Challenges in childbirth research – caesarean section, obesity and postpartum haemorrhage

Challenges in childbirth research – caesarean section,

obesity and postpartum haemorrhage

Prof Cecily Begley

Trinity College Dublin, Irelandand

Visiting Professor, University of Gothenburg, Sweden

Challenges in ChildbirthChallenges in Childbirth

… …and Challenges in and Challenges in Childbirth Childbirth

Research…Research…

tend to tend to

be linkedbe linked

Challenges in European ChildbirthChallenges in European Childbirth

Problem: Problem:

The present solutionThe present solution

33

The industrial model of The industrial model of childbirthchildbirth

Caesarean section rates:Caesarean section rates:

Low (17%) Norway, Sweden, the Low (17%) Norway, Sweden, the NetherlandsNetherlands

Moderate (20 - 22 %) in Spain, France, Moderate (20 - 22 %) in Spain, France, Belgium, DenmarkBelgium, Denmark

High in (24.6-27.8%) England, Wales, High in (24.6-27.8%) England, Wales, Scotland, (29.9%) in Northern Ireland Scotland, (29.9%) in Northern Ireland and (27%) in Ireland (EURO-PERISTAT and (27%) in Ireland (EURO-PERISTAT 2010) 2010)

Caesarean sectionCaesarean section

• CS, when performed for medical indications such as placenta praevia or transverse lie, for example, is a necessary and sometimes life-saving operation (Neilson 2003).

BUT• CS does double the risk (compared with

vaginal birth) of maternal mortality and severe maternal morbidity (hysterectomy, intensive care admission, blood transfusion) (Villar et al 2006)

Caesarean sectionCaesarean section

•So – CS is not an operation to be undertaken lightly.

Challenges in trying to reduce CS Challenges in trying to reduce CS rates rates

(and trying to conduct research (and trying to conduct research testing interventions to reduce CS testing interventions to reduce CS

rates)rates)Takes a long time to Takes a long time to reverse the trendreverse the trend

Challenges (continued)Challenges (continued)

Hard to change people’s mindsHard to change people’s minds

Need large sample sizes to find any significant Need large sample sizes to find any significant difference difference

E.g. E.g. 24 maternity units with 624 women included in each site, to detect a 7 percentage point difference between control & intervention groups; so, many any countries are not big enough to conduct a large countries are not big enough to conduct a large enough trialenough trial

Challenges (continued)Challenges (continued)

• Needs to be an interdisciplinary approach….Needs to be an interdisciplinary approach….

• Clinicians have expert clinical knowledge, know Clinicians have expert clinical knowledge, know what research is needed, & how to apply the what research is needed, & how to apply the findings.findings.

• Researchers know how to collect data in a valid & Researchers know how to collect data in a valid & reliable fashion, & how to analyse & interpret it.reliable fashion, & how to analyse & interpret it.

• Women and their families know what they want.Women and their families know what they want.

The OptiBIRTH Study

Aim of OptiBIRTHAim of OptiBIRTH

To increase VBAC rates from 25 to 53% (approximately)…..

through enhanced women-centred care…

OptiBIRTH studyOptiBIRTH study

• A cluster randomised trial in Ireland, Germany and Italy, with 15 clusters (maternity units) of 120 women in each.

• To test an educational intervention for women and clinicians.

InterventionIntervention

Was developed through:Was developed through:– Two systematic reviews of interventions to Two systematic reviews of interventions to

increase VBAC, targeting clinicians and women.increase VBAC, targeting clinicians and women.

– Focus group and individual interviews involving Focus group and individual interviews involving 115 clinicians and 71 women, held in Ireland, 115 clinicians and 71 women, held in Ireland, Italy, Germany (low VBAC rates), and Finland, Italy, Germany (low VBAC rates), and Finland, Sweden and the Netherlands (high VBAC rates).Sweden and the Netherlands (high VBAC rates).

What is happening What is happening nownow

• Randomised trial has started in April/May 2014

• Outcomes will be measured in both groups

• Costs will be assessed in both groups

Future studiesFuture studies

ObesityObesity

Major challenge in this decadeMajor challenge in this decade

High levels of morbidity and mortalityHigh levels of morbidity and mortality

Increases all other childbirth Increases all other childbirth challenges (CS, PPH)challenges (CS, PPH)

Difficult to modify people’s behaviourDifficult to modify people’s behaviour

Work of the Childbirth Work of the Childbirth Research GroupResearch Group

Bertz F, Sparud-Lundin, C & Winkvist A. (2013). Transformative Lifestyle Change: Key to Sustainable Weight Loss among Women in a Postpartum Diet and Exercise Intervention. Maternal & Child Nutrition Nov 15 [Epub ahead of print].

