Trends in private maternity care in Ireland's capital during and after the Great Economic Recession 2009-2017.

BACKGROUND: Maternity care in hospitals in the Republic of Ireland is funded by a hybrid of public finance and private health insurance. AIMS: The aim of this longitudinal observational study was to investigate the annual trends in maternity care from 2009 to 2017 during and after the Great Economic Recession. METHODS: All women who delivered a singleton baby weighing ≥ 500 g during the 9 years (2009-2017) were included. Detailed clinical and sociodemographic details were computerised at the first antenatal visit by a trained midwife. Women who delivered their first baby during the study were analysed longitudinally if they delivered again during the 9 years. RESULTS: The mean age of the 73,266 women was 31.3 ± 5.6 years, 40.1% were nulliparas, and 70.3% were Irish-born. Overall, 75.2% opted for the public, 10.8% for the semi-private, and 14.0% for the private package of maternity care. Over the 9 years, the number of women choosing private and semi-private care decreased by 21.6% and 35.3%, respectively, whereas the number of women using public care increased by 12.3%. Most women opted for the same package of care in subsequent pregnancies. CONCLUSIONS: Ireland's recent economic recession was accompanied by an overall decrease in the number of women choosing private maternity care after 2009. Furthermore, economic recovery with increasing female employment after 2012 was not associated with a recovery in demand for private care. These findings have important implications for healthcare policies and for the future organisation and funding of our maternity services.

Prospective cohort study of water immersion for labour and birth compared with standard care in an Irish maternity setting.

OBJECTIVE: To examine the birth outcomes for women and babies following water immersion for labour only, or for labour and birth. DESIGN: Prospective cohort study. SETTING: Maternity hospital, Ireland, 2016-2019. PARTICIPANTS: A cohort of 190 low-risk women who used water immersion; 100 gave birth in water and 90 laboured only in water. A control group of 190 low-risk women who received standard care. METHODS: Logistic regression analyses examined associations between water immersion and birth outcomes adjusting for confounders. A validated Childbirth Experience Questionnaire was completed. MAIN OUTCOME MEASURES: Perineal tears, obstetric anal sphincter injuries (OASI), postpartum haemorrhage (PPH), neonatal unit admissions (NNU), breastfeeding and birth experiences. RESULTS: Compared with standard care, women who chose water immersion had no significant difference in perineal tears (71.4% vs 71.4%, adj OR 0.83; 95% CI 0.49 to 1.39) or in OASI (3.3% vs 3.8%, adj OR 0.91; 0.26-2.97). Women who chose water immersion were more likely to have a PPH ≥500 mL (10.5% vs 3.7%, adj OR 2.60; 95% CI 1.03 to 6.57), and to exclusively breastfeed at discharge (71.1% vs 45.8%, adj OR 2.59; 95% CI 1.66 to 4.05). There was no significant difference in NNU admissions (3.7% vs 3.2%, adj OR 1.06; 95% CI 0.33 to 3.42). Women who gave birth in water were no more likely than women who used water for labour only to require perineal suturing (64% vs 80.5%, adj OR 0.63; 95% CI 0.30 to 1.33), to experience OASI (3.0% vs 3.7%, adj OR 1.41; 95% CI 0.23 to 8.79) or PPH (8.0% vs 13.3%, adj OR 0.73; 95% CI 0.26 to 2.09). Women using water immersion reported more positive memories than women receiving standard care (p<0.01). CONCLUSIONS: Women choosing water immersion for labour or birth were no more likely to experience adverse birth outcomes than women receiving standard care and rated their birth experiences more highly.

Caesarean section rates in women in the Republic of Ireland who chose to attend their obstetrician privately: a retrospective observational study.

BACKGROUND: Caesarean section (CS) rates are increasing and there are wide variations in rates internationally and nationally. There is evidence that women who attend their obstetrician privately have a higher incidence of CS than those who attend publicly. The purpose of this observational study was to further investigate why CS rates may be higher in women who chose to attend their obstetrician privately. METHODS: This study analysed data collected as part of the clinical records by midwives at the woman's first antenatal appointment in a large European maternity hospital. All women who delivered between the years 2009 and 2017 were included. Data were analysed both cross-sectionally and longitudinally. RESULTS: Overall, 73,266 women had a singleton pregnancy and 1830 had a multiple pregnancy. Of the packages of maternity care, 75.2% chose public, 10.8% chose semiprivate and 14.0% chose private. During the study, 11,991 women attended the hospital for their first and second pregnancies. Overall, women who attended privately were older and had higher proportions of infertility treatment and history of miscarriage (all p < 0.001) compared to those publicly-funded. Private patients were more likely to have a history of infertility, a history of miscarriage, a multiple pregnancy and to be ≥35 yrs. They had lower rates of obesity, smoking and illicit drug use in pregnancy (all p < 0.001). In women who chose private care, the overall rate of CS was higher compared to women choosing publicly-funded (42.7% vs 25.3%, p < 0.001) The increase was due to an increase in elective rather than emergency CS. The increase in elective CS fell after adjustment for clinical risks. In the longitudinal analysis, 89.7% chose the same package second time around. Women who changed from public to private care for the second pregnancy were more likely to have had a previous emergency CS or admission to the Neonatal Unit. CONCLUSIONS: This study suggests that the increased CS rate in women privately insured may be attributed, in part, to the fact that women who can afford health insurance choose continuity of care from a senior obstetrician because they are risk adverse and wish to have the option of an elective CS.

