Margaret Flood

Effects of continuity of care by a primary midwife (caseload midwifery) on caesarean section rates in women of low obstetric risk: the COSMOS randomised controlled trial

Please cite this paper as: McLachlan H, Forster D, Davey M, Farrell T, Gold L, Biro M, Albers L, Flood M, Oats J, Waldenström U. Effects of continuity of care by a primary midwife (caseload midwifery) on caesarean section rates in women of low obstetric risk: the COSMOS randomised controlled trial. BJOG 2012;119:1483–1492.

Assessing obstetric risk factors for maternal morbidity: congruity between medical records and mothers' reports of obstetric exposures

OBJECTIVE We sought to assess congruity between data abstracted from medical records with answers to self-administered questionnaires. STUDY DESIGN This was a multicenter prospective nulliparous pregnancy cohort. RESULTS A total of 1507 women enrolled. Analyses were reported for 1296 with medical record data and 3-month postpartum follow-up. There was near-perfect agreement (κ ≥ 0.80) between maternal report and abstracted data for reproductive history, induction/augmentation method, epidural/spinal analgesia, method of birth, perineal repair, infant birthweight, and gestation. Agreement was poor to moderate for maternal position in second stage and duration of pushing. CONCLUSION Maternal report of pregnancy, labor, and birth factors was very reliable and considered more accurate in relation to maternal position in labor and birth, smoking, prior terminations, and miscarriages. Use of routine birthing outcome summaries may introduce measurement error as hospitals differ in their definitions and reporting practices. Using primary data sources (eg, partograms) with clearly defined prespecified criteria will provide the most accurate obstetric exposure and outcome data.

The effect of primary midwife-led care on women's experience of childbirth: results from the COSMOS randomised controlled trial.

To determine the effect of primary midwife‐led care (‘caseload midwifery’) on womens experiences of childbirth.

Influence of timing of admission in labour and management of labour on method of birth: Results from a randomised controlled trial of caseload midwifery (COSMOS trial)

OBJECTIVE to explore the relationship between the degree to which labour is established on admission to hospital and method of birth. BACKGROUND a recent randomised controlled trial found fewer caesarean sections (CS) in women allocated to caseload midwifery (19.4%) compared with standard care (24.9%). There is interest in exploring what specific aspects of the care might have resulted in this reduction. SETTING a large tertiary-level maternity service in Melbourne, Australia. PARTICIPANTS English-speaking women with no previous caesarean section at low risk of complications in pregnancy were recruited to a randomised controlled trial. Trial participants whose management did not include a planned caesarean and who were admitted to hospital in spontaneous labour were included in this secondary analysis of trial data (n=1532). METHODS this secondary analysis included women admitted to hospital in spontaneous labour who were randomised to caseload midwifery compared with those randomised to standard care with regard to timing of admission in labour, augmentation of labour and use of epidural analgesia. In a further analysis randomised groups were pooled to examine predictors of caesarean section for first births only using multiple logistic regression. RESULTS nulliparous women randomised to standard care were more likely to have labour augmented than those having caseload care (54.2% and 45.5% respectively, p=0.008), but were no more likely to use epidural analgesia. They were admitted earlier in labour, spending 1.1 hours longer than those in the caseload arm in hospital before the birth (p=0.003). Parous women allocated to standard care were more likely than those in the caseload arm to use epidural analgesia (10.0% and 5.3% respectively, p=0.047), but were no more likely to have labour augmented. They were also admitted earlier in labour, with a median cervical dilatation of 4 cm compared with 5 cm in the caseload arm (p=0.012). Pooling the two randomised groups of nulliparous women, and after adjusting for randomised group, maternal age and maternal body mass index, early admission to hospital was strongly associated with caesarean section. Admission before the cervix was 5 cm dilated increased the odds 2.4-fold (95%CI 1.4, 4.0; p=0.001). Augmentation of labour and use of epidural analgesia were each strongly associated with caesarean section (adjusted odds ratios 3.10 (95%CI 2.1, 4.5) and 5.77 (95%CI 4.0, 8.4) respectively. CONCLUSION these findings that women allocated to caseload care were admitted to hospital later in labour, and that earlier admission was strongly associated with birth by caesarean section, suggest that remaining at home somewhat longer in labour may be one of the mechanisms by which caseload care was effective in reducing caesarean section in the COSMOS trial.

Researching labour and birth events using health information records: methodological challenges.

