Women's choice? The impact of private health insurance on episiotomy rates in Australian hospitals

Statistical trends of episiotomy around the world: Comparative systematic review of changing practices

The authors' purpose for this article is to identify, review and interpret all publications about the episiotomy rates worldwide. Based on the criteria from the PRISMA guidelines, twenty databases were scrutinized. All studies which include national statistics related to episiotomy were selected, as well as studies presenting estimated data. Sixty-one papers were selected with publication dates between 1995 and 2016. A static and dynamic analysis of all the results was carried out. The assumption for the decline in the number of episiotomies is discussed and confirmed, recalling that nowadays high rates of episiotomy remain in less industrialized countries and East Asia. Finally, our analysis aims to investigate the potential determinants which influence apparent statistical disparities.

Episiotomy and severe perineal trauma among Eastern African immigrant women giving birth in public maternity care: A population based study in Victoria, Australia

BACKGROUND

Eastern African immigrants from countries affected by female genital mutilation have resettled in many developed countries, including Australia. Although possibly at risk of perineal trauma and episiotomy, research investigating their perineal status post-migration is sparse.

AIM

To investigate variations in episiotomy use and incidence of severe perineal tear for women born in Eritrea, Ethiopia, Somalia and Sudan compared with Australian-born women.

METHODS

A population-based study of 203,206 Australian-born and 3502 Eastern African immigrant women admitted as public patients, with singleton vaginal births between 1999 and 2007, was conducted using the Victorian Perinatal Data Collection. Descriptive and multivariable logistic regression analysis adjusting for confounders selected a priori, were performed to compute incidence and adjusted odds ratios.

FINDINGS

Overall, 30.5% Eastern African immigrants had episiotomy compared to 17.2% Australian-born women. Severe perineal trauma occurred in 2.1% of Eastern African immigrants and 1.6% of Australian-born women. While the odds of severe perineal trauma was significantly elevated only during non-instrumental vaginal births for Eastern African immigrants {OR_adj1.56 95%CI(1.17, 2.12)}; that of episiotomy was increased during both non-instrumental {OR_adj4.47 95%CI(4.10, 4.88)} and instrumental {OR_adj2.51 95%CI(1.91, 3.29)} vaginal births.

CONCLUSIONS

Overall, Eastern African immigrant women experienced elevated odds of episiotomy and severe perineal tear. Health care providers need to be mindful of the increased risk of severe perineal tear in these women and enhance efforts in identification and treatment of severe perineal trauma to minimise associated short and long term morbidity. Strategies to reduce unneeded episiotomy and ways of enhancing perineal safety are also needed.

Beyond the hospital door: a retrospective, cohort study of associations between birthing in the public or private sector and women's postpartum care

Background

In Australia, maternity care is available through universal coverage and a parallel, competitive private health insurance system. Differences between sectors in antenatal and intrapartum care and associated outcomes are well documented but few studies have investigated differences in postpartum care following hospital discharge and their impact on maternal satisfaction and confidence.

Methods

Women who birthed in Queensland, Australia from February to May 2010 were mailed a self-report survey 4 months postpartum. Regression analysis was used to determine associations between sector of birth and postpartum care, and whether postpartum care experiences explained sector differences in postpartum well-being (satisfaction, parenting confidence and feeling depressed).

Results

Women who birthed in the public sector had higher odds of health professional contact in the first 10 days post-discharge and satisfaction with the amount of postpartum care. After adjusting for demographic and postpartum contact variables, sector of birth no longer had an impact on satisfaction (AOR 0.95, 99% CI 0.78-1.31), but any form of health professional contact did. Women who had a care provider’s 24 hour contact details had higher odds of being satisfied (AOR 3.64, 95% CI 3.00-4.42) and confident (AOR 1.34, 95% CI 1.08- 1.65).

Conclusion

Women who birthed in the public sector appeared more satisfied because they had higher odds of receiving contact from a health professional within 10 days post-discharge. All women should have an opportunity to speak to and/or see a doctor, midwife or nurse in the first 10 days at home, and the details of a person they can contact 24 hours a day.

Childbirth policies and practices in Ireland and the journey towards midwifery-led care

OBJECTIVE

To describe the dominant policies and practices that have governed childbirth in Ireland, and to outline the progress made towards the introduction of midwifery-led care in one health region.

