Interventional radiology in obstetric patients: A population-based record linkage study of use and outcomes

INTRODUCTION

Interventional radiology (IR) is a technique for controlling hemorrhage and preserving fertility for women with serious obstetric conditions such as placenta accreta spectrum (PAS) or postpartum hemorrhage. This study examined maternal, pregnancy and hospital characteristics and outcomes for women receiving IR in pregnancy and postpartum.

MATERIAL AND METHODS

A population-based record linkage study was conducted, including all women who gave birth in hospital in New South Wales or the major tertiary hospital in the neighboring Australian Capital Territory, Australia, between 2003 and 2019. Data were obtained from birth and hospital records. Characteristics and outcomes of women who underwent IR in pregnancy or postpartum are described. Outcomes following IR were compared in a high-risk cohort of women: those with PAS who had a planned cesarean with hysterectomy. Women were grouped by those who did and those who did did not have IR and were matched using propensity score and other factors.

RESULTS

We identified IR in 236 pregnancies of 1 584 708 (15.0 per 100 000), including 208 in the delivery and 26 in a postpartum admission. Two-thirds of women receiving IR in the birth admission received a transfusion of red cells or blood products, 28% underwent hysterectomy and 12.5% were readmitted within 6 weeks. Other complications included: severe maternal morbidity (29.8%), genitourinary tract trauma/repair (17.3%) and deep vein thrombosis/pulmonary embolism (4.3%). Outcomes for women with PAS who underwent planned cesarean with hysterectomy were similar for those who did and did not receive IR, with a small reduction in transfusion requirement for those who received IR.

CONCLUSIONS

Interventional radiology is infrequently used in pregnant women. In our study it was performed at a limited number of hospitals, largely tertiary centers, with the level of adverse outcomes reflecting use in a high-risk population. For women with PAS undergoing planned cesarean with hysterectomy, most outcomes were similar for those receiving IR and those not receiving IR, but IR may reduce bleeding.

Benefits of not smoking during pregnancy for non-Aboriginal women and their babies in New South Wales, Australia: a record linkage study

BACKGROUND

Smoking rates among pregnant women in New South Wales (NSW) have plateaued at 8-9%. To inform relevant smoking reduction efforts, we aimed to quantify the benefits of not smoking during pregnancy for non-Aboriginal NSW mothers and their babies. The benefits of not smoking during pregnancy for NSW Aboriginal mothers have previously been described. These data are important inputs in modelling health and economic impacts of smoking cessation interventions.

METHODS

This population-based cohort study used linked-data from routinely collected data sets. Not smoking during pregnancy was the exposure of interest among all NSW non-Aboriginal women who became mothers of singleton babies in 2012-2016. Unadjusted and adjusted relative risks (aRR) were used to examine associations between not smoking during pregnancy and adverse outcomes including severe morbidity, inter-hospital transfer, perinatal death, preterm birth and small-for-gestational age. Population attributable fractions (PAFs) were calculated to quantify adverse perinatal outcomes avoided in the population if all mothers were non-smokers.

RESULTS

Compared with babies born to mothers who smoked during pregnancy, babies born to non-smoking mothers had a lower risk of all adverse perinatal outcomes including perinatal death (aRR = 0.68, 95%CI 0.61-0.76), preterm birth (aRR = 0.58, 95%CI 0.56-0.61) and small-for-gestational age (aRR = 0.48, 95%CI 0.47-0.50). PAFs(%) were 3.9% for perinatal death, 5.6% for preterm birth and 7.3% for small-for-gestational-age. Compared with women who smoked during pregnancy (n = 36,518), those who did not smoke (n = 413,072) had a lower risk of suffering severe maternal morbidity (aRR = 0.87, 95%CI 0.81-0.93) and being transferred to another hospital (aRR = 0.92, 95%CI 0.86-0.99).

CONCLUSIONS

Mothers who reported not smoking during pregnancy had a small reduction in their risk of morbidity and of being transferred to another hospital whilst their babies had substantially reduced risks of all adverse perinatal outcomes. Results have implications for clinician training, clinical care standards, and performance management.

Validation of anaemia, haemorrhage and blood disorder reporting in hospital data in New South Wales, Australia

OBJECTIVE

Hospital data are a useful resource for studying pregnancy complications, including bleeding-related conditions, however, the reliability of these data is unclear. This study aims to examine reliability of reporting of bleeding-related conditions, including anaemia, obstetric haemorrhage and blood disorders, and procedures, such as blood transfusion and hysterectomy, in coded hospital records compared with obstetric data from two large tertiary hospitals in New South Wales.

RESULTS

There were 36,051 births between 2011 and 2015 included in the analysis. Anaemia and blood disorders were poorly reported in the hospital data, with sensitivity ranging from 2.5% to 24.8% (positive predictive value (PPV) 12.0-82.6%). Reporting of postpartum haemorrhage, transfusion and hysterectomy showed high sensitivity (82.8-96.0%, PPV 78.0-89.6%) while moderate consistency with the obstetric data was observed for other types of obstetric haemorrhage (sensitivity: 41.9-65.1%, PPV: 50.0-56.8%) and placental complications (sensitivity: 68.2-81.3%, PPV: 20.3-72.3%). Our findings suggest that hospital data may be a reliable source of information on postpartum haemorrhage, transfusion and hysterectomy. However, they highlight the need for caution for studies of anaemia and blood disorders, given high rates of uncoded and 'false' cases, and suggest that other sources of data should be sought where possible.

Reporting of gestational diabetes and other maternal medical conditions: validation of routinely collected hospital data from New South Wales, Australia

Introduction

Hospital datasets are a valuable resource for examining prevalence and outcomes of medical conditions during pregnancy. To enable effective research and health planning, it is important to determine whether variables are reliably captured.

Objective

To examine the reliability of reporting of gestational and pre-existing diabetes, hypertension, thyroid conditions, and morbid obesity in coded hospital records that inform the population-level New South Wales Admitted Patient Data Collection.

Methods

Coded hospital admission data from two large tertiary hospitals in New South Wales, from 2011 to 2015, were compared with obstetric data, collected by midwives at outpatient pregnancy booking and in hospital after birth, as the reference standard. Records were deterministically linked and sensitivity, specificity, positive predictive values and negative predictive values for the conditions of interest were obtained.

Results

There were 36,051 births included in the analysis. Sensitivity was high for gestational diabetes (83.6%, 95% CI 82.4–84.7%), pre-existing diabetes (88.2%, 95% CI 84.1–91.6%), and gestational hypertension (80.1%, 95% CI 78.2–81.9%), moderate for chronic hypertension (53.5%, 95% CI 47.8–59.1%), and low for thyroid conditions (12.9%, 95% CI 11.7–14.2%) and morbid obesity (9.8%, 95% CI 7.6–12.4%). Specificity was high for all conditions (≥97.8%, 95% CI 97.7–98.0) and positive predictive value ranged from 53.2% for chronic hypertension (95% CI 47.5–58.8%) to 92.7% for gestational diabetes (95% CI 91.8–93.5%).

Conclusion

Our findings suggest that coded hospital data are a reliable source of information for gestational and pre-existing diabetes and gestational hypertension. Chronic hypertension is less consistently reported, which may be remedied by grouping hypertension types. Data on thyroid conditions and morbid obesity should be used with caution, and if possible, other sources of data for those conditions should be sought.

Rates of neonatal morbidity by maternal region of birth and gestational age in New South Wales, Australia 2003-2016

INTRODUCTION

Research suggests that neonatal morbidity differs by maternal region of birth at different gestational ages. This study aimed to determine the overall and gestation-specific risk of neonatal morbidity by maternal region of birth, after adjustment for maternal, infant and birth characteristics, for women giving birth in New South Wales, Australia, from 2003 to 2016.

