Factors associated with admission of children to an intensive care unit and readmission to hospital within 28 days of discharge: A population-based study.

AIM: Hospital readmissions within 28 days are an important performance measurement of quality and safety of health care. The aims of this study were to examine the rates, trends and characteristics of paediatric intensive care unit admissions, and factors associated with readmissions to hospital within 28 days of discharge. METHODS: This retrospective, population-based record linkage study included all children ≥28 days and <16 years old admitted to an intensive care unit (ICU) in a New South Wales (NSW) public hospital from 2004 to 2013. Data were sourced from the NSW Admitted Patients Data Collection and the NSW Registry of Births, Deaths and Marriages, Death Registration. RESULTS: We identified 21 200 ICU admissions involving 17 130 children. Admissions increased by 24% over the study period with the greatest increase attributed to respiratory and musculoskeletal conditions. A higher proportion of children were <5 years, male, lived in major cities, were publicly insured and had chronic conditions. The median length of ICU stay was 42 h and overall hospital stay was 7 days. There were 905 deaths, two-thirds during the index admission with the leading causes being injuries, cancer and infections. Twenty-three per cent of ICU admissions were readmitted to hospital within 28 days of discharge. Associated independent factors were younger age, longer index hospital stay and emergency index admission. Children with chronic conditions of cancer and genitourinary disorders were more likely to be readmitted. CONCLUSIONS: Identification of complex chronic conditions, consideration of long-term health planning and interventions intended to reduce readmission is warranted in order to reduce the burden to families and the health-care system.

Using population data to understand the epidemiology and risk factors for diabetic ketoacidosis in Australian children with type 1 diabetes.

BACKGROUND: Children with type 1 diabetes (T1D) are at risk of diabetic ketoacidosis (DKA) at T1D diagnosis and/or subsequently. OBJECTIVE: The objective is to determine the incidence and prevalence of T1D by the presence of DKA and identify the characteristics of subsequent DKA episodes. SUBJECTS: The study population included all children aged <15 years with T1D during a hospital/day-stay admission in New South Wales, Australia, from 1 January 2001 to 31 December 2013. T1D and DKA were identified using International Classification of Diseases Australian Modification codes. METHODS: Data sources included routinely collected longitudinally linked population hospitalization and birth records. Chi-squared analyses, logistic, and multinomial regression were used to determine the association between child characteristics and admissions with and without DKA. RESULTS: The point prevalence of T1D among 0-14-year olds on 31 December 2013 was 144.2 per 100 000. For children aged 0-12 years, the incidence of T1D was 16.3 per 100 000 child-years. One-third had DKA at T1D diagnosis and were more likely to be readmitted with DKA than those without DKA at T1D diagnosis. Children with more than one readmission for DKA were more likely to be female, reside in an inner regional area or an area of socioeconomic disadvantage, and be Australian-born. Among all hospitalizations of children with T1D, those with DKA were more likely to be aged 10-14 years, require intensive care, have longer length of stay, and admitted outside school days. CONCLUSION: Routinely collected administrative health data are a reliable source to monitor incidence and health service use of childhood T1D. Children at risk of repeated DKA, particularly females, adolescents, and those from inner regional or socioeconomically disadvantaged areas, should be targeted during education and follow-up.

Formula supplementation in hospital and subsequent feeding at discharge among women who intended to exclusively breastfeed: An administrative data retrospective cohort study.

