Preferences for a third-trimester ultrasound scan in a low-risk obstetric population: a discrete choice experiment

Objective: Establish maternal preferences for a third-trimester ultrasound scan in a healthy, low-risk pregnant population.

Design: Cross-sectional study incorporating a discrete choice experiment.

Setting: A large, urban maternity hospital in Northern Ireland.

Participants: One hundred and forty-six women in their second trimester of pregnancy.

Methods: A discrete choice experiment was designed to elicit preferences for four attributes of a third-trimester ultrasound scan: health-care professional conducting the scan, detection rate for abnormal foetal growth, provision of non-medical information, cost. Additional data collected included age, marital status, socio-economic status, obstetric history, pregnancy-specific stress levels, perceived health and whether pregnancy was planned. Analysis was undertaken using a mixed logit model with interaction effects.

Main outcome measures: Women's preferences for, and trade-offs between, the attributes of a hypothetical scan and indirect willingness-to-pay estimates.

Results: Women had significant positive preference for higher rate of detection, lower cost and provision of non-medical information, with no significant value placed on scan operator. Interaction effects revealed subgroups that valued the scan most: women experiencing their first pregnancy, women reporting higher levels of stress, an adverse obstetric history and older women.

Conclusions: Women were able to trade on aspects of care and place relative importance on clinical, non-clinical outcomes and processes of service delivery, thus highlighting the potential of using health utilities in the development of services from a clinical, economic and social perspective. Specifically, maternal preferences exhibited provide valuable information for designing a randomized trial of effectiveness and insight for clinical and policy decision makers to inform woman-centred care.

The impact of body mass index on maternal and neonatal outcomes: a retrospective study in a UK obstetric population, 2004-2011

Objective: To assess the prevalence of overweight and obesity, and the impact of body mass index (BMI) on maternal and neonatal outcomes, in a UK obstetric population.
Design: Retrospective study.
Setting: A tertiary referral unit in Northern Ireland.
Population: A total of 30 298 singleton pregnancies over an 8-year period, 2004–2011.
Methods: Women were categorised according to World Health Organization classification: underweight (BMI < 18.50 kg/m2); normal weight (BMI 18.50–24.99 kg/m2; reference group); overweight (BMI 25.00–29.99 kg/m2); obese class I (BMI 30.00–34.99 kg/m2); obese class II (BMI 35–39.99 kg/m2); and obese class III (BMI = 40 kg/m2). Maternal and neonatal outcomes were examined using logistic regression, adjusted for confounding variables.
Main outcome measures: Maternal and neonatal outcomes.
Results: Compared with women of normal weight, women who were overweight or obese class I were at significantly increased risk of hypertensive disorders of pregnancy (OR 1.9, 99% CI 1.7–2.3; OR 3.5, 99% CI 2.9–4.2); gestational diabetes mellitus (OR 1.7, 99% CI 1.3–2.3; OR 3.7, 99% CI 2.8–5.0); induction of labour (OR 1.2, 99% CI 1.1–1.3; OR 1.3, 99% CI 1.2–1.5); caesarean section (OR 1.4, 99% CI 1.3–1.5; OR 1.8, 99% CI 1.6–2.0); postpartum haemorrhage (OR 1.4, 99% CI 1.3–1.5; OR 1.8, 1.6–2.0); and macrosomia (OR 1.5, 99% CI 1.3–1.6; OR 1.9, 99% CI 1.6–2.2), with the risks increasing for obese classes II and III. Women in obese class III were at increased risk of preterm delivery (OR 1.6, 99% CI 1.1–2.5), stillbirth (OR 3.0, 99% CI 1.0–9.3), postnatal stay > 5 days (OR 2.1, 99% CI 1.5–3.1), and infant requiring admission to a neonatal unit (OR 1.6, 99% CI 1.0–2.6).
Conclusions: By categorising women into overweight and obesity subclassifications (classes I –III), this study clearly demonstrates an increasing risk of adverse outcomes across BMI categories, with women who are overweight also at significant risk.
Keywords Body mass index, maternal and neonatal outcomes,obesity, pregnancy

Timing and mode of delivery in twins : the ongoing controversy

Tese de doutoramento, Medicina (Ginecologia e Obstetrícia), Universidade de Lisboa, Faculdade de Medicina, 2014

Women's Attachment as a Predictor of Pain During Labour and Post-Delivery: a Prospective Observational Study

