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Torres JA, Leite TH, Fonseca TCO, Domingues RMSM, Figueiró AC, Pereira APE, Theme-Filha MM, da Silva Ayres BV, Scott O, de Cássia Sanchez R, Borem P, de Maio Osti MC, Rosa MW, Andrade AS, Filho FMP, Nakamura-Pereira M, do Carmo Leal M. An implementation analysis of a quality improvement project to reduce cesarean section in Brazilian private hospitals. Reprod Health 2024; 20:190. [PMID: 38671479 PMCID: PMC11052714 DOI: 10.1186/s12978-024-01773-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 03/11/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND Brazil has one of the highest prevalence of cesarean sections in the world. The private health system is responsible for carrying out most of these surgical procedures. A quality improvement project called Adequate Childbirth Project ("Projeto Parto Adequado"- PPA) was developed to identify models of care for labor and childbirth, which place value on vaginal birth and reduce the frequency of cesarean sections without a clinical indication. This research aims to evaluate the implementation of PPA in private hospitals in Brazil. METHOD Evaluative hospital-based survey, carried out in 2017, in 12 private hospitals, including 4,322 women. We used a Bayesian network strategy to develop a theoretical model for implementation analysis. We estimated and compared the degree of implementation of two major driving components of PPA-"Participation of women" and "Reorganization of care" - among the 12 hospitals and according to type of hospital (belonging to a health insurance company or not). To assess whether the degree of implementation was correlated with the rate of vaginal birth data we used the Bayesian Network and compared the difference between the group "Exposed to the PPA model of care" and the group "Standard of care model". RESULTS PPA had a low degree of implementation in both components "Reorganization of Care" (0.17 - 0.32) and "Participation of Women" (0.21 - 0.34). The combined implementation score was 0.39-0.64 and was higher in hospitals that belonged to a health insurance company. The vaginal birth rate was higher in hospitals with a higher degree of implementation of PPA. CONCLUSION The degree of implementation of PPA was low, which reflects the difficulties in changing childbirth care practices. Nevertheless, PPA increased vaginal birth rates in private hospitals with higher implementation scores. PPA is an ongoing quality improvement project and these results demonstrate the need for changes in the involvement of women and the care offered by the provider.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Paulo Borem
- Institute for Healthcare Improvement, Brasília, Brazil
| | | | | | | | - Fernando Maia Peixoto Filho
- Oswaldo Cruz Foundation, National Institute of Health for Women, Children and Adolescents Fernandes Figueira, Rio de Janeiro, Brazil
| | - Marcos Nakamura-Pereira
- Oswaldo Cruz Foundation, National Institute of Health for Women, Children and Adolescents Fernandes Figueira, Rio de Janeiro, Brazil
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Węgrzynowska M, Nenko I, Raczkiewicz D, Baranowska B. Investment in the peace of mind? How private services change the landscape of maternity care in Poland. Soc Sci Med 2023; 337:116283. [PMID: 37857238 DOI: 10.1016/j.socscimed.2023.116283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 08/23/2023] [Accepted: 09/26/2023] [Indexed: 10/21/2023]
Abstract
For over two decades midwifery research advocated for the continuity of care and the ability to establish a relationship between care providers and care users as an important features of quality maternity services. In many countries, while unavailable through public services, continuity of care became commercialized and can be access as a private service. In Poland, private prenatal consultations and dedicated midwifery care allow women to access continuity and establish personal relationships with care providers. In this study, we explore, how accessing these private services, impact the rates of medical interventions and type of care women receive during labour and birth. We analyse data collected through an online questionnaire from 4402 first-time mothers in healthy pregnancy who had given birth in Poland between 2020 and 2021. We show that while private consultation did not translate into any significant differences in care, women who accessed private dedicated midwifery services experienced more attentive and less medicalized care, namely were more likely to give birth in vertical position, move freely during labour and less likely to experience emergency caesarean section. However, private dedicated midwifery care did not shield them from negative experience. While private care offers benefits for women who can afford it, it also contributes to inequalities in access to quality care and puts women with less social and financial resources in a vulnerable position. Efforts should be made to develop a more universal and equitable model of care that allows for building personal relationships between maternity care providers and women.
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Affiliation(s)
- Maria Węgrzynowska
- Department of Midwifery, Centre of Postgraduate Medical Education, Warsaw, Poland.
| | - Ilona Nenko
- Department of Environmental Health, Faculty of Health Sciences, Jagiellonian University Medical College, Krakow, Poland.
| | - Dorota Raczkiewicz
- Department of Medical Statistics, Centre of Postgraduate Medical Education, Warsaw, Poland.
| | - Barbara Baranowska
- Department of Midwifery, Centre of Postgraduate Medical Education, Warsaw, Poland.
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Cesar JA, Marmitt LP, Mendoza-Sassi RA. Episiotomy in Southern Brazil: prevalence, trend, and associated factors. Rev Saude Publica 2022; 56:26. [PMID: 35476104 PMCID: PMC9004702 DOI: 10.11606/s1518-8787.2022056003908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 08/24/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To identify and analyze the prevalence, trend, and factors associated with episiotomy in Rio Grande, in the state of Rio Grande do Sul, Southern Brazil. METHODS A single, standardized questionnaire was applied to all pregnant women, residents in the municipality of Rio Grande, who had children in local hospitals between January 1 and December 12 of the years 2007, 2010, 2013, 2016 e 2019. Demographic and socioeconomic characteristics were investigated, as well as the assistance received during pregnancy and delivery. Chi-square test was used to compare proportions and Poisson regression with robust variance adjustment was used for multivariable analysis. Prevalence ratio (PR) was used as effect measure. RESULTS Among the 12,645 births that occurred in the five years, 5,714 (45.2%) were vaginal delivery. Of these mothers, 2,930 (51.3%; 95%CI: 50.0%–52.6%) underwent episiotomy. Over this period, the episiotomy rate decreased from 70.9% (68.4–73.5) in 2007 to 19.4% (17.1–21.7) in 2019. Adjusted analysis showed a high PR of episiotomy occurrence among women who were young (PR = 2.23; 95%CI: 1.89–2.63), had higher education (PR = 1.21; 95%Cl: 1.03–1.42), had a higher family income (PR = 1.25; 95%CI: 1.10–1.41), were primiparous (PR = 3.41; 95%CI: 2.95–3.95), had prenatal care in the private sector (PR = 1.25; 95%CI: 1.07–1.46), had oxytocin-induced labor (PR = 1.18; 95%CI:1.09–1.27), underwent forceps (PR = 1.32; 95%CI: 1.16–1.50), and whose newborn weighed 4,000 g or more (PR = 1.43; 95%CI: 1.14–1.80). CONCLUSION Although the prevalence of episiotomy fell sharply within the studied period, its occurrence is more likely among women at lower risk of birth complications.
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Affiliation(s)
- Juraci A Cesar
- Universidade Federal do Rio Grande. Faculdade de Medicina. Programa de Pós-graduação em Saúde Pública. Rio Grande, RS, Brasil
| | - Luana P Marmitt
- Universidade do Oeste de Santa Catarina. Programa de Pós-Graduação em Biociências e Saúde. Flor da Serra, SC, Brasil
| | - Raúl A Mendoza-Sassi
- Universidade Federal do Rio Grande. Faculdade de Medicina. Programa de Pós-graduação em Saúde Pública. Rio Grande, RS, Brasil
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Zakiyah N, Tuytten R, Baker PN, Kenny LC, Postma MJ, van Asselt ADI. Early cost-effectiveness analysis of screening for preeclampsia in nulliparous women: A modelling approach in European high-income settings. PLoS One 2022; 17:e0267313. [PMID: 35446907 PMCID: PMC9022877 DOI: 10.1371/journal.pone.0267313] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 04/06/2022] [Indexed: 11/18/2022] Open
Abstract
Background Preeclampsia causes substantial maternal and perinatal morbidity and mortality and significant societal economic impact. Effective screening would facilitate timely and appropriate prevention and management of preeclampsia. Objectives To develop an early cost-effectiveness analysis to assess both costs and health outcomes of a new screening test for preeclampsia from a healthcare payer perspective, in the United Kingdom (UK), Ireland, the Netherlands and Sweden. Methods A decision tree over a 9-month time horizon was developed to explore the cost-effectiveness of the new screening test for preeclampsia compared to the current screening strategy. The new test strategy is being developed so that it can stratify healthy low risk nulliparous women early in pregnancy to either a high-risk group with a risk of 1 in 6 or more of developing preeclampsia, or a low-risk group with a risk of 1 in 100 or less. The model simulated 25 plausible scenarios in a hypothetical cohort of 100,000 pregnant women, in which the sensitivity and specificity of the new test were varied to set a benchmark for the minimum test performance that is needed for the test to become cost-effective. The input parameters and costs were mainly derived from published literature. The main outcome was incremental costs per preeclampsia case averted, expressed as an incremental cost-effectiveness ratio (ICER). Deterministic and probabilistic sensitivity analyses were conducted to assess uncertainty. Results Base case results showed that the new test strategy would be more effective and less costly compared to the current situation in the UK. In the Netherlands, the majority of scenarios would be cost-effective from a threshold of €50,000 per preeclampsia case averted, while in Ireland and Sweden, the vast majority of scenarios would be considered cost-effective only when a threshold of €100,000 was used. In the best case analyses, ICERs were more favourable in all four participating countries. Aspirin effectiveness, prevalence of preeclampsia, accuracy of the new screening test and cost of regular antenatal care were identified as driving factors for the cost-effectiveness of screening for preeclampsia. Conclusion The results indicate that the new screening test for preeclampsia has potential to be cost-effective. Further studies based on proven accuracy of the test will confirm whether the new screening test is a cost-effective additional option to the current situation.
