Trends in childbirth before 39 weeks' gestation without medical indication

Uncharted territory: a narrative review of parental involvement in decision-making about late preterm and early term delivery

Almost 30% of live births in England and Wales occur late preterm or early term (LPET) and are associated with increased risks of adverse health outcomes throughout the lifespan. However, very little is known about the decision-making processes concerning planned LPET births or the involvement of parents in these. This aim of this paper is to review the evidence on parental involvement in obstetric decision-making in general, to consider what can be extrapolated to decisions about LPET delivery, and to suggest directions for further research.A comprehensive, narrative review of relevant literature was conducted using Medline, MIDIRS, PsycInfo and CINAHL databases. Appropriate search terms were combined with Boolean operators to ensure the following broad areas were included: obstetric decision-making, parental involvement, late preterm and early term birth, and mode of delivery.This review suggests that parents' preferences with respect to their inclusion in decision-making vary. Most mothers prefer sharing decision-making with their clinicians and up to half are dissatisfied with the extent of their involvement. Clinicians' opinions on the limits of parental involvement, especially where the safety of mother or baby is potentially compromised, are highly influential in the obstetric decision-making process. Other important factors include contextual factors (such as the nature of the issue under discussion and the presence or absence of relevant medical indications for a requested intervention), demographic and other individual characteristics (such as ethnicity and parity), the quality of communication; and the information provided to parents.This review highlights the overarching need to explore how decisions about potential LPET delivery may be reached in order to maximise the satisfaction of mothers and fathers with their involvement in the decision-making process whilst simultaneously enabling clinicians both to minimise the number of LPET births and to optimise the wellbeing of women and babies.

Induction of labour as compared with spontaneous labour in low-risk women: A multicenter study in Catalonia

OBJECTIVE

To compare birth and neonatal outcomes in low-risk women undergoing induced labour with those undergoing spontaneous onset.

METHODS

This retrospective multicentre study included 30 public maternity hospitals in Catalonia between 2016 and 2017. The study population consisted of 5,717 women.

RESULTS

Of the 5,717 births, 75.8% had spontaneous onset and 24.2% had an induction. Induced labour was more likely at week 41 of gestation and in nulliparous women. Induced labour increased the likelihood of undergoing caesarean section (adjusted OR [ORa], 2.59; 95% confidence interval [CI], 2.11-3.16), assisted vaginal birth (ORa, 1.70; 95% CI, 1.46-1.98), epidural analgesia (ORa, 2.64; CI, 2.14-3.27), postpartum haemorrhage (ORa, 1.56; 95% CI, 1.14-2.15) and episiotomy (ORa, 1.26; 95% CI, 1.08-1.47). Induced labour was also associated with not performing skin-to-skin contact with the mother (ORa, 0.47; 95% CI, 0.39-0.58) and with not performing early breastfeeding (ORa, 0.49; 95% CI, 0.39-0.61).

CONCLUSIONS

The frequency of labour inductions among low-risk women exceeds the level recommended by scientific organisations in Catalonia and Spain, and is associated with adverse birth outcomes such as increased caesarean section rates, assisted vaginal births, and episiotomy rates. It is also associated with the failure to perform early skin-to-skin contact with the mother and failure to initiate early breastfeeding.

Exploring variation in the performance of planned birth: A mixed method study

OBJECTIVE

Variation in practice in relation to indications and timing for both induction of labour (IOL) and planned caesarean section (CS) clearly exists. However, the extent of this variation, and how this variation is explained by clinicians remains unclear. The aim of this study was to map the variation in IOL and planned CS at eight Australian hospitals, and understand why variation occurs from the perspective of clinicians at these hospitals. Our ultimate aim was to identify opportunities for improvement as evidenced by hospital data, clinician experiences, and feedback.

DESIGN

A two-phased mixed method study using sequential explanatory study design. The first phase consisted of an analysis of routinely collected patient data to map variation between hospitals. The second phase consisted of focus groups with clinicians to gain their perspectives on the reasons for variation.

SETTING AND PARTICIPANTS

Patient data consisted of routine data from 19,073 women giving birth at eight Sydney hospitals between November 2017 and October 2018. Focus groups were attended by a total of 61 medical staff and 121 midwives.