INTRODUCTION: Labour is considered to be one of the most painful and significant experiences in a woman's life. The aim of this study was to examine whether women's attachment style is a predictor of the pain experienced throughout labour and post-delivery. MATERIAL AND METHODS:Thirty-two pregnant women were assessed during the third trimester of pregnancy and during labour. Adult attachment was assessed with the Adult Attachment Scale ' Revised. The perceived intensity of labour pain was measured using a visual analogue scale for pain in the early stage of labour, throughout labour and post-delivery. RESULTS:Women with an insecure attachment style reported more pain at 3 cm of cervical dilatation (p < 0.05), before the administration of analgesia (p < 0.01) and post-delivery (p < 0.05) than those securely attached. In multivariate models, attachment style was a significant predictor of labour pain at 3 cm of cervical dilatation and before the first administration of analgesia but not of the perceived pain post-delivery. DISCUSSION: These findings confirm that labour pain is influenced by relevant psychological factors and suggest that a woman's attachment style may be a risk factor for greater pain during labour. CONCLUSION:Future studies in the context of obstetric pain may consider the attachment style as an indicator of individual differences in the pain response during labour. This may have important implications in anaesthesiology and to promote a relevant shift in institutional practices and therapeutic procedures.

Small-area variation in health care affecting the choice of cesarean delivery: the case of a Colombian health insurer

In the midst of health care reform, Colombia has succeeded in increasing health insurance coverage and the quality of health care. In spite of this, efficiency continues to be a matter of concern, and small-area variations in health care are one of the plausible causes of such inefficiencies. In order to understand this issue, we use individual data of all births from a Contributory-Regimen insurer in Colombia. We perform two different specifications of a multilevel logistic regression model. Our results reveal that hospitals account for 20% of variation on the probability of performing cesarean sections. Geographic area only explains 1/3 of the variance attributable to the hospital. Furthermore, some variables from both demand and supply sides are found to be also relevant on the probability of undergoing cesarean sections. This paper contributes to previous research by using a hierarchical model and by defining hospitals as cluster. Moreover, we also include clinical and supply induced demand variables.

Serum oxytocin concentrations in elective caesarean delivery: a randomized comparison of three infusion regimens

Background: The aim of this study was to determine serum oxytocin concentrations following different regimens of prophylactic oxytocin administration in women undergoing elective caesarean delivery. Methods: Thirty healthy pregnant patients were randomized, after clamping of the umbilical cord, to receive intravenous oxytocin in one of the following groups: G1 (n = 9), 10 IU of oxytocin infused over 30 min (0.33 IU/min); G2 (n = 11), 10 IU of oxytocin infused over 3 min and 45 s (2.67 IU/min); and G3 (n = 10), 80 IU of oxytocin infused over 30 min (2.67 IU/min). Both patient and surgeon were blinded to allocation. Uterine tone was assessed by surgical palpation. Serum oxytocin concentration was determined by enzyme immunoassay before anaesthesia (T0) and at 5 (T5), 30 (T30) and 60 (T60) min after the start of oxytocin infusion. Results: Serum oxytocin concentrations (mean standard error, ng/mL) were not significantly different in the groups at T0 (0.06 +/- 0.02, 0.04 +/- 0.02 and 0.07 +/- 0.04, respectively, P = 0.76), and T60 (0.65 +/- 0.26, 0.36 +/- 0.26 and 0.69 +/- 0.26, respectively, P = 0.58). G3 showed higher concentrations than G1 at 15 (3.65 +/- 0.74 versus 0.71 +/- 0.27, P = 0.01) and at T30 (6.19 +/- 1.19 versus 1.17 +/- 0.37, P < 0.01), and were higher than G2 at T30 (6.19 +/- 1.19 versus 0.41 +/- 0.2, P < 0.01). Haemodynamic data and uterine tone were considered satisfactory and similar in all groups. No additional uterotonic agents were needed. Conclusion: Serum oxytocin measurements made using enzyme immunoassay in healthy pregnant women undergoing elective caesarean delivery showed that administration of 80 IU oxytocin over 30 min resulted in higher serum oxytocin levels after 5 and 30 min than the two other regimens. The concentrations did not differ between groups at 60 min. (C) 2011 Elsevier Ltd. All rights reserved.

Delivery care in Quang Ninh province, Northern Vietnam : resources and access to safe care.

Every mother and child has the right to survive childbirth which requires skilled birth attendants together with referral and available emergency obstetric care (EmOC). The objective of the study was to describe delivery care routines at different levels in the health care system in Quang Ninh province, Northern Vietnam. The design was cross sectional using a structured questionnaire. Two districts in Quang Ninh province with 40 Community Health Centres (CHC), three district hospitals and one region hospital was included in the study, in total 138 (CHC n=105 and hospitals n=33) health care providers participated. In our study 20% (CHC) of the health care providers assisting deliveries at CHC were midwives and health care provider’s in our study further report to have assisted at less then 10 deliveries/year (81% of respondents at CHC). Findings show that the health care provider’s routines and care for women during labour and delivery vary and that there is a need for re-training and that women in labour should be cared for by health care providers with adequate training like midwifery. In our study CHC had poor resources to provide basic or comprehensive EmOC. Our findings indicate that there is a need for re-training in delivery care among health care providers and since the number of deliveries at CHC is few they should be handled by someone who is a skilled birth attendant. Our findings also show a variation in care routines during labour and delivery among health care providers at CHC and hospital levels and this also show the need for re-training and support from proper authorities in order to improve maternal and newborn health.

