Patient choice cesarean: an evidence-based review

Epidemiology of emergency and elective caesarean section and its association with early neonatal mortality in sub-Saharan African countries

INTRODUCTION

Investigating elective and emergency caesarean section (CS) separately is important for a better understanding of birth delivery modes in the sub-Saharan Africa (SSA) region and identifying bottlenecks that prevent favourable childbirth outcomes in SSA. This study aimed at evaluating the prevalences of both CS types, determining their associated socioeconomic factors and their association with early neonatal mortality in SSA.

METHODS

SSA countries Demographic and Health Surveys data that had collected information on the CS' timing were included in our study. A total of 21 countries were included in this study, with a total of 155 172 institutional live births. Prevalences of both CS types were estimated at the countries' level using household sampling weights. Multilevel models were fitted to identify associated socioeconomic factors of both CS types and their associations with early neonatal mortality.

RESULTS

The emergency CS prevalence in SSA countries was estimated at 4.6% (95% CI 4.4-4.7) and was higher than the elective CS prevalence estimated at 3.4% (95% CI 3.3-3.6). Private health facilities' elective CS prevalence was estimated at 10.2% (95% CI 9.3-11.2) which was higher than the emergency CS prevalence estimated at 7.7% (95% CI 7.0-8.5). Conversely, in public health facilities, the emergency CS prevalence was estimated at 4.0% (95% CI 3.8-4.2) was higher than the elective CS prevalence estimated at 2.7% (95% CI 2.6-2.8). The richest women were more likely to have birth delivery by both CS types than normal vaginal delivery. Emergency CS was positively associated with early neonatal mortality (adjusted OR=2.37, 95% CI 1.64-3.41), while no association was found with elective CS.

CONCLUSIONS

Findings suggest shortcomings in pregnancy monitoring, delivery preparation and postnatal care. Beyond antenatal care (ANC) coverage, more attention should be put on quality of ANC, postnatal care, emergency obstetric and newborn care for favourable birth delivery outcomes in SSA.

The role of personality traits on mode of delivery

PURPOSE

The aim of this study is to understand the motives behind CS requests in nulliparous women in their late pregnancy better and to investigate if specific personality traits affect the maternal decision on mode of delivery.

MATERIAL AND METHOD

This prospective study was conducted with 70 healthy, nulliparous parturient with singleton pregnancies. Women at their 28-32. weeks of gestation were asked to fill a socio-demographic data form and the questionnaires; Personality Belief Questionnaire - Short Form (PBQ-SF) and The Childbirth Attitudes Questionnaire (CAQ). After delivery, all the results of pre-filled questionnaires and women's mode of delivery were analyzed and compared.

RESULTS

There were significant differences in personality types; dependent (p = 0.033), passive-aggressive (p = 0.031), obsessive-compulsive (p = 0.001), antisocial (p = 0.014), narcissistic (p = 0.014) and borderline (p = 0.014) between vaginal delivery and CS groups. The CAQ scores of the mothers who requested CS were significantly higher (p:0.007). Weak but significant positive relation was found between total CAQ scores and avoidant (p = 0.022), dependent (p = 0.034), passive-aggressive (p = 0.040), narcissistic (p = 0,006), schizoid (p = 0.007), paranoid (p = 0.007) and borderline (p = 0.007) personality types.

CONCLUSION

This is the first study that investigates the relationship between mode of delivery and personality traits according to the Diagnostic and Statistical Manual of Mental Disorders (DSM) and cognitive behavioral perspective in the literature. These personality traits can be carried at a level that is not clinically significant to create an obvious pathology, yet they might play a role as the motives behind the apparent reasons for women who request CS. Understanding women's motives and attitudes for childbirth during their pregnancy may help healthcare providers to tailor women's approach to childbirth to avoid unnecessary CS.

Is it Necessary to Evaluate Fear of Childbirth in Pregnant Women? A Scoping Review

OBJECTIVE

 To review concepts, definitions, and findings about fear of childbirth (FOC).

METHODS

 A bibliographic review was carried out through the main scientific databases in 2020.

RESULTS

 All 32 articles considered potentially relevant were analyzed. A recent study suggests that the global prevalence of FOC can reach up to 14%. Factors such as parity, gestational age, previous birth experience, age and nationality of the woman seem to influence FOC.

CONCLUSION

 Fear of childbirth could be related to an increased risk of adverse obstetric outcomes such as maternal request for cesarean delivery, preterm birth, prolonged labor, postpartum depression, and post-traumatic stress. These evidence highlight the importance of the discussion regarding this topic.

Cesarean Section Rate and Perinatal Outcome Analyses According to Robson's 10-Group Classification System

OBJECTIVES

The cesarean delivery (CD) rate is increasing worldwide. An internationally recognized classification system had been required to analyse the trend and its possible consequences in a standardized manner. The goal of this study was to identify the main contributors to the CD rate at the Medical University of Vienna in an 11-year time period (2003-2013) and to analyse neonatal outcome parameters within the ten Robson categories.

METHODS

This is a retrospective data-analysis of singleton and twin pregnancies in cephalic, breech and transverse presentation with a gestational age between 23 and 42 weeks. The cases were divided into ten classes based on the Robson criteria. CD rates and perinatal outcome parameters were analysed within each Robson class. The outcome parameters included: NICU-admission rate and 5 min Apgar score values < 7.

RESULTS

The overall CD rate was at 44.2%. Within Robson class 5 the CD rate was the highest at 99.1%. Main contributors were Robson class 5 at 20.6%, followed by class 2 at 17.1% and class 8 at 15.0%. Neonatal outcome analyses revealed significant differences between the Robson classes.

CONCLUSIONS

The main contributors to the CD rate were determined. We suggest reconsidering the frequently applied birth mode especially for Robson class 2, 4, 5 and 8. Lowering the CD rate could be achievable, if a careful delivery management and an individual risk evaluation is provided. It is important to reduce the CD rate in the individual Robson classes under consideration of perinatal outcome parameters, since a reduction should only take place where it is clinically useful and relevant.

Tokophobia and fear of birth: a workshop consensus statement on current issues and recommendations for future research

Objective: To discuss and develop a statement on the current state of the evidence and opinion in Fear of Childbirth (FoC) and Tokophobia (Tocophobia), and to provide recommendations. Background: A group met in 2019 to discuss the state of clinical and academic knowledge relating to FoC/Tokophobia. Five key areas were agreed as the focus of the meeting. Methods: 12 internationally acknowledged experts, in this or a closely related area (e.g. PTSD) met to discuss their understanding of the evidence for FoC/ Tokophobia and current practice. The consensus described in this paper constitutes the expression of the general opinion of the participants and does not necessarily imply unanimity. Keys points: Work focussed on tokophobia is recent and there remains a wide range of issues, which were addressed in the workshop including complexity in defining prevalence, a theoretical lack of understanding, which creates challenge for robust assessment and the identification of risk factors. An improved aetiological and developmental understanding of the tokophobia is required to underpin appropriate, effective and evidence-based interventions. Evaluation of pathways of care and relevant interventions, should be a focus of future research. Conclusion: Significant gaps remain within the FoC/tokophobia knowledge base. Further research is necessary.

