Caesarean section (CS) rates around the world have been increasing and in Australia have reached 30% of all births. Robson's Ten-Group Classification System (10-group classification) provides a ...clinically relevant classification of CS rates that provides a useful basis for international comparisons and trend analyses. This study aimed to investigate trends in CS rates in New South Wales (NSW), including trends in the components of the 10-group classification.
We undertook a cross-sectional study using data from the Midwives Data Collection, a state-wide surveillance system that monitors patterns of pregnancy care, services and pregnancy outcomes in New South Wales, Australia. The study population included all women giving birth between 1st January 1998 and 31st December 2008. Descriptive statistics are presented including age-standardised CS rates, annual percentage change as well as regression analyses.
From 1998 to 2008 the CS rate in NSW increased from 19.1 to 29.5 per 100 births. There was a significant average annual increase in primary 4.3% (95%CI 3.0-5.7%) and repeat 4.8% (95% CI 3.9-5.7%) CS rates from 1998 to 2008. After adjusting for maternal and pregnancy factors, the increase in CS delivery over time was maintained. When examining CS rates classified according to the 10-group classification, the greatest contributors to the overall CS rate and the largest annual increases occurred among nulliparae at term having elective CS and multipara having elective repeat CS.
Given that the increased CS rate cannot be explained by known and collected maternal or pregnancy characteristics, the increase may be related to differences in clinical decision making or maternal request. Future efforts to reduce the overall CS rate should be focussed on reducing the primary CS rate.
Background
Changes in clinical practice and in the characteristics of childbearing women have the potential to influence the rate of obstetric anal sphincter injuries (OASIS). To date, little ...investigation has been undertaken to assess the effect of risk factor trends for the Australian population on OASIS rates.
Aims
To ascertain the OASIS rates amongst singleton vaginal births ≥37 weeks gestation in NSW, 2001 – 2009; to determine risk factor effect sizes and trends; and to compare predicted with observed OASIS rates.
Methods
Using two linked population‐based data sets, risk factors for OASIS were determined by logistic regression. Contingency tables and predictive modelling were used to determine trends and predicted rates of OASIS, respectively.
Results
The OASIS rate increased from 2.2% in 2001 to 2.9% in 2009. Highest risks were for forceps deliveries without episiotomy (primiparas aOR 6.10, multiparas aOR 6.15), followed by multiparas with no previous vaginal birth (aOR 5.61). High birthweight, vacuum delivery and Asian country of birth posed risks for all women. The greatest risk factor trends were increases in Asian country of birth and vacuum delivery, while the greatest trend amongst protective factors was an increase in maternal age ≥35 years for primiparas. Predicted OASIS rates were lower than observed rates.
Conclusion
In an environment of changing demographic and clinical risk factors, the OASIS rate has increased. This increase is only minimally explained by the identified risk factors and may be related to other unmeasured risk factors or a possible increase in clinical ascertainment and/or documentation of OASIS.
Background
Surveys have shown that women are highly satisfied with their maternity care. Their satisfaction has been associated with various demographic, personal, and care factors. Isolating the ...factors that most matter to women about their care can guide quality improvement efforts. This study aimed to identify the most significant factors associated with high ratings of care by women in the three maternity periods (antenatal, birth, and postnatal).
Methods
A survey was sent to 2,048 women who gave birth at seven public hospitals in New South Wales, Australia, exploring their expectations of, and experiences with maternity care. Women's overall ratings of care for the antenatal, birth, and postnatal periods were analyzed, and a number of maternal characteristics and care factors examined as potential predictors of “Very good” ratings of care.
Results
Among 886 women with a completed survey, 65 percent assigned a “Very good” rating for antenatal care, 74 percent for birth care, 58 percent for postnatal care, and 44 percent for all three periods. One factor was strongly associated with care ratings in all three maternity periods: women who were “always or almost always” treated with kindness and understanding were 1.8–2.8 times more likely to rate their antenatal, birth, and postnatal care as “Very good.” A limited number of other factors were significantly associated with high care ratings for one or two of the maternity periods.
