Assisted Vaginal Deliveries in Mothers Admitted as Public or Private Patients in Western Australia

Background: Mothers delivering as private patients in Australia have a high rate of assisted deliveries, which could lead to adverse infant outcomes in this group of patients. We investigated whether the risk of adverse infant outcomes after assisted deliveries was different for mothers admitted as public or private patients for delivery, when compared with unassisted deliveries. Methods and findings: We included 158,241 vaginal, singleton, term birth admissions in our study where the infant was live born and without birth defects. The study population was identified from statutory birth and hospital data collections held by the Western Australian (WA) Department of Health. We estimated odds ratios and confidence intervals using logistic regression models adjusted for a range of maternal demographic, pregnancy and birth characteristics. Interaction was assessed by including interaction terms in the models. Outcomes included low Apgar scores at five minutes (,7), neonatal resuscitation and special care admission. Mothers delivering as private patients had an increased risk of assisted vaginal delivery compared with public patients (adjusted OR 1.74, 95% CI = 1.68–1.80). Compared with unassisted vaginal deliveries, assisted deliveries were associated with increased risk of Apgar scores at five minutes below 7 (OR 1.25, 1.08–1.45), neonatal resuscitation (OR = 1.69, 1.42–2.00) and admission to special care nursery (OR = 1.64, 1.53–1.76). The increased risk of neonatal resuscitation was higher for mothers admitted as private patients for delivery (OR = 2.13) than public patients (OR = 1.55, pinteraction = 0.03). Conclusions: Our results suggested that the high risk of neonatal resuscitation following assisted vaginal deliveries compared to unassisted is higher in private patients than public patients. Whether this phenomenon is due to the twofold higher rate of assisted vaginal deliveries in this group of patients or a higher rate of fetal indications for assisted vaginal delivery remains to be answered

The Australian Baby Bonus Maternity Payment and Birth Characteristics in Western Australia

Background: The Australian baby bonus maternity payment introduced in 2004 has been reported to have successfully increased fertility rates in Australia. We aimed to investigate the influence of the baby bonus on maternal demographics and birth characteristics in Western Australia (WA). Methods and Findings: This study included 200,659 birth admissions from WA during 2001–2008, identified from administrative birth and hospital data-systems held by the WA Department of Health. We estimated average quarterly birth rates after the baby bonus introduction and compared them with expected rates had the policy not occurred. Rate and percentage differences (including 95% confidence intervals) were estimated separately by maternal demographics and birth characteristics. WA birth rates increased by 12.8% following the baby bonus implementation with the greatest increase being in mothers aged 20–24 years (26.3%, 95%CI = 22.0,30.6), mothers having their third (1.6%, 95%CI = 0.9,2.4) or fourth child (2.2%, 95%CI = 2.1,2.4), mothers living in outer regional and remote areas (32.4%, 95%CI = 30.2,34.6), mothers giving birth as public patients (1.5%, 95%CI = 1.3,1.8), and mothers giving birth in public hospitals (3.5%, 95%CI = 2.6,4.5). Interestingly, births to private patients (24.3%, 95%CI =24.8,23.7) and births in private hospitals (26.3%, 95%CI =26.8,25.8) decreased following the policy implementation. Conclusions: The introduction of the baby bonus maternity payment may have served as an incentive for women in their early twenties and mothers having their third or fourth child and may have contributed to the ongoing pressure and staff shortages in Australian public hospitals, particularly those in outer regional and remote areas

The Smoking MUMS (Maternal Use of Medication and Safety) Study: protocol for a population-based cohort study using linked administrative data

Introduction: Approximately 14% of Australian women smoke during pregnancy. Although the risk of adverse outcomes is reduced by smoking cessation, less than 35% of Australian women quit smoking spontaneously during pregnancy. Evidence for the efficacy of bupropion, varenicline or nicotine replacement therapy as smoking cessation aids in the non-pregnant population suggest that pharmacotherapy for smoking cessation is worth exploring in women of childbearing age. Currently, little is known about the utilisation, effectiveness and safety of pharmacotherapies for smoking cessation during pregnancy; neither the extent to which they are used prior to pregnancy nor whether their use has changed in response to related policy reforms. The Smoking MUMS (Maternal Use of Medications and Safety) Study will explore these issues using linked person-level data for a population-based cohort of Australian mothers. Methods and analysis: The cohort will be assembled by linking administrative health records for all women who gave birth in New South Wales or Western Australia since 2003 and their children, including records relating to childbirth, use of pharmaceuticals, hospital admissions, emergency department presentations and deaths. These longitudinal linked data will be used to identify utilisation of smoking cessation pharmacotherapies during and between pregnancies and to explore the associated smoking cessation rates and maternal and child health outcomes. Subgroup and temporal analyses will identify potential differences between population groups including indigenous mothers and social security recipients and track changes associated with policy reforms that have made alternative smoking cessation pharmacotherapies available.Ethics and dissemination: Ethical approval has been obtained for this study. To enhance the translation of the project's findings into policy and practice, policy and clinical stakeholders will be engaged through a reference group and a policy forum will be held. Outputs from the project will include scientific papers and summary reports designed for policy audiences

