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Wyss C, Inauen J, Cignacco E, Raio L, Aubry EM. Mediating processes underlying the associations between maternal obesity and the likelihood of cesarean birth. Birth 2024; 51:52-62. [PMID: 37621158 DOI: 10.1111/birt.12751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 08/21/2022] [Accepted: 07/10/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND Pregnant women with obesity are more likely to experience cesarean birth compared to women without obesity. Yet, little is known about the underlying mechanisms. The objective of this study was therefore to evaluate how mediators contribute to the association between obesity and prelabor/intrapartum cesarean birth. METHODS We retrospectively analyzed Swiss cohort data from 394,812 singleton, cephalic deliveries between 2005 and 2020. Obesity (BMI ≥ 30 kg/m2 ) was defined as the exposure and prelabor or intrapartum cesarean birth as the outcomes. Hypothesized mediators included gestational comorbidities, large-for-gestational-age infant, pregnancy duration >410/7 weeks, slower labor progress, labor induction, and history of cesarean birth. We performed path analyses using generalized structural equation modeling and assessed mediation by a counterfactual approach. RESULTS Women with obesity had a cesarean birth rate of 39.36% vs. 24.12% in women without obesity. The path models mainly showed positive direct and indirect associations between obesity and cesarean birth. In the total sample, the mediation models explained up to 39.47% (95% CI 36.92-42.02) of the association between obesity and cesarean birth, and up to 57.13% (95% CI 54.10-60.16) when including history of cesarean birth as mediator in multiparous women. Slower labor progress and history of cesarean birth were found to be the most clinically significant mediators. CONCLUSIONS This study provides empirical insights into how obesity may increase cesarean birth rates through mediating processes. Particularly allowing for a slower labor progress in women with obesity might reduce cesarean birth rates and prevent subsequent repeat cesarean births in multiparous women.
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Affiliation(s)
- Carmen Wyss
- Applied Research and Development, Division of Midwifery, Department of Health Professions, Bern University of Applied Sciences, Bern, Switzerland
- Graduate School for Health Sciences, University of Bern, Bern, Switzerland
| | - Jennifer Inauen
- Department of Health Psychology and Behavioral Medicine, Institute of Psychology, University of Bern, Bern, Switzerland
| | - Eva Cignacco
- Applied Research and Development, Division of Midwifery, Department of Health Professions, Bern University of Applied Sciences, Bern, Switzerland
| | - Luigi Raio
- Department of Obstetrics and Gynecology, University Hospital of Bern, Bern, Switzerland
| | - Evelyne M Aubry
- Applied Research and Development, Division of Midwifery, Department of Health Professions, Bern University of Applied Sciences, Bern, Switzerland
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Ängeby K, VanGompel EW, Johansson K, Edqvist M. Labor unit culture and attitudes toward supporting vaginal birth-The Swedish version of the labor culture survey (S-LCS)-Psychometric properties. Birth 2024; 51:163-175. [PMID: 37803969 DOI: 10.1111/birt.12777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 06/27/2023] [Accepted: 09/12/2023] [Indexed: 10/08/2023]
Abstract
BACKGROUND In order to evaluate interventions aimed at reducing cesarean births, care practitioners' attitudes are important to measure. The Labor Culture Survey (LCS) is a scale that measures individual and unit attitudes towards supporting vaginal birth. As no equivalent scale exists in Sweden, the aim was to translate, adapt, and validate the LCS and to investigate whether there were differences in attitudes toward supporting vaginal birth between maternity care practitioners. METHODS A cross-sectional study including midwives, physicians, and nurse assistants working with intrapartum care in five labor wards in Sweden. The original LCS was translated into Swedish, and six context-specific items were developed for the Swedish setting (SLCS). The translation was tested for face validity. Psychometric analysis was conducted using exploratory factor analysis with principal component analysis, parallel analysis, and principal axis factoring. Reliability was estimated using Cronbach's alpha. One-way ANOVA and Tukey HSD were calculated to analyze differences in attitudes between professions on the subscales of the S-LCS. RESULTS A total of 539 midwives, physicians, and nurse assistants participated. The final S-LCS showed a five-factor solution with the following subscales: Best Practices to reduce cesarean overuse, Unpredictability of vaginal birth, Unit Microculture, Maternal Agency, and Organizational Oversight. Chronbach alpha values varied from 0.60 to 0.83. Midwives were more supportive towards vaginal birth and less fearful of potential consequences of vaginal birth compared with physicians. CONCLUSIONS The S-LCS demonstrated satisfactory psychometric properties for use in Swedish maternity care. Further work to improve the scale should include additional items reflecting the subscale Maternal Agency.
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Affiliation(s)
- Karin Ängeby
- Centre for Clinical Research and Education, Region Värmland, Sweden
- School of Education, Health and Social Studies, Dalarna University, Falun, Sweden
| | - Emily White VanGompel
- Departments of Family Medicine and Obstetrics and Gynecology, NorthShore University HealthSystem, Evanston, Illinois, USA
- The University of Chicago, Pritzker School of Medicine, Chicago, Illinois, USA
| | - Kari Johansson
- Department of Medicine Solna, Clinical Epidemiology Division, Karolinska Institutet, Stockholm, Sweden
- Department of Women's Health, Karolinska University Hospital, Stockholm, Sweden
| | - Malin Edqvist
- Department of Medicine Solna, Clinical Epidemiology Division, Karolinska Institutet, Stockholm, Sweden
- Department of Women's Health, Karolinska University Hospital, Stockholm, Sweden
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Clerke T, Margetts J, Donovan H, Shepherd HL, Makris A, Canty A, Ruhotas A, Catling C, Henry A. Piloting a shared decision-making clinician training intervention in maternity care in Australia: A mixed methods study. Midwifery 2023; 126:103828. [PMID: 37717344 DOI: 10.1016/j.midw.2023.103828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 08/28/2023] [Accepted: 09/11/2023] [Indexed: 09/19/2023]
Abstract
PROBLEM Implementation of woman-centred care in evidence-based maternity practice requires clinicians to be skilled in shared decision-making, yet there is limited training or research into such interventions. BACKGROUND Shared decision-making enables women to make informed decisions in partnership with clinicians where there are varied clinical options in relation to indications for and timing of planned birth. AIM We aimed to develop a shared decision-making training intervention and evaluate its feasibility and acceptability to midwives and obstetricians. METHODS The intervention was co-designed by midwifery and medical clinician-researchers, and a consumer representative. Online training and demonstration videos were distributed to midwives and obstetricians in three Sydney hospitals, followed by two online workshops in 2021 and 2022 where participants practised shared decision-making in roleplaying scenarios tailored to timing of birth. Training was evaluated using post-workshop and post-training surveys and semi-structured qualitative interviews. FINDINGS The training workshop format, duration and content were well received. Barriers to the uptake of shared decision-making were time, paternalistic practices and fear of repercussions of centring women in the decision-making process. DISCUSSION The intervention enabled midwifery and medical colleagues to learn communication repertoires from each other in woman-centred discussions around timing of birth. Roleplay scenarios enabled participants to observe and provide feedback on their colleagues' shared decision-making practices, while providing a space for collective reflection on ways to promote, and mitigate barriers to, its implementation in practice. CONCLUSION Shared decision-making training supports maternity clinicians in developing skills that implement woman-centred care in the timing of planned birth.
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Affiliation(s)
- Teena Clerke
- Maridulu Budyari Gumal, Sydney Partnership for Health, Education, Research and Enterprise (SPHERE), Australia; University of Technology Sydney, Faculty of Health, Australia.
| | - Jayne Margetts
- Maridulu Budyari Gumal, Sydney Partnership for Health, Education, Research and Enterprise (SPHERE), Australia; University of Technology Sydney, Faculty of Health, Australia
| | - Helen Donovan
- Maridulu Budyari Gumal, Sydney Partnership for Health, Education, Research and Enterprise (SPHERE), Australia; University of Technology Sydney, Faculty of Health, Australia
| | - Heather L Shepherd
- The University of Sydney, Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, Australia
| | - Angela Makris
- Maridulu Budyari Gumal, Sydney Partnership for Health, Education, Research and Enterprise (SPHERE), Australia; University of New South Wales, Australia; Liverpool Hospital, South West Sydney Local Health District, Australia; Western Sydney University, Women's Health Initiative Translation Unit (WHITU), Australia
| | - Alison Canty
- Maridulu Budyari Gumal, Sydney Partnership for Health, Education, Research and Enterprise (SPHERE), Australia; Liverpool Hospital, South West Sydney Local Health District, Australia; Western Sydney University, Women's Health Initiative Translation Unit (WHITU), Australia
| | - Annette Ruhotas
- Maridulu Budyari Gumal, Sydney Partnership for Health, Education, Research and Enterprise (SPHERE), Australia
| | - Christine Catling
- Maridulu Budyari Gumal, Sydney Partnership for Health, Education, Research and Enterprise (SPHERE), Australia; University of Technology Sydney, Faculty of Health, Australia
| | - Amanda Henry
- Maridulu Budyari Gumal, Sydney Partnership for Health, Education, Research and Enterprise (SPHERE), Australia; University of New South Wales, Australia; St George Hospital, South East Sydney Local Health District, Australia
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Offerhaus P, van Haaren-Ten Haken TM, Keulen JKJ, de Jong JD, Brabers AEM, Verhoeven CJM, Scheepers HCJ, Nieuwenhuijze M. Regional practice variation in induction of labor in the Netherlands: Does it matter? A multilevel analysis of the association between induction rates and perinatal and maternal outcomes. PLoS One 2023; 18:e0286863. [PMID: 37289749 PMCID: PMC10249899 DOI: 10.1371/journal.pone.0286863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 05/25/2023] [Indexed: 06/10/2023] Open
Abstract
BACKGROUND Practice variation in healthcare is a complex issue. We focused on practice variation in induction of labor between maternity care networks in the Netherlands. These collaborations of hospitals and midwifery practices are jointly responsible for providing high-quality maternity care. We explored the association between induction rates and maternal and perinatal outcomes. METHODS In a retrospective population-based cohort study, we included records of 184,422 women who had a singleton, vertex birth of their first child after a gestation of at least 37 weeks in the years 2016-2018. We calculated induction rates for each maternity care network. We divided networks in induction rate categories: lowest (Q1), moderate (Q2-3) and highest quartile (Q4). We explored the association of these categories with unplanned caesarean sections, unfavorable maternal outcomes and adverse perinatal outcomes using descriptive statistics and multilevel logistic regression analysis corrected for population characteristics. FINDINGS The induction rate ranged from 14.3% to 41.1% (mean 24.4%, SD 5.3). Women in Q1 had fewer unplanned caesarean sections (Q1: 10.2%, Q2-3: 12.1%; Q4: 12.8%), less unfavorable maternal outcomes (Q1: 33.8%; Q2-3: 35.7%; Q4: 36.3%) and less adverse perinatal outcomes (Q1: 1.0%; Q2-3: 1.1%; Q4: 1.3%). The multilevel analysis showed a lower unplanned caesarean section rate in Q1 in comparison with reference category Q2-3 (OR 0.83; p = .009). The unplanned caesarean section rate in Q4 was similar to the reference category. No significant associations with unfavorable maternal or adverse perinatal outcomes were observed. CONCLUSION Practice variation in labor induction is high in Dutch maternity care networks, with limited association with maternal outcomes and no association with perinatal outcomes. Networks with low induction rates had lower unplanned caesarean section rates compared to networks with moderate rates. Further in-depth research is necessary to understand the mechanisms that contribute to practice variation and the observed association with unplanned caesarean sections.
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Affiliation(s)
- Pien Offerhaus
- Research Centre for Midwifery Science, Zuyd University, Maastricht, the Netherlands
| | | | - Judit K. J. Keulen
- Research Centre for Midwifery Science, Zuyd University, Maastricht, the Netherlands
| | - Judith D. de Jong
- Nivel–Netherlands Institute for Health Services Research, Utrecht, The Netherlands
- Department of Health Services Research, Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
| | - Anne E. M. Brabers
- Nivel–Netherlands Institute for Health Services Research, Utrecht, The Netherlands
| | - Corine J. M. Verhoeven
- Department of Midwifery Science, Amsterdam University Medical Centre (UMC), Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
- Midwifery Academy Amsterdam Groningen, Inholland, Amsterdam, the Netherlands
- Amsterdam Public Health, Quality of Care, Amsterdam, the Netherlands
- Department of General Practice & Elderly Care Medicine, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
- Division of Midwifery, School of Health Sciences, University of Nottingham, Nottingham, United Kingdom
- Department of Obstetrics and Gynaecology, Maxima Medical Centre, Veldhoven, the Netherlands
| | - Hubertina C. J. Scheepers
- Department of Obstetrics and Gynecology, GROW School for Oncology and Reproduction, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Marianne Nieuwenhuijze
- Research Centre for Midwifery Science, Zuyd University, Maastricht, the Netherlands
- Maastricht University, Care and Public Health Research Institute, Maastricht, the Netherlands
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Ganeriwal SA, Ryan GA, Geary M, Purandare NC. Caesarean section rates in primigravid women categorised by age and BMI. J OBSTET GYNAECOL 2021; 42:941-945. [PMID: 34704524 DOI: 10.1080/01443615.2021.1962820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The rising caesarean section (CS) rate is a complex issue, particularly in an increasingly heterogenous nulliparous population. The study aim was to stratify the CS rate in nulliparous women by age and BMI to determine if any difference existed. This was a retrospective review of CS procedures of nulliparous women in two centres in Ireland (2014 through 2017). Data were obtained for 17,177 women from the hospital databases and CS procedures determined for each age and BMI category. Significant differences were observed when CS rates were stratified in this manner. The CS rates for women <20 years/BMI < 18.5 was 8.8 versus 57.6% for women 35 - 39 years/BMI 30 - 34 and 76 - 100% for all women >45 years (p<.005). The development of customised charts subdivided by age and BMI may be a useful counselling tool and assist in the comparison of rates between units.Impact statementWhat is already known on this subject? It is well known that along with rising CS rates globally, there have also been significant changes in maternal demographics-with increasing maternal age at first birth and increasing maternal BMI. It is well established that both of these factors affect the rate of CS in a population.What do the results of this study add? This study sought to stratify the CS rate in nulliparous women by age and BMI to determine if any difference existed. The results of the study showed an increasing CS rate for increasing age and BMI categories that was statistically significant.What are the implications of these findings for clinical practice and/or further research? Additional research using larger population data sets could allow the development of customised charts for nulliparous women subdivided by age and BMI which could act as a useful counselling tool in clinical practice, as well as assist in the comparison of CS rates between units.
