Cesarean Delivery and Gender of Delivering Physicians: A Systematic Review and Meta-analysis

Systematic review and meta-analysis examining the effects of midwife care on cesarean birth

BACKGROUND

The increasing number of unnecessary cesarean births is a cause for concern and may be addressed by increasing access to midwifery care. The objective of this review was to assess the effect of midwifery care on the likelihood of cesarean births.

METHODS

We searched five databases from the beginning of records through May 2020. We included observational studies that reported odds ratios or data allowing the calculation of odds ratios of cesarean birth for births with and without midwife involvement in care or presence at the institution. Standard inverse-variance random-effects meta-analysis was used to generate overall odds ratios (ORs).

RESULTS

We observed a significantly lower likelihood of cesarean birth in midwife-led care, midwife-attended births, among those who received instruction pre-birth from midwives, and within institutions with a midwifery presence.

CONCLUSIONS

Care from midwives reduces the likelihood of cesarean birth in all the analyses, perhaps due to their greater preference and skill for physiologic births. Increased use of midwives in maternal care can reduce cesarean births and should be further researched and implemented broadly, potentially as the default modality in maternal care.

Assessing the Gap Between Women's Expectations and Perceptions of the Quality of Intrapartum Care in Jordan: A Two-Stage Study Using the SERVQUAL Model

INTRODUCTION

Although Jordan has made significant progress toward expanding the utilization of facility-based intrapartum care, prior research highlights that poor service quality is still persistent. This study aimed to identify quality gaps between women's expectations and perceptions of the actual intrapartum care received, while exploring the contributing factors.

METHODS

Utilizing a pre-post design, quality gaps in intrapartum care were assessed among 959 women pre- and postchildbirth at a prominent tertiary hospital in northern Jordan. Data were gathered using the SERVQUAL scale, measuring service quality across reliability, responsiveness, tangibles, assurance, and empathy dimensions.

RESULTS

The overall mean gap score between women's expectations and perceptions of the quality of intrapartum care was -0.60 (±0.56). The lowest and highest mean gap scores were found to be related to tangibles and assurance dimensions, -0.24 (±0.39) and -0.88 (±0.35), respectively. Significant negative quality gaps were identified in the dimensions of assurance, empathy, and responsiveness, as well as overall service quality (p < 0.001). The MLR analyses highlighted education (β = 0.61), mode of birth (β = -0.60), admission timing (β = -0.41), continuity of midwifery care (β = -0.43), physician's gender (β = -0.62), active labour duration (β = 0.37), and pain management (β = -0.33) to be the key determinants of the overall quality gap in intrapartum care.

CONCLUSION

Our findings underscore the importance of fostering a labour environment that prioritizes enhancing caregivers' empathetic, reassuring, and responsive skills to minimize service quality gaps and enhance the overall childbirth experience for women in Jordan.

PATIENT OR PUBLIC CONTRIBUTION

This paper is a collaborative effort involving women with lived experiences of childbirth, midwives, and obstetrics and gynaecologist physicians. The original idea, conceptualization, data generation, and coproduction, including manuscript editing, were shaped by the valuable contributions of stakeholders with unique perspectives on intrapartum care in Jordan.

Staff Resources in Public and Private Hospitals and Their Implication for Medical Practice: A French Study of Caesareans

This study aimed to investigate the effect of hospital staffing resources on medical practice in public versus private hospitals. We used exhaustive delivery data from a French district of 11 hospitals over an 11-year period, from 2008 to 2018, including 168,120 observations. We performed multilevel logistic regression models with hospital fixed or random effects, while controlling for factors known to influence obstetric practice. We found that hospital staff ratios of obstetricians and that of midwives affected caesarean rates, but with different effects depending on the hospital sector. In public hospitals, the higher the ratio of obstetricians and that of midwives, the lower the probability of planned caesareans. In private hospitals, the higher the ratio of obstetricians, the greater the probability of planned caesareans. Indeed, in public hospitals, obstetricians and midwives, both salaried employees, do not have financial or organizational incentives to perform more caesareans. In private hospitals, obstetricians, who are independent doctors, may have such incentives. Our results underline the importance of having an adequate supply of health professionals in healthcare facilities to ensure appropriate care, with specific regard to the different characteristics of the public and private sectors.