RESULTS

Hospital data analysis found substantial variation, before and after adjustment for case-mix, in rates of both IOL (adjusted rates 27.6%-42%) and planned CS (adjusted rate 15.4%-22.6%). Planned CS by gestation also showed variation, although after restricting analysis to term (≥37 weeks gestation) births, variation was reduced. At focus groups, five main themes explaining variation emerged: local guidelines, policies and procedures (inconsistency and ambiguity); uncertainty of the evidence/what is best practice (contradictory research and different interpretations of evidence); clinician preferences, beliefs and values; the culture of the unit; and organisational influences (access to specialised clinics, theatre time).

KEY CONCLUSIONS

Considerable variation in IOL and planned CS, even after case-mix adjustment, was found in this sample of Australian hospitals. Engagement with hospital clinicians identified likely sources of this variation and enabled clinicians at each hospital to consider appropriate local responses to address variation, such as more detailed review of their planned birth cases.

IMPLICATIONS FOR PRACTICE

At a macro level, measures to reduce unwarranted variation should initially focus on consistent national guidelines, while supporting equitable access to operating theatres for optimal CS timing, and shared decision-making training to reduce influence of clinician preference.

Gestational Age and Risk of Mortality in Term-Born Critically Ill Neonates Admitted to PICUs in Australia and New Zealand

OBJECTIVES

Gestational age at birth is declining, probably because more deliveries are being induced. Gestational age is an important modifiable risk factor for neonatal mortality and morbidity. We aimed to investigate the association between gestational age and mortality in hospital for term-born neonates (≥ 37 wk') admitted to PICUs in Australia and New Zealand.

DESIGN

Observational multicenter cohort study.

SETTING

PICUs in Australia and New Zealand.

PATIENTS

Term-born neonates (≥ 37 wk) admitted to PICUs.

INTERVENTIONS

None MEASUREMENTS AND MAIN RESULTS:: We studied 5,073 infants born with a gestational age greater than or equal to 37 weeks and were less than 28 days old when admitted to a PICU in Australia or New Zealand between 2007 and 2016. The association between gestational age and mortality was estimated using a multivariable logistic regression model, adjusting for age, sex, indigenous status, Pediatric Index of Mortality version 2, and site. The median gestational age was 39.1 weeks (interquartile range, 38.2-40 wk) and mortality in hospital was 6.6%. Risk of mortality declined log-linearly with gestational age. The adjusted analysis showed a 20% (95% CI, 11-28%) relative reduction in mortality for each extra week of gestation beyond 37 weeks. The effect of gestation was stronger among those who received extracorporeal life support: each extra week of gestation was associated with a 44% (95% CI, 25-57%) relative reduction in mortality. Longer gestation was also associated with reduced length of stay in hospital: each week increase in gestation, the average length of stay decreased by 4% (95% CI, 2-6%).

CONCLUSIONS

Among neonates born at "term" who are admitted to a PICU, increasing gestational age at birth is associated with a substantial reduction in the risk of dying in hospital. The maturational influence on outcome was more strongly noted in the sickest neonates, such as those requiring extracorporeal life support. This information is important in view of the increasing proportion of planned births in both high- and low-/middle-income countries.

Adverse perinatal outcomes in 665,244 term and post-term deliveries-a Norwegian population-based study

OBJECTIVE

To assess the prevalence and risk of adverse perinatal outcomes in early-term (37⁺⁰-38⁺⁶ weeks), full-term (39⁺⁰-40⁺⁶ weeks), late-term (41⁺⁰-41⁺⁶ weeks), and post-term (>42⁺⁰ weeks) deliveries with spontaneous labor onset.

STUDY DESIGN

A population-based cohort with data from the Medical Birth Registry Norway (MBRN) and Statistics Norway (SSB) was conducted. The study population consisted of 665,244 women with cephalic singleton live births at term or post-term with spontaneous labor onset during the period of 1999-2014 in Norway. Maternal, obstetric, and fetal characteristics were obtained from the MBRN. Maternal education data were obtained from the SSB. The prevalence rates of adverse perinatal outcomes for each gestational age (GA) group were estimated. Inter-group differences were detected with Chi square tests. Multivariable regression analysis adjusted for maternal age, educational level, smoking, parity, maternal diabetes, and preeclampsia was used to assess adverse outcome prevalence for early- late-, and post-term births compared to full-term births.