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Affiliation(s)
| | - Gillian A Ryan
- Department of Obstetrics and Gynaecology, National Maternity Hospital, Dublin, Ireland
| | - Michael Geary
- Department of Obstetrics and Gynaecology, The Rotunda Hospital, Dublin, Ireland
| | - Nikhil C Purandare
- Department of Obstetrics and Gynaecology, University Hospital Galway, Galway, Ireland
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Thirukumar P, Henry A, Coates D. Women's Experiences and Involvement in Decision-Making in Relation to Planned Cesarean Birth: An Interview Study. J Perinat Educ 2021; 30:213-222. [PMID: 34908820 PMCID: PMC8663766 DOI: 10.1891/j-pe-d-20-00034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Actively engaging women in decision-making about their own care is critical to providing woman-centered maternity care. The aim was to understand women's mode-of-birth preferences and shared decision-making experiences during planned cesarean birth (CB). Semi-structured telephone interviews were conducted with 33 women who had planned CB at eight Australian metropolitan hospitals. Inductive thematic analysis was conducted using NVivo-12. Many women preferred a vaginal birth but were willing to have a CB if the clinician recommended. Most women looked to their clinicians for information and guidance. Although many women reported receiving enough information to make informed decisions, others felt pressured into having or not having a CB, or expected to make decisions themselves. Women wished for longer consultation times, more information, and care continuity.
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Coates D, Donnolley N, Foureur M, Henry A. Inter-hospital and inter-disciplinary variation in planned birth practices and readiness for change: a survey study. BMC Pregnancy Childbirth 2021; 21:391. [PMID: 34016068 PMCID: PMC8135152 DOI: 10.1186/s12884-021-03844-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 04/19/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND How the application of evidence to planned birth practices, induction of labour (IOL) and prelabour caesarean (CS), differs between Australian maternity units remains poorly understood. Perceptions of readiness for practice change and resources to implement change in individual units are also unclear. AIM To identify inter-hospital and inter-professional variations in relation to current planned birth practices and readiness for change, reported by clinicians in 7 maternity units. METHOD Custom-created survey of maternity staff at 7 Sydney hospitals, with questions about women's engagement with decision making, indications for planned birth, timing of birth and readiness for change. Responses from midwives and medical staff, and from each hospital, were compared. FINDINGS Of 245 completed surveys (27% response rate), 78% were midwives and 22% medical staff. Substantial inter-hospital variation was noted for stated planned birth indication, timing, women's involvement in decision-making practices, as well as in staff perceptions of their unit's readiness for change. Overall, 48% (range 31-64%) and 64% (range 39-89%) agreed on a need to change their unit's caesarean and induction practices respectively. The three units where greatest need for change was perceived also had least readiness for change in terms of leadership, culture, and resources. Regarding inter-disciplinary variation, medical staff were more likely than midwifery staff to believe women were appropriately informed and less likely to believe unit practice change was required. CONCLUSION Planned birth practices and change readiness varied between participating hospitals and professional groups. Hospitals with greatest perceived need for change perceived least resources to implement such change.
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Affiliation(s)
- Dominiek Coates
- Faculty of Health, Centre for Midwifery and Child and Family Health, University of Technology Sydney, Sydney, Australia.
- Maridulu Budyari Gumal, the Sydney Partnership for Health, Education, Research and Enterprise (SPHERE), Sydney, Australia.
| | - Natasha Donnolley
- National Perinatal Epidemiology and Statistics Unit, Centre for Big Data Research in Health, UNSW, Sydney, Australia
| | - Maralyn Foureur
- Hunter New England Nursing and Midwifery Research Centre, Newcastle, Australia
- Faculty of Health and Medicine, University of Newcastle, Newcastle, Australia
| | - Amanda Henry
- School of Women's and Children's Health, UNSW Medicine, UNSW, Sydney, Australia
- Department of Women's and Children's Health, St George Hospital, Sydney, Australia
- The George Institute for Global Health, UNSW Medicine, Sydney, Australia
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Dominiek C, Amanda H, Georgina C, Repon P, Angela M, Teena C, Donnolley N. Exploring variation in the performance of planned birth: A mixed method study. Midwifery 2021; 98:102988. [PMID: 33765483 DOI: 10.1016/j.midw.2021.102988] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 12/19/2020] [Accepted: 03/07/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Variation in practice in relation to indications and timing for both induction of labour (IOL) and planned caesarean section (CS) clearly exists. However, the extent of this variation, and how this variation is explained by clinicians remains unclear. The aim of this study was to map the variation in IOL and planned CS at eight Australian hospitals, and understand why variation occurs from the perspective of clinicians at these hospitals. Our ultimate aim was to identify opportunities for improvement as evidenced by hospital data, clinician experiences, and feedback. DESIGN A two-phased mixed method study using sequential explanatory study design. The first phase consisted of an analysis of routinely collected patient data to map variation between hospitals. The second phase consisted of focus groups with clinicians to gain their perspectives on the reasons for variation. SETTING AND PARTICIPANTS Patient data consisted of routine data from 19,073 women giving birth at eight Sydney hospitals between November 2017 and October 2018. Focus groups were attended by a total of 61 medical staff and 121 midwives. RESULTS Hospital data analysis found substantial variation, before and after adjustment for case-mix, in rates of both IOL (adjusted rates 27.6%-42%) and planned CS (adjusted rate 15.4%-22.6%). Planned CS by gestation also showed variation, although after restricting analysis to term (≥37 weeks gestation) births, variation was reduced. At focus groups, five main themes explaining variation emerged: local guidelines, policies and procedures (inconsistency and ambiguity); uncertainty of the evidence/what is best practice (contradictory research and different interpretations of evidence); clinician preferences, beliefs and values; the culture of the unit; and organisational influences (access to specialised clinics, theatre time). KEY CONCLUSIONS Considerable variation in IOL and planned CS, even after case-mix adjustment, was found in this sample of Australian hospitals. Engagement with hospital clinicians identified likely sources of this variation and enabled clinicians at each hospital to consider appropriate local responses to address variation, such as more detailed review of their planned birth cases. IMPLICATIONS FOR PRACTICE At a macro level, measures to reduce unwarranted variation should initially focus on consistent national guidelines, while supporting equitable access to operating theatres for optimal CS timing, and shared decision-making training to reduce influence of clinician preference.
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Affiliation(s)
- Coates Dominiek
- Faculty of Health, University of Technology Sydney, Centre for Midwifery, Child and Family Health, Sydney, Australia; Level 11, Room 131, Building 10, City Campus, PO Box 123 Broadway NSW 2007.
| | - Henry Amanda
- School of Women's and Children's Health, UNSW Medicine, UNSW, Australia; Department of Women's and Children's Health, St George Hospital, Sydney, Australia; The George Institute for Global Health, UNSW Medicine, Australia. .
| | - Chambers Georgina
- National Perinatal Epidemiology and Statistics Unit, Centre for Big Data Research in Health (CBDRH), UNSW, Sydney, Australia. .
| | - Paul Repon
- National Perinatal Epidemiology and Statistics Unit, Centre for Big Data Research in Health (CBDRH), UNSW, Sydney, Australia. .
| | - Makris Angela
- Department of Medicine, Western Sydney University, Australia; Women's Health Initiative Translational Unit (WHITU), Liverpool Hospital, Australia. .
| | - Clerke Teena
- Faculty of Health, University of Technology Sydney, Centre for Midwifery, Child and Family Health, Sydney, Australia. .
| | - Natasha Donnolley
- National Perinatal Epidemiology and Statistics Unit, Centre for Big Data Research in Health (CBDRH), UNSW, Sydney, Australia. .
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Segraves RL, Segraves JM. Reducing Maternal Morbidity on the Frontline: Acute Care Physical Therapy After Cesarean Section During and Beyond the COVID-19 Pandemic. Phys Ther 2021; 101:6169701. [PMID: 33713410 PMCID: PMC7989147 DOI: 10.1093/ptj/pzab093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 01/13/2021] [Accepted: 02/28/2021] [Indexed: 11/13/2022]
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Yang Y, Lin J, Lu X, Xun G, Wu R, Li Y, Ou J, Shen Y, Xia K, Zhao J. Anesthesia, sex and miscarriage history may influence the association between cesarean delivery and autism spectrum disorder. BMC Pediatr 2021; 21:62. [PMID: 33522911 PMCID: PMC7849114 DOI: 10.1186/s12887-021-02518-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 01/21/2021] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND To explore the association between cesarean section (CS) and risk of autism spectrum disorder (ASD), and evaluate the possible factors influencing this association. METHODS In total, 950 patients diagnosed with ASD and 764 healthy controls were recruited in this study. Socio-demographic characteristics and prenatal, perinatal, and neonatal characteristics were compared between the two groups. Univariate and multivariable conditional logistic regression analyses were applied to adjust for confounders. Further stratified analyses based on sex and miscarriage history were similarly performed to explore the factors influencing the association between CS and ASD. RESULTS CS was evidently associated with an elevated risk of ASD (adjusted odds ratio [aOR] = 1.606, 95% confidence interval (CI) = 1.311-1.969). Unlike regional anesthesia (RA), only CS performed under general anesthesia (GA) consistently elevated the risk of ASD (aOR = 1.887, 95% CI = 1.273-2.798) in females and males in further stratified analysis. The risk of children suffering from ASD following emergency CS was apparently increased in males (aOR = 2.390, 95% CI = 1.392-5.207), whereas a higher risk of ASD was observed among voluntary CS and indicated CS subgroups (aOR = 2.167, 95% CI = 1.094-4.291; aOR = 2.919, 95% CI = 1.789-4.765, respectively) in females. Moreover, the interaction term of CS and past miscarriage history (β = - 0.68, Wald χ2 = 7.5, df = 1, p = 0.006)) was similarly defined as influencing ASD. CONCLUSIONS The exposure of children to GA during CS may explain the possible/emerging association between CS and ASD. In addition, sex and miscarriage history could equally be factors influencing the association between CS and ASD.
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Affiliation(s)
- Ye Yang
- National Clinical Research Center for Mental Disorders, Department of Psychiatry, and China National Technology Institute on Mental Disorders, The Second Xiangya Hospital of Central South University, Changsha, 410011, Hunan, China
| | - Jingjing Lin
- National Clinical Research Center for Mental Disorders, Department of Psychiatry, and China National Technology Institute on Mental Disorders, The Second Xiangya Hospital of Central South University, Changsha, 410011, Hunan, China
| | - Xiaozi Lu
- Qingdao Mental Health Center, Qingdao, 266034, Shangdong, China
| | - Guanglei Xun
- Shandong Mental Health Center, 49 East Wenhua Road, Jinan, 250014, Shandong, China
| | - Renrong Wu
- National Clinical Research Center for Mental Disorders, Department of Psychiatry, and China National Technology Institute on Mental Disorders, The Second Xiangya Hospital of Central South University, Changsha, 410011, Hunan, China
| | - Yamin Li
- Clinical Nursing Teaching and Research Section, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, China
| | - Jianjun Ou
- National Clinical Research Center for Mental Disorders, Department of Psychiatry, and China National Technology Institute on Mental Disorders, The Second Xiangya Hospital of Central South University, Changsha, 410011, Hunan, China.
| | - Yidong Shen
- National Clinical Research Center for Mental Disorders, Department of Psychiatry, and China National Technology Institute on Mental Disorders, The Second Xiangya Hospital of Central South University, Changsha, 410011, Hunan, China.
| | - Kun Xia
- Center for Medical Genetics and School of Life Sciences, Central South University, Changsha, 410078, Hunan, China
| | - Jingping Zhao
- National Clinical Research Center for Mental Disorders, Department of Psychiatry, and China National Technology Institute on Mental Disorders, The Second Xiangya Hospital of Central South University, Changsha, 410011, Hunan, China
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Coates D, Donnolley N, Henry A. The Attitudes and Beliefs of Australian Midwives and Obstetricians About Birth Options and Labor Interventions. J Midwifery Womens Health 2020; 66:161-173. [PMID: 33368913 DOI: 10.1111/jmwh.13168] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 08/07/2020] [Accepted: 08/12/2020] [Indexed: 01/10/2023]
Abstract
INTRODUCTION The global rise in the rate of induction of labor and cesarean birth shows considerable unexplained variation both within and between countries. Prior research suggests that the extent to which women are engaged in the decision-making process about birth options, such as elective cesarean, induction of labor, or use of fetal monitoring, is heavily influenced by clinician beliefs and preferences. The aim of this study was to investigate the beliefs about labor interventions and birth options held by midwives and obstetric medical staff from 8 Sydney hospitals and assess how the health care providers' beliefs were associated with discipline or years of experience. METHODS This is a survey study of midwives and obstetric staff that was distributed between November 2018 and July 2019. Modified from the previously validated birth attitudes survey for the Australian context, survey domains include (1) maternal choice and woman's role in birth, (2) safety by mode or place of birth, (3) attitudes toward cesarean birth for preventing urinary incontinence, (4) approaches to decrease cesarean birth rates, and (5) fears of birth mode. Responses were compared between professions and within professions by years of experience using Mann-Whitney U testing. RESULTS A total of 217 midwives and 58 medical staff completed the survey (response rate, 30.5%). Midwifery staff responses generally favored a physiologic approach to birth, versus beliefs more in favor of intervention (particularly cesarean birth) among medical staff. There was interprofessional discrepancy on most items, particularly regarding safety of mode or place of birth and approaches to decrease cesarean birth rates. Within disciplines, there was more variation in medical staff attitudes than within the midwifery staff. No clinically important differences in beliefs by years of experience were noted. DISCUSSION Clinicians need to be aware of their own beliefs and preferences about birth as a potential source of bias when counselling women, particularly when there are a range of treatment options and the evidence may not strongly favor one option over another. As both groups had similar perceptions about the importance of women's autonomy, shared decision-making training could help bridge belief gaps and improve care around birth decisions.
