General practitioner obstetricians' models of care in rural Western Australia.

BACKGROUND: In Australia, a significant proportion of women live rurally and deliver their babies in services supported by general practitioner obstetricians (GPOs). While GPOs are known to be an important backbone in the provision of maternity care in Australia, little attention has been paid to their models of care. AIMS: To describe the models of maternity care provided by GPOs across Western Australia. MATERIALS AND METHODS: This was a multi-phase mixed-methods cross-sectional exploratory study. We invited rural GPOs in Western Australia to complete an online survey about their models of care and a sub-group of GPOs agreed to an interview to further explore their responses. RESULTS: Thirty-five GPOs completed the survey and 12 completed an interview. We found that GPOs work in a variety of models, dependent on local community needs, resources and geography. Key attributes of GPO models are continuity of care, safety, generalism, accessibility and affordability. GPO care involves continuity of care beyond the time limits of pregnancy. CONCLUSIONS: GPOs' models of care make up an essential part of rural maternity services and have evolved to meet the needs of the communities they serve. This work informs rural generalist trainees of career pathways and policymakers about rural service provision.

Satisfaction with general practitioner obstetrician-led maternity care in rural Western Australia.

OBJECTIVE: To measure satisfaction with general practitioner obstetrician-led maternity care in Western Australia and to explore perspectives of maternity service users DESIGN: Women were recruited at antenatal visits with their general practitioner obstetrician. Participants completed a validated three-part survey about their satisfaction with antenatal, intrapartum and postpartum care. They were all offered a semi-structured interview. SETTING: Nine general practitioner obstetrician practices located in regional Western Australia. PARTICIPANTS: 155 women receiving general practitioner obstetrician-led maternity care within the South West or Great Southern regions of Western Australia. 13 of these women also participated in an interview. MAIN OUTCOME MEASURES: We quantified satisfaction with aspects of antenatal, intrapartum and postpartum care using a Likert scale. Descriptive variables included demographic information and birth outcomes. Qualitative data described valued aspects of maternity care. RESULTS: 116 women completed all 3 surveys. General practitioner obstetrician-led care resulted in high rates of satisfaction across all 3 stages of care, with 78%-100% agreement with positively worded satisfaction statements. Thematic analysis identified four key aspects of care women valued when receiving maternity care: the woman-centred care experience, the skills of the general practitioner obstetrician, support from the health care team and the health care environment. CONCLUSION: General practitioner obstetrician-led maternity care is a highly regarded model of maternity care, valued by rural women with high rates of satisfaction.

Characteristics and in-hospital outcomes of patients requiring aeromedical retrieval for pregnancy, compared to non-retrieved metropolitan cohorts.

BACKGROUND: Limited access to obstetrics and gynaecology (O&G) services in rural and remote Australia is believed to contribute to suboptimal birth outcomes. AIMS: To describe the characteristics of pregnancy aeromedical transfers, in-hospital outcomes, and patient access to O&G services, as compared to whole of Australia data. MATERIALS AND METHODS: We conducted a cohort study of women who required aeromedical retrieval for pregnancy-related issues between the 1 January 2015 and 31 December 2017. RESULTS: Hospital outcome data were collected on 2171 (65.2%) mothers and 2438 (100.0%) babies. The leading retrieval reason was threatened preterm labour and delivery (n = 883; 40.7%). Most patients were retrieved from rural and remote areas (n = 2224; 93.0%). Retrieved patients were significantly younger (28.0 vs 30.0 years, 95% CI 27.7-28.3), more likely to be overweight or obese (52.2% vs 45.1%, 95% CI 47.5-56.9) and to have smoked during their pregnancy (14.0% vs 9.9%, 95% CI 12.5-15.5) compared to Australian pregnant women overall. Over one-third of transferred women gave birth by Caesarean section (n = 812; 37.4%); the median gestational age at birth was 33.0 (95% CI 32.7-33.3) weeks. Early gestation is associated with low birth weights (median = 2579.5 g; 95% CI 2536.1-2622.9), neonatal resuscitation (35.4%, 95% CI 33.5-37.3), and special care nursery admission (41.2%, 95% CI 39.3-43.2). There were 42 (1.7%, 95% CI 1.2-2.2) stillbirths, which was significantly higher than seen Australia-wide (n = 6441; 0.7%). CONCLUSION: This study found that pregnant women retrieved by the Royal Flying Doctor Service were younger, with higher rates of obesity and smoking.

Diabetes screening in pregnancy failing women in rural Western Australia: An audit of oral glucose tolerance test completion rates.

OBJECTIVE: To quantify screening rate for gestational diabetes mellitus and completion of oral glucose tolerance test in rural and remote Western Australia. DESIGN AND PARTICIPANTS: Retrospective audit of 551 antenatal records from women of 16 years and older without pre-existing diabetes and with singleton pregnancies delivered in 2013. MAIN OUTCOME MEASURES: Number of women recorded screened for gestational diabetes mellitus in second or third trimester using oral glucose tolerance test or other tests; gestational diabetes mellitus rate. RESULTS: Only 278 (50.5%) women were screened with oral glucose tolerance test; 113 (20.5%) had no record of any screening related to gestational diabetes mellitus. In a nested mixed-effects logistic regression model, women with a previous gestational diabetes mellitus diagnosis, two or more risk factors (excluding ethnicity) or high-risk gestational diabetes mellitus ethnicity other than Australian Aboriginal were more likely to be screened, while Australian Aboriginal women were less likely to be screened with oral glucose tolerance test. Clinicians reported patient and clinician factors and logistical difficulties as reasons for the oral glucose tolerance test not being completed at their site. Of those screened with oral glucose tolerance test, a high rate of gestational diabetes mellitus was diagnosed (14.7% versus Western Australia state-wide average of 7.4%). CONCLUSION: Adherence to oral glucose tolerance test screening in rural Western Australia is inadequate for effective screening for gestational diabetes mellitus. Screening was not acceptable or available for a significant proportion of women at risk. Efforts to improve oral glucose tolerance test adherence and exploration of alternative gestational diabetes mellitus screening strategies are required.

