The development of a classification system for maternity models of care

© The Author(s) 2016. Background: A lack of standard terminology or means to identify and define models of maternity care in Australia has prevented accurate evaluations of outcomes for mothers and babies in different models of maternity care. Objective: As part of the Commonwealth-funded National Maternity Data Development Project, a classification system was developed utilising a data set specification that defines characteristics of models of maternity care. Method: The Maternity Care Classification System or MaCCS was developed using a participatory action research design that built upon the published and grey literature. Results: The study identified the characteristics that differentiate models of care and classifies models into eleven different Major Model Categories. Conclusion: The MaCCS will enable individual health services, local health districts (networks), jurisdictional and national health authorities to make better informed decisions for planning, policy development and delivery of maternity services in Australia

Vasa Praevia: a descriptive review of existing literature and the evolving role of ultrasound in prenatal screening

Introduction: Literature addressing the feasibility of prenatal detection of vasa praevia during the mid-trimester morphology ultrasound scan is scarce, as is a lack of consensus about the appropriate management of pregnancies once it is detected.Method: The following descriptive review will provide historical context about the clinical significance, epidemiology, diagnosis and outcomes of pregnancies complicated by vasa praevia. It will also examine the role of ultrasound in the diagnosis of vasa praevia, and will examine current evidence surrounding this debate of whether routine screening for vasa praevia is possible, beneficial, or cost-effective.Conclusion: Finally, it will highlight the need for increased research into effective management of pregnancies at high risk of, or affected by vasa praevia to reduce fetal mortality and maternal and fetal morbidity associated with the condition

The Attitudes and Beliefs of Australian Midwives and Obstetricians About Birth Options and Labor Interventions.

IntroductionThe global rise in the rate of induction of labor and cesarean birth shows considerable unexplained variation both within and between countries. Prior research suggests that the extent to which women are engaged in the decision-making process about birth options, such as elective cesarean, induction of labor, or use of fetal monitoring, is heavily influenced by clinician beliefs and preferences. The aim of this study was to investigate the beliefs about labor interventions and birth options held by midwives and obstetric medical staff from 8 Sydney hospitals and assess how the health care providers' beliefs were associated with discipline or years of experience.MethodsThis is a survey study of midwives and obstetric staff that was distributed between November 2018 and July 2019. Modified from the previously validated birth attitudes survey for the Australian context, survey domains include (1) maternal choice and woman's role in birth, (2) safety by mode or place of birth, (3) attitudes toward cesarean birth for preventing urinary incontinence, (4) approaches to decrease cesarean birth rates, and (5) fears of birth mode. Responses were compared between professions and within professions by years of experience using Mann-Whitney U testing.ResultsA total of 217 midwives and 58 medical staff completed the survey (response rate, 30.5%). Midwifery staff responses generally favored a physiologic approach to birth, versus beliefs more in favor of intervention (particularly cesarean birth) among medical staff. There was interprofessional discrepancy on most items, particularly regarding safety of mode or place of birth and approaches to decrease cesarean birth rates. Within disciplines, there was more variation in medical staff attitudes than within the midwifery staff. No clinically important differences in beliefs by years of experience were noted.DiscussionClinicians need to be aware of their own beliefs and preferences about birth as a potential source of bias when counselling women, particularly when there are a range of treatment options and the evidence may not strongly favor one option over another. As both groups had similar perceptions about the importance of women's autonomy, shared decision-making training could help bridge belief gaps and improve care around birth decisions

The Attitudes and Beliefs of Australian Midwives and Obstetricians About Birth Options and Labor Interventions

Introduction: The global rise in the rate of induction of labor and cesarean birth shows considerable unexplained variation both within and between countries. Prior research suggests that the extent to which women are engaged in the decision-making process about birth options, such as elective cesarean, induction of labor, or use of fetal monitoring, is heavily influenced by clinician beliefs and preferences. The aim of this study was to investigate the beliefs about labor interventions and birth options held by midwives and obstetric medical staff from 8 Sydney hospitals and assess how the health care providers’ beliefs were associated with discipline or years of experience. Methods: This is a survey study of midwives and obstetric staff that was distributed between November 2018 and July 2019. Modified from the previously validated birth attitudes survey for the Australian context, survey domains include (1) maternal choice and woman's role in birth, (2) safety by mode or place of birth, (3) attitudes toward cesarean birth for preventing urinary incontinence, (4) approaches to decrease cesarean birth rates, and (5) fears of birth mode. Responses were compared between professions and within professions by years of experience using Mann-Whitney U testing. Results: A total of 217 midwives and 58 medical staff completed the survey (response rate, 30.5%). Midwifery staff responses generally favored a physiologic approach to birth, versus beliefs more in favor of intervention (particularly cesarean birth) among medical staff. There was interprofessional discrepancy on most items, particularly regarding safety of mode or place of birth and approaches to decrease cesarean birth rates. Within disciplines, there was more variation in medical staff attitudes than within the midwifery staff. No clinically important differences in beliefs by years of experience were noted. Discussion: Clinicians need to be aware of their own beliefs and preferences about birth as a potential source of bias when counselling women, particularly when there are a range of treatment options and the evidence may not strongly favor one option over another. As both groups had similar perceptions about the importance of women's autonomy, shared decision-making training could help bridge belief gaps and improve care around birth decisions

Women's experiences of decision-making and attitudes in relation to induction of labour: A survey study.