MATERIAL AND METHODS

The study utilized a retrospective cohort study design using linked births, hospital and deaths data. Modified Poisson regression was used to determine risk with 95% confidence intervals (95% CI) of neonatal morbidity by maternal region of birth, overall and at each gestational age, compared with Australian or New Zealand-born women giving birth at 39 weeks.

RESULTS

There were 1 074 930 live singleton births ≥32 weeks' gestation that met the study inclusion criteria, and 44 394 of these were classified as morbid, giving a neonatal morbidity rate of 4.13 per 100 live births. The gestational age-specific neonatal morbidity rate declined from 32 weeks' gestation, reaching a minimum at 39 weeks in all maternal regions of birth. The unadjusted neonatal morbidity rate was highest in South Asian-born women at most gestations. Adjusted rates of neonatal morbidity between 32 and 44 weeks were significantly lower for babies born to East (adjusted relative risk [aRR] 0.65, 95% CI 0.62-0.68), South-east (aRR 0.76, 95% CI 0.73-0.79) and West Asian-born (aRR 0.93, 95% CI 0.88-0.98) mothers, and higher for babies of Oceanian-born (aRR 1.11, 95% CI 1.04-1.18) mothers, compared with Australian or New Zealand-born mothers. Babies of African, Oceanian, South Asian and West Asian-born women had a lower adjusted risk of neonatal morbidity than Australian or New Zealand-born women until 37 or 38 weeks' gestation, and thereafter an equal or higher risk in the term and post-term periods.

CONCLUSIONS

Maternal region of birth is an independent risk factor for neonatal morbidity in New South Wales.

Determining a strategy to reduce smoking in pregnancy

BACKGROUND

Further efforts, informed by current data, are needed to reduce smoking during pregnancy.

AIMS

To describe trends in smoking during pregnancy and identify regions most likely to benefit from targeted smoking cessation interventions, in New South Wales (NSW), Australia.

MATERIALS AND METHODS

All women who gave birth in NSW between 1994 and 2016 were included. Smoking status was identified from the Perinatal Data Collection. For births between 2012 and 2016, women were grouped into Local Health District (LHD) of residence, and smoking rates calculated. The impacts of a hypothetical smoking cessation intervention in four LHDs with (i) high smoking rates and (ii) high numbers of smokers, were compared.

RESULTS

The overall smoking rate during pregnancy decreased from 22.1% in 1994 to 8.3% in 2016. [Correction added on 13 August 2020, after first online publication: the overall smoking rate during pregnancy in 1994 has been corrected from 14.5% to 22.1%.]. The decrease was lowest among women living in the most socioeconomically disadvantaged areas (41%) and highest among those living in the most advantaged areas (83%). Between 2012 and 2016, over half the women who smoked during pregnancy lived in one of four LHDs. Only 1% of women reporting smoking during pregnancy resided in the LHD with the highest smoking rate (34.7%). A simulated intervention targeting only four regions showed greater effect on the statewide smoking rate when targeting LHDs with high numbers of smokers rather than high smoking rates.

CONCLUSIONS

Despite decreases in rates of smoking during pregnancy, there was evidence of geographic clustering of smokers. The greatest reduction in overall smoking may come from interventions targeting the four LHDs with the highest number of smokers.

The association between haemoglobin levels in the first 20 weeks of pregnancy and pregnancy outcomes

BACKGROUND

Low haemoglobin has been linked to adverse pregnancy outcomes. Our study aimed to assess the association of haemoglobin (Hb) in the first 20 weeks of pregnancy, and restoration of low Hb levels, with pregnancy outcomes in Australia.

METHODS

Clinical data for singleton pregnancies from two tertiary public hospitals in New South Wales were extracted for 2011-2015. The relationship between the lowest Hb result in the first 20 weeks of pregnancy and adverse outcomes was determined using adjusted Poisson regression. Those with Hb <110 g/L were classified into 'restored' and 'not restored' based on Hb results from 21 weeks onwards, and risk of adverse outcomes explored with adjusted Poisson regression.

RESULTS

Of 31,906 singleton pregnancies, 4.0% had Hb <110 and 10.2% had ≥140 g/L at ≤20 weeks. Women with low Hb had significantly higher risks of postpartum haemorrhage, transfusion, preterm birth, very low birthweight, and having a baby transferred to higher care or stillbirth. High Hb was also associated with higher risks of preterm, very low birthweight, and transfer to higher care/stillbirth. Transfusion was the only outcome where risk decreased with increasing Hb. Risk of transfusion was significantly lower in the 'restored' group compared with the 'not restored' group (OR 0.39, 95% CI 0.22-0.70), but restoration of Hb did not significantly affect the other outcomes measured.

CONCLUSIONS

Women with both low and high Hb in the first 20 weeks of pregnancy had higher risks of adverse outcomes than those with normal Hb. Restoring Hb after 20 weeks did not improve most adverse outcome rates but did reduce risk of transfusion.

Mortality and hospital readmissions in the first year of life after intra-uterine and neonatal blood product transfusions: A population data linkage study

AIM

Blood product transfusions are a potentially life-saving therapy for fetal and neonatal anaemia, but there is limited population-based research on outcomes. We aimed to describe mortality, readmission and average hospital stay in the first year of life for infants with or without intra-uterine or neonatal blood product transfusions.

METHODS

Linked birth, hospital and deaths data from New South Wales, Australia (January 2002-June 2014) were used to identify singleton infants (≥23 weeks' gestation, surviving to 29 days; n = 1 089 750) with intra-uterine or neonatal transfusion or no transfusion. Rates of mortality and readmission in the first year (29-365 days) and days in hospital were calculated.

RESULTS

Overall, 68 (0.06/1000) infants had experienced intra-uterine transfusion and 4332 (3.98/1000) neonatal transfusion. Transfusion was more common among those born at earlier gestational ages requiring invasive ventilation. Mortality, readmissions and average days in hospital were higher among transfused than non-transfused infants. Over half of infants with intra-uterine and neonatal transfusion had ≥1 readmission in the first 29-365 days (55.9 and 51.8%, respectively), and around a quarter had ≥2 (20.6 and 28.5%, respectively) compared with 15.3% with ≥1 and 3.5% with ≥2 in the non-transfused group.

CONCLUSION

Infants with a history of blood product transfusion, particularly those needing a neonatal transfusion, had higher mortality and more frequent contact with the hospital system in the first year of life than those infants with no history of transfusion.

Comparison of group O Rh(D)- red blood cell use in pregnant women across hospitals of various sizes and obstetric capabilities prior to the introduction of patient blood management guidelines

BACKGROUND

O Rh(D)- red blood cell (RBC) units can generally be transfused to most patients regardless of their ABO blood type and are frequently used during emergency situations. Detailed usage patterns of O Rh(D)- RBC units in obstetric populations have not been well characterised. With the introduction of patient blood management guidelines, historical usage patterns are important for providing comparative data.

AIMS

To determine how the use of O Rh(D)- RBC units in pregnant women differs between hospitals of different sizes and obstetric capabilities prior to patient blood management guidelines.

METHODS

Data from 67 New South Wales public hospital blood banks were linked with hospital and perinatal databases to identify RBC transfusions during pregnancy, birth and postnatally between July 2006 and December 2010. RBC transfusions were divided into O Rh(D)- or other blood types. Hospitals were classified according to birth volume, obstetric capability and location, with transfusions classified by timing and diagnosis.

