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Kelly C, Whitten M, Kennedy S, Lanceley A, Nicholls J. Women's experiences of consent to induction of labour: A qualitative study. SEXUAL & REPRODUCTIVE HEALTHCARE 2024; 39:100928. [PMID: 38056385 DOI: 10.1016/j.srhc.2023.100928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 11/15/2023] [Accepted: 11/23/2023] [Indexed: 12/08/2023]
Abstract
OBJECTIVE Induction of labour (IOL) does not require formal written consent, and little is known about how consent operates in this context. This prospective study explores pregnant women's experiences of the IOL consent process. METHODS Qualitative study using semi-structured, interviews with thirteen women admitted to hospital for IOL. Data were analysed using thematic analysis. RESULTS Three themes emerged: 1) Voluntary nature of consent: Some women experienced genuine choice; others perceived pressure to prioritise their baby. 2) Understanding the why and how, risks and benefits: Information provision and explanation was often minimal, particularly regarding risks and alternatives to induction. The possibility of IOL failing was not discussed 3) Non-personalised information process: Few women received information specific and relevant to their circumstance. PRACTICE IMPLICATIONS There is an urgent need for healthcare professionals to be supported in actively facilitating consent consultations which enable women undergoing IOL to make a fully autonomous, informed choice. CONCLUSIONS Women did not always experience choice about whether to be induced. This sense of disempowerment was sometimes exacerbated by inadequate information provision. The study reveals a practice imperative to address consent in IOL and we suggest there is an urgent need for HCPs to be offered high quality training specific to IOL.
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Affiliation(s)
- Clodagh Kelly
- University College London Medical School, Institute for Women's Health, 74 Huntley Street, London WC1E 6AU, UK
| | - Melissa Whitten
- University College London Medical School, Institute for Women's Health, 74 Huntley Street, London WC1E 6AU, UK; UCLH, Division of Women's Health, 235 Euston Road, London NW1 2BU, UK
| | - Sophie Kennedy
- University College London Medical School, Institute for Women's Health, 74 Huntley Street, London WC1E 6AU, UK
| | - Anne Lanceley
- University College London Medical School, Institute for Women's Health, 74 Huntley Street, London WC1E 6AU, UK
| | - Jacqueline Nicholls
- University College London Medical School, Institute for Women's Health, 74 Huntley Street, London WC1E 6AU, UK.
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Peterwerth NH, Halek M, Schäfers R. Association of personal and systemic factors on intrapartum risk perception and obstetric intervention rates: a cross-sectional study. BMC Pregnancy Childbirth 2024; 24:155. [PMID: 38389073 PMCID: PMC10882933 DOI: 10.1186/s12884-024-06338-w] [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: 09/21/2023] [Accepted: 02/09/2024] [Indexed: 02/24/2024] Open
Abstract
BACKGROUND Risk perception is fundamental to decision-making; therefore its exploration is essential to gaining a comprehensive understanding of the decision-making process for peripartum interventions. The aim of this study was to investigate associations between personal and systemic factors of the work setting and the risk perception of obstetric healthcare professionals, and in turn how this might influence decisions regarding obstetric interventions. METHODS Case vignettes were used to measure risk perception. A quantitative cross-sectional online survey was performed within an exploratory sequential mixed-methods design, and an intervention readiness score created. Associations were calculated using location and dispersion measures, t-tests and correlations in addition to multiple linear regression. RESULTS Risk perception, as measured by the risk assessment score, was significantly lower (average 0.8 points) for midwives than for obstetricians (95%-CI [-0.673; -0.317], p < .001). Statistically significant correlations were found for: years of experience and annual number of births in the current workplace, but this was not clinically relevant; hours worked, with the groups of participants working ≥ 30,5 h showing a statistically significant higher risk perception than participants working 20,5-30 h (p = .005); and level of care of the current workplace, with the groups of participants working in a birth clinic (Level IV) showing a statistically significant lower risk perception than participants working in Level I hospital (highly specialised obstetric and neonatal care; p = .016). The option of midwife-led birthing care showed no correlation with risk perception. The survey identified that risk perception, occupation, years in the profession and number of hours worked (i.e. full or part time) represent significant influences on obstetric healthcare professionals' willingness to intervene. CONCLUSIONS The results of the survey give rise to the hypothesis that the personal and systemic factors of professional qualification, occupation, number of hours worked and level of acuity of the workplace are related to the risk perception of obstetric healthcare professionals. In turn, risk perception itself made a significant contribution to explaining differences in willingness to intervene, suggesting that it influences obstetricians' and midwives' decision-making. Overall, however, the correlations were weak and should be interpreted cautiously. The significant variations in the use of interventions must be addressed in order to provide the highest quality and best possible care for childbearing women and their families. To this end, developing strategies to improve interdisciplinary relationships and collaboration is of great importance. TRIAL REGISTRATION German Clinical Trials Register DRKS00017172 (18.06.2019).
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Affiliation(s)
- Nina H Peterwerth
- Department of Applied Health Sciences - Midwifery, University of Applied Sciences-Hochschule für Gesundheit, Gesundheitscampus 6-8, 44801, Bochum, Germany.
