Risk factors associated with preterm birth among singletons following assisted reproductive technology in Australia 2007-2009-a population-based retrospective study

© Xu et al. Background: Preterm birth, a leading cause of neonatal death, is more common in multiple births and thus there has being an increasing call for reducing multiple births in ART. However, few studies have compared risk factors for preterm births amongst ART and non-ART singleton birth mothers. Methods: A population-based study of 393,450 mothers, including 12,105 (3.1%) ART mothers, with singleton gestations born between 2007 and 2009 in 5 of the 8 jurisdictions in Australia. Univariable and multivariable logistic regression models were conducted to evaluate socio-demographic, medical and pregnancy factors associated with preterm births in contrasting ART and non-ART mothers. Results: Ten percent of singleton births to ART mothers were preterm compared to 6.8% for non-ART mothers (P 34), socioeconomic disadvantage (most disadvantaged quintile Odds Ratio (OR) 0.95, 95% Confidence Interval (CI): 0.77-1.17), smoking (OR 1.12, 95%CI: 0.79-1.61) and priminarity (OR 1.19, 95% CI: 1.05-1.35, AOR not significant) shown to be associated with elevated risk of preterm birth for non-ART mothers were not demonstrated for ART mothers, even after adjusting for potential confounders. Nonetheless, in multivariable analysis, the association between ART and the elevated risk for singleton preterm birth persisted after controlling for all included confounding medical, pregnancy and socio-economic factors (AOR 1.51, 95% CI: 1.42-1.61). Conclusions: Preterm birth rate is approximately one-and-a-half-fold higher in ART mothers than non-ART mothers albeit for singleton births after controlling for confounding factors. However, ART mothers were less subject to the adverse influence from socio-demographic factors than non-ART mothers. This has implications for counselling prospective parents

Mapping maternity services in Australia: Location, classification and services

Objective. To describe maternity services available to Australian women and, in particular, the location, classification of services and support services available. Design. A descriptive study was conducted using an online survey that was emailed to eligible hospitals. Inclusion criteria for the study included public and private maternity units with greater than 50 births per year. In total, 278 maternity units were identified. Units were asked to classify their level of acuity (Levels 26). Results. A total of 150 (53%) maternity units responded. Those who responded were reasonably similar to those who did not respond, and were representative of Australian maternity units. Almost three-quarters of respondents were from public maternity units and almost 70% defined themselves as being in a rural or remote location. Maternity units with higher birth rates were more likely to classify themselves as providing higher acuity services, that is, Levels 5 and 6. Private maternity units were more likely to have higher acuity classifications. Interventions such as induction of labour, either using an artificial rupture of membranes (ARM) and oxytocin infusion or with prostaglandins, were common across most units. Although electronic fetal monitoring (EFM) was also widely available, access to fetal scalp pH monitoring was low. Conclusion. Maternity service provision varies across the country and is defined predominately by location and annual birth rate. What is known about the topic? In 2007, over 99% of the 289496 women who gave birth in Australia did so in a hospital. It is estimated that there are more than 300 maternity units in the country, ranging from large tertiary referral centres in major cities to smaller maternity units in rural towns, some of which only provide postnatal care with the woman giving birth at a larger facility. Geographical location, population and ability to attract a maternity workforce determine the number of maternity units within a region, although the means of determining the number of maternity units within a region is often unclear. In recent years, a large number of small maternity units have closed, particularly in rural areas, often due to difficulties securing an adequate workforce, particularly midwives and general practitioner obstetricians. There is a lack of understanding about the nature of maternity service provision in Australia and considerable differences across states and territories. What does this paper add? This paper provides a description of the geographic distribution and level of maternity services, the demand on services, the available obstetric interventions, the level of staffing (paediatric and anaesthetic) and support services available and the private and public mix of maternity units. The paper also provides an exploration of the different interventions and discusses whether these are appropriate, given the level of acuity and access to emergency Caesarean section services. What are the implications for practitioners? This study provides useful information particularly for policy-makers, managers and practitioners. This is at a time when considerable maternity reform is underway and changes at a broader level to the health system are planned. Understanding the nature of maternity services is critical to this debate and ongoing planning decisions. © 2011 AHHA

