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Background: As age is not modifiable, pregnancy risk information based on age alone is unhelpful for older women. Aim: To determine severe morbidity/mortality rates for women aged ≥35 years according to maternal profile based on parity, pre‐existing medical conditions and prior pregnancy complications, and to assess the independent contribution of age. Materials and methods: Population‐based record‐linkage study using NSW hospitalisation and birth records 2006–2012. Maternal and perinatal mortality/morbidity were assessed for non‐anomalous singleton births to women aged ≥35 years. Results: For 117 357 pregnancies among 99 375 women aged ≥35 years, the median age at delivery was 37 years (range 35–56 years), including: 35 652 (30.4%) multiparae without pre‐existing medical or obstetric complications, 33,058 (28.2%) nulliparae without pre‐existing medical conditions and 30 325 (25.8%) multiparae with prior pregnancy complications. Maternal and perinatal mortality/morbidity varied by maternal profile with ranges of 0.9–3.5% and 2.4–11.9%, respectively. For nulliparae, each five‐year increase in age did not contribute significantly to maternal risk after controlling for medical conditions (adjustedodds ratio 1.08, 95% CI 0.93–1.25), but did confer perinatal risk (1.14; 1.05–1.25). For multiparae, each five‐year increase in age beyond 35 years was independently associated with adverse maternal (1.23; 1.09–1.39) and perinatal outcomes (1.23; 1.09–1.39). Conclusions: For women aged ≥35 years, presence of medical conditions conferred a greater risk for morbidity/mortality than age itself. For multiparous women, the effects of medical and obstetric history were additive. The contribution of maternal age to adverse outcomes in pregnancies without significant medical and obstetric history is modest. [ABSTRACT FROM AUTHOR]

Background Cervical cerclage is used in an attempt to reduce recurrence risk of preterm birth, but evidence for use is limited. Aims To compare pregnancy outcomes among women with a single previous midtrimester delivery when managed with or without a cervical cerclage. Materials and methods Population-based cohort study of all women in New South Wales, Australia with a singleton pregnancy ending in birth/miscarriage ≥14 and <28 weeks, between 2003 and 2011. Modified Poisson regression was used to compare outcomes in the next subsequent pregnancy, for women with a cerclage inserted <14 weeks, and those without cerclage. The primary outcome was gestational age <37 weeks at birth/miscarriage in the next pregnancy. Secondary outcomes included: maternal morbidity, preterm prelabour rupture of membranes ( PPROM), stillbirth/neonatal death and composite neonatal morbidity for liveborn infants ≥28 weeks. Adjusted risk ratios ( ARR) and 95% confidence intervals ( CI) were determined. Results Five thousand, six hundred and ninety-eight births/miscarriages were potential index deliveries. Of these, 2175 women had an eligible subsequent pregnancy: 108 received cerclage at <14 weeks gestation, 2067 did not. Women with cerclage were significantly more likely to deliver <37 weeks than those without (39.8% vs 19.3%, ARR 1.92, 95% CI 1.48-2.48), and had increased risks of PPROM ( ARR 4.38, 95% CI 2.62-7.32) and stillbirth/neonatal death ( ARR 2.20, 95% CI 1.02-4.73). Following cerclage, liveborn infants ≥28 weeks had double the risk of severe morbidity ( ARR 2.54, 95% CI 1.55-4.16). Conclusions In women with a single previous midtrimester delivery, cervical cerclage <14 weeks gestation in subsequent pregnancy was associated with worse pregnancy outcomes. [ABSTRACT FROM AUTHOR]

Background Surveys have shown that women are highly satisfied with their maternity care. Their satisfaction has been associated with various demographic, personal, and care factors. Isolating the factors that most matter to women about their care can guide quality improvement efforts. This study aimed to identify the most significant factors associated with high ratings of care by women in the three maternity periods (antenatal, birth, and postnatal). Methods A survey was sent to 2,048 women who gave birth at seven public hospitals in New South Wales, Australia, exploring their expectations of, and experiences with maternity care. Women's overall ratings of care for the antenatal, birth, and postnatal periods were analyzed, and a number of maternal characteristics and care factors examined as potential predictors of 'Very good' ratings of care. Results Among 886 women with a completed survey, 65 percent assigned a 'Very good' rating for antenatal care, 74 percent for birth care, 58 percent for postnatal care, and 44 percent for all three periods. One factor was strongly associated with care ratings in all three maternity periods: women who were 'always or almost always' treated with kindness and understanding were 1.8-2.8 times more likely to rate their antenatal, birth, and postnatal care as 'Very good.' A limited number of other factors were significantly associated with high care ratings for one or two of the maternity periods. Conclusions Women's perceptions about the quality of their interpersonal interactions with health caregivers have a significant bearing on women's views about their maternity care journey. [ABSTRACT FROM AUTHOR]