Work of the Childbirth Work of the Childbirth Research GroupResearch Group

Mériaux, Benita Gunnarsson; Berg, Marie; Hellström, Anna-Lena (2010) Everyday experiences of life, body and well-being in children with overweight.. Scandinavian journal of caring sciences, 24 (1) s. 14-23.

If mother obese - 2 times higher risk of LGA

If the baby is a girl and is obese when she is pregnant - 3 times higher risk of LGA

Future Work of the Future Work of the Childbirth Research GroupChildbirth Research Group

Promoting a healthy lifestyle among women with obesity in pregnancy and early motherhood

– MoObese Person-centred Care – key challenge is the need for sensitivity


1 )To what extent is Person-Centred Care Used in Interventions to Limit the Gestational Weight Gain in Pregnant Women with Obesity? A Systematic Review (submitted)

2) Support to adopt a healthy lifestyle for

pregnant women with BMI ≥ 30 - women's perceptions 2½ year after childbirth.


3 ) Health outcomes for mother and baby related to BMI ≥ 30 during pregnancy - a review of reviews.

4) Community midwives´ use of person-centred care aspects when caring for pregnant women with BMI ≥ 30.

Reducing obesity in Reducing obesity in pregnant womenpregnant women

Challenging – but worth it!Challenging – but worth it!

Postpartum haemorrhagePostpartum haemorrhage

Is this a challenge?Is this a challenge?

Does it need more research?Does it need more research?

Postpartum haemorrhagePostpartum haemorrhage

A major challenge in low-income countries – A major challenge in low-income countries – further research is neededfurther research is needed

A major challenge for women at high risk – A major challenge for women at high risk – medical complications, deprived medical complications, deprived backgrounds – further research is neededbackgrounds – further research is needed

But not a challenge for low-risk women, so But not a challenge for low-risk women, so further research is needed to prevent harms further research is needed to prevent harms due to preventative treatment.due to preventative treatment.

Cochrane review on third Cochrane review on third stage managementstage management

Compares AMTSL and EMTSL Compares AMTSL and EMTSL

Includes 5 studies (6486 Includes 5 studies (6486 women), all undertaken in women), all undertaken in high-income countrieshigh-income countries (Begley (Begley et al 2011).et al 2011).

In women at low risk of In women at low risk of bleeding (3 studies, 3134 bleeding (3 studies, 3134

women)women) No difference was identified in No difference was identified in

severe blood loss (greater severe blood loss (greater than 1000 ml)than 1000 ml)

No difference was identified in No difference was identified in postnatal anaemiapostnatal anaemia

In women at low risk of In women at low risk of bleeding bleeding

ActiveActive ExpectantExpectant 500ml+ 500ml+ 4.8%4.8% 10.5%10.5% BTBT .4% .4% 1.5% 1.5% BWBW -67 gms-67 gms BP >90BP >90 2.8% 2.8% .4% .4% PainPain 4.5% 4.5% 1.8% 1.8% Bleed (treat) Bleed (treat) 5.7%5.7% 3.7% 3.7% Bleed (return)Bleed (return) 2.8%2.8% 1.3% 1.3%

So, for women at low risk of So, for women at low risk of bleeding bleeding

Is AMTSL causing more harm than Is AMTSL causing more harm than good?good?

Clinicians argue against Clinicians argue against physiological management : physiological management :

““Women die of PPH”Women die of PPH”

Do they????Do they????

Esscher, A. 2014. Maternal Mortality Esscher, A. 2014. Maternal Mortality in Sweden. Classification, Country of in Sweden. Classification, Country of Birth, and Quality of Care. - Did not Birth, and Quality of Care. - Did not mention PPHmention PPH

CMACE UK 2011CMACE UK 2011

Out of 2.3 million women birthing 2006-Out of 2.3 million women birthing 2006-2008, only 5 died of PPH.2008, only 5 died of PPH.

3/5 lacked post-operative observations 3/5 lacked post-operative observations using MEOWS chart – failure of staff to using MEOWS chart – failure of staff to realise they were bleeding.realise they were bleeding.

1 had Hb of 7.5 prior to CS, then bled 1-2 1 had Hb of 7.5 prior to CS, then bled 1-2 litres, then died months later after litres, then died months later after pneumoniapneumonia

1 concealed pregnancy, died at home.1 concealed pregnancy, died at home.

NONE of these women NONE of these women were at “low risk” to were at “low risk” to haemorrhagehaemorrhage

So…..So…..

……for low-risk women, there are benefits to both for low-risk women, there are benefits to both methods, and harms from both methods.methods, and harms from both methods.

The Cochrane review states that they should The Cochrane review states that they should be informed of benefits and harms of both be informed of benefits and harms of both methods of care.methods of care.

