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Rationale, aims and objectivesThe authors undertook this qualitative study as part of a larger evaluation of the effect of eight clinical practice guidelines issued by an arm's-length government agency in a Canadian province. Using Orlandi and colleagues' version of the Rogers diffusion of innovation model as a framework, the authors mapped doctors' views on implementation of clinical practice guidelines. Methods In semi-structured interviews with 45 representative doctors, the authors elicited doctors' framework of meaning for behaviour change in general and for clinical practice guideline uptake in particular. These were then compared with the adapted Orlandi/Rogers diffusion of innovation model to confirm, amend or challenge that model. Results Doctors identified the following influences on changes to their clinical practice and on clinical practice guideline uptake, within a five-step innovation model: 1 innovation: evidence change is required, perceived need for change; 2 communication: awareness of innovation; 3 adoption: evidence of improved outcomes without increased patient risk, opinion leader support, consistency with current trends; 4 implementation: patient and family acceptability; and 5 maintenance: system support, patient and family support, observed improved patient outcomes without increased risk Conclusions Innovation for doctors is a complex decision process rather than a single decision point. Change occurs in the context of professional networks and patient and family support and demand.

Neonatal intensive care units (NICUs) and intensive care units (ICUs) provide care for newborns in need of specialized medical attention. Across Canada, rates of NICU/ICU admission vary. Due to the high cost of monitoring and interventions these admissions cost more than general newborn stays-whether the newborn is in a specialized NICU or in an ICU in those facilities without specialized units for newborns. This study explores the variation in NICU/ICU admissions and the characteristics of mothers and newborns associated with an increased likelihood of NICU/ICU admission. We focus further on the association between NICU/ICU admission and Caesarean section (C-section). After excluding multiple births, preterm births, small for gestational age births and those delivered by women with select complications, we find an increased risk for NICU/ICU admission for babies born by C-section as their only indication. NICU/ICU admission following C-section alone may not represent the most desirable pathway of care for these newborns.

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Multiple gestations are associated with an increased risk of maternal morbidity and mortality independent of maternal age. Previous reports by the Canadian Institute for Health Information established the overall association between advanced maternal age and complications related to pregnancy and childbirth. This article takes a more focused look at the association between advanced maternal age and maternal outcomes in multiple gestation pregnancies. We found, for mothers aged 35 years and older carrying multiples -after adjusting for mothers' parity, neighbourhood income and residence (rural/urban) -an increased risk of pregnancy complications including pre-existing hypertension, gestational hypertension, pre-eclampsia/eclampsia, gestational diabetes and placenta previa and an increased risk for Caesarean delivery. M ultiple gestations are pregnancies in which more than one fetus develops simultaneously in the mother's womb, with the subsequent delivery of multiple neonates. Rates of multiple births have been increasing in the past three decades in industrialized countries (Urquia et al. 2006). In Canada, the rate of multiple births rose by 18% between 199318% between and 200218% between (Qiu et al. 2008 and by 32% between 2000 (Statistics Canada 2009b.Like other developed countries, the average maternal age in Canada has been increasing as more babies are born to women aged 35 years and older. Between 1998 and 2007, the proportion of live births in this age group rose by more than 20% (Statistics Canada 2009a).Mother's age accounts for about one third of the increase in multiple pregnancies as women of advanced maternal age are physiologically more likely to have multiples (Beemsterboer et al. 2006;Martin et al. 2009). The remaining growth in the rate of multiples has been attributed to the availability of assisted reproductive technologies (Martin and Park 1999). Since women 35 years old and over may face difficulty conceiving, they are more likely to undergo fertility treatment, which, in turn, increases the chance of multiple gestations.To date, most research on the impact of advanced maternal age has not focused on multiple gestations. In this study, we examined the characteristics of mothers with multiple gestations and explored the association between advanced maternal age and adverse pregnancy complications and delivery interventions. Data Sources and MethodsThe study population was mothers 20 years of age and older with multiple gestations. All records of maternal delivery leading to multiple live births in Canadian hospitals between fiscal years 2006-2007 and 2008-2009 were included. Data were from the Canadian Institute for Health Information (CIHI) Discharge Abstract Database (DAD) and Fichier des hospitalisations MED-ÉCHO, ministère de la Santé et des Services sociaux du Québec. All maternal records were selected based on the discharge date.Multiple gestations were defined as delivery leading to two or more births in the same episode. Mothers 20-34 years of age with multiples made up o...