Interventions for supporting pregnant women's decision-making about mode of birth after a caesarean.

BACKGROUND: Pregnant women who have previously had a caesarean birth and who have no contraindication for vaginal birth after caesarean (VBAC) may need to decide whether to choose between a repeat caesarean birth or to commence labour with the intention of achieving a VBAC. Women need information about their options and interventions designed to support decision-making may be helpful. Decision support interventions can be implemented independently, or shared with health professionals during clinical encounters or used in mediated social encounters with others, such as telephone decision coaching services. Decision support interventions can include decision aids, one-on-one counselling, group information or support sessions and decision protocols or algorithms. This review considers any decision support intervention for pregnant women making birth choices after a previous caesarean birth. OBJECTIVES: To examine the effectiveness of interventions to support decision-making about vaginal birth after a caesarean birth.Secondary objectives are to identify issues related to the acceptability of any interventions to parents and the feasibility of their implementation. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 June 2013), Current Controlled Trials (22 July 2013), the WHO International Clinical Trials Registry Platform Search Portal (ICTRP) (22 July 2013) and reference lists of retrieved articles. We also conducted citation searches of included studies to identify possible concurrent qualitative studies. SELECTION CRITERIA: All published, unpublished, and ongoing randomised controlled trials (RCTs) and quasi-randomised trials with reported data of any intervention designed to support pregnant women who have previously had a caesarean birth make decisions about their options for birth. Studies using a cluster-randomised design were eligible for inclusion but none were identified. Studies using a cross-over design were not eligible for inclusion. Studies published in abstract form only would have been eligible for inclusion if data were able to be extracted. DATA COLLECTION AND ANALYSIS: Two review authors independently applied the selection criteria and carried out data extraction and quality assessment of studies. Data were checked for accuracy. We contacted authors of included trials for additional information. All included interventions were classified as independent, shared or mediated decision supports. Consensus was obtained for classifications. Verification of the final list of included studies was undertaken by three review authors. MAIN RESULTS: Three randomised controlled trials involving 2270 women from high-income countries were eligible for inclusion in the review. Outcomes were reported for 1280 infants in one study. The interventions assessed in the trials were designed to be used either independently by women or mediated through the involvement of independent support. No studies looked at shared decision supports, that is, interventions designed to facilitate shared decision-making with health professionals during clinical encounters.We found no difference in planned mode of birth: VBAC (risk ratio (RR) 1.03, 95% confidence interval (CI) 0.97 to 1.10; I² = 0%) or caesarean birth (RR 0.96, 95% CI 0.84 to 1.10; I² = 0%). The proportion of women unsure about preference did not change (RR 0.87, 95% CI 0.62 to 1.20; I² = 0%).There was no difference in adverse outcomes reported between intervention and control groups (one trial, 1275 women/1280 babies): permanent (RR 0.66, 95% CI 0.32 to 1.36); severe (RR 1.02, 95% CI 0.77 to 1.36); unclear (0.66, 95% CI 0.27, 1.61). Overall, 64.8% of those indicating preference for VBAC achieved it, while 97.1% of those planning caesarean birth achieved this mode of birth. We found no difference in the proportion of women achieving congruence between preferred and actual mode of birth (RR 1.02, 95% CI 0.96 to 1.07) (three trials, 1921 women).More women had caesarean births (57.3%), including 535 women where it was unplanned (42.6% all caesarean deliveries and 24.4% all births). We found no difference in actual mode of birth between groups, (average RR 0.97, 95% CI 0.89 to 1.06) (three trials, 2190 women).Decisional conflict about preferred mode of birth was lower (less uncertainty) for women with decisional support (standardised mean difference (SMD) -0.25, 95% CI -0.47 to -0.02; two trials, 787 women; I² = 48%). There was also a significant increase in knowledge among women with decision support compared with those in the control group (SMD 0.74, 95% CI 0.46 to 1.03; two trials, 787 women; I² = 65%). However, there was considerable heterogeneity between the two studies contributing to this outcome ( I² = 65%) and attrition was greater than 15 per cent and the evidence for this outcome is considered to be moderate quality only. There was no difference in satisfaction between women with decision support and those without it (SMD 0.06, 95% CI -0.09 to 0.20; two trials, 797 women; I² = 0%). No study assessed decisional regret or whether women's information needs were met.Qualitative data gathered in interviews with women and health professionals provided information about acceptability of the decision support and its feasibility of implementation. While women liked the decision support there was concern among health professionals about their impact on their time and workload. AUTHORS' CONCLUSIONS: Evidence is limited to independent and mediated decision supports. Research is needed on shared decision support interventions for women considering mode of birth in a pregnancy after a caesarean birth to use with their care providers.