- School of Nursing Science, Faculty of Health, Department für Pflegewissenschaft, Fakultät für Gesundheit, Witten/Herdecke University, Alfred-Herrhausen-Straße 50, 58455, Witten, Germany.
| | - Margareta Halek
- School of Nursing Science, Faculty of Health, Department für Pflegewissenschaft, Fakultät für Gesundheit, Witten/Herdecke University, Alfred-Herrhausen-Straße 50, 58455, Witten, Germany
| | - Rainhild Schäfers
- Institute of Midwifery Science, Faculty of Medicine, University of Münster, Malmedyweg 17-19, 48149, Münster, Germany
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3
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Chua JYX, Choolani M, Lalor JG, Yi H, Chong YS, Shorey S. Perceptions of healthcare professionals regarding labour induction and augmentation: A qualitative systematic review. Women Birth 2024; 37:79-87. [PMID: 37718194 DOI: 10.1016/j.wombi.2023.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 09/09/2023] [Accepted: 09/12/2023] [Indexed: 09/19/2023]
Abstract
BACKGROUND Labour induction and augmentation procedures are commonly used in maternity units with or without medical indications. Research shows that healthcare professionals play a significant role in women's childbirth decisions. AIM To consolidate healthcare professionals' perceptions about labour induction and augmentation. METHODS Seven electronic databases were searched from their inception dates till January 2023: PubMed, Embase, CINAHL, PsycINFO, Web of Science, Scopus, ProQuest Dissertations, and Theses Global. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis and Sandelowski and Barroso's guidelines guided this review. Included studies' quality was appraised by the Critical Appraisal Skills Program tool. Data were thematically synthesised. Review findings were assessed using the Grading of Recommendations Assessment, Development, and Evaluation-Confidence in the Evidence from Reviews of Qualitative research approach. FINDINGS Three main themes were identified from the 17 included studies: 1) Making sense of the phenomenon, 2) Two sides of the coin, and 3) The enlightened path ahead. DISCUSSION Healthcare professionals' labour induction and augmentation decisions were affected by personal (knowledge and moral philosophies), and external factors (women, community members, colleagues, and healthcare institutions). Some clinicians were unfamiliar with the proper labour induction/augmentation procedures, while others were worried about their decisions and outcomes. CONCLUSION Suggestions for improvement include conducting labour induction/augmentation training for clinicians, having sufficient resources in facilities, and developing appropriate labour induction/augmentation clinical guidelines. Women and their partners, community members, and traditional healers could benefit from receiving labour induction/augmentation education. To improve health outcomes, healthcare professionals could deliver woman-centred care and collaborate.
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Affiliation(s)
- Joelle Yan Xin Chua
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Mahesh Choolani
- Department of Obstetrics and Gynaecology, National University Hospital, Singapore
| | | | - Huso Yi
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Yap Seng Chong
- Department of Obstetrics and Gynaecology, National University Hospital, Singapore
| | - Shefaly Shorey
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
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Peralta A, Drainoni ML, Declercq ER, Belanoff CM, Radoff K, Bearse E, Iverson RE. Development and testing of a decision aid to achieve shared decision-making for routine labor induction. Birth 2023; 50:636-645. [PMID: 36825853 DOI: 10.1111/birt.12716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 09/20/2022] [Accepted: 01/27/2023] [Indexed: 02/25/2023]
Abstract
BACKGROUND This quality improvement project aimed to create a decision aid for labor induction in healthy pregnancies at or beyond 39 weeks that met the needs of pregnant people least likely to experience shared decision-making and to identify and test implementation strategies to support its use in prenatal care. METHODS We used quality improvement and qualitative methods to develop, test, and refine a patient decision aid. The decision aid was tested in three languages by providers across obstetrics, family medicine, and midwifery practices at a tertiary care hospital and two community health centers. Outcomes included patients' understanding of their choices, pros and cons of choices, and the decision being theirs or a shared one with their provider. RESULTS Patient interview data indicated that shared decision-making on labor induction was achieved. Across three Plan-Do-Study-Act cycles, we interviewed a diverse group of 24 pregnant people: 20 were people of color, 16 were publicly insured, and 15 were born outside the United States. All but one (23/24) reported feeling the decision was theirs or a shared one with their provider. The majority could name induction choices they had along with pros and cons. Interviewees described the decision-making experience as empowering and positive. Nine medical providers tested the decision aid and gave feedback. Providers stated the tool helped improve the quality of their counseling and reduce bias. CONCLUSION This project suggests that using an evidence-based and well-tested decision aid can help achieve shared decision-making on labor induction for a diverse group of pregnant people.
