Women's experiences of care and their concerns and needs following a significant primary postpartum hemorrhage.

BACKGROUND: In the context of rising rates of postpartum hemorrhage and little data about its effect on women, this study aimed to describe the experiences of care, and the concerns and needs of women after a significant postpartum hemorrhage. METHODS: A cohort of 206 women with a primary postpartum hemorrhage of 1,500 mL or more and/or a peripartum fall in hemoglobin concentration to 7 g/dL or less and/or of 4 g/dL or more was recruited from 17 major hospitals in Australasia. Women rated their satisfaction with care and provided written responses to questions in postpartum questionnaires completed in the first week and at 2 and 4 months postpartum. RESULTS: In relation to care in hospital, consistently over 20 percent women responded that their needs for information, acknowledgment, and reassurance were only met sometimes, rarely, or never. Sixty-two percent reported that they were given adequate information about their likely physical recovery, and 48 percent about their likely emotional recovery. Four major themes were identified in response to the open-ended questions: adequacy of care, emotional responses to the experience, implications for the future, and concerns for their baby. CONCLUSIONS: This study is an important step in identifying the negative impact of experiencing a significant postpartum hemorrhage during childbirth for women who survive. Our results suggest that health professionals should pay greater attention to these women's informational and emotional needs.

Emotional and physical health outcomes after significant primary post-partum haemorrhage (PPH): a multicentre cohort study.

BACKGROUND: Post-partum haemorrhage (PPH) rates are rising; however, data on the health impact on women are lacking. AIMS: To describe the emotional and physical health outcomes for women following PPH. METHODS: A cohort of 206 women with primary PPH of 1500 mL or more, and/or peripartum fall in haemoglobin concentration to 7 g/dL or less, and/or of 4 g/dL or less, was recruited from 17 Australian/New Zealand hospitals. Women completed questionnaires in the first week, and at two and four months post-partum. Obstetric details came from hospital records. Outcomes were anxiety; post-natal depression (PND); fatigue; post-traumatic stress disorder (PTSD); general health (SF-36); physical health problems; post-natal bleeding duration; hospital readmission. RESULTS: Eighty-three percent completed the two-month and 81% the four-month questionnaires; 28% reported bleeding continuously for more than six weeks; 10% required hospital readmission within two months. Anxiety scores were in the medium range; 11 and 13% were at risk of PND at two and four months, respectively; median total fatigue scores were 17 at two and 15 at four months; 5% showed evidence of PTSD at two and 3% at four months; women scored highly in most SF-36 categories and showed improvements over time in all but general and mental health. Physical health concerns were comparable to those reported for general post-natal populations, with the exception of uterine infection (6% at two months). CONCLUSIONS: In a cohort of women experiencing PPH, emotional and physical health outcomes were similar to those reported in general post-natal populations, with the exception of post-natal bleeding duration, uterine infection and hospital readmission.

Women's breastfeeding experiences following a significant primary postpartum haemorrhage: A multicentre cohort study.

BACKGROUND: Postpartum haemorrhage (PPH) is a significant and increasing contributor to maternal mortality and morbidity. Following a PPH, women may have difficulties initiating and sustaining breastfeeding, although little has been published on this issue. The aim of this study was to describe breastfeeding experiences in a cohort of women following a significant PPH. METHODS: This is a descriptive study based on quantitative and qualitative data collected via questionnaires completed in the first week postpartum and at two and four months postpartum, by 206 women participating in a multicentre study of women's experiences of a significant primary postpartum haemorrhage (blood loss of 1500 mL or more in the 24 hours following childbirth, and/or a peripartum fall in haemoglobin (Hb) concentration to 7g/dL or less, or of >/= 4g/dL). RESULTS: Among women with a significant PPH, 63% fully breastfed their babies from birth, whereas 85% said they had hoped to do so (p < 0.001). Only 52% of mothers who intended to either fully or partially breastfeed were able to give their baby the opportunity to suckle within an hour of the birth. Delays were longer in women with greater estimated blood loss and women with the longest delays in breastfeeding were less likely to initiate full breastfeeding. 70% of women with PPH of < 2000 mL were fully breastfeeding in the first postpartum week, whereas less than 50% of those with blood loss >/= 3000 mL were able to do so. Overall, 58% of women with significant PPH were fully breastfeeding at two and 45% at four months postpartum.In qualitative data, three major themes were identified: 1) Difficulty initiating or sustaining breastfeeding, 2) Need for education and support; and 3) Emotional sequelae. CONCLUSIONS: Following a significant PPH, women with greater blood loss are less likely to initiate and sustain full breastfeeding and this may be related, in part, to delays in initial contact with their baby as a consequence of the PPH. These findings have implications for postnatal care as these women may require greater support, education and assistance in initiating and sustaining breastfeeding. In particular, enabling the opportunity for the newborn to suckle as soon as is practicable should be encouraged.

Population rates of haemorrhage and transfusions among obstetric patients in NSW: a short communication.

We estimated the population rates of obstetric haemorrhage and transfusion among women giving birth, utilising data collected in a review of the delivery admissions of 1200 randomly selected women in New South Wales in 2002. The estimated population obstetric haemorrhage rate was 13.1% (11.4% post-partum haemorrhage (PPH), 2.2% antepartum haemorrhage) and the transfusion rate was 1.06% (0.9% vaginal births, 1.6% of caesarean sections). When variations in definitions and denominators were accounted for, the difference in PPH rates among vaginal births (13.1%) and caesarean sections (6.3%) disappeared, suggesting PPH is under-ascertained for women delivered by caesarean section.