Very advanced maternal age and morbidity in Victoria, Australia: a population based study.

BACKGROUND: In Australia, approximately 0.1% of births occur to women 45 years or older and this rate has been increasing in recent years. There are however, few population based studies examining perinatal outcomes among this age group. The aim of this study was to determine the maternal and perinatal outcomes of pregnancies in women aged 45 years or older compared to women aged 30-34 years. METHODS: Data on births at 20 or more weeks' gestation were obtained from the Victorian Perinatal Data Collection for the years 2005 and 2006. We examined selected maternal and perinatal outcomes for women of very advanced maternal age (VAMA) aged 45 years or older (n = 217) and compared them to women aged 30-34 years (n = 48,909). Data were summarised using numbers and percentages. Categorical data were analysed by Chi-square tests and Fisher's exact test. Comparisons are presented using unadjusted odds ratios, 95 percent confidence intervals (CIs) and p-values. RESULTS: Women aged 45 years and older had higher odds of gestational diabetes (OR 2.05; 95% CI 1.3-3.3); antepartum haemorrhage (OR 1.89; 95% CI 1.01-3.5), and placenta praevia (OR 4.88; 95% CI 2.4-9.5). The older age-group also had higher odds of preterm birth between 32-36 weeks (OR 2.61; 95% CI 1.8-3.8); low birth-weight (<2,500 gr) (OR 2.22; 95% CI 1.5-3.3) and small for gestational age (OR 1.53; 95% CI 1.0-2.3). Stratified analysis revealed that VAMA was most strongly associated with caesarean section in primiparous women (OR 8.24; 95% CI 4.5, 15.4) and those using ART (OR 5.75; 95% CI 2.5, 13.3), but the relationship persisted regardless of parity, ART use and plurality. Low birthweight was associated with VAMA only in first births (OR 3.90; 95% CI 2.3, 6.6), while preterm birth was more common in older women for both first (OR 3.13; 95% CI 1.8, 5.3) and subsequent (OR 2.08; 95% CI 1.2, 3.5) births, and for those having singleton births (OR 2.11; 95% CI 1.3, 3.4), and those who did not use ART (OR 2.10; 95% CI 1.3, 3.4). Preterm birth was very common in multiple births and following ART use, regardless of maternal age. CONCLUSIONS: This study demonstrates that women aged 45 years and older, in Victoria, Australia, have higher rates of pregnancy and perinatal complications, compared to women aged 30-34 years.

Advanced maternal age and obstetric morbidity for women giving birth in Victoria, Australia: A population-based study.

BACKGROUND: As the proportions of older women giving birth increase, there is a growing body of evidence on the increased risks of poorer maternal and perinatal outcomes for this group. However, the associations are not completely understood. This study aimed to establish the prevalence of selected maternal morbidities and examine whether advanced maternal age is associated with a higher risk of morbidity for women giving birth in Victoria. METHOD: Data on all births over 20 weeks‧ gestation for 2005 and 2006 were obtained from the Victorian Perinatal Data Collection. Unadjusted and adjusted analyses were undertaken using logistic regression to examine and quantify the association between advanced maternal age (35 years and older) and selected obstetric morbidities and complications. RESULTS: There was evidence of an association between older maternal age and selected morbidities and complications. Older nulliparous women were at highest odds of gestational diabetes (AdjOR, 1.83; 95% CI, 1.67-2.02), placenta praevia (AdjOR, 2.02; 95% CI, 1.68-2.44), multiple birth (AdjOR, 1.80; 95% CI, 1.58-2.06) and caesarean delivery (AdjOR, 1.93; 95% CI, 1.84-2.02). Older multiparous women were at highest odds of gestational diabetes (AdjOR, 2.01; 95% CI, 1.88-2.15) and placenta praevia (AdjOR, 2.11; 95% CI, 1.83-2.44). CONCLUSIONS: Older women giving birth in Victoria are at an increased risk of a range of obstetric morbidities. Delayed childbearing for an increasing number of women has societal and public health ramifications and will potentially place greater demand on healthcare services.

Maternal age, ethnicity and gestational diabetes mellitus.

