The dangers of the day of birth

Maternal and pregnancy predictive risk factors for having a compensated maternal injury claim: a Swedish nationwide cohort study

To describe trends and identify maternal and pregnancy predictive risk factors for having a compensated claim for a maternal injury during delivery, as a proxy for having received suboptimal care. This nationwide retrospective cohort study included 1 754 869 births in Sweden between 2000 and 2016, including 4488 maternal injury claims filed with The National Swedish Patient Insurance Company (Löf), of which 1637 were compensated. Descriptive statistics on maternal and pregnancy characteristics, trends in filed/compensated claims over time, and distribution of compensated claims by clinical classification are presented. Characteristics associated with suboptimal care were identified using multivariable logistic regression, with mutual adjustment in the final model. Compensated claims were sorted into 14 clinical classifications (ICD-10 codes for main condition, injury, and causality). Overall, there was a two-fold increase in filed claims from 2000 to 2016, peaking in 2014. The rate of compensated claims only increased marginally, and 36.5% of filed claims were deemed avoidable. Perineal and pelvic floor injuries, as well as medical and diagnostic errors, were responsible for the majority of compensated claims. Women with a previous caesarean section, post term delivery, chronic or gestational disease, > 13 antenatal visits, or a multiple pregnancy had increased risk of having a compensated claim for a maternal injury during delivery. Understanding the risk factors for having a compensated maternal injury claim may guide health workers and maternity wards in improving the quality and organisation of care to reduce the risk of childbirth related injuries.

Individual risk evaluation for landslides: key details

Risk-taking is an essential part of life. As individuals, we evaluate risks intuitively and often subconsciously by comparing the perceived risks with expected benefits. We do this so commonly that it passes unnoticed, like when we decide to speed home from work or go for a swim. The comparison changes, however, when one entity (such as a government) imposes a risk evaluation on another person. For example, in a quantitative risk management framework, the estimated risk is compared with a tolerable risk threshold to decide if the person is 'safe enough'. Landslide risk management methods are well established and there is consensus on tolerable life-loss risk thresholds. However, beneath this consensus lie several key details that are explored by this article, along with suggestions for refinement. Specifically, we suggest using the risk unit, micromort (one micromort equals a life loss risk of 1 in 1 million), in describing risk estimates and thresholds, to improve risk communication. For risk estimation, we provide guidance for defining and combining landslide scenarios and for recognizing where unquantified risk from low-probability/high-consequence scenarios ought to inform risk management decisions. For risk tolerance thresholds, we highlight the pitfalls of selecting unachievably low thresholds and suggest that there is no single universal threshold. Additionally, we argue that gross disproportion between costs and benefits of further risk reduction, which is integral to the As Low As Reasonably Practicable (ALARP) principle, is a commonly unachievable and counter-productive condition for risk tolerance, and other conditions centered on proportionality often apply. Finally, we provide several figures that can be used as risk communication tools, to provide context for risk estimates and risk tolerance thresholds when these values are reported to decision makers and the public.

Comparing mortality from covid-19 to mortality due to overdose: A micromort analysis

OBJECTIVE

To compare the mortality risk due to covid-19 with death due to overdose in British Columbia, Canada. The opioid epidemic was declared a public health emergency in 2016.

METHODS

Mortality risk was calculated in micromorts with covid-19 data for January-October 2020, derived from the BC center for Disease Control, and illicit drug toxicity deaths for January 2010-September 2020, derived from the BC Coroners Service. Age-stratified covid-19 incidence and deaths per 100,000 population and age-stratified illicit drug toxicity death rates per 100,000 population were calculated. A micromort is a unit of risk equivalent to a one-in-a-million chance of death.

RESULTS

During the covid-19 pandemic, illicit drug toxicity deaths reached 1.0 micromorts per day, representing an increase of 0.5 micromorts per day relative to 2019 rates. In comparison, covid-19 mortality risk was 0.05 micromorts per day among individuals from the general population living in British Columbia and 21.1 micromorts per day among those infected with covid-19. Covid-related mortality risk was significantly lower among individuals aged <60 years, relative to older adults, whereas drug toxicity-related mortality was highest for individuals aged 30-59 years.