BACKGROUND: Among women who intend to exclusively breastfeed, it is important to identify mothers and their infants who have a greater risk of formula supplementation in hospital, and are unlikely to recover exclusive breastfeeding at discharge. We investigated factors associated with in-hospital formula feeding among healthy term infants born to women who intended to exclusively breastfeed, and among this group, predictors of infant feeding at discharge. METHODS: Retrospective cohort study utilizing routinely collected clinical data for women who intended to exclusively breastfeed and gave birth to healthy term infants in five hospitals in New South Wales, Australia, 2010-2013. Robust Poisson regression was used to obtain adjusted relative risks (aRR) for the associations between formula feeding in hospital, feeding at discharge, and associated factors. RESULTS: Of 24 713 mother-infant dyads in the study population, 16.5% received formula in hospital. After adjustment, the strongest predictors of formula supplementation were breastfeeding difficulties (aRR 2.90 [95% confidence interval {CI} 2.74-3.07]), Asian born mother (aRR 2.07 [95% CI 1.92-2.23]), and neonatal conditions (aRR 2.00 [95% CI 1.89-2.13]). Among infants who received formula (n=3998), 49.3% were fully breastfeeding at discharge, 33.1% partially breastfeeding, and 17.5% formula-only feeding. Compared with formula-only feeding, special care nursery admission (aRR 1.23 [95% CI 1.17-1.30]) and ≥1 neonatal conditions (compared with none) were most strongly associated with fully breastfeeding at discharge (aRR 1.21 [95% CI 1.16-2.16]). CONCLUSION: Women and their infants who receive formula in hospital need additional support to attain exclusive breastfeeding by hospital discharge. Such support is especially needed for younger women, smokers, and women with breastfeeding difficulties.

"Very Good" Ratings in a Survey of Maternity Care: Kindness and Understanding Matter to Australian Women.

BACKGROUND: Surveys have shown that women are highly satisfied with their maternity care. Their satisfaction has been associated with various demographic, personal, and care factors. Isolating the factors that most matter to women about their care can guide quality improvement efforts. This study aimed to identify the most significant factors associated with high ratings of care by women in the three maternity periods (antenatal, birth, and postnatal). METHODS: A survey was sent to 2,048 women who gave birth at seven public hospitals in New South Wales, Australia, exploring their expectations of, and experiences with maternity care. Women's overall ratings of care for the antenatal, birth, and postnatal periods were analyzed, and a number of maternal characteristics and care factors examined as potential predictors of "Very good" ratings of care. RESULTS: Among 886 women with a completed survey, 65 percent assigned a "Very good" rating for antenatal care, 74 percent for birth care, 58 percent for postnatal care, and 44 percent for all three periods. One factor was strongly associated with care ratings in all three maternity periods: women who were "always or almost always" treated with kindness and understanding were 1.8-2.8 times more likely to rate their antenatal, birth, and postnatal care as "Very good." A limited number of other factors were significantly associated with high care ratings for one or two of the maternity periods. CONCLUSIONS: Women's perceptions about the quality of their interpersonal interactions with health caregivers have a significant bearing on women's views about their maternity care journey.

Vulvoplasty in New South Wales, 2001-2013: a population-based record linkage study.

OBJECTIVES: To compare the characteristics of women who have undergone vulvoplasty with those of other women of reproductive age; to quantify short term adverse events and complications; to determine any association between vulvoplasty and subsequent outcomes for women giving birth. DESIGN, SETTING AND PARTICIPANTS: A population-based record linkage study, analysing New South Wales Admitted Patient Data Collection and NSW Perinatal Data Collection data. The characteristics of all women who had vulvoplasties in NSW hospitals during 2001-2013 were compared with those of all women of reproductive age. MAIN OUTCOME MEASURES: Admissions for vulvoplasty and repeat vulvoplasties; serious complications or adverse events after vulvoplasty; birth mode and perineal outcomes for primiparous women with and without vulvoplasty. RESULTS: 4592 vulvoplasty procedures were performed on 4381 women in NSW hospitals and day-stay centres; the annual rate increased by 64.5% between 2001 and 2013. Compared with the reference population, women who had vulvoplasty were more likely to have been born in Australia (74.6% v 67.6%), to have other cosmetic surgery (10.1% v 1.7%), and to have never been married (43.0% v 33.1%). The serious short term adverse event rate was 7.2%. Of 257 women who had a first birth after their vulvoplasty procedure, 40.0% had caesarean deliveries, compared with 30.3% of other women (P < 0.001). There were no significant differences in the rates of perineal outcomes for women who had vaginal births. CONCLUSIONS: The number of vulvoplasties performed in NSW has increased dramatically since 2001. The procedure is not without serious complications that can necessitate re-admission to hospital. We provide objective information about outcomes for counselling women who are contemplating vulvoplasty.

