Assessing the performance of maternity care in Europe: A critical exploration of tools and indicators

Background: This paper critically reviews published tools and indicators currently used to measure maternity care performance within Europe, focusing particularly on whether and how current approaches enable systematic appraisal of processes of minimal (or non-) intervention in support of physiological or "normal birth". The work formed part of COST Actions IS0907: "Childbirth Cultures, Concerns, and Consequences: Creating a dynamic EU framework for optimal maternity care" (2011-2014) and IS1405: Building Intrapartum Research Through Health - an interdisciplinary whole system approach to understanding and contextualising physiological labour and birth (BIRTH) (2014-). The Actions included the sharing of country experiences with the aim of promoting salutogenic approaches to maternity care. Methods: A structured literature search was conducted of material published between 2005 and 2013, incorporating research databases, published documents in english in peer-reviewed international journals and indicator databases which measured aspects of health care at a national and pan-national level. Given its emergence from two COST Actions the work, inevitably, focused on Europe, but findings may be relevant to other countries and regions. Results: A total of 388 indicators were identified, as well as seven tools specifically designed for capturing aspects of maternity care. Intrapartum care was the most frequently measured feature, through the application of process and outcome indicators. Postnatal and neonatal care of mother and baby were the least appraised areas. An over-riding focus on the quantification of technical intervention and adverse or undesirable outcomes was identified. Vaginal birth (no instruments) was occasionally cited as an indicator; besides this measurement few of the 388 indicators were found to be assessing non-intervention or "good" or positive outcomes more generally. Conclusions: The tools and indicators identified largely enable measurement of technical interventions and undesirable health (or pathological medical) outcomes. A physiological birth generally necessitates few, or no, interventions, yet most of the indicators presently applied fail to capture (a) this phenomenon, and (b) the relationship between different forms and processes of care, mode of birth and good or positive outcomes. A need was identified for indicators which capture non-intervention, reflecting the reality that most births are low-risk, requiring few, if any, technical medical procedures

A Survey of University Students’ Preferences for Midwifery Care and Community Birth Options in 8 High‐Income Countries

Background: Midwifery care is associated with positive birth outcomes, access to community birth options, and judicious use of interventions. The aim of this study was to characterize and compare maternity care preferences of university students across a range of maternity care systems and to explore whether preferences align with evidence- based recommendations and options available. Methods: A cross-sectional, web-based survey was completed in 2014-2015 by a convenience sample of university students in 8 high-income countries across 4 continents (n=4,569). In addition to describing preferences for midwifery care and community birth options across countries, socio-demographic characteristics, psychological factors, knowledge about pregnancy and birth, and sources of information that shaped students’ attitudes towards birth were examined in relation to preferences for midwifery care and community birth options. Results: Approximately half of the student respondents (48. 2%) preferred midwifery-led care for a healthy pregnancy, 9.5% would choose to birth in a birthing center, and 4.5% preferred a home birth. Preference for midwifery care varied from 10.3% among women in the United States to 78.6% among women in England. Preferences for home birth varied from 0.3% among US women to 18.3% among Canadian women. Women, health science students, those with low childbirth fear, who learned about pregnancy and birth from friends (compared to other sources, e.g. the media) and those who responded from Europe were significantly more likely to prefer midwifery care and community birth. High confidence in knowledge of pregnancy and birth was linked to significantly higher odds of community birth preferences and midwifery care preferences Conclusions: It would be beneficial to integrate childbirth education into high school curricula, to promote knowledge of midwifery care, pregnancy and childbirth and reduce fear among prospective parents. Community birth options need to be expanded, to meet demand among the next generation of maternity service users

Temporal trends in fetal mortality at and beyond term and induction of labor in Germany 2005-2012 : data from German routine perinatal monitoring