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Affiliation(s)
- Dominiek Coates
- Faculty of Health, Centre for Midwifery and Child and Family Health, University of Technology Sydney, Ultimo, Australia.,School of Women's and Children's Health, UNSW Medicine, University of New South Wales, Sydney, Australia
| | - Natasha Donnolley
- National Perinatal Epidemiology and Statistics Unit, Centre for Big Data Research in Health, University of New South Wales, Sydney, Australia
| | - Amanda Henry
- School of Women's and Children's Health, UNSW Medicine, University of New South Wales, Sydney, Australia.,Department of Women's and Children's Health, St George Hospital, Sydney, Australia.,The George Institute for Global Health, UNSW Medicine, University of New South Wales, Australia
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12
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Martín-Arribas A, Vila-Candel R, O’Connell R, Dillon M, Vila-Bellido I, Beneyto MÁ, De Molina-Fernández I, Rodríguez-Conesa N, González-Blázquez C, Escuriet R. Transfers of Care between Healthcare Professionals in Obstetric Units of Different Sizes across Spain and in a Hospital in Ireland: The MidconBirth Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17228394. [PMID: 33202745 PMCID: PMC7696735 DOI: 10.3390/ijerph17228394] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Revised: 11/08/2020] [Accepted: 11/11/2020] [Indexed: 11/16/2022]
Abstract
Background: In Europe, the majority of healthy women give birth at conventional obstetric units with the assistance of registered midwives. This study examines the relationships between the intrapartum transfer of care (TOC) from midwife to obstetrician-led maternity care, obstetric unit size (OUS) with different degrees of midwifery autonomy, intrapartum interventions and birth outcomes. Methods: A prospective, multicentre, cross-sectional study promoted by the COST Action IS1405 was carried out at eight public hospitals in Spain and Ireland between 2016–2019. The primary outcome was TOC. The secondary outcomes included type of onset of labour, oxytocin stimulation, epidural analgesia, type of birth, episiotomy/perineal injury, postpartum haemorrhage, early initiation of breastfeeding and early skin-to-skin contact. A logistic regression was performed to ascertain the effects of studied co-variables on the likelihood that participants had a TOC; Results: Out of a total of 2,126 low-risk women, those whose intrapartum care was initiated by a midwife (1772) were selected. There were statistically significant differences between TOC and OUS (S1 = 29.0%, S2 = 44.0%, S3 = 52.9%, S4 = 30.2%, p < 0.001). Statistically differences between OUS and onset of labour, oxytocin stimulation, type of birth and episiotomy or perineal injury were observed (p = 0.009, p < 0.001, p < 0.001, p < 0.001 respectively); Conclusions: Findings suggest that the model of care and OUS have a significant effect on the prevalence of intrapartum TOC and the birth outcomes. Future research should examine how models of care differ as a function of the OUS in a hospital, as well as the cost-effectiveness for the health care system.
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Affiliation(s)
- Anna Martín-Arribas
- GHenderS Research Group, School of Health Sciences Blanquerna, Universitat Ramon Llull, Carrer Padilla 326, 08025 Barcelona, Spain; (A.M.-A.); (R.E.)
- Faculty of Medicine, Universidad Autónoma de Madrid, Calle Arzobispo Morcillo 4, 28029 Madrid, Spain;
| | - Rafael Vila-Candel
- La Ribera Hospital Health Department, Carretera Corbera km 1, 46600 Valencia, Spain
- Foundation for the Promotion of Health and Biomedical Research in the Valencian Region (FISABIO), 46020 Valencia, Spain
- Faculty of Nursing and Podiatry, Universitat de València, Jaume Roig, s/n, 46010 Valencia, Spain
- Correspondence:
| | - Rhona O’Connell
- School of Nursing and Midwifery, University College Cork, T12 YN60 Cork, Ireland;
| | - Martina Dillon
- Cork University Maternity Hospital, Wilton, T12 YE02 Cork, Ireland;
| | - Inmaculada Vila-Bellido
- Verge dels Lliris Hospital, Poligon de Caramanxel s/n, 03804 Alcoi, Spain; (I.V.-B.); (M.Á.B.)
| | - M. Ángeles Beneyto
- Verge dels Lliris Hospital, Poligon de Caramanxel s/n, 03804 Alcoi, Spain; (I.V.-B.); (M.Á.B.)
| | | | | | | | - Ramón Escuriet
- GHenderS Research Group, School of Health Sciences Blanquerna, Universitat Ramon Llull, Carrer Padilla 326, 08025 Barcelona, Spain; (A.M.-A.); (R.E.)
- Catalan Health Service, Government of Barcelona, 08028 Catalonia, Spain
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13
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Xu C, Zhong W, Fu Q, Yi L, Deng Y, Cheng Z, Lin X, Cai M, Zhong S, Wang M, Tao H, Xiong H, Jiang X, Chen Y. Differential effects of different delivery methods on progression to severe postpartum hemorrhage between Chinese nulliparous and multiparous women: a retrospective cohort study. BMC Pregnancy Childbirth 2020; 20:660. [PMID: 33129300 PMCID: PMC7603680 DOI: 10.1186/s12884-020-03351-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 10/20/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Delivery methods are associated with postpartum hemorrhage (PPH) both in nulliparous and multiparous women. However, few studies have examined the difference in this association between nulliparous and multiparous women. This study aimed to explore the difference of maternal and neonatal characteristics and delivery methods between Chinese nulliparous and multiparous women, and then examine the differential effects of different delivery methods on PPH between these two-type women. METHODS Totally 151,333 medical records of women who gave birth between April 2013 to May 2016 were obtained from the electronic health records (EHR) in a northern province, China. The severity of PPH was estimated and classified into blood loss at the level of < 900 ml, 900-1500 ml, 1500-2100 ml, and > 2100 ml. Neonatal and maternal characteristics related to PPH were derived from the same database. Multiple ordinal logistic regression was used to estimate associations. RESULTS Medical comorbidities, placenta previa and accreta were higher in the nulliparous group and the episiotomy rate was higher in the multiparous group. Compared with spontaneous vaginal delivery (SVD), the adjusted odds (aOR) for progression to severe PPH due to the forceps-assisted delivery was much higher in multiparous women (aOR: 9.32; 95% CI: 3.66-23.71) than in nulliparous women (aOR: 1.70; 95% CI: 0.91-3.18). The (aOR) for progression to severe PPH due to cesarean section (CS) compared to SVD was twice as high in the multiparous women (aOR: 4.32; 95% CI: 3.03-6.14) as in the nulliparous women (aOR: 2.04; 95% CI: 1.40-2.97). However, the (aOR) for progression to severe PPH due to episiotomy compared to SVD between multiparous (aOR: 1.24; 95% CI: 0.96-1.62) and nulliparous women (aOR: 1.55; 95% CI: 0.92-2.60) was not significantly different. The (aOR) for progression to severe PPH due to vacuum-assisted delivery compared to SVD in multiparous women (aOR: 2.41; 95% CI: 0.36-16.29) was not significantly different from the nulliparous women (aOR: 1.05; 95% CI: 0.40-2.73). CONCLUSIONS Forceps-assisted delivery and CS methods were found to increase the risk of severity of the PPH. The adverse effects were even greater for multiparous women. Episiotomy and the vacuum-assisted delivery, and SVD were similar to the risk of progression to severe PPH in either nulliparous or multiparous women. Our findings have implications for the obstetric decision on the choice of delivery methods, maternal and neonatal health care, and obstetric quality control.
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Affiliation(s)
- Chang Xu
- Peking University Shenzhen Hospital, Shenzhen, 518036, China
| | - Wanting Zhong
- Department of medical administration, Zhuhai People's Hospital (Zhuhai hospital affiliated with Jinan University), Zhuhai, 519000, China
| | - Qiang Fu
- Department of Epidemiology and Biostatistics, College for Public Health and Social Justice, Saint Louis University, St. Louis, MO, 63013, USA
| | - Li Yi
- Peking University Shenzhen Hospital, Shenzhen, 518036, China
| | - Yuqing Deng
- Peking University Shenzhen Hospital, Shenzhen, 518036, China
| | - Zhaohui Cheng
- Department of Health Statistics and Research Development, Chongqing Health Information Center, Chongqing, 401120, China
| | - Xiaojun Lin
- West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, 610041, China
| | - Miao Cai
- Department of Epidemiology and Biostatistics, College for Public Health and Social Justice, Saint Louis University, St. Louis, MO, 63013, USA
| | - Shilin Zhong
- Peking University Shenzhen Hospital, Shenzhen, 518036, China
| | - Manli Wang
- China Center for Special Economic Zone Research, Shenzhen University, Shenzhen, 518060, Guangdong, China.
| | - Hongbing Tao
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430016, China
| | - Haoling Xiong
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430016, China
| | - Xin Jiang
- Peking University Shenzhen Hospital, Shenzhen, 518036, China
| | - Yun Chen
- Peking University Shenzhen Hospital, Shenzhen, 518036, China
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14
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Dominiek C, Natasha D, Foureur M, Spear V, Amanda H. Exploring unwarranted clinical variation: The attitudes of midwives and obstetric medical staff regarding induction of labour and planned caesarean section. Women Birth 2020; 34:352-361. [PMID: 32674990 DOI: 10.1016/j.wombi.2020.07.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 06/17/2020] [Accepted: 07/07/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND Unexplained clinical variation is a major issue in planned birth i.e. induction of labour and planned caesarean section. AIM To map attitudes and knowledge of maternity care professionals regarding indications for planned birth, and assess inter-professional (midwifery versus medical) and intra-professional variation. METHODS A custom-created survey of medical and midwifery staff at eight Sydney hospitals. Staff were asked to rate their level of agreement with 45 "evidence-based" statements regarding caesareans and inductions on a five-point Likert scale. Responses were grouped by profession, and comparisons made of inter- and intra-professional responses. FINDINGS Total 275 respondents, 78% midwifery and 21% medical. Considerable inter- and intra-professional variation was noted, with midwives generally less likely to consider any of the planned birth indications "valid" compared to medical staff. Indications for induction with most variation in midwifery responses included maternal characteristics (age≥40, obesity, ethnicity) and fetal macrosomia; and for medical personnel in-vitro fertilisation, maternal request, and routine induction at 39 weeks gestation. Indications for caesarean with most variation in midwifery responses included previous lower segment caesarean section, previous shoulder dystocia, and uncomplicated breech; and for medical personnel uncomplicated dichorionic twins. Indications with most inter-professional variation were induction at 41+ weeks versus 42+ weeks and cesarean for previous lower segment caesarean section. DISCUSSION Both inter- and intra-professional variation in what were considered valid indications reflected inconsistency in underlying evidence and/or guidelines. CONCLUSION Greater focus on interdisciplinary education and consensus, as well as on shared decision-making with women, may be helpful in resolving these tensions.
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Affiliation(s)
- Coates Dominiek
- University of Technology Sydney, Faculty of Health, Centre for Midwifery and Child and Family Health, Australia; School of Women's and Children's Health, UNSW Medicine, UNSW, Sydney, Australia.
| | - Donnolley Natasha
- National Perinatal Epidemiology and Statistics Unit, Centre for Big Data Research in Health, UNSW, Sydney, Australia.
| | - Maralyn Foureur
- Hunter New England Nursing and Midwifery Research Centre, Australia; University of Newcastle, Faculty of Health and Medicine, Australia.
| | - Virginia Spear
- Royal Hospital for Women, South Easters Sydney Local Health District, Australia
| | - Henry Amanda
- School of Women's and Children's Health, UNSW Medicine, UNSW, Sydney, Australia; Department of Women's and Children's Health, St George Hospital, Sydney, Australia; The George Institute for Global Health, UNSW Medicine, Australia.
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15
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Coates D, Thirukumar P, Henry A. Women's experiences and satisfaction with having a cesarean birth: An integrative review. Birth 2020; 47:169-182. [PMID: 31891986 DOI: 10.1111/birt.12478] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 12/11/2019] [Accepted: 12/12/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND With around one third of woman having a cesarean birth, better understanding of women's experiences of having a cesarean is vital to improve women's experiences of care. The aim of this review was to gain insight into women's experiences of and satisfaction with cesarean and to identify factors that contribute to women's poor experiences of care. METHODS Using an integrative methodology, evidence was systematically considered in relation to women's experiences of cesarean birth and whether they were satisfied with their experience of care. To identify studies, PubMed, Maternity and Infant Care, MEDLINE, and Web of Science were searched for the period from 2008 to 2018, and reference lists of included studies were examined. RESULTS Twenty-six studies were included. Although the majority of women were satisfied with their cesarean, a large minority of women were dissatisfied and reported a negative experience. In particular, women who had an emergency cesarean were less satisfied than women who had a vaginal birth. Nonmedical factors or experiences that appear associated with dissatisfaction include (a) feeling ignored and disempowered; (b) experiencing a loss of control; (c) not being informed; and (d) birth values that favor vaginal birth. CONCLUSIONS Women's experiences of cesarean birth appear influenced by the circumstances (emergency vs planned), the extent to which they felt involved in decision-making and in control of their experience, and their birth values and beliefs. Increasing antenatal, intrapartum, and postpartum communication and shared decision-making may help engage women as an active participant in their own birth.
