Variability in caesarean section rates for very preterm births at 28-31 weeks of gestation in 10 European regions: results of the MOSAIC project

Using Robson's Ten-Group Classification System for comparing caesarean section rates in Europe: an analysis of routine data from the Euro-Peristat study

Objective

Robson's Ten Group Classification System (TGCS) creates clinically relevant sub‐groups for monitoring caesarean birth rates. This study assesses whether this classification can be derived from routine data in Europe and uses it to analyse national caesarean rates.

Design

Observational study using routine data.

Setting

Twenty‐seven EU member states plus Iceland, Norway, Switzerland and the UK.

Population

All births at ≥22 weeks of gestational age in 2015.

Methods

National statistical offices and medical birth registers derived numbers of caesarean births in TGCS groups.

Main outcome measures

Overall caesarean rate, prevalence and caesarean rates in each of the TGCS groups.

Results

Of 31 countries, 18 were able to provide data on the TGCS groups, with UK data available only from Northern Ireland. Caesarean birth rates ranged from 16.1 to 56.9%. Countries providing TGCS data had lower caesarean rates than countries without data (25.8% versus 32.9%, P = 0.04). Countries with higher caesarean rates tended to have higher rates in all TGCS groups. Substantial heterogeneity was observed, however, especially for groups 5 (previous caesarean section), 6, 7 (nulliparous/multiparous breech) and 10 (singleton cephalic preterm). The differences in percentages of abnormal lies, group 9, illustrate potential misclassification arising from unstandardised definitions.

Conclusions

Although further validation of data quality is needed, using TGCS in Europe provides valuable comparator and baseline data for benchmarking and surveillance. Higher caesarean rates in countries unable to construct the TGCS suggest that effective routine information systems may be an indicator of a country's investment in implementing evidence‐based caesarean policies.

Tweetable abstract

Many European countries can provide Robson's Ten‐Group Classification to improve caesarean rate comparisons.

Many European countries can provide Robson's Ten‐Group Classification to improve caesarean rate comparisons.

Mode of Delivery in Preterm Births - Bosnian and Herzegovinian Experience

INTRODUCTION

The method of carrying out PTB is one of the most controversial topics of modern perinatology, because there are no clear and undeniable works and studies that would in any case support vaginal delivery (VD) or delivery to the cesarean section (CS).

AIM

To determine more frequent mode of delivery in different groups of birth weights and degrees of prematurity from single and twin pregnancies. To determine the degree of vitality of premature born vaginal delivery (VD) in relation to the cesarean section (CS) in different degrees of prematurity from single and twin pregnancies.

PATIENTS AND METHODS

Research has retrospective cohort character. Data were collected from the databases of University Clinic of Gynecology and Obstetrics Tuzla for the period of five years (January 1st, 2012-December 31st, 2016). The study included newborns of both genders, gestational age from 24 to 37 weeks of gestation (WG) in singleton and twin pregnancies.

RESULTS

Out of 19506 births, 1350 (6.92%) were preterm birth (PTB). Singleton PTB was 1180 (87.40%), and the twins were 170 (12.59%). Vaginal delivery (VD) was born 788 (58.37%). Cesarean section (CS) was born 562 (41.63%). There was statistically significant association between the mode of delivery (MD) in singleton and twins pregnancy in all three subgroups of birth weight (BW) 1000-1499, 2000-2499 and >2500 grams in 33-37 WG. In this group was more frequent VD than CS mode of singleton delivery, and CS than VD mode of twins delivery. In contrast to newborn with BW 1500-1999 grams (chi-square = 23.16, P <0.0001) in same gestational period where was more frequent CS than VD (OR: 2.56, 95% CI: 1.71-3,85). Apgar score (AS) at first and five minute 5-7 and 8-10 in the period 28-32 and 33-37 was a statistically significant frequent in VD and singletons in contrast to CS and twins.

CONCLUSION

VD was more frequent in the higher WG, as well as the higher AS in singletons in contrast to twins delivery.

Delivery mode and intraventricular hemorrhage risk in very-low-birth-weight infants: Observational data of the German Neonatal Network

BACKGROUND

Very-low-birth-weight infants (VLBWI) are frequently delivered by cesarean section (CS). However, it is unclear at what gestational age the benefits of spontaneous delivery outweigh the perinatal risks, i.e. intraventricular hemorrhage (IVH) or death.

OBJECTIVES

To assess the short-term outcome of VLBWI on IVH according to mode of delivery in a population-based cohort of the German Neonatal Network (GNN).

STUDY DESIGN

A total cohort of 2203 singleton VLBWI with a birth weight <1500g and gestational age between 22 0/7 and 36 6/7 weeks born and discharged between 1st of January 2009 and 31st of December 2015 was available for analysis. VLBWI were stratified into three categories according to mode of delivery: (1) planned cesarean section (n=1381), (2) vaginal delivery (n=632) and (3) emergency cesarean section (n=190). Outcome was assessed in univariate and logistic regression analyses.

