Improving maternal and neonatal outcomes for women with gestational diabetes through continuity of midwifery care: A cross-sectional study

PROBLEM

Gestational Diabetes Mellitus (GDM) is a complication of pregnancy which may exclude women from midwife-led models of care.

BACKGROUND

There is a paucity of research evaluating the safety and feasibility of continuity of midwifery care (CoMC) for women with GDM.

AIM

To investigate the impact of CoMC on maternal and neonatal outcomes, for otherwise low-risk women with GDM.

METHODS

This exploratory cross-sectional study observed maternal and neonatal outcomes including onset of labour, augmentation, labour analgesia, mode of birth, perineal trauma, gestation at birth, shoulder dystocia, infant birth weight, neonatal feeding at discharge.

FINDINGS

Participants were 287 otherwise low-risk pregnant women, who developed GDM, and either received CoMC (n=36) or standard hospital maternity care (non-CoMC) (n=251). Women with GDM who received CoMC were significantly more likely to experience an spontaneous onset of labour (OR 6.3; 95% CI 2.7-14.5; p<.001), labour without an epidural (OR 4.2; 95% CI 2.0 - 9.2,<0.001) and exclusively breastfeed (OR 4.3; 95% CI 1.26 - 14.32; p=0.02).

DISCUSSION

Receiving CoMC may be a public health initiative which not only improves maternal and neonatal outcomes, but also long-term morbidity associated with GDM.

CONCLUSION

Findings provide preliminary evidence suggesting CoMC improves maternal and neonatal outcomes and is likely a safe and viable option for otherwise low-risk women with GDM. Larger studies are recommended to confirm findings and explore the full impact of CoMC for women with GDM.

Likelihood of primary cesarean section following induction of labor in singleton cephalic pregnancies at term, compared with expectant management: An Australian population-based, historical cohort study

INTRODUCTION

There has been increased use of both induction of labor (IOL) and cesarean section for women with term pregnancies in many high-income countries, and a trend toward birth at earlier gestational ages. Existing evidence regarding the association between IOL and cesarean section for term pregnancies is mixed and conflicting, and little evidence is available on the differential effect at each week of gestation, stratified by parity.

MATERIAL AND METHODS

To explore the association between IOL and primary cesarean section for singleton cephalic pregnancies at term, compared with two definitions of expectant management (first: at or beyond the week of gestation at birth following IOL; and secondary: only beyond the week of gestation at birth following IOL), we performed analyses of population-based historical cohort data on women who gave birth in one Australian state (Queensland), between July 1, 2012 and June 30, 2018. Women who gave birth before 37+0 or after 41+6 weeks of gestation, had stillbirths, no-labor, multiple births (twins or triplets), non-cephalic presentation at birth, a previous cesarean section, or missing data on included variables were excluded. Four sub-datasets were created for each week at birth (37-40). Unadjusted relative risk, adjusted relative risk using modified Poisson regression, and their 95% confidence intervals were calculated in each sub-dataset. Analyses were stratified by parity (nulliparas vs. parous women with a previous vaginal birth). Sensitivity analyses were conducted by limiting to women with low-risk pregnancies.

RESULTS

A total of 239 094 women were included in the analysis, 36.7% of whom gave birth following IOL. The likelihood of primary cesarean section following IOL in a Queensland population-based cohort was significantly higher at 38 and 39 weeks, compared with expectant management up to 41+6 weeks, for both nulliparas and paras with singleton cephalic pregnancies, regardless of risk status of pregnancy and definition of expectant management. No significant difference was found for nulliparas at 37 and 40 weeks; and for paras at 40 weeks.

CONCLUSIONS

Future studies are suggested to investigate further the association between IOL and other maternal and neonatal outcomes at each week of gestation in different maternal populations, before making any recommendation.

The financial impact of offering publicly funded homebirths: A population-based microsimulation in Queensland, Australia

BACKGROUND

Despite strong evidence of benefits and increasing consumer demand for homebirth, Australia has failed to effectively upscale it. To promote the adoption and expansion of homebirth in the public health care system, policymakers require quantifiable results to evaluate its economic value. To date, there has been limited evaluation of the financial impact of birth settings for women at low risk of pregnancy complications.

OBJECTIVE

This study aimed to examine the difference in inpatient costs around birth between offering homebirth in the public maternity system versus not offering public homebirth to selected women who meet low-risk pregnancy criteria.