Maternal request caesareans and COVID-19: the virus does not diminish the importance of choice in childbirth

It has recently been reported that some hospitals in the UK have placed a blanket restriction on the provision of maternal request caesarean sections (MRCS) as a result of the COVID-19 pandemic. Pregnancy and birthing services are obviously facing challenges during the current emergency, but we argue that a blanket ban on MRCS is both inappropriate and disproportionate. In this paper, we highlight the importance of MRCS for pregnant people's health and autonomy in childbirth and argue that this remains crucial during the current emergency. We consider some potential arguments-based on pregnant people's health and resource allocation-that might be considered justification for the limitation of such services. We demonstrate, however, that these arguments are not as persuasive as they might appear because there is limited evidence to indicate either that provision of MRCS is always dangerous for pregnant people in the circumstances or would be a substantial burden on a hospital's ability to respond to the pandemic. Furthermore, we argue that even if MRCS was not a service that hospitals are equipped to offer to all pregnant persons who seek it, the current circumstances cannot justify a blanket ban on an important service and due attention must be paid to individual circumstances.

Pediatrics Consequences of Caesarean Section-A Systematic Review and Meta-Analysis

BACKGROUND

Cesarean section is a surgical procedure, which is the most frequently performed in gynecology and obstetrics. It is commonly believed that an operative delivery is a less painful and safer mode of delivery, which translates into an increasing number of the procedures performed without medical indications. The maternal sequelae of cesarean sections are well elucidated and widely discussed in the literature, while long-term neonatal consequences still remain the issue of research and scientific dispute. The aim of the present paper was to perform a systematic review of current literature regarding pediatrics consequences of cesarean section.

METHODS

We reviewed available data from PubMed, Science Direct as well as Google Scholar bases concerning early and long-term neonatal sequelae of operative deliveries. The following key words were used: "cesarean section", "caesarean section", "neonatal outcomes", "respiratory disorders", "asthma", "obesity", "overweight", and "neurological disorders". A total of 1636 papers were retrieved out of which 27 were selected for the final systematic review whereas 16 articles provided data for meta-analysis. Statistical analyses were performed using RevMan 5.4. To determine the strength of association between the caesarean section and respiratory tract infections, asthma, diabetes type 1 as well as obesity the pooled odds ratios (OR) with the 95% confidence intervals (CI) were calculated.

RESULTS

Conducted meta-analyses revealed that caesarean section is a risk factor for respiratory tract infections (pooled OR = 1.30 95%CI 1.06-1.60, p = 0.001), asthma (pooled OR = 1.23 95%CI 1.14-1.33, p < 0.00001) as well as obesity (pooled OR = 1.35 95%CI 1.29-1.41, p < 0.00001) in offspring.

CONCLUSIONS

The results of the studies included indicated that children delivered by cesarean section more commonly developed respiratory tract infections, obesity and the manifestations of asthma than children delivered vaginally. The risk of developing diabetes mellitus type 1 or neurological disorders in offspring after caesarean section is still under discussion.

Lessons from a multidisciplinary partnership involving women parliamentarians to address the overuse of caesarean section in Italy

The increase of caesarean sections (CS) represents a global concern. Interventions tested to reduce unnecessary caesareans have shown limited success to date, partly because they have focused on medical perspectives or on single faceted interventions targeting only one group of stakeholders. Limited attention has been given to examining multidisciplinary and advocacy activities that could reduce unnecessary CS by raising awareness and engaging the media, advocacy groups, healthcare professionals and politicians. In 2009 in Italy, the national CS rate was the highest in Europe and momentum was building for action.

This case study includes a description of the activities conducted in Italy during 2009–2012 by a partnership that included the non-governmental organisation Osservatorio Nazionale sulla Salute della Donna, a bipartisan group of Italian women parliamentarians and the WHO. The objectives were to generate awareness about the increase and overuse of CS in Italy, to foster political actions to reverse this trend, to engage with the media and journalists and to better understand women’s birth preferences and needs.

A reduction of the CS rate has been observed in Italy following the activities of the initiative from 38.4% in 2009 to 34.2% in 2015 according to the Ministry of Health. Although we cannot infer a casual association between the Partnership and the CS decrease, it did contribute to political momentum and specific actions that should, in theory, have contributed to this reduction. These include the engagement of women parliamentarians for policy change, improved understanding of the local drivers of increases of CS including women’s needs and preferences, raising awareness and working with the media to convey appropriate information and an inclusive strategy giving the opportunity to local stakeholders to make their voices heard.

This partnership initiative illustrates a model for generating dialogue, reflection and action in countries showing signs of readiness to address escalating CS.

Why the Elective Caesarean Lottery is Ethically Impermissible

In the United Kingdom the law and medical guidance is supportive of women making choices in childbirth. NICE guidelines are explicit that a competent woman's informed request for MRCS (elective caesarean in the absence of any clinical indications) should be respected. However, in reality pregnant women are routinely denied MRCS. In this paper I consider whether there is sufficient justification for restricting MRCS. The physical and emotive significance of childbirth as an event in a woman's life cannot be understated. It is, therefore, concerning that women are having their wishes ignored, and we must ascertain whether the denial of agency is justifiable. To answer this question I first demonstrate that access to MRCS is a lottery in the UK. Second, I argue that there is nothing unique about pregnancy that displaces the ethical norm of respecting patents' sufficiently autonomous choices. Thus, the starting presumption is that all informed choices regarding MRCS should be respected. To ascertain whether any restriction of MRCS is justifiable the burden of proof must be placed on those who argue that MRCS is ethically impermissible. I argue that the most common justifications in the literature against MRCS are insufficient to displace the presumption in favour of autonomous choice in childbirth. I conclude that MRCS should be available to pregnant women, and we must strive to reduce the lottery in access to choice.