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Affiliation(s)
| | - Mari-Lynn Drainoni
- School of Public Health, Boston University, Boston, MA, USA
- School of Medicine, Boston University, Boston, MA, USA
| | - Eugene R Declercq
- School of Public Health, Boston University, Boston, MA, USA
- School of Medicine, Boston University, Boston, MA, USA
| | | | - Kari Radoff
- School of Medicine, Boston University, Boston, MA, USA
- Boston Medical Center, Boston, MA, USA
| | - Emily Bearse
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
- Dartmouth, Geisel School of Medicine, Hanover, New Hampshire, USA
| | - Ronald E Iverson
- School of Medicine, Boston University, Boston, MA, USA
- Boston Medical Center, Boston, MA, USA
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Murano M, Chou D, Costa ML, Turner T. Using the WHO-INTEGRATE evidence-to-decision framework to develop recommendations for induction of labour. Health Res Policy Syst 2022; 20:125. [PMID: 36344986 PMCID: PMC9641799 DOI: 10.1186/s12961-022-00901-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 08/18/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND In 2019, WHO prioritized updating recommendations relating to three labour induction topics: labour induction at or beyond term, mechanical methods for labour induction, and outpatient labour induction. As part of this process, we aimed to review the evidence addressing factors beyond clinical effectiveness (values, human rights and sociocultural acceptability, health equity, and economic and feasibility considerations) to inform WHO Guideline Development Group decision-making using the WHO-INTEGRATE evidence-to-decision framework, and to reflect on how methods for identifying, synthesizing and integrating this evidence could be improved. METHODS We adapted the framework to consider the key criteria and sub-criteria relevant to our intervention. We searched for qualitative and other evidence across a variety of sources and mapped the eligible evidence to country income setting and perspective. Eligibility assessment and quality appraisal of qualitative evidence syntheses was undertaken using a two-step process informed by the ENTREQ statement. We adopted an iterative approach to interpret the evidence and provided both summary and detailed findings to the decision-makers. We also undertook a review to reflect on opportunities to improve the process of applying the framework and identifying the evidence. RESULTS Using the WHO-INTEGRATE framework allowed us to explore health rights and equity in a systematic and transparent way. We identified a lack of qualitative and other evidence from low- and middle-income settings and in populations that are most impacted by structural inequities or traditionally excluded from research. Our process review highlighted opportunities for future improvement, including adopting more systematic evidence mapping methods and working with social science researchers to strengthen theoretical understanding, methods and interpretation of the evidence. CONCLUSIONS Using the WHO-INTEGRATE evidence-to-decision framework to inform decision-making in a global guideline for induction of labour, we identified both challenges and opportunities relating to the lack of evidence in populations and settings of need and interest; the theoretical approach informing the development and application of WHO-INTEGRATE; and interpretation of the evidence. We hope these insights will be useful for primary researchers as well as the evidence synthesis and health decision-making communities, and ultimately contribute to a reduction in health inequities.
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Affiliation(s)
- Melissa Murano
- grid.1002.30000 0004 1936 7857Cochrane Australia, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004 Australia
| | - Doris Chou
- grid.3575.40000000121633745Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Maria Laura Costa
- grid.411087.b0000 0001 0723 2494Department of Obstetrics and Gynecology, Faculty of Medical Sciences, University of Campinas, Campinas, SP Brazil
| | - Tari Turner
- grid.1002.30000 0004 1936 7857Cochrane Australia, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004 Australia
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Foggin H, Hutcheon JA, Liauw J. Making sense of harms and benefits: Assessing the numeric presentation of risk information in ACOG obstetrical clinical practice guidelines. PATIENT EDUCATION AND COUNSELING 2022; 105:1216-1223. [PMID: 34509341 DOI: 10.1016/j.pec.2021.08.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 07/31/2021] [Accepted: 08/24/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE To assess the presentation of risk information in American College of Obstetricians and Gynecologists (ACOG) obstetrical Practice Bulletins. METHODS We reviewed B- and C-graded recommendations in Practice Bulletins published from January 2017 to March 2020. We calculated the proportion of recommendations and outcomes that were presented numerically and, of these, the proportion that were presented in accordance with best practices of risk communication - in absolute formats, or as absolute changes in risk from baseline risks. We categorized outcomes as harms or benefits to compare their risk presentation. RESULTS In 21 obstetrical Practice Bulletins, there were 125 recommendations, with 46 (37%) describing risks numerically. Sixteen of these 46 recommendations (35%) presented an absolute change in risk from a baseline risk. For harms, 65% were presented as absolute risks and 25% as relative risks. For benefits, this was 55% and 48% respectively. CONCLUSION Most recommendations do not present numeric risk information. Of those that do, most do not use absolute risk measures. PRACTICE IMPLICATIONS Obstetrical practice guidelines should present numerical risk information wherever possible to support recommendations, increasing the use of absolute risk formats and absolute changes from baseline risks to increase risk comprehension.
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Affiliation(s)
- Hannah Foggin
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, Canada
| | - Jennifer A Hutcheon
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, Canada
| | - Jessica Liauw
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, Canada.
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7
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Peterwerth NH, Halek M, Schäfers R. Intrapartum risk perception-A qualitative exploration of factors affecting the risk perception of midwives and obstetricians in the clinical setting. Midwifery 2021; 106:103234. [PMID: 34998073 DOI: 10.1016/j.midw.2021.103234] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 12/01/2021] [Accepted: 12/18/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE to gain an in-depth view of the specific risk perception of midwives and obstetricians, in order to achieve a deeper understanding of the situations which midwives and obstetricians perceive as risky and of the factors affecting their risk perception. DESIGN a qualitative approach using focus group discussions was used as part of the first strand within a sequential explorative mixed methods project. PARTICIPANTS 24 midwives and obstetricians providing labour care in the clinical setting ANALYSIS: according to qualitative content analysis. FINDINGS both external and internal factors were identified which potentially influence the risk perception of midwives and obstetricians: (i) the individual perception of the obstetric health professional, (ii) the dyad of obstetric health professional & woman, (iii) being part of a team and (iv) being part of an institution. While risk definitions/classifications and obstetric risk factors were less common topics, structural and organisational factors, such as lack of staff and excessive workload, dominated the discussions about risky situations in the delivery room. KEY CONCLUSION Obstetric health professionals' risk perception is multifactorial and risky situations in the delivery room can be described as a complex construct of various factors. The results suggest that there are different forms of risk perception and different factors which are perceived as risky. IMPLICATIONS FOR PRACTICE Reflection on one's own role and actions should be included in the training of obstetric professionals and also be maintained in everyday professional life.
