Impact of clinical audits on cesarean section rate

Inconsistent definitions of prolonged labor in international literature: a scoping review

Objective

Prolonged labor is the commonest indication for intrapartum cesarean section, but definitions are inconsistent and some common definitions were recently found to overestimate the speed of physiological labor. The objective of this review is to establish an overview of synonyms and definitions used in the literature for prolonged labor, separated into first and second stages, and establish types of definitions used.

Data sources

A systematic search was conducted in PubMed, Embase, Web of Science, Cochrane Library, Emcare, and Academic Search Premier.

Study eligibility criteria

All articles in English that (1) attempted to define prolonged labor, (2) included a definition of prolonged labor, or (3) included any synonym for prolonged labor, were included.

Methods

Data on study design, year of publication, country or region of origin, synonyms used, definition of prolonged first and/or second stage, and origin of provided definition (if not primarily established by the study) were collected into a database.

Results

In total, 3402 abstracts and 536 full-text papers were screened, and 232 papers were included. Our search established 53 synonyms for prolonged labor. Forty-three studies defined prolonged labor and 189 studies adopted a definition of prolonged labor. Definitions for prolonged first stage of labor were categorized into: time-based (n=14), progress-based (n=12), clinician-based (n=5), or outcome-based (n=4). For the 33 studies defining prolonged second stage, the majority of definitions (n=25) were time-based, either based on total duration or duration of no descent of the presenting part.

Conclusions

Despite efforts to arrive at uniform labor curves, there is still little uniformity in definitions of prolonged labor. Consensus on which definition to use is called for, in order to safely and respectfully allow physiological labor progress, ensure timely management, and assess and compare incidence of prolonged labor between settings.

Comparison of cesarean section rates between obstetricians preferring labor induction at early versus late gestational age

OBJECTIVE

To compare the cesarean section (CS) rates of obstetricians with a preference of labor induction at early versus late gestational age.

MATERIAL AND METHODS

Medical records of women who were low risk, nulliparous, singleton pregnancy, and >37 weeks and delivered their babies, were reviewed. Obstetricians, who preferred labor induction at<41 weeks, were allocated to the early induction group; and the other obstetricians were allocated to the late induction group.

RESULTS

The late induction group had a higher percentage of labor induction at ≥41 weeks, compared with the early induction group (21% vs. 8%, p = 0.007). The late induction group had a lower CS rate (11.0% vs. 19.1%, p < 0.001). Multivariable Cox proportional hazard model revealed that the early induction group (hazard ratio [HR] = 2.14, p < 0.001), maternal age (HR = 1.04, p = 0.001), premature rupture of membranes (HR = 1.59, p = 0.006), and birth body weight (kg, HR = 2.13, p < 0.001) were independent predictors of CS. In women receiving labor induction (n = 312), birth body weight (kg, HR = 1.72, p = 0.04) was the sole predictor of CS; and there is a trend that the early induction group (HR = 1.54, p = 0.051) has a higher CS rate, compared with the late induction group. However, gestational age at labor induction was not a predictor of CS.

CONCLUSION

In low-risk pregnancies, obstetricians preferring labor induction at early gestational age seem to be associated with a higher CS rate, compared with obstetricians preferring labor induction at late gestational age. Nonetheless, the above finding seems to be associated with physician's factor, instead of gestational age at labor induction.

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.

Variability in cesarean delivery rates among individual labor and delivery nurses compared to physicians at three attribution time points

OBJECTIVE

To examine the variability in the cesarean delivery (CD) rates of individual labor and delivery nurses compared with physicians at three attribution time points.

DATA SOURCES

Medical record data from nine hospitals in Washington State from January 2016 through September 2018.

STUDY DESIGN

Retrospective, observational cohort design using an aggregated database of birth records.

DATA COLLECTION/EXTRACTION METHODS

Chart-abstracted clinical data from a subset of nulliparous, term, singleton, vertex births attributed at admission, labor management, and delivery to nurses and physicians. Two classification methods were used to categorize nurse- and physician-level CD rates at three attribution time points and the reliability of these methods compared.

