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doi:10.1111/jpc.12490
ORIGINAL ARTICLE
Medical and midwifery attitudes towards vitamin K prophylaxis in New Zealand neonates Sonal Gosai,1 Roland S Broadbent,2 David P Barker,2 Pamela M Jackson2 and Benjamin J Wheeler2 1
Dunedin School of Medicine and 2Department of Women’s and Child Health, University of Otago, Dunedin, New Zealand
Aim: Neonates are at risk for potentially life-threatening vitamin K deficiency bleeding. This can be readily prevented with prophylactic vitamin K following delivery. In this context, most vitamin K-deficiency bleeding occurs in those whose parents decline newborn vitamin K. One factor influencing parental decision-making is information received from health professionals. This study examined attitudes and perceptions towards newborn vitamin K in relevant health-care professionals. Methods: A literature review and one-on-one semi-structured interviews were conducted to inform questionnaire design. Midwives and selected medical staff employed in the South Island of New Zealand were then invited to complete an anonymous survey exploring attitudes and perceptions towards vitamin K prophylaxis in newborns. Results: The survey achieved an overall response rate of 57%. Almost all responding medical staff and 76% of midwives agreed with the current New Zealand Ministry of Health vitamin K guideline. All medical staff but only 55% of midwives feel that all babies should receive vitamin K. Differences were also seen between professionals with respect to vitamin K education and risks. Conclusion: This is the first study to examine attitudes and perceptions of midwives and doctors to vitamin K prophylaxis in neonates. Considerable discrepancies in attitude are evident, and in some midwives, a lack of confidence in this intervention is apparent. How this affects education to families is unknown. Increased understanding of this phenomenon, along with improved education and communication to professionals and families, is required. Key words:
neonatology; prophylaxis; vitamin K; vitamin K deficiency; vitamin K deficiency bleeding.
What is already known on this topic
What this paper adds
1 Neonates are at risk of vitamin K deficiency and subsequent vitamin K deficiency bleeding. 2 The majority of vitamin K deficiency bleeding occurs in those whose parents decline newborn vitamin K. 3 Little is known regarding the attitudes of health professionals towards newborn vitamin K prophylaxis.
1 Of those surveyed, all medical staff but only half of midwives believe that all babies should receive vitamin K. 2 All health professionals agree that midwives have a key role in informing families about newborn vitamin K. 3 Important differences in attitude, practice and trust exist among midwives and doctors with regard to this public health intervention.
Vitamin K plays an essential role in the regulation of blood coagulation, with the production of coagulation factors II, VII, IX and X, and proteins C, S and Z dependent on its presence.1,2 A number of factors contribute to an increased risk of neonatal vitamin K deficiency: Vitamin K stores at birth are limited by relatively poor placental transport of vitamin K; the gut microflora in neonates is not yet developed enough to
Correspondence: Dr Benjamin J Wheeler, Women’s and Children’s Health, Dunedin School of Medicine, University Of Otago, Dunedin 9016, New Zealand. Fax: 0064 3474 7817; email: [email protected] Conflict of interest: The authors declare that they have no conflicts of interest. At the time of manuscript submission, Dr Benjamin J Wheeler was on sabbatical at the Children’s Hospital at Westmead, Sydney, Australia. Accepted for publication 30 November 2013.
adequately synthesise vitamin K, and insufficient intake also plays a part, as breast milk levels of vitamin K are low, irrespective of maternal diet.1,3,4 For the neonate, the most important consequence of vitamin K deficiency is vitamin K deficiency bleeding (VKDB). This can present with spontaneous bleeding or bruising in the first few hours to weeks of life.1–3 Most commonly, this is relatively insignificant muco-cutaneous or gastrointestinal bleeding, but on occasion, this can precede catastrophic and/or lethal haemorrhage.1–3,5,6 To prevent VKDB, New Zealand, as in some other countries, has a developed consensus statement guideline.5 The primary recommendations are that all infants should receive vitamin K prophylaxis at birth and that an intramuscular injection of 1 mg is the preferred option because of issues of reliability of administration and compliance. In this context, VKDB is rarely seen,2,6 the incidence is approximately 1/100 000 live births; in the
Journal of Paediatrics and Child Health (2014) © 2014 The Authors Journal of Paediatrics and Child Health © 2014 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