RESULTS

Of the 12 078 RBC units transfused into pregnant women, 1062 (8.8%) were O Rh(D)-. Higher use of O Rh(D)- RBC units was seen in antenatal transfusions, preterm deliveries and in regional or smaller hospitals. There was wide variation in rates of O Rh(D)- RBC transfusion among hospitals.

CONCLUSIONS

The rate of O Rh(D)- RBC unit use in obstetrics was lower during the period assessed than the nationally reported usage. It is encouraging that O Rh(D)- RBCs were more commonly used in emergency or specialised situations, or in facilities where holding a large blood inventory is not feasible.

Educational outcomes for children with cerebral palsy: a linked data cohort study

AIM

To identify a cohort of children with cerebral palsy (CP) from hospital data; determine the proportion that participated in standardized educational testing and attained a score within the normal range; and describe the relationship between test results and motor symptoms.

METHOD

This population-based retrospective cohort study used data from New South Wales, Australia. We linked hospital data for children younger than 16 years of age admitted between 1st July 2000 and 31st March 2014 to education data from 2009 to 2014. Hospital diagnosis codes were used to identify a cohort of children with CP (n=3944) and describe their motor symptoms. Educational outcomes in the CP cohort were compared with those among children without CP.

RESULTS

Of those with educational data (n=1770), 46% were exempt from reading assessment because of intellectual or functional disability, 7% were absent or withdrawn from testing and 47% participated in testing. About 30% of all children with educational data had test scores in the normal range. The proportion was greatest among those with hemiplegia (>40%) and lowest among those with tetraplegia (<10%).

INTERPRETATION

One-third of children with CP participated in standardized testing and achieved a result in the normal range. The proportions were lower in children with more severe motor symptoms.

WHAT THIS PAPER ADDS

From 2009 to 2014, most Australian children with cerebral palsy (CP) attended a mainstream school. The rate of disability-related exemption from standardized educational testing was almost 50%. Thirty per cent of children with CP achieved educational scores in the normal range.

Comparison of neonatal red cell transfusion reporting in neonatal intensive care units with blood product issue data: a validation study

BACKGROUND

Infants in Neonatal Intensive Care Units represent a heavily transfused population, and are the focus of much research interest. Such research commonly relies on custom research databases or routinely collected data. Knowledge of the accuracy of transfusion recording in these databases is important. This study aims to assess the reporting of red blood cell transfusion neonatal intensive care unit data compared with routinely collected hospital blood bank ("Blood Watch") data.

METHODS

Blood Watch data was linked with the NICUS Data Collection, and with routinely collected birth and hospital data for births between 2007 and 2010. The sensitivity, specificity, and positive and negative predictive values for transfusion were calculated, compared to the Blood Watch data. The agreement between the NICUS and Blood Watch datasets on quantity transfused was also assessed.

RESULTS

Data was available on 3934 infants, of which 16.2% were transfused. Transfusion was reported in the NICUS Data Collection with high specificity (98.3%, 95% confidence interval (97.8%,98.7%)), but with some under-enumeration (sensitivity 89.2% (95% CI 86.5%,91.5%)). There was excellent agreement between the NICUS and Blood Watch datasets on quantity transfused (Kappa 0.90, 95% CI (0.88,0.92)). Transfusion reporting in the hospital data for these infants was also reliably reported (Sensitivity 83.7% (95% CI 80.6%,86.5%), specificity 99.1% (95% CI 98.7%,99.4%)).

CONCLUSIONS

Transfusion is reliably reported in the neonatal intensive care unit data, with some under-reporting, and quantity transfused is well recorded. The NICUS Data Collection provides useful information on blood transfusions, including quantity of blood transfused in a high risk population.

Assessing the Accuracy of Reporting of Maternal Red Blood Cell Transfusion at Birth Reported in Routinely Collected Hospital Data

Introduction Hospital administrative data collections have been used to describe transfusion practice, particularly in relation to the maternity population. Knowledge of the accuracy of this data is important in order to interpret the results of such studies. The aim of this study was to compare the accuracy of reporting of red cell transfusion around childbirth within hospital data with data submitted by hospital blood banks. Methods Linked hospital and birth data from New South Wales, Australia, between June 2006 and December 2010 were used to identify blood transfusions occurring at delivery. This reporting was compared with the gold standard of blood pack level information submitted by hospital blood banks, and sensitivity, specificity, and positive and negative predictive values calculated. Reporting related to quantity and timing of transfusion were also considered. Results Data were available for 235,796 births, with blood bank data identifying that 2.0 % of received a blood transfusion. Overall the sensitivity of hospital data for identifying transfusion was 84.8 % (95 % CI 83.7 %, 85.8 %) with specificity 99.9 % (99.9 %, 99.9 %). Sensitivity was better for births involving a postpartum haemorrhage [Sn 90.9 % (89.9 %, 91.9 %)], and poorer for births in regional hospitals [Sn 78.8 % (76.0 %, 81.5 %)]. Almost all (96 %) transfusions of 10 or more units were identified in hospital data, and there was no difference in reporting depending on whether the transfusion was on the baby's date of birth or not. Discussion The reliability of hospital reporting of transfusion in maternity patients is high, however with some underreporting of cases.

Triggers for Preeclampsia Onset: a Case-Crossover Study

BACKGROUND

Risk factors for preeclampsia are well established, whereas, the triggers associated with timing of preeclampsia onset are not. The aim of this study was to establish whether recent infection or other triggers were associated with timing of preeclampsia onset.

METHODS

We used a case-crossover design with preeclampsia cases serving as their own controls. Women with singleton pregnancies of ≥20 weeks gestation presenting at three hospitals were eligible for inclusion. Exposures to potential triggers were identified via guided questionnaire. Infective episodes included symptoms lasting >24 h. Preeclampsia was defined as hypertension (BP ≥140 mmHg and/or ≥90 mmHg) and proteinuria (protein/creatinine ratio ≥30 mg/mmol). Conditional logistic regression was used to compare the odds of exposure to potential triggers in the case windows (1-7 days preceding diagnosis of preeclampsia) and control windows (8-14 days prior to diagnosis); unadjusted odds ratios (ORs) are reported.

RESULTS

Among 286 recruited women, 25 (8.7%) reported a new infection in the 7 days prior to preeclampsia onset and 21 (7.3%) in the 8-14 days prior. There was no significant association between onset of infection in the 7 days prior and preeclampsia diagnosis (OR 1.24, 95% CI 0.65, 2.34). Consumption of caffeine (OR 0.51, 95% CI 0.33, 0.77), spicy food (OR 0.49, 95% CI 0.30, 0.81), and alcohol (OR 0.26, 95% CI 0.10, 0.71) were strongly inversely associated with preeclampsia onset.

CONCLUSION

Recent infection does not appear to trigger preeclampsia. Decreased consumption of caffeine, spicy food, and alcohol may be prodromal markers. Such behaviours may be early markers of imminent preeclampsia.

Use of propensity score methods to address adverse events associated with the storage time of blood in an obstetric population: a comparison of methods

Background

A recent topic of interest in the blood transfusion literature is the existence of adverse effects of transfusing red cells towards the end of their storage life. This interest has been sparked by conflicting results in observational studies, however a number of methodological difficulties with these studies have been noted. One potential strategy to address these difficulties is the use of propensity scores, of which there are a number of possible methods. This study aims to compare the traditional methods for binary exposures with more recently developed generalised propensity score methods.