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Affiliation(s)
- Neily Zakiyah
- Unit of PharmacoTherapy, Epidemiology & Economics (PTE2), Department of Pharmacy, University of Groningen, Groningen, The Netherlands
- Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Universitas Padjadjaran, Bandung, Indonesia
- Center of Excellence in Higher Education for Pharmaceutical Care Innovation, Universitas Padjadjaran, Bandung, Indonesia
- * E-mail:
| | - Robin Tuytten
- Research & Development, Metabolomic Diagnostics, Little Island, Ireland
| | - Philip N. Baker
- College of Life Sciences, University of Leicester, Leicester, United Kingdom
| | - Louise C. Kenny
- Department of Women’s and Children’s Health, the Faculty of Health and Life Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Maarten J. Postma
- Unit of PharmacoTherapy, Epidemiology & Economics (PTE2), Department of Pharmacy, University of Groningen, Groningen, The Netherlands
- Center of Excellence in Higher Education for Pharmaceutical Care Innovation, Universitas Padjadjaran, Bandung, Indonesia
- Unit of Global Health, Department of Health Sciences, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Department of Economics, Econometrics & Finance, Faculty of Economics & Business, University of Groningen, Groningen, The Netherlands
| | - Antoinette D. I. van Asselt
- Unit of PharmacoTherapy, Epidemiology & Economics (PTE2), Department of Pharmacy, University of Groningen, Groningen, The Netherlands
- Unit of Global Health, Department of Health Sciences, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Unit of Patient Centered Health Technology Assessment, Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Yu S, Fiebig DG, Viney R, Scarf V, Homer C. Private provider incentives in health care: The case of caesarean births. Soc Sci Med 2022; 294:114729. [DOI: 10.1016/j.socscimed.2022.114729] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 01/10/2022] [Accepted: 01/14/2022] [Indexed: 11/29/2022]
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Milcent C, Zbiri S. Supplementary private health insurance: The impact of physician financial incentives on medical practice. HEALTH ECONOMICS 2022; 31:57-72. [PMID: 34636088 DOI: 10.1002/hec.4443] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 09/17/2021] [Accepted: 09/28/2021] [Indexed: 06/13/2023]
Abstract
In the French diagnosis-related group (DRG)-based payment system, both private and public hospitals are financed by a public single payer. Public hospitals are overcrowded and have no direct financial incentives to choose one procedure over another. If a patient has a strong preference, they can switch to a private hospital. In private hospitals, the preference does come into play, but the patient has to pay for the additional cost, for which they are reimbursed if they have supplementary private health insurance. Do financial incentives from the fees received by physicians for different procedures drive their behavior? Using French exhaustive data on delivery, we find that private hospitals perform significantly more cesarean deliveries than public hospitals. However, for patients without private health insurance, the two sectors differ much less in terms of cesareans rate. We determine the impact of the financial incentive for patients who can afford the additional cost. Affordability is mainly ensured by the reimbursement of costs by private health insurance. These findings can be interpreted as evidence that, in healthcare systems where a public single payer offers universal coverage, the presence of supplementary private insurance can contribute to creating incentives on the supply side and lead to practices and an allocation of resources that are not optimal from a social welfare perspective.
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Affiliation(s)
- Carine Milcent
- Paris-Jourdan Sciences Economiques, French National Center for Scientific Research, Paris, France
| | - Saad Zbiri
- EA 7285, Versailles Saint Quentin University, Montigny-le-Bretonneux, France
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Leahy-Warren P, Mulcahy H, Corcoran P, Bradley R, O'Connor M, O'Connell R. Factors influencing women's perceptions of choice and control during pregnancy and birth: a cross-sectional study. BMC Pregnancy Childbirth 2021; 21:667. [PMID: 34598709 PMCID: PMC8487111 DOI: 10.1186/s12884-021-04106-8] [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] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 09/07/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Women across the world value choice and control throughout their maternity care experiences. In response to this health policy and frameworks are adapting and developing. The concepts of choice and control are extrinsically complex and open to interpretation by healthcare professionals and service users, with the two not necessarily aligning. Depending on a number of factors, women's experiences of choice and control within the same maternity care system may be very different. This study aimed to investigate the factors influencing women's perceptions of choice and control during pregnancy and birth in Ireland. METHODS We conducted a cross-sectional study using an adapted version of the UK national maternity experience survey (National Perinatal Epidemiology Unit). During March - July 2017, a sample of 1277 women were recruited from the postnatal wards of three maternity units and a tertiary maternity hospital. Poisson regression was used to assess the association between twelve factors and a series of measures of the women's perception of choice and control. RESULTS Most women reported not having choice in the model or location of their maternity care but most reported being involved enough in decision-making, especially during birth. Women who availed of private maternity care reported higher levels of choice and control than those who availed of public maternity care. This factor was the most influential factor on almost all choice and control measures. CONCLUSION Most women experiencing maternity care in Ireland report not having choice in the model and location of care. These are core elements of the Irish maternity strategy and significant investment will be required if improved choice is to be provided. Availing of private maternity care has the strongest influence on a woman's perceived choice and control but many women cannot afford this type of care, nor may they want this model of care.
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Affiliation(s)
- Patricia Leahy-Warren
- School of Nursing and Midwifery, Brookfield Health Sciences Complex, College Road, Cork, T12 AK54, Ireland.
| | - Helen Mulcahy
- School of Nursing and Midwifery, Brookfield Health Sciences Complex, College Road, Cork, T12 AK54, Ireland
| | - Paul Corcoran
- National Perinatal Epidemiology Centre, Cork University Maternity Hospital, Wilton, Cork, T12 DC4A, Ireland
| | - Róisín Bradley
- School of Nursing and Midwifery, Brookfield Health Sciences Complex, College Road, Cork, T12 AK54, Ireland
| | - Mary O'Connor
- School of Nursing and Midwifery, Brookfield Health Sciences Complex, College Road, Cork, T12 AK54, Ireland
| | - Rhona O'Connell
- School of Nursing and Midwifery, Brookfield Health Sciences Complex, College Road, Cork, T12 AK54, Ireland
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Craven S, Byrne F, Mahony R, Walsh JM. Do you pay to go private?: a single centre comparison of induction of labour and caesarean section rates in private versus public patients. BMC Pregnancy Childbirth 2020; 20:746. [PMID: 33261564 PMCID: PMC7706013 DOI: 10.1186/s12884-020-03443-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 11/19/2020] [Indexed: 02/08/2023] Open
Abstract
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.
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Affiliation(s)
- Simon Craven
- National Maternity Hospital, Holles Street, Dublin 2, Ireland.
| | - Fionnuala Byrne
- National Maternity Hospital, Holles Street, Dublin 2, Ireland
| | - Rhona Mahony
- National Maternity Hospital, Holles Street, Dublin 2, Ireland
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Turner MJ, Reynolds CME, McMahon LE, O'Malley EG, O'Connell MP, Sheehan SR. Caesarean section rates in women in the Republic of Ireland who chose to attend their obstetrician privately: a retrospective observational study. BMC Pregnancy Childbirth 2020; 20:548. [PMID: 32957947 PMCID: PMC7504647 DOI: 10.1186/s12884-020-03199-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 08/20/2020] [Indexed: 12/22/2022] Open
Abstract
Background Caesarean section (CS) rates are increasing and there are wide variations in rates internationally and nationally. There is evidence that women who attend their obstetrician privately have a higher incidence of CS than those who attend publicly. The purpose of this observational study was to further investigate why CS rates may be higher in women who chose to attend their obstetrician privately. Methods This study analysed data collected as part of the clinical records by midwives at the woman’s first antenatal appointment in a large European maternity hospital. All women who delivered between the years 2009 and 2017 were included. Data were analysed both cross-sectionally and longitudinally. Results Overall, 73,266 women had a singleton pregnancy and 1830 had a multiple pregnancy. Of the packages of maternity care, 75.2% chose public, 10.8% chose semiprivate and 14.0% chose private. During the study, 11,991 women attended the hospital for their first and second pregnancies. Overall, women who attended privately were older and had higher proportions of infertility treatment and history of miscarriage (all p < 0.001) compared to those publicly-funded. Private patients were more likely to have a history of infertility, a history of miscarriage, a multiple pregnancy and to be ≥35 yrs. They had lower rates of obesity, smoking and illicit drug use in pregnancy (all p < 0.001). In women who chose private care, the overall rate of CS was higher compared to women choosing publicly-funded (42.7% vs 25.3%, p < 0.001) The increase was due to an increase in elective rather than emergency CS. The increase in elective CS fell after adjustment for clinical risks. In the longitudinal analysis, 89.7% chose the same package second time around. Women who changed from public to private care for the second pregnancy were more likely to have had a previous emergency CS or admission to the Neonatal Unit. Conclusions This study suggests that the increased CS rate in women privately insured may be attributed, in part, to the fact that women who can afford health insurance choose continuity of care from a senior obstetrician because they are risk adverse and wish to have the option of an elective CS.
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Affiliation(s)
- Michael J Turner
- UCD Centre for Human Reproduction, Coombe Women and Infants University Hospital, Cork Street, Dublin 8, Ireland
| | - Ciara M E Reynolds
- UCD Centre for Human Reproduction, Coombe Women and Infants University Hospital, Cork Street, Dublin 8, Ireland.
| | - Léan E McMahon
- UCD Centre for Human Reproduction, Coombe Women and Infants University Hospital, Cork Street, Dublin 8, Ireland
| | - Eimer G O'Malley
- UCD Centre for Human Reproduction, Coombe Women and Infants University Hospital, Cork Street, Dublin 8, Ireland
| | - Michael P O'Connell
- UCD Centre for Human Reproduction, Coombe Women and Infants University Hospital, Cork Street, Dublin 8, Ireland
| | - Sharon R Sheehan
- UCD Centre for Human Reproduction, Coombe Women and Infants University Hospital, Cork Street, Dublin 8, Ireland
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Kuliukas L, Bayes S, Geraghty S, Bradfield Z, Davison C. Graduating midwifery students' preferred model of practice and first job decisions: A qualitative study. Women Birth 2020; 34:61-68. [PMID: 32814673 DOI: 10.1016/j.wombi.2020.07.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 06/30/2020] [Accepted: 07/19/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To explore and describe the preferred model of practice and first job decisions of final stage midwifery students from three Western Australian universities. DESIGN Qualitative descriptive. SETTING Three Western Australian (WA) universities offering courses leading to registration as a midwife. PARTICIPANTS Twenty-seven midwifery students from undergraduate and postgraduate (pre-registration) courses. METHODS Data were collected from recorded interviews and focus groups. Thematic analysis of interview transcripts was used to identify commonalities. Data saturation guided when recruitment ceased and final sample size was achieved. FINDINGS Participants' preferred model of maternity care was influenced by learning about and witnessing both autonomous midwifery practice and collaborative care during their studies. The greatest influence was clinical experience, with most preferring a continuity of midwifery model (CoM) but first consolidating their practice in a public hospital. Most students reported that they would not choose a private hospital as their first option. Work/life balance was also considered, with some accepting that family commitments and a need to work close to home may prevent them from choosing a CoM model. CONCLUSION AND IMPLICATIONS Although many Australian midwifery students start their midwifery course with preconceived ideology of their eventual workplace, the influences of their educators, clinical placement environment, preceptors and continuity of care experience relationships with women helped determine their final direction. To provide students with the experiences to become woman-centred autonomous practitioners it is important for universities and all maternity care providers to carefully consider their responsibility in how they influence midwifery students in education and practice.