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Affiliation(s)
- Dominiek Coates
- Faculty of Health, Centre for Midwifery and Child and Family Health, University of Technology Sydney, Sydney, NSW, Australia
| | - Purshaiyna Thirukumar
- School of Women's and Children's Health, UNSW Medicine, UNSW, Sydney, NSW, Australia
| | - Amanda Henry
- School of Women's and Children's Health, UNSW Medicine, UNSW, Sydney, NSW, Australia.,Department of Women's and Children's Health, St George Hospital, Sydney, NSW, Australia.,The George Institute for Global Health, UNSW Medicine, Sydney, NSW, Australia
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16
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Coates D, Thirukumar P, Henry A. Making shared decisions in relation to planned caesarean sections: What are we up to? PATIENT EDUCATION AND COUNSELING 2020; 103:1176-1190. [PMID: 31836248 DOI: 10.1016/j.pec.2019.12.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 12/02/2019] [Accepted: 12/03/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To map the literature in relation to shared decision making (SDM) for planned caesarean section (CS), particularly women's experiences in receiving the information they need to make informed decisions, their knowledge of the risks and benefits of CS, the experiences and attitudes of clinicians in relation to SDM, and interventions that support women to make informed decisions. METHODS Using a scoping review methodology, quantitative and qualitative evidence was systematically considered. To identify studies, PubMed, Maternity and Infant Care, MEDLINE, and Web of Science were searched for the period from 2008 to 2018. RESULTS 34 studies were included, with 9750 women and 3313 clinicians. Overall women reported limited SDM, and many did not have the information required to make informed decisions. Clinicians generally agreed with SDM, while recognising it often does not occur. Decision aids and educational interventions were viewed positively by women. CONCLUSION Many women were not actively involved in decision-making. Decision aids show promise as a SDM-enhancing tool. Studies that included clinicians suggest uncertainty regarding SDM, although willingness to engage. PRACTICE IMPLICATIONS Moving from clinician-led decision-making to SDM for CS has potential to improve patient experiences, however this will require considerable clinician training, and implementation of SDM interventions.
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Affiliation(s)
- Dominiek Coates
- University of Technology Sydney, Faculty of Health, Centre for Midwifery and Child and Family Health, Sydney, Australia; School of Women's and Children's Health, UNSW Medicine, UNSW, Australia; Maridulu Budyari Gumal, the Sydney Partnership for Health, Education, Research and Enterprise (SPHERE), Sydney, Australia.
| | | | - Amanda Henry
- School of Women's and Children's Health, UNSW Medicine, UNSW, Australia; Department of Women's and Children's Health, St George Hospital, Sydney, Australia; The George Institute for Global Health, UNSW Medicine, Australia
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17
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Murphy NC, Burke N, Breathnach FM, Burke G, McAuliffe FM, Morrison JJ, Turner MJ, Dornan S, Higgins J, Cotter A, Geary MP, Cody F, McParland P, Mulcahy C, Daly S, Dicker P, Tully EC, Malone FD. Inter-hospital comparison of Cesarean delivery rates should not be considered to reflect quality of care without consideration of patient heterogeneity: An observational study. Eur J Obstet Gynecol Reprod Biol 2020; 250:112-116. [PMID: 32438274 DOI: 10.1016/j.ejogrb.2020.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 04/29/2020] [Accepted: 05/02/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Contemporary approaches to monitoring quality of care in obstetrics often focus on comparing Cesarean Delivery rates. Varied rates can complicate interpretation of quality of care. We previously developed a risk prediction tool for nulliparous women who may require intrapartum Cesarean delivery which identified five key predictors. Our objective with this study was to ascertain if patient heterogeneity can account for much of the observed variation in Cesarean delivery rates, thereby enabling Cesarean delivery rates to be a better marker of quality of care. MATERIALS AND METHODS This is a secondary analysis of the Genesis study. This was a large prospective study of 2336 nulliparous singleton pregnancies recruited at seven hospitals. A heterogeneity score was calculated for each hospital. An adjusted Cesarean delivery rate was also calculated incorporating the heterogeneous risk score. RESULTS A cut-off at the 90th percentile was determined for each predictive factor. Above the 90th percentile was considered to represent 'high risk' (with the exception of maternal height which identified those below the 10th percentile). The patient heterogeneous risk score was defined as the number of risk factors > 90th percentile (<10th percentile for height). An unequal distribution of high-risk patients between centers was observed (p < 0.001). The correlation between the Cesarean delivery rate and the patient heterogeneous risk score was high (0.76, p < 0.05). When adjusted for patient heterogeneity, Cesarean delivery rates became closer aligned. CONCLUSION Inter-institutional diversity is common. We suggest that crude comparison of Cesarean delivery rates between different hospitals as a marker of care quality is inappropriate. Allowing for marked differences in patient characteristics is essential for correct interpretation of such comparisons.
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Affiliation(s)
| | - Naomi Burke
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | | | - Gerard Burke
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | - Fionnuala M McAuliffe
- UCD School of Medicine and Medical Science, National Maternity Hospital, Dublin, Ireland
| | | | - Michael J Turner
- UCD Centre for Human Reproduction Coombe Women and Infants University Hospital, Dublin, Ireland
| | | | - John Higgins
- University College Cork, Cork University Maternity Hospital, Cork, Ireland
| | - Amanda Cotter
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | | | | | - Peter McParland
- UCD School of Medicine and Medical Science, National Maternity Hospital, Dublin, Ireland
| | - Cecelia Mulcahy
- UCD School of Medicine and Medical Science, National Maternity Hospital, Dublin, Ireland
| | - Sean Daly
- Coombe Women and Infants University Hospital, Dublin, Ireland
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Zaiden L, Nakamura-Pereira M, Gomes MAM, Esteves-Pereira AP, Leal MDC. Influence of hospital characteristics on the performance of elective cesareans in Southeast Brazil. CAD SAUDE PUBLICA 2020; 36:e00218218. [PMID: 31939550 DOI: 10.1590/0102-311x00218218] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 07/08/2019] [Indexed: 11/22/2022] Open
Abstract
This article aims to assess the influence of hospital characteristics on the odds of performing an elective cesarean in the Southeast region of Brazil. Data were obtained from the Birth in Brazil study, conducted from February 2011 to October 2012. The current analysis includes the sample from Southeast Brazil, with 10,155 women. The group of women that underwent elective cesareans was compared to the women who went into labor or underwent labor induction, regardless they had intrapartum cesarean or vaginal delivery. Except for gestational age, all the obstetric characteristics analyzed were associated with elective cesarean. In this group, 60.5% had no prior cesarean and 64.7% had low-risk gestations. Among the births with public financing, there were higher odds of elective cesareans in women treated at hospitals with < 1,500 births/year (OR = 2.11; 95%CI: 1.37-3.26) and 1,500-2,999 births/year (OR = 1.45; 95%CI: 1.04-2.02) and in mixed hospitals (OR = 1.81; 95%CI: 1.37-2.39). In the mixed hospitals, the association was stronger when located in non-capital cities with > 3,000 births/year (OR = 3.45; 95%CI: 1.68-7.08), reaching the highest level in hospitals in non-capital cities with < 3,000 births/year (OR = 4.08; 95%CI: 2.61-6.37). Meanwhile, no association was seen between elective cesarean and public hospitals located in non-capital cities of the Southeast region. Prevalence rates of elective cesareans in public hospitals in Southeast Brazil are high when compared to other countries, and they are heavily influenced by hospital characteristics.
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Affiliation(s)
- Laura Zaiden
- Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil.,Faculdade de Medicina de Petrópolis, Petrópolis, Brasil
| | - Marcos Nakamura-Pereira
- Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil
| | - Maria Auxiliadora Mendes Gomes
- Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil
| | | | - Maria do Carmo Leal
- Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil
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Coates D, Homer C, Wilson A, Deady L, Mason E, Foureur M, Henry A. Indications for, and timing of, planned caesarean section: A systematic analysis of clinical guidelines. Women Birth 2019; 33:22-34. [PMID: 31253513 DOI: 10.1016/j.wombi.2019.06.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 06/12/2019] [Accepted: 06/13/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND There has been a worldwide rise in planned caesarean sections over recent decades, with significant variations in practice between hospitals and countries. Guidelines are known to influence clinical decision-making and, potentially, unwarranted clinical variation. The aim of this study was to review guidelines for recommendations in relation to the timing and indications for planned caesarean section as well as recommendations around the process of decision-making. METHOD A systematic search of national and international English-language guidelines published between 2008 and 2018 was undertaken. Guidelines were reviewed, assessed in terms of quality and extracted independently by two reviewers. FINDINGS In total, 49 guidelines of varying quality were included. There was consistency between the guidelines in potential indications for caesarean section, although guidelines vary in terms of the level of detail. There was substantial variation in timing of birth, for example recommended timing of caesarean section for women with uncomplicated placenta praevia is between 36 and 39weeks depending on the guideline. Only 11 guidelines provided detailed guidance on shared decision-making. In general, national-level guidelines from Australia, and overseas, received higher quality ratings than regional guidelines. CONCLUSION The majority of guidelines, regardless of their quality, provide very limited information to guide shared decision-making or the timing of planned caesarean section, two of the most vital aspects of guidance. National guidelines were generally of better quality than regional ones, suggesting these should be used as a template where possible and emphasis placed on improving national guidelines and minimising intra-country, regional, variability of guidelines.
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Affiliation(s)
- Dominiek Coates
- University of Technology Sydney, Faculty of Health, Centre for Midwifery and Child and Family Health, NSW, Australia; Maridulu Budyari Gumal, The Sydney Partnership for Health, Education, Research and Enterprise (SPHERE), Australia; School of Women's and Children's Health, UNSW Medicine, UNSW, Australia.
| | - Caroline Homer
- University of Technology Sydney, Faculty of Health, Centre for Midwifery and Child and Family Health, NSW, Australia; Burnet Institute, Victoria, Australia
| | - Alyssa Wilson
- Maridulu Budyari Gumal, The Sydney Partnership for Health, Education, Research and Enterprise (SPHERE), Australia
| | - Louise Deady
- South Eastern Sydney Local Health District, District Offices, Sutherland Hospital Locked Bag 21, Taren Point, NSW 2229, Australia.
| | - Elizabeth Mason
- South Eastern Sydney Local Health District, District Offices, Sutherland Hospital Locked Bag 21, Taren Point, NSW 2229, Australia.
| | - Maralyn Foureur
- Hunter New England Nursing and Midwifery Research Centre, Australia; University of Newcastle, Faculty of Health and Medicine, Australia.
| | - Amanda Henry
- School of Women's and Children's Health, UNSW Medicine, UNSW, Australia; Department of Women's and Children's Health, St. George Hospital, Sydney, Australia; The George Institute for Global Health, UNSW Medicine, Australia
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20
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Nguyen DB, Pare-Miron V, Czuzoj-Shulman N, Abenhaim HA. Effect of Hospital Choice on the Risk of Caesarean Delivery. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2019; 41:1302-1310. [PMID: 30879777 DOI: 10.1016/j.jogc.2018.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 11/07/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVE This study aimed to evaluate the variation in Caesarean delivery rate (CDR) among hospitals across the United States, its effect on maternal and neonatal outcomes, and whether differences in pregnancy and hospital characteristics can explain the higher CDRs seen in certain hospitals. METHODS This retrospective population-based cohort study was conducted using the 2014 Healthcare and Utilization Project Nationwide Inpatient Sample. The investigators identified all hospitals with birth admissions and compared hospitals with high CDRs with hospitals with low/mid CDRs, in terms of hospital characteristics, maternal characteristics, and maternal and neonatal outcomes. Regression analyses within multiple hospital and patient characteristic strata were used to evaluate the adjusted independent effect of the hospital on the risk of Caesarean delivery (Canadian Task Force Classification II-2). RESULTS In this study population, 96% of U.S. hospitals had a CDR above 20%, and 5% had a CDR >40%. High-CDR hospitals (>40%) were more often privately owned, non-teaching hospitals with an older patient population. When adjusting for baseline obstetrical and hospital characteristics, high-CDR hospitals remained independently associated with an elevated risk of Caesarean delivery. These findings persisted in stratified analyses of each hospital and patient-level characteristic. Obstetrical and neonatal outcomes were comparable in all hospitals irrespective of CDR. CONCLUSION Hospital characteristics and case mix do not account for the significant variation in CDRs across U.S. hospitals. Individual hospitals are in themselves independent risk factors for Caesarean delivery. Choosing to give birth in a certain hospital may put women at an increased risk of having a Caesarean delivery, without maternal or neonatal benefit.
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Affiliation(s)
- Dong Bach Nguyen
- Department of Obstetrics and Gynecology, Jewish General Hospital, McGill University, Montréal, QC
| | - Valerie Pare-Miron
- Department of Obstetrics and Gynecology, Jewish General Hospital, McGill University, Montréal, QC
| | - Nicholas Czuzoj-Shulman
- Centre for Clinical Epidemiology and Community Studies, Jewish General Hospital, Montréal, QC
| | - Haim A Abenhaim
- Department of Obstetrics and Gynecology, Jewish General Hospital, McGill University, Montréal, QC; Centre for Clinical Epidemiology and Community Studies, Jewish General Hospital, Montréal, QC.
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21
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A conceptual framework for the impact of obesity on risk of cesarean delivery. Am J Obstet Gynecol 2018; 219:356-363. [PMID: 29902446 DOI: 10.1016/j.ajog.2018.06.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 06/01/2018] [Accepted: 06/05/2018] [Indexed: 11/22/2022]
Abstract
Cesarean deliveries accounted for 32.2% of nearly 4 million births in the United States in 2014. Obesity affects a third of reproductive-age women and is associated with worse cesarean delivery outcomes. Studies have shown that increasing maternal body mass index correlates linearly with cesarean delivery rates, but little is known about the potential mediating and moderating mechanisms. Thus, a conceptual framework for understanding how obesity correlates with risk of cesarean delivery is crucial to determining safe ways to reduce the cesarean delivery rate among obese gravidas. Based on an extensive review and synthesis of the literature, we present a conceptual framework that posits how obesity may operate through several pathways to lead to a cesarean delivery. Our framework explores the complexity of obesity as an exposure that operates through potential mediating pathways, a moderator of cesarean delivery risk, and a covariate with other cesarean delivery risk factors. Among nulliparas, obesity appears to operate through 3 main proximal mediating mechanisms to increase risk of cesarean delivery including: (1) preexisting comorbidities and obstetric complications; (2) a slower progression of first-stage labor, potentially increasing the risk of cesarean delivery secondary to failure to progress; and (3) a prolongation of pregnancy, which is associated with risk of maternal postdates. For multiparas, a fourth proximal mediator of prior uterine scar may also increase cesarean delivery risk. Distal mediating mechanisms, which operate through one of the proximal mechanisms, may include an induction of labor or planned prelabor cesarean delivery. Obesity may also moderate the likelihood of cesarean delivery by interacting with clinician-level or hospital-level factors. Future research should assess the validity of this framework and seek to understand the relative contributions of each potential pathway between obesity and cesarean delivery. This will allow for evidence-based recommendations to reduce preventable cesareans among obese women by targeting modifiable mediators and moderators of the relationship between obesity and increased risk of cesarean delivery.
