Rates of obstetric intervention and associated perinatal mortality and morbidity among low-risk women giving birth in private and public hospitals in NSW (2000-2008): a linked data population-based cohort study

Prevalence of anxiety and depression and their associated risk factors throughout pregnancy and postpartum: a prospective cross-sectional descriptive multicentred study

OBJECTIVE

To assess the prevalence of anxiety and depression and their associated risk factors throughout the pregnancy and postpartum process using a new screening for the early detection of mental health problems.

DESIGN

A prospective cross-sectional descriptive multicentred study. Participants were consecutively enrolled at ≥ 12 weeks' gestation and followed at three different time points: at 12-14 weeks of pregnancy, at 29-30 weeks of pregnancy, and 4-6 weeks postpartum. All women completed a mental screening at week 12-14 of pregnancy consisting of two questions from the Generalised Anxiety Disorder Scale (GAD-2) and the two Whooley questions. If this screening was positive, the woman completed the Edinburgh Postnatal Depression Scale (EPDS).

SETTING

Seven primary care centres coordinated by a Gynaecology and Obstetrics Department in the city of Terrassa (Barcelona) in northern Spain.

PARTICIPANTS

Pregnant women (N = 335, age 18-45 years), in their first trimester of pregnancy, and receiving prenatal care in the public health system between July 2018 and July 2020.

FINDINGS

The most relevant factors associated with positive screening for antenatal depression or anxiety during pregnancy, that appear after the first trimester of pregnancy, are systematically repeated throughout the pregnancy, and are maintained in the postpartum period were: a history of previous depression, previous anxiety, abuse, and marital problems. In weeks 12-14 early risk factors for positive depression and anxiety screening and positive EPDS were: age, smoking, educational level, employment status, previous psychological/psychiatric history and treatment, suicide in the family environment, voluntary termination of pregnancy and current planned pregnancy, living with a partner and partner's income. In weeks 29-30 risk factors were: being a skilled worker, a history of previous depression or anxiety, and marital problems. In weeks 4-6 postpartum, risk factors were: age, a history of previous depression or anxiety or psychological/psychiatric treatment, type of treatment, having been mistreated, and marital problems.

CONCLUSIONS

Early screening for anxiety and depression in pregnancy may enable the creation of more effective healthcare pathways, by acting long before mental health problems in pregnant women worsen or by preventing their onset. Assessment of anxiety and depression symptoms before and after childbirth and emotional support needs to be incorporated into routine practice.

Model of perinatal care but not prenatal stress exposure is associated with birthweight and gestational age at Birth: The Australian birth in the time of COVID (BITTOC) study

OBJECTIVE

The present study aimed to understand, relative to standard care, whether continuity of care models (private midwifery, continuity of care with a private doctor, continuity of care with a public midwife), and women's experience of maternity care provision, during the perinatal period buffered the association between prenatal maternal stress (PNMS) and infant birth outcomes (gestational age [GA], birth weight [BW] and birth weight for gestational age [BW for GA]).

METHODS

2207 women who were pregnant in Australia while COVID-19 restrictions were in place reported on their COVID-19 related objective hardship and subjective distress during pregnancy and provided information on their model of maternity care. Infant birth outcomes (BW, GA) were reported on at 2-months postpartum.

RESULTS

Multiple linear regressions showed no relationship between PNMS and infant BW, GA or BW for GA, and neither experienced continuity of care, nor model of maternity care moderated this relationship. However, compared with all other models of care, women enrolled in private midwifery care reported the highest levels of experienced continuity of care and birthed infants at higher GA. BW and BW for GA were higher in private midwifery care, relative to standard care.

CONCLUSION

Enrollment in continuous models of perinatal care may be a better predictor of infant birth outcomes than degree of PNMS exposure. These results highlight the possibility that increased, continuous support to women during pregnancy may play an important role in ensuring positive infant birth outcomes during future pandemics.

Antenatal education - Putting research into practice: A guideline review

PROBLEM

Antenatal care guidelines used in Australia are inconsistent in their recommendations for childbirth and parenting education (CBPE) classes for preparation of women and parents for pregnancy, childbirth, and early parenting.

BACKGROUND

Clinical practice guidelines in maternity care are developed to assist healthcare practitioners and consumers to make decisions about appropriate care. The benefit of such guidelines relies on the translation and quality of the evidence contained within them. In the context of antenatal care guidelines, there is a potential evidence-practice gap with regard to CBPE.

AIMS

This review aims to appraise the quality of Australian antenatal care guidelines in their recommendations for CBPE for women and partners.

METHODS

Publicly available Australian antenatal care guidelines were identified including local health district websites and professional organisations pertaining to maternity care. Guidelines were reviewed independently, and the quality was assessed using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool.

FINDINGS

Five guidelines were included in the review and appraised using AGREE II. With the exception of the Department of Health Pregnancy Care Guidelines, guidelines scored poorly across all six domains. When appraised according to specific CBPE recommendations for rigour of development, presentation, and applicability; all guidelines received low scores.

DISCUSSION

Prenatal services remain largely unregulated across the board, with no systematic approach to make recommendations for CBPE and guidelines lacking in rigour with regard to CBPE.

CONCLUSION

Within the guidelines reviewed there was a lack of evidence-based recommendations provided for educators or consumers regarding childbirth and parenting education.

Using a birth ball to reduce pain perception in the latent phase of labour: a randomised controlled trial

BACKGROUND

Admission in the latent phase of labour is associated with higher rates of obstetric intervention. Women are frequently admitted due to pain. This study aimed to determine whether using a birth ball at home in the latent phase of labour reduces pain perception on admission.

METHOD

A prospective, pragmatic randomised controlled trial of 294 low risk pregnant women aged 18 and over planning a hospital birth. An animated educational video was offered at 36 weeks' gestation along with a birth ball. The primary outcome was pain on a Visual Analogue Scale on admission in labour. Participants who experienced a spontaneous labour were invited to respond to an online questionnaire 6 weeks' postpartum.

RESULTS

There were no differences in the mean pain scores; (6.3 versus 6.5; 90%CI -0.72 to 0.37 p = 0.6) or mean cervical dilatation on admission (4.7 cm versus 5.0 cm; 95% CI -1.1 to 0.5 p = 0.58). More Intervention participants were admitted in active labour (63.6% versus 55.7%; p = 0.28) and experienced an unassisted vaginal birth (70.3% v. 65.8%; p = 0.07) with fewer intrapartum caesarean sections (7.5% v. 17.9%; p = 0.07) although the trial was not powered to detect these differences in secondary outcomes. Most participants found the birth ball helpful (89.2%) and would use it in a future labour (92.5%).

CONCLUSION

Using the birth ball at home in the latent phase is a safe and acceptable strategy for labouring women to manage their labour, potentially postpone admission and reduce caesarean section. Further research is warranted.

