FIGO position paper: how to stop the caesarean section epidemic

Join point trends of instrumental vaginal deliveries and cesarean sections at the Lagos University Teaching Hospital, Lagos, Nigeria (2002-2017)

OBJECTIVE

To determine the trends of instrumental vaginal delivery (IVD) and cesarean section (CS) at the Lagos University Teaching Hospital (LUTH), Nigeria, over 16 years, from 2002 to 2017.

METHODS

A retrospective cross-sectional study. The case records of all women who had IVD and CS during the study period were reviewed. The trends in the IVD and CS rates were evaluated using join point regression modeling. The average annual percent change (AAPC) and annual percent change (APC) with associated 95% confidence interval of segmental trends were calculated.

RESULTS

The overall IVD rate was 1.36%. Vacuum delivery rate was higher than forceps (0.79% vs 0.57%). The CS rate was 44.9 per 100 deliveries; the rate increased by about 3.7% per annum. CS rates were 7.1-89.9 times the IVD rates within the study period. The number of IVDs performed in the hospital declined by about 83.02%, from 53 cases in 2002 to nine cases in 2017. Forceps delivery declined at a faster rate than vacuum delivery between 2002 and 2017 (AAPC for forceps: -12.6% [-17.5 to -7.5], P < 0.001 vs AAPC for vacuum: -6.2% [-14.3 to 2.7], P = 0.200). The commonest indication for IVD was prolonged second stage of labor (47/162, 29.01%) and shortening of the second stage of labor for maternal conditions (47/162, 29.01%).

CONCLUSION

IVD rates are low and declining at LUTH. There is need to train accoucheurs on the safe use of IVDs to potentially reduce the CS rate.

Delivery mode after cervical ripening among patients with no prior vaginal births

PURPOSE

To compare mode of delivery and maternal and neonatal outcomes using cervical ripening balloon (CRB) for induction of labor (IOL) in nulliparous patients vs. those undergoing first trial of labor after cesarean (TOLAC).

METHODS

Retrospective cohort study including data from two tertiary medical centers. Included were all patients with a singleton pregnancy and a gestational age > 37+0 weeks and no prior vaginal birth undergoing IOL with CRB. Nulliparous patients (nulliparous group) were compared to patients with one prior cesarean delivery (CD) and no prior vaginal delivery (TOLAC group). Patients who withdrew consent for trial of labor at any time in both groups were excluded. The primary outcome was mode of delivery.

RESULTS

Overall, 161 patients were included in the TOLAC group and 1577 in the nulliparous group. The rate of CD was similar in both groups and remained similar after adjusting for confounders (29.8 % vs. 28.9 %, p = 0.86, OR 1.1, 95 %, CI 0.76-1.58). CD due to fetal distress was more common in the TOLAC group (75 % vs. 56 %, p = 0.014). Other maternal outcomes and neonatal outcomes were similar in the two groups.

CONCLUSION

Comparable vaginal delivery rates may be achieved in patients with or without a previous CD attempting their first trial of labor, with a cervical ripening balloon for labor induction, without increasing adverse maternal or neonatal outcomes.

Variations over time in mode of birth and perinatal outcomes in women with one previous cesarean in the Netherlands: A 20-year population-based study

BACKGROUND

Globally, cesarean birth rates are rising, and while it can be a lifesaving procedure, cesarean birth is also associated with increased maternal and perinatal risks. This study aims to describe changes over time about the mode of birth and perinatal outcomes in second-pregnancy women with one previous cesarean birth in the Netherlands over the past 20 years.

METHODS

We conducted a nationwide, population-based study using the Dutch perinatal registry. The mode of birth (intended vaginal birth after cesarean (VBAC) compared with planned cesarean birth) was assessed in all women with one previous cesarean birth and no prior vaginal birth who gave birth to a term singleton in cephalic presentation between 2000 and 2019 in the Netherlands (n = 143,146). The reported outcomes include the trend of intended VBAC, VBAC success rate, and adverse perinatal outcomes (perinatal mortality up to 7 days, low Apgar score at 5 min, asphyxia, and neonatal intensive care unit admission ≥24 h).

RESULTS

Intended VBAC decreased by 21.5% in women with one previous cesarean birth and no prior vaginal birth, from 77.2% in 2000 to 55.7% in 2019, with a marked deceleration from 2009 onwards. The VBAC success rate dropped gradually, from 71.0% to 65.3%, across the same time period. Overall, the cesarean birth rate (planned and unplanned) increased from 45.2% to 63.6%. Adverse perinatal outcomes were higher in women intending VBAC compared with those planning a cesarean birth. Perinatal mortality initially decreased but remained stable from 2009 onwards, with only minimal differences between both modes of birth.

CONCLUSIONS

In the Netherlands, the proportion of women intending VBAC after one previous cesarean birth and no prior vaginal birth has decreased markedly. Particularly from 2009 onwards, this decrease was not accompanied by a synchronous reduction in perinatal mortality.

Deliveries in Lebanon, the Country with the Highest Refugee Density in the World: A Descriptive Review

PURPOSE

The aim of this study is to analyze obstetrical and reproductive health parameters in Lebanon from 2015 until 2018 in the setting of the Syrian refugee influx in order to evaluate potential risks and provide a management plan to improve outcomes.

DESCRIPTION

Data from the Lebanese Ministry of Public Health (LMPH) on all obstetrical deliveries that occurred in Lebanon between 2015 and 2018 was screened and analyzed. Number and mode of delivery as well as maternal and neonatal outcomes were included. Joinpoint regression analysis was used for trends of selected parameters. Independent two-sample t-tests were used for comparisons.

ASSESSMENT

Women of non-Lebanese nationality residing in Lebanon had a significantly greater number of total deliveries (p-value < 0.001), vaginal deliveries (p-value = 0.002), cesarean sections (p-value = 0.02). When looking at delivery trends from 2015 to 2018, Lebanese women had a significant decrease in total number of deliveries (p-value < 0.001) and vaginal deliveries (p-value < 0.001).

CONCLUSION

Total number of deliveries and cesarean sections is on the rise in Lebanon. Cesarean section practice should be audited by the LMPH and the Lebanese Order of Physicians (LOP). Local and international agencies should prioritize the implementation and management of family planning facilities in refugee hosting countries.

An Analysis of the Mode of Delivery, Risk Factors, and Subgroups with High Caesarean Birth Rates Using Robson Classification System

OBJECTIVE

We aimed to understand the utilization of the mode of delivery and related risk factors. Further aimed to apply the Robson classification system to evaluate the data quality and analyze the CS rates in subgroups.

METHODS

We conducted a retrospective descriptive study by reviewing the medical records of all women who delivered at the State Hospital in 2019. A proforma was developed for extracting data from patient records. All women with six obstetric parameters were categorized into Robson groups to determine the absolute and relative contributions of each group to the overall CS rate.

RESULTS

Of 797 deliveries, 401 (50.2%) were CSs. Being older, being Turkish Cypriot, having preterm births, previous CS, multiple fetuses, and having breech or transverse fetal presentations were related to having higher risks of CS. The most common medical indication for CSs (52.3%) was a history of previous CSs. Robson Group 5 contributed the most (50.7%) to the overall CS rate, with the highest absolute contribution of 21.8%. Group 10 and Group 8 were the second and third highest contributors to the overall CS rate, with relative contributions of 25.3% and 9.0%, respectively.

CONCLUSIONS

Findings revealed the substandard quality of obstetric data and a noticeably high overall CS rate. The top priority should be given to improving the quality of medical records. It underscored the necessity of implementing the Robson classification system as a standard clinical practice to enhance data quality, which helps to effectively evaluate and monitor the CS rates in obstetric populations.

EUROPEAN ASSOCIATION OF PERINATAL MEDICINE (EAPM) EUROPEAN MIDWIVES ASSOCIATION (EMA) Joint position statement: Caesarean delivery rates at a country level should be in the 15-20 % range

While cesarean deliveries performed for health indications can save lives, unnecessary cesareans cause unjustifiable health risks for the mother, newborn, and for future pregnancies. Previous recommendations for cesarean delivery rates at a country level in the 10-15% range are currently unrealistic, and the proposed concept that striving to achieve specific rates is not important has resulted in a confusing message reaching healthcare professionals and the public. It is important to have a clear understanding of when cesarean delivery rates are deviating from internationally acceptable ranges, to trigger the implementation of healthcare policies needed to correct this problem. Based on currently existing scientific evidence, we recommend that cesarean delivery rates at a country level should be in the 15-20% range. This advice is based on the demonstration of decreased maternal and neonatal mortalities when national cesarean delivery rates rise to circa 15%, but values exceeding 20% are not associated with further benefits. It is also based on real-world experiences from northern European countries, where cesarean delivery rates in the 15-20% range are associated with some of the best maternal and perinatal quality indicators in the world. With the increase in cesarean delivery rates projected for the coming years, experience in provision of intrapartum care may come under threat in many hospitals, and recovering from this situation is likely to be a major challenge. Professional and scientific societies, together with healthcare authorities and governments need to prioritize actions to reverse the upward trend in cesarean delivery rates observed in many countries, and to strive to achieve values as close as possible to the recommended range.

