Higher order multiple pregnancies in New South Wales 1990-1999

OBJECTIVE: To examine higher order multiple pregnancy and birth rates in NSW, and to describe trends in the characteristics and management of these births. DESIGN: Cross-sectional analytic study. SETTING: New South Wales, Australia. POPULATION: Two hundred and ninety-one women who gave birth to triplets, quadruplets or quintuplets (880 babies) from 1 January 1990 to 31 December 1999. METHODS: Data were obtained from the NSW Midwives Data Collection and rates over time were calculated. MAIN OUTCOME MEASURES: Higher order multiple birth and pregnancy rates (> or = 20 weeks), place of birth, mode of delivery, fetal death rates and Apgar scores. RESULTS: There was no significant change in the number or rate of higher order multiple births in NSW during the 1990s with an average annual rate of 10.3/10,000 births or 3.5/10,000 pregnancies > or = 20 weeks. Among women with higher order multiple pregnancies, those aged > or = 35 years increased from 19% in 1990 to 47% in 1999. There was also a trend towards delivery in a perinatal centre from 56% to 70%, and vaginal birth from 18% to 28%. There were no significant changes in infant outcomes. CONCLUSIONS: The increases in higher order multiple pregnancies observed in Australia in the 1980s, and into the 1990s in other countries, have not persisted in NSW, suggesting that guidelines for limiting the number of embryos/oocytes transferred in assisted reproductive technologies have been widely adopted.     

Term breech birth in New South Wales, 1990-1997

Data on 636,708 women delivering a singleton infant of gestational age > or =37 weeks in NSW from 1 January 1990 to 31 December 1997 were used to examine trends in breech births at term and the mode of delivery. From 1990 to 1997, although the crude rate of breech births at term remained stable at 3.4%, the adjusted odds ratio for breech birth compared with cephalic birth decreased over time. Among live breech births, the crude rate of vaginal breech birth declined from 29.4% to 19.7%, with an attendant increase in elective Caesarean sections from 49.1% to 58.4%. Most of this increase was at 38 and 39 weeks gestation. There was no change in the perinatal mortality rate among breech births during the study period. Despite increasing maternal age, the adjusted odds of a breech birth at term decreased over time. This could be due to offsetting factors, such as increased use of external cephalic version. If the decrease in vaginal breech birth continues, it may lead to the skills for this procedure being lost.     

Late entry to antenatal care in New South Wales, Australia

Aims  

This study aimed to assess the prevalence of women who entered antenatal care (ANC) late and to identify factors related to the late entry to ANC in New South Wales (NSW) in 2004.     

The impact of the baby bonus on maternity services in New South Wales

Background:  In 2004, the Federal Government introduced the baby bonus, a one-off payment upon the birth of a child.
Aims:  To assess the impact of an increase in the number of births on maternity services in New South Wales following the introduction of the baby bonus payment in July 2004.
Methods:  A population-based study, using NSW birth records, of 965 635 deliveries from 1998 to 2008 was carried out. The difference between the predicted number of births in 2005–2008, estimated from trends in births from 1998 to 2004, and the observed number of births in NSW hospitals in 2005–2008 were calculated. We also estimated the increase in cost to the health system of births in 2008 compared with previous years.
Results:  Compared with trends prior to the introduction of the baby bonus, there were an estimated 11 283 extra singleton births per year in NSW hospitals by 2008. There were significant increases in the number of deliveries performed in tertiary, urban and rural public hospitals; however, the number of deliveries in private hospitals remained stable. Compared with predicted estimates, in 2008, there were over 8700 more vaginal deliveries, over 1000 more preterm births and over 45 000 extra infant hospital days each year. Compared with 2004, in 2008, the estimated cost of births in NSW hospitals increased by $60 million,
Conclusions:  The increase in births following the introduction of the baby bonus has significantly impacted maternity services in NSW.     