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Affiliation(s)
- Lesley Kuliukas
- Curtin University School of Nursing, Midwifery & Paramedicine, GPO Box U1987, Perth, Western Australia 6845, Australia.
| | - Sara Bayes
- Edith Cowan University, School of Nursing & Midwifery, 270 Joondalup Drive, Joondalup, Western Australia 6027, Australia.
| | - Sadie Geraghty
- Edith Cowan University, School of Nursing & Midwifery, 270 Joondalup Drive, Joondalup, Western Australia 6027, Australia.
| | - Zoe Bradfield
- Curtin University School of Nursing, Midwifery & Paramedicine, GPO Box U1987, Perth, Western Australia 6845, Australia.
| | - Clare Davison
- Edith Cowan University, School of Nursing & Midwifery, 270 Joondalup Drive, Joondalup, Western Australia 6027, Australia.
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Does programmed intermittent epidural bolus improve childbirth conditions of nulliparous women compared with patient-controlled epidural analgesia?: A multicentre, randomised, controlled, triple-blind study. Eur J Anaesthesiol 2020; 36:755-762. [PMID: 31335447 DOI: 10.1097/eja.0000000000001053] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Epidural analgesia may change the mechanics of childbirth. These changes are related to the concentration of the local anaesthetic used epidurally but probably also to its mode of delivery into the epidural space. OBJECTIVE To determine whether the administration of programmed intermittent epidural boluses (PIEB) improves the mechanics of second-stage labour compared with patient-controlled epidural analgesia (PCEA) with a background infusion. DESIGN A randomised, controlled, triple-blind study. SETTING Multicentre study including four level III maternity units, January 2014 until June 2016. PATIENTS A total of 298 nulliparous patients in spontaneous labour were randomised to a PIEB or PCEA group. INTERVENTION After epidural initiation with 15 ml of 0.1% levobupivacaine containing 10 μg of sufentanil, patients received either an hourly bolus of 8 ml (PIEB) or a continuous rate infusion of 8 ml h (PCEA): the drug mixture used was levobupivacaine 0.1% and sufentanil 0.36 μg ml. MAIN OUTCOME MEASURES The primary outcome was a composite endpoint of objective labour events: a posterior occiput position in the second stage, an occiput position at birth, waiting time at full cervical dilatation before active maternal pushing more than 3 h, maternal active pushing duration more than 40 min, and foetal heart rate alterations. Vaginal instrumental delivery rates, analgesia and motor blockade scores were also recorded. RESULTS From the 298 patients randomised, data from 249 (124 PIEB, 125 PCEA) were analysed. No difference was found in the primary outcome: 48.0% (PIEB) and 45.5% (PCEA) of patients, P = 0.70. In addition, no difference was observed between the groups for each of the individual events of the composite endpoint, nor in the instrumental vaginal delivery rate, nor in the degree of motor blockade. Despite an equivalent volume of medication in the groups, a significantly higher analgesia score at full dilatation was observed in the PIEB group, odds-ratio = 1.9 (95% confidence interval, 1.0 to 3.5), P = 0.04. CONCLUSION The mechanics of the second stage did not differ whether PIEB or PCEA was used. Analgesic conditions appeared to be superior with PIEB, especially at full dilation. TRIAL REGISTRATION NCT01856166.
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Moran PS, Daly D, Wuytack F, Carroll M, Turner M, Normand C, Begley C. Predictors of choice of public and private maternity care among nulliparous women in Ireland, and implications for maternity care and birth experience. Health Policy 2020; 124:556-562. [PMID: 32284156 DOI: 10.1016/j.healthpol.2020.02.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 02/13/2020] [Accepted: 02/17/2020] [Indexed: 11/28/2022]
Abstract
Maternity care in Ireland is provided through a mixture of free public and fee-based private or semi-private services. We examined factors associated with choice of care pathway among nulliparous women and how this influences the care they receive and their experience of childbirth using data from a prospective cohort study. Complete data were available for 1,789 women on choice of care pathway and birth outcomes, and for 1,336 women on birth experience. Maternal age (marginal effect [ME] 1.6 percentage points [ppts], p < 0.01), socioeconomic status (ME 0.5ppts, p < 0.01) and being born in Ireland (ME 10.3ppts, p < 0.01) were all positively associated with choosing private care, but level of risk in early pregnancy did not influence this decision. Intervention rates in public and semi-private care were comparable, but women in private care were more likely to receive epidural anaesthesia (odds ratio [OR] 1.65, p < 0.01) and give birth by caesarean section (ratio of relative risks [RRR] 1.98, p < 0.01). Private care was also associated with longer hospital stays (28 % longer, p < 0.01). Increased risk was negatively correlated with birth experience in public and semi-private care, but not in private care. Policies promoting the allocation of maternity care resources by level of risk, along with the standardisation of clinical practice across care pathways, could reduce rates of obstetric intervention and address risk-based disparities in birth experience outcomes.
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Affiliation(s)
- Patrick S Moran
- School of Nursing and Midwifery, Trinity College Dublin, Ireland.
| | - Deirdre Daly
- School of Nursing and Midwifery, Trinity College Dublin, Ireland.
| | | | - Margaret Carroll
- School of Nursing and Midwifery, Trinity College Dublin, Ireland.
| | | | - Charles Normand
- Centre for Health Policy and Management, Trinity College Dublin, Ireland; Economics of Palliative Care and Rehabilitation, Cicely Saunders Institute, King's College London, United Kingdom.
| | - Cecily Begley
- School of Nursing and Midwifery, Trinity College Dublin, Ireland.
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Shen Y, Li Q, Liu X, Xiao S, Yan H. Training and financial intervention for encouraging maternal health service utilization: Results of cluster randomized trials in Shaanxi Province. Medicine (Baltimore) 2019; 98:e17709. [PMID: 31702622 PMCID: PMC6855503 DOI: 10.1097/md.0000000000017709] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The rising maternal and child healthcare costs and the lack of training and educational resources for healthcare workers have reduced service quality in primary health centers of China. We sought to compare strategies promoting healthcare service utilization in rural western China. METHOD A randomized community trial was carried out in Zhen'an country between 2007 and 2009. Two cross-sectional surveys were conducted to compare the outcomes of financial subsidy for pregnant women seeking antenatal care and clinical training provided to healthcare workers by difference-in-difference estimation. RESULTS In all, 1113 women completed the questionnaires. The proportion of postnatal visits increased three times in the training group, reaching 35.7%. The number of women who received advice from their doctors regarding nutrition and warning signs necessitating immediate medical attention also improved significantly (5.8% and 8.2%, respectively). Furthermore, the percentage of women who underwent blood tests increased significantly to 19.5% in the training group. Compared to the financial group, the training group had more women who breastfed for longer than 4 months (15.8%) and provided timely complementary feeding (8.9%). CONCLUSION The training intervention appeared to have improved prenatal care utilization. Essential obstetric training helped enhance knowledge and self-efficacy among healthcare workers.
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Affiliation(s)
- Yuan Shen
- Department of Epidemiology and Biostatistics, School of Public Health, Xi’an Jiaotong University Health Science Center, Xi’an, Shaanxi
| | - Qiang Li
- Department of Epidemiology and Biostatistics, School of Public Health, Xi’an Jiaotong University Health Science Center, Xi’an, Shaanxi
| | - Xiaoning Liu
- Department of Epidemiology and Health Statistics, School of Public Health, LanZhou University, Lanzhou, Gansu, China
| | - Shengbin Xiao
- Department of Epidemiology and Biostatistics, School of Public Health, Xi’an Jiaotong University Health Science Center, Xi’an, Shaanxi
| | - Hong Yan
- Department of Epidemiology and Biostatistics, School of Public Health, Xi’an Jiaotong University Health Science Center, Xi’an, Shaanxi
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Clesse C, Lighezzolo-Alnot J, De Lavergne S, Hamlin S, Scheffler M. Factors related to episiotomy practice: an evidence-based medicine systematic review. J OBSTET GYNAECOL 2019; 39:737-747. [DOI: 10.1080/01443615.2019.1581741] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- Christophe Clesse
- Interpsy Laboratory (EA4432), Université de Lorraine, Nancy, France
- Hospital Centre of Jury-les-Metz – Route d’Ars Laquenexy, Jury-Lesmetz, France
- Polyclinic Majorelle, Nancy, France
| | | | | | | | - Michèle Scheffler
- Polyclinic Majorelle, Nancy, France
- Cabinet de Gynécologie Médicale et Obstétrique, Nancy, France
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Abstract
OBJECTIVE To investigate the association of caesarean section rates with the health system characteristics in the public hospitals of Kosovo. DESIGN Cross-sectional survey. SETTING Five largest public hospitals in Kosovo. PARTICIPANTS 859 women with low-risk deliveries who delivered from April to May 2015 in five public hospitals in Kosovo. OUTCOME MEASURES The prespecified outcomes were the crude and adjusted OR of births delivered with caesarean section by health system characteristics such as delivery by the physician who provided antenatal care, health insurance status and other. Additional prespecified outcomes were caesarean section rates and crude ORs for delivery with caesarean in each public hospital. RESULTS Women with personal monthly income had increased odds for caesarean (OR 1.55, 95% CI 1.06 to 2.27), as did women with private health insurance coverage (OR 3.44, 95% CI 1.20 to 9.85). Women instructed by a midwife on preparation for delivery had decreasing odds (OR 0.32, 95% CI 0.19 to 0.51) while women having preference for a caesarean had increasing odds for delivery with caesarean (OR 3.84, 95% CI 1.96 to 7.51). The odds for caesarean increased also in the case of delivery by a physician who provided antenatal care (OR 2.06, 95% CI 1.16 to 3.67) and delivery during office hours (OR 2.36, 95% CI 1.37 to 4.05), while delivery at the University Clinical Centre of Kosovo decreased the odds for caesarean (OR 0.46, 95% CI 0.24 to 0.90). CONCLUSIONS We found that several health system characteristics are associated with the increase of caesarean sections in a low-risk population of delivering women in public hospitals of Kosovo. These findings should be explored further and addressed via policy measures that would tackle provision of unnecessary caesareans. The study findings could assist Kosovo to develop corrective policies in addressing overuse of caesareans and may provide useful information for other middle-income countries.