METHODS

We used a whole-of-population linked administrative dataset containing all women who gave birth in Queensland (one Australian State) between 01/07/2012 and 30/06/2018 where publicly funded homebirth is not currently offered. We created a static microsimulation model to compare the inpatient cost difference for mother and baby around birth based on the women who gave birth between 01/07/2017 and 30/06/2018 (n = 36,314). The model comprised of a base model - representing standard public hospital care, and a counterfactual model - representing a hypothetical scenario where 5 % of women who gave birth in public hospitals planned to give birth at home prior to the onset of labour (n = 1816). Costs were reported in 2021/22 AUD.

RESULTS

In our hypothetical scenario, after considering the effect of assumptive place and mode of birth for these planned homebirths, the estimated State-level inpatient cost saving around birth (summed for mother and babies) per pregnancy were: AU$303.13 (to Queensland public hospitals) and AU$186.94 (to Queensland public hospital funders). This calculates to a total cost saving per annum of AU$11 million (to Queensland public hospitals) and AU$6.8 million (to Queensland public hospital funders).

CONCLUSION

A considerable amount of inpatient health care costs around birth could be saved if 5 % of women booked at their local public hospitals, planned to give birth at home through a public-funded homebirth program. This finding supports the establishment and expansion of the homebirth option in the public health care system.

Development, women-centricity and psychometric properties of maternity patient-reported outcome measures (PROMs): A systematic review

BACKGROUND

Measuring maternity care outcomes based on what women value is critical to promoting woman-centred maternity care. Patient-reported outcome measures (PROMs) are instruments that enable service users to assess healthcare service and system performance.

AIM

To identify and critically appraise the risk of bias, woman-centricity (content validity) and psychometric properties of maternity PROMs published in the scientific literature.

METHODS

MEDLINE, CINAHL Plus, PsycINFO and Embase were systematically searched for relevant records between 01/01/2010 and 07/10/2021. Included articles underwent risk of bias, content validity and psychometric properties assessments in line with COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) guidance. PROM results were summarised according to language subgroups and an overall recommendation for use was determined.

FINDINGS

Forty-four studies reported on the development and psychometric evaluation of 9 maternity PROMs, grouped into 32 language subgroups. Risk of bias assessments for the PROM development and content validity showed inadequate or doubtful methodological quality. Internal consistency reliability, hypothesis testing (for construct validity), structural validity and test-retest reliability varied markedly in sufficiency and evidence quality. No PROMs received a level 'A' recommendation, required for real-world use.

CONCLUSION

Maternity PROMs identified in this systematic review had poor quality evidence for their measurement properties and lacked sufficient content validity, indicating a lack of woman-centricity in instrument development. Future research should prioritise women's voices in deciding what is relevant, comprehensive and comprehensible to measure, as this will impact overall validity and reliability and facilitate real-world use.

Development, woman-centricity and psychometric properties of maternity patient-reported experience measures: a systematic review

OBJECTIVE

Valid and reliable maternity patient-reported experience measures are critical to understanding women's experiences of care. They can support clinical practice, health service and system performance measurement, and research. The aim of this review is to identify and critically appraise the risk of bias, woman-centricity (content validity), and psychometric properties of maternity patient-reported experience measures published in the scientific literature.

DATA SOURCES

MEDLINE, CINAHL Plus, PsycINFO, and Embase were systematically searched for relevant records between January 1, 2010 and July 10, 2021.

STUDY ELIGIBILITY CRITERIA

We searched for articles describing the instrument development of maternity patient-reported experience measures and measurement properties associated with instrument validity and reliability testing. Articles that described patient-reported experience measures developed outside of the maternity context and articles that did not contribute to the instruments' development, content validation, and/or psychometric evaluation were excluded.

METHODS

Included articles underwent risk of bias, content validity, and psychometric properties assessments in line with the COSMIN (COnsensus-based Standards for the selection of health Measurement INstruments) guidance. Patient-reported experience measure results were summarized according to language subgroups. An overall recommendation for use was determined for each patient-reported experience measure language subgroup.

RESULTS

A total of 54 studies reported on the development and psychometric evaluation of 25 maternity patient-reported experience measures, grouped into 45 language subgroups. The quality of evidence underpinning the instruments' development was generally poor. Only 2 (4.4%) patient-reported experience measures reported sufficient content validity, and only 1 (2.2%) received a level "A" recommendation, required for real-world use.