CONCLUSIONS

The mortality associated with covid-19 is apparent and distributed unevenly across subpopulations. The mortality due to overdose has increased during covid-19 and exceeds mortality due to covid-19. Our results instantiate the triple threat caused by covid-19 (i.e., public health crisis, economic crisis and mental health crisis) and quantitatively highlight the externality of increased mortality due to deaths of despair in response to public health efforts to reduce covid-related mortality.

Feasibility and design of a trial regarding the optimal mode of delivery for preterm birth: the CASSAVA multiple methods study

BACKGROUND

Around 60,000 babies are born preterm (prior to 37 weeks' gestation) each year in the UK. There is little evidence on the optimal birth mode (vaginal or caesarean section).

OBJECTIVE

The overall aim of the CASSAVA project was to determine if a trial to define the optimal mode of preterm birth could be carried out and, if so, determine what sort of trial could be conducted and how it could best be performed. We aimed to determine the specific groups of preterm women and babies for whom there are uncertainties about the best planned mode of birth, and if there would be willingness to recruit to, and participate in, a randomised trial to address some, but not all, of these uncertainties. This project was conducted in response to a Heath Technology Assessment programme commissioning call (17/22 'Mode of delivery for preterm infants').

METHODS

We conducted clinician and patient surveys (n = 224 and n = 379, respectively) to identify current practice and opinion, and a consensus survey and Delphi workshop (n = 76 and n = 22 participants, respectively) to inform the design of a hypothetical clinical trial. The protocol for this clinical trial/vignette was used in telephone interviews with clinicians (n = 24) and in focus groups with potential participants (n = 13).

RESULTS

Planned sample size and data saturation was achieved for all groups except for focus groups with participants, as this had to be curtailed because of the COVID-19 pandemic and data saturation was not achieved. There was broad agreement from parents and health-care professionals that a trial is needed. The clinician survey demonstrated a variety of practice and opinion. The parent survey suggested that women and their families generally preferred vaginal birth at later gestations and caesarean section for preterm infants. The interactive workshop and Delphi consensus process confirmed the need for more evidence (hence the case for a trial) and provided rich information on what a future trial should entail. It was agreed that any trial should address the areas with most uncertainty, including the management of women at 26-32 weeks' gestation, with either spontaneous preterm labour (cephalic presentation) or where preterm birth was medically indicated. Clear themes around the challenges inherent in conducting any trial emerged, including the concept of equipoise itself. Specific issues were as follows: different clinicians and participants would be in equipoise for each clinical scenario, effective conduct of the trial would require appropriate resources and expertise within the hospital conducting the trial, potential participants would welcome information on the trial well before the onset of labour and minority ethnic groups would require tailored approaches.

CONCLUSION

Given the lack of evidence and the variation of practice and opinion in this area, and having listened to clinicians and potential participants, we conclude that a trial should be conducted and the outlined challenges resolved.

FUTURE WORK

The CASSAVA project could be used to inform the design of a randomised trial and indicates how such a trial could be carried out. Any future trial would benefit from a pilot with qualitative input and a study within a trial to inform optimal recruitment.

LIMITATIONS

Certainty that a trial could be conducted can be determined only when it is attempted.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN12295730.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 61. See the NIHR Journals Library website for further project information.