Background Caesarean section ( CS) is a significant risk factor for venous thromboembolism; however, the optimal method of thromboprophylaxis around the time of CS is unknown. Aims To examine current thromboprophylaxis practice during and following CS in Australia and New Zealand, and the willingness of obstetricians to participate in a randomised controlled trial ( RCT) comparing different methods of thromboprophylaxis after CS. Materials and Methods An online survey was sent to fellows and trainees of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Results There were 488 responses from currently practising obstetricians (response rate 23.4%). During CS, 48% and 80% of obstetricians recommended intermittent pneumatic compression ( IPC) and elastic stockings ( ES), respectively. Following CS, 96-97% of obstetricians recommended early ambulation, 87-90% recommended ES, 23-36% recommended IPC, and 42-65% recommended low molecular weight heparin ( LMWH) depending on clinical factors. Increased BMI ( OR 3.42; 95% CI 2.87-4.06), emergency CS ( OR 1.88; 95% CI 1.67-2.16) and older maternal age ( OR 1.37; 95% CI 1.26-1.49) were associated with more frequent LMWH use. Of obstetricians who prescribed LMWH, 70% adjusted the dose depending on maternal weight. LMWH therapy was most commonly recommended until discharge from hospital (31%), <5 days (24%) and 5-7 days (15%). Most obstetricians (58-79%) were willing to enrol women in a RCT, but less likely if the woman had an increased BMI or emergency CS. Conclusions There is considerable variation in clinical practice regarding thromboprophylaxis during and following CS. Obstetricians support a RCT to assess different methods of thromboprophylaxis following CS. [ABSTRACT FROM AUTHOR]

Objective To examine pregnancy outcomes and pregnancy-related health service utilization among women with rare autoimmune diseases. Methods This population-based cohort study of an Australian obstetric population (2001-2011) used birth records linked to hospital records for identification of rare autoimmune diseases including systemic vasculitis, vasculitis limited to the skin, Sjögren's syndrome, systemic sclerosis, Behçet's disease, polymyositis/dermatomyositis, and other systemic involvement of connective tissue. We excluded births in women with systemic lupus erythematosus or rheumatoid arthritis as well as births occurring ≥6 months before the diagnosis of the rare autoimmune disease. Modified Poisson regression was used to compare study outcomes between women with autoimmune diseases and the general obstetric population. Results There were 991,701 births, including 409 births (0.04%) in 293 women with rare autoimmune diseases. Of the 409 births, 202 (49%) were delivered by cesarean section and 72 (18%) were preterm; these rates were significantly higher than those in the general obstetric population (28% and 7%, respectively). Compared to the general population, women with autoimmune diseases had higher rates of hypertensive disorders, antepartum hemorrhage, and severe maternal morbidity and required longer hospitalization at delivery, more hospital admissions, and tertiary obstetric care. Compared to other infants, those whose mothers had a rare autoimmune disease were at increased risk of admission to a neonatal intensive care unit, severe neonatal morbidity, and perinatal death. Conclusion While the majority of women with rare autoimmune diseases delivered healthy infants, they were at increased risk of having both maternal complications and adverse neonatal outcomes, suggesting that their pregnancies should be closely monitored. [ABSTRACT FROM AUTHOR]

Background There is controversy about the interaction between melanoma and pregnancy. There is a lack of Australian data on pregnancy outcomes associated with melanoma in pregnancy, despite Australia having the highest incidence of melanoma in the world. Aims Describe trends, maternal characteristics and pregnancy outcomes associated with pregnancy-associated melanoma in New South Wales. Materials and Methods Population-based cohort study of all births ( n = 1 309 501) of at least 20-week gestation or 400 g birthweight in New South Wales, 1994-2008. Logistic regression was used to analyse the association between melanoma in pregnancy and adverse birth outcomes. Results 577 pregnancy-associated melanomas were identified, including 195 diagnosed during pregnancy and 382 diagnosed within 12 months postpartum. The crude incidence of pregnancy-associated melanoma increased from 37.1 per 100 000 maternities in 1994 to 51.84 per 100 000 maternities in 2008. Adjusting for maternal age accounted for the trend in pregnancy-associated melanoma. Melanomas diagnosed in pregnancy were thicker (median = 0.75 mm) than melanomas diagnosed postpartum (median = 0.60 mm) ( P = 0.002). Pregnancy-associated melanoma was associated with the increased risk of large-for-gestational-age infant but not preterm birth, planned birth, caesarean section or stillbirth. Parity was inversely associated with pregnancy-associated melanoma, as women with three or more previous pregnancies had 0.59 times the odds of pregnancy-associated melanoma compared to nulliparous women (95% CI 0.42-0.84, P = 0.003). Conclusions The incidence of pregnancy-associated melanoma has increased with increasing maternal age. The observation of thicker melanomas in pregnancy and increased risk of large-for-gestational-age infants may suggest a role for growth-related pregnancy factors in pregnancy-associated melanoma. [ABSTRACT FROM AUTHOR]