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Affiliation(s)
- Ilir Hoxha
- Department of Community and Family Medicine, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
- Heimerer College, Prishtina, Kosovo
- Action for Mother and Children, Prishtina, Kosovo
| | | | - Mrika Aliu
- Action for Mother and Children, Prishtina, Kosovo
| | - Peter Jüni
- Applied Health Research Centre (AHRC), Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Department of Medicine, and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - David C Goodman
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire, USA
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Masukume G, McCarthy FP, Baker PN, Kenny LC, Morton SM, Murray DM, Hourihane JO, Khashan AS. Association between caesarean section delivery and obesity in childhood: a longitudinal cohort study in Ireland. BMJ Open 2019; 9:e025051. [PMID: 30878984 PMCID: PMC6429933 DOI: 10.1136/bmjopen-2018-025051] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 08/08/2018] [Accepted: 11/13/2018] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVES To investigate the association between caesarean section (CS) birth and body fat percentage (BF%), body mass index (BMI) and being overweight or obese in early childhood. DESIGN Prospective longitudinal cohort study. SETTING Babies After Screening for Pregnancy Endpoints: Evaluating the Longitudinal Impact on Neurological and Nutritional Endpoints cohort. PARTICIPANTS Infants born to mothers recruited from the Screening for Pregnancy Endpoints study, Cork University Maternity Hospital between November 2007 and February 2011. OUTCOME MEASURE Overweight or obese defined according to the International Obesity Task Force criteria. RESULTS Of the 1305 infants, 362 (27.8%) were delivered by CS. On regression analysis, BF% at 2 months did not differ significantly by delivery mode. Infants born by CS had a higher mean BMI at 6 months compared with those born vaginally (adjusted mean difference=0.24; 95% CI 0.06 to 0.41, p value=0.009). At 2 years, no difference was seen across the exposure groups in the risk of being overweight or obese. At 5 years, the association between prelabour CS and the risk of overweight or obesity was not statistically significant (adjusted relative risk ratio, aRRR=1.37; 95% CI 0.69 to 2.69) and the association remained statistically nonsignificant when children who were macrosomic at birth were excluded from the model (aRRR=0.86; 95% CI 0.36 to 2.08). CONCLUSION At 6 months of age, children born by CS had a significantly higher BMI but this did not persist into future childhood. There was no evidence to support an association between mode of delivery and long-term risk of obesity in the child.
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Affiliation(s)
- Gwinyai Masukume
- The Irish Centre for Fetal and Neonatal Translational Research (INFANT), University College Cork, Cork, Ireland
- Department of Obstetrics and Gynaecology, University College Cork, Cork, Ireland
| | - Fergus P McCarthy
- The Irish Centre for Fetal and Neonatal Translational Research (INFANT), University College Cork, Cork, Ireland
- Department of Obstetrics and Gynaecology, University College Cork, Cork, Ireland
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, United Kingdom
| | - Philip N Baker
- College of Life Sciences, University of Leicester, Leicester, United Kingdom
| | - Louise C Kenny
- Department of Women's and Children's Health, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Susan Mb Morton
- Centre for Longitudinal Research - He Ara ki Mua, University of Auckland, Auckland, New Zealand
| | - Deirdre M Murray
- The Irish Centre for Fetal and Neonatal Translational Research (INFANT), University College Cork, Cork, Ireland
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Jonathan O'B Hourihane
- The Irish Centre for Fetal and Neonatal Translational Research (INFANT), University College Cork, Cork, Ireland
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Ali S Khashan
- The Irish Centre for Fetal and Neonatal Translational Research (INFANT), University College Cork, Cork, Ireland
- School of Public Health, University College Cork, Cork, Ireland
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Hernández-Martínez A, Martínez-Galiano JM, Rodríguez-Almagro J, Delgado-Rodríguez M, Gómez-Salgado J. Evidence-based Birth Attendance in Spain: Private versus Public Centers. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16050894. [PMID: 30871065 PMCID: PMC6427791 DOI: 10.3390/ijerph16050894] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 03/07/2019] [Accepted: 03/09/2019] [Indexed: 12/17/2022]
Abstract
The type of hospital (public or private) has been associated with the type of clinical practice carried out. The purpose of this study was to determine the association between the type of hospital (public or private) and delivery attendance with practices based on the recommendations by the World Health Organization (WHO). A cross-sectional study with puerperal women (n = 2906) was conducted in Spain during 2017. The crude Odds Ratios (OR), adjusted (aOR) and their 95% confidence intervals (CI) were calculated through binary logistic regression. For multiparous women in private centers, a higher rate of induced labor was observed (aOR: 1.49; 95% CI: 1.11⁻2.00), fewer natural methods were used to relieve pain (aOR: 0.51; 95% CI: 0.35⁻0.73), and increased odds of cesarean section (aOR: 2.50; 95% CI: 1.81⁻3.46) were found as compared to public hospitals. For primiparous women in private centers, a greater use of the epidural was observed (aOR: 1.57; 95% CI: 1.03⁻1.40), as well as an increased likelihood of instrumental birth (aOR: 1.53; 95% CI: 1.09⁻2.15) and of cesarean section (aOR: 1.77; 95% CI: 1.33⁻2.37) than in public hospitals. No differences were found in hospitalization times among women giving birth in public and private centers (p > 0.05). The World Health Organization birth attendance recommendations are more strictly followed in public hospitals than in private settings.
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Affiliation(s)
| | - Juan Miguel Martínez-Galiano
- Department of Nursing, University of Jaén, Campus de Las Lagunillas s/n, Building B3 Office 266, 23071 Jaén, Spain.
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBERESP), 28029 Madrid, Spain.
| | | | - Miguel Delgado-Rodríguez
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBERESP), 28029 Madrid, Spain.
- Division of Preventive Medicine and Public Health, University of Jaen, 23071 Jaen, Spain.
| | - Juan Gómez-Salgado
- Department of Nursing, Faculty of Nursing, University of Huelva, 21071 Huelva, Spain.
- Espíritu Santo University, Guayaquil 092301, Ecuador.
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18
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Hoxha I, Braha M, Syrogiannouli L, Goodman DC, Jüni P. Caesarean section in uninsured women in the USA: systematic review and meta-analysis. BMJ Open 2019; 9:e025356. [PMID: 30833323 PMCID: PMC6443081 DOI: 10.1136/bmjopen-2018-025356] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 11/14/2018] [Accepted: 12/19/2018] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE The aim of this study is to assess the odds of caesarean section (CS) for uninsured women in the USA and understand the underlying mechanisms as well as consequences of lower use. STUDY DESIGN Systematic review and meta-analysis. DATA SOURCES PubMed, Embase, the Cochrane Library and CINAHL from the first year of records to April 2018. ELIGIBILITY CRITERIA We included studies that reported data to allow the calculation of ORs of CS of uninsured as compared with insured women. OUTCOMES The prespecified primary outcome was the adjusted OR of deliveries by CS of uninsured women as compared with privately or publicly insured women. The prespecified secondary outcome was the crude OR of deliveries by CS of uninsured women as compared with insured women. RESULTS 12 articles describing 16 separate studies involving more than 8.8 million women were included in this study. We found: 0.70 times lower odds of CS in uninsured as compared with privately insured women (95% CI 0.63 to 0.78), with no relevant heterogeneity between studies (τ2=0.01); and 0.92 times lower odds for CS in uninsured as compared with publicly insured women (95% CI 0.80 to 1.07), with no relevant heterogeneity between studies (τ2=0.02). We found 0.70 times lower odds in uninsured as compared with privately and publicly insured women (95% CI 0.69 to 0.72). CONCLUSIONS CSs are less likely to be performed in uninsured women as compared with insured women. While the higher rates for CS among privately insured women can be explained with financial incentives associated with private insurance, the lower odds among uninsured women draw attention at barriers to access for delivery care. In many regions, the rates for uninsured women are above, close or below the benchmarks for appropriate CS rates and could imply both, underuse and overuse.