RESULTS

Deliveries at early-term were associated with an increased prevalence of neonatal jaundice, polyhydramnios, small for gestational age (SGA) status, respiratory support, and neonatal intensive care unit (NICU) admission compared with deliveries at GAs of 39-43 weeks (p < 0.001). Low 5-min Apgar scores and newborn antibiotic treatment occurred at an increased prevalence in both early-term and post-term infants, relative to the full-term group (p < 0.001). The prevalence of oligohydramnios, meconium-stained amniotic fluid, and newborn birth injuries increased with increasing GA.

CONCLUSIONS

More perinatal morbidity was observed among early-term infants compared to infants with later term deliveries, underscoring the need for cautious management of low-risk early-term deliveries.

Indications for, and timing of, planned caesarean section: A systematic analysis of clinical guidelines

BACKGROUND

There has been a worldwide rise in planned caesarean sections over recent decades, with significant variations in practice between hospitals and countries. Guidelines are known to influence clinical decision-making and, potentially, unwarranted clinical variation. The aim of this study was to review guidelines for recommendations in relation to the timing and indications for planned caesarean section as well as recommendations around the process of decision-making.

METHOD

A systematic search of national and international English-language guidelines published between 2008 and 2018 was undertaken. Guidelines were reviewed, assessed in terms of quality and extracted independently by two reviewers.

FINDINGS

In total, 49 guidelines of varying quality were included. There was consistency between the guidelines in potential indications for caesarean section, although guidelines vary in terms of the level of detail. There was substantial variation in timing of birth, for example recommended timing of caesarean section for women with uncomplicated placenta praevia is between 36 and 39weeks depending on the guideline. Only 11 guidelines provided detailed guidance on shared decision-making. In general, national-level guidelines from Australia, and overseas, received higher quality ratings than regional guidelines.

CONCLUSION

The majority of guidelines, regardless of their quality, provide very limited information to guide shared decision-making or the timing of planned caesarean section, two of the most vital aspects of guidance. National guidelines were generally of better quality than regional ones, suggesting these should be used as a template where possible and emphasis placed on improving national guidelines and minimising intra-country, regional, variability of guidelines.

Induction of labour: Experiences of care and decision-making of women and clinicians

BACKGROUND

There has been a rise in induction of labour over recent decades. There is some tension in the literature in relation to when induction is warranted and when not, with variability between guidelines and practice. Given these tensions, the importance of shared decision-making between clinicians and women is increasingly highlighted as paramount, but it remains unclear to what extent this occurs in routine care.

METHOD

Using a scoping review methodology, quantitative and qualitative evidence were considered to answer the research question "What are the views, preferences and experiences of women and clinicians in relation to induction of labour more broadly, and practices of decision-making specifically?" To identify studies, the databases PubMed, Maternity and Infant Care, CINAHL and EMBASE were searched from 2008 to 2018, and reference lists of included studies were examined.

FINDINGS

20 papers met inclusion criteria, in relation to (a) women's preferences, experiences and satisfaction with IOL; (b) women's experience of shared-decision making in relation to induction; (c) interventions that improve shared decision-making and (d) factors that influence decision-making from the perspective of clinicians. Synthesis of the included studies indicates that decision-making in relation to induction of labour is largely informed by medical considerations. Women are not routinely engaged in the decision making process with expectations and preferences largely unmet.

CONCLUSION

There is a need to develop strategies such as decision aids, the redesign of antenatal classes, and clinician communication training to improve the quality of information available to women and their capacity for informed decision-making.

Evaluation of a Tennessee statewide initiative to reduce early elective deliveries using quasi-experimental methods

BACKGROUND

Concerted quality improvement (QI) efforts have been taken to discourage the practice of early elective deliveries (EEDs), but few studies have robustly examined the impact of directed QI interventions in reducing EED practices. Using quasi-experimental methods, we sought to evaluate the impact of a statewide QI intervention to reduce the practice of EEDs.