Intravenous iron: barriers and facilitators to its use at nine maternity hospitals in New South Wales, Australia.

BACKGROUND: Anaemia in pregnancy is mostly due to iron deficiency, and the use of intravenous (IV) iron is gaining acceptance as a treatment option. Recently released obstetric transfusion guidelines recommend IV iron for obstetric patients in certain situations, including when oral formulations are poorly tolerated, unlikely to be well absorbed, or when rapid restoration of iron stores is required. AIMS: To identify barriers and facilitators to the use of IV iron in pregnancy among nine maternity hospitals in New South Wales, Australia. MATERIALS & METHODS: A qualitative research study was undertaken using semi-structured interviews. Nine maternity units were chosen to cover a range of clinical settings and obstetric blood transfusion rates. Interviews were conducted with haematologists, obstetricians and midwives, and included questions about the use of IV iron in each institution. Interviews were transcribed and coded, and NVivo software was used to develop themes. RESULTS: A total of 125 interviews were conducted: 61 with doctors. The use of IV iron differed between hospitals and individual doctors. There were hospital/pharmaceutical, clinician and patient factors which acted as either barriers or facilitators to the use of IV iron. Where perceived barriers outweighed facilitators in a particular hospital, doctors were less likely to use IV iron. DISCUSSION: The use of IV iron, as perceived by doctors, differed across hospitals. There are some potentially modifiable barriers to the use of IV iron that may need to be addressed for IV iron to be available to obstetric patients not tolerating oral formulations or requiring rapid restoration of iron stores.

Ascertaining severe perineal trauma and associated risk factors by comparing birth data with multiple sources.

OBJECTIVES: Population data are often used to monitor severe perineal trauma trends and investigate risk factors. Within New South Wales (NSW), two different datasets can be used, the Perinatal Data Collection ('birth' data) or a linked dataset combining birth data with the Admitted Patient Data Collection ('hospital' data). Severe perineal trauma can be ascertained by birth data alone, or by hospital International Classification of Diseases Australian Modification (ICD-10-AM) diagnosis and procedure coding in the linked dataset. The aim of this study was to compare rates and risk factors for severe perineal trauma using birth data alone versus using linked data. METHODS: The study population consisted of all vaginal births in NSW between 2001 and 2011. Perineal injury coding in birth data was revised in 2006, so data were analysed separately for 2001-06 and 2006-11. Rates of severe perineal injury over time were compared in birth data alone versus linked data. Kappa and agreement statistics were calculated. Risk factor distributions (maternal age, primiparity, instrumental birth, birthweight ≥4 kg, Asian country of birth and episiotomy) were compared between women with severe perineal trauma identified by birth data alone, and those identified by linked data. Multivariable logistic regression was used to calculate the adjusted odds ratios (aORs) of severe perineal trauma. RESULTS: Among 697 202 women with vaginal births, 2.1% were identified with severe perineal trauma by birth data alone, and 2.6% by linked data. The rate discrepancy was higher among earlier data (1.7% for birth data, 2.4% for linked data). Kappa for earlier data was 0.78 (95% CI 0.78, 0.79), and 0.89 (95% CI 0.89, 0.89) for more recent data. With the exception of episiotomy, differences in risk factor distributions were small, with similar aORs. The aOR of severe perineal trauma for episiotomy was higher using linked data (1.33, 95% CI 1.27, 1.40) compared with birth data (1.02, 95% CI 0.97, 1.08). CONCLUSIONS: Although discrepancies in ascertainment of severe perineal trauma improved after revision of birth data coding in 2006, higher ascertainment by linked data was still evident for recent data. There were also higher risk estimates of severe perineal trauma with episiotomy by linked data than by birth data.

