Ascertaining severe perineal trauma and associated risk factors by comparing birth data with multiple sources

Objectives Population data are often used to monitor severe perineal trauma trends and association of risk factors. Within NSW, two different datasets can be used; the Perinatal Data Collection (‘birth’ data), or a linked dataset combining birth data with the Admitted Patient Hospital Data Collection (‘hospital’ data). Severe perineal trauma can be ascertained by birth data alone, or by hospital ICD-10-AM diagnosis and procedure coding in the linked dataset. The aim of this study is to compare rates and risk factors for severe perineal trauma using birth data alone, with those using linked data. Methods The study population consisted of all vaginal births in NSW 2001-2011. As perineal injury coding in birth data was revised in 2006, data were analysed separately for 2 ‘earlier data’ and ‘more recent data’. Rates of severe perineal injury over time were compared in birth data alone, and in linked data. Kappa and agreement statistics were calculated. Risk factor distributions (primiparity, instrumental birth, birthweight≥4kg, Asian country of birth and episiotomy) were compared between women with severe perineal trauma identified by birth data alone, and identified by linked data. Multivariable logistic regression was used to calculate the adjusted odds ratios of severe perineal trauma. Results Among 697,202 vaginal births, 2.1% were identified with severe perineal trauma by birth data alone, and 2.6% by linked data. The rate discrepancy was higher among earlier data (1.7% for birth data, 2.4% for linked data). Kappa for earlier data was 0.78 (95% CI 0.78, 0.79), and 0.89 (95% CI 0.89, 0.89) for more recent data. With the exception of episiotomy, differences in risk factor distributions were small, with similar adjusted odds ratios. Adjusted odds ratio of severe perineal trauma for episiotomy was higher (1.34 95% CI 1.27, 1.41) using linked data compared with birth data (1.03 95% CI 0.97, 1.09). Conclusions While discrepancies in ascertainment of severe perineal trauma improved after revision of birth data coding in 2006, higher ascertainment by linked data was still evident for recent data. There were also higher risk estimates of severe perineal trauma with episiotomy by linked data than by birth data.Australian Research Council; Dr Albert S McKern Research Scholarshi

Knowledge, attitude and experience of episiotomy use among obstetricians and midwives in Viet Nam

Background: Episiotomy remains a routine procedure at childbirth in many South-East Asian countries but the reasons for this are unknown. The aim of this study was to determine the knowledge of, attitudes towards and experience of episiotomy use among clinicians in Viet Nam. Methods: All obstetricians and midwives who provide delivery care at Hung Vuong Hospital were surveyed about their practice, knowledge and attitudes towards episiotomy use. Data were analysed using frequency tabulations and contingency table analysis. Results: 148 (88%) clinicians completed the questionnaire. Fewer obstetricians (52.2%) than midwives (79.7%) thought the current episiotomy rate of 86% was about right (P<0.01). Most obstetricians (82.6%) and midwives (98.7%) reported performing episiotomies on nulliparous women over 90% of the time. Among multipara, 24.6% of obstetricians reported performing episiotomy less than 60% of the time compared with only 3 (3.8%) midwives (P<0.01). Aiming to reduce 3rd-4th degree perineal tears was the most commonly reported reason for performing an episiotomy by both obstetricians (76.8%) and midwives (82.3%), and lack of training in how to minimize tears and keep the perineum intact was the mostly commonly reported obstacle (obstetricians 56.5%, midwives 36.7% P=0.02) to reducing the episiotomy rate. Conclusion: Although several factors that may impede or facilitate episiotomy practice change were identified by our survey, training and confidence in normal vaginal birth without episiotomy is a priority.The authors would like to acknowledge the midwives and obstetricians at Hung Vuong Hospital who gave generously of their time in completing the questionnaire. Christine Roberts is supported by an Australian National Health and Medical Research Council Senior Research Fellowship (APP1021025). Amanda Ampt is supported by the Albert S McKern Research Scholarship

Vulvoplasty in NSW 2001-2013: A population-based record-linkage study

Objectives: To compare characteristics of women who have vulvoplasty procedures with other women; quantify short-term adverse events and complications; and determine any association of vulvoplasty on future births. Design, setting and participants: A population-based record-linkage study was undertaken using the New South Wales (NSW) Admitted Patient Data Collection and NSW Perinatal Data Collection. All women who had vulvoplasties in hospital during 2001 - 2013 were identified, and their characteristics compared with all women of reproductive age (reference population). Main outcome measures: Admissions for vulvoplasty and repeat vulvoplasties; serious complications or adverse events following vulvoplasty procedures; birth mode and perineal outcomes for primiparous women with and without prior vulvoplasty. Results: There were 4,592 vulvoplasty procedures performed on 4,381 women, increasing by 64.5% over the study period. Compared to the reference population, women who had vulvoplasty were more likely to be Australian born (74.6% vs 67.6%); have other cosmetic surgery (10.1% vs 1.7%); and never been married (43.1% vs 33.1%). The serious adverse event/complication rate was 7.2%. Of those with a subsequent first birth, 40.0% had a caesarean section, compared with 30.3% of other women (p<0.001); while among vaginal births, perineal outcomes including tears and episiotomies were not significantly different (p=0.87; p=0.20). Conclusions: Since 2001, the number of vulvoplasties performed in NSW has increased dramatically, with no obvious biological reason for the rise. The procedure was not without serious complications necessitating hospital readmission in some instances. This study provides objective outcome information for counselling women who are contemplating vulvoplastyNHMR