The impact of revised diagnostic criteria on hospital trends in gestational diabetes mellitus rates in a high income country.

OBJECTIVE: In 2010, national guidelines were published in Ireland recommending more sensitive criteria for the diagnosis of Gestational Diabetes Mellitus (GDM). The criteria were based on the 2008 Hyperglycemia and Adverse Pregnancy Outcomes (HAPO) Study and were endorsed subsequently by the World Health Organization (WHO). Screening nationally is selective based on risk factors. We examined the impact of the new criteria on hospital trends nationally for GDM over the 10 years 2008-17. RESEARCH DESIGN AND METHODS: Data from three national databases, the Hospital Inpatient Enquiry System (HIPE), National Perinatal Reporting System (NPRS) and the Irish Maternity Indicator System (IMIS), were analyzed using descriptive statistics, analysis of variance, and Poisson loglinear modelling. RESULTS: The overall incidence of GDM nationally increased almost five-fold from 3.1% in 2008 to 14.8% in 2017 (p ≤ 0.001). The incidence varied widely across maternity units. In 2008, the incidence varied from 0.4 to 5.9% and in 2017 it varied from 1.9 to 29.4%. There were increased obstetric interventions among women with GDM over the decade, specifically women with GDM having increased cesarean sections (CS) and induction of labor (IOL) (p ≤ 0.001). These trends were significant in large and mid-sized maternity hospitals (p ≤ 0.001). The increase in GDM diagnosis could not be explained by an increase in maternal age nationally over the decade. The data did not include information on other risk factors such as obesity. The increased incidence in GDM diagnosis was accompanied by a decrease in high birthweight ≥ 4.5 kg nationally. CONCLUSIONS: We found adoption of the new criteria for diagnosis of GDM resulted in a major increase in the incidence of GDM rates. Inter-hospital variations increased over the decade, which may be explained by variations in the implementation of the new national guidelines in different maternity units. It is likely to escalate further as compliance with national guidelines improves at all maternity hospitals, with implications for provision and configuration of maternity services. We observed trends that may indicate improvements for women and their offspring, but more research is required to understand patterns of guideline implementation across hospitals and to demonstrate how increased GDM diagnosis will improve clinical outcomes.

Maternal employment and pregnancy outcomes in a large European maternity hospital.

OBJECTIVE: Epidemiological studies have previously reported that maternal socioeconomic disadvantage is associated with adverse feto-maternal outcomes. However, little attention has been paid to the question of the woman's employment status. The aim of this observational study was to examine the relationship between maternal employment status at the first antenatal visit and pregnancy outcomes. STUDY DESIGN: The study was confined to women with a singleton pregnancy who attended for maternity care between the years 2010 and 2017 and delivered a baby weighing ≥500 g. Self-reported sociodemographic and clinical details were recorded at the first antenatal visit by a trained midwife and updated before hospital discharge. The hospital is one of the largest in Europe and accepts women from all socioeconomic groups, including women in the public system and those with private health insurance, across the rural-urban spectrum. RESULTS: Of the 62,395 women, the mean age was 31.5 years (SD 5.4), 39.3% were nulliparas and 70.7% were Irish born. Compared with the 45,028 (72.2%) women who reported as being in paid employment, the 4984 (8.0%) women who were unemployed had a higher rate of stillbirth (8/4984 vs. 27/45,028, p = 0.005) and homemakers had a higher incidence of neonatal death (31/12,383 vs. 73/45,028, p = 0.02). On multivariable analysis, women who were unemployed or homemakers had increased adjusted odds ratios for neonatal unit (NNU) admissions, preterm birth, low birth weight, and small-for-gestational-age. Compared to women in paid employment, women who were unemployed or homemakers were associated with younger age (<30 years) in pregnancy, multiparity, unplanned pregnancy, no or postconceptional only folic acid supplementation, anxiolytic/antidepressant use, as well as persistent smoking and illicit drug use during pregnancy. CONCLUSIONS: In a high-income European country, women who reported as unemployed or homemakers were associated with higher rates of adverse pregnancy outcomes. Furthermore, these women were associated with suboptimal lifestyle behaviours such as smoking and illicit drug use in early pregnancy. This highlights the need for long term public policies on female unemployment and retaining women with children in employment.

