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PROBLEM: Breastfeeding has many important benefits for both mother and baby but sustained breastfeeding is sub-optimal. BACKGROUND: Identifying women who need increased support to establish breastfeeding has the potential to improve this. Analysis of the relationship between primary postpartum haemorrhage (PPH) and primary severe PPH and breastfeeding may prove informative as PPH has potentially negative impacts on breastfeeding. AIM: To determine the relationship between PPH and severe PPH and breastfeeding at postnatal discharge and formula use for breastfed babies in hospital. METHODS: Population-based retrospective cohort study using the Victorian Perinatal Data Collection for all liveborn singleton births at ≥ 37 weeks' gestation (n = 339,854) for 2009-13 in Victoria. Estimated blood loss was categorised as PPH ≥ 500 mL and severe PPH ≥ 1500 mL. Descriptive analysis was conducted and multivariable logistic regression was used to determine the adjusted odds ratio for the relationship between PPH/severe PPH and breastfeeding outcomes after adjustment for relevant confounders. FINDINGS: Overall, 94.9% of women initiated breastfeeding. Babies whose mother had a PPH or severe PPH were less likely than others to be exclusively breastfeeding at discharge (aOR 0.88; (95% CI 0.86, 0.90) and aOR 0.57; (95% CI 0.53, 0.61) respectively). Formula - given to 25.9% of all breastfed babies - was more likely for those whose mothers had a PPH or severe PPH (aOR 1.15; (95% CI 1.12, 1.17) and aOR 2.15; (95% CI 2.01, 2.29) respectively. CONCLUSIONS: Women have greater challenges establishing exclusive breastfeeding following PPH and severe PPH. Improving support in hospital for women following PPH may increase breastfeeding success.
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BACKGROUND: Midwives play a critical role in ensuring that HIV, hepatitis B and hepatitis C screening occurs during early pregnancy, in accordance with national consensus guidelines and policies. Limited opportunities exist for midwives to gain the knowledge, skills and confidence required to initiate testing discussions at the first antenatal visit. AIM: To design, deliver and evaluate a workforce education intervention to build midwives' capacity to initiate testing for HIV and viral hepatitis. METHOD: Victorian midwives were invited to enrol in an intervention which comprised a pre-learning package and a one-day study day covering clinical, epidemiological and psychosocial aspects of HIV, hepatitis B and hepatitis C testing in early pregnancy. A pre-/post-test design, incorporating a survey with eight knowledge items and four confidence items, was used to measure impact. FINDINGS: Of the 69 participating midwives, 55 completed the pre-survey, 69 completed the post-survey and 19 completed a three-month follow up survey. Participant knowledge improved across all domains, with the most significant increases in the areas of HIV and viral hepatitis testing, transmission and treatment. Midwives' confidence levels increased following the intervention, and this was generally sustained among the smaller sample at the three-months. CONCLUSION: Our findings demonstrate that short educational interventions, designed and delivered by content experts, result in longer-term improvements in clinical practice which are crucial to ensuring women and their partners are given adequate information and recommendations about screening for HIV, hepatitis B and hepatitis C and during pregnancy.