Investigating Racial and Ethnic Disparities in Maternal Care at the System Level Using Patient Safety Incident Reports

BACKGROUND

Maternal mortality in the United States is high, and women and birthing people of color experience higher rates of mortality and severe maternal morbidity (SMM). More than half of maternal deaths and cases of SMM are considered preventable. The research presented here investigated systems issues contributing to adverse outcomes and racial/ethnic disparities in maternal care using patient safety incident reports.

METHODS

The authors reviewed incidents reported in the labor and delivery unit (L&D) and the antepartum and postpartum unit (A&P) of a large academic hospital in 2019 and 2020. Deliveries associated with a reported incident were described by race/ethnicity, age group, method of delivery, and several other process variables. Differences across racial/ethnic group were statistically evaluated.

RESULTS

Almost two thirds (64.8%) of the 528 reports analyzed were reported in L&D, and 35.2% were reported in A&P. Non-Hispanic white (NHW) patients accounted for 43.9% of reported incidents, non-Hispanic Black (NHB) patients accounted for 43.2%, Hispanic patients accounted for 8.9%, and patients categorized as "other" accounted for 4.0%. NHB patients were disproportionally represented in the incident reports, as they accounted for only 36.5% of the underlying birthing population. The odds ratio (OR) demonstrated a higher risk of a reported adverse incident for NHB patients; however, adjustment for cesarean section attenuated the association (OR 1.25, 95% confidence interval 1.01-1.54).

CONCLUSION

Greater integration of patient safety and health equity efforts in hospitals are needed to promptly identify and alleviate racial and ethnic disparities in maternal health outcomes. Although additional systems analysis is necessary, the authors offer recommendations to support safer, more equitable maternal care.

Variation of caesarean section rates in Palestinian governmental hospitals

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Cesarean delivery on maternal request: How do French obstetricians feel about it?

OBJECTIVE

The number of cesarean deliveries on maternal request (CDMR) is unknown in France. We aimed to evaluate the rate of obstetricians willing to perform a CDMR in 2020 in Paris and to compare OB/GYN seniors' and residents' points of view about CDMR using six hypothetical clinical scenarios.

STUDY DESIGN

A survey was conducted between January to March 2020 with an anonymous self-administrated questionnaire sent by email to OB/GYN seniors working in 16 public and private maternity units and residents of Paris. Questionnaire was based on previous peer-reviewed literature. Socio professional characteristics were collected. OB/GYN seniors were asked if they agree to perform a CDMR and have already done one. OB/GYN seniors' and residents' points of view on six hypothetical clinical scenarios (CDMR, scarred uterus, breech presentation, multiple pregnancy, history of perineal tears or stillbirth) were compared.

RESULTS

Eighty-three OB/GYN seniors and one hundred and fifteen residents answered to our questionnaire. Twenty-three (27,7%) OB/GYN seniors were ready to perform a CDMR, mostly because they think that mode of delivery is a woman's choice. Physicians working in a private maternity unit or having an exclusive private practice were significantly more willing to perform a cesarean delivery on maternal request. No differences were found between the OB/GYN seniors' and residents' point of view on the six hypothetical clinical scenarios. A third of OB/GYN seniors and residents reported having done at least one CDMR during their career or during their residency.

CONCLUSION

One out of four OB/GYN senior interviewed is ready to perform a CDMR in Paris in 2020. OB/GYN seniors and residents share the same point of view concerning CDMR.

Intrapartum ultrasound for the management of the active pushing phase

The anxiety and anticipation that accompany pregnancy, labor, and delivery may be relieved by education, providing knowledge regarding the physiological process of childbirth. Intrapartum ultrasound is an available, simple, intuitive, real-time tool that enables visualization of the fetal head within the birth canal. Both the attending staff and expectant parent can assess its movements and descent in response to the pushing efforts during the active pushing phase. This review described the potential obstetrical and psychological advantages of intrapartum ultrasound in managing the active pushing phase.

Caesarean sections and health financing: a global analysis

OBJECTIVES

The objective of this study is to explore the association of health financing indicators with the proportion of births by caesarean section (CS) across countries.

DESIGN

Ecological cross-country study.