Longitudinal Study of Maternal BMI in Successive Pregnancies.

OBJECTIVE: This longitudinal observational study examined BMI changes between successive pregnancies. METHODS: The computerized medical records of women who attended a large maternity hospital between 2009 and 2017 for their first and second singleton deliveries were analyzed. Women who had their weight first measured after 15 weeks of gestation in either pregnancy were excluded. RESULTS: Of the 9,724 women, the incidence of obesity increased from 11.6% in the first pregnancy to 16.0% in the second. The mean interpregnancy interval was 32.5 ± 15.7 months, and median BMI change was +0.6 kg/m2 (interquartile range 2.2; P < 0.001). Overall, 10.3% (1,006/9,724) developed overweight and 5.9% (571/9,724) developed obesity by the second pregnancy. Of the nulliparas in the overweight category, 20.6% (526/2,558) entered the obesity category. The development of obesity by the second pregnancy was independently associated with a longer interpregnancy interval, formula feeding at hospital discharge, taking antidepressants or anxiolytics, and postnatal depression. Professional/managerial employment was associated with a lower odds ratio of developing obesity. CONCLUSIONS: Maternal obesity increased between the first and second pregnancy, with one-fifth of nulliparas in the overweight category developing obesity. Pregnancy-related factors were identified as predictors of developing obesity. Further research is needed to assess whether interventions targeting these related factors could optimize maternal weight management between pregnancies.

Maternal obesity trends in a large Irish university hospital.

OBJECTIVE(S): This study aimed to examine recent trends in maternal obesity. STUDY DESIGN: This retrospective observational study used routinely computerised clinical and sociodemographic data of women who presented for antenatal care in a large maternity hospital in Ireland during the eight years 2010-17. Women with complete body mass index (BMI) data who delivered a baby weighing ≥500 g were included in the study. BMI was based on the measurement of weight and height and was categorised into the World Health Organizations (WHO) classifications. RESULTS: The number of women delivered was 67,949 and 99.1% had complete data. The overall obesity rate increased from 16.0% (95% CI 15.3-16.8%) in 2010 to 18.9% (95% CI 18.0-19.7%) in 2017 (+18.1%, p < 0.001). This increase occurred in the mild, moderate and severe obesity subcategories (all p < 0.01). Overall, obesity was associated with multiparity, maternal age, maternal birth in Ireland or the United Kingdom (UK), depression, unemployment and unplanned pregnancy. The increase in obesity was more pronounced in nulliparas than in multiparas, particularly nulliparas <30 years. The increased obesity levels were accompanied by major sociodemographic changes in the hospital population from 2010 to 2017 with an increase in the average maternal age from 30.5 years to 32.2 years (p < 0.001) and a decrease in the proportion of nulliparas aged <30 years (from 40.6% to 28.8%, p < 0.001). CONCLUSION(S): It is likely that the escalating maternal obesity levels will lead to further increases in obstetric complications and interventions. The escalation was accompanied by major sociodemographic changes which have implications for healthcare planning and public health interventions.

Fetal growth and maternal alcohol consumption during early pregnancy.

OBJECTIVE: The relationship between light maternal alcohol consumption and fetal outcome remains contentious and the professional advice women receive is conflicting. The aim of this large epidemiological study was to examine the relationship between fetal growth and maternal alcohol behaviour before and during early pregnancy. STUDY DESIGN: Clinical and sociodemographic details of women who delivered a baby weighing ≥500 g during the eight years 2010-18 were analysed. Details on lifestyle behaviour before pregnancy and at the time of the first antenatal hospital visit were computerised using a standardised questionnaire. RESULTS: Of 68,925 women, 33.6% abstained from alcohol consumption before pregnancy and 98.4% reported they were abstaining at their first antenatal visit. Only 1.2% reported light consumption (1-2 units/week, median 1.0 IQR 1.0), 0.4% reported moderate/heavy consumption (>3 units/week, median 4.0 IQR 4.0) and 0.3% reported binge drinking (>5 units in one sitting, median 3.0 IQR 4.0). Women who consumed alcohol in binges were more likely to be <30years whereas women who consumed alcohol weekly were more likely to be ≥30years. Women who who consumed any alcohol during early pregnancy were more likely to be multiparous, Irish-born, to have an unplanned pregnancy, to be unemployed, on medications for depression or anxiety, current smokers and abusing illicit drugs. In the absence of persistent smoking or illicit drug abuse, there was no relationship between light alcohol consumption during early pregnancy and the subsequent mean birth weight, preterm delivery (%), small-for-gestational age (%) and mean neonatal head circumference. CONCLUSION(S): Women who consume alcohol should continue to be advised of the fetal and maternal risks of heavy consumption and, if applicable, of the need to quit smoking and avoid illicit drugs. However, women who have consumed alcohol before realising that they were pregnant or who consumed alcohol in light amounts during early pregnancy, may be reassured that their alcohol consumption did not impact adversely on their baby's growth.