Conclusions
Women's perceptions about the quality of their interpersonal interactions with health caregivers have a significant bearing on women's views about their maternity care journey.
Aim
To identify a cohort of children with cerebral palsy (CP) from hospital data; determine the proportion that participated in standardized educational testing and attained a score within the normal ...range; and describe the relationship between test results and motor symptoms.
Method
This population‐based retrospective cohort study used data from New South Wales, Australia. We linked hospital data for children younger than 16 years of age admitted between 1st July 2000 and 31st March 2014 to education data from 2009 to 2014. Hospital diagnosis codes were used to identify a cohort of children with CP (n=3944) and describe their motor symptoms. Educational outcomes in the CP cohort were compared with those among children without CP.
Results
Of those with educational data (n=1770), 46% were exempt from reading assessment because of intellectual or functional disability, 7% were absent or withdrawn from testing and 47% participated in testing. About 30% of all children with educational data had test scores in the normal range. The proportion was greatest among those with hemiplegia (>40%) and lowest among those with tetraplegia (<10%).
Interpretation
One‐third of children with CP participated in standardized testing and achieved a result in the normal range. The proportions were lower in children with more severe motor symptoms.
What this paper adds
From 2009 to 2014, most Australian children with cerebral palsy (CP) attended a mainstream school.
The rate of disability‐related exemption from standardized educational testing was almost 50%.
Thirty per cent of children with CP achieved educational scores in the normal range.
Resumen
Resultados académicos de niños con parálisis cerebral: un estudio de cohorte de datos vinculados
Objetivos
Identificar una cohorte de niños con parálisis cerebral (PC) entre los datos hospitalarios, determinar la proporción que participan en evaluaciones académicas estandarizadas; alcanzan un puntaje dentro del rango normal y describir la relación entre los resultados de las evaluaciones y los síntomas motores.
Metodos
este estudio poblacional de cohorte retrospectivo usa datos de New South Wales, Australia. Vinculamos los datos hospitalarios de niños menores a 16 años de edad, ingresados entre el 1 de Julio del 2000 y el 31 de Marzo del 2014 con los datos académicos del 2009 al 2014. Se utilizaron los códigos diagnósticos del hospital para identificar la cohorte de niños con PC (n= 3.944) y describir sus síntomas motores. Los resultados académicos en la cohorte de PC se comparó con aquellos niños sin PC.
Resultados
El 46% de aquellos con información académica (n=1.770), fueron eximidos de la evaluación de la lectura por discapacidad intelectual o funcional, el 7% estuvieron ausentes o se retiraron de las evaluaciones y el 47% participaron de las evaluaciones. Aproximadamente el 30% de los niños con datos académicos obtuvieron puntajes de prueba en el rango normal. La proporción fue mayor dentro de aquellos con hemiplejia (> 40%), y más bajo dentro de aquellos con tetraplejia (< 10%).
Interpretacion
un tercio de los niños con PC participaron en evaluaciones estandarizadas y alcanzaron resultados dentro del rango normal. La proporción fue más baja en niños con síntomas motores severos.
Resumo
Resultados educacionais para crianças com paralisia cerebral: um estudo de coorte com dados relacionados
Objetivo
Identificar uma coorte de crianças com paralisia cerebral (PC) a partir de dados de hospitais, determinar a proporção que participava de testes educacionais padronizados e obtiveram escores dentro da amplitude normal, e descrever a relação entre os resultados dos testes e sintomas motores.
Método
Este estudo retrospectivo de coorte populacional utilizou dados de New South Wales, Australia. Nós relacionamos dados hospitalares de crianças com menos de 16 anos admitidas entre 1 de julho de 2000 e 31 de março de 2014 a dados educacionais de 2009 a 2014. Os códigos diagnósticos hospitalares foram utilizados para identificar uma coorte de crianças com PC (n=3944) e descrever seus sintomas motores. Os resultados educacionais na coorte com PC foram comparados com crianças sem PC.