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Affiliation(s)
- Nina H Peterwerth
- Department of Applied Health Sciences - Midwifery, University of Applied Sciences-Hochschule für Gesundheit, Gesundheitscampus 6-8, 44801 Bochum, Germany; School of Nursing Science, Faculty of Health, Department für Pflegewissenschaft, Fakultät für Gesundheit, Witten/Herdecke University, Stockumer Strasse 12, 58453 Witten, Germany.
| | - Margareta Halek
- School of Nursing Science, Faculty of Health, Department für Pflegewissenschaft, Fakultät für Gesundheit, Witten/Herdecke University, Stockumer Strasse 12, 58453 Witten, Germany
| | - Rainhild Schäfers
- Department of Applied Health Sciences - Midwifery, University of Applied Sciences-Hochschule für Gesundheit, Gesundheitscampus 6-8, 44801 Bochum, Germany
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Coates R. Attitudes of pregnant women and healthcare professionals to labour induction and obtaining consent for labour induction. Best Pract Res Clin Obstet Gynaecol 2021; 77:64-75. [PMID: 34625350 DOI: 10.1016/j.bpobgyn.2021.08.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 08/03/2021] [Accepted: 08/04/2021] [Indexed: 10/20/2022]
Abstract
Induction of labour is experienced by up to one third of women and can be a negative experience, in relation to both the decision about whether to have an induction of labour (IoL) and the experience of the process of IoL. This paper reviews the limited evidence of women's views on and experiences of: information provision; shared decision-making; preferences for method and location of IoL; indications for IoL; pain management; and effective communication and support. Healthcare professionals' views are reviewed, but are underrepresented, and further research is needed to understand experiences of gaining consent for IoL. Systematic review evidence is drawn on where possible, but reviews often found small numbers of papers for inclusion, and provide insights rather than conclusive evidence. Future research would benefit from using validated measures to assess the experience of IoL.
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Affiliation(s)
- Rose Coates
- Centre for Maternal and Child Health Research, School of Health Sciences, City University of London, Northampton Square, London, EC1V 0HB, UK.
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Owen KB, Ibiebele I, Simpson JM, Morton RL, Morris JM, Torvaldsen S. Comparison of costs related to infant hospitalisations for spontaneous, induced and Caesarean births: population-based cohort study. AUST HEALTH REV 2021; 45:418-424. [PMID: 34097850 DOI: 10.1071/ah20237] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 02/16/2021] [Indexed: 12/19/2022]
Abstract
Objective This study examined hospitalisations and associated in-patient costs for babies during the first year of life following spontaneous labour, compared with labour induction or prelabour Caesarean section, at each gestational age. Methods Birth data for singleton liveborn babies from 33 weeks gestation in New South Wales from 2005 to 2014 were linked to hospital and death data. Generalised linear models were used to examine the association between the type of labour and the length of hospitalisations and hospital costs. Results From 2005 to 2014, 598640 women gave birth to 1187451 liveborn singleton babies. The mean total length of hospitalisations and costs of hospitalisations for babies in the first year of life decreased significantly as week of gestational age increased to 39 weeks, then plateaued. Overall, the total length of hospitalisations and hospital costs were significantly (P<0.001) lower for babies born after spontaneous labour (5.6 days and A$8405 respectively) than for babies born following labour induction (6.1 days and A$9452 respectively) or prelabour Caesarean section (8.2 days and A$12320 respectively). Conclusions Babies born following spontaneous labour spend less time in hospital and have lower hospital costs than those born following labour induction or prelabour Caesarean section. Hospitalisations and costs decrease with each week of gestational age until 39 weeks. What is known about the topic? It is known that induction of labour and prelabour Caesarean sections are increasing, and this increase has changed the distribution of gestational age towards birth at earlier ages. It is also known that babies born before 39 weeks of gestation are at increased risk of mortality and morbidity. What does this paper add? This study shows that babies born following spontaneous labour spend the least amount of time in hospital and subsequently have the lowest hospital costs at each week of gestation compared with babies born following labour induction or prelabour Caesarean section. This study also shows a small but significant economic advantage of labour induction compared with prelabour Caesarean delivery. This study quantifies the mean time babies spend in hospital in their first year of life, by week of gestational age and mode of birth. What are the implications for practitioners? The findings from this study can assist clinicians in judicious decision making when balancing the risks and benefits of early planned births. Clinicians can use the results of this study to inform women who are intending to have a planned birth of risks they may not have anticipated, such as the increased risk of rehospitalisation. The finding that hospitalisations and costs continue to decline until 39 weeks gestation can be used to reinforce the importance of continuing the pregnancy beyond 37 weeks if safe to do so, even though 37 weeks is considered term.
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Affiliation(s)
- Katherine B Owen
- The University of Sydney Northern Clinical School, Women and Babies Research, Sydney, NSW, Australia. ; ; ; and Biostatistics Training Program, NSW Ministry of Health, Sydney, NSW, Australia; and SPRINTER, Prevention Research Collaboration, Charles Perkins Centre, School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; and Corresponding author.
| | - Ibinabo Ibiebele
- The University of Sydney Northern Clinical School, Women and Babies Research, Sydney, NSW, Australia. ; ; ; and Northern Sydney Local Health District, Kolling Institute, Sydney, NSW, Australia
| | - Judy M Simpson
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia.
| | - Rachael L Morton
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia.