Challenges to achieving appropriate and equitable access to Caesarean section: ethnographic insights from rural Pakistan

Access to Caesarean section (C-section) remains inadequate for some groups of women while others have worryingly high rates. Understanding differential receipt demands exploration of the socio-cultural, and political economic, characteristics of the health systems that produce them. This extensive institutional ethnography investigated under- and over-receipt of C-section in two rural districts in Pakistan - Jhelum and Layyah. Data were collected between November and July 2013 using semi-structured interviews from a randomly selected sample of 11 physicians, 38 community midwives, 18 Lady Health Visitors and nurses and 15 Traditional Birth Attendants. In addition, 78 mothers, 35 husbands and 23 older women were interviewed. The understandings of birth by C-section held by women and their family members were heavily shaped by gendered constructions of womanhood, patient-provider power differentials and financial constraints. They considered C-section an expensive and risky procedure, which often lacked medical justification, and was instead driven by profit motive. Physicians saw C-section as symbolizing obstetric skill and status and a source of legitimate income. Physician views and practices were also shaped by the wider health care system characterized by private practice, competition between providers and a lack of regulation and supervision. These multi-layered factors have resulted in both unnecessary intervention, and missed opportunities for appropriate C-sections. The data indicate a need for synergistic action at patient, provider and system levels. Recommendations include: improving physician communication with patients and family so that the need for C-section is better understood as a life-saving procedure, challenging negative attitudes and promoting informed decision-making by mothers and their families, holding physicians accountable for their practice and introducing price caps and regulations to limit financial incentives associated with C-sections. The current push for privatization of health care in low-income countries also needs scrutiny given its potential to encourage unnecessary intervention.

Rising rates of cesarean delivery in Ecuador: Socioeconomic and institutional determinants over two decades

BACKGROUND

Ecuador's cesarean delivery rate far exceeds that recommended by the Pan American Health Organization (PAHO) and the World Health Organization (WHO). Using data from three iterations of Ecuador's nationally representative, population-based survey Encuesta Nacional de Salud y Nutrición (ENSANUT/ENDEMAIN), spanning 23 years, this study examines women's mode of delivery outcomes by sociodemographic characteristics and hospital type (private, public, social security) in light of Ecuador's major health care reform over the past two decades.

METHODS

Using data from the 1994, 2004, and 2012 iterations of the data set, we analyzed trends in cesarean delivery based on province, year, and institution of care. Logistic regression was used to test the odds of cesarean delivery based on hospital type, sociodemographics, and birth complications for the full sample and primiparous women. Predicted probabilities were derived from this model.

RESULTS

Ecuador's cesarean rate increased from 22% in 1989 to 41% in 2012. From 2008 to 2012, the probability of cesarean delivery in private centers was significantly higher than in public centers, and from 2009 to 2012, the probability of cesarean delivery in social security centers was significantly higher than in public centers. Higher maternal age, income, education, and parity, earlier prenatal care initiation, and more prenatal visits were associated with risk for cesarean delivery.

CONCLUSIONS

To decrease the adverse effects of cesarean delivery for women and their babies, cesarean delivery should be reduced. Future research should investigate how incentive structures are used and how medical indication is defined within health institutions in Ecuador.

Preference for caesarean attitudes toward birth in a Chilean sample of young adults

BACKGROUND

Little empirical research exists about what motivates birth mode preferences, and even less about this topic in Latin America, where obstetric interventions and caesareans are some of the highest worldwide.

AIM

To identify factors associated with caesarean preference among Chilean men and women who plan to have children and to inform childbirth education and informed consent procedures.

METHODS

An online cross-sectional survey measuring attitudes toward birth was administered to graduate students at a large public university in Chile. Eligible students were under the age of 40 and had no children but intended to have children. Logistic regression modelling was used to determine which sociodemographic factors, knowledge and beliefs were associated with caesarean preference.

FINDINGS

Among eligible students, 730 responded and 664 provided complete answers to the variables of interest. Respondents had a mean age of 28.8; 38% were male and 62% female. Positive attitude toward technological intervention (Odds Ratio 7.4, 95% Confidence Interval 3.9-14.0), high risk perception of vaginal birth (Odds Ratio 1.8, 95% Confidence Interval 1.1-2.8), family history of caesarean (Odds Ratio 1.9, 95% Confidence Interval 1.0-3.8) and high fear of birth (Odds Ratio 3.7, 95% Confidence Interval 2.0-6.8) were associated with caesarean preference.

DISCUSSION

Preference for caesarean birth was highly associated with positive attitudes toward technological intervention and may be related to a lack of knowledge about the realities of caesarean and vaginal birth.

CONCLUSIONS

Patient-centered education on the relative benefits and risks of birth modes has the potential to influence preferences toward vaginal birth.

Prenatal care and socioeconomic status: effect on cesarean delivery

Cesarean deliveries are widely used in many high- and middle-income countries. This overuse both increases costs and lowers quality of care and is thus a major concern in the healthcare industry. The study first examines the impact of prenatal care utilization on cesarean delivery rates. It then determines whether socioeconomic status affects the use of prenatal care and thereby influences the cesarean delivery decision. Using exclusive French delivery data over the 2008-2014 period, with multilevel logit models, and controlling for relevant patient and hospital characteristics, we show that women who do not participate in prenatal education have an increased probability of a cesarean delivery compared to those who do. The study further indicates that attendance at prenatal education varies according to socioeconomic status. Low socioeconomic women are more likely to have cesarean deliveries and less likely to participate in prenatal education. This result emphasizes the importance of focusing on pregnancy health education, particularly for low-income women, as a potential way to limit unnecessary cesarean deliveries. Future studies would ideally investigate the effect of interventions promoting such as care participation on cesarean delivery rates.

Risk of childhood otitis media with focus on potentially modifiable factors: A Danish follow-up cohort study

INTRODUCTION

Otitis media is the primary cause of antibiotic prescription in children. Two-thirds of all children experience at least one episode of otitis media before the age of 7 years. The aim of this study was to characterise the attributable effect of several modifiable risk exposures on the risk of >3 episodes of otitis media at age 18 months and 7 years within a large prospective national birth cohort.

METHODS

The study used the Danish National Birth Cohort comprising information about otitis media and risk exposures from more than 50,000 mother-child pairs from the period 1996-2002. Logistic regression models were used to estimate odds ratios for the risk factors and to calculate the population attributable fraction.

RESULTS

Short time with breastfeeding, early introduction to daycare, cesarean section, and low compliance to the national vaccination program were all associated with an increased risk of >3 episodes of otitis media at 18 months of age and at 7 years of age. The fraction of children with otitis media attributed from breastfeeding lasting for less than 6 months was 10%. Introduction to daycare before the age of 12 months attributed with 20% of the cases of >3 episodes of otitis media.

CONCLUSIONS

Short duration of breastfeeding, early introduction into daycare, cesarean section, and low compliance with the national vaccination program increased the risk of experiencing >3 episodes of otitis media at 18 months, and at 7 years of age. These are factors that all can be modulated.

Maternal-choice caesarean section versus planned vaginal birth in low-risk primigravid women

Rising rates of caesarean section (CS) have been attributed, in part, to maternal-choice CS (MCCS). There are few published data regarding maternal and perinatal risks comparing MCCS with planned vaginal birth (VB) in uncomplicated first pregnancies to inform choice. We report the results of a pragmatic patient-preference cohort study of private patients in Australia: 64 women planning MCCS and 113 women planning VB. There were few differences in outcome between the two groups. The study highlighted the well-recognised difficulties in undertaking prospective research into MCCS.

