Interventional radiology in obstetric patients: A population-based record linkage study of use and outcomes.

INTRODUCTION: Interventional radiology (IR) is a technique for controlling hemorrhage and preserving fertility for women with serious obstetric conditions such as placenta accreta spectrum (PAS) or postpartum hemorrhage. This study examined maternal, pregnancy and hospital characteristics and outcomes for women receiving IR in pregnancy and postpartum. MATERIAL AND METHODS: A population-based record linkage study was conducted, including all women who gave birth in hospital in New South Wales or the major tertiary hospital in the neighboring Australian Capital Territory, Australia, between 2003 and 2019. Data were obtained from birth and hospital records. Characteristics and outcomes of women who underwent IR in pregnancy or postpartum are described. Outcomes following IR were compared in a high-risk cohort of women: those with PAS who had a planned cesarean with hysterectomy. Women were grouped by those who did and those who did did not have IR and were matched using propensity score and other factors. RESULTS: We identified IR in 236 pregnancies of 1 584 708 (15.0 per 100 000), including 208 in the delivery and 26 in a postpartum admission. Two-thirds of women receiving IR in the birth admission received a transfusion of red cells or blood products, 28% underwent hysterectomy and 12.5% were readmitted within 6 weeks. Other complications included: severe maternal morbidity (29.8%), genitourinary tract trauma/repair (17.3%) and deep vein thrombosis/pulmonary embolism (4.3%). Outcomes for women with PAS who underwent planned cesarean with hysterectomy were similar for those who did and did not receive IR, with a small reduction in transfusion requirement for those who received IR. CONCLUSIONS: Interventional radiology is infrequently used in pregnant women. In our study it was performed at a limited number of hospitals, largely tertiary centers, with the level of adverse outcomes reflecting use in a high-risk population. For women with PAS undergoing planned cesarean with hysterectomy, most outcomes were similar for those receiving IR and those not receiving IR, but IR may reduce bleeding.

Rates of neonatal morbidity by maternal region of birth and gestational age in New South Wales, Australia 2003-2016.

INTRODUCTION: Research suggests that neonatal morbidity differs by maternal region of birth at different gestational ages. This study aimed to determine the overall and gestation-specific risk of neonatal morbidity by maternal region of birth, after adjustment for maternal, infant and birth characteristics, for women giving birth in New South Wales, Australia, from 2003 to 2016. MATERIAL AND METHODS: The study utilized a retrospective cohort study design using linked births, hospital and deaths data. Modified Poisson regression was used to determine risk with 95% confidence intervals (95% CI) of neonatal morbidity by maternal region of birth, overall and at each gestational age, compared with Australian or New Zealand-born women giving birth at 39 weeks. RESULTS: There were 1 074 930 live singleton births ≥32 weeks' gestation that met the study inclusion criteria, and 44 394 of these were classified as morbid, giving a neonatal morbidity rate of 4.13 per 100 live births. The gestational age-specific neonatal morbidity rate declined from 32 weeks' gestation, reaching a minimum at 39 weeks in all maternal regions of birth. The unadjusted neonatal morbidity rate was highest in South Asian-born women at most gestations. Adjusted rates of neonatal morbidity between 32 and 44 weeks were significantly lower for babies born to East (adjusted relative risk [aRR] 0.65, 95% CI 0.62-0.68), South-east (aRR 0.76, 95% CI 0.73-0.79) and West Asian-born (aRR 0.93, 95% CI 0.88-0.98) mothers, and higher for babies of Oceanian-born (aRR 1.11, 95% CI 1.04-1.18) mothers, compared with Australian or New Zealand-born mothers. Babies of African, Oceanian, South Asian and West Asian-born women had a lower adjusted risk of neonatal morbidity than Australian or New Zealand-born women until 37 or 38 weeks' gestation, and thereafter an equal or higher risk in the term and post-term periods. CONCLUSIONS: Maternal region of birth is an independent risk factor for neonatal morbidity in New South Wales.

Determining a strategy to reduce smoking in pregnancy.