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22
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Nakamura-Pereira M, Esteves-Pereira AP, Gama SGN, Leal M. Elective repeat cesarean delivery in women eligible for trial of labor in Brazil. Int J Gynaecol Obstet 2018; 143:351-359. [PMID: 30182481 DOI: 10.1002/ijgo.12660] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 07/04/2018] [Accepted: 09/03/2018] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To assess the hospital, maternal, and obstetric characteristics associated with elective repeat cesarean delivery (ERCD) among women eligible for trial of labor after cesarean (TOLAC) delivery in Brazil. METHODS The present data were retrieved from the Birth in Brazil study, a national hospital-based cohort study conducted during 2011-2012. Data were collected from medical records and by interview. Univariate and hierarchical multiple logistic regression analyses were performed to analyze factors associated with ERCD among women with a previous cesarean delivery who were eligible for TOLAC. RESULTS Among 2295 women considered eligible for TOLAC, 1516 (66.1%) had an ERCD; the overall cesarean delivery rate was 79.4%. In the private sector, almost all deliveries (95.3%) were performed by ERCD. In the public sector, ERCD was associated with socioeconomic (more years of schooling), obstetric (women's preference, no previous vaginal delivery, macrosomia), and hospital (mixed hospital, location in noncapital city, fewer than 1500 deliveries per year) characteristics. CONCLUSION The ERCD rate in Brazil was high even in a low-risk group, indicating that nonclinical factors may be driving the decision for cesarean delivery. Efforts aiming to reduce cesarean deliveries in Brazil should target women with a previous cesarean delivery.
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Affiliation(s)
- Marcos Nakamura-Pereira
- Fernandes Figueira National Institute for Women's, Children's and Adolescents' Health, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil.,Department of Epidemiology and Quantitative Methods in Health, Sérgio Arouca National School of Public Health, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Ana Paula Esteves-Pereira
- Department of Epidemiology and Quantitative Methods in Health, Sérgio Arouca National School of Public Health, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Silvana G N Gama
- Department of Epidemiology and Quantitative Methods in Health, Sérgio Arouca National School of Public Health, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Maria Leal
- Department of Epidemiology and Quantitative Methods in Health, Sérgio Arouca National School of Public Health, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
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Rose A, Raja EA, Bhattacharya S, Black M. Intervention thresholds and cesarean section rates: A time-trends analysis. Acta Obstet Gynecol Scand 2018; 97:1257-1266. [PMID: 29900544 DOI: 10.1111/aogs.13409] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 05/22/2018] [Indexed: 12/01/2022]
Abstract
INTRODUCTION To improve understanding of rising cesarean section (CS) rates in the UK, this study assessed the relation between clinician thresholds for performing CS for delayed labor progress or suspected fetal distress and corresponding CS rates in Aberdeen, UK. MATERIAL AND METHODS Time-trends analysis of term births from 1988 to 2012 in a population of nulliparous women (N = 53 745) in Aberdeen, UK, using Chi-square test for trend, and binary logistic regression. Data were obtained from the Aberdeen Maternity and Neonatal Databank. RESULTS Unplanned CS rates per quintile increased from 11.0% (1391/12 686) to 21.1% (2383/11 273) between 1988 and 2012, while planned CS rates increased from 2.7% (338/12 686) to 5.2% (591/11 273). The median duration of labor before CS for delayed progress per quintile decreased from 17.2 (IQR 12.5-22.3) to 13.1 hours (9.6-16.9) before first stage CS and from 17.1 (12.6-22.3) to 15.3 (11.5-19.1) hours before second stage CS (P < .001). The proportion of CS for suspected fetal distress performed with evidence of fetal acidosis declined from 23.4% (98/418) to 17.4% (106/608) per quintile (P < .01). Neonatal unit admission (adjusted OR 1.99, 95% CI 1.85-2.14) was more likely following unplanned CS than vaginal births. Birth trauma was less likely following both unplanned (adjusted OR 0.48, 95% CI 0.39-0.60) and planned (adjusted OR 0.33, 95% CI 0.18-0.63) CS. CONCLUSION Increased CS rates can be partly attributed to lowered clinical thresholds for intrapartum CS. Higher CS rates are associated with less birth trauma for the offspring.
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Affiliation(s)
- Anna Rose
- NHS Greater Glasgow and Clyde, Glasgow, UK
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24
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Seijmonsbergen-Schermers AE, Zondag DC, Nieuwenhuijze M, Van den Akker T, Verhoeven CJ, Geerts C, Schellevis F, De Jonge A. Regional variations in childbirth interventions in the Netherlands: a nationwide explorative study. BMC Pregnancy Childbirth 2018; 18:192. [PMID: 29855270 PMCID: PMC5984340 DOI: 10.1186/s12884-018-1795-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 04/30/2018] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Although interventions in childbirth are important in order to prevent neonatal and maternal morbidity and mortality, non-indicated use may cause avoidable harm. Regional variations in intervention rates, which cannot be explained by maternal characteristics, may indicate over- and underuse. The aim of this study is to explore regional variations in childbirth interventions in the Netherlands and their associations with interventions and adverse outcomes, controlled for maternal characteristics. METHODS Childbirth intervention rates were compared between twelve Dutch regions, using data from the national perinatal birth register for 2010-2013. All single childbirths from 37 weeks' gestation onwards were included. Primary outcomes were induction and augmentation of labour, pain medication, instrumental birth, caesarean section (prelabour, intrapartum) and paediatric involvement. Secondary outcomes were adverse neonatal and maternal outcomes. Multivariable logistic regression analyses were used to adjust for maternal characteristics. Associations were expressed in Spearman's rank correlation coefficients. RESULTS Most variation was found for type of pain medication and paediatric involvement. Epidural analgesia rates varied from between 12 and 38% (nulliparous) and from between 5 and 14% (multiparous women). These rates were negatively correlated with rates of other pharmacological pain relief, which varied from between 15 and 43% (nulliparous) and from between 10 and 27% (multiparous). Rates of paediatric involvement varied from between 37 and 60% (nulliparous) and from between 26 and 43% (multiparous). For instrumental vaginal births, rates varied from between 16 and 19% (nulliparous) and from between 3 and 4% (multiparous). For intrapartum caesarean section, the variation was 13-15% and 5-6%, respectively. A positive correlation was found between intervention rates in midwife-led and obstetrician-led care at the onset of labour within the same region. Adverse neonatal and maternal outcomes were not lower in regions with higher intervention rates. Higher augmentation of labour rates correlated with higher rates of severe postpartum haemorrhage. CONCLUSIONS Most variation was found for type of pain medication and paediatric involvement, and least for instrumental vaginal births and intrapartum caesarean sections. Care providers and policy makers should critically audit remarkable variations, since these may be unwarranted. Limited variation for some interventions may indicate consensus for their use. Further research should focus on variations in evidence-based interventions and indications for the use of interventions in childbirth.
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Affiliation(s)
- A. E. Seijmonsbergen-Schermers
- Department of Midwifery Science, AVAG, Amsterdam Public Health research Institute, VU University Medical Center, Van der Boechorststraat 7, 1081 BT Amsterdam, the Netherlands
| | - D. C. Zondag
- Department of Midwifery Science, AVAG, Amsterdam Public Health research Institute, VU University Medical Center, Van der Boechorststraat 7, 1081 BT Amsterdam, the Netherlands
| | - M. Nieuwenhuijze
- Research Centre for Midwifery Science, Zuyd University, Universiteitssingel 60, 6229 ER Maastricht, the Netherlands
| | - T. Van den Akker
- Department of Obstetrics, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, the Netherlands
| | - C. J. Verhoeven
- Department of Midwifery Science, AVAG, Amsterdam Public Health research Institute, VU University Medical Center, Van der Boechorststraat 7, 1081 BT Amsterdam, the Netherlands
- Department of Obstetrics and Gynaecology, Maxima Medical Centre, De Run 4600, PO Box 7777, 5500 MB Veldhoven, the Netherlands
| | - C. Geerts
- Department of Midwifery Science, AVAG, Amsterdam Public Health research Institute, VU University Medical Center, Van der Boechorststraat 7, 1081 BT Amsterdam, the Netherlands
| | - F. Schellevis
- NIVEL (Netherlands Institute for Health Services Research), PO Box 1568, 3500 BN Utrecht, the Netherlands
- Department of General Practice & Elderly Care Medicine, Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, the Netherlands
| | - A. De Jonge
- Department of Midwifery Science, AVAG, Amsterdam Public Health research Institute, VU University Medical Center, Van der Boechorststraat 7, 1081 BT Amsterdam, the Netherlands
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Pasko DN, McGee P, Grobman WA, Bailit JL, Reddy UM, Wapner RJ, Varner MW, Thorp JM, Leveno KJ, Caritis SN, Prasad M, Saade G, Sorokin Y, Rouse DJ, Blackwell SC, Tolosa JE. Variation in the Nulliparous, Term, Singleton, Vertex Cesarean Delivery Rate. Obstet Gynecol 2018; 131:1039-1048. [PMID: 29742665 PMCID: PMC6033063 DOI: 10.1097/aog.0000000000002636] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To estimate the contributions of patient and health care provider-hospital characteristics to the variation in the frequency of nulliparous, term, singleton, vertex cesarean delivery in a multi-institutional U.S. cohort. METHODS We performed a secondary analysis of the multicenter Assessment of Perinatal Excellence cohort of 115,502 mother and neonatal pairs who were delivered at 25 hospitals between March 2008 and February 2011. Women met inclusion criteria if they were nulliparous and delivered a singleton in vertex presentation at term. Hospital ranks for nulliparous, term, singleton, vertex cesarean delivery frequency were determined after risk adjustment. The fraction of variation in nulliparous, term, singleton, vertex cesarean delivery frequency attributable to patient and health care provider-hospital characteristics was assessed using hierarchical logistic regression. RESULTS Of the 115,502 deliveries in the initial cohort, 38,275 nulliparous, term, singleton, vertex deliveries met inclusion criteria. The median hospital nulliparous, term, singleton, vertex cesarean delivery frequency was 25.3% with a range from 15.0% to 35.2%. The majority of hospitals (16/25) changed rank quintiles after risk adjustment; overall the changes in rank were not statistically significant (P=.53). Patient characteristics accounted for 24% of the nulliparous, term, singleton, vertex cesarean delivery variation. The analyzed health care provider-hospital characteristics were not significantly associated with cesarean delivery frequency. CONCLUSION Although patient characteristics accounted for some of the variation in nulliparous, term, singleton, vertex cesarean delivery frequency and accounting for case mix had implications for hospital cesarean delivery rankings, the majority of the variation was not explained by the characteristics evaluated. These findings emphasize the importance of continued efforts to understand aspects of obstetric care, including case mix, that contribute to cesarean delivery variation.
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Affiliation(s)
- Daniel N Pasko
- Departments of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama; Northwestern University, Chicago, Illinois; MetroHealth Medical Center-Case Western Reserve University, Cleveland, Ohio; Columbia University, New York, New York; the University of Utah Health Sciences Center, Salt Lake City, Utah; the University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; the University of Texas Southwestern Medical Center, Dallas, Texas; the University of Pittsburgh, Pittsburgh, Pennsylvania; The Ohio State University, Columbus, Ohio; the University of Texas Medical Branch, Galveston, Texas; Wayne State University, Detroit, Michigan; Brown University, Providence, Rhode Island; the University of Texas Health Science Center at Houston, McGovern Medical School-Children's Memorial Hermann Hospital, Houston, Texas; Oregon Health & Science University, Portland, Oregon; the George Washington University Biostatistics Center, Washington, DC; and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
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26
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Yip BHK, Leonard H, Stock S, Stoltenberg C, Francis RW, Gissler M, Gross R, Schendel D, Sandin S. Caesarean section and risk of autism across gestational age: a multi-national cohort study of 5 million births. Int J Epidemiol 2018; 46:429-439. [PMID: 28017932 DOI: 10.1093/ije/dyw336] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2016] [Indexed: 12/16/2022] Open
Abstract
Background The positive association between caesarean section (CS) and autism spectrum disorder (ASD) may be attributed to preterm delivery. However, due to lack of statistical power, no previous study thoroughly examined this association across gestational age. Moreover, most studies did not differentiate between emergency and planned CS. Methods Using population-based registries of four Nordic countries and Western Australia, our study population included 4 987 390 singletons surviving their first year of life, which included 671 646 CS deliveries and 31 073 ASD children. We used logistic regression to estimate odds ratios (OR) and their 95% confidence intervals (CI) for CS, adjusted for gestational age, site, maternal age and birth year. Stratified analyses were conducted by both gestational age subgroups and by week of gestation. We compared emergency versus planned CS to investigate their potential difference in the risk of ASD. Results Compared with vaginal delivery, the overall adjusted OR for ASD in CS delivery was 1.26 (95% CI 1.22-1.30). Stratified ORs were 1.25 (1.15-1.37), 1.16 (1.09-1.23), 1.34 (1.28-1.40) and 1.17 (1.04-1.30) for subgroups of gestational weeks 26-36, 37-38, 39-41 and 42-44, respectively. CS was significantly associated with risk of ASD for each week of gestation, from week 36 to 42, consistently across study sites (OR ranged 1.16-1.38). There was no statistically significant difference between emergency and planned CS in the risk of ASD. Conclusion Across the five countries, emergency or planned CS is consistently associated with a modest increased risk of ASD from gestational weeks 36 to 42 when compared with vaginal delivery.