Factors relating caesarean section to persistent pulmonary hypertension of the newborn

BACKGROUND

Several studies have clearly demonstrated a significantly higher incidence of persistent pulmonary hypertension of the newborn (PPHN) in neonates delivered by caesarean section (CS) compared to those delivered vaginally. The pathophysiological factors underlying the link between CS and PPHN are still poorly understood. In this review, we describe the mechanisms that could explain the association between CS delivery and subsequent PPHN, as well as potential preventive measures.

DATA SOURCES

A literature search was conducted by electronic scanning of databases such as PubMed and Web of Science using the key words "persistent pulmonary hypertension of the newborn", "caesarean section", "iatrogenic prematurity", "oxidative stress", "late preterm", "labor" and "vasoactive agents".

RESULTS

Iatrogenic prematurity, higher rates of late preterm delivery and lack of physiological changes of labor play an important role in the association between CS and PPHN. CS delivery also results in limited endogenous pulmonary vasodilator synthesis and lower levels of protective anti-oxidants in the neonates. In addition, CS delivery exposes infants to a higher risk of respiratory distress syndrome and its concomitant increase in endothelin-1 levels, which might indirectly lead to a higher risk of developing PPHN. We believe that neonates delivered by CS are exposed to a combination of these pathophysiological events, culminating in an endpoint of respiratory distress, hypoxia, acidosis, and delayed transition and thereby increased risks of PPHN. The use of antenatal corticosteroids prior to elective CS in late preterm deliveries, promoting accurate informedconsent process, delaying elective CS to 39 weeks of gestation or beyond and antenatal maternal anti-oxidant supplementation could potentially mitigate the effects of CS delivery and minimize CS-related PPHN.

CONCLUSIONS

The link between CS delivery and PPHN is complex. In view of the rising rates of CS worldwide, there is an urgent need to further explore the mechanisms linking CS to PPHN and experimentally test therapeutic options in order to allow effective targeted interventions.

Rates and Predictors of Caesarean Section for First and Second Births: A Prospective Cohort of Australian Women

Objective To determine rates of vaginal delivery, emergency caesarean section, and elective caesarean section for first and second births in Australia, and to identify maternal predictors of caesarean section. Methods Data were from the Australian Longitudinal Study on Women's Health. A total of 5275 women aged 18-38 years, who had given birth to their first child between 1996 and 2012 were included; 75.0% (n = 3956) had delivered a second child. Mode of delivery for first and second singleton birth(s) was obtained from longitudinal survey data. Socio-demographic, lifestyle, anthropometric and medical history variables were tested as predictors of mode of delivery for first and second births using multinomial logistic regression. Results Caesarean sections accounted for 29.1% (n = 1535) of first births, consisting of 18.2% emergency and 10.9% elective caesareans. Mode of delivery for first and second births was consistent for 85.5% of women (n = 3383) who delivered both children either vaginally or via caesarean section. Higher maternal age and body mass index, short-stature, anxiety and having private health insurance were predictive of caesarean section for first births. Vaginal birth after caesarean section was more common in women who were older, short-statured, or had been overweight or obese for both children, compared to women who had two vaginal deliveries. Conclusions for Practice Rates of caesarean section in Australia are high. Renewed efforts are needed to reduce the number of unnecessary caesarean births, with particular caution applied to first births. Interventions could focus on elective caesareans for women with private health insurance or a history of anxiety.

Frequency and evaluation of the perceptions towards caesarean section among pregnant women attending public hospitals in Pakistan and the implications

OBJECTIVES

There is increasing prevalence of caesarean sections (CS) worldwide; however, there are concerns about their rates in some countries, including potential fears among mothers. Consequently, we aimed to determine the frequency of CS, and explore patient's perception towards CS attending public hospitals in Pakistan, to provide future guidance.

METHODS

A two-phased study design (retrospective and cross sectional) was adopted. A retrospective study was conducted to assess the frequency of CS over one year among four public hospitals. A cross sectional study was subsequently conducted to determine patients' perception towards CS attending the four tertiary care public hospitals in Quetta city, Pakistan, which is where most births take place.

RESULTS

Overall prevalence of CS was 13.1% across the four hospitals. 728 patients were approached and 717 responded to the survey. Although 78.8% perceived CS as dangerous, influenced by education (p = 0.004), locality (p = 0.001) and employment status (p = 0.001), 74.5% of patients were in agreement that this is the best approach to save mother's and baby's lives if needed. 62% of respondents reported they would like to avoid CS if they could due to post-operative pain, and 58.9% preferred a normal delivery. There was also a significant association with education (p = 0.001) and locality (p = 0.001) where respondents considered normal vaginal delivery as painful.

CONCLUSION

The overall frequency of CS approximates to WHO recommendations, although there is appreciable variation among the four hospitals. When it comes to perception towards CS, women had limited information. There is a need to provide mothers with education during the antenatal period, especially those with limited education, to accept CS where needed.

Healthcare utilisation, induced labour and caesarean section in the pregnancy after stillbirth: a prospective study

OBJECTIVE

To investigate healthcare utilisation, induced labour and caesarean section (CS) in the pregnancy after stillbirth and assess anxiety and dread of childbirth as mediators for these outcomes.

DESIGN

Population-based pregnancy cohort study.

SETTING

The Norwegian Mother and Child Cohort Study.

SAMPLE

A total of 901 pregnant women; 174 pregnant after stillbirth, 362 pregnant after live birth and 365 previously nulliparous.

METHODS

Data from questionnaires answered in the second and third trimesters of pregnancy and information from the Medical Birth Registry of Norway.

MAIN OUTCOME MEASURES

Self-reported assessment of antenatal care, register-based assessment of onset and mode of delivery.

RESULTS

Women with a previous stillbirth had more frequent antenatal visits (mean 10.0; 95% CI 9.4-10.7) compared with women with a previous live birth (mean 6.0; 95% CI 5.8-6.2) and previously nulliparous women (mean 6.3; 95% CI 6.1-6.6). Induced labour and CS, elective and emergency, were also more prevalent in the stillbirth group. The adjusted odds ratio for elective CS was 2.5 (95% CI 1.3-5.0) compared with women with previous live birth and 3.7 (1.8-7.6) compared with previously nulliparous women. Anxiety was a minor mediator for the association between stillbirth and frequency of antenatal visits, whereas dread of childbirth was not a significant mediator for elective CS.

CONCLUSIONS

Women pregnant after stillbirth were more ample users of healthcare services and more often had induced labour and CS. The higher frequency of antenatal visits and elective CS could not be accounted for by anxiety or dread of childbirth.

TWEETABLE ABSTRACT

Women pregnant after stillbirth are ample users of healthcare services and interventions during childbirth.