BACKGROUND: Further efforts, informed by current data, are needed to reduce smoking during pregnancy. AIMS: To describe trends in smoking during pregnancy and identify regions most likely to benefit from targeted smoking cessation interventions, in New South Wales (NSW), Australia. MATERIALS AND METHODS: All women who gave birth in NSW between 1994 and 2016 were included. Smoking status was identified from the Perinatal Data Collection. For births between 2012 and 2016, women were grouped into Local Health District (LHD) of residence, and smoking rates calculated. The impacts of a hypothetical smoking cessation intervention in four LHDs with (i) high smoking rates and (ii) high numbers of smokers, were compared. RESULTS: The overall smoking rate during pregnancy decreased from 22.1% in 1994 to 8.3% in 2016. [Correction added on 13 August 2020, after first online publication: the overall smoking rate during pregnancy in 1994 has been corrected from 14.5% to 22.1%.]. The decrease was lowest among women living in the most socioeconomically disadvantaged areas (41%) and highest among those living in the most advantaged areas (83%). Between 2012 and 2016, over half the women who smoked during pregnancy lived in one of four LHDs. Only 1% of women reporting smoking during pregnancy resided in the LHD with the highest smoking rate (34.7%). A simulated intervention targeting only four regions showed greater effect on the statewide smoking rate when targeting LHDs with high numbers of smokers rather than high smoking rates. CONCLUSIONS: Despite decreases in rates of smoking during pregnancy, there was evidence of geographic clustering of smokers. The greatest reduction in overall smoking may come from interventions targeting the four LHDs with the highest number of smokers.

Comparison of group O Rh(D)- red blood cell use in pregnant women across hospitals of various sizes and obstetric capabilities prior to the introduction of patient blood management guidelines.

BACKGROUND: O Rh(D)- red blood cell (RBC) units can generally be transfused to most patients regardless of their ABO blood type and are frequently used during emergency situations. Detailed usage patterns of O Rh(D)- RBC units in obstetric populations have not been well characterised. With the introduction of patient blood management guidelines, historical usage patterns are important for providing comparative data. AIMS: To determine how the use of O Rh(D)- RBC units in pregnant women differs between hospitals of different sizes and obstetric capabilities prior to patient blood management guidelines. METHODS: Data from 67 New South Wales public hospital blood banks were linked with hospital and perinatal databases to identify RBC transfusions during pregnancy, birth and postnatally between July 2006 and December 2010. RBC transfusions were divided into O Rh(D)- or other blood types. Hospitals were classified according to birth volume, obstetric capability and location, with transfusions classified by timing and diagnosis. RESULTS: Of the 12 078 RBC units transfused into pregnant women, 1062 (8.8%) were O Rh(D)-. Higher use of O Rh(D)- RBC units was seen in antenatal transfusions, preterm deliveries and in regional or smaller hospitals. There was wide variation in rates of O Rh(D)- RBC transfusion among hospitals. CONCLUSIONS: The rate of O Rh(D)- RBC unit use in obstetrics was lower during the period assessed than the nationally reported usage. It is encouraging that O Rh(D)- RBCs were more commonly used in emergency or specialised situations, or in facilities where holding a large blood inventory is not feasible.

Rates of stillbirth by maternal region of birth and gestational age in New South Wales, Australia 2004-2015.

BACKGROUND: Research suggests that in Australia, maternal region of birth is a risk factor for stillbirth. AIMS: We aimed to examine the relationship between stillbirth and maternal region of birth in New South Wales (NSW), Australia from 2004 to 2015. METHODS: Adjusted logistic regression was used to determine odds of stillbirth by maternal region of birth, compared with Australian or New Zealand-born (AUS/NZ-born) women. Intervention rates (induction or pre-labour caesarean) by maternal region of birth, over time, were also examined. Interaction terms were used to assess change in relative odds of stillbirth, over two time periods (2004-2011 and 2012-2015). RESULTS: There were 944 457 singleton births ≥24 weeks gestation that met the study inclusion criteria and 3221 of these were stillbirths, giving a stillbirth rate of 3.4 per 1000 births. After adjustment for confounders, South Asian (adjusted odds ratio (aOR) 1.42, 95% CI 1.24-1.62), Oceanian (aOR 1.45, 95% CI 1.17-1.80) and African (aOR 1.46, 96% CI 1.19-1.80) born women had significantly higher odds of stillbirth that AUS/NZ-born women. Intervention rates increased from the earlier to the later time period by 13.1% across the study population, but the increase was larger in African and South Asian-born women (18.1% and 19.6% respectively) than AUS/NZ-born women (11.2%). There was a significant interaction between ethnicity and time period for South Asian-born women in the all-births model, with their stillbirth rates becoming closer to AUS/NZ-born women in the later period. CONCLUSION: South Asian, African and Oceanian maternal region of birth are independent risk factors for stillbirth in NSW.

Haemoglobin trajectories during pregnancy and associated outcomes using pooled maternity and hospitalization data from two tertiary hospitals.