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Affiliation(s)
- Ilir Hoxha
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Department of Community & Family Medicine, Geisel School of Medicine at Dartmouth Hanover, New Hampshire, USA
- Heimerer College, Prishtina, Kosovo
| | - Medina Braha
- International Business College Mitrovica, Mitrovica, Kosovo
| | | | - David C Goodman
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, USA
| | - Peter Jüni
- Applied Health Research Centre (AHRC), Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Department of Medicine, and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
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Peel A, Bhartia A, Spicer N, Gautham M. 'If I do 10-15 normal deliveries in a month I hardly ever sleep at home.' A qualitative study of health providers' reasons for high rates of caesarean deliveries in private sector maternity care in Delhi, India. BMC Pregnancy Childbirth 2018; 18:470. [PMID: 30509211 PMCID: PMC6276145 DOI: 10.1186/s12884-018-2095-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2017] [Accepted: 11/16/2018] [Indexed: 11/23/2022] Open
Abstract
Background Although the overall rate of caesarean deliveries in India remains low, rates are higher in private than in public facilities. In a household survey in Delhi, for instance, more than half of women delivering in private facilities reported a caesarean section. Evidence suggests that not all caesarean sections are clinically necessary and may even increase morbidity. We present providers’ perspectives of the reasons behind the high rates of caesarean births in private facilities, and possible solutions to counter the trend. Methods Fourteen in-depth interviews were conducted with high-end private sector obstetricians and other allied providers in Delhi and its neighbouring cities, Gurgaon and Ghaziabad. Results Respondents were of the common view that private sector caesarean rates were unreasonably high and perceived time and doctors’ convenience as the foremost reasons. Financial incentives had an indirect effect on decision-making. Obstetricians felt that they must maintain high patient loads to be commercially successful. Many alluded to their busy working lives, which made it challenging for them to monitor every delivery individually. Besides fearing for patient safety in these situations, they were fearful of legal action if anything went wrong. A lack of context specific guidelines and inadequate support from junior staff and nurses exacerbated these problems. Maternal demand also played a role, as the consumer-provider relationship in private healthcare incentivised obstetricians to fulfil patient demands for caesarean section. Suggested solutions included more support, from either well-trained midwives and junior staff or using a ‘shared practice’ model; guidelines introduced by an Indian body; increased regulation within the sector and public disclosure of providers’ caesarean rates. Conclusions Commercial interests contribute indirectly to high caesarean rates, as solo obstetricians juggle the need to maintain high patient loads with inadequate support staff. Perceptions amongst providers and consumers of caesarean section as the ‘safe’ option have re-defined caesareans as the new ‘normal’, even for low-risk deliveries. At the policy level, guidelines and public disclosures, strong initiatives to develop professional midwifery, and increasing public awareness, could bring about a sustainable reduction in the present high rates.
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Affiliation(s)
- Alison Peel
- London School of Hygiene and Tropical Medicine, London, UK
| | - Abhishek Bhartia
- Sitaram Bhartia Institute of Science and Research, New Delhi, India
| | - Neil Spicer
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Meenakshi Gautham
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK.
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Masukume G, O'Neill SM, Baker PN, Kenny LC, Morton SMB, Khashan AS. The Impact of Caesarean Section on the Risk of Childhood Overweight and Obesity: New Evidence from a Contemporary Cohort Study. Sci Rep 2018; 8:15113. [PMID: 30310162 PMCID: PMC6181954 DOI: 10.1038/s41598-018-33482-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 09/26/2018] [Indexed: 11/23/2022] Open
Abstract
Caesarean section (CS) rates are increasing globally and exceed 50% in some countries. Childhood obesity has been linked to CS via lack of exposure to vaginal microflora although the literature is inconsistent. We investigated the association between CS birth and the risk of childhood obesity using the nationally representative Growing-Up-in-Ireland (GUI) cohort. The GUI study recruited randomly 11134 infants. The exposure was categorised into normal vaginal birth (VD) [reference], assisted VD, elective (planned) CS and emergency (unplanned) CS. The primary outcome measure was obesity defined according to the International Obesity Taskforce criteria. Statistical analysis included multinomial logistic regression with adjustment for potential confounders. Infants delivered by elective CS had an adjusted relative risk ratio (aRRR) = 1.32; [95% confidence interval (CI) 1.01-1.74] of being obese at age three years. This association was attenuated when macrosomic children were excluded (aRRR = 0.99; [95% CI 0.67-1.45]). Infants delivered by emergency CS had an increased risk of obesity aRRR = 1.56; [95% CI 1.20-2.03]; this association remained after excluding macrosomic children. We found insufficient evidence to support a causal relationship between elective CS and childhood obesity. An increased risk of obesity in children born by emergency CS, but not elective, suggests that there is no causal effect due to vaginal microflora.
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Affiliation(s)
- Gwinyai Masukume
- The Irish Centre for Fetal and Neonatal Translational Research (INFANT), Department of Obstetrics and Gynaecology, University College Cork, Cork, Ireland
| | - Sinéad M O'Neill
- The Irish Centre for Fetal and Neonatal Translational Research (INFANT), Department of Obstetrics and Gynaecology, University College Cork, Cork, Ireland
| | - Philip N Baker
- College of Life Sciences, University of Leicester, Leicester, United Kingdom
| | - Louise C Kenny
- Department of Women's and Children's Health, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Susan M B Morton
- Centre for Longitudinal Research, University of Auckland, Auckland, New Zealand
| | - Ali S Khashan
- The Irish Centre for Fetal and Neonatal Translational Research (INFANT), Department of Obstetrics and Gynaecology, University College Cork, Cork, Ireland.
- School of Public Health, University College Cork, Cork, Ireland.
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Bradfield Z, Kelly M, Hauck Y, Duggan R. Midwives 'with woman' in the private obstetric model: Where divergent philosophies meet. Women Birth 2018; 32:157-167. [PMID: 30093349 DOI: 10.1016/j.wombi.2018.07.013] [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: 03/12/2018] [Revised: 06/14/2018] [Accepted: 07/19/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND The phenomenon of being 'with woman' is central to the profession of midwifery. There is currently no available evidence that explicitly explores this phenomenon. In Western Australia, over a third of childbearing women choose to engage the services of a private obstetrician who provides antenatal care and manages the care provided by midwives during labour and birth. AIM The aim of this study was to explore midwives' experiences of being 'with woman' during labour and birth in the private obstetric model. METHODS Using a descriptive phenomenological approach, 11 midwives working in the private obstetric model in Western Australia were interviewed. Data analysis was conducted using Giorgi's framework. FINDINGS Two main themes emerged (1) triad of relationships and (2) the intersection between being 'with woman' and the private obstetric model; seven subthemes are reported. DISCUSSION Being 'with woman' is an important element of midwifery practice and fundamental to midwifery theory and philosophy. Relationships between the woman, midwife and obstetrician are key to implementing 'with woman' practices in the private obstetric model. The interrelatedness of midwifery philosophy and practice is revealed through shared common challenges and enablers to being 'with woman' from the perspective of midwives. CONCLUSION Findings offer insight into midwives' experiences of being 'with woman' within the context of the private obstetric model. New understandings are revealed of a phenomenon central to midwifery professional philosophy that is embedded within midwifery practices which has implications for service mangers, professional leaders and educators.
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Affiliation(s)
- Zoe Bradfield
- School of Nursing, Midwifery and Paramedicine, Curtin University, Western Australia, Australia.
| | - Michelle Kelly
- School of Nursing, Midwifery and Paramedicine, Curtin University, Western Australia, Australia
| | - Yvonne Hauck
- School of Nursing, Midwifery and Paramedicine, Curtin University, Western Australia, Australia
| | - Ravani Duggan
- School of Nursing, Midwifery and Paramedicine, Curtin University, Western Australia, Australia
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22
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Panda S, Begley C, Daly D. Clinicians' views of factors influencing decision-making for caesarean section: A systematic review and metasynthesis of qualitative, quantitative and mixed methods studies. PLoS One 2018; 13:e0200941. [PMID: 30052666 PMCID: PMC6063415 DOI: 10.1371/journal.pone.0200941] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2017] [Accepted: 06/26/2018] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Caesarean section rates are increasing worldwide and are a growing concern with limited explanation of the factors that influence the rising trend. Understanding obstetricians' and midwives' views can give insight to the problem. This systematic review aimed to offer insight and understanding, through aggregation, summary, synthesis and interpretation of findings from studies that report obstetricians' and midwives' views on the factors that influence the decision to perform caesarean section. METHODS The electronic databases of PubMed (1958-2016), CINAHL (1988-2016), Maternity and Infant Care (1971-2016), PsycINFO (1980-2016) and Web of Science (1991-2016) were searched in September 2016. All quantitative, qualitative and mixed methods studies, published in English, whose aim was to explore obstetricians' and/or midwives' views of factors influencing decision-making for caesarean section were included. Papers were independently reviewed by two authors for selection by title, abstract and full text. Thomas et al's 12 assessment criteria checklist (2003) was used to assess methodological quality of the included studies. RESULT The review included 34 studies: 19 quantitative, 14 qualitative, and one using mixed methods, involving 7785 obstetricians and 1197 midwives from 20 countries. Three main themes, each with several subthemes, emerged. Theme 1: "clinicians' personal beliefs"-('Professional philosophies'; 'beliefs in relation to women's request for CS'; 'ambiguous versus clear clinical reasons'); Theme 2: "health care systems"-('litigation'; 'resources'; 'private versus public/insurance/payments'; 'guidelines and management policy'). Theme 3: "clinicians' characteristics" ('personal convenience'; 'clinicians' demographics'; 'confidence and skills'). CONCLUSION This systematic review and metasynthesis identified clinicians' personal beliefs as a major factor that influenced the decision to perform caesarean section, further contributed by the influence of factors related to the health care system and clinicians' characteristics. Obstetricians and midwives are directly involved in the decision to perform a caesarean section, hence their perspectives are vital in understanding various factors that have influence on decision-making for caesarean section. These results can help clinicians identify and acknowledge their role as crucial members in the decision-making process for caesarean section within their organisation, and to develop intervention studies to reduce caesarean section rates in future.
