Development of the Conversational Health Literacy Assessment Tool for maternity care (CHAT-maternity-care): participatory action research.

BACKGROUND: Limited health literacy in (expectant) parents is associated with adverse health outcomes. Maternity care providers often experience difficulties assessing (expectant) parents' level of health literacy. The aim was to develop, evaluate, and iteratively adapt a conversational tool that supports maternity care providers in estimating (expectant) parents' health literacy. METHODS: In this participatory action research study, we developed a conversational tool for estimating the health literacy of (expectant) parents based on the Conversational Health Literacy Assessment Tool for general care, which in turn was based on the Health Literacy Questionnaire. We used a thorough iterative process including different maternity care providers, (expectant) parents, and a panel of experts. This expert panel comprised representatives from knowledge institutions, professional associations, and care providers with whom midwives and maternity care assistants work closely. Testing, evaluation and adjustment took place in consecutive rounds and was conducted in the Netherlands between 2019 and 2022. RESULTS: The conversational tool 'CHAT-maternity-care' covers four key domains: (1) supportive relationship with care providers; (2) supportive relationship within parents' personal network; (3) health information access and comprehension; (4) current health behaviour and health promotion. Each domain contains multiple example questions and example observations. Participants contributed to make the example questions and example observations accessible and usable for daily practice. The CHAT-maternity-care supports maternity care providers in estimating (expectant) parents' health literacy during routine conversations with them, increased maternity care providers' awareness of health literacy and helped them to identify where attention is necessary regarding (expectant) parents' health literacy. CONCLUSIONS: The CHAT-maternity-care is a promising conversational tool to estimate (expectant) parents' health literacy. It covers the relevant constructs of health literacy from both the Conversational Health Literacy Assessment Tool and Health Literacy Questionnaire, applied to maternity care. A preliminary evaluation of the use revealed positive feedback. Further testing and evaluation of the CHAT-maternity-care is required with a larger and more diverse population, including more (expectant) parents, to determine the effectiveness, perceived barriers, and perceived facilitators for implementation.

Induction of labour at 41 weeks or expectant management until 42 weeks: A systematic review and an individual participant data meta-analysis of randomised trials.