Applying the Modified Ten-Group Robson Classification in a Spanish Tertiary Hospital

BACKGROUND

Caesarean section is necessary to save the lives of mothers and newborns at times, but it is important to perform it only when it is essential due to all the risks involved. This study aimed to examine the rate of caesarean sections performed at a tertiary hospital using the Robson classification to detect methods for the detection of and/or reduction in these caesarean section rates.

METHODS

A descriptive, cross-sectional study of a retrospective database was carried out.

RESULTS

A total of 10,317 births were assessed. The Robson classification was used to assess these interventions and verify whether the indication for performed caesarean sections was appropriate. In total, 2036 births by caesarean section were performed in the whole sample. The annual caesarean section rate varied between 18.67% and 21.18%.

CONCLUSIONS

Caesarean sections increased by about 20% in 2021 compared to 2020 even though the trend over the years of study was decreasing. Vaginal delivery after caesarean section is a reasonable and safe option. Caesarean section rates could be improved, mostly in Robson's Group 2. The Robson classification facilitated progress in the implementation of measures aimed at improving care and adjusting caesarean section rates.

Association of Maternal Risk Factors with the Prevalence of Caesarean Section Deliveries: A Cross-Sectional Study

In the last few years, there has been a gradually increasing rate of caesarean section deliveries worldwide that negatively affects both mothers' and children's health. The present survey intended to explore the relations of common maternal risk factors with the prevalence of caesarean sections. This is a cross-sectional study including 5182 healthy mothers from geographically diverse regions of Greece, which has applied relevant inclusion and exclusion criteria. An elevated 56.4% incidence of caesarean sections was noted. The prevalence of caesarean section deliveries was estimated to be 51.5% in private hospitals and 48.5% in public hospitals. Maternal age, pre-pregnancy overweight/obesity, excess gestational weight gain, preterm birth, financial status, smoking habits, and private type of birth hospital were considerably associated with a high probability of caesarean section, regardless of several confounders. In conclusion, caesarean section rates are constantly increasing, and various maternal risk factors additively elevate its incidence, which additionally enhances the likelihood of postpartum complications for both the mothers and their infants. Public health procedures and approaches are strongly recommended to notify future mothers of the potential risk factors that may result in adverse pregnancy outcomes of caesarean section delivery, highlighting its use only for emergency medical reasons and also promoting healthier nutritional and lifestyle habits that may reduce the increasing prevalence of caesarean section deliveries.

FIGO good practice recommendations for cesarean delivery: Prep-for-Labor triage to minimize risks and maximize favorable outcomes

Cesarean delivery is an abdominal surgical procedure performed for child delivery when the vaginal route is not feasible or desired due to maternal/fetal indications. All childbirth facilities should be able to safely perform a cesarean, which is not the current reality. For planned cesarean delivery, the facility must be prepared for the patient. In contrast, for unplanned arrivals at the facility, FIGO's Prep-for-Labor triage method allows rapid decision-making on whether cesarean delivery can be safely performed on site or whether transfer to an advanced care center is needed. A checklist of staff/tools for safe on-site cesarean delivery is provided to enable timely decision-making. Maternal complications following cesarean are three-fold higher than vaginal delivery. To prevent nonmedically indicated cesarean by favoring vaginal delivery, up-to-date safe and effective guidance is provided, defining labor, second stage length, and status before an arrested labor is confirmed. Whether cesarean delivery is planned or emergency, the Misgav Ladach simplified procedure is proposed as it is suitable for both low- and high-risk cases, including twins, thereby reducing both operative morbidity and postoperative recovery. A trial of labor after first cesarean (TOLAC) should be pursued when feasible, for which the indications, contraindications, safeguards, and steps of safe labor induction are delineated. Implementation of these good practice recommendations will improve childbirth by reducing excessive nonindicated cesareans, while precisely defining the resources and postoperative care required for safe performance on site. Enabling safe childbirth by cesarean and TOLAC, even at sites with low rates currently, will significantly improve maternal and fetal outcomes.

Prep-for-Labor: Overview of FIGO's labor and delivery triage bundles of care to optimize maternal and newborn outcomes

Childbirth is an intense event in which decisions may need to be made in seconds to guarantee the health of both mother and newborn. Despite health systems and care approaches varying widely according to real-life scenarios, availability of facilities, beliefs, resources, staff, and geography, among others, optimal outcomes should be ensured worldwide. Triaging low-risk pregnancies from high-risk pregnancies is the first step to ensure proper allocation of resources. From this need, we developed FIGO's Prep-For-Labor triage methods, a series of 2-minute labor and delivery bundles of care, with special regard given to low- and middle-income countries and rural settings. Around 80% of women, once properly triaged, can pursue vaginal delivery with minimal intervention, while those at risk can either be managed on site or transferred promptly to an advanced care site. FIGO's bundles of care and good practice recommendations for labor and delivery and immediate newborn triage cover four clinical scenarios: (1) preterm labor; (2) induced or spontaneous labor at term; (3) cesarean delivery; and (4) newborn care. From rapid triage of the mother (low vs high risk) to the list of required equipment, description of skilled staff, and coordination of resources, the recommendations for care are introduced across these four areas in this overview article. Implementing the proposed management steps described in each summary can improve maternal and neonatal outcomes.

FIGO good practice recommendations for cesarean delivery on maternal request: Challenges for medical staff and families

Elective cesarean delivery on maternal request is a challenging topic of discussion for patients, their families, and clinicians. Efforts to reduce the rate of cesarean deliveries should include the proportion of cesarean deliveries at term that occur solely due to maternal request rather than a maternal or fetal indication. Additionally, clinicians should follow good clinical practice, which includes family counseling, discussions on the benefits and potential risks of elective cesarean delivery, timing of delivery, and ethical and legal considerations. Furthermore, there is the need for a sustained workforce of perinatal clinicians and staff trained in the appropriate technique and management of operative complications. This article reviews global rates of elective cesarean on maternal request and outlines FIGO's good practice recommendations for counseling expectant mothers and the conduct of elective cesarean versus vaginal delivery.

Influence of organizational factors on the offer and success rate of a trial of labor after cesarean section in Belgium: an ecological study

BACKGROUND

Trial of Labor After Cesarean is an important strategy for reducing the overall rate of cesarean delivery. Offering the option of vaginal delivery to a woman with a history of cesarean section requires the ability to manage a potential uterine rupture quickly and effectively. This requires infrastructure and organization of the maternity unit so that the decision-to-delivery interval is as short as possible when uterine rupture is suspected. We hypothesize that the organizational characteristics of maternity units in Belgium have an impact on their proposal and success rates of trial of labour after cesarean section.

METHODS

We collected data on the organizational characteristics of Belgian maternity units using an online questionnaire. Data on the frequency of cesarean section, trial of labor and vaginal birth after cesarean section were obtained from regional perinatal registries. We analyzed the determinants of the proposal and success of trial of labor after cesarean section and report the associations as mean proportions.

RESULTS

Of the 101 maternity units contacted, 97 responded to the questionnaire and data from 95 was included in the analysis. Continuous on-site presence of a gynecologist and an anesthetist was associated with a higher proportion of trial of labor after cesarean section, compared to units where staff was on-call from home (51% versus 46%, p = 0.04). There is a non-significant trend towards more trial of labor after cesarean section in units with an operating room in or near the delivery unit and a shorter transfer time, in larger units (> 1500 deliveries/year) and in units with a neonatal intensive care unit. The proposal of trial of labor after cesarean section and its success was negatively correlated to the number of cesarean section in the maternity unit (Spearman' rho = 0.50 and 0.42, p value < 0.001).

CONCLUSIONS

Organizational differences in maternity units appear to affect the proposal of trial of labor after cesarean section. Addressing these organizational factors may not be sufficient to change practice, given that general tendency to perform a cesarean section in the maternity unit is the main contributor to the percentage of trial of labor after cesarean.

'Maternal Request' Caesarean Sections and Medical Necessity

Currently, many women who are expecting to give birth have no option but to attempt vaginal delivery, since access to elective planned caesarean sections (PCS) in the absence of what is deemed to constitute ‘clinical need’ is variable. In this paper, we argue that PCS should be routinely offered to women who are expecting to give birth, and that the risks and benefits of PCS as compared with planned vaginal delivery should be discussed with them. Currently, discussions of elective PCS arise in the context of what are called ‘Maternal Request Caesarean Sections’ (MRCS) and there is a good deal of support for the position that women who request PCS without clinical indication should be provided with them. Our argument goes further than support for acceding to requests for MRCS: we submit that healthcare practitioners caring for women with uncomplicated pregnancies have a positive duty to inform them of the option of PCS as opposed to assuming vaginal delivery as a default, and to provide (or arrange for the provision of) PCS if that is the woman's preferred manner of delivery.

Different management strategies for cesarean scar pregnancy: Short-term outcomes and reproductive prognosis

PURPOSE

To investigate the impact on future reproductive potential of systemic methotrexate (MTX) administration, uterine artery embolization (UAE) and expectant management as treatments of caesarean scar pregnancy (CSP) and to assess their efficacy and safety.