Resultados
Daqueles com dados educacionais (n=1770), 46% estavam isentos de realizar avaliação da leitura por causa de deficiência intelectual ou funcional, 7% se ausentaram ou se retiraram do teste e 47% participaram do teste. Cerca de 30% de todas as crianças com dados educacionais tiveram escores do teste dentro da amplitude normal. A proporção foi maior entre aqueles com hemiplegia (>40%), e menor entre aqueles com tetraplegia (<10%).
Interpretação
Um terço das crianças com PC participaram de avaliação padronizada e atingiram um resultado dentro do normal. As proporções foram menores nas crianças com sintomas motores mais severos.
What this paper adds
From 2009 to 2014, most Australian children with cerebral palsy (CP) attended a mainstream school.
The rate of disability‐related exemption from standardized educational testing was almost 50%.
Thirty per cent of children with CP achieved educational scores in the normal range.
This article is commented on by Lebeer on pages 336–337 of this issue.
This article's has been translated into Spanish and Portuguese.
Follow the links from the to view the translations.
To compare the characteristics of women who have undergone vulvoplasty with those of other women of reproductive age; to quantify short term adverse events and complications; to determine any ...association between vulvoplasty and subsequent outcomes for women giving birth.
A population-based record linkage study, analysing New South Wales Admitted Patient Data Collection and NSW Perinatal Data Collection data. The characteristics of all women who had vulvoplasties in NSW hospitals during 2001-2013 were compared with those of all women of reproductive age.
Admissions for vulvoplasty and repeat vulvoplasties; serious complications or adverse events after vulvoplasty; birth mode and perineal outcomes for primiparous women with and without vulvoplasty.
4592 vulvoplasty procedures were performed on 4381 women in NSW hospitals and day-stay centres; the annual rate increased by 64.5% between 2001 and 2013. Compared with the reference population, women who had vulvoplasty were more likely to have been born in Australia (74.6% v 67.6%), to have other cosmetic surgery (10.1% v 1.7%), and to have never been married (43.0% v 33.1%). The serious short term adverse event rate was 7.2%. Of 257 women who had a first birth after their vulvoplasty procedure, 40.0% had caesarean deliveries, compared with 30.3% of other women (P < 0.001). There were no significant differences in the rates of perineal outcomes for women who had vaginal births.
The number of vulvoplasties performed in NSW has increased dramatically since 2001. The procedure is not without serious complications that can necessitate re-admission to hospital. We provide objective information about outcomes for counselling women who are contemplating vulvoplasty.
Low birthweight (<2500 g) is often used as a population-level indicator of maternal-child health, as it is easy to measure and correlates with poorer infant health outcomes. However, it conflates ...preterm birth and intrauterine growth restriction, which have different causal pathways and require different approaches to prevention. Small for gestational age (SGA) (a proxy for growth restriction) and preterm birth may be more informative measures. We evaluated low birthweight as a population-level indicator.
We conducted a population-based cohort study of singleton live births in New South Wales (NSW), Australia, using linked data from 1994-2006 birth, hospital, death and educational records, with follow-up until 2014. Outcomes of babies born of low birthweight, preterm and SGA were compared with well-grown term infants (i.e. not low birthweight or SGA). Overlap between groups and temporal trends were also examined.
Of 1 093 765 singleton live births, 47 946 (4.4%) infants were low birthweight and had poorer outcomes than well-grown term infants (2.7% vs. 0.1% infant mortality; 13% vs. 6% below national minimum numeracy standard). SGA and preterm infants also had poorer outcomes (0.5%, 2.3% infant mortality respectively; 10%, 11% below numeracy standard) but 80% of SGA and 47% of preterm infants were not low birthweight. For all outcomes, low birthweight identified a smaller proportion of infants with poor outcomes than preterm birth and than either SGA or low birthweight at term. The proportion of low-birthweight births remained constant over time, while the proportion of births that were preterm increased and proportion of SGA decreased.
