Association between rates of caesarean section and maternal and neonatal mortality in the 21st century: a worldwide population-based ecological study with longitudinal data

Has the cesarean epidemic in Czechia been reversed despite fertility postponement?

Background

Although the percentage of cesarean sections (CS) in Czechia is below the average of that of other developed countries (23.6%), it still exceeds WHO recommendations (15%). The first aim of the study is to examine the association between a CS birth and the main health factors and sociodemographic characteristics involved, while the second aim is to examine recent trends in the CS rate in Czechia. 

Methods

Anonymized data on all mothers in Czechia for 2018 taken from the National Register of Expectant Mothers was employed. The risk of cesarean delivery for the observed factors was tested via the construction of a binary logistic regression model that allowed for adjustments for all the other covariates in the model.

Results

Despite all the covariates being found to be statistically significant, it was determined that health factors represented a higher risk of a CS than sociodemographic characteristics. A previous CS was found to increase the risk of its recurrence by 33 times (OR = 32.96, 95% CI 30.95–35.11, p<0.001). The breech position increased the risk of CS by 31 times (OR = 31.03, 95% CI 28.14–34.29, p<0.001). A multiple pregnancy increased the odds of CS six-fold and the use of ART 1.8-fold. Mothers who suffered from diabetes before pregnancy were found to be twice as likely to give birth via CS (OR = 2.14, 95% CI 1.76–2.60, p<0.001), while mothers with gestational diabetes had just 23% higher odds of a CS birth (OR = 1.23, 95% CI 1.16–1.31, p<0.001). Mothers who suffered from hypertension gave birth via CS twice as often as did mothers without such complications (OR = 2.01, 95% CI 1.86–2.21, p<0.001).

Conclusions

The increasing age of mothers, a significant risk factor for a CS, was found to be independent of other health factors. Accordingly, delayed childbearing is thought to be associated with the increase in the CS rate in Czechia. However, since other factors come into play, further research is needed to assess whether the recent slight decline in the CS rate is not merely a temporal trend.

Is a single dose of commonly used antibiotics effective in preventing maternal infection after cesarean section? A network meta-analysis

Objective

This study aimed to compare the efficacy of different antibiotic classes and dosages in preventing maternal infection after cesarean delivery.

Methods

Databases were searched for randomized controlled trials (RCTs) published between January 1980 and January 2021 on antibiotic use for the prevention of maternal infection after cesarean delivery. The outcomes were endometritis, febrile morbidity, and wound infection, reported as odds ratios (OR) and surface under the cumulative ranking curve analysis scores.

Results

A total of 31 RCTs met the inclusion criteria. In the network meta-analysis (NMA) for endometritis, pooled network OR values indicated that the following interventions were superior to placebo: cephalosporins (OR: 0.18, 95% credibility interval [CrI]: 0.07–0.45), penicillins (OR: 0.19, 95% CrI: 0.07–0.50), penicillins (multiple doses) (OR: 0.20, 95% CrI: 0.05–0.65), combination therapies (OR: 0.22, 95% CrI: 0.09–0.54), and cephalosporins (multiple doses) (OR: 0.25, 95% CrI: 0.08–0.74). In the NMA for febrile morbidity, placebo was more effective than the other interventions. In the NMA for wound infection, pooled network OR values indicated that the following interventions were superior to placebo: penicillin (OR: 0.14, 95% CrI: 0.05–0.37), cephalosporins (OR: 0.19, 95% CrI: 0.08–0.41), cephalosporins (multiple doses) (OR: 0.20, 95% CrI: 0.06–0.58), combination therapies (OR: 0.29, 95% CrI: 0.13–0.57), macrolides (OR: 0.33, 95% CrI: 0.15–0.74), and penicillins (multiple doses) (OR: 0.40, 95% CrI: 0.17–0.91).

Conclusions

Compared with placebo, a single dose of commonly used antibiotics may prevent maternal infection after cesarean delivery. However, the incidence of febrile morbidity was not reduced.

Stillbirth, neonatal and maternal mortality among caesarean births in Kenya and Uganda: a register-based prospective cohort study

OBJECTIVE

To investigate the interaction of risks for adverse maternal and perinatal outcomes (stillbirth, predischarge neonatal and maternal mortality) among caesarean section (CS) compared with vaginal deliveries (VD).

DESIGN

Prospective cohort study.

SETTING

10 CS-capable facilities in Busoga Region, East-Central Uganda and Migori County, Kenya.

PARTICIPANTS

Individual birth data were extracted from maternity registers between October 2016 and April 2019. There were a total of 77 242 livebirths and 3734 stillbirths. Overall, 24% of deliveries were by CS with a range of 9%-49% across facilities.

PRIMARY OUTCOME MEASURES

Stillbirth, predischarge neonatal mortality and maternal mortality.

RESULTS

The adjusted ORs for stillbirth, predischarge neonatal mortality and maternal mortality after a CS were 1.3 (95% CI 1.1 to 1.6), 1.9 (95% CI 1.6 to 2.2) and 3.3 (95% CI 2.2 to 4.9), respectively, compared with a VD. The association between maternal mortality and CS was 3.9 (95% CI 2.8 to 5.5) when the delivery was a live birth and 1.7 (95% CI 1.0 to 3.0) when it was a stillbirth. Post hoc analyses showed that mothers who received a CS had a lower risk of stillbirth if they were documented as a referral.

CONCLUSION

In this context, CS births were at higher risk for worse outcomes compared with VD. Better understanding of CS use and associated adverse outcomes within the mother-baby dyad is necessary to identify opportunities to improve quality of intrapartum care.

TRIAL REGISTRATION NUMBER

NCT03112018.

The Inconsistency Between Women's Preference and Actual Mode of Delivery in China: Findings From a Prospective Cohort Study

Background

Previous studies have found that the rates of cesarean preference were much lower than the actual rates of cesarean births in China. We aimed to observe this inconsistency between preferred and actual modes of delivery and the factors associated with the inconsistency.

Methods

We conducted a prospective cohort study at the maternity hospital with the largest number of deliveries in Beijing. We collected data through a questionnaire applied in the outpatient department, and medical records from the hospital's information system. Unconditional logistic regression was used to identify factors influencing the inconsistency between preferred and actual delivery mode.

Results

The rates of actual cesarean section and of cesarean preference were 41 and 17%, respectively (χ2 = 82.9, P < 0.0001). The overall inconsistency rate was 31%, with 119 women preferred vaginal delivery but experienced cesarean section, accounting for 67% women undergoing cesarean section. Risk factors for this inconsistency between preferred vaginal delivery and actual cesarean section included: maternal obesity, receiving assisted reproduction, having an abnormal amniotic fluid volume, and fetal distress. Pre-labor rupture of membranes was a unique factor associated with such inconsistency between cesarean section preference and vaginal delivery at delivery.

Conclusions

The inconsistent rate between preferred delivery at late pregnancy and actual delivery is high in China. Further research is needed to understand how to lower cesarean rates in China, taking maternal preferences for vaginal deliveries into account.

The development and the psychometric evaluation of the Adolescents Intentions towards the Birth Options Scale in Greek

INTRODUCTION

Worldwide, the rising of caesarean section rates is a major public health issue. Little is known regarding birth attitudes held by students who are the next generation of parents. The aim of this study was to develop and assess the psychometric properties of the Adolescents Intentions towards Birth Options Scale (AIBOS), a self-report and short instrument assessing intentions towards birth options in young adolescents.

METHODS

The AIBOS was framed by Ajzen's theory of planned behavior and developed in a three-phase process using an integrated mixed-methods approach that included literature reviews, professional focus groups, and a psychometric survey evaluation. The psychometric evaluation was conducted by recruiting a sample of 480 high school students. Content validity, exploratory factor analysis, discriminant and construct validity, test-retest reliability and internal consistency were explored.

RESULTS

The expert panel determined that the content validity was satisfactory. The final 17-item scale consisted of five factors explaining 48.9% of the total variance in the data. Discriminant validity was satisfactory. Cronbach's α coefficient was over 0.7 for each factor, indicating acceptable internal consistency of the questionnaire. There was significant agreement in all subscales as emerged from test-retest.

CONCLUSIONS

The AIBOS demonstrated good content validity, an easily interpretable five-factor structure, acceptable internal consistency, high test-retest reliability, and satisfactory discriminant and construct validity with sample characteristics. It is an easily comprehensible, easily completed tool, which matches the culture of young adolescents.

Incidence of Intrapartum-Related Events at the Largest Obstetric Hospital in Hanoi, Vietnam: A Retrospective Study

Every year, 2.4 million neonates die during their first month of life and even more suffer permanent injury. The main causes are intrapartum-related events, prematurity, and infection, with sub-Saharan Africa and southern Asia being the worst affected regions. With a focus on intrapartum-related events, we aimed to assess the neonatal demographic characteristics, clinical management, and outcomes among neonates born at the largest obstetric hospital in Hanoi, Vietnam. This was a retrospective cross-sectional study that included all the inborn neonates in November 2019, which was selected as a representative month. A total of 4554 neonates were born during the study period. Of these, 1.0% (n = 44) were stillbirths, 0.15% (n = 7) died in hospital, 0.61% (n = 28) received positive pressure ventilation at birth, and 0.15% (n = 7) were diagnosed with hypoxic ischemic encephalopathy. A total of 581 (13%) neonates were admitted to the neonatal unit, among which the most common diagnoses were prematurity (37%, n = 217) and infection (15%, n = 89). Except for the intrapartum-related events, our findings are consistent with the previously documented data on neonatal morbidity. The intrapartum-related events, however, were surprisingly low in number even in comparison to high-income countries. Research on the current clinical practice at Phu San Hanoi Hospital may bring further clarity to identify the success factors.

Distribution of cesarean delivery by Robson classification and predictors of postspinal anesthesia hypotension in Windhoek referral hospitals: A cross-sectional study

Background

There are concerns that high cesarean section (CS) rates are driven by nonmedical indications and unmitigated maternal hypotension following spinal anesthesia (SA) has materno fetal effects.

Aims

Our objective was to investigate CS rates using Robson classification, identify patient groups for focused intervention as well as assess the incidence and predictors of maternal hypotension following SA for cesarean delivery.

Subjects and Methods

A cross sectional design was employed over 3 months (February-April, 2019). Data about total deliveries (vaginal and operative) were obtained from the hospital medical records. For parturients who had CS, variables which covered maternal characteristics, conduct of anesthesia, and the index pregnancy according to Robson classification system were entered into a proforma designed for the study.