BACKGROUND: in Australia, and globally, rates for gestational diabetes mellitus (GDM) have risen dramatically in recent decades. This is of concern as GDM is associated with adverse pregnancy outcomes and additional health-care costs. Factors linked to increasing incidence include older maternal age and non-Caucasian ethnicity. However, as yet, there is no clear consensus on the magnitude of effect associated with these factors in combination. This study therefore investigated the effect of maternal age and country/region of birth on GDM incidence. METHODS: all women who gave birth in Victoria, Australia in 2005 and 2006 (n=133,359) were included in this population-based cross-sectional study. Stratified cross-tabulations were conducted to examine the incidence of GDM by maternal age group and country/region of birth. Primiparous women were further analysed separately from parous women. The proportion of women with GDM was reported, along with the χ(2) for linear trend. FINDINGS: whilst women born outside Australia constituted just 24.6% of women giving birth during the study period, they accounted for 41.4% of GDM cases. The highest GDM incidence was seen among Asian women at 11.5%, compared with Australian born women at 3.7%. There was strong evidence that women born in all regions except North America were increasingly likely to develop GDM in pregnancies at older ages (p<0.001).On examining age related GDM trends by maternal region of birth, higher rates were seen across all regions studied but were most marked among women born in Asia and the Middle East. CONCLUSIONS: older maternal age and non-Australian birth increased a woman's risk of developing GDM and this increase was most evident among Asian women. As GDM is associated with adverse maternal and infant outcomes, it is important to explore ways of preventing GDM, and to put in place strategies to effectively manage GDM during pregnancy and to reduce the later risk of developing type 2 diabetes. Pregnancy presents midwives with a unique opportunity to provide education and to encourage dietary and behavioural modifications as women have repeated contact with the health system during this time.

Older maternal age and intervention in labor: a population-based study comparing older and younger first-time mothers in Victoria, Australia.

BACKGROUND: In Australia, birth rates for women aged 35 years or more are significant and increasing and a considerable percentage are first births. This study investigated the effect of maternal age on interventions in labor and birth for primiparous women aged 35 to 44 years compared with primiparous women aged 25 to 29 years. METHODS: All primiparous women who gave birth in Victoria, Australia, in 2005 and 2006 (n = 57,426) were included in this population-based cross-sectional study. Women were stratified by admission status (private/public). Main outcome measures were induction of labor, augmentation of labor, use of epidural analgesia, and method of birth. Multivariate logistic regression was used to explore the relationship between maternal age and cesarean adjusted for confounders. RESULTS: Older women were more likely to give birth by cesarean section whether admitted as public or private patients. For private patients, total cesarean rates were 31.8 percent (25-29 yr), 46.0 percent (35-39 yr), and 60.0 percent (40-44 yr; p < 0.001) compared with 27.5, 41.6, and 53.4 percent for public patients (p < 0.001). Older women who experienced labor were more likely to have an instrumental vaginal birth or an emergency cesarean section than younger women. Both were more common in women admitted as private patients. Age-related trends were also seen for induction of labor and use of epidural analgesia. Rates were higher for private patients. Rates of induction were (37.8, 40.2, and 42.5%) for private patients compared with (32.1, 36.7, and 40.1%) for public patients and rates for epidural were (45.3, 49.9, and 48.1%) among private patients compared with (33.3, 38.8, and 39.3%) among public patients. CONCLUSIONS: Interventions in labor and birth increased with maternal age, and this effect was seen particularly for cesarean section among women admitted privately. These findings were not fully explained by the complications we considered.

Recovery after caesarean birth: a qualitative study of women's accounts in Victoria, Australia.