BACKGROUND AND OBJECTIVES: This study aimed to describe how haemoglobin trajectories in pregnant Australian women were associated with subsequent postpartum haemorrhage, blood transfusion and other outcomes. MATERIALS AND METHODS: The study was conducted in two tertiary public hospitals in Australia, using routinely collected maternity and hospital data on singleton pregnancies (2011-2015). Latent class growth modelling defined trajectories among those with at least one haemoglobin in each of three antenatal time periods (0-15, 16-30 and 31+ weeks; n = 7104). Observed over expected ratios were calculated after predicting expected outcomes with adjusted logistic regression. RESULTS: The mean minimum haemoglobin levels across the three periods were 127·9, 116·5 and 119·3 g/l. We identified seven groups of women with similar haemoglobin trajectories: five with parallel U-shaped trajectories, one with increasing and one with decreasing trajectory. Thirty-eight women (0.5%) had very low haemoglobin across the pregnancy and the highest adverse outcomes, including higher than expected blood transfusion risk. One hundred thirteen women (1.6%) with a progressively decreasing trajectory also had higher risk of transfusion. Women with high haemoglobin across the antenatal period had higher than expected risk of preterm birth, small for gestational age and infants transferred to higher care. CONCLUSIONS: Haemoglobin trajectories across pregnancy can predict women at higher risk of requiring transfusion around birth. Women who maintain high haemoglobins across the pregnancy are worthy of increased surveillance as they carry increased risks of newborn morbidity.

Mortality and hospital readmissions in the first year of life after intra-uterine and neonatal blood product transfusions: A population data linkage study.

AIM: Blood product transfusions are a potentially life-saving therapy for fetal and neonatal anaemia, but there is limited population-based research on outcomes. We aimed to describe mortality, readmission and average hospital stay in the first year of life for infants with or without intra-uterine or neonatal blood product transfusions. METHODS: Linked birth, hospital and deaths data from New South Wales, Australia (January 2002-June 2014) were used to identify singleton infants (≥23 weeks' gestation, surviving to 29 days; n = 1 089 750) with intra-uterine or neonatal transfusion or no transfusion. Rates of mortality and readmission in the first year (29-365 days) and days in hospital were calculated. RESULTS: Overall, 68 (0.06/1000) infants had experienced intra-uterine transfusion and 4332 (3.98/1000) neonatal transfusion. Transfusion was more common among those born at earlier gestational ages requiring invasive ventilation. Mortality, readmissions and average days in hospital were higher among transfused than non-transfused infants. Over half of infants with intra-uterine and neonatal transfusion had ≥1 readmission in the first 29-365 days (55.9 and 51.8%, respectively), and around a quarter had ≥2 (20.6 and 28.5%, respectively) compared with 15.3% with ≥1 and 3.5% with ≥2 in the non-transfused group. CONCLUSION: Infants with a history of blood product transfusion, particularly those needing a neonatal transfusion, had higher mortality and more frequent contact with the hospital system in the first year of life than those infants with no history of transfusion.

Outcomes associated with transfusion in low-risk women with obstetric haemorrhage.

BACKGROUND AND OBJECTIVES: Obstetric haemorrhage is associated with increased blood transfusion, morbidity and health service usage in women. While the use of transfusion in actively bleeding patients is supported, there is little evidence for the use of blood as treatment in the nonbleeding patient following obstetric haemorrhage. Transfusion may expose women to increased morbidity. This study aims to compare outcomes between low-risk women receiving no or 1-2 units of blood in the context of obstetric haemorrhage. MATERIALS AND METHODS: The study population included women giving birth in hospital in New South Wales, Australia, between July 2006 and December 2010, with a diagnosis of obstetric haemorrhage. Women with medical or obstetric conditions making them high risk were excluded, as were women receiving more than 2 units of blood. Data were obtained from linked hospital, birth and blood bank databases. Propensity score matching was used to compare outcomes between transfused and nontransfused women in order to estimate the impact of the transfusion itself on outcomes. RESULTS: There were 14989 women with obstetric haemorrhage, of whom, 1702 received a transfusion, including 1069 receiving a transfusion of 1-2 units. Women receiving transfusion were more likely to experience severe maternal morbidity (relative risk 7·0, 95% Confidence interval (2·8, 17·8)), be admitted to intensive care (RR 2·1 95% CI(1·2, 3·8)), and have a length of stay >5 days (RR 2·0, 95% CI (1·6, 2·5)). CONCLUSIONS: Small volume transfusion in the context of obstetric haemorrhage among low-risk women is associated with poorer maternal outcomes and increased healthcare utilisation.

Educational outcomes for children with cerebral palsy: a linked data cohort study.