Out-of-pocket expenditure, need, utilisation, and private health insurance in the Australian healthcare system

Despite widespread public service provision, public funding, and private health insurance (PHI), 20% of all healthcare expenditure across the OECD is covered by out-of-pocket expenditure (OOPE). This creates an equity concern for the increasing number of individuals with chronic conditions and greater need, particularly if higher need coincides with lower income. Theoretically, individuals may mitigate OOPE risk by purchasing PHI, replacing variable OOPE with fixed expenditure on premiums. Furthermore, if PHI premiums are not risk-rated, PHI may redistribute some of the financial burden from less healthy PHI holders that have greater need to healthier PHI holders that have less need. We investigate if the burden of OOPE for individuals with greater need increases less strongly for individuals with PHI in the Australian healthcare system. The Australian healthcare system provides public health insurance with full, partial, or limited coverage, depending on the healthcare service used, and no risk rating of PHI premiums. Using data from the Household, Income and Labour Dynamics in Australia survey we find that individuals with PHI spend a greater share of their disposable income on OOPE and that the difference in OOPE share between PHI and non-PHI holders increases with greater need and utilisation, contrary to the prediction that PHI may mitigate OOPE. We also show that OOPE is a greater concern for poorer individuals for whom the difference in OOPE by PHI is the greatest.

"Make it better for the women and babies who come after me": Findings from women in Australia completing the international Babies Born Better survey

BACKGROUND

Woman-centered maternity service delivery is endorsed by Australian federal health policy. Despite this, little evaluation of maternity care is conducted through the lens of women. We examined the responses of women birthing in Australia to the international Babies Born Better 2018 (Version 2) open-response survey.

METHODS

An online international survey was distributed primarily by means of social media for women who had given birth in the last 5 years. In addition to closed-ended questions to describe the sample, a series of open-ended questions recorded women's experiences and satisfaction with their maternity care and place of birth.

RESULTS

Of 1249 women who reported birthing their most recent baby in Australia and speaking English, 84% responded to at least one open-ended evaluation question. We thematically analyzed the data to identify three related themes of safety, choice, and respect for women. Women's experiences of these were closely tied to their model of care; those birthing at home with a private midwife more so reported positive experiences than those discussing obstetric care or, to a lesser extent, midwifery-led care in a hospital. There was a strong preference and need for (1) access to affordable care with a known practitioner from early pregnancy to postpartum, and (2) individualized care with the removal of restrictive hospital policies not aligned with woman-centered practice.

DISCUSSION

This is the first Australian national study of women's maternity experiences and evaluations. Consistent with previous state-based research, women birthing in Australia continue to report maternity "care" that is physically and emotionally harmful. They also stated a need to address the psychosocial aspects of becoming a mother, in addition to the biological ones. Women and other birthing people must be at the center of defining quality maternity health service delivery, and services must be accountable for preventing and addressing harm, as defined by all birthing people.

The perception of childbearing sense of coherence among Chinese couples: a qualitative study

BACKGROUND

Although childbearing health care is wellness-based and promotes normal physiology, it is in a medical model and focuses on risk aversion and disease prevention. The salutogenic theory might provide an alternative perspective to health care concerning childbearing, supporting health-promoting factors, not solely on avoiding adverse events. However, there is a dearth of qualitative research exploring couples' perceptions of childbearing from the salutogenic lens. This study aimed to explore perceptions and experiences concerning childbearing among couples in the perinatal period and identify salutogenic aspects of it.

METHODS

The qualitative descriptive study adopted a directed content analysis to analyse data from a semi-structured and individual interview with 25 purposively selected Chinese couples between July 2022 and December 2022. The concepts of the sense of coherence (SOC) from the salutogenic theory were used as the theory framework for coding.

RESULTS

Definitions and content for the salutogenic aspects of Chinese couples' perception of childbearing sense of coherence were developed. For comprehensibility of childbearing, four subthemes were extracted (the challenge to health and endurance; transition to and identification with the new role; conflict and reconciliation in relationships; resistance and compromise between social culture and personal development). For manageability of childbearing, two subthemes were extracted (helplessness and hope of childbearing; self-doubt and self-assurance of childbearing). For meaningfulness of childbearing, three subthemes were extracted (personal realisation; family bonding and harmony; the continuation of life).

CONCLUSIONS

The findings of this study could give a greater understanding in maintaining couples' health in the perinatal period from the salutogenic lens and provide a guide to further research that the salutogenic theory could bring a health and wellness-focused agenda in practice and policy-making in the perinatal period.

A comparison of the Woman-centred care: strategic directions for Australian maternity services (2019) national strategy with other international maternity plans

BACKGROUND

In 2019 the Australian government released a guiding document for maternity care: Woman-centred care strategic directions for Australian maternity services (WCC Strategy), with mixed responses from providers and consumers. The aims of this paper were to: examine reasons behind reported dissatisfaction, and compare the WCC Strategy against similar international strategies/plans. The four guiding values in the WCC strategy: safety, respect, choice, and access were used to facilitate comparisons and provide recommendations to governments/health services enacting the plan.

METHODS

Maternity plans published in English from comparable high-income countries were reviewed.

FINDINGS

Eight maternity strategies/plans from 2011 to 2021 were included. There is an admirable focus in the WCC Strategy on respectful care, postnatal care, and culturally appropriate maternity models. Significant gaps in support for continuity of midwifery care and place of birth options were notable, despite robust evidence supporting both. In addition, clarity around women's right to make decisions about their care was lacking or contradictory in the majority of the strategies/plans. Addressing hierarchical, structure-based obstacles to regulation, policy, planning, service delivery models and funding mechanisms may be necessary to overcome concerns and barriers to implementation. We observed that countries where midwifery is more strongly embedded and autonomous, have guidelines recommending greater contributions from midwives.

CONCLUSION

Maternity strategy/plans should be based on the best available evidence, with consistent and complementary recommendations. Within this framework, priority should be given to women's preferences and choices, rather than the interests of organisations and individuals.

Characteristics and co-admissions of mothers and babies admitted to residential parenting services in the year following birth in NSW: a linked population data study (2000-2012)

Background

There is a tiered healthcare system in Australia to support maternal and child health, including, non-psychiatric day stay and residential parenting services (RPS) such as Tresillian and Karitane (in New South Wales [NSW]). RPS are unique to Australia, and currently there is limited information regarding the healthcare trajectory of women accessing RPS and if they are more likely to have admissions to other health facilities within the first-year post-birth. This study aimed to examine differences in hospital co-admissions for women and babies admitted to RPS in NSW in the year following birth compared to non-RPS admitted women.

Methods

A linked population data study of all women giving birth in NSW 2000–2012. Statistical differences were calculated using chi-square and student t-tests.

Results

Over the 12-year timeframe, 32,071 women and 33,035 babies were admitted to RPS, with 5191 of these women also having one or more hospital admissions (7607 admissions). The comparator group comprised of 99,242 women not admitted to RPS but having hospital admissions over the same timeframe (136,771 admissions). Statistically significant differences between cohorts were observed for the following parameters (p ≤ .001). Based upon calculated percentages, women who were admitted to RPS were more often older, Australian born, socially advantaged, private patients, and having their first baby. RPS admitted women also had more multiple births and labour and birth interventions (induction, instrumental birth, caesarean section, epidural, episiotomy). Their infants were also more often male and admitted to Special Care Nursery/Neonatal Intensive Care. Additionally, RPS admitted women had more admissions for mental health and behavioural disorders, which appeared to increase over time. There was no statistical difference between cohorts regarding the number of women admitted to a psychiatric facility; however, women attending RPS were more likely to have mood affective, or behavioural and personality disorder diagnoses.

