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

2. Challenges in Childbirth …and Challenges in Childbirth Research… …and Challenges in Childbirth Research… tend to be linked be linked

3. Challenges in European Childbirth Problem: Problem: The present solution The present solution 3

4. The industrial model of childbirth Caesarean section rates: 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)

5. Caesarean section 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)

6. Caesarean section Caesarean section So – CS is not an operation to be undertaken lightly.

7. 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 Takes a long time to reverse the trend

8. Challenges (continued) Hard to change people’s minds Hard to change people’s minds Need large sample sizes to find any significant difference Need large sample sizes to find any significant difference E.g. any countries are not big enough to conduct a large enough trial 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

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

10. The OptiBIRTH Study

18. Aim of OptiBIRTH Aim of OptiBIRTH To increase VBAC rates from 25 to 53% (approximately)….. through enhanced women-centred care…

19. OptiBIRTH study 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.

20. Intervention Was developed through: 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).

21. What is happening now 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

23. Future studies Future studies

24. Obesity Major challenge in this decade Major challenge in this decade High levels of morbidity and mortality High levels of morbidity and mortality Increases all other childbirth challenges (CS, PPH) Increases all other childbirth challenges (CS, PPH) Difficult to modify people’s behaviour Difficult to modify people’s behaviour

25. 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].

26. 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

27. 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

28. 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.

29. 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.

30. Reducing obesity in pregnant women Challenging – but worth it! Challenging – but worth it!

31. Postpartum haemorrhage Is this a challenge? Is this a challenge? Does it need more research? Does it need more research?

32. Postpartum haemorrhage A major challenge in low-income countries – further research is needed 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 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. But not a challenge for low-risk women, so further research is needed to prevent harms due to preventative treatment.

33. Cochrane review on third stage management Compares AMTSL and EMTSL Compares AMTSL and EMTSL Includes 5 studies (6486 women), all undertaken in high-income countries (Begley et al 2011). Includes 5 studies (6486 women), all undertaken in high-income countries (Begley et al 2011).

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

35. In women at low risk of bleeding ActiveExpectant ActiveExpectant 500ml+ 4.8%10.5% 500ml+ 4.8%10.5% BT.4% 1.5% BT.4% 1.5% BW -67 gms BW -67 gms BP >90 2.8%.4% BP >90 2.8%.4% Pain 4.5% 1.8% Pain 4.5% 1.8% Bleed (treat) 5.7% 3.7% Bleed (treat) 5.7% 3.7% Bleed (return)2.8% 1.3% Bleed (return)2.8% 1.3%

36. 36

37. So, for women at low risk of bleeding Is AMTSL causing more harm than good? Is AMTSL causing more harm than good?

38. Clinicians argue against physiological management : “Women die of PPH” “Women die of PPH” Do they???? Do they???? Esscher, A. 2014. Maternal Mortality in Sweden. Classification, Country of Birth, and Quality of Care. - Did not mention PPH Esscher, A. 2014. Maternal Mortality in Sweden. Classification, Country of Birth, and Quality of Care. - Did not mention PPH

39. CMACE UK 2011 Out of 2.3 million women birthing 2006-2008, only 5 died of PPH. 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. 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 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. 1 concealed pregnancy, died at home.

40. NONE of these women were at “low risk” to haemorrhage NONE of these women were at “low risk” to haemorrhage

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

42. New Zealand (Dixon 2013) Population based, retrospective cohort study, reporting on MTSL Population based, retrospective cohort study, reporting on MTSL Included 33,752 low-risk women who had no oxytocic for induction/ acceleration Included 33,752 low-risk women who had no oxytocic for induction/ acceleration 48% had EMTSL, 52% had AMTSL 48% had EMTSL, 52% had AMTSL

43. New Zealand (2) EMTSL - 3.7% had PPH > 500 ml EMTSL - 3.7% had PPH > 500 ml AMTSL - 6.9% had PPH > 500 ml AMTSL - 6.9% had PPH > 500 ml

44. 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

45. Results All women (n=1521) had   spontaneous onset of labour   no oxytocic for augmentation   spontaneous vaginal birth.   738 women (48.52%) had EMTSL   783 women (51.48%) received AMTSL

46. 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, p=0.76).

47. Results (2): PPH rates Postpartum haemorrhage rates were: 2.71% (n=20) in the ‘expectant’ group 2.17% (n=17) in the ‘active’ group No significant difference (chi-square = 0.465, d.f.=1, p=0.50).

48. Results (3): No difference in length of 3 rd stage: AMTSL: 19 mins 2 secs (SD 1 min 11 secs) EMTSL: 20 mins 18 secs (SD 1 min 8 secs)

49. 49 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.

50. 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.

51. Challenge (2) Need research comparing giving oxytocin before, compared with after, delayed cord clamping. Need research comparing different timings of delayed cord clamping.

52. Challenges in Childbirth …and Challenges in Childbirth Research… …and Challenges in Childbirth Research…

53. Caesarean section, obesity and postpartum haemorrhage Person-centred care Person-centred care

54. 54 ….helps women to have happy childbirth, as well as healthy

55. 55 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. 30 th 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 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.comwww.europeristat.com Neilson JP. 2003. Interventions for suspected placenta praevia. Cochrane Database of Systematic Reviews, Issue 2[DOI:10.1002/14651858.CD001998] Neilson JP. 2003. Interventions for suspected placenta praevia. Cochrane Database of Systematic Reviews, Issue 2[DOI:10.1002/14651858.CD001998] Villar J, Valladares E, Wojdyla D, Zavaleta N, Carroli G, Velazco A, et al. (2007) WHO (2005) Global Survey on Maternal and Perinatal Health. BMJ, 335(7628) pp. 1025.