Obstetric anal sphincter injury rates among primiparous women with different modes of vaginal delivery.

OBJECTIVE: To determine whether rates of obstetric anal sphincter injuries (OASIS) are continuing to increase and whether risk of OASIS according to mode of delivery is constant over time. METHODS: In a retrospective population-based study, data were obtained for vaginal singleton vertex deliveries at 37-41 weeks of pregnancy among primiparous women in New South Wales, Australia, between January 2001 and December 2011. Annual OASIS rates were determined among non-instrumental, forceps, and vacuum deliveries with and without episiotomy. Multivariable logistic regression was used to determine adjusted odds ratios for each delivery mode category by year. Trends in adjusted odds ratios over time for each delivery category were compared. RESULTS: OASIS occurred in 955 (4.1%) of 23 081 deliveries in 2001 and 1487 (5.9%) of 25 081 deliveries in 2011. After adjustment for known risk factors, the only delivery categories to show statistically significant increases in OASIS over the study period were non-instrumental deliveries without episiotomy (linear trend P<0.001) and forceps deliveries with episiotomy (linear trend P=0.004). CONCLUSION: Overall, OASIS rates have continued to increase. Known risk factors do not fully explain the increase in OASIS rates in non-instrumental deliveries without an episiotomy and in forceps deliveries with an episiotomy.

Perineal management techniques among midwives at five hospitals in New South Wales - a cross-sectional survey.

BACKGROUND: Midwives are reported to have changed from 'hands on' to 'hands poised or off' approaches to birth at the same time as obstetric anal sphincter injuries (OASIs) are increasing. As perineal management details are not routinely collected, it is difficult to quantify practice. AIMS: To determine which perineal protections techniques midwives prefer for low-risk non-water births; whether preference is associated with technique taught or with other characteristics; and whether midwives change preference according to clinical scenario. MATERIALS AND METHODS: Midwives in Northern Sydney Local Health District (NSLHD) were surveyed during a 2-week period in 2014. Multiple-choice questions were used, with free text option. Descriptive analyses, chi-square and McNemar tests were undertaken. RESULTS: One hundred and eight midwives participated (response rate 76.7%). 'Hands poised or off' was preferred by 63.0% for a low-risk birth. Current practice was associated with technique taught (P < 0.01). For scenarios with increased OASI risk midwives reported switching to 'hands on', with 83.4% employing 'hands on' whether there was concern about an impending OASI. There has been a shift over time from teaching 'hands on' to 'hands poised or off'. CONCLUSION: The preferred technique for a low-risk birth appears to have changed from 'hands on' to 'hands poised or off', but most midwives adopt 'hands on' in situations of high risk for OASI. Further research is needed to establish whether there is an association with the rising OASI rate and the change in preferred perineal management technique for a low-risk birth.

The impact of first birth obstetric anal sphincter injury on the subsequent birth: a population-based linkage study.

BACKGROUND: With rising obstetric anal sphincter injury (OASI) rates, the number of women at risk of OASI recurrence is in turn increasing. Decisions regarding mode of subsequent birth following an OASI are complex, and depend on a variety of factors. We sought to identify the risk factors for OASI recurrence from first and subsequent births, and to investigate the effect of OASI birth factors on planned caesarean for the second birth. METHODS: Using two linked population datasets from New South Wales, Australia, we selected women giving birth between 2001 and 2011 with a first birth OASI and a subsequent birth. Multivariable logistic regression was used to identify the association of first and second birth factors with OASI recurrence, and to determine which factors were associated with a planned pre-labour caesarean at the second birth. RESULTS: Of 6,380 women with a first birth OASI who proceeded to a subsequent birth, 75.4% had a vaginal second birth, 19.4% a pre-labour caesarean, and 5.2% an intrapartum caesarean. Although the OASI recurrence rate of 5.7% was significantly higher than the first birth OASI rate of 4.5% (p < 0.01), this may not reflect a clinically significant increase. Following adjustment for first and second birth factors, first birth diabetes and second birthweight ≥3.5 kg were associated with increased likelihood of OASI recurrence, while first birthweight ≥4.0 kg and second gestation at 37-38 weeks were associated with decreased likelihood. A fourth degree tear at the first birth was the strongest factor associated with planned caesarean at the second birth, with other factors including epidural, spinal or general anaesthetic, birthweight, gestation, country of birth and maternal age. CONCLUSIONS: Compared with previous reports, the low OASI recurrence rate (approximately one in twenty) may reflect appropriate decision-making about subsequent mode of delivery following first birth OASI. This assertion is supported by evidence of different risk profiles for women who have planned caesareans compared with planned vaginal births.

