Factors predicting cesarean delivery for American Indian women in New Mexico

Ever-increasing Caesarean section and its economic burden in Bangladesh

BACKGROUND

Cesarean Section (CS) delivery has been increasing rapidly worldwide and Bangladesh is no exception. In Bangladesh, the CS rate has increased from about 3% in 2000 to about 24% in 2014. This study examines trend in CS in Bangladesh over the last fifteen years and implications of this increasing CS rates on health care expenditures.

METHODS

Birth data from Bangladesh Demographic and Health Survey (BDHS) for the years 2000-2014 have been used for the trend analysis and 2010 Bangladesh Maternal Mortality Survey (BMMS) data were used for estimating health care expenditure associated with CS.

RESULTS

Although the share of institutional deliveries increased four times over the years 2000 to 2014, the CS deliveries increased eightfold. In 2000, only 33% of institutional deliveries were conducted through CS and the rate increased to 63% in 2014. Average medical care expenditure for a CS delivery in Bangladesh was about BDT 22,085 (USD 276) in 2010 while the cost of a normal delivery was BDT 3,565 (USD 45). Health care expenditure due to CS deliveries accounted for about 66.5% of total expenditure on all deliveries in Bangladesh in 2010. About 10.3% of Total Health Expenditure (THE) in 2010 was due to delivery costs, while CS costs contribute to 6.9% of THE and rapid increase in CS deliveries will mean that delivering babies will represent even a higher proportion of THE in the future despite declining crude birth rate.

CONCLUSION

High CS delivery rate and the negative health outcomes associated with the procedure on mothers and child births incur huge economic burden on the families. This is creating inappropriate allocation of scarce resources in the poor economy like Bangladesh. Therefore it is important to control this unnecessary CS practices by the health providers by introducing litigation and special guidelines in the health policy.

Systematic Review of Interventions for Racial/Ethnic-Minority Pregnant Smokers

INTRODUCTION

Large disparities exist in smoking rates during pregnancy by racial/ethnic status.

AIMS

The current review examined controlled studies that predominantly included racial/ethnic-minority pregnant smokers for providing smoking cessation treatment.

METHODS

Two authors independently conducted the literature searches in the standard databases using a combination of the keywords with minority, pregnancy, smoking, and cessation identifiers.

RESULTS

The searches identified nine articles that met the inclusion criteria. Only two studies exclusively targeted specific minority groups. Most of them provided some form of brief smoking cessation counseling, with two combining with incentives and one combining with pharmacotherapy. Two studies provided intensive cognitive interventions. Pregnant smokers of American Indian or Alaska Native, Hispanic subgroups, and Asian or Pacific Islander are under-studied.

CONCLUSIONS

Future studies to treat minority pregnant smokers could target under-studied minority groups and may need to directly and intensely target smoking behavior, address cultural and psychosocial issues in an individualized and comprehensive manner, and analyze cost-benefit of an intervention.

Diabetes in pregnancy among indigenous women in Australia, Canada, New Zealand and the United States

Recently proposed international guidelines for screening for gestational diabetes mellitus (GDM) recommend additional screening in early pregnancy for sub-populations at a high risk of type 2 diabetes mellitus (T2DM), such as indigenous women. However, there are criteria that should be met to ensure the benefits outweigh the risks of population-based screening. This review examines the published evidence for early screening for indigenous women as related to these criteria. Any publications were included that referred to diabetes in pregnancy among indigenous women in Australia, Canada, New Zealand and the United States (n = 145). The risk of bias was appraised. There is sufficient evidence describing the epidemiology of diabetes in pregnancy, demonstrating that it imposes a significant disease burden on indigenous women and their infants at birth and across the lifecourse (n = 120 studies). Women with pre-existing T2DM have a higher risk than women who develop GDM during pregnancy. However, there was insufficient evidence to address the remaining five criteria, including the following: understanding current screening practice and rates (n = 7); acceptability of GDM screening (n = 0); efficacy and cost of screening for GDM (n = 3); availability of effective treatment after diagnosis (n = 6); and effective systems for follow-up after pregnancy (n = 5). Given the impact of diabetes in pregnancy, particularly undiagnosed T2DM, GDM screening in early pregnancy offers potential benefits for indigenous women. However, researchers, policy makers and clinicians must work together with communities to develop effective strategies for implementation and minimizing the potential risks. Evidence of effective strategies for primary prevention, GDM treatment and follow-up after pregnancy are urgently needed.

