Brett Shorten

The Importance of Mode of Birth After Previous Cesarean: Success, Satisfaction, and Postnatal Health

INTRODUCTION The recent National Institutes of Health consensus conference on vaginal birth after cesarean (VBAC) recommended a focus on strategies that increase womens opportunities to make informed choices about VBAC. This study aimed to expand knowledge of womens experiences of planned VBAC by focusing on postnatal experiences of women who participated in an Australian birth-after-cesarean study. METHODS At 6 to 8 weeks after birth, 165 women who experienced childbirth after a previous cesarean rated satisfaction with their birth experiences using a 10-point visual analogue scale, reported on postnatal health problems, and indicated whether they would make the same birth choice again. RESULTS Significant differences were found in satisfaction scores by mode of birth. Mean scores out of a possible score of 10 ranged from 8.86 for spontaneous vaginal birth, 7.86 for elective repeat cesarean delivery, 6.71 for emergency cesarean delivery, to 6.15 for instrumental vaginal birth (F = 5.33; P = .002). Mean satisfaction scores for spontaneous vaginal birth and elective repeat cesarean delivery were statistically higher than for instrumental vaginal birth and emergency cesarean birth. Women who experienced instrumental vaginal birth and emergency cesarean birth also reported a higher number of postnatal health-related problems and were least likely to agree that they would make the same birth choice again. DISCUSSION Mode of birth was the most important determinant of postnatal satisfaction, postnatal health, and whether women felt they would make the same birth choice again. Clinicians, researchers, and policymakers should identify effective labor management practices that enhance womens opportunities to achieve spontaneous vaginal birth during planned VBAC.

What is meta-analysis?

When clinicians begin their search for the best available evidence to inform decision-making, they are usually directed to the top of the ‘evidence pyramid’ to find out whether a systematic review and meta-analysis have been conducted. The Cochrane Library1 is fast filling with systematic reviews and meta-analyses that aim to answer important clinical questions and provide the most reliable evidence to inform practice and research. So what is meta-analysis and how can it contribute to practice? Meta-analysis is a research process used to systematically synthesise or merge the findings of single, independent studies, using statistical methods to calculate an overall or ‘absolute’ effect.2 Meta-analysis does not simply pool data from smaller studies to achieve a larger sample size. Analysts use well recognised, systematic methods to account for differences in sample size, variability (heterogeneity) in study approach and findings (treatment effects) and test how sensitive their results are to their own systematic review protocol (study selection and statistical analysis).2 ,3 There is debate about the best practice for meta-analysis, however there are five common steps. ### Step 1: the research question A clinical research question is identified and a hypothesis proposed. The likely clinical significance is explained and the study design and analytical plan are justified. ### Step 2: systematic review A systematic review (SR) is specifically designed to address the research question and conducted …

Perineal outcomes in NSW public and private hospitals: Analysis recent trends

Women using private health insurance for pregnancy care may be unaware of the impact that this choice has in increasing their risk of experiencing a range of interventions during childbirth. This paper identifies recent trends in episiotomy rates and perineal outcomes for New South Wales (NSW) public and private hospitals between 1997 and 1999. Clear and consistent differences exist in birth outcomes in NSW private hospitals in respect to greater episiotomy use and poorer overall perineal outcomes, higher caesarean section rates and higher instrumental birth rates. Given the potential health impact for women who experience intervention during childbirth, identification of clinically unjustified practices is an important step towards ensuring that womens choices provide them with optimal childbirth outcomes regardless of their health insurance status.

Ocupational segregation, labour force participation and the relative earnings of men and women

A model of the labour market is developed in which particiaption rates of men and women,wages rates of men and women and occupational segregation are determined simultaneously. The model is estimated using cross-sectional data from Australia. The most important empirical results are that (a) particiaption rates,wage rates and occupational segregation should be viewed as being simultaneously determined,(b) differences in male and female labour-force attactment and human capital attainment are important determinants of the gender composition of occupations and (c)there is little direct evidence in this study to support discrimination-based theories of occupational segregation.

Trends in birth choices after caesarean section in Japan: A national survey examining information and access to vaginal birth after caesarean

OBJECTIVES in the context of a rising caesarean section (CS) rate in Japan, the objectives of this study were; to investigate the national situation for womens birth options after primary CS; to explore characteristics of institutions accepting planned vaginal birth after caesarean (VBAC); to identify the timing and type of information given to women about their birth options by health professionals. DESIGN a national census study using a self-administered postal survey of nursing managers within obstetric departments in Japanese hospitals and clinics was conducted. Data were analyzed to explore characteristics of institutions accepting or not accepting VBAC and information given to women about planned VBAC and planned repeat CS. SETTING institutions included hospitals and clinics providing childbirth services throughout Japan. PARTICIPANTS nursing managers from hospitals (n=303) and clinics (n=196) completed surveys about their institutional policies and practices around birth after CS. FINDINGS only 154 (30.9%) of 499 institutions examined, accepted planned vaginal birth as an option for birth after CS. The success rate of VBAC was 77.0% in these institutions. Availability of transport services for institutional transfer and existence of a Maternal Fetal Intensive Care Unit (MFICU) were significantly associated with acceptance of VBAC (OR=5.39, p<0.001; OR=2.96, p=0.04). Information about options for birth method was mostly provided in the form of consent documents, and doctors were the sole provider of information about method of childbirth in 55.7% of institutions. Nursing managers described challenges in caring for women who strongly desire VBAC when women did not have access to information or if institutional policies conflicted with womens wishes. They recommended evidence-based information for women regarding birth choices after CS and recognised the necessity of emotional support for women faced with decision dilemmas. KEY CONCLUSIONS institutional policies and practices for birth after CS vary widely in Japan, with evidence of limited opportunities for women to make informed choices about planned VBAC. It was difficult for nurse managers to support women to choose VBAC when institutional policy conflicted with this choice and when women did not have consistent or balanced information. IMPLICATIONS FOR PRACTICE strategies are needed to support women as well as pregnancy care providers to support women to consider VBAC as a possible birth option after CS and to expand the use of shared decision making in pregnancy care settings in Japan.