AIM: To identify a cohort of children with cerebral palsy (CP) from hospital data; determine the proportion that participated in standardized educational testing and attained a score within the normal range; and describe the relationship between test results and motor symptoms. METHOD: This population-based retrospective cohort study used data from New South Wales, Australia. We linked hospital data for children younger than 16 years of age admitted between 1st July 2000 and 31st March 2014 to education data from 2009 to 2014. Hospital diagnosis codes were used to identify a cohort of children with CP (n=3944) and describe their motor symptoms. Educational outcomes in the CP cohort were compared with those among children without CP. RESULTS: Of those with educational data (n=1770), 46% were exempt from reading assessment because of intellectual or functional disability, 7% were absent or withdrawn from testing and 47% participated in testing. About 30% of all children with educational data had test scores in the normal range. The proportion was greatest among those with hemiplegia (>40%) and lowest among those with tetraplegia (<10%). INTERPRETATION: One-third of children with CP participated in standardized testing and achieved a result in the normal range. The proportions were lower in children with more severe motor symptoms. WHAT THIS PAPER ADDS: From 2009 to 2014, most Australian children with cerebral palsy (CP) attended a mainstream school. The rate of disability-related exemption from standardized educational testing was almost 50%. Thirty per cent of children with CP achieved educational scores in the normal range.

Comparison of neonatal red cell transfusion reporting in neonatal intensive care units with blood product issue data: a validation study.

BACKGROUND: Infants in Neonatal Intensive Care Units represent a heavily transfused population, and are the focus of much research interest. Such research commonly relies on custom research databases or routinely collected data. Knowledge of the accuracy of transfusion recording in these databases is important. This study aims to assess the reporting of red blood cell transfusion neonatal intensive care unit data compared with routinely collected hospital blood bank ("Blood Watch") data. METHODS: Blood Watch data was linked with the NICUS Data Collection, and with routinely collected birth and hospital data for births between 2007 and 2010. The sensitivity, specificity, and positive and negative predictive values for transfusion were calculated, compared to the Blood Watch data. The agreement between the NICUS and Blood Watch datasets on quantity transfused was also assessed. RESULTS: Data was available on 3934 infants, of which 16.2% were transfused. Transfusion was reported in the NICUS Data Collection with high specificity (98.3%, 95% confidence interval (97.8%,98.7%)), but with some under-enumeration (sensitivity 89.2% (95% CI 86.5%,91.5%)). There was excellent agreement between the NICUS and Blood Watch datasets on quantity transfused (Kappa 0.90, 95% CI (0.88,0.92)). Transfusion reporting in the hospital data for these infants was also reliably reported (Sensitivity 83.7% (95% CI 80.6%,86.5%), specificity 99.1% (95% CI 98.7%,99.4%)). CONCLUSIONS: Transfusion is reliably reported in the neonatal intensive care unit data, with some under-reporting, and quantity transfused is well recorded. The NICUS Data Collection provides useful information on blood transfusions, including quantity of blood transfused in a high risk population.

Immediate delivery compared with expectant management after preterm pre-labour rupture of the membranes close to term (PPROMT trial): a randomised controlled trial.