Purpose: While a variety of factors may play a role in fetal and neonatal deaths, postmaturity as a cause of stillbirth remains a topic of debate. It still is unclear, whether induction of labor at a particular gestational age may prevent fetal deaths. Methods: A multidisciplinary working group was granted access to the most recent set of relevant German routine perinatal data, comprising all 5,291,011 hospital births from 2005 to 2012. We analyzed correlations in rates of induction of labor (IOL), perinatal mortality (in particular stillbirths) at different gestational ages, and fetal morbidity. Correlations were tested with Pearson's product-moment analysis (α = 5 %). All computations were performed with SPSS version 22. Results: Induction rates rose significantly from 16.5 to 21.9 % (r = 0.98; p \ 0.001). There were no significant changes in stillbirth rates (0.28-0.35 per 100 births; r = 0.045; p = 0.806). Stillbirth rates 2009-2012 remained stable in all gestational age groups irrespective of induction. Fetal morbidity (one or more ICD-10 codes) rose significantly during 2005–2012. This was true for both children with (from 33 to 37 %, r = 0.784, p \ 0.001) and without (from 25 to 31 %, (r = 0.920, p \ 0.001) IOL. Conclusions: An increase in IOL at term is not associated with a decline in perinatal mortality. Perinatal morbidity increased with and without indiction of labor

Reviewing scientific evidence for one's own practice: A new method for midwives

Theoretischer Hintergrund: Viele Hebammen kennen Ergebnisse von Reviews wie etwa die der Cochrane Collaboration. Sie fragen sich jedoch, ob das Gelesene 1:1 in ihren beruflichen Alltag übertragbar ist und wie sie mit Ergebnissen umgehen, die (noch) keinen Vorteil für eine von zwei möglichen Interventionen aufzeigen. Fragestellung: So stellt sich die Frage, ob die Studienpopulation mit den von ihnen begleiteten (werdenden) Eltern oder die beschriebene Intervention mit den von ihnen angewandten Maßnahmen vergleichbar sind. Daher ist eine Methode zu erarbeiten, wie jede Hebamme für sich überprüfen kann, ob die Empfehlung eines Reviews auch für sie den optimalen Weg bedeutet. Ziel: Die Anwendung der hier vorgestellten Methode zielt darauf ab, einerseits die Arbeit jeder einzelnen Hebamme zu unterstützen und andererseits die Übertragbarkeit der wissenschaftlichen Evidenz zu überprüfen. Background: Many midwives are aware of evidence from reviews, such as those from the Cochrane Collaboration. But they are asking themselves if they can transfer these results to their every-day work and how they should handle results that do not (yet) indicate a preference for one of the interventions examined. Objective: The question arises, for example, if the study population is comparable to the parents-to-be in the midwives’ practice or if the interventions presented correspond to the ones the midwives use. Therefore, a method should be elaborated as to how a midwife can assess whether the recommendations of a review indicate the best way for her own practice. Aim: This method seeks to support the decision-making process of a midwife and to contribute to the transferability of scientific evidence

A new method supporting decision-making in case of unclear scientific evidence: Test implementation and simulation