BACKGROUND:Rates of induction of labour have been increasing globally to up to one in three pregnancies in many high-income countries. Although guidelines around induction, and strength of the underlying evidence, vary considerably by indication, shared decision-making is increasingly recognised as key. The aim of this study was to identify women's mode of birth preferences and experiences of shared decision-making for induction of labour. METHOD:An antenatal survey of women booked for an induction at eight Sydney hospitals was conducted. A bespoke questionnaire was created assessing women's demographics, indication for induction, pregnancy model of care, initial birth preferences, and their experience of the decision-making process. RESULTS:Of 189 survey respondents (58% nulliparous), major reported reasons for induction included prolonged pregnancy (38%), diabetes (25%), and suspected fetal growth restriction (8%). Most respondents (72%) had hoped to labour spontaneously. Major findings included 19% of women not feeling like they had a choice about induction of labour, 26% not feeling adequately informed (or uncertain if informed), 17% not being given alternatives, and 30% not receiving any written information on induction of labour. Qualitative responses highlight a desire of women to be more actively involved in decision-making. CONCLUSION:A substantial minority of women did not feel adequately informed or prepared, and indicated they were not given alternatives to induction. Suggested improvements include for face-to-face discussions to be supplemented with written information, and for shared decision-making interventions, such as the introduction of decision aids and training, to be implemented and evaluated

Assessment of the societal and individual preferences for fertility treatment in Australia: Study protocol for stated preference discrete choice experiments

In Australia, societal and individual preferences for funding fertility treatment remain largely unknown. This has resulted in a lack of evidence about willingness to pay (WTP) for fertility treatment by either the general population (the funders) or infertile individuals (who directly benefit). Using a stated preference discrete choice experiment (SPDCE) approach has been suggested as a more appropriate method to inform economic evaluations of fertility treatment. We outline the protocol for an ongoing study which aims to assess fertility treatment preferences of both the general population and infertile individuals, and indirectly estimate their WTP for fertility treatment. Methods and analysis Two separate but related SPDCEs will be conducted for two population samples - the general population and infertile individuals - to elicit preferences for fertility treatment to indirectly estimate WTP. We describe the qualitative work to be undertaken to design the SPDCEs. We will use D-efficient fractional experimental designs informed by prior coefficients from the pilot surveys. The mode of administration for the SPDCE is also discussed. The final results will be analysed using mixed logit or latent class model. Ethics and dissemination This study is being funded by the Australian National Health and Medical Research Council (NHMRC) project grant AP1104543 and has been approved by the University of New South Wales Human Research Ethics Committee (HEC 17255) and a fertility clinic's ethics committee. Findings of the study will be disseminated in peer-reviewed journals and presented at various conferences. A lay summary of the results will be made publicly available on the University of New South Wales National Perinatal Epidemiology and Statistics Unit website. Our results will contribute to the development of an evidence-based policy framework for the provision of cost-effective and patient-centred fertility treatment in Australia

Inter-hospital and inter-disciplinary variation in planned birth practices and readiness for change: a survey study

Background How the application of evidence to planned birth practices, induction of labour (IOL) and prelabour caesarean (CS), differs between Australian maternity units remains poorly understood. Perceptions of readiness for practice change and resources to implement change in individual units are also unclear. Aim To identify inter-hospital and inter-professional variations in relation to current planned birth practices and readiness for change, reported by clinicians in 7 maternity units. Method Custom-created survey of maternity staff at 7 Sydney hospitals, with questions about women’s engagement with decision making, indications for planned birth, timing of birth and readiness for change. Responses from midwives and medical staff, and from each hospital, were compared. Findings Of 245 completed surveys (27% response rate), 78% were midwives and 22% medical staff. Substantial inter-hospital variation was noted for stated planned birth indication, timing, women’s involvement in decision-making practices, as well as in staff perceptions of their unit’s readiness for change. Overall, 48% (range 31–64%) and 64% (range 39–89%) agreed on a need to change their unit’s caesarean and induction practices respectively. The three units where greatest need for change was perceived also had least readiness for change in terms of leadership, culture, and resources. Regarding inter-disciplinary variation, medical staff were more likely than midwifery staff to believe women were appropriately informed and less likely to believe unit practice change was required. Conclusion Planned birth practices and change readiness varied between participating hospitals and professional groups. Hospitals with greatest perceived need for change perceived least resources to implement such change

Societal preferences for fertility treatment in Australia: a stated preference discrete choice experiment

