Parent engagement in perinatal mortality reviews: an online survey of clinicians from six high-income countries.

OBJECTIVE: Parent engagement in perinatal mortality review meetings following stillbirth may benefit parents and improve patient safety. We investigated perinatal mortality review meeting practices, including the extent of parent engagement, based on self-reports from healthcare professionals from maternity care facilities in six high-income countries. DESIGN: Cross-sectional online survey. SETTING: Australia, Canada, Ireland, New Zealand, UK and USA. POPULATION: A total of 1104 healthcare professionals, comprising mainly obstetricians, gynaecologists, midwives and nurses. METHODS: Data were drawn from responses to a survey covering stillbirth-related topics. Open- and closed-items that focused on 'Data quality on causes of stillbirth' were analysed. MAIN OUTCOME MEASURES: Healthcare professionals' self-reported practices around perinatal mortality review meetings following stillbirth. RESULTS: Most clinicians (81.0%) were aware of regular audit meetings to review stillbirth at their maternity facility, although this was true for only 35.5% of US respondents. For the 854 respondents whose facility held regular meetings, less than a third (31.1%) reported some form of parent engagement, and this was usually in the form of one-way post-meeting feedback. Across all six countries, only 17.1% of respondents described an explicit approach where parents provided input, received feedback and were represented at meetings. CONCLUSIONS: We found no established practice of involving parents in the perinatal mortality review process in six high-income countries. Parent engagement may hold the key to important lessons for stillbirth prevention and care. Further understanding of approaches, barriers and enablers is warranted. TWEETABLE ABSTRACT: Parent engagement in mortality review after stillbirth is rare, based on data from six countries. We need to understand the barriers.

Parents' and healthcare professionals' experiences of care after stillbirth in low- and middle-income countries: a systematic review and meta-summary.

BACKGROUND: Stillbirth has a profound impact on women, families, and healthcare workers. The burden is highest in low- and middle-income countries (LMICs). There is need for respectful and supportive care for women, partners, and families after bereavement. OBJECTIVE: To perform a qualitative meta-summary of parents' and healthcare professionals' experiences of care after stillbirth in LMICs. SEARCH STRATEGY: Search terms were formulated by identifying all synonyms, thesaurus terms, and variations for stillbirth. Databases searched were AMED, EMBASE, MEDLINE, PsychINFO, BNI, CINAHL. SELECTION CRITERIA: Qualitative, quantitative, and mixed method studies that addressed parents' or healthcare professionals' experience of care after stillbirth in LMICs. DATA COLLECTION AND ANALYSIS: Studies were screened, and data extracted in duplicate. Data were analysed using the Sandelowski meta-summary technique that calculates frequency and intensity effect sizes (FES/IES). MAIN RESULTS: In all, 118 full texts were screened, and 34 studies from 17 countries were included. FES range was 15-68%. Most studies had IES 1.5-4.5. Women experience a broad range of manifestations of grief following stillbirth, which may not be recognised by healthcare workers or in their communities. Lack of recognition exacerbates negative experiences of stigmatisation, blame, devaluation, and loss of social status. Adequately developed health systems, with trained and supported staff, are best equipped to provide the support and information that women want after stillbirth. CONCLUSIONS: Basic interventions could have an immediate impact on the experiences of women and their families after stillbirth. Examples include public education to reduce stigma, promoting the respectful maternity care agenda, and investigating stillbirth appropriately. TWEETABLE ABSTRACT: Reducing stigma, promoting respectful care and investigating stillbirth have a positive impact after stillbirth for women and families in LMICs.

Planned elective repeat caesarean section versus planned vaginal birth for women with a previous caesarean birth.

