Outcomes of breech birth by mode of delivery: a population linkage study

Background: Trial evidence supports a policy of caesarean section for singleton breech presentations at term but vaginal breech birth is considered a safe option for selected women. Aims: To provide recent Australian data on outcomes associated with intended mode of delivery for term breech singletons in women who meet conservative eligibility criteria for vaginal breech birth. Materials and Methods: Birth and hospital records from 2009 to 2012 in New South Wales were used to identify women with non-anomalous pregnancies who would be considered eligible for vaginal breech birth. Intended mode of delivery was inferred from labour onset and management. Results: Of 10,133 women with term breech singleton pregnancies, 5,197 (51.3%) were classified as eligible for vaginal breech delivery. Of these, 6.8% intended vaginal breech birth, 76.4% planned caesarean section, and intention could not be determined for 16.8%. Women intending vaginal delivery had higher rates of neonatal morbidity (6.0% vs. 2.1%), neonatal birth trauma (7.4% vs. 0.9%), Apgar <4 at 1 minute (10.5% vs. 1.1%), Apgar<7 at 5 minutes (4.3% vs. 0.5%), and NICU/SCN admissions (16.2% vs. 6.6%) than those planning caesarean section. Increased perinatal risks remained after adjustment for maternal characteristics. Severe maternal morbidity (1.4% vs. 0.7%) and postpartum readmission (4.6% vs. 4.0%) were higher in the intended vaginal compared to planned caesarean births but these differences were not statistically significant. Conclusions: In a population of women classified as being eligible for vaginal breech birth, intended vaginal delivery was associated with higher rates of neonatal morbidity than planned caesarean section.NHMRC, AR

Contribution of Changing Risk Factors to the Trend in Breech Presentation at Term

Background: Recent population-wide changes in perinatal risk factors may affect rates of breech presentation at birth, and have implications for the provision of breech services and clinical training in breech management. Aims: To determine the trend in breech presentation at term and investigate whether changes in maternal and pregnancy characteristics explain the observed trend. Materials and Methods: All singleton term (≥37 week) births in New South Wales during 2002 – 2012 were identified through birth and associated hospital records. Annual rates of breech presentation were determined. Logistic regression modelling was used to predict expected rates of breech presentation over time and these were compared with observed rates. A priori predictors included maternal age, country of birth, parity, smoking during pregnancy, diabetes, pregnancy hypertension, placenta praevia, previous singleton term breech, previous caesarean section, infant sex, gestational age, birthweight, and congenital anomalies. Hospital and Medicare data were used to assess trends in external cephalic version. Results: Among 914,147 singleton term births, 3.1% were breech at delivery. Rates declined from 3.6% in 2002 to 2.7% in 2012 (test for trend p<0.001). Breech presentation was predicted to increase from 3.6% in 2002 to 4.3% in 2012 because of increased maternal age, nulliparity, maternal diabetes, history of breech presentation and previous caesarean section. Use of external cephalic version appears to have increased over time. Conclusions: Breech presentation at delivery has decreased in New South Wales. Increased use of external cephalic version likely accounts for this decline, as changes in risk factors do not.NHMRC, AR

Woman-centred maternity care: what do women say? Protocol for a survey of women receiving maternity care in NSW

Background: Over the past decade or so, recommendations for improvements in maternity care have emphasised the importance of providing woman-centred care. Feedback from women about existing maternity services can help to identify whether services are currently meeting women’s needs. The present study aims to capture women’s expectations of, and experiences with maternity care, and to explore whether maternal and birth characteristics are associated with those experiences. Methods: A survey will be undertaken with a sample of approximately 2,000 women who have given birth over a 3-month period at seven public maternity units in two neighbouring health districts in New South Wales (NSW), Australia. The survey will be mailed out three-four months after birth. The study will also examine two strategies intended to increase survey response rates: use of two types of pre-notification letters, and request for consent from women to link survey responses with health information recorded at the time of birth. Data analysis will examine response rate, evidence of sample bias and effect of pre-notification letters; describe expectations and experiences with maternity care and associations with maternal and/or health characteristics; and where possible, compare results with maternity satisfaction data reported by others. Discussion: This study will provide, for the first time in NSW, comprehensive information about women’s expectations, experiences and satisfaction with maternity services in two local health districts. It will identify aspects of care that are meeting women’s needs, and areas where care and service provision may be improved in line with the aspirations of Towards Normal Birth. The survey tool may also prove to be appropriate for use by other health districts and/or state-wide.NHMR