BACKGROUND: The risk of perinatal death and severe neonatal morbidity increases gradually after 41 weeks of pregnancy. Several randomised controlled trials (RCTs) have assessed if induction of labour (IOL) in uncomplicated pregnancies at 41 weeks will improve perinatal outcomes. We performed an individual participant data meta-analysis (IPD-MA) on this subject. METHODS AND FINDINGS: We searched PubMed, Excerpta Medica dataBASE (Embase), The Cochrane Library, Cumulative Index of Nursing and Allied Health Literature (CINAHL), and PsycINFO on February 21, 2020 for RCTs comparing IOL at 41 weeks with expectant management until 42 weeks in women with uncomplicated pregnancies. Individual participant data (IPD) were sought from eligible RCTs. Primary outcome was a composite of severe adverse perinatal outcomes: mortality and severe neonatal morbidity. Additional outcomes included neonatal admission, mode of delivery, perineal lacerations, and postpartum haemorrhage. Prespecified subgroup analyses were conducted for parity (nulliparous/multiparous), maternal age (<35/≥35 years), and body mass index (BMI) (<30/≥30). Aggregate data meta-analysis (MA) was performed to include data from RCTs for which IPD was not available. From 89 full-text articles, we identified three eligible RCTs (n = 5,161), and two contributed with IPD (n = 4,561). Baseline characteristics were similar between the groups regarding age, parity, BMI, and higher level of education. IOL resulted overall in a decrease of severe adverse perinatal outcome (0.4% [10/2,281] versus 1.0% [23/2,280]; relative risk [RR] 0.43 [95% confidence interval [CI] 0.21 to 0.91], p-value 0.027, risk difference [RD] -57/10,000 [95% CI -106/10,000 to -8/10,000], I2 0%). The number needed to treat (NNT) was 175 (95% CI 94 to 1,267). Perinatal deaths occurred in one (<0.1%) versus eight (0.4%) pregnancies (Peto odds ratio [OR] 0.21 [95% CI 0.06 to 0.78], p-value 0.019, RD -31/10,000, [95% CI -56/10,000 to -5/10,000], I2 0%, NNT 326, [95% CI 177 to 2,014]) and admission to a neonatal care unit ≥4 days occurred in 1.1% (24/2,280) versus 1.9% (46/2,273), (RR 0.52 [95% CI 0.32 to 0.85], p-value 0.009, RD -97/10,000 [95% CI -169/10,000 to -26/10,000], I2 0%, NNT 103 [95% CI 59 to 385]). There was no difference in the rate of cesarean delivery (10.5% versus 10.7%; RR 0.98, [95% CI 0.83 to 1.16], p-value 0.81) nor in other important perinatal, delivery, and maternal outcomes. MA on aggregate data showed similar results. Prespecified subgroup analyses for the primary outcome showed a significant difference in the treatment effect (p = 0.01 for interaction) for parity, but not for maternal age or BMI. The risk of severe adverse perinatal outcome was decreased for nulliparous women in the IOL group (0.3% [4/1,219] versus 1.6% [20/1,264]; RR 0.20 [95% CI 0.07 to 0.60], p-value 0.004, RD -127/10,000, [95% CI -204/10,000 to -50/10,000], I2 0%, NNT 79 [95% CI 49 to 201]) but not for multiparous women (0.6% [6/1,219] versus 0.3% [3/1,264]; RR 1.59 [95% CI 0.15 to 17.30], p-value 0.35, RD 27/10,000, [95% CI -29/10,000 to 84/10,000], I2 55%). A limitation of this IPD-MA was the risk of overestimation of the effect on perinatal mortality due to early stopping of the largest included trial for safety reasons after the advice of the Data and Safety Monitoring Board. Furthermore, only two RCTs were eligible for the IPD-MA; thus, the possibility to assess severe adverse neonatal outcomes with few events was limited. CONCLUSIONS: In this study, we found that, overall, IOL at 41 weeks improved perinatal outcome compared with expectant management until 42 weeks without increasing the cesarean delivery rate. This benefit is shown only in nulliparous women, whereas for multiparous women, the incidence of mortality and morbidity was too low to demonstrate any effect. The magnitude of risk reduction of perinatal mortality remains uncertain. Women with pregnancies approaching 41 weeks should be informed on the risk differences according to parity so that they are able to make an informed choice for IOL at 41 weeks or expectant management until 42 weeks. Study Registration: PROSPERO CRD42020163174.

Risk of adverse pregnancy outcomes of late- and postterm pregnancies in advanced maternal age: A national cohort study.

INTRODUCTION: There is an increase in women delivering ≥35 years of age. We analyzed the association between advanced maternal age and pregnancy outcomes in late- and postterm pregnancies. MATERIAL AND METHODS: A national cohort study was performed on obstetrical low-risk women using data from the Netherlands Perinatal Registry from 1999 to 2010. We included women ≥18 years of age with a singleton pregnancy at term. Women with a pregnancy complicated by congenital anomalies, hypertensive disorders or diabetes mellitus were excluded. Composite adverse perinatal outcome was defined as stillbirth, neonatal death, meconium aspiration syndrome, 5-minute Apgar score <7, neonatal intensive care unit admittance and sepsis. Composite adverse maternal outcome was defined as maternal death, placental abruption and postpartum hemorrhage of >1000 mL. RESULTS: We stratified the women into three age groups: 18-34 (n = 1 321 366 [reference]); 35-39 (n = 286 717) and ≥40 (n = 40 909). Composite adverse perinatal outcome occurred in 1.6% in women aged 18-34, 1.7% in women aged 35-39 (relative risk [RR] 1.06, 95% confidence interval [95% CI] 1.03-1.08) and 2.2% in women aged ≥40 (RR 1.38, 95% CI 1.29-1.47), with 5-minute Apgar score <7 as the factor contributing most to the outcome. Composite adverse maternal outcome occurred in 4.6% in women aged 18-34, 5.0% in women aged 35-39 (RR 1.08, 95% CI 1.06-1.10) and 5.2% in women aged ≥40 (RR 1.14, 95% CI 1.09-1.19), with postpartum hemorrhage >1000 mL as the factor contributing most to the outcome. In all age categories, the risk of adverse pregnancy outcomes was higher for nulliparous than for multiparous women. The risk of adverse outcomes increased in both nulliparous and parous women with advancing gestational age. When adjusted for parity, onset of labor and gestational age, advanced maternal age is associated with an increase in both composite adverse perinatal and maternal outcomes. CONCLUSIONS: The risk of adverse pregnancy outcome increases with advancing maternal age. Women aged ≥40 have an increased risk of adverse perinatal and maternal outcome when pregnancy goes beyond 41 weeks.