| | - Jonathan M Morris
- The University of Sydney Northern Clinical School, Women and Babies Research, Sydney, NSW, Australia. ; ; ; and Northern Sydney Local Health District, Kolling Institute, Sydney, NSW, Australia
| | - Siranda Torvaldsen
- The University of Sydney Northern Clinical School, Women and Babies Research, Sydney, NSW, Australia. ; ; ; and Northern Sydney Local Health District, Kolling Institute, Sydney, NSW, Australia; and School of Public Health and Community Medicine, UNSW, Sydney, NSW, Australia
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Farnworth A, Graham RH, Haighton CA, Robson SC. How is high quality research evidence used in everyday decisions about induction of labour between pregnant women and maternity care professionals? An exploratory study. Midwifery 2021; 100:103030. [PMID: 34048941 DOI: 10.1016/j.midw.2021.103030] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 04/29/2021] [Accepted: 05/03/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To explore the use of high quality research evidence in women's and maternity care professionals' decisions about induction of labour (IOL). METHODS A qualitative study underpinned by a social constructionist framework, using semi-structured interviews and generative thematic analysis. SETTING A large tertiary referral maternity unit in northern England in 2013/14. PARTICIPANTS 22 randomly selected health care professionals involved in maternity care (midwives, obstetricians, maternity service managers), and 16 postnatal women, 3-8 weeks post-delivery, who were offered IOL in their most recent pregnancy. FINDINGS Three themes were identified in the data; (1) the value of different forms of knowledge, (2) accessing and sharing knowledge, and (3) constrained pathways and default choices. Findings echo other evidence in suggesting that women do not feel informed about IOL or that they have choices about the procedure. This study illuminates potential explanatory factors by considering the complex context within which IOL is discussed and offered (e.g. presentation of IOL as routine rather than a choice, care pathways that make declining IOL appear undesirable, blanket use of clinical guidelines without consideration of individual circumstances and preferences). KEY CONCLUSIONS This study suggests that organisational, social, and professional factors conspire towards a culture where (a) IOL has become understood as a routine part of maternity care rather than an intervention to make an informed choice about, (b) several factors contribute to demotivate women and health care practitioners from seeking to understand the evidence base regarding induction, and (c) health care professionals can find themselves ill-equipped to discuss the relative risks and benefits of IOL and its alternatives. IMPLICATIONS FOR PRACTICE It is important that IOL is recognised as an optional intervention and is not presented to women as a routine part of maternity care. When IOL is offered it should be accompanied by an evidence informed discussion about the options available to support informed decision making. Health care professionals should be supported to understand the evidence base and our findings suggest that any attempt to facilitate this needs to acknowledge and tackle complex organisational, social and professional influences that contribute to current care practices.
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Affiliation(s)
- Allison Farnworth
- Newcastle University, Level 6, Leazes Wing, Royal Victoria Infirmary. Richardson Road, Newcastle upon Tyne. NE1 7RU, United Kingdom.
| | - Ruth H Graham
- Newcastle University, Level 6, Leazes Wing, Royal Victoria Infirmary. Richardson Road, Newcastle upon Tyne. NE1 7RU, United Kingdom
| | - Catherine A Haighton
- Newcastle University, Level 6, Leazes Wing, Royal Victoria Infirmary. Richardson Road, Newcastle upon Tyne. NE1 7RU, United Kingdom
| | - Stephen C Robson
- Newcastle University, Level 6, Leazes Wing, Royal Victoria Infirmary. Richardson Road, Newcastle upon Tyne. NE1 7RU, United Kingdom
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Dominiek C, Amanda H, Georgina C, Repon P, Angela M, Teena C, Donnolley N. Exploring variation in the performance of planned birth: A mixed method study. Midwifery 2021; 98:102988. [PMID: 33765483 DOI: 10.1016/j.midw.2021.102988] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 12/19/2020] [Accepted: 03/07/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Variation in practice in relation to indications and timing for both induction of labour (IOL) and planned caesarean section (CS) clearly exists. However, the extent of this variation, and how this variation is explained by clinicians remains unclear. The aim of this study was to map the variation in IOL and planned CS at eight Australian hospitals, and understand why variation occurs from the perspective of clinicians at these hospitals. Our ultimate aim was to identify opportunities for improvement as evidenced by hospital data, clinician experiences, and feedback. DESIGN A two-phased mixed method study using sequential explanatory study design. The first phase consisted of an analysis of routinely collected patient data to map variation between hospitals. The second phase consisted of focus groups with clinicians to gain their perspectives on the reasons for variation. SETTING AND PARTICIPANTS Patient data consisted of routine data from 19,073 women giving birth at eight Sydney hospitals between November 2017 and October 2018. Focus groups were attended by a total of 61 medical staff and 121 midwives. RESULTS Hospital data analysis found substantial variation, before and after adjustment for case-mix, in rates of both IOL (adjusted rates 27.6%-42%) and planned CS (adjusted rate 15.4%-22.6%). Planned CS by gestation also showed variation, although after restricting analysis to term (≥37 weeks gestation) births, variation was reduced. At focus groups, five main themes explaining variation emerged: local guidelines, policies and procedures (inconsistency and ambiguity); uncertainty of the evidence/what is best practice (contradictory research and different interpretations of evidence); clinician preferences, beliefs and values; the culture of the unit; and organisational influences (access to specialised clinics, theatre time). KEY CONCLUSIONS Considerable variation in IOL and planned CS, even after case-mix adjustment, was found in this sample of Australian hospitals. Engagement with hospital clinicians identified likely sources of this variation and enabled clinicians at each hospital to consider appropriate local responses to address variation, such as more detailed review of their planned birth cases. IMPLICATIONS FOR PRACTICE At a macro level, measures to reduce unwarranted variation should initially focus on consistent national guidelines, while supporting equitable access to operating theatres for optimal CS timing, and shared decision-making training to reduce influence of clinician preference.