Giving birth: Expectations of first time mothers in Switzerland at the mid point of pregnancy

PROBLEM AND BACKGROUND

Despite a generally affluent society, the caesarean section rate in Switzerland has steadily climbed in recent years from 22.9% in 1998 to 33.7% in 2014. Speculation by the media has prompted political questions as to the reasons. However, there is no clear evidence as to why the Swiss rate should be so high especially in comparison with neighbouring countries.

AIM

To describe the emerging expectations of giving birth of healthy primigravid women in the early second semester of pregnancy in four Swiss cantons.

METHODS

Qualitative individual interviews with 58 healthy primigravid women, were audio recorded, transcribed and subjected to thematic analysis. Recruitment took place through public and private hospitals, birth centres, obstetricians and independent midwives. The main ethical issues were informed consent, autonomy, confidentiality and anonymity.

FINDINGS

The three main themes identified were taking or avoiding decisions, experiencing a continuum of emotions and planning the care.

DISCUSSION

Being pregnant was part of a project women had mapped out for their lives. Only three women in our sample expressed a wish for a caesarean section. One of the strongest emotions was that of fear but in contrast some participants expressed faith that their bodies would cope with the experience.

CONCLUSION

Bringing together the three languages and cultures produced a truly "Swiss" study showing contrasts between a matter of fact approach to pregnancy and the concept of fear. Such a contrast is worthy of further and deeper exploration by a multi-disciplinary research team.

A Predictive Model for Cesarean Among Low-Risk Nulliparous Women in Spontaneous Labor at Hospital Admission

BACKGROUND

To determine if maternal characteristics measurable upon admission to hospital predict cesarean among low-risk spontaneously laboring nulliparous women.

METHODS

We undertook a secondary analysis of data from a clinical trial of early labor support for nulliparous women carrying a singleton fetus in cephalic presentation at 37-41 weeks of gestation in British Columbia, Canada. Study participants did not have any discernible risk factors for cesarean at the onset of labor. We developed a prediction model using logistic regression from a sample of 1,302 participants. Internal validation of the model was accomplished by 10-fold cross validation, after which probability scores were calculated based on the mean logistic regression model. To determine the accuracy of our predictive model, we calculated the specificity and sensitivity and the area under the receiver operating curve.

RESULTS

Advanced maternal age, shorter maternal height, greater gestational age, perception of labor lasting more than 24 hours, and mild or moderate contractions, less cervical dilation, and higher fetal station at time of hospital admission independently predicted cesarean. The C-statistic for the predictive model was 0.71 (0.64-0.75) and the sensitivity and specificity of the model were 0.80 (95% CI 0.76-0.84) and 0.48 (95% CI 0.44-0.52), respectively.

CONCLUSIONS

Among nulliparous women without apparent risk for cesarean at the time of hospital admission, cesarean delivery can be predicted with 70 percent accuracy using routinely collected information. Tailoring intrapartum care to promote vaginal birth according to a prediction model for cesarean risk deserves further study among apparently low risk women.

Gestational weight gain, cesarean delivery, and cesarean delivery on maternal request: a cohort analysis of Chinese nulliparous women

PURPOSE

To examine the association between gestational weight gain (GWG) and cesarean delivery including cesarean delivery on maternal request (CDMR) among low-risk women.

METHODS

A total of 1,009,987 Chinese nulliparous women who delivered live term singletons during 1993-2010 were included. GWG, according to maternal pre-pregnancy body mass index-specified z-scores, was categorized into five groups: less than -1.2, -1.2 to less than -0.6, -0.6 to 0.6 (reference), more than 0.6 to 1.2, and more than 1.2. Multivariate log-binomial regression models were used to estimate the adjusted risk ratios and 95% confidence intervals (95% CIs).

RESULTS

GWG was positively associated with overall cesarean and CDMR after adjusting for various confounders. Adjusted risk ratios for cesarean were 0.75 (95% CI, 0.73-0.77), 0.84 (95% CI, 0.82-0.85), 1.00, 1.16 (95% CI, 1.14-1.19), and 1.32 (95% CI, 1.29-1.35) in five ascending GWG categories, and 0.70 (95% CI, 0.67-0.73), 0.80 (95% CI, 0.78-0.82), 1.00, 1.20 (95% CI, 1.18-1.23), and 1.43 (95% CI, 1.40-1.45) for CDMR. The graded positive associations were consistent across levels of maternal pre-pregnancy body mass index, and in strata defined by southern and/or northern provinces, urban and/or rural residence, maternal age at delivery, year of delivery, and level of delivering hospital.

CONCLUSIONS

Even among low-risk women, higher GWG was monotonically associated with an increased risk of cesarean delivery, indicating that limiting GWG could benefit to curb the rate of both medically necessary and unnecessary cesareans.

Elective cesarean section or not? Maternal age and risk of adverse outcomes at term: a population-based registry study of low-risk primiparous women

Background

Maternal age at delivery and cesarean section rates are increasing. In older women, the decision on delivery mode may be influenced by a reported increased risk of surgical interventions during labor and complications with increasing maternal age. We examined the association between maternal age and adverse outcomes in low-risk primiparous women, and the risk of adverse outcomes by delivery modes, both planned and performed (elective and emergency cesarean section, operative vaginal delivery, and unassisted vaginal delivery) in women aged ≥ 35 years.

Methods

A population-based registry study was conducted using data from the Medical Birth Registry of Norway and Statistics Norway including 169,583 low-risk primiparas with singleton, cephalic labors at ≥ 37 weeks during 1999 − 2009. Outcomes studied were obstetric blood loss, maternal transfer to intensive care units, 5-min Apgar score, and neonatal complications. We adjusted for potential confounders using relative risk models and multinomial logistic regression.

Results

Most adverse outcomes increased with increasing maternal age. However, the increase in absolute risks was low, except for moderate obstetric blood loss and transfer to the neonatal intensive care unit (NICU). Operative deliveries increased with increasing maternal age and in women aged ≥ 35 years, the risk of maternal complications in operative delivery increased. Neonatal adverse outcomes increased mainly in emergency operative deliveries. Moderate blood loss was three times more likely in elective and emergency cesarean section than in unassisted vaginal delivery, and twice as likely in operative vaginal delivery. Low Apgar score and neonatal complications occurred two to three times more often in emergency operative deliveries than in unassisted vaginal delivery. However, comparing outcomes after elective cesarean section and planned vaginal delivery, only moderate blood loss (higher in elective cesarean section), neonatal transfer to NICU and neonatal infections (both higher in planned vaginal delivery) differed significantly.

Conclusions

Most studied adverse outcomes increased with increasing maternal age, as did operative delivery. Although emergency operative procedures were associated with an increased risk of adverse outcomes, the absolute risk difference in complications between the modes of delivery was low for the majority of outcomes studied.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-016-1028-3) contains supplementary material, which is available to authorized users.