Reduced breast milk feeding subsequent to cosmetic breast augmentation surgery.

OBJECTIVE: To determine the effect of cosmetic breast augmentation on subsequent infant feeding. PARTICIPANTS, DESIGN AND SETTING: Population-based record linkage study of women giving birth in New South Wales, January 2006 - December 2011. Birth records were linked longitudinally to maternal hospitalisations up to 11 years before birth. Breast augmentation was identified by surgical procedure codes in hospital records. MAIN OUTCOME MEASURES: Any breast milk feeding at discharge from birth care, and among infants receiving any breast milk, exclusive breast milk feeding. The before-and-after effect of breast augmentation was assessed among women who had the surgery between births. RESULTS: Among 378 389 women who gave birth in the study period, 892 (0.2%) had prior breast augmentation. Among women with breast augmentation, 705 (79%) provided any breast milk to their infant at discharge, compared with 89% among women without augmentation. After adjusting for sociodemographic and pregnancy factors, infants of women with breast augmentation were less likely to receive breast milk at discharge than infants of women without augmentation (adjusted relative risk [ARR], 0.90; 95% CI, 0.87-0.93). However, infants receiving breast milk were not more or less likely to receive breast milk exclusively (ARR, 0.99; 95% CI, 0.97-1.01). Women with augmentation surgery between births changed their breastfeeding behaviour (reduced rates), while those with no augmentation or augmentation before both births did not. CONCLUSIONS: Reduced rates of breast milk feeding among women who have undergone breast augmentation underscore the importance of identifying, supporting and encouraging women who are vulnerable to a lower likelihood of breastfeeding.

Knowledge, attitude and experience of episiotomy use among obstetricians and midwives in Viet Nam.

BACKGROUND: Episiotomy remains a routine procedure at childbirth in many South-East Asian countries but the reasons for this are unknown. The aim of this study was to determine the knowledge of, attitudes towards and experience of episiotomy use among clinicians in Viet Nam. METHODS: All obstetricians and midwives who provide delivery care at Hung Vuong Hospital were surveyed about their practice, knowledge and attitudes towards episiotomy use. Data were analysed using frequency tabulations and contingency table analysis. RESULTS: 148 (88%) clinicians completed the questionnaire. Fewer obstetricians (52.2%) than midwives (79.7%) thought the current episiotomy rate of 86% was about right (P < 0.01). Most obstetricians (82.6%) and midwives (98.7%) reported performing episiotomies on nulliparous women over 90% of the time. Among multipara, 24.6% of obstetricians reported performing episiotomy less than 60% of the time compared with only 3 (3.8%) midwives (P < 0.01). Aiming to reduce 3rd-4th degree perineal tears was the most commonly reported reason for performing an episiotomy by both obstetricians (76.8%) and midwives (82.3%), and lack of training in how to minimize tears and keep the perineum intact was the mostly commonly reported obstacle (obstetricians 56.5%, midwives 36.7% P = 0.02) to reducing the episiotomy rate. CONCLUSION: Although several factors that may impede or facilitate episiotomy practice change were identified by our survey, training and confidence in normal vaginal birth without episiotomy is a priority.

The impact of cosmetic breast implants on breastfeeding: a systematic review and meta-analysis.

