amanda Daley). A pilot RCT and systematic review showed feasibility of the regime. A parallel RCT is exercise for women with menopausal vasomotor symptoms (Active Women) and a team Cochrane review supports this.
Effects of epidural analgesia
Christine’s work on this arose out of her ‘Health After Childbirth’ study, which indicated a possible increase in certain long-term health problems in women who had epidural pain relief in labour (3 BMJ papers). Epidurals result in more instrumental births and subsequent RCTs examine possible ways to reduce this. An RCT (COMET) in two centres, funded by DoH NHS research programme (Prof Andy Shennan CI of other centre) found low dose mobile techniques resulted in fewer instrumental deliveries than traditional higher dose epidurals. The results (Lancet) have been credited as indicating that the traditional technique is no longer justified in practice. There are still more instrumental births with mobile epidurals than in woman without epidurals and a current NIHR funded trial (BUMPES - led by Prof Peter Brocklehurst) is recruiting 3000 women with epidurals in 5 centres to investigate effects of maternal position in 2nd stage labour. Delivery mode and health effects, including incontinence, will be examined 12 months after birth.
Smoking in pregnancy
Professor Christine MacArthur has undertaken two trials of anti-smoking education in pregnancy: one found a reduction in smoking; the second showed that anti-smoking intervention by midwives and obstetricians was effective in increasing infant birthweight. Funded by an MRC grant, she followed up the study groups when children were aged 9-10 using IQ and neurological soft-sign testing of children, interviews of parents and teachers questionnaires. Findings showed no long-term effects on cognitive development.
Maternal health in developing world
Christine has been involved with studies and systematic reviews of maternal health issues, including reduction of perinatal and maternal mortality and morbidity, also with colleagues in developing world including Pakistan and Africa