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Affiliation(s)
- Benjamin Hon Kei Yip
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Helen Leonard
- Telethon Kids Institute.,Centre for Child Health Research, University of Western Australia, Crawley, WA, Australia
| | - Sarah Stock
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.,MRC Centre for Reproductive Health, University of Edinburgh Queen's Medical Research Institute, Edinburgh, UK.,Norwegian Institute of Public Health, Oslo, Norway
| | - Camilla Stoltenberg
- Norwegian Institute of Public Health, Oslo, Norway.,Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Richard W Francis
- Telethon Kids Institute.,Centre for Child Health Research, University of Western Australia, Crawley, WA, Australia
| | - Mika Gissler
- National Institute for Health and Welfare, Helsinki, Finland.,Department of Child Psychiatry, Turku University and Turku University Hospital, Turku, Finland
| | - Raz Gross
- Department of Epidemiology and Preventive Medicine, Tel Aviv University, Tel Aviv, Israel.,Division of Psychiatry, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Diana Schendel
- Department of Public Health, Institute of Epidemiology and Social Medicine, Aarhus University, Aarhus, Denmark.,Department of Economics and Business, National Centre for Register-based Research, Aarhus, Denmark.,Lundbeck Foundation Initiative for Integrative Psychiatric Research, Aarhus University, Aarhus, Denmark
| | - Sven Sandin
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.,Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA and
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27
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Wehberg S, Guldberg R, Gradel KO, Kesmodel US, Munk L, Andersson CB, Jølving LR, Nielsen J, Nørgård BM. Risk factors and between-hospital variation of caesarean section in Denmark: a cohort study. BMJ Open 2018; 8:e019120. [PMID: 29440158 PMCID: PMC5829888 DOI: 10.1136/bmjopen-2017-019120] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES The aim of this study was to estimate the effects of risk factors on elective and emergency caesarean section (CS) and to estimate the between-hospital variation of risk-adjusted CS proportions. DESIGN Historical registry-based cohort study. SETTINGS AND PARTICIPANTS The study was based on all singleton deliveries in hospital units in Denmark from January 2009 to December 2012. A total of 226 612 births by 198 590 mothers in 29 maternity units were included. PRIMARY AND SECONDARY OUTCOME MEASURES We estimated (1) OR of elective and emergency CS adjusted for several risk factors, for example, body mass index, parity, age and size of maternity unit and (2) risk-adjusted proportions of elective and emergency CS to evaluate between-hospital variation. RESULTS The CS proportion was stable at 20%-21%, but showed wide variation between units, even in adjusted models. Large units performed significantly more elective CSs than smaller units, and the risk of emergency CS was significantly reduced compared with smaller units. Many of the included risk factors were found to influence the risk of CS. The most important risk factors were breech presentation and previous CS. Four units performed more CSs and one unit fewer CSs than expected. CONCLUSION The main risk factors for elective CS were breech presentation and previous CS; for emergency CS they were breech presentation and cephalopelvic disproportion. The proportions of CS were stable during the study period. We found variation in risk-adjusted CS between hospitals in Denmark. Although exhaustive models were applied, the results indicated the presence of systematic variation between hospital units, which was unexpected in a small, well-regulated country such as Denmark.
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Affiliation(s)
- Sonja Wehberg
- Center for Clinical Epidemiology, Odense University Hospital, Odense, Denmark
- Research Unit of Clinical Epidemiology, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Rikke Guldberg
- Center for Clinical Epidemiology, Odense University Hospital, Odense, Denmark
- Research Unit of Clinical Epidemiology, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Kim Oren Gradel
- Center for Clinical Epidemiology, Odense University Hospital, Odense, Denmark
- Research Unit of Clinical Epidemiology, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | | | - Lis Munk
- Swedish Association for Health Professionals, Stockholm, Sweden
| | | | - Line Riis Jølving
- Center for Clinical Epidemiology, Odense University Hospital, Odense, Denmark
- Research Unit of Clinical Epidemiology, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Jan Nielsen
- Center for Clinical Epidemiology, Odense University Hospital, Odense, Denmark
- Research Unit of Clinical Epidemiology, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Bente Mertz Nørgård
- Center for Clinical Epidemiology, Odense University Hospital, Odense, Denmark
- Research Unit of Clinical Epidemiology, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
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Hitti J, Walker S, Benedetti TJ. Effect of severity of illness on cesarean delivery rates in Washington State. Am J Obstet Gynecol 2017; 217:474.e1-474.e5. [PMID: 28666693 DOI: 10.1016/j.ajog.2017.06.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 06/06/2017] [Accepted: 06/21/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND Hospitals and providers are increasingly held accountable for their cesarean delivery rates. In the perinatal quality improvement arena, there is vigorous debate about whether all hospitals can be held to the same benchmark for an acceptable cesarean rate regardless of patient acuity. However, the causes of variation in hospital cesarean delivery rates are not well understood. OBJECTIVE We sought to evaluate the association and temporal trends between severity of illness at admission and the primary term singleton vertex cesarean delivery rate among hospitals in Washington State. We hypothesized that hospitals with higher patient acuity would have higher cesarean delivery rates and that this pattern would persist over time. STUDY DESIGN In this cross-sectional analysis, we analyzed aggregate hospital-level data for all nonmilitary hospitals in Washington State with ≥100 deliveries/y during federal fiscal years 2010 through 2014 (287,031 deliveries). Data were obtained from the Washington State Comprehensive Hospital Abstract Reporting System, which includes inpatient demographic, diagnosis, procedure, and discharge information derived from hospital billing systems. Age, admission diagnoses and procedure codes were converted to patient-level admission severity-of-illness scores using the All Patient Refined Diagnosis Related Groups classification system. This system is widely used throughout the United States to adjust hospital data for severity of illness. Mean admission hospital-level severity-of-illness scores were calculated for each fiscal year among the term singleton vertex population with no history of cesarean delivery. We used linear regression to evaluate the association between hospital admission severity of illness and the primary term singleton vertex cesarean delivery rate, calculated Pearson correlation coefficients, and compared regression line slopes and 95% confidence intervals for each fiscal year. RESULTS Hospitals were diverse with respect to delivery volume, level of care, and geographic location within Washington. Hospital aggregate admission severity-of-illness score correlated with primary term singleton vertex cesarean delivery rate in all fiscal years (R2 0.38-0.58, P < .001). For every year in the study interval, as admission severity of illness increased so did the primary term singleton vertex cesarean rate. The slope of the regression line decreased during the study interval, suggesting that statewide decrease in primary term singleton vertex cesarean rate occurred across the range of severity of illness. CONCLUSION Admission severity-of-illness score is strongly associated with the primary term singleton vertex cesarean delivery rate among hospitals in Washington State. Approximately 50% of variation in hospital primary term singleton vertex cesarean delivery rates appeared to be related to admission severity of illness. This relationship persisted over time despite a statewide decrease in cesarean delivery, suggesting that patient acuity will likely continue to contribute to hospital variation in cesarean delivery rates despite perinatal quality improvement efforts. The major implication of this study is that patient acuity should be considered when determining optimal cesarean delivery rates. High-acuity hospitals are likely to have high cesarean rates because they provide a specific role in serving regional needs. To hold these centers to an arbitrary benchmark may jeopardize the funding necessary to support regional safety net institutions.
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Affiliation(s)
- Jane Hitti
- Department of Obstetrics/Gynecology, University of Washington Medical Center, Seattle, WA.
| | - Suzan Walker
- Department of Obstetrics/Gynecology, University of Washington Medical Center, Seattle, WA
| | - Thomas J Benedetti
- Department of Obstetrics/Gynecology, University of Washington Medical Center, Seattle, WA
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Quality measures in high-risk pregnancies: Executive Summary of a Cooperative Workshop of the Society for Maternal-Fetal Medicine, National Institute of Child Health and Human Development, and the American College of Obstetricians and Gynecologists. Am J Obstet Gynecol 2017; 217:B2-B25. [PMID: 28735702 DOI: 10.1016/j.ajog.2017.07.018] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 07/14/2017] [Indexed: 01/07/2023]
Abstract
Providers perceive current obstetric quality measures as imperfect and insufficient. Our organizations convened a "Quality Measures in High-Risk Pregnancies Workshop." The goals were to (1) review the current landscape regarding quality measures in obstetric conditions with increased risk for adverse maternal or fetal outcomes, (2) evaluate the available evidence for management of common obstetric conditions to identify those that may drive the highest impact on outcomes, quality, and value, (3) propose measures for high-risk obstetric conditions that reflect enhanced quality and efficiency, and (4) identify current research gaps, improve methods of data collection, and recommend means of change.
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30
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Inter-institutional Variation in Use of Caesarean Delivery for Labour Dystocia. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2017; 39:988-995. [PMID: 28916125 DOI: 10.1016/j.jogc.2017.05.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 04/28/2017] [Accepted: 05/01/2017] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To establish the degree of variation across hospitals in the use of Caesarean delivery for the indication of labour dystocia before and after accounting for maternal, fetal, and hospital characteristics. METHODS This study was a retrospective, population-based cohort study of nulliparous women delivering term singletons in cephalic position following labour. Delivery visits were extracted from three provincial perinatal registries in the Canadian provinces of Ontario, Alberta, and British Columbia, from 2008-2012. Crude hospital-specific rates of Caesarean delivery for labour dystocia were reported, and these rates were then stabilized to account for hospitals with low delivery volumes. Rates were then adjusted for maternal, fetal, and hospital characteristics using hierarchical logistic regression. RESULTS Among 403 205 women delivering at 170 hospitals, the overall Caesarean delivery rate was 21.0%, and the rate of Caesarean delivery for labour dystocia was 12.7%, indicating that 60% of all Caesarean deliveries were performed in part for this indication. The middle 95% of hospitals had Caesarean delivery rates for labour dystocia ranging from 4.5% to 24.7%. Differences in maternal case mix and hospital characteristics explained only a small proportion of this variation (95% central range 6.3%-21.7%). CONCLUSION Considerable inter-hospital variation in rates of Caesarean delivery for labour dystocia remained after accounting for differences in maternal and hospital factors. Reporting systems that monitor variation in inter-institutional rates should incorporate stabilization and adjustment for case-mix differences and consider indication-specific rates of Caesarean delivery to more fairly compare hospital performance and better target interventions to reduce Caesarean delivery for specific indications.
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Rossen J, Lucovnik M, Eggebø TM, Tul N, Murphy M, Vistad I, Robson M. A method to assess obstetric outcomes using the 10-Group Classification System: a quantitative descriptive study. BMJ Open 2017; 7:e016192. [PMID: 28706102 PMCID: PMC5726112 DOI: 10.1136/bmjopen-2017-016192] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Internationally, the 10-Group Classification System (TGCS) has been used to report caesarean section rates, but analysis of other outcomes is also recommended. We now aim to present the TGCS as a method to assess outcomes of labour and delivery using routine collection of perinatal information. DESIGN This research is a methodological study to describe the use of the TGCS. SETTING Stavanger University Hospital (SUH), Norway, National Maternity Hospital Dublin, Ireland and Slovenian National Perinatal Database (SLO), Slovenia. PARTICIPANTS 9848 women from SUH, Norway, 9250 women from National Maternity Hospital Dublin, Ireland and 106 167 women, from SLO, Slovenia. MAIN OUTCOME MEASURES All women were classified according to the TGCS within which caesarean section, oxytocin augmentation, epidural analgesia, operative vaginal deliveries, episiotomy, sphincter rupture, postpartum haemorrhage, blood transfusion, maternal age >35 years, body mass index >30, Apgar score, umbilical cord pH, hypoxic-ischaemic encephalopathy, antepartum and perinatal deaths were incorporated. RESULTS There were significant differences in the sizes of the groups of women and the incidences of events and outcomes within the TGCS between the three perinatal databases. CONCLUSIONS The TGCS is a standardised objective classification system where events and outcomes of labour and delivery can be incorporated. Obstetric core events and outcomes should be agreed and defined to set standards of care. This method provides continuous and available observations from delivery wards, possibly used for further interpretation, questions and international comparisons. The definition of quality may vary in different units and can only be ascertained when all the necessary information is available and considered together.