Management of late-term pregnancy in midwifery- and obstetrician-led care.

Management of late-term pregnancy in midwifery- and obstetrician-led care. BACKGROUND: Since there is no consensus regarding the optimal management in late-term pregnancies (≥41.0 weeks), we explored the variety of management strategies in late-term pregnancy in the Netherlands to identify the magnitude of this variety and the attitude towards late-term pregnancy. METHODS: Two nationwide surveys amongst all midwifery practices (midwifery-led care) and all hospitals with an obstetric unit (obstetrician-led care) were performed with questions on timing, frequency and content of consultations/surveillance in late-term pregnancy and on timing of induction. Propositions about late-term pregnancy were assessed using Likert scale questions. RESULTS: The response rate was 40% (203/511) in midwifery-led care and 92% (80/87) in obstetrician-led care. All obstetric units made regional protocols with their collaborating midwifery practices about management in late-term pregnancy. Most midwifery-led care practices (93%) refer low-risk women at least once for consultation in obstetrician-led care in late-term pregnancy. The content of consultations varies among hospitals. Membrane sweeping is performed more in midwifery-led care compared to obstetrician-led care (90% vs 31%, p < 0.001). Consultation at 41 weeks should be standard care according to 47% of midwifery-led care practices and 83% of obstetrician-led care units (p < 0.001). Induction of labour at 41.0 weeks is offered less often to women in midwifery-led care in comparison to obstetrician-led care (3% vs 21%, p < 0.001). CONCLUSIONS: Substantial practice variation exists within and between midwifery-and obstetrician-led care in the Netherlands regarding timing, frequency and content of antenatal monitoring in late-term pregnancy and timing of labour induction. An evidence based interdisciplinary guideline will contribute to a higher level of uniformity in the management in late- term pregnancies.

Perinatal death beyond 41 weeks pregnancy: an evaluation of causes and substandard care factors as identified in perinatal audit in the Netherlands.