[Fear of childbirth among nulliparous women: Relations with pain during delivery, post-traumatic stress symptoms, and postpartum depressive symptoms]

OBJECTIVE

Fear of childbirth is common in women who are pregnant with their first child and is associated with important consequences such as abortions and miscarriages. Twenty percent of nulliparous women seem to exhibit a mild or moderate fear, while 6% present an excessive and irrational fear known as tocophobia. Tocophobia is suggested to be associated with many negative consequences such as postpartum depression (PPD) and Post-traumatic stress (PTS). However, there is little empirical evidence to support these relationships. Recently, Fairbrother and Woody (2007) did not observe a link between the fear of childbirth and symptoms of PPD and PTS in nulliparous women. Some results, near the significance level, could be explained by a lack of statistical power. The present study focused on the link between the fear of childbirth and the process of delivery, the perception of pain, PPD and PTS. More specifically, it aimed to test three hypotheses: (i) fear of childbirth will be linked to the process of delivery, especially regarding the perception of pain, the use of anaesthesia and the use of Caesarean section; (ii) a high level of fear of childbirth will be associated with more negative postpartum consequences (namely PPD/PTS symptoms); (iii) the process of delivery and pain will also be related to post-delivery symptoms. Mediation effects were tested.

METHOD

Data from a longitudinal study were used to meet the hypotheses. A total of 176 nulliparous pregnant women responded to questionnaires at two time measurements (during pregnancy and at 5weeks postpartum).

RESULTS

Fear of childbirth is related to the perception of pain at birth among women delivering vaginally, in the absence of anaesthesia. It is also linked to symptoms of PPD and PTS, regardless of whether or not anaesthesia was used. Fear of childbirth also appears to be strongly associated to symptoms of PTS in women who have experienced an unplanned caesarean section. Thus, symptoms of postpartum PTS could play a mediating role in the link between fear of childbirth and PPD.

CONCLUSIONS

These results support the relevance of taking into account the fear of childbirth and perception of pain in connection with symptoms of PTS and PPD in nulliparous women. The unplanned caesarean section (including emergency caesarean) also appears to be important in the study of the relationship between fear and symptoms of PTS. Fear of childbirth could render the experience of childbearing more negative and predispose to PTS and PPD. Enabling psychological vulnerabilities could also be an interesting avenue for understanding these links. Limitations are discussed.

Salient beliefs towards vaginal delivery in pregnant women: A qualitative study from Iran

BACKGROUND

Childbirth by cesarean section has increased at an alarming rate over the past few years in Iran. The present study was designed to explore pregnant women's beliefs about the mode of delivery in order to provide some suggestions for future interventions to increase vaginal delivery.

METHODS

This was a qualitative study framed by the Theory of Planned Behavior conducted in Tehran, Iran in 2013. Pregnant women attending public hospitals were recruited. The data were collected via in-depth interviews and focus group discussions. Interviews were conducted in a semi-structured manner. All interviews were tape recorded and transcribed verbatim. A content analysis approach was used to explore the data.

RESULTS

In all 36 pregnant women participated in the study. The mean age of women was 27.8 (SD = 4.5) years. In general, women preferred vaginal delivery. During interviews and focus group discussions several themes emerged related to the pain associated with vaginal delivery, fears of childbirth, related health concerns, and the role of decision makers. The findings were grouped into three main themes namely: behavioral beliefs (negative and positive beliefs towards outcomes of vaginal delivery), normative beliefs (injunctive norms and descriptive norms), and control beliefs (internal and external barriers).

CONCLUSION

Despite the fact that there were positive beliefs regarding vaginal delivery, participants indicated concerns related to loss of control and fear. It is essential that health care providers realize the psychological needs of women during pregnancy and the need for continuous support during childbirth. This type of support may improve their self-control during labor, and decrease fear of childbirth.

Indications for and Risks of Elective Cesarean Section

BACKGROUND

Rates of cesarean section have risen around the world in recent years. Accordingly, much effort is being made worldwide to understand this trend and to counteract it effectively. A number of factors have been found to make it more likely that a cesarean section will be chosen, but the risks cannot yet be clearly defined.

METHODS

This review is based on pertinent publications that were retrieved by a selective search in the PubMed, Scopus, and DIMDI databases, as well as on media communications, analyses by the German Federal Statistical Office, and guidelines of the Association of Scientific Medical Societies in Germany (AWMF).

RESULTS

The increased rates of cesarean section are thought to be due mainly to changed risk profiles both for expectant mothers and for their yet unborn children, as well as an increase in cesarean section by maternal request. In 1991, 15.3% of all newborn babies in Germany were delivered by cesarean section; by 2012, the corresponding figure was 31.7%, despite the fact that a medical indication was present in less than 10% of all cases. This development may perhaps be explained by an increasing tendency toward risk avoidance, by risk-adapted obstetric practice, and increasing media attention. The intraoperative and postoperative risks of cesarean section must be considered, along with complications potentially affecting subsequent pregnancies.

CONCLUSION

Scientific advances, social and cultural changes, and medicolegal considerations seem to be the main reasons for the increased acceptibility of cesarean sections. Cesarean section is, however, associated with increased risks to both mother and child. It should only be performed when it is clearly advantageous.

The Influence of Back Pain and Urinary Incontinence on Daily Tasks of Mothers at 12 Months Postpartum

Objective

The present study examined back pain (BP) and/or urinary incontinence (UI) impact on the ability to perform daily tasks at 12 months after childbirth in healthy reproductive women who sought maternity care in community based family practice clinics.

Methods

This study is a secondary analysis from the All Our Babies Study, a prospective, community-based pregnancy cohort in Calgary, Alberta. Maternal self-reported information on demographics, lifestyle, experiences with pregnancy and childbirth, occurrence of BP, UI and consequent impairment of daily tasks were collected by questionnaires administered before 25 weeks, at 34-36 weeks gestation and at 4 and 12 months postpartum. The occurrence and severity of BP and UI at one year after childbirth was assessed using descriptive and bivariate analyses. Logistic regression models examined the association between demographic and obstetrical variables and the severity of functional impairment due to UI and BP.

Results

From 1574 women with singleton pregnancies included in the study, 1212 (77%) experienced BP, 773 (49%) UI, and 620 (40%) both BP and UI. From the 821 women reporting impairment of daily tasks due to BP, 199 (24 %) were moderately and 90 (11%) severely affected with the remainder, 532 (64%) being mildly affected. From 267 women with functional impairment due to UI, 52 (19%) reported moderately to severe impairment in their ability to perform daily tasks. Obesity and parity were risk factors for impairment of daily functioning due to BP, whereas obesity and vaginal delivery increased the risk of moderate to severe impairment due to UI.

Conclusions

BP and UI are common occurrences 1 year after childbirth. Maternal performance of daily tasks and women’s health and quality of life are more often impaired due to BP than UI. Our study brings new evidence of the risk factors that predict severity and impact of these conditions on women functioning at 12 months postpartum.