Effect of periodontal treatment on the incidence of preterm delivery: a systematic review.

Preterm birth is a major problem in public health in developed and developing countries and the search for risk factors of this event is important. The aim of this study was to review the effect of periodontal treatment on the incidence of preterm delivery. A wide research was executed considering an evaluation period between November of 1998 and October of 2009 at MEDLINE/PUBMED databases. The selection strategy consisted of the search for the following key-words: periodontal therapy or periodontal disease and pregnancy outcome or preterm birth. The search was limited for articles written in English. The randomized clinical trials that evaluated the effect of the non-surgical periodontal treatment on the incidence of Preterm Low Birth Weight (PLBW) were selected. In a total of 7 papers selected, the incidence of PLBW was lower in groups of women who were submitted to periodontal treatment. Reductions of Preterm Birth (PTB) ranged from 0.8% to 28.01%, while reduction of Low Birth Weight (LBW) ranged from 0.44% to 33%. In studies that analyzed these two variables together, there was variation between 4.57% to 71.5% in rates reduction. Due to heterogeneity of the data, the meta-analysis was not applied. The majority of the studies concluded that non-surgical periodontal treatment in pregnant women reduces incidence of preterm babies with low weight.

OUT-OF-HOSPITAL CHILDBEARING CENTERS IN THE UNITED STATES: A DESCRIPTIVE STUDY OF THE DEMOGRAPHIC AND MEDICAL-OBSTETRIC CHARACTERISTICS OF WOMEN BEGINNING LABOR THEREIN 1972-1979

There is currently much interest in the appropriate use of obstetrical technology, cost containment and meeting consumers' needs for safe and satisfying maternity care. At the same time, there has been an increase in professionally unattended home births. In response, a new type of service, the out-of-hospital childbearing center (CBC) has been developed which is administratively and structurally separate from the hospital. In the CBC, maternity care is provided by certified nurse-midwives to carefully screened low risk childbearing families in conjunction with physician and hospital back-up.^ It was the purpose of this study to accomplish the following objectives: (1) To describe in a historical prospective study the demographic and medical-obstetric characteristics of patients laboring in eleven selected out-of-hospital childbearing centers in the United States from May 1, 1972, to December 15, 1979. Labor is defined as the onset of regular contractions as determined by the patient. (2) To describe any differences between those patients who require transfer to a back-up hospital and those who do not. (3) To describe administrative and service characteristics of eleven selected out-of-hospital childbearing centers in the United States. (4) To compare the demographic and medical-obstetric characteristics of women laboring in eleven selected out-of-hospital childbearing centers with a national sample of women of similar obstetric risk who according to birth certificates delivered legitimate infants in a hospital setting in the United States in 1972.^ Research concerning CBCs and supportive to the development of CBCs including studies which identified factors associated with fetal and perinatal morbidity and mortality, obstetrical risk screening, and the progress of technological development in obstetrics were reviewed. Information concerning the organization and delivery of care at each selected CBC was also collected and analyzed.^ A stratified, systematic sample of 1938 low risk women who began labor in a selected CBC were included in the study. These women were not unlike those described previously in small single center studies reported in the literature. The mean age was 25 years. Sixty-three per cent were white, 34 per cent Hispanic, 88 per cent married, 45 per cent had completed at least two years of college, nearly one-third were professionals and over a third were housewives. . . . (Author's abstract exceeds stipulated maximum length. Discontinued here with permission of school.) UMI ^

Pre-term delivery and periodontal disease: a case-control study from Croatia

Aim: The aim of this report was to assess the strength and influence of periodontitis as a possible risk factor for pre-term birth (PTB) in a cohort of 81 primiparous Croatian mothers aged 18-39 years. Methods: PTB cases (n=17; mean age 25 +/- 2.9 years; age range 20-33 years) were defined as spontaneous delivery after less than 37 completed weeks of gestation that were followed by spontaneous labour or spontaneous rupture of membranes. Controls (full-time births) were normal births at or after 37 weeks of gestation (n=64; mean age 25 +/- 2.9 years; age range 19-39 years). Information on known risk factors and obstetric factors included the current pregnancy history, maternal age at delivery, pre-natal care, nutritional status, tobacco use, alcohol use, genitourinary infections, vaginosis, gestational age, and birth weight. Full-mouth periodontal examination was performed on all mothers within 2 days of delivery. Results: PTB cases had significantly worse periodontal status than controls (p=0.008). Multivariate logistic regression model, after controlling for other risk factors, demonstrated that periodontal disease is a significant independent risk factor for PTB, with an adjusted odds ratio of 8.13 for the PTB group (95% confidence interval 2.73-45.9). Conclusion: Periodontal disease represents a strong, independent, and clinically significant risk factor for PTB in the studied cohort. There are strong indicators that periodontal therapy should form a part of preventive prenatal care in Croatia.