The impact of first birth obstetric anal sphincter injury on the subsequent birth: a population-based linkage study

Background With rising obstetric anal sphincter injury (OASI) rates, the number of women at risk of OASI recurrence is in turn increasing. Decisions regarding mode of subsequent birth following an OASI are complex, and depend on a variety of factors. We sought to identify the risk factors for OASI recurrence from first and subsequent births, and to investigate the effect of OASI birth factors on planned caesarean for the second birth. Methods Using two linked population datasets from New South Wales, Australia, we selected women giving birth between 2001 and 2011 with a first birth OASI and a subsequent birth. Multivariable logistic regression was used to identify the association of first and second birth factors with OASI recurrence, and to determine which factors were associated with a planned pre-labour caesarean at the second birth. Results Of 6,380 women with a first birth OASI who proceeded to a subsequent birth, 75.4% had a vaginal second birth, 19.4% a pre-labour caesarean, and 5.2% an intrapartum caesarean. The OASI recurrence rate of 5.7% was significantly higher than the first birth OASI rate of 4.5% (p<0.01). Following adjustment for first and second birth factors, risk factors for recurrence included diabetes at first birth (adjusted odds ratio (aOR) 1.82), and birthweight at second birth ≥4.0kg (aOR 2.34); second birth at 37-38 weeks was associated with decreased odds of OASI (aOR 0.56). First birth factors associated with planned caesarean at second birth included epidural, spinal or general anaesthetic (aOR 1.88); birthweight ≥4.0kg (aOR 1.68); while factors associated with decreased likelihood included Asian country of birth (aOR 0.73), and maternal age< 25 years (aOR 0.81). Conclusions Compared with previous reports, the low OASI recurrence rate (approximately one in twenty) potentially indicates that appropriate decisions are being made about subsequent mode of delivery following first birth OASI. This assertion is supported by evidence of different risk profiles for women who have planned caesareans compared with planned vaginal births.Dr Albert S McKern Research Scholarship; Australian Research Council Future Fellowship (FT12010069); Australian National Health and Medical Research Council Senior Research Fellowship (1021028)

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

Objective: To determine whether OASI rates are increasing at equal rates among different vaginal birth modes. Methods: Using New South Wales (NSW) linked population data, the overall yearly OASI rates were determined among the 261,008 primiparous vertex singleton term births which occurred from 2001-2011. OASI rates among non-instrumental, forceps and vacuum births with and without episiotomy were also determined. Multivariable logistic regression was used to ascertain the adjusted odds ratios (aORs) for each birth category by year. The trends of the aORs over time for each birth category were compared. Results: The overall OASI rate was 4.1% in 2001 and 5.9% in 2011. The highest OASI rates were among forceps births without episiotomy (12.2% in 2001, 14.8% in 2011), and lowest for non-instrumental births without episiotomy (2.6% in 2001, 4.4% in 2011). After adjustment for known risk factors, the only birth categories to show significant increases with OASI over the study period were non-instrumental without episiotomy and forceps with episiotomy (linear trend p<0.01). Conclusion: Overall OASI rates have continued to increase. Known risk factors do not fully explain the increase for non-instrumental births without episiotomy and forceps with episiotomy. Changes in clinical management and/or reporting may be contributing.Australian National Health and Medical Research Council; Australian Research Council; Dr Albert S McKern Research Scholarshi

The impact of cosmetic breast implants on breastfeeding: a systematic review and meta-analysis