BASIC PROCEDURES

We retrospectively analysed patients with a diagnosis of CSP treated in a five years' period (2014-2018). Hospitalization, hCG normalization, menstrual cycle recovery, ultrasound restitutio ad integrum times, reproductive desire accomplishment after the resolution of the picture, and outcomes of subsequent pregnancies were considered. Only patients for whom complete diagnosis, treatment and follow-up data were available could be considered for study entry.

MAIN FINDINGS

A total of 21 patients were included. Three of them were managed expectantly. In two cases spontaneous abortion occurred and one case underwent caesarean delivery at 35 weeks of gestation for complete placenta previa with hysterectomy for post partum haemorrhage. Seven patients were treated with systemic MTX. Median [IQR] times of hospitalization, hCG normalization, menstrual cycle recovery and ultrasound restitutio ad integrum were 21 days [10-26 days], 52 days [18-64 days], 8 weeks [6-10 weeks] and 8 weeks [6-11 weeks] respectively. At the end of follow up, 80% (95%CI [38-96%]) of patients with reproductive desire achieved at least one live birth. Eleven patients were treated with UAE combined with MTX. Median [IQR] times of hospitalization, hCG normalization, menstrual cycle recovery and ultrasound restitutio ad integrum were 14 days [12-20 days], 43 days [30-52 days], 8 weeks [4-12 weeks] and 8 weeks [8-10 weeks], respectively. Of those who expressed a reproductive desire after treatment, 80% (95%CI [49-94%]) achieved at least one live birth. In all included patients, the menstrual cycle was restored.

PRINCIPAL CONCLUSIONS

Reproductive potential of women treated for CSP was preserved after both systemic MTX administration and systemic MTX combined with UAE. Both strategies proved to be safe.

Analysis of Cesarean Section Rates in a Public Tertiary Hospital During Teaching and Non-teaching Periods Using the Robson Ten Group Classification System

INTRODUCTION

The rising cesarean section (CS) rate is a global concern. One of the hospital characteristics that may explain the variation in CS among hospitals is hospital teaching status. This study aims to assess the rate of CS in a tertiary hospital during the teaching and non-teaching periods and to conduct an analysis using the Robson ten-group classification system.

METHODS

This study is a retrospective cohort that assessed pregnant mothers who gave birth at a tertiary hospital in Bandar Abbas. The study population was divided into two groups: those who gave birth during the hospital's teaching period (November 1st, 2019 to October 30th, 2020) and those who gave birth after that (November 1st, 2020 to October 30th, 2021). The primary outcome was the rate of CS according to Robson's classification system. The secondary outcome was the contributions of each group of Robson to the overall CS rate. Data were extracted by trained collectors from the "Iranian Maternal and Neonatal Network (IMaN Net)," a valid national system, using electronic patient records.

RESULTS

Of the total number of births (8382), 62.9 % occurred during the teaching period and 37.1 % during the non-teaching period. A 7% increase in CS was observed during the teaching period of the hospital compared to the non-teaching period (p<0.01). CS rate in Robson groups 1,2,4,7, and 10 differs significantly between teaching and non-teaching periods. According to the findings, Groups 5, 10, and 2 were the three most significant contributors to overall CS in our hospital during the study period.

CONCLUSION

The efforts to reduce the overall CS rate should be focused on groups 2,5, and 10 of Robson.

Exploring the shared decision making process of caesarean sections at a teaching hospital in Ghana: a mixed methods study

BACKGROUND

Caesarean section (CS) rates are rising. Shared decision making (SDM) is a component of patient-centered communication which requires adequate information and awareness. Women in Ghana have varying perceptions about the procedure. We sought to explore mothers' knowledge. perceptions and SDM-influencing factors about CSs.

METHODS

A transdisciplinary mixed-methods study was conducted at the maternity unit of Korle-Bu Teaching Hospital in Accra, Ghana from March to May, 2019. Data collection was done in four phases: in-depth interviews (n = 38), pretesting questionnaires (n = 15), three focus group discussions (n = 18) and 180 interviewer administered questionnaires about SDM preferences. Factors associated with SDM were analyzed using Pearson's Chi-square test and multiple logistic regression.

RESULTS

Mothers depicted a high level of knowledge regarding medical indications for their CS but had low level of awareness of SDM. The perception of a CS varied from dangerous, unnatural and taking away their strength to a life-saving procedure. The mothers had poor knowledge about pain relief in labour and at Caesarean section. Health care professionals attributed the willingness of mothers to be involved in SDM to their level of education. Husbands and religious leaders are key stakeholders in SDM. Insufficient consultation time was a challenge to SDM according to health care professionals and post-partum mothers. Women with parity ≥ 5 have a reduced desire to be more involved in shared decision making for Caesarean section. AOR = 0.09, CI (0.02-0.46).

CONCLUSION

There is a high knowledge about the indications for CS but low level of awareness of and barriers to SDM. The fewer antenatal care visits mothers had, the more likely they were to desire more involvement in decision making. Aligned to respectful maternity care principles, greater involvement of pregnant women and their partners in decision making process could contribute to a positive pregnancy experience. Education, including religious leaders and decision- making tools could contribute to the process of SDM.

Caesarean Section Delivery Is Associated with Childhood Overweight and Obesity, Low Childbirth Weight and Postnatal Complications: A Cross-Sectional Study

Background and Objectives: In the last decades, simultaneously increasing trends have been recorded for both caesarean section delivery and childhood overweight/obesity around the world, which are considered serious public health concerns, negatively affecting child health. Aim: The present study aims to investigate whether caesarean section is associated with the increased rates of childhood overweight/obesity, low childbirth anthropometric indices and postnatal complications in pre-school age. Materials and Methods: This is a cross-sectional study in which 5215 pre-school children aged 2–5 years old were enrolled from nine different Greek regions after applying specific inclusion and exclusion criteria. Non-adjusted and adjusted statistical analysis was performed to assess the impact of caesarean section in comparison to vaginal delivery. Results: Children delivered by caesarean section were significantly more frequently overweight or obese at the age of 2–5 years, also presenting a higher prevalence of low birth weight, length and head circumference. Caesarean section was also associated with higher incidence of asthma and diabetes type I at the age of 2–5 years. In a multivariate analysis, caesarean section increased the risk of childhood overweight/obesity and low childbirth anthropometric indices even if adjusting for several childhood and maternal confounding factors. Conclusions: Increasing trends were recorded for both caesarean section delivery and childhood overweight/obesity, which are considered serious public health concerns. Caesarean section independently increased childhood overweight/obesity in pre-school age, highlighting the emergent need to promote health policies and strategies to inform future mothers about its short and long-term risks and that this mode of delivery should preferably be performed only when there are strong medical recommendations in emergency obstetric conditions.

Uterine niche is associated with adverse in vitro fertilization and intracytoplasmic sperm injection outcomes: a retrospective cohort study

OBJECTIVE

To investigate the relationship between uterine niche and reproductive outcomes of in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI).

DESIGN

A retrospective cohort study.

SETTING

A reproductive medicine center.

PATIENT(S)

A total of 2,449 women with cesarean section history who underwent 2,874 IVF/ICSI cycles between January 2015 and December 2019.

INTERVENTION(S)

A defect deeper than 2 mm visible under three-dimensional transvaginal sonography or hysteroscopy was defined as uterine niche. The IVF/ICSI outcomes of the first embryo transfer were obtained by telephone interview 1 year after embryo transfer regardless of fresh embryos or frozen-thawed embryos. Generalized estimating equations, logistic regression analyses, and propensity score matching were applied to clarify the relationship between uterine niche and IVF/ICSI outcomes.

MAIN OUTCOME MEASURE(S)

Primary outcome was live birth rate. Secondary outcomes were positive human chorionic gonadotropin test results, clinical pregnancy rate, implantation rate, miscarriage rate, and ectopic pregnancy rate.

RESULTS

After excluding 48 cycles for uterine malformation; 18 cycles for chromosome abnormality; 281 cycles for no available embryo or no embryo transfer; 5 cycles for oocyte donation; and 7 cycles for loss of follow-up, we finally included 2,231 women with 2,515 cycles in our study. Compared with women without niche, women with niche had reduced live birth rate (18.99% vs. 31.51%, : 0.51, 95% CI: 0.34-0.77), positive human chorionic gonadotropin test rate (34.08% vs. 46.40%, adjusted odds ratio [aOR]: 0.61, 95% confidence interval [CI]: 0.43-0.87), clinical pregnancy rate (29.05% vs. 42.25%, aOR: 0.57, 95% CI: 0.39-0.82) and implantation rate (25.87% vs. 36.95%, aOR: 0.53, 95% CI: 0.38-0.76). In all the sensitivity analyses, the niche group had a 7.28% to 18.22% increase in miscarriage rate even not all of them were statistically significant.

CONCLUSION(S)

Uterine niche may have a detrimental effect on subsequent fertility of women with cesarean section history undergoing IVF/ICSI treatment. Practitioners should be noted that women with uterine niches may be associated with adverse IVF/ICSI outcomes.