PRINCIPAL FINDINGS

The sample included 12 556 births, 319 nurses, and 126 physicians. Overall, variation in nurse-level CD rates did not differ significantly across the three attribution time points, and the extent of variation was similar to that observed in physicians. However, agreement between attribution time points varied between 35 percent and 65 percent when classifying individual nurses into the top and bottom deciles. The average reliability of nurse-level CD rates was 32 percent at admission (IQR 22.0 percent to 38.7 percent), 32.6 percent at labor (IQR 23.1 percent to 40.9 percent), and 29.3 percent (IQR 20.9 percent to 35.8 percent) at delivery. The average reliability of physician-level CD rates was higher: 54.2 percent (IQR 38.7 percent to 71.4 percent) at admission, 62.5 percent (IQR 49.0 percent to 79.6 percent) at labor management, and 66.1 percent (IQR 53.7 percent to 81.2 percent) at delivery.

CONCLUSION

Feedback on nurse-level CD rates as part of routine clinical quality audits can provide insight into nurse performance in the context of other individual-level and unit-level information. To reliably distinguish individual nurse performance, larger sample sizes are needed.

General methods for measuring and comparing medical interventions in childbirth: a framework

Background

The continue increase of interventions during labour in low risk population is a controversial issue of the current obstetric literature, given the lack of evidence demonstrating the benefits of unnecessary interventions for women or infants’ health. This makes it important to have approaches to assess the burden of all medical interventions performed.

Methods

Exploiting the nature of childbirth intervention as a staged process, we proposed graphic representations allowing to generate alternative formulas for the simplest measures of the intervention intensity namely, the overall and type-specific treatment ratios. We applied the approach to quantify the change in interventions following a protocol termed Comprehensive Management (CM), using data from Robson classification, collected in a prospective longitudinal cohort study carried out at the Obstetric Unit of the Cà Granda Niguarda Hospital in Milan, Italy.

Results

Following CM a substantial reduction was observed in the Overall Treatment Ratio, as well as in the ratios for augmentation (amniotomy and synthetic oxytocin use) and for caesarean section ratio, without any increase in neonatal and maternal adverse outcomes. The key component of this reduction was the dramatic decline in the proportion of women progressing to augmentation, which resulted not only the most practiced intervention, but also the main door towards further treatments.

Conclusions

The proposed framework, once combined with Robson Classification, provides useful tools to make medical interventions performed during childbirth quantitatively measurable and comparable. The framework allowed to identifying the key components of interventions reduction following CM. In its turn, CM proved useful to reduce the number of medical interventions carried out during childbirth, without worsening neonatal and maternal outcomes.

Value-based health care in obstetrics

RATIONALE, AIMS, AND OBJECTIVES

We strive to maximize outcomes that are relevant to the women who deliver in our hospital. We demonstrate a practical method of using value-based health care (VBHC) concepts to analyse how care can be improved.

METHOD

Using International Consortium of Health Outcome Measurements (ICHOM) set, a practical outcome set was constructed for women who go into spontaneous labour at term of a singleton in cephalic presentation and used for benchmarking. We included data on interventions that are major drivers of outcomes. Data from two hospitals in Amsterdam and for The Netherlands for 2011 to 2015 were collected.

RESULTS

Benchmarking of readily available data helped identify a number of statistically significant and clinically relevant differences in obstetric outcomes. Caesarean section rate was significantly different at 13.7% in hospital 2 compared with 11.5% in hospital 1 with similar neonatal outcomes. Third and fourth degree tearing rates were significantly higher for hospital 1 at 5.5% compared with 3.6% for hospital 2 and the national average of 3.5%. On the basis of the guidelines, literature, and discussion, initiatives on how to improve these outcomes were then identified. These include caesarean section audit and guidelines regarding caesarean section decision making. In order to reduce the rate of third and fourth degree tearing, routine episiotomy on vaginal operative deliveries was introduced, and a training programme was set up to make care providers more aware of risk factors and potential preventive measures.

CONCLUSION

Defining, measuring, and comparing relevant outcomes enable care providers to identify improvements. Collection and comparison of readily available data can provide insights in where care can be improved. Insights from literature and comparison of care practices and processes can lead to how care can be improved. Continuous monitoring of outcomes and expanding the set of outcomes that is readily available are key in the process towards value-based care provision.

