The purpose of this study is to explore and quantify perceptions and experiences of women with a traumatic childbirth experience in order to identify areas for prevention and to help midwives and obstetricians improve woman-centered care. A retrospective survey was conducted online among 2192 women with a self-reported traumatic childbirth experience. Women were recruited in March 2016 through social media, including specific parent support groups. They filled out a 35-item questionnaire of which the most important items were (1) self-reported attributions of the trauma and how they believe the traumatic experience could have been prevented (2) by the caregivers or (3) by themselves. The responses most frequently given were (1) Lack and/or loss of control (54.6%), Fear for baby’s health/life (49.9%), and High intensity of pain/physical discomfort (47.4%); (2) Communicate/explain (39.1%), Listen to me (more) (36.9%), and Support me (more/better) emotionally/practically (29.8%); and (3) Nothing (37.0%), Ask for (26.9%), or Refuse (16.5%) certain interventions. Primiparous participants chose High intensity of pain/physical discomfort, Long duration of delivery, and Discrepancy between expectations and reality more often and Fear for own health/life, A bad outcome, and Delivery went too fast less often than multiparous participants. Women attribute their traumatic childbirth experience primarily to lack and/or loss of control, issues of communication, and practical/emotional support. They believe that in many cases, their trauma could have been reduced or prevented by better communication and support by their caregiver or if they themselves had asked for or refused interventions.

Maternal sepsis is an infrequent, but important complication of pregnancy, childbirth and puerperium, resulting in significant maternal morbidity and mortality worldwide. Improved outcome is possible through improved service provision.

Objective To compare induction of labour at 41 weeks with expectant management until 42 weeks in low risk women. Design Open label, randomised controlled non-inferiority trial. Setting 123 primary care midwifery practices and 45 hospitals (secondary care) in the Netherlands, 2012-16. Participants 1801 low risk women with an uncomplicated singleton pregnancy: randomised to induction (n=900) or to expectant management until 42 weeks (n=901). Interventions Induction at 41 weeks or expectant management until 42 weeks with induction if necessary. Primary outcome measures Primary outcome was a composite of perinatal mortality and neonatal morbidity (Apgar score <7 at five minutes, arterial pH <7.05, meconium aspiration syndrome, plexus brachialis injury, intracranial haemorrhage, and admission to a neonatal intensive care unit (NICU). Secondary outcomes included maternal outcomes and mode of delivery. The null hypothesis that expectant management is inferior to induction was tested with a non-inferiority margin of 2%. Results Median gestational age at delivery was 41 weeks+0 days (interquartile range 41 weeks+0 days-41 weeks+1 day) for the induction group and 41 weeks+2 days (41 weeks+0 days-41 weeks+5 days) for the expectant management group. The primary outcome was analysed for both the intention-to-treat population and the per protocol population. In the induction group, 15/900 (1.7%) women had an adverse perinatal outcome versus 28/901 (3.1%) in the expectant management group (absolute risk difference −1.4%, 95% confidence interval −2.9% to 0.0%, P=0.22 for non-inferiority). 11 (1.2%) infants in the induction group and 23 (2.6%) in the expectant management group had an Apgar score <7 at five minutes (relative risk (RR) 0.48, 95% CI 0.23 to 0.98). No infants in the induction group and three (0.3%) in the expectant management group had an Apgar score <4 at five minutes. One fetal death (0.1%) occurred in the induction group and two (0.2%) in the expectant management group. No neonatal deaths occurred. 3 (0.3%) neonates in the induction group versus 8 (0.9%) in the expectant management group were admitted to an NICU (RR 0.38, 95% CI 0.10 to 1.41). No significant difference was found in composite adverse maternal outcomes (induction n=122 (13.6%) v expectant management n=102 (11.3%)) or in caesarean section rate (both groups n=97 (10.8%)). Conclusions This study could not show non-inferiority of expectant management compared with induction of labour in women with uncomplicated pregnancies at 41 weeks; instead a significant difference of 1.4% was found for risk of adverse perinatal outcomes in favour of induction, although the chances of a good perinatal outcome were high with both strategies and the incidence of perinatal mortality, Apgar score <4 at five minutes, and NICU admission low. Trial registration Netherlands Trial Register NTR3431.

