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Introduction: Innovative midwifery schemes must be robustly evaluated to establish whether they should be modified or can be replicated. Assessing quality of care can help to ascertain a scheme's acceptability and effectiveness. We used an established quality care framework as a benchmark in our qualitative evaluation of a combined continuity of caregiver and planned home birth scheme in Scotland., Methods: Qualitative evaluation of stakeholder perceptions using the Quality Maternal and Newborn Care Framework was the basis for six focus groups and two one-to-one interviews with stakeholders (new mothers, partners, midwives). A thematic analytical approach was used., Results: The qualitative evaluation found universal approval among participants. Flexible working patterns helped to nurture positive relationships, and information and support were highly valued. The principal themes-Organization of Care/Work Culture; Information and Support; Relationships-were strongly inter-related. They shared several subthemes, notably continuity of caregiver, flexible family-centered care, and the benefits of being at home. Flexibility and mutual respect helped women to express autonomy and develop agency. Women related their birth experiences to friends, family, and colleagues, thereby helping to normalize home birth., Conclusions: This qualitative evaluation of an innovative scheme used an established quality framework as a benchmark against which to assess stakeholder experiences. This approach helped to identify the critical codependence of factors involved in care delivery, which in turn helps to identify lessons for others considering similar schemes. Although our evaluation relates to one specific scheme, identifying the scheme's critical quality care aspects may assist others when planning similar schemes., (© 2020 Wiley Periodicals LLC.)

Background: Clinical practice guidelines on uncomplicated birth provide clinical practice guidance and help to reduce unnecessary, non-evidence-based and potentially harmful intrapartum care practices. Little is known about the trustworthiness and consistency of these guidelines., Objectives: To appraise guidelines relevant to uncomplicated birth, and summarise consensus and non-consensus recommendations., Search Strategy: Eight literature databases and the websites of guideline development institutions and organisations of obstetricians, gynaecologists and midwives were searched from January 2008 to October 2018., Selection Criteria: Guidelines that: reported in Chinese or English; labelled guideline, or recommendation, or consensus, or practice parameter, or position paper/stand; with uncomplicated birth being the primary objectives or comprised chapter(s); and were the most recently published or updated versions., Data Collection and Analysis: Two reviewers independently assessed guideline quality using the AGREE II instrument, and synthesised consensus and non-consensus recommendations using the content analysis approach., Main Results: Eleven guidelines met the inclusion criteria. The WHO and NICE guidelines were deemed to have the highest methodological quality. Twenty-three discrepant recommendations and 39 groups of unanimous recommendations (containing 113 individual ones) were identified, among which 14 recommendations including eating and drinking as desired, prophylactic uterotonics, routine amniotomy and episiotomy were included in five or more guidelines. Perineal massage, uterine massage, active or expectant management at the third stage and use of hands-on or hands-poised technique were identified as the main discrepant recommendations., Conclusions: Two guidelines with higher methodological quality and key clinical guideline recommendations, including both consensus and non-consensus ones, on uncomplicated birth were identified., Tweetable Abstract: Clinical guidelines of uncomplicated birth agree and disagree on several key recommendations., (© 2019 Royal College of Obstetricians and Gynaecologists.)

Objective: To validate the NHSLA maternity claims taxonomy at the level of a single maternity service and assess its ability to direct quality improvement., Design: Qualitative descriptive study., Setting: Medico-legal claims between 1 January 2000 and 31 December 2016 from a maternity service in metropolitan Melbourne, Australia., Population: All obstetric claims and incident notifications occurring within the date range were included for analysis., Methods: De-identified claims and notifications data were derived from the files of the insurer of Victorian public health services. Data included claim date, incident date and summary, and claim cost. All reported issues were coded using the NHSLA taxonomy and the lead issue identified., Main Outcome Measures: Rate of claims and notifications, relative frequency of issues, a revised taxonomy., Results: A combined total of 265 claims and incidents were reported during the 6 years. Of these 59 were excluded, leaving 198 medico-legal events for analysis (1.66 events/1000 births). The costs for all claims was $46.7 million. The most common claim issues were related to management of labour (n = 63, $17.7 million), cardiotocographic interpretation (n = 43, $24.4 million), and stillbirth (n = 35, $656,750). The original NHSLA classification was not sufficiently detailed to inform care improvement programmes. A revised taxonomy and coding flowchart is presented., Conclusions: Systematic analysis of obstetric medico-legal claims data can potentially be used to inform quality and safety improvement., Tweetable Abstract: New taxonomy to target health improvement from maternity claims based on NHSLA Ten Years of Maternity Claims., (© 2019 Royal College of Obstetricians and Gynaecologists.)