Conclusion

Women accessing RPS in the year post-birth were more socially advantaged, had higher birth intervention and more co-admissions and treatment for mental health disorders than those not accessing RPS. More research is needed into the impact of birth intervention and mental health issues on subsequent parenting difficulties.

Is there unwarranted variation in obstetric practice in Australia? Obstetric intervention trends in Queensland hospitals

Objective The aim of this study was to report on the rates of obstetric interventions within each hospital jurisdiction in the state of Queensland, Australia. Methods This project used a whole-of-population linked dataset that included the health and cost data of all mothers who gave birth in Queensland, Australia, between 2012 and 2015 (n=186789), plus their babies (n=189909). Adjusted and unadjusted rates of obstetric interventions and non-instrumental vaginal delivery were reported within each hospital jurisdiction in Queensland. Results High rates of obstetric intervention exist in both the private and public sectors, with higher rates demonstrated in the private than public sector. Within the public sector, there is substantial variation in rates of intervention between hospital and health service jurisdictions after adjusting for confounding variables that influence the need for obstetric intervention. Conclusions Due to the high rates of obstetric interventions statewide, a deeper understanding is needed of what factors may be driving these high rates at the health service level, with a focus on the clinical necessity of the provision of Caesarean sections. What is known about the topic? Variation in clinical practice exists in many health disciplines, including obstetric care. Variation in obstetric practice exists between subpopulation groups and between states and territories in Australia. What does this paper add? What we know from this microlevel analysis of obstetric intervention provision within the Australian population is that the provision of obstetric intervention varies substantially between public sector hospital and health services and that this variation is not wholly attributable to clinical or demographic factors of mothers. What are the implications for practitioners? Individual health service providers need to examine the factors that may be driving high rates of Caesarean sections within their institution, with a focus on the clinical necessity of Caesarean section.

"Cos You're Quite Normal, Aren't You?": Epistemic and Deontic Orientations in the Presentation of Model of Care Talk in Antenatal Consultations

Women's involvement in decision-making around antenatal care is an issue of ongoing debate and discussion. Most research on the topic has used interview and focus group methods to examine women's perspectives. The present study uses a different kind of evidence. By analyzing recordings of actual antenatal consultations, this paper presents a preliminary exploration of model-of-care talk in a hospital setting where a policy of woman-centered care underpinned practice. Conversation Analysis was used to examine how model-of-care pathways were introduced by midwives and discussed with women in consultations. Drawing on interactional work on deontic (i.e., the rights and responsibilities of speakers to determine courses of action) and epistemic (i.e., speakers' claims to knowledge) orientations, this paper offers an account of how woman-centered care is accomplished in a hospital setting. The findings demonstrate how midwives routinely relied on their epistemic knowledge regarding women's health to invoke a "normal" categorization that worked to position midwifery-led care as an appropriate pathway. Examination of model-of-care talk also demonstrated how authority to choose a pathway was typically managed so as to reside with the woman. Talk that topicalized epidural forms of pain management were also examined, as institutional policy around where birth could occur in the hospital system under study restricted women's options (a planned epidural precluded woman access to midwifery-led care during delivery). The findings demonstrate the various ways in which midwives created opportunities for woman-centered care in an institutional setting in which there were logistical restrictions on women's choices.

A scoping review of evidence comparing models of maternity care in Australia

OBJECTIVES

To synthesize available evidence comparing outcomes and experiences of care received in different maternity models in Australia and identify the information gaps hindering women's decisions between alternative models.

DESIGN

A literature search was conducted to identify published research over the last twenty years that directly compared clinical and/or experiential outcomes of women in different maternity models of care in Australia. Outcome measures of included articles were identified and assessed to evaluate current comparative information available to women and health professionals. The quality of included studies was assessed using Joanna Briggs Institute (JBI) critical appraisal tools for randomised controlled studies (RCTs) and cohort studies. Quantitative data were extracted and synthesised for further analysis.

SETTING/PARTICIPANTS

Published studies comparing at least two maternity care models providing antenatal, intrapartum and postpartum care in Australia.

RESULTS

Eight studies (five RCTs and three observational studies) met inclusion criteria. Seven studies compared the outcomes of public midwifery continuity care and standard public care and one compared the outcomes of public midwifery continuity care, standard care and private obstetric care. There was no evidence directly comparing all broadly categorised available models in Australia. Data for clinical outcomes were collected from hospital records and experiential data were self-reported. Seven out of eight studies used data collected from single public hospital settings and one study included data from two tertiary hospitals. Women in public midwifery continuity models were more likely to have unassisted vaginal births, continuity of care and satisfaction and lower use of interventions (i.e., episiotomy, induction of labour, use of analgesia) and neonatal admission in intensive care units (ICU), compared with those in standard public models (and private obstetric care in one study).

CONCLUSION

This scoping review reveals lack of reliable direct comparison of clinical and experiential outcomes across the multiple available public and private maternity models of care in Australia. Quality alignment between women's needs and their maternity model of care can prevent under or over specialised care and avoidable health system costs. Comprehensive information comparing all available maternity care models can guide gatekeeper health professionals and women to choose the best model according to women's needs and preferences. There is a need for research providing more comprehensive and ecological comparisons between available models of maternity care to inform such decision making support. Moreover, women's experiential data across maternity model of care comparisons could be used more consistently to better represent the relative outcomes of alternative models from a consumer-centred perspective.

Do you pay to go private?: a single centre comparison of induction of labour and caesarean section rates in private versus public patients

Background

The aim of this study was to compare rates of induction and subsequent caesarean delivery among nulliparous women with private versus publicly funded health care at a single institution. This is a retrospective cohort study using the electronic booking and delivery records of nulliparous women with singleton pregnancies who delivered between 2010 and 2015 in an Irish Tertiary Maternity Hospital (approx. 9000 deliveries per annum).

Methods

Data were extracted from the National Maternity Hospital (NMH), Dublin, Patient Administration System (PAS) on all nulliparous women who delivered a liveborn infant at ≥37 weeks gestation during the 6-year period. At NMH, all women in spontaneous labour are managed according to a standardised intrapartum protocol. Twenty-two thousand two hundred thirty-two women met the inclusion criteria. Of these, 2520 (12.8%) were private patients; the remainder (19,712; 87.2%) were public. Mode of and gestational age at delivery, rates of and indications for induction of labour, rates of pre-labour caesarean section, and maternal and neonatal outcomes were examined. Rates of labour intervention and subsequent maternal and neonatal outcomes were compared between those with and without private health cover.

Results

Women attending privately were more than twice as likely to have a pre-labour caesarean section (12.7% vs. 6.5%, RR = 2.0, [CI 1.8–2.2])); this finding persisted following adjustment for differences in maternal age and body mass index (BMI) (adjusted relative risk 1.74, [CI 1.5–2.0]). Women with private cover were also more likely to have induction of labour and significantly less likely to labour spontaneously. Women who attended privately were significantly more likely to have an operative vaginal delivery, whether labour commenced spontaneously or was induced.

Conclusions

These findings demonstrate significant differences in rates of obstetric intervention between those with private and public health cover. This division is unlikely to be explained by differences in clinical risk factors as no significant difference in outcomes following spontaneous onset of labour were noted. Further research is required to determine the roots of the disparity between private and public decision-making. This should focus on the relative contributions of both mothers and maternity care professionals in clinical decision making, and the potential implications of these choices.