“Wrapping myself in cotton wool“: Australian women's experience of being diagnosed with vasa praevia

© 2014 Javid et al.; licensee BioMed Central Ltd. Background: Vasa praevia (VP) is an obstetric condition that is associated with significant perinatal mortality and morbidity. Although the incidence of VP is low, it is one of the few causes of perinatal death that can be potentially prevented through detection and appropriate care. The experience of women diagnosed with or suspected to have VP is largely unknown. The aim of this study was to explore the experiences and impact that a diagnosis or suspected diagnosis of VP had on a group of Australian women.Method: A qualitative study using a descriptive exploratory design was conducted and Australian women diagnosed with VP were recruited via online methods in 2012. An inductive approach was undertaken and interviews were analysed using the stages of thematic analysis. Results: Of the 14 women interviewed, 11 were diagnosed with VP during pregnancy with 5 subsequently found not to have VP (non-confirmed diagnosis). Three women were diagnosed during childbirth with one neonatal death. Five major themes were identified: feeling like a ticking time bomb; getting diagnosis right; being taken seriously; coping with inconsistent information; and, just a massive relief when it was all over.Conclusions: This is the first study to describe women's experience of being diagnosed with or suspected to have VP. The findings from this research reveal the dilemmas these women face even if their baby is ultimately born healthy. Their need for clear and consistent information, sensitive care, support and continuity is evident. Clinicians can use these findings in developing information, counselling and models of care for these women

Length of stay for mental and behavioural disorders postpartum in primiparous mothers: A cohort study

Background: Previous research showed that there was a significant increase in psychiatric hospital admission of postpartum mothers. The aim of the current study is to describe the length of hospital stays and patient days for mental and behavioural disorders (MBD) of new mothers in the first year after birth. Method: This was a cohort study based on linked population data between the New South Wales (NSW) Midwives Data Collection (MDC) and the NSW Admitted Patients Data Collection (APDC). The study population included primiparous mothers aged from 18 to 44 who gave birth between 1 July 2000 and 31 December 2005. The Kaplan-Meier method was used to describe the length of hospital stay for MBD. Results: For principal diagnoses of MBD, the entire length of hospital stay in the first year postpartum was 11.38 days (95% CI: 10.70-12.06) for mean and 6 days (95% CI: 5.87-6.13) for median. The length of hospital stay per admission was 8.47 days (95% CI: 8.03-8.90) for mean and 5 days (95% CI: 4.90-5.10) for median. There were 5,129 patient days of hospital stay per year for principal diagnoses of postpartum MBD in new mothers between 1 July 2000 and 31 December 2005 in NSW, Australia. Conclusions: MBD, especially unipolar depressions, adjustment disorders, acute psychotic episodes, and schizophrenia, or schizophrenia-like disorders during the first year after birth, placed a significant burden on hospital services due to long hospital stays and large number of admissions. © 2014 by the authors; licensee MDPI, Basel, Switzerland

What guidance are researchers given on how to present network meta-analyses to end-users such as policymakers and clinicians? A systematic review

© 2014 Sullivan et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.Introduction: Network meta-analyses (NMAs) are complex methodological approaches that may be challenging for non-technical end-users, such as policymakers and clinicians, to understand. Consideration should be given to identifying optimal approaches to presenting NMAs that help clarify analyses. It is unclear what guidance researchers currently have on how to present and tailor NMAs to different end-users. Methods: A systematic review of NMA guidelines was conducted to identify guidance on how to present NMAs. Electronic databases and supplementary sources were searched for NMA guidelines. Presentation format details related to sample formats, target audiences, data sources, analysis methods and results were extracted and frequencies tabulated. Guideline quality was assessed following criteria developed for clinical practice guidelines. Results: Seven guidelines were included. Current guidelines focus on how to conduct NMAs but provide limited guidance to researchers on how to best present analyses to different end-users. None of the guidelines provided reporting templates. Few guidelines provided advice on tailoring presentations to different end-users, such as policymakers. Available guidance on presentation formats focused on evidence networks, characteristics of individual trials, comparisons between direct and indirect estimates and assumptions of heterogeneity and/or inconsistency. Some guidelines also provided examples of figures and tables that could be used to present information. Conclusions: Limited guidance exists for researchers on how best to present NMAs in an accessible format, especially for non-technical end-users such as policymakers and clinicians. NMA guidelines may require further integration with end-users' needs, when NMAs are used to support healthcare policy and practice decisions. Developing presentation formats that enhance understanding and accessibility of NMAs could also enhance the transparency and legitimacy of decisions informed by NMAs.The Canadian Institute of Health Research (CIHR) Drug Safety and Effectiveness Network (Funding reference number – 116573)

