Sally Tracy

Rates for obstetric intervention among private and public patients in Australia: population based descriptive study

Abstract Objective: To compare the risk profile of women receiving public and private obstetric care and to compare the rates of obstetric intervention among women at low risk in these groups. Design: Population based descriptive study. Setting: New South Wales, Australia. Subjects: All 171 157 women having a live baby during 1996 and 1997. Interventions: Epidural, augmentation or induction of labour, episiotomy, and births by forceps, vacuum, or caesarean section. Main outcome measures: Risk profile of public and private patients, intervention rates, and the accumulation of interventions by both patient and hospital classification (public or private). Results: Overall, the frequency of women classified as low risk was similar (48%) among those choosing private obstetric care and those receiving standard care in a public hospital. Among low risk women, rates of obstetric intervention were highest in private patients in private hospitals, lowest in public patients, and generally intermediate for private patients in public hospitals. Among primiparas at low risk, 34% of private patients in private hospitals had a forceps or vacuum delivery compared with 17% of public patients. For multiparas the rates were 8% and 3% respectively. Private patients were significantly more likely to have interventions before birth (epidural, induction or augmentation) but this alone did not account for the increased interventions at birth, particularly the high rates of instrumental births. Conclusions: Public patients have a lower chance of an instrumental delivery. Women should have equal access to quality maternity services, but information on the outcomes associated with the various models of care may influence their choices.

Caseload midwifery care versus standard maternity care for women of any risk: M@NGO, a randomised controlled trial

BACKGROUND Women at low risk of pregnancy complications benefit from continuity of midwifery care, but no trial evidence exists for women with identified risk factors. We aimed to assess the clinical and cost outcomes of caseload midwifery care for women irrespective of risk factors. METHODS In this unblinded, randomised, controlled, parallel-group trial, pregnant women at two metropolitan teaching hospitals in Australia were randomly assigned to either caseload midwifery care or standard maternity care by a telephone-based computer randomisation service. Women aged 18 years and older were eligible if they were less than 24 weeks pregnant at the first booking visit. Those who booked with another care provider, had a multiple pregnancy, or planned to have an elective caesarean section were excluded. Women allocated to caseload care received antenatal, intrapartum, and postnatal care from a named caseload midwife (or back-up caseload midwife). Controls received standard care with rostered midwives in discrete wards or clinics. The participant and the clinician were not masked to assignment. The main primary outcome was the proportion of women who had a caesarean section. The other primary maternal outcomes were the proportions who had an instrumental or unassisted vaginal birth, and the proportion who had epidural analgesia during labour. Primary neonatal outcomes were Apgar scores, preterm birth, and admission to neonatal intensive care. We analysed all outcomes by intention to treat. The trial is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12609000349246. FINDINGS Publicly insured women were screened at the participating hospitals between Dec 8, 2008, and May 31, 2011. 1748 pregnant women were randomly assigned, 871 to caseload and 877 to standard care. The proportion of caesarean sections did not differ between the groups (183 [21%] in the caseload group vs 204 [23%] in the standard care group; odds ratio [OR] 0·88, 95% CI 0·70-1·10; p=0·26). The proportion of women who had elective caesarean sections (before onset of labour) differed significantly between caseload and standard care (69 [8%] vs 94 [11%]; OR 0·72, 95% CI 0·52-0·99; p=0·05). Proportions of instrumental birth were similar (172 [20%] vs 171 [19%]; p=0·90), as were the proportions of unassisted vaginal births (487 [56%] vs 454 [52%]; p=0·08) and epidural use (314 [36%] vs 304 [35%]; p=0·54). Neonatal outcomes did not differ between the groups. Total cost of care per woman was AUS

Costing the cascade: estimating the cost of increased obstetric intervention in childbirth using population data

566·74 (95% 106·17-1027·30; p=0·02) less for caseload midwifery than for standard maternity care. INTERPRETATION Our results show that for women of any risk, caseload midwifery is safe and cost effective. FUNDING National Health and Medical Research Council (Australia).

Rates of obstetric intervention among low-risk women giving birth in private and public hospitals in NSW: a population-based descriptive study

Objective To estimate the cost of ‘the cascade’ of obstetric interventions introduced during labour for low risk women.