Cost of maternity care to public hospitals: a first 1000-days perspective from Queensland

Objective This study sought to compare costs for women giving birth in different public hospital services across Queensland and their babies. Methods A whole-of-population linked administrative dataset was used containing all health service use in a public hospital in Queensland for women who gave birth between 1 July 2012 and 30 June 2015 and their babies. Generalised linear models were used to compare costs over the first 1000 days between hospital and health services. Results The mean unadjusted cost for each woman and her baby (n = 134910) was A$17406 in the first 1000 days. After adjusting for clinical and demographic factors and birth type, women and their babies who birthed in the Cairns Hospital and Health Service (HHS) had costs 19% lower than those who birthed in Gold Coast HHS (95% confidence interval (CI) -32%, -4%); women and their babies who birthed at the Mater public hospitals had costs 28% higher than those who birthed at Gold Coast HHS (95% CI 8, 51). Conclusions There was considerable variation in costs between hospital and health services in Queensland for the costs of delivering maternity care. Cost needs to be considered as an important additional element of monitoring programs. What is known about the topic? The Australian maternal care system delivers high-quality, safe care to Australian mothers. However, this comes at a considerable financial cost to the Australian public health system. It is known that there are variations in the cost of care depending upon the model of care a woman receives, and the type of delivery she has, with higher-cost treatment not necessarily being safer or producing better outcomes. What does this paper add? This paper compares the cost of delivering a full cycle of maternity care to a woman at different HHSs across Queensland. It demonstrates that there is considerable variation in cost across HHSs, even after adjusting for clinical and demographic factors. What are the implications for practitioners? Reporting of cost should be an ongoing part of performance monitoring in public hospital maternity care alongside clinical outcomes to ensure the sustainability of the high-quality maternal health care Australian public hospitals deliver.

The AEDUCATE Collaboration. Comprehensive antenatal education birth preparation programmes to reduce the rates of caesarean section in nulliparous women. Protocol for an individual participant data prospective meta-analysis

INTRODUCTION

Rates of medical interventions in normal labour and birth are increasing. This prospective meta-analysis (PMA) proposes to assess whether the addition of a comprehensive multicomponent birth preparation programme reduces caesarean section (CS) in nulliparous women compared with standard hospital care. Additionally, do participant characteristics, intervention components or hospital characteristics modify the effectiveness of the programme? METHODS AND ANALYSIS: Population: women with singleton vertex pregnancies, no planned caesarean section (CS) or epidural.Intervention: in addition to hospital-based standard care, a comprehensive antenatal education programme that includes multiple components for birth preparation, addressing the three objectives: preparing women and their birth partner/support person for childbirth through education on physiological/hormonal birth (knowledge and understanding); building women's confidence through psychological preparation (positive mindset) and support their ability to birth without pain relief using evidence-based tools (tools and techniques). The intervention could occur in a hospital-based or community setting.Comparator: standard care alone in hospital-based maternity units.

OUTCOMES

Primary: CS.Secondary: epidural analgesia, mode of birth, perineal trauma, postpartum haemorrhage, newborn resuscitation, psychosocial well-being.Subgroup analysis: parity, model of care, maternal risk status, maternal education, maternal socio-economic status, intervention components.

STUDY DESIGN

An individual participant data (IPD) prospective meta-analysis (PMA) of randomised controlled trials, including cluster design. Each trial is conducted independently but share core protocol elements to contribute data to the PMA. Participating trials are deemed eligible for the PMA if their results are not yet known outside their Data Monitoring Committees.

ETHICS AND DISSEMINATION

Participants in the individual trials will consent to participation, with respective trials receiving ethical approval by their local Human Research Ethics Committees. Individual datasets remain the property of trialists, and can be published prior to the publication of final PMA results. The overall data for meta-analysis will be held, analysed and published by the collaborative group, led by the Cochrane PMA group.

TRIAL REGISTRATION NUMBER

CRD42020103857.

Midwifery student's perceptions of completing a portfolio of evidence for initial registration: A qualitative exploratory study

The Australian Nursing and Midwifery Accreditation Council (ANMAC) has set regulatory standards, that require midwifery students to verify how they have met ANMAC standard 8.11 requirements prior to registration as a midwife. The most common formats for recording achievement of the ANMAC requirements are paper-based or electronic portfolios. Research was conducted to compare student's experiences of completing their university portfolio format. Focus group interviews were held at two south east Queensland universities. This study has found that there is disparity between universities in the level of detail documenting evidence of midwifery experiences. The paper-based portfolio was criticised for not having sufficient space for the students to explain the extent of their experiences, in contrast students completing the ePortfolio felt their reflective entries were excessive. Some students felt the portfolio was not being used to its full potential with suggestions that all experiences that fall within the midwife scope of practice should be recorded as evidence of practice experiences. Students felt the current ANMAC Standard 8.11 requirements limit the range of experiences and are repetitive in requiring up to 100 recordings for some experiences. No nationally agreed format exists of how students are required to document their required ANMAC experiences.

Conceptual and ethical problems underpinning calls to abandon vaginal breech birth

The view that vaginal breech birth is unjustifiable due to neonatal safety concerns has resulted in continued calls for breech pregnancies to be managed via a policy of planned caesarean birth. Vaginal breech birth has of course always occurred, but women with term breech pregnancies who seek to have a vaginal birth often face coercive pressures to have a caesarean birth instead. In this paper I argue that even if there is population level evidence that vaginal birth is relatively riskier for the breech presenting fetus, implementing a policy of planned caesarean birth would essentially be an unjustified attempt at forced medical intervention upon women. Advocates of a policy of planned caesarean birth often conflate the acceptability of allocating participants to a treatment group (policy) within the context of a randomized controlled trial with the justifiability of doing that as part of individual health care. Calls for obstetricians to "abandon vaginal breech birth" mistakenly position vaginal breech birth itself as a form of medical intervention that can simply be removed as an option for women by obstetricians. In reality, abandoning vaginal breech birth would entail abandoning women by denying them access to healthcare options that are otherwise available to any woman having a vaginal birth.

Characteristics and changes in characteristics of women and babies admitted to residential parenting services in New South Wales, Australia in the first year following birth: a population-based data linkage study 2000-2012

OBJECTIVE

To examine the characteristics of women and babies admitted to the residential parenting services (RPS) of Tresillian and Karitane in the first year following birth.

DESIGN

A linked population data cohort study was undertaken for the years 2000-2012.

SETTING

New South Wales (NSW), Australia.

PARTICIPANTS

All women giving birth and babies born in NSW were compared with those admitted to RPS.

RESULTS

During the time period there were a total of 1 097 762 births (2000-2012) in NSW and 32 991 admissions to RPS. Women in cohort 1: (those admitted to RPS) were older at the time of birth, more likely to be admitted as a private patient at the time of birth, be born in Australia and be having their first baby compared with women in cohort 2 (those not admitted to an RPS). Women admitted to RPS experienced more birth intervention (induction, instrumental birth, caesarean section), had more multiple births and were more likely to have a male infant. Their babies were also more likely to be resuscitated and have experienced birth trauma to the scalp. Between 2000 and 2012 the average age of women in the RPS increased by nearly 2 years; their infants were older on admission and women were less likely to smoke. Over the time period there was a drop in the numbers of women admitted to RPS having a normal vaginal birth and an increase in women having an instrumental birth.

