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- ItemFactors affecting third‐stage management and postpartum hemorrhage in planned midwife‐led home and birth center births in the United States(John Wiley & Sons, Inc., 2020-07-29) Erickson, Elise N.; Bovbjerg, Marit L.; Cheyney, Melissa J.; Foundation for the Advancement of Midwifery; National Institutes of Health; Eunice Kennedy Shriver National Institute of Child Health and Human Development; Fulbright Association; Health Resources and Services AdministrationBackground: Postpartum hemorrhage (PPH) is a potential childbirth complication. Little is known about how third-stage labor is managed by midwives in the United States, including use of uterotonic medication during community birth. Access to uterotonic medication may vary based on credentials of the midwife or state regulations governing midwifery. Methods: Using data from the Midwives of North America 2.0 database (2004-2009), we describe the PPH incidence for women giving birth in the community, their demographic and clinical characteristics, and methods used by midwives to address PPH. We also examined PPH rates by midwifery credentials and by the presence of regulations for legal midwifery practice. Results: Of the 17 836 vaginal births, 15.9% had blood loss of over 500 mL and 3.3% had 1000 mL or greater blood loss. Midwives used pharmaceuticals to prevent or treat postpartum bleeding in 6.3% and 13.9% of births, respectively, and the rate of hospital transfer after birth was 1.4% (n = 247). In adjusted analyses, PPH was less likely when births occurred at home vs a birth center, if the midwife had a CNM/CM credential vs a CPM/LM/LDM credential, or if the woman was multiparous without a history of PPH or prior cesarean birth. PPH was more likely in states with barriers to midwifery practice compared with regulated states (OR: 1.26; 95% CI, 1.16-1.38).Conclusions: Women giving birth in the community experienced low overall incidence of PPH-related hospital transfer. However, the occurrence of PPH itself would likely be reduced with improved legal access to uterotonic medication.
- ItemDischarge age and weight for very preterm infants in six countries: 2012-2020(Karger International, 2023-01) Edwards, Erika M.; Greenberg, Lucy T.; Horbar, Jeffrey D.; Gagliardi, Luigi; Adams, Mark; Berger, Angelika; Leitao, Sara; Luyt, Karen; Ehret, Danielle E. Y.; Rogowski, Jeannette A.Postmenstrual age for surviving infants without congenital anomalies born at 24-29 weeks' gestational age from 2005 to 2018 in the USA increased 8 days, discharge weight increased 316 grams, and median discharge weight z-score increased 0.19 standard units. We asked whether increases were observed in other countries. We evaluated postmenstrual age, weight, and weight z-score at discharge of surviving infants without congenital anomalies born at 24-29 weeks' gestational age admitted to Vermont Oxford Network member hospitals in Austria, Ireland, Italy, Switzerland, the UK, and the USA from 2012 to 2020. After adjustment, the median postmenstrual age at discharge increased significantly in Austria (3.6 days, 99% CI [1.0, 6.3]), Italy (4.0 days [2.3, 5.6]), and the USA (5.4 days [5.0, 5.8]). Median discharge weight increased significantly in Austria (181 grams, 99% CI [95, 267]), Ireland (234 [143, 325]), Italy (133 [83, 182]), and the USA (207 [194, 220]). Median discharge weight z-score increased in Ireland (0.24 standard units, 99% CI [0.12, 0.36]) and the USA (0.15 [0.13, 0.16]). Discharge on human milk increased in Italy, Switzerland, and the UK, while going home on cardiorespiratory monitors decreased in Austria, Ireland, and USA and going home on oxygen decreased in Ireland. In this international cohort of neonatal intensive care units, postmenstrual discharge age and weight increased in some, but not all, countries. Processes of care at discharge did not change in conjunction with age and weight increases.