1
Attitudes towards vitamin K prophylaxis
S. Gosai et al.
absence of vitamin K, the risk can be as high as 1/1500.6 When cases do occur, they are almost without exception confined to those who do not receive vitamin K at birth, the majority in babies where consent is withheld by parents.6–8 The New Zealand health-care system places a strong emphasis on informed choice. However, one factor that may influence parental decision-making is the personal attitudes of advising health-care professionals. The aim of this study was to determine the attitudes and perceptions towards newborn vitamin K prophylaxis in health-care professionals routinely interacting with parents in the newborn period. This has not previously been investigated.
Methods During October/November 2012, health-care professionals across three public hospitals from the South Island of New Zealand were invited to participate. We invited all paediatric and obstetric medical staff (including registrars in formal training schemes) from the three hospitals and midwives from Dunedin City only (from both public and community practice), as identified by current Department of Women’s Health email and staff lists. In total, this process resulted in a total of 189 invitations (47 medical and 142 midwifery). The survey was conducted in two ways. The majority of staff was approached via email, with an explanation of the survey and its purpose given, and for those consenting to proceed, a link provided, which connected to a Survey Monkey (Palo Alto, CA, USA) Internet-based survey. Additionally, at study onset, a minority of participants were approached during work hours and given paper copies of the survey to return anonymously via hospital internal mail. Those contacted in this way were removed from email lists to avoid duplication of responses. Survey content was informed by three techniques: 1 A literature review was conducted involving a MEDLINE search for relevant articles published between 1966 and 2012 using the following words or terms: vitamin K, vitamin K deficiency bleeding, neonate, vitamin K prophylaxis and haemorrhage. 2 A pilot qualitative study was conducted (December 2011 to January 2012) using one-on-one semi-structured interviews with 15 Dunedin midwives to explore ideas and themes regarding newborn vitamin K prophylaxis. The interviews used an open-question technique but also covered the following three categories: opinions on current guidelines, adherence to current guidelines and barriers to implementation. These midwives were recruited via an online directory of Otago midwives, or direct approach by investigator BW. Every effort was made to sample a range of midwives of varying age, experience and practice (hospital, independent and home birth). All interviews were conducted by the same interviewer (SG). The interviews were recorded, transcribed verbatim and then analysed using in-depth thematic analysis to identify common themes. 3 Subsequent open discussions with local paediatricians and obstetricians. IBM SPSS Statistics for Windows, Version 20.0 software (IBM Corp., Armonk, NY, USA) was used for all descriptive analyses. 2
The study protocol was approved by the University of Otago ethics committee and conforms to the provisions of the Declaration of Helsinki.
Results In total, 189 doctors and midwives were approached, with 107 responses received, giving an overall response rate of 56.6%: doctors 87.2% (41/47) and midwives 46.5% (66/142). Table 1 highlights basic demographics of those surveyed.
Awareness/education In total, 72.9% (78/107) of participants were aware of the Ministry of Health (MOH) guideline on vitamin K in neonates, including 81.8% (54/66) of midwives, 73.9% (17/23) of paediatric doctors and 38.9% (7/18) of obstetric doctors. Of these, 94.1% (16/17) of paediatricians, 100% (7/7) of obstetricians and 75.9% (41/54) of midwives strongly agreed or agreed with the guideline. A 24.1% (13/54) of midwives were neutral or disagreed with the guideline as did 5.9% (1/17) of paediatricians. Of the respondents, 51.1% (48/94) believed MOH education available to professionals regarding the vitamin K guideline needs improving, and 59.6% (56/94) believed education to prospective parents needs improving.
Professional views regarding newborn vitamin K Regarding the role of the health professional in the provision of vitamin K information/education, 95.4% (62/65) of midwives felt their role was very important or important. In comparison, 65.2% (15/23) of paediatric and 38.9% (7/18) of obstetric medical staff thought their roles were important. Overall, 96.9% (94/97) of all responders felt that midwives had the most important role in informing families about newborn vitamin K. The remaining three wrote that everybody had an equal role.