Objective: Little is known about how teams' non-technical performance influences clinical performance in obstetric emergencies such as postpartum haemorrhage., Design: Video review - observational study., Setting: A university hospital (5000 deliveries) and a regional hospital (2000 deliveries) in Denmark., Population: Obstetric teams managing real-life postpartum haemorrhage., Methods: We systematically assessed 99 video recordings of obstetric teams managing real-life major postpartum haemorrhage. Exposure was the non-technical score (AOTP); outcomes were the clinical performance score (TeamOBS) and the delayed transfer to the operating theatre (defined as blood loss >1500 ml in the delivery room)., Results: Teams with an excellent non-technical score performed significantly better than teams with a poor non-technical score: 83.7 versus 0.3% chance of a high clinical performance score (P < 0.001), 0.2 versus 80% risk of a low clinical performance score (P < 0.001), and 3.5 versus 31.7% risk of delayed transfer to the operating theatre (P = 0.008). The results remained robust when adjusting for potential confounders such as bleeding velocity, aetiology, time of day, team size, and hospital. The specific non-technical skills associated with high clinical performance were vigilance, role assignment, problem-solving, management of disruptive behavior, and leadership. Communication with the patient and closing the loop were of minor importance. All performance assessments showed good reliability: the intraclass correlation was 0.97 (95% CI 0.96-0.98) for the non-technical score and 0.84 (95% CI 0.76-0.89) for the clinical performance score., Conclusion: Video review offers a new method and new perspectives for research in obstetric teams to identify how teams become effective and safe; the skills identified in this study can be included in future obstetric training programmes., Tweetable Abstract: Non-technical performance is important for teams managing postpartum haemorrhage; video review of 99 obstetric teams., (© 2019 Royal College of Obstetricians and Gynaecologists.)

Background: This study aims to examine hospital variation in both maternal and neonatal morbidities and identify institutional characteristics associated with hospital performance in a combined measure of maternal and neonatal outcomes., Methods: Using the California Linked Birth File containing data from birth certificate and hospital discharge records, we identified 1 322 713 term births delivered at 248 hospitals during 2010-2012. For each hospital, a risk-standardized rate of severe maternal morbidities and a risk-standardized rate of severe newborn morbidities were calculated after adjusting for patient clinical risk factors. Hospitals were ranked based on combined information on their maternal and newborn morbidity rates., Results: Risk-standardized severe maternal and severe newborn morbidity rates varied substantially across hospitals (10th to 90th percentile range = 67.5-148.2 and 141.8-508.0 per 10 000 term births, respectively), although there was no significant association between the two (P = 0.15). Government hospitals (non-Federal) were more likely than other hospitals to be in worse rank quartiles (P value for trend = 0.004), whereas larger volume was associated with better rank among hospitals in the first three quartiles (P = 0.004). The most prevalent morbidities that differed progressively across hospital rank quartiles were severe hemorrhage, disseminated intravascular coagulation, and heart failure during procedure/surgery for mothers, and severe infection, respiratory complication, and shock/resuscitation for neonates., Conclusions: Hospitals with low maternal morbidity rates may not have low neonatal morbidity rates and vice versa, highlighting the importance of assessing joint maternal-newborn outcomes in order to fully characterize a hospital's obstetrical performance. Hospitals with smaller volume and government ownership tend to have less desirable outcomes and warrant additional attention in future quality improvement efforts., (© 2018 Wiley Periodicals, Inc.)

Background: Antenatal corticosteroids (ANC) reduce mortality and morbidity in preterm babies, but prescription practices vary., Aims: To assess obstetricians' compliance with the recommendations of the Australian and New Zealand clinical practice guidelines on use of ANC., Materials and Methods: An anonymous online questionnaire was distributed to Fellows of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists., Results: All respondents reported prescribing an initial course of ANC according to the guidelines if preterm birth at 28 weeks' gestation was expected within 24 or 72 h. However, 22% reported prescribing ANC even if birth was not expected within seven days. This was reported more often by practitioners not using adjunct tests to predict preterm birth (14% vs 69%; P < 0.001). An initial course of ANC at ≥35 weeks was prescribed by 52% of respondents. However, 93% reported prescribing ANC at ≥35 weeks prior to elective caesarean section. Repeat courses of ANC were prescribed by 76% of respondents. Of these, 89% reported prescribing repeat courses beyond the guideline recommendations at ≥33 weeks and 29% exceeded the recommendations on number of repeat courses., Conclusions: For infants born at <35 weeks, current ANC prescribing patterns in Australia and New Zealand are consistent with the guideline recommendations and result in high rates of administration in this group. However, administration of ANC to groups where benefits have not been demonstrated is commonly reported. Adherence to the guideline recommendations would decrease ANC exposure to babies for whom there is no strong evidence of benefit., (© 2018 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)

Background: Female genital mutilation (FGM) is a cultural practice defined as the partial or total removal of the external female genitalia for nontherapeutic indications. Due to changing patterns of migration, clinicians in high-income countries are seeing more women from countries where the practice is prevalent. This review aims to understand the sociocultural and health needs of these women and identify opportunities to improve the quality of maternity care for women with FGM., Methods: We undertook a systematic review and meta-synthesis of peer-reviewed primary qualitative research to explore the experience and needs of migrant women with FGM receiving maternity care. A structured search of nine databases was undertaken, screened papers appraised, and a thematic analysis undertaken on data extracted from the findings and discussion sections of included papers., Results: Sixteen peer-reviewed studies were included in the systematic review. Four major themes were revealed: Living with fear, stigma, and anxiety; Feelings of vulnerability, distrust, and discrimination; Dealing with past and present ways of life after resettlement; and Seeking support and involvement in health care., Conclusions: The findings suggest that future actions for improving maternity care quality should be focused on woman-centered practice, demonstrating cultural safety and developing mutual trust between a woman and her care providers. Meaningful consultation with women affected by FGM in high-income settings requires cultural sensitivity and acknowledgment of their specific circumstances. This can be achieved by engaging women affected by FGM in service design to provide quality care and ensure woman-focused policy is developed and implemented., (© 2018 Wiley Periodicals, Inc.)