FIGO good clinical practice paper: management of the second stage of labor

This good clinical practice paper provides an overview of the current evidence around second stage care, highlighting the challenges and the importance of maintaining high-quality, safe, and respectful care in all settings. It includes a series of recommendations based on best available evidence regarding length of second stage, judicious use of episiotomy, and the importance of competent attendants and adequate resource to facilitate all aspects of second stage management, from physiological birth to assisted vaginal delivery and cesarean at full dilatation. The second stage of labor is potentially the most dangerous time for the baby and can have significant consequences for the mother, including death or severe perineal trauma or fistula, especially where there are failures to recognize and repair. This paper sets out principles of care, including the vital role of skilled birth attendants and birth companions, and the importance of obstetricians and midwives working together effectively and speaking with one voice, whether to women or to policy makers. The optimization of high-quality, safe, and personalized care in the second stage of labor for all women globally can only be achieved by appropriate attention to the training of birth attendants, midwives, and obstetricians. FIGO is committed to this aim alongside the WHO, ICM, and all FIGO's 132 member societies.

Reproductive health research in Australia and New Zealand: highlights from the Annual Meeting of the Society for Reproductive Biology, 2019

The 2019 meeting of the Society for Reproductive Biology (SRB) provided a platform for the dissemination of new knowledge and innovations to improve reproductive health in humans, enhance animal breeding efficiency and understand the effect of the environment on reproductive processes. The effects of environment and lifestyle on fertility and animal behaviour are emerging as the most important modern issues facing reproductive health. Here, we summarise key highlights from recent work on endocrine-disrupting chemicals and diet- and lifestyle-induced metabolic changes and how these factors affect reproduction. This is particularly important to discuss in the context of potential effects on the reproductive potential that may be imparted to future generations of humans and animals. In addition to key summaries of new work in the male and female reproductive tract and on the health of the placenta, for the first time the SRB meeting included a workshop on endometriosis. This was an important opportunity for researchers, healthcare professionals and patient advocates to unite and provide critical updates on efforts to reduce the effect of this chronic disease and to improve the welfare of the women it affects. These new findings and directions are captured in this review.

Digital Simulation Improves, Maintains, and Helps Transfer Health-Care Providers' Neonatal Resuscitation Knowledge

Purpose: To safely care for their newborn patients, health-care professionals (HCP) must undergo frequent training to improve and maintain neonatal resuscitation knowledge and skills. However, the current approach to neonatal resuscitation simulation training is time and resource-intensive, and often inaccessible. Digital neonatal resuscitation simulation may present a convenient alternative for more frequent training. Method: Fifty neonatal HCPs participated in the study (44 female; 27 nurses, 3 nurse practitioners, 14 respiratory therapists, 6 doctors). This study was conducted at a tertiary perinatal center in Edmonton, Canada from April-August 2019, with 2-month (June-October 2019) and 5-month (September 2019-January 2020) follow-up. Neonatal HCPs were recruited by volunteer sampling to complete a demographic survey, pre-test (baseline knowledge), two digital simulation scenarios (intervention), and post-test (knowledge acquisition). Two months later, participants repeated the post-test (knowledge retention). Five months after the initial intervention, participants completed a post-test using a table-top simulation (knowledge transfer). Longitudinal analyses were used to compare participants' performance over time. Results: Overall the proportion of correct performance increased: 21/50 (42%) passed the pre-test, 39/50 (78%) the post-test, 30/43 (70%) the 2-month post-test, and 32/40 (80%) the 5-month post-test. GLMM and GEE analyses revealed that performance on all post-tests was significantly better than the performance on the pre-test. Therefore, training with the RETAIN digital simulation effectively improves, maintains, and transfers HCPs' neonatal resuscitation knowledge. Conclusions: Digital simulation improved, maintained, and helped transfer HCPs' neonatal resuscitation knowledge over time. Digital simulation presents a promising approach for frequent neonatal resuscitation training, particularly for distance-learning applications.

The risks of a range of maternal pregnancy choices, expressed as "baby micromorts" (risk of death per million births)

OBJECTIVE

To present the risks of baby death from various maternal choices on a common scale.

DESIGN

Review of published data.

METHODS

Mortality calculated as the attributable risk per activity, expressed in "baby micromorts", the number of one in a million chances of the baby dying.