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Affiliation(s)
- Janne Rossen
- Department of Obstetrics and Gynecology, Sørlandet Hospital HF Kristiansand, Kristiansand, Norway
- Department of Laboratory Medicine, Children’s and Women’s Health, Norwegian University of Science and Technology, Trondheim, Norway
| | - Miha Lucovnik
- Department of Perinatology, Division of Obstetrics and Gynecology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Torbjørn Moe Eggebø
- Department of Laboratory Medicine, Children’s and Women’s Health, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Obstetrics and Gynecology, Stavanger University Hospital, Stavanger, Norway
- National Center for Fetal Medicine, Trondheim University Hospital, St Olavs Hospital, Trondheim, Norway
| | - Natasa Tul
- Department of Perinatology, Division of Obstetrics and Gynecology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | | | - Ingvild Vistad
- Department of Obstetrics and Gynecology, Sørlandet Hospital HF Kristiansand, Kristiansand, Norway
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Lundgren C, Brudin L, Wanby AS, Blomberg M. Ante- and intrapartum risk factors for neonatal hypoxic ischemic encephalopathy. J Matern Fetal Neonatal Med 2017; 31:1595-1601. [DOI: 10.1080/14767058.2017.1321628] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Cecilia Lundgren
- Department of Obstetrics and Gynecology, Kalmar County Hospital, Kalmar, Sweden
| | - Lars Brudin
- Department of Clinical Physiology, Kalmar County Hospital, Kalmar, Sweden
- Department of Medicine and Health Sciences, University Hospital Linköping, Linköping, Sweden
| | - Anna-Stina Wanby
- Department of Obstetrics and Gynecology, Kalmar County Hospital, Kalmar, Sweden
| | - Marie Blomberg
- Department of Obstetrics and Gynecology Linköping University, Linköping, Sweden
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
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Mesterton J, Ladfors L, Ekenberg Abreu A, Lindgren P, Saltvedt S, Weichselbraun M, Amer-Wåhlin I. Case mix adjusted variation in cesarean section rate in Sweden. Acta Obstet Gynecol Scand 2017; 96:597-606. [DOI: 10.1111/aogs.13117] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Accepted: 02/13/2017] [Indexed: 11/26/2022]
Affiliation(s)
- Johan Mesterton
- Medical Management Center; Department of Learning, Informatics, Management and Ethics; Karolinska Institutet; Stockholm Sweden
- Ivbar Institute; Stockholm Sweden
| | - Lars Ladfors
- Institute of Clinical Sciences; Department of Obstetrics and Gynecology; Sahlgrenska University Hospital; Gothenburg Sweden
| | - Anna Ekenberg Abreu
- Department of Obstetrics and Gynecology; Akademiska Hospital; Uppsala Sweden
| | - Peter Lindgren
- Medical Management Center; Department of Learning, Informatics, Management and Ethics; Karolinska Institutet; Stockholm Sweden
| | - Sissel Saltvedt
- Department of Obstetrics and Gynecology; Karolinska University Hospital; Stockholm Sweden
| | - Marianne Weichselbraun
- Institute of Clinical Sciences; Department of Obstetrics and Gynecology; Sahlgrenska University Hospital; Gothenburg Sweden
| | - Isis Amer-Wåhlin
- Medical Management Center; Department of Learning, Informatics, Management and Ethics; Karolinska Institutet; Stockholm Sweden
- Department of Women's and Children's Health; Karolinska Institutet; Stockholm Sweden
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Gerli S, Favilli A, Franchini D, De Giorgi M, Casucci P, Parazzini F. Is the Robson's classification system burdened by obstetric pathologies, maternal characteristics and assistential levels in comparing hospitals cesarean rates? A regional analysis of class 1 and 3. J Matern Fetal Neonatal Med 2017; 31:173-177. [PMID: 28056581 DOI: 10.1080/14767058.2017.1279142] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To assess if maternal risk profile and Hospital assistential levels were able to influence the inter-Hospitals comparison in the class 1 and 3 of the "The Ten Group Classification System" (TGCS). METHODS A population-based analysis using data from Institutional data-base of an Italian Region was carried out. The 11 maternity wards were divided into two categories: second-level hospitals (SLH), and first-level hospitals (FLH). The recorded deliveries were classified according to the TGCS. To analyze if different maternal characteristics and the hospitals assistential level could influence the cesarean section (CS) risk, a multivariate analysis was done considering separately women in the TGCS class 1 and 3. RESULTS From January 2011 to December 2013 were recorded 19,987 deliveries. Of those 7,693 were in the TGCS class 1 and 4,919 in the class 3. The CS rates were 20.8% and 14.7% in class 1 (p < 0.0001) and 6.9% and 5.3% (p < 0.0230) in class 3, respectively in the FLH and SLH. The multivariate logistic regression showed that the FLH, older maternal age and gestational diabetes were independent risk factors for CS in groups 1 and 3. Obesity and gestational hypertension were also independent risk factors for group 1. CONCLUSIONS TGCS is a useful tool to analyze the incidence of CS in a single center but in comparing different Hospitals, maternal characteristics and different assistential levels should be considered as potential bias.
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Affiliation(s)
- Sandro Gerli
- a Department of Obstetrics and Gynecology , University of Perugia , S. Andrea delle Fratte , Perugia , Italy
| | - Alessandro Favilli
- a Department of Obstetrics and Gynecology , University of Perugia , S. Andrea delle Fratte , Perugia , Italy
| | | | | | - Paola Casucci
- c Regione Umbria , Direzione Regionale Salute , Perugia , Italy
| | - Fabio Parazzini
- d Dipartimento Materno Infantile, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico , Università di Milano , Milan , Italy.,e Dipartimento di Scienze Cliniche e di Comunità , Universita' di Milano , Milan , Italy
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Kearney L, Kynn M, Craswell A, Reed R. The relationship between midwife-led group-based versus conventional antenatal care and mode of birth: a matched cohort study. BMC Pregnancy Childbirth 2017; 17:39. [PMID: 28103820 PMCID: PMC5244557 DOI: 10.1186/s12884-016-1216-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Accepted: 12/29/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Midwife facilitated, group models of antenatal care have emerged as an alternative to conventional care both within Australia and internationally. Group antenatal care can be offered in a number of different ways, however usually constitutes a series of sessions co-ordinated by a midwife combining physical assessment, antenatal education and peer support in a group setting. Midwife-led group antenatal care is viewed positively by expectant mothers, with no associated adverse outcomes identified in the published literature for women or their babies when compared with conventional care. Evidence of an improvement in outcomes is limited. The aim of this study was to compare mode of birth (any vaginal birth with caesarean birth) between pregnant women accessing midwife-led group antenatal care and conventional individual antenatal care, in Queensland, Australia. METHODS This was a retrospective matched cohort study, set within a collaborative antenatal clinic between the local university and regional public health service in Queensland, Australia. Midwife-led group antenatal care (n = 110) participants were compared with controls enrolled in conventional antenatal care (n = 330). Groups were matched by parity, maternal age and gestation to form comparable groups, selecting a homogeneous sample with respect to confounding variables likely to affect outcomes. RESULTS There was no evidence that group care resulted in a greater number of caesarean births. The largest increase in the odds of caesarean birth was associated with a previous caesarean birth (p < 0.001), no previous birth (compared with previous vaginal birth) (p < 0.003), and conventional antenatal care (p < 0.073). The secondary outcomes (breastfeeding and infant birth weight) which were examined between the matched cohorts were comparable between groups. CONCLUSIONS There is no evidence arising from this study that there was a significant difference in mode of birth (caesarean or vaginal) between group and conventional care. Group care was associated with a lower risk of caesarean birth after controlling for previous births, with the highest chance for a vaginal birth being a woman who has had a previous vaginal birth and was in group care. Conversely, the highest risk of caesarean birth was for women who have had a previous caesarean birth and conventional care.
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Affiliation(s)
- Lauren Kearney
- University of the Sunshine Coast, Locked Bag 4, Maroochydore DC, 4558 Queensland Australia
- Women and Families Service Group, Sunshine Coast Hospital and Health Service, Maroochydore DC, Queensland Australia
| | - Mary Kynn
- University of the Sunshine Coast, Locked Bag 4, Maroochydore DC, 4558 Queensland Australia
| | - Alison Craswell
- University of the Sunshine Coast, Locked Bag 4, Maroochydore DC, 4558 Queensland Australia
| | - Rachel Reed
- University of the Sunshine Coast, Locked Bag 4, Maroochydore DC, 4558 Queensland Australia
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Dias MAB, Domingues RMSM, Schilithz AOC, Nakamura-Pereira M, do Carmo Leal M. Factors associated with cesarean delivery during labor in primiparous women assisted in the Brazilian Public Health System: data from a National Survey. Reprod Health 2016; 13:114. [PMID: 27766983 PMCID: PMC5073796 DOI: 10.1186/s12978-016-0231-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND The rate of cesarean delivery (CD) in Brazil has increased over the past 40 years. The CD rate in public services is three times above the World Health Organization recommended values. Among strategies to reduce CD, the most important is reduction of primary cesarean. This study aimed to describe factors associated with CD during labor in primiparous women with a single cephalic pregnancy assisted in the Brazilian Public Health System (SUS). METHODS This study is part of the Birth in Brazil survey, a national hospital-based study of 23,894 postpartum women and their newborns. The rate of CD in primiparous women was estimated. Univariate and multivariable logistic regression was performed to analyze factors associated with CD during labor in primiparous women with a single cephalic pregnancy, including estimation of crude and adjusted odds ratios and their respective 95 % confidence intervals. RESULTS The analyzed data are related to the 2814 eligible primiparous women who had vaginal birth or CD during labor in SUS hospitals. In adjusted analyses, residing in the Southeast region was associated with lower CD during labor. Occurrence of clinical and obstetric conditions potentially related to obstetric emergencies before delivery, early admission with < 4 cm of dilatation, a decision late in pregnancy for CD, and the use of analgesia were associated with a greater risk for CD. Favorable advice for vaginal birth during antenatal care, induction of labor, and the use of any good practices during labor were protective factors for CD. The type of professional who attended birth was not significant in the final analyses, but bivariate analysis showed a higher use of good practices and a smaller proportion of epidural analgesia in women cared for by at least one nurse midwife. CONCLUSIONS The CD rate in primiparous women in SUS in Brazil is extremely high and can compromise the health of these women and their newborns. Information and support for vaginal birth during antenatal care, avoiding early admission, and promoting the use of good practices during labor assistance can reduce unnecessary CD. Considering the experience of other countries, incorporation of nurse midwives in childbirth care may increase the use of good practices during labor.
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Affiliation(s)
| | | | | | - Marcos Nakamura-Pereira
- Instituto Fernandes Figueira/FIOCRUZ, Av. Rui Barbosa 716, Rio de Janeiro, CEP: 22250-020 Brasil
| | - Maria do Carmo Leal
- Escola Nacional Saúde Publica Sérgio Arouca/FIOCRUZ, Av. Brasil, 4365 - Manguinhos, Rio de Janeiro, CEP: 21040-360 Brasil
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37
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Labour induction for late-term or post-term pregnancy. Women Birth 2016; 29:394-8. [DOI: 10.1016/j.wombi.2016.01.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Revised: 01/22/2016] [Accepted: 01/24/2016] [Indexed: 11/20/2022]
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38
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Reduction in the Cesarean Delivery Rate After Obstetric Care Consensus Guideline Implementation. Obstet Gynecol 2016; 128:145-152. [DOI: 10.1097/aog.0000000000001488] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Smithers LG, Mol BW, Wilkinson C, Lynch JW. Implications of caesarean section for children's school achievement: A population-based study. Aust N Z J Obstet Gynaecol 2016; 56:374-80. [DOI: 10.1111/ajo.12475] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Accepted: 04/09/2016] [Indexed: 12/30/2022]
Affiliation(s)
- Lisa G. Smithers
- School of Public Health; University of Adelaide; Adelaide South Australia Australia
- The Robinson Institute; School of Paediatrics and Reproductive Health; University of Adelaide; Adelaide South Australia Australia
| | - Ben W. Mol
- The Robinson Institute; School of Paediatrics and Reproductive Health; University of Adelaide; Adelaide South Australia Australia
| | - Chris Wilkinson
- Maternal Fetal Medicine; Women's and Children's Hospital; North Adelaide South Australia Australia
| | - John W. Lynch
- School of Public Health; University of Adelaide; Adelaide South Australia Australia
- The Robinson Institute; School of Paediatrics and Reproductive Health; University of Adelaide; Adelaide South Australia Australia
- School of Social & Community Medicine; University of Bristol; England UK
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40
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Mesterton J, Lindgren P, Ekenberg Abreu A, Ladfors L, Lilja M, Saltvedt S, Amer-Wåhlin I. Case mix adjustment of health outcomes, resource use and process indicators in childbirth care: a register-based study. BMC Pregnancy Childbirth 2016; 16:125. [PMID: 27245845 PMCID: PMC4888656 DOI: 10.1186/s12884-016-0921-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Accepted: 05/24/2016] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Unwarranted variation in care practice and outcomes has gained attention and inter-hospital comparisons are increasingly being used to highlight and understand differences between hospitals. Adjustment for case mix is a prerequisite for meaningful comparisons between hospitals with different patient populations. The objective of this study was to identify and quantify maternal characteristics that impact a set of important indicators of health outcomes, resource use and care process and which could be used for case mix adjustment of comparisons between hospitals. METHODS In this register-based study, 139 756 deliveries in 2011 and 2012 were identified in regional administrative systems from seven Swedish regions, which together cover 67 % of all deliveries in Sweden. Data were linked to the Medical birth register and Statistics Sweden's population data. A number of important indicators in childbirth care were studied: Caesarean section (CS), induction of labour, length of stay, perineal tears, haemorrhage > 1000 ml and post-partum infections. Sociodemographic and clinical characteristics deemed relevant for case mix adjustment of outcomes and resource use were identified based on previous literature and based on clinical expertise. Adjustment using logistic and ordinary least squares regression analysis was performed to quantify the impact of these characteristics on the studied indicators. RESULTS Almost all case mix factors analysed had an impact on CS rate, induction rate and length of stay and the effect was highly statistically significant for most factors. Maternal age, parity, fetal presentation and multiple birth were strong predictors of all these indicators but a number of additional factors such as born outside the EU, body mass index (BMI) and several complications during pregnancy were also important risk factors. A number of maternal characteristics had a noticeable impact on risk of perineal tears, while the impact of case mix factors was less pronounced for risk of haemorrhage > 1000 ml and post-partum infections. CONCLUSIONS Maternal characteristics have a large impact on care process, resource use and outcomes in childbirth care. For meaningful comparisons between hospitals and benchmarking, a broad spectrum of sociodemographic and clinical maternal characteristics should be accounted for.