Results

The total deliveries were 3031, of which 556 were CSs, giving a CS rate of 18.3%. Twenty one nonconsenting parturients were excluded, so 535 responded. Robson groups 5, 10, and 1 combined contributed 75% [401/535] to the overall CS. Two or more previous CS, 29.7% [159/535], was the main indication for performing CS, followed by maternal request 12.9% [69/535]. The incidence of maternal hypotension was 62.6% (293/468); the independent predictors were elective CS and having comorbidities.

Conclusion

We found a low CS rate and Robson groups 5, 10, and 1 were the major contributors - previous CS (≥2) and maternal request were the predominant indications for performing CS. The independent predictors of SA induced hypotension were presence of comorbidities and elective CS.

Caesarean birth in public maternities in Argentina: a formative research study on the views of obstetricians, midwives and trainees

OBJECTIVES

To explore obstetricians', midwives' and trainees' perceptions of caesarean section (CS) determinants in the context of public obstetric care services provision in Argentina. Our hypothesis is that known determinants of CS use may differ in settings with limited access to essential obstetric services.

SETTING

We conducted a formative research study in 19 public maternity hospitals in Argentina. An institutional survey assessed the availability of essential obstetric services. Subsequently, we conducted online surveys and semistructured interviews to assess the opinions of providers on known CS determinants.

RESULTS

Obstetric services showed an adequate provision of emergency obstetric care but limited services to support women during birth. Midwives, with some exceptions, are not involved during labour. We received 680 surveys from obstetricians, residents and midwives (response rate of 63%) and interviewed 26 key informants. Six out of 10 providers (411, 61%) indicated that the use of CS is associated with the complexities of our caseload. Limited pain management access was deemed a potential contributing factor for CS in adolescents and first-time mothers. Providers have conflicting views on the adequacy of training to deal with complex or prolonged labour. Obstetricians with more than 10 years of clinical experience indicated that fear of litigation was also associated with CS. Overall, there is consensus on the need to implement interventions to reduce unnecessary CS.

CONCLUSIONS

Public maternity hospitals in Argentina have made significant improvements in the provision of emergency services. The environment of service provision does not seem to facilitate the physiological process of vaginal birth. Providers acknowledged some of these challenges.

Inequalities in prevalence of birth by caesarean section in Ghana from 1998-2014

BACKGROUND

Caesarean section (CS) is an intervention to reduce maternal and perinatal mortality, for complicated pregnancy and labour. We analysed trends in the prevalence of birth by CS in Ghana from 1998 to 2014.

METHODS

Using the World Health Organization's (WHO) Health Equity Assessment Toolkit (HEAT) software, data from the 1998-2014 Ghana Demographic and Health Surveys (GDHS) were analysed with respect of inequality in birth by CS. First, we disaggregated birth by CS by four equity stratifiers: wealth index, education, residence, and region. Second, we measured inequality through simple unweighted measures (Difference (D) and Ratio (R)) and complex weighted measures (Population Attributable Risk (PAR) and Population Attributable Fraction (PAF)). A 95% confidence interval was constructed for point estimates to measure statistical significance.

RESULTS

The proportion of women who underwent CS increased significantly between 1998 (4.0%) and 2014 (12.8%). Throughout the 16-year period, the proportion of women who gave birth by CS was positively skewed towards women in the highest wealth quintile (i.e poorest vs richest: 1.5% vs 13.0% in 1998 and 4.0% vs 27.9% in 2014), those with secondary education (no education vs secondary education: 1.8% vs 6.5% in 1998 and 5.7% vs 17.2% in 2014) and women in urban areas (rural vs urban 2.5% vs 8.5% in 1998 and 7.9% vs 18.8% in 2014). These disparities were evident in both complex weighted measures of inequality (PAF, PAR) and simple unweighted measures (D and R), although some uneven trends were observed. There were also regional disparities in birth by CS to the advantage of women in the Greater Accra Region over the years (PAR 7.72; 95% CI 5.86 to 9.58 in 1998 and PAR 10.07; 95% CI 8.87 to 11.27 in 2014).

CONCLUSION

Ghana experienced disparities in the prevalence of births by CS, which increased over time between 1998 and 2014. Our findings indicate that more work needs to be done to ensure that all subpopulations that need medically necessary CS are given access to maternity care to reduce maternal and perinatal deaths. Nevertheless, given the potential complications with CS, we advocate that the intervention is only undertaken when medically indicated.

Identification of Hypoxia-Ischemia by chemometrics considering systemic changes of the physiology

Perinatal asphyxia represents a major medical disorder and is related to around a fourth of all neonatal deaths worldwide. Specific thresholds for lactate or pH levels define the gold standard for detecting hypoxic-ischemic events as physiological abnormalities. In contrast to current gold standard, we analyze the systemic picture, represented by the whole set of biochemical parameters from blood gas analysis, by multiparametric machine learning algorithms. In a swine model with 22 objects, we investigate the impact of neonatal hypoxic-ischemic encephalopathy on 18 individual physiological parameters. In a first approach, we study the statistical significance of individual parameters by univariate analysis methods. In a second approach, we take the most relevant parameters as input for the development of predictive models by different hybrid and non hybrid classification algorithms. The predictive power of our multiparametric models outperforms by far the limited performance of pH and lactate as reliable indicators, despite strong correlation with hypoxic-ischemic events. We have been able to detect hypoxic-ischemic events even one hour after the episode, with accuracies close to 100% in contrast to pH or lactate-based diagnosis with 62% and 78%, respectively. By all machine learning algorithms, lactate is recognized as the main contributor due to its longer-term evidence of hypoxia-ischemia episodes. However, substantial improvement of the diagnosis is achieved by predictions based on a systemic picture of different physiological parameters. Our results prove the potential applicability of our method as a support tool for decision-making that will allow obstetricians to identify hypoxic ischemic episodes more accurately during labor.

Assessment of Medicalization of Pregnancy and Childbirth in Low-risk Pregnancies: A Cross-sectional Study

BACKGROUND

Medicalization may lead to over-testing during pregnancy and increased cesarean section (CS). This study investigated the medicalization of low-risk pregnancies and childbirths in Rasht, Iran.

METHODS

In this cross-sectional study, 337 postpartum women completed a demographic questionnaire and the Medicalized Pregnancy and Childbirth checklist. In this study, medicalization indicators were the source of providing prenatal care, prenatal screening for aneuploidy, number of received care, hospitalization before the onset of labor, intrapartum drug use, and CS. Demographic data were reported using descriptive statistics. Chi-square or Fisher's exact and Man-Whitney tests were used for comparison purposes. Logistic regression was run to determine the medicalization indicators associated with the mode of childbirth.

RESULTS

Of the participants, 82.2% received prenatal care from obstetricians, 85.8% had undergone prenatal screening tests. There was a significant difference between the median number of ultrasound examinations (P=0.006), prenatal screening for aneuploidy (P=0.002), and multivitamin/mineral supplements use (P<0.001), according to the source of providing prenatal care. Of the participants, 67.1% had CS. Women who received prenatal care from obstetricians had about 2.3 times more odds of CS (OR=2.23, P=0.019). Furthermore, with the increased number of ultrasounds, the odds of CS augmented by 25% (OR=1.25, P=0.013). Finally, 26.4% of the participants were hospitalized before the onset of labor; the intervention increased the odds of CS more than twice (OR=2.08, P=0.026).

CONCLUSION

The study showed a picture of medicalization in low-risk pregnancies. Of the medicalization indicators, the source of providing prenatal care, time of admission, and use of ultrasounds were associated with CS. Midwife-led care could diminish medicalization.

Rates and indications of caesarean section deliveries in Bhutan 2015-2019: a national review

BACKGROUND

Bhutan has made much efforts to provide timely access to health services during pregnancy and increase institutional deliveries. However, as specialist obstetric services became available in seven hospitals in the country, there has been a steady increase in the rates of caesarean deliveries. This article describes the national rates and indications of caesarean section deliveries in Bhutan.

METHODS

This is a review of hospital records and a qualitative analysis of peer-reviewed articles on caesarean deliveries in Bhutan. Data on the volume of all deliveries that happened in the country from 2015 to 2019 were retrieved from the Annual Health Bulletins published by the Ministry of Health. The volume of deliveries and caesarean deliveries were extracted from the Annual Report of the National Referral Hospital 2015-2019 and the data were collected from hospital records of six other obstetric centres. A national rate of caesarean section was calculated as a proportion out of the total institutional deliveries at all hospitals combined. At the hospital level, the proportion of caesarean deliveries are presented as a proportion out of total institutional deliveries conducted in that hospital.

RESULTS

For the period 2015-2019, the average national rate of caesarean section was 20.1% with a statistically significant increase from 18.1 to 21.5%. The average rate at the six obstetric centres was 29.9% with Phuentsholing Hospital (37.2%), Eastern Regional Referral Hospital (34.2%) and Samtse General Hospital (32.0%) reporting rates higher than that of the National Referral Hospital (28.1%). Except for the Eastern Regional Referral and Trashigang Hospitals, the other three centres showed significant increase in the proportion of caesarean deliveries during the study period. The proportion of emergency caesarean section at National Referral Hospital, Central Regional Referral Hospital and the Phuentsholing General Hospital was 58.8%. The National Referral Hospital (71.6%) and Phuentsholing General Hospital reported higher proportions of emergency caesarean sections (64.4%) while the Central Regional Referral Hospital reported higher proportions of elective sections (59.5%). The common indications were 'past caesarean section' (27.5%), foetal distress and non-reassuring cardiotocograph (14.3%), failed progress of labour (13.2%), cephalo-pelvic disproportion or shoulder dystocia (12.0%), and malpresentation including breech (8.8%).

CONCLUSION

Bhutan's caesarean section rates are high and on the rise despite a shortage of obstetricians. This trend may be counterproductive to Bhutan's efforts towards 2030 Sustainable Development Goal agendas and calls for a review of obstetric standards and practices to reduce primary caesarean sections.

Predictors of immediate neonatal outcome after cesarean section in Uganda

OBJECTIVE

To identify predictors of low Apgar score, immediate neonatal death, and stillbirth after cesarean section in Uganda.

METHODS

Records of cesarean sections performed at all 14 regional referral hospitals and also 14 first-level (district) hospitals in Uganda were reviewed. Both elective and emergency cases were included. Data comprised mother's age, indication, type of anesthesia, and immediate outcome of the newborn. To evaluate the relation of the predictor variables to outcome, regression analysis was performed.