Three-dimensional cephalometric evaluation of maxillary growth following in utero repair of cleft lip and alveolar-like defects in the mid-gestational sheep model

Objective: To evaluate maxillary growth following in utero repair of surgically created cleft lip and alveolar (CLA)-like defects by means of three-dimensional (3D) computer tomographic (CT) cephalometric analysis in the mid-gestational sheep model. Methods: In 12 sheep fetuses a unilateral CLA-like defect was created in utero (untreated control group: 4 fetuses). Four different bone grafts were used for the alveolar defect closure. After euthanasia, CT scans of the skulls of the fetuses, 3D re-constructions, and a 3D-CT cephalometric analysis were performed. Results: The comparisons between the operated and nonoperated skull sides as well as of the maxillary asymmetry among the experimental groups revealed no statistically significant differences of the 12 variables used. Conclusions: None of the surgical approaches used for the in utero correction of CLA-like defects seem to affect significantly postsurgical maxillary growth; however, when bone graft healing takes place, a tendency for almost normal maxillary growth can be observed. Copyright (c) 2006 S. Karger AG, Basel

Is self-advocacy universally achievable for patients? The experiences of Australian women with cardiac disease in pregnancy and postpartum.

PURPOSE: Patient self-advocacy is valued and promoted; however, it may not be readily accessible to all. This analysis examines the experiences of women in Australia who had cardiac disease in pregnancy or the first year postpartum through the lenses of self-advocacy and gender, specifically seeking to elaborate on the contexts, impacts, barriers, and women's responses to the barriers to self-advocacy. METHOD: A qualitative study design was used. Twenty-five women participated in semi-structured in-depth interviews. Data were analysed using thematic analysis. RESULTS: Analysis of findings generated the following themes: 1) Silent dream scream, 2) Easier said than done, 3) Crazy-making, and 4) Concentric circles of advocacy. Regardless of women's personal attributes, knowledge and experience, self-advocating for their health was complex and difficult and had negative cardiac and psychological outcomes. CONCLUSION: While the women encountered significant barriers to self-advocating, they were resilient and ultimately developed strategies to be heard and to advocate on their own behalf and that of other women. Findings can be used to identify ways to support women to self-advocate and to provide adequately resourced and culturally safe environments to enable healthcare professionals to provide person-centred care

Cardiac disease in pregnancy and the first year postpartum: a story of mental health, identity and connection.

BACKGROUND: Women with cardiac disease in pregnancy and the first year postpartum often face uncertainty about their condition and the trajectory of their recovery. Cardiac disease is a leading cause of serious maternal morbidity and mortality, and the prevalence is increasing. Affected women are at risk of worsening cardiac disease, chronic illness, mental illness and trauma. This compounded risk may lead to significant and long-term negative outcomes. The aim of this study is to correct the lack of visibility and information on the experiences of women with cardiac disease in pregnancy and the first year postpartum. METHODS: A qualitative study using in-depth semi-structured interviews with twenty-five women who had acquired, congenital or genetic cardiac disease during pregnancy or the first year postpartum. Data were analysed and interpreted using a thematic analysis framework. RESULTS: Analysis of the interviews produced three major themes: 1) Ground zero: index events and their emotional and psychological impact, 2) Self-perception, identity and worthiness, and 3) On the road alone; isolation and connection. There was a narrative consistency across the interviews despite the women being diverse in age, cardiac diagnosis and cardiac health status, parity and timing of diagnosis. The thread prevailing over the temporal and clinical differences was one of distress, biographical disruption, identity, isolation, a necessitated re-imagining of their lives, and the process of multi-layered healing. CONCLUSION: Acknowledging and understanding the breadth, complexity and depth of women's experiences is fundamental to improving outcomes. Our findings provide unique insights into women's experiences and challenges across a spectrum of diseases. Most women did not report an isolated trauma or distressing event, rather there was a layering and persistence of psychological distress necessitating enhanced assessment, management and continuity of care beyond the routine 6-week postpartum check. Further research is required to understand long-term outcomes and to refine the findings for specific disease cohorts to be able to respond effectively

