60% of planned caesareans performed before 39 weeks without medical indication – Australian Atlas of Healthcare Variation Series 2018
The Third Australian Atlas of Healthcare Variation 2018 has been published. The report explores variations in healthcare across Australia investigating unwarranted variations and providing actions to reduce variation.
The report this year has looked at neonatal and paediatric health amongst other topics including information on early planned caesarean sections without a medical or obstetric indication. The Atlas highlights recent research showing increases in both short-term and long-term effects for children born via caesarean section before 39 weeks. It is the recommendation of certain organisations and Australian states to wait until 39 weeks gestation if there are no medical reasons for earlier birth. Data of sufficient quality was available from 4 states on the topic.
The atlas found that:
‘between 42% and 60% of planned caesarean sections performed before 39 weeks’ gestation did not have a medical or obstetric indication, and between 10% and 22% of caesarean sections performed before 37 weeks did not have a medical or obstetric indication.’
The rates were generally higher for privately funded patients compared to publicly funded.
There are 7 recommendations in the atlas relating to early planned caesarean section without medical indication including:
The full list of recommendation and the remainder of the atlas can be view here.
Labour outcomes in caseload midwifery and standard care: a register-based cohort study
A study has been published by BMC Pregnancy and Childbirth looking at labour outcomes in caseload midwifery. The study conducted in North Denmark looked at births allocated to caseload midwifery over a 3 year period. Out of 13,115 births there were 2679 allocated to caseload midwives.
Findings of the study include:
The study concludes:
‘We found that most outcomes were equal across models of care but there seemed to be a small but unexpected finding of more augmentation and adverse neonatal outcomes in caseload midwifery.’
The full study can be read here.
RCOG 2018 Workforce report
The RCOG has published its latest workforce report providing an update on recommendations and actions to address workforce issues.
The report highlights that 9 out of 10 obstetric units have a gap in their middle-grade rota, there is a 30% attrition rate from the O&G training programme, 54% of those on O&G specialist register are international medical graduates and there are disproportionate litigation rates for those working in O&G. The report also highlights high rates of bullying and undermining.
Included in the report is an update on recommendations from the 2017 report including:
Also provided is an update on the work of the RCOG supporting our doctors task group which includes work on a peer to peer support service, development of workplace behavior champions network and complaints handling work.
The full report can be viewed here.
Experience of young mums
A short film has been produced by a young mum after her experiences during her pregnancy. The film aims to encourage medical professionals to provide more support to young mums. Watch it below
Each baby counts: Learn and support
The Royal College of Midwives and the Royal College of Obstetricians and Gynaecologists are working together to launch a new programme to work with local maternity units to support multi-professional learning helping to improve joint working.
The partnership will be supported and funded by the Department of Health and Social Care and will support the implementation of recommendations from each baby counts reports to support the provision of safe maternity care.
The full report can be found here.
RCM Guidance for Midwifery care in labour
The royal college of Midwives has launched new guidance ‘Midwifery care in labour guidance for all women in all settings’.
The document provides evidence-based recommendations for care of women during labour and birth. The guidance cover topics including eating and drinking in labour, Fetal heart rate assessment and preventing severe genital trauma. It covers recommendations for practice and good practice points.
Some of the recommendations include:
The RCM has published a document for midwives and also for women and their companions.
US Obstetric Trauma for vaginal deliveries is decreasing
The Agency for Healthcare Research and Quality has released their ‘Chartbook on patient safety report’ which reviews data across a number of areas to highlight areas of strength and weakness. Included in this report is data measuring obstetric trauma from 2000 to 2015.
Over the period obstetric trauma for deliveries both with and without an instrument has decreased. The overall rate in 2015 was , the rate of obstetric trauma was 119.3 for instrument-assisted vaginal deliveries and 17.7 per 1,000 vaginal deliveries without instrument assistance.
There were some disparities across age groups, ethnicities and states with Vermont having the lowest obstetric trauma rate and Nebraska the highest.
The full report an be viewed here.
RCOG Clinical Guidance – Care of Women with obesity in pregnancy
The RCOG has published an update of its green top guideline ‘Care of Women with Obesity in Pregnancy’. The guideline includes recommendations for interventions prior to conception, during pregnancy and the period after.
The recommendations cover:
The document provides specific guidance as to what actions can be taken on the above topics and also outlines the evidence for that particular recommendation.
Read the full guideline here.