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Infecções por HIV , Hepatite B , Hepatite C , Tocologia , Feminino , Infecções por HIV/diagnóstico , Infecções por HIV/prevenção & controle , Hepatite B/diagnóstico , Hepatite B/prevenção & controle , Hepatite C/diagnóstico , Hepatite C/prevenção & controle , Humanos , Gravidez , Cuidado Pré-Natal , Inquéritos e QuestionáriosRESUMO
BACKGROUND: Severe postpartum haemorrhage (PPH) is a serious clinical problem that is increasing in incidence. AIM: To identify risk factors for severe PPH. MATERIALS AND METHODS: Population-based retrospective cohort study of all women who gave birth in Victoria in 2009-2013 using the validated Victorian Perinatal Data Collection. Three multivariable logistic regression models estimated the adjusted risk of severe PPH. Adjusted odds ratios (aOR) and their 95% confidence intervals are reported. The primary outcome was severe PPH (estimated blood loss of ≥1500 mL). RESULTS: Severe PPH occurred in 1.4% of all births (n = 5122). Maternal characteristics significantly associated with severe PPH included: multiple pregnancy; older maternal age; overweight/obesity; first births. Other risk factors included placental complications, macrosomia, instrumental vaginal birth, third and fourth degree perineal lacerations, in-labour caesarean section, birth at a gestation other than 37-41 weeks, duration of labour 12 to <24 h, and use of oxytocin infusions in labour. Planned pre-labour caesarean section was associated with reduced odds of severe PPH. Severe PPH also occurred in 0.7% (n = 104) of women with none of the identified risk factors. CONCLUSIONS: Numerous risk factors for severe PPH are identified but some cases are not modifiable or predictable. Limiting use of oxytocin infusions in labour to cases with clear indications, and strategies to prevent severe perineal lacerations would prevent some severe PPHs. Close surveillance of all women in the hours immediately following birth is crucial to detect and manage excessive blood loss and reduce severe PPH and associated morbidity.
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Hemorragia Pós-Parto , Cesárea , Feminino , Humanos , Ocitocina , Hemorragia Pós-Parto/epidemiologia , Hemorragia Pós-Parto/etiologia , Gravidez , Estudos Retrospectivos , Fatores de RiscoRESUMO
BACKGROUND: Increasing incidence and severity of postpartum haemorrhage, together with postpartum haemorrhage-associated morbidities, have been reported in many high-resource countries. In-depth analysis of such factors in Victorian births since 2002 was lacking. AIMS: Our aim was to determine the incidence and trends for primary postpartum haemorrhage (World Health Organization and International Classification of Diseases 10th revision, Australian Modification definitions) for all confinements in Victoria, Australia, for the years 2003-2013 and the incidence and trends for severe postpartum haemorrhage (≥1500 mL) for 2009-2013. MATERIALS AND METHODS: In this population-based cross-sectional study de-identified data from the Victorian Perinatal Data Collection were analysed for confinements (excluding terminations) from 2003 to 2013 (n = 764 244). Perinatal information for all births ≥20 weeks (or of at least 400 g birthweight if gestation was unknown) were prospectively collected. RESULTS: One in five women (21.8%) who gave birth between 2009 and 2013 experienced a primary postpartum haemorrhage and one in 71 women (1.4%) experienced a severe primary postpartum haemorrhage. The increasing trends in incidence of primary postpartum haemorrhage, severe primary postpartum haemorrhage, blood transfusion, admission to an intensive care or high dependency unit and peripartum hysterectomy were significant (P < 0.001). Women who had an unassisted vaginal birth had the lowest incidence of primary postpartum haemorrhage. The highest incidence was experienced by women who had an unplanned caesarean section birth. Women who had a forceps birth had the highest incidence of severe primary postpartum haemorrhage. CONCLUSIONS: The incidence of primary postpartum haemorrhage, severe primary postpartum haemorrhage and associated maternal morbidities have increased significantly over time in Victoria.
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Hemorragia Pós-Parto/epidemiologia , Estudos Transversais , Parto Obstétrico , Feminino , Humanos , Histerectomia , Incidência , Fatores de Risco , Vitória/epidemiologiaRESUMO
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.