Timing the provision of a pregnancy decision-aid: Temporal patterns of preference for mode of birth during pregnancy

OBJECTIVE To help identify the optimal timing for provision of pregnancy decision-aids, this paper examines temporal patterns in womens preference for mode of birth after previous cesarean, prior to a decision-aid intervention. METHODS Pregnant women (n=212) with one prior cesarean responded to surveys regarding their preference for elective repeat cesarean delivery (ERCD) or trial of labor (TOL) at 12-18 weeks and again at 28 weeks gestation. Patterns of adherence or change in preference were examined. RESULTS Womens preferences for birth were not set in early pregnancy. There was evidence of increasing uncertainty about preferred mode of birth during the first two trimesters of pregnancy (McNemar value=4.41, p=0.04), decrease in preference for TOL (McNemar value=3.79, p=0.05) and stability in preference for ERCD (McNemar value=0.31, p=0.58). Adherence to early pregnancy choice was associated with previous birth experience, maternal country of birth, emotional state and hospital site. CONCLUSION Womens growing uncertainty about mode of birth prior to 28 weeks indicates potential readiness for a decision-aid earlier in pregnancy. PRACTICE IMPLICATIONS Pregnancy decision-aids affecting mode of birth could be provided early in pregnancy to increase womens opportunity to improve knowledge, clarify personal values and reduce decision uncertainty.

Independent midwifery care versus NHS care in the UK

A need to balance risks, benefits, and choice

Earnings differentials and occupational segregation by gender: A simultaneous equations approach

Abstract Models of male/female earnings differentials which include explanatory variables such as occupational distribution and participation rates are criticized for failing to account for the simultaneity of the relationships involved. An alternative, eight-equation model of earnings differentials, participation differentials and occupational segregation is developed. Application of the model to Australian census data is discussed.

A Study to Assess the Feasibility of Implementing a Web-Based Decision Aid for Birth after Cesarean to Increase Opportunities for Shared Decision Making in Ethnically Diverse Settings

INTRODUCTION Decision aids are central to shared decision making and are recommended for value-sensitive pregnancy decisions, such as birth after cesarean. However, effective strategies for widespread decision aid implementation, with interactive web-based platforms, are lacking. This study tested the feasibility and acceptability of implementing a Health Insurance Portability and Accountability Act-secure, web-based decision aid to support shared decision making about birth choices after cesarean, within urban, ethnically diverse outpatient settings. METHODS A before-and-after design was used to assess feasibility and acceptability for decision aid implementation. Measures included womens knowledge, decisional conflict, birth preferences, birth outcomes, decision aid use, decision aid acceptability ratings (content, features, and functions), and views on how the decision aid supported shared decision making. RESULTS Of the 68 women who participated, most were black (46.2%) or Hispanic (35.4%). Their knowledge scores increased by 2.58 points out of 15 (P < .001; d = 0.87), and decisional conflict score reduced by 0.45 points out of 5 points (P < .001; d = 0.69). Forty-four women (65.9%) attempted a vaginal birth after cesarean, of whom 29 (65.7%) succeeded. Women rated decision aid content, features, and functions as good or excellent. Most indicated they would recommend it to others. Health care providers recommended additional strategies to simplify decision aid access and integration into routine care. DISCUSSION Implementing web-based decision aids within ethnically diverse practice settings is potentially feasible and worthwhile. However, strategies are needed to improve womens access and to encourage timely decision aid usage to prepare them for decision discussions with health care providers. Sustained implementation will require seamless integration into clinic workflow, which could include health care provider tools (counselling guides) embedded within the electronic health record, along with continuing education to support and engage health care providers in their use.

Which statistical tests should I use

Statistical tests can be powerful tools for researchers. They provide valuable evidence from which we make decisions about the significance or robustness of research findings. Statistical tests are a critical part of the answers to our research questions and ultimately determine how confident we can be in the evidence to inform clinical practice. In addition to analysing data to answer research questions, readers of research also need to understand the underlying principles of common statistical tests. It is helpful to know whether statistical tests have been applied in the right way, at the right time with the right data. There are dozens of statistical tests for researchers to choose from. The statistical tests we use help us gather evidence on which we will either accept or reject our stated null hypotheses1 and therefore make conclusions about the findings of an experiment or exploration. The best way for researchers to ensure they are using the right statistical tests is to consult a specialist in statistics when research is being planned and before data is collected. Mapping out the analysis is an important step in research planning. Statistical tests should not be used as a substitute for good research design or to attempt to correct serious flaws in data. We will use a hypothetical example to outline some common statistical tests we could use to answer common research questions. Lets say we developed a new ‘mobile phone app’ for patients recently diagnosed with diabetes, with the aim improving patient knowledge about healthy food choices. A sample of patients attending a diabetic clinic was carefully selected according to sound principles2 and 200 patients were randomised into two groups. One group (n=100) would use the ‘mobile phone app’ over a period of 3 months and the other group would be the control (n=100), …