Table 1
Basic demographics
Age
Years of experience
Qualification by country
20–29 30–39 40–49 50–59 ≥60 15 years NZ/AUS UK USA/Canada Other
Midwives n (%)
Doctors n (%)
5 (7.8) 11 (17.2) 24 (37.5) 17 (26.6) 7 (10.9) 15 (23.4) 16 (25.0) 11 (17.2) 22 (34.4) 48 (70.8) 10 (15.4) 0 7 (13.8)
5 (11.9) 8 (19) 12 (29.3) 9 (21.4) 7 (16.7) 7 (16.7) 14 (33.3) 7 (16.7) 14 (33.3) 24 (57.1) 9 (21.4) 5 (11.9) 4 (9.5)
AUS, Australia; NZ, New Zealand; UK, United Kingdom; USA, United States of America.
Journal of Paediatrics and Child Health (2014) © 2014 The Authors Journal of Paediatrics and Child Health © 2014 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
S. Gosai et al.
Table 2
Attitudes towards vitamin K prophylaxis
Professional actions when parents decline vitamin K prophylaxis
Possible responses
Total (n = 107) n (%)
Midwives (n = 66) n (%)
Doctors (n = 41) n (%)
P-values
Document it Provide written/verbal information Discuss and reinforce importance Encourage mother to eat vitamin K-rich foods Educate regarding warning signs of vitamin K deficiency bleeding Do nothing further Don’t know Recommend they speak with another health professional
93 (86.9%) 83 (77.6%) 74 (69.2%) 38 (35.5%) 79 (73.8%) 2 (1.9%) 1 (0.9%) 21 (19.6%)
62 (93.9%) 60 (90.9%) 36 (54.5%) 37 (56.1%) 55 (83.3%) 0 (0.0%) 0 (0.0%) 13 (19.7%)
31 (75.6%) 23 (56.1%) 38 (92.7%) 1 (2.4%) 24 (58.5%) 2 (4.9%) 1 (2.4%) 8 (19.5%)
doi:10.1111/jpc.12490
ORIGINAL ARTICLE
Medical and midwifery attitudes towards vitamin K prophylaxis in New Zealand neonates Sonal Gosai,1 Roland S Broadbent,2 David P Barker,2 Pamela M Jackson2 and Benjamin J Wheeler2 1
Dunedin School of Medicine and 2Department of Women’s and Child Health, University of Otago, Dunedin, New Zealand
Aim: Neonates are at risk for potentially life-threatening vitamin K deficiency bleeding. This can be readily prevented with prophylactic vitamin K following delivery. In this context, most vitamin K-deficiency bleeding occurs in those whose parents decline newborn vitamin K. One factor influencing parental decision-making is information received from health professionals. This study examined attitudes and perceptions towards newborn vitamin K in relevant health-care professionals. Methods: A literature review and one-on-one semi-structured interviews were conducted to inform questionnaire design. Midwives and selected medical staff employed in the South Island of New Zealand were then invited to complete an anonymous survey exploring attitudes and perceptions towards vitamin K prophylaxis in newborns. Results: The survey achieved an overall response rate of 57%. Almost all responding medical staff and 76% of midwives agreed with the current New Zealand Ministry of Health vitamin K guideline. All medical staff but only 55% of midwives feel that all babies should receive vitamin K. Differences were also seen between professionals with respect to vitamin K education and risks. Conclusion: This is the first study to examine attitudes and perceptions of midwives and doctors to vitamin K prophylaxis in neonates. Considerable discrepancies in attitude are evident, and in some midwives, a lack of confidence in this intervention is apparent. How this affects education to families is unknown. Increased understanding of this phenomenon, along with improved education and communication to professionals and families, is required. Key words:
neonatology; prophylaxis; vitamin K; vitamin K deficiency; vitamin K deficiency bleeding.
What is already known on this topic
What this paper adds
1 Neonates are at risk of vitamin K deficiency and subsequent vitamin K deficiency bleeding. 2 The majority of vitamin K deficiency bleeding occurs in those whose parents decline newborn vitamin K. 3 Little is known regarding the attitudes of health professionals towards newborn vitamin K prophylaxis.