OBJECTIVES as little has been published about the particular challenges of researching labour and birth events using health information records (HIRs), this study aimed to describe the methodological and quality assurance (QA) issues encountered in reviewing such records for a study of health and recovery after operative birth, and to report on how these issues were tackled. DESIGN AND SETTING retrospective review of HIRs, recording details of the labour and birth events of 394 women for 630 confinements at 32 hospitals, chiefly situated in the State of Victoria, Australia. PARTICIPANTS three hundred and ninety-four women, a subset of a cohort of 534 women participating in the Health and Recovery after Operative Birth Project, who gave consent to review of their HIRs. METHODS a data abstraction form (DAF) and comprehensive accompanying study manual were designed, with the forms layout based on the HIR used by the hospital where the majority of confinements occurred. Amendments were made following piloting of the DAF. Three data abstractors were carefully trained for the task of reviewing records, and issues were dealt with as they arose at fortnightly meetings. Double data abstraction (cross-coding) exercises were conducted three times during the project and reported on for QA purposes. FINDINGS a number of limitations were found with labour and birth event data recorded in the HIRs. For example, maternal position in active second stage labour could not be established for 65% of births, documentation of onset of second stage was not accompanied by definitive evidence for second stage onset in 23.9% of cases, and maternal position at birth was missing in 26.4% of cases. Other relevant variables also proved problematic. For example, infant head circumference was not documented for 24.4% of births, and 52.9% of records did not document maternal height. Time and effort put into data abstractor training, and careful design and piloting of the DAF enabled both the form and data abstraction methods to be adapted following recognition of some of the limitations identified with the records, and also allowed subsequent analytic possibilities to be maximised. Cross-coding exercises also increased data abstractor reliability. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE the likelihood of obtaining reliable data from HIRs is increased by a keen awareness of the challenges presented by the records themselves, careful training of staff, careful DAF design which allows for documentation of problems, conducting QA checks such as cross-coding exercises, and cautious reporting of findings with appropriate recognition of inherent limitations of the method.

Perinatal mortality and planned home birth

e18 American Journal of Obstetrics & Gynecology APRIL 2011 2. Daviss BA, Johnson KC. Home v hospital birth: recent meta-analysis is misleading. BMJ 2010;341:c4699. 3. Elsevier news release. June 30, 2010. Available at: http://www. alphagalileo.org/ViewItem.aspx?ItemId 80051&CultureCode en. Accessed Sept. 30, 2010. 4. Kleinert S. Singapore statement: a global agreement on responsible research conduct. Lancet 2010;376:1125-7.

Data accuracy in the Victorian Perinatal Data Collection: Results of a validation study of 2011 data

Objective: Public health data sets such as the Victorian Perinatal Data Collection (VPDC) provide an important source for health planning, monitoring, policy, research and reporting purposes. Data quality is paramount, requiring periodic assessment of data accuracy. This article describes the conduct and findings of a validation study of data on births in 2011 extracted from the VPDC. Method: Data from a random sample of one percent of births in Victoria in 2011 were extracted from original medical records at the birth hospital and compared with data held in the VPDC. Accuracy was determined for 93 variables. Sensitivity, specificity, positive predictive value and negative predictive value were calculated for dichotomous items. Results: Accuracy of 17 data items was 99% or more, the majority being neonatal and intrapartum items, and 95% or more for 46 items. Episodes of care with the highest proportion of items with accuracy of 95% or more were neonatal and postnatal items at 80 and 64%, respectively. Accuracy was below 80% for nine items introduced in 2009. Agreement between medical records and VPDC data ranged from 48% to 100%, the exception being two highly inaccurate smoking-related items. Reasons for discrepancies between VPDC data and medical records included miscoding, missing and inconsistent information. Conclusion: This study found high levels of accuracy for data reported to the VPDC for births in 2011; however, some data items introduced in 2009 and not previously validated were less accurate. Data may be used with confidence overall and with awareness of limitations for some new items.

Accuracy of postpartum haemorrhage data in the 2011 Victorian Perinatal Data Collection: Results of a validation study

The postpartum haemorrhage (PPH) rate in Victoria in 2009 for women having their first birth, based on information reported to the Victorian Perinatal Data Collection (VPDC), was 23.6% (primiparas). Prior to 2009 PPH was collected via a tick box item on the perinatal form. Estimated blood loss (EBL) volume is now collected and it is from this item the PPH rate is calculated. Periodic assessment of data accuracy is essential to inform clinicians and others who rely on these data of their quality and limitations.

Monitoring postpartum haemorrhage in Australia: Opportunities to improve reporting

PROBLEM The rate and severity of postpartum haemorrhage (PPH) are increasing, according to research reports and clinical anecdote, causing a significant health burden for Australian women giving birth. However, reporting a national Australian rate is not possible due to inconsistent reporting of PPH. BACKGROUND Clinician concerns about the incidence and severity of PPH are growing. Midwives contribute perinatal data on every birth, yet published population-based data on PPH seems to be limited. What PPH information is contributed? What data are publicly available? Do published data reflect the PPH concerns of clinicians? AIM To examine routine public reporting on PPH across Australia. METHODS We systematically analysed routine, publicly reported data on PPH published in the most recent perinatal data for each state, territory and national report (up to and including October 2016). We extracted PPH data on definitions, type and method of data recorded, markers of severity, whether any analyses were done and whether any trends or concerns were noted. FINDINGS PPH data are collected by all Australian states and territories however, definitions, identification method and documentation of data items vary. Not all states and territories published PPH rates; those that did ranged from 3.3% to 26.5% and were accompanied by minimal reporting of severity and possible risk factors. Whilst there are plans to include PPH as a mandatory reporting item, the timeline is uncertain. CONCLUSIONS Routinely published PPH data lack nationally consistent definitions and detail. All states and territories are urged to prioritise the adoption of nationally recommended PPH items.

Trams, trains, planes and automobiles: logistics of conducting a statewide audit of medical records

Objective: This paper reports on the logistics of conducting a validation study of a routinely collected dataset against medical records at hospitals to inform planning of similar studies.