BACKGROUND: Late- and postterm pregnancy are associated with adverse perinatal outcomes, like perinatal death. We evaluated causes of death and substandard care factors (SSFs) in term and postterm perinatal death. METHODS: We used data from the Perinatal Audit Registry of the Netherlands (PARS). Women with a term perinatal death registered in PARS were stratified by gestational age into early-/full-term (37.0-40.6) and late-/postterm (≥41.0 weeks) death. Cause of death and SSFs ≥41 weeks were scored and classified by the local perinatal audit teams. RESULTS: During 2010-2012, 947/479,097 (0.21%) term deaths occurred, from which 707 cases (75%) were registered and could be used for analyses. Five hundred ninety-eight early-/full-term and 109 late-/postterm audited deaths were registered in the PARS database. Of all audited cases of perinatal death in the PARS database, 55.2% in the early-/fullterm group occurred antepartum compared to 42.2% in the late-/postterm group, while intrapartum death occurred in 7.2% in the early-/full-term group compared to 19.3% in the late-/postterm group in the audited cases from the PARS database. According to the local perinatal audit, the most relevant causes of perinatal death ≥41 weeks were antepartum asphyxia (7.3%), intrapartum asphyxia (9.2%), neonatal asphyxia (10.1%) and placental insufficiency (10.1%). In the group with perinatal death ≥41 weeks there was ≥1SSF identified in 68.8%. The most frequent SSFs concerned inadequate cardiotocography (CTG) evaluation and/or classification (10.1%), incomplete registration or documentation in medical files (4.6%) or inadequate action on decreased foetal movements (4.6%). CONCLUSIONS: In the Netherlands Perinatal Audit Registry, stillbirth occurred relatively less often antepartum and more often intrapartum in pregnancies ≥41 weeks compared to pregnancies at 37.0-40.6 weeks in the audited cases from the PARS database. Foetal, intrapartum and neonatal asphyxia were identified more frequently as cause of death in pregnancies ≥41 weeks. The most identified SSFs related to death in pregnancies ≥41 weeks concerned inadequate CTG monitoring (evaluation, classification, registration or documentation) and inadequate action on decreased foetal movements.

Effects of induction of labour versus expectant management in women with impending post-term pregnancies: the 41 week - 42 week dilemma.

BACKGROUND: Post-term pregnancy, a pregnancy exceeding 294 days or 42 completed weeks, is associated with increased perinatal morbidity and mortality and is considered a high-risk condition which requires specialist surveillance and induction of labour. However, there is uncertainty on the policy concerning the timing of induction for post-term pregnancy or impending post-term pregnancy, leading to practice variation between caregivers. Previous studies on induction at or beyond 41 weeks versus expectant management showed different results on perinatal outcome though conclusions in meta-analyses show a preference for induction at 41 weeks. However, interpretation of the results is hampered by the limited sample size of most trials and the heterogeneity in design. Most control groups had a policy of awaiting spontaneous onset of labour that went far beyond 42 weeks, which does not reflect usual care in The Netherlands where induction of labour at 42 weeks is the regular policy. Thus leaving the question unanswered if induction at 41 weeks results in better perinatal outcomes than expectant management until 42 weeks. METHODS/DESIGN: In this study we compare a policy of labour induction at 41 + 0/+1 weeks with a policy of expectant management until 42 weeks in obstetrical low risk women without contra-indications for expectant management until 42 weeks and a singleton pregnancy in cephalic position. We will perform a multicenter randomised controlled clinical trial. Our primary outcome will be a composite outcome of perinatal mortality and neonatal morbidity. Secondary outcomes will be maternal outcomes as mode of delivery (operative vaginal delivery and Caesarean section), need for analgesia and postpartum haemorrhage (≥1000 ml). Maternal preferences, satisfaction, wellbeing, pain and anxiety will be assessed alongside the trial. DISCUSSION: This study will provide evidence for the management of pregnant women reaching a gestational age of 41 weeks. TRIAL REGISTRATION: Dutch Trial Register (Nederlands Trial Register): NTR3431. Registered: 14 May 2012.

Regional practice variation in induction of labor in the Netherlands: Does it matter? A multilevel analysis of the association between induction rates and perinatal and maternal outcomes.