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Affiliation(s)
- Coates Dominiek
- Faculty of Health, University of Technology Sydney, Centre for Midwifery, Child and Family Health, Sydney, Australia; Level 11, Room 131, Building 10, City Campus, PO Box 123 Broadway NSW 2007.
| | - Henry Amanda
- School of Women's and Children's Health, UNSW Medicine, UNSW, Australia; Department of Women's and Children's Health, St George Hospital, Sydney, Australia; The George Institute for Global Health, UNSW Medicine, Australia. .
| | - Chambers Georgina
- National Perinatal Epidemiology and Statistics Unit, Centre for Big Data Research in Health (CBDRH), UNSW, Sydney, Australia. .
| | - Paul Repon
- National Perinatal Epidemiology and Statistics Unit, Centre for Big Data Research in Health (CBDRH), UNSW, Sydney, Australia. .
| | - Makris Angela
- Department of Medicine, Western Sydney University, Australia; Women's Health Initiative Translational Unit (WHITU), Liverpool Hospital, Australia. .
| | - Clerke Teena
- Faculty of Health, University of Technology Sydney, Centre for Midwifery, Child and Family Health, Sydney, Australia. .
| | - Natasha Donnolley
- National Perinatal Epidemiology and Statistics Unit, Centre for Big Data Research in Health (CBDRH), UNSW, Sydney, Australia. .
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Skeith L, Rodger MA, Bates SM, Gonsalves C, Karovitch A, Taylor TS. "Part of the Ritual": Exploring Patient and Physician Decision Making Regarding Anticoagulation Use in Obstetric Antiphospholipid Syndrome. Thromb Haemost 2021; 121:1353-1360. [PMID: 33472256 DOI: 10.1055/a-1366-9261] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Antiphospholipid syndrome is associated with recurrent pregnancy loss. Low-molecular-weight heparin (LMWH) and/or aspirin (ASA) prophylaxis during pregnancy to prevent future loss is based on limited trial data with mixed results. OBJECTIVES Given the clinical equipoise, we sought to understand how patients and physicians navigate the decision-making process for use of LMWH and/or ASA in pregnancy. METHODS We interviewed 10 patients and 10 thrombosis physicians in Ottawa, Canada from January 2017 to March 2018. Patients who had ≥1 late pregnancy loss or ≥2 early losses and persistently positive antiphospholipid antibodies based on the revised Sapporo/Sydney criteria were identified in the a Thrombosis Clinic. Patients were also identified by the TIPPS Study screening logs of excluded patients. Data collection and analysis occurred iteratively, in keeping with constructivist grounded theory methodology. RESULTS Our analysis generated three themes, present across both patient and physician interviews, which captured a patient-led decision-making experience: (1) managing high stakes, (2) accepting uncertainty, and (3) focusing on safety. Patients and physicians acknowledged the high emotional burden and what was at stake: avoiding further pregnancy loss. Patients responded to their situation by taking action (i.e., using LMWH injections became a "ritual"), whereas physicians reacted by removing themselves from the final decision by "[leaving] it up to the patient." CONCLUSION Our findings should be considered when designing future research on studying the role for LMWH/ASA in this population, as it suggests that the perceived benefits of treatment go beyond improving pregnancy rates. Rather, patients described potential benefit from the process of taking action, even in the absence of a guaranteed good outcome.
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Affiliation(s)
- Leslie Skeith
- Division of Hematology and Hematological Malignancies, Department of Medicine, University of Calgary, Calgary, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Canada
| | - Marc A Rodger
- Department of Medicine, McGill University, Montreal, Canada
| | - Shannon M Bates
- Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, Canada
| | - Carol Gonsalves
- Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Alan Karovitch
- Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Taryn S Taylor
- Department of Obstetrics and Gynaecology, Western University, London, Canada
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Dominiek C, Natasha D, Foureur M, Spear V, Amanda H. Exploring unwarranted clinical variation: The attitudes of midwives and obstetric medical staff regarding induction of labour and planned caesarean section. Women Birth 2020; 34:352-361. [PMID: 32674990 DOI: 10.1016/j.wombi.2020.07.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 06/17/2020] [Accepted: 07/07/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND Unexplained clinical variation is a major issue in planned birth i.e. induction of labour and planned caesarean section. AIM To map attitudes and knowledge of maternity care professionals regarding indications for planned birth, and assess inter-professional (midwifery versus medical) and intra-professional variation. METHODS A custom-created survey of medical and midwifery staff at eight Sydney hospitals. Staff were asked to rate their level of agreement with 45 "evidence-based" statements regarding caesareans and inductions on a five-point Likert scale. Responses were grouped by profession, and comparisons made of inter- and intra-professional responses. FINDINGS Total 275 respondents, 78% midwifery and 21% medical. Considerable inter- and intra-professional variation was noted, with midwives generally less likely to consider any of the planned birth indications "valid" compared to medical staff. Indications for induction with most variation in midwifery responses included maternal characteristics (age≥40, obesity, ethnicity) and fetal macrosomia; and for medical personnel in-vitro fertilisation, maternal request, and routine induction at 39 weeks gestation. Indications for caesarean with most variation in midwifery responses included previous lower segment caesarean section, previous shoulder dystocia, and uncomplicated breech; and for medical personnel uncomplicated dichorionic twins. Indications with most inter-professional variation were induction at 41+ weeks versus 42+ weeks and cesarean for previous lower segment caesarean section. DISCUSSION Both inter- and intra-professional variation in what were considered valid indications reflected inconsistency in underlying evidence and/or guidelines. CONCLUSION Greater focus on interdisciplinary education and consensus, as well as on shared decision-making with women, may be helpful in resolving these tensions.