Low birthweight, SGA and preterm infants are all at higher risk of poorer outcomes but low birthweight inadequately captures, and masks trends in, both preterm births and births that are SGA. Reporting preterm births and an indicator of growth restriction at term will identify vulnerable groups better than using the measure of low birthweight.
Although the connection between ascending infection and preterm birth is undisputed, research focused on finding effective treatments has been disappointing. However evidence that eradication of ...Candida in pregnancy may reduce the risk of preterm birth is emerging. We conducted a pilot study to assess the feasibility of conducting a large randomized controlled trial to determine whether treatment of asymptomatic candidiasis in early pregnancy reduces the incidence of preterm birth.
We used a prospective, randomized, open-label, blinded-endpoint (PROBE) study design. Pregnant women presenting at <20 weeks gestation with singleton pregnancies self-collected a vaginal swab. Those who were asymptomatic and culture positive for Candida were randomized to 6-days of clotrimazole vaginal pessaries (100mg) or usual care (screening result is not revealed, no treatment). The primary outcomes were the rate of asymptomatic vaginal candidiasis, participation and follow-up. The proposed primary trial outcome of spontaneous preterm birth <37 weeks gestation was also assessed.
Of 779 women approached, 500 (64%) participated in candidiasis screening, and 98 (19.6%) had asymptomatic vaginal candidiasis and were randomized to clotrimazole or usual care. Women were not inconvenienced by participation in the study, laboratory testing and medication dispensing were problem-free, and the follow-up rate was 99%. There was a tendency towards a reduction in spontaneous preterm birth among women with asymptomatic candidiasis who were treated with clotrimazole RR = 0.33, 95%CI 0.04-3.03.
A large, adequately powered, randomized trial of clotrimazole to prevent preterm birth in women with asymptomatic candidiasis is both feasible and warranted.
Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12609001052224.
While rates of postpartum haemorrhage (PPH) have continued to rise, it is not clear if the association with other morbidity and transfusion has changed over time. This study explores the recent trend ...in postpartum haemorrhage and whether postpartum haemorrhage is associated with increased transfusions or adverse outcomes over time.
Linked birth and hospital data were used to examine ICD-10 AM coded PPH and outcomes in maternal birth admission records, 2003--2011 in hospitals in New South Wales (NSW), Australia (N = 818,965 pregnancies). Trends were calculated on the whole population, and among subgroups, and tested using the Cochran Armitage test for trend. Logistic regression models were developed separately for vaginal and caesarean births, and for a maternal morbidity composite indicator (excluding transfusion) and red cell transfusion. Adjusted odds ratios (aOR) for each year relative to 2003 and 95% confidence intervals (CI) are presented with adjustment for maternal (eg. age, country of birth) and pregnancy factors (eg. parity, interventions, pregnancy complications).
Overall, there was a significant increase in the PPH rate, from 6.1% in 2003 to 8.3% in 2011 (p < 0.0001). Crude rates of postpartum haemorrhage with transfusion increased from 0.75% (n = 636) to 1.21% (n = 1145) (p < 0.0001) while crude rates of postpartum haemorrhage with maternal morbidity increased from 0.18% (n = 149) to 0.23% (n = 221) (p = 0.02). Having accounted for maternal and pregnancy factors, there were significant overall decreases in the odds of morbidity among women with a PPH delivering vaginally (in 2006, 2007 and 2010, aORs were 0.70 (95 % CI 0.52, 0.96) 0.69 (0.51, 0.94) and 0.64 (0.47, 0.87) relative to 2003; p < 0.05), and no significant decrease among women delivered by caesarean section (aOR 0.87 (0.58, 1.29) in 2011; p = 0.37). Among women with a PPH delivering vaginally, there was a trend towards a non-linear increase in the adjusted odds of transfusion by birth year. Compared to women who had vaginal births with PPH in 2003, the adjusted odds for transfusion was between 1.1 and 1.2 fold higher for those with a PPH delivering vaginally in 2007, 2009, 2010 and 2011. However there was no significant trend amongst caesarean births (aOR 0.84 (0.66, 1.06) in 2011; p = 0.29).