Woman-centred maternity care: what do women say? Protocol for a survey of women receiving maternity care in NSW

Background: Over the past decade or so, recommendations for improvements in maternity care have emphasised the importance of providing woman-centred care. Feedback from women about existing maternity services can help to identify whether services are currently meeting women’s needs. The present study aims to capture women’s expectations of, and experiences with maternity care, and to explore whether maternal and birth characteristics are associated with those experiences. Methods: A survey will be undertaken with a sample of approximately 2,000 women who have given birth over a 3-month period at seven public maternity units in two neighbouring health districts in New South Wales (NSW), Australia. The survey will be mailed out three-four months after birth. The study will also examine two strategies intended to increase survey response rates: use of two types of pre-notification letters, and request for consent from women to link survey responses with health information recorded at the time of birth. Data analysis will examine response rate, evidence of sample bias and effect of pre-notification letters; describe expectations and experiences with maternity care and associations with maternal and/or health characteristics; and where possible, compare results with maternity satisfaction data reported by others. Discussion: This study will provide, for the first time in NSW, comprehensive information about women’s expectations, experiences and satisfaction with maternity services in two local health districts. It will identify aspects of care that are meeting women’s needs, and areas where care and service provision may be improved in line with the aspirations of Towards Normal Birth. The survey tool may also prove to be appropriate for use by other health districts and/or state-wide.NHMR

Predicting date of birth: the best time to date a pregnancy?

Objective: To compare the estimated date of birth calculations from last menstrual period (LMP) and ultrasounds at varying gestations (<70, 70-106, 110-140, 141-196 and 200-276) against the actual date of birth (DOB). Methods: This cohort study in a single local health district, Australia included 18,708 women with spontaneous labor who gave birth to a single live born infant without major anomalies between 2007 and 2011. Data were sourced from a computerized population birth database. The outcome of interest was duration of pregnancy expressed as total days, and the difference between actual DOB and estimated date of birth by dating method. Results: Only 5% of births occurred on the estimated date of birth regardless of the timing of the estimate. Approximately 66% of births occurred +/-7 days of the estimated date of birth, and there was little difference between ultrasound gestational week bands. The 110-140 weeks of gestation ultrasound performed as well if not better than ultrasounds conducted at other gestations. Maternal factors such as ethnicity and smoking status during pregnancy influenced duration of pregnancy; however, their explanatory power was too low to support incorporating these characteristics in dating estimations. Conclusion: An early dating scan (10 weeks or earlier) is unnecessary if LMP is reliable.Australian National Health and Medical Research Council (NHMRC) Centre for Research Excellence Grant (#APP1001066), Sydney Medical School Summer Research Scholarship, NHMRC Senior Research Fellowship (#APP1021025)

Maternity Care in NSW - Having Your Say 2013-14. A survey about women’s views of their maternity care

This report details the findings of a survey with women about their expectations and experiences of maternity care in public hospitals in New South Wales (NSW), Australia. The report provides background information about the survey project, and a summary of the responses from the women participating in the survey. The survey and this report have been structured around the three main maternity care periods: antenatal (pregnancy); birth; and postnatal (the first days and weeks after birth). All women who gave birth between 1 May and 31 July 2013 at seven public maternity units in NSW were eligible to participate in the survey. These seven maternity units account for approximately 11% of births in public hospitals in NSW, and represent a mixture of urban and regional, and tertiary and smaller health services. A total of 2048 women were mailed a survey. Survey packs were returned as undeliverable for 59 women, and 913 women returned a completed survey, representing a response rate of 46% (913/1989).NHMR

Rate of spontaneous onset of labour before planned repeat caesarean section at term

