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Objective: This study is an economic evaluation of immediate birth compared with expectant management in women with preterm prelabour rupture of the membranes near term (PPROMT).Design: A cost-effectiveness analysis alongside the PPROMT randomised controlled trial.Setting: Obstetric departments in 65 hospitals across 11 countries.Population: Women with a singleton pregnancy with ruptured membranes between 34+0 and 36+6 weeks gestation.Methods: Women were randomly allocated to immediate birth or expectant management. Costs to the health system were identified and valued. National hospital costing data from both the UK and Australia were used. Average cost per recruit in each arm was calculated and 95% confidence intervals were estimated using bootstrap re-sampling. Averages costs during antenatal care, delivery and postnatal care, and by country were estimated.Main Outcomes Measures: Total mean cost difference between immediate birth and expectant management arms of the trial.Results: From 11 countries 923 women were randomised to immediate birth and 912 were randomised to expectant management. Total mean costs per recruit were £8852 for immediate birth and £8740 for expectant delivery resulting in a mean difference in costs of £112 (95% CI: -431 to 662). The expectant management arm had significantly higher antenatal costs, whereas the immediate birth arm had significantly higher delivery and neonatal costs. There was large variation between total mean costs by country.Conclusion: This economic evaluation found no evidence that expectant management was more or less costly than immediate birth. Outpatient management may offer opportunities for cost savings for those women with delayed delivery.Tweetable Abstract: For women with preterm prelabour rupture of the membranes, the relative benefits and harms of immediate and expectant management should inform counselling as costs are similar. [ABSTRACT FROM AUTHOR]

Background A lack of reproducible methods for classifying women having an induction of labour ( IOL) has led to controversies regarding IOL and related maternal and perinatal health outcomes. Objectives To evaluate articles that classify IOL and to develop a novel IOL classification system. Search strategy Electronic searches using CINAHL, EMBASE, WEB of KNOWLEDGE, and reference lists. Selection criteria Two reviewers independently assessed studies that classified women having an IOL. Data collection and analysis For the systematic review, data were extracted on study characteristics, quality, and results. Pre-specified criteria were used for evaluation. A multidisciplinary collaboration developed a new classification system using a clinically logical model and stakeholder feedback, demonstrating applicability in a population cohort of 909 702 maternities in New South Wales, Australia, over the period 2002-2011. Main results All seven studies included in the systematic review categorised women according to the presence or absence of varying medical indications for IOL. Evaluation identified uncertainties or deficiencies across all studies, related to the criteria of total inclusivity, reproducibility, clinical utility, implementability, and data availability. A classification system of ten groups was developed based on parity, previous caesarean, gestational age, number, and presentation of the fetus. Nulliparous and parous women at full term were the largest groups (21.2 and 24.5%, respectively), and accounted for the highest proportion of all IOL (20.7 and 21.5%, respectively). Author's conclusions Current methods of classifying women undertaking IOL based on medical indications are inadequate. We propose a classification system that has the attributes of simplicity and clarity, uses information that is readily and reliably collected, and enables the standard characterisation of populations of women having an IOL across and within jurisdictions. Tweetable abstract Methods classifying pregnant women having IOL are inadequate; we suggest a new classification system [ABSTRACT FROM AUTHOR]

Objective To explore the variation in hospital caesarean section (CS) rates for nulliparous women, to determine whether different case-mix, labour and delivery, and hospital factors can explain this variation and to examine the association between hospital CS rates and outcomes. Design Population-based cohort study. Setting New South Wales, 2009-2010. Population Nulliparous women with singleton cephalic live births at term. Methods Random effect multilevel logistic regression models using linked hospital discharge and birth data. Main outcome measures Prelabour and intrapartum CS rates following spontaneous labour or labour induction; maternal and neonatal severe morbidity rates. Results Of 67 239 nulliparous women, 4902 (7.3%) had a prelabour CS, 39 049 (58.1%) laboured spontaneously, and 23 288 (34.6%) had labour induced. Overall, there were 18 875 (28.1%) CSs, with labour inductions twice as likely to result in an intrapartum CS compared with women with a spontaneous onset of labour (34.0% versus 15.5%). After adjusting for differences in case-mix, labour and delivery, and hospital factors, the overall variation in CS rates decreased by 78% for prelabour CSs, 52% for intrapartum CSs following spontaneous labour and 9% following labour induction. Adjusting for labour and delivery practices increased the unexplained variation in intrapartum CSs. The adjusted rates of severe maternal and neonatal morbidity were not significantly different across CS rate quintile groups, except for women in spontaneous labour, where the hospitals in the lowest CS quintile had the lowest neonatal morbidity rate. Conclusions Differences in clinical practice were substantial contributors to variation in intrapartum CS rates. Our findings suggest that CS rates in some hospitals could be lowered without adversely affect pregnancy outcomes. [ABSTRACT FROM AUTHOR]