RESULTS

A total of 37 585 cesarean sections were recorded. The indications for cesarean section that led to the highest neonatal mortality and stillbirth rates and lowest mean Apgar scores were uterine rupture and hemorrhage. Emergency surgery and general anesthesia had worse neonatal outcomes than elective surgery and spinal anesthesia. Compared with general anesthesia, spinal anesthesia was favorable for neonatal outcomes.

CONCLUSION

Elective surgical planning and scale-up of the use of spinal anesthesia may potentially reduce stillbirths and immediate neonatal deaths.

Caesarean section and increased neonatal mortality risk in meta-analysis of 33 sub-Saharan Africa Demographic and Health Surveys

AIM

To examine the factors associated with the risk of neonatal mortality following caesarean births at country-level in sub-Saharan Africa.

METHODS

We used meta-analytic procedure to synthesize the results of most recent nationally representative cross-sectional Demographic and Health Survey (DHS) datasets for 33 sub-Saharan Africa countries conducted between 2010 and 2018. Pooled odds ratio (OR) and 95% confidence intervals (CI) were computed for all countries.

RESULTS

The overall caesarean section (CS) rate was 4.9%, neonatal mortality was 2.8% and Post-CS neonatal mortality was 4.3%. The rates of CS were generally low and only five countries had CS rates at or above 10%. The overall pooled result showed a statistically significant increase in the odds of neonatal mortality after a caesarean section (CS) OR 1.7 (95% CI 1.53 -1.89; I²  = 39.3%, p < 0.012); such that children delivered via CS were 70% more likely not to survive beyond the first 30 days. Geographical variations existed in the measure of association between caesarean section and neonatal mortality.

CONCLUSION

This paper has provided evidence on the low rates of CS and the associated neonatal mortality risk compared to normal deliveries in sub-Saharan Africa.

Concept Analysis: The Scope of Practice of a Nurse Anesthetist in South Africa

PURPOSE

The purpose of this article is to propose a definition for the concept "scope of practice" as it applies to a nurse anesthetist in South Africa.

DESIGN

Concept analysis.

METHODS

Walker and Avant's procedure of concept analysis was followed. The actions included "Select a concept"; "Determine the purpose of analysis"; "Identifying uses of the concept"; "Determining the defining attributes"; "Identifying antecedents and consequences"; "Define empirical referents"; "Identify model case"; and "Identifying additional cases."

FINDINGS

The concept 'scope of practice' as it applies to the nurse anesthetist in South Africa can be defined as the individual's competence, accountability, and responsibility as a health professional. The nurse anesthetist is (1) competent: ready to use skills and judgement in practice; (2) accountable: able to be registered as a nurse anesthetist and willing to abide by the regulations; and (3) responsible: upholding professionalism and demanding recognition from the public and peers.

CONCLUSIONS

A definition (revealing the concept's structure) and it's uses (revealing the concept's function) for "scope of practice" of a South African nurse anesthetist is proposed for the consideration of introducing nurse anesthesia to provide safe and affordable anesthesia services in South Africa. This article forms part of a larger study titled "A Model for Nurse Anaesthesia Practice in South Africa."

Proposed cutoff for fetal scalp blood lactate in intrapartum fetal surveillance based on neonatal outcomes: a large prospective observational study

OBJECTIVE

Determination of lactate in fetal scalp blood (FBS) during labour has been recognised since the 1970s. The internationally accepted cutoff of >4.8 mmol/l indicating fetal acidosis is exclusive for the point-of-care device (POC) LactatePro™, which is no longer in production. The aim of this study was to establish a new cutoff for scalp lactate based on neonatal outcomes with the use of the StatstripLactate^® /StatstripXpress^® Lactate system, the only POC designed for hospital use.

DESIGN

Observational study.

SETTING

January 2016 to March 2020 labouring women with indication for FBS were prospectively included from seven Swedish and one Australian delivery unit.

POPULATION

Inclusion criteria: singleton pregnancy, vertex presentation, ≥35⁺⁰  weeks of gestation.

METHOD

Based on the optimal correlation between FBS lactate and cord pH/lactate, only cases with ≤25 minutes from FBS to delivery were included in the final calculations.

MAIN OUTCOME MEASURES

Metabolic acidosis in cord blood defined as pH <7.05 plus BD_ecf >10 mmol/l and/or lactate >10 mmol/l.

RESULTS

A total of 3334 women were enrolled of whom 799 were delivered within 25 minutes. The areas under the receiver operating characteristics curves (AUC) and corresponding optimal cutoff values were as follows; metabolic acidosis AUC 0.87 (95% CI 0.77-0.97), cutoff 5.7 mmol/l; pH <7.0 AUC 0.83 (95% CI 0.68-0.97), cutoff 4.6 mmol/l; pH <7.05 plus BD_ecf ≥12 mmol/l AUC 0.97 (95% CI 0.92-1), cutoff 5.8 mmol/l; Apgar score <7 at 5 minutes AUC 0.74 (95% CI 0.63-0.86), cutoff 5.2 mmol/l; and pH <7.10 plus composite neonatal outcome AUC 0.76 (95% CI 0.67-0.85), cutoff 4.8 mmol/l.

CONCLUSION

A scalp lactate level <5.2 mmol/l using the StatstripLactate^® /StatstripXpress^® system will safely rule out fetal metabolic acidosis.

TWEETABLE ABSTRACT

Scalp blood lactate <5.2 mmol/l using the StatstripLactate^® /StatstripXpress system has an excellent ability to rule out fetal acidosis.

Association between morbidity among term newborns and low-risk caesarean delivery rates

OBJECTIVE

To examine the association between county-level caesarean delivery (CD) rates among women at low risk and morbidity among term newborns.

DESIGN

Cross-sectional study.

SETTING

Population-based study of US county-level birth data from 2015 to 2017.

POPULATION

Nulliparous women with term, singleton, vertex-presenting infants (NTSV) at low risk for morbidity.

METHODS

The primary exposure was county-level CD rates.

MAIN OUTCOME MEASURES

The outcome was morbidity among the low-risk NTSV cohort, categorised as severe (5-minute Apgar score of ≤3, assisted ventilation for ≥6 hours, severe neurologic injury or seizure, transfer or death) or moderate (5-minute Apgar score of <7 but >3, administration of antibiotics or assisted ventilation at delivery). We used linear regression models to determine the association between county NTSV CD and neonatal morbidity rates with cluster robust standard errors.

RESULTS

The analysis included data from 2 753 522 births in 952 counties from all 48 states. The mean NTSV CD rate was 23.6% (standard deviation 4.8%). The median severe and moderate neonatal morbidity rates were 15.2 (interquartile range, IQR 9.4-23.6) and 52.5 (IQR 33.4-75.7) per 1000 births, respectively. In the unadjusted analysis using the risk-adjusted exposure and outcome, every percentage point increase in the CD rate of a county was associated with 0.6 (95% CI -0.9, -0.3) and 2.3 fewer (95% CI -3.4, -1.1) cases of severe and moderate neonatal morbidity per 1000 live births. After adjustment for other county factors, the relationships remained significant. These findings were tested in multiple sensitivity analyses.

CONCLUSIONS

Lower county-level NTSV CD rates were associated with a small increase in morbidity among term newborns in the USA.

TWEETABLE ABSTRACT

Lower county-level caesarean delivery rates were associated with an increase in morbidity among term newborns in the USA.

The Project Appropriate Birth and a reduction in caesarean section rates: an analysis using the Robson classification system

OBJECTIVE

The objective of this study was to assess caesarean section (CS) rates before and after the implementation of the Project Appropriate Birth (PPA), based on the Robson ten group classification system.

DESIGN

A before-and-after study.

SETTING

Maternity hospital in South Brazil.

POPULATION

All pregnant women attending from April 2016 to April 2017 (period 1, pre-implementation of PPA) and from June 2017 to June 2018 (period 2, post-implementation of PPA).

METHODS

Maternal and obstetric characteristics were evaluated, including Robson's classification, based on the characteristics of pregnancy and childbirth. A chi-square test and crude and adjusted relative rates were used to analyse the study variables. The significance level was set at 5%.

MAIN OUTCOME MEASURES

The CS rate for each group, their contribution to the overall CS rate and the differences in these contributions before and after PPA implementation.

RESULTS

The CS rates decreased from 62.4 to 55.6%, which represented a 10.9% reduction after the implementation of the PPA. Pregnant women in Robson classification groups 1-4 had a 21.4% reduction in CS rates, ranging from 49.1 to 38.6%. The greatest contributors to the overall CS rates were group 5 and group 2, accounting for more than 60% of the CS deliveries.

CONCLUSION

The study results suggest that Project Appropriate Birth had an impact on the reduction of CS rates, especially in Robson classification groups 1 through 4, which indicates that providing mothers with evidence-based interventions for labour and childbirth assistance contributed to reduce CS rates.

TWEETABLE ABSTRACT

The Project Appropriate Birth is an innovative project that has demonstrated promising results, suggesting that interventions based on scientific evidence can lead to real changes in childbirth care, contributing to reduce CS rates. The aim of the PPA is to promote activities to improve childbirth care and encourage vaginal delivery. In this study, 6238 pregnant women admitted to the hospital for delivery were included and classified into one of the Robson 10-group classification. Findings revealed a 10.9% reduction in the overall CS rate and a 21.4% reduction for pregnant women in Robson classification groups 1 through 4, after the implementation of the PPA.

Association between hospital-level cesarean delivery rates and severe maternal morbidity and unexpected newborn complications

BACKGROUND

Although there are many indications for a cesarean delivery, the "optimal" cesarean delivery rate is unknown. Neonatal and maternal morbidity have largely not been considered in the generation of hospital-level cesarean delivery rate targets.

OBJECTIVE

We sought to examine if the widely adopted and reported markers of maternal and neonatal morbidity were associated with hospital cesarean delivery rates to provide context for potential comparison and consideration for defining cesarean delivery rate targets. We hypothesized that hospitals with higher cesarean delivery rates would have increased rates of severe maternal morbidity, though we were less certain of the associations of the cesarean delivery rates with unexpected newborn complications.