The prevalence and impact of overweight and obesity in an Australian obstetric population

Objective: To assess the prevalence and impact of overweight and obesity in an Australian obstetric population. Design, setting and participants: The Mater Mother's Hospital (MMH), South Brisbane, is an urban tertiary referral maternity hospital. We reviewed data for the 18401 women who were booked for antenatal care at the MMH, delivered between January 1998 and December 2002, and had a singleton pregnancy. Of those women, 14 230 had an estimated pre-pregnancy body mass index (BMI) noted in their record; 2978 women with BMI 40 kg/m(2)). Main outcome measures: Prevalence of overweight and obesity in an obstetric population; maternal, peripartum and neonatal outcomes associated with raised BMI. Results: Of the 14230 women, 6443 (45%) were of normal weight, and 4809 (34%) were overweight, obese or morbidly obese. Overweight, obese and morbidly obese women were at increased risk of adverse outcomes (figures represent adjusted odds ratio [AOR] [95% Cl]): hypertensive disorders of pregnancy (overweight 1.74 [1.45-2.15], obese 3.00 [2.40-3.74], morbidly obese 4.87 [3.27-7.24]); gestational diabetes (overweight 1.78 [1.25-2.52], obese 2.95 [2.05-4.25], morbidly obese 7.44 [4.42-12.54]); hospital admission longer than 5 days (overweight 1.36 [1.13-1.63], obese 1.49 [1.21-1.86], morbidly obese 3.18 [2.19-4.61]); and caesarean section (overweight 1.50 [1.36-1.66], obese 2.02 [1.79-2.29], morbidly obese 2.54 [1.94-3.321). Neonates born to obese and morbidly obese women had an increased risk of birth defects (obese 1.58 (1.02-2.46], morbidly obese 3.41 [1.67-6.94]); and hypoglycaemia (obese 2.57 [1.39-4.78], morbidly obese 7.14 [3.04-16.74]). Neonates born to morbidly obese women were at increased risk of admission to intensive care (2.77 [1.81-4.25]); premature delivery (< 34 weeks' gestation) (2.13 [1.13-4.01]); and jaundice (1.44 [1.09-1.89]). Conclusions: Overweight and obesity are common in pregnant women. Increasing BMI is associated with maternal and neonatal outcomes that may increase the costs of obstetric care. To assist in planning health service delivery, we believe that BMI should be routinely recorded on perinatal data collection sheets

Knowledge and perceptions of quality of obstetric and newborn care of local health providers: a cross-sectional study in three districts in Malawi

Aim Quality of service delivery for maternal and newborn health in Malawi is influenced by human resource shortages and knowledge and care practices of the existing service providers. We assessed Malawian healthcare providers’ knowledge of management of routine labour, emergency obstetric care and emergency newborn care; correlated knowledge with reported confidence and previous study or training; and measured perception of the care they provided. Methods his study formed part of a large-scale quality of care assessment in three districts (Kasungu, Lilongwe and Salima) of Malawi. Subjects were selected purposively by their role as providers of obstetric and newborn care during routine visits to health facilities by a research assistant. Research assistants introduced and supervised the self-completed questionnaire by the service providers. Respondents included 42 nurse midwives, 1 clinical officer, 4 medical assistants and 5 other staff. Of these, 37 were staff working in facilities providing Basic Emergency Obstetric Care (BEMoC) and 15 were from staff working in facilities providing Comprehensive Emergency Obstetric Care (CEMoC). Results Knowledge regarding management of routine labour was good (80% correct responses), but knowledge of correct monitoring during routine labour (35% correct) was not in keeping with internationally recognized good practice. Questions regarding emergency obstetric care were answered correctly by 70% of respondents with significant variation depending on clinicians’ place of work. Knowledge of emergency newborn care was poor across all groups surveyed with 58% correct responses and high rates of potentially life-threatening responses from BEmOC facilities. Reported confidence and training had little impact on levels of knowledge. Staff in general reported perception of poor quality of care. Conclusion Serious deficiencies in providers’ knowledge regarding monitoring during routine labour and management of emergency newborn care were documented. These may contribute to maternal and neonatal deaths in Malawi. The knowledge gap cannot be overcome by simply providing more training.