CONCLUSION

Maternity patient-reported experience measures demonstrated poor-quality evidence for their measurement properties and insufficient detail about content validity. Future maternity patient-reported experience measure development needs to prioritize women's involvement in deciding what is relevant, comprehensive, and comprehensible to measure. Improving the content validity of maternity patient-reported experience measures will improve overall validity and reliability and facilitate real-world practice improvements. Standardized patient-reported experience measure implementation also needs to be prioritized to support advancements in clinical practice for women.

Cost-effectiveness of public caseload midwifery compared to standard care in an Australian setting: a pragmatic analysis to inform service delivery

BACKGROUND

Decision-makers need quantifiable data on costs and outcomes to determine the optimal mix of antenatal models of care to offer. This study aimed to examine the cost utility of a publicly funded Midwifery Group Practice (MGP) caseload model of care compared to other models of care and demonstrate the feasibility of conducting such an analysis to inform service decision-making.

OBJECTIVE

To provide a methodological framework to determine the value of public midwifery in different settings.

METHODS

Incremental costs and incremental utility (health gains measured in quality-adjusted life years (QALYs)) of public MGP caseload were compared to other models of care currently offered at a large tertiary hospital in Australia. Patient Reported Outcomes Measurement Information System Global Short Form scores were converted into utility values by mapping to the EuroQol 5 dimensions and then converting to QALYs. Costs were assessed from a health system funder's point of view.

RESULTS

There were 85 women in the public MGP caseload care group and 72 received other models of care. Unadjusted total mean cost for mothers' and babies' health service use from study entry to 12 months post-partum was $27 618 for MGP caseload care and $33 608 for other models of care. After adjusting for clinical and demographic differences between groups, total costs were 22% higher (cost ratio: 1.218, P = 0.04) for other models of maternity care. When considering costs to all funders, public MGP caseload care cost $5208 less than other models of care. There was no significant difference in QALY between the two groups (difference: 0.010, 95% CI: -0.038, 0.018).

CONCLUSION

Public MGP caseload care costs 22% less than other models of care, after accounting for differences in baseline characteristics between groups. There were no significant differences in QALYs. Public MGP caseload care produced comparable health outcomes, with some indication that outcomes may be better for lower cost per woman.

Core Outcome Sets Relevant to Maternity Service Users: A Scoping Review

INTRODUCTION

Variation in outcomes reported in maternity-related clinical trials and practice stifles data synthesis and contributes to ineffective or harmful treatments and interventions. Variation can be addressed using core outcome sets (COSs), minimum agreed sets of outcomes that should be measured and reported in all clinical trials in a specific area of health or health care. This scoping review identified studies that developed maternity-related COSs; evaluated the extent, scope, quality, and consistency of outcomes across similar COSs; and identified current gaps in evidence.

METHODS

A multifaceted search of 2 COS registers (Core Outcome Measures in Effectiveness Trials, Core Outcomes in Women's and Newborn Health), the International Consortium for Health Outcomes Measurement website, electronic databases (MEDLINE, Embase, CINAHL), and hand search was conducted. Published, English-language studies describing maternal and neonatal COSs for any health condition and published from inception to January 2020 were included. COS development process was evaluated against recently published COS Standards for Development: scope, stakeholder involvement, and consensus process.

RESULTS

Thirty-two articles relating to 26 COSs were included (maternal: 18 articles that addressed 17 COSs; neonatal: 14 articles that addressed 9 COSs) and covered a range of obstetric and neonatal conditions. COSs were published between 2006 and 2020, 58% since 2017. Maternal COSs included more outcomes (median, 17; range, 50) than neonatal COSs (median, 8; range, 20). Overlap in COSs was seen for maternity care and gestational diabetes. Overlap in outcomes was seen across similar COSs, which were mostly inconsistent or poorly defined. No included COS met all minimum standards for development. Two COSs extended recommendations for how and when to measure outcomes.

DISCUSSION

Growth in COS development in the last 3 years signifies increasing commitment to address variation and improve data synthesis. Although the quality of the development process has improved in the last 3 years, there is a need for improvement. This article presents an urgent need to minimize overlap in outcomes and standardize outcome measurement, case definitions, and timing of measurement between COSs.

Single Item Measure of Social Supports: Evaluation of construct validity during pregnancy

BACKGROUND

Lack of social support during pregnancy is associated with psychosocial vulnerability. The Single Item Measure of Social Supports (SIMSS) is included in a core outcome set to facilitate case-adjustment based on social support. Validity of the SIMSS has not been evaluated in childbearing women. We aimed to evaluate the construct validity of the SIMSS during pregnancy. Secondary aim was to evaluate an alternative short-measure of social support.

