Variations in intervention rates, without subsequent reductions in adverse outcomes, can indicate overuse. We studied variations in and associations between commonly used childbirth interventions and ...adverse outcomes, adjusted for population characteristics.
In this multinational cross-sectional study, existing data on 4,729,307 singleton births at ≥37 weeks in 2013 from Finland, Sweden, Norway, Denmark, Iceland, Ireland, England, the Netherlands, Belgium, Germany (Hesse), Malta, the United States, and Chile were used to describe variations in childbirth interventions and outcomes. Numbers of births ranged from 3,987 for Iceland to 3,500,397 for the USA. Crude data were analysed in the Netherlands, or analysed data were shared with the principal investigator. Strict variable definitions were used and information on data quality was collected. Intervention rates were described for each country and stratified by parity. Uni- and multivariable analyses were performed, adjusted for population characteristics, and associations between rates of interventions, population characteristics, and outcomes were assessed using Spearman's rank correlation coefficients. Considerable intercountry variations were found for all interventions, despite adjustments for population characteristics. Adjustments for ethnicity and body mass index changed odds ratios for augmentation of labour and episiotomy. Largest variations were found for augmentation of labour, pain relief, episiotomy, instrumental birth, and cesarean section (CS). Percentages of births at ≥42 weeks varied from 0.1% to 6.7%. Rates among nulliparous versus multiparous women varied from 56% to 80% versus 51% to 82% for spontaneous onset of labour; 14% to 36% versus 8% to 28% for induction of labour; 3% to 13% versus 7% to 26% for prelabour CS; 16% to 48% versus 12% to 50% for overall CS; 22% to 71% versus 7% to 38% for augmentation of labour; 50% to 93% versus 25% to 86% for any intrapartum pain relief, 19% to 83% versus 10% to 64% for epidural anaesthesia; 6% to 68% versus 2% to 30% for episiotomy in vaginal births; 3% to 30% versus 1% to 7% for instrumental vaginal births; and 42% to 70% versus 50% to 84% for spontaneous vaginal births. Countries with higher rates of births at ≥42 weeks had higher rates of births with a spontaneous onset (rho = 0.82 for nulliparous/rho = 0.83 for multiparous women) and instrumental (rho = 0.67) and spontaneous (rho = 0.66) vaginal births among multiparous women and lower rates of induction of labour (rho = -0.71/-0.66), prelabour CS (rho = -0.61/-0.65), overall CS (rho = -0.61/-0.67), and episiotomy (multiparous: rho = -0.67). Variation in CS rates was mainly due to prelabour CS (rho = 0.96). Countries with higher rates of births with a spontaneous onset had lower rates of emergency CS (nulliparous: rho = -0.62) and higher rates of spontaneous vaginal births (multiparous: rho = 0.70). Prelabour and emergency CS were positively correlated (nulliparous: rho = 0.74). Higher rates of obstetric anal sphincter injury following vaginal birth were found in countries with higher rates of spontaneous birth (nulliparous: rho = 0.65). In countries with higher rates of epidural anaesthesia (nulliparous) and spontaneous births (multiparous), higher rates of Apgar score < 7 were found (rhos = 0.64). No statistically significant variation was found for perinatal mortality. Main limitations were varying quality of data and missing information.
Considerable intercountry variations were found for all interventions, even after adjusting for population characteristics, indicating overuse of interventions in some countries. Multivariable analyses are essential when comparing intercountry rates. Implementation of evidence-based guidelines is crucial in optimising intervention use and improving quality of maternity care worldwide.
Full text
Available for:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Women usually conceptualize pregnancy as a normal physiological state. In contrast, formal maternity care provision tends to be focused on pathology and risk. The authors aim to explore the extent to ...which childbearing women apply a sickness lens to pregnancy. We have therefore examined antenatal problems spontaneously reported by 4,000 UK and Norwegian women who responded to the international social media-based Babies Born Better survey. We coded and classified the free-text comments of the respondents as either complaint or disease. We found striking differences in the rates and types of problems reported by the women. We discuss our findings by applying different perspectives of medicalization and of lay and biomedical knowledge.