Background: Increasing numbers of childbearing women with a history of female genital mutilation (FGM) are accessing maternity services in high-income countries across the world. For many of these women, their first contact with the health services in their host country is when they are pregnant. While the clinical consequences of certain categories of FGM are well documented, how high-risk maternity services - designed to mitigate the obstetric consequences of FGM - impact upon women's experience of childbearing is less clear., Methods: Using a meta-synthesis approach, this paper synthesizes 12 qualitative research papers, conducted in 5 high-income countries, to explore how migrant women with a history of FGM experience maternity care in their host countries., Results: One over-arching theme and four discrete subthemes of migrant women's experience of the maternity services in their host country were identified: feelings of alienation; fatalism and divine providence, positive and negative feelings about maternity care, different understandings of the birthing process, and feelings about FGM., Conclusions: The findings illustrate that migrant women with a history of FGM frequently encounter negative attitudes when accessing the maternity services in their host countries. Women's experiences suggest a concerning absence of sensitive and empathetic care; a more woman-centered approach is recommended., (© 2018 Wiley Periodicals, Inc.)

Rationale: Defensive caesarean section (CS) has become one of the most common medical procedure worldwide. Additionally, performing CS in accordance with the patient's choice is an appropriate professional practice., Aims and Objective: This paper reports a prospective, observational, multicenter study to quantify the use of this type of practice that is performed by obstetricians to avoid medico-legal complaints and decrease the frequency of malpractice litigations., Methods: We interviewed 73 obstetricians from three distinct units of obstetrics and gynaecology, to assess their opinion regarding defensive caesarean delivery and caesarean delivery performed upon maternal request. We conducted an opinion-based survey using questionnaires based on nine, close-ended questions., Results: Out of 73 respondents, 51 (69.9%) stated that they perform defensive CS; 63 (86.3%) declared that their choice of birth delivery is influenced by the risk of being accused of malpractice; 60 (82.2%) indicated that it is normal for the patient to be able to decide on the type of delivery; and 63 (86.3%) declared that they consult their patients regarding their delivery preferences. We found statistically significant differences between the respondents who declare that they perform defensive CS (69.9%) and those who said that they are influenced by the risk of malpractice when they choose the method of delivery for their patients (86.3%) (P < .001; McNemar Test)., Conclusions: The results of our study indicate that defensive caesarean section is a widespread practice among obstetrics practitioners in Romania., (© 2018 The Authors Journal of Evaluation in Clinical Practice Published by John Wiley & Sons Ltd.)

Objective: To examine whether disparities in stillbirth, and neonatal and perinatal mortality rates, between public and private hospitals are the result of differences in population characteristics and/or clinical practices., Design: Retrospective cohort study., Setting: A metropolitan tertiary centre encompassing public and private hospitals. Women accessed care from either a private obstetrician or from public models of care - predominantly midwife-led care or care shared between midwives, general practitioners, and obstetricians., Population: A total of 131 436 births during 1998-2013: 69 037 public and 62 399 private., Methods: Propensity score matching was used to select equal-sized public and private cohorts with similar characteristics. Logistic regression analysis was then used to explore the impact of public-private differences in the use of assisted reproductive technologies, plurality, major congenital anomalies, birth method, and gestational age., Main Outcome Measures: Stillbirth, and neonatal and perinatal mortality rates., Results: After controlling for maternal and pregnancy factors, perinatal mortality rates were higher in the public than in the private cohort (adjusted odds ratio, aOR 1.53; 95% confidence interval, 95% CI 1.29-1.80; stillbirth aOR 1.56, 95% CI 1.26-1.94; neonatal death aOR 1.48, 95% CI 1.15-1.89). These disparities reduced by 15.7, 20.5, and 19.6%, respectively, after adjusting for major congenital anomalies, birth method, and gestational age., Conclusions: Perinatal mortality occurred more often among public than private births, and this disparity was not explained by population differences. Differences in clinical practices seem to be partly responsible. The impact of differences in clinical practices on maternal and neonatal morbidity was not examined. Further research is required., Tweetable Abstract: Private obstetrician-led care: more obstetric intervention and earlier births reduce perinatal mortality., Plain Language Summary: Background Babies born in Australian public hospitals tend to die more often than those born in private hospitals. Our aim was to determine whether this pattern is a result of public-private differences in care or merely linked with differences in the characteristics of the two groups. In Australian private hospitals, a private obstetrician almost always provides continuing care to each woman during pregnancy and birth. Public hospitals provide a number of care options, which usually involve midwives and/or a family doctor. Method The study population included 131 436 births (52.5% public; 47.5% private) from 1998-2013 at a single metropolitan centre with co-located public and private facilities. To isolate the effect of differences in care, we used a statistical technique called propensity score matching to select a public group and a private group with similar characteristics and equal size. This enabled us to compare 'apples with apples' when comparing public versus private perinatal death rates. Perinatal deaths include stillbirths and babies that die within 28 days of birth. Main findings After matching and after accounting for different patterns in the use of fertility treatments and multiple-birth pregnancies (such as twins), babies born in the public sector were approximately 1.5 times more likely to die than babies born in the private sector. This difference was reduced to 1.3 times more likely to die than babies born in the private sector after taking into account other factors that could skew the data, such as major congenital anomalies, birth method, and duration of pregnancy. Limitations This was a single-centre study, so the results may not apply to all settings. Despite our efforts to create highly similar public and private cohorts, some differences between the groups are likely to have remained and this may have affected the results. Implications Our findings suggest that private obstetrician-led care has a beneficial impact on perinatal deaths, despite, or possibly because of, higher obstetric intervention rates and earlier births in the private hospital. Further research is required., (© 2017 Royal College of Obstetricians and Gynaecologists.)