CONCLUSION

Women who access RPS in the first year after birth are more socially advantaged and have higher birth intervention than those who do not, due in part to higher numbers birthing in the private sector where intervention rates are high. The rise in women admitted to RPS (2000-2012) who have had instrumental births is intriguing as overall rates did not increase.

What is the total impact of an obstetric anal sphincter injury? An Australian retrospective study

Introduction

Most data on obstetric anal sphincter injury (OASI) reflect short-term (< 12 months) or much longer term (> 10 years) impact. This study aimed to collate the extent of medium-term symptomology (1–6 years) and observe the effect on future birth choices to evaluate the cumulative impact of OASI in affected women.

Methods

A retrospective cohort of women affected by OASI completed a questionnaire covering bowel symptomology, sexual function, life impact and future birth choices. A custom-created adverse composite outcome for OASI incorporating effects on daily life, flatal/fecal incontinence and sexual function (OASIACO) was used as a threshold score to identify women with high levels of symptoms.

Results

Of 265 eligible and contactable women, 210 questionnaires were received (response rate 79%) at a mean of 4 years post-OASI. More than half (54%) experienced an OASIACO. A forceps birth (p = 0.03) or more severe grade of tear (p = 0.03) was predictive of OASIACO. One hundred one women had further children, with 48% reporting their delivery choices were impacted, 32% electing a cesarean delivery and 26% shifting to private care. Eighty women (40%) had not given birth again, and 29 (36%) of these indicated their OASI influenced this decision.

Conclusions

The total impact of an OASI on women affected is substantial. More than half experience ongoing symptoms and close to half report an impact on their future birth choices. It follows there would be a consequential load on the healthcare sector, and improved management and prevention programs should be implemented.

Electronic supplementary material

The online version of this article (10.1007/s00192-019-04108-3) contains supplementary material, which is available to authorized users.

Have public hospitals outlived their usefulness? Is it possible to assess with health care parameters the impact of public hospitals on major American cities?

BACKGROUND

Short-term acute care public county hospitals in the US were a mainstay of much "safety net" medical care in the early twentieth century. The private sector currently provides much of what was in the past public medical care. Does this transition affect health care indices?

METHODS

The presence of public hospitals was determined for the 50 largest metropolitan areas using the American Hospital Directory databases. Health care indices assessed included birth rate, death rate, infant mortality, the American Fitness Index, and a derived Composite Health Index. Co-variables included size of population and geographic location. Data were compiled in 2017, using databases between 2006 and 2017.

RESULTS

Over half (56%) the largest fifty metropolitan areas in the US still have acute care public hospitals, less often in the East. Birth rates were higher (Kruskal-Wallis, P = 0.02) and death rates lower (KW, P = 0.03) in metropolitan areas with such public hospitals, infant mortality (P = 0.09), the AFI (P = 0.73) and the Composite Health Index (P = 0.64) did not differ by their presence. With a multivariable analysis, geographic area most affected the Composite Health Index.

CONCLUSION

By this model, health care indices do not differ by the presence of an acute care, publically funded and administered governmental hospital and the future of acute-care public hospitals in their traditional format is in doubt.

Creating the first national linked dataset on perinatal and maternal outcomes in Australia: Methods and challenges

BACKGROUND

Data linkage offers a powerful mechanism for examining healthcare outcomes across populations and can generate substantial robust datasets using routinely collected electronic data. However, it presents methodological challenges, especially in Australia where eight separate states and territories maintain health datasets. This study used linked data to investigate perinatal and maternal outcomes in relation to place of birth. It examined data from all eight jurisdictions regarding births planned in hospitals, birth centres and at home. Data linkage enabled the first Australia-wide dataset on birth outcomes. However, jurisdictional differences in data collection created challenges in obtaining comparable cohorts of women with similar low-risk pregnancies in all birth settings. The objective of this paper is to describe the techniques for managing previously linked data, and specifically for ensuring the resulting dataset contained only low-risk pregnancies.

METHODS

This paper indicates the procedures for preparing and merging linked perinatal, inpatient and mortality data from different sources, providing technical guidance to address challenges arising in linked data study designs.

RESULTS

We combined data from eight jurisdictions linking four collections of administrative healthcare and civil registration data. The merging process ensured that variables were consistent, compatible and relevant to study aims. To generate comparable cohorts for all three birth settings, we developed increasingly complex strategies to ensure that the dataset eliminated women with pregnancies at risk of complications during labour and birth. It was then possible to compare birth outcomes for comparable samples, enabling specific examination of the impact of birth setting on maternal and infant safety across Australia.

CONCLUSIONS

Data linkage is a valuable resource to enhance knowledge about birth outcomes from different settings, notwithstanding methodological challenges. Researchers can develop and share practical techniques to address these challenges. Study findings suggest that jurisdictions develop more consistent data collections to facilitate future data linkage.

The effect of medical and operative birth interventions on child health outcomes in the first 28 days and up to 5 years of age: A linked data population-based cohort study

BACKGROUND

Spontaneous vaginal birth rates are decreasing worldwide, while cesarean delivery, instrumental births, and medical birth interventions are increasing. Emerging evidence suggests that birth interventions may have an effect on children's health. Therefore, the aim of our study was to examine the association between operative and medical birth interventions on the child's health during the first 28 days and up to 5 years of age.

METHODS

In New South Wales (Australia), population-linked data sets were analyzed, including data on maternal characteristics, child characteristics, mode of birth, interventions during labor and birth, and adverse health outcomes of the children (ie, jaundice, feeding problems, hypothermia, asthma, respiratory infections, gastrointestinal disorders, other infections, metabolic disorder, and eczema) registered with the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification codes. Logistic regression analyses were performed for each adverse health outcome.

RESULTS

Our analyses included 491 590 women and their children; of those 38% experienced a spontaneous vaginal birth. Infants who experienced an instrumental birth after induction or augmentation had the highest risk of jaundice, adjusted odds ratio (aOR) 2.75 (95% confidence interval [CI] 2.61-2.91) compared with spontaneous vaginal birth. Children born by cesarean delivery were particularly at statistically significantly increased risk for infections, eczema, and metabolic disorder, compared with spontaneous vaginal birth. Children born by emergency cesarean delivery showed the highest association for metabolic disorder, aOR 2.63 (95% CI 2.26-3.07).

CONCLUSION

Children born by spontaneous vaginal birth had fewer short- and longer-term health problems, compared with those born after birth interventions.

The influence of mode of delivery on neonatal and maternal short and long-term outcomes

OBJECTIVE

To evaluate the impact of mode of delivery on breastfeeding incentive practices and on neonatal and maternal short and long-term complications.

METHODS

A cohort study was conducted between June 2015 and April 2016 with 768 puerperal women from 11 maternities in Sergipe, interviewed in the first 24 hours, 45-60 days and 6-8 months after delivery. Associations between breastfeeding incentive practices, neonatal and maternal, both short-term and late complications, and the exposure variables were evaluated by the relative risk (95%CI) and the Fisher exact test.