Methods

Data were obtained from probabilistically linked hospital, births and blood bank databases for all women giving birth from 23 weeks gestation in New South Wales, Australia, between July 2006 and December 2010 with complete information on the birth admission and blood issued. Analysis was restricted to women who received 1–4 units of red cells. Three different propensity score methods (for binary, ordinal and continuous exposures) were compared, using each of four different approaches to estimating the effect (matching, stratifying, weighting and adjusting by the propensity score). Each method was used to determine the effect of blood storage time on rates of severe morbidity and readmission or transfer.

Results

Data were available for 2990 deliveries to women receiving 1–4 units of red cells. The rate of severe maternal morbidity was 3.7 %, and of readmission or transfer was 14.4 %. There was no association between blood storage time and rates of severe morbidity or readmission irrespective of the approach used. There was no single optimal propensity score method; the approaches differed in their ease of implementation and interpretation.

Conclusions

Within an obstetric population, there was no evidence of an increase in adverse events following transfusion of older blood. Propensity score methods provide a useful tool for addressing the question of adverse events with increasing storage time of blood, as these methods avoid many of the pitfalls of previous studies. In particular, generalised propensity scores can be used in situations where the exposure is not binary.

Immediate delivery compared with expectant management after preterm pre-labour rupture of the membranes close to term (PPROMT trial): a randomised controlled trial

BACKGROUND

Preterm pre-labour ruptured membranes close to term is associated with increased risk of neonatal infection, but immediate delivery is associated with risks of prematurity. The balance of risks is unclear. We aimed to establish whether immediate birth in singleton pregnancies with ruptured membranes close to term reduces neonatal infection without increasing other morbidity.

METHODS

The PPROMT trial was a multicentre randomised controlled trial done at 65 centres across 11 countries. Women aged over 16 years with singleton pregnancies and ruptured membranes before the onset of labour between 34 weeks and 36 weeks and 6 days weeks who had no signs of infection were included. Women were randomly assigned (1:1) by a computer-generated randomisation schedule with variable block sizes, stratified by centre, to immediate delivery or expectant management. The primary outcome was the incidence of neonatal sepsis. Secondary infant outcomes included a composite neonatal morbidity and mortality indicator (ie, sepsis, mechanical ventilation ≥24 h, stillbirth, or neonatal death); respiratory distress syndrome; any mechanical ventilation; and duration of stay in a neonatal intensive or special care unit. Secondary maternal outcomes included antepartum or intrapartum haemorrhage, intrapartum fever, postpartum treatment with antibiotics, and mode of delivery. Women and caregivers could not be masked, but those adjudicating on the primary outcome were masked to group allocation. Analyses were by intention to treat. This trial is registered with the International Clinical Trials Registry, number ISRCTN44485060.

FINDINGS

Between May 28, 2004, and June 30, 2013, 1839 women were recruited and randomly assigned: 924 to the immediate birth group and 915 to the expectant management group. One woman in the immediate birth group and three in the expectant group were excluded from the primary analyses. Neonatal sepsis occurred in 23 (2%) of 923 neonates whose mothers were assigned to immediate birth and 29 (3%) of 912 neonates of mothers assigned to expectant management (relative risk [RR] 0·8, 95% CI 0·5-1·3; p=0·37). The composite secondary outcome of neonatal morbidity and mortality occurred in 73 (8%) of 923 neonates of mothers assigned to immediate delivery and 61 (7%) of 911 neonates of mothers assigned to expectant management (RR 1·2, 95% CI 0·9-1·6; p=0·32). However, neonates born to mothers in the immediate delivery group had increased rates of respiratory distress (76 [8%] of 919 vs 47 [5%] of 910, RR 1·6, 95% CI 1·1-2·30; p=0·008) and any mechanical ventilation (114 [12%] of 923 vs 83 [9%] of 912, RR 1·4, 95% CI 1·0-1·8; p=0·02) and spent more time in intensive care (median 4·0 days [IQR 0·0-10·0] vs 2·0 days [0·0-7·0]; p<0·0001) compared with neonates born to mothers in the expectant management group. Compared with women assigned to the immediate delivery group, those assigned to the expectant management group had higher risks of antepartum or intrapartum haemorrhage (RR 0·6, 95% CI 0·4-0·9), intrapartum fever (0·4, 0·2-0·9), and use of postpartum antibiotics (0·8, 0·7-1·0), and longer hospital stay (p<0·0001), but a lower risk of caesarean delivery (RR 1·4, 95% CI 1·2-1·7).

INTERPRETATION

In the absence of overt signs of infection or fetal compromise, a policy of expectant management with appropriate surveillance of maternal and fetal wellbeing should be followed in pregnant women who present with ruptured membranes close to term.

FUNDING

Australian National Health and Medical Research Council, the Women's and Children's Hospital Foundation, and The University of Sydney.

Trends and outcomes of postpartum haemorrhage, 2003-2011

BACKGROUND

While rates of postpartum haemorrhage (PPH) have continued to rise, it is not clear if the association with other morbidity and transfusion has changed over time. This study explores the recent trend in postpartum haemorrhage and whether postpartum haemorrhage is associated with increased transfusions or adverse outcomes over time.

METHODS

Linked birth and hospital data were used to examine ICD-10 AM coded PPH and outcomes in maternal birth admission records, 2003--2011 in hospitals in New South Wales (NSW), Australia (N = 818,965 pregnancies). Trends were calculated on the whole population, and among subgroups, and tested using the Cochran Armitage test for trend. Logistic regression models were developed separately for vaginal and caesarean births, and for a maternal morbidity composite indicator (excluding transfusion) and red cell transfusion. Adjusted odds ratios (aOR) for each year relative to 2003 and 95% confidence intervals (CI) are presented with adjustment for maternal (eg. age, country of birth) and pregnancy factors (eg. parity, interventions, pregnancy complications).

RESULTS

Overall, there was a significant increase in the PPH rate, from 6.1% in 2003 to 8.3% in 2011 (p < 0.0001). Crude rates of postpartum haemorrhage with transfusion increased from 0.75% (n = 636) to 1.21% (n = 1145) (p < 0.0001) while crude rates of postpartum haemorrhage with maternal morbidity increased from 0.18% (n = 149) to 0.23% (n = 221) (p = 0.02). Having accounted for maternal and pregnancy factors, there were significant overall decreases in the odds of morbidity among women with a PPH delivering vaginally (in 2006, 2007 and 2010, aORs were 0.70 (95 % CI 0.52, 0.96) 0.69 (0.51, 0.94) and 0.64 (0.47, 0.87) relative to 2003; p < 0.05), and no significant decrease among women delivered by caesarean section (aOR 0.87 (0.58, 1.29) in 2011; p = 0.37). Among women with a PPH delivering vaginally, there was a trend towards a non-linear increase in the adjusted odds of transfusion by birth year. Compared to women who had vaginal births with PPH in 2003, the adjusted odds for transfusion was between 1.1 and 1.2 fold higher for those with a PPH delivering vaginally in 2007, 2009, 2010 and 2011. However there was no significant trend amongst caesarean births (aOR 0.84 (0.66, 1.06) in 2011; p = 0.29).

CONCLUSIONS

PPH has become more frequent, however this has not been associated with a clear pattern of increased severe maternal morbidity. This suggests that the increase in PPH may represent fewer severe haemorrhages, better management of severe haemorrhage or better recording of PPH. The increase in transfusions following vaginal births with PPH warrants further investigation.

Pre-notification letter type and response rate to a postal survey among women who have recently given birth

BACKGROUND

Surveys are commonly used in health research to assess patient satisfaction with hospital care. Achieving an adequate response rate, in the face of declining trends over time, threatens the quality and reliability of survey results. This paper evaluates a strategy to increase the response rate in a postal satisfaction survey with women who had recently given birth.