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Affiliation(s)
- Johan Mesterton
- Medical Management Centre, Karolinska Institutet, Tomtebodavägen 18 A, 171 77, Stockholm, Sweden. .,Ivbar Institute, Stockholm, Sweden.
| | - Peter Lindgren
- Medical Management Centre, Karolinska Institutet, Tomtebodavägen 18 A, 171 77, Stockholm, Sweden
| | - Anna Ekenberg Abreu
- Departement of Obstetrics and Gynecology, Akademiska Hospital, Uppsala, Sweden
| | - Lars Ladfors
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Monica Lilja
- Department of Obstetrics and Gynecology, Skane University Hospital, Lund, Sweden
| | - Sissel Saltvedt
- Department of Obstetrics and Gynecology, Karolinska University Hospital, Stockholm, Sweden
| | - Isis Amer-Wåhlin
- Medical Management Centre, Karolinska Institutet, Tomtebodavägen 18 A, 171 77, Stockholm, Sweden.,Department of Women and Child Health, Karolinska Institutet, Stockholm, Sweden.,Stockholm County Council, Stockholm, Sweden
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Paul Frohlich E. Re: 'Previous caesarean delivery and the risk of unexplained stillbirth: retrospective cohort study and meta-analysis'. BJOG 2016; 123:1232-3. [PMID: 27206041 DOI: 10.1111/1471-0528.13838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/10/2015] [Indexed: 11/28/2022]
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Blomberg M. Avoiding the first cesarean section-results of structured organizational and cultural changes. Acta Obstet Gynecol Scand 2016; 95:580-6. [DOI: 10.1111/aogs.12872] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Accepted: 02/06/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Marie Blomberg
- Department of Obstetrics and Gynecology and Department of Clinical and Experimental Medicine; Linköping University; Linköping Sweden
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Nippita TA, Trevena JA, Patterson JA, Ford JB, Morris JM, Roberts CL. Inter‐hospital variations in labor induction and outcomes for nullipara: an Australian population‐based linkage study. Acta Obstet Gynecol Scand 2016; 95:411-9. [DOI: 10.1111/aogs.12854] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Accepted: 01/18/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Tanya A. Nippita
- Clinical and Population Perinatal Health Research Kolling Institute Northern Sydney Local Health District St Leonards NSW Australia
- Sydney Medical School‐Northern, University of Sydney St Leonards NSW Australia
- Department of Obstetrics and Gynecology Royal North Shore Hospital Northern Sydney Local Health District St Leonards NSW Australia
| | - Judy A. Trevena
- Clinical and Population Perinatal Health Research Kolling Institute Northern Sydney Local Health District St Leonards NSW Australia
| | - Jillian A. Patterson
- Clinical and Population Perinatal Health Research Kolling Institute Northern Sydney Local Health District St Leonards NSW Australia
- Sydney Medical School‐Northern, University of Sydney St Leonards NSW Australia
| | - Jane B. Ford
- Clinical and Population Perinatal Health Research Kolling Institute Northern Sydney Local Health District St Leonards NSW Australia
- Sydney Medical School‐Northern, University of Sydney St Leonards NSW Australia
| | - Jonathan M. Morris
- Clinical and Population Perinatal Health Research Kolling Institute Northern Sydney Local Health District St Leonards NSW Australia
- Sydney Medical School‐Northern, University of Sydney St Leonards NSW Australia
| | - Christine L. Roberts
- Clinical and Population Perinatal Health Research Kolling Institute Northern Sydney Local Health District St Leonards NSW Australia
- Sydney Medical School‐Northern, University of Sydney St Leonards NSW Australia
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Zielinski RE, Brody MG, Low LK. The Value of the Maternity Care Team in the Promotion of Physiologic Birth. J Obstet Gynecol Neonatal Nurs 2016; 45:276-84. [PMID: 26820357 DOI: 10.1016/j.jogn.2015.12.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/01/2015] [Indexed: 12/01/2022] Open
Abstract
The benefits of normal, physiologic birth have been well documented. Health care providers such as nurses, midwives, and physicians have distinct and significant roles in the promotion of physiologic birth processes. By supporting women and families, doulas can enhance the maternity care team and further facilitate physiologic birth. A collaborative maternity care team can foster and support a common goal of safe, satisfying, and affordable care practices associated with physiologic birth.
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45
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Rossen J, Østborg TB, Lindtjørn E, Schulz J, Eggebø TM. Judicious use of oxytocin augmentation for the management of prolonged labor. Acta Obstet Gynecol Scand 2015; 95:355-61. [DOI: 10.1111/aogs.12821] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 11/09/2015] [Indexed: 11/27/2022]
Affiliation(s)
- Janne Rossen
- Department of Obstetrics and Gynecology; Sørlandet Hospital HF; Kristiansand Norway
- Department of Laboratory Medicine; Children's and Women's Health; Norwegian University of Science and Technology; Trondheim Norway
| | - Tilde B. Østborg
- Department of Obstetrics and Gynecology; Stavanger University Hospital; Stavanger Norway
| | - Elsa Lindtjørn
- Department of Obstetrics and Gynecology; Stavanger University Hospital; Stavanger Norway
| | - Jørn Schulz
- Department of Clinical Science; University of Stavanger; Stavanger Norway
| | - Torbjørn M. Eggebø
- Department of Obstetrics and Gynecology; Stavanger University Hospital; Stavanger Norway
- National Center for Fetal Medicine; St. Olavs Hospital - Trondheim University Hospital; Trondheim Norway
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Nippita TA, Trevena JA, Patterson JA, Ford JB, Morris JM, Roberts CL. Variation in hospital rates of induction of labour: a population-based record linkage study. BMJ Open 2015; 5:e008755. [PMID: 26338687 PMCID: PMC4563219 DOI: 10.1136/bmjopen-2015-008755] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Revised: 07/24/2015] [Accepted: 08/04/2015] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVES To examine interhospital variation in rates of induction of labour (IOL) to identify potential targets to reduce high rates of practice variation. DESIGN Population-based record linkage cohort study. SETTING New South Wales, Australia, 2010-2011. PARTICIPANTS All women with live births of ≥24 weeks gestation in 72 hospitals. PRIMARY OUTCOME MEASURE Variation in hospital IOL rates adjusted for differences in case-mix, according to 10 mutually exclusive groups derived from the Robson caesarean section classification; groups were categorised by parity, plurality, fetal presentation, prior caesarean section and gestational age. RESULTS The overall IOL rate was 26.7% (46,922 of 175,444 maternities were induced), ranging from 9.7% to 41.2% (IQR 21.8-29.8%) between hospitals. Nulliparous and multiparous women at 39-40 weeks gestation with a singleton cephalic birth were the greatest contributors to the overall IOL rate (23.5% and 20.2% of all IOL respectively), and had persisting high unexplained variation after adjustment for case-mix (adjusted hospital IOL rates ranging from 11.8% to 44.9% and 7.1% to 40.5%, respectively). In contrast, there was little variation in interhospital IOL rates among multiparous women with a singleton cephalic birth at ≥41 weeks gestation, women with singleton non-cephalic pregnancies and women with multifetal pregnancies. CONCLUSIONS 7 of the 10 groups showed high or moderate unexplained variation in interhospital IOL rates, most pronounced for women at 39-40 weeks gestation with a singleton cephalic birth. Outcomes associated with divergent practice require determination, which may guide strategies to reduce practice variation.
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Affiliation(s)
- Tanya A Nippita
- Clinical and Population Perinatal Health, Kolling Institute, Northern Sydney Local Health District, St Leonards, New South Wales, Australia Sydney Medical School Northern, University of Sydney, St Leonards, New South Wales, Australia Department of Obstetrics and Gynaecology, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, New South Wales, Australia
| | - Judy A Trevena
- Clinical and Population Perinatal Health, Kolling Institute, Northern Sydney Local Health District, St Leonards, New South Wales, Australia
| | - Jillian A Patterson
- Clinical and Population Perinatal Health, Kolling Institute, Northern Sydney Local Health District, St Leonards, New South Wales, Australia Sydney Medical School Northern, University of Sydney, St Leonards, New South Wales, Australia
| | - Jane B Ford
- Clinical and Population Perinatal Health, Kolling Institute, Northern Sydney Local Health District, St Leonards, New South Wales, Australia Sydney Medical School Northern, University of Sydney, St Leonards, New South Wales, Australia
| | - Jonathan M Morris
- Clinical and Population Perinatal Health, Kolling Institute, Northern Sydney Local Health District, St Leonards, New South Wales, Australia Sydney Medical School Northern, University of Sydney, St Leonards, New South Wales, Australia
| | - Christine L Roberts
- Clinical and Population Perinatal Health, Kolling Institute, Northern Sydney Local Health District, St Leonards, New South Wales, Australia Sydney Medical School Northern, University of Sydney, St Leonards, New South Wales, Australia
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Schemann K, Patterson JA, Nippita TA, Ford JB, Roberts CL. Variation in hospital caesarean section rates for women with at least one previous caesarean section: a population based cohort study. BMC Pregnancy Childbirth 2015; 15:179. [PMID: 26285692 PMCID: PMC4545707 DOI: 10.1186/s12884-015-0609-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Accepted: 08/04/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Internationally, repeat caesarean sections make the largest contribution to overall caesarean section rates and inter-hospital variation has been reported. The aim of this study was to determine if casemix and hospital factors explain variation in hospital rates of repeat caesarean sections and whether these rates are associated with maternal and neonatal morbidity. METHODS This population-based record linkage study utilised data from New South Wales, Australia between 2007 and 2011. The study population included maternities with any previous caesarean section(s) and were singleton, cephalic and ≥ 37 weeks' gestation (Robson Group 5). Multilevel regression models were used to examine variation in hospital rates of 'planned repeat caesarean section' and, among women who planned a vaginal birth, 'intrapartum caesarean section'. We assessed associations between risk-adjusted hospital rates of planned and intrapartum caesarean sections and rates of casemix adjusted maternal and neonatal morbidity, postpartum haemorrhage and Apgar score <7 at five minutes. RESULTS Of 61894 maternities with a previous caesarean section in 81 hospitals, 82.1% resulted in a caesarean section (72.7% planned and 9.4% unplanned intrapartum caesareans) and 17.9% in vaginal birth. Observed hospital rates of planned caesarean sections ranged from 50.7% to 98.4%. Overall 49.0% of between-hospital variation in planned repeat caesarean section rates was explained by patient (17.3%) and hospital factors (31.7%). Increased odds of planned caesarean section were associated with private hospital status and lower hospital propensity for vaginal birth after caesarean. There were no associations between hospital rates of planned repeat caesarean section and adjusted morbidity rates. Among women who intended a vaginal birth, the observed rates of intrapartum caesarean section ranged from 12.9% to 71.9%. In total, 27.5% of between-hospital variation in rates of intrapartum caesarean section was explained by patient (19.5%) and hospital factors (8.0%). The adjusted morbidity rates differed among hospital intrapartum caesarean section rates, but were influenced by a few hospitals with outlying morbidity rates. CONCLUSIONS Among women with at least one previous caesarean section, less than half of the variation in hospital caesarean section rates was explained by differences in hospital's patient characteristics and practices. Strategies aimed at modifying caesarean section rates for these women should not affect morbidity rates.
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Affiliation(s)
- Kathrin Schemann
- Clinical and Population Perinatal Health Research, Kolling Institute of Medical Research, University of Sydney at Royal North Shore Hospital, St Leonards, NSW, 2065, Australia. .,NSW Biostatistics Training Program, NSW Ministry of Health, North Sydney, NSW, 2060, Australia.
| | - Jillian A Patterson
- Clinical and Population Perinatal Health Research, Kolling Institute of Medical Research, University of Sydney at Royal North Shore Hospital, St Leonards, NSW, 2065, Australia.
| | - Tanya A Nippita
- Clinical and Population Perinatal Health Research, Kolling Institute of Medical Research, University of Sydney at Royal North Shore Hospital, St Leonards, NSW, 2065, Australia. .,Department of Obstetrics and Gynaecology, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW, 2065, Australia.
| | - Jane B Ford
- Clinical and Population Perinatal Health Research, Kolling Institute of Medical Research, University of Sydney at Royal North Shore Hospital, St Leonards, NSW, 2065, Australia.
| | - Christine L Roberts
- Clinical and Population Perinatal Health Research, Kolling Institute of Medical Research, University of Sydney at Royal North Shore Hospital, St Leonards, NSW, 2065, Australia.
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Bannister-Tyrrell M, Patterson JA, Ford JB, Morris JM, Nicholl MC, Roberts CL. Variation in hospital caesarean section rates for preterm births. Aust N Z J Obstet Gynaecol 2015. [PMID: 26223538 DOI: 10.1111/ajo.12351] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Evidence about optimal mode of delivery for preterm birth is lacking, and there is thought to be considerable variation in practice. OBJECTIVE To assess whether variation in hospital preterm caesarean section rates (Robson Classification Group 10) and outcomes are explained by casemix, labour or hospital characteristics. MATERIALS AND METHODS Population-based cohort study in NSW, 2007-2011. Births were categorised according to degree of prematurity and hospital service capability: 26-31, 32-33 and 34-36 weeks' gestation. Hospital preterm caesarean rates were investigated using multilevel logistic regression models, progressively adjusting for casemix, labour and hospital factors. The association between hospital caesarean rates, and severe maternal and neonatal morbidity rates was assessed. RESULTS At 26-31 weeks' gestation, the caesarean rate was 55.2% (seven hospitals, range 43.4-58.4%); 50.9% at 32-33 weeks (12 hospitals, 43.4-58.1%); and 36.4% at 34-36 weeks (51 hospitals, 17.4-48.3%). At 26-31 weeks and 32-33 weeks' gestation, 81% and 59% of the variation between hospitals was explained with no hospital significantly different from the state average after adjustment. At 34-36 weeks' gestation, although 59% of the variation was explained, substantial unexplained variation persisted. Hospital caesarean rates were not associated with severe maternal morbidity rates at any gestational age. At 26-31 weeks' gestation, medium and high caesarean rates were associated with higher severe neonatal morbidity rates, but there was no evidence of this association ≥32 weeks. CONCLUSION Both casemix and practice differences contributed to the variation in hospital caesarean rates. Low preterm caesarean rates were not associated with worse outcomes.
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Affiliation(s)
- Melanie Bannister-Tyrrell
- Clinical and Population Perinatal Health Research, Kolling Institute, University of Sydney, St Leonards, NSW, Australia
| | - Jillian A Patterson
- Clinical and Population Perinatal Health Research, Kolling Institute, University of Sydney, St Leonards, NSW, Australia
| | - Jane B Ford
- Clinical and Population Perinatal Health Research, Kolling Institute, University of Sydney, St Leonards, NSW, Australia
| | - Jonathan M Morris
- Kolling Institute, University of Sydney, St Leonards, NSW, Australia
| | - Michael C Nicholl
- Department of Obstetrics and Gynaecology, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Christine L Roberts
- Clinical and Population Perinatal Health Research, Kolling Institute, University of Sydney, St Leonards, NSW, Australia
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Roberts CL, Nippita TA. International caesarean section rates: the rising tide. LANCET GLOBAL HEALTH 2015; 3:e241-2. [PMID: 25866356 DOI: 10.1016/s2214-109x(15)70111-7] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Christine L Roberts
- Clinical and Population Perinatal Health Research, The Kolling Institute, University of Sydney, NSW 2065, Australia.
| | - Tanya A Nippita
- Clinical and Population Perinatal Health Research, The Kolling Institute, University of Sydney, NSW 2065, Australia; Department of Obstetrics and Gynaecology, Royal North Shore Hospital, St Leonards, NSW 2065, Australia
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