BACKGROUND: Preterm pre-labour ruptured membranes close to term is associated with increased risk of neonatal infection, but immediate delivery is associated with risks of prematurity. The balance of risks is unclear. We aimed to establish whether immediate birth in singleton pregnancies with ruptured membranes close to term reduces neonatal infection without increasing other morbidity. METHODS: The PPROMT trial was a multicentre randomised controlled trial done at 65 centres across 11 countries. Women aged over 16 years with singleton pregnancies and ruptured membranes before the onset of labour between 34 weeks and 36 weeks and 6 days weeks who had no signs of infection were included. Women were randomly assigned (1:1) by a computer-generated randomisation schedule with variable block sizes, stratified by centre, to immediate delivery or expectant management. The primary outcome was the incidence of neonatal sepsis. Secondary infant outcomes included a composite neonatal morbidity and mortality indicator (ie, sepsis, mechanical ventilation ≥24 h, stillbirth, or neonatal death); respiratory distress syndrome; any mechanical ventilation; and duration of stay in a neonatal intensive or special care unit. Secondary maternal outcomes included antepartum or intrapartum haemorrhage, intrapartum fever, postpartum treatment with antibiotics, and mode of delivery. Women and caregivers could not be masked, but those adjudicating on the primary outcome were masked to group allocation. Analyses were by intention to treat. This trial is registered with the International Clinical Trials Registry, number ISRCTN44485060. FINDINGS: Between May 28, 2004, and June 30, 2013, 1839 women were recruited and randomly assigned: 924 to the immediate birth group and 915 to the expectant management group. One woman in the immediate birth group and three in the expectant group were excluded from the primary analyses. Neonatal sepsis occurred in 23 (2%) of 923 neonates whose mothers were assigned to immediate birth and 29 (3%) of 912 neonates of mothers assigned to expectant management (relative risk [RR] 0·8, 95% CI 0·5-1·3; p=0·37). The composite secondary outcome of neonatal morbidity and mortality occurred in 73 (8%) of 923 neonates of mothers assigned to immediate delivery and 61 (7%) of 911 neonates of mothers assigned to expectant management (RR 1·2, 95% CI 0·9-1·6; p=0·32). However, neonates born to mothers in the immediate delivery group had increased rates of respiratory distress (76 [8%] of 919 vs 47 [5%] of 910, RR 1·6, 95% CI 1·1-2·30; p=0·008) and any mechanical ventilation (114 [12%] of 923 vs 83 [9%] of 912, RR 1·4, 95% CI 1·0-1·8; p=0·02) and spent more time in intensive care (median 4·0 days [IQR 0·0-10·0] vs 2·0 days [0·0-7·0]; p<0·0001) compared with neonates born to mothers in the expectant management group. Compared with women assigned to the immediate delivery group, those assigned to the expectant management group had higher risks of antepartum or intrapartum haemorrhage (RR 0·6, 95% CI 0·4-0·9), intrapartum fever (0·4, 0·2-0·9), and use of postpartum antibiotics (0·8, 0·7-1·0), and longer hospital stay (p<0·0001), but a lower risk of caesarean delivery (RR 1·4, 95% CI 1·2-1·7). INTERPRETATION: In the absence of overt signs of infection or fetal compromise, a policy of expectant management with appropriate surveillance of maternal and fetal wellbeing should be followed in pregnant women who present with ruptured membranes close to term. FUNDING: Australian National Health and Medical Research Council, the Women's and Children's Hospital Foundation, and The University of Sydney.

Maternal and neonatal outcomes following abnormally invasive placenta: a population-based record linkage study.

INTRODUCTION: Abnormally invasive placenta involves abnormal adherence of the placenta to the myometrium and is associated with severe pregnancy complications such as blood transfusion and hysterectomy. Knowledge of outcomes has been limited by small sample sizes and a focus on maternal rather than neonatal outcomes. This study uses population-level data collected over 10 years to investigate maternal and neonatal outcomes and trends in incidence of abnormally invasive placenta (also known as placenta accreta, increta and percreta). MATERIAL AND METHODS: A population-based record linkage study was performed, including all women who gave birth in New South Wales, Australia, between 2003 and 2012. Data were obtained from birth records, hospital admissions and deaths registrations. Modified Poisson regression models, adjusted for confounding factors, were used to quantify the effect of abnormally invasive placenta on adverse maternal and neonatal outcomes. RESULTS: Abnormally invasive placenta was significantly associated with morbidity for mothers (adjusted relative risk 17.6, 99% confidence interval 14.5-21.2) and infants (adjusted relative risk 3.1, 99% confidence interval 2.7-3.5). Abnormally invasive placenta increased risk of stillbirth (relative risk 5.4, 99% confidence interval 4.0-7.3) and neonatal death (relative risk 8.0, 99% confidence interval 1.5-41.6). The overall rate of abnormally invasive placenta was 24.8 per 10 000 deliveries, and 22.7 per 10 000 among primiparae. Incidence increased by 30%, from 20.6 to 26.9 per 10 000, over the 10-year study period. CONCLUSIONS: Abnormally invasive placenta substantially increases the risk of severe adverse outcomes for mothers and babies, and the incidence is increasing. Delivery should occur in tertiary hospitals equipped with neonatal intensive care units. Clinicians should be cognizant of the risks, particularly to infants, and maintain a high index of suspicion of abnormally invasive placenta, including in primiparae.

Triggers for Preeclampsia Onset: a Case-Crossover Study.