SETTING

This study examines CS proportions across 172 countries.

MAIN OUTCOME MEASURES

The primary outcome was the percentage excess of CS proportion, defined as CS proportions above the global target of 19%. We also analysed continuous CS proportions, as well as excess proportion with a more restrictive 9% global target. Multivariable linear regressions were performed to test the association of health financing factors with the percentage excess proportions of CS. The health financing factors considered were total available health system resources (as percentage of gross domestic product), total contributions from private households (out-of-pocket, compulsory and voluntary health insurance contributions) and total national income.

RESULTS

We estimate that in 2018 there were a total of 8.8 million unnecessary CS globally, roughly two-thirds of which occurred in upper middle-income countries. Private health financing was positively associated with percentage excess CS proportion. In models adjusted for income and total health resources as well as human resources, each 10 per cent increase in out-of-pocket expenditure was associated with a 0.7 per cent increase in excess CS proportions. A 10 per cent increase in voluntary health insurance was associated with a 4 per cent increase in excess CS proportions.

CONCLUSIONS

We have found that health system finance features are associated with CS use across countries. Further monitoring of these indicators, within countries and between countries will be needed to understand the effect of financial arrangements in the provision of CS.

Caesarean sections in teaching hospitals: systematic review and meta-analysis of hospitals in 22 countries

OBJECTIVE

The aim of this study is to determine the odds of caesarean section in all births in teaching hospitals as compared with non-teaching hospitals.

SETTING

Over 3600 teaching and non-teaching hospitals in 22 countries. We searched CINAHL, The Cochrane Library, PubMed, sciELO, Scopus and Web of Science from the beginning of records until May 2020.

PARTICIPANTS

Women at birth. Over 18.5 million births.

INTERVENTION

Caesarean section.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome measures are the adjusted OR of caesarean section in a variety of teaching hospital comparisons. The secondary outcome is the crude OR of caesarean section in a variety of teaching hospital comparisons.

RESULTS

In adjusted analyses, we found that university hospitals have lower odds than non-teaching hospitals (OR=0.66, 95% CI 0.56 to 0.78) and other teaching hospitals (OR=0.46, 95% CI 0.24 to 0.89), and no significant difference with unspecified teaching status hospitals (OR=0.92, 95% CI 0.80 to 1.05, τ2=0.009). Other teaching hospitals had higher odds than non-teaching hospitals (OR=1.23, 95% CI 1.12 to 1.35). Comparison between unspecified teaching hospitals and non-teaching hospitals (OR=0.91, 95% CI 0.50 to 1.65, τ2=1.007) and unspecified hospitals (OR=0.95, 95% CI 0.76 to 1.20), τ2<0.001) showed no significant difference. While the main analysis in larger sized groups of analysed studies reveals no effect between hospitals, subgroup analyses show that teaching hospitals carry out fewer caesarean sections in several countries, for several study populations and population characteristics.

CONCLUSIONS

With smaller sample of participants and studies, in clearly defined hospitals categories under comparison, we see that university hospitals have lower odds for caesarean. With larger sample size and number of studies, as well as less clearly defined categories of hospitals, we see no significant difference in the likelihood of caesarean sections between teaching and non-teaching hospitals. Nevertheless, even in groups with no significant effect, teaching hospitals have a lower or higher likelihood of caesarean sections in several analysed subgroups. Therefore, we recommend a more precise examination of forces sustaining these trends.

PROSPERO REGISTRATION NUMBER

CRD42020158437.

Motherhood in Europe: An Examination of Parental Leave Regulations and Breastfeeding Policy Influences on Breastfeeding Initiation and Duration

This study examines how European variation in breastfeeding initiation and duration rates is related to the presence of baby-friendly hospitals, the international code of marketing of breast-milk substitutes, and different constellations of maternal, paternal, and parental leave. We use Eurobarometer data (2005) to compare initiation and duration levels across 21 European countries within a multilevel regression framework. We find that countries play a significant role in determining breastfeeding through their different social policies. Breastfeeding practices across different leave regulation models differ substantially. We conclude that ongoing changes in paid maternity and parental leave length combined with uptake flexibility and paternal involvement help determine breastfeeding rates and should put infant feeding issues on governmental policy agendas across European countries.