Community factors affecting rising caesarean section rates in developing countries: an analysis of six countries

Caesarean section rates have risen dramatically in several developing countries, especially in Latin America and South Asia. This raises a range of concerns about the use of caesarean section for non-emergency cases, not least the progressive shift of resources to non-essential medical interventions in resource-poor settings and additional health risks to mothers and newborns following a caesarean section. There are only a few studies that have systematically examined the factors influencing the recent increase in caesarean rates. In particular, it is not clear whether high elective caesarean rates are driven by medical, institutional or individual and family decisions. Where a woman's decisions predominate her interaction with peers and significant others have an impact on her caesarean section choices. Using random intercept logistic regression analyses, this paper analyses the institutional, socio-economic and community factors that influence caesarean section in six countries: Bangladesh, Colombia, Dominican Republic, Egypt, Morocco and Vietnam. The analyses, based on data from over 20,000 births, show that women of higher socio-economic background, who had better access to antenatal services are the most likely to undergo a caesarean section. Women who exchange reproductive health information with friends and family are less likely to experience a caesarean section than their counterparts. The study concludes that there is a need to pursue community-based approaches for curbing rising caesarean section rates in resource-poor settings.

Cesarean delivery among nulliparous women in Beirut: assessing predictors in nine hospitals

BACKGROUND

Obstetric practice has witnessed a worldwide trend of increasing cesarean section rates in recent years. Similar trends have been observed in Lebanon, according to 2 studies conducted in 1996 and 1999. The objective of the present study was to assess the differences in predictors of cesarean delivery among nulliparous women in a "control hospital" with a low cesarean delivery rate (12.5%) and the rest of the National Collaborative Perinatal Neonatal Network (NCPNN) "study hospitals" with a higher cesarean delivery rate (31.4%).

METHODS

Data were collected by the NCPNN database, which covers deliveries at 9 major hospitals located in the Greater Beirut area. Data analysis was performed on the 6,668 consecutive deliveries occurring between January 1, 2001, and December 31, 2002, at the NCPNN participating centers. The questionnaires included items that cover parental sociodemographic characteristics and maternal and newborn health characteristics. Sources of data included direct interviews with mothers after delivery and before hospital discharge and reviews of obstetric and nursery medical charts. Chi-square tests and t tests were performed for categorical and continuous clinical predictors of cesarean section. Logistic regression was performed to determine the odds of having a cesarean section for the study hospitals when compared with the control hospital. Odds ratios and 95% confidence intervals are reported.

RESULTS

Variables in the study hospitals that correlated with a higher cesarean delivery rate were male obstetricians, day of the week, and mode of payment compared with the control hospital.

CONCLUSIONS

In a country with a high cesarean section rate, 1 hospital met World Health Organization criteria for acceptable cesarean section rates, with no compromise in neonatal outcome. Further studies are needed to investigate potential policies to decrease the high cesarean section rate.

Cesarean delivery in Native American women: are low rates explained by practices common to the Indian health service?

BACKGROUND

Studying populations with low cesarean delivery rates can identify strategies for reducing unnecessary cesareans in other patient populations. Native American women have among the lowest cesarean delivery rates of all United States populations, yet few studies have focused on Native Americans. The study purpose was to determine the rate and risk factors for cesarean delivery in a Native American population.

METHODS

We used a case-control design nested within a cohort of Native American live births, > or = 35 weeks of gestation (n = 789), occurring at an Indian Health Service hospital during 1996-1999. Data were abstracted from the labor and delivery logbook, the hospital's primary source of birth certificate data. Univariate and multivariate analyses examined demographic, prenatal, obstetric, intrapartum, and fetal factors associated with cesarean versus vaginal delivery.