Objective: To investigate preferences for fertility treatment from the Australian general population with the aims of calculating the willingness to pay in tax contribution for attributes (characteristics) that make up treatment and for an “ideal” fertility treatment program. We also assessed whether willingness-to-pay varies by the relationship status or sexual orientation of the patient. Methods: A stated preference discrete choice experiment was administered to a panel of 801 individuals representative of the Australian general population. Seven attributes of fertility treatment under three broad categories were included: outcome, process, and cost. Attributes were identified through published literature, focus group discussions, expert knowledge, and a pilot study. A Bayesian fractional experimental design was used, and data analysis was performed using a generalized multinomial logit model. Further analyses included interaction terms and latent class modeling. Results: Six of the seven attributes influenced the choice of a treatment program. Under process attributes, individuals preferred: continuity of care of clinic staff, where patients are seen by the same doctor but different nurses at each visit; “alternative” treatments being offered to all patients; and onsite clinic counseling and peer-support groups. Personalization and tailoring of the treatment journey were not important. Among outcome attributes, the improved success rate of having a baby per cycle and significant side-effects were considered important. Cost of treatment also influenced the choice of treatment program. Individual preferences for fertility treatment were not associated with patients’ relationship status or sexual orientation. Latent class modeling revealed sub-groups with distinct fertility treatment preferences. Conclusion: This study provides important insights into the attributes that influence the preferences of fertility treatment in Australia. It also estimates socially-inclusive willingness-to-pay values in tax contributions for an “ideal” package of treatment. The results can inform economic evaluations of fertility treatment programs.Willings Botha, Natasha Donnolley, Marian Shanahan, Robert J. Norman and Georgina M. Chamber

Exploring unwarranted clinical variation: The attitudes of midwives and obstetric medical staff regarding induction of labour and planned caesarean section.

BACKGROUND:Unexplained clinical variation is a major issue in planned birth i.e. induction of labour and planned caesarean section. AIM:To map attitudes and knowledge of maternity care professionals regarding indications for planned birth, and assess inter-professional (midwifery versus medical) and intra-professional variation. METHODS:A custom-created survey of medical and midwifery staff at eight Sydney hospitals. Staff were asked to rate their level of agreement with 45 "evidence-based" statements regarding caesareans and inductions on a five-point Likert scale. Responses were grouped by profession, and comparisons made of inter- and intra-professional responses. FINDINGS:Total 275 respondents, 78% midwifery and 21% medical. Considerable inter- and intra-professional variation was noted, with midwives generally less likely to consider any of the planned birth indications "valid" compared to medical staff. Indications for induction with most variation in midwifery responses included maternal characteristics (age≥40, obesity, ethnicity) and fetal macrosomia; and for medical personnel in-vitro fertilisation, maternal request, and routine induction at 39 weeks gestation. Indications for caesarean with most variation in midwifery responses included previous lower segment caesarean section, previous shoulder dystocia, and uncomplicated breech; and for medical personnel uncomplicated dichorionic twins. Indications with most inter-professional variation were induction at 41+ weeks versus 42+ weeks and cesarean for previous lower segment caesarean section. DISCUSSION:Both inter- and intra-professional variation in what were considered valid indications reflected inconsistency in underlying evidence and/or guidelines. CONCLUSION:Greater focus on interdisciplinary education and consensus, as well as on shared decision-making with women, may be helpful in resolving these tensions

Factors associated with women's birth beliefs and experiences of decision-making in the context of planned birth: A survey study.

Objective In many high-income countries, approximately half of all births are now planned regarding timing, either by elective Caesarean Section (CS) or induction of labour (IOL). To what degree this is explained by women's birth beliefs and preferences, and in turn, factors such as parity and ethnicity that may influence them, is contentious. Within a broader study on Timing of Birth by planned CS or IOL, we aimed to explore the association between demographic and pregnancy factors, with women's birth beliefs and experiences of planned birth decision-making in late pregnancy. Design Survey study of women's birth beliefs and experiences of planned birth decision-making. Both univariate analysis and ordinal regression modelling was performed to examine the influence of; parity; cultural background; continuity of pregnancy care; CS or IOL; and whether CS was “recommended” or “requested”, on women's stated birth beliefs and decision-making experience. Setting 8 Sydney hospitals Participants Women planned to have an IOL or CS between November 2018-July 2019. Measurement The survey included four statements regarding birth beliefs and ten statements about experiences of decision-making on a 5-item Likert scale, as well as questions about demographic and pregnancy factors that might influence these beliefs. Findings Of 340 included surveys, 56% regarded IOL and 44% CS. Women indicated strong belief both that they should be supported to make decisions about their birth and that their doctor/midwife knows what is best for them (over 90% agreement for both). Regarding decision-making, over 90% also agreed they had trust in the person providing information, understood it, and had sufficient time for both questions and decision-making. However only 58% were provided written information, 19% felt they “didn't really have a choice”, and 9% felt pressure to make a decision. On both univariate and multivariate analysis, women having CS (versus IOL) expressed more positive views of their experience and involvement in decision-making, as did women experiencing a pregnancy continuity-of-care model. Women identifying as from a specific cultural or ethnic background expressed more negative experiences. On modelling, the studied factors accounted for only a small proportion of the variation in responses (3–19%). Conclusions Continuity of pregnancy care was associated with positive decision-making experiences and cultural background with more negative experiences. Women whose planned birth was IOL versus CS also reported more negative decision-making experiences. Implications for practice Attention to improving quality of information provision, including written information, to women having IOL and women of diverse background, is recommended to improve women's experiences of planned birth decision-making