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Affiliation(s)
- Coates Dominiek
- University of Technology Sydney, Faculty of Health, Centre for Midwifery and Child and Family Health, Australia; School of Women's and Children's Health, UNSW Medicine, UNSW, Sydney, Australia.
| | - Donnolley Natasha
- National Perinatal Epidemiology and Statistics Unit, Centre for Big Data Research in Health, UNSW, Sydney, Australia.
| | - Maralyn Foureur
- Hunter New England Nursing and Midwifery Research Centre, Australia; University of Newcastle, Faculty of Health and Medicine, Australia.
| | - Virginia Spear
- Royal Hospital for Women, South Easters Sydney Local Health District, Australia
| | - Henry Amanda
- School of Women's and Children's Health, UNSW Medicine, UNSW, Sydney, Australia; Department of Women's and Children's Health, St George Hospital, Sydney, Australia; The George Institute for Global Health, UNSW Medicine, Australia.
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Examining Cesarean Section Rates in Canada Using the Modified Robson Classification. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2019; 42:757-765. [PMID: 31883751 DOI: 10.1016/j.jogc.2019.09.009] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 09/06/2019] [Accepted: 09/09/2019] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Canada's cesarean delivery (CD) rate continues to increase. The Society of Obstetricians and Gynaecologists of Canada advocates the use of the modified Robson classification for comparisons. This study describes national and provincial CD rates according to this classification system. METHODS All 2016-2017 in-hospital births in Canada (outside Québec) reported to the Discharge Abstract Database were categorized using the modified Robson classification system. CD rates, group size, and contributions of each group to the overall volume of CD were reported. Rates by province and hospital peer group were also examined (Canadian Task Force Classification III). RESULTS A total of 286 201 women gave birth; among these, 83 262 (29.1%) had CDs. Robson group 5 (term singleton previous CD) had a CD rate of 80.5% and was the largest contributing group to the overall number of CD (36.6%). Women whose labour was induced (Robson group 2A) had a CD rate almost double the rate of women with spontaneous labour (Robson group 1): 33.5% versus 18.4%. These latter two groups made the next largest contributions to overall CD (15.7% and 14.1%, respectively). There were substantial variations in CD rates across provinces and among hospital peer groups. CONCLUSION The study found large variations in CD rates across provinces and hospitals within each Robson group, thus suggesting that examining variations to determine the groups contributing the most to CD rates (Robson groups 5, 2A, and 1) may provide valuable insight for reducing CD rates. This study provides a benchmark for measuring the impact of future initiatives to reduce CD rates in Canada.
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Bergholt T, Skjeldestad FE, Pyykönen A, Rasmussen SC, Tapper AM, Bjarnadóttir RI, Smárason A, Másdóttir BB, Klungsøyr K, Albrechtsen S, Källén K, Gissler M, Løkkegaard ECL. Maternal age and risk of cesarean section in women with induced labor at term-A Nordic register-based study. Acta Obstet Gynecol Scand 2019; 99:283-289. [PMID: 31583694 DOI: 10.1111/aogs.13743] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 09/26/2019] [Accepted: 09/30/2019] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Over the last decades, induction of labor has increased in many countries along with increasing maternal age. We assessed the effects of maternal age and labor induction on cesarean section at term among nulliparous and multiparous women without previous cesarean section. MATERIAL AND METHODS We performed a retrospective national registry-based study from Denmark, Finland, Iceland, Norway, and Sweden including 3 398 586 deliveries between 2000 and 2011. We investigated the impact of age on cesarean section among 196 220 nulliparous and 188 158 multiparous women whose labor was induced, had single cephalic presentation at term, and no previous cesarean section. Confounders comprised country, time-period, and gestational age. RESULTS In nulliparous women with induced labor the rate of cesarean section increased from 14.0% in women less than 20 years of age to 39.9% in women 40 years and older. Compared with women aged 25-29 years, the corresponding relative risks were 0.60 (95% confidence interval [95% CI] 0.57 to 0.64) and 1.72 (95% CI 1.66 to 1.79). In multiparous induced women the risk of cesarean section was 3.9% in women less than 20 years rising to 9.1% in women 40 years and older. Compared with women aged 25-29 years, the relative risks were 0.86 (95% CI 0.54 to 1.37) and 1.98 (95% CI 1.84 to 2.12), respectively. There were minimal confounding effects of country, time-period, and gestational age on risk for cesarean section. CONCLUSIONS Advanced maternal age is associated with increased risk of cesarean section in women undergoing labor induction with a single cephalic presentation at term without a previous cesarean section. The absolute risk of cesarean section is 3-5 times higher across 5-year age groups in nulliparous relative to multiparous women having induced labor.
