Frequency of, indications for and clinical epidemiological characteristics of first time cesarean section, compared with repeated cesarean section

Prenatal and perinatal factors associated with intellectual disability

Prenatal and perinatal risk factors associated with intellectual disability (ID) were studied in 8-year-old Utah children from a 1994 birth cohort (N  =  26,108) using broad ascertainment methods and birth records following the most current recording guidelines. Risk factor analyses were performed inclusive and exclusive of children with a known or suspected underlying genetic disorder. Risk factors identified were poly/oligohydramnios, advanced paternal/maternal age, prematurity, fetal distress, premature rupture of membranes, primary/repeat cesarean sections, low birth weight, assisted ventilation greater than 30 min, small-for-gestational age, low Apgar scores, and congenital infection. Although several risk factors lost significance once children with underlying genetic disorders were excluded, socioeconomic variables were among those that maintained a prominent association with increased ID risk.

The experience of labor, maternal perception of the infant, and the mother's postpartum mood in a low-risk community cohort

Postpartum negative mood interferes with maternal-infant bonding and carries long-term negative consequences for infant growth. We examined the effects of birth-related risks on mother's postpartum anxiety and depression. A community cohort of 1,844 low-risk women who delivered a singleton term baby completed measures assessing delivery, emotions during labor, attitudes toward pregnancy and infant, mood regulation, and postpartum anxiety and depression. Under conditions of low risk, 20.5% of parturient women reported high levels of depressive symptoms. Following Cesarean Section Delivery (CSD), 23% reported high depressive symptoms, compared to 19% following Vaginal Delivery (VGD), and 21% after Assisted Vaginal Delivery (AVGD). State anxiety was highest in CSD and lowest in VGD. Mothers undergoing CSD experienced labor as most negative, reported highest somatic symptoms during the last trimester, and were least efficient in regulating negative mood. Postpartum depression was independently associated with higher maternal age, CSD, labor pain, lower negative and higher positive emotions during labor, inefficient mood regulation, somatic symptoms, and more negative and less positive perception of fetus during last trimester. Results demonstrate that elevated depressive symptoms are prevalent in the postpartum even under optimal socioeconomic and health conditions and increase following CSD. Interventions to increase positive infant-related perceptions and emotions may be especially important for promoting bond formation following CSD.

Risk factors for cesarean section by category of health service

OBJECTIVE: To analyze the rate of cesarean section and differences in risk factors by category of health service, either public or private. METHODS: A cross-sectional study was carried out including all pregnant women in labor admitted to hospitals in the city of Rio Grande, Southern Brazil, between January 1 and December 31, 2007. A pre-coded and pre-tested questionnaire was used to collect on social, demographic, obstetric and newborn care information. Two regression models were constructed: one for public users and the other one for private ones. Poisson regression was used in each model in the multivariate analysis. Prevalence rates and 95% confidence intervals were calculated for each adjusted factor. RESULTS: The rate of cesarean section was 43% and 86% among public and private users. Sociodemographic factors and twin births have a more significant impact among public users as well as number of pregnancies (25% vs. 13% reduction in public and private users, respectively) and previous cesarean section (86% vs. 24% increase in public and private users, respectively). Prenatal care visits and hospital admissions affected the outcome only in women users of public services. CONCLUSIONS: Cesarean section rates were high in both groups studied, but it was twice as high among women cared in the private sector. Associated factors differ in magnitude by category of service used.

Maternal brain response to own baby-cry is affected by cesarean section delivery

A range of early circumstances surrounding the birth of a child affects peripartum hormones, parental behavior and infant wellbeing. One of these factors, which may lead to postpartum depression, is the mode of delivery: vaginal delivery (VD) or cesarean section delivery (CSD). To test the hypothesis that CSD mothers would be less responsive to own baby-cry stimuli than VD mothers in the immediate postpartum period, we conducted functional magnetic resonance imaging, 2-4 weeks after delivery, of the brains of six mothers who delivered vaginally and six who had an elective CSD. VD mothers' brains were significantly more responsive than CSD mothers' brains to their own baby-cry in the superior and middle temporal gyri, superior frontal gyrus, medial fusiform gyrus, superior parietal lobe, as well as regions of the caudate, thalamus, hypothalamus, amygdala and pons. Also, within preferentially active regions of VD brains, there were correlations across all 12 mothers with out-of-magnet variables. These include correlations between own baby-cry responses in the left and right lenticular nuclei and parental preoccupations (r = .64, p < .05 and .67, p < .05 respectively), as well as in the superior frontal cortex and Beck depression inventory (r = .78, p < .01). First this suggests that VD mothers are more sensitive to own baby-cry than CSD mothers in the early postpartum in sensory processing, empathy, arousal, motivation, reward and habit-regulation circuits. Second, independent of mode of delivery, parental worries and mood are related to specific brain activations in response to own baby-cry.