BACKGROUND: Cosmetic breast augmentation (breast implants) is one of the most common plastic surgery procedures worldwide and uptake in high income countries has increased in the last two decades. Women need information about all associated outcomes in order to make an informed decision regarding whether to undergo cosmetic breast surgery. We conducted a systematic review to assess breastfeeding outcomes among women with breast implants compared to women without. METHODS: A systematic literature search of Medline, Pubmed, CINAHL and Embase databases was conducted using the earliest inclusive dates through December 2013. Eligible studies included comparative studies that reported breastfeeding outcomes (any breastfeeding, and among women who breastfed, exclusive breastfeeding) for women with and without breast implants. Pairs of reviewers extracted descriptive data, study quality, and outcomes. Rate ratios (RR) and 95% confidence intervals (CI) were pooled across studies using the random-effects model. The Newcastle-Ottawa scale (NOS) was used to critically appraise study quality, and the National Health and Medical Research Council Level of Evidence Scale to rank the level of the evidence. This systematic review has been registered with the international prospective register of systematic reviews (PROSPERO): CRD42014009074. RESULTS: Three small, observational studies met the inclusion criteria. The quality of the studies was fair (NOS 4-6) and the level of evidence was low (III-2 - III-3). There was no significant difference in attempted breastfeeding (one study, RR 0.94, 95% CI 0.76, 1.17). However, among women who breastfed, all three studies reported a reduced likelihood of exclusive breastfeeding amongst women with breast implants with a pooled rate ratio of 0.60 (95% CI 0.40, 0.90). CONCLUSIONS: This systematic review and meta-analysis suggests that women with breast implants who breastfeed were less likely to exclusively feed their infants with breast milk compared to women without breast implants.

Are pregnancy outcomes associated with risk factor reporting in routinely collected perinatal data?

AIM: To assess reporting characteristics of commonly dichotomised pregnancy outcomes (e.g. preterm/term birth); and to investigate whether behaviours (e.g. smoking), medical conditions (e.g. diabetes) or interventions (e.g. induction) were reported differently by pregnancy outcomes. METHODS: Further analysis of a previous validation study was undertaken, in which 1680 perinatal records were compared with data extracted from medical records. Continuous and polytomous variables were dichotomised, and risk factor reporting was assessed within the dichotomised outcome groups. Agreement, kappa, sensitivity and positive predictive value calculations were undertaken. RESULTS: Gestational age, birthweight, Apgar scores, perineal trauma, regional analgesia and baby discharge status (live birth/stillbirth) were reported with high accuracy and reliability when dichotomised (kappa values 0.95-1.00, sensitivities 94.7-100.0%). Although not statistically significant, there were trends for hypertension, infant resuscitation and instrumental birth to be more accurately reported among births with adverse outcomes. In contrast, smoking ascertainment tended to be poorer among preterm births and when babies were <2500 g. CONCLUSION: Dichotomising variables collected as continuous or polytomous variables in birth data results in accurate and well ascertained data items. There is no evidence of systematic differential reporting of risk factors.

Episiotomy rate in Vietnamese-born women in Australia: support for a change in obstetric practice in Viet Nam.

OBJECTIVE: To describe the use of episiotomy among Vietnamese-born women in Australia, including risk factors for, and pregnancy outcomes associated with, episiotomy. METHODS: This population-based, retrospective cohort study included data on 598 305 singleton, term (i.e. ≥ 37 weeks' gestation) and vertex-presenting vaginal births between 2001 and 2010. Data were obtained from linked, validated, population-level birth and hospitalization data sets. Contingency tables and multivariate analysis were used to compare risk factors and pregnancy outcomes in women who did or did not have an episiotomy. FINDINGS: The episiotomy rate in 12 208 Vietnamese-born women was 29.9%, compared with 15.1% in Australian-born women. Among Vietnamese-born women, those who had an episiotomy were significantly more likely than those who did not to be primiparous, give birth in a private hospital, have induced labour or undergo instrumental delivery. In these women, having an episiotomy was associated with postpartum haemorrhage (adjusted odds ratio, aOR: 1.26; 95% confidence interval, CI: 1.08-1.46) and postnatal hospitalization for more than 4 days (aOR: 1.14; 95% CI: 1.00-1.29). Among multiparous women only, episiotomy was positively associated with a third- or fourth-degree perineal tear (aOR: 2.00; 95% CI: 1.31-3.06); in contrast, among primiparous women the association was negative (aOR: 0.47; 95% CI: 0.37-0.60). CONCLUSION: Episiotomy was performed in far fewer Vietnamese-born women giving birth in Australia than in Viet Nam, where more than 85% undergo the procedure, and was not associated with adverse outcomes. A lower episiotomy rate should be achievable in Viet Nam.