In an auditory lexical decision experiment, 5,541 spoken content words and pseudo-words were presented to 20 native speakers of Dutch. The words vary in phonological makeup and in number of syllables and stress pattern, and are further representative of the native Dutch vocabulary in that most are morphologically complex, comprising two stems or one stem plus derivational and inflectional suffixes, with inflections representing both regular and irregular paradigms; the pseudo-words were matched in these respects to the real words. The BALDEY data file includes response times and accuracy rates, with for each item morphological information plus phonological and acoustic information derived from automatic phonemic segmentation of the stimuli. Two initial analyses illustrate how this data set can be used. First, we discuss several measures of the point at which a word has no further neighbors, and compare the degree to which each measure predicts our lexical decision response outcomes. Second, we investigate how well four different measures of frequency of occurrence (from written corpora, spoken corpora, subtitles and frequency ratings by 70 participants) predict the same outcomes. These analyses motivate general conclusions about the auditory lexical decision task. The (publicly available) BALDEY database lends itself to many further analyses

Maternity Care in NSW - Having Your Say 2013-14. A survey about women’s views of their maternity care

This report details the findings of a survey with women about their expectations and experiences of maternity care in public hospitals in New South Wales (NSW), Australia. The report provides background information about the survey project, and a summary of the responses from the women participating in the survey. The survey and this report have been structured around the three main maternity care periods: antenatal (pregnancy); birth; and postnatal (the first days and weeks after birth). All women who gave birth between 1 May and 31 July 2013 at seven public maternity units in NSW were eligible to participate in the survey. These seven maternity units account for approximately 11% of births in public hospitals in NSW, and represent a mixture of urban and regional, and tertiary and smaller health services. A total of 2048 women were mailed a survey. Survey packs were returned as undeliverable for 59 women, and 913 women returned a completed survey, representing a response rate of 46% (913/1989).NHMR

Rate of spontaneous onset of labour before planned repeat caesarean section at term

BACKGROUND: Guidelines recommend that, in the absence of compelling medical indications (low risk) elective caesarean section should occur after 38 completed weeks gestation. However, implementation of these guidelines will mean some women go into labour before the planned date resulting in an intrapartum caesarean section. The aim of this study was to determine the rate at which low-risk women planned for repeat caesarean section go into spontaneous labour before 39 weeks. METHODS: We conducted a population-based cohort study of women who were planned to have an elective repeat caesarean section (ERCS) at 39-41 weeks gestation in New South Wales Australia, 2007-2010. Labour, delivery and health outcome information was obtained from linked birth and hospital records for the entire population. Women with no pre-existing medical or pregnancy complications were categorized as ‘low risk’. The rate of spontaneous labour before 39 weeks was determined and variation in the rate for subgroups of women was examined using univariate and multivariate analysis. RESULTS: Of 32,934 women who had ERCS as the reported indication for caesarean section, 17,314 (52.6%) were categorised as ‘low-risk’. Of these women, 1,473 (8.5% or 1 in 12) had spontaneous labour or prelabour rupture of the membranes before 39 weeks resulting in an intrapartum caesarean section. However the risk of labour <39 weeks varied depending on previous delivery history: 25% (1 in 4) for those with spontaneous preterm labour in a prior pregnancy; 15% (1 in 7) for women with a prior planned preterm birth (by labour induction or prelabour caesarean) and 6% (1 in 17) among those who had only previously had a planned caesarean section at term. Smoking in pregnancy was also associated with spontaneous labour. Women with spontaneous labour prior to a planned CS in the index pregnancy were at increased risk of out-of-hours delivery, and maternal and neonatal morbidity. CONCLUSIONS: These findings allow clinicians to more accurately determine the likelihood that a planned caesarean section may become an intrapartum caesarean section, and to advise their patients accordingly

WHAT FACTORS CONTRIBUTE TO HOSPITAL VARIATION IN OBSTETRIC TRANSFUSION RATES?

Background & 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 & 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 2008-2010 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 to 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. At a hospital level, high transfusion rates were moderately correlated with maternal morbidity (0.56, p=0.01) and low Apgar scores (0.54, p=0.002), but not with readmission rates (0.18, p=0.28). 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.Partnership Grant from the Australian National Health and Medical Research Council NHMRC (#1027262), the Australian Red Cross and the NSW Clinical Excellence Commission, NHMRC Senior Research Fellowship (#1021025). ARC Future Fellowship (#120100069)