Background Rapid development in health care has resulted in an increasing number of screening and treatment options. Consequently, there is an urgency to provide people with relevant information about benefits and risks of healthcare options in an unbiased way. Decision aids help people to make decisions by providing unbiased non-directive research evidence about all treatment options. Objective To determine the effectiveness of decision aids to improve informed decision making in pregnancy care. Search strategy We searched MEDLINE (1953-2011), EMBASE (1980-2011), CENTRAL ( CENTRAL, the Cochrane Library; 2011, Issue 4), Psycinfo (1806-2011) and Research Registers of ongoing trials (www.clinicaltrials.gov, www.controlled-trials.com). Selection criteria We included randomised controlled trials comparing decision aids in addition to standard care. The study population needed to be pregnant women making actual decisions concerning their pregnancy. Data collection and analysis Two independent researchers extracted data on quality of the randomised controlled trial ( GRADE criteria), quality of the decision aid ( IPDAS criteria), and outcome measures. Data analysis was undertaken by assessing group differences at first follow up after the interventions. Main results Ten randomised controlled trials could be included. Pooled analyses showed that decision aids significantly increased knowledge, (weighted mean difference 11.06, 95% confidence interval 4.85-17.27), decreased decisional conflict scores (weighted mean difference −3.66, 95% confidence interval −6.65 to −0.68) and decreased anxiety (weighted mean difference −1.56, 95% confidence interval −2.75 to −0.43). Conclusions Our systematic review showed the positive effect of decision aids on informed decision making in pregnancy care. Future studies should focus on increasing the uptake of decision aids in clinical practice by identifying barriers and facilitators to implementation. [ABSTRACT FROM AUTHOR]

Please cite this paper as: Vivian-Taylor J, Sheng J, Hadfield R, Morris J, Bowen J, Roberts C. Trends in obstetric practices and meconium aspiration syndrome: a population-based study. BJOG 2011;118:1601-1607. Objective To determine trends in the incidence of meconium aspiration syndrome (MAS), and maternal factors and obstetric practices associated with any decline. Design Population-based cohort study. Setting New South Wales (NSW), Australia. Population All 877 037 liveborn, singleton, term infants (≥37 weeks of gestation) in the period 1997-2007. Methods Data were obtained from birth records linked to the neonatal hospital discharge records. The birth data provided information on maternal and obstetric factors, whereas the outcome of interest, MAS, was obtained from hospital data on the neonates. Multivariable logistic regression was used to estimate the risk of MAS while simultaneously adjusting for the explanatory variables. Main outcome measures The incidence of MAS per 1000 births, and odds ratios and 95% confidence intervals for maternal and obstetric factors for the development of MAS. Results The incidence of MAS declined significantly by 11.3% per annum (95% CI 10.1-12.6; P < 0.001) from 4.1 per 1000 births in 1997 to 1.3 per 1000 births in 2007. This was associated with a statistically significant decline in risk factors: maternal smoking (from 20 to 12%), gestational age (from 57 to 47% ≥ 40 weeks of gestation), delivery at small hospitals (from 15 to 9%) and infants with birthweight below the third percentile (from 3.3 to 2.4%). There were simultaneous statistically significant increases in practices that reduce the risk of MAS: labour inductions (from 22 to 27%) and birth by caesarean section, both elective, prior to 40 weeks of gestation (from 7.3 to 13.8%), and emergency (from 3.0 to 5.3% prior to 40 weeks of gestation, and from 5.1 to 6.7% at 40 weeks of gestation or later). Conclusions The rate of MAS is declining, and this decline is associated with a reduction in maternal and pregnancy risk factors, and an increase in protective obstetric practices. [ABSTRACT FROM AUTHOR]

Please cite this paper as: Roberts C, Algert C, Knight M, Morris J. Amniotic fluid embolism in an Australian population-based cohort. BJOG 2010;117:1417–1421. We utilised linked birth, hospital and death data for the entire population to determine the incidence of amniotic fluid embolism (AFE) and its mortality and morbidity. AFE diagnoses were identified from International Classification of Diseases, 10th Revision (ICD10)-coded hospital and/or death records with additional case definition criteria imposed. The AFE incidence was 3.3 per 100 000 (95% CI, 1.9–4.7), maternal fatality rate 35% (95% CI, 15–59) and perinatal mortality rate 32% (95% CI, 12–56). Newly identified risk factors included induction with vaginal prostaglandin and manual removal of the placenta, and survivors were at increased risk of cerebral infarction. Although two-thirds of women and infants survived, AFE also caused severe morbidity. [ABSTRACT FROM AUTHOR]