RESULTS

The C-section newborns had less skin-to-skin contact immediately after delivery (intrapartum C-section: 0.18, 95%CI 0.1-0.31 and elective C-section: 0.36, 95%CI 0.27-0.47) and less breastfeeding within one hour of birth (intrapartum C-section: 0.43, 95%CI 0.29-0.63 and elective C-section: 0.44, 95%CI 0.33-0.59). Newborns from elective C-section were less frequently breastfed in the delivery room 0.42 (95%CI 0.2-0.88) and roomed-in less 0.85 (95%CI 0.77-0.95). Women submitted to intrapartum C-section had greater risk of early complications 1.3 (95%CI 1.04-1.64, p = 0.037) and sexual dysfunction 1.68 (95%CI 1.14-2.48, p = 0.027). The frequency of neonatal complications, urinary incontinence and depression according to the mode of delivery was similar.

CONCLUSIONS

The C-section was negatively associated with breastfeeding incentive practices; in addition, C-section after labor increased the risk of early maternal complications and sexual dysfunction.

Factors promoting or inhibiting normal birth

BACKGROUND

In response to rising rates of medical intervention in birth, there has been increased international interest in promoting normal birth (without induction of labour, epidural/spinal/general anaesthesia, episiotomy, forceps/vacuum, or caesarean section). However, there is limited evidence for how best to achieve increased rates of normal birth. In this study we examined the role of modifiable and non-modifiable factors in experiencing a normal birth using retrospective, self-reported data.

METHODS

Women who gave birth over a four-month period in Queensland, Australia, were invited to complete a questionnaire about their preferences for and experiences of pregnancy, labour, birth, and postnatal care. Responses (N = 5840) were analysed using multiple logistic regression models to identify associations with four aspects of normal birth: onset of labour, use of anaesthesia, mode of birth, and use of episiotomy. The probability of normal birth was then estimated by combining these models.

RESULTS

Overall, 28.7% of women experienced a normal birth. Probability of a normal birth was reduced for women who were primiparous, had a history of caesarean, had a multiple pregnancy, were older, had a more advanced gestational age, experienced pregnancy-related health conditions (gestational diabetes, low-lying placenta, high blood pressure), had continuous electronic fetal monitoring during labour, and knew only some of their care providers for labour and birth. Women had a higher probability of normal birth if they lived outside major metropolitan areas, did not receive private obstetric care, had freedom of movement throughout labour, received continuity of care in labour and birth, did not have an augmented labour, or gave birth in a non-supine position.

CONCLUSIONS

Our findings highlight several relevant modifiable factors including mobility, monitoring, and care provision during labour and birth, for increasing normal birth opportunity. An important step forward in promoting normal birth is increasing awareness of such relationships through patient involvement in informed decision-making and implementation of this evidence in care guidelines.

Practices and obstetric interventions in women from a state in the Northeast of Brazil

OBJECTIVE

To describe practices and interventions used during labor and childbirth and factors associated with such practices in puerperae in the state of Sergipe.

METHOD

A cross-sectional study with 768 postpartum women from 11 maternity hospitals interviewed 6 hours after delivery, and hospital records review. The associations between best practices and interventions used during labor and delivery with exposure variables were described using simple frequencies, percentages, crude and adjusted odds ratio (ORa) with the confidence interval.

RESULTS

Of the women in the study, 10.6% received food and 27.8% moved during labor; non-pharmacological methods for pain relief were performed in 26.1%; a partogram was filled in 39.4% of the charts; and an accompanying person was present in 40.6% of deliveries. Oxytocin, amniotomy and labor analgesia were used in 59.1%, 49.3% and 4.2% of women, respectively. Lithotomy position during childbirth was used in 95.2% of the cases, episiotomy in 43.9% and Kristeller maneuver in 31.7%. The variables most associated with cesarean section were private financing (ORa=4.27, 95CI 2.44-7.47), higher levels of education (ORa=4.54, 95CI 2.56-8.3) and high obstetric risk (ORa=1.9, 95CI 1.31-2.74). Women whose delivery was funded privately were more likely to have an accompanying person present (ORa=2.12, 95CI 1.18-3.79) and to undergo labor analgesia (ORa=4.96, 95CI 1.7-14.5).

CONCLUSION

Best practices are poorly performed and unnecessary interventions are frequent. The factors most associated with c-section were private funding, greater length of education and high obstetric risk.

Gastro-oesophageal reflux: a mixed methods study of infants admitted to hospital in the first 12 months following birth in NSW (2000-2011)

BACKGROUND

Gastro-oesophageal reflux (GOR) is common in infants. When the condition causes pathological symptoms and/or complications it is considered gastro-oesophageal reflux disease (GORD). It appears to be increasingly diagnosed and causes great distress in the first year of infancy. In New South Wales (NSW), residential parenting services support families with early parenting difficulties. These services report a large number of babies admitted with a label of GOR/GORD. The aim of this study was to explore the maternal and infant characteristics, obstetric interventions, and reasons for clinical reporting of GOR/GORD in NSW in the first 12 months following birth (2000-2011).

METHODS

A three phase, mixed method sequential design was used. Phase 1 included a linked data population based study (n = 869,188 admitted babies). Phase 2 included a random audit of 326 medical records from admissions to residential parenting centres in NSW (2013). Phase 3 included eight focus groups undertaken with 45 nurses and doctors working in residential parenting centres in NSW.

RESULTS

There were a total of 1,156,020 admissions recorded of babies in the first year following birth, with 11,513 containing a diagnostic code for GOR/GORD (1% of infants admitted to hospitals in the first 12 months following birth). Babies with GOR/GORD were also more likely to be admitted with other disorders such as feeding difficulties, sleep problems, and excessive crying. The mothers of babies admitted with a diagnostic code of GOR/GORD were more likely to be primiparous, Australian born, give birth in a private hospital and have: a psychiatric condition; a preterm or early term infant (37-or-38 weeks); a caesarean section; an admission of the baby to SCN/NICU; and a male infant. Thirty six percent of infants admitted to residential parenting centres in NSW had been given a diagnosis of GOR/GORD. Focus group data revealed two themes: "It is over diagnosed" and "A medical label is a quick fix, but what else could be going on?"

CONCLUSIONS

Mothers with a mental health disorder are nearly five times as likely to have a baby admitted with GOR/GORD in the first year after birth. We propose a new way of approaching the GOR/GORD issue that considers the impact of early birth (immaturity), disturbance of the microbiome (caesarean section) and mental health (maternal anxiety in particular).

Factors influencing midwives' use of an evidenced based Normal Birth Guideline

Problem or issue

Rates of elective and unplanned caesarean section continue to increase in high income countries. Evidence-based clinical guidelines aim to promote and support normal birth but are rarely evaluated.

What is already known

The Queensland Normal Birth Guideline was developed in consultation with stakeholders and disseminated to public and private hospitals and released in 2012. Impact of the Guideline on practice has not been investigated.

What this paper adds

Although most midwives (90%) were aware of the guideline, only 71% reported that it routinely guided practice.

