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Gurney L, Al Wattar BH, Sher A, Echevarria C, Simpson H. Comparison of perinatal outcomes for all modes of second stage delivery in obstetric theatres: a retrospective observational study. BJOG 2020; 128:1248-1255. [PMID: 33142034 DOI: 10.1111/1471-0528.16589] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/27/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To compare rates of vaginal delivery and adverse outcomes of instrumental delivery trials in obstetric theatre compared to primary emergency full dilation caesarean section. DESIGN Retrospective cohort study. SETTING University teaching hospital. POPULATION Women with singleton, non-anomalous, pregnancy undergoing instrumental delivery trial in obstetric theatre. METHODS Data were collected from consecutive cases during 2014 until 2018 using clinical records. Multivariate regression analysis was used comparing outcomes per first delivery method. MAIN OUTCOME MEASURES Primary outcome was completion of vaginal delivery between all methods of instrumental delivery. Secondary outcome was a composite of immediate perinatal adverse outcomes for instrumental delivery modes and primary full dilation caesarean section. RESULTS From 971 deliveries analysed: ventouse delivery was significantly less likely to achieve vaginal delivery compared with Keilland's forceps delivery (odds ratio [OR] 0.42, 95% CI 0.22-0.79). Once confounding factors were adjusted for, adverse outcome rates were less frequent in the Keilland's forceps group than with primary full dilation caesarean section (OR 0.37, 95% CI 0.16-0.81); however, the receiver operating characteristic curve produced from this model demonstrated a low predictive value (AUC 0.64). CONCLUSIONS Attempting instrumental delivery in delivery suite theatre, as an alternative to primary emergency full dilation caesarean section, is both reasonable and safe. In this study, ventouse delivery performed poorly in comparison with other modes of instrumental delivery. Further research in the form of randomised controlled trials to identify the optimal mode of second stage delivery is paramount. TWEETABLE ABSTRACT Instrumental delivery trials in theatre are safe but use of ventouse was associated with a higher rate of failure.
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Affiliation(s)
- L Gurney
- West Midlands Fetal Medicine Centre, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - B H Al Wattar
- Warwick Medical School, University of Warwick, Coventry, UK
| | - A Sher
- Maternity Department, James Cook University Hospital, Middlesbrough, UK
| | - C Echevarria
- Respiratory Department, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - H Simpson
- Maternity Department, James Cook University Hospital, Middlesbrough, UK
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The effectiveness of financial intervention strategies for reducing caesarean section rates: a systematic review. BMC Public Health 2019; 19:1080. [PMID: 31399068 PMCID: PMC6688325 DOI: 10.1186/s12889-019-7265-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Accepted: 06/30/2019] [Indexed: 01/08/2023] Open
Abstract
Background The increasing trend of Caesarean section (CS) in childbirth has become a global public health challenge. Previous studies have proposed financial intervention strategies for reducing CS rates by limiting caesarean delivery on maternal request (CDMR). This study synthesizes such strategies while evaluating their effectiveness. Methods The sources of data for this study are Cochrane Library, PubMed, EMBASE, and CINAHL. The publication period included in this study is from January 1991 to November 2018. The financial intervention strategies are divide into two categories: healthcare provider interventions and patient interventions. Risk of Bias in Non-randomized Studies - of Interventions (ROBINS-I) was employed to assess the risk of bias of included studies. The outcome of each study was evaluated with Grades of Recommendation, Assessment, Development and Evaluation (GRADE) through the GRADEpro Guideline Development Tool software. Results Nine studies were included in this systematic review: five with high certainty evidence (HCE), three with moderate certainty evidence (MCE), and one with low certainty evidence (LCE). Of the nine studies, seven are centered on the effect of provider-side interventions. Three of the HCE studies found that the diagnosis-related group payment system, risk-adjusted capitation, and equalizing fee for both facilities and physicians were effective intervention strategies. One HCE and one MCE study showed that only equalizing facility fees between vaginal and CS deliveries in healthcare service settings had no significant effect on reducing the CS rate. The MCE study showed that case payment had a negative effect on reducing the CS rates. One LCE study revealed that the effect of a global budget system was uncertain, and one HCE and one MCE study focused on combining both provider and patient-side interventions. However, equalizing fees for vaginal and CS deliveries and a co-payment policy for CDMRs failed to reduce the CS rate. Conclusions The effectiveness of risk-adjusted payment methods appears promising and should be the subject of further research. Financial interventions should consider stakeholders’ characteristics, especially the personal interests of doctors. Finally, high-quality randomized control trials and comparative studies on different financial intervention methods are needed to confirm or refute previous studies’ outcomes. Electronic supplementary material The online version of this article (10.1186/s12889-019-7265-4) contains supplementary material, which is available to authorized users.