- ItemPredicting risk of postpartum haemorrhage during the intrapartum period in a general obstetric population(Elsevier B. V., 2022-09) Maher, Gillian M.; McKernan, Joye; O'Byrne, Laura; Corcoran, Paul; Greene, Richard A.; Khashan, Ali S.; McCarthy, Fergus P.; Health Research BoardObjective: To develop and validate (both internally and externally) a prediction model examining a combination of risk factors in order to predict postpartum haemorrhage (PPH) in a general obstetric Irish population of singleton pregnancies. Study design: We used data from the National Maternal and Newborn Clinical Management System (MN-CMS), including all singleton deliveries at Cork University Maternity Hospital (CUMH), Ireland during 2019. We defined PPH as an estimated blood loss of = 1000 ml following the birth of the baby. Multivariable logistic regression with backward stepwise selection was used to develop the prediction model. Candidate predictors included maternal age, maternal body mass index, parity, previous caesarean section, assisted fertility, gestational age, fetal macrosomia, mode of delivery and history of PPH. Discrimination was assessed using the area under the receiver operating characteristic curve (ROC) C-statistic. We used bootstrapping for internal validation to assess overfitting, and conducted a temporal external validation using data from all singleton deliveries at CUMH during 2020. Results: Out of 6,077 women, 5,807 with complete data were included in the analyses, and there were 270 (4.65%) cases of PPH. Four variables were considered the best combined predictors of PPH, including parity (specifically nulliparous), macrosomia, mode of delivery (specifically operative vaginal delivery, emergency caesarean section and prelabour caesarean section), and history of PPH. These predictors were used to develop a nomogram to provide individualised risk assessment for PPH. The original apparent C-statistic was 0.751 (95% CI: 0.721, 0.779) suggesting good discriminative performance. There was minimal optimism adjustment to the C-statistic after bootstrapping, indicating good internal performance (optimism adjusted C-statistic: 0.748). Results of external validation were comparable with the development model suggesting good reproducibility. Conclusions: Four routinely collected variables (parity, fetal macrosomia, mode of delivery and history of PPH) were identified when predicting PPH in a general obstetric Irish population of singleton pregnancies. Use of our nomogram could potentially assist with individualised risk assessment of PPH and inform clinical decision-making allowing those at highest risk of PPH be actively managed.
- ItemFetal medicine specialist experiences of providing a new service of termination of pregnancy for fatal fetal anomaly: a qualitative study(John Wiley & Sons, Inc., 2020-09-15) Power, S; Meaney, Sarah; O'Donoghue, KeelinObjective: To explore fetal medicine specialists' experiences of caring for parents following a diagnosis of fatal fetal anomaly (FFA) during the implementation of termination of pregnancy (TOP) for FFA for the first time. Design: Qualitative study. Setting: Fetal medicine units in the Republic of Ireland. Population: Ten fetal medicine specialists from five of the six fetal medicine units. Methods: nvivo 12 assisted in the thematic analysis of semi-structured in-depth face-to-face interviews. Main outcome measures: Fetal medicine specialists' experiences of prenatal diagnosis and holistic management of pregnancies complicated by FFA. Results: Four themes were identified: 'not fatal enough', 'interactions with colleagues', 'supporting pregnant women' and 'internal conflict and emotional challenges'. Fetal medicine specialists feared getting an FFA diagnosis incorrect because of media scrutiny and criminal liability associated with the TOP for FFA legislation. Challenges with the ambiguous and 'restrictive' legislation were identified that 'ostracised' severe anomalies. Teamwork was essential to facilitate opportunities for learning and peer support; however, conflict with colleagues was experienced regarding the diagnosis of FFA, the provision of feticide and palliative care to infants born alive following TOP for FFA. Participants reported challenges implementing TOP for FFA, including the absence of institutional support and 'stretched' resources. Fetal medicine specialists experienced internal conflict and a psychological burden providing TOP for FFA, but did so to 'provide full care for women'. Conclusions: Our study identified challenges regarding the suitability of the Irish legislation for TOP for FFA and its rapid introduction into clinical practice. It illustrates the importance of institutional and peer support, as well as the need for supportive management, in the provision of a new service. Tweetable abstract: The implementation of termination services for fatal fetal anomaly is complex and requires institutional support.
- ItemInfluence of cost on contraceptive choices amongst university students(Irish Medical Organisation, 2021) McConnell, Roisin; Meaney, Sarah; O'Donoghue, KeelinIntroduction: Cost remains a major barrier in accessing effective contraception especially long-acting reversible contraception. This study sought to assess the current contraception choices amongst university students including the influence of cost on choices. Methods: A cross-sectional study of Irish university students at University College Cork was undertaken. The online survey examined current contraception use, justifications for this choice of contraception and the effect that hypothetical provision of free contraception would have on their choices. Results: A total of 1,840 sexually active students completed the online survey. Condoms were used by 1,020 students (55.4%), the combined pill was used by 729 (39.6%) and ‘coitus interruptus’ was used by 169 students (9.1%). Statistically males were more likely to spend under €50 annually (47.6%, n=182 of 382, p<0.001) and female students were more likely to spend over €100 on contraception (41.2%, n=470 of 1,141, p<0.001).By removing cost, 394 (34.3%) sexually active women would definitely change contraception, with another 250 women (21.8%) considering changing. Discussion: Students often rely on unreliable or user-dependent methods of contraception. Our study has demonstrated that cost influences contraceptive choice with nearly half of the women surveyed stating they would change contraception if cost was removed.