BACKGROUND: Practice variation in healthcare is a complex issue. We focused on practice variation in induction of labor between maternity care networks in the Netherlands. These collaborations of hospitals and midwifery practices are jointly responsible for providing high-quality maternity care. We explored the association between induction rates and maternal and perinatal outcomes. METHODS: In a retrospective population-based cohort study, we included records of 184,422 women who had a singleton, vertex birth of their first child after a gestation of at least 37 weeks in the years 2016-2018. We calculated induction rates for each maternity care network. We divided networks in induction rate categories: lowest (Q1), moderate (Q2-3) and highest quartile (Q4). We explored the association of these categories with unplanned caesarean sections, unfavorable maternal outcomes and adverse perinatal outcomes using descriptive statistics and multilevel logistic regression analysis corrected for population characteristics. FINDINGS: The induction rate ranged from 14.3% to 41.1% (mean 24.4%, SD 5.3). Women in Q1 had fewer unplanned caesarean sections (Q1: 10.2%, Q2-3: 12.1%; Q4: 12.8%), less unfavorable maternal outcomes (Q1: 33.8%; Q2-3: 35.7%; Q4: 36.3%) and less adverse perinatal outcomes (Q1: 1.0%; Q2-3: 1.1%; Q4: 1.3%). The multilevel analysis showed a lower unplanned caesarean section rate in Q1 in comparison with reference category Q2-3 (OR 0.83; p = .009). The unplanned caesarean section rate in Q4 was similar to the reference category. No significant associations with unfavorable maternal or adverse perinatal outcomes were observed. CONCLUSION: Practice variation in labor induction is high in Dutch maternity care networks, with limited association with maternal outcomes and no association with perinatal outcomes. Networks with low induction rates had lower unplanned caesarean section rates compared to networks with moderate rates. Further in-depth research is necessary to understand the mechanisms that contribute to practice variation and the observed association with unplanned caesarean sections.

Timing induction of labour at 41 or 42 weeks? A closer look at time frames of comparison: A review.

BACKGROUND: Postterm pregnancy is associated with increased perinatal risk. The WHO defines postterm pregnancy as a pregnancy at or beyond 42 weeks + 0 days, though currently labour is induced at 41 weeks in many settings. Guidelines on timing of labour induction are frequently based on the Cochrane systematic review 'Induction of labour for improving birth outcomes for women at or beyond term' in which is concluded that a policy of induction of labour is associated with fewer adverse perinatal outcome and fewer Caesarean sections. However, the included trials differed regarding the timing of induction, ranging from 39 to beyond 42 weeks while the upper limit of expectant management exceeded a gestational age of 42 weeks in most studies. OBJECTIVE: to evaluate perinatal mortality, meconium aspiration syndrome and Caesarean section rate of trials comparing a policy of elective induction of labour and expectant management according to timeframes of comparison with a focus on studies within the 41-42 weeks' timeframe. DESIGN: Review. METHODS: The systematic review of Cochrane was used as a starting point for assessing relevant trials and a search was performed for additional recent trials. We evaluated incidence and causes of perinatal mortality, incidence of meconium aspiration syndrome and Caesarean section according to three time frames of comparison. We pooled estimates and heterogeneity was tested. The quality of the included trials was assessed using the Quality Assessment Tool for Quantative Studies (EPHPP). FINDINGS: In total 22 trials were included which had all different timeframes of comparison. Only one trial compared induction of labour at 41 weeks + 0-2 days with induction at 42 weeks + 0 days, three other trials compared induction of labour at 41 weeks + 0-6 days with induction at 42 weeks + 0-6 days. In 18 trials the comparison was outside the 41-42 weeks' timeframe: in six trials induction was planned ≤ 40 weeks and in another 12 trials expectant management was beyond 43 weeks. The incidence of potentially gestational age associated perinatal mortality between 41 and 42 weeks was 0/2.444 [0%] (induction) versus 4/2.452 [0.16%] (expectant management), NNT 613; 95%CI 613 - infinite. Two trials in the timeframe of comparison 41-42 weeks were available for evaluation of meconium aspiration syndrome (6/554 (induction) versus 14/554 (expectant management), RR 0.44; 95%CI 0.17-1.16). Three trials in the timeframe 41-42 weeks could be evaluated for Caesarean section, with different inclusion criteria regarding Bishop score. There was no significant difference in the Caesarean section rate 93/629 (induction) versus 106/629 (expectant management), RR 0.88; 95%CI 0.68-1.13. CONCLUSION: Evidence is lacking for the recommendation to induce labour at 41 weeks instead of 42 weeks for the improvement of perinatal outcome. More studies comparing both timeframes with an adequate sample size are needed to establish the optimal timing of induction of labour in late-term pregnancies.