Background: Cosmetic breast augmentation (breast implants) is one of the most common plastic surgery procedures worldwide and uptake in high income countries has increased in the last two decades. Women need information about all associated outcomes in order to make an informed decision regarding whether to undergo cosmetic breast surgery. We conducted a systematic review to assess breastfeeding outcomes among women with breast implants compared to women without. Methods: A systematic literature search of Medline, Pubmed, CINAHL and Embase databases was conducted using the earliest inclusive dates through December 2013. Eligible studies included comparative studies that reported breastfeeding outcomes (any breastfeeding, and among women who breastfed, exclusive breastfeeding) for women with and without breast implants. Pairs of reviewers extracted descriptive data, study quality, and outcomes. Rate ratios (RR) and 95% confidence intervals (CI) were pooled across studies using the random-effects model. The Newcastle-Ottawa scale (NOS) was used to critically appraise study quality, and the National Health and Medical Research Council Level of Evidence Scale to rank the level of the evidence. Results: Three small, observational studies met the inclusion criteria. The quality of the studies was fair (NOS 4-6) and the level of evidence was low (III-2 - III-3). There was no significant difference in attempted breastfeeding (one study, RR 0.94, 95%CI 0.76, 1.17). However, among women who breastfed, all three studies reported a reduced likelihood of exclusive breastfeeding amongst women with breast implants with a pooled rate ratio of 0.60 (95%CI 0.40, 0.90). Conclusions: This systematic review and meta-analysis suggests that women with breast implants who breastfeed were less likely to exclusively feed their infants with breast milk compared to women without breast implants.NHMRC, Dr Albert McKern Research Scholarshi

The impact of cosmetic breast implants on breastfeeding: a systematic review and meta-analysis

Background: Cosmetic breast augmentation (breast implants) is one of the most common plastic surgery procedures worldwide and uptake in high income countries has increased in the last two decades. Women need information about all associated outcomes in order to make an informed decision regarding whether to undergo cosmetic breast surgery. We conducted a systematic review to assess breastfeeding outcomes among women with breast implants compared to women without. Methods: A systematic literature search of Medline, Pubmed, CINAHL and Embase databases was conducted using the earliest inclusive dates through December 2013. Eligible studies included comparative studies that reported breastfeeding outcomes (any breastfeeding, and among women who breastfed, exclusive breastfeeding) for women with and without breast implants. Pairs of reviewers extracted descriptive data, study quality, and outcomes. Rate ratios (RR) and 95% confidence intervals (CI) were pooled across studies using the random-effects model. The Newcastle-Ottawa scale (NOS) was used to critically appraise study quality, and the National Health and Medical Research Council Level of Evidence Scale to rank the level of the evidence. Results: Three small, observational studies met the inclusion criteria. The quality of the studies was fair (NOS 4-6) and the level of evidence was low (III-2 - III-3). There was no significant difference in attempted breastfeeding (one study, RR 0.94, 95%CI 0.76, 1.17). However, among women who breastfed, all three studies reported a reduced likelihood of exclusive breastfeeding amongst women with breast implants with a pooled rate ratio of 0.60 (95%CI 0.40, 0.90). Conclusions: This systematic review and meta-analysis suggests that women with breast implants who breastfeed were less likely to exclusively feed their infants with breast milk compared to women without breast implants.NHMRC, Dr Albert McKern Research Scholarshi

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

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

Attitudes, norms and controls influencing lifestyle risk factor management in general practice

<p>Abstract</p> <p>Background</p> <p>With increasing rates of chronic disease associated with lifestyle behavioural risk factors, there is urgent need for intervention strategies in primary health care. Currently there is a gap in the knowledge of factors that influence the delivery of preventive strategies by General Practitioners (GPs) around interventions for smoking, nutrition, alcohol consumption and physical activity (SNAP). This qualitative study explores the delivery of lifestyle behavioural risk factor screening and management by GPs within a 45–49 year old health check consultation. The aims of this research are to identify the influences affecting GPs' choosing to screen and choosing to manage SNAP lifestyle risk factors, as well as identify influences on screening and management when multiple SNAP factors exist.</p> <p>Methods</p> <p>A total of 29 audio-taped interviews were conducted with 15 GPs and one practice nurse over two stages. Transcripts from the interviews were thematically analysed, and a model of influencing factors on preventive care behaviour was developed using the Theory of Planned Behaviour as a structural framework.</p> <p>Results</p> <p>GPs felt that assessing smoking status was straightforward, however some found assessing alcohol intake only possible during a formal health check. Diet and physical activity were often inferred from appearance, only being assessed if the patient was overweight. The frequency and thoroughness of assessment were influenced by the GPs' personal interests and perceived congruence with their role, the level of risk to the patient, the capacity of the practice and availability of time. All GPs considered advising and educating patients part of their professional responsibility. However their attempts to motivate patients were influenced by perceptions of their own effectiveness, with smoking causing the most frustration. Active follow-up and referral of patients appeared to depend on the GPs' orientation to preventive care, the patient's motivation, and cost and accessibility of services to patients.</p> <p>Conclusion</p> <p>General practitioner attitudes, normative influences from both patients and the profession, and perceived external control factors (time, cost, availability and practice capacity) all influence management of behavioural risk factors. Provider education, community awareness raising, support and capacity building may improve the uptake of lifestyle modification interventions.</p