BACKGROUND: Risk factors for preeclampsia are well established, whereas, the triggers associated with timing of preeclampsia onset are not. The aim of this study was to establish whether recent infection or other triggers were associated with timing of preeclampsia onset. METHODS: We used a case-crossover design with preeclampsia cases serving as their own controls. Women with singleton pregnancies of ≥20 weeks gestation presenting at three hospitals were eligible for inclusion. Exposures to potential triggers were identified via guided questionnaire. Infective episodes included symptoms lasting >24 h. Preeclampsia was defined as hypertension (BP ≥140 mmHg and/or ≥90 mmHg) and proteinuria (protein/creatinine ratio ≥30 mg/mmol). Conditional logistic regression was used to compare the odds of exposure to potential triggers in the case windows (1-7 days preceding diagnosis of preeclampsia) and control windows (8-14 days prior to diagnosis); unadjusted odds ratios (ORs) are reported. RESULTS: Among 286 recruited women, 25 (8.7%) reported a new infection in the 7 days prior to preeclampsia onset and 21 (7.3%) in the 8-14 days prior. There was no significant association between onset of infection in the 7 days prior and preeclampsia diagnosis (OR 1.24, 95% CI 0.65, 2.34). Consumption of caffeine (OR 0.51, 95% CI 0.33, 0.77), spicy food (OR 0.49, 95% CI 0.30, 0.81), and alcohol (OR 0.26, 95% CI 0.10, 0.71) were strongly inversely associated with preeclampsia onset. CONCLUSION: Recent infection does not appear to trigger preeclampsia. Decreased consumption of caffeine, spicy food, and alcohol may be prodromal markers. Such behaviours may be early markers of imminent preeclampsia.

Inter-hospital variations in labor induction and outcomes for nullipara: an Australian population-based linkage study.

INTRODUCTION: This study aimed to describe variation in inter-hospital induction of labor (IOL) rates, determine whether variation is explained by individual and hospital factors and examine birth outcomes. MATERIAL AND METHODS: Nullipara at term with a singleton cephalic birth were identified using linked hospital discharge and birth data for 66 hospitals in New South Wales, Australia, 2010-2011. Random effects multilevel logistic regression models were fitted for early term, full term, and late term births, adjusting for individual and hospital factors. Hospital intrapartum cesarean rates, and severe maternal and neonatal morbidity outcomes were determined according to hospital IOL rate. RESULTS: Of 69 549 nullipara, 24 673 (35%) had an IOL. For early term births, adjusted hospital IOL (aIOL) rates varied (3.3-13.9%), with 11 of 66 (17%) hospitals having aIOL rates significantly different from the average aIOL rate. For births at full term, the hospital aIOL rates varied (10.6-32.6%), with 29 hospitals (44%) having aIOL rates significantly different from the average aIOL rate. For late term births, the hospital aIOL rates varied (45.1-67.5%), with 11 hospitals (17%) having aIOL rates significantly different from the overall average aIOL rate for women with late term births. There was generally no relationship between higher or lower hospital IOL rates and intrapartum cesarean section rates, or maternal or neonatal adverse outcomes. CONCLUSIONS: Inter-hospital IOL rates for nullipara with a singleton cephalic term birth had high unexplained variation, with no clear association with intrapartum cesarean section rates, or maternal or neonatal adverse outcomes.

Assessing the Accuracy of Reporting of Maternal Red Blood Cell Transfusion at Birth Reported in Routinely Collected Hospital Data.

Introduction Hospital administrative data collections have been used to describe transfusion practice, particularly in relation to the maternity population. Knowledge of the accuracy of this data is important in order to interpret the results of such studies. The aim of this study was to compare the accuracy of reporting of red cell transfusion around childbirth within hospital data with data submitted by hospital blood banks. Methods Linked hospital and birth data from New South Wales, Australia, between June 2006 and December 2010 were used to identify blood transfusions occurring at delivery. This reporting was compared with the gold standard of blood pack level information submitted by hospital blood banks, and sensitivity, specificity, and positive and negative predictive values calculated. Reporting related to quantity and timing of transfusion were also considered. Results Data were available for 235,796 births, with blood bank data identifying that 2.0 % of received a blood transfusion. Overall the sensitivity of hospital data for identifying transfusion was 84.8 % (95 % CI 83.7 %, 85.8 %) with specificity 99.9 % (99.9 %, 99.9 %). Sensitivity was better for births involving a postpartum haemorrhage [Sn 90.9 % (89.9 %, 91.9 %)], and poorer for births in regional hospitals [Sn 78.8 % (76.0 %, 81.5 %)]. Almost all (96 %) transfusions of 10 or more units were identified in hospital data, and there was no difference in reporting depending on whether the transfusion was on the baby's date of birth or not. Discussion The reliability of hospital reporting of transfusion in maternity patients is high, however with some underreporting of cases.

Red blood cell transfusion after postpartum haemorrhage and breastmilk feeding at discharge: A population-based study.