METHODS

Retrospective cohort study of vital records data (2007 to 2013) for all singleton births occurring ≥36 weeks in 66 Tennessee hospitals grouped into three QI cohorts. We used interrupted-time series to estimate the effect of the QI intervention on the likelihood of an EED birth statewide, and by hospital cohort. We compared the distribution of hospital EED percentages pre- and post-intervention. Lastly, we used multivariable logistic regression to estimate the effect of QI interventions on maternal and infant outcomes.

RESULTS

Implementation of the QI intervention was associated with significant declines in likelihood of EEDs immediately following the intervention (odds ratio, OR = 0.72; p < 0.001), but these results varied by hospital cohort. Hospital risk-adjusted EED percentages ranged from 1.6-13.6% in the pre-intervention period, which significantly declined to 2.2-9.6% in the post-intervention period (p < 0.001). The QI intervention was also associated with significant reductions in operative vaginal delivery and perineal laceration, and immediate infant ventilation, but increased NICU admissions.

CONCLUSIONS

A statewide QI intervention to reduce EEDs was associated with modest but significant declines in EEDs beyond concurrent and national trends, and showed mixed results in related infant and maternal outcomes.

Elective Deliveries and Neonatal Outcomes in Full-Term Pregnancies

Cesarean and induced delivery rates have risen substantially in recent decades and currently account for over one-third and one-fourth of US births, respectively. Initiatives to encourage delaying deliveries until a gestational age of 39 weeks appear to have slowed the increases but have not led to declines. The rates are at historic highs and the consequences of these interventions when not medically necessary have not been systematically explored at the population level. In this study, we used population-level data on births in New Jersey (1997-2011) to document trends in elective deliveries (induced vaginal delivery, cesarean delivery with no labor trial, and cesarean delivery after induction) and estimate logistic and linear regression models of associations between delivery method and neonatal morbidities and cost-related outcomes in low-risk pregnancies. We found that elective deliveries more than doubled during the observation period and were associated with neonatal morbidities and cost-related outcomes even at gestational ages of 39 and 40 weeks. Findings suggest that delaying beyond 39 weeks and avoiding delivery interventions when not medically necessary would improve infant health and reduce health-care costs.

Examining Trends in Obstetric Quality Measures for Monitoring Health Care Disparities

BACKGROUND

Elective delivery (ED) before 39 weeks, low-risk cesarean delivery, and episiotomy are routinely reported obstetric quality measures and have been the focus of quality improvement initiatives over the past decade.

OBJECTIVE

To estimate trends and differences in obstetric quality measures by race/ethnicity.

RESEARCH DESIGN

We used 2008-2014 linked birth certificate-hospital discharge data from New York City to measure ED before 39 gestational weeks (ED <39), low-risk cesarean, and episiotomy by race/ethnicity. Measures were following the Joint Commission and National Quality Forum specifications. Average annual percent change (AAPC) was estimated using Poisson regression for each measure by race/ethnicity. Risk differences (RD) for non-Hispanic black women, Hispanic women, and Asian women compared with non-Hispanic white women were calculated.

RESULTS

ED<39 decreased among whites [AAPC=-2.7; 95% confidence interval (CI), -3.7 to -1.7), while it increased among blacks (AAPC=1.3; 95% CI, 0.1-2.6) and Hispanics (AAPC=2.4; 95% CI, 1.4-3.4). Low-risk cesarean decreased among whites (AAPC=-2.8; 95% CI, -4.6 to -1.0), and episiotomy decreased among all groups. In 2008, white women had higher risk of most measures, but by 2014 incidence of ED<39 was increased among Hispanics (RD=2/100 deliveries; 95% CI, 2-4) and low-risk cesarean was increased among blacks (RD=3/100; 95% CI, 0.5-6), compared with whites. Incidence of episiotomy was lower among blacks and Hispanics than whites, and higher among Asian women throughout the study period.