Challenges in migrant women's maternity care in a high-income country: A population-based cohort study of maternal and perinatal outcomes

Introduction This study aims to explore maternal and perinatal outcomes of migrant women in Iceland.Material and methods This prospective population-based cohort study included women who gave birth to a singleton in Iceland between 1997 and 2018, comprising a total of 92 403 births. Migrant women were defined as women with citizenship other than Icelandic, including refugees and asylum seekers, and categorized into three groups, based on their country of citizenship Human Development Index score. The effect of country of citizenship was estimated. The main outcome measures were onset of labor, augmentation, epidural, perineum support, episiotomy, mode of birth, obstetric anal sphincter injury, postpartum hemorrhage, preterm birth, a 5-minute Apgar = 0.900) had similar or better outcomes compared with Icelandic women, whereas migrant women from countries with a lower Human Development Index score than that of Iceland (<0.900) had additionally increased odds of maternal and perinatal complications and interventions, such as emergency cesarean and postpartum hemorrhage.Conclusions Women's citizenship and country of citizenship Human Development Index scores are significantly associated with a range of maternal and perinatal complications and interventions, such as episiotomy and instrumental birth. The results indicate the need for further exploration of whether Icelandic perinatal healthcare services meet the care needs of migrant women

Tobacco policy reform and population-wide antismoking activities in Australia: the impact on smoking during pregnancy

Publisher's version (útgefin grein)Introduction This study examined the impact of antismoking activities targeting the general population and an advertising campaign targeting smoking during pregnancy on the prevalence of smoking during pregnancy in New South Wales (NSW), Australia. Methods Monthly prevalence of smoking during pregnancy was calculated using linked health records for all pregnancies resulting in a birth (800 619) in NSW from 2003 to 2011. Segmented regression of interrupted time series data assessed the effects of the extension of the ban on smoking in enclosed public places to include licensed premises (evaluated in combination with the mandating of graphic warnings on cigarette packs), television advertisements targeting smoking in the general population, print and online magazine advertisements targeting smoking during pregnancy and increased tobacco tax. Analyses were conducted for all pregnancies, and for the population stratified by maternal age, parity and socioeconomic status. Further analyses adjusted for the effect of the Baby Bonus maternity payment. Results Prevalence of smoking during pregnancy decreased from 2003 to 2011 overall (0.39% per month), and for all strata examined. For pregnancies overall, none of the evaluated initiatives was associated with a change in the trend of smoking during pregnancy. Significant changes associated with increased tobacco tax and the extension of the smoking ban (in combination with graphic warnings) were found in some strata. Conclusions The declining prevalence of smoking during pregnancy between 2003 and 2011, while encouraging, does not appear to be directly related to general population antismoking activities or a pregnancy-specific campaign undertaken in this period.This research was supported by an Australian National Health and Medical Research Council Project Grant (#1028543) and AH is supported by a National Heart Foundation Future Leader Fellowship (#100411). The funders had no involvement in the study design; the collection, analysis or interpretation of the data; in the writing of the report or the decision to submit the report for publication.Peer Reviewe

Varenicline is More Effective than Nicotine Replacement Therapy During Pregnancy: Findings from the Smoking MUMS (Maternal Use of Medications and Safety) Study