Birth outcomes for teenage women in New South Wales, 1998-2003

BACKGROUND: Pregnancy and childbirth in teenage women are associated with obstetric and social risks, and there is evidence that the birth rate among teenagers in rural and remote areas of Australia is not in decline. The combination of non-urban residence and young age at delivery might define a subgroup of women at special risk of adverse birth outcomes. AIMS: To compare birth outcomes of New South Wales (NSW) teenagers residing in rural and remote areas with those living in larger centres with greater access to services. METHODS: Outcomes for all singleton deliveries to teenage women living in NSW during the period 1998-2003 were reviewed. The women's place of residence was assigned an ARIA (Accessibility/Remoteness Index of Australia) classification according to remoteness and access to services. Analysis included obstetric factors (such as parity), and smoking status. Logistic regression analysis was undertaken to examine the impact of maternal factors on obstetric outcomes. RESULTS: During the study period, 21 880 teenage women had singleton deliveries. Babies of teenage mothers in very remote areas had higher rates of preterm birth, small-for-gestational age and stillbirth. Rates of smoking were higher in more remote areas, and smoking correlated with preterm birth and stillbirth. CONCLUSIONS: Teenagers living in remote areas of NSW face a higher risk of adverse pregnancy outcomes than their urban cousins.     

Female Sterilization in New South Wales, 1981 to 1994–1995

Summary: This paper investigates and confirms the dramatic decline in female sterilization in New South Wales over the past decade, a period when male sterilization has remained fairly constant. The most significant decline occurred among women under 30 years of age, which resulted in a rise in the mean age at sterilization. In 1994–1995, 70% of sterilization operations were performed for contraceptive management only, 11% were concurrent with Caesarean section, and 9% with abortion. Incidental findings were an increase in Caesarean section and the proportion of women having concurrent sterilization, and a large decline in intrauterine device removals, more than half of which were accompanied with sterilization in 1994–1995. Currently-married women accounted for 80% of sterilization cases. Immigrant women generally had lower incidence of sterilization compared to the Australian-born.     

The Incidence of Gestational Diabetes Mellitus in the Illawarra Area of New South Wales

Summary: The incidence of gestational diabetes in the Illawarra area is 7.2% (95% CI: 6.0–8.4). This was determined by data collected by 2 prenatal clinics and 3 private practitioners during 1993. The incidence rate varied between 5.1% at one hospital to 11.3% with a private practitioner. This variation was mainly due to differences in age and ethnic background. The highest incidence rate of 11.9% was found in women of Asian background.     

Maternal deaths in New South Wales, Australia: a data linkage project

Background: The magnitude of maternal mortality is underestimated as deaths occurring beyond the traditional 42-day time period after the pregnancy ending ('late death') have not been reported routinely in Australia.
Aims: The aims of this study were to undertake a data linkage study to improve the ascertainment of maternal deaths and to determine the number of deaths occurring 43–365 days after the pregnancy ended ('late maternal death').
Methods: Data from the New South Wales Midwives Data Collection were linked with the Australian Institute of Health and Welfare National Death Index. Australian identified pregnancy-related deaths were then coded as direct, indirect and incidental to the pregnancy.
Results: During the period 1994–2001, 173 maternal deaths were identified. Of these, 97 were classified as occurring up to 42 days of the pregnancy ending, 15 (15.5%) of which were previously unknown to the maternal mortality committee. In addition, 76 deaths were classified as occurring between 43 and 365 days after the pregnancy ended. The majority (70 of 76) of these late deaths were only identified through the linkage study. Most (73 of 76) of these deaths were classified as indirect maternal deaths with the most common causes of deaths suicide ( n = 23), cardiac disorders ( n = 16) or accident/violence ( n = 16).
Conclusions: The ascertainment of maternal and late maternal mortality was enhanced through data linkage of birth and mortality data. Data linkage is a viable method for monitoring late maternal deaths.     

Trends in labour and birth interventions among low-risk women in New South Wales

OBJECTIVE: To examine recent trends in obstetric intervention rates among women at low-risk of poor pregnancy outcome. DESIGN: Cross-sectional analytic study SETTING AND POPULATION: A population of 336,189 women categorised as low-risk of a poor pregnancy outcome who gave birth to a live singleton in NSW from 1 January 1990 to 31 December 1997. MAIN OUTCOME MEASURES: Obstetric intervention rates including oxytocin induction and augmentation of labour, epidural analgesia, instrumental births, caesarean section and episiotomy METHODS: Trends over time were assessed by fitting trend-lines to numbers of births or by trends in proportions. Unconditional logistic regression was used to assess the impact of epidural analgesia on instrumental birth over time. RESULTS: Rates of operative births did not rise despite increases in maternal age and use of epidural analgesia. Instrumental births declined over time from 26% to 22% among primiparas and 5% to 4% among multiparas. There was also a shift to vacuum extraction rather than forceps. Although instrumental birth was strongly associated with epidural analgesia, the strength of the association declined over the study period, for primiparas from an adjusted odds ratio of 7.2 to 5.2 and for multiparas from 13.2 to 10.3. CONCLUSIONS: Increased use of epidural analgesia for labour has been a feature of the management of birth at term during the 1990s. The decline in the strength of association between epidural analgesia and instrumental birth may reflect improved epidural techniques and management of epidural labour, and recognition of the adverse maternal outcomes associated with forceps and vacuum births.     