RESULTS

Amniocentesis and chorionic villous sampling carry procedure related risks of 9142 (-600 to 19,000) and 37,902 (23,302 to 52,502) micromorts respectively. Smoking carries a risk of 0.21 micromorts per cigarette or 300 micromorts for a woman smoking 5/day throughout pregnancy. Drinking a unit of alcohol in the first trimester carries a risk of 400 micromorts via miscarriage or 19,200 micromorts for a woman drinking 4 units/week in the first trimester. The risk per unit due to stillbirth is only about 19 or 3,710 micromorts when drinking 5 units/week throughout pregnancy. Cocaine use carries a risk of about 45 micromorts per single use; 3,630 micromorts using cocaine twice/week during pregnancy. For low risk women in the UK, planned first birth at home carries an additional 843 (-200 to 2620) micromorts compared with in hospital, and planned vaginal breech birth an additional 5870 (-4400 to 18,500), compared with planned caesarean. The risk of delaying conception by a year varies by age group. For women aged 35-39 the risk increases by 220 (-430 to 870) micromorts each year versus 600 (-800 to 2000) micromorts for women aged over 40. Compared with the above, the risk from the mother eating a serving of unpasteurised cheese, is negligible at 0.00026 micromorts.

CONCLUSIONS

This way of expressing risk may help put choices which pregnant women make into perspective, although it needs evaluating in well conducted experimental studies.

Factors influencing utilisation of ‘free-standing’ and ‘alongside’ midwifery units for low-risk births in England: a mixed-methods study

Background

Midwifery-led units (MUs) are recommended for ‘low-risk’ births by the National Institute for Health and Care Excellence but according to the National Audit Office were not available in one-quarter of trusts in England in 2013 and, when available, were used by only a minority of the low-risk women for whom they should be suitable. This study explores why.

Objectives

To map the provision of MUs in England and explore barriers to and facilitators of their development and use; and to ascertain stakeholder views of interventions to address these barriers and facilitators.

Design

Mixed methods – first, MU access and utilisation across England was mapped; second, local media coverage of the closure of free-standing midwifery units (FMUs) were analysed; third, case studies were undertaken in six sites to explore the barriers and facilitators that have an impact on the development of MUs; and, fourth, by convening a stakeholder workshop, interventions to address the barriers and facilitators were discussed.

Setting

English NHS maternity services.

Participants

All trusts with maternity services.

Interventions

Establishing MUs.

Main outcome measures

Numbers and types of MUs and utilisation of MUs.

Results

Births in MUs across England have nearly tripled since 2011, to 15% of all births. However, this increase has occurred almost exclusively in alongside units, numbers of which have doubled. Births in FMUs have stayed the same and these units are more susceptible to closure. One-quarter of trusts in England have no MUs; in those that do, nearly all MUs are underutilised. The study findings indicate that most trust managers, senior midwifery managers and obstetricians do not regard their MU provision as being as important as their obstetric-led unit provision and therefore it does not get embedded as an equal and parallel component in the trust’s overall maternity package of care. The analysis illuminates how provision and utilisation are influenced by a complex range of factors, including the medicalisation of childbirth, financial constraints and institutional norms protecting the status quo.

Limitations

When undertaking the case studies, we were unable to achieve representativeness across social class in the women’s focus groups and struggled to recruit finance directors for individual interviews. This may affect the transferability of our findings.

Conclusions

Although there has been an increase in the numbers and utilisation of MUs since 2011, significant obstacles remain to MUs reaching their full potential, especially FMUs. This includes the capacity and willingness of providers to address women’s information needs. If these remain unaddressed at commissioner and provider level, childbearing women’s access to MUs will continue to be restricted.

Future work

Work is needed on optimum approaches to improve decision-makers’ understanding and use of clinical and economic evidence in service design. Increasing women’s access to information about MUs requires further studies of professionals’ understanding and communication of evidence. The role of FMUs in the context of rural populations needs further evaluation to take into account user and community impact.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 12. See the NIHR Journals Library website for further project information.