RESULTS

Prevalence of IVH was significantly higher in the vaginal delivery (VD) (26.6%) and emergency CS group (31.1%) as compared to planned CS (17.2%), respectively. In a logistic regression analysis including known risk factors for IVH, vaginal delivery (OR 1.725 [1.325-2.202], p≤0.001) and emergency cesarean section (OR 1.916 [1.338-2.746], p≤0.001) were independently associated with IVH risk. In the subgroup of infants >30 weeks of gestation prevalence for IVH was not significantly different in VD and planned CS (5.3% vs. 4.4%).

CONCLUSIONS

Our observational data demonstrate that elective cesarean section is associated with a reduced risk of IVH in preterm infants <30 weeks gestational age when presenting with preterm labor.

Variation in hospital caesarean section rates for preterm births

BACKGROUND

Evidence about optimal mode of delivery for preterm birth is lacking, and there is thought to be considerable variation in practice.

OBJECTIVE

To assess whether variation in hospital preterm caesarean section rates (Robson Classification Group 10) and outcomes are explained by casemix, labour or hospital characteristics.

MATERIALS AND METHODS

Population-based cohort study in NSW, 2007-2011. Births were categorised according to degree of prematurity and hospital service capability: 26-31, 32-33 and 34-36 weeks' gestation. Hospital preterm caesarean rates were investigated using multilevel logistic regression models, progressively adjusting for casemix, labour and hospital factors. The association between hospital caesarean rates, and severe maternal and neonatal morbidity rates was assessed.

RESULTS

At 26-31 weeks' gestation, the caesarean rate was 55.2% (seven hospitals, range 43.4-58.4%); 50.9% at 32-33 weeks (12 hospitals, 43.4-58.1%); and 36.4% at 34-36 weeks (51 hospitals, 17.4-48.3%). At 26-31 weeks and 32-33 weeks' gestation, 81% and 59% of the variation between hospitals was explained with no hospital significantly different from the state average after adjustment. At 34-36 weeks' gestation, although 59% of the variation was explained, substantial unexplained variation persisted. Hospital caesarean rates were not associated with severe maternal morbidity rates at any gestational age. At 26-31 weeks' gestation, medium and high caesarean rates were associated with higher severe neonatal morbidity rates, but there was no evidence of this association ≥32 weeks.

CONCLUSION

Both casemix and practice differences contributed to the variation in hospital caesarean rates. Low preterm caesarean rates were not associated with worse outcomes.

Haemoglobin level at birth is associated with short term outcomes and mortality in preterm infants

BACKGROUND

Blood volume and haemoglobin (Hb) levels are increased by delayed umbilical cord clamping, which has been reported to improve clinical outcomes of preterm infants. The objective was to determine whether Hb level at birth was associated with short term outcomes in preterm infants born at ≤32 weeks gestation.

METHODS

Data were collected retrospectively from electronic records: Standardised Electronic Neonatal Database, Electronic Patient Record, Pathology (WinPath), and Blood Bank Electronic Database. The study was conducted in a tertiary perinatal centre with around 5,500 deliveries and a neonatal unit admission of 750 infants per year. All inborn preterm infants of 23 to 32 weeks gestational age (GA) admitted to the neonatal unit from January 2006 to September 2012 were included. The primary outcomes were intra-ventricular haemorrhage, necrotising entero-colitis, broncho-pulmonary dysplasia, retinopathy of prematurity, and death before discharge. The secondary outcomes were receiving blood transfusion and length of intensive care and neonatal unit days. The association between Hb level (g/dL) at birth and outcomes was analysed by multiple logistic regression adjusting for GA and birth weight (BWt).

RESULTS

Overall, 920 infants were eligible; 28 were excluded because of missing data and 2 for lethal congenital malformation. The mean (SD) GA was 28.3 (2.7) weeks, BWt was 1,140 (414) g, and Hb level at birth was 15.8 (2.6) g/dL.Hb level at birth was significantly associated with all primary outcomes studied (P <0.001) in univariate analyses. Once GA and BWt were adjusted for, only death before discharge remained statistically significant; the OR of death for infants with Hb level at birth <12 g/dL compared with those with Hb level at birth of ≥18 g/dL was 4.1 (95% CI, 1.4-11.6). Hb level at birth was also significantly associated with blood transfusion received (P <0.01) but not with duration of intensive care or neonatal unit days.

CONCLUSIONS

Low Hb level at birth was significantly associated with mortality and receiving blood transfusion in preterm infants born at ≤32 weeks gestation. Further studies are needed to determine the association between Hb level at birth and long-term neurodevelopmental outcomes.