Objective: To evaluate the reliability of a four-level triage scale for obstetrics and gynaecology emergencies and to explore the factors associated with an optimal triage., Design: Thirty clinical vignettes presenting the most frequent indications for obstetrics and gynaecology emergency consultations were evaluated twice using a computerised simulator., Setting: The study was performed at the emergency unit of obstetrics and gynaecology at the Geneva University Hospitals., Sample: The vignettes were submitted to nurses and midwives., Methods: We assessed inter- and intra-rater reliability and agreement using a two-way mixed-effects intra-class correlation (ICC). We also performed a generalised linear mixed model to evaluate factors associated triage correctness., Main Outcome Measures: Triage acuity., Results: We obtained a total of 1191 evaluations. Inter-rater reliability was good (ICC 0.748; 95% CI 0.633-0.858) and intra-rater reliability was almost perfect (ICC 0.812; 95% CI 0.726-0.889). We observed a wide variability: the mean number of questions varied from 6.9 to 18.9 across individuals and from 8.4 to 16.9 across vignettes. Triage acuity was underestimated in 12.4% of cases and overestimated in 9.3%. Undertriage occurred less frequently for gynaecology compared with obstetric vignettes [odds ratio (OR) 0.45; 95% CI 0.23-0.91; P = 0.035] and decreased with the number of questions asked (OR 0.94; 95% CI 0.88-0.99; P = 0.047). Certification in obstetrics and gynaecology emergencies was an independent factor for the avoidance of undertriage (OR 0.35; 95% CI 0.17-0.70; P = 0.003)., Conclusion: The four-level triage scale is a valid and reliable tool for the integrated emergency management of obstetrics and gynaecology patients., Tweetable Abstract: The Swiss Emergency Triage Scale is a valid and reliable tool for obstetrics and gynaecology emergency triage., (© 2017 Royal College of Obstetricians and Gynaecologists.)

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., (© 2016 Wiley Periodicals, Inc.)

Background: Cesarean delivery is one of the most widely used surgical interventions in Latin America and in many cases it is performed with no clear medical indication. Our objective was to analyze the relationship between reported indications for a cesarean and support for that indication in the clinical record in four Mexican hospitals, during the 2006-2007 period., Methods: The data are from 604 (37.1%) women from a total of 1,625 who were admitted to the hospital in labor, and who gave birth through cesarean. Multivariate logistical regression analysis was used to explore the association between indications for clinically justified or unjustified surgery and other clinical and sociodemographic variables., Results: Supporting clinical information for indications of cesarean delivery were found in only 45 percent of the cases considered. The adjusted statistical analysis showed that the variables associated with an unjustified indication for cesarean were: not having had a prior birth (OR 1.84 [95% CI 1.16-2.89]), having a maximum cervical dilation of 4 centimeters or less at time of cesarean (OR 2.44 [95% CI 1.53-3.87]), and having received care in a private hospital (OR 6.11 [95% CI 1.90-19.57])., Discussion: The indications for cesarean related to labor dynamics were those least supported. Not having had a prior birth poses the greatest risk of having a poorly supported indication for a cesarean delivery. It would be prudent to institute audits, and greater requirements for and surveillance of documentation for cesarean delivery indications., (© 2016 Wiley Periodicals, Inc.)

Background: China has one of the highest cesarean delivery rates in the world, with most cesareans done without indication., Methods: Observation of how perinatal care is delivered in a range of Shanghai hospitals was done to gain insight into the 50 percent cesarean delivery rate. A mixed methods approach combined a descriptive structured survey of obstetric services with standardized interview with obstetricians and qualitative observation of obstetric services in six different Shanghai obstetric facilities., Results: The volume was extremely high: physicians in public hospitals routinely saw up to 80-120 prenatal patients per day. Frequent prenatal testing substituted for time spent in patient-doctor interactions. Family members were not allowed in delivery wards where women labored alone. Obstetrics services had low levels of nursing support and anesthesia for labor. Physical space favored rapid surgical turnover over longer labor. Physicians reported practical incentives to perform cesarean sections., Discussion: Cesarean delivery was an efficient way to move patients through the systems observed, given the staffing and physical limitations of the public facilities. Physicians reported that patients and families perceived cesarean delivery as safer. Physicians also reported fear of charges of malpractice, for which they might be found to be financially liable or in physical danger. Societal expectations are high, and in a "one child" society, perception that cesarean section was safer may also have driven cesarean rates. Given the end of the One Child Policy, the preference for cesarean delivery may change., (© 2016 Wiley Periodicals, Inc.)