METHODS

A sample of 2048 Australian women who had recently given birth at seven maternity units in New South Wales were invited to participate in a postal survey about their recent experiences with maternity care. The study design included a randomised controlled trial that tested two types of pre-notification letter (with or without the option of opting out of the survey). The study also explored the acceptability of a request for consent to link survey data with existing routinely collected health data (omitting the latter data items from the survey reduced survey length and participant burden). This consent was requested of all women.

RESULTS

The survey had an overall response rate of 46% (913 completed surveys returned, total sample 1989). Women receiving the pre-notification letter with the option of opting out of the survey were more likely to actively decline to participate than women receiving the letter without this option, although the overall numbers of women declining were small (27 versus 12). Letter type was not significantly associated with the return of a completed survey. Among women who completed the survey, 97% gave consent to link their survey data with existing health data.

CONCLUSIONS

The two types of pre-notification letters used in our study did not influence the survey response rate. However, seeking consent for record linkage was highly acceptable to women who completed the survey, and represents an important strategy to add to the arsenal for designing and implementing effective surveys. In addition to aspects of survey design, future research should explore how to more effectively influence personal constructs that contribute to the decision to participate in surveys.

Variation in hospital rates of induction of labour: a population-based record linkage study

OBJECTIVES

To examine interhospital variation in rates of induction of labour (IOL) to identify potential targets to reduce high rates of practice variation.

DESIGN

Population-based record linkage cohort study.

SETTING

New South Wales, Australia, 2010-2011.

PARTICIPANTS

All women with live births of ≥24 weeks gestation in 72 hospitals.

PRIMARY OUTCOME MEASURE

Variation in hospital IOL rates adjusted for differences in case-mix, according to 10 mutually exclusive groups derived from the Robson caesarean section classification; groups were categorised by parity, plurality, fetal presentation, prior caesarean section and gestational age.

RESULTS

The overall IOL rate was 26.7% (46,922 of 175,444 maternities were induced), ranging from 9.7% to 41.2% (IQR 21.8-29.8%) between hospitals. Nulliparous and multiparous women at 39-40 weeks gestation with a singleton cephalic birth were the greatest contributors to the overall IOL rate (23.5% and 20.2% of all IOL respectively), and had persisting high unexplained variation after adjustment for case-mix (adjusted hospital IOL rates ranging from 11.8% to 44.9% and 7.1% to 40.5%, respectively). In contrast, there was little variation in interhospital IOL rates among multiparous women with a singleton cephalic birth at ≥41 weeks gestation, women with singleton non-cephalic pregnancies and women with multifetal pregnancies.

CONCLUSIONS

7 of the 10 groups showed high or moderate unexplained variation in interhospital IOL rates, most pronounced for women at 39-40 weeks gestation with a singleton cephalic birth. Outcomes associated with divergent practice require determination, which may guide strategies to reduce practice variation.

Red cell and platelet transfusions in neonates: a population-based study

OBJECTIVES

This study aimed to describe the use of red cells, platelets and exchange transfusions among all neonates in a population cohort, to examine trends in transfusion over time and to determine transfusion rates in at-risk neonates.

DESIGN

Linked population-based birth and hospital data from New South Wales (NSW), Australia, were used to determine rates of blood product transfusion in the first 28 days of life. The study included all live births ≥23 weeks' gestation in NSW between 2001 and 2011.

RESULTS

Between 2001 and 2011, 5326 of 989 491 live born neonates received a red cell, platelet or exchange transfusion (5.4/1000 births). Transfusion rates were 4.8 per 1000 for red cells, 1.3 per 1000 for platelets and 0.3 per 1000 for exchange transfusion. Overall transfusion rate remained constant from 2001 to 2011 (p=0.27). Among transfused neonates, 60% were <32 weeks' gestation (n=3210, 331/1000 births), 40% were ≥32 weeks' gestation (n= 2116, 2/1000 births) and 7% received transfusions in a hospital without a neonatal intensive care unit (NICU). Factors other than prematurity associated with higher transfusion rates were prior in utero transfusion (631/1000), congenital anomaly requiring surgery (440/1000) and haemolytic disorder (106/1000).

CONCLUSIONS

In this population-based study, preterm neonates had a higher rate of transfusion than term neonates; however, 40% of those who received a transfusion were born ≥32 weeks' gestation and 7% were transfused in hospitals without an NICU. These findings need to be considered by transfusion services and personnel developing neonatal transfusion guidelines.

Obstetric anal sphincter injury rates among primiparous women with different modes of vaginal delivery

OBJECTIVE

To determine whether rates of obstetric anal sphincter injuries (OASIS) are continuing to increase and whether risk of OASIS according to mode of delivery is constant over time.

METHODS

In a retrospective population-based study, data were obtained for vaginal singleton vertex deliveries at 37-41 weeks of pregnancy among primiparous women in New South Wales, Australia, between January 2001 and December 2011. Annual OASIS rates were determined among non-instrumental, forceps, and vacuum deliveries with and without episiotomy. Multivariable logistic regression was used to determine adjusted odds ratios for each delivery mode category by year. Trends in adjusted odds ratios over time for each delivery category were compared.

RESULTS

OASIS occurred in 955 (4.1%) of 23 081 deliveries in 2001 and 1487 (5.9%) of 25 081 deliveries in 2011. After adjustment for known risk factors, the only delivery categories to show statistically significant increases in OASIS over the study period were non-instrumental deliveries without episiotomy (linear trend P<0.001) and forceps deliveries with episiotomy (linear trend P=0.004).

CONCLUSION

Overall, OASIS rates have continued to increase. Known risk factors do not fully explain the increase in OASIS rates in non-instrumental deliveries without an episiotomy and in forceps deliveries with an episiotomy.

Variation in hospital caesarean section rates for women with at least one previous caesarean section: a population based cohort study

BACKGROUND

Internationally, repeat caesarean sections make the largest contribution to overall caesarean section rates and inter-hospital variation has been reported. The aim of this study was to determine if casemix and hospital factors explain variation in hospital rates of repeat caesarean sections and whether these rates are associated with maternal and neonatal morbidity.

METHODS

This population-based record linkage study utilised data from New South Wales, Australia between 2007 and 2011. The study population included maternities with any previous caesarean section(s) and were singleton, cephalic and ≥ 37 weeks' gestation (Robson Group 5). Multilevel regression models were used to examine variation in hospital rates of 'planned repeat caesarean section' and, among women who planned a vaginal birth, 'intrapartum caesarean section'. We assessed associations between risk-adjusted hospital rates of planned and intrapartum caesarean sections and rates of casemix adjusted maternal and neonatal morbidity, postpartum haemorrhage and Apgar score <7 at five minutes.

RESULTS

Of 61894 maternities with a previous caesarean section in 81 hospitals, 82.1% resulted in a caesarean section (72.7% planned and 9.4% unplanned intrapartum caesareans) and 17.9% in vaginal birth. Observed hospital rates of planned caesarean sections ranged from 50.7% to 98.4%. Overall 49.0% of between-hospital variation in planned repeat caesarean section rates was explained by patient (17.3%) and hospital factors (31.7%). Increased odds of planned caesarean section were associated with private hospital status and lower hospital propensity for vaginal birth after caesarean. There were no associations between hospital rates of planned repeat caesarean section and adjusted morbidity rates. Among women who intended a vaginal birth, the observed rates of intrapartum caesarean section ranged from 12.9% to 71.9%. In total, 27.5% of between-hospital variation in rates of intrapartum caesarean section was explained by patient (19.5%) and hospital factors (8.0%). The adjusted morbidity rates differed among hospital intrapartum caesarean section rates, but were influenced by a few hospitals with outlying morbidity rates.