METHODS

Recruited women (n = 309) attending antenatal care were invited to complete the SIMSS, Multidimensional Scale of Perceived Social Support (MSPSS), Antenatal Risk Questionnaire (ANRQ), and Edinburgh Postnatal Depression Scale (EPDS). Convergent validity of SIMSS with MSPSS and hypothesis testing for psychosocial risk and depressive symptoms were conducted.

RESULTS

Correlations were moderate between the SIMSS and MSPSS (r_s = .35), but weak between the SIMSS and EPDS (r_s = -.18); and SIMSS and ANRQ (r_s = -.22). In contrast, correlations were moderate between the MSPSS and EPDS (r_s = -.39) and ANRQ (r_s = -.45). A shortened 3-item version of the MSPSS showed good psychometric properties and internal consistency reliability (a = .86).

LIMITATIONS

Findings relate to one Australian birthing sample during pregnancy. Replication of this study in larger, diverse maternity populations, including postpartum is recommended.

CONCLUSIONS

The SIMSS is a poor measure of social support during pregnancy with poor predictive ability to detect maternal vulnerability including depression and psychosocial risk. A revised 3-item version of the MSPSS was found to be a valid and reliable measure of social support.

Comparison of screening accuracy of the Patient Health Questionnaire-2 using two case-identification methods during pregnancy and postpartum

Background

Variation exists regarding perinatal depression screening. A two-step screening method has been recommended. According to a maternity-focused core outcome set developed by the International Consortium for Health Outcomes Measurement, women who score 3 or more on the PHQ-2 then complete the Edinburgh Postnatal Depression Scale (EPDS). Limited evidence exists regarding the screening accuracy of the PHQ-2 in childbearing women. An alternative case-identification method may be more sensitive for perinatal women. We aimed to [1] evaluate the screening accuracy of the PHQ-2 during the perinatal period using two case-identification methods, and [2] measure the variability of accuracy over four time-points during pregnancy and postpartum.

Methods

A prospective, longitudinal cohort study was conducted with 309 consecutive women who completed the PHQ-2 and EPDS during pregnancy (booking, 36-weeks) and postpartum (6-, 26-weeks). EPDS was the reference standard using cut-off scores for ‘at least probable minor depression’ during pregnancy (≥ 13) and postpartum (≥ 10) and for ‘probable major depression’ during pregnancy (≥ 15) and postpartum (≥ 13). PHQ-2 was analysed using two methods: [1] scored (cut-points ≥ 2 and ≥ 3), [2] dichotomous yes/no (positive response to either question) against EPDS cut-points for at least probable minor and probable major depression. Receiver operating characteristic analyses determined accuracy.

Results

Probable major depression: Over four timepoints PHQ-2 ≥ 3 revealed lowest sensitivity (36–79%) but highest specificity (94–98%). An alternative case-identification method revealed high sensitivity (93–100%), but lowest specificity (58–71%). Minor depression: PHQ-2 ≥ 3 revealed the lowest sensitivity (19–50%) but highest specificity (95–98%). An alternative case-identification method revealed the highest sensitivity (81–100%) and moderate specificity (60–74%).

Conclusions

Recommended method of case-identification (PHQ-2 ≥ 3) missed an unacceptable number of women at-risk of depression. As a clinical decision-making tool, an alternative, dichotomous method maximized case-identification and is recommended. Further, the literature identified inconsistent reporting of the PHQ-2 and the alternative case-identification method hindering the ability to synthesise data. The future use and reporting of consistent question wording and response format will improve outcome reporting and synthesis. Further research in larger and diverse maternity populations is recommended.

Measuring physical and mental health during pregnancy and postpartum in an Australian childbearing population - validation of the PROMIS Global Short Form

Background

Health related quality of life is a critical concept during the perinatal period but remains under-researched. The International Consortium for Health Outcomes Measurement have included the Patient Reported Outcomes Measurement Information System (PROMIS®) Global Short Form (GSF) in their core outcome set for pregnancy and childbirth to measure health related quality of life. The PROMIS GSF has not been fully evaluated as a valid and reliable instrument in this population. This study assessed the psychometric properties of the PROMIS GSF during pregnancy and postpartum period.