Varying gestational age patterns in cesarean delivery: an international comparison

Background

While international variations in overall cesarean delivery rates are well documented, less information is available for clinical sub-groups. Cesarean data presented by subgroups can be used to evaluate uptake of cesarean reduction policies or to monitor delivery practices for high and low risk pregnancies based on new scientific evidence. We studied differences and patterns in cesarean delivery rates by multiplicity and gestational age in Europe and the United States.

Methods

This study used routine aggregate data from 17 European countries and the United States on the number of singleton and multiple live births with cesarean versus vaginal delivery by week of gestation in 2008. Overall and gestation-specific cesarean delivery rates were analyzed. We computed rate differences to compare mode of delivery (cesarean vs vaginal birth) between selected gestational age groups and studied associations between rates in these subgroups namely: very preterm (26–31 weeks GA), moderate preterm (32–36 weeks GA), near term (37–38 weeks GA), term (39–41 weeks GA) and post-term (42+ weeks GA) births, using Spearman’s rank tests.

Results

High variations in cesarean rates for singletons and multiples were observed everywhere. Rates for singletons varied from 15% in The Netherlands and Slovenia, to over 30% in the US and Germany. In singletons, rates were highest for very preterm births and declined to a nadir at 40 weeks of gestation, ranging from 8.0% in Sweden and Norway, to 22.5% in the US. These patterns differed across countries; the average rate difference between very preterm and term births was 43 percentage points, but ranged from 14% to 61%. High variations in rate differences were also observed for near term versus term births. For multiples, rates declined by gestational age in some countries, whereas in others rates were similar across all weeks of gestation. Countries’ overall cesarean rates were highly correlated with gestation-specific subgroup rates, except for very preterm births.

Conclusions

Gestational age patterns in cesarean delivery were heterogeneous across countries; these differences highlight areas where consensus on best practices is lacking and could be used in developing strategies to reduce cesareans.

[Variables determining the amount of care for very preterm neonates: the concept of medical stance]

OBJECTIVE

To compare the amount of medical interventions on very preterm neonates (24-31 weeks of gestation) in two French university tertiary care centers, one of which is involved in a Neonatal Developmental Care program. A secondary objective is to assess whether this difference in medical interventions can be linked to a difference in mortality and morbidity rates.

METHODS

We prospectively included all very preterm neonates free from lethal malformation born live in these two centers between 2006 and 2010. These inclusion criteria were met by 1286 patients, for whom we compared the rate of five selected medical interventions: birth by caesarean section, chest intubation in the delivery room, surfactant therapy, pharmacological treatment of patent ductus arteriosus, and red blood cell transfusion.

RESULTS

The rates of the five medical interventions were systematically lower in the center that is involved in Neonatal Developmental Care. There was no significant difference in survival at discharge with no severe cerebral ultrasound scan abnormalities between the two centers. There were, however, significantly higher rates of bronchopulmonary dysplasia and nosocomial sepsis and longer hospital stays when the patients were not involved in a Neonatal Developmental Care program.

DISCUSSION

This benchmarking study shows that in France, in the first decade of the 21st century, there are as many ways to handle very preterm neonates as there are centers in which they are born. This brings to light the concept of medical stance, which is the general care approach prior to the treatment itself. This medical stance creates the overall framework for the staff's decision-making regarding neonate care. The different parameters structuring medical stance are discussed. Moreover, this study raises the problematic issue of the aftermath of benchmarking studies when the conclusion is an increase of morbidity in cases where procedure leads to more interventions.

Recurrence risk of preterm birth in subsequent singleton pregnancy after preterm twin delivery

OBJECTIVE

The purpose of this study was to investigate the recurrence risk of preterm birth (<37 weeks' gestation) in a subsequent singleton pregnancy after a previous nulliparous preterm twin delivery.

STUDY DESIGN

We included 1957 women who delivered a twin gestation and a subsequent singleton pregnancy from the Netherlands Perinatal Registry. We compared the outcome of subsequent singleton pregnancy of women with a history of preterm delivery to the pregnancy outcome of women with a history of term twin delivery.

RESULTS

Preterm birth in the twin pregnancy occurred in 1075 women (55%) vs 882 women (45%) who delivered at term. The risk of subsequent spontaneous singleton preterm birth was significantly higher after preterm twin delivery (5.2% vs 0.8%; odds ratio, 6.9; 95% confidence interval, 3.1-15.2).

CONCLUSION

Women who deliver a twin pregnancy are at greater risk for delivering prematurely in a subsequent singleton pregnancy.

Prenatally diagnosed fetal conditions in the age of fetal care: does who counsels matter?