Trends in obstetric anal sphincter injuries and associated risk factors for vaginal singleton term births in New South Wales 2001-2009.

BACKGROUND: Changes in clinical practice and in the characteristics of childbearing women have the potential to influence the rate of obstetric anal sphincter injuries (OASIS). To date, little investigation has been undertaken to assess the effect of risk factor trends for the Australian population on OASIS rates. AIMS: To ascertain the OASIS rates amongst singleton vaginal births ≥37 weeks gestation in NSW, 2001 - 2009; to determine risk factor effect sizes and trends; and to compare predicted with observed OASIS rates. METHODS: Using two linked population-based data sets, risk factors for OASIS were determined by logistic regression. Contingency tables and predictive modelling were used to determine trends and predicted rates of OASIS, respectively. RESULTS: The OASIS rate increased from 2.2% in 2001 to 2.9% in 2009. Highest risks were for forceps deliveries without episiotomy (primiparas aOR 6.10, multiparas aOR 6.15), followed by multiparas with no previous vaginal birth (aOR 5.61). High birthweight, vacuum delivery and Asian country of birth posed risks for all women. The greatest risk factor trends were increases in Asian country of birth and vacuum delivery, while the greatest trend amongst protective factors was an increase in maternal age ≥35 years for primiparas. Predicted OASIS rates were lower than observed rates. CONCLUSION: In an environment of changing demographic and clinical risk factors, the OASIS rate has increased. This increase is only minimally explained by the identified risk factors and may be related to other unmeasured risk factors or a possible increase in clinical ascertainment and/or documentation of OASIS.

Characteristics in the first vaginal birth and their association with mode of delivery in the subsequent birth.

BACKGROUND: The extent to which complications or adverse outcomes in a first vaginal birth may contribute to mode of delivery in the next birth remains unclear. This study examines the impact of the first birth on subsequent mode of delivery. METHODS: The study population included women with a first vaginal birth and a consecutive second birth. Data were obtained from linked birth and hospital records for the state of New South Wales, Australia 2000-09. The primary outcome was the mode of delivery for the second birth. Planned caesarean was modelled using logistic regression; intrapartum caesarean and instrumental delivery were modelled using multinomial logistic regression. RESULTS: Of the 114 287 second births, 4.2% were planned caesarean, 3.0% were intrapartum caesarean and 4.8% were instrumental deliveries. Adjusted risk factors from the first birth for a planned second birth caesarean were third to fourth degree tear [odds ratio (OR) = 5.0 [95% confidence interval (CI) 4.6, 5.4]], severe neonatal morbidity (OR = 3.2 [95% CI 2.9, 3.6]), perinatal death (OR = 3.2 [95% CI 2.3, 4.4]), severe maternal morbidity (OR = 2.8 [95% CI 2.3, 3.3]), instrumental delivery, large infant, labour induction, epidural use, use of oxytocin for augmentation and episiotomy. Important risk factors (OR > 2) for intrapartum caesarean in the second birth were perinatal death or severe neonatal morbidity in the first birth. Risk factors for instrumental delivery in the second birth were perinatal death, preterm delivery and instrumental delivery. CONCLUSIONS: Obstetrical interventions and adverse pregnancy outcomes in the first birth were associated with increased risk of operative delivery in the second birth.