Psychosocial sequelae of cesarean delivery: review and analysis of their causes and implications

A growing number of children around the world are being born by surgical delivery, or cesarean section. Concerns over rising rates of cesareans have focused on the risk of death and medical complications associated with surgical delivery but have largely neglected psychosocial and behavioral factors that affect and are affected by cesarean delivery. We summarize research which indicates that women who deliver by cesarean section have more negative perceptions of their birth experience, their selves, and their infants, exhibit poorer parenting behaviors, and may be at higher risk for postpartum mood disturbance compared to women delivering infants vaginally. We also review evidence that suggests that cesareans adversely influence women's moods and perceptions by restricting the control that they can exercise over birth and by violating expectations about childbirth. Based on these findings, we recommend ways to reduce the aversiveness of cesareans, offer recommendations for future research, and discuss implications of escalating rates of cesareans, including medically non-indicated cesareans by request.

Could elective cesarean sections influence the birth weight of full-term infants?

CONTEXT AND OBJECTIVE

There are no studies on birth weights among full-term infants born by means of elective cesarean section. We aimed to study this in private and public hospitals.

DESIGN AND SETTING

Retrospective study at Universidade Federal do Triângulo Mineiro, Uberaba, Brazil.

METHODS

Data were collected from the municipal medical birth register of Uberaba from January to December 2000. The data obtained (maternal age, type of delivery, number of prenatal care visits and birth weight, from full-term pregnancy) from the university hospital (UH), which is a tertiary hospital that only attends patients within the National Health System (SUS), were compared with data from four private hospitals (PHs) that attend health insurance plans and private patients. Student's t test, chi2 test and multiple logistic regression were used for statistical analysis, with the significance level set at p < 0.05.

RESULTS

In the PHs, 1,100 out of 1,354 births (81.2%) were by cesarean section and in the UH, 373 out of 1,332 (28%). Birth weight increased significantly in association with increasing numbers of prenatal care visits, except for cesarean section cases in PHs. Birth weights among vaginal delivery cases in PHs were greater than in the UH (p < 0.05), but this was not observed among cesarean section cases. Multiple logistic regression showed that there was greater risk of low birth weight in PHs (odds ratio: 2.33; 95% confidence interval: 1.19 to 4.55).

CONCLUSION

Elective cesarean section performed in PHs may be associated with low birth weight among full-term infants.

Association between maternal occupational status and utilization of antenatal care Study based on the perinatal survey of Baden-Wuerttemberg 1998-2003

OBJECTIVES

Adequate utilization of antenatal care reduces the morbidity of mother and child. How frequent a pregnant woman attends antenatal care is dependent on many factors. The aim of this study was to assess the current influence of educational level and occupational status on maternal utilization of antenatal care under the conditions of an industrialized country and provision of universal coverage.

METHODS

The perinatal database 1998-2003 of the German state of Baden-Wuerttemberg (556.948 pregnancies) was studied comparing antenatal care utilization for the different occupational categories obtained in the survey. For statistical analysis descriptive statistics and t test on equity of proportions for independent samples were used.

RESULTS

As occupational groups at risk of insufficient antenatal care unskilled workers, trainees, students, and housewives were identified. High rates of utilization were found for the categories "top management/executive position" and "skilled workers". Rate of one or less consultations per pregnancy has declined significantly compared to 1998, but has increased again since 2000. Low utilization (2-5 consultations per pregnancy) has not decreased, showing rather constant differences between the occupational categories throughout the observed 6-year period. Unskilled workers, trainees, students, and housewives avail less of prenatal care above standard (more than ten consultations per pregnancy).

