Centralisation of acute obstetric care in the Netherlands : a qualitative study to explore the experiences of stakeholders with adaptations in organisation of care

Background: In the past decade, acute obstetric care (AOC) has become centralised in many high-income countries. In this qualitative study, we explored how stakeholders in maternity care perceived and experienced adaptations in the organisation of maternity care in areas in the Netherlands where AOC was centralised. Methods: A heterogenic group of fifteen maternity care stakeholders, including patients, were purposively selected for semi-structured interviews. An inductive thematic analysis was used. Results: Three main themes were identified: (1) lack of involvement. (2) the process of making adaptations in the organisation of maternity care. (3) maintaining quality of care. Stakeholders in this study were highly motivated to maintain a high quality of maternity care and therefore made adaptations at several organisational levels. However, they felt a lack of involvement during the planning of centralisation of AOC and highlighted the importance of a collaborative process when making adaptations after centralisation of AOC. Conclusions: Regions with AOC centralisation plans should invest time and money in change management, encourage early involvement of all maternity care stakeholders and acknowledge centralisation of AOC as a professional life event with associated emotions, including a feeling of unsafety

Continuity of care is an important and distinct aspect of childbirth experience: findings of a survey evaluating experienced continuity of care, experienced quality of care and women’s perception of labor

Background: To compare experienced continuity of care among women who received midwife-led versus obstetrician-led care. Secondly, to compare experienced continuity of care with a. experienced quality of care during labor and b. perception of labor. Methods: We conducted a questionnaire survey in a region in the Netherlands in 2014 among 790 women after they gave birth. To measure experienced continuity of care, the Nijmegen Continuity Questionnaire was used. Quality of care during labor was measured with the Pregnancy and Childbirth Questionnaire, and to measure perception of labor we used the Childbirth Perception Scale. Results: Three hundred twenty five women consented to participate (41%). Of these, 187 women completed the relevant questions in the online questionnaire. 136 (73%) women were in midwife-led care at the onset of labor, 15 (8%) were in obstetrician-led care throughout pregnancy and 36 (19%) were referred to obstetrician-led care during pregnancy. Experienced personal and team continuity of care during pregnancy were higher for women in midwife-led care compared to those in obstetrician-led care at the onset of labor. Experienced continuity of care was moderately correlated with experienced quality of care although not significantly so in all subgroups. A weak negative correlation was found between experienced personal continuity of care by the midwife and perception of labor. Conclusion: This study suggests that experienced continuity of care depends on the care context and is significantly higher for women who are in midwife-led compared to obstetrician-led care during labor. It will be a challenge to maintain the high level of experienced continuity of care in an integrated maternity care system. Experienced continuity of care seems to be a distinctive concept that should not be confused with experienced quality of care or perception of labor and should be considered as a complementary aspect of quality of care

Development and measurement of guidelines-based quality indicators of caesarean section care in the Netherlands: A RAND-modified delphi procedure and retrospective medical chart review

Background There is an ongoing discussion on the rising CS rate worldwide. Suboptimal guideline adherence may be an important contributor to this rise. Before improvement of care can be established, optimal CS care in different settings has to be defined. This study aimed to develop and measure quality indicators to determine guideline adherence and identify target groups for improvement of care with direct effect on caesarean section (CS) rates. Method Eighteen obstetricians and midwives participated in an expert panel for systematic CS quality indicator development according to the RAND-modified Delphi method. A multi-center study was performed and medical charts of 1024 women with a CS and a stratified and weighted randomly selected group of 1036 women with a vaginal delivery were analysed. Quality indicator frequency and adherence were scored in 2060 women with a CS or vaginal delivery. Results The expert panel developed 16 indicators on planned CS and 11 indicators on unplanned CS. Indicator adherence was calculated, defined as the number of women in a specific obstetrical situation in which care was performed as recommended in both planned and unplanned CS settings. The most frequently occurring obstetrical situations with low indicator adherence were: 1) suspected fetal distress (frequency 17%, adh

25th annual computational neuroscience meeting: CNS-2016

The same neuron may play different functional roles in the neural circuits to which it belongs. For example, neurons in the Tritonia pedal ganglia may participate in variable phases of the swim motor rhythms [1]. While such neuronal functional variability is likely to play a major role the delivery of the functionality of neural systems, it is difficult to study it in most nervous systems. We work on the pyloric rhythm network of the crustacean stomatogastric ganglion (STG) [2]. Typically network models of the STG treat neurons of the same functional type as a single model neuron (e.g. PD neurons), assuming the same conductance parameters for these neurons and implying their synchronous firing [3, 4]. However, simultaneous recording of PD neurons shows differences between the timings of spikes of these neurons. This may indicate functional variability of these neurons. Here we modelled separately the two PD neurons of the STG in a multi-neuron model of the pyloric network. Our neuron models comply with known correlations between conductance parameters of ionic currents. Our results reproduce the experimental finding of increasing spike time distance between spikes originating from the two model PD neurons during their synchronised burst phase. The PD neuron with the larger calcium conductance generates its spikes before the other PD neuron. Larger potassium conductance values in the follower neuron imply longer delays between spikes, see Fig. 17.Neuromodulators change the conductance parameters of neurons and maintain the ratios of these parameters [5]. Our results show that such changes may shift the individual contribution of two PD neurons to the PD-phase of the pyloric rhythm altering their functionality within this rhythm. Our work paves the way towards an accessible experimental and computational framework for the analysis of the mechanisms and impact of functional variability of neurons within the neural circuits to which they belong