The Obstetric Anaesthetists' Association and Difficult Airway Society have developed the first national obstetric guidelines for the safe management of difficult and failed tracheal intubation during general anaesthesia. They comprise four algorithms and two tables. A master algorithm provides an overview. Algorithm 1 gives a framework on how to optimise a safe general anaesthetic technique in the obstetric patient, and emphasises: planning and multidisciplinary communication; how to prevent the rapid oxygen desaturation seen in pregnant women by advocating nasal oxygenation and mask ventilation immediately after induction; limiting intubation attempts to two; and consideration of early release of cricoid pressure if difficulties are encountered. Algorithm 2 summarises the management after declaring failed tracheal intubation with clear decision points, and encourages early insertion of a (preferably second-generation) supraglottic airway device if appropriate. Algorithm 3 covers the management of the 'can't intubate, can't oxygenate' situation and emergency front-of-neck airway access, including the necessity for timely perimortem caesarean section if maternal oxygenation cannot be achieved. Table 1 gives a structure for assessing the individual factors relevant in the decision to awaken or proceed should intubation fail, which include: urgency related to maternal or fetal factors; seniority of the anaesthetist; obesity of the patient; surgical complexity; aspiration risk; potential difficulty with provision of alternative anaesthesia; and post-induction airway device and airway patency. This decision should be considered by the team in advance of performing a general anaesthetic to make a provisional plan should failed intubation occur. The table is also intended to be used as a teaching tool to facilitate discussion and learning regarding the complex nature of decision-making when faced with a failed intubation. Table 2 gives practical considerations of how to awaken or proceed with surgery. The background paper covers recommendations on drugs, new equipment, teaching and training., (© 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists of Great Britain and Ireland.)

Background: Maternity care in Serbia is an integrated part of the centralized health care system inherited from the former Yugoslavia. Childbirth is often perceived as a medical event instead of a physiological process. This paper examines quality and access indicators, and patient payments for maternity care in Serbia., Methods: We apply a method of triangulation using data collected through three sources: online questionnaires filled in by mothers who delivered in one of the maternity wards in Serbia in the period 2000-2008, research publications, and official guidelines. To compare the qualitative data from all three sources, we apply framework analysis., Results: The results show a good network of maternity wards in Serbia. On the other hand, many women who gave birth in maternity wards in Serbia indicate problems with the treatment they received. The existence of informal patient payments and so-called "special connections" make the position of Serbian women in maternity wards vulnerable, especially when they have neither connections nor the ability to pay. Poor communication and bedside manner of medical staff (obstetricians, other physicians, midwives, and nurses) during the birth process are also frequently reported., Discussion: Actions should be taken to improve bedside manners of medical staff. In addition, the government should consider the involvement of private practitioners paid by the national insurance fund to create competition and decrease the need for informal payments and "connections.", (© 2014, Copyright the Authors Journal compilation © 2014, Wiley Periodicals, Inc.)

Background: In 2009, the Institute of Medicine revised gestational weight gain recommendations; revisions included body mass index (BMI) category cut-point changes and provision of range of gain for obese women. Our objective was to examine resident prenatal caregivers' knowledge of revised guidelines., Methods: Anonymous electronic survey of obstetrics/gynecology and family medicine residents across the United States from January to April 2010., Results: Overall, 660 completed the survey; 79 percent female and 69 percent aged between 21 and 30. When permitted to select ≥ 1 response, 87.0 percent reported using BMI to assess weight status at initial visits, 44.4 percent reported using "clinical impression based on patient appearance," and 1.4 percent reported not using any parameters. When asked the most important baseline parameter for providing recommendations, 35.8 percent correctly identified prepregnancy BMI, 2.1 percent reported "I don't provide guidelines," and 4.5 percent reported "I do not discuss gestational weight gain." Among respondents, 57.6 percent reported not being aware of new guidelines. Only 7.6 percent selected correct BMI ranges for each category, and only 5.8 percent selected correct gestational weight gain ranges. Only 2.3 percent correctly identified both BMI cutoffs and recommended gestational weight gain ranges per 2009 guidelines., Conclusions: Guideline knowledge is the foundation of accurate counseling, yet resident prenatal caregivers were minimally aware of the 2009 Institute of Medicine gestational weight gain guidelines almost a year after their publication., (© 2013, Copyright the Authors Journal compilation © 2013, Wiley Periodicals, Inc.)

