Challenges in childbirth research

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Challenges in childbirth research caesarean
section, obesity and postpartum haemorrhage
Prof Cecily Begley Trinity College
Dublin, Ireland and Visiting Professor,
University of Gothenburg, Sweden

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Challenges in Childbirth

• and Challenges in
  Childbirth Research
• tend to
• be linked

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Challenges in European Childbirth

• Problem
• The present solution

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The industrial model of childbirth

• Caesarean section rates
• Low (17) Norway, Sweden, the Netherlands
• Moderate (20 - 22 ) in Spain, France, Belgium,
  Denmark
• High in (24.6-27.8) England, Wales, Scotland,
  (29.9) in Northern Ireland and (27) in Ireland
  (EURO-PERISTAT 2010)

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Caesarean 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)

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Caesarean section

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

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Challenges in trying to reduce CS rates (and
trying to conduct research testing interventions
to reduce CS rates)

• Takes a long time to
  reverse the trend

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Challenges (continued)

• Hard to change peoples minds
• Need large sample sizes to find any significant
  difference
• 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 countries are not big enough to conduct
  a large enough trial

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Challenges (continued)

• Needs to be an interdisciplinary approach.
• Clinicians have expert clinical knowledge, know
  what research is needed, how to apply the
  findings.
• Researchers know how to collect data in a valid
  reliable fashion, how to analyse interpret
  it.
• Women and their families know what they want.

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The OptiBIRTH Study
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Aim of OptiBIRTH

• To increase VBAC rates from 25 to 53
  (approximately)..
• through enhanced women-centred care

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OptiBIRTH 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.

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Intervention

• Was developed through
• Two systematic reviews of interventions to
  increase VBAC, targeting clinicians and women.
• Focus group and individual interviews involving
  115 clinicians and 71 women, held in Ireland,
  Italy, Germany (low VBAC rates), and Finland,
  Sweden and the Netherlands (high VBAC rates).

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What is happening now

• Randomised trial has started in April/May 2014
• Outcomes will be measured in both groups
• Costs will be assessed in both groups

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Future studies
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Obesity

• Major challenge in this decade
• High levels of morbidity and mortality
• Increases all other childbirth challenges (CS,
  PPH)
• Difficult to modify peoples behaviour

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Work of the Childbirth Research 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.

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Work of the Childbirth Research 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

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Future Work of the Childbirth 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

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Future Work of the Childbirth Research Group

• 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.

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Future Work of the Childbirth Research Group

• 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.

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Reducing obesity in pregnant women

• Challenging but worth it!

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Postpartum haemorrhage

• Is this a challenge?
• Does it need more research?

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Postpartum haemorrhage

• A major challenge in low-income countries
  further research is needed
• A major challenge for women at high risk
  medical complications, deprived backgrounds
  further research is needed
• But not a challenge for low-risk women, so
  further research is needed to prevent harms due
  to preventative treatment.

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Cochrane review on third stage management

• Compares AMTSL and EMTSL
• Includes 5 studies (6486 women), all undertaken
  in high-income countries (Begley et al 2011).

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

• No difference was identified in severe blood loss
  (greater than 1000 ml)
• No difference was identified in postnatal anaemia

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In women at low risk of bleeding

• Active Expectant
• 500ml 4.8 10.5
• BT .4 1.5
• BW -67 gms
• BP gt90 2.8 .4
• Pain 4.5 1.8
• Bleed (treat) 5.7 3.7
• Bleed (return) 2.8 1.3

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So, for women at low risk of bleeding

• Is AMTSL causing more harm than good?

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Clinicians argue against physiological management

• Women die of PPH
• Do they????
• Esscher, A. 2014. Maternal Mortality in Sweden.
  Classification, Country of Birth, and Quality of
  Care. - Did not mention PPH

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CMACE UK 2011

• Out of 2.3 million women birthing 2006-2008, only
  5 died of PPH.
• 3/5 lacked post-operative observations using
  MEOWS chart failure of staff to realise they
  were bleeding.
• 1 had Hb of 7.5 prior to CS, then bled 1-2
  litres, then died months later after pneumonia
• 1 concealed pregnancy, died at home.

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• NONE of these women were at low risk to
  haemorrhage

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So..

• for low-risk women, there are benefits to both
  methods, and harms from both methods.
• The Cochrane review states that they should be
  informed of benefits and harms of both methods of
  care.

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New Zealand (Dixon 2013)

• Population based, retrospective cohort study,
  reporting on MTSL
• Included 33,752 low-risk women who had no
  oxytocic for induction/ acceleration
• 48 had EMTSL, 52 had AMTSL

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New Zealand (2)

• EMTSL - 3.7 had PPH gt 500 ml
• AMTSL - 6.9 had PPH gt 500 ml

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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

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Results

• All women (n1521) had
• spontaneous onset of labour
• no oxytocic for augmentation
• spontaneous vaginal birth.
• 738 women (48.52) had EMTSL
• 783 women (51.48) received AMTSL

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Results (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, p0.76).
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Results (2) PPH rates
Postpartum haemorrhage rates were 2.71 (n20)
in the expectant group 2.17 (n17) in the
active group No significant difference
(chi-square 0.465, d.f.1, p0.50).
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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)

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Discussion

• 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.

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Challenge

• 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.

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Challenge (2)

• Need research comparing giving oxytocin before,
  compared with after, delayed cord clamping.
• Need research comparing different timings of
  delayed cord clamping.

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Challenges in Childbirth

• and Challenges in
  Childbirth Research

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Caesarean section, obesity and postpartum
haemorrhage

• Person-centred care

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• .helps women to have happy childbirth, as well
  as healthy

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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 Health Report. The
  health and care of pregnant women and babies in
  Europe in 2010.May 2013. Available
  www.europeristat.com
• Neilson JP. 2003. Interventions for suspected
  placenta praevia. Cochrane Database of Systematic
  Reviews, Issue 2DOI10.1002/14651858.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.