An analysis of media reporting on the closure of freestanding midwifery units in England

PROBLEM

Despite clinical guidelines and policy promoting choice of place of birth, 14 Freestanding Midwifery Units were closed between 2008 and 2015, closures reported in the media as justified by low use and financial constraints.

BACKGROUND

The Birthplace in England Programme found that freestanding midwifery units provided the most cost-effective birthplace for women at low risk of complications. Women planning birth in a freestanding unit were less likely to experience interventions and serious morbidity than those planning obstetric unit birth, with no difference in outcomes for babies.

METHODS

This paper uses an interpretative technique developed for policy analysis to explore the representation of these closures in 191 news articles, to explore the public climate in which they occurred.

FINDINGS AND DISCUSSION

The articles focussed on underuse by women and financial constraints on services. Despite the inclusion of service user voices, the power of framing was held by service managers and commissioners. The analysis exposed how neoliberalist and austerity policies have privileged representation of individual consumer choice and market-driven provision as drivers of changes in health services. This normative framing presents the reasons given for closure as hard to refute and cultural norms persist that birth is safest in an obstetric setting, despite evidence to the contrary.

CONCLUSION

The rise of neoliberalism and austerity in contemporary Britain has influenced the reform of maternity services, in particular the closure of midwifery units. Justifications given for closure silence other narratives, predominantly from service users, that attempt to present women's choice in terms of rights and a social model of care.

Feto-maternal Outcomes of Emergency Caesarean Section following Residential Posting at Dhading District Hospital

INTRODUCTION

Caesarean section is a commonly performed major obstetric surgery to deliver baby under certain indications which may be maternal or fetal. If performed timely, it is helpful to save the life of mother and fetus and if not, it increases both maternal and fetal risks.

METHODS

A hospital based descriptive cross-sectional study was conducted at Dhading district hospital from 17th October 2016 to 17th October 2017. Total of 41 patients undergoing emergency caesarean section meeting the selection criteria were included.

RESULTS

The incidence of emergency caesarean section was 41 (5.5%). Most common indication for caesarean delivery was fetal distress in 12 (29.3%) followed by failed induction and cephalopelvic disproportion each accounting 6 (14.6%) cases. The least common causes being chorioamnionitis and cord prolapse in 1 (2.4%). Regarding perinatal outcomes, 33 (80.5%) babies delivered were of normal weight. Low Apgar score (<7) at one minute was noted in 8 (19.5%) cases. Neonatal resuscitation in the form of oxygen supplementation was required in 2 (4.9%) cases whereas bag and mask ventilation was required in 5 (12.2%) cases. Referral for neonatal intensive care unit admission was done in 6 (14.6%) cases. There were three neonatal deaths.

CONCLUSIONS

Residential posting was fruitful to decrease feto-maternal morbidities and mortalities. Even to minimize the delay of treatment, government should provide adequate equipments and skilled man-power to run neonatal intensive care unit.

Cost-effectiveness of simulation-based team training in obstetric emergencies (TOSTI study)

OBJECTIVE

Team training is frequently applied in obstetrics. We aimed to evaluate the cost-effectiveness of obstetric multi-professional team training in a medical simulation centre.

STUDY DESIGN

We performed a model-based cost-effectiveness analysis to evaluate four strategies for obstetric team training from a hospital perspective (no training, training without on-site repetition and training with 6 month or 3-6-9 month repetition). Data were retrieved from the TOSTI study, a randomised controlled trial evaluating team training in a medical simulation centre. We calculated the incremental cost-effectiveness ratio (ICER), which represent the costs to prevent the adverse outcome, here (1) the composite outcome of obstetric complications and (2) specifically neonatal trauma due to shoulder dystocia.