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Affiliation(s)
- Sunita Panda
- School of Nursing and Midwifery, Trinity College Dublin, Dublin, Ireland
| | - Cecily Begley
- School of Nursing and Midwifery, Trinity College Dublin, Dublin, Ireland
- Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Deirdre Daly
- School of Nursing and Midwifery, Trinity College Dublin, Dublin, Ireland
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Health policies for the reduction of obstetric interventions in singleton full-term births in Catalonia. Health Policy 2018; 122:367-372. [PMID: 29452718 DOI: 10.1016/j.healthpol.2018.01.016] [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: 01/09/2017] [Revised: 01/18/2018] [Accepted: 01/26/2018] [Indexed: 01/03/2023]
Abstract
AIM To explore the effect of hospital's characteristics in the proportion of obstetric interventions (OI) performed in singleton fullterm births (SFTB) in Catalonia (2010-2014), while incentives were employed to reduce C-sections. METHODS Data about SFTB assisted at 42 public hospitals were extracted from the dataset of hospital discharges. Hospitals were classified according to the level of complexity, the volume of births attended, and the adoption of a non-medicalized delivery (NMD) strategy. The annual average change in the percentage for OI was calculated based on Poisson regression models. RESULTS The rate of OI (35% of all SFTB) including C-sections (20.6%) remained stable through the period. Hospitals attending less complex cases had a lower average of OI, while hospitals attending lower volumes had the highest average. Higher levels of complexity increased the use of C-sections (+4% yearly) and forceps (+16%). The adoption of the NMD strategy decreased the rate of C-sections. CONCLUSIONS The proportion of OI, including C-sections, remained stable in spite of public incentives to reduce them. The adoption of the NMD strategy could help in decreasing the rate of OI. To reduce the OI rate, new strategies should be launched as the development of low-risk pregnancies units, alignment of incentives and hospital payment, increased value of incentives and encouragement of a cultural shift towards non-medicalized births.
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Jang W, Flatley C, Greer RM, Kumar S. Comparison between public and private sectors of care and disparities in adverse neonatal outcomes following emergency intrapartum cesarean at term - A retrospective cohort study. PLoS One 2017; 12:e0187040. [PMID: 29149182 PMCID: PMC5693444 DOI: 10.1371/journal.pone.0187040] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Accepted: 10/10/2017] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Perinatal outcomes may be influenced by a variety of factors including maternal demographics and medical condition as well as socio-economic status. The evidence for disparities in health outcomes stratified by type of care (public or private) is lacking. The aim of this study was to investigate short term neonatal outcomes following category 1 and 2 emergency cesareans at term between publicly and privately funded women at a single major tertiary centre in Australia. Category 1-immediate threat to life (maternal or fetal); Category 2-maternal or fetal compromise that is not immediately life-threatening. METHODS This was a retrospective, cross sectional study of 61355 term singleton babies born at the Mater Mother's Hospital in Brisbane, Australia in 2007-2014. We collected data from the hospital's maternity database and compared maternal demographics, indications for cesarean and neonatal outcomes for publicly and privately funded women. RESULTS Over the study period there were 32477 public and 28878 private, term singleton births. Compared to the publicly funded cohort, privately insured women were older, had lower BMI, were of Caucasian ethnicity, Australian born, nulliparous, had shorter labors and had lower rates of hypertensive disorders and diabetes. The most common indications for category 1 and category 2 cesareans in combination were non-reassuring fetal status followed by failure to progress in labor and malpresentation. For both category 1 and 2 cesareans, neonatal outcomes (Apgar score <7 at 5 minutes, abnormal cord gases, Neonatal Critical Care Unit admission rates, rates of severe respiratory distress and jaundice) were significantly worse in the publicly funded compared to the privately insured cohort Multivariate analyses controlling for maternal age, ethnicity, country of birth, parity, hypertension, diabetes mellitus, gestational age at birth and length of labour confirmed that private insurance status was highly protective for the perinatal outcomes of Apgar score <7 at 5 minutes (aOR 0.26, 95% CI 0.13-0.55), admission to NCCU (OR 0.51, 95% CI 0.30-0.92) and respiratory distress (aOR 0.60, 95% CI 0.41-0.86). CONCLUSION Birth in the private health sector was inversely associated with adverse neonatal outcomes following category 1 and 2 cesareans.
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Affiliation(s)
- Woonji Jang
- Mater Research Institute—University of Queensland, South Brisbane, Queensland, Australia
| | - Christopher Flatley
- Mater Research Institute—University of Queensland, South Brisbane, Queensland, Australia
| | - Ristan M. Greer
- Mater Research Institute—University of Queensland, South Brisbane, Queensland, Australia
| | - Sailesh Kumar
- Mater Research Institute—University of Queensland, South Brisbane, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
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Healy S, Humphreys E, Kennedy C. A qualitative exploration of how midwives’ and obstetricians’ perception of risk affects care practices for low-risk women and normal birth. Women Birth 2017; 30:367-375. [DOI: 10.1016/j.wombi.2017.02.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 12/11/2016] [Accepted: 02/11/2017] [Indexed: 10/20/2022]
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Hoxha I, Syrogiannouli L, Braha M, Goodman DC, da Costa BR, Jüni P. Caesarean sections and private insurance: systematic review and meta-analysis. BMJ Open 2017; 7:e016600. [PMID: 28827257 PMCID: PMC5629699 DOI: 10.1136/bmjopen-2017-016600] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE Financial incentives associated with private insurance may encourage healthcare providers to perform more caesarean sections. We therefore sought to determine the association of private insurance and odds of caesarean section. DESIGN Systematic review and meta-analysis. DATA SOURCES MEDLINE, Embase and The Cochrane Library from the first year of records through August 2016. ELIGIBILITY CRITERIA We included studies that reported data to allow the calculation of OR of caesarean section of privately insured as compared with publicly insured women. OUTCOMES The prespecified primary outcome was the adjusted OR of births delivered by caesarean section of women covered with private insurance as compared with women covered with public insurance. The prespecified secondary outcome was the crude OR of births delivered by caesarean section of women covered with private insurance as compared with women covered with public insurance. RESULTS Eighteen articles describing 21 separate studies in 12.9 million women were included in this study. In a meta-analysis of 13 studies, the adjusted odds of delivery by caesarean section was 1.13 higher among privately insured women as compared with women with public insurance coverage (95% CI 1.07 to 1.18) with no relevant heterogeneity between studies (τ2=0.006). The meta-analysis of crude estimates from 12 studies revealed a somewhat more pronounced association (pooled OR 1.35, 95% CI 1.27 to 1.44) with no relevant heterogeneity between studies (τ2=0.011). CONCLUSIONS Caesarean sections are more likely to be performed in privately insured women as compared with women using public health insurance coverage. Although this effect is small on average and variable in its magnitude, it is present in all analyses we performed.
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Affiliation(s)
- Ilir Hoxha
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Institute of Primary Health Care, University of Bern, Bern, Switzerland
| | | | - Medina Braha
- Department of Management and Marketing, International Business College Mitrovica, Mitrovica, Kosovo
| | - David C Goodman
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire, USA
| | - Bruno R da Costa
- Institute of Primary Health Care, University of Bern, Bern, Switzerland
| | - Peter Jüni
- Applied Health Research Centre (AHRC), Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Nilsson C, Lalor J, Begley C, Carroll M, Gross MM, Grylka-Baeschlin S, Lundgren I, Matterne A, Morano S, Nicoletti J, Healy P. Vaginal birth after caesarean: Views of women from countries with low VBAC rates. Women Birth 2017; 30:481-490. [PMID: 28545775 DOI: 10.1016/j.wombi.2017.04.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Revised: 04/01/2017] [Accepted: 04/25/2017] [Indexed: 11/27/2022]
Abstract
PROBLEM AND BACKGROUND Vaginal birth after caesarean section is a safe option for the majority of women. Seeking women's views can be of help in understanding factors of importance for achieving vaginal birth in countries where the vaginal birth rates after caesarean is low. AIM To investigate women's views on important factors to improve the rate of vaginal birth after caesareanin countries where vaginal birth rates after previous caesarean are low. METHODS A qualitative study using content analysis. Data were gathered through focus groups and individual interviews with 51 women, in their native languages, in Germany, Ireland and Italy. The women were asked five questions about vaginal birth after caesarean. Data were translated to English, analysed together and finally validated in each country. FINDINGS Important factors for the women were that all involved in caring for them were of the same opinion about vaginal birth after caesarean, that they experience shared decision-making with clinicians supportive of vaginal birth, receive correct information, are sufficiently prepared for a vaginal birth, and experience a culture that supports vaginal birth after caesarean. DISCUSSION AND CONCLUSION Women's decision-making about vaginal birth after caesarean in these countries involves a complex, multidimensional interplay of medical, psychosocial, cultural, personal and practical considerations. Further research is needed to explore if the information deficit women report negatively affects their ability to make informed choices, and to understand what matters most to women when making decisions about vaginal birth after a previous caesarean as a mode of birth.
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Affiliation(s)
- Christina Nilsson
- Institute of Health and Care Sciences, The Sahlgrenska Academy, University of Gothenburg, Sweden.