The purpose of this paper is to consider the role of women's views in maternity care research and practice: what we mean by that, how and when women's views are sought (or not), and what we should do next. It is argued that women's views are not a stand-alone extra, but integral at every stage, including having an impact on clinical outcomes. Attending to "women's views" should not only mean a post hoc assessment of experiences but also needs to consider expectations and values. Importantly, this approach needs to apply not only to the care of individual women but also to the shaping of research and policy agendas. Recommendations are made for ways in which women's views can have a more central role in research and practice in the future., (© 2012, Copyright the Authors Journal compilation © 2012, Wiley Periodicals, Inc.)

Background: Statewide (Queensland) Clinical Guidelines reflecting current best practice have recently become available for the management of pregnancy-related obesity. However, dissemination of guidelines alone do not change practice., Aim: To systematically assess evidence-practice gap in the multidisciplinary management of overweight and obesity (ow/ob) in pregnancy to inform an intervention to facilitate translating obesity guidelines into practice in a tertiary maternity service., Materials and Methods: An online survey, available over a three-week period (May-June 2011), was disseminated to obstetric, midwifery and allied health staff. Outcomes of interest included a 15-point guideline adherence score, knowledge of guideline content, advice given, knowledge of obesity-pregnancy-related complications, previous training and referral patterns., Results: Eighty-four staff completed surveys (57% response rate). Widespread discordance with the guideline was noted. The majority (88.1%) reported overweight/obesity (ow/ob) as an important/very important general obstetric issue, most correctly identified associated complications. However, only 32.1% were aware of existing guidelines, with only half correctly identifying BMI categories for ow/ob. Compliance with referral recommendations varied; 20% of staff considered referral 'was not their job'., Conclusions: Staff are aware of negative outcomes associated with maternal ow/ob, although few are fully compliant with referral guidelines or provide advice in line with recommendations. These findings will be categorised using implementation of science methodological frameworks, and effective behaviour change interventions will be constructed to facilitate translation of this important guideline into practice., (© 2012 The Authors ANZJOG © 2012 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)

Aims: To determine whether healthcare providers apply the best interest principle equally to different resuscitation decisions., Methods: An anonymous questionnaire was distributed to consultants, trainees in neonatology, paediatrics, obstetrics and 4th medical students. It examined resuscitation scenarios of critically ill patients all needing immediate resuscitation. Outcomes were described including survival and potential long-term sequelae. Respondents were asked whether they would intubate, whether resuscitation was in the patients best interest, would they accept surrogate refusal to initiate resuscitation and in what order they would resuscitate., Results: The response rate was 74%. The majority would wish resuscitation for all except the 80-year-old. It was in the best interest of the 2-month-old and the 7-year-old to be resuscitated compared to the remaining scenarios (p value <0.05 for each comparison). Approximately one quarter who believed it was in a patient best interests to be resuscitated would nonetheless accept the family refusing resuscitation. Medical students were statistically more likely to advocate resuscitation in each category., Conclusion: These results suggest resuscitation is not solely related to survival or long-term outcome and the best interest principle is applied differently, more so at the beginning of life., (© 2010 The Author(s)/Acta Paediatrica © 2010 Foundation Acta Paediatrica.)

Objective:   To investigate whether publication of the results of the ORACLE Children's Study, a 7-year follow-up of the ORACLE trial, changed practice with regard to the routine prescription of antibiotics to women with preterm rupture of membranes or spontaneous preterm labour (intact membranes)., Design:   A comparative questionnaire survey of clinical practice in November 2007 (before publication) and March 2009 (after publication)., Population:   Lead obstetricians for labour wards of all maternity units in the UK., Methods:   Self-administered questionnaires requested information about the routine prescription of antibiotics to women with either preterm rupture of membranes or spontaneous preterm labour (intact membranes)., Main Outcome Measures:   Change in practice for prescription of antibiotics., Results:   The response rate was 166/214 (78%) in 2007 and 158/209 (76%) in 2009. In total, 120 maternity units responded on both occasions. For women with preterm rupture of membranes, 162/214 (98%) in 2007 and 151/158 (96%) in 2009 maternity units reported that they prescribed antibiotics, with the majority using erythromycin (98%). For women with spontaneous preterm labour (intact membranes), 35/166 (21%) in 2007 and 25/158 (16%) in 2009 maternity units reported that they routinely prescribed antibiotics. The findings from units who responded on both occasions are similar., Conclusions:   There has been little change in the reported prescription of antibiotics to women with either preterm rupture of membranes or spontaneous preterm labour following publication of the ORACLE Children's Study. This suggests that current practice may require updated guidance.

Objectives: The objectives of this study were to define the components of a skilled low-cavity non-rotational vacuum delivery (occiput anterior, vertex at station +2 or below and less than 45-degree rotation from midline) and to facilitate the transfer of skills from expert to trainee obstetricians., Design: Qualitative study using interviews and video recordings., Setting: Two university teaching hospitals (St Michael's Hospital, Bristol, and Ninewell's Hospital, Dundee)., Participants: Ten obstetricians and eight midwives identified as experts in conducting or supporting operative vaginal deliveries., Methods: Semi-structured interviews were carried out using routine clinical scenarios. The experts were also video recorded conducting low-cavity vacuum deliveries in a simulation setting. The interviews and video recordings were transcribed verbatim and analysed using thematic coding. The anonymised data were independently coded by three researchers and compared for consistency of interpretation. The experts reviewed the coded interviews and video data for respondent validation and clarification. The themes that emerged following the final coding were used to formulate a list of skills., Main Outcome Measures: Key technical skills of a low-cavity non-rotational delivery., Results: The final list included detailed technical skills required for conducting a low-cavity vacuum delivery. The combination of semi-structured interviews and simulation videos allowed the formulation of a comprehensive skills tool for future evaluation., Conclusion: This explicitly defined skills list could aid trainees understanding of the technique of low-cavity vacuum delivery. This is an important first step in evaluating clinical competence in intrapartum procedures.