Objective. To describe the background characteristics of women who gave birth to their first child at an advanced and very advanced maternal age, including their sociodemographic background, social ...relationships, health behavior, physical and mental health, and reproductive history. Design. Cross‐sectional data from the Norwegian Mother and Child Cohort Study (MoBa) conducted by the Norwegian Institute of Public Health. Setting. Norway. Sample. 41 236 Norwegian‐speaking nulliparous women. Methods. Data were collected by the first questionnaire distributed in week 17 of pregnancy during the recruitment period 1999–2008. The distribution of descriptive variables in relation to age was investigated, by means of bivariate and multivariate logistic regression analyses. Main outcome measures. Advanced (33–37 years) and very advanced (≥38 years) maternal age. Results. Women who had their first baby at an advanced or very advanced age differed from the younger women with regard to a wide range of background characteristics, and this difference was most pronounced for the very advanced group. Problems related to physical aging were more common (infertility, physical health problems, sleep problems, depression and fatigue). Of the sociodemographic factors; high annual income and low level of education were most strongly correlated with high maternal age, followed by single status, unemployment, unsatisfactory relationship with partner and unplanned pregnancy. Conclusions. Besides having more age‐related reproductive and physical health problems, women who had their first baby at an advanced or very advanced age constituted a heterogeneous group characterized by either socioeconomic prosperity or vulnerability.
Full text
Available for:
BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
IntroductionThere are growing concerns about the increase in rates of commonly used childbirth interventions. When indicated, childbirth interventions are crucial for preventing maternal and ...perinatal morbidity and mortality, but their routine use in healthy women and children leads to avoidable maternal and neonatal harm. Establishing ideal rates of interventions can be challenging. This study aims to describe the range of variations in the use of commonly used childbirth interventions in high-income countries around the world, and in outcomes in nulliparous and multiparous women.Methods and analysisThis multinational cross-sectional study will use data from births in 2013 with national population data or representative samples of the population of pregnant women in high-income countries. Data from women who gave birth to a single child from 37 weeks gestation onwards will be included and the results will be presented for nulliparous and multiparous women separately. Anonymised individual level data will be analysed. Primary outcomes are rates of commonly used childbirth interventions, including induction and/or augmentation of labour, intrapartum antibiotics, epidural and pharmacological pain relief, episiotomy in vaginal births, instrument-assisted birth (vacuum or forceps), caesarean section and use of oxytocin postpartum. Secondary outcomes are maternal and perinatal mortality, Apgar score below 7 at 5 min, postpartum haemorrhage and obstetric anal sphincter injury. Univariable and multivariable logistic regression analyses will be conducted to investigate variations among countries, adjusted for maternal age, body mass index, gestational weight gain, ethnic background, socioeconomic status and infant birth weight. The overall mean rates will be considered as a reference category, weighted for the size of the study population per country.Ethics and disseminationThe Medical Ethics Review Committee of VU University Medical Center Amsterdam confirmed that an official approval of this study was not required. Results will be disseminated at national and international conferences and published in peer-reviewed journals.
Abstract
Aim
To explore midwives' experiences with providing home‐based postpartum care during the COVID‐19 pandemic in Norway.
Design
A descriptive and explorative qualitative study.
Methods
The ...study is based on semi‐structured individual interviews with 11 midwives experienced in offering home‐based postpartum care. We explored their experiences of such care during the first wave of the COVID‐19 pandemic. Data collection occurred from October through November 2020. An inductive thematic analysis was performed using Systematic Text Condensation (STC) by Malterud (2012).
Results
The following two main results emerged from the analyses: (1) the midwives adapted quickly to changes in postpartum care during the pandemic and (2) midwives saw the experience as an opportunity to re‐evaluate their practices.
Conclusion
This study highlights midwives' resilience and adaptability during the first wave of COVID‐19 pandemic. It emphasises the crucial role of face‐to‐face interactions in postpartum care, while recognising the value of technology when direct access is limited. By shedding light on midwives' experiences, this research contributes to improving postpartum care in unforeseen circumstances. It underscores the significance of interdisciplinary integration in planning postpartum care services and the lasting influence of lessons learned on addressing future challenges.
Implications for Practice
The valuable insights gained from lessons learned during the COVID‐19 pandemic may have a lasting influence on the postpartum care system, empowering it to tackle unforeseen challenges both today and in the future.
Impact
The current study addressed midwives' experience with providing home‐based postpartum care during the COVID‐19 pandemic in Norway. Midwives received an opportunity to re‐evaluate their own practices and valued being included when changes were implemented. The current findings should alert policy makers, leaders and clinicians in postpartum care services when planning future practice.
Full text
Available for:
FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK, VSZLJ
The rising prevalence of gestational diabetes mellitus (GDM) calls for the use of innovative methods to inform and empower these pregnant women. An information chatbot, Dina, was developed for women ...with GDM and is Norway's first health chatbot, integrated into the national digital health platform.