Repeat low order caesarean delivery, risk factors for complications: A retrospective, longitudinal study

One-third of cesarean deliveries (CDs) are repeat operations, of which the majority are low-order, second (CD2) and third (CD3). The study objectives were to identify risk factors for a complicated maternal CD among women undergoing a repeat low-order CD and to develop a predictive model for at-risk women. A retrospective longitudinal follow-up study was conducted in a single medical center, during 2005-2016. Women who underwent both CD2 and CD3 at the site were included. Those with placenta accreta or a caesarean hysterectomy were excluded. A composite complicated maternal CD was defined by either uterine rupture/dehiscence, blood transfusion, relaparotomy, admission to the intensive care unit or prolonged operative time >90th percentile. Data was analyzed comparing between CD2 to CD3, each woman served as her own control. Univariate analysis followed by a multivariate logistic regression modeling were performed with an OR of 95% CI defining significance. The study group comprised of 1,331 women. A complicated CD occurred in 159 (12%) vs. 226 (17%) of CD2 vs. CD3 respectively, (p<0.001). Women with a complicated CD2 were at higher risk for complications in CD3, aOR 2.3 (95% CI 1.5, 3.3). Sub-Saharan African origin and preterm delivery at CD3 were both risk factors for a complicated CD3, aOR 3.7 (95% CI 1.9, 7.3) and aOR 1.7 (95% CI 1.1, 2.7), respectively. The multivariate regression model included 1328 cases, was statistically significant, χ2(7) = 50.760, p <0.001, explained 6.3% of the variance of composite complicated maternal CD3 and correctly classified 82.9% of cases. Although a complicated CD2, Sub-Saharan African origin and preterm delivery are risk factors for maternal complications in CD3, it is hard to predict which specific women will experience complications. Sensitivity, specificity, positive and negative predictive value of a complicated CD2 for detecting complications in CD3 were 21%, 90%, 30% and 85% respectively.

Variation of caesarean section rates in Palestinian governmental hospitals

BACKGROUND

Globally, the increased use of cesarean sections has become prevalent in high-income and low and middle-income countries. In Palestine, the rate had risen from 20.3% in 2014 to 25.1% in 2018. We have rates as high as 35.8% in some governmental hospitals and some as low as 15%. This study aimed to understand better why there is a variation in cesarean rates in governmental hospitals that use the same guidelines.

METHODS

A qualitative and quantitative research approach was used. In-depth interviews were conducted with 27 specialists, obstetrics and gynecologists, and midwives in five government hospitals. The hospitals were selected based on the 2017 Annual Health Report reported cesarean section rates. The interview guide was created with the support of specialists and researchers and was piloted. Questions focused mainly on adherence to the obstetric guidelines and barriers to the use, sources of information, training for healthcare providers, the hospital system, and the factors that affect decision-making. Each hospital's delivery records for one month were analyzed to determine the reason for each cesarean section.

RESULTS

The results indicated that each governmental hospital at the system level had a different policy on cesarean sections. The National Guidelines were found to be interpreted differently among hospitals. One obstetrician-gynecologist decided on a cesarean section at high-rate hospitals, while low-rate hospitals used collective decision-making with empowered midwives. At the professional level, all hospitals urged the importance of a continuous training program to refresh the medical team knowledge, in-house training of new members joining the hospital, and discussion of cases subjective to obstetrician-gynecologists interpretations.

CONCLUSION

Several institutional factors were identified to strengthen the implementation of the national obstetric guidelines. For example, encouraging collective decision-making between obstetrician-gynecologists and midwives, promoting the use of a second opinion, and mandatory training.

Value in maternal care: Using the Learning Health System to facilitate action

There is an increasing need to deliver high-value health care. Here, we discuss how value should be measured and implemented in maternity care through a Learning Health System. High-value maternity care will produce the highest level of benefit for women at a given cost. As pregnancy is not an illness state, and there is no cure or remission to be achieved, we believe that patient-reported outcomes should be an integral component of benefit quantification when measuring value. Furthermore, as care impacts more than just health outcomes-particularly in maternity care-there is also a need to consider patient-reported experiences as a part of defining the level of benefit. However, to move beyond traditional narrow and passive measurement of value, we need to partner with stakeholders to identify priorities for change, identify evidence for how to achieve this change, integrate measurement activities, and promote effective implementation, in a continuous, learning cycle-a Learning Health System. A robust Framework for implementing a Learning Health System has been developed, which could be applied in maternity care.

Safe Service Delivery of a Complex Early Pregnancy Problem: Caesarean Scar Pregnancy

Caesarean Scar Pregnancy (CSP) is an ectopic pregnancy with implantation into the niche of the uterine scar. We aimed to describe the local management of consecutive cases of CSP to develop a standard operating procedure (SOP). Between December 2019 and June 2022, there were 19,100 maternities. Of these, 23 were CSPs in 19 patients. Median BMI was 29 (range 20.5-52), median number of Caesarean deliveries (CS) was 2 (range 1-4) and 7/23 (30%) were cigarette smokers. At diagnosis, 9/23 were live pregnancies, 3/23 were retained products of conception (RPOC), 9/23 were pregnancies of uncertain viability (PUV), and 2/23 were non-viable. In six, the initial management was expectant, surgical suction evacuation with transrectal ultrasound guidance in 16, and one had a hysterectomy. The median blood loss was 100 mL (range 50-2000 mL). Two patients (9%) required a blood transfusion. Median hospital stay was 1 day (range 0-4). At follow-up after 10 weeks, no patients had an ongoing haematoma, and one had significant RPOC electing hysterectomy. Eight women were known to have 9 subsequent pregnancies (recurrent CSP n = 4, livebirth n = 2, miscarriage n = 2, tubal ectopic n = 1). Outcomes as rated by low blood loss, short hospital stay, and rare need for further intervention were favorable. Factors associated included prompt ultrasonographic diagnosis, availability of transrectal ultrasound guided surgery, and specialist follow-up, which form the basis of the SOP.

HEALTHCARE PROFESSIONALS’ ATTITUDES TOWARDS VAGINAL BIRTH AFTER CESAREAN SECTION; İSTANBUL EXAMPLE

Rapidly increasing cesarean birth rates around the world continue to cause concern. Repeated cesarean sections are the most important causes of this increase. Vaginal birth after cesarean section (VBAC) is a good solution, but is not used widely enough in clinical practice. This cross-sectional descriptive study aimed to determine the attitudes of healthcare professionals towards VBAC and the factors that affect them. The study was conducted at a maternity hospital in Istanbul and sample included 254 healthcare professionals. The data were collected using a personal information form and the VBAC Attitudes Form. Percentages, means, Pearson’s chi-squared test, the Kruskal-Wallis H test and the Mann-Whitney U test were used. The threshold for statistical significance was p

Development of a co-designed, evidence-based, multi-pronged strategy to support normal birth

Australia's caesarean section (CS) rate has been steadily increasing for decades. In response to this, we co-designed an evidence-based, multi-pronged strategy to increase the normal birth rate in Queensland and reduce the need for CS. We conducted three workshops with a multi-stakeholder group to identify a broad range of options to reduce CS, prioritise these options, and achieve consensus on a final strategy. The strategy comprised of: universal access to midwifery continuity-of-care and choice of place of birth; multi-disciplinary normal birth education; resources to facilitate informed decision-making; respectful maternity care and positive workplace culture; and establishment of a Normal Birth Collaborative.

'Labour Hopscotch': Women's evaluation of using the steps during labor

INTRODUCTION

Concerns have been expressed globally about the decline in rates of physiological birth and rising intervention rates during labor and birth. The 'Labour Hopscotch' Framework, a visual depiction of steps required to remain active during labor was implemented in a large tertiary maternity hospital in Ireland. The aim of this study was to evaluate the steps of the Labour Hopscotch women found most useful, examine the use of non-pharmacological and pharmacological methods of pain relief used during labor and finally to investigate the labor and birth outcomes of women who used 'Labour Hopscotch' during labor.

METHODS

A descriptive cross-sectional study was conducted using a study specific questionnaire.

RESULTS

A total of 809 women completed the questionnaire. The Labour Hopscotch Framework was positively evaluated. Mobilizing, the birthing ball, birthing stool, and water therapy were found to be the most useful steps. Primiparous women were more likely to use non-pharmacological methods of pain relief. Pharmacological methods used by women were entonox (67.5%), pethidine (8%) and epidural analgesia (38.5%). Primiparous women were more likely to have epidural analgesia than multiparous women (p<0.00001). Women that attended either private (p=0.004) or public-led obstetric (p=0.005) antenatal care were more likely to have epidural analgesia in labor. Women attending the community midwives were least likely to receive epidural analgesia during labor. The rates of spontaneous vaginal birth, assisted birth and cesarean section, were 77.1%, 14% and 8.7%, respectively.

CONCLUSIONS

Our study findings contribute to the increasing national and international evidence that initiatives such as Labour Hopscotch can promote and advocate for women to be active and mobile during labor to support physiological birth.

Trial of labor following cesarean in preterm deliveries: success rates and maternal and neonatal outcomes: a multicenter retrospective study

PURPOSE

To evaluate the rates of vaginal birth after cesarean (VBAC) among parturients attempting preterm trial of labor following a cesarean delivery (TOLAC) vs. term TOLAC.