LITERATURE REVIEW

A review of maternity-care policies in Ireland was conducted using government and regional health-authority documents and two historical reviews of government policies. A search was also carried out in PubMed and cinahl databases, using the keywords 'maternity care', 'childbirth', 'policy', 'midwifery-led', 'Ireland/Irish', with relevant Boolean and string operands. Childbirth as a social process is influenced by the model of care, and affects the physical and psychological outcomes for the woman and her family. In Ireland, routine intervention in labour is common, but, since the early 1990s, some changes in the Irish maternity services have taken place. Pilot projects on community midwifery have been introduced in some areas. Challenges to the provision of maternity care in the Health Service Executive, North Eastern area (formerly the North-Eastern Health Board) led to the production of the Kinder report, which included a recommendation to introduce pilot midwifery-led units (MLUs). THE INTRODUCTION OF MIDWIFERY-LED CARE: A Maternity Services Taskforce was established in January 2002 with a wide remit, including facilitation of the establishment of MLUs in Cavan General Hospital, Cavan and Our Lady of Lourdes Hospital, Drogheda, Co. Louth. The MLUs are being evaluated within the context of a randomised trial known as 'the MidU study', which compares midwife-led care with the present system of medical-led care for women who are at low risk of complications during pregnancy and labour.

CONCLUSION

The journey to midwifery-led care in Ireland has been a long one. The phased introduction of MLUs, which are subject to rigorous evaluation, will provide quality evidence upon which to base the future development of maternity care across Ireland.

What is the relevance of women's sexual and reproductive rights to the practising obstetrician/gynaecologist?

Women's sexual and reproductive rights are an integral part of daily practice for obstetricians/gynaecologists and the key to the survival and health of women around the world. Women's sexual and reproductive health is often compromised because of infringements of their basic human rights, not the lack of medical knowledge. Understanding the relevance of respecting and promoting sexual and reproductive rights is critical for providing current standards of care, and includes access to information and care, confidentiality, informed consent and evidence-based practice. The violation of women's rights in their daily lives through common problems such as gender-based violence and discrimination results in serious consequences for their health. Obstetricians/gynaecologists are natural advocates for women's health, yet may be lacking in their understanding of relevant laws or the limits of conscientious objection. This chapter outlines the framework for sexual and reproductive rights, and explores its relevance to the practising clinician.

Birth position, accoucheur, and perineal outcomes: informing women about choices for vaginal birth

BACKGROUND

The literature is tentative in establishing links between birth position and perineal outcome. Evidence is inconclusive about risks and benefits of women's options for birth position. The objective of this study was to gain further evidence to inform perinatal caregivers about the effect of birth position on perineal outcome, and to assist birth attendants in providing women with information and opportunities for minimizing perineal trauma.

METHODS

Data from 2891 normal vaginal births were analyzed. Descriptive statistics were obtained for variables of interest, and cross-tabulations were generated to explore possible relationships between perineal outcomes, birth positions, and accoucheur type. Logistic regression models were used to examine potential confounding and interaction effects of relevant variables.

RESULTS

Multiple regression analysis revealed a statistically significant association between birth position and perineal outcome. Overall, the lateral position was associated with the highest rate of intact perineum (66.6%) and the most favorable perineal outcome profile. The squatting position was associated with the least favorable perineal outcomes (intact rate 42%), especially for primiparas. A statistically significant association was demonstrated between perineal outcome and accoucheur type. The obstetrician group generated an episiotomy rate of 26 percent, which was more than five times higher than episiotomy rates for all midwife categories. The rate for tear requiring suture of 42.1 percent for the obstetric category was 5 to 7 percentage points higher than that for midwives. Intact perineum was achieved for 31.9 percent of women delivered by obstetricians compared with 56 to 61 percent for three midwifery categories.

CONCLUSION

Findings contribute to growing evidence that birth position may affect perineal outcome. Women's childbirth experiences should reflect decisions made in partnership with midwives and obstetricians who are equipped with knowledge of risks and benefits of birthing options and skills to implement women's choices for birth. Further identification and recognition of the strategies used by midwives to achieve favorable perineal outcomes is warranted.