Prevalence and causes of cesarean births among women residing at high altitude in Lhasa, Tibet: A retrospective observational study of 7365 women

OBJECTIVE

Currently, there is paucity of data on the rate of vaginal deliveries and cesarean section among women in Tibet. In this study, we carried out an observational study of 7365 consecutive pregnant women in Lhasa, Tibet who gave birth at our tertiary care institution between 2012 and 2015.

MATERIALS AND METHODS

In this retrospective study, we reviewed the hospital records for demographic data, obstetric history, and the number of vaginal and emergency cesarean section deliveries. The overall and annual rate of vaginal and cesarean section deliveries was calculated. Causes, indications or risks for cesarean section were also analyzed.

RESULTS

During the review period, 7365 neonates were delivered at our hospital, including 1690 (23.0%) deliveries via cesarean section. The yearly rate of cesarean section progressively declined from 26.7% in 2012 to 18% in 2015 (P < 0.001). Furthermore, the annual rate of emergency cesarean section declined 53.9%between 2012 and 2015(P < 0.001). Fetal risk factors (39.9%) and maternal risk factors (40.3%) were the major causes of cesarean section in the women. Social factors as a cause of cesarean section fluctuated between 7.9% and 11.1%.

CONCLUSION

This study has demonstrated a steady decline in the annual rate of cesarean section in women in Tibet between 2012 and 2015. A decrease in the rate of emergency cesarean section contributed substantially to this decline. Moreover, approximately 10% caesarian sections were performed without clear indications, highlighting the need for strengthening prenatal counseling for pregnant women in Tibet.

Interventions in Reducing Caesarean Section in the World: A Systematic Review

Caesarean section without medical indication imposes many problems to families, personnel and medical equipment causing some side effects to pregnant woman and foetus, compared to natural childbirth. The present study aimed to evaluate the interventions in reducing caesarean section in the world. This study was a systematic review using Embase, PubMed, Scopus, Web of Science, Science Direct, Magiran and SID databases and grey literature. All studies conducted during 2000-2018 were reviewed and finally the studies with inclusion and exclusion criteria were selected. A total of 19 studies were selected among 5,559 studies. The interventions conducted for reducing caesarean section included training the specialists and women by using Six Sigma method, changing the guidelines, reviewing the definition of natural childbirth various stages, encouraging the natural childbirth and expanding painless childbirth. All interventions were divided into educational strategy and managerial strategy. The interventions can be implemented to change the behaviour of physicians and attitude of pregnant women in order to reduce caesarean section. In this regard, the authorities are recommended to make more efforts.

Rates and trends in cesarean sections between 2008 and 2012 in Iraq

BACKGROUND

The prevalence of cesarean sections is increasing globally; however, it can lead to significant increases in maternal and infant morbidity and mortality. This study aimed to determine the rates and trends of cesarean sections in Iraq.

METHODS

The cesarean section rates of all births and public and private hospital-based births were calculated from the data on births provided by the annual reports of the Iraqi Ministry of Health for the years 2008 and 2012. The comparable rates for the Center/South and Kurdistan Region and the individual governorates were determined. The cesarean section rates for all births in 2008 were computed and compared with the 2012 rates.

RESULTS

The cesarean section rate for all births in Iraq was 24.4% in 2012, which was similar to the rates in the Iraqi Kurdistan Region (25.4%) and the Center/South of Iraq (24.3%). The cesarean section rates were specifically high in the governorates containing a larger number of private hospitals, and there was a significant positive relationship between the number of private hospitals and the cesarean section rate (beta = 0.671; r = 0.671; P < 0.002). The hospital-based cesarean section rate was 34.7%. The cesarean section rate in private hospitals (77.9%) was remarkably higher than the rate in public hospitals (29.3%). The overall rate of cesarean sections in Iraq increased from 18.0% in 2008 to 24.4% in 2012.

CONCLUSIONS

The cesarean section rate in Iraq is far above the recommended rate. Iraq witnessed a rapid upward trend in the cesarean section rate from 2008 to 2012, with most of this trend attributable to the Kurdistan Region. There is a potential relationship between the expansion of the private health sector and the increasing cesarean section rate, and further studies of this relationship are necessary. Future research should consider an audit of the indications for a cesarean section rather than measuring the cesarean section rate alone.