METHODS

A multicenter historic cohort study was conducted at two university-affiliated centers between August 2005 and March 2021. Parturients in their second delivery, attempting TOLAC after a single low segment transverse cesarean delivery were included. We retrospectively examined computerized medical records of all preterm (< 37 weeks) and term (37-42 weeks) births. Multifetal gestations and postterm deliveries (≥ 42 weeks) were excluded. A univariate analysis was conducted, followed by a multivariate analysis.

RESULTS

4865 second deliveries following previous cesarean were identified: 212 (4.4%) preterm and 4653 (95.6%) term. Hypertensive disorders, diabetes and fertility treatments were significantly more prevalent in the preterm group. VBAC rate was significantly lower in preterm group (57.5 vs 79.7%., p < 0.01), including both spontaneous and vaginal-assisted deliveries. In multivariate analysis, preterm TOLAC was independently associated with TOLAC failure [adjusted odds ratio 2.24, [95% confidence interval 1.62-3.09]. Overall, maternal outcomes were favorable. Rates of uterine rupture, re-laparotomy and postpartum hemorrhage were comparable between groups. Neonatal outcomes were less favorable among the preterm group; however, preterm vs. term TOLAC was not associated with low 5 min Apgar score (aOR 1.76, 95% CI 0.92-3.40).

CONCLUSION

In our study, VBAC rates were lower in preterm compared to term deliveries. Maternal outcomes were comparable. Neonatal outcomes were less favorable in the preterm group, more likely due to prematurity than delivery mode.

Achieving an appropriate cesarean birth (CB) rate and analyzing the changes using the Robson Ten-Group Classification System (TGCS): Lessons from a Tertiary Care Hospital in Italy

BACKGROUND

To describe the interventions that were implemented at a Tertiary University Hospital and how they affected the rate of cesarean birth (CB) and main obstetrics and neonatal outcomes.

STUDY DESIGN

An analysis of the contemporaneously collected data from all deliveries that occurred from 2014 to 2018. Major obstetric and neonatal outcomes were analyzed and grouped according to the Ten-Group Classification System (TGCS).

RESULTS

A significant decrease in CB rates, from 28.4% to 23.0% (P < 0.001), was found over the study period. Although the relative sizes of both nulliparous (groups 1 + 2) and multiparous (groups 3 + 4) women remained stable over the study period, a significantly higher incidence of CB was reported in 2014 for both groups, compared with 2018 (2.6% vs. 13.0%, P < 0.001 for nulliparous women and 7.5% vs. 3.3%, P < 0.001 for multiparous women). In contrast, the relative size of Group 5 was significantly lower in 2014 than in 2018 (9.9% vs. 11.5%, P = 0.003), but a 13.3% reduction in CB was also reported for this group. No significant differences were noted in the occurrence of major obstetrics and neonatal outcomes that were reported.

CONCLUSIONS

A reduction in CB rate may be safely achieved through implementing a multifaceted strategy.

Impact of cesarean versus vaginal delivery on the risk of postpartum acute kidney injury: A retrospective database controlled study in 116,876 parturients

STUDY OBJECTIVE

The rate of cesarean delivery is increasing globally but the risk of perioperative organ injury associated with cesarean delivery is not well defined. The objective of this study was to determine the risk of postpartum acute kidney injury, a peripartum complication defined by an acute decrease in kidney function, associated with cesarean delivery compared to vaginal delivery.

SETTING

Population-based discharge database.

PATIENTS

The Optum Clinformatics® Data Mart was queried for parturients that underwent cesarean or vaginal delivery between January 2016 to January 2018. Using a propensity score model based on 27 antepartum characteristics, we generated a final matched cohort of 116,876 parturients.

INTERVENTION/EXPOSURE

Cesarean delivery as the mode of delivery.

MEASUREMENTS

The risk of acute kidney injury associated with each delivery mode and the effect of acute kidney injury on the length of hospital stay for parturients.

MAIN RESULTS

The matched cohort consisted of 116,876 deliveries, with 58,438 cases in each group. In the cesarean delivery group, the incidence of postpartum acute kidney injury was 24.5 vs. 7.9 per 10,000 deliveries in the vaginal delivery group (adjusted odds ratio = 3; 95% CI, 2.13-4.22; P < .001). The median of the length of hospital stay [interquartile range] was longer by 50% in parturients who developed postpartum acute kidney injury after vaginal delivery (3 [2-4] days vs. those who did not, 2 [2, 3] days; P < .001) and by 67% after cesarean delivery (5 [4-7] days vs. 3 [3, 4] days; P < .001).

CONCLUSIONS

Cesarean delivery is associated with a significantly increased risk of postpartum acute kidney injury as compared to vaginal delivery. The development of postpartum acute kidney injury is associated with prolonged length of hospital stay.

Prediction model for prolonged hospitalization following cesarean delivery

INTRODUCTION

A rise in the rate of cesarean delivery (CD) has been found to be associated with a higher length of hospital stay, making it a public health concern. We aimed to evaluate risk factors for prolonged hospitalization following CD.

METHODS

A retrospective cohort study, in a single tertiary medical center, was conducted (2011-2019). Cesarean deliveries were categorized into three groups according to the postpartum length of stay (a) up to 3 days (the routine post cesarean hospital stay in our center, reference group) (b) 4-9 days, and (c) 10 days or above (prolonged hospitalization). Risk factors were examined using univariate analysis as well as multivariate logistic regression. A specific risk prediction score was developed to predict the need for prolonged hospitalization and ROC curve was assessed utilizing the performance of our model.

RESULTS

Overall, 87,424 deliveries occurred during the study period. Of them, 19,732 (22.5%) were cesarean deliveries. Hospitalization period was distributed as follows: 10,971 (55.6%) women were hospitalized for up to 3 days, 7,576 (38.4%) stayed for 4-9 days and 1,185 (6%) had a prolonged hospitalization period (≥10 days). Using multivariate analysis, multiple pregnancy (OR = 1.29, 95%CI 1.05-1.58), preterm delivery < 37 weeks (OR = 8.32, 95%CI 6.7-10.2), Apgar score < 7 (OR = 1.41, 95%CI 1.11-1.78) and non-elective CD (OR = 1.44, 95%CI 1.15-1.8) were identified as independent risk factors for prolonged hospitalization. Antenatal thrombocytopenia (PLT < 100 K) was found to be a protective factor (OR = 0.51, 95%CI 0.28-0.92). Our score model included antenatal risk factors and was found to be predicting the outcome, with an AUC of 0.845 (95%CI 0.83-0.86, p-value < 0.001).

CONCLUSION

A prediction score model for prolonged hospitalization after CD may be beneficial for risk assessment and post-partum management.

Which classification system could empower the understanding of caesarean section rates in Greece? A review of systematic reviews

INTRODUCTION

Worldwide there is an alarming increase in the caesarean delivery rate which has become a controversial topic. However, the reasons for this tendency are not clear. For example, in Greece alone, rates increased by almost 50% from 1983 to 1996. In order to better understand the causes of this phenomenon, we need to examine closely what groups of women undergo caesarean section (CS). To achieve this, it is essential to use a system that will enable us to monitor and compare caesarean delivery rates. Such a classification system should be easily adopted by obstetricians, midwives, and public health services.

METHODS

A review search of electronic databases concerning medical care was held from December 2020 to January 2021 in order to find systematic reviews which describe either theoretical or practical CS classification systems.

RESULTS

The most common classification systems fall into three main categories based on indication, urgency and maternal-based characteristics. According to users the highest rated classification system was women-based classifications in general. In particular the Robson Ten Group Classification System was considered to be the most valid to meet current local and international standards. The Robson classification system is praised for its robustness, simplicity, flexibility, and reproducibility.

CONCLUSIONS

The right implementation of the Robson Ten Group Classification System can facilitate an in-depth analysis of the main groups that increase CS rates and can be used to both review and monitor delivery practices both in Greece and abroad.

Survey of mode of delivery and maternal and perinatal outcomes in Canada

OBJECTIVE

To identify determinants of cesarean delivery (CD) and examine associations between mode of delivery (MOD) and maternal and perinatal outcomes.

METHODS

We conducted a retrospective analysis of a Canadian multicentre birth cohort derived from provincial data collected in 2008/2009. Maternal and perinatal characteristics and outcomes were compared between vaginal and cesarean birth and between the following MOD subgroups: spontaneous vaginal delivery (VD), assisted VD, planned cesarean delivery (CD), and intrapartum CD. Multivariate regression identified determinants of CD and the effects of MOD and previous CD on maternal and perinatal outcomes.

RESULTS

The cohort included 264 755 births (72.1% VD and 27.9% CD) from 91 participating institutions. Determinants of CD included maternal age, parity, previous CD, chronic hypertension, diabetes, urinary tract infection or pyelonephritis, gestational hypertension, vaginal bleeding, labour induction, preterm gestational age, low birth weight, large for gestational age, malpresentation, and male sex. CD was associated with greater risk of maternal and perinatal morbidity and mortality. Subgroup analysis demonstrated higher risk of adverse pregnancy outcomes with assisted VD and intrapartum CD than spontaneous VD. Planned CD reduced the risk of obstetric wound hematoma and perinatal mortality but increased maternal and neonatal morbidity. Previous CD increased the risk of maternal and neonatal morbidity among multiparous women.