Automated detection of malaria pigment: feasibility for malaria diagnosing in an area with seasonal malaria in northern Namibia

OBJECTIVE: To evaluate the feasibility of automated malaria detection with the Cell-Dyn 3700 (Abbott Diagnostics, Santa Clara, CA, USA) haematology analyser for diagnosing malaria in northern Namibia. METHODS: From April to June 2003, all patients with a positive blood smear result and a subset of patients with no suspicion of malaria were included. Blood smear and a venous blood sample (to determine haemoglobin, platelet and malaria pigment levels) were collected from each patient. Malaria pigment test characteristics, correlations with blood parameters and pigment clearance time were calculated. Finally, a subset of blood samples was run twice to evaluate the consistency of test outcome. RESULTS: Two hundred and eight patients were included. Ninety had a positive blood smear result of which 84 tested positive for malaria pigment and 118 patients had a negative blood smear result of which four tested positive for malaria pigment. Test characteristics as compared with microscopy were as follows: sensitivity 0.93, specificity 0.97, positive predictive value 0.95, negative predictive value 0.95. Rerun of the blood samples resulted in a change of diagnosis in 14%. After 4 weeks, 33% of patients with an initially positive pigment result still tested positive. Malaria pigment was found to be negatively correlated with haemoglobin. CONCLUSIONS: Automated detection of malaria pigment is a useful diagnostic tool in this semi-rural area. In low-risk malaria season, the test can be used for diagnosing malaria because of the high sensitivity. In high-risk malaria season, the test can be used for excluding malaria in case of a negative pigment result because of the high specificit

Severe Adverse Maternal Outcomes among Women in Midwife-Led versus Obstetrician-Led Care at the Onset of Labour in the Netherlands: A Nationwide Cohort Study

<div><p>Objective</p><p>To test the hypothesis that it is possible to select a group of low risk women who can start labour in midwife-led care without having increased rates of severe adverse maternal outcomes compared to women who start labour in secondary care.</p><p>Design and Methods</p><p>We conducted a nationwide cohort study in the Netherlands, using data from 223 739 women with a singleton pregnancy between 37 and 42 weeks gestation without a previous caesarean section, with spontaneous onset of labour and a child in cephalic presentation. Information on all cases of severe acute maternal morbidity collected by the national study into ethnic determinants of maternal morbidity in the Netherlands (LEMMoN study), 1 August 2004 to 1 August 2006, was merged with data from the Netherlands Perinatal Registry of all births occurring during the same period.</p><p>Our primary outcome was severe acute maternal morbidity (SAMM, i.e. admission to an intensive care unit, uterine rupture, eclampsia or severe HELLP, major obstetric haemorrhage, and other serious events). Secondary outcomes were postpartum haemorrhage and manual removal of placenta.</p><p>Results</p><p>Nulliparous and parous women who started labour in midwife-led care had lower rates of SAMM, postpartum haemorrhage and manual removal of placenta compared to women who started labour in secondary care. For SAMM the adjusted odds ratio’s and 95% confidence intervals were for nulliparous women: 0.57 (0.45 to 0.71) and for parous women 0.47 (0.36 to 0.62).</p><p>Conclusions</p><p>Our results suggest that it is possible to identify a group of women at low risk of obstetric complications who may benefit from midwife-led care. Women can be reassured that we found no evidence that midwife-led care at the onset of labour is unsafe for women in a maternity care system with a well developed risk selection and referral system.</p></div

Severe acute maternal morbidity, postpartum haemorrhage and manual removal of placenta among nulliparous and parous women.

<p>*Model 1: adjusted for gestational age, maternal age, ethnic background, socioeconomic position.</p><p>^¥Model 2: adjusted for gestational age, maternal age, ethnic background, socioeconomic position, augmentation of labour and operative delivery.</p><p>Missing values: see Tables <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0126266#pone.0126266.t001" target="_blank">1</a> and <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0126266#pone.0126266.t003" target="_blank">3</a>.</p><p>Severe acute maternal morbidity, postpartum haemorrhage and manual removal of placenta among nulliparous and parous women.</p

Severe acute maternal morbidity (SAMM), postpartum haemorrhage and manual removal of placenta among women who started labour in midwife-led and obstetrician-led care.

<p>HELLP = haemolysis, elevated liver enzymes and low platelet count</p><p>Missing values: postpartum haemorrhage N = 3213 (1.4%), manual removal of placenta N = 5927 (2.6%)</p><p>Women could have more than one type of adverse outcome.</p><p>Severe acute maternal morbidity (SAMM), postpartum haemorrhage and manual removal of placenta among women who started labour in midwife-led and obstetrician-led care.</p

Medical interventions among nulliparous and parous women who started labour in midwife-led and obstetrician-led care.

<p>*Operative delivery: caesarean section, vacuum or forceps delivery</p><p>Medical interventions among nulliparous and parous women who started labour in midwife-led and obstetrician-led care.</p