Introduction Studies in the general population suggest that varenicline is more effective than nicotine replacement therapy (NRT) for smoking cessation. However, clinical guidelines recommend against the use of varenicline during pregnancy and suggest NRT be used when the expected benefits outweigh the potential risks. Objectives and Approach We evaluated whether varenicline was more effective than NRT for smoking cessation when used during pregnancy. Routinely-collected records of all births (01/01/2011-12/31/2012) in New South Wales and Western Australia were used to identify a cohort of women who smoked during the first 20 weeks of pregnancy. Pharmaceutical dispensing data were then linked to identify varenicline or NRT dispensing in the first 20 weeks of pregnancy. Smoking cessation was defined as women reported not smoking after the first 20 weeks of pregnancy. Inverse probability of treatment weighting with propensity scores were used to account for differences between the two treatment groups. Results Overall, 117 women used varenicline and 135 NRT in the first 20 weeks of pregnancy. In the unweighted sample, more women who used varenicline quit smoking after the first 20 weeks than women using NRT (28.2% vs. 11.1%, crude rate difference:17.1%, 95% confidence intervals[CI]:7.4-26.8%). In the weighted sample, quitting rate was 12.7% (95%CI:0.8-24.6%) higher in pregnant smokers who used varenicline (27.4% vs. 14.7%) when compared to those who used NRT. Conclusion/Implications Pregnant smokers using varenicline were more likely to quit smoking than those using NRT. This information will assist healthcare providers to make informed recommendations, but data regarding safety of varenicline in pregnancy are also urgently needed. Future studies with greater statistical power are required to confirm our results

Antipsychotic use in pregnancy and risk of attention/ deficit-hyperactivity disorder and autism spectrum disorder: a Nordic cohort study

Background Antipsychotics are increasingly used among women of childbearing age and during pregnancy. Objective To determine whether children exposed to antipsychotics in utero are at increased risk of attention-deficit/hyperactivity disorder (ADHD) or autism spectrum disorder (ASD), accounting for maternal diagnoses of bipolar, psychotic and other psychiatric disorders. Design Population-based cohort study, including a sibling analysis. Setting Nationwide data on all pregnant women and their live-born singletons in Denmark (1997-2017), Finland (1996-2016), Iceland (2004-2017), Norway (2004-2017), and Sweden (2006-2016). Participants 4 324 086 children were eligible for inclusion to the study cohort. Intervention Antipsychotic exposure in utero, assessed by pregnancy trimester, type of antipsychotic, and varying patterns of use. Main outcome measures Non-mutually exclusive diagnoses of ADHD and ASD. We used Cox proportional hazard models to calculate hazard ratios (HRs) controlling for maternal psychiatric disorders and other potential confounding factors. Findings Among 4 324 086 singleton births, 15 466 (0.4%) were exposed to antipsychotics in utero. During a median follow-up of 10 years, we identified 72 257 children with ADHD and 38 674 children with ASD. Unadjusted HRs were raised for both outcomes but shifted substantially towards the null after adjustment; 1.10 (95%CI 1.00 to 1.27) for ADHD and 1.12 (0.97 to 1.29) for ASD. Adjusted HRs remained consistent by trimester of exposure and type of antipsychotic. Comparing in utero exposure with pre-pregnancy use yielded HRs of 0.74 (0.62 to 0.87) for ADHD and 0.88 (0.70 to 1.10) for ASD. Sibling analyses yielded HRs of 1.14 (0.79 to 1.64) for ADHD and 1.34 (0.75 to 2.39) for ASD. Discussion Our findings suggest little or no increased risk of child ADHD or ASD after in utero exposure to antipsychotics. Clinical implications Results regarding child neurodevelopment are reassuring for women who need antipsychotics during pregnancy.publishedVersio

Cancer Survival and Excess Mortality Estimates among Adolescents and Young Adults in Western Australia, 1982-2004: A Population-Based Study

Background: Data are limited on cancer outcomes in adolescents and young adults. Methods: Based on data from the Western Australian Data Linkage System, this study modelled survival and excess mortality in all adolescents and young adults aged 15-39 years in Western Australia who had a diagnosis of cancer in the period 1982-2004. Relative survival and excess all-cause mortality for all cancers combined and for principal tumour subgroups were estimated, using the Ederer II method and generalised linear Poisson modelling, respectively. Results: A cancer diagnosis in adolescents and young adults conferred substantial survival decrement. However, overall outcomes improved over calendar period (excess mortality hazard ratio [HR], latest versus earliest diagnostic period: 0.52, trend <0.0001). Case fatality varied according to age group (HR, oldest versus youngest: 1.38, trend <0.0001), sex (HR, female versus male: 0.66, 95% confidence interval [CI] 0.62-0.71), ethnicity (HR, Aboriginal versus others: 1.47, CI 1.23-1.76), geographical area (HR, rural/remote versus urban: 1.13, CI 1.04-1.23) and residential socioeconomic status (HR, lowest versus highest quartile: 1.14, trend <0.05). Tumour subgroups differed substantially in frequency according to age group and sex, and were critical outcome determinants. Conclusions: Marked progressive calendar-time improvement in overall outcomes was evident. Further research is required to disentangle the contributions of tumour biology and health service factors to outcome disparities between ethno-demographic, geographic and socioeconomic subgroups of adolescents and young adults with cancer. © 2013 Haggar et al