Background American evidence suggests women are not well informed about the optimal duration of pregnancy or the earliest time for safe birth. Similar evidence does not exist in Australia. Aims To explore pregnant women's beliefs about the duration of pregnancy and the earliest time for safe birth, and to compare the results with US data. Methods A cross-sectional survey of pregnant women attending antenatal clinics at four public hospitals in Sydney, Australia, included information on maternal and pregnancy characteristics, and two questions exploring women's beliefs about the duration of pregnancy, and the earliest time for safe birth. Responses were grouped as: late preterm (34-36 weeks), early term (37-38 weeks) and full term (39-40 weeks). Results Of the 784 surveyed women, 52% chose 39-40 weeks as the duration of a full-term pregnancy, while for the earliest time for safe birth, 10% chose 39-40 weeks and 57% chose 37-38 weeks. Some maternal characteristics were associated with women's beliefs, including having a medical and/or pregnancy complication, country of birth, level of education, employment status and attending a tertiary hospital. The associations were different for each question. In comparison with US studies, Australian women were more likely to choose later gestations for both the duration of pregnancy and the earliest time for safe birth. Conclusions A significant proportion of women believe that full-term pregnancy and earliest time for safe birth occur before 39 weeks, suggesting opportunities for better communication about the benefits and risks of birthing at different gestations. [ABSTRACT FROM AUTHOR]

Background Incisional hernias occur at surgical abdominal incision sites, but the association with caesarean section (CS) has not been examined. Aim To determine whether CS is a risk factor for incisional hernia repair. Materials and Methods Population-based cohort study in Australia using linked birth and hospital data for women who gave birth from 2000 to 2011. Survival analysis was used to explore the association between CS and subsequent incisional hernia repair. Analyses were adjusted for confounding factors, including other abdominal surgery. The main outcome measure was surgical repair of an incisional hernia. Results Of 642,578 women, 217,555 (33.9%) had at least one CS and 1,554 (0.2%) women had a subsequent incisional hernia repair. The rate of incisional hernia repair in women who had ever had a caesarean section was 0.47%, compared to 0.12% in women who never had a caesarean section. After controlling for the duration of follow-up and known explanatory variables (eg other abdominal surgery, parity and multiple pregnancy), the adjusted hazard ratio (aHR) was 2.73 (95% confidence interval (CI) 2.45-3.06, P < 0.001). Incisional hernia repair risk increased with number of caesarean sections: women with two CS had a threefold increased risk of incisional hernia repair, which increased to sixfold after five CS (aHR = 6.29, 95% CI 3.99-9.93, P < 0.001) compared to women with no CS. Conclusions There was a strong association between maternal CS and subsequent incisional hernia repair, which increased as the number of CSs increased, but the absolute risk of incisional hernia repair was low. [ABSTRACT FROM AUTHOR]

Background Changes in clinical practice and in the characteristics of childbearing women have the potential to influence the rate of obstetric anal sphincter injuries ( OASIS). To date, little investigation has been undertaken to assess the effect of risk factor trends for the Australian population on OASIS rates. Aims To ascertain the OASIS rates amongst singleton vaginal births ≥37 weeks gestation in NSW, 2001 - 2009; to determine risk factor effect sizes and trends; and to compare predicted with observed OASIS rates. Methods Using two linked population-based data sets, risk factors for OASIS were determined by logistic regression. Contingency tables and predictive modelling were used to determine trends and predicted rates of OASIS, respectively. Results The OASIS rate increased from 2.2% in 2001 to 2.9% in 2009. Highest risks were for forceps deliveries without episiotomy (primiparas aOR 6.10, multiparas aOR 6.15), followed by multiparas with no previous vaginal birth ( aOR 5.61). High birthweight, vacuum delivery and Asian country of birth posed risks for all women. The greatest risk factor trends were increases in Asian country of birth and vacuum delivery, while the greatest trend amongst protective factors was an increase in maternal age ≥35 years for primiparas. Predicted OASIS rates were lower than observed rates. Conclusion In an environment of changing demographic and clinical risk factors, the OASIS rate has increased. This increase is only minimally explained by the identified risk factors and may be related to other unmeasured risk factors or a possible increase in clinical ascertainment and/or documentation of OASIS. [ABSTRACT FROM AUTHOR]