CONCLUSIONS

The CD rate in Canada is consistent with global trends reflecting demographic and obstetric intervention factors. The risk of adverse pregnancy outcomes with CD warrants evaluation of interventions to safely prevent nonessential cesarean birth.

What would reduce caesarean section rates?—Views from pregnant women and clinicians in Ireland

Background

Caesarean section rates continue to rise in most parts of the world. While CS is a lifesaving procedure there is evidence that, beyond a certain threshold, CS rates may contribute to increased maternal and perinatal morbidity. This study aimed to elicit the views of pregnant women’s and clinicians’ on how CS rates might be reduced.

Methods

Pregnant women and their partners, and clinicians working with pregnant women in a maternity hospital in the Republic of Ireland of Ireland, were invited to participate in focus groups. Eligibility criteria included all women attending antenatal classes and clinicians working with pregnant women. A convenience sample was used and interviews were audio recorded, transcribed, and analysed using thematic analysis.

Results

Four focus group interviews were conducted with 30 clinicians and 15 pregnant women and two partners participated in three focus groups. A further two women were interviewed individually. Participants expressed a view that rising CS rates were impacted by a societal perception that CS had become a ‘normal mode of birth’. Suggestions for reducing CS rates were offered by clinicians and pregnant women and their partners.

Conclusions

Clinicians and pregnant women consider that CS rates can be reduced if a shared philosophy supporting normal birth is prioritised alongside adequate resourcing. Women and their partners also believe that enhanced communication with clinicians is central to reducing CS rates.

A new index for obstetrics safety and quality of care: integrating cesarean delivery rates with maternal and neonatal outcomes

BACKGROUND

Cesarean delivery rates have been used as obstetrical quality indicators. However, these approaches do not consider the accompanying maternal and neonatal morbidities. A challenge in the field of obstetrics has been to establish a valid outcomes quality measure that encompasses preexisting high-risk maternal factors and associated maternal and neonatal morbidities and is universally acceptable to all stakeholders, including patients, healthcare providers, payers, and governmental agencies.

OBJECTIVE

This study aimed to (1) establish a new single metric for obstetrical quality improvement among nulliparous patients with term singleton vertex-presenting fetus, integrating cesarean delivery rates adjusted for preexisting high-risk maternal factors with associated maternal and neonatal morbidities, and (2) determine whether obstetrician quality ranking by this new metric is different compared with the rating based on individual crude and/or risk-adjusted cesarean delivery rates. The single metric has been termed obstetrical safety and quality index.

STUDY DESIGN

This was a cross-sectional study of all nulliparous patients with term singleton vertex-presenting fetuses delivered by 12 randomly chosen obstetricians in a single institution. A review of all records was performed, including a review of maternal high-risk factors and maternal and neonatal outcomes. Maternal and neonatal medical records were reviewed to determine crude and adjusted cesarean delivery rates by obstetricians and quantify maternal and neonatal complications. We estimated the obstetrician-specific crude cesarean delivery rates and rates adjusted for obstetrician-specific maternal and neonatal complications from logistic regression models. From this model, we derived the obstetrical safety and quality index for each obstetrician. The final ranking based on the obstetrical safety and quality index was compared with the initial ranking by crude cesarean delivery rates. Maternal and neonatal morbidities were analyzed as ≥1 and ≥2 maternal and/or neonatal complications.

RESULTS

These 12 obstetricians delivered a total of 535 women; thus, 1070 (535 maternal and 535 neonatal) medical records were reviewed to determine crude and adjusted cesarean delivery rates by obstetricians and quantify maternal and neonatal complications. The ranking of crude cesarean delivery rates was not correlated (rho=0.05; 95% confidence interval, -0.54 to 0.60) to the final ranking based on the obstetrical safety and quality index. Of note, 8 of 12 obstetricians shifted their rank quartiles after adjustments for high-risk maternal conditions and maternal and neonatal outcomes. There was a strong correlation between the ranking based on ≥1 maternal and/or neonatal complication and ranking based on ≥2 maternal and/or neonatal complications (rho=0.63; 95% confidence interval, 0.08-0.88).

CONCLUSION

Ranking based on crude cesarean delivery rates varied significantly after considering high-risk maternal conditions and associated maternal and neonatal outcomes. Therefore, the obstetrical safety and quality index, a single metric, was developed to identify ways to improve clinician practice standards within an institution. Use of this novel quality measure may help to change initiatives geared toward patient safety, balancing cesarean delivery rates with optimal maternal and neonatal outcomes. This metric could be used to compare obstetrical quality not only among individual obstetricians but also among hospitals that practice obstetrics.

Mifepristone versus balloon catheter for labor induction: a cohort study

OBJECTIVE

to compare trans-cervical balloon catheter with oral administration of mifepristone for induction of labor.

METHODS

Retrospective cohort study including a total of 325 patients; labor was induced with Foley catheter (group I, n = 220) or mifepristone (group II, n = 105). We selected patients with cervical ripening ≤5 cm according to Bishop score (n = 208) and divided into 2 subgroups depending on the parity: group I, primiparous with a Bishop score of ≤5, n = 70 - I (1, ≤5); group I, multiparous with a Bishop score of ≤5, n = 44 - I (2,≤5); group II, primiparous with a Bishop score of ≤5, n = 65 - II (1, ≤5); group II, multiparous with a Bishop score of ≤5, n = 29 - II (2, ≤5). Frequencies and percentages were presented using analysis of variance.

RESULTS

Vaginal delivery occurred more frequently in patients induced by mifepristone (76.5%) vs. Foley catheter (74.5%). However, vaginal delivery within 24 h from the onset of induction occurred in the majority of patients in the Foley catheter groups: 39 (55.7%) and 28 (63.6%) versus 15 (23.1%) and 6 (20.7%) in groups induced with mifepristone. The frequency of cesarean section in the primiparas induced using a Foley catheter was 14%, with the use of mifepristone 21%. However, all multiparas induced with mifepristone delivered vaginally, in contrast to 30.7% of multiparas with the placement of a Foley catheter which required a cesarean delivery.

CONCLUSION

Comparison of the effectiveness of induction of labor with the use of mifepristone and an intracervical balloon Foley catheter showed that both of these methods are successful, with more deliveries within the first 24 hrs achieved by using Foley catheter. The results of this study support the postulate that the success of an induction is largely dependent on the degree of cervical ripening and parity.

Cesarean section and breastfeeding outcomes in an Indigenous Qom community with high breastfeeding support

BACKGROUND AND OBJECTIVES

Cesarean section may lead to suboptimal breastfeeding outcomes, though evidence has been mixed. Factors, such as premature birth, birth weight and maternal age may independently increase risk of cesarean and hinder breastfeeding initiation, while maternal preferences, support and sociostructural barriers may influence breastfeeding practices beyond the immediate postpartum period.

METHODOLOGY

We assessed impacts of cesarean section and gestational factors on breastfeeding duration among Indigenous Qom mothers in Argentina who have strong traditional breastfeeding support. We modeled transitions from exclusive breastfeeding to complementary feeding and from complementary feeding to full weaning in a Bayesian time-to-event framework with birth mode and gestational covariates (n = 89 infants).

RESULTS

Estimated median time to full weaning was 30 months. Cesarean-delivered babies were weaned an average of 5 months later adjusting for gestational age, maternal parity and infant sex. No factors were associated with time-to-complementary feeding, and time-to-complementary feeding was not associated with time-to-full weaning.

CONCLUSIONS AND IMPLICATIONS

Among Indigenous Qom mothers in Argentina, cesarean section was not associated with suboptimal breastfeeding outcomes. Although some Qom mothers do experience early breastfeeding problems, particularly following first birth, problems are not more frequent following cesarean delivery. Traditional postpartum kin and community support during prolonged postpartum periods may be instrumental in helping mothers to overcome early breastfeeding problems due to cesarean or other risk factors.

An impact evaluation of the strategy for normal birth care on caesarean section rates and perinatal mortality in Spain

The objectives of this research are to evaluate the impact of a health policy (the Strategy for Normal Birth Care, EAPN) on caesarean rates and perinatal mortality in Spanish public hospitals belonging to the National Health System (NHS) and to assess the related cost savings. Data from the Spanish Ministry of Health for the period 2002-2011 and quantitative impact evaluation techniques (double difference method) are used to compare the effects of this policy in a treatment group composed of the NHS hospitals and a control group made up of private for-profit hospitals outside the scope of the EAPN. Both groups are compared some years before and after the health policy initiated in 2006 and approved in October 2007. The estimation results show that the EAPN had a significant effect in reducing caesarean rates of approximately 2 percentage points between 2007 and 2011, with increasing cost savings over the years ranging from 24 to 44 million euros depending on the year. Furthermore, EAPN reduced perinatal mortality levels by 0.08% in years 2008-2009.

Demonstration of the application of the global cesarean section rate model (C-Model) and the Robson Classification to estimate and characterize excess numbers of institutional c-sections

Objective

To carry out an academic exercise based on real local data regarding the application of the C-Model v1.0 to determine how data are gathered and used to generate the model, how the model is applied in order to identify potential excess numbers of cesarean sections in an institution, and when identified, how the model is applied to distribute deliveries according to the Robson Classification system and explain excess numbers.