CONCLUSIONS

Differences in an individual woman's use of antenatal care is, besides many other factors, associated with occupational status. Antenatal care promotion should target trainees, students, and unskilled workers prone to insufficient utilization and its consequences, an increase in obstetrical risk. For these groups, the occupational physician may play a key role in reaching the pregnant women on time, as obstetric care reaches them insufficiently and too late. Although housewives are the most numerous group, inhomogeneity regarding their educational level and previous occupational status has to be assumed, calling for further clinical studies to design appropriate interventional concepts.

How much variation in CS rates can be explained by case mix differences?

OBJECTIVE

To quantify the amount of variation in caesarean section (CS) rates between maternity units explained by case mix differences.

DESIGN

Cross-sectional study.

SETTING

All 216 maternity units in England and Wales.

POPULATION

Women giving birth at these maternity units between May and July 2000.

METHODS

Logistic regression models were developed to investigate the relationship between case mix characteristics, and odds of (i) CS before labour, (ii) CS in labour. Using these results, overall CS rates standardised for case mix were calculated for each maternity unit. Random-effects meta-analysis was used to examine heterogeneity between maternity units.

MAIN OUTCOME MEASURES

CS before labour and CS during labour.

RESULTS

Adjustment for case mix differences between maternity units explained 34% of the variance in CS rates. Odds of CS (before and in labour) increased with maternal age. Women from ethnic minority groups had lower odds of CS before labour, and increased odds of CS in labour. Women with a previous vaginal delivery had lower odds of CS, although the magnitude of this for CS before and in labour is markedly different.

CONCLUSIONS

Case mix adjustment is important to enable understanding of the factors that influence the CS rate. These include organisational and staffing levels as well as women's preferences for childbirth and clinician's attitudes. An understanding of how these factors influence the CS rate is essential for evaluation of quality and appropriateness of obstetric care provided to women.

Occupation and risk of cesarean section: study based on the perinatal survey of Baden-Württemberg, Germany

OBJECTIVES

The aim of this study was to assess the current influence of educational attainment and occupation on maternal obstetrical risk associated with cesarean section under the conditions of an industrialized country and provision of universal coverage.

MATERIALS AND METHODS

The perinatal survey data 1998-2001 of the German state of Baden-Württemberg were studied comparing method of delivery for the different occupational categories raised in the survey and the influence of antenatal care utilization. For statistical analysis chi square test, Fisher's exact test and chi square test for trends were used. Relative risks describe the risk for the exposed.

RESULTS

Cesarean section rate increased for all groups over the studied four years period. High rates of surgical deliveries were found for the categories "high salaried position" and "unskilled workers". Housewives, the largest group of pregnant women in Baden-Württemberg, delivered significantly less often by cesarean section (75% vaginal deliveries) than women of all other groups (66% vaginal deliveries on the average). In case of low utilization of antenatal care (<5 checks) risk of cesarean section and rate of complications (as blood loss >1,000 ml, hysterectomy) associated with cesarean section are significantly higher.

CONCLUSIONS

Differences in an individual woman's risk of having a cesarean section is, besides many other factors, associated with occupation. Antenatal care promotion should target the collective of unskilled workers, at special risk for insufficient use of prenatal care and high rate of cesarean delivery.

The Effect of Computer-Assisted Evaluation of Labor on Cesarean Rates

Dystocia, or slow labor, is the leading cause of first-time cesarean sections. Current diagnostic guidelines for dystocia are vague, and there is no clear postoperative confirmatory evidence to assess the correctness of this diagnosis. For several decades, various professional organizations have indicated that cesarean rates could be lowered safely and have recommended levels that are far below national averages. The three major factors, of roughly equal importance, associated with cesarean for slow labor are the baby's weight, the mother's height, and the threshold at which the physician believes it is reasonable to intervene. The last is the only modifiable factor, and quality programs are a major part of changing medical behavior. By using two study designs, the effect of a mathematical method for evaluating labor progress on the rate of cesarean section was measured. In the prospective randomized clinical trial, the relative risk of cesarean in the experimental group was unchanged at 1.04. In the pretest-posttest analysis, the rates fell from 19.54% to 17.04% at 6 months and 16.62% at 12 months.