Neonatal Transfer Rate and Mode of Delivery from 37th Week of Gestation in a German Perinatal Center Level 1

Introduction: Rates for caesarean section are on the rise and the reasons for this are being discussed worldwide. As the data is unclear, the identification of additional predictive factors for caesarean section is important as caesarean sections are closely linked to maternal and neonatal morbidity. The aim of the study was to identify predictive factors for the transfer of the neonate to a neonatal intensive care unit (NICU) depending on the mode of delivery. The study investigated the neonatal transfer rates for singleton and twin pregnancies delivered at ≥ 36 + 0 weeks of gestation. Material and Methods: The data of all singleton (n = 4181) and twin pregnancies (n = 305 neonates), delivered between 1 January 2009 and 31 March 2012 in the OB/Gyn Department of the University Hospital Frankfurt/M, Germany, (perinatal center level 1) were evaluated. The indications for transfer to the NICU and possible predictive factors were evaluated. Results: Our study found a two times lower neonatal transfer rate for vaginal deliveries of pregnant women without risk factors compared to women with risk factors. The following neonatal transfer rates to the NICU were noted for singleton pregnancies: 4.7 % without risk factors, 8.3 % high-risk pregnancy, 6.2 % vaginal breech delivery, 9.3 % forceps delivery, 10 % elective primary caesarean section and 14 % secondary caesarean section. There was a statistically signific.

Fear of childbirth in nulliparous and multiparous women: a population-based analysis of all singleton births in Finland in 1997-2010

OBJECTIVE

To identify risk factors for fear of childbirth (FOC) according to parity and socioeconomic status, and to evaluate associations between FOC and adverse perinatal outcomes.

DESIGN

A cohort study.

SETTING

The Finnish Medical Birth Register.

POPULATION

All 788 317 singleton births during 1997-2010 in Finland.

METHODS

Fear of childbirth was defined according to the International Classification of Diseases code O99.80, and its associations with several risk factors and perinatal outcomes were analysed by multivariable logistic regression.

MAIN OUTCOME MEASURES

Prevalence of, risk factors for and outcomes of FOC.

RESULTS

Fear of childbirth was experienced by 2.5% of nulliparous women and 4.5% of multiparous women. The strongest risk factors for FOC in nulliparous women were depression [adjusted odds ratio (aOR), 6.35; 95% confidence interval (CI), 5.25-7.68], advanced maternal age (aOR, 3.78; 95% CI, 3.23-4.42) and high or unspecified socioeconomic status. In multiparous women, the strongest risk factors for FOC were depression (aOR, 5.47; 95% CI, 4.67-6.41), previous caesarean section (CS) (aOR, 3.02; 95% CI, 2.93-3.11) and high or unspecified socioeconomic status. Among both nulliparous and multiparous women, FOC was associated with higher rates of CS (3.3-fold and 4.5-fold higher, respectively) and a lower incidence of low birthweight (<2500 g), small for gestational age babies, preterm birth and low Apgar scores at 1 minute.

CONCLUSIONS

High and unspecified socioeconomic status, advanced maternal age and depression are predisposing factors for FOC regardless of parity. Among multiparous women, a previous CS increases vulnerability to FOC. FOC is associated with increased rates of CS, but does not adversely affect other pregnancy outcomes.

Development and psychometric properties of the Birth Satisfaction Scale-Revised (BSS-R)

OBJECTIVE

to assess factor structure, validity and reliability of the Birth Satisfaction Scale (BSS) and to develop a short-form version of the tool.

DESIGN

a quantitative design focused on evaluating psychometric properties of the BSS using factor structure, internal consistency, divergent reliability and known groups validity.

SETTING

Ayrshire Maternity Unit community midwife bases that serve the obstetric population of Ayrshire, Scotland (UK).

PARTICIPANTS

a convenience sample of healthy women (n=228) <10 days post partum who had delivered a term infant. Data was collected from October 2010 to January 2011.

MEASUREMENT

the BSS contains 30 self report items, rated on a 5-point Likert scale that measure women's perceptions of: (1) quality of care provision, (2) women's personal attributes, and (3) stress experienced during labour (8, 8 and 14 items per factor).

FINDINGS

post data analysis the BSS was reconfigured into the 10 item BSS-Revised (BSS-R) comprised of three sub-scales that measure distinct but correlated domains of: (1) quality of care provision, (2) women's personal attributes, and (3) stress experienced during labour. These domains now consist of relatively few items (4, 2 and 4 items per factor), but offer a good fit to the data.

KEY CONCLUSIONS

the BSS-R would appear to be a robust, valid and reliable multidimensional psychometric instrument for measuring postnatal women's birth satisfaction. Further research to confirm the veracity of the instruments measurement properties highlighted in the current study is desirable. The BSS-R is available for use at a national/international level from the first author.

Mode of delivery and persistence of pelvic girdle syndrome 6 months postpartum

OBJECTIVE

We sought to study the association between mode of delivery and persistent pelvic girdle syndrome (PGS) (pain in anterior and bilateral posterior pelvis) 6 months postpartum.

STUDY DESIGN

We followed up 10,400 women with singleton deliveries in the Norwegian Mother and Child Cohort Study who reported PGS in pregnancy week 30 (1999 through 2008). Data were obtained by 3 self-administered questionnaires and linked to the Medical Birth Registry of Norway.

RESULTS

Planned cesarean section was associated with the presence of severe PGS 6 months postpartum (adjusted odds ratio [OR], 2.3; 95% confidence interval [CI], 1.4-3.9). In women who used crutches during pregnancy, emergency (adjusted OR, 2.0; 95% CI, 1.0-4.0) and planned (adjusted OR, 3.3; 95% CI, 1.9-5.9) cesarean section were each associated with severe PGS.

CONCLUSION

The results suggest an increased risk of severe PGS 6 months postpartum in women who underwent a cesarean section vs women who had an unassisted vaginal delivery.

Do Italian women prefer cesarean section? Results from a survey on mode of delivery preferences

BACKGROUND

About 20 million cesareans occur each year in the world and rates have steadily increased in almost all middle- and high-income countries over the last decades. Maternal request is often argued as one of the key forces driving this increase. Italy has the highest cesarean rate of Europe, yet there are no national surveys on the views of Italian women about their preferences on route of delivery. This study aimed to assess Italian women's preference for mode of delivery, as well as reasons and factors associated with this preference, in a nationally representative sample of women.

METHODS

This cross sectional survey was conducted between December 2010-March 2011. An anonymous structured questionnaire asked participants what was their preferred mode of delivery and explored the reasons for this preference by assessing their agreement to a series of statements. Participants were also asked to what extent their preference was influenced by a series of possible sources. The 1st phase of the study was carried out among readers of a popular Italian women's magazine (Io Donna). In a 2nd phase, the study was complemented by a structured telephone interview.