| | - Joan Lalor
- School of Nursing and Midwifery, Trinity College Dublin, Ireland
| | - Cecily Begley
- School of Nursing and Midwifery, Trinity College Dublin, Ireland
| | - Margaret Carroll
- School of Nursing and Midwifery, Trinity College Dublin, Ireland
| | - Mechthild M Gross
- Midwifery Research and Education Unit, Hannover Medical School, Hannover, Germany
| | | | - Ingela Lundgren
- Institute of Health and Care Sciences, The Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Andrea Matterne
- Midwifery Research and Education Unit, Hannover Medical School, Hannover, Germany
| | - Sandra Morano
- Department of Neurologic, Oculistic, Gynaecologic, Maternal and Infant Sciences, University of Genoa, Italy
| | - Jane Nicoletti
- Department of Neurologic, Oculistic, Gynaecologic, Maternal and Infant Sciences, University of Genoa, Italy
| | - Patricia Healy
- School of Nursing and Midwifery, National University of Ireland, Galway, Ireland
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Lundgren I, Healy P, Carroll M, Begley C, Matterne A, Gross MM, Grylka-Baeschlin S, Nicoletti J, Morano S, Nilsson C, Lalor J. Clinicians' views of factors of importance for improving the rate of VBAC (vaginal birth after caesarean section): a study from countries with low VBAC rates. BMC Pregnancy Childbirth 2016; 16:350. [PMID: 27832743 PMCID: PMC5103375 DOI: 10.1186/s12884-016-1144-0] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 11/01/2016] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Caesarean section (CS) rates are increasing worldwide and the most common reason is repeat CS following previous CS. For most women a vaginal birth after a previous CS (VBAC) is a safe option. However, the rate of VBAC differs in an international perspective. Obtaining deeper knowledge of clinicians' views on VBAC can help in understanding the factors of importance for increasing VBAC rates. Focus group interviews with clinicians and women in three countries with high VBAC rates (Finland, Sweden and the Netherlands) and three countries with low VBAC rates (Ireland, Italy and Germany) are part of "OptiBIRTH", an ongoing research project. The study reported here aims to explore the views of clinicians from countries with low VBAC rates on factors of importance for improving VBAC rates. METHODS Focus group interviews were held in Ireland, Italy and Germany. In total 71 clinicians participated in nine focus group interviews. Five central questions about VBAC were used and interviews were analysed using content analysis. The analysis was performed in each country in the native language and then translated into English. All data were then analysed together and final categories were validated in each country. RESULTS The findings are presented in four main categories with several sub-categories: 1) "prameters for VBAC", including the importance of the obstetric history, present obstetric factors, a positive attitude among those who are centrally involved, early follow-up after CS and antenatal classes; 2) "organisational support and resources for women undergoing a VBAC", meaning a successful VBAC requires clinical expertise and resources during labour; 3) "fear as a key inhibitor of successful VBAC", including understanding women's fear of childbirth, clinicians' fear of VBAC and the ways that clinicians' fear can be transferred to women; and 4) "shared decision making - rapport, knowledge and confidence", meaning ensuring consistent, realistic and unbiased information and developing trust within the clinician-woman relationship. CONCLUSIONS The findings indicate that increasing the VBAC rate depends on organisational factors, the care offered during pregnancy and childbirth, the decision-making process and the strategies employed to reduce fear in all involved.
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Affiliation(s)
- Ingela Lundgren
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Box 457, SE-405 30 Gothenburg, Sweden
| | - Patricia Healy
- School of Nursing and Midwifery, National University of Ireland, Upper Newcastle Road, Galway, Ireland
| | - Margaret Carroll
- School of Nursing and Midwifery, Trinity College Dublin, 24 D’Olier Street, Dublin 2, Ireland
| | - Cecily Begley
- School of Nursing and Midwifery, Trinity College Dublin, 24 D’Olier Street, Dublin 2, Ireland
| | - Andrea Matterne
- Midwifery Research and Education Unit, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Mechthild M. Gross
- Midwifery Research and Education Unit, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Susanne Grylka-Baeschlin
- Midwifery Research and Education Unit, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Jane Nicoletti
- Universita Degli Studi di Genova, Via Balbi 5, 16126 Genova, Italy
| | - Sandra Morano
- IRCCS Azienda Ospedaliera Universitaria S. Martino IST, Largo R. Benzi, 10 16132 Genova, Italy
| | - Christina Nilsson
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Box 457, SE-405 30 Gothenburg, Sweden
| | - Joan Lalor
- School of Nursing and Midwifery, Trinity College Dublin, 24 D’Olier Street, Dublin 2, Ireland
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What women want: Exploring pregnant women's preferences for alternative models of maternity care. Health Policy 2016; 121:66-74. [PMID: 27884492 DOI: 10.1016/j.healthpol.2016.10.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Revised: 10/05/2016] [Accepted: 10/27/2016] [Indexed: 11/21/2022]
Abstract
Depending on obstetric risk, maternity care may be provided in one of two locations at hospital level: a consultant-led unit (CLU) or a midwifery-led unit (MLU). Care in a MLU is sparsely provided in Ireland, comprising as few as two units out of a total 21 maternity units. Given its potential for greater efficiencies of care and cost-savings for the state, there has been an increased interest to expand MLUs in Ireland. Yet, very little is known about women's preferences for midwifery-led care, and whether they would utilise this service when presented with the choice of delivering in a CLU or MLU. This study seeks to involve women in the future planning of maternity care by investigating their preferences for care and subsequent motivations when choosing place of birth. Qualitative research is undertaken to explore maternal preferences for these different models of care. Women only revealed a preference for the MLU when co-located with a CLU due to its close proximity to medical services. However, the results suggest women do not have a clear preference for either model of care, but rather a hybrid model of care which encompasses features of both consultant- and midwifery-led care.
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Chuilon AL, Le Ray C, Prunet C, Blondel B. L’épisiotomie en France en 2010 : variations des pratiques selon le contexte obstétrical et le lieu d’accouchement. ACTA ACUST UNITED AC 2016; 45:691-700. [DOI: 10.1016/j.jgyn.2015.10.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Revised: 10/13/2015] [Accepted: 10/22/2015] [Indexed: 10/22/2022]
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Brick A, Layte R, Nolan A, Turner MJ. Differences in nulliparous caesarean section rates across models of care: a decomposition analysis. BMC Health Serv Res 2016; 16:239. [PMID: 27392410 PMCID: PMC4938942 DOI: 10.1186/s12913-016-1494-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Revised: 06/27/2016] [Accepted: 06/29/2016] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND To evaluate the extent of the difference in elective (ELCS) and emergency (EMCS) caesarean section (CS) rates between nulliparous women in public maternity hospitals in Ireland by model of care, and to quantify the contribution of maternal, clinical, and hospital characteristics in explaining the difference in the rates. METHODS Cross-sectional analysis using a combination of two routinely collected administrative databases was performed. A non-linear extension of the Oaxaca-Blinder method is used to decompose the difference between public and private ELCS and EMCS rates into the proportion explained by the differences in observable maternal, clinical, and hospital characteristics and the proportion that remains unexplained. RESULTS Of the 29,870 babies delivered to nulliparous women, 7,792 were delivered via CS (26.1 %), 79.6 % of which were coded as EMCS. Higher prevalence of ELCS was associated with breech presentation, other malpresentation, and the mother being over 40 years old. Higher prevalence of EMCS was associated with placenta praevia or placental abruption, diabetes (pre-existing and gestational), and being over 40 years old. The private model of care is associated with ELCS and EMCS rates 6 percentage points higher compared than the public model of care but this differential is insignificant in the fully adjusted models for EMCS. Just over half (53 %) of the 6 percentage point difference in ELCS rates between the two models of care can be accounted for by maternal, clinical and hospital characteristics. Almost 80 % of the difference for EMCS can be accounted for. CONCLUSIONS The majority of the difference in EMCS rates across models of care can be explained by differing characteristics between the two groups of women. The main contributor to the difference was advancing maternal age. The unexplained component of the difference for ELCS is larger; an excess private effect remains after accounting for maternal, clinical, and hospital characteristics. This requires further investigation and may be mitigated in future with the introduction of clinical guidelines related to CS.
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Affiliation(s)
- Aoife Brick
- />Economic and Social Research Institute, Whitaker Square, Sir John Rogerson`s Quay, Dublin 2, Ireland
- />Trinity College, Dublin, Ireland
| | - Richard Layte
- />Economic and Social Research Institute, Whitaker Square, Sir John Rogerson`s Quay, Dublin 2, Ireland
- />Department of Sociology, Trinity College, Dublin 2, Ireland
| | - Anne Nolan
- />Economic and Social Research Institute, Whitaker Square, Sir John Rogerson`s Quay, Dublin 2, Ireland
- />Trinity College, Dublin, Ireland
| | - Michael J. Turner
- />UCD Centre for Human Reproduction, Coombe Women and Infants University Hospital, Dublin 8, Ireland
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Hauck YL, Stoll KH, Hall WA, Downie J. Association between childbirth attitudes and fear on birth preferences of a future generation of Australian parents. Women Birth 2016; 29:511-517. [PMID: 27233945 DOI: 10.1016/j.wombi.2016.05.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Revised: 04/20/2016] [Accepted: 05/09/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND The reality of childbirth fear is recognised for expectant parents but we lack knowledge about the childbirth attitudes of the next generation of Australian parents. AIM Examination of adults' attitudes toward childbirth including influencing contributing factors, fear scores, birth preferences and reasons for this preference. METHODS A cross-sectional online study was conducted with 654 Western Australian students attending one tertiary institution. Students (male and female) were eligible to participate if they were less than 40 years of age and did not currently have children but confirmed their intention to become parents. To assess associations or comparison of means, bi-variable analyses (Chi square test, Fisher's Exact test, Independent Student's t-test or one way ANOVA) were used. Factors associated with childbirth fear and birth preferences were assessed with binary logistic regression analysis. FINDINGS Childbirth attitudes were shaped by family members' (82.0%) and friends' experiences (64.4%) plus media (TV, YouTube, and movies) (63.5%). Furthermore, 15.6% of adults indicated a preference for a caesarean birth, even without obstetric complications. Likewise, 26.1% reported elevated fear; students with elevated fear scores had 2.6 times greater odds of wanting a caesarean birth. Only 23.4% of students felt confident about their childbirth knowledge. CONCLUSION Adults reported fear levels that warrant attention prior to a future pregnancy. Although the majority would choose a vaginal birth, they require awareness of benefits and risks for both vaginal and caesarean births to ensure their decisions reflect informed choice rather than influences of inadequate knowledge or fear.
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Affiliation(s)
- Yvonne L Hauck
- School of Nursing, Midwifery and Paramedicine, Curtin University, Perth, WA 6845 Australia; Department of Nursing and Midwifery Education and Research, King Edward Memorial Hospital, Bagot Rd, Subiaco, WA 6008, Australia.
| | - Kathrin H Stoll
- School of Population and Public Health, Faculty of Medicine, University of British Columbia, East Mall, Vancouver, BC V6T-1Z3, Canada.
| | - Wendy A Hall
- School of Nursing, University of British Columbia, Westbrook Mall, Vancouver, BC V6T 2B5, Canada.
| | - Jill Downie
- Office of the Deputy Vice-Chancellor, Academic, Curtin University, Perth, WA 6845, Australia.