BACKGROUND: Recently released patient blood management guidelines for maternity patients in Australia highlighted the lack of evidence on functional outcomes post-transfusion. AIM: This study aimed to determine the association between red blood cell transfusion and breastmilk feeding at discharge. MATERIALS AND METHODS: Population-based cohort study of all births (n = 522 534) of at least 20 weeks gestation or 400 g birthweight in New South Wales, 2007-2012. Multivariable Poisson regression was used to analyse the association between red cell transfusion post-delivery and breastfeeding at discharge among women experiencing a postpartum haemorrhage (PPH). RESULTS: Overall, 461 395 of 522 534 maternities were breastmilk feeding at discharge, a rate of 88% (82% exclusive; 6% partial). Of 35 588 maternities with a PPH that did not receive a transfusion, 31 387 were breastmilk feeding at discharge (88%; 81% exclusive; 7% partial). There were 4561 maternities with a PPH that were transfused and 3737 were breastmilk feeding at discharge (82%; 70% exclusive; 12% partial). After adjusting for differences in clinical and demographic characteristics, women receiving transfusions are 0.91 (99%CI: 0.89-0.93) times as likely to exclusively breastmilk feed at discharge, compared to nontransfused women. The rate of any breastmilk feeding is 0.94 (99% CI: 0.92-0.95) times lower for transfused women, compared to nontransfused women. CONCLUSIONS: Transfused women have reduced breastmilk feeding rates at discharge. Caution is warranted when advising women that transfusion promotes breastmilk feeding. Additional lactation support may be required for transfused women.

Age of blood and adverse outcomes in a maternity population.

BACKGROUND: In recent times there has been debate around whether longer storage time of blood is associated with increased rates of adverse outcomes after transfusion. It is unclear whether results focused on cardiac or critically ill patients apply to a maternity population. This study investigates whether older blood is associated with increased morbidity and readmission in women undergoing obstetric transfusion. STUDY DESIGN AND METHODS: Women giving birth in hospitals in New South Wales, Australia, between July 2006 and December 2010 were included in the study population if they had received between 1 and 4 red blood cell units during the birth admission. Information on women's characteristics, transfusions, and outcomes were obtained from five routinely collected data sets including blood collection, birth, and hospitalization data. Generalized propensity score methods were used to determine the effect of age of blood on rates of severe morbidity and readmission, independent of confounding factors. RESULTS: Transfusion data were available for 2990 women, with a median age of blood transfused of 20 days (interquartile range, 14-27 days). There were no differences in the maximum age of blood transfused between women with and without severe morbidity (21 [14-28] days vs. 22 [15-30] days) and in women readmitted or not (22 [14-28] days vs. 22 [16-30] days). After potential confounding factors were considered, no relationship was found between the age of blood transfused and rates of severe morbidity and readmission. CONCLUSION: Among women receiving low-volume transfusions during a birth admission, there was no evidence of increased rates of adverse outcomes after transfusion with older blood.

Pre-notification letter type and response rate to a postal survey among women who have recently given birth.

BACKGROUND: Surveys are commonly used in health research to assess patient satisfaction with hospital care. Achieving an adequate response rate, in the face of declining trends over time, threatens the quality and reliability of survey results. This paper evaluates a strategy to increase the response rate in a postal satisfaction survey with women who had recently given birth. METHODS: A sample of 2048 Australian women who had recently given birth at seven maternity units in New South Wales were invited to participate in a postal survey about their recent experiences with maternity care. The study design included a randomised controlled trial that tested two types of pre-notification letter (with or without the option of opting out of the survey). The study also explored the acceptability of a request for consent to link survey data with existing routinely collected health data (omitting the latter data items from the survey reduced survey length and participant burden). This consent was requested of all women. RESULTS: The survey had an overall response rate of 46% (913 completed surveys returned, total sample 1989). Women receiving the pre-notification letter with the option of opting out of the survey were more likely to actively decline to participate than women receiving the letter without this option, although the overall numbers of women declining were small (27 versus 12). Letter type was not significantly associated with the return of a completed survey. Among women who completed the survey, 97% gave consent to link their survey data with existing health data. CONCLUSIONS: The two types of pre-notification letters used in our study did not influence the survey response rate. However, seeking consent for record linkage was highly acceptable to women who completed the survey, and represents an important strategy to add to the arsenal for designing and implementing effective surveys. In addition to aspects of survey design, future research should explore how to more effectively influence personal constructs that contribute to the decision to participate in surveys.

Trends and outcomes of postpartum haemorrhage, 2003-2011.