We determined recent trends and recurrence rates of placenta praevia in 790,366 deliveries in NSW. From 2001 to 2009, the rate of placenta praevia increased by 26%, from 0. 69% to 0. 87% (trend P < 0.001). The placenta praevia recurrence rate in a second birth was 4.8%. Two-thirds of the increase in placenta praevia was accounted for by trends in known risk factors, and the unexplained portion may reflect changes in unidentified risk factors or in the threshold for placenta praevia diagnosis. [ABSTRACT FROM AUTHOR]

Aim To determine the trends in oxytocin use at a population level within New South Wales and to assess the maternal and neonatal morbidities associated with the use of oxytocin. Methods Trends in oxytocin use were assessed for women in NSW who were nulliparas at term with a singleton, cephalic fetus between 1998 and 2008. Maternal and neonatal morbidities were assessed in 2007-2008 using linked hospital and birth data with regression analysis. Oxytocin was also assessed by indication for use being either induction or augmentation of labour. Results The overall use of oxytocin increased from 10 291 (36.5%) of births in 1998 to 14 440 (45.4%) of births in 2008 ( P < 0.0001) with the increase entirely because of the increased use for induction of labour. The use of oxytocin was associated with an increase in regional analgesia (65 to 22%), instrumental delivery (21 to 18%) and caesarean section (29 to 14%) as compared to women who did not receive oxytocin in labour. Oxytocin was also associated with an increase in severe maternal adjusted odds ratios (( aOR) 1.48, 95% CI 1.30-1.68) and neonatal morbidity ( aOR 1.29, 95% CI 1.17-1.41). This increase in morbidity was maintained when both augmentation and induction were assessed separately. Conclusion Oxytocin has an important role in the management of labour. However, its use should be carefully monitored with standardised treatment regimes to minimise maternal and neonatal morbidity. [ABSTRACT FROM AUTHOR]

This study investigated strategies for ascertaining pre-eclampsia, pregnancy hypertension and gestational diabetes mellitus from birth records and/or hospital discharge data. The results showed that ascertaining these conditions from a data set that linked birth records to the corresponding maternal hospital record for birth was sufficient for health outcomes research. Antenatal hospital records provided few extra cases and may be necessary only for the ascertainment when a very accurate estimate of the prevalence is required. [ABSTRACT FROM AUTHOR]

Background: Post-partum haemorrhage (PPH) rates are rising; however, data on the health impact on women are lacking. Aims: To describe the emotional and physical health outcomes for women following PPH. Methods: A cohort of 206 women with primary PPH of 1500 mL or more, and/or peripartum fall in haemoglobin concentration to 7 g/dL or less, and/or of 4 g/dL or less, was recruited from 17 Australian/New Zealand hospitals. Women completed questionnaires in the first week, and at two and four months post-partum. Obstetric details came from hospital records. Outcomes were anxiety; post-natal depression (PND); fatigue; post-traumatic stress disorder (PTSD); general health (SF-36); physical health problems; post-natal bleeding duration; hospital readmission. Results: Eighty-three percent completed the two-month and 81% the four-month questionnaires; 28% reported bleeding continuously for more than six weeks; 10% required hospital readmission within two months. Anxiety scores were in the medium range; 11 and 13% were at risk of PND at two and four months, respectively; median total fatigue scores were 17 at two and 15 at four months; 5% showed evidence of PTSD at two and 3% at four months; women scored highly in most SF-36 categories and showed improvements over time in all but general and mental health. Physical health concerns were comparable to those reported for general post-natal populations, with the exception of uterine infection (6% at two months). Conclusions: In a cohort of women experiencing PPH, emotional and physical health outcomes were similar to those reported in general post-natal populations, with the exception of post-natal bleeding duration, uterine infection and hospital readmission. [ABSTRACT FROM AUTHOR]

Prenatal risk ratios for Down syndrome adjust for maternal weight because maternal serum biomarker levels decrease with increasing maternal weight. This is accomplished by converting serum biomarker values into a multiple of the expected median ( MoM) for women of the same gestational age. Weight is frequently not recorded, and the impact of using MoMs not adjusted for weight for calculating risk ratios is unknown. The aim of this study is to examine the effect of missing weight on first trimester Down syndrome risk ratios by comparing risk ratios calculated using weight-unadjusted-and-adjusted MoMs. Findings at the population level indicate that the impact of not adjusting for maternal weight on first trimester screening results for chromosomal anomalies would lead to under-identification of 84 per 10 000 pregnancies. [ABSTRACT FROM AUTHOR]