Cesarean section on demand

The cost of preterm birth and cesarean section as a result of infertility and its treatment: A review

Infertility, irrespective of receipt of fertility treatment, is associated with an increased risk of adverse pregnancy outcomes, including cesarean section (CS) and preterm birth (PTB). These complications are associated with significant physical, mental, emotional, social, and financial costs to individuals, healthcare systems, and society at large. Although multiple pregnancy is one of the most significant contributors to the elevated CS and PTB rates in women receiving fertility treatment, singleton pregnancy is also at an increased risk of these outcomes. Single embryo transfer policies through publicly funded in vitro fertilization programs have demonstrated beneficial health outcomes and cost savings. Low-dose aspirin prophylaxis may be considered for PTB reduction in patients with infertility. Finally, upstream prevention strategies such as lifestyle modification and social policies to address the underlying needs for fertility treatment may also beneficially impact both CS and PTB rates.

Factors associated with shorter night-time sleep in toddlers: The Survey of Young Canadians

OBJECTIVES

Adequate sleep in childhood is important for healthy development. No information exists on the predictors of night-time sleep among toddlers in Canada. The aim of this study was to determine the prevalence of and to identify factors associated with sleeping <11 consecutive hours per night among children aged 1-2 years in Canada.

METHODS

Data from the cross sectional Survey of Young Canadians (SYC) 2010 were used. The biological mother reported on toddlers' sleep duration at night. Based on cut-off values used in previous studies, shorter night-time sleep was defined as sleeping <11 hours per night. Multivariable logistic regression was conducted to identify the associations between socio-demographic, maternal, sleep and child-related variables with shorter sleep at night.

RESULTS

Analysis of 3675 toddlers revealed that 57% slept <11 hours per night. Results of the regression analysis showed that being from an immigrantfamily was significantly associated with shorter night-time sleep. Being from a higher income household, having a mother aged between 25 and 34 years at the time of the survey, and napping ≥2 hours during the day were significantly related to sleeping ≥11 hours per night. Other socio-demographic, maternal and child-related variables were not associated with night-time sleep.

CONCLUSION

This was the first population-based, nationally representative study to examine factors related to shorter night-time sleep in Canadian toddlers. Socio-demographic factors and nap duration were associated with night-time sleep duration. More adequate early childhood sleep hygiene awareness efforts are recommended, especially in vulnerable populations.

Determinants of patient satisfaction after cesarean delivery at a university teaching hospital in Nigeria

OBJECTIVES

To assess the prevalence of satisfaction, and associated factors, among parturients who had recently delivered by cesarean.

METHODS

In a descriptive cross-sectional study, women who delivered by cesarean at the University of Benin Teaching Hospital, Nigeria, were enrolled between April and July 2010. A simple, qualitative, semi-structured researcher-administered questionnaire was used for data collection. Data analysis was done via SPSS version 16.

RESULTS

Among 220 women who delivered by cesarean, 211 women were enrolled in the study and were interviewed 2-5 days after delivery. The mean age was 30.8 ± 5.1 years, and the median parity was 1. An initial negative reaction to the decision for cesarean delivery was reported by 76% of respondents, 19% were indifferent, and 5% reported an initial positive reaction. Satisfaction with delivery by cesarean was reported by 80% of the respondents. Satisfaction with cesarean delivery was significantly associated with age, level of education, initial reaction to the decision for cesarean delivery, and elective cesarean.

CONCLUSION

Most parturients expressed overall satisfaction after delivery by cesarean. There is a need for in-depth studies in low-income countries to further evaluate satisfaction with regard to various aspects of the cesarean delivery experience.

Birth preferences that deviate from the norm in Sweden: planned home birth versus planned cesarean section

BACKGROUND

Opting for a home birth or requesting a cesarean section in a culture where vaginal birth in a hospital is the norm challenges the health care system. The aim of this study was to compare background characteristics of women who chose these very different birth methods and to see how these choices affected factors of care and the birth experience.

METHODS

This descriptive study employed a secondary data analysis of a sample of women who gave birth from 1997 to 2008, including 671 women who had a planned home birth and 126 women who had a planned cesarean section based on maternal request. Data were collected by means of questionnaires. Logistic regression with crude and adjusted odds ratios (OR) with a 95 percent confidence interval (95% CI) was calculated.

