Variation in and factors associated with timing of low risk, pre-labour repeat caesarean sections in NSW, 2008-2011

Australia's persistently high rate of early-term prelabour Caesarean delivery

Objective To compare the incidence of prelabour Caesarean delivery (PCD) at early term (37 weeks and 0 days (370) to 38 weeks and 6 days (386) of gestation) between Australian states and hospital sectors over time and to compare these rates with those of England and the United States of America (USA). Method A population-based descriptive study of 556040 singleton PCDs at term (370-406 weeks) in all public and private hospitals in Australian states, 2005-16, was performed. The primary outcome was the early-term PCD rate, defined as early-term PCDs as a percentage of all term PCDs. Results Across Australian states, the early-term PCD rate fell from 56.4% in 2005 to 52.0% in 2016. Over a similar period, England's rate fell from 48.2% in 2006-07 to 35.2% in 2016-17, while the USA's rate fell from 47.4% in 2006 to 34.2% in 2016. Australian public hospitals reduced their rate from 54.2% in 2005 to 44.7% in 2016, but the rate increased in private hospitals from 59.1% in 2005 to 62.5% in 2016. There was considerable variation between states and hospital sectors. Conclusions The early-term PCD rate increased in Australian private hospitals from 2005 to 2016. The public hospital rate fell by nearly 10% over the period but remained ~10% above the English and USA national rates. What is known about the topic? Babies born at early term (370-386 weeks) are at greater risk of morbidity than babies born at full term (390-406 weeks). Australia has a persistently high rate of early-term prelabour Caesarean delivery (PCD). What does this paper add? This paper reveals concerning differences in the early-term PCD rate between Australian states and hospital sectors. Further, the paper highlights that both Australian hospital sectors (public and private) have not reduced their rates to levels achieved in England and the USA. What are the implications for practitioners? These results should inform efforts to reduce Australia's early-term PCD rate to prevent harm to babies.

Exploring variation in the performance of planned birth: A mixed method study

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.

Making shared decisions in relation to planned caesarean sections: What are we up to?

OBJECTIVE

To map the literature in relation to shared decision making (SDM) for planned caesarean section (CS), particularly women's experiences in receiving the information they need to make informed decisions, their knowledge of the risks and benefits of CS, the experiences and attitudes of clinicians in relation to SDM, and interventions that support women to make informed decisions.

METHODS

Using a scoping review methodology, quantitative and qualitative evidence was systematically considered. To identify studies, PubMed, Maternity and Infant Care, MEDLINE, and Web of Science were searched for the period from 2008 to 2018.

RESULTS

34 studies were included, with 9750 women and 3313 clinicians. Overall women reported limited SDM, and many did not have the information required to make informed decisions. Clinicians generally agreed with SDM, while recognising it often does not occur. Decision aids and educational interventions were viewed positively by women.

CONCLUSION

Many women were not actively involved in decision-making. Decision aids show promise as a SDM-enhancing tool. Studies that included clinicians suggest uncertainty regarding SDM, although willingness to engage.

PRACTICE IMPLICATIONS

Moving from clinician-led decision-making to SDM for CS has potential to improve patient experiences, however this will require considerable clinician training, and implementation of SDM interventions.

Indications for, and timing of, planned caesarean section: A systematic analysis of clinical guidelines

BACKGROUND

There has been a worldwide rise in planned caesarean sections over recent decades, with significant variations in practice between hospitals and countries. Guidelines are known to influence clinical decision-making and, potentially, unwarranted clinical variation. The aim of this study was to review guidelines for recommendations in relation to the timing and indications for planned caesarean section as well as recommendations around the process of decision-making.

METHOD

A systematic search of national and international English-language guidelines published between 2008 and 2018 was undertaken. Guidelines were reviewed, assessed in terms of quality and extracted independently by two reviewers.

FINDINGS

In total, 49 guidelines of varying quality were included. There was consistency between the guidelines in potential indications for caesarean section, although guidelines vary in terms of the level of detail. There was substantial variation in timing of birth, for example recommended timing of caesarean section for women with uncomplicated placenta praevia is between 36 and 39weeks depending on the guideline. Only 11 guidelines provided detailed guidance on shared decision-making. In general, national-level guidelines from Australia, and overseas, received higher quality ratings than regional guidelines.

CONCLUSION

The majority of guidelines, regardless of their quality, provide very limited information to guide shared decision-making or the timing of planned caesarean section, two of the most vital aspects of guidance. National guidelines were generally of better quality than regional ones, suggesting these should be used as a template where possible and emphasis placed on improving national guidelines and minimising intra-country, regional, variability of guidelines.

Caesarean section in uninsured women in the USA: systematic review and meta-analysis

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.

Planned Birth Before 39 Weeks and Child Development: A Population-Based Study

OBJECTIVE

To investigate the association of gestational age and mode of birth with early child development.

METHODS

Population-based record linkage cohort study was conducted among 153 730 live-born infants of ≥32 weeks' gestation with developmental assessments at school age, in New South Wales, Australia, 2002 to 2007. Children were assessed in 5 domains: physical health and well-being, language and cognition, social competence, emotional maturity, and general knowledge and communication. Children scoring in the bottom 10% of national domains were considered developmentally vulnerable, and children developmentally vulnerable for ≥2 domains were classified as developmentally high risk (DHR), the primary outcome. Robust multivariable Poisson models were used to obtain individual and combined adjusted relative risks (aRRs) of gestational age and mode of birth for DHR children.

RESULTS

Overall, 9.6% of children were DHR. The aRR (95% confidence interval) of being DHR increased with decreasing gestational age (referent: 40 weeks); 32 to 33 weeks 1.25 (1.08-1.44), 34 to 36 weeks 1.26 (1.18-1.34), 37 weeks 1.17 (1.10-1.25), 38 weeks 1.06 (1.01-1.10), 39 weeks 0.98 (0.94-1.02), ≥41 weeks 0.99 (0.94-1.03), and for labor induction or prelabor cesarean delivery (planned birth; referent: vaginal birth after spontaneous labor), 1.07 (1.04-1.11). The combined aRR for planned birth was 1.26 (1.18-1.34) at 37 weeks and 1.13 (1.08-1.19) at 38 weeks.

CONCLUSIONS

Early (at <39 weeks) planned birth is associated with an elevated risk of poor child development at school age. The timing of planned birth is modifiable, and strategies to inform more judicious decision-making are needed to ensure optimal child health and development.