General obstetrics: Does size matter? A population-based study of birth in lower volume maternity hospitals for low risk women

Objectives To compare the risk profile of women giving birth in private and public hospitals and the rate of obstetric intervention during birth compared with previous published rates from a decade ago. Design Population-based descriptive study. Setting New South Wales, Australia. Participants 691 738 women giving birth to a singleton baby during the period 2000 to 2008. Main outcome measures Risk profile of women giving birth in public and private hospitals, intervention rates and changes in these rates over the past decade. Results Among low-risk women rates of obstetric intervention were highest in private hospitals and lowest in public hospitals. Low-risk primiparous women giving birth in a private hospital compared to a public hospital had higher rates of induction (31% vs 23%); instrumental birth (29% vs 18%); caesarean section (27% vs 18%), epidural (53% vs 32%) and episiotomy (28% vs 12%) and lower normal vaginal birth rates (44% vs 64%). Low-risk multiparous women had higher rates of instrumental birth (7% vs 3%), caesarean section (27% vs 16%), epidural (35% vs 12%) and episiotomy (8% vs 2%) and lower normal vaginal birth rates (66% vs 81%). As interventions were introduced during labour, the rate of interventions in birth increased. Over the past decade these interventions have increased by 5% for women in public hospitals and by over 10% for women in private hospitals. Among low-risk primiparous women giving birth in private hospitals 15 per 100 women had a vaginal birth with no obstetric intervention compared to 35 per 100 women giving birth in a public hospital. Conclusions Low-risk primiparous women giving birth in private hospitals have more chance of a surgical birth than a normal vaginal birth and this phenomenon has increased markedly in the past decade.

Spontaneous preterm birth of liveborn infants in women at low risk in Australia over 10 years: a population-based study

Objective  To study the association between volume of hospital births per annum and birth outcome for low risk women.

Trends in labour and birth interventions among low-risk women in New South Wales.

Objectives  To describe a 10‐year trend in preterm birth.

Maternal and perinatal outcomes amongst low risk women giving birth in water compared to six birth positions on land : a descriptive cross sectional study in a birth centre over 12 years

To examine recent trends in obstetric intervention rates among women at low‐risk of poor pregnancy outcome.

Perinatal Outcomes of Women Intending to Give Birth in Birth Centers in Australia

BACKGROUND the option of giving birth in water is available to most women in birth centres in Australia but there continues to be resistance in mainstream delivery wards due to safety concerns. Women in birth centres are more likely to give birth in upright positions and be attended by experienced midwives and obstetricians who are comfortable facilitating normal birth. The aim of this study was to determine rates of perineal trauma, postpartum haemorrhage and five-minute Apgar scores amongst low risk women in a birth centre who gave birth in water compared to six birth positions on land. METHODS this was a descriptive cross sectional study of births occurring in a large alongside Sydney birth centre from January 1996 to April 2008. Handwritten records were kept by midwives on each birth in the birth centre over twelve and a half years (n=6,144). Descriptive statistics and logistic regression were applied controlling for risk factors for perineal trauma, postpartum haemorrhage and the five-minute Apgar score. FINDINGS waterbirth (13%) and six main birth positions on land were identified: kneeling/all fours (48%), semi-recumbent (12%), lateral (5%), standing (8%), birth stool (10%) and squatting (3%). Compared to waterbirth, birth on a birth stool led to a higher rate of major perineal trauma (second, third, fourth degree tear and episiotomy) (OR 1.40 [1.12-1.75]) and postpartum haemorrhage (OR 2.04 [1.44-2.90]). Compared to waterbirth, babies born in a semi-recumbent position had a significantly greater incidence of five-minute Apgar scores <7 (OR 4.61 [1.29-16.52]). CONCLUSIONS waterbirth does not lead to more infants born with Apgar score <7 at 5 mins when compared to other birth positions. Waterbirth provides advantages over the birth stool for maternal outcomes of major perineal trauma and postpartum haemorrhage.

Australian caseload midwifery: The exception or the rule

BACKGROUND A recent Australian study showed perinatal mortality was lower among women who gave birth in a birth center than in a comparable low-risk group of women who gave birth in a hospital. The current study used the same large population database to investigate whether perinatal outcomes were improved for women intending to give birth in a birth center at the onset of labor, regardless of the actual place of birth. METHODS Data were obtained from the National Perinatal Data Collection (NPDC) in Australia. The study included 822,955 mothers who gave birth during the 5-year period, 2001 to 2005, and their 836,919 babies. Of these, 22,222 women (2.7%) intended to give birth in a birth center at the onset of labor. Maternal and perinatal factors and outcomes were compared according to the intended place of birth. Data were not available on congenital anomalies, or cause, or timing of death. RESULTS Women intending to give birth in a birth center at the onset of labor had lower rates of intervention and of adverse perinatal outcomes compared with women intending to give birth in a hospital, including less preterm birth and low birthweight. No statistically significant difference was found in perinatal mortality for term babies of mothers intending to give birth in a birth center compared with term babies of low-risk women intending to give birth in a hospital (1.3 per 1,000 births [99% CI = 0.66, 1.95] vs 1.7 per 1,000 births [99% CI = 1.50, 1.80], respectively). CONCLUSIONS Term babies of women who intended to give birth in a birth center were less likely to be admitted to a neonatal intensive care unit or special care nursery, and no significant difference was found in other perinatal outcomes compared with term babies of low-risk women who intended to give birth in a hospital labor ward. Birth center care remains a viable option for eligible women giving birth at term.