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1.  Pathways to a rising caesarean section rate: a population-based cohort study 
BMJ Open  2012;2(5):e001725.
To determine whether the obstetric pathways leading to caesarean section changed from one decade to another. We also aimed to explore how much of the increase in caesarean rate could be attributed to maternal and pregnancy factors including a shift towards delivery in private hospitals.
Population-based record linkage cohort study.
New South Wales, Australia.
For annual rates, all women giving birth in NSW during 1994 to 2009 were included. To examine changes in obstetric pathways two cohorts were compared: all women with a first-birth during either 1994–1997 (82 988 women) or 2001–2004 (85 859 women) and who had a second (sequential) birth within 5 years of their first-birth.
Primary outcome measures
Caesarean section rates, by parity and onset of labour.
For first-births, prelabour and intrapartum caesarean rates increased from 1994 to 2009, with intrapartum rates rising from 6.5% to 11.7%. This fed into repeat caesarean rates; from 2003, over 18% of all multiparous births were prelabour repeat caesareans. In the 1994–1997 cohort, 17.7% of women had a caesarean delivery for their first-birth. For their second birth, the vaginal birth after caesarean (VBAC) rate was 28%. In the 2001–2004 cohort, 26.1% of women had a caesarean delivery for their first-birth and the VBAC rate was 16%. Among women with a first-birth, maternal and pregnancy factors and increasing deliveries in private hospitals, only explained 24% of the rise in caesarean rates from 1994 to 2009.
Rising first-birth caesarean rates drove the overall increase. Maternal factors and changes in public/private care could explain only a quarter of the increase. Changes in the perceived risks of vaginal birth versus caesarean delivery may be influencing the pregnancy management decisions of clinicians and/or mothers.
PMCID: PMC3437430  PMID: 22952166
OBSTETRICS; Maternal medicine; Statistics & Research Methods; SURGERY; Adult surgery
2.  Population-based trends in pregnancy hypertension and pre-eclampsia: an international comparative study 
BMJ Open  2011;1(1):e000101.
The objective of this study was to compare international trends in pre-eclampsia rates and in overall pregnancy hypertension rates (including gestational hypertension, pre-eclampsia and eclampsia).
Population data (from birth and/or hospital records) on all women giving birth were available from Australia (two states), Canada (Alberta), Denmark, Norway, Scotland, Sweden and the USA (Massachusetts) for a minimum of 6 years from 1997 to 2007. All countries used the 10th revision of the International Classification of Diseases, except Massachusetts which used the 9th revision. There were no major changes to the diagnostic criteria or methods of data collection in any country during the study period. Population characteristics as well as rates of pregnancy hypertension and pre-eclampsia were compared.
Absolute rates varied across the populations as follows: pregnancy hypertension (3.6% to 9.1%), pre-eclampsia (1.4% to 4.0%) and early-onset pre-eclampsia (0.3% to 0.7%). Pregnancy hypertension and/or pre-eclampsia rates declined over time in most populations. This was unexpected given that factors associated with pregnancy hypertension such as pre-pregnancy obesity and maternal age are generally increasing. However, there was also a downward shift in gestational age with fewer pregnancies reaching 40 weeks.
The rate of pregnancy hypertension and pre-eclampsia decreased in northern Europe and Australia from 1997 to 2007, but increased in Massachusetts. The use of a different International Classification of Diseases coding version in Massachusetts may contribute to the difference in trend. Elective delivery prior to the due date is the most likely explanation for the decrease observed in Europe and Australia. Also, the use of interventions that reduce the risk of pregnancy hypertension and/or progression to pre-eclampsia (low-dose aspirin, calcium supplementation and early delivery for mild hypertension) may have contributed to the decline.
Article summary
Article focus
The population prevalence of factors associated with increased and decreased risk of pregnancy hypertension and pre-eclampsia has changed over time, but the impact of these changes is unknown.
International comparisons of absolute population rates of pregnancy hypertension and pre-eclampsia are hindered by different diagnostic criteria and methods of data collection.
Comparing trends between countries overcomes the difficulties in comparing absolute rates.
Key message
Pregnancy hypertension and/or pre-eclampsia rates declined over time in northern Europe and Australia, but not Massachusetts (USA).
Declining hypertension rates were accompanied by a downward shift in gestational age with fewer pregnancies reaching term, the time when the pregnancy hypertension and pre-eclampsia are most likely to occur.
Strengths and limitations of this study
Strengths include numerous validation studies indicating that the hypertensive disorders are reliably reported in the population data sets used for the study and the consistency of trends across most countries.
Limitations include a different International Classification of Diseases coding version in Massachusetts and lack of available information on clinical interventions.
PMCID: PMC3191437  PMID: 22021762
Trends; pregnancy; pre-eclampsia; gestational hypertension; international classification of diseases; maternal medicine; obstetrics; hypertension; epidemiology; statistics; epidmiology; delivery; birth; infant mortality; information; public health; health economics; health policy; international health services; quality in healthcare; health and socio-economic inequalities; maternal and child health; statistics and research methods; parturition; preterm birth
3.  A survey of acute self-reported infections in pregnancy 
BMJ Open  2011;1(1):e000083.
The objective of this study was to estimate the weekly prevalence of self-reported recently acquired infections in women at least 20 weeks pregnant.
We conducted a cross-sectional survey of pregnant women in a hospital antenatal clinic in Sydney, Australia between August 2008 and April 2009. Women were asked to report whether they had onset of a new infection in the 7 days before completing the questionnaire, and were asked for details of symptoms and medication taken.
737 women at least 20 weeks pregnant completed the survey (94% of women approached). Five per cent of the completed questionnaires reported the onset of an infection in the 7 days prior to survey completion. When symptoms were analysed, 3.5% of women were classified as having a moderate or severe infection in the past 7 days. The most common infection reported was a cold/upper respiratory tract infection followed by gastroenteritis. Women pregnant with their first child had a lower rate of self-reported infection than women who had other children (2.9% vs 7.2%).
These results can be used to inform future research examining acute infection as a trigger for pregnancy complications.
Article summary
Article focus
This was a survey to ascertain the period prevalence of self-reported new infections in any 7-day period during the second half of pregnancy.
Information regarding the type of infection and medication taken to treat the infection was also collected.
Key messages
Five per cent of women at least 20 weeks pregnant reported the onset of a new infection in the previous 7 days and 3.5% of these women had a moderate or severe infection.
Only 21% of women reporting an infection sought medical care, while 65% took medication to treat the infection.
This information can be used to inform future research into acute infections as a possible trigger for pregnancy complications such as pre-eclampsia.
Strengths and limitations of this study
Strengths include the prevalence estimate of infection in a short period of time rather than at any time during pregnancy to inform research into acute triggers of pregnancy complications, and the use of information regarding symptoms and medication taken to distinguish between mild and more severe infections.
Limitations include the use of self-reported infection; however, this method has previously been used to report infection in a number of populations.
PMCID: PMC3191429  PMID: 22021755

Results 1-3 (3)