Objective: To describe the implementation of facility-based case reviews (medical audits) in a maternity unit and their effect on the staff involved., Design: Cross-sectional descriptive study., Setting: A 26-bed obstetric unit in a district hospital in Ouagadougou, Burkina Faso., Sample: Sixteen audit sessions conducted between February 2004 and June 2005. Thirty-five staff members were interviewed., Methods: An analysis of all the tools used in the management of the audit was performed: attendance lists, case summary cards and register of recommendations. The perceptions of the staff about the audits were collected through a questionnaire administrated by an external investigator from 10 June 2005 to 16 June 2005., Main Outcome Measures: Session participation, types of problems identified, recommendations proposed and implemented and staff reaction to the audits., Results: Only 7 midwives from a total of 15 regularly attended the sessions. Eighty-two percent of the recommendations made during the audits have been implemented, but sometimes after a delay of several months. Interviewed personnel had a good understanding of the audit goals and viewed audit as a factor in changing their practice. However, midwives highlighted problems of bad interpersonal communication and lack of anonymity during the audit sessions, and pointed out the difficulty of practising self-criticism., Conclusions: A lack of staff commitment and the resistance of maternity personnel to being evaluated by their peers or service users are reducing acceptance of routine audits. The World Health Organization must take all these factors into account when promoting the institutionalisation of medical audits in obstetrics.

Background: Hemorrhage and hypertensive disorders are major contributors to death after delivery in developing countries. The GIRMMAHP Initiative was designed to describe the actual delivery care in five Latin American countries and to educate and motivate clinical staff at 17 hospitals with the purpose of implementing their own clinical practice guidelines to prevent postpartum hemorrhage., Methods: A multicountry education intervention was developed in four consecutive stages, using two analyses: (a) an observational study of the clinical records in eight teaching and nine nonteaching hospitals and (b) a study of the long-term changes measured 12 months after completion of an education intervention and writing a local clinical guideline., Results: Data from 2,247 pregnant women showed that only 23.3 percent had an active management of the third stage of labor and that 22.7 percent received no prenatal care visit. These data were used to prepare local clinical practice guidelines in each participant hospital. The proportion of active management increased to 72.6 percent of deliveries at 3 months and 58.7 percent 1 year later. Use of oxytocin during the third stage of labor increased to 85.9 percent of included deliveries. The proportion of women who had postpartum hemorrhage decreased from 12.7 percent at baseline to 5 percent at 1 year after the intervention., Conclusions: An education intervention and discussion of actual clinical practice problems with health professionals and their involvement in drafting clinical guidelines helped improve health care quality and practitioners' adherence to these guidelines.

Objective: Modern postgraduate medical training requires both accurate and reliable selection procedures. An essential first step is to conduct detailed job analysis studies. This paper reports data on a series of job analyses to develop a competency model for three secondary care specialties (anaesthesia, obstetrics and gynaecology, and paediatrics)., Methods: Three independent job analysis studies were conducted. The content validity of the resulting competency domains was tested using a questionnaire-based study with specialty trainees (specialist registrars [SpRs]) and consultants drawn from the three specialties. Job analysis was carried out in the Yorkshire and the Humber region in the UK. The validation study was administered with additional participants from the West Midlands and Trent regions in the UK. This was an exploratory study. The outcome is a set of competency domains with data on their importance at senior house officer, SpR and consultant grade in each specialty., Results: The study produced a model comprising 14 general competency domains that were common to all the three specialties. However, there were significant between-specialty differences in both definitions of domains and the ratings of importance attached to them., Conclusions: The results indicate that a wide range of attributes beyond clinical knowledge and academic achievement need to be considered in order to ensure doctors train and work within a specialty for which they have a particular aptitude. This has significant implications for developing selection criteria for specialty training. Future research should explore the content validity of these competency domains in other secondary care specialties.

This article argues that the continuing reluctance on the part of professional and bureaucratic bodies in Australia to provide for and support planned attended homebirth for low-risk women is unfounded according to the research evidence. It also suggests that such lack of support might be encouraging some planned but intentionally unattended homebirths to occur in Australia, particularly as in recent years there appears to have been an increase in popularity in freebirth (or do-it-yourself homebirth). The article calls for RANZCOG and Australian state health departments to support planned attended homebirth for low-risk women in the face of what is now a considerable amount of evidence showing its safety, when compared with unplanned homebirth and hospital birth. The article raises a number of challenging issues for obstetricians, midwives and managers or planners of maternity services.