STUDY DESIGN

This is a cross-sectional, ecological study using data from the 2016 Nationwide Readmission Database of hospitals with at least 100 deliveries per year. The exposure of interest was hospital cesarean delivery rate. The outcomes were (1) severe maternal morbidity with and without transfusion-in accordance with the Centers for Disease Control and Prevention's definition, and (2) neonatal morbidity-defined using The Joint Commission's Perinatal Quality metric of moderate and severe unexpected newborn complications among term, singleton, and nonanomalous neonates. Before assuming a single linear relationship to model the associations between morbidity and cesarean delivery rates, the Joinpoint Regression Analysis program was used to examine for potential splines in the relationships with both severe maternal morbidity (with and without transfusion) and severe and moderate unexpected newborn complications. Poisson regression model was then used to determine the association between morbidity and cesarean delivery rates.

RESULTS

The analysis included 831,111 deliveries from 621 hospitals. The mean cesarean delivery rate was 30.5%. The median severe maternal morbidity rate was 1.40 per 100 deliveries (interquartile range, 0.71-2.21 per 1000 deliveries). Excluding transfusion, the median severe maternal morbidity rate was 0.47 per 100 deliveries (interquartile range, 0.22-0.73 per 100 deliveries). The median rate of severe and moderate unexpected newborn complications was 1.01 per 100 low-risk newborns (interquartile range, 0.64-1.69 per 100 low-risk newborns) and 1.79 per 1000 low-risk newborns (interquartile range, 0.94-2.93 per 100 low-risk newborns), respectively. In the unadjusted analysis, every percentage point increase in a hospital's cesarean delivery rate was associated with a 3.4% (95% confidence interval, 2.3%-4.4%) and a 2.3% (95% confidence interval, 1.0%-3.5%) increase in severe maternal morbidity including and excluding transfusion, respectively. After adjustment for the case mix and hospital factors, only the relationship with severe maternal morbidity including transfusion remained significant: 3.3% (95% confidence interval, 1.7%-4.9%) increase in severe maternal morbidity per 1 percentage point increase in the cesarean delivery rate. There was no observed association between cesarean delivery rates and unexpected newborn complications CONCLUSION: Severe maternal morbidity and unexpected newborn complications occur in fewer than 5 in 100 births. Findings from this analysis of hospitals with cesarean delivery rates ranging from 6.8%-56.3% suggest that those with lower cesarean delivery rates have lower severe maternal morbidity (which includes transfusion) and similar unexpected newborn complications compared with hospitals with higher cesarean delivery rates. This work may provide a helpful context to providers, hospitals, and policymakers who are measuring and reporting outcomes. Regarding neonatal morbidity in particular, the Joint Commission manual notes that the unexpected newborn complication metric was specifically designed to be compared against maternal-focused metrics such as cesarean delivery rates. More work is needed to define and identify appropriate measures of maternal and neonatal morbidity for these types of comparisons.

Reproductive and pregnancy outcomes following embryo transfer in women with previous cesarean section: A systematic review and meta-analysis

INTRODUCTION

Cesarean section affects subsequent spontaneous pregnancies because of implantation issues. However, its impact on post-embryo transfer pregnancies is still debated. This review aimed to evaluate the impact of a previous cesarean section on fertility and pregnancy outcomes of women undergoing fresh or frozen embryo transfer.

MATERIAL AND METHODS

MEDLINE, Scopus, ClinicalTrials.gov, Scielo, EMBASE, Cochrane Library at the CENTRAL, and LILACS were searched from inception to February 2021. Studies were included if they evaluated reproductive or pregnancy outcomes after fresh or frozen embryo transfer in infertile women with a previous cesarean section relative to women with a previous vaginal delivery. Random-effect meta-analyses to calculate risk ratio (RR) or mean differences with 95% confidence intervals (CI) followed by subgroup analysis for fresh and frozen embryo transfer were performed. Risk of bias and quality assessment were conducted using Newcastle-Ottawa scale and GRADE criteria. The review was registered in the International Prospective Register of Systematic Reviews (CRD42021226297).

RESULTS

Ten studies, with data provided for 13 696 participants, were eligible. For embryo transfers after cesarean section, compared with vaginal delivery, there was a significant reduction of the live birth rate (RR 0.88, 95% CI 0.79-0.99) and biochemical pregnancy rate (RR 0.89, 95% CI 0.82-0.96). No statistically significant differences were found for clinical pregnancy rate (RR 0.92, 95% CI 0.84-1.02), ectopic pregnancies (RR 1.00, 95% CI 0.68-1.46), pregnancy loss (RR 1.05, 95% CI 0.94-1.18), multiple pregnancies (RR 0.80, 95% CI 0.63-1.02), stillbirths (RR 0.86, 95% CI 0.27-2.69), birth defects (RR 1.71, 95% CI 0.49-5.96) or birthweight (mean difference 46.82, 95% CI -40.16 to 133.80). Subgroup analysis revealed an increased risk for preterm birth in post-cesarean section fresh embryo transfer pregnancies (RR 1.59, 95% CI 1.16-2.19).

CONCLUSIONS

Low-grade evidence shows that post-embryo transfer pregnancies in infertile women who had a previous cesarean delivery result in reduced biochemical pregnancy and live birth rates relative to women with a previous vaginal delivery. An increased risk for preterm birth is notable in post-fresh embryo transfer pregnancies.

A national assessment of elective cesarean sections in Bangladesh and the need for health literacy and accessibility

There has been a gradual rise in the number of cesarean sections (CSs) in Bangladesh. The present study identified the cohort of women, who were more likely to opt for an elective CS based on their sociodemographic characteristics, pre-delivery care history, and media exposure, using the Bangladesh Multiple Indicator Cluster Survey-2019. The survey stratification adjusted logistic regression model and interpretable machine learning method of building classification trees were utilized to analyze a sample of 9202 women, alongside district-wise heat maps. One-in-five births (20%) were elective CSs in the 2 years prior to the survey. Women residing in affluent households with educated house-heads, who accessed antenatal care prior to delivery (AOR 4.12; 95% CI 3.06, 5.54) with regular access to media (AOR 1.31; 95% CI 1.10, 1.56) and who owned a mobile phone (AOR 1.25; 95% CI 1.04, 1.50) were more likely to opt for elective CSs, which suggests that health access and health literacy were crucial factors in women's mode of delivery. Spatial analyses revealed that women living in larger cities had more elective CS deliveries, pointing towards the availability of better health and access to multiple safe delivery options in peripheral areas.

Results of Using the Robson Classification in Kazakhstan

BACKGROUND: Over the past few decades, the cesarean section frequency has increased significantly in many countries around the world, especially in the countries with high and medium income. The World Health Organization recommends 10–15% as the optimum cesarean section frequency. In Kazakhstan, the frequency of operative delivery in 2018 was 23.5%. AIM: The article is aimed at analyzing the caesarean section frequency following the Robson classification in Kazakhstan at Level II and III obstetric institutions, identifying the groups that make the greatest contribution to the overall cesarean section frequency, studying the clinical reasons in these groups, and identifying the ways to reduce unneeded cesarean sections. METHODS: A prospective study was performed at the Level II and III obstetric facilities in Almaty. On admission for delivery, all women were assigned following the Robson classification. The indices of cesarean section in each of 10 groups and the absolute and relative contribution to the overall cesarean section frequency were calculated. The patient data were prospectively entered into a computer application and processed in MS Excel and Statistica version 23. The results were presented using the Robson classification. The odds ratios were calculated with a confidence interval of 95%. RESULTS: For the period from January 1, 2019, to December 31, 2019, 12,395 women parturiated at Level II and III obstetric facilities. The main contributors to the overall cesarean section frequency at Level II and III obstetric facilities were Group 5 (multiparous women with uterine scars) – 46.3% (Level II facility) and 37.5% (Level III facility), Group 2 (12.4%) and (12.4%), Group 1 (12%) and (9.6%), and Group 10 (11.4%) at the Level III facility. CONCLUSION: The Robson classification has been used for the 1st time in Kazakhstan which has made it possible to identify the reasons that make the greatest contribution to the overall cesarean section frequency. The use of monitoring for analyzing the cesarean section frequency will make it possible to compare the Kazakhstan data with the foreign data and determine the organizational measures aimed at reducing the frequency of operative delivery. The strategies to reduce unneeded cesarean section should focus on reducing the cesarean section frequency in nulliparous women. In the absence of contraindications, natural delivery should be advised to the women with uterine scars.

Cardiovascular complications following cesarean section and vaginal delivery: a national population-based study

INTRODUCTION

Rates of cesarean section are rising in both developed and developing countries and while pregnancy and cesarean section are established as risk factors for thromboembolism and stroke, large population-based investigations focusing on all types of cardiovascular complication after delivery is missing. The aim was to analyze the risk of severe cardiovascular complications in the post-partum period following delivery by cesarean section. We also had a control group of vaginal deliveries and a reference group with nulliparas.

MATERIALS AND METHODS

This Swedish population-based study used three national registers between 2005 and 2017 and comprised a total of 1 165 684 individuals. Unselected register data was cross-linked and cardiovascular adverse events were identified by ICD diagnosis codes. 140 128 women (209 391 deliveries) were included in the cesarean group and 614 355 women (973 429 deliveries) in the vaginal control group. The reference group comprised 411 201 age-matched nulliparous women. The primary analysis was the risk of severe cardiovascular complications within 42 days of cesarean section or vaginal delivery. The secondary analysis evaluated risk factors for cardiovascular complications.

RESULTS

In the cesarean section group, 410 (0.20%) had a serious cardiovascular event within 42 days after delivery, and in the vaginal control group the number was 857 (0.09%). The risk of having an adverse cardiovascular event was significantly greater in the cesarean group (OR 2.23, CI 1.98 to 2.51) for all types of cardiovascular events. Risk factors were high BMI, preeclampsia, greater maternal age, tobacco use and acute cesarean delivery.

CONCLUSIONS

The absolute numbers on severe maternal morbidity after delivery are low. However, since almost half of the world's population are affected and the frequency of elective cesarean section continues to rise, a doubling of the risk for a severe cardiovascular event within 42 days of delivery is important to consider globally.