Trends in maternal obesity in a large university hospital 2009-2013.

INTRODUCTION: Maternal obesity has been identified as an important clinical priority in contemporary obstetrics. This study aimed to determine the incidence of maternal obesity in early pregnancy and track recent trends in body mass index (BMI) categories over 5 years 2009-2013. MATERIAL AND METHODS: This prospective observational study included all women who delivered an infant weighing ≥500 g during the 5 years 2009-2013 in a large university teaching hospital in Ireland. Body mass index was calculated using early pregnancy weight and height measured at first antenatal visits. Sociodemographic and clinical data were gathered prospectively. Trends in maternal obesity were tracked over 5 years and epidemiological associations with obesity were examined using logistic regression, adjusted for confounding variables. RESULTS: Of 42 362 women, 99.0% (n = 41 927) were eligible for analysis with a mean BMI of 25.5 kg/m(2) , mean age of 30.7 years and 40.7% (n = 17054) primigravidas. The absolute number of cases of severe obesity (BMI ≥40.0 kg/m(2) ) increased by 48.5% from 2009 to 2013 (p < 0.001). After multivariate logistic regression analyses, obesity incidence increased with increasing parity, advancing age and socioeconomic disadvantage. The maternal obesity rate among women born in the 13 European Union Accession countries was 8.6%, nearly half that of those born in existing European Union countries (p < 0.001). CONCLUSION: It is concerning that while the overall obesity rate remained stable, the number of cases of severe obesity increased over 5 years. We recommend renewed public health efforts addressing obesity rates before pregnancy and reinforcing attempts to optimize a woman's weight after delivery.

The relationship between unplanned pregnancy and maternal body mass index 2009-2012.

OBJECTIVE: To analyse the relationship between unplanned pregnancy and maternal Body Mass Index (BMI). METHODS: A prospective case-control study of planned vs. unplanned pregnancies among women who delivered an infant weighing ≥ 500 g during the four years 2009-2012 in a large maternity hospital in Ireland. Maternal weight and height were measured at the first antenatal visit before calculation of BMI. Clinical and sociodemographic details were computerised. BMI was categorised according to the World Health Organization. The epidemiological associations were examined using logistic regression, adjusted for confounding variables. RESULTS: Between 2009 and 2012, 34,377 women were included, 31.7% (n = 10,894) reported an unplanned pregnancy and 16.6% (n = 5647) were obese. The odds ratios of unplanned pregnancy were greater among obese women compared with those of normal BMI (unadjusted Odds Ratio (OR) 1.3; 95% Confidence Interval (CI) 1.3-1.4 p < 0.001). These ratios increased with increasing BMI (mild unadjusted OR 1.3; CI 1.2-1.4 p < 0.001; moderate unadjusted OR 1.4; CI 1.2-1.6 p < 0.001; severe obesity unadjusted OR 1.7; CI 1.4-2.0 p < 0.001). The higher rate of unplanned pregnancy among obese women was associated with a lower rate of contraception usage and a higher rate of contraceptive failure. Only 37.6% (n = 2112) of obese women took preconceptional folic acid to prevent neural tube defects compared with 46.1% (n = 8176) of women with a normal BMI (p < 0.001). CONCLUSION: Higher rates of unplanned pregnancy among obese women compared with women with a normal BMI is associated with compromised prepregnancy care in this high-risk population.

A longitudinal study of unplanned pregnancy in a maternity hospital setting.

OBJECTIVE: To review family planning in a cohort of women who delivered a second child within 3 years of their first. METHODS: A longitudinal, observational study included women aged at least 18 years who had delivered a singleton weighing at least 500 g in 2009 after their first pregnancy at a hospital in Dublin, Ireland, and who returned to the hospital for prenatal care for a second pregnancy before January 2012. Logistic regression analyses were performed to examine the effect of maternal characteristics on pregnancy intention. RESULTS: Of 3284 primigravidas who delivered in 2009, 1220 (37.1%) returned with a second pregnancy. The second pregnancy was unplanned in 248 (20.3%) women, and both pregnancies were unplanned in 124 (10.2%). The second pregnancy was more likely to be unplanned in women whose first pregnancy was also unplanned than in those whose first was planned (adjusted odds ratio 6.5; 95% confidence interval 4.6-8.4; P<0.001). Among the 99 women with recurrent unplanned pregnancy who had not been using contraception before the first pregnancy, 85 (85.9%) were also not using contraception before the second. CONCLUSION: Women whose first pregnancy is unplanned are at increased risk of subsequent unplanned pregnancies. Postnatal contraceptive advice in this high-risk group should be prioritized.