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Escuriet R, Pueyo MJ, Perez-Botella M, Espada X, Salgado I, Gómez A, Biescas H, Espiga I, White J, Fernandez R, Fusté J, Ortún V. Cross-sectional study comparing public and private hospitals in Catalonia: is the practice of routine episiotomy changing? BMC Health Serv Res 2015; 15:95. [PMID: 25889079 PMCID: PMC4365515 DOI: 10.1186/s12913-015-0753-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Accepted: 02/17/2015] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND In Spain, the Strategy for Assistance in Normal Childbirth (SANC) promoted a model of care, which respects the physiological birth process and discards unnecessary routine interventions, such as episiotomies. We evaluated the rate of episiotomy use and perineal trauma as indicators of how selective introduction of the SANC initiative has impacted childbirth outcomes in hospitals of Catalonia. METHODS Cross-sectional study of all singleton vaginal term deliveries without instrument registered in the Minimum Basic Data Set (MBDS) of Catalonia in 2007, 2010 and 2012. Hospitals were divided into types according to funding (public or private), and four strata were differentiated according to volume of births attended. Episiotomies and perineal injury were considered dependent variables. The relationship between qualitative variables was analysed using the chi-squared test, and Student's t-test was used for quantitative variables. Comparison of proportions was performed on the two hospital groups between 2007 and 2012 using a Z-test. Logistic regression models were used to analyse the relationship between episiotomy or severe perineal damage and maternal age, volume of births and hospital type, obtaining odds ratios (OR) and 95% confidence intervals (CI). RESULTS The majority of normal singleton term deliveries were attended in public hospitals, where maternal age was lower than for women attended in private hospitals. Analysis revealed a statistically significant (P < 0.001) decreasing trend in episiotomy use in Catalonia for both hospital types. Private hospitals appeared to be associated with increased episiotomy rate in 2007 (OR = 1.099, CI: 1,057-1,142), 2010 (OR = 1.528, CI: 1,472-1,587) and 2012 (OR = 1.459, CI: 1,383-1,540), and a lower rate of severe perineal trauma in 2007 (OR = 0.164, CI: 0.095-0.283), 2010 (OR = 0.16, CI: 0.110-0.232) and 2012 (OR = 0.19, CI: 0.107-0.336). Regarding severe perineal injury, when independent variables were adjusted, maternal age ceased to have a significant correlation in 2012 (OR = 0.994, CI: 0.970-1.018). CONCLUSIONS Episiotomy procedures during normal singleton vaginal term deliveries in Catalonia has decreased steadily since 2007. Study results show a stable incidence trend below 1% for severe perineal trauma over the study period.
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Affiliation(s)
- Ramón Escuriet
- Directorate-General for Health Planning and Research, Ministry of Health of the Government of Catalonia, Barcelona, Spain.
- Department of Experimental and Health Sciences, Universitat Pompeu Fabra (UPF), Barcelona, Spain.
- Consorci Sanitari Integral, Hospital General de l'Hospitalet, L'Hospitalet de Llobregat, Barcelona, Spain.
| | - María J Pueyo
- Directorate-General for Health Planning and Research, Ministry of Health of the Government of Catalonia, Barcelona, Spain.
| | - Mercedes Perez-Botella
- University of Central Lancashire, School of Health, Midwifery, Neonatal and Sexual Health Division, Preston, UK.
| | - Xavi Espada
- Institut Català de la Salut, Unitat Atenció a la Salut Sexual i Reproductiva, Granollers, Spain.
- Fundació Hospital Asil de Granollers, Granollers, Spain.
| | - Isabel Salgado
- Consorci Sanitari Integral, Hospital General de l'Hospitalet, L'Hospitalet de Llobregat, Barcelona, Spain.
| | - Analía Gómez
- Consorci Sanitari Integral, Hospital General de l'Hospitalet, L'Hospitalet de Llobregat, Barcelona, Spain.
| | - Herminia Biescas
- Directorate-General for Health Planning and Research, Ministry of Health of the Government of Catalonia, Barcelona, Spain.
| | - Isabel Espiga
- Women's Health Observatory, Subdirectorate for Quality and Cohesion, Ministry of Health, Social Services and Equality, Madrid, Spain.
| | - Joanna White
- Centre for Research in Anthropology (CRIA-IUL), Lisbon, Portugal.
- Visiting Fellow, King's College, London, UK.
| | - Rosa Fernandez
- Public Health Agency of Catalonia, Maternal and Infant Health Programme, Government of Catalonia, Barcelona, Spain.
| | - Josep Fusté
- The Union, Health and Social Entities Association, Barcelona, Spain.
| | - Vicente Ortún
- Universitat Pompeu Fabra (UPF), Faculty of Economic and Business Sciences, Barcelona, Spain.
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Escuriet-Peiró R, Goberna-Tricas J, Pueyo-Sanchez MJ, Garriga-Comas N, Úbeda-Bonet I, Caja-López C, Espiga-López I, Ortún-Rubio V. Impact of maternity care policy in Catalonia: a retrospective cross-sectional study of service delivery in public and private hospitals. BMC Pregnancy Childbirth 2015; 15:23. [PMID: 25881263 PMCID: PMC4337058 DOI: 10.1186/s12884-015-0446-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Accepted: 01/20/2015] [Indexed: 11/10/2022] Open
Abstract
Background As a result of the growing number of interventions that are now performed in the context of maternity care, health authorities have begun to examine the possible repercussions for service provision and for maternal and neonatal health. In Spain the Strategy Paper on Normal Childbirth was published in 2008, and since then the authorities in Catalonia have sought to implement its recommendations. This paper reviews the current provision of maternity care in Catalonia. Methods This was a descriptive study. Hospitals were grouped according to their source of funding (public or private) and were stratified (across four strata) on the basis of the annual number of births recorded within their respective maternity service. Data regarding the distribution of obstetric professionals were taken from an official government survey of hospitals published in 2010. The data on obstetric interventions (caesarean, use of forceps, vacuum or non-specified instruments) performed in 2007, 2010 and 2012 were obtained by consulting discharge records of 44 public and 20 private hospitals, which together provide care in 98% of all births in Catalonia. Proportions and confidence intervals were calculated for each intervention performed in all full-term (37–42 weeks) singleton births. Results Analysis of staff profiles according to the stratification of hospitals showed that almost all the hospitals had more obstetricians than midwives among their maternity care staff. Public hospitals performed fewer caesareans [range between 19.20% (CI 18.84-19.55) and 28.14% (CI 27.73-28.54)] than did private hospitals [range between 32.21% (CI 31.78-32.63) and 39.43% (CI 38.98-39.87)]. The use of forceps has decreased in public hospitals. The use of a vacuum extractor has increased and is more common in private hospitals. Conclusions Caesarean section is the most common obstetric intervention performed during full-term singleton births in Catalonia. The observed trend is stable in the group of public hospitals, but shows signs of a rise among private institutions. The number of caesareans performed in accredited public hospitals covers a limited range with a stable trend. Among public hospitals the highest rate of caesareans is found in non-accredited hospitals with a lower annual number of births.
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Affiliation(s)
- Ramón Escuriet-Peiró
- Department of Experimental and Health Sciences, Universitat Pompeu Fabra (UPF), Barcelona, Spain. .,Directorate-General for Health Planning and Research, Ministry of Health of the Government of Catalonia, Barcelona, Spain.
| | - Josefina Goberna-Tricas
- Department of Public Health, Mental Health and Perinatal Nursing, Universitat de Barcelona, Bellvitge Health Sciences Campus, Pavelló de Govern, 3a planta, C/Feixa Llarga s/n, 08907, L'Hospitalet de Llobregat, Barcelona, Spain.
| | - Maria J Pueyo-Sanchez
- Directorate-General for Health Planning and Research, Ministry of Health of the Government of Catalonia, Barcelona, Spain.
| | - Neus Garriga-Comas
- Department of Public Health, Mental Health and Perinatal Nursing, Universitat de Barcelona, Bellvitge Health Sciences Campus, Pavelló de Govern, 3a planta, C/Feixa Llarga s/n, 08907, L'Hospitalet de Llobregat, Barcelona, Spain. .,Hospital de Manresa, Fundació Althaia, Manresa, Spain.
| | - Immaculada Úbeda-Bonet
- Department of Public Health, Mental Health and Perinatal Nursing, Universitat de Barcelona, Bellvitge Health Sciences Campus, Pavelló de Govern, 3a planta, C/Feixa Llarga s/n, 08907, L'Hospitalet de Llobregat, Barcelona, Spain.
| | - Carmen Caja-López
- Department of Public Health, Mental Health and Perinatal Nursing, Universitat de Barcelona, Bellvitge Health Sciences Campus, Pavelló de Govern, 3a planta, C/Feixa Llarga s/n, 08907, L'Hospitalet de Llobregat, Barcelona, Spain.
| | - Isabel Espiga-López
- Observatory on Women's Health, Subdirectorate for Quality and Cohesion, Ministry of Health, Social Services and Equality, Madrid, Spain.
| | - Vicente Ortún-Rubio
- Faculty of Economic and Business Sciences, Universitat Pompeu Fabra (UPF), Barcelona, Spain.
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do Carmo Leal M, Pereira APE, Domingues RMSM, Theme Filha MM, Dias MAB, Nakamura-Pereira M, Bastos MH, da Gama SGN. Expanding the discussion. CAD SAUDE PUBLICA 2014; 30 Suppl 1:S27-31. [PMID: 25167188 DOI: 10.1590/0102-311xco07s114] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Grylka-Baeschlin S, van Teijlingen E, Gross MM. Cultural differences in postnatal quality of life among German-speaking women - a prospective survey in two countries. BMC Pregnancy Childbirth 2014; 14:277. [PMID: 25128290 PMCID: PMC4261596 DOI: 10.1186/1471-2393-14-277] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Accepted: 08/05/2014] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
| | | | - Mechthild M Gross
- Midwifery Research and Education Unit, Hannover Medical School, Carl-Neuberg-Str, 1, D-30625 Hannover, Germany.
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