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Chapman A, Nagle C, Bick D, Lindberg R, Kent B, Calache J, Hutchinson AM. Maternity service organisational interventions that aim to reduce caesarean section: a systematic review and meta-analyses. BMC Pregnancy Childbirth 2019; 19:206. [PMID: 31286892 PMCID: PMC6615143 DOI: 10.1186/s12884-019-2351-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 06/04/2019] [Indexed: 12/13/2022] Open
Abstract
Background Caesarean sections (CSs) are associated with increased maternal and perinatal morbidity, yet rates continue to increase within most countries. Effective interventions are required to reduce the number of non-medically indicated CSs and improve outcomes for women and infants. This paper reports findings of a systematic review of literature related to maternity service organisational interventions that have a primary intention of improving CS rates. Method A three-phase search strategy was implemented to identify studies utilising organisational interventions to improve CS rates in maternity services. The database search (including Cochrane CENTRAL, CINAHL, MEDLINE, Maternity and Infant Care, EMBASE and SCOPUS) was restricted to peer-reviewed journal articles published from 1 January 1980 to 31 December 2017. Reference lists of relevant reviews and included studies were also searched. Primary outcomes were overall, planned, and unplanned CS rates. Secondary outcomes included a suite of birth outcomes. A series of meta-analyses were performed in RevMan, separated by type of organisational intervention and outcome of interest. Summary risk ratios with 95% confidence intervals were presented as the effect measure. Effect sizes were pooled using a random-effects model. Results Fifteen articles were included in the systematic review, nine of which were included in at least one meta-analysis. Results indicated that, compared with women allocated to usual care, women allocated to midwife-led models of care implemented across pregnancy, labour and birth, and the postnatal period were, on average, less likely to experience CS (overall) (average RR 0.83, 95% CI 0.73 to 0.96), planned CS (average RR 0.75, 95% CI 0.61 to 0.93), and episiotomy (average RR 0.84, 95% CI 0.74 to 0.95). Narratively, audit and feedback, and a hospital policy of mandatory second opinion for CS, were identified as interventions that have potential to reduce CS rates. Conclusion Maternity service leaders should consider the adoption of midwife-led models of care across the maternity episode within their organisations, particularly for women classified as low-risk. Additional studies are required that utilise either audit and feedback, or a hospital policy of mandatory second opinion for CS, to facilitate the quantification of intervention effects within future reviews. PROSPERO registration CRD42016039458; prospectively registered. Electronic supplementary material The online version of this article (10.1186/s12884-019-2351-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Anna Chapman
- School of Nursing and Midwifery, Centre for Quality and Patient Safety Research, Deakin University, Geelong, VIC, Australia.,Monash Medical Centre, Monash Health, Level 2 I Block, 246 Clayton Rd, Clayton, 3168, VIC, Australia
| | - Cate Nagle
- Centre for Nursing and Midwifery Research, James Cook University, Townsville, Queensland, Australia.,Townsville Hospital and Health Service, Townsville, Queensland, Australia
| | - Debra Bick
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Rebecca Lindberg
- Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, Geelong, Victoria, Australia
| | - Bridie Kent
- Faculty of Health and Human Sciences, University of Plymouth, Plymouth, Devon, UK
| | - Justin Calache
- School of Nursing and Midwifery, Centre for Quality and Patient Safety Research, Deakin University, Geelong, VIC, Australia.,Monash Medical Centre, Monash Health, Level 2 I Block, 246 Clayton Rd, Clayton, 3168, VIC, Australia
| | - Alison M Hutchinson
- School of Nursing and Midwifery, Centre for Quality and Patient Safety Research, Deakin University, Geelong, VIC, Australia. .,Monash Medical Centre, Monash Health, Level 2 I Block, 246 Clayton Rd, Clayton, 3168, VIC, Australia.
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