CONCLUSIONS

Existing measures do not adequately assess health care disparities due to modest risk differences; nonetheless, continued monitoring of trends is warranted to detect possible emergent disparities.

Birth Hospitalization Costs and Days of Care for Mothers and Neonates in California, 2009-2011

OBJECTIVE

To provide population-based estimates of the hospital-related costs of maternal and newborn care, and how these vary by gestational age and birth weight.

STUDY DESIGN

We conducted a retrospective analysis of 2009-2011 California in-hospital deliveries at nonfederal hospitals with the infant and maternal discharge data successfully (96%) linked to birth certificates. Cost-to-charge ratios were used to estimate costs from charges. Physician hospital payments were estimated by mean diagnosis related group-specific reimbursement and costs were adjusted for inflation to December 2017 values. After exclusions for incomplete or missing data, the final sample was 1 265 212.

RESULTS

The mean maternal costs for all in-hospital deliveries was $8204, increasing to $13 154 for late preterm (32-36 weeks) and $22 702 for very preterm (<32 weeks) mothers. The mean cost for all newborns was $6389: $2433 for term infants, $22 102 for late preterm, $223 931 for very preterm infants, and $317 982 for extremely preterm infants (<28 weeks). Preterm infants were 8.1% of cases but incurred 60.9% of costs; for very preterm and extremely preterm infants, these shares were 1.0% and 36.5%, and 0.4% and 20.0%, respectively. Overall, mothers incurred 56% of the total costs during the delivery hospitalization.

CONCLUSIONS

Both maternal and neonatal costs are skewed, with this being much more pronounced for infants. Preterm birth is much more expensive than term delivery, with the additional costs predominately incurred by the infants. The small share of infants who require extensive stays in neonatal intensive care incur a large share of neonatal costs and these costs have increased over time.

Early Elective Delivery Disparities between Non-Hispanic Black and White Women after Statewide Policy Implementation

BACKGROUND

In 2011, Oregon implemented a policy that reduced the state's rate of early (before 39 weeks' gestation) elective (without medical need) births.

OBJECTIVE

This analysis measured differential policy effects by race, examining whether Oregon's policy was associated with changes in non-Hispanic Black-White disparities in early elective cesarean and labor induction.

METHODS

We used Oregon birth certificate data, defining prepolicy (2008-2010) and postpolicy (2012-2014) periods, including non-Hispanic Black and White women who gave birth during these periods (n = 121,272). We used longitudinal spline models to assess policy impacts by race and probability models to measure policy-associated changes in Black-White disparities.

RESULTS

We found that the prepolicy Black-White differences in early elective cesarean (6.1% vs. 4.3%) were eliminated after policy implementation (2.8% vs. 2.5%); adjusted models show decreases in the odds of elective early cesarean among Black women after the policy change (adjusted odds ratio, 0.47; 95% confidence interval, 0.22-1.00; p = .050) and among White women (adjusted odds ratio, 0.79; 95% confidence interval, 0.67-0.93; p = .006). Adjusted probability models indicated that policy implementation resulted in a 1.75-percentage point narrowing (p = .011) in the Black-White disparity in early elective cesarean. Early elective induction also decreased, from 4.9% and 4.7% for non-Hispanic Black and non-Hispanic White women to 3.8% and 2.5%, respectively; the policy was not associated with a statistically significant change in disparities.

CONCLUSIONS

A statewide policy reduced racial disparities in early elective cesarean, but not early elective induction. Attention to differential policy effects by race may reveal changes in disparities, even when that is not the intended focus of the policy.

Shifting Patterns in Cesarean Delivery Scheduling and Timing in Oregon before and after a Statewide Hard Stop Policy

OBJECTIVES

To assess the use and timing of scheduled cesareans and other categories of cesarean delivery and the prevalence of neonatal morbidity among cesareans in Oregon before and after the implementation of Oregon's statewide policy limiting elective early deliveries.

DATA SOURCES

Oregon vital statistics records, 2008-2013.

STUDY DESIGN

Retrospective cohort study, with multivariable logistic regression, regression controlling for time trends, and interrupted time series analyses, to compare the odds of different categories of cesarean delivery and the odds of neonatal morbidity pre- and postpolicy.