Caesarian section (CS) delivery in Bangladesh: A nationally representative cross-sectional study

A growing trend in the caesarian section (CS) for delivery is a threat to child health as well as maternal health. This study was conducted to identify the potential socioeconomic and demographic factors associated with CS delivery in Bangladesh. Data obtained from the Bangladesh Demographic and Health Survey (BDHS) 2014 has been used for this study. The prevalence of CS delivery among Bangladeshi mothers was 24% (Urban: 36.9%, Rural: 17.9%). A two-level logistic regression showed that mothers having delivery in the private sector or private hospital (adjusted odds ratio [AOR] = 38.70, 95% confidence interval [CI] = 29.58 to 50.62), mother's age 25-35 years (AOR = 1.73, 95% CI = 1.26 to 2.37), wealth index average (AOR = 1.61, 95% CI = 1.15 to 2.27) and rich (AOR = 1.80, 95% CI = 1.29 to 2.51), antenatal visit 1-2 (AOR = 2.31, 95% CI = 1.47 to 3.64) and ≥ 3 (AOR = 3.68, 95% CI = 2.35 to 5.76), overweight mothers (AOR = 1.44, 95% CI = 1.09 to 1.90), multiple births (AOR = 3.87, 95% CI = 1.15 to 12.58), husband's occupation professional/technical/managerial (AOR = 1.68, 95% CI = 1.15 to 2.47) were significantly more prone to CS delivery. Also, place of residence, number of family members, birth order, child's size during birth, and divisions of Bangladesh, were potentially associated with CS delivery. The current epidemiological findings and evidence suggest adopting and implementing some urgent clinical practices and strict guidelines in the healthcare system to avoid unnecessary CS delivery in Bangladesh.

Single-center task analysis and user-centered assessment of physical space impacts on emergency Cesarean delivery

Cesarean delivery is the most common surgery performed in the United States, accounting for approximately 32% of all births. Emergency Cesarean deliveries are performed in the event of critical maternal or fetal distress and require effective collaboration and coordination of care by a multidisciplinary team with a high level of technical expertise. It is not well understood how the physical environment of the operating room (OR) impacts performance and how specialties work together in the space.

Assessing the Factors Affecting Cesarean Section Selection in Iranian Women Using Multilevel Count Models with Excess Zeros

Background

Iran has ranked second in the frequency of cesarean delivery (CD) and this rate in 2014 has increased by 56 percent. The CD has multiple complications for the woman and newborn, and due to the women's readmission after surgery impose additional costs to the countries. Although CD has many complications and is not recommended by obstetrician and midwives; some factors affect the choice of this method of delivery.

Methods

We used data from the Iranian Institute for Health Sciences Research (IIHSR) in 2015. We studied the effects of factors such as socioeconomic and demographic factors and supplemental insurance status in the choice of CD. We used multilevel Zero-Inflated models for the modeling of data.

Results

The employed women resident in urban areas with the high-income and age greater than 34-yr old and supplemental insurance more likely chose CD. On the other hand, women with high education level, women who use at least one media (e.g. Radio, television, etc.) and women that use contraceptive methods have chosen the less CD.

Conclusion

Our findings highlighted the importance of supplemental insurance and socio-economic status in choosing a CD by women. However, in some cases especially in the rich class of society, the high cost of this type of delivery does not affect the choice decrease of it, and governments should adopt rigorous policies in using this method.

Impact of manual removal of the placenta and intrauterine cleaning during elective cesarean delivery on maternal infectious morbidity and blood loss

OBJECTIVE

to assess the impact of manual removal of the placenta and intrauterine cleaning during elective cesarean delivery on maternal infectious morbidity and blood loss.

METHODS

This prospective multicenter trial was conducted on 436 pregnant women at term who were intended for elective cesarean delivery and allocated into four groups; group 1 (n = 110) who underwent manual removal of the placenta with intrauterine cleaning, group 2 (n = 106) who underwent manual removal of the placenta without intrauterine cleaning, group 3 (n = 108) who underwent spontaneous placental delivery with intrauterine cleaning and group 4 (n = 112) who underwent spontaneous placental delivery without intrauterine cleaning. Maternal operative blood loss, the rate of endometritis and surgical site infections (SSIs) was assessed and recorded.

RESULTS

There was no significant difference between the four groups regarding drop of hemoglobin concentration, drop of hematocrit value, re-operation, re-admission to hospital, duration of hospital stay, the rate of endometritis and SSIs as well as maternal acceptability in terms of overall discomfort, overall satisfaction with delivery and recommendation to other women (p > .05). Intrauterine cleaning was associated with a significantly shorter duration of discharge of lochia and rapid return to daily activity compared to non-intrauterine cleaning (p < .05).

CONCLUSION

Manual removal of the placenta and intrauterine cleaning have no deleterious impact on maternal blood loss and infectious morbidity after elective cesarean section. Also, intrauterine cleaning was associated with faster cessation of lochia and faster return to daily activity.

Trends and changes in cesarean delivery rates in Iraq: findings from the multiple indicator cluster surveys, 2011-2018

BACKGROUND

The increasing trend of cesarean section (CS) delivery can significantly increase the morbidity and mortality among infants and mothers, especially when it is medically unjustified. This study aimed to assess the trends and changes in the CS rates in Iraq between 2011 and 2018 and determine the factors associated with increased rates.

MATERIALS AND METHODS

This study included secondary data analysis of the Iraq Multiple Indicator Cluster Survey 2011 and 2018. The CS rates were calculated for both 2011 and 2018 surveys by governorate and by other exposure variables. The relative change in the CS rates between 2011 and 2018 surveys was computed for each variable.

RESULTS

The CS rates in the 2018 survey remarkably increased compared to the rates of the 2011 survey. The relative change (RC) for Iraq was 49.5%, 58.5% for the Kurdistan Region, and 45.1% for the rest of Iraq. The increase was highest in Kirkuk (RC = 119.5%), Ninewa (RC = 81.1%), and Erbil (RC = 75.4%). The increase was highest among women aged less than 20 years (RC = 80.7%), women with no education (RC = 85.1%), women in the poorest and the middle wealth quintiles (RC = 55.9 and 55.8%), and women from rural areas (RC = 86.3%).

CONCLUSION

The CS rate in Iraq is significantly higher than the recommended rate. The rates are higher in the Kurdistan Region, while the whole country has witnessed a remarkable increasing trend from 2011 to 2018. The CS rates are higher among women with higher socioeconomic status, while the increasing trend is higher among women with lower socioeconomic status.

Does continuous cardiotocography during labor cause excessive fetal distress diagnosis and unnecessary cesarean sections?

OBJECTIVE

We aimed to evaluate the perinatal outcomes of patients who were continuously monitored by cardiotocography (CTG) during the labor and experienced cesarean operation with a diagnosis of fetal distress.

MATERIAL AND METHODS

This is a retrospective study in which records of the patients, who were diagnosed of fetal distress at Umraniye Training and Research Hospital, Department of Obstetrics and Gynecology, Istanbul, Turkey, between January 2015 and October 2020 were collated. The statistical analysis was done using the Statistical Packagefor Social Sciences version 22 software (SPSS Inc., Chicago IL, USA).

RESULTS

Of the 32,338 deliveries in this study period, 13,077 (40.4%) deliveries were through caesarean section. A total of 1504 (11.5%) of the 13,077 caesarean sections were due to fetal distress within the study period. A total of 1301 (86.5%) babies were born with ≥7 Apgar score at the1st min of delivery. NICU admission rate was 11.2% and perinatal mortality was 0.1%. More so, in the low-risk pregnancy group, the rate of the babies were born with ≥7 Apgar score at the1st min of delivery was 93.7% and NICU admission rate 2.1% and no perinatal mortality was seen. In the patient group in which pregestational and gestational diseases complicating pregnancy were excluded, newborns with meconium-stained amniotic fluid had statistically significantly lower 1st and 5th-min Apgar scores compared to the group without meconium and higher NICU admission (p = .000, p = .004 and p = .000, respectively).

CONCLUSION

The diagnosis of fetal distress should not be made only with fetal heart rate changes in CTG because this causes excessive fetal distress diagnosis and many unnecessary cesarean operations. We believe that rate of cesarean sections will decrease to the desired levels with the routine use of a method such as CTG which is easy to apply, but more sensitive and specific in the diagnosis of fetal distress.

Cesarean Delivery and Gender of Delivering Physicians: A Systematic Review and Meta-analysis

OBJECTIVE

To assess the association of the gender of the delivering physician and the odds of performing cesarean delivery.

DATA SOURCES

CINAHL, ClinicalTrials.gov, Cochrane Library, PubMed, Scopus and Web of Science from the first year of records through May 2020.

METHODS OF STUDY SELECTION

We included studies that reported odds ratios (OR), or data allowing the calculation of ORs, for cesarean delivery performed by female and male delivering physicians. We also included studies that reported the preference of physicians for performing cesarean deliveries.

TABULATION, INTEGRATION, AND RESULTS

Independent data extraction was carried out by at least two researchers. Standard inverse-variance random effects meta-analysis was used to generate overall ORs. Finally, in two separate meta-analyses, we analyzed 15 studies containing clinical data for 1,269,625 births, and 11 studies containing data for the preference for delivery mode of 4,911 obstetricians. Both the crude and adjusted odds of a cesarean delivery were lower for those performed by female physicians (crude OR 0.75, 95% CI 0.68-0.84, τ=0.029, adjusted OR 0.74, 95% CI 0.65-0.85, τ=0.031). We also found that female physicians had a lower preference for cesarean delivery in both crude and adjusted analysis (crude OR 0.59, 95% CI 0.36-0.96, I=77%, adjusted OR 0.58, 95% CI 0.40-0.84, I=67%).

CONCLUSION

Female physicians are less likely to perform cesarean delivery and less likely to prefer it. This was observed across different health systems and populations.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42020158442.

The rates and medical necessity of cesarean delivery in China, 2012-2019: an inspiration from Jiangsu

BACKGROUND

The World Health Organization (WHO) in 2015 stated that every effort should be made to provide cesarean delivery (CD) for women in need. In China, the two-child policy largely prompts the number of advanced age childbirth, which raises the possibility of an increasing number of women who need a c-section. The aim of this study was to assess the trends in the overall and medical indication-classified CD rates in the era of the two-child policy in Jiangsu, China.

METHODS

A retrospective cross-sectional study of 291,448 women who delivered in 11 hospitals in Jiangsu province between 2012 and 2019 was conducted. Medical cesarean indication for each woman was ascertained by manually reviewing the medical records. The 291,448 women were divided into two subgroups according to the presence of the indications: the indicated group (7.80%) and the non-indicated group (92.20%). We then fitted joinpoint regression and log-binomial regression models to estimate trends in the CD rates across the study period.