RESULTS

Women with a planned home birth had a higher level of education (OR: 2.3; 95% CI: 1.5-3.6), were less likely to have a high body mass index (OR: 0.1; 95% CI: 0.01-0.6), and were less likely to be smokers (OR: 0.2; 95% CI: 0.1-0.4) when compared with women who had planned cesarean sections. When adjusted for background variables, women with a planned home birth felt less threat to the baby's life during birth (OR: 0.1; 95% CI: 0.03-0.4), and were more satisfied with their participation in decision making (OR: 6.0; 95% CI: 3.3-10.7) and the support from their midwife (OR 3.9; 95% CI: 2.2-7.0). They also felt more in control (OR: 3.3; 95% CI: 1.6-6.6), had a more positive birth experience (OR: 2.9; 95% CI: 1.7-5.0), and were more satisfied with intrapartum care (OR: 2.3; 95% CI: 1.3-4.1) compared with women who had a planned cesarean section on maternal request.

CONCLUSIONS

Women who planned a home birth and women who had a cesarean section based on maternal request are significantly different groups of mothers in terms of sociodemographic background. In a birth context that promotes neither home birth nor cesarean section without medical reasons, we found that those women who had a planned home birth felt more involvement in decision making and had a more positive birth experience than those who had a requested, planned cesarean section.

Decision making in patient-initiated elective cesarean delivery: the influence of birth stories

Patient-initiated elective cesarean delivery is emerging as an urgent issue for practitioners, hospitals, and policy makers and for pregnant women. This exploratory qualitative study looks at the birth stories and cultural knowledge that women use to inform the decision about an elective cesarean without medical indication. Data collection consisted of exploratory qualitative in-depth interviews with 17 primiparous women in British Columbia, Canada. Interviews revealed the influence of socially circulated birth stories and cultural narratives on their attitudes towards mode of delivery. Participants included in their decision making process both medical information and informal birth stories that were technologically inclined and confirmed their preference for cesarean delivery. Results indicate that women who participated in this study drew heavily from social and cultural knowledge in forming their decision to give birth by patient-initiated elective cesarean delivery. Although the numbers of women who request a cesarean delivery for social reasons is still small, the persuasive influence on parturient women of positive cesarean stories and negative vaginal stories must be considered. Care providers and childbirth educators need to become familiar with the social influences impacting women's decisions for mode of delivery so that truly informed choice discussions can be undertaken.

Developing and pre-testing a decision board to facilitate informed choice about delivery approach in uncomplicated pregnancy

BACKGROUND

The rate of caesarean sections is increasing worldwide, yet medical literature informing women with uncomplicated pregnancies about relative risks and benefits of elective caesarean section (CS) compared with vaginal delivery (VD) remains scarce. A decision board may address this gap, providing systematic evidence-based information so that patients can more fully understand their treatment options. The objective of our study was to design and pre-test a decision board to guide clinical discussions and enhance informed decision-making related to delivery approach (CS or VD) in uncomplicated pregnancy.

METHODS

Development of the decision board involved two preliminary studies to determine women's preferred mode of risk presentation and a systematic literature review for the most comprehensive presentation of medical risks at the time (VD and CS). Forty women were recruited to pre-test the tool. Eligible subjects were of childbearing age (18-40 years) but were not pregnant in order to avoid raising the expectation among pregnant women that CS was a universally available birth option. Women selected their preferred delivery approach and completed the Decisional Conflict Scale to measure decisional uncertainty before and after reviewing the decision board. They also answered open-ended questions reflecting what they had learned, whether or not the information had helped them to choose between birth methods, and additional information that should be included. Descriptive statistics were used to analyse sample characteristics and women's choice of delivery approach pre/post decision board. Change in decisional conflict was measured using Wilcoxon's sign rank test for each of the three subscales.

RESULTS

The majority of women reported that they had learned something new (n = 37, 92%) and that the tool had helped them make a hypothetical choice between delivery approaches (n = 34, 85%). Women wanted more information about neonatal risks and personal experiences. Decisional uncertainty decreased (p < 0.001) and perceived effectiveness of decisions increased (p < 0.001) post-intervention.

CONCLUSION

Non-pregnant women of childbearing age were positive about the decision board and stated their hypothetical delivery choices were informed by risk presentation, but wanted additional information about benefits and experiences. This study represents a preliminary but integral step towards ensuring women considering delivery approaches in uncomplicated pregnancies are fully informed.

Elective caesarean section as a transformative technological process: players, power and context

AIM

In this paper we present a critical analysis of the debate surrounding elective caesarean section using the Social Construction of Technology perspective as a framework of analysis.