Background: Many health workers are aware of the results of reviews like those of the Cochrane Collaboration. Some results of these reviews show, at that stage of the research, no advantage for one of two promising interventions. In these cases, Beck-Bornholdt and Dubben propose a modified, never-change-a-winning-team algorithm. Similar algorithms are used in cases of study group assignments or adjustments to the design of a study in progress.Research question: Is the method proposed by Beck-Bornholdt and Dubben in 2003 helpful for the daily work of midwives when they have to choose between two interventions with similar evidence of success?Methodology: The application of the algorithm is being simulated for possible use by health workers. This includes all existing experiences made with both interventions to decide on the intervention for the next person to be treated.Results: Simulations were carried out for various scenarios with different likelihood for success with regard to both interventions. It can be demonstrated that the average success rate in all scenarios is already improved starting with the second person treated, in comparison to the average success rate for both interventions.Conclusions: The results can serve as a basis for discussion for the applicability of the suggested method. If the evidence is unclear, the algorithm can support the decision of health workers for one of two possible treatments, with positive effect. The special conditions of the setting in question (clientele, treatment realization) are hereby taken into account in each case.Hintergrund: Viele Gesundheitsfachpersonen kennen Ergebnisse von Reviews wie etwa die der Cochrane Collaboration. Manche Ergebnisse dieser Reviews zeigen, dass (noch) kein Vorteil für eine von zwei vielversprechenden Interventionen erkannt wird. In diesem Fall schlagen Beck-Bornholdt und Dubben den Algorithmus einer modifizierten never-change-a-winning-team Strategie vor. Ähnliche Methoden werden für die Gruppenzuteilung in Studien oder für die Anpassung des Studiendesigns im Verlauf einer Studie genutzt.Forschungsfrage: Ist die von Beck-Bornholdt und Dubben (2003) vorgeschlagene Methode für den Praxisalltag der Hebammen tauglich, bei der Wahl zwischen zwei in der Literatur als gleichwertig erscheinenden Interventionen eine sinnvolle Entscheidungshilfe zu bieten?Methodik: Die Anwendung des Algorithmus wird für eine mögliche Anwendung durch Gesundheitsfachpersonen simuliert. Er bezieht alle Erfahrungen ein, die mit den beiden zu vergleichenden Interventionen gemacht werden, um die Intervention für die nächste zu behandelnde Person festzulegen.Ergebnisse: Für verschiedene Szenarien mit unterschiedlichen Erfolgswahrscheinlichkeiten der beiden Interventionen wurden Simulationen durchgeführt. Die durchschnittliche Erfolgsrate ist dabei in allen Szenarien bereits ab der zweiten zu behandelnden Person besser als die mittlere Erfolgsrate der beiden Interventionen.Schlussfolgerung: Die vorliegenden Ergebnisse sollen als Diskussionsgrundlage für die Anwendbarkeit der vorgeschlagenen Methode dienen. Bei unklarer wissenschaftlicher Evidenz aus Metaanalysen kann der Algorithmus die Entscheidung von Gesundheitsfachpersonen für eine von zwei Behandlungsmöglichkeiten gewinnbringend unterstützen. Der Subjektivität des eigenen Settings (Klientel, Durchführungsweise der Behandlung) wird dabei stets Rechnung getragen

Individual length of gestation - maturity is not predictable

Background: The estimated due date is used as a planning point for interventions. It is unclear, however, whether the calculated gestational age (GA) correlates with the maturation of the foetus in utero.Objective: The aim of the study was to assess the maturity of newborns compared to their GA.Method: 100 newborns were examined within 72 hours of birth for their maturity using the New Ballard Score. The correlation between GA and attained maturity was analysed along with differences after spontaneous parturition and induced birth.Results: The earlier babies were born before the calculated due date, the more mature they were found to be on clinical assessment compared to their calculated GA. The more the calculated due date was exceeded, the less the newborn maturity was found to correlate with the calculated GA. There was a significant difference (p<0.001) between the assessed maturity and the calculated GA at term (40+0) and after term (n=49). Induction of labour was a risk for a distinct downward deviation of maturity against GA (RR=3.35; [95% CI 1.89-4.15]).Conclusion: The calculated GA had no diagnostic power for maturity of the newborn in prolonged or post-term pregnancies. Given the results presented here, the calculation of a clearly defined due date and its use as a basis for interventions should be critically scrutinised. Further research with a larger population is required.Hintergrund: Der errechnete Termin (ET) wird routinemäßig als Ausgangspunkt für Interventionen genutzt. Es ist jedoch fraglich, wie stark das rechnerische Gestationsalter (GA) mit den klinischen Reifezeichen des Neugeborenen (NG) übereinstimmt.Ziel: Überprüfung der Übereinstimmung von errechnetem Schwangerschaftsalter und den klinischen Reifezeichen des Neugeborenen.Methode: 100 NG wurden innerhalb 72 Stunden post partum nach dem New Ballard Score auf ihre Reife hin untersucht. Das Verhältnis zwischen GA und befundeter Reife, auch differenziert nach Art des Geburtsbeginns, wurde mittels SPSS 24 analysiert. Ergebnisse: Je früher vor dem ET die Geburt stattfand, desto reifer im Verhältnis zum GA wurden die NG nach den klinischen Befunden eingestuft. Je weiter der ET überschritten wurde, desto unreifer waren die NG im Verhältnis zum errechneten GA. Für Geburten rechnerisch nach SSW 40+0 (n=49) unterscheidet sich das rechnerische Gestationsalter in der Stichprobe signifikant vom befundeten Reifealter (p<0,001). Bei Einleitungen war eine Unreife wahrscheinlicher als bei spontanem Geburtsbeginn (RR=3,35; [95% CI 1,89-4,15]).Schlussfolgerung: Bei Überschreitung des errechneten Termins hat das rechnerische Gestationsalter keine diagnostische Aussagekraft für den Reifezustand des NG. Die Festlegung eines taggenauen ET und dessen Verwendung für Interventionen ist daher kritisch zu hinterfragen. Weitere Forschung mit einer größeren Stichprobe ist erforderlich