RESULTS

The overall CD rate was observed with a declining trend from 52.51% in 2012-2015 to 49.76% in 2016-2019 (adjusted RR, 0.92; 95% CI, 0.91-0.93; P < 0.001), along with an annual percentage change (APC) to be - 1.0 (95% CI, - 2.1 to 0.0) across the period. The participants were then divided into two subgroups according to the presence of medical CD indications: the indicated group (7.80%) and the non-indicated group (92.20%).We found the declining trend was most pronounced in the non-indicated group, with the CD rates decreased from 50.02% in 2012-2015 to 46.27% in 2016-2019 (adjusted RR, 0.90; 95% CI, 0.89-0.90; P < 0.001). By contrast, we observed a steady trend in the CD rate of the indicated group, which maintained from 87.47% in 2012-2015 to 86.57% in 2016-2019 (P = 0.448). In the indicated group, a higher risk of adverse pregnancy outcomes was revealed for those women who delivered vaginally as compared with those who received c-section. We further investigated that women with following specific indications had a higher proportion of vaginal delivery, i.e., pregnancy complications, fetal macrosomia, and pregnancy complicated with tumor (34.70%, 10.84%, and 16.34%, respectively). Women with the above 3 indications were observed with a higher risk of adverse pregnancy outcomes if delivered vaginally. The incidence rates of the medical indications among the general population increased considerably over the 8-year period (P < 0.001).

CONCLUSIONS

Although the overall CD rate apparently decreased in the recent years, along with the decline of the unnecessary CD rate, a considerable proportion of indicated women were not provided with CD service in Jiangsu, China. Instead of targeting the overall CD rate, we need to take actions to reduce unnecessary CD rate and provide adequate c-section service for women with indications, particularly for those with underlying diseases and suspected fetal macrosomia.

Perinatal Outcomes in a Population of Diabetic and Obese Pregnant Women-The Results of the Polish National Survey

Obesity and diabetes increase the risk of complications during gestation and at delivery. The aim of this study was to compare the perinatal outcomes in the populations of diabetic and obese Polish women, based on the results of a national survey performed in years 2012 and 2017, as well as to determine the risk factors of the gestational diabetes mellitus (GDM). Questionnaires from 6276 women were collected. Obese women constituted 5.5% and 7.5% of study population in years 2012 and 2017, respectively. Among women whose pregnancies were complicated by diabetes mellitus, GDM constituted the most common type of glucose intolerance during both time periods (2012: 89% vs. 2017: 85.6%). In the group of obese women an insignificant increase in the rate of induced deliveries was noted (2012: 9.9% vs. 2017: 11.7%), whereas the fetal birth-weight decreased significantly (2012: 3565 g vs. 2017: 3405 g, p < 0.05). In the group of diabetic pregnant women the percentage of cesarean sections, labour inductions and fetal birth defects was characterized by an insignificant upward trend. Risk of GDM was significantly increased in women aged over 35 years—(2012: OR 1.9 (95% CI: 1.1–2.9) and 2017: OR = 2.1 (95% CI: 1.5–2.9), p < 0.05—, as well as in overweight women—2012: OR 1.8 (95% CI: 1.2–2.7) and 2017: OR 2.6 (95% CI: 1.9–3.4), p < 0.05—during both analysed time periods. Based on the study results, it is necessary to develop population-based programmes to prevent obesity and to introduce and enforce the rules of appropriate screening for glucose tolerance disorders during pregnancy.

Prevalence of and reasons for women's, family members', and health professionals' preferences for cesarean section in Iran: a mixed-methods systematic review

BACKGROUND

Cesarean section (CS) rates have been increasing globally. Iran has one of the highest CS rates in the world (47.9%). This review was conducted to assess the prevalence of and reasons for women's, family members', and health professionals' preferences for CS in Iran.

METHODS AND FINDINGS

In this mixed-methods systematic review, we searched MEDLINE/PubMed, Embase, CINAHL, POPLINE, PsycINFO, Global Health Library, Google scholar; as well as Iranian scientific databases including SID, and Magiran from 1 January 1990 to 8th October 2019. Primary quantitative, qualitative, and mixed-methods studies that had been conducted in Iran with Persian or English languages were included. Meta-analysis of quantitative studies was conducted by extracting data from 65 cross-sectional, longitudinal, and baseline measurements of interventional studies. For meta-synthesis, we used 26 qualitative studies with designs such as ethnography, phenomenology, case studies, and grounded theory. The Review Manager Version 5.3 and the Comprehensive Meta-Analysis (CMA) software were used for meta-analysis and meta-regression analysis. Results showed that 5.46% of nulliparous women (95% CI 5.38-5.50%; χ² = 1117.39; df = 28 [p < 0.00001]; I² = 97%) preferred a CS mode of delivery. Results of subgroup analysis based on the time of pregnancy showed that proportions of preference for CS reported by women were 5.94% (95% CI 5.86-5.99%) in early and middle pregnancy, and 3.81% (95% CI 3.74-3.83%), in late pregnancy. The heterogeneity was high in this review. Most women were pregnant, regardless of their parity; the risk level of participants were unknown, and some Persian publications were appraised as low in quality. A combined inductive and deductive approach was used to synthesis the qualitative data, and CERQual was used to assess confidence in the findings. Meta-synthesis generated 10 emerging themes and three final themes: 'Women's factors', 'Health professional factors', andex 'Health organization, facility, or system factors'.

CONCLUSION

Despite low preference for CS among women, CS rates are still so high. This implies the role of factors beyond the individual will. We identified a multiple individual, health facility, and health system factors which affected the preference for CS in Iran. Numerous attempts were made in recent years to design, test and implement interventions to decrease unnecessary CS in Iran, such as mother-friendly hospitals, standard protocols for labor and birth, preparation classes for women, midwives, and gynaecologists, and workshops for specialists and midwives through the "health sector evolution policy". Although these programs were effective, high rates of CS persist and more efforts are needed to optimize the use of CS.

Maternal and fetal characteristics to predict c-section delivery: A scoring system for pregnant women

INTRODUCTION

Cesarean section is one of the most common obstetrical interventions that has been performed at an increasing rate globally, due to both medical and non-medical reasons. This study aims to develop a prediction tool for pregnant women potentially needing c-section, such that necessary preparations from the mothers, families, and health providers can be made.

METHODS

A total of 603 pregnant women were recruited in the first phase of c-section prediction tool development. The association between the maternal and fetal factors on the risk of c-section were analyzed, followed by a stepwise multivariate regression analysis. In the next phase, 61 pregnant women were enrolled for external validation. Discrimination was assessed using area under the curve. The calibration plot was then made and assessed using the Hosmer-Lemeshow test.

RESULTS

There were 251 (41.6%) cases of vaginal delivery and 352 (58.4%) of c-section assessed. Multivariate analysis showed that gestational age < 37 wg (OR: 1.66, 95% CI: 1.10-2.51), pre-pregnancy body mass index (underweight) (OR: 0.40, 95% CI: 0.22-0.76), no history of vaginal delivery (OR: 2.66, 95% CI: 1.76-4.02), history of uterine surgery (OR: 8.34, 95% CI: 4.54-15.30), obstetrical complications (OR: 5.61, 95% CI: 3.53-8.90), birthweight ⩾ 3500 g (OR: 4.28, 95% CI: 2.16-8.47), and non-cephalic presentation (OR: 2.74, 95% CI: 1.53-4.89) were independently associated with c-section delivery. Those parameters were included in a 7-item scoring tool, with consecutive predictive scores of 1,-1,2,3,3,2,2,1. The area under the curve result was 0.813 (95% CI: 0.779-0.847), indicating a good predictive ability. The external validation showed AUC: 0.806, 95% CI: 0.694-0.917, Hosmer-Lemeshow test p = 0.666 and calibration plot coefficient of r = 0.939.

CONCLUSION

A total of 7 maternal-fetal factors were found to be strongly associated with c-section delivery, including gestational age < 37, maternal underweight body mass index, previous uterine surgery, obstetrical complications, birthweight ⩾ 3500, history of vaginal delivery, and non-cephalic presentation. Using these factors, a prediction tool was developed and validated with good quality.

Analysis of Cesarean Sections using Robson's Ten Group Classification System

Objective:

To analyze trends of CSs and evaluating them according to Robson’s Ten Groups Classification System (TGCS) at a leading government tertiary care hospital of South Punjab, Pakistan.

Methods:

This cross-sectional study was conducted at Department of Obstetrics and Gynaecology, Nishtar Medical University Hospital, Multan Pakistan, from October 2019 to March 2020.The study population included a total of 167 women who underwent CS in the hospital during the specified study period. For each case, we collected data regarding maternal characteristics and pregnancy-related information. The dependent variable was Robson classification group.

Results:

Overall, mean age was 26.53+5.1 years. Majority of the women, 116 (69.5%) belonged to urban areas of residence, 74 (44.3%) gestational aged between 37-42 years while 108 (64.7%) had history of cesarean section. Most of the patients, 85 (50.9%) turned out to be from TGCS Group-10. Group-5 and Group-1 were the 2nd and 3rd most common group, accounted for 24 (14.4%) and 19 (11.4%) cases respectively. Previous cesarean section (20.4%) and fetal distress (19.8%) were found to be most common indications leading to cesarean section.

Conclusion:

As per Robson’s Ten-Group Classification, Group-10 and Group-5 were found to be the most contributing among deliveries done. Previous cesarean section and fetal distress were the most common indications of cesarean section.

Effect of Elective Cesarean Section on Children's Obesity From Birth to Adolescence: A Systematic Review and Meta-Analysis

BACKGROUND

Elective cesarean section (ECS) is the most common reason for the increasing cesarean section rate worldwide, and it is reported to be related to adverse short-term and long-term outcomes in both mothers and infants. Findings on the association between ECS and overweight and obesity in children are controversial in recent studies. Therefore, we conducted a systematic review and meta-analysis to examine the effect of ECS on offspring's overweight and obesity.

METHODS

PubMed, Science Direct, Web of Science, CNKI (China National Knowledge Infrastructure), Wanfang Database (in Chinese), and China Biology Medicine disc databases were searched using different combinations of three groups of keywords: "elective cesarean section," "overweight/obesity," and "children." Nine cohort studies and 11 independent risk estimates were finally identified.