Each Baby Counts Report published – UK review of safe maternity care
The recently published Each Baby Counts report provides recommendations and key findings from the analysis of data for care given to mothers in 2016. The report focuses on 3 different areas – Guidelines, Anaesthesia and barriers to reporting.
In 2016 there were almost 700,000 babies born, of those, 1123 met the Each Baby Counts criteria. The report identified 124 stillbirths, 145 babies who died early and 854 babies who sustained severe brain injuries during labour at term. 674 of those babies (71%) may have had a different outcome if their care had been different. An increase compared to the report for 2015 data that identified a possible different outcome for 556 babies.
The report identifies that many factors contribute to care outcomes with an average of 7 factors for each baby, both clinical and non-clinical. It provides key recommendations for improvement focusing on 2 clinical areas:
Also identified in the report are areas where reporting can be improved including improved resource (IT available, correct people involved), Neonatal input and education of all teams to highlight the importance of an effective review.
The full report, available here, provides examples of where things have gone wrong and details what you can do to improve care.
What We Can Do about Maternal Mortality — 4 actions all hospitals can take
An article has been published in the New England Journal of Medicine recommending 4 actions that can be taken by hospitals providing obstetric care to help reverse the trend in pregnancy related deaths.
The goal is to provide high-quality care, creating a culture of safety with a management system and training to support.
The full article available here provides more details on the 4 actions that can be taken.
You can also listen to this interview with Dr Susan Mann who is discussing these actions.
Maternity Outcomes Matter – Website Live
The Maternity Outcomes Matter project is working to reduce avoidable harm to mothers and babies that occurs during maternity care. It provides the perspective and experiences of families who have experienced harm, charities working on the avoidance of harm and health care professionals.
The website shares stories of the families who have experienced harm, provides resources on current maternity projects and blogs on all things relevant to reducing harm. The latest post highlights the study working on providing better care for grieving parents with the below video.
Visit the website here.
Mental Health: Speak out, seek help, get treatment
An Australian doctor has spoken out about his experiences with mental health to encourage other health care professionals to speak out and get help.
The Professor, President of RANZCOG, wrote about his experiences as a young doctor and his attempt to take his own life.
He highlights the importance of seeking help and providing support for colleagues writing:
‘For every doctor, especially our juniors, it is important to understand that mental health and emotional issues are nothing to be embarrassed about or ashamed of. They are important and need acknowledgement and treatment. We need to support each other and make this message abundantly clear.’
Read about his experiences in full here.
MBRRACE-UK has published its most recent report ‘Saving Lives, Improving Mothers’ Care’ which reviews lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2014–16.
Between 2014 – 16 there were 225 women who died during or up to 42 days of the end of pregnancy with a direct or indirect cause being pregnancy. The top 3 causes of direct deaths were thrombosis & thromboembolism, major obstetric haemorrhage & suicide. There were an additional 286 women who died between 6 weeks and 1 year of the end of pregnancy with the main cause being suicide. Improvements in care may have made a difference to the outcome for 38% of women who died.
Key areas for action highlighted are:
The full report included a number of recommendations and can be viewed in full here.
Perinatal Mental Health
This video produced by the International Forum for Wellbeing in Pregnancy has been designed to help raise global awareness of mental health conditions during pregnancy and post-childbirth period. It highlights some of the experiences mums and dads may see and how that can affect the baby.
FIGO position paper: how to stop the caesarean section epidemic
FIGO has published a position paper with suggestions on how to reduce the worldwide caesarean section rate. To help reduce the caesarean section rates the paper asks stakeholders to consider:
NHS Digital report – Maternity Figures
NHS digital has published maternity data for 2017-18. The data is taken from Hospital Episodes Statistics (HES) and the Maternity Services Data Set (MSDS). Key outcomes from the data show:
The report and associate documents can be viewed here.
,This week much of the focus has been on the global rise in the number of caesarean births following The Lancet publication of a 3-part series ‘Optimising caesarean section use’. The series, available here, details the occurrence of caesarean births from data collected from 169 countries, reviews the short and long term effects of CS on the health of women and children and outlines interventions to reduce unnecessary CS in health women and babies.
Global epidemiology of use of and disparities in caesarean sections
The first part of the series titled ‘Global epidemiology of use of and disparities in caesarean sections’ reviews the trends in CS use globally estimating 29.7 millions births occurred through CS in 2015.
