Exploring unwarranted clinical variation: The attitudes of midwives and obstetric medical staff regarding induction of labour and planned caesarean section

BackgroundUnexplained clinical variation is a major issue in planned birth i.e. induction of labour and planned caesarean section.AimTo map attitudes and knowledge of maternity care professionals regarding indications for planned birth, and assess inter-professional (midwifery versus medical) and intra-professional variation.MethodsA custom-created survey of medical and midwifery staff at eight Sydney hospitals. Staff were asked to rate their level of agreement with 45 “evidence-based” statements regarding caesareans and inductions on a five-point Likert scale. Responses were grouped by profession, and comparisons made of inter- and intra-professional responses.FindingsTotal 275 respondents, 78% midwifery and 21% medical. Considerable inter- and intra-professional variation was noted, with midwives generally less likely to consider any of the planned birth indications “valid” compared to medical staff. Indications for induction with most variation in midwifery responses included maternal characteristics (age≥40, obesity, ethnicity) and fetal macrosomia; and for medical personnel in-vitro fertilisation, maternal request, and routine induction at 39 weeks gestation. Indications for caesarean with most variation in midwifery responses included previous lower segment caesarean section, previous shoulder dystocia, and uncomplicated breech; and for medical personnel uncomplicated dichorionic twins. Indications with most inter-professional variation were induction at 41+ weeks versus 42+ weeks and cesarean for previous lower segment caesarean section.DiscussionBoth inter- and intra-professional variation in what were considered valid indications reflected inconsistency in underlying evidence and/or guidelines.ConclusionGreater focus on interdisciplinary education and consensus, as well as on shared decision-making with women, may be helpful in resolving these tensions.     

Timing of hospital admission in labour: latent versus active phase,mode of birth and intrapartum interventions. A correlational study

Background

Hospitalization of women in latent labour often leads to a cascade of unnecessary intrapartum interventions, to avoid potential disadvantages the recommendation should be to stay at home to improve women’s experience and perinatal outcomes.

Normal childbirth and evidence based practice

This paper was presented at a Health Conference in March 2007, celebrating the 150th birthday of the Royal Women's Hospital in Melbourne. It discusses the definition of "normal childbirth", and the pros and cons of three medical technologies: caesarean section, epidural analgesia during labour and routine ultrasound screening during pregnancy, and whether clinical practices, in Australia and Sweden (author is Swedish), in relation to these methods are evidence based. It also discusses the impact of non-scientific reasons, such as anxiety, on clinical decision making.     

Seeking control in the midst of uncertainty: Women’s experiences of choosing mode of birth after caesarean

Problem

Clinical practice guidelines indicate that over 80% of women with a previous caesarean should be offered a planned vaginal birth after caesarean (VBAC), however only one third of eligible women choose to plan a VBAC. To support informed choices for birth after caesarean, it is necessary to understand the factors that influence women’s decision-making.

Conceptual and ethical problems underpinning calls to abandon vaginal breech birth

The view that vaginal breech birth is unjustifiable due to neonatal safety concerns has resulted in continued calls for breech pregnancies to be managed via a policy of planned caesarean birth. Vaginal breech birth has of course always occurred, but women with term breech pregnancies who seek to have a vaginal birth often face coercive pressures to have a caesarean birth instead. In this paper I argue that even if there is population level evidence that vaginal birth is relatively riskier for the breech presenting fetus, implementing a policy of planned caesarean birth would essentially be an unjustified attempt at forced medical intervention upon women. Advocates of a policy of planned caesarean birth often conflate the acceptability of allocating participants to a treatment group (policy) within the context of a randomized controlled trial with the justifiability of doing that as part of individual health care. Calls for obstetricians to “abandon vaginal breech birth” mistakenly position vaginal breech birth itself as a form of medical intervention that can simply be removed as an option for women by obstetricians. In reality, abandoning vaginal breech birth would entail abandoning women by denying them access to healthcare options that are otherwise available to any woman having a vaginal birth.     

Pregnancy care and birth outcomes for women with moderate to super-extreme obesity

PurposeTo describe the health service utilisation and birth outcomes of pregnant women with moderate to super-extreme obesity.BackgroundMaternal obesity is increasingly recognised as a key risk factor for adverse outcomes for both women and their babies. Little is known about the service utilisation and perinatal outcomes of women with obesity beyond a body mass index of 40.MethodWomen with a self-reported pre-pregnancy BMI of 40 or more, who had received care and birthed a baby at the study site between 1 January 2009 and 31 December 2010. Clinical audit was used to identify the health service utilisation and birth outcomes of these women.Results153 women had a BMI of 40 or more. Women saw 6 different health professionals during pregnancy (1–16). Most of their visits were with a medical practitioner, often with limited experience, and almost all women only saw a midwife once at their booking visit (n = 150, 98.0%). While the majority of women experienced a normal pregnancy, free from any complications, almost half the women in this study experienced a caesarean section (n = 74, 48.4%).ConclusionClinical audit has been useful in providing additional information which suggests current maternity care provision is not meeting the needs of this group of women. The model of antenatal care provision may be a mediating factor in the birth outcomes experienced by obese women. The development of effective, targeted antenatal care, designed to meet the needs of these women is recommended.