Attitudes, norms and controls influencing lifestyle risk factor management in general practice.

BACKGROUND: With increasing rates of chronic disease associated with lifestyle behavioural risk factors, there is urgent need for intervention strategies in primary health care. Currently there is a gap in the knowledge of factors that influence the delivery of preventive strategies by General Practitioners (GPs) around interventions for smoking, nutrition, alcohol consumption and physical activity (SNAP). This qualitative study explores the delivery of lifestyle behavioural risk factor screening and management by GPs within a 45-49 year old health check consultation. The aims of this research are to identify the influences affecting GPs' choosing to screen and choosing to manage SNAP lifestyle risk factors, as well as identify influences on screening and management when multiple SNAP factors exist. METHODS: A total of 29 audio-taped interviews were conducted with 15 GPs and one practice nurse over two stages. Transcripts from the interviews were thematically analysed, and a model of influencing factors on preventive care behaviour was developed using the Theory of Planned Behaviour as a structural framework. RESULTS: GPs felt that assessing smoking status was straightforward, however some found assessing alcohol intake only possible during a formal health check. Diet and physical activity were often inferred from appearance, only being assessed if the patient was overweight. The frequency and thoroughness of assessment were influenced by the GPs' personal interests and perceived congruence with their role, the level of risk to the patient, the capacity of the practice and availability of time. All GPs considered advising and educating patients part of their professional responsibility. However their attempts to motivate patients were influenced by perceptions of their own effectiveness, with smoking causing the most frustration. Active follow-up and referral of patients appeared to depend on the GPs' orientation to preventive care, the patient's motivation, and cost and accessibility of services to patients. CONCLUSION: General practitioner attitudes, normative influences from both patients and the profession, and perceived external control factors (time, cost, availability and practice capacity) all influence management of behavioural risk factors. Provider education, community awareness raising, support and capacity building may improve the uptake of lifestyle modification interventions.

Design, application and testing of the Work Observation Method by Activity Timing (WOMBAT) to measure clinicians' patterns of work and communication.

BACKGROUND: Evidence regarding how health information technologies influence clinicians' patterns of work and support efficient practices is limited. Traditional paper-based data collection methods are unable to capture clinical work complexity and communication patterns. The use of electronic data collection tools for such studies is emerging yet is rarely assessed for reliability or validity. AIM: Our aim was to design, apply and test an observational method which incorporated the use of an electronic data collection tool for work measurement studies which would allow efficient, accurate and reliable data collection, and capture greater degrees of work complexity than current approaches. METHODS: We developed an observational method and software for personal digital assistants (PDAs) which captures multiple dimensions of clinicians' work tasks, namely what task, with whom, and with what; tasks conducted in parallel (multi-tasking); interruptions and task duration. During field-testing over 7 months across four hospital wards, fifty-two nurses were observed for 250 h. Inter-rater reliability was tested and validity was measured by (i) assessing whether observational data reflected known differences in clinical role work tasks and (ii) by comparing observational data with participants' estimates of their task time distribution. RESULTS: Observers took 15-20 h of training to master the method and data collection process. Only 1% of tasks observed did not match the classification developed and were classified as 'other'. Inter-rater reliability scores of observers were maintained at over 85%. The results discriminated between the work patterns of enrolled and registered nurses consistent with differences in their roles. Survey data (n=27) revealed consistent ratings of tasks by nurses, and their rankings of most to least time-consuming tasks were significantly correlated with those derived from the observational data. Over 40% of nurses' time was spent in direct care or professional communication, with 11.8% of time spent multi-tasking. Nurses were interrupted approximately every 49 min. One quarter of interruptions occurred while nurses were preparing or administering medications. CONCLUSIONS: This method efficiently produces reliable and valid data. The multi-dimensional nature of the data collected provides greater insights into patterns of clinicians' work and communication than has previously been possible using other methods.