The aim of this study is to investigate what kind of information users seek in a health chatbot providing support on GDM. Furthermore, we sought to explore when and how the chatbot is used by time of day and the number of questions in each dialogue and to categorize the questions the chatbot was unable to answer (fallback). The overall goal is to explore quantitative user data in the chatbot's log, thereby contributing to further development of the chatbot.
An observational study was designed. We used quantitative anonymous data (dialogues) from the chatbot's log and platform during an 8-week period in 2018 and a 12-week period in 2019 and 2020. Dialogues between the user and the chatbot were the unit of analysis. Questions from the users were categorized by theme. The time of day the dialogue occurred and the number of questions in each dialogue were registered, and questions resulting in a fallback message were identified. Results are presented using descriptive statistics.
We identified 610 dialogues with a total of 2838 questions during the 20 weeks of data collection. Questions regarding blood glucose, GDM, diet, and physical activity represented 58.81% (1669/2838) of all questions. In total, 58.0% (354/610) of dialogues occurred during daytime (8 AM to 3:59 PM), Monday through Friday. Most dialogues were short, containing 1-3 questions (340/610, 55.7%), and there was a decrease in dialogues containing 4-6 questions in the second period (P=.013). The chatbot was able to answer 88.51% (2512/2838) of all posed questions. The mean number of dialogues per week was 36 in the first period and 26.83 in the second period.
Frequently asked questions seem to mirror the cornerstones of GDM treatment and may indicate that the chatbot is used to quickly access information already provided for them by the health care service but providing a low-threshold way to access that information. Our results underline the need to actively promote and integrate the chatbot into antenatal care as well as the importance of continuous content improvement in order to provide relevant information.
The modern phenomenon of delayed parenthood applies not only to women but also to men, but less is known about what characterises men who are expecting their first child at an advanced age. This ...study investigates the sociodemographic characteristics, health behaviour, health problems, social relationships and timing of pregnancy in older first-time fathers.
A cross-sectional study was conducted of 14 832 men who were expecting their first child, based on data from the Norwegian Mother and Child Cohort Study (MoBa) carried out by the Norwegian Institute of Public Health. Data were collected in 2005-2008 by means of a questionnaire in gestational week 17-18 of their partner's pregnancy, and from the Norwegian Medical Birth Register. The distribution of background variables was investigated across the age span of 25 years and above. Men of advanced age (35-39 years) and very advanced age (40 years or more) were compared with men aged 25-34 years by means of bivariate and multivariate logistic regression analyses.
The following factors were found to be associated with having the first child at an advanced or very advanced age: being unmarried or non-cohabitant, negative health behaviour (overweight, obesity, smoking, frequent alcohol intake), physical and mental health problems (lower back pain, cardiovascular diseases, high blood pressure, sleeping problems, previous depressive symptoms), few social contacts and dissatisfaction with partner relationship. There were mixed associations for socioeconomic status: several proxy measures of high socioeconomic status (e.g. income >65,000 €, self-employment) were associated with having the first child at an advanced or very advanced age, as were several other proxy measures of low socioeconomic status (e.g. unemployment, low level of education, immigrant background).The odds of the child being conceived after in vitro fertilisation were threefold in men aged 34-39 and fourfold from 40 years and above.
Men who expect their first baby at an advanced or very advanced age constitute a socioeconomically heterogeneous group with more health problems and more risky health behaviour than younger men. Since older men often have their first child with a woman of advanced age, in whom similar characteristics have been reported, their combined risk of adverse perinatal outcomes needs further attention by clinicians and researchers.
Full text
Available for:
IZUM, KILJ, NUK, PILJ, PNG, SAZU, UL, UM, UPUK
The aim of this study was to explore midwives’ experiences with a safe childbirth checklist used in handover situations from birth to hospital discharge. Quality of care and patient safety is highly ...recognised and a priority within health services globally. In handover situations, checklists have proven to reduce unwanted variation by standardising processes, which in turn contribute to increased quality of care. To improve the quality of care, a safe childbirth checklist was implemented at a large maternity hospital in Norway.
We conducted a Glaserian grounded theory (GT) study.
A total of 16 midwives were included. We included three midwives in one focus group and conducted 13 individual interviews. Years of experience as midwives ranged from one to 30 years. All included midwives worked in a large maternity hospital in Norway.
The main concern faced by the midwives who used the checklist included no common understanding of the purpose of the checklist nor consensus on how to use the checklist. The generated grounded theory, individualistic interpretation of the checklist, involved the following three strategies that all seemed to explain how the midwives solved their main concern: 1) not questioning the checklist, 2) constantly evaluating the checklist, and 3) distancing oneself from the checklist. Experiencing an unfortunate event concerning the healthcare of both mother or newborn was a condition that could alter the midwives understanding and use of the checklist.