New Zealand (Dixon 2013)New Zealand (Dixon 2013)

Population based, retrospective cohort Population based, retrospective cohort study, reporting on MTSLstudy, reporting on MTSL

Included 33,752 low-risk women who Included 33,752 low-risk women who had no oxytocic for induction/ had no oxytocic for induction/ accelerationacceleration

48% had EMTSL, 52% had AMTSL48% had EMTSL, 52% had AMTSL

New Zealand (2)New Zealand (2)

EMTSL - 3.7% had PPH > 500 mlEMTSL - 3.7% had PPH > 500 ml

AMTSL - 6.9% had PPH > 500 mlAMTSL - 6.9% had PPH > 500 ml

Ireland (Begley et al 2014)Ireland (Begley et al 2014)

Retrospective analysis

Data drawn from the electronic database of a midwifery-led unit in Ireland

5-year period 2008-2012

ResultsResults

All women (n=1521) had

spontaneous onset of labourno oxytocic for augmentationspontaneous vaginal birth.

738 women (48.52%) had EMTSL

783 women (51.48%) received AMTSL

Results (1): blood lossResults (1): blood loss

Average estimated blood loss was:

258 mls (SD 197 mls) in the ‘expectant’ group

241 mls (SD 177 mls) in the ‘active’ group

This was a non-significant difference of -17 mls (95% CI -35.835 to 1.778) (t=-1.78, d.f. = 1519, p=0.76).

Results (2): PPH ratesResults (2): PPH rates

Postpartum haemorrhage rates were:

2.71% (n=20) in the ‘expectant’ group

2.17% (n=17) in the ‘active’ group

No significant difference (chi-square = 0.465, d.f.=1, p=0.50).

Results (3):Results (3):

No difference in length of 3rd stage: AMTSL: 19 mins 2 secs (SD 1 min 11

secs) EMTSL: 20 mins 18 secs (SD 1 min 8

secs)

4949

DiscussionDiscussion

The New Zealand (Dixon 2013) and Irish (Begley et al 2014) studies show that when:

midwives are experienced in expectant third stage care, and

women are low-risk

……. mean blood loss amounts, and PPH rates, are similar regardless of whether active or expectant care is used.

ChallengeChallenge

Low risk women are not being offered EMTSL, nor are they being informed of the risks of AMTSL, to allow them to make an informed choice.

Need research comparing AMTSL and EMTSL in women who are genuinely ‘low-risk’, cared for by midwives skilled in both methods of care.

Challenge (2)Challenge (2)

Need research comparing giving oxytocin before, compared with after, delayed cord clamping.

Need research comparing different timings of delayed cord clamping.

Challenges in ChildbirthChallenges in Childbirth

… …and Challenges in and Challenges in Childbirth Childbirth Research…Research…

Caesarean section, obesity and postpartum haemorrhage Person-centred carePerson-centred care

5454

…….helps .helps women to women to have happy have happy childbirth, as childbirth, as well as well as healthyhealthy

5555

References References Begley CM, Gyte GML, Devane D, McGuire W, Weeks A. Active versus expectant

management for women in the third stage of labour. Cochrane Database of Systematic Reviews 2011, Issue 11. Art. No.: CD007412. DOI: 10.1002/14651858.CD007412.pub3.

Begley C, Dencker A, Keegan C, Martin M, McCann C, Smith V. Postpartum haemorrhage and blood loss in midwifery-led care in Ireland. 30th ICM (International Confederation of Midwives) Triennial Congress, 1-5 June 2014, Prague, Czech Republic.

Dixon L, Tracy SK, Guilliland K, Fletcher L, Hendry C, Pairman S. 2013 Outcomes of physiological and active third stage labour care amongst women in New Zealand. Midwifery 29(1):67-74.

Esscher, A. 2014. Maternal Mortality in Sweden. Classification, Country of Birth, and Quality of Care. Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine 970. 69 pp. Uppsala: Acta Universitatis Upsaliensis. ISBN 978-91-554-8863-5.

EURO-PERISTAT Project with SCPE and EUROCAT. 2013. European Perinatal EURO-PERISTAT Project with SCPE and EUROCAT. 2013. European Perinatal Health Report. The health and care of pregnant women and babies in Europe in Health Report. The health and care of pregnant women and babies in Europe in 2010.May 2013. Available www.europeristat.com2010.May 2013. Available www.europeristat.com

Neilson JP. 2003. Interventions for suspected placenta praevia. Neilson JP. 2003. Interventions for suspected placenta praevia. Cochrane Cochrane Database of Systematic Reviews, Issue 2Database of Systematic Reviews, Issue 2[DOI:10.1002/14651858.CD001998][DOI:10.1002/14651858.CD001998]

Villar J, Valladares E, Wojdyla D, Zavaleta N, Carroli G, Velazco A, et al. (2007) WHO (2005) Global Survey on Maternal and Perinatal Health. BMJ, 335(7628) pp. 1025.

Challenges in childbirth research – caesarean section, obesity and postpartum haemorrhage

Documents

Transcript of Challenges in childbirth research – caesarean section, obesity and postpartum haemorrhage