Teaching University Students About Evidence-Based Perinatal Care: Effects on Learning and Future Care Preferences

U.S. university students hold generally medicalized views on childbirth, which contrast with evidence indicating that low-intervention birth is safest for most. Therefore, intentional efforts are needed to educate childbearing populations on perinatal care evidence. Toward that aim, this study involved teaching university students in an introductory class (N = 50) about evidence-based perinatal care. Students completed a "future birth plan" and an essay on how their learning affected care preferences. Analyses revealed that students selected evidence-based care components up to 100 times more frequently than what the national data indicate they are used. Students based care selections on evidence, costs, and personal views. Their interest in physiologic birth has important implications for advancing education on perinatal care, practice, and policy.

Labor and birth care by nurse with midwifery skills in Brazil

BACKGROUND

The participation of nurses and midwives in vaginal birth care is limited in Brazil, and there are no national data regarding their involvement. The goal was to describe the participation of nurses and nurse-midwives in childbirth care in Brazil in the years 2011 and 2012, and to analyze the association between hospitals with nurses and nurse-midwives in labor and birth care and the use of good practices, and their influence in the reduction of unnecessary interventions, including cesarean sections.

METHODS

Birth in Brazil is a national, population-based study consisting of 23,894 postpartum women, carried out in the period between February 2011 and October 2012, in 266 healthcare settings. The study included all vaginal births involving physicians or nurses/nurse-midwives. A logistic regression model was used to examine the association between the implementation of good practices and suitable interventions during labor and birth, and whether care was a physician or a nurse/nurse-midwife led care. We developed another model to assess the association between the use of obstetric interventions during labor and birth to the personnel responsible for the care of the patient, comparing hospitals with decisions revolving exclusively around a physician to those that also included nurses/nurse-midwives as responsible for vaginal births.

RESULTS

16.2 % of vaginal births were assisted by a nurse/nurse-midwife. Good practices were significantly more frequent in those births assisted by nurses/nurse-midwives (ad lib. diet, mobility during labor, non-pharmacological means of pain relief, and use of a partograph), while some interventions were less frequently used (anesthesia, lithotomy position, uterine fundal pressure and episiotomy). In maternity wards that included a nurse/nurse-midwife in labour and birth care, the incidence of cesarean section was lower.

CONCLUSIONS

The results of this study illustrate the potential benefit of collaborative work between physicians and nurses/nurse-midwives in labor and birth care. The adoption of good practices in managing labor and birth could be the first step toward more effective obstetric and midwifery care in Brazil. It may be easier to introduce new approaches rather than to eliminate old ones, which may explain why the reduction of unnecessary interventions during labor and birth was less pronounced than the adoption of new practices.

Midwifery-led antenatal care models: mapping a systematic review to an evidence-based quality framework to identify key components and characteristics of care

BACKGROUND

Implementing effective antenatal care models is a key global policy goal. However, the mechanisms of action of these multi-faceted models that would allow widespread implementation are seldom examined and poorly understood. In existing care model analyses there is little distinction between what is done, how it is done, and who does it. A new evidence-informed quality maternal and newborn care (QMNC) framework identifies key characteristics of quality care. This offers the opportunity to identify systematically the characteristics of care delivery that may be generalizable across contexts, thereby enhancing implementation. Our objective was to map the characteristics of antenatal care models tested in Randomised Controlled Trials (RCTs) to a new evidence-based framework for quality maternal and newborn care; thus facilitating the identification of characteristics of effective care.

METHODS

A systematic review of RCTs of midwifery-led antenatal care models. Mapping and evaluation of these models' characteristics to the QMNC framework using data extraction and scoring forms derived from the five framework components. Paired team members independently extracted data and conducted quality assessment using the QMNC framework and standard RCT criteria.

RESULTS

From 13,050 citations initially retrieved we identified 17 RCTs of midwifery-led antenatal care models from Australia (7), the UK (4), China (2), and Sweden, Ireland, Mexico and Canada (1 each). QMNC framework scores ranged from 9 to 25 (possible range 0-32), with most models reporting fewer than half the characteristics associated with quality maternity care. Description of care model characteristics was lacking in many studies, but was better reported for the intervention arms. Organisation of care was the best-described component. Underlying values and philosophy of care were poorly reported.

CONCLUSIONS

The QMNC framework facilitates assessment of the characteristics of antenatal care models. It is vital to understand all the characteristics of multi-faceted interventions such as care models; not only what is done but why it is done, by whom, and how this differed from the standard care package. By applying the QMNC framework we have established a foundation for future reports of intervention studies so that the characteristics of individual models can be evaluated, and the impact of any differences appraised.

Estimation of country-specific and global prevalence of male circumcision

BACKGROUND

Male circumcision (MC) status and genital infection risk are interlinked and MC is now part of HIV prevention programs worldwide. Current MC prevalence is not known for all countries globally. Our aim was to provide estimates for country-specific and global MC prevalence.

METHODS

MC prevalence data were obtained by searches in PubMed, Demographic and Health Surveys, AIDS Indicator Surveys, and Behavioural Surveillance Surveys. Male age was ≥15 years in most surveys. Where no data were available, the population proportion whose religious faith or culture requires MC was used. The total number of circumcised males in each country and territory was calculated using figures for total males from (i) 2015 US Central Intelligence Agency (CIA) data for sex ratio and total population in all 237 countries and territories globally and (ii) 2015 United Nations (UN) figures for males aged 15-64 years.

RESULTS

The estimated percentage of circumcised males in each country and territory varies considerably. Based on (i) and (ii) above, global MC prevalence was 38.7 % (95 % confidence interval [CI]: 33.4, 43.9) and 36.7 % (95 % CI: 31.4, 42.0). Approximately half of circumcisions were for religious and cultural reasons. For countries lacking data we assumed 99.9 % of Muslims and Jews were circumcised. If actual prevalence in religious groups was lower, then MC prevalence in those countries would be lower. On the other hand, we assumed a minimum prevalence of 0.1 % related to MC for medical reasons. This may be too low, thereby underestimating MC prevalence in some countries.

CONCLUSIONS

The present study provides the most accurate estimate to date of MC prevalence in each country and territory in the world. We estimate that 37-39 % of men globally are circumcised. Considering the health benefits of MC, these data may help guide efforts aimed at the use of voluntary, safe medical MC in disease prevention programs in various countries.

Childbirth and consequent atopic disease: emerging evidence on epigenetic effects based on the hygiene and EPIIC hypotheses

BACKGROUND

In most high and middle income countries across the world, at least 1:4 women give birth by cesarean section. Rates of labour induction and augmentation are rising steeply; and in some countries up to 50% of laboring women and newborns are given antibiotics. Governments and international agencies are increasingly concerned about the clinical, economic and psychosocial effects of these interventions.

DISCUSSION

There is emerging evidence that certain intrapartum and early neonatal interventions might affect the neonatal immune response in the longer term, and perhaps trans-generationally. Two theories lead the debate in this area. Those aligned with the hygiene (or 'Old Friends') hypothesis have examined the effect of gut microbiome colonization secondary to mode of birth and intrapartum/neonatal pharmacological interventions on immune response and epigenetic phenomena. Those working with the EPIIC (Epigenetic Impact of Childbirth) hypothesis are concerned with the effects of eustress and dys-stress on the epigenome, secondary to mode of birth and labour interventions. This paper examines the current and emerging findings relating to childbirth and atopic/autoimmune disease from the perspective of both theories, and proposes an alliance of research effort. This is likely to accelerate the discovery of important findings arising from both approaches, and to maximize the timely understanding of the longer-term consequences of childbirth practices.