The findings in this study showed that a general lack of common understanding and consensus on the rationale for implementing a safe childbirth checklist led to variations between midwives in how and whether the checklist was used. The safe childbirth checklist was described as long and detailed. It was not necessarily the midwife who was expected to sign the checklist who had carried out the tasks signed for. To ensure patient safety, recommendations for future practice include securing that separate sections of a safe childbirth checklist are limited to a specific time-point and midwife.
Findings emphasise the importance of implementation strategies supervised by the leaders of the healthcare services. Further research should explore the understanding of organisational and cultural context when implementing a safe childbirth checklist to clinical practice.
Full text
Available for:
GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Background
Most vaginal births are associated with trauma to the genital tract. The morbidity associated with perineal trauma can be significant, especially when it comes to third‐ and fourth‐degree ...tears. Different interventions including perineal massage, warm or cold compresses, and perineal management techniques have been used to prevent trauma. This is an update of a Cochrane review that was first published in 2011.
Objectives
To assess the effect of perineal techniques during the second stage of labour on the incidence and morbidity associated with perineal trauma.
Search methods
We searched Cochrane Pregnancy and Childbirth's Trials Register (26 September 2016) and reference lists of retrieved studies.
Selection criteria
Published and unpublished randomised and quasi‐randomised controlled trials evaluating perineal techniques during the second stage of labour. Cross‐over trials were not eligible for inclusion.
Data collection and analysis
Three review authors independently assessed trials for inclusion, extracted data and evaluated methodological quality. We checked data for accuracy.
Main results
Twenty‐two trials were eligible for inclusion (with 20 trials involving 15,181 women providing data). Trials were at moderate to high risk of bias; none had adequate blinding, and most were unclear for both allocation concealment and incomplete outcome data. Interventions compared included the use of perineal massage, warm and cold compresses, and other perineal management techniques.
Most studies did not report data on our secondary outcomes. We downgraded evidence for risk of bias, inconsistency, and imprecision for all comparisons.
Hands off (or poised) compared to hands on
Hands on or hands off the perineum made no clear difference in incidence of intact perineum (average risk ratio (RR) 1.03, 95% confidence interval (CI) 0.95 to 1.12, two studies, Tau² 0.00, I² 37%, 6547 women; moderate‐quality evidence), first‐degree perineal tears (average RR 1.32, 95% CI 0.99 to 1.77, two studies, 700 women; low‐quality evidence), second‐degree tears (average RR 0.77, 95% CI 0.47 to 1.28, two studies, 700 women; low‐quality evidence), or third‐ or fourth‐degree tears (average RR 0.68, 95% CI 0.21 to 2.26, five studies, Tau² 0.92, I² 72%, 7317 women; very low‐quality evidence). Substantial heterogeneity for third‐ or fourth‐degree tears means these data should be interpreted with caution. Episiotomy was more frequent in the hands‐on group (average RR 0.58, 95% CI 0.43 to 0.79, Tau² 0.07, I² 74%, four studies, 7247 women; low‐quality evidence), but there was considerable heterogeneity between the four included studies.
There were no data for perineal trauma requiring suturing.
Warm compresses versus control (hands off or no warm compress)
A warm compress did not have any clear effect on the incidence of intact perineum (average RR 1.02, 95% CI 0.85 to 1.21; 1799 women; four studies; moderate‐quality evidence), perineal trauma requiring suturing (average RR 1.14, 95% CI 0.79 to 1.66; 76 women; one study; very low‐quality evidence), second‐degree tears (average RR 0.95, 95% CI 0.58 to 1.56; 274 women; two studies; very low‐quality evidence), or episiotomy (average RR 0.86, 95% CI 0.60 to 1.23; 1799 women; four studies; low‐quality evidence). It is uncertain whether warm compress increases or reduces the incidence of first‐degree tears (average RR 1.19, 95% CI 0.38 to 3.79; 274 women; two studies; I² 88%; very low‐quality evidence).
Fewer third‐ or fourth‐degree perineal tears were reported in the warm‐compress group (average RR 0.46, 95% CI 0.27 to 0.79; 1799 women; four studies; moderate‐quality evidence).
