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Recent Developments in Securities Settlement Systems: Challenges for Emerging Markets

Recent Developments in Securities Settlement Systems: Challenges for Emerging Markets. Global Payments Week 2008 Vienna, Austria September 9 th -12 th Mario Guadamillas The World Bank. Legal framework (more complex in a global environment) Protection of custody arrangements

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Recent Developments in Securities Settlement Systems: Challenges for Emerging Markets

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  1. Determining the Main Contributors to the Rising C/S Rate at the Women’sPresenter: Tanya FarrellHospital: Royal Women’s HospitalKey contact person for this project: Lynne Rigg / lynne.rigg@thewomens.org.au / 03 8345 2016 29 July 2008 - Brisbane

  2. KEY PROBLEM • The Caesarean section birth rate at the Women’s increased from 23.2% in 2000 to 29.3% in 2007. • We know the elective Caesarean section rate is stable. • Therefore, the rising overall Caesarean section rate is due to the emergency Caesarean sections. • There have been several claims that the complexity of the casemix has driven the rising Caesarean section rate .

  3. AIM OF THIS PROJECT • To apply the Ten Group Classification System (TGCS) to all the women who gave birth at the Women’s, in order to accurately determine the main contributors to the rising Caesarean section rate (and dispel the myths). • The TGCS divides women into 10 groups according to parity, past obstetric history, singleton or multiple pregnancy, presentation of the fetus, gestational age and mode of onset of labour / birth. • Electronic birth outcome data was utilised to populate the TGCS.

  4. KEY FINDINGS • There were 5,833 women who gave birth at the Women’s in 2005. • Contrary to popular belief, the “high risk” groups (eg preterm, abnormal presentation, multiple pregnancy etc) are not driving the rising C/S rates. • The greatest contributors to the overall Caesarean section rate are women who have had: • No previous viable pregnancy, having a singleton pregnancy with cephalic presentation at term and enter labour spontaneously (15%) – Group 1 • No previous viable pregnancy, having a singleton pregnancy with cephalic presentation at term and do not enter labour spontaneously (21%) – Group 2 • Previous viable pregnancy (no previous C/S) having a singleton pregnancy with cephalic presentation at term and do not enter labour spontaneously (7%) – Group 4 • Previous Caesarean section, having a singleton pregnancy with cephalic presentation at term (25%) – Group 5 • Therefore, to make the greatest impact, the Women’s has focussed on strategies for these groups of women.

  5. KEY CHANGES IMPLEMENTED-to date • Normal labour and birth (2004-2005): Targets TGCS Groups 1 and 3 • Developed an evidence-based CPG for normal labour and birth - low risk • Currently being updated (Jul 2008) • Induction of labour (2005-2006) : Targets TGCS Groups 2 and 4 • Developed and implemented an evidence-based CPG (and procedures) for induction of labour (Nov. 2006) • VBAC (2005-2007): Targets TGCS Group 5 • Revised the VBAC resources (evidence-based CPGs for antenatal and intrapartum care) patient record assessment tool and consumer decision aid (Jun 2007) • Focus on resources to inform decision for emergency C/Section (2008) • Developed and implemented an evidence-based CPG, algorithm and stickers to guide the interpretation and response to cardiotocographs (CTGs) (Jan 2008) • Commenced fortnightly case reviews with Junior Medical Staff of selected emergency Caesarean sections following IOL (Jan 2008) • Currently identifying additional resources to inform JMS escalation (to involve consultant) • 3 Centres collaborative project • Audit of all emergency Caesarean sections for Groups 1 and 2 (Nov 2007) • Compare (and publish) findings

  6. OUTCOMES SO FAR TGCS Group : Actual C/Section rate & rate of contribution to overall C/Sections

  7. PROJECT EVALUATION (1) Has this been a waste of effort? • NO – the project has forced us to look more closely at the factors influencing CS rates. • We are continuing to drill down on the data and refine our investigations so that we can truly understand the real drivers of the CS rates • Through a better understanding of the key groups, we are undertaking targeted audits, and have identified issues related to escalation, clinical decision-making etc… So, in other words… • We are getting much closer to understanding our problem • We have put an end to the myths regarding our complex women driving the CS rates • We have raised a new sense of curiosity regarding the strategies and approaches we can take to address the rates • We are frustrated that our first set of strategies didn’t create a massive shift in the rates…. But we are persevering and are optimistic that we are on the right track.

  8. EVALUATION (2) Recommendations to other organisations: • Apply the TGCS to establish the key contributors to the your hospital’s Caesarean section rate • Quality control the data • Strategic initiatives to target contributors • Benchmark / collaborate with like organisations

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