Methods

PROMIS GSF was administered to a sample of 309 pregnant women at four time-points during pregnancy (≤ 27 and 36-weeks) and postpartum (6- and 26-weeks). The structural validity, internal consistency reliability, construct validity, and responsiveness of the PROMIS GSF were evaluated. The internal structure of the PROMIS GSF was explored using Rasch Measurement Theory. Response format, item fit, differential item functioning (item bias), dimensionality of the scale and its targeting were assessed.

Results

Two revised subscales (Mental Health: four items; and Physical Health: five items) showed good fit to the Rasch model. The revised mental health subscale demonstrated good internal consistency reliability during pregnancy and postpartum period (α = .88 and .87, respectively). The internal consistency reliability of the physical health subscale was adequate (α = .76 and .75, respectively). The revised mental health subscale was sensitive to group differences according to a history of mental health disorder, income, smoking status, drug use, stress levels and planned versus unplanned pregnancy. Differences in scores on the revised physical subscale were detected for groups based on obesity, income, drug use, smoking status, stress, and history of mental health disorders. Scores on both subscales recorded significant changes across the four time-points, spanning pregnancy and postpartum period.

Conclusions

The revised version of the PROMIS GSF was better able to measure mental and physical health during pregnancy and postpartum period compared to the original version. Findings support the clinical and research application of the PROMIS GSF within the International Consortium for Health Outcomes Measurement Standard Set of Outcome Measures for Pregnancy and Childbirth. Ongoing psychometric analysis of the PROMIS GSF is recommended in other maternity populations.

Perinatal incontinence: Psychometric evaluation of the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form and Wexner Scale

AIM

The International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF) and the Wexner Scale have been included in the International Consortium for Health Outcomes Measurement core outcome set during pregnancy and childbirth, to measure urinary and anal incontinence. The reliability and validity of these instruments have not been fully evaluated in maternity populations. The aim of this study was to conduct a psychometric evaluation of the ICIQ-UI SF and Wexner Scale.

METHODS

Consecutive pregnant women (n = 309) who booked for care at one Australian birth facility between August 2017 and April 2018 completed the online surveys. Women who screened positive for urinary and/or anal incontinence were administered the ICIQ-UI SF and/or Wexner Scale during pregnancy ( <27 and 36-weeks) and postpartum (6 and 26-weeks). Scale internal consistency, construct validity, and responsiveness were evaluated.

FINDINGS

In women with urinary incontinence, the ICIQ-UI SF demonstrated good internal consistency during pregnancy (baseline and 36 weeks) and 6-weeks postpartum (mean inter-item correlation: 0.47, 0.39, and 0.46, respectively), recorded significant change across three time-points, and was sensitive to group differences in age and obesity during pregnancy. Wexner Scale was unsuitable for psychometric analysis due to insufficient numbers of women with anal incontinence.

CONCLUSION

The ICIQ-UI SF is a valid and reliable instrument to measure urinary incontinence during pregnancy and postpartum. The findings support the inclusion of the ICIQ-UI SF in the International Consortium for Health Outcomes Measurement core outcome set for use during the perinatal period. Psychometric analysis of the Wexner Scale in larger maternity populations is recommended.

Identifying Barriers and Enablers as a First Step in the Implementation of a Midwife-Led Psychoeducation Counseling Framework for Women Fearful of Birth

BACKGROUND:Around 20% of women report high levels of childbirth fear. An evidence-based psychoeducation intervention delivered by midwives reduced maternal childbirth fear and increased confidence for birth. Implementation of the intervention into practice is now required. Translating evidence into practice, however, remains challenging.

AIM:This study aimed to explore organizational factors, including barriers and possible solutions that may impact on the successful application of the midwife psychoeducation intervention in practice.

METHODS:Mixed methods data collection included a self-administered survey (n= 62), clinician-led focus groups (n= 28), and interviews with key stakeholders (n= 5). Simple descriptive statistics were used to analyze the quantitative data. Latent content analysis was used to analyze the qualitative data.

RESULTS:Midwives were perceived to be best placed to deliver psychoeducation to women fearful of birth. Support for normal birth was high. There was, however, disparity between positive attitudes toward evidence-based practice in theory and its clinical application. Similarly, although the workplace learning culture was generally assessed as positive, many participants believed changing practice was difficult and reported a low sense of agency for challenging or facilitating change. Participants reported that barriers to implementing the evidence included time constraints and heavy workloads. There was a lack of awareness and confidence to implement evidence-based practice (EBP) with participants identifying that resistance to change was often the result of clinician fear and self-interest. The way services were routinely structured was considered problematic as fragmentation actively worked against midwives forming meaningful relationships with women. Enablers included organizational support, education, local champions, and continuity of midwifery care.