Objectives: To assess obstetric outcomes of different models of antenatal care., Methods: The study was historical cohort analysis of population birth data of 67,675 singleton births delivered in all public hospitals in Sydney South-west. Maternal and neonatal outcomes were compared for different models of antenatal care received. The care was provided within the hospitals in doctor's clinic, midwives' clinic, birth centre, or by a team of midwives in the caseload midwifery. In the non-hospital settings, the care was provided by private obstetricians or by the general practitioner (GP) as part of the GP Shared Care program. The data for those women who received no antenatal care were also analysed., Results: This study provided information that the obstetric outcomes were very similar regardless of whether a woman received her antenatal care in the midwives' clinic, the birth centre, under the GP Shared Care program or in the doctor's clinic in Sydney South-west hospitals., Conclusions: This study provides evidence for the view that different models of maternity care can be provided with good outcomes.

Background: The worrying trend of an ever-increasing incidence of delivery by cesarean section has been commented on repeatedly. Studies from the United Kingdom and the United States have found that many obstetricians would choose cesarean section for themselves without strict medical indication, whereas similar studies from Denmark and Norway have indicated that almost none would choose cesarean section for themselves. The purpose of this study was to report the proportion of Norwegian obstetricians who have children born by cesarean section and to compare the rate with that among other physicians and that with the general population., Methods: Questionnaires were sent to 1,500 random members of the Norwegian general public, 1,500 randomly selected physicians, and 423 random surgeons asking whether they had children born by cesarean section. All were between the ages of 40 and 65 years., Results: The response rate was 78 percent. In the general public with children, 12 percent reported that one or more of them were born by cesarean section. The average was 8 percent among those with only basic schooling compared with 16 percent (p < 0.02) among those who had been to university for more than 4 years. This figure was 19 percent among physicians in general (p < 0.001 compared with the general population), 26 percent among surgeons, and 27 percent among the 189 specialists in obstetrics and gynecology (p < 0.02 compared with the physicians in general)., Conclusion: The rate of cesarean section in the general population is unlikely to fall as long as so many obstetricians have their own children delivered by cesarean section.

Objective: Nonphysicians in Mozambique have been performing major surgery for more than 20 years, with documented outcomes equivalent to those of specialists. The purpose of this study was to make an inventory of all government hospitals so as to document obstetric surgery performed by 'técnicos de cirurgia' (TCs) and to elucidate their retention at district level., Design: Cross-sectional study of surgical procedures during 2002; longitudinal study of TCs and doctors graduating in 1987, 1988 and 1996., Setting: All 34 hospitals with an operating theatre in Mozambique., Population: Records of 12,178 major surgical obstetric operations were examined, and 59 medical officers and 34 TCs were interviewed., Methods: Analysis of all surgical registers during 2002 in all government rural, provincial, general and central hospitals in Mozambique. TCs and doctors who had graduated in the specified years were traced and interviewed; health ministry records were reviewed to confirm assignments., Main Outcome Measures: Proportion of major obstetric surgeries performed by TCs. Proportion of TCs and medical doctors still at rural/district level at 7 years after graduation., Results: Major obstetric surgery is conducted by nonphysicians in 57% of the 12,178 operations scrutinised. In district hospitals, they conducted 92% of 3246 operations. Retention of TCs and medical doctors at district hospital level differed markedly: after 7 years, 88% of the TCs remained in post compared with none of the medical doctors., Conclusion: Nonphysicians, trained in surgery, do most of the emergency obstetric surgery in Mozambique, and almost all of that performed in district hospitals. Nonphysicians, compared with physicians, stay longer in rural areas. After 7 years, around 90% of nonphysicians are still working in district hospitals, while almost no physicians remain there.

Objectives: To explore the effect of obstetric emergency training on knowledge. Furthermore, to assess if acquisition of knowledge is influenced by the training setting or teamwork training., Design: A prospective randomised controlled trial., Setting: Training was completed in six hospitals in the South West of England, UK and at the Bristol Medical Simulation Centre, UK., Population: Midwives and obstetric doctors working for the participating hospitals were eligible for inclusion in the study. A total of 140 participants (22 junior and 23 senior doctors, 47 junior and 48 senior midwives) were studied., Methods: Participants were randomised to one of four obstetric emergency training interventions: (1) 1-day course at local hospital, (2) 1-day course at simulation centre, (3) 2-day course with teamwork training at local hospital and (4) 2-day course with teamwork training at simulation centre., Main Outcome Measures: Change in knowledge was assessed by a 185 question Multiple-Choice Questionnaire (MCQ) completed up to 3 weeks before and 3 weeks after the training intervention., Results: There was a significant increase in knowledge following training; mean MCQ score increased by 20.6 points (95% CI 18.1-23.1, P < 0.001). Overall, 123/133 (92.5%) participants increased their MCQ score. There was no significant effect on the MCQ score of either the location of training (two-way analysis of variants P = 0.785) or the inclusion of teamwork training (P = 0.965)., Conclusions: Practical, multiprofessional, obstetric emergency training increased midwives' and doctors' knowledge of obstetric emergency management. Furthermore, neither the location of training, in a simulation centre or in local hospitals, nor the inclusion of teamwork training made any significant difference to the acquisition of knowledge in obstetric emergencies.