Figures suggest rates have almost doubled since 2000 from 12.1% to 21.1% of births however there was significant variation in rates across regions. Caesarean birth rates ranged from 58.15% of births in Dominican Republic to 0.6% in South Sudan. Those low-income countries have inadequate access to CS posing higher risk of mortality to those women. In comparison use of CS for higher income families was well above the rate expected based on obstetric indications.
The paper recommends:
‘Optimisation of CS use is needed, underpinned by a better understanding of demand and supply factors that drive the overuse of CS and by greater efforts to ensure universal access to CS for all women.’
Short-term and long-term effects of caesarean section on the health of women and children
The second part of the series titled ‘Short-term and long-term effects of caesarean section on the health of women and children’ highlights that the prevalence of maternal morbidity and mortality is higher after CS than vaginal birth.
It is suggested that the estimated risk of death from an emergency intrapartum CS is up to 4 time higher than vaginal birth with severe acute maternal morbidity (including haemorrhage, uterine rupture, anaesthetic complication and cardiac arrest) also higher. The paper highlights that almost everyone who has a CS increases risk of certain morbidities in future pregnancies.
Interventions to reduce unnecessary caesarean sections in healthy women and babies
The final part of the series titled ‘Interventions to reduce unnecessary caesarean sections in healthy women and babies’ investigates factors for CS use and the type and effects of interventions to reduce CS.
Clinical interventions including external cephalic version for breech delivery at term, vaginal breech delivery in appropriately selected women, and vaginal birth after CS could reduce CS rates. Additional approaches including labour companionship and midwife led care have been associated with safer outcomes and positive maternal experiences.
One of the key messages is:
‘…approaches that prioritise positive human relationships, promote respectful and collaborative multidisciplinary teamwork, and address clinicians’ beliefs and attitudes and women’s fear of labour pain and of poor quality of care, might be effective in reducing CS use or increasing physiological labour and birth.’
Schematic representation of factors related to women, society, health providers, and health-care organisations that affect the frequency of caesarean section use at the local level; these factors surround the obstetric and clinical factors that also affect the frequency of births by caesarean section, which are represented in the middle by the Robson 10-group classification
This week the UK has been raising awareness of baby loss through it baby loss awareness week and around the world babies who passed away from miscarriage, stillbirth or new born death will be remembered on October 15th - International Pregnancy & Infant Loss Remembrance Day.
Break the silence animation
Charities have come together to raise awareness of the issues that affect those who have experienced pregnancy loss or baby death in the UK. Watch their animation below:
Launch of movements matter campaign
Safer Care Victoria and the Centre of research excellence in stillbirth have worked to launch the movements matter campaign. The movements matters website provides information and resources for women and clinicians on babies movements. It includes fact sheets, videos & e-learning guides to help provide the best care when a woman reports a change in her babys movements.
Visit the website here.
BJOG Free access - Stillbirth: understand, standardise, educate – time to end preventable harm
BJOG has provided free access to its special issue on stillbirth published earlier this year. The issue covers a number of stillbirth topics including understanding stillbirth, reporting stillbirth and fetal death, interventions to reduce stillbirth and the global impact of stillbirth.
The issue highlights that the financial cost of stillbirth is about £700 million per year with much bigger implications of the emotional impact. It recognises the importance of improving the experience of parents and the necessity to involve them to educate and reduce stillbirths.
The issue can be viewed here.
Quiz: Hot to prevent postpartum haemorrhage
This quiz from contemporary OB/GYN tests your knowledge on postpartum haemorrhage (PPH). It is based on an article from Gary A. Dildy testing your ability to recognise signs of PPH in a patient. Have a go here and let us know how you did.
Video: Perinatal Mortality Reviews - Journey of Improvement
This video outlines the journey that one hospital has been on to improve their perinatal review process identifying challenges faced, engaging clinicians and their preparations.
Cochrane review - Non-clinical interventions for reducing unnecessary caesarean section
An updated review has been produced into ‘whether non-clinical interventions, which aim to reduce unnecessary caesarean sections, such as providing education to healthcare workers and mothers, are safe and effective’. The review will inform new WHO guidelines.
The key message from the review is that ‘Based on high-quality evidence, few interventions have been shown to reduce caesarean section rates without adverse effects on maternal or neonatal outcomes’.
There were 29 studies included in the review mainly representing high income countries. There were 8 interventions found to have a beneficial effect including:
Read the review in full here.