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Saúde Materna/etnologia , Prontuários Médicos/estatística & dados numéricos , Hemorragia Pós-Parto/epidemiologia , Adulto , Austrália/epidemiologia , Feminino , Humanos , Incidência , Mortalidade Materna , Parto , Hemorragia Pós-Parto/prevenção & controle , Gravidez , Resultado da Gravidez , Fatores de RiscoRESUMO
BACKGROUND: 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. AIMS: This paper describes the results of a state-wide validation study of the accuracy of EBL volume and EBL-related data items reported to VPDC. MATERIALS AND METHODS: PPH data from a random sample of 1% of births in Victoria in 2011 were extracted from source medical records and compared with information submitted to the VPDC. Accuracy was determined, together with sensitivity, specificity, positive predictive value and negative predictive value for dichotomous items. RESULTS: Accuracy of reporting for EBL ≥ 500 mL was 97.2% and for EBL ≥ 1500 mL was 99.7%. Sensitivity for EBL ≥ 500 mL was 89.0% (CI 83.1-93.0) and for EBL ≥ 1500 mL was 71.4% (CI 35.9-91.8). Blood product transfusion, peripartum hysterectomy and procedures to control bleeding were all accurately reported in >99% of cases. CONCLUSIONS: Most PPH-related data items in the 2011 VPDC may be considered reliable. Our results suggest EBL ≥ 1500 mL is likely to be under-reported. Changes to policies and practices of recording blood loss could further increase accuracy of reporting.
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Perda Sanguínea Cirúrgica/estatística & dados numéricos , Prontuários Médicos/normas , Hemorragia Pós-Parto/epidemiologia , Cuidado Pré-Natal , Adulto , Volume Sanguíneo , Confiabilidade dos Dados , Coleta de Dados , Feminino , Humanos , Hemorragia Pós-Parto/etiologia , Gravidez , Resultado da Gravidez , Reprodutibilidade dos Testes , Vitória/epidemiologiaRESUMO
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.
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Coleta de Dados/normas , Assistência Perinatal/normas , Adulto , Confiabilidade dos Dados , Bases de Dados Factuais/normas , Feminino , Humanos , Recém-Nascido , Prontuários Médicos/normas , Gravidez , VitóriaRESUMO
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. METHOD: A stratified random sample of 15 hospitals and two homebirth practitioners was included. Site visits were arranged following consent. In addition to the validation of perinatal data, information was collected regarding logistics. RESULTS: Records at 14 metropolitan and rural hospitals up to 500 km from the research centre, and two homebirth practitioners, were audited. Obtaining consent to participate took between 5 days and 10 months. Auditors visited sites on 101 days, auditing 737 medical record pairs at 16 sites. Median audit time per record was 51.3 minutes; electronic records each took 36 minutes longer than paper. Travel time accounted for nearly one-quarter of audit time. CONCLUSIONS: Delays obtaining consents, long travel times and electronic records prolonged audit duration and expense. Employment of experts maximised use of available audit time. Conducting a validation study is a time-consuming and expensive exercise; however, confidence in the accuracy of public health data is vital. IMPLICATIONS: Validation studies are unquestionably important. Three alternative strategies have been proposed to make future studies viable.
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Auditoria Médica/métodos , Prontuários Médicos/estatística & dados numéricos , Viagem/estatística & dados numéricos , Aeronaves , Automóveis , Humanos , Auditoria Médica/estatística & dados numéricos , Estudos Prospectivos , Ferrovias , Reprodutibilidade dos Testes , Saúde da População Rural/estatística & dados numéricos , Tempo , Saúde da População Urbana/estatística & dados numéricos , VitóriaRESUMO
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.
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Analgesia Obstétrica/métodos , Cesárea/métodos , Trabalho de Parto , Tocologia/métodos , Ocitócicos/uso terapêutico , Administração dos Cuidados ao Paciente/métodos , Adulto , Austrália , Índice de Massa Corporal , Intervenção Médica Precoce , Feminino , Hospitalização , Humanos , Início do Trabalho de Parto , Modelos Logísticos , Idade Materna , Paridade , Gravidez , Resultado da Gravidez , Prognóstico , Tempo para o Tratamento , Prova de Trabalho de PartoRESUMO
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.
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Trabalho de Parto , Complicações do Trabalho de Parto/etiologia , Autorrelato , Adolescente , Adulto , Feminino , Humanos , Paridade , Gravidez , Estudos Prospectivos , História Reprodutiva , Fatores de Risco , Inquéritos e QuestionáriosRESUMO
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 form's 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.