1 Of those surveyed, all medical staff but only half of midwives believe that all babies should receive vitamin K. 2 All health professionals agree that midwives have a key role in informing families about newborn vitamin K. 3 Important differences in attitude, practice and trust exist among midwives and doctors with regard to this public health intervention.
Vitamin K plays an essential role in the regulation of blood coagulation, with the production of coagulation factors II, VII, IX and X, and proteins C, S and Z dependent on its presence.1,2 A number of factors contribute to an increased risk of neonatal vitamin K deficiency: Vitamin K stores at birth are limited by relatively poor placental transport of vitamin K; the gut microflora in neonates is not yet developed enough to
Correspondence: Dr Benjamin J Wheeler, Women’s and Children’s Health, Dunedin School of Medicine, University Of Otago, Dunedin 9016, New Zealand. Fax: 0064 3474 7817; email: [email protected] Conflict of interest: The authors declare that they have no conflicts of interest. At the time of manuscript submission, Dr Benjamin J Wheeler was on sabbatical at the Children’s Hospital at Westmead, Sydney, Australia. Accepted for publication 30 November 2013.
adequately synthesise vitamin K, and insufficient intake also plays a part, as breast milk levels of vitamin K are low, irrespective of maternal diet.1,3,4 For the neonate, the most important consequence of vitamin K deficiency is vitamin K deficiency bleeding (VKDB). This can present with spontaneous bleeding or bruising in the first few hours to weeks of life.1–3 Most commonly, this is relatively insignificant muco-cutaneous or gastrointestinal bleeding, but on occasion, this can precede catastrophic and/or lethal haemorrhage.1–3,5,6 To prevent VKDB, New Zealand, as in some other countries, has a developed consensus statement guideline.5 The primary recommendations are that all infants should receive vitamin K prophylaxis at birth and that an intramuscular injection of 1 mg is the preferred option because of issues of reliability of administration and compliance. In this context, VKDB is rarely seen,2,6 the incidence is approximately 1/100 000 live births; in the
Journal of Paediatrics and Child Health (2014) © 2014 The Authors Journal of Paediatrics and Child Health © 2014 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
1
Attitudes towards vitamin K prophylaxis
S. Gosai et al.
absence of vitamin K, the risk can be as high as 1/1500.6 When cases do occur, they are almost without exception confined to those who do not receive vitamin K at birth, the majority in babies where consent is withheld by parents.6–8 The New Zealand health-care system places a strong emphasis on informed choice. However, one factor that may influence parental decision-making is the personal attitudes of advising health-care professionals. The aim of this study was to determine the attitudes and perceptions towards newborn vitamin K prophylaxis in health-care professionals routinely interacting with parents in the newborn period. This has not previously been investigated.
Methods During October/November 2012, health-care professionals across three public hospitals from the South Island of New Zealand were invited to participate. We invited all paediatric and obstetric medical staff (including registrars in formal training schemes) from the three hospitals and midwives from Dunedin City only (from both public and community practice), as identified by current Department of Women’s Health email and staff lists. In total, this process resulted in a total of 189 invitations (47 medical and 142 midwifery). The survey was conducted in two ways. The majority of staff was approached via email, with an explanation of the survey and its purpose given, and for those consenting to proceed, a link provided, which connected to a Survey Monkey (Palo Alto, CA, USA) Internet-based survey. Additionally, at study onset, a minority of participants were approached during work hours and given paper copies of the survey to return anonymously via hospital internal mail. Those contacted in this way were removed from email lists to avoid duplication of responses. Survey content was informed by three techniques: 1 A literature review was conducted involving a MEDLINE search for relevant articles published between 1966 and 2012 using the following words or terms: vitamin K, vitamin K deficiency bleeding, neonate, vitamin K prophylaxis and haemorrhage. 2 A pilot qualitative study was conducted (December 2011 to January 2012) using one-on-one semi-structured interviews with 15 Dunedin midwives to explore ideas and themes regarding newborn vitamin K prophylaxis. The interviews used an open-question technique but also covered the following three categories: opinions on current guidelines, adherence to current guidelines and barriers to implementation. These midwives were recruited via an online directory of Otago midwives, or direct approach by investigator BW. Every effort was made to sample a range of midwives of varying age, experience and practice (hospital, independent and home birth). All interviews were conducted by the same interviewer (SG). The interviews were recorded, transcribed verbatim and then analysed using in-depth thematic analysis to identify common themes. 3 Subsequent open discussions with local paediatricians and obstetricians. IBM SPSS Statistics for Windows, Version 20.0 software (IBM Corp., Armonk, NY, USA) was used for all descriptive analyses. 2
The study protocol was approved by the University of Otago ethics committee and conforms to the provisions of the Declaration of Helsinki.