CONCLUSION:The study identified the clinicians’ readiness, barriers, and possible solutions to the widespread implementation of an evidence-based psychoeducation intervention delivered by midwives for women fearful of birth at one maternity facility in South East Queensland, Australia. Many of the identified barriers were commensurate with the international literature on translating evidence into practice.

Area law scaling for the entropy of disordered quasifree fermions

We study theoretically and numerically the entanglement entropy of the d-dimensional free fermions whose one-body Hamiltonian is the Anderson model. Using the basic facts of the exponential Anderson localization, we show first that the disorder averaged entanglement entropy ⟨S(Λ)⟩ of the d dimension cube Λ of side length l admits the area law scaling ⟨S(Λ)⟩ ∼ l((d-1)),l ≫ 1, even in the gapless case, thereby manifesting the area law in the mean for our model. For d = 1 and l ≫ 1 we obtain then asymptotic bounds for the entanglement entropy of typical realizations of disorder and use them to show that the entanglement entropy is not self-averaging, i.e., has nonvanishing random fluctuations even if l ≫ 1.

Research priorities of midwives: a Delphi study

The aim of this study was to identify the research priorities of midwives at Gold Coast Hospital (GCH), South East Queensland, Australia. It was also hoped that the study would help foster a culture of inquiry and reflection. Establishing and maintaining a research culture is essential to the provision of high quality maternity services. A two phase Delphi design was used. Fifty eight midwives participated in round one (50 per cent response rate) and 54 in round two (60 per cent response rate). Midwives identified post dates induction of labour and work place culture as areas of research interest.

Level of burnout in a small population of Australian midwives

The aim of the study was to describe the level of burnout in midwives working at a maternity unit in South East Queensland, Australia.

METHOD

A self-administered questionnaire was distributed to all registered midwives (N=110) working at the study site during November 2011. The questionnaire included a demographic survey and the Copenhagen Burnout Inventory. Fifty-eight (52.7%) staff completed the package. Data was entered into SPSS database version 19 and descriptive statistics were used to determine means, ranges and frequencies.

RESULTS

Almost 30% of the sample experienced moderate to high levels of burnout some 50% of participants scored moderate to high for personal burnout with a similar number scoring high for work-related burnout. In comparison, burnout related to working with clients was very low. Differences between participants were associated with years of experience, area of work and employment position (FT/PT, level of position and work area). Participants aged 35years or younger and with less than 10years midwifery experience scored highest on the personal and work-related domains whereas participants over 35years scored highest within the client-related domain. Midwives at level 1 (lowest pay group) scored highest for work-related burnout and client-related burnout. Midwives in more senior positions (level 2 and above) scored highest for personal burnout.

CONCLUSION

Personal and work-related burnout was high in this group of midwives while burnout related to caring for women was low. These results provide insight into the emotional health of midwives in one maternity unit. While more work is needed, strategies to decrease and/or prevent burnout may include clinical mentorship and reorganising models of maternity care to increase work satisfaction and autonomy and strengthen relationships between midwives and women.

Use of a Classification Tool to Determine Groups of Women That Contribute to the Cesarean Section Rate: Establishing a Baseline for Clinical Decision Making and Quality Improvement

OBJECTIVE:To identify the groups of women who are the largest contributors to the cesarean section rate at a maternity facility in South East Queensland, Australia. Examining the characteristics of these women will allow the development of unit-focused initiatives aimed at reducing cesarean sections in these groups of women.

METHOD:A modified version of the Robson Ten Group Classification System was identified as the most appropriate tool to determine cesarean section rates in different groups of women. A prospective clinical audit was then carried out during a 6-month period in 2010 using the tool.

FINDINGS:The Robson Ten Group Classification System identified that planned repeat cesarean section was the largest contributor to the cesarean rate. This was followed by women having their first baby, women having an induction, and women who have a breech presentation at term.

CONCLUSIONS AND IMPLICATIONS:The Robson classification tool was useful in identifying groups of women at risk of a cesarean section. Unit-specific strategies can now be developed and implemented in an effort to lower the rate. These include increasing the vaginal birth after cesarean rate, the uptake of external cephalic version, supporting nonintervention birth environments, and implementing models of care where clinicians are skilled in facilitating normal birth. The value of using such a tool is the ability to monitor change over time as well as facilitating the comparison of data between units of a similar nature.