Quality of life and mental health of women who had cardiac disease in pregnancy and postpartum.

PURPOSE: Cardiac disease is a leading cause of maternal morbidity and mortality yet there is limited research on women's experiences and quality of life (QoL) outcomes. The aim of this study is to explore the general and health-related QoL (HRQoL) and mental health outcomes for women who have experienced cardiac disease in pregnancy and the first 12 months postpartum (CDPP). METHODS: This exploratory descriptive study recruited 43 women with acquired, genetic and congenital CDPP. Patient reported outcomes measures (PROMs) used were: WHOQoL-Bref, a Kansas City Cardiac Questionnaire (KCCQ), the Depression, Anxiety and Stress Scales-21 (DASS-21), the Cardiac Anxiety Questionnaire (CAQ) plus newly developed questions. RESULTS: Women reported low health satisfaction (51.7/100), physical health (55.2/100) and low HRQoL (63.1/100). Women had clinically significant scores for depression (24%), anxiety (22%) and stress (19.5%) (DASS-21) and 44.5% scored at least moderate anxiety on the CAQ. Most women (83.7%) were advised to avoid pregnancy which 88.9% found "upsetting" to "devastating"; 10.0% were offered counselling. Most women were concerned about reduced longevity (88.1%), offspring developing a cardiac condition (73.8%), and the limitations on enjoyment of life (57.1%). Women missed medical appointments due to cost (25.03%) and difficulty arranging childcare (45.5%). CONCLUSION: The majority of women reported inadequate information and counselling support, with women with CDPP having sustained impaired QoL and mental health outcomes. The new and modified questions relating to mothering and children reflected the primacy of mothering to women's identity and needs

The healthcare experiences of women with cardiac disease in pregnancy and postpartum: A qualitative study.

INTRODUCTION: Cardiac disease affects an estimated 1%-4% of all pregnancies and is a leading cause of maternal morbidity and mortality. There is a lack of data on the healthcare experiences of affected women to inform health service delivery and person-centred care. This study sought to explore and understand the healthcare experiences of women with cardiac disease in pregnancy and postpartum. METHODS: This qualitative study used semi-structured interviews with women who had cardiac disease in pregnancy or the first 12 months postpartum. Data were analysed using thematic analysis. RESULTS: Participants were 25 women with pre-existing or newly diagnosed acquired, genetic and congenital cardiac disease. Analysis of the interviews highlighted the discrepancy between care aspirations and experiences. The participants had a wide range of cardiac diseases and timing of diagnoses, but had similar healthcare experiences of being dismissed, not receiving the information they required, lack of continuity of care and clinical guidelines and of feeling out of place within a healthcare system that did not accommodate their combined needs as a mother and a cardiac patient. CONCLUSION: This study identified a lack of person-centred care and responsiveness of the healthcare system in providing fit-for-purpose healthcare for women with complex disease who are pregnant or new mothers. In particular, cardiac and maternity care providers have an opportunity to listen to women who are the experts on their emergent healthcare needs, contributing to development of the knowledge base on the healthcare experiences of having cardiac disease in pregnancy and postpartum. PATIENT OR PUBLIC CONTRIBUTION: Public and patient input into the value and design of the study was gained through NSW Heart Foundation forums, including the Heart Foundation's women's patient group