RESULTS

The total cesarean rate was 9.6 percent (95% CI 7.2-12.0). Nulliparity, a medical diagnosis, malpresentation, induction, labor length > 12.1 hours, arrested labor, fetal distress, meconium, and gestations < 37 weeks were each significantly associated with cesarean delivery in unadjusted analyses. The final multivariate model included a significant interaction between induction and arrested labor (p < 0.001); the effect of arrested labor was far greater among induced (OR 161.9) than noninduced (OR 6.0) labors. Other factors significantly associated with cesarean delivery in the final logistic model were an obstetrician labor attendant (OR 2.4; p = 0.02) and presence of meconium (OR 2.3; p = 0.03).

CONCLUSIONS

Despite a higher prevalence of medical risk factors for cesarean delivery, the rate at this hospital was well below New Mexico (16.4%, all races) and national (21.2%, all races) cesarean rates for 1998. Medical and practice-related factors were the only observed independent correlates of cesarean delivery. Implementation of institutional and practitioner policies common to the Indian Health Service may reduce cesarean deliveries in other populations.

The reporting of pre-existing maternal medical conditions and complications of pregnancy on birth certificates and in hospital discharge data

OBJECTIVE

The purpose of this study was to determine the accuracy of live-birth certificates and hospital discharge data that reported of pre-existing maternal medical conditions and complications of pregnancy.

STUDY DESIGN

We conducted a population-based validation study in 19 non-federal short-stay hospitals in Washington state with a stratified random sample of 4541 women who had live births between January 1, 2000, and December 31, 2000. True- and false-positive fractions were calculated.

RESULTS

Birth certificate and hospital discharge data combined had substantially higher true-positive fractions than did birth certificate data alone for cardiac disease (54% vs 29%), acute or chronic lung disease (24% vs 10%), gestational diabetes mellitus (93% vs 64%), established diabetes mellitus (97% vs 52%), active genital herpes (77% vs 38%), chronic hypertension (70% vs 47%), pregnancy-induced hypertension (74% vs 49%), renal disease (13% vs 2%), and placenta previa (70% vs 33%). For the 2 medical risk factors that are available only on birth certificates, true-positive fractions were 37% for established genital herpes and 68% for being seropositive for hepatitis B surface antigen.

CONCLUSION

In Washington, most medical conditions and complications of pregnancy that affect mothers are substantially underreported on birth certificates, but hospital discharge data are accurate in the reporting of gestational and established diabetes mellitus and placenta previa. Together, birth certificate and hospital discharge data are much superior to birth certificates alone in the reporting of gestational diabetes mellitus, active genital herpes, and chronic hypertension.

Patients' attitudes vs. physicians' determination: implications for cesarean sections

Most research studies identifying non-clinical factors that influence the choice of Cesarean Section as a method of obstetric delivery assume that the physician makes the decision. This paper arguably shows the role played by the mother. Owing to the fact that Chinese people generally believe that choosing the right days for certain life events, such as marriage, can change a person's fate into a better one, the hypothesis is tested that the probability of Cesarean Sections being performed is significantly higher on auspicious days and significantly lower on inauspicious days. By employing a logistic model and utilizing 1998 birth certificate data for Taiwan, we are able to show that the hypothesis is accepted.

A Native American community with a 7% cesarean delivery rate: does case mix, ethnicity, or labor management explain the low rate?

PURPOSE

Cesarean delivery rates vary widely across populations. Studying communities with low rates of cesarean delivery may identify practices that can lower the cesarean rate.

METHODS

A population-based historical cohort study included all pregnant women (N = 1132) from 1992 through 1996 in a predominantly Native American region of northwestern New Mexico known to have a high prevalence of gestational diabetes and preeclampsia. The outcomes studied included delivery type (eg, cesarean, operative vaginal, spontaneous vaginal), indication for cesarean delivery, presence of obstetrical risk factors, and use of labor induction or augmentation.