RESULTS

Mean costs of a one-day multi-professional team training in a medical simulation centre were €25,546 to train all personnel of one hospital. A single training in a medical simulation centre was less effective and more costly compared to strategies that included repetition training. Compared to no training, the ICERs to prevent a composite outcome of obstetric complications were €3432 for a single repetition training course on-site six months after the initial training and €5115 for a three monthly repetition training course on-site after the initial training during one year. When we considered neonatal trauma due to shoulder dystocia, a three monthly repetition training course on-site after the initial training had an ICER of €22,878.

CONCLUSION

Multi-professional team training in a medical simulation centre is cost-effective in a scenario where repetition training sessions are performed on-site.

Perinatal consequences of a category 1 caesarean section at term

OBJECTIVE

To characterise maternal demographics, obstetric risk factors and neonatal outcomes associated with term category 1 caesarean sections (CS).

DESIGN AND SETTING AND MAIN OUTCOME MEASURES

Retrospective study of term singleton pregnancies delivering at a major tertiary unit in Brisbane, Australia. Category 1 CS were defined as one that required a decision-to-delivery time interval of <30 min when there was an immediate threat to the life of a woman or fetus. Neonatal outcomes analysed were gestation at delivery, birth weight, Apgar scores, acidosis at birth, need for resuscitation, admission to neonatal intensive care and neonatal seizures and death.

RESULTS

A total of 30,719 women delivering at term were included. Of these, 1179 (3.8%) women required a category 1 CS. A further 3527 women underwent non-category 1 CS. Most category 1 CS were performed for non-reassuring fetal status (65.9%, 777/1179). The indications for non-category 1 CS were for failure to progress (46.5%, 1641/3527) and non-reassuring fetal status (19%, 671/3527). Maternal age, body mass index and medical disease did not differ significantly between the two cohorts. Caucasian women were equally as likely to undergo a category 1 CS as a non-category 1 CS, while indigenous women and women of Asian ethnicity were more likely to undergo a category 1 CS. Significantly higher (p<0.001) perinatal complications were seen in the category 1 CS cohort--Apgar scores <7 at 1 min (20.4%, 241/1179 vs 10.7%, 377/3527) and 5 min (5.8%, 68/1179 vs 1.9%, 67/3527), umbilical arterial pH<7.2 (23.7%, 279/1179 vs 9.1%, 321/3527), neonatal resuscitation (59.9%, 706/1179 vs 51.8%, 1828/3527), neonatal intensive care unit admission (9.8%, 116/1179 vs 2.5%, 87/3527) and seizures (0.8%, 10/1179 vs 0.3%, 9/3527), respectively.

CONCLUSIONS

These results demonstrate significantly poorer outcomes associated with term category 1 CS compared with non-category 1 emergency CS.

The outcome of midwife-led labor in low-risk women within an obstetric referral unit

OBJECTIVE

To analyze maternal and neonatal outcomes of midwife-led labor in low-risk women at term.

METHODS

Prospective observational cohort of 1788 singleton low-risk pregnancies in spontaneous term labor, managed according to a specific midwife-led labor protocol. Primary outcomes were mode of delivery, episiotomy, 3rd-4th degree lacerations, post-partum hemorrhage (PPH), need for blood transfusions, pH and Apgar score and NICU admissions.

RESULTS

A total 1754 low-risk women (50.3% of all deliveries) were included in the analysis. Epidural analgesia was performed in 29.8% of cases. The rate of cesarean section was 3.7%. Episiotomy was performed in 17.6% of women. PPH > 1000 ml occurred in 1.7% of cases. 3.2% and 0.3% of the cases had an Apgar score <7 and pH < 7.10, respectively, while 0.3% of the newborns were admitted to NICU. Consultant-led labor was required for emerging risk factors during 1st and 2nd stage of labor in 16.1 and 8.6% of cases, respectively. Although maternal outcome were worse in women with emerging risk factors in labor, while neonatal outcomes were not affected by the presence these complications.

CONCLUSIONS

In hospital settings, midwife-led labor in low-risk women might unfold its major advantages without additional risks of medicalization for the mother and the neonate.