BACKGROUND: The caesarean section rate is increasing globally, especially in high income countries. The reasons for this continue to create wide debate. There is good epidemiological evidence on the maternal morbidity associated with caesarean section. Few studies have used women's personal accounts of their experiences of recovery after caesarean. The aim of this paper is to describe women's accounts of recovery after caesarean birth, from shortly after hospital discharge to between five months and seven years after surgery. METHOD: Women who had at least one caesarean birth in a tertiary hospital in Victoria, Australia, participated in an interview study. Women were selected to ensure diversity in experiences (type of caesarean, recency), caesarean and vaginal birth, and maternal request caesarean section. Interviews were audiotaped and transcribed verbatim. A theoretical framework was developed (three Zones of clinical practice) and thematic analysis informed the findings. RESULTS: Thirty-two women were interviewed who between them had 68 births; seven women had experienced both caesarean and vaginal births. Three zones of clinical practice were identified in women's descriptions of the reasons for their first caesareans. Twelve women described how, at the time of their first caesarean section, the operation was performed for potentially life-saving reasons (Central Zone), 11 described situations of clinical uncertainty (Grey Zone), and nine stated they actively sought surgical intervention (Peripheral Zone).Thirty of the 32 women described difficulties following the postoperative advice they received prior to hospital discharge and their physical recovery after caesarean was hindered by a range of health issues, including pain and reduced mobility, abdominal wound problems, infection, vaginal bleeding and urinary incontinence. These problems were experienced across the three zones of clinical practice, regardless of the reasons women gave for their caesarean. CONCLUSION: The women in this study reported a range of unanticipated and unwanted negative physical health outcomes following caesarean birth. This qualitative study adds to the existing epidemiological evidence of significant maternal morbidity after caesarean section and underlines the need for caesarean section to be reserved for circumstances where the benefit is known to outweigh the harms.

What have sampling and data collection got to do with good qualitative research?

OBJECTIVE: To highlight the importance of sampling and data collection processes in qualitative interview studies, and to discuss the contribution of these processes to determining the strength of the evidence generated and thereby to decisions for public health practice and policy. APPROACH: This discussion is informed by a hierarchy-of-evidence-for-practice model. The paper provides succinct guidelines for key sampling and data collection considerations in qualitative research involving interview studies. The importance of allowing time for immersion in a given community to become familiar with the context and population is discussed, as well as the practical constraints that sometimes operate against this stage. The role of theory in guiding sample selection is discussed both in terms of identifying likely sources of rich data and in understanding the issues emerging from the data. It is noted that sampling further assists in confirming the developing evidence and also illuminates data that does not seem to fit. The importance of reporting sampling and data collection processes is highlighted clearly to enable others to assess both the strength of the evidence and the broader applications of the findings. CONCLUSION: Sampling and data collection processes are critical to determining the quality of a study and the generalisability of the findings. We argue that these processes should operate within the parameters of the research goal, be guided by emerging theoretical considerations, cover a range of relevant participant perspectives, and be clearly outlined in research reports with an explanation of any research limitations.

The essential role of social theory in qualitative public health research.

OBJECTIVE: To define the role of social theory and examine how research studies using qualitative methods can use social theory to generalize their results beyond the setting of the study or to other social groups. APPROACH: The assumptions underlying public health research using qualitative methods derive from a range of social theories that include conflict theory, structural functionalism, symbolic interactionism, the sociology of knowledge and feminism. Depending on the research problem, these and other social theories provide conceptual tools and models for constructing a suitable research framework, and for collecting and analysing data. In combination with the substantive health literature, the theoretical literature provides the conceptual bridge that links the conclusions of the study to other social groups and settings. CONCLUSION: While descriptive studies using qualitative research methods can generate important insights into social experience, the use of social theory in the construction and conduct of research enables researchers to extrapolate their findings to settings and groups broader than the ones in which the research was conducted.

A hierarchy of evidence for assessing qualitative health research.

OBJECTIVE: The objective of this study is to outline explicit criteria for assessing the contribution of qualitative empirical studies in health and medicine, leading to a hierarchy of evidence specific to qualitative methods. STUDY DESIGN AND SETTING: This paper arose from a series of critical appraisal exercises based on recent qualitative research studies in the health literature. We focused on the central methodological procedures of qualitative method (defining a research framework, sampling and data collection, data analysis, and drawing research conclusions) to devise a hierarchy of qualitative research designs, reflecting the reliability of study conclusions for decisions made in health practice and policy. RESULTS: We describe four levels of a qualitative hierarchy of evidence-for-practice. The least likely studies to produce good evidence-for-practice are single case studies, followed by descriptive studies that may provide helpful lists of quotations but do not offer detailed analysis. More weight is given to conceptual studies that analyze all data according to conceptual themes but may be limited by a lack of diversity in the sample. Generalizable studies using conceptual frameworks to derive an appropriately diversified sample with analysis accounting for all data are considered to provide the best evidence-for-practice. Explicit criteria and illustrative examples are described for each level. CONCLUSION: A hierarchy of evidence-for-practice specific to qualitative methods provides a useful guide for the critical appraisal of papers using these methods and for defining the strength of evidence as a basis for decision making and policy generation.