Obstetric and psychosocial risk factors for Australian-born and non-Australian born women and associated pregnancy and birth outcomes: a population based cohort study

BACKGROUND

One in four Australians is born overseas and 47% are either born overseas or have a parent who was. Obstetric and psychosocial risk factors for these women may differ.

METHOD

Data from one Sydney hospital (2012-2013) of all births recorded in the ObstetriX database were analysed (n = 3,092). Demographics, obstetric and psychosocial risk profile, obstetric interventions and complications and selected maternal and neonatal outcomes were examined for women born in Australia and overseas.

RESULTS

Women born in Australia were younger, more likely to be primiparous (28.6 v 27.5%), be obese (32.0% v 21.4%), smoke (19.7 % v 3.0%), have an epidural (26.2% v 20.2%) and were less likely to have gestational diabetes mellitus (GDM) (6.8% v 13.7% when compared to non-Australian born women. The highest rates of GDM, Gestational Hypertension (GH) and maternal anaemia were seen in women born in China, the Philippines and Pakistan respectively. Differences were also seen in psychosocial screening between Australian and non-Australian women with Australian-born women more likely to smoke and report a mental health disorder. There was an association between having an Edinburgh Postnatal Depression Scale (EPDS) ≥ 13 and other psychosocial issues, such as thoughts of self-harm, domestic violence, childhood abuse etc. These women were also less likely to breastfeed. Women with an EPDS ≥ 13 at booking compared to women with EPDS ≤12 had a higher chance of being diagnosed with GDM (AOR 1.85 95% CI 1.14-3.0).

CONCLUSIONS

There are significant differences in obstetric and psychosocial risk profiles and maternal and neonatal outcomes between Australian-born and non-Australian born women. In particular there appears to be an association between an EPDS of ≥13 and developing GDM, which warrants further investigation.

The impact of obstetric mode of delivery on childhood behavior

PURPOSE

We investigated the hypothesis that mode of delivery affects childhood behavior and motor development and examined whether there are sex-specific associations, i.e., whether males and females have different risk estimates.

METHODS

Families with infants born between December 2007 and May 2008 (N = 11,134) were randomly selected and recruited to the Growing Up in Ireland study. Mode of delivery was classified into spontaneous vaginal delivery; instrumental vaginal delivery; emergency Cesarean section (CS); and elective CS. The 'Ages and Stages Questionnaire' was completed at age 9-months and the 'Strengths and Difficulties Questionnaire' at 3 years. Data were weighted to represent the national sample (N = 73,662) and multivariate logistic regression was used for the statistical analyses.

RESULTS

At age 9 months, elective CS was associated with a delay in personal social skills [adjusted odds ratio, aOR 1.24; (95% confidence interval, CI 1.04, 1.48)] and gross motor function [aOR 1.62, (95% CI 1.34, 1.96)], whereas emergency CS was associated with delayed gross motor function [aOR 1.30, (95% CI 1.06, 1.59)]. At age 3 years there was no significantly increased risk of an abnormal total SDQ score across all modes of delivery.

CONCLUSIONS

Children born by elective CS may face a delay in cognitive and motor development at age 9 months. No increase in total SDQ score was found across all modes of delivery. Further investigation is needed to replicate these findings in other populations and explore the potential biological mechanisms.

Back to normal: A retrospective, cross-sectional study of the multi-factorial determinants of normal birth in Queensland, Australia

BACKGROUND

currently, care providers and policy-makers internationally are working to promote normal birth. In Australia, such initiatives are being implemented without any evidence of the prevalence or determinants of normal birth as a multidimensional construct. This study aimed to better understand the determinants of normal birth (defined as without induction of labour, epidural/spinal/general anaesthesia, forceps/vacuum, caesarean birth, or episiotomy) using secondary analyses of data from a population survey of women in Queensland, Australia.

METHODS

women who birthed in Queensland during a two-week period in 2009 were mailed a survey approximately three months after birth. Women (n=772) provided retrospective data on their pregnancy, labour and birth preferences and experiences, socio-demographic characteristics, and reproductive history. A series of logistic regressions were conducted to determine factors associated with having labour, having a vaginal birth, and having a normal birth.

FINDINGS

overall, 81.9% of women had labour, 66.4% had a vaginal birth, and 29.6% had a normal birth. After adjusting for other significant factors, women had significantly higher odds of having labour if they birthed in a public hospital and had a pre-existing preference for a vaginal birth. Of women who had labour, 80.8% had a vaginal birth. Women who had labour had significantly higher odds of having a vaginal birth if they attended antenatal classes, did not have continuous fetal monitoring, felt able to 'take their time' in labour, and had a pre-existing preference for a vaginal birth. Of women who had a vaginal birth, 44.7% had a normal birth. Women who had a vaginal birth had significantly higher odds of having a normal birth if they birthed in a public hospital, birthed outside regular business hours, had mobility in labour, did not have continuous fetal monitoring, and were non-supine during birth.

CONCLUSIONS

these findings provide a strong foundation on which to base resources aimed at increasing informed decision-making for maternity care consumers, providers, and policy-makers alike. Research to evaluate the impact of modifying key clinical practices (e.g., supporting women׳s mobility during labour, facilitating non-supine positioning during birth) on the likelihood of a normal birth is an important next step.

Cultural differences in postnatal quality of life among German-speaking women - a prospective survey in two countries

BACKGROUND

Assessment of quality of life after childbirth is an important health-outcome measurement for new mothers and is of special interest in midwifery. The Mother-Generated Index (MGI) is a validated instrument to assess postnatal quality of life. The tool has not been applied for making a cross-cultural comparison before. This study investigated (a) responses to the MGI in German-speaking women in Germany and Switzerland; and (b) associations between MGI scores on the one hand and maternity and midwifery care on the other.

METHODS

A two-stage survey was conducted in two rural hospitals 10 km apart, on opposite sides of the German-Swiss border. The questionnaires included the MGI and questions on socio-demographics, physical and mental health and maternity care, and were distributed during the first days after birth and six weeks postpartum. Parametric and non-parametric tests were computed with the statistical programme SPSS.

RESULTS

A total of 129 questionnaires were returned an average of three days after birth and 83 in the follow-up after seven weeks. There were no statistically significant differences in the MGI scores between the German and the Swiss women (p = 0.22). Significantly more favourable MGI scores were found associated with more adequate information during pregnancy (p = 0.02), a more satisfactory birth experience (p < .01), epidural anaesthesia (p < 0.01), more information (p = 0.01) and better support (p = 0.02) during the time in hospital and less disturbed sleep (p < 0.01). Significantly lower MGI scores were associated with the presence of a private doctor during birth (p = 0.01) and with exclusive breastfeeding during the first postnatal days (p = 0.04).

CONCLUSION

The MGI scores of these German-speaking women were higher than those in other studies reported previously. Thus the tool may be able to detect differences in postnatal quality of life among women with substantially divergent cultural backgrounds. Shortcomings in maternity and midwifery care were detected, as for example the inadequate provision of information during pregnancy, a lack of individualised postpartum care during the hospital stay and insufficient support for exclusively breastfeeding mothers. The MGI is an appropriate instrument for maternity care outcome measurement in cross-cultural comparison research.