BACKGROUND: While rates of postpartum haemorrhage (PPH) have continued to rise, it is not clear if the association with other morbidity and transfusion has changed over time. This study explores the recent trend in postpartum haemorrhage and whether postpartum haemorrhage is associated with increased transfusions or adverse outcomes over time. METHODS: Linked birth and hospital data were used to examine ICD-10 AM coded PPH and outcomes in maternal birth admission records, 2003--2011 in hospitals in New South Wales (NSW), Australia (N = 818,965 pregnancies). Trends were calculated on the whole population, and among subgroups, and tested using the Cochran Armitage test for trend. Logistic regression models were developed separately for vaginal and caesarean births, and for a maternal morbidity composite indicator (excluding transfusion) and red cell transfusion. Adjusted odds ratios (aOR) for each year relative to 2003 and 95% confidence intervals (CI) are presented with adjustment for maternal (eg. age, country of birth) and pregnancy factors (eg. parity, interventions, pregnancy complications). RESULTS: Overall, there was a significant increase in the PPH rate, from 6.1% in 2003 to 8.3% in 2011 (p < 0.0001). Crude rates of postpartum haemorrhage with transfusion increased from 0.75% (n = 636) to 1.21% (n = 1145) (p < 0.0001) while crude rates of postpartum haemorrhage with maternal morbidity increased from 0.18% (n = 149) to 0.23% (n = 221) (p = 0.02). Having accounted for maternal and pregnancy factors, there were significant overall decreases in the odds of morbidity among women with a PPH delivering vaginally (in 2006, 2007 and 2010, aORs were 0.70 (95 % CI 0.52, 0.96) 0.69 (0.51, 0.94) and 0.64 (0.47, 0.87) relative to 2003; p < 0.05), and no significant decrease among women delivered by caesarean section (aOR 0.87 (0.58, 1.29) in 2011; p = 0.37). Among women with a PPH delivering vaginally, there was a trend towards a non-linear increase in the adjusted odds of transfusion by birth year. Compared to women who had vaginal births with PPH in 2003, the adjusted odds for transfusion was between 1.1 and 1.2 fold higher for those with a PPH delivering vaginally in 2007, 2009, 2010 and 2011. However there was no significant trend amongst caesarean births (aOR 0.84 (0.66, 1.06) in 2011; p = 0.29). CONCLUSIONS: PPH has become more frequent, however this has not been associated with a clear pattern of increased severe maternal morbidity. This suggests that the increase in PPH may represent fewer severe haemorrhages, better management of severe haemorrhage or better recording of PPH. The increase in transfusions following vaginal births with PPH warrants further investigation.

Variation in hospital caesarean section rates for women with at least one previous caesarean section: a population based cohort study.

BACKGROUND: Internationally, repeat caesarean sections make the largest contribution to overall caesarean section rates and inter-hospital variation has been reported. The aim of this study was to determine if casemix and hospital factors explain variation in hospital rates of repeat caesarean sections and whether these rates are associated with maternal and neonatal morbidity. METHODS: This population-based record linkage study utilised data from New South Wales, Australia between 2007 and 2011. The study population included maternities with any previous caesarean section(s) and were singleton, cephalic and ≥ 37 weeks' gestation (Robson Group 5). Multilevel regression models were used to examine variation in hospital rates of 'planned repeat caesarean section' and, among women who planned a vaginal birth, 'intrapartum caesarean section'. We assessed associations between risk-adjusted hospital rates of planned and intrapartum caesarean sections and rates of casemix adjusted maternal and neonatal morbidity, postpartum haemorrhage and Apgar score <7 at five minutes. RESULTS: Of 61894 maternities with a previous caesarean section in 81 hospitals, 82.1% resulted in a caesarean section (72.7% planned and 9.4% unplanned intrapartum caesareans) and 17.9% in vaginal birth. Observed hospital rates of planned caesarean sections ranged from 50.7% to 98.4%. Overall 49.0% of between-hospital variation in planned repeat caesarean section rates was explained by patient (17.3%) and hospital factors (31.7%). Increased odds of planned caesarean section were associated with private hospital status and lower hospital propensity for vaginal birth after caesarean. There were no associations between hospital rates of planned repeat caesarean section and adjusted morbidity rates. Among women who intended a vaginal birth, the observed rates of intrapartum caesarean section ranged from 12.9% to 71.9%. In total, 27.5% of between-hospital variation in rates of intrapartum caesarean section was explained by patient (19.5%) and hospital factors (8.0%). The adjusted morbidity rates differed among hospital intrapartum caesarean section rates, but were influenced by a few hospitals with outlying morbidity rates. CONCLUSIONS: Among women with at least one previous caesarean section, less than half of the variation in hospital caesarean section rates was explained by differences in hospital's patient characteristics and practices. Strategies aimed at modifying caesarean section rates for these women should not affect morbidity rates.