Letters to the Editor

data collection, any attempt to accurately report on initiatives to address a perceived or actual problem with respect to VBAC rates will be problematic. Finally, even though there are many challenges in the collection and reporting of a quantitative indicator such as VBAC rates, we must not ignore the importance of patient experience and satisfaction. Although Brock et al’s review refers to the higher levels of satisfaction experienced by women offered continuity of carer for their pregnancy; as the authors acknowledge, the association between this and positive pregnancy outcomes is less clear2. As Donabedian stated in his landmark article on health quality in 1988, ‘whatever its strengths and limitations as an indicator of quality, information about patient satisfaction should be as indispensable to assessments of quality as to the design and management of health care systems’3. Saman M. MOEED Paediatric & Adolescent Gynaecologist, Royal Children’s Hospital Melbourne, Melbourne, Victoria, Obstetrician & Gynaecologist, Bendigo Health, Bendigo, Victoria, Australia E-mail: [email protected], [email protected]

before them, dismiss this substantial risk of mortality2 in one single sentence. Do we expect women to accept an increased risk of stillbirth, only to save their baby a 2% increase in the risk of ‘serious respiratory morbidity’, which turns out to be NICU admission and ≥ 4 h of assisted ventilation? Surely any risk of death, even if, say, 1:2000 or 1:5000, outweighs short-term morbidity, even if it is 1:50? Doan et al. dismiss the one randomised controlled trial in this field3 as ‘underpowered’. What kind of effect size do we expect if n = 1274 is considered too small a study? Surely not an effect sufficient in magnitude to convince obstetric colleagues to change practice in a way that actually risks lives. The shift from 38+ to 39+ weeks’ gestation for elective CS has to date been based on very limited evidence. An unbiased assessment of this limited evidence is not helped by a selective focus on neonatal outcomes rather than the inevitable antenatal consequences of such a momentous change in practice. Hans Peter DIETZ Obstetrics and Gynaecology, Sydney Medical School Nepean, Nepean Hospital, Penrith, New South Wales, Australia E-mail: [email protected] DOI: 10.1111/ajo.12304

DOI: 10.1111/ajo.12275

References

References

1 Gardner K, Henry A, Thou S et al. Improving VBAC rates: the combined impact of two management strategies. Aust N Z J Obstet Gynaecol 2014; 54: 327–332. 2 Brock E, Charlton KE, Yeatman H. Identification and evaluation of models of antenatal care in Australia – A review of the evidence. Aust N Z J Obstet Gynaecol 2014; 54: 300–311. 3 Donabedian A. The quality of care: how can it be assessed? JAMA 1988; 260: 1743–1748. 4 National Health and Hospitals Reform Commission. A Healthier Future for All Australians. Canberra: Department of Health and Ageing, Final Report June 2009. 5 AIHW National Perinatal Epidemiology and Statistics Unit and AIHW 2013. National core maternity indicators. Cat. No. PER 58. Canberra: AIHW.

Re: The timing of elective caesarean deliveries and early neonatal outcomes in singleton infants born 37–41 weeks’ gestation

The timing of elective caesarean deliveries and early neonatal outcomes in singleton infants born 37–41 weeks’ gestation I am confused by the assumption, raised by colleagues time and again, that delaying elective caesarean section (CS) from 38+ to 39+ weeks’ gestation should have no effect on the stillbirth rate.1 One would have to assume that the risk of stillbirth during that week of delay is zero. Surely that makes no sense. Of course, delaying elective CS will cost the lives of babies, and Doan et al., like others 602

1 Doan E, Gibbons K, Tudehope D. The timing of elective caesarean deliveries and early neonatal outcomes in singleton infants born 37–41 weeks’ gestation. Aust N Z J Obstet Gynaecol 2014; 54: 340–347. 2 Vashevnik S, Walker S, Permezel M. Stillbirths and neonatal deaths in appropriate, small and large birthweight for gestational age fetuses. Aust N Z J Obstet Gynaecol 2007; 47: 302–306. 3 Glavind J, Kindberg S, Uldbjerg N et al. Elective caesarean section at 38 weeks versus 39 weeks: neonatal and maternal outcomes in a randomised controlled trial. BJOG 2013; 120: 1123–1132.

We thank authors for their interest in our paper, The timing of elective caesarean deliveries and early neonatal outcomes in singleton infants born 37–41 weeks’ gestation1 and wish to address the points raised. We acknowledge the increased risk of stillbirth associated with delaying delivery in our paper and do not dismiss this risk lightly as suggested by the author. Our statement that studies report no increase in stillbirth rates was not intended to imply that, ‘the risk of stillbirth would

© 2014 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists The Australian and New Zealand Journal of Obstetrics and Gynaecology

Letters to the Editor

be zero’.1 Instead, it aimed to summarise the literature, which currently reports no significant difference in stillbirth rate with implementation of a policy to limit elective deliveries

Re: the timing of elective caesarean deliveries and early neonatal outcomes in singleton infants born 37-41 weeks' gestation.

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