CONCLUSIONS

Among women with at least one previous caesarean section, less than half of the variation in hospital caesarean section rates was explained by differences in hospital's patient characteristics and practices. Strategies aimed at modifying caesarean section rates for these women should not affect morbidity rates.

Variation in hospital caesarean section rates for preterm births

BACKGROUND

Evidence about optimal mode of delivery for preterm birth is lacking, and there is thought to be considerable variation in practice.

OBJECTIVE

To assess whether variation in hospital preterm caesarean section rates (Robson Classification Group 10) and outcomes are explained by casemix, labour or hospital characteristics.

MATERIALS AND METHODS

Population-based cohort study in NSW, 2007-2011. Births were categorised according to degree of prematurity and hospital service capability: 26-31, 32-33 and 34-36 weeks' gestation. Hospital preterm caesarean rates were investigated using multilevel logistic regression models, progressively adjusting for casemix, labour and hospital factors. The association between hospital caesarean rates, and severe maternal and neonatal morbidity rates was assessed.

RESULTS

At 26-31 weeks' gestation, the caesarean rate was 55.2% (seven hospitals, range 43.4-58.4%); 50.9% at 32-33 weeks (12 hospitals, 43.4-58.1%); and 36.4% at 34-36 weeks (51 hospitals, 17.4-48.3%). At 26-31 weeks and 32-33 weeks' gestation, 81% and 59% of the variation between hospitals was explained with no hospital significantly different from the state average after adjustment. At 34-36 weeks' gestation, although 59% of the variation was explained, substantial unexplained variation persisted. Hospital caesarean rates were not associated with severe maternal morbidity rates at any gestational age. At 26-31 weeks' gestation, medium and high caesarean rates were associated with higher severe neonatal morbidity rates, but there was no evidence of this association ≥32 weeks.

CONCLUSION

Both casemix and practice differences contributed to the variation in hospital caesarean rates. Low preterm caesarean rates were not associated with worse outcomes.

Age of blood and adverse outcomes in a maternity population

BACKGROUND

In recent times there has been debate around whether longer storage time of blood is associated with increased rates of adverse outcomes after transfusion. It is unclear whether results focused on cardiac or critically ill patients apply to a maternity population. This study investigates whether older blood is associated with increased morbidity and readmission in women undergoing obstetric transfusion.

STUDY DESIGN AND METHODS

Women giving birth in hospitals in New South Wales, Australia, between July 2006 and December 2010 were included in the study population if they had received between 1 and 4 red blood cell units during the birth admission. Information on women's characteristics, transfusions, and outcomes were obtained from five routinely collected data sets including blood collection, birth, and hospitalization data. Generalized propensity score methods were used to determine the effect of age of blood on rates of severe morbidity and readmission, independent of confounding factors.

RESULTS

Transfusion data were available for 2990 women, with a median age of blood transfused of 20 days (interquartile range, 14-27 days). There were no differences in the maximum age of blood transfused between women with and without severe morbidity (21 [14-28] days vs. 22 [15-30] days) and in women readmitted or not (22 [14-28] days vs. 22 [16-30] days). After potential confounding factors were considered, no relationship was found between the age of blood transfused and rates of severe morbidity and readmission.

CONCLUSION

Among women receiving low-volume transfusions during a birth admission, there was no evidence of increased rates of adverse outcomes after transfusion with older blood.

Effect of ethanol and methanol on growth of ruminal bacteria Selenomonas ruminantium and Butyrivibrio fibrisolvens

The effect of ethanol and methanol on growth of several ruminal bacterial strains was examined. Ethanol concentrations as low as 0.2% had a significant, but moderate, inhibitory effect on lag time or growth over time and 3.3% ethanol significantly inhibited maximum optical density obtained by both Selenomonas ruminantium and Butyrivibrio fibrisolvens. Little growth of either strain occurred at 10% ethanol concentrations. Methanol concentrations below 0.5% had little effect on either growth or maximum optical density of Selenomonas ruminantium whereas methanol concentrations below 3.3% had little effect on growth or maximum optical density of Butyrivibrio fibrisolvens. Higher methanol concentrations increasingly inhibited growth of both strains and no growth occurred at a 10% methanol concentration. Concentrations of ethanol or methanol used to add hydrophobic compounds to culture media should be kept below 1%.

Does clinical presentation predict response to a nonsurgical chronic disease management program for endstage hip and knee osteoarthritis?

OBJECTIVE

To identify baseline characteristics of participants who will respond favorably following 6 months of participation in a chronic disease management program for hip and knee osteoarthritis (OA).

METHODS

This prospective cohort study assessed 559 participants at baseline and following 6 months of participation in the Osteoarthritis Chronic Care Program. Response was defined as the minimal clinically important difference of an 18% and 9-point absolute improvement in the Western Ontario and McMaster Universities Arthritis Index global score. Multivariate logistic regression modeling was used to identify predictors of response.

RESULTS

Complete data were available for 308 participants. Those who withdrew within the study period were imputed as nonresponders. Three variables were independently associated with response: signal joint (knee vs hip), sex, and high level of comorbidity. Index joint and sex were significant in the multivariate model, but the model was not a sensitive predictor of response.

CONCLUSION

Strong predictors of response to a chronic disease management program for hip and knee OA were not identified. The significant predictors that were found should be considered in future studies.

Reporting postpartum haemorrhage with transfusion: a comparison of NSW birth and hospital data

AIM

Postpartum haemorrhage rates have been increasing in NSW and internationally, and blood transfusion is required in severe cases. Using routinely collected administrative data provides a convenient method with which to monitor trends in both postpartum haemorrhage and associated transfusion use. In order for this to be feasible however, the reliability of reporting of the conditions needs to be assessed.

METHODS

This study used linked data to compare the reporting of postpartum haemorrhage with transfusion as reported in the NSW Admitted Patient Data Collection (hospital data), with the same information obtained from the Perinatal Data Collection (birth data), for births in NSW from 2007 to 2010.

RESULTS

The rate of postpartum haemorrhage requiring blood transfusion was 1.0% based on the hospital data and 1.1% based on the birth data, with a rate of 1.7% if identifying cases from either source. Agreement between the two sources improved from fair to moderate over the time period.

CONCLUSION

Postpartum haemorrhage requiring transfusion recorded in the birth data shows only moderate agreement with hospital data, so caution is recommended when using this variable for analysis. Linkage of both datasets is recommended to identify birth information from birth data and postpartum haemorrhage with transfusion from hospital data until further validation work has been undertaken.

What factors contribute to hospital variation in obstetric transfusion rates?

Background and Objectives

To explore variation in red blood cell transfusion rates between hospitals, and the extent to which this can be explained. A secondary objective was to assess whether hospital transfusion rates are associated with maternal morbidity.

Materials and Methods

Linked hospital discharge and birth data were used to identify births (n = 279 145) in hospitals with at least 10 deliveries per annum between 2008 and 2010 in New South Wales, Australia. To investigate transfusion rates, a series of random-effects multilevel logistic regression models were fitted, progressively adjusting for maternal, obstetric and hospital factors. Correlations between hospital transfusion and maternal, neonatal morbidity and readmission rates were assessed.

Results

Overall, the transfusion rate was 1·4% (hospital range 0·6–2·9) across 89 hospitals. Adjusting for maternal casemix reduced the variation between hospitals by 26%. Adjustment for obstetric interventions further reduced variation by 8% and a further 39% after adjustment for hospital type (range 1·1–2·0%). At a hospital level, high transfusion rates were moderately correlated with maternal morbidity (0·59, P = 0·01), but not with low Apgar scores (0·39, P = 0·08), or readmission rates (0·18, P = 0·29).