RESULTS

We have observed significant association between ECS and children's obesity, the total pooled risk ratio (RR) being 1.10 (95% CI: 1.01-1.18; I ² = 32.4%). In subgroup analysis, ECS was found to be associated with the occurrence of obesity in preschoolers (RR = 1.12, 95% CI: 1.02-1.22; I ² = 16.8%). Furthermore, it revealed that ECS was related with the high risk of children's obesity where the rate of ECS exceeded 10%. No significant association was observed between ECS and children's overweight, and the RR was 1.12 (95% CI: 0.94-1.30; I ² = 55.6%).

CONCLUSIONS

Overall, it indicated that children born via ECS had an increased risk of later-life obesity. Given the global increase in childhood obesity, our findings would provide evidence-based reference for early life intervention on children's obesity.

SYSTEMATIC REVIEW REGISTRATION

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021267211, identifier: CRD42021267211.

Cesarean delivery and associated socioeconomic factors and neonatal survival outcome in Kenya and Tanzania: analysis of national survey data

Background: The increasing trends in cesarean delivery are globally acknowledged. However, in many low-resource countries, socioeconomic disparities have created a pattern of underuse and overuse among lower and higher socioeconomic groups. The impact of rising cesarean delivery rates on neonatal survival is also unclear.Objective: To examine cesarean delivery and its associated socioeconomic patterns and neonatal survival outcome in Kenya and Tanzania.Methods: We employed binary logistic regression to analyze cross-sectional demographic and health survey data on neonates born in health facilities in Kenya (2014) and Tanzania (2016).Results: Cesarean delivery rates ranged from 5% among uneducated, rural Tanzanian women to 26% among educated urban women in Kenya to 37.5% among managers in urban Tanzania. Overall findings indicated higher odds of cesarean delivery among mothers from richest households, adjusted odds ratio (aOR) 1.4 (95% CI 1.2-1.8), those insured, aOR 1.6 (95% CI 1.3-1.9), highly educated, aOR 1.6 (95% CI 1.2-2.0) and managers aOR 1.7 (95% CI 1.3-2.2), compared to middle class, no insurance, primary education and unemployed, respectively. Overall, compared to normal births and while adjusting for maternal risk factors, cesarean delivery was significantly associated with neonatal mortality in Kenya and Tanzania, overall aOR 1.7 (95% CI 1.2-2.7). However, statistical significance ceased when fetal risk factors and number of antenatal care visits were further controlled for, aOR 1.6 (95% CI 0.9-2.6).Conclusion: Disproportionate access to cesarean delivery has widened in Kenya and Tanzania. Higher risks of cesarean-related neonatal deaths exist. Medically indicated or not, the safety and/or choice of cesarean delivery is best addressed on individual basis at the health-facility level. However, policy initiatives to eliminate incentives, improve equitable access and accountability to reduce unnecessary cesarean deliveries through well-informed decisions are needed. Efforts to prevent unintended pregnancies among adolescents as well as training of health workers and continuous research to improve neonatal outcomes are vital.

Indications and factors associated with cesarean section in Bhutan: A hospital-based study

OBJECTIVE

To investigate the factors associated with cesarean section (CS) in Bhutan.

METHODS

This was a cross-sectional study, using the retrospective data from the birth registers maintained in comprehensive emergency obstetric care centers for the year 2018. The data were entered in excel 2013 and analyzed using STATA 13. Multiple logistic regression was used to understand the factors associated with CS in Bhutan.

RESULTS

The rate of CS in Bhutan was 18.7%. The indications for CS were previous CS, fetal distress, prolonged labor, and failed induction. The factors associated with CS were maternal age over 25 years, male child, women with smaller number of living children, multiple pregnancy, and gestation over 40 weeks. In addition, mothers delivering in Samtse Hospital and Central Regional Referral Hospital had higher odds of CS.

CONCLUSION

In Bhutan, CS was commonly performed for mothers with previous CS, fetal distress, and prolonged labor. Increasing maternal age, multiple pregnancy, and postdated pregnancy and those with one child, or none, were more likely to undergo CS. To reduce the CS rate, Bhutan should focus on decreasing the primary CS rate as well as preventing over-diagnosis of prolonged labor by focusing on the partograph.

Placenta Accreta Spectrum

Placenta accreta spectrum is a term used to describe abnormal adherence and abnormal invasion of the placenta into the uterine wall during pregnancy. The incidence of placenta accreta spectrum has steadily increased over the last 40 years and is most notably linked to rising cesarean birth rates. This condition is associated with increased maternal morbidity and mortality because of the high risk of severe hemorrhage and likely need for hysterectomy at the time of birth. Early diagnosis of abnormal placentation is preferable in order to coordinate birth planning with a interprofessional collaborative team within a high-level perinatal care center. This article describes the case of a woman diagnosed with placenta accreta spectrum and the clinical course of her pregnancy and birth.

Analysis of nationwide reflection of rising cesarean section rate in neonatal outcomes of Hungary

AIM

The authors investigated the effect of rising cesarean rates on maternal and perinatal mortality and in neonatal morbidity in Hungary.

METHODS

The authors searched the validated Hungarian National Health database of neonatal discharge records for ICD-10 codes: P0590 (growth restriction); P2010 (fetal hypoxia in labor); P2090 (intrauterine hypoxia); P2200 (respiratory distress syndrome); P2390 (congenital pneumonia); P2400 (meconium aspiration); P2850 (respiratory insufficiency); P3990 (neonatal infection); P9130 (cerebral irritability) and P9141 (cerebral depression) collected between 2006 and 2015. County-specific number of deliveries, perinatal deaths, and data on the route of delivery from the national database were also collected. Controlling for regional disparities with Human Development Index was also performed. Logistic regression analysis was performed to identify determinants of early neonatal mortality.

RESULTS

While cesarean section-rate rose from 28.6% to 38.2% perinatal mortality stayed within the range between 7.8‰ and 6.1‰. Early (0-6 days) neonatal mortality (NMR) of the whole country in 2006 was 2.8‰ and showed a significant decrease over the years to reach 1.7‰ in 2015. The rate of most neonatal morbidities decreased significantly. Controlled regression analysis proved that cesarean rates negatively influenced neonatal mortality rates.

CONCLUSION

The rise of the cesarean section rate in Hungary between 2006 and 2015 was associated with a detectable reduction of perinatal mortality and morbidity; however, the proportion of improvement in neonatal morbidity is far less than the increment in cesarean rate.

Impact of Medical Doctors Global Health and Tropical Medicine on decision-making in caesarean section: a pre- and post-implementation study in a rural hospital in Malawi

BACKGROUND

Medical doctors with postgraduate training in Global Health and Tropical Medicine (MDGHTM) from the Netherlands, a high-income country with a relatively low caesarean section rate, assist associate clinicians in low-income countries regarding decision-making during labour. Objective of this study was to assess impact of the presence of MDGHTMs in a rural Malawian hospital on caesarean section rate and indications.

METHODS

This retrospective pre- and post-implementation study was conducted in a rural hospital in Malawi, where MDGHTMs were employed from April 2015. Indications for caesarean section were audited against national protocols and defined as supported or unsupported by these protocols. Caesarean section rates and numbers of unsupported indications for the years 2015 and 2016 per quarter for different staff cadres were assessed by linear regression.

RESULTS

Six hundred forty-five women gave birth by caesarean section in the study period. The caesarean rate dropped from 20.1 to 12.8% (p < 0.05, R² = 0.53, y = - 0.0086x + 0.2295). Overall 132 of 501 (26.3%) auditable indications were not supported by documentation in medical records. The proportion of unsupported indications dropped significantly over time from 47.0 to 4.4% (p < 0.01, R² = 0.71, y = - 0.0481x + 0.4759). Stratified analysis for associate clinicians only (excluding caesarean sections performed by medical doctors) showed a similar decrease from 48.3 to 6.5% (p < 0.05, R² = 0.55, y = - 0.0442x + 0.4805).

CONCLUSIONS

Our results indicate that presence of MDGHTMs was accompanied by considerable decreases in caesarean section rate and proportion of unsupported indications for caesarean section in this facility. Their presence is likely to have influenced decision-making by associate clinicians.

Rate, Risk Factors, and Causes of Neonatal Deaths in Jordan: Analysis of Data From Jordan Stillbirth and Neonatal Surveillance System (JSANDS)

Background: It has been estimated that 27.8 million neonates will die worldwide between 2018 and 2030 if no improvements in neonatal and maternal care take place. The aim of this study was to determine the rate, risk factors, and causes of neonatal mortality in Jordan. Methods: In August 2019, an electronic stillbirths and neonatal deaths surveillance system (JSANDS) was established in in three large cities through five hospitals. Data on all births, neonatal mortality and their causes, and other characteristics in the period between August 2019 and January 2020 were exported from the JSANDS and analyzed. Results: A total of 10,328 births [10,226 live births (LB) and 102 stillbirths] were registered in the study period, with a rate of 14.1 deaths per 1,000 LBs; 76% were early neonatal deaths and 24% were late deaths. The odds of deaths in the Ministry of Health hospitals were almost 21 times (OR = 20.8, 95% CI: 2.8, 153.1) higher than that in private hospitals. Low birthweight and pre-term babies were significantly more likely to die during the neonatal period compared to full-term babies. The odds of neonatal mortality were significantly higher among babies born to housewives compared to those who were born to employed women (OR = 2.7; 95% CI: 1.2, 6.0). Main causes of neonatal deaths that occurred pre-discharge were respiratory and cardiovascular disorders (43%) and low birthweight and pre-term (33%). The main maternal conditions that attributed to these deaths were complications of the placenta and cord, complications of pregnancy, and medical and surgical conditions. The main cause of neonatal deaths that occurred post-discharge were low birthweight and pre-term (42%). Conclusions: The rate of neonatal mortality have not decreased since 2012 and the majority of neonatal deaths occurred could have been prevented. Regular antenatal visits, in which any possible diseases or complications of pregnant women or fetal anomalies, need to be fully documented and monitored with appropriate and timely medical intervention to minimize such deaths.