BACKGROUND

The rate of caesarean section births is increasing worldwide in industrialized countries. Reasons given for the increase include women's characteristics, care providers' attitudes, prevention of pelvic floor disorders and adverse outcomes.

DATA SOURCES

CINAHL, PubMed, Ovid, Academic Search Premier and Cochrane Data bases were searched for the years 2000 to 2007 using search terms elective caesarean section, caesarean section on demand and maternal choice caesarean section.

DISCUSSION

The social constructivist approach explains how caesarean section as a mode of delivery has been transformed from an emergency to an elective procedure. Analysing elective caesarean section as a socially constructed technological process exposes positions taken by obstetricians, midwives, perinatal nurses and women, including the power dynamics and contextual influences.

CONCLUSION

The Social Construction of Technology perspective creates space for perinatal nurses to examine the implications of the use and meaning of elective caesarean section in a broader social context. Examining elective caesarean section from the Social Construction of Technology perspective exposes an emphasis on safety and risk for the foetus, while avoiding the equally important goal of promoting optimal postnatal health for mothers and infants. The Social Construction of Technology perspective highlights how those who define the problem control the solution.

Challenges in small animal parturition--timing elective and emergency cesarian sections

Given the societal emphasis placed on the deliberate breeding of purebred animals, the practitioner today is faced with issues relative to successful parturition in these animals. Today, the serious hobby breeder expects to use planned breeding management to result in a high conception and pregnancy rate and survival rates of offspring that may exceed published parameters. These clients may elect to schedule cesarean section to maximize puppy survival and assure that they have access to quality veterinary care. Using a combination of hormone assays, temperature changes in the dam and carefully timed and documented breeding management, a cesarean section can be planned. Emergency cesarean sections will still be required for the bitch that experiences dystocia or a medical condition that warrants intervention. Timed cesarean section results in a favorable medical outcome for the dam and litter and a better financial outcome for the owner.

Cesarean births in Taiwan

OBJECTIVE

To evaluate the use of cesarean delivery in Taiwan by comparing local clinical indications with those in international cohorts.

METHODS

In-patient claims from the National Health Insurance (NHI) in Taiwan were analyzed. Indications for cesarean delivery were evaluated with primary diagnosis codes and procedure codes from the NHI dataset. To produce a stable numerator for cesarean section, 3 years (1998-2000) of claims for cesarean delivery were abstracted and annualized.

RESULTS

Rates ranged between 27.3% and 28.7% for primary cesarean delivery and were below 5% for vaginal birth after a cesarean section (VBAC). Compared with rates in other countries, rates for overall and primary cesarean section as well as for VBAC were significantly higher in medical centers in Taiwan (P<0.001). However, the clinics contributed the most to the difference in both overall and primary cesarean rates. The most common indication for cesarean section was prior cesarean section (43.3%-45.5%), followed by malpresentation (19.6%-23.4%). The proportion of fetuses with malpresentation delivered by cesarean section in Taiwan was 7.9%, almost twice the upper limit expected for all pregnancies as indicated in international studies.

CONCLUSION

It is important to use appropriately documented data and to compare them with international data when monitoring local obstetric practices. The disproportionately high cesarean delivery rates in Taiwan may hold major lessons for the many countries contemplating or having universal health insurance coverage with a similar mix of providers.

[Secular evolution and evolution according to autonomous communities of the frequency of fertility treatments, multiple deliveries and cesarean sections in Spain]

BACKGROUND AND OBJECTIVE

Fertility treatments, multiple deliveries and caesarean sections are related to maternal age. Because maternal age has increased in Spain, it can also be expected an increase in these variables. We analyzed their evolution over the time and by maternal age, either globally and by Spanish Autonomous Communities.

SUBJECTS AND METHOD

We studied a sample of 30,956 mothers of non-malformed newborn infants from all over Spain.

STUDY PERIOD

between 1977 and June 2002.

RESULTS

The percentage of fertility treatments shows a statistically significant increasing trend in all of the maternal ages groups. However, this was higher in mothers older than 34 years, among whom the frequency of multiple deliveries also increased (p = 0.01). The same trends were observed by Spanish Autonomous Communities, yet with differences between them. In the Comunidad Valenciana, we identified the highest frequency of fertility treatments, while the highest mean maternal age was observed in Aragón. Galicia has one of the lowest proportions of multiple deliveries, while the percentage of fertility treatments is similar to other regions. The percentage of caesarean sections (over 25%, globally) shows a statistically significant increasing trend in all the maternal ages groups, the highest one being among mothers older than 39 years.