PPH has become more frequent, however this has not been associated with a clear pattern of increased severe maternal morbidity. This suggests that the increase in PPH may represent fewer severe haemorrhages, better management of severe haemorrhage or better recording of PPH. The increase in transfusions following vaginal births with PPH warrants further investigation.
To assess recent hospital caesarean section (CS) rates in New South Wales, adjusted for case mix; to quantify the amount of variation that can be explained by case mix differences; and to examine the ...potential impact on the overall CS rate of reducing variation in practice.
Population-based record linkage study of births in 81 hospitals in New South Wales, 2009-2010, using the Robson classification to categorise births, and multilevel logistic regression to examine variation in hospital CS rates within Robson groups.
Hospital CS rates.
The overall CS rate was 30.9%, ranging from 11.8% to 47.4% (interquartile range, 23.9%-33.1%) among hospitals. The three groups contributing most to the overall CS rate all comprised women with a single cephalic pregnancy who gave birth at term, including: those who had had a previous CS (36.4% of all CSs); nulliparous women with an elective delivery (prelabour CS or labour induction, 23.4%); and nulliparous women with spontaneous labour (11.1%). After adjustment for case mix, marked unexplained variation in hospital CS rates persisted for: nulliparous women at term; women who had had a previous CS; multifetal pregnancies; and preterm births. If variation in practice was reduced for these risk-based groups by achieving the "best practice" rate, this would lower the overall rate by an absolute reduction of 3.6%, from 30.9% to 27.3%.
Understanding hospital heterogeneity in performing CS and implementing evidence-based practices may result in improved maternity care. We have identified five risk-based groups as priority targets for reducing practice variation in CS rates.
Context:
High serum levels of TSH have been associated with adverse pregnancy outcomes by some studies, and not by others.
Objective:
The aim of the study was to assess the association between high ...levels of TSH in the first trimester of pregnancy and adverse pregnancy outcomes; and to examine the predictive accuracy as a screening test.
Setting and Participants:
Serum levels of TSH were measured in a cohort of 2801 women with a singleton pregnancy attending first trimester Down syndrome screening. Information on maternal and infant outcomes was obtained through record linkage to population-based birth and hospital data. Association between high TSH (>95th and >97.5th centiles) multiple of the median levels, and risk of adverse pregnancy outcomes was evaluated using multivariable logistic regression, and the predictive accuracy of models was assessed.
Main Outcomes:
Rates of infants being small for gestational age (SGA), preterm birth, preeclampsia, miscarriage, and stillbirth were investigated.
Results:
High TSH multiple of the median levels were associated with SGA (<10th centile) adjusted odds ratio (aOR), 1.71; 95% confidence interval (CI), 0.99–2.94; preterm birth at less than 37 wk gestation (aOR, 2.59; 95% CI, 1.21–5.53); miscarriage (aOR, 3.66; 95% CI, 1.59–8.44); and a composite measure of any study outcome (aOR, 2.10; 95% CI, 1.23–3.59). The area under the receiver operator characteristic curves were 0.69 (95% CI, 0.65–0.73) for SGA; 0.56 (95% CI, 0.51–0.61) for preterm birth; 0.70 (95% CI, 0.61–0.79) for miscarriage; and 0.63 (95% CI, 0.60–0.65) for any adverse pregnancy outcome.
Conclusions:
High TSH serum levels during the first trimester of pregnancy were associated with adverse pregnancy outcomes; however, the predictive accuracy was poor. Screening for high TSH levels in the first trimester would be of no benefit to identify women at risk.
PDF