Methodology

The standardized ratio and absolute difference between the observed proportion and the expected probability of c-sections according to the C-Model v1.0 were estimated for each institution using real databases of five hospitals in Colombia. Convenience selection was used to meet the objectives. Based on the assumptions underpinning group distributions according to the Robson classification, proposed explanations for excess numbers and differences among institutions are presented.

Results

Applying the C-Model, the c-section standardized ratio identified different excess numbers of the procedure in the presence of similar institutional c-section proportions. Important variability was found in the proportion of c-sections among women with similar clinical and obstetric characteristics, which might explain the excess numbers identified.

Conclusion

The C-Model allows to estimate expected c-section proportions according to the specific characteristics of the women seen at each institution; their distribution according to the Robson Classification is a way to explore the origin and particulars of those differences.

Collaborative model of intrapartum care: qualitative study on barriers and facilitators to implementation in a private Brazilian hospital

INTRODUCTION

A collaborative (midwife-obstetrician) model of intrapartum care (CMIC) is associated with lower caesarean section (CS) rates than physician-led models. In 2019, the largest private maternity hospital in Latin America (14.000 deliveries/year, 89% CS) created a quality improvement initiative to optimise intrapartum care and safely reduce CS in low-risk women managed by its internal team of healthcare providers (HCP). We conducted formative research to identify potential barriers and facilitators to the implementation of a CMIC.

METHODS

Three groups of stakeholders participated in focus groups and interviews: hospital managers and clinical coordinators, HCP working in labour/delivery wards and pregnant women intending to give birth in the hospital. We explored participants' views about the acceptability of implementing a CMIC where a nurse-midwife (NM) on shift would be the main intrapartum HCP, with continuous support/supervision of a dedicated, in-house, obstetrician-gynaecologist (OB-GYN). A thematic analysis approach was used.

RESULTS

12 HCPs, 5 clinical coordinators, 2 hospital managers and 7 women participated. OB-GYNs, coordinators and managers highlighted health system, organisational and structural factors (NMs' limited experience/skills, professional roles, financial reimbursement) as potential barriers. NMs identified logistical and human resources as additional barriers. Women viewed the CMIC with perplexity and insecurity because of cultural beliefs about the dominant role of OB-GYNs, and limited information about NM's capabilities. All professionals agreed that women's acceptance of a CMIC will require educational interventions and communication strategies to inform potential users about the advantages and safety of this model.

CONCLUSION

There are important barriers and facilitators to implement a CMIC in a private Brazilian maternity hospital. Factors related to health system structure and organisation may have the greatest impact. A CMIC is more likely to succeed if stakeholders' concerns about responsibilities, power and financial revenues are addressed, and educational interventions targeted at users are deployed prior to its implementation.

Characteristics of Women Receiving Emergency Caesarean Section: A Cross-Sectional Analysis from Ghana and Dominican Republic

BACKGROUND

Significant inequalities still exist between low- and high-income countries regarding access to optimum emergency obstetric care including life-saving emergency caesarean section. These relationships are considerably stronger between population-based caesarean section rates and socio-economic characteristics with poorest households experiencing significant unmet needs persistently.

OBJECTIVE

To explore the characteristics of women receiving emergency C-section using a new, validated definition in Ghana and the Dominican Republic.

MATERIALS AND METHODS

This was a cross-sectional study conducted in Ghana and the Dominican Republic. Multivariable logistic regression analysis was used to determine women's characteristics associated with emergency C-section.

RESULTS

This analysis included 2166 women who had recently delivered via C-section comprising 653 and 1513 participants from Accra and Santo Domingo, DR, respectively. Multivariable analyses showed that women, both in Ghana and the DR, were more likely to have an emergency C-section if they did not have a previous C-Section (adjusted Odds Ratio (aOR): 2.45, 95% CI [1.57-3.81]; and aOR: 15.5, 95% CI [10.5-22.90], respectively) and if they were having their first childbirth, compared to women with previous childbirth (aOR: 1.77, 95%CI [1.13-2.79]; and aOR: 1.46, 95%CI [1.04-2.04], respectively). Also, preterm birth was associated with significantly decreased likelihood of emergency C-section compared with childbirth occurring at term in both Ghana and the DR (aOR: 0.31, 95%CI [0.20-0.48]; and aOR: 0.43, 95%CI [0.32-0.58], respectively). Among the Ghanaian participants, having an emergency C-section was positively associated with being referred and negatively associated with being older than 35 years of age. Characteristics such as education, religion, marital status, and residence did not differ between women's emergency versus non-emergency C-section status.

CONCLUSION

Emergency C-section was found to be significantly higher in women with no prior C-section or those having their first births but lower in those with preterm birth in both Ghana and the DR. Data from additional countries are needed to confirm the relationship between emergency C-section status and socio-economic and obstetric characteristics, given that the types of interventions required to assure equitable access to potentially life-saving C-section will be determined by how and when access to care is being denied or not available.

Composite non-clinical interventions for a safe cesarean section rate reduction: results of a pre-post interventional study

OBJECTIVE

To evaluate the impact on cesarean section (CS) rate with of a program of multiple non-clinical interventions targeted at health-care professional within a hospital maternity ward.

MATERIALS AND METHODS

Retrospective quasi-experimental pre-post intervention study with an historical control group conducted in a second-level teaching hospital. All women who gave birth in the period 2014 to 2018 were included. A series of multiple non-clinical interventions including a dedicated team of obstetricians for delivery room and antenatal counseling, monthly internal audits and physician education by local opinion leader were prospectively introduced from September 2016. The primary outcome of the study was the CS rate. The incidences of operative vaginal delivery, 3rd-/4th-degree perineal tears and further maternal and neonatal complications were considered as secondary outcomes.

RESULTS

The CS rate dropped from 33.05 to 26.06% after starting the interventions (p < 0.01); in particular, the cumulative rate of CS performed during labor decreased significantly from 19.46 to 14.11% (p < 0.01). CS reduction was still statistically significant after multivariate correction (OR = 0.66, CI.95 = 0.57-0.76, p < 0.01). Results further showed an increased prevalence of 3rd-degree perineal tears (0.97% versus 2.24%, p < 0.01), present also after correcting for possible confounding factors (OR = 2.36, CI.95 = 1.48-3.76, p < 0.01). No differences were found in the rate of vaginal-operative births and further maternal complications, while the composite neonatal outcome was found to be improved (OR = 0.73, CI.95 = 0.57-0.93, p = 0.010).

CONCLUSIONS

The introduction of multiple non-clinical interventions can significantly reduce the CS rate. However, beside an improvement in neonatal composite outcome, a potential increase in high-degree perineal tears should be taken in account.

Uterine contraction frequency in the last hour of labor: how many contractions are too many?

OBJECTIVE

Increased frequency of uterine contractions is a component in the cluster of causal conditions that can lead to fetal hypoxia and acidosis and increase the risk for neonatal neurologic injury. For most international obstetrical societies, 5 contractions per 10 min averaged over 30 min is considered as the upper limit of normal uterine activity. We hypothesize that it might be safer to adopt an upper limit of 4 contractions per 10 min.

METHODS

We reviewed our 1970's research database containing 475 patients with closely monitored and well-documented labor and neonatal assessments that included cord blood (CB) pH, base excess (BE), and continuous recording of neonatal heart rate (NHR). Using data segregated by the proportion of the last hour before delivery when uterine contraction frequency (UCF) exceeded 4 and 5 contractions per 10 min respectively, we evaluated outcomes (CB BE, pH, Apgar scores at 1 min, the status of NHR at 16 min after birth, and the proportion of births that did not the result from normal spontaneous vaginal deliveries (NSVDs). ANOVA established relationships between UCF cutoffs and these outcomes. Our sample size is sufficiently large to provide the ability of UCF, per se, to accurately detect an alpha region of .05 88% of the time with an effect size of .15.

RESULTS

During the last hour prior to delivery, a UCF cutoff at 4 contractions per 10 min performed better than a UCF cutoff at 5 contractions per 10 min to enable the earlier identification of risks for abnormal outcomes. The longer UCF was increased, the worse were the outcomes that were measured, and the region >4 but ≤5 contractions identifies the beginnings of worsening conditions in a variety of measures of poor outcomes.

CONCLUSION

Lowering the recommended threshold for UCF from 5 to 4 contractions per 10-minute period as averaged over 30 min facilitates earlier detection of potentially compromised fetuses and is also an important contributor to a multicomponent contextualized approach to risk assessment.

Cesarean section: More than a maternal health issue

A cesarean section (CS) can be a lifesaving intervention when medically indicated, but it may also lead to adverse short- and long-term health effects for women and children.

Analysis of cesarean section rates in two German hospitals applying the 10-Group Classification System

OBJECTIVES

In Germany, cesarean section (CS) rates more than doubled within the past two decades. For analysis, auditing and inter-hospital comparison, the 10-Group Classification System (TGCS) is recommended. We used the TGCS to analyze CS rates in two German hospitals of different levels of care.

METHODS

From October 2017 to September 2018, data were prospectively collected. Unit A is a level three university hospital, unit B a level one district hospital. The German birth registry was used for comparison with national data. We performed two-sample Z tests and bootstrapping to compare aggregated (unit A + B) with national data and unit A with unit B.