Objective: To determine whether the proportion of babies born large for gestational age (LGA) in New South Wales has increased, and to identify possible reasons for any increase.Design and Setting: Population-based study using data obtained from the NSW Midwives Data Collection, a legislated surveillance system of all births in NSW.Participants: All 1 273 924 live-born singletons delivered at term (> or = 37 complete weeks' gestation) in NSW from 1990 to 2005.Main Outcome Measures: LGA, defined as > 90th centile for sex and gestational age using 1991-1994 Australian centile charts; maternal factors associated with LGA were assessed using logistic regression.Results: The proportion of babies born LGA increased from 9.2% to 10.8% (18% increase) for male infants and from 9.1% to 11.0% (21% increase) for female infants. The mean birthweight increased by 23 g for boys and 25 g for girls over the study period. Increasing maternal age, higher rates of gestational diabetes and a decline in smoking contributed significantly to these increases, but did not fully explain them.Conclusions: There is an increasing trend in the proportion of babies born LGA, which is only partly attributable to decreasing maternal smoking, increasing maternal age and increasing gestational diabetes. [ABSTRACT FROM AUTHOR]

Objective: To assess the change in birth rates, both overall and in age, parity, socioeconomic and geographical subgroups of the population, after the introduction of the Baby Bonus payment in Australia on 1 July 2004.Design and Setting: Population-based study using New South Wales birth records and Australian Bureau of Statistics population estimates for the period 1 January 1997 - 31 December 2006.Participants: All 853 606 women aged 15-44 years with a pregnancy resulting in a birth at > or = 20 weeks' gestation or a baby > or = 400 g birthweight.Main Outcome Measure: Change in birth rate in 2005 and 2006 compared with the trend in birth rates before the introduction of the Baby Bonus.Results: The crude annual birth rate showed a downward trend from 1997 to 2004; after 2004 this trend reversed with a sharp increase in 2005 and a further increase in 2006. All age-specific birth rates increased after 2004, with the greatest increase in birth rate, relative to the trend before the Baby Bonus, being seen in teenagers. Rates of first births were not significantly affected by the bonus; however, rates of third or subsequent births increased across all age, socioeconomic and geographical subgroups.Conclusions: In the first 2 years after the introduction of the Baby Bonus, birth rates increased, especially among women having a third or subsequent birth. This could represent an increase in family size and/or a change in the timing of births. [ABSTRACT FROM AUTHOR]

Population health datasets are a valuable resource for studying maternal and obstetric health outcomes. However, their validity has not been thoroughly examined. We compared medical records from a random selection of New South Wales (NSW) women who gave birth in a NSW hospital in 2002 with coded hospital discharge records. We estimated the population prevalence of maternal medical conditions during pregnancy and found a tendency towards underreporting although specificities were high, indicating that false positives were uncommon. [ABSTRACT FROM AUTHOR]

Background: Maternal mortality is too rare in high income countries to be used as a marker of the quality of maternity care. Consequently severe maternal morbidity has been suggested as a better indicator. Using the maternal morbidity outcome indicator (MMOI) developed and validated for use in routinely collected population health data, we aimed to determine trends in severe adverse maternal outcomes during the birth admission and in particular to examine the contribution of postpartum haemorrhage (PPH).Methods: We applied the MMOI to the linked birth-hospital discharge records for all women who gave birth in New South Wales, Australia from 1999 to 2004 and determined rates of severe adverse maternal outcomes. We used frequency distributions and contingency table analyses to examine the association between adverse outcomes and maternal, pregnancy and birth characteristics, among all women and among only those with PPH. Using logistic regression, we modelled the effects of these characteristics on adverse maternal outcomes. The impact of adverse outcomes on duration of hospital admission was also examined.Results: Of 500,603 women with linked birth and hospital records, 6242 (12.5 per 1,000) suffered an adverse outcome, including 22 who died. The rate of adverse maternal outcomes increased from 11.5 in 1999 to 13.8 per 1000 deliveries in 2004, an annual increase of 3.8% (95%CI 2.3-5.3%). This increase occurred almost entirely among women with a PPH. Changes in pregnancy and birth factors during the study period did not account for increases in adverse outcomes either overall, or among the subgroup of women with PPH. Among women with severe adverse outcomes there was a 12% decrease in hospital days over the study period, whereas women with no severe adverse outcome occupied 23% fewer hospital days in 2004 than in 1999.Conclusion: Severe adverse maternal outcomes associated with childbirth have increased in Australia and the increase was entirely among women who experienced a PPH. Reducing or stabilising PPH rates would halt the increase in adverse maternal outcomes. [ABSTRACT FROM AUTHOR]