Reproductive Outcomes of Single Embryo Transfer in Women with Previous Cesarean Section

The aim of this study is to evaluate the reproductive outcomes of patients with previous cesarean section (CS) undergoing single-embryo transfer (SET). A total of 5479 patients previously underwent CS or vaginal delivery (VD) were included. The patients with previous CS included single/double cleavage (SCT/DCT), single/double blastocyst stage embryo transfer (SBT/DBT). The comparison of reproductive outcomes between CS and VD, SET, and double-embryo transfer of CS was conducted. The main outcome measures included clinical pregnancy rate (CPR), multiple pregnancy rate (MPR), live birth rate (LBR), and cumulative live birth rate (CLBR). There were no differences in CPR and LBR between patients previously underwent CS and VD, and the preterm birth rate of multiple births in patients underwent CS were significantly higher than underwent VD. As for patients underwent CS, the CPR, MPR, and LBR were lower in patients treated with SCT than DCT in IVF/ICSI cycles. The CPR and LBR of patients treated with SCT were not statistically different compared with DCT and SBT when patients' age were younger than 35 years in FET cycles, and the MPR of patients treated with SCT was lower. The CPR and LBR of patients treated with SCT were lower than DCT/SBT when patients' age were 35 years or older in FET cycles. The CPR, LBR, and CLBR of patients treated with SBT were not lower than DCT in IVF/ICSI-ET, FET, and complete cycles, but the MPR was lower. Reducing the number of embryos transferred should be considered seriously for CS. SCT under the 35 years of FET cycles is feasible. SBT is an effective strategy to reduce MPR of IVF/ICSI, FET, and complete cycles regardless of overall or age stratification.

Risk Factors for Postcesarean Wound Infection in a Tertiary Hospital in Lagos, Nigeria

Background:

There has been a global increase in cesarean section rates. While this has improved perinatal outcome, it is associated with complications such as wound infection. We determined risk factors for cesarean section wound infection in a tertiary hospital in Lagos, Nigeria.

Materials and Methods:

We prospectively studied a cohort of 906 women who had cesarean section at the Obstetrics Unit of the Lagos State University Teaching Hospital between January 1, 2011, and December 31, 2011. A comparison was made between 176 women who had wound infection and 730 women who did not using logistic regression.

Results:

Of the 2134 deliveries during the study, 906 (42.5%) had cesarean section and of which 176 (19.4%) had wound infection. Independent risk factors for wound infection were: preoperative anemia (adjusted odds ratio [aOR] = 1.88; 95% confidence intervals [CI] = 1.03–3.41; P = 0.0396), presence of diabetes mellitus (aOR = 7.94; 95% CI = 1.60–39.27; P = 0.0111), HIV infection (aOR = 6.34; 95% CI = 1.74–23.06; P = 0.0051), prolonged operation time (aOR = 2.30; 95% CI = 1.19–4.42; P = 0.0127), excessive blood loss at surgery (aOR = 5.05; 95% CI = 2.18–11.66; P = 0.0002), and chorioamnionitis (aOR = 9.00; 95% CI = 1.37–59.32; P = 0.0224).

Conclusions:

Patients with HIV infection, diabetes mellitus, preoperative anemia and chorioamnionitis have an increased risk of postcesarean wound infection as is when surgical time exceeds 1 h or when associated with blood loss >11.

Association between maternal mortality and caesarean section in Ethiopia: a national cross-sectional study

BACKGROUND

Several studies concluded that there is a reduction of maternal deaths with improved access to caesarean section, while other studies showed the existence of a direct association between the two variables. In Ethiopia, literature about the association between maternal mortality and caesarean section is scarce. This study was aimed to assess the association between maternal mortality ratios and caesarean section rates in hospitals in Ethiopia.

METHODS

Analysis was done of a national maternal health dataset of 293 hospitals that accessed from the Ethiopian Public Health Institute. Hospital specific characteristics, maternal mortality ratios and caesarean section rates were described. Pearson's correlation coefficient was used to determine the direction of association between maternal mortality ratios and caesarean section rate, taking regions into consideration. Presence of a linear association between these variables was declared statistically significant at p-value < 0.05.

RESULTS

The overall maternal mortality ratio in Ethiopian hospitals was 149 (95% CI: 136-162) per 100,000 livebirths. There was significant regional variation in maternal mortality ratios, ranging from 74 (95% CI: 51-104) per 100,000 livebirths in Tigray region to 548 (95% CI: 251-1,037) in Afar region. The average annual caesarean section rate in hospitals was 20.3% (95% CI: 20.2-20.5). The highest caesarean section rate of 38.5% (95% CI: 38.1-38.9) was observed in Addis Ababa, while the lowest rate of 5.7% (95% CI: 5.2-6.2) occurred in Somali region. At national level, a statistically non-significant inverse association was observed between maternal mortality ratios and caesarean section rates. Similarly, unlike in other regions, there were inverse associations between maternal mortality ratios and caesarean section rates in Addis Ababa, Afar Oromia and Somali, although associations were not statistically significant.

CONCLUSIONS

At national level, a statistically non-significant inverse association was observed between maternal mortality ratios and caesarean section rates in hospitals, although there were regional variations. Additional studies with a stronger design should be conducted to assess the association between population-based maternal mortality ratios and caesarean section rates.

Magnitude and trends in socio-economic and geographic inequality in access to birth by cesarean section in Tanzania: evidence from five rounds of Tanzania demographic and health surveys (1996-2015)

Background

Majority of maternal deaths are avoidable through quality obstetric care such as Cesarean Section (CS). However, in low-and middle-income countries, many women are still dying due to lack of obstetric services. Tanzania is one of the African countries where maternal mortality is high. However, there is paucity of evidence related to the magnitude and trends of disparities in CS utilization in the country. This study examined both the magnitude and trends in socio-economic and geographic inequalities in access to birth by CS.

Methods

Data were extracted from the Tanzania Demographic and Health Surveys (TDHSs) (1996–2015) and analyzed using the World Health Organization’s (WHO) Health Equity Assessment Toolkit (HEAT) software. First, access to birth by CS was disaggregated by four equity stratifiers: wealth index, education, residence and region. Second, we measured the inequality through summary measures, namely Difference (D), Ratio (R), Slope Index of Inequality (SII) and Relative Index of Inequality (RII). A 95% confidence interval was constructed for point estimates to measure statistical significance.

Results

The results showed variations in access to birth by CS across socioeconomic, urban-rural and regional subgroups in Tanzania from 1996 to 2015. Among the poorest subgroups, there was a 1.38 percentage points increase in CS coverage between 1996 and 2015 whereas approximately 11 percentage points increase was found among the richest subgroups within same period of time. The coverage of CS increased by nearly 1 percentage point, 3 percentage points and 9 percentage points among non-educated, those who had primary education and secondary or higher education, respectively over the last 19 years. The increase in coverage among rural residents was 2 percentage points and nearly 8 percentage points among urban residents over the last 19 years. Substantial disparity in CS coverage was recorded in all the studied surveys. For instance, in the most recent survey, pro-rich (RII = 15.55, 95% UI; 10.44, 20.66, SII = 15.8, 95% UI; 13.70, 17.91), pro-educated (RII = 13.71, 95% UI; 9.04, 18.38, SII = 16.04, 95% UI; 13.58, 18.49), pro-urban (R = 3.18, 95% UI; 2.36, 3.99), and subnational (D = 16.25, 95% UI; 10.02, 22.48) absolute and relative inequalities were observed.

Conclusion

The findings showed that over the last 19 years, women who were uneducated, poorest/poor, living in rural settings and from regions such as Zanzibar South, appeared to utilize CS services less in Tanzania. Therefore, such subpopulations need to be the central focus of policies and programmes implemmentation to improve CS services coverage and enhance equity-based CS services utilization.

Adverse infant outcomes associated with caesarean section delivery in India

Background

Caesarean section delivery is increasing worldwide and in India, yet little is known about the effect on infants. We examined the association between caesarean delivery and adverse infant outcomes in an Indian national survey, accounting for factors related to the mode of delivery.

Methods

Inverse probability weighted logistic regression analysis of the 2015–2016 India National Family Health Survey obtained adjusted ORs (aORs) and 95% CIs. Infant outcomes were maternal report of recent concomitant diarrhoea and acute respiratory infection (ARI) in infants age ≤6 mo and neonatal death.

Results

Of the 189 143 reported most recent singleton births, 15.4% were delivered by caesarean, 860 (3.2%) of all infants age ≤6 mo had concomitant diarrhoea and ARI and 3480 (1.8%) neonatal deaths were reported. In adjusted analysis, caesarean delivery was not associated with concomitant diarrhoea and ARI (aOR 0.96 [95% CI 0.71 to 1.32]) but was associated with neonatal death (aOR 1.19 [95% CI 1.02 to 1.39]).

Conclusions

Using nationally representative cross-sectional data for India, caesarean section delivery was found to be associated with neonatal death after accounting for factors associated with the mode of delivery. Prospective exploration of the relationship between caesarean delivery and adverse infant outcomes is warranted.

Does caesarean delivery in the first pregnancy increase the risk for adverse outcome in the second? A registry-based cohort study on first and second singleton births in Norway

OBJECTIVE

To explore if newborns in the second pregnancy following a previous caesarean delivery (CD) have higher risk of perinatal mortality or cerebral palsy than newborns in pregnancies following a previous vaginal delivery (VD).

DESIGN

Cohort study with information from the Medical Birth Registry of Norway and the Cerebral Palsy Registry of Norway.

SETTING

Births in Norway.

PARTICIPANTS

294 598 women with their first and second singleton delivery during 1996-2015.

MAIN OUTCOME MEASURES

Stillbirth, perinatal mortality, neonatal mortality and cerebral palsy.

RESULTS

Among 294 598 included women, 42 962 (15%) had a CD in their first pregnancy while 251 636 (85%) had a VD. Compared with the second delivery of mothers with a previous VD, the adjusted OR (adjOR), for stillbirth in the second pregnancy following a previous CD was 1.45, 95% CI 1.22 to 1.73; for perinatal death the adjOR was 1.42 (1.22 to 1.73) and for neonatal death 1.13 (0.86 to 1.49). Among children who survived the neonatal period, the adjOR for cerebral palsy was 1.27 (0.99 to 1.64). Secondary outcomes, including small for gestational age, preterm and very preterm birth, uterine rupture and placental complications (eg, postpartum haemorrhage and pre-eclampsia) were more frequent in the subsequent pregnancy following a previous CD compared with a previous VD, in particular for uterine rupture adjOR 86.7 (48.2 to 156.1). Adjustment for potential confounders attenuated the ORs somewhat, but the excess risk in the second pregnancy persisted for all outcomes.

CONCLUSION

A previous CD was in this study associated with increased risk for stillbirth and perinatal death compared with a previous VD. Although less robust, we also found that a previous CD was associated with a slightly increased risk of cerebral palsy among children surviving the neonatal period. The aetiology behind these associations needs further investigation.