Hysterectomy and endometrial ablation in New South Wales, 1981 to 1999-2000

OBJECTIVE: To examine the trends in hysterectomy in New South Wales (NSW) from 1981 to 1999-2000 and the impact of endometrial ablation. DATA: Computerised discharge summaries from private and public hospitals for the years 1981, 1991, 1994-1995 and 1999-2000 obtained from the NSW Health Department. All records listing hysterectomy in women over the age of 20 in each period were selected and those listing endometrial ablation since 1991 were also selected. Operative procedure, diagnosis, hospital type, length of stay and demographic data were recorded. Annual figures since 1988-1989 for hysterectomy and ablation were also obtained. FINDINGS: Initially it appeared that the introduction of endometrial ablation might reduce hysterectomy rates, but the combined rate of hysterectomy and endometrial ablation continued to rise to a peak in 1992-1993 and has declined since. The hysterectomy rate in 1999-2000 was lower than in 1981. There has been a marked shift from abdominal to vaginal hysterectomy, with an increase in laparoscopically assisted operations. Overall, the mean age at operation has been rising, although the mean age for vaginal hysterectomy has fallen. The shift to private hospitals and reduction in hospital stay have continued. CONCLUSION: The trends are consistent with the increased use of laparoscopic and ablation techniques, improvements in hormonal contraceptive use, and better access to abortion, which have facilitated women's decisions to postpone their births and to conserve their childbearing to older ages. Further development of these techniques will have an impact on gynaecological training and practice in the next decade.     

Epidemiology of Pregnancy-associated Venous Thromboembolism: A Population-based Study in Canada

ObjectiveTo estimate the frequency of, and to identify risk factors for, pregnancy-associated venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE) requiring hospitalization.MethodsWe conducted a population-based cohort study (N = 3 852 569) using the Discharge Abstract Database of the Canadian Institute for Health Information (CIHI), for the fiscal years 1991–1992 to 2005–2006. All women with pregnancy-related hospitalizations in Canada (excluding Quebec and Manitoba) were identified. DVT and PE rates were calculated using the number of hospital deliveries (i.e., cohort of women at risk) as the denominator for the antepartum and peripartum (labour and delivery) hospitalizations and for postpartum readmissions. Risk factors for DVT/PE were identified using logistic regression.ResultsDuring the antepartum, peripartum, and postpartum periods, 5.4, 7.2, and 4.3 VTE cases per 10 000 pregnancies, respectively were observed. The total incidence of DVT was 12.1 per 10 000 pregnancies (0.26 deaths per 100 000), and the rate for PE was 5.4 per 10 000 (0.96 deaths per 100 000). The strongest risk factors for DVT occurrence during the peripartum period were thrombophilia (adjusted odds ratio [aOR] 15.4; 95% CI 10.8–22.0), a past history of circulatory disease, and major puerperal infection, whereas those for PE were previous DVT (aOR 56.9; 95% CI 40.9–79.1), heart disease (aOR 43.4, 95% CI 35.0–53.9), antiphospholipid syndrome, past history of circulatory disease, transfusion, and major puerperal infection.ConclusionCases of VTE and associated deaths occur most frequently during the peripartum period. Although mortality from pregnancy-associated VTE is low, maternal characteristics and other factors can be used to identify women at risk for VTE.     

Hysterectomy and Endometrial Ablation in New South Wales, 1981 to 1994–1995

Summary: This study analyses the New South Wales hospital data on hysterectomies from 1981 to 1994–1995, and on endometrial ablations since 1991. The hysterectomy rate declined by about 16% during 1981–1991 and has risen since; the endometrial ablation rate has increased by 28% between 1991 and 1994–1995. Other findings indicate a trend towards older mean age at operation, a swing to vaginal hysterectomy with or without laparoscopy, a shift to private hospitals, and a dramatic decline in length of hospital stay. The majority of endometrial ablations were performed on a day-only basis. Immigrant and Aboriginal women experienced lower hysterectomy rates. Endometrial ablation techniques introduced in the late 1980s, as an alternative to hysterectomy for dysfunctional uterine bleeding, have had a major impact on hysterectomy rates; without these techniques the rates would be much higher.