Intrapartum epidural analgesia and breastfeeding: a prospective cohort study.

BACKGROUND: Anecdotal reports suggest that the addition of fentanyl (an opioid) to epidural analgesia for women during childbirth results in difficulty establishing breastfeeding. The aim of this paper is to determine any association between epidural analgesia and 1) breastfeeding in the first week postpartum and 2) breastfeeding cessation during the first 24 weeks postpartum. METHODS: A prospective cohort study of 1280 women aged > or = 16 years, who gave birth to a single live infant in the Australian Capital Territory in 1997 was conducted. Women completed questionnaires at weeks 1, 8, 16 and 24 postpartum. Breastfeeding information was collected in each of the four surveys and women were categorised as either fully breastfeeding, partially breastfeeding or not breastfeeding at all. Women who had stopped breastfeeding since the previous survey were asked when they stopped. RESULTS: In the first week postpartum, 93% of women were either fully or partially breastfeeding their baby and 60% were continuing to breastfeed at 24 weeks. Intrapartum analgesia and type of birth were associated with partial breastfeeding and breastfeeding difficulties in the first postpartum week (p < 0.0001). Analgesia, maternal age and education were associated with breastfeeding cessation in the first 24 weeks (p < 0.0001), with women who had epidurals being more likely to stop breastfeeding than women who used non-pharmacological methods of pain relief (adjusted hazard ratio 2.02, 95% CI 1.53, 2.67). CONCLUSION: Women in this cohort who had epidurals were less likely to fully breastfeed their infant in the few days after birth and more likely to stop breastfeeding in the first 24 weeks. Although this relationship may not be causal, it is important that women at higher risk of breastfeeding cessation are provided with adequate breastfeeding assistance and support.

Prevalence and persistence of health problems after childbirth: associations with parity and method of birth.

BACKGROUND: Awareness about the extent of maternal physical and emotional health problems after childbirth is increasing, but few longitudinal studies examining their duration have been published. The aim of this study was to describe changes in the prevalence of maternal health problems in the 6 months after birth and their association with parity and method of birth. METHODS: A population-based, cohort study was conducted in the Australian Capital Territory (ACT), Australia. The study population, comprising women who gave birth to a live baby from March to October 1997, completed 4 questionnaires on the fourth postpartum day, and at 8, 16, and 24 weeks postpartum. Outcome measures were self-reported health problems during each of the three 8-week postpartum periods up to 24 weeks. RESULTS: A total of 1295 women participated, and 1193 (92) completed the study. Health problems showing resolution between 8 and 24 weeks postpartum were exhaustion/extreme tiredness (60-49), backache (53-45), bowel problems (37-17), lack of sleep/baby crying (30-15), hemorrhoids (30-13), perineal pain (22-4), excessive/prolonged bleeding (20-2), urinary incontinence (19-11), mastitis (15-3), and other urinary problems (5-3). No significant changes occurred in the prevalence of frequent headaches or migraines, sexual problems, or depression over the 6 months. Adjusting for method of birth, primiparas were more likely than multiparas to report perineal pain and sexual problems. Compared with unassisted vaginal births, women who had cesarean sections reported more exhaustion, lack of sleep, and bowel problems; reported less perineal pain and urinary incontinence in the first 8 weeks; and were more likely to be readmitted to hospital within 8 weeks of the birth. Women with forceps or vacuum extraction reported more perineal pain and sexual problems than those with unassisted vaginal births after adjusting for parity, perineal trauma, and length of labor. CONCLUSIONS: Health problems commonly occurred after childbirth with some resolution over the 6 months postpartum. Some important differences in prevalence of health problems were evident when parity and method of birth were considered.

Hospital system costs of artificial infant feeding: estimates for the Australian Capital Territory.

OBJECTIVE: To estimate the attributable ACT hospital system costs of treating selected infant and childhood illnesses having known associations with early weaning from human milk. METHOD: We identified relative risks of infant and childhood morbidity associated with exposure to artificial feeding in the early months of life vs. breastfeeding from cohort studies cited by the American Academy of Pediatrics in 1997 as establishing the protective effect of breastfeeding. Data for ACT breastfeeding prevalence is assessed from a 1997 prospective population-based cohort study of 1,295 women. ACT Hospital Morbidity Data and DRG treatment costs were used to estimate the attributable fraction of costs of hospitalisation for gastrointestinal illness, respiratory illness and otitis media, eczema, and necrotising enterocolitis. RESULTS: Although initiation rates were high (92%), less than one in 10 ACT infants are exclusively breastfed for the recommended six months, mainly due to supplementation or weaning on to formula within the first three months and the early introduction of solids by breastfeeding mothers. This study suggests the attributable hospitalisation costs of early weaning in the ACT are about $1-2 million a year for the five illnesses. CONCLUSIONS AND IMPLICATIONS: Early weaning from breastmilk is associated with significant hospital costs for treatment of gastrointestinal illness, respiratory illness and otitis media, eczema, and necrotising enterocolitis. These costs are minimum estimates of the cost of early weaning as they exclude numerous other chronic or common illnesses and out-of-hospital health care costs. Higher rates of exclusive breastfeeding would reduce these costs. Interventions to protect and support breastfeeding are likely to be cost-effective for the public health system.