BACKGROUND: When a woman has had a previous caesarean birth, there are two options for her care in a subsequent pregnancy: planned elective repeat caesarean or planned vaginal birth. While there are risks and benefits for both planned elective repeat caesarean birth and planned vaginal birth after caesarean, current sources of information are limited to non-randomised cohort studies. Studies designed in this way have significant potential for bias and consequently conclusions based on these results are limited in their reliability and should be interpreted with caution. OBJECTIVES: To assess, using the best available evidence, the benefits and harms of a policy of planned elective repeat caesarean section with a policy of planned vaginal birth after caesarean section for women with a previous caesarean birth. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group trials register (24 June 2004), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 1, 2004), and PubMed (1966 to 24 June 2004). SELECTION CRITERIA: Randomised controlled trials with reported data that compared outcomes in mothers and babies who planned a repeat elective caesarean section with outcomes in women who planned a vaginal birth, where a previous birth had been by caesarean. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trial quality and extracted data. MAIN RESULTS: There were no randomised controlled trials identified. REVIEWERS' CONCLUSIONS: Planned elective repeat caesarean section and planned vaginal birth after caesarean section for women with a prior caesarean birth are both associated with benefits and harms. Evidence for these care practices is drawn from non-randomised studies, associated with potential bias. Any results and conclusions must therefore be interpreted with caution. Randomised controlled trials are required to provide the most reliable evidence regarding the benefits and harms of both planned elective repeat caesarean section and planned vaginal birth for women with a previous caesarean birth.

Information for pregnant women about caesarean birth.

BACKGROUND: Information is routinely given to pregnant women, but information about caesarean birth may be inadequate. OBJECTIVES: To examine the effectiveness of information about caesarean birth. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth register, CENTRAL (26 November 2002), MEDLINE [online via PubMed 1966-] and the Web of Science citation database [1995-] (20 September 2002), and reference lists of relevant articles. SELECTION CRITERIA: Randomised controlled trials, non-randomised clinical trials and controlled before-and-after studies of information given to pregnant women about caesarean birth. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trial quality and extracted data. Missing and further data were sought from trial authors unsuccessfully. Analyses were based on 'intention to treat'. Relative risk and confidence intervals were calculated and reported. Consumer reviewers commented on adequacy of information reported in each study. MAIN RESULTS: Two randomised controlled trials involving 1451 women met the inclusion criteria. Both studies aimed to reduce caesarean births by encouraging women to attempt vaginal delivery. One used a program of prenatal education and support, and the other cognitive therapy to reduce fear. Results were not combined because of differences in the study populations. Non-clinical outcomes were ascertained in both studies through questionnaires, but were subject to rates of loss to follow-up exceeding 10%.A number of important outcomes cannot be reported: knowledge or understanding; decisional conflict; and women's perceptions: of their ability to discuss care with clinicians or family/friends, of whether information needs were met, and of satisfaction with decision-making. Neither study assessed women's perception of participation in decision-making about caesarean birth, but Fraser 1997, who examined the effect of study participation on decision making, found that women in the intervention group were more likely to consider that attempting vaginal birth was easier (51% compared to 28% in control group), or more difficult (10% compared to 6%). These results could be affected by the attrition rate of 11%, and are possibly subject to bias. Neither intervention used in these trials made any difference to clinical outcomes. About 70% or more women attempted vaginal delivery in both trials, yet caesarean delivery rates exceeded 40%, at least 10% higher than was hoped. There was no significant difference between control and intervention groups for any of the outcomes measured: vaginal birth, elective/scheduled caesarean, and attempted vaginal delivery. Outcome data, although similar for both groups, were not sufficient to compare maternal and neonatal morbidity or neonatal mortality. There was no difference in the psychological outcomes for the intervention and control groups reported by either of the included trials. Consumer reviewers said information for women considering a vaginal birth after caesarean (VBAC) should include: risks of VBAC and elective caesarean; warning signs in labour; philosophy and policies of hospital and staff; strategies to improve chances of success; and information about probability of success with specific care givers. REVIEWER'S CONCLUSIONS: Research has focussed on encouraging women to attempt vaginal delivery. Trials of interventions to encourage women to attempt vaginal birth showed no effect, but shortcomings in study design mean that the evidence is inconclusive. Further research on this topic is urgently needed.