ESR1 and EGF genetic variation in relation to breast cancer risk and survival

The main purposes of this thesis were to analyse common genetic variation in candidate genes and candidate pathways in relation to breast cancer risk, prognosticators and survival, to develop statistical methods for genetic association analysis for evaluating the joint importance of genes, and to investigate the potential impact of adding genetic information to clinical risk factors for projecting individualised risk of developing breast cancer over specific time periods. In Paper I we studied genetic variation in the estrogen receptor α and epidermal growth factor genes in relation to breast cancer risk and survival. We located a region in the estrogen receptor α gene which showed a moderate signal for association with breast cancer risk but were unable to link common variation in the epidermal growth factor gene with breast cancer aetiology or prognosis. In Paper II we investigated whether suspected breast cancer risk SNPs within genes involved in androgen-to-estrogen conversion are associated with breast cancer prognosticators grade, lymph node status and tumour size. The strongest association was observed for a marker within the CYP19A1 gene with histological grade. We also found evidence that a second marker from the same gene is associated with histological grade and tumour size. In Paper III we developed a novel test of association which incorporates multivariate measures of categorical and continuous heterogeneity. In this work we described both a single-SNP and a global multi-SNP test and used simulated data to demonstrate the power of the tests when genetic effects differ across disease subtypes. In Paper IV we assessed the extent to which recently associated genetic risk variants improve breast cancer risk-assessment models. We investigated empirically the performance of eighteen breast cancer risk SNPs together with mammographic density and clinical risk factors in predicting absolute risk of breast cancer. We also examined the usefulness of various prediction models considered at a population level for a variety of individualised breast cancer screening approaches. The goal of a genetic association study is to establish statistical associations between genetic variants and disease states. Each variant linked to a disease can lead the way to a better understanding of the underlying biological mechanisms that govern the development of a disease. Increased knowledge of molecular variation provides the opportunity to stratify populations according to genetic makeup, which in turn has the potential to lead to improved disease prevention programs and improved patient care

Cancer incidence and mortality trends in Australian adolescents and young adults, 1982-2007

Background: Increasing incidence and lack of survival improvement in adolescents and young adults (AYAs) with cancer have led to increased awareness of the cancer burden in this population. The objective of this study was to describe overall and type-specific cancer incidence and mortality trends among AYAs in Western Australia from 1982-2007.Methods: Age-adjusted incidence and mortality rates were calculated for all malignancies combined and for each of the most common diagnostic groups, using five-year age-specific rates. Joinpoint regression analysis was used to derive annual percentage changes (APC) for incidence and mortality rates.Results: The annual incidence rate for all cancers combined increased in males from 1982 until 2000 (APC = 1.5%, 95%CI: 0.9%; 2.1%) and then plateaued, whilst rates for females remained stable across the study period (APC = -0.1%; 95%CI: -0.2%; 0.4%) across the study period. For males, significant incidence rate increases were observed for germ cell tumors, lymphoblastic leukemia and thyroid cancer. In females, the incidence of Hodgkin's lymphoma, colorectal and breast cancers increased. Significant incidence rate reductions were noted for cervical, central nervous system and lung cancers. Mortality rates for all cancers combined decreased from 1982 to 2005 for both males (APC = -2.6%, 95%CI:-3.3%;-2.0%) and females (APC = -4.6%, 95%CI:-5.1%;-4.1%). With the exception of bone sarcoma and lung cancer in females, mortality rates for specific cancer types decreased significantly for both sexes during the study period.Conclusions: Incidence of certain AYA cancers increased, whilst it decreased for others. Mortality rates decreased for most cancers, with the largest improvement observed for breast carcinomas. Further research is needed to identify the reasons for the increasing incidence of certain cancers. © 2012 Haggar et al.; licensee BioMed Central Ltd