Underestimation of risk for large babies in rural and remote Australia: Time to change plasma glucose collection protocols.

AIMS: Preanalytical glycolysis in oral glucose tolerance tests (OGTT) leads to substantial underestimation of gestational diabetes mellitus (GDM) and hence risk for large-for-gestational-age (LGA) babies. This paper quantified the impact of glycolysis on identification of LGA risk in a prospective rural and remote Australian cohort. METHODS: For 495 women, OGTT results from room temperature fluoride-oxalate (FLOX) tubes were algorithmically corrected for estimated glycolysis compared to 1) the Hyperglycaemia and Adverse Pregnancy Outcomes (HAPO) study protocol (FLOX tubes in ice-slurry); and 2) room temperature fluoride-citrate (FC) tubes. GDM was defined by International Association of the Diabetes and Pregnancy Study Groups (IADPSG) criteria. Unadjusted and corrected OGTT were related to LGA outcome. RESULTS: Correction for FC tubes increased GDM incidence from 9.7% to 44.6%. After correction for HAPO protocol, GDM incidence was 27.7% and prediction of LGA risk (RR 1.82, [1.11-2.99]) improved compared to unadjusted rates (RR 1.12, [0.51-2.47]). To provide similar results for FC tube correction (29.3% GDM; RR 1.81, [1.11-2.96]) required + 0.2 mmol/L adjustment of IADPSG criteria. CONCLUSIONS: FC tubes present a practical alternative to the HAPO protocol in remote settings but give + 0.2 mmol/L higher glucose readings. Modification of IADPSG criteria would reduce perceived 'overdiagnosis' and improve LGA risk-assessment.

Real-world screening for diabetes in early pregnancy: Improved screening uptake using universal glycated haemoglobin.

AIMS: To improve perinatal outcomes, screening for hyperglycaemia using 75 g oral glucose tolerance test (OGTT) is recommended for all pregnant women at 24-28 weeks gestation (routine), and earlier if high-risk. Screening coverage for remote and Aboriginal Australian women is less than ideal. This study examined OGTT completion (early and routine) by women from rural and remote Western Australia compared with early glycated haemoglobin (HbA1c). METHODS: In 2015-2018, 27 primary health care sites recruited 600 (233 Aboriginal) women aged ≥16-years, without pre-existing diabetes, who delivered >30-weeks gestation. All women presenting <20-weeks gestation (541) were offered an early study HbA1c. Early OGTTs were requested at the discretion of the local clinician, with routine OGTT offered at 24-28 weeks. RESULTS: HbA1c uptake was high (85.7% Aboriginal, 86.4% non-Aboriginal); OGTT completion in Aboriginal women was low (early OGTT: 38.6% v 69.6% non-Aboriginal, P < 0.001; routine OGTT: 44.5% v 84.7% non-Aboriginal, P < 0.001). Aboriginal women with both early tests had HbA1c completed 3-weeks prior to OGTT (9.6 ± 3.5 v 12.5 ± 3.5 weeks gestation, P < 0.001). CONCLUSIONS: Universal early pregnancy HbA1c appears feasible as an early screening test for women at risk of hyperglycaemia in pregnancy and would expedite and increase screening in Aboriginal women compared to an early OGTT.

Prediabetes and pregnancy: Early pregnancy HbA1c identifies Australian Aboriginal women with high-risk of gestational diabetes mellitus and adverse perinatal outcomes.

AIMS: To assess whether early pregnancy HbA1c can predict gestational diabetes mellitus (GDM) and adverse birth outcomes in Australian women. METHODS: Prospective study of 466 women without diabetes, aged ≥16-years at first antenatal presentation. Recruitment was from 27 primary healthcare sites in rural and remote Australia from 9-January 2015 to 31-May 2018. HbA1c was measured with first antenatal investigations (<20-weeks gestation). Primary outcome measure was predictive value of HbA1c for GDM, by routine 75 g oral glucose tolerance test (OGTT; ≥24-weeks gestation), and for large-for-gestational-age (LGA) newborn. RESULTS: Of 396 (129 Aboriginal) women with routine OGTT, 28.8% had GDM (24.0% Aboriginal). HbA1c ≥5.6% (≥38 mmol/mol) was highly predictive (71.4%, 95% CI; 47.8-88.7%) for GDM in Aboriginal women, and in the total cohort increased risk for LGA newborn (RR 2.04, 95% CI; 1.03-4.01, P = 0.040). There were clear differences between Aboriginal and non-Aboriginal women: 16.3% v 5.2% (P < 0.001) had elevated HbA1c whereas 12.4% v 29.6% (P < 0.001) developed hyperglycemia during pregnancy. CONCLUSIONS: Early pregnancy HbA1c ≥5.6% (≥38 mmol/mol) identifies Aboriginal women with apparent prediabetes and elevated risk of having an LGA newborn. Universal HbA1c at first antenatal presentation could facilitate earlier management of hyperglycemia and improved perinatal outcome in this high-risk population.