Out-of-hospital midwifery care of perineal tears grade 1 and 2

Background: First-degree or second-degree perineal tears can heal with or without suture. With regard to these two options, only short-term healing effects are currently known. As long-term studies are lacking, evidence on their effects, or harms, is weak. No data from German-speaking regions are presently available to indicate how midwives treat first-degree or second-degree perineal tears.Methods: In the current online survey, undertaken for a master's degree, 117 independent midwives from Germany and Austria, who participated, were asked about the postpartal prerequisites for their decision on the treatment and the actual care of perineal tears. In addition, their interest in further training was investigated. Quantitative analysis of the multiple-choice questions was descriptive; additional items for free text were content-analysed according to Mayring.Results: Only 18% of the participants learned how to treat perinatal tears during formal training. 83% of the midwives felt confident when diagnosing the grade of the tear. Half of them had experience with first-degree perineal tears and 12% with second-degree perineal tears healing unsutured. About half of the midwives (45% in Germany) and (51% in Austria) were interested in further training. Conclusion: Both suturing and spontaneous perineal healing should be part of any formal training for midwives, as evidence for a preferred option does not currently exist.Hintergrund: Dammrisse ersten und zweiten Grades (DR I° und DR II°) heilen entweder mit oder ohne Naht. Zu diesen Versorgungsalternativen sind bislang Kurzzeiteffekte bekannt. Da Langzeitstudien fehlen, ist die Evidenzlage hinsichtlich ihrer (Neben-)Wirkungen unzureichend. Darüber hinaus liegen bislang für deutschsprachige Regionen keine Angaben vor, wie Hebammen einen DR I° oder DR II° versorgen.Methodik: Im vorliegenden Survey, der im Rahmen einer Masterarbeit durchgeführt wurde, wurde danach gefragt, welche Voraussetzungen nach der Geburt gegeben sein müssen, um die Dammrissversorgung festzulegen und wie Hebammen diese vornehmen. Zudem wurde der Frage nachgegangen, ob Hebammen in diesem Bereich Fortbildungsbedarf für sich sehen. Die Online-Befragung richtete sich an außerklinisch geburtshilflich tätige Hebammen in Deutschland und Österreich, von welchen sich 117 beteiligten. Die quantitative Analyse der Multiple-Choice Fragen erfolgte deskriptiv; die offenen Items mit Bemerkungen der Hebammen wurden inhaltsanalytisch nach Mayring ausgewertet.Ergebnisse: Nur ca. 18% der Befragten konnten auf Wissen aus ihrer Aus- und Fortbildung zurückgreifen. Insgesamt 83% waren sich in der Differenzierung nach Dammrissgraden sicher. Mit einer spontanen Heilung hatten über 50% der Hebammen Erfahrung bei DR I° und 12% bei DR II°. Rund die Hälfte aller Hebammen (45% in Deutschland, 51% in Österreich) hatte ein weiteres Fortbildungsinteresse.Schlussfolgerung: Beide Versorgungsarten sollten derzeit in der Aus- und Fortbildung vermittelt werden, da die Evidenzlage keine klare Präferenz vorgibt