Massage versus control (hands off or routine care)
The incidence of intact perineum was increased in the perineal‐massage group (average RR 1.74, 95% CI 1.11 to 2.73, six studies, 2618 women; I² 83% low‐quality evidence) but there was substantial heterogeneity between studies. This group experienced fewer third‐ or fourth‐degree tears (average RR 0.49, 95% CI 0.25 to 0.94, five studies, 2477 women; moderate‐quality evidence).
There were no clear differences between groups for perineal trauma requiring suturing (average RR 1.10, 95% CI 0.75 to 1.61, one study, 76 women; very low‐quality evidence), first‐degree tears (average RR 1.55, 95% CI 0.79 to 3.05, five studies, Tau² 0.47, I² 85%, 537 women; very low‐quality evidence), or second‐degree tears (average RR 1.08, 95% CI 0.55 to 2.12, five studies, Tau² 0.32, I² 62%, 537 women; very low‐quality evidence). Perineal massage may reduce episiotomy although there was considerable uncertainty around the effect estimate (average RR 0.55, 95% CI 0.29 to 1.03, seven studies, Tau² 0.43, I² 92%, 2684 women; very low‐quality evidence). Heterogeneity was high for first‐degree tear, second‐degree tear and for episiotomy ‐ data should be interpreted with caution.
Ritgen's manoeuvre versus standard care
One study (66 women) found that women receiving Ritgen's manoeuvre were less likely to have a first‐degree tear (RR 0.32, 95% CI 0.14 to 0.69; very low‐quality evidence), more likely to have a second‐degree tear (RR 3.25, 95% CI 1.73 to 6.09; very low‐quality evidence), and neither more nor less likely to have an intact perineum (RR 0.17, 95% CI 0.02 to 1.31; very low‐quality evidence). One larger study reported that Ritgen's manoeuvre did not have an effect on incidence of third‐ or fourth‐degree tears (RR 1.24, 95% CI 0.78 to 1.96,1423 women; low‐quality evidence). Episiotomy was not clearly different between groups (RR 0.81, 95% CI 0.63 to 1.03, two studies, 1489 women; low‐quality evidence).
Other comparisons
Delivery of posterior versus anterior shoulder first, use of a perineal protection device, different oils/wax, and cold compresses did not show any effects on outcomes with the exception of increased incidence of intact perineum with the perineal device. Only one study contributed to each of these comparisons.
Authors' conclusions
Moderate‐quality evidence suggests that warm compresses, and massage, may reduce third‐ and fourth‐degree tears but the impact of these techniques on other outcomes was unclear or inconsistent. Poor‐quality evidence suggests hands‐off techniques may reduce episiotomy, but this technique had no clear impact on other outcomes. There were insufficient data to show whether other perineal techniques result in improved outcomes.
Further research could be performed evaluating perineal techniques, warm compresses and massage, and how different types of oil used during massage affect women and babies. It is important for any future research to collect information on women's views.
Most vaginal births are associated with some form of trauma to the genital tract. The morbidity associated with perineal trauma is significant, especially when it comes to third- and fourth-degree ...tears. Different perineal techniques and interventions are being used to prevent perineal trauma. These interventions include perineal massage, warm compresses and perineal management techniques.
The objective of this review was to assess the effect of perineal techniques during the second stage of labour on the incidence of perineal trauma.
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (20 May 2011), the Cochrane Central Register of ControlledTrials (The Cochrane Library 2011, Issue 2 of 4), MEDLINE (January 1966 to 20 May 2011) and CINAHL (January 1983 to 20 May 2011).
Published and unpublished randomised and quasi-randomised controlled trials evaluating any described perineal techniques during the second stage.
Three review authors independently assessed trails for inclusion, extracted data and evaluated methodological quality. Data were checked for accuracy.
We included eight trials involving 11,651 randomised women. There was a significant effect of warm compresses on reduction of third- and fourth-degree tears (risk ratio (RR) 0.48, 95% confidence interval (CI) 0.28 to 0.84 (two studies, 1525 women)). There was also a significant effect towards favouring massage versus hands off to reduce third- and fourth-degree tears (RR 0.52, 95% CI 0.29 to 0.94 (two studies, 2147 women)). Hands off (or poised) versus hand on showed no effect on third- and fourth-degree tears, but we observed a significant effect of hands off on reduced rate of episiotomy (RR 0.69, 95% CI 0.50 to 0.96 (two studies, 6547 women)).
The use of warm compresses on the perineum is associated with a decreased occurrence of perineal trauma. The procedure has shown to be acceptable to women and midwives. This procedure may therefore be offered to women.
Full text
Available for:
NUK, OILJ, UL, UM, UPUK, VSZLJ
PDF