Conclusion

Both casemix and practice differences contributed to the variation in transfusion rates between hospitals. The relationship between outcomes and transfusion rates was variable; however, low transfusion rates were not associated with worse outcomes.

Trends and recurrence of stillbirths in NSW

OBJECTIVE

To examine the trend in stillbirth rates adjusted for the trends in the maternal risk profile, and to use local data to estimate the stillbirth recurrence risk.

METHODS

Linked hospital, birth and perinatal death review data were used to identify risk factors and stillbirths among women giving birth to singletons in NSW between 2001 and 2009. Logistic regression models were developed to predict stillbirth rates based on the changes in the maternal population.

RESULTS

Between 2001 and 2009 there were 3,449 stillbirths (4.4 per 1,000 births), with no significant change in rate overall (p=0.6) or across older gestational age categories (26-33 weeks p=0.67, ≥34 weeks p=0.36), and a slight increase at <26 weeks (p=0.01). However, when changes in the maternal population were taken into account, there was a significant increase in stillbirths at <26 weeks (p<0.001). Women with a stillbirth in a first pregnancy were at increased risk of stillbirth in their second pregnancy (4.3 95%CI 2.4-7.7).

CONCLUSION

There has been no decline in the stillbirth rate in NSW in recent years, which, at late gestations, may be accounted for by changes in the maternal population. At early gestations, there has been an increase in stillbirths where a decrease in rate may be expected based on the maternal population.

IMPLICATIONS

Further focus on addressing risk factors for stillbirths is needed to ensure continued progress is made in reducing stillbirths.

Unexplained variation in hospital caesarean section rates

OBJECTIVES

To assess recent hospital caesarean section (CS) rates in New South Wales, adjusted for case mix; to quantify the amount of variation that can be explained by case mix differences; and to examine the potential impact on the overall CS rate of reducing variation in practice.

DESIGN AND SETTING

Population-based record linkage study of births in 81 hospitals in New South Wales, 2009-2010, using the Robson classification to categorise births, and multilevel logistic regression to examine variation in hospital CS rates within Robson groups.

MAIN OUTCOME MEASURES

Hospital CS rates.

RESULTS

The overall CS rate was 30.9%, ranging from 11.8% to 47.4% (interquartile range, 23.9%-33.1%) among hospitals. The three groups contributing most to the overall CS rate all comprised women with a single cephalic pregnancy who gave birth at term, including: those who had had a previous CS (36.4% of all CSs); nulliparous women with an elective delivery (prelabour CS or labour induction, 23.4%); and nulliparous women with spontaneous labour (11.1%). After adjustment for case mix, marked unexplained variation in hospital CS rates persisted for: nulliparous women at term; women who had had a previous CS; multifetal pregnancies; and preterm births. If variation in practice was reduced for these risk-based groups by achieving the "best practice" rate, this would lower the overall rate by an absolute reduction of 3.6%, from 30.9% to 27.3%.

CONCLUSION

Understanding hospital heterogeneity in performing CS and implementing evidence-based practices may result in improved maternity care. We have identified five risk-based groups as priority targets for reducing practice variation in CS rates.

Determining pore size distribution in wet cellulose by measuring solute exclusion using a differential refractometer

Solute exclusion was used to determine the pore volume and micropore size distribution of wet cellulosic materials. Glucose, cellobiose, and polyethylene glycol (PEG) (8 to 130 A in diameter) were used as molecular probes. Four replicates of cellulosic samples, with each sample being analyzed 4 to 8 times, gave the concentrations of each molecular probe before and after contact with cellulose. Sugar concentrations were determined by the DNS method and PEG concentrations by a differential refractometer. Deviations arising from sample-to-sample variability result in variations of solute uptake from which the pore size distribution was determined. The need for replicate samples and a statistical approach to data analysis is indicated. Consequently, the data were fitted to an empirical logistic model function based on the minimum of the residual sum of squares using the finite-difference, Levenberg-Marquardt algorithm. A smooth increasing function resulted. We report experimental methodology employing a differential refractometer, common in many laboratories having a liquid chromato-graph instrument, combined with statistical treatment of the data. This method may also find application in determining pore size distribution in wet, hydrophilic polymers used in some types of membranes, chromatographic supports, and gel-type resins.

Incidence of metastatic breast cancer in an Australian population-based cohort of women with non-metastatic breast cancer at diagnosis

OBJECTIVES

To estimate the incidence of metastatic breast cancer (MBC) in Australian women with an initial diagnosis of non-metastatic breast cancer.

DESIGN, SETTING AND PARTICIPANTS

A population-based cohort study of all women with non-metastatic breast cancer registered on the New South Wales Central Cancer Register (CCR) in 2001 and 2002 who received care in a NSW hospital.

MAIN OUTCOME MEASURES

5-year cumulative incidence of MBC; prognostic factors for MBC.

RESULTS

MBC was recorded within 5 years in 218 of 4137 women with localised node-negative disease (5-year cumulative incidence, 5.3%; 95% CI, 4.6%-6.0%); and 455 of 2507 women with regional disease (5-year cumulative incidence, 18.1%; 95% CI, 16.7%-19.7%). The hazard rate for developing MBC was highest in the second year after the initial diagnosis of breast cancer. Determinants of increased risk of MBC were regional disease at diagnosis, age less than 50 years and living in an area of lower socio-economic status.

CONCLUSIONS

Our Australian population-based estimates are valuable when communicating average MBC risks to patients and planning clinical services and trials. Women with node-negative disease have a low risk of developing MBC, consistent with outcomes of adjuvant clinical trials. Regional disease at diagnosis remains an important prognostic factor.

Eye health services for Aboriginal people in the western region of NSW, 2010

AIM

To assess the availability, accessibility and uptake of eye health services for Aboriginal people in western NSW in 2010.

METHODS

The use of document review, observational visits, key stakeholder consultation and service data reviews, including number of cataract operations performed, to determine regional service availability and use.

RESULTS

Aboriginal people in western NSW have a lower uptake of tertiary eye health services, with cataract surgery rates of 1750 per million for Aboriginal people and 9702 per million for non-Aboriginal people. Public ophthalmology clinics increase access to tertiary services for Aboriginal people.

CONCLUSION

Eye health services are not equally available and accessible for Aboriginal people in western NSW. Increasing the availability of culturally competent public ophthalmology clinics may increase access to tertiary ophthalmology services for Aboriginal people. The report of the review was published online, and outlines a list of recommendations.

Dietary fiber content influences soluble carbohydrate levels in ruminal fluids

The soluble carbohydrate concentration of ruminal fluid, as affected by dietary forage content (DFC) and/or ruminally undegradable intake protein content (UIPC), was determined. Four ruminally cannulated steers, in a 4 × 4 Latin square design, were offered diets containing high (75 % of DM) or low (25 % of DM) DFC and high (6 % of DM) or low (5 % of DM) UIPC, in a 2 × 2 factorial arrangement. Zinc-treated SBM was the primary UIP source. Soluble hexose concentration (145.1 μM) in ruminal fluid (RF) of steers fed low DFC diets exhibited a higher trend (P = 0.08) than that (124.5 μM) of steers fed high DFC diets. UIPC did not modulate (P = 0.54) ruminal soluble hexose concentrations. Regardless of diet, soluble hexose concentration declined immediately after feeding and did not rise until 3 h after feeding (P < 0.0001). Cellobiose (≈90 %) and glucose (≈10 %) were the major soluble hexoses present in RF. Maltose was not detected. Soluble glucose concentration (13.0 μM) was not modified by either UIPC (P = 0.40) nor DFC (P = 0.61). However, a DFC by post-prandial time interaction was detected (P = 0.02). Pentose concentrations were greater (P = 0.02) in RF of steers fed high DFC (100.2 μM) than steers fed low DFC (177.0 μM). UIPC did not influence (P = 0.35) soluble pentose concentration. The identity of soluble pentoses in ruminal fluid could not be determined. However, unsubstituted xylose and arabinose were excluded. These data indicate that: (i) soluble carbohydrate concentrations remain in ruminal fluid during digestion and fermentation; (ii) slight diurnal changes began after feeding; (iii) DFC influences the soluble carbohydrate concentration in RF; and (iv) UIPC of these diets does not affect the soluble carbohydrate concentration of RF.