RESULTS

The cesarean delivery rate of the study group (7.3%) was only 35% of the 1996 US rate of 20.7%. Among study participants, the relative risk of a primary cesarean delivery for dystocia was 0.22 (95% CI, 0.14, 0.35). Trial of labor after cesarean delivery was attempted by 93% of study participants compared with 42% of women nationwide in 1994. The cesarean delivery rates for women with diabetes in pregnancy (11.5% versus 35.4%) and preeclampsia (14.8% versus 37.4%) were significantly lower than nationwide rates. Case-mix analysis comparison with a standardized population and comparison of standard (ie, term, singleton, vertex) primiparous women demonstrate that the low rate of cesarean delivery was not because of a lower prevalence of risk factors.

CONCLUSIONS

The community's low rate of cesarean delivery is primarily the result of a decreased use of cesarean delivery for labor dystocia and an almost universal acceptance of trial of labor after cesarean delivery. Cultural attitudes toward childbirth, design of the perinatal system, and genetic factors also may explain the low rate of cesarean delivery.

Influence of aboriginal and socioeconomic status on birth outcome and maternal morbidity

OBJECTIVE

To assess the association of Aboriginal and socioeconomic status with birth outcome and maternal morbidity in Alberta.

METHODS

A retrospective cohort study using Alberta health service and vital statistics data from 1997 to 2000. Aboriginal women registered with the Department of Indian and Northern Development (DIAND) were linked to a personal health number. Low socioeconomic status was defined as either receiving subsidization for the Alberta Health Care Insurance premium or receiving welfare.

RESULTS

Women registered with DIAND and women receiving subsidy or welfare were younger, more often unmarried, smoked more, consumed more alcohol, and abused more illicit drugs than other women in Alberta during the time period studied. Fewer women registered with DIAND and women receiving subsidy or welfare had physician prenatal visits, attended prenatal classes, had forceps or vacuum deliveries, and more of these women frequently had gestation ages less than 37 weeks. Women registered with DIAND had more deliveries in smaller, non-metropolitan facilities; and more of these women delivered outside their region of residence; more had longer lengths of hospital stay; more mothers and neonates were re-admitted to hospital within 28 days of discharge after delivery; fewer delivered small for gestational age neonates; fewer delivered neonates with birth weight less than 2500 g, but more delivered neonates with birth weight greater than 4000 g. There were fewer Caesarean sections in women registered with DIAND (OR = 0.84, 95% CI 0.76-0.93) and in women receiving subsidy or welfare (OR = 0.88, 95% CI 0.82-0.93).

CONCLUSION

Women receiving subsidy or welfare and women registered with DIAND had many demographic similarities and generally had worse maternal and neonatal outcomes than other women in Alberta. Medical system interaction may be different for these two groups of women than it is for other women in Alberta.

[Characteristics of pregnant women and routine antenatal care in Barcelona, 1994-1999]

OBJECTIVE

To analyse socio-demographic and pregnancy-control aspects of pregnant women residents in Barcelona city and their evolution during the period 1994-1999 using the controls of the Barcelona Birth Defects Registry.

METHODS

The information was collected by mean of an interview to the mother and from hospital records. The Mantel-Haenszel method for lineal association was used to analyse trends. A chi-squared test for proportions was used to compare pregnancy-control variables between public and private centers.

RESULTS

Data on 1,337 pregnant women were obtained. An increasing proportion of women older than 34 years is observed, from 19% in 1994-95 to 25% in 1998-99. An increase in the social class and a decrease of housewives is noticed. 40% of pregnancies were not planned and half of these finished in induced abortion. These proportions are higher in less than 25 and more than 39 years old mothers. 97% had their first obstetrical visit during the first trimester, almost all had at least an obstetrical ultrasound with a mean of 5.2, although 25% of the mothers did not undergo an ecography during the 5th month. An increase of invasive procedures and caesarean sections (C-section) is shown, with 33% of C-sections in the 98-99 period. The medical control of pregnancies is higher in mothers delivering in private centers, which are 55% of the total.

CONCLUSIONS

There is a high lack of pregnancy planning, as well as an increasing pregnancy medicalization, with positive (first trimester visit) and debatable aspects (obstetrical ultrasound, caesarean section and invasive procedures).