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Affiliation(s)
- Thomas Bergholt
- Clinical Research Unit, Department of Obstetrics and Gynecology, North Zeeland Hospital, University of Copenhagen, Hillerød, Denmark
| | - Finn E Skjeldestad
- Department of Community Medicine, Faculty of Health Sciences, UiT the Arctic University of Norway, Tromsø, Norway
| | - Aura Pyykönen
- Department of Obstetrics and Gynecology, Helsinki University Hospital, Helsinki, Finland
| | - Steen C Rasmussen
- Clinical Research Unit, Department of Obstetrics and Gynecology, North Zeeland Hospital, University of Copenhagen, Hillerød, Denmark
| | - Anna-Maija Tapper
- Hyvinkää Hospital, Hyvinkää, Finland.,University of Helsinki, Helsinki, Finland
| | - Ragnheiður I Bjarnadóttir
- The Icelandic Birth Registry, Akureyri, Iceland.,Institute of Health Science Research, University of Akureyri, Akureyri, Iceland.,Landspitali University Hospital, Reykjavik, Iceland
| | - Alexander Smárason
- Institute of Health Science Research, University of Akureyri, Akureyri, Iceland
| | | | - Kari Klungsøyr
- Division of Mental and Physical Health, Norwegian Institute of Public Health, Bergen, Norway.,Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Susanne Albrechtsen
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.,Haukeland University Hospital, Bergen, Norway
| | - Karin Källén
- Swedish National Board of Health and Welfare, Stockholm, Sweden.,University of Lund, Lund, Sweden
| | - Mika Gissler
- Finnish Institute for Health and Welfare THL, Helsinki, Finland.,Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Stockholm, Sweden
| | - Ellen C L Løkkegaard
- Clinical Research Unit, Department of Obstetrics and Gynecology, North Zeeland Hospital, University of Copenhagen, Hillerød, Denmark
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Lou S, Hvidman L, Uldbjerg N, Neumann L, Jensen TF, Haben JG, Carstensen K. Women's experiences of postterm induction of labor: A systematic review of qualitative studies. Birth 2019; 46:400-410. [PMID: 30561053 DOI: 10.1111/birt.12412] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Revised: 11/19/2018] [Accepted: 11/19/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND Over the last decade, induction of labor (IOL) in postterm pregnancies has increased. Studies have shown the medical advantages of postterm IOL, but less is known about the perspectives of the pregnant women. This review aimed to summarize the current qualitative evidence on women's experience of postterm IOL. METHODS A systematic literature search was performed in three databases. A total of 3193 publications were identified, but only eight studies met the inclusion criteria. Thematic analysis guided the data extraction and synthesis. The Confidence in the Evidence for Reviews of Qualitative research (CERQual) approach was used to assess confidence in the findings. RESULTS Three major findings were identified. First, for some women, IOL required a shift in expectations because the hope of spontaneous labor had to be given up. Second, the IOL decision was considered a recommendation from health care professionals and was experienced as a nondecision. Finally, the induction process was experienced as a sequential set of steps where the women were expected to fit into the existing hospital organization. The CERQual assessment suggested moderate confidence in all findings. DISCUSSION The negative experiences identified in this review can be greatly reduced by a communicative and patient-centered approach. To support informed choice and shared decision making, women need high-quality, unbiased information about IOL, alternative options, and potential outcomes, in addition to time for reflection on their personal values and preferences. Women may need a professionally initiated and supported opportunity to re-evaluate their hopes and expectations before IOL.
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Affiliation(s)
- Stina Lou
- DEFACTUM -Public Health and Health Services Research, Central Denmark Region, Aarhus, Denmark.,Center for Fetal Diagnostics, Department of Obstetrics and Gynaecology, Aarhus University Hospital, Aarhus, Denmark
| | - Lone Hvidman
- Department of Obstetrics and Gynaecology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Niels Uldbjerg
- Department of Obstetrics and Gynaecology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Lone Neumann
- Department of Obstetrics and Gynaecology, Randers Regional Hospital, Randers, Denmark
| | - Trine Fritzner Jensen
- Department of Obstetrics and Gynaecology, Randers Regional Hospital, Randers, Denmark
| | - Joke-Gesine Haben
- Department of Obstetrics and Gynaecology, Aarhus University Hospital, Aarhus, Denmark
| | - Kathrine Carstensen
- DEFACTUM -Public Health and Health Services Research, Central Denmark Region, Aarhus, Denmark
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Induction of labour: Experiences of care and decision-making of women and clinicians. Women Birth 2019; 33:e1-e14. [PMID: 31208865 DOI: 10.1016/j.wombi.2019.06.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 05/31/2019] [Accepted: 06/03/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND There has been a rise in induction of labour over recent decades. There is some tension in the literature in relation to when induction is warranted and when not, with variability between guidelines and practice. Given these tensions, the importance of shared decision-making between clinicians and women is increasingly highlighted as paramount, but it remains unclear to what extent this occurs in routine care. METHOD Using a scoping review methodology, quantitative and qualitative evidence were considered to answer the research question "What are the views, preferences and experiences of women and clinicians in relation to induction of labour more broadly, and practices of decision-making specifically?" To identify studies, the databases PubMed, Maternity and Infant Care, CINAHL and EMBASE were searched from 2008 to 2018, and reference lists of included studies were examined. FINDINGS 20 papers met inclusion criteria, in relation to (a) women's preferences, experiences and satisfaction with IOL; (b) women's experience of shared-decision making in relation to induction; (c) interventions that improve shared decision-making and (d) factors that influence decision-making from the perspective of clinicians. Synthesis of the included studies indicates that decision-making in relation to induction of labour is largely informed by medical considerations. Women are not routinely engaged in the decision making process with expectations and preferences largely unmet. CONCLUSION There is a need to develop strategies such as decision aids, the redesign of antenatal classes, and clinician communication training to improve the quality of information available to women and their capacity for informed decision-making.
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