RESULTS

A total of 1000 Italian women participated in the survey and 80% declared they would prefer to deliver vaginally if they could opt. The preference for vaginal delivery was significantly higher among older (84.7%), more educated (87.6%), multiparous women (82.3%) and especially among those without any previous cesareans (94.2%). The main reasons for preferring a vaginal delivery were not wanting to be separated from the baby during the first hours of life, a shorter hospital stay and a faster postpartum recovery. The main reasons for preferring a cesarean were fear of pain, convenience to schedule the delivery and because it was perceived as being less traumatic for the baby. The source which most influenced the preference of these Italian women was their obstetrician, followed by friends or relatives.

CONCLUSION

Four in five Italian women would prefer to deliver vaginally if they could opt. Factors associated with a higher preference for cesarean delivery were youth, nulliparity, lower education and a previous cesarean.

A mixed-method study of factors associated with differences in caesarean section rates at community level: the case of rural China

OBJECTIVE

to assess population-based caesarean section (CS) rates in rural China and explore determinants and reasons for choosing a CS.

DESIGN

cross-sectional study, quantitative and qualitative methods, statistical modelling.

SETTING

two rural counties in Anhui province, China.

PARTICIPANTS

(a) household survey participants: 2326 women who gave birth in the two counties from January 2005 to December 2006; (b) qualitative study participants: health providers at township and village level and maternal health-care providers (N=58).

MEASUREMENTS AND FINDINGS

the household survey were conducted among 2326 women, collecting data on socio-economic and health status and utilisation of maternal health services. Eleven Focus Group Discussions with health-care providers and users to explore perceptions surrounding CS. the CS rate in the two areas were 46.0% and 64.7%. There were complex and different interactions among social-economic and clinical determinants associated with differences in CS rates. The main determinants that emerged were maternal age, maternal education, yearly income, primiparity, uptake of antenatal care and recorded obstetric complications with complex and differing interactions for each county. Maternal fear of pain, worry about mothers' and infants' safety, not satisfied with doctors' competences and physicians' low confidence in vaginal delivery, and absence of a strong midwifery cadre together contributed to final determination of CS.

KEY CONCLUSIONS

the CS rates were extremely high in the two counties in rural China. Maternal socio-economic, clinic characteristics and health providers' preference contributed together to the high rates of CS.

IMPLICATIONS FOR PRACTICE

evidence-based knowledge and methods to reduce unnecessary CS should be communicated to medical professionals and women. Greater comprehensive attention needs to be paid to a complex pattern of medical, socio-cultural, political and economic contexts of maternity care.

A Paradigm Shift to Check the Increasing Trend of Cesarean Delivery is the Need of Hour: But How?

OBJECTIVES

To check the progressive increasing trend of caesarean delivery in a tertiary facility care centre.

AIMS

The purpose of this study is to implement a paradigm shift in caesarean delivery by introducing a new classification system and a check list based management protocol.

METHODS

The study was conducted from 1st January, 2007 to 31st December, 2008 at CNMC G&O Department. All deliveries in the year 2007 were compared retrospectively and all deliveries in the year 2008 under prospective study with implementation of a new strategic protocol. Comparative audit and analysis of deliveries in retrospective and prospective year reveals significant changes in the caesarean delivery rate.

RESULTS

In retrospective group all women in labour were allowed for spontaneous delivery and in prospective group all women were subjected to intervention protocol and caesarean delivery done in both the groups in need for risk of fetal and maternal salvage. Incidence of caesarean delivery (CD) in retrospective group was 29 % while in the prospective group it was 18.4 %. Marked decrease in CD was observed for augmentation, induction and trial of labour (TOL) for delivery in prospective group. The result was compared with Robson's studies following similar type of classification system.

CONCLUSION

Marked improvement was noticed in this new paradigm and more multicentric trial is needed to check the increasing trend of CD.

Decision making for primary cesarean delivery: the role of patient and provider preferences

Primary cesarean delivery requires both the clinical assessment and judgment of the provider performing the procedure and the consent of the patient. The interaction between patient and provider and the relative weight and influence of patient preferences and provider recommendations may vary depending on whether a cesarean delivery is planned or unplanned, elective or indicated; understanding the range of contexts in which decision making takes place and the interplay of patient and provider factors in each of these situations is crucial to identifying ways to impact the cesarean rate that are safe and acceptable to both patients and providers. We conducted a review of the literature on patient and provider preferences and obstetrical decision making in the context of primary cesarean delivery, and offer recommendations for future research directions, including potential interventions that may impact the patient and provider factors affecting the primary cesarean rate.

Impact of alternative reimbursement strategies in the new cooperative medical scheme on caesarean delivery rates: a mixed-method study in rural China

BACKGROUND

The rate of caesarean delivery (CD) in rural China has been rapidly increasing in recent decades. Due to the exorbitant costs associated with CD, paying for this expensive procedure is often a great challenge for the majority of rural families. Since 2003, the Chinese government has re-established the New Cooperative Medical Scheme (NCMS), aimed to improve the access of essential healthcare to rural residents and reduce financial burden owing to high out of pocket payments. This paper seeks to test the hypothesis that NCMS may provide service users and providers with financial incentives to select CD. It also assesses the effect of different health insurance reimbursement strategies of NCMS on CD rates in rural China.

METHODS

Mixed quantitative and qualitative methods were adopted for data collection. Two cross-sectional household surveys were conducted with women having babies delivered in 2006 and 2009; 2326 and 1515 women, respectively, from the study sites were interviewed using structured questionnaires, to collect demographic and socio-economic data, maternal and child care characteristics and health-related expenditures. Focus group discussions (FGDs) and in-depth key informant interviews (KIIs) were undertaken with policy makers, health managers, providers and mothers to understand their perceptions of the influence of NCMS on the choices of delivery mode.

RESULTS

The CD rates in the two study counties were 46.0 percent and 64.7 percent in 2006, increasing to 63.6 percent and 82.1 percent, respectively, in 2009. The study found that decisions on the selection of CD largely came from the pregnant women. Logistic regression analysis, after adjusting for socio-economic, maternal and fetal characteristics, did not indicate a significant effect of either proportional reimbursement or fixed amount reimbursement on the choice of CD for both study years. Interviews with stakeholders reflected that different reimbursable rates for CD and vaginal deliveries did not have a significant effect on controlling the rising CD rate in the study countries.

CONCLUSION

NCMS reimbursement strategies adopted in the study counties of China did not have a significant effect on the selection of CD for baby deliveries. The rapid rise of the CD rates of rural China has remained a serious issue. Other effective measures, such as health education to increase awareness of mothers' knowledge, and improving training of health staff in evidence-based delivery care, maybe could do more to promote rational baby delivery in rural China.