RESULTS

In both datasets (national data and aggregated data unit A + B), Robson group (RG) 5 was the largest contributor to the overall CS rate. Compared to national data, group sizes in RG 1 and 3 were significantly smaller in the units under investigation, RG 8 and 10 significantly larger. Total CS rates between the two units differed (40.7 vs. 28.4%, p<0.001). The CS rate in RG 5 and RG 10 was different (p<0.01 for both). The most relative frequent RG in both units consisted of group 5, followed by group 10 and 2a.

CONCLUSIONS

The analysis allowed us to explain different CS rates with differences in the study population and with differences in the clinical practice. These results serve as a starting point for audits, inter-hospital comparisons and for interventions aiming to reduce CS rates.

Changes in maternal risk factors and their association with changes in cesarean sections in Norway between 1999 and 2016: A descriptive population-based registry study

BACKGROUND

Increases in the proportion of the population with increased likelihood of cesarean section (CS) have been postulated as a driving force behind the rise in CS rates worldwide. The aim of the study was to assess if changes in selected maternal risk factors for CS are associated with changes in CS births from 1999 to 2016 in Norway.

METHODS AND FINDINGS

This national population-based registry study utilizes data from 1,055,006 births registered in the Norwegian Medical Birth Registry from 1999 to 2016. The following maternal risk factors for CS were included: nulliparous/≥35 years, multiparous/≥35 years, pregestational diabetes, gestational diabetes, hypertensive disorders, previous CS, assisted reproductive technology, and multiple births. The proportion of CS births in 1999 was used to predict the number of CS births in 2016. The observed and predicted numbers of CS births were compared to determine the number of excess CS births, before and after considering the selected risk factors, for all births, and for births stratified by 0, 1, or >1 of the selected risk factors. The proportion of CS births increased from 12.9% to 16.1% (+24.8%) during the study period. The proportion of births with 1 selected risk factor increased from 21.3% to 26.3% (+23.5%), while the proportion with >1 risk factor increased from 4.5% to 8.8% (+95.6%). Stratification by the presence of selected risk factors reduced the number of excess CS births observed in 2016 compared to 1999 by 67.9%. Study limitations include lack of access to other important maternal risk factors and only comparing the first and the last year of the study period.

CONCLUSIONS

In this study, we observed that after an initial increase, proportions of CS births remained stable from 2005 to 2016. Instead, both the size of the risk population and the mean number of risk factors per birth continued to increase. We observed a possible association between the increase in size of risk population and the additional CS births observed in 2016 compared to 1999. The increase in size of risk population and the stable CS rate from 2005 and onward may indicate consistent adherence to obstetric evidence-based practice in Norway.

Guideline No. 402: Diagnosis and Management of Placenta Previa

OBJECTIVES

To summarize the current evidence and to make recommendations for diagnosis and classification of placenta previa and for managing the care of women with this diagnosis.

OPTIONS

To manage in hospital or as an outpatient and to perform a cesarean delivery preterm or at term or to allow a trial of labour when a diagnosis of placenta previa or a low-lying placenta is suspected or confirmed.

OUTCOMES

Prolonged hospitalization, preterm birth, rate of cesarean delivery, maternal morbidity and mortality, and postnatal morbidity and mortality.

INTENDED USERS

Family physicians, obstetricians, midwives, and other maternal care providers.

TARGET POPULATION

Pregnant women with placenta previa or low-lying placenta.

EVIDENCE

Medline, PubMed, Embase, and the Cochrane Library were searched from inception to October 2018. Medical Subject Heading (MeSH) terms and key words related to pregnancy, placenta previa, low-lying placenta, antepartum hemorrhage, short cervical length, preterm labour, and cesarean. This document represents an abstraction of the evidence rather than a methodological review.

VALIDATION METHODS

This guideline has been reviewed by the Maternal-Fetal Medicine and Diagnostic Imaging committees of the Society of Obstetricians and Gynaecologists of Canada (SOGC) and approved by the SOGC Board of Directors.

BENEFITS, HARMS, AND/OR COSTS

Women with placenta previa or low-lying placenta are at increased risk of maternal, fetal and postnatal adverse outcomes that include a potentially incorrect diagnosis and possibly unnecessary hospitalization, restriction of activities, early delivery, or cesarean delivery. Optimization of diagnosis and management protocols has potential to improve maternal, fetal and postnatal outcomes.

SUMMARY STATEMENTS (GRADE RATINGS IN PARENTHESES)

RECOMMENDATIONS (GRADE RATINGS IN PARENTHESES).

Measuring health professionals' beliefs about skin-to-skin care during a cesarean

Women and their newborns are at risk of delayed or withheld skin‐to‐skin care (SSC) during a caesarean, which is about one‐third of births, worldwide. To date, no instrument exists to assess health professionals' (HPs) beliefs, and potential barriers and strategies for implementing SSC during a cesarean. The study aims were to (1) develop an instrument, Health Professionals' Beliefs about Skin‐to‐Skin Care During a Cesarean (SSC_B), (2) establish its validity and reliability and (3) describe HPs' beliefs about SSC during a caesarean. Quantitative and qualitative analyses were used to test the SSC_B and describe HPs' beliefs. SSC_B analysis yielded a content validity of 0.83 and reliability of α = 0.9. We grouped all practice roles as either nurses or physicians. The mean rank score for nurses (n = 120, M = 90) was significantly higher (p = 0.001) than physicians (n = 46, M = 79). Despite this difference, scores for both roles reflected support for SSC. Participants identified hospital readiness to implement SSC and maintaining maternal and newborn safety as major issues. SSC_B is a valid, reliable instrument to measure HPs' beliefs about SSC during a caesarean birth. HPs can use the SSC_B during quality improvement initiatives to improve access to immediate SSC for women who have a caesarean birth. Improved access can enhance breastfeeding outcomes and promote optimal maternal and child health.

The Myometrium in Pregnant Women with Obesity

Obesity is a worldwide public health problem, affecting at least one-third of pregnant women. One of the main problems of obesity during pregnancy is the resulting high rate of cesarean section. The leading cause of this higher frequency of cesarean sections in obese women, compared with that in nonobese women, is an altered myometrial function that leads to lower frequency and potency of contractions. In this article, the disruptions of myometrial myocytes were reviewed in obese women during pregnancy that may explain the dysfunctional labor. The myometrium of obese women exhibited lower expression of connexin43, a lower function of the oxytocin receptor, and higher activity of the potassium channels. Adipokines, such as leptin, visfatin, and apelin, whose concentrations are higher in obese women, decreased myometrial contractility, perhaps by inhibiting the myometrial RhoA/ROCK pathway. The characteristically higher cholesterol levels of obese women alter myometrial myocyte cell membranes, especially the caveolae, inhibiting oxytocin receptor function, and increasing the K+ channel activity. All these changes in the myometrial cells or their environment decrease myometrial contractility, at least partially explaining the higher rate of cesarean of sections in obese women.

Characteristics and outcomes of pregnant women with placenta accreta spectrum in Italy: A prospective population-based cohort study

Introduction

Placenta accreta spectrum (PAS) is a rare but potentially life-threatening event due to massive hemorrhage. Placenta previa and previous cesarean section are major risk factors for PAS. Italy holds one of the highest rates of primary and repeated cesarean section in Europe; nonetheless, there is a paucity of high-quality Italian data on PAS. The aim of this paper was to estimate the prevalence of PAS in Italy and to evaluate its associated factors, ante- and intra-partum management, and perinatal outcomes. Also, since severe morbidity and mortality in Italy show a North-South gradient, we assessed and compared perinatal outcomes of women with PAS according to the geographical area of delivery.

Material and methods

This was a prospective population-based study using the Italian Obstetric Surveillance System (ItOSS) and including all women aged 15–50 years with a diagnosis of PAS between September 2014 and August 2016. Six Italian regions were involved in the study project, covering 49% of the national births. Cases were prospectively reported by a trained clinician for each participating maternity unit by electronic data collection forms. The background population comprised all women who delivered in the participating regions during the study period.

Results

A cohort of 384 women with PAS was identified from a source population of 458 995 maternities for a prevalence of 0.84/1000 (95% CI, 0.75–0.92). Antenatal suspicion was present in 50% of patients, who showed reduced rates of blood transfusion compared to unsuspected patients (65.6% versus 79.7%, P = 0.003). Analyses by geographical area showed higher rates of both concomitant placenta previa and prior CS (62.1% vs 28.7%, P<0.0001) and antenatal suspicion (61.7% vs 28.7%, P<0.0001) in women in Southern compared to Northern Italy. Also, these women had lower rates of hemorrhage ≥2000 mL (29.6% vs 51.2%, P<0.0001), blood transfusion (64.5% vs 87.5%, P = 0.001), and severe maternal morbidity (5.0% vs 11.1%, P = 0.036). Delivery in a referral center for PAS occurred in 71.9% of these patients.

Conclusions

Antenatal suspicion of PAS is associated with improved maternal outcomes, also among high-risk women with both placenta previa and prior CS, likely because of their referral to specialized centers for PAS management.