Results In total, 189 doctors and midwives were approached, with 107 responses received, giving an overall response rate of 56.6%: doctors 87.2% (41/47) and midwives 46.5% (66/142). Table 1 highlights basic demographics of those surveyed.
Awareness/education In total, 72.9% (78/107) of participants were aware of the Ministry of Health (MOH) guideline on vitamin K in neonates, including 81.8% (54/66) of midwives, 73.9% (17/23) of paediatric doctors and 38.9% (7/18) of obstetric doctors. Of these, 94.1% (16/17) of paediatricians, 100% (7/7) of obstetricians and 75.9% (41/54) of midwives strongly agreed or agreed with the guideline. A 24.1% (13/54) of midwives were neutral or disagreed with the guideline as did 5.9% (1/17) of paediatricians. Of the respondents, 51.1% (48/94) believed MOH education available to professionals regarding the vitamin K guideline needs improving, and 59.6% (56/94) believed education to prospective parents needs improving.
Professional views regarding newborn vitamin K Regarding the role of the health professional in the provision of vitamin K information/education, 95.4% (62/65) of midwives felt their role was very important or important. In comparison, 65.2% (15/23) of paediatric and 38.9% (7/18) of obstetric medical staff thought their roles were important. Overall, 96.9% (94/97) of all responders felt that midwives had the most important role in informing families about newborn vitamin K. The remaining three wrote that everybody had an equal role.
Table 1
Basic demographics
Age
Years of experience
Qualification by country
20–29 30–39 40–49 50–59 ≥60 15 years NZ/AUS UK USA/Canada Other
Midwives n (%)
Doctors n (%)
5 (7.8) 11 (17.2) 24 (37.5) 17 (26.6) 7 (10.9) 15 (23.4) 16 (25.0) 11 (17.2) 22 (34.4) 48 (70.8) 10 (15.4) 0 7 (13.8)
5 (11.9) 8 (19) 12 (29.3) 9 (21.4) 7 (16.7) 7 (16.7) 14 (33.3) 7 (16.7) 14 (33.3) 24 (57.1) 9 (21.4) 5 (11.9) 4 (9.5)
AUS, Australia; NZ, New Zealand; UK, United Kingdom; USA, United States of America.
Journal of Paediatrics and Child Health (2014) © 2014 The Authors Journal of Paediatrics and Child Health © 2014 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
S. Gosai et al.
Table 2
Attitudes towards vitamin K prophylaxis
Professional actions when parents decline vitamin K prophylaxis
Possible responses
Total (n = 107) n (%)
Midwives (n = 66) n (%)
Doctors (n = 41) n (%)
P-values
Document it Provide written/verbal information Discuss and reinforce importance Encourage mother to eat vitamin K-rich foods Educate regarding warning signs of vitamin K deficiency bleeding Do nothing further Don’t know Recommend they speak with another health professional
93 (86.9%) 83 (77.6%) 74 (69.2%) 38 (35.5%) 79 (73.8%) 2 (1.9%) 1 (0.9%) 21 (19.6%)
62 (93.9%) 60 (90.9%) 36 (54.5%) 37 (56.1%) 55 (83.3%) 0 (0.0%) 0 (0.0%) 13 (19.7%)
31 (75.6%) 23 (56.1%) 38 (92.7%) 1 (2.4%) 24 (58.5%) 2 (4.9%) 1 (2.4%) 8 (19.5%)