CONCLUSIONS

The observed increasing maternal age implies a higher use of fertility treatments, multiple deliveries and caesarean sections. All these variables show statistically significant variations between Spanish Autonomous Communities and over the time.

Active management of risk in pregnancy at term in an urban population: an association between a higher induction of labor rate and a lower cesarean delivery rate

OBJECTIVE

The purpose of this study was to determine whether exposure to an alternative method of care, called the active management of risk in pregnancy at term, was associated with a lower group cesarean delivery rate.

STUDY DESIGN

Active management of risk in pregnancy at term used risk factors for cesarean delivery to guide an increased use of labor induction. A retrospective cohort design was used to compare clinical outcomes of 100 pregnant women who were exposed to active management of risk in pregnancy at term to 300 randomly selected subjects who received standard management.

RESULTS

The 2 groups had comparable levels of prenatal risk. The group exposed to the active management of risk in pregnancy at term exposure group encountered a higher induction rate (63% vs 25.7%; P < .001) and a lower cesarean delivery rate (4% vs 16.7%; P = .01). Findings were similar for both nulliparous and multiparous subgroups. Active management of risk in pregnancy at term exposure was not associated with higher rates of other major birth outcomes.

CONCLUSION

Exposure to the active management of risk in pregnancy at term exposure was associated with a significantly lower group cesarean delivery rate. A prospective randomized trial that involved active management of risk in pregnancy at term exposure is needed to further explore this association.

Patient choice cesarean: an evidence-based review

Primary elective cesarean performed on a patient's request now comprises 4% to 18% of all cesareans and 14% to 22% of elective cesareans in reported series. Patients most commonly choose cesarean because of tocophobia, or fear of childbirth. Almost two thirds of obstetricians surveyed are willing to perform cesarean on request, citing decreased risk of pelvic floor or fetal injury, maintenance of sexual functioning, and physician and patient convenience. Contrasting these beliefs are the limited available data on short- and long-term maternal and perinatal morbidity and mortality that generally favor vaginal delivery. Moreover, comprehensive economic impact assessments of cesarean on request are lacking, and professional organizations do not agree on the ethics of offering patient choice cesarean.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader should be able to list the reasons that women and obstetricians choose elective cesarean delivery, to outline the ethical aspects of cesarean delivery, and to describe the material and fetal morbidity and mortality associated with cesarean delivery compared to vaginal delivery.

Primary nonmedically indicated cesarean section ("section on request"): evidence based or modern vogue?

Cesarean section, initially described as an emergency operative procedure for delivering moribund parturients, is now advocated by many as a routine technique with major advantages over vagi-nal delivery. In fact, it has been suggested that labor and vaginal delivery are no longer the desired consequence of pregnancy, a conclusion that reflects perceived medical advantages and patient and physician convenience. This article systematically reviews the various medical implications to the mother and infant of this procedure in the hope of facilitating a more rational approach to this spreading and controversial phenomenon.

Institutional Factors in Cesarean Delivery Rates: Policy and Research Implications

OBJECTIVE

To examine the association of health care institutional characteristics with cesarean delivery.

METHODS

Cross-sectional data from Taiwan's National Health Insurance database was used, covering all 270774 women admitted for singleton deliveries, in 2000. Bivariate and multiple logistic regression analyses were used.

RESULTS

The overall cesarean rate was 32.3% of all deliveries. Obstetrics and gynecology clinics (with fewer than 10 beds) had a very high likelihood of cesarean delivery compared with all categories of hospitals (odds ratios 17-25), after adjusting for clinical complications and patient, physician, and institutional characteristics. The likelihood of cesarean delivery was similar across hospitals, regardless of level and ownership category. High cesarean propensity at clinics arose from higher cesarean rates in all complication categories, including "No complications." The overall hospital cesarean rate, 31.2%, is also higher than that in other developed countries with universal health care coverage.

CONCLUSION

Taiwan has very high cesarean rates, with a particularly high propensity for this procedure at clinics. The cesarean delivery profile in the various clinical complication categories suggests a significantly lower clinical threshold triggering cesarean delivery decisions in Taiwan, especially at obstetrics and gynecology clinics. Countries currently having or contemplating large expansions in health insurance coverage should document obstetric practice profiles before initiating coverage expansions. There is also a need for well designed research on the medical and life-satisfaction impacts of cesarean compared with vaginal delivery to enable an informed policy stand on this issue.