Objectives To test the hypothesis that low risk women at the onset of labour with planned home birth have a higher rate of severe acute maternal morbidity than women with planned hospital birth, and to compare the rate of postpartum haemorrhage and manual removal of placenta.Design Cohort study using a linked dataset.Setting Information on all cases of severe acute maternal morbidity in the Netherlands collected by the national study into ethnic determinants of maternal morbidity in the netherlands (LEMMoN study), 1 August 2004 to 1 August 2006, merged with data from the Netherlands perinatal register of all births occurring during the same period.Participants 146 752 low risk women in primary care at the onset of labour. Main outcome measuresSevere acute maternal morbidity (admission to an intensive care unit, eclampsia, blood transfusion of four or more packed cells, and other serious events), postpartum haemorrhage, and manual removal of placenta.Results Overall, 92 333 (62.9%) women had a planned home birth and 54 419 (37.1%) a planned hospital birth. The rate of severe acute maternal morbidity among planned primary care births was 2.0 per 1000 births. For nulliparous women the rate for planned home versus planned hospital birth was 2.3 versus 3.1 per 1000 births (adjusted odds ratio 0.77, 95% confidence interval 0.56 to 1.06), relative risk reduction 25.7% (95% confidence interval −0.1% to 53.5%), the rate of postpartum haemorrhage was 43.1 versus 43.3 (0.92, 0.85 to 1.00 and 0.5%, −6.8% to 7.9%), and the rate of manual removal of placenta was 29.0 versus 29.8 (0.91, 0.83 to 1.00 and 2.8%, −6.1% to 11.8%). For parous women the rate of severe acute maternal morbidity for planned home versus planned hospital birth was 1.0 versus 2.3 per 1000 births (0.43, 0.29 to 0.63 and 58.3%, 33.2% to 87.5%), the rate of postpartum haemorrhage was 19.6 versus 37.6 (0.50, 0.46 to 0.55 and 47.9%, 41.2% to 54.7%), and the rate of manual removal of placenta was 8. 5 versus 19.6 (0.41, 0.36 to 0.47 and 56.9%, 47.9% to 66.3%).Conclusions Low risk women in primary care at the onset of labour with planned home birth had lower rates of severe acute maternal morbidity, postpartum haemorrhage, and manual removal of placenta than those with planned hospital birth. For parous women these differences were statistically significant. Absolute risks were small in both groups. There was no evidence that planned home birth among low risk women leads to an increased risk of severe adverse maternal outcomes in a maternity care system with well trained midwives and a good referral and transportation system.

ObjectivePresenting the results of 5 years of implementing health facility-based maternal death audits in Rwanda, showing maternal death classification, identification of substandard (care) factors that have contributed to death, and conclusive recommendations for quality improvements in maternal and obstetric care.DesignNationwide facility-based retrospective cohort study.SettingsAll cases of maternal death audited by district hospital-based audit teams between January 2009 and December 2013 were reviewed. Maternal deaths that were not subjected to a local audit are not part of the cohort.Population987 audited cases of maternal death.Main outcome measuresCharacteristics of deceased women, timing of onset of complications, place of death, parity, gravida, antenatal clinic attendance, reported cause of death, service factors and individual factors identified by committees as having contributed to death, and recommendations made by audit teams.Results987 cases were audited, representing 93.1% of all maternal deaths reported through the national health management information system over the 5-year period. Almost 3 quarters of the deaths (71.6%) occurred at district hospitals. In 44.9% of these cases, death occurred in the post-partum period. Seventy per cent were due to direct causes, with post-partum haemorrhage as the leading cause (22.7%), followed by obstructed labour (12.3%). Indirect causes accounted for 25.7% of maternal deaths, with malaria as the leading cause (7.5%). Health system failures were identified as the main responsible factor for the majority of cases (61.0%); in 30.3% of the cases, the main factor was patient or community related.ConclusionsThe facility-based maternal death audit approach has helped hospital teams to identify direct and indirect causes of death, and their contributing factors, and to make recommendations for actions that would reduce the risk of reoccurrence. Rwanda can complement maternal death audits with other strategies, in particular confidential enquiries and near-miss audits, so as to inform corrective measures.