Sugar phosphorylation activity in ruminal acetogens

Acetogenic bacteria Acetitomaculum ruminis, Acetobacterium woodii, and Eubacterium limosum were compared for phosphoenolpyruvate (PEP) and ATP-dependent phosphorylation of glucose and 2-deoxy-glucose. Rate of phosphorylation activity was measured in toluene-treated acetogenic cells using PEP and ATP and radiolabled glucose or 2-deoxy glucose. Eubacterium limosum, most likely has a glucose phosphotransferase system (PTS). In contrast, A. ruminis, and A. woodii had PEP-dependent glucose phosphorylation rates very similar to control rates, suggesting the lack of PTS activity. These results were confirmed by PEP dependent 2-deoxyglucose phosphorylation data. The rates of ATP-dependent glucose phosphorylation were higher than PEP-dependent glucose dependent in all organisms surveyed. Only E. limosum appeared to have PTS. The presence of PTS in E. limosum could explain why it is not capable of utilizing sugars and H(2)/CO(2) simultaneously and why acetogenesis is not as prominant in the rumen because of the availability of carbohydrates as alternative energy substrates.

Yeast culture supplement during nursing and transport affects immunity and intestinal microbial ecology of weanling pigs

The objectives of this study were to determine the influence of a Saccharomyces cerevisiae fermentation product on innate immunity and intestinal microbial ecology after weaning and transport stress. In a randomized complete block design, before weaning and in a split-plot analysis of a 2 × 2 factorial arrangement of yeast culture (YY) and transport (TT) after weaning, 3-d-old pigs (n = 108) were randomly assigned within litter (block) to either a control (NY, milk only) or yeast culture diet (YY; delivered in milk to provide 0.1 g of yeast culture product/kg of BW) from d 4 to 21. At weaning (d 21), randomly, one-half of the NY and YY pigs were assigned to a 6-h transport (NY-TT and YY-TT) before being moved to nursery housing, and the other one-half were moved directly to nursery housing (NY-NT and YY-NT, where NT is no transport). The yeast treatment was a 0.2% S. cerevisiae fermentation product and the control treatment was a 0.2% grain blank in feed for 2 wk. On d 1 before transport and on d 1, 4, 7, and 14 after transport, blood was collected for leukocyte assays, and mesenteric lymph node, jejunal, and ileal tissue, and jejunal, ileal, and cecal contents were collected for Toll-like receptor expression (TLR); enumeration of Escherichia coli, total coliforms, and lactobacilli; detection of Salmonella; and microbial analysis. After weaning, a yeast × transport interaction for ADG was seen (P = 0.05). Transport affected (P = 0.09) ADFI after weaning. Yeast treatment decreased hematocrit (P = 0.04). A yeast × transport interaction was found for counts of white blood cells (P = 0.01) and neutrophils (P = 0.02) and for the neutrophil-to-lymphocyte ratio (P = 0.02). Monocyte counts revealed a transport (P = 0.01) effect. Interactions of yeast × transport (P = 0.001) and yeast × transport × day (P = 0.09) for TLR2 and yeast × transport (P = 0.08) for TLR4 expression in the mesenteric lymph node were detected. Day affected lactobacilli, total coliform, and E. coli counts. More pigs were positive for Salmonella on d 7 and 14 than on d 4, and more YY-TT pigs were positive (P = 0.07) on d 4. The number of bands for microbial amplicons in the ileum was greater for pigs in the control treatment than in the yeast treatment on d 0, and this number tended to decrease (P = 0.066) between d 1 and 14 for all pigs. Similarity coefficients for jejunal contents were greater (P = 0.03) for pigs fed NY than for those fed YY, but pigs fed YY had greater similarity coefficients for ileal (P = 0.001) and cecal (P = 0.058) contents. The number of yeast × transport × day interactions demonstrates the complexity of the stress and dietary relationship.

Trends and outcomes of induction of labour among nullipara at term

AIM

  To determine induction trends and delivery, maternal and neonatal health outcomes by gestational age following induction at term for women having a first baby.

METHODS

  Linked birth and hospital data were used to examine the rates of adverse maternal and neonatal health outcomes for the period 2001-2007, among the 212,389 nullipara with singleton cephalic-presenting fetuses delivering between 37(0) and 41(6) weeks of gestation. Rates of caesarean delivery, neonatal transfers and overall severe neonatal and maternal adverse outcomes were determined by gestational age.

RESULTS

  Between 1990 and 2008, nulliparous term inductions as a proportion of all births increased from 5518 (6.8%) to 11,166 (12.5%). More than 60% of these inductions are performed before 41 weeks. Among induced nullipara, 30.4% delivered by caesarean section. Adverse neonatal outcomes and transfer rates were lowest at 39-40 weeks (overall 2.1 and 0.5%, respectively), regardless of labour onset. Maternal morbidity increased at 40 weeks (from 1.1 to 1.3%) for women in spontaneous labour, was relatively stable in those undergoing induction of labour between 37 and 40 weeks (1.8%) and decreased with gestational age until 40 weeks in those undergoing a prelabour caesarean delivery (from 3.1 to 0.8%).

CONCLUSION

  NSW has high rates of both induction and caesarean section following induction. This study highlights the changes to clinical practice that may help reduce the rate of caesarean births in nullipara.

Patterns of transfer in labour and birth in rural New Zealand

INTRODUCTION

For many women, and particularly rural women, birthing locally and within their own community is important for personal, social and/or cultural reasons. If concerns about the woman or her baby mean transfer to a secondary or tertiary facility is necessary, this can be disruptive and stressful, especially if road transfer is complicated by terrain, weather or distance, as is often the case in rural New Zealand. The objective of this study was to explore the number of and reason for transfers during labour and birth for well women, close to full term, from primary rural maternity facilities to specialist care in rural New Zealand.

METHODS

This retrospective survey of 45 rural maternity units in the North and South Islands of New Zealand was conducted over a 2 year period ending on 30 June 2006. The participants were the 4678 women who began labour in a rural facility during this time period.

RESULTS

The survey response rate was 66.6%. The data revealed that 16.6% of women who commenced labour in a rural unit were transferred in labour or within 6 hours of birth; 3% of babies born in rural units were transferred after birth and up to 7 days post-birth. The primary reason for maternal transfer was slow progress in labour (49.67%). Of the 123 babies transferred, this was most often due to respiratory problems (43%). Key features of the rural context (times and distances to be travelled, geological and climatic characteristics, types of transport systems and availability of local assistance) influenced the timeliness of the decision to transfer.

CONCLUSIONS

Within New Zealand's regionalised perinatal system, midwives make cautious decisions about transfer, taking into account the local rural local circumstances, and also the topography as it impacts on transport.