OBJECTIVE

We sought to characterize practices and attitudes of maternal-fetal medicine (MFM) and fetal care pediatric (FCP) specialists regarding fetal abnormalities.

STUDY DESIGN

This was a self-administered survey of 434 MFMs and FCPs (response rate: MFM 60.9%; FCP 54.2%).

RESULTS

For Down syndrome (DS), congenital diaphragmatic hernia (CDH), spina bifida: MFMs were more likely than FCPs to support termination (DS 52% vs 35%, P < .001; CDH 49% vs 36%, P < .001; spina bifida 54% vs 35%, P < .001), and consider offering termination options as highly important (DS 90% vs 70%, P < .001; CDH 88% vs 69%, P < .001; spina bifida 88% vs 70%, P < .001). For DS only, MFMs were less likely than FCPs to think that pediatric specialist consultation should be offered prior to a decision regarding termination (54% vs 75%, P < .001). MFMs reported report higher termination rates among patients only for DS (DS 51% vs 21%, P < .001).

CONCLUSION

MFM and FCP specialists' counseling attitudes differ for fetal abnormalities.

Review of the recent literature on the mode of delivery for singleton vertex preterm babies

Choosing the safest method of delivery and preventing preterm labour are obstetric challenges in reducing the number of preterm births and improving outcomes for mother and baby. Optimal route of delivery for preterm vertex neonates has been a controversial topic in the obstetric and neonatal community for decades and continues to be debated. We reviewed 22 studies, most of which have been published over the last five years with an aim to find answers to the clinical questions relevant to deciding the mode of delivery. Findings suggested that the neonatal outcome does not depend on the mode of delivery. Though Caesarean section rates are increasing for preterm births, it does not prevent neurodisability and cannot be recommended unless there are other obstetric indications to justify it. Therefore, clinical judgement of the obstetrician depending on the individual case still remains important in deciding the mode of delivery.

Trends in preterm birth: singleton and multiple pregnancies in the Netherlands, 2000-2007

OBJECTIVE

Several studies have reported increasing trends in preterm birth in developed countries, mainly attributable to an increase in medically indicated preterm births. Our aim was to describe trends in preterm birth among singleton and multiple pregnancies in the Netherlands.

DESIGN

Prospective cohort study.

SETTING

Nationwide study.

POPULATION

We studied 1,451,246 pregnant women from 2000 to 2007.

METHODS

We assessed trends in preterm birth. We subdivided preterm birth into spontaneous preterm birth after premature prelabour rupture of membranes (pPROM), medically indicated preterm birth and spontaneous preterm birth without pPROM. We performed analyses separately for singletons and multiples.

MAIN OUTCOME MEASURES

The primary outcome was preterm birth, defined as birth before 37 weeks of gestation, with very preterm birth (<32 weeks of gestation) being a secondary outcome.

RESULTS

The risk of preterm birth was 7.7% and the risk of very preterm birth was 1.3%. In singleton pregnancies, the preterm birth risk decreased significantly from 6.4% to 6.0% (P < 0.0001), mainly as a result of the decrease in spontaneous preterm birth without pPROM (3.6-3.1%, P < 0.0001). In multiple pregnancies, the preterm birth risk increased significantly (47.3-47.7%, P = 0.047), mainly as a result of medically indicated preterm birth, which increased from 15.0% to 17.9% (P < 0.0001).

CONCLUSION

In the Netherlands, the preterm birth risk in singleton pregnancies decreased significantly over the years. The trend of increasing preterm birth risk reported in other countries was only observed in (medically indicated) preterm birth in multiple pregnancies.

National maternal mortality ratio for Jordan, 2007-2008

OBJECTIVE

To estimate the number of maternal deaths per 100000 live births during 2007-2008 among Jordanian women; to identify the causes of maternal mortality; and to compare the results with those of the last report for 1995-1996.

METHODS

Reproductive-age mortality study of maternal deaths among women aged 15-49 years in Jordan in 2007-2008.

RESULTS

Among 1406 identified deaths of reproductive-aged women, 76 maternal deaths were identified out of 397588 live births, for a maternal mortality ratio of 19.1 deaths per 100000 live births. Forty-three (56.6%) deaths were attributable to hemorrhage, thrombosis and thromboembolism, and sepsis. Avoidable factors were present in 53.9% of women, 52.6% had substandard care, and 31.5% had 3 or fewer antenatal visits. Of those with available information on family planning, only 29.4% had ever used any form of contraception.

CONCLUSIONS

Maternal deaths in Jordan are declining. The maternal mortality ratio of 19.1 deaths per 100000 live births reported for 2007-2008 showed a remarkable reduction of 53.9% achieved in the 12 years since the 1995-1996 report (a 4.5% annual reduction), which is approaching the 75% reduction recommended by Millennium Development Goal 5.