DATA COLLECTION/EXTRACTION METHODS

We analyzed vital statistics data on all term births in Oregon (2008-2013), excluding births in 2011.

PRINCIPAL FINDINGS

The odds of early-term scheduled cesareans decreased postpolicy (adjusted odds ratio [aOR], 0.70; 95 percent confidence interval [CI], 0.66-0.74). In the postpolicy period, there were mixed findings regarding assisted neonatal ventilation and neonatal intensive care unit admission, with regression models indicating higher postpolicy odds in some categories, but lower postpolicy odds after controlling for time trends.

CONCLUSIONS

Oregon's hard stop policy limiting elective early-term cesarean delivery was associated with lower odds of cesarean delivery in the category of women who were targeted by the policy; more research is needed on impact of such policies on neonatal outcomes.

Maternity care access, quality, and outcomes: A systems-level perspective on research, clinical, and policy needs

The quality of maternity care in the United States is variable, and access to care is tenuous for rural residents, low-income individuals, and people of color. Without accessible, timely, and high-quality care, certain clinical and sociodemographic characteristics of individuals may render them more vulnerable to poor birth outcomes. However, risk factors for poor birth outcomes do not occur in a vaccum; rather, health care financing, delivery, and organization as well as the policy environment shape the context in which patients seek and receive maternity care. This paper describes the relationship between access and quality in maternity care and offers a systems-level perspective on the innovations and strategies needed in research, clinical care, and policy to improve equity in maternal and infant health.

Perinatal legislative policies and health outcomes

Perinatal epidemiology examines the variation and determinants of pregnancy outcomes from a maternal and neonatal perspective. However, improving public and population health also requires the translation of this evidence base into substantive public policies. Assessing the impact of such public policies requires sufficient data to include potential confounding factors in the analysis, such as coexisting medical conditions and socioeconomic status, and appropriate statistical and epidemiological techniques. This review will explore policies addressing three areas of perinatal medicine-elective deliveries prior to 39 weeks' gestation; perinatal regionalization; and mandatory paid maternity leave policies-to illustrate the challenges when assessing the impact of specific policies at the patient and population level. Data support the use of these policies to improve perinatal health, but with weaker and less certain effect sizes when compared to the initial patient-level studies. Improved data collection and epidemiological techniques will allow for improved assessment of these policies and the identification of potential areas of improvement when translating patient-level studies into public policies.

National Quality Measures in Perinatal Medicine

There are numerous measures of perinatal quality endorsed by national agencies such as the National Quality Forum (NQF). The sheer number of metrics may lead to confusion about what these measures truly assess, and how to interpret variation in these measures across hospitals, health care systems, and geographic regions. This review presents a conceptual model for the numerous validated measures, an overview of the types of measures endorsed for perinatal quality by NQF in 2016, and potential measures absent from endorsement by these national bodies.

Oregon's Hard-Stop Policy Limiting Elective Early-Term Deliveries: Association With Obstetric Procedure Use and Health Outcomes

OBJECTIVE

To evaluate the association of Oregon's hard-stop policy limiting early elective deliveries (before 39 weeks of gestation) and the rate of elective early-term inductions and cesarean deliveries and associated maternal-neonatal outcomes.

METHODS

This was a population-based retrospective cohort study of Oregon births between 2008 and 2013 using vital statistics data and multivariable logistic regression models. Our exposure was the Oregon hard-stop policy, defined as the time periods prepolicy (2008-2010) and postpolicy (2012-2013). We included all term or postterm, cephalic, nonanomalous, singleton deliveries (N=181,034 births). Our primary outcomes were induction of labor and cesarean delivery at 37 or 38 weeks of gestation without a documented indication on the birth certificate (ie, elective early term delivery). Secondary outcomes included neonatal intensive care unit admission, stillbirth, macrosomia, chorioamnionitis, and neonatal death.

RESULTS

The rate of elective inductions before 39 weeks of gestation declined from 4.0% in the prepolicy period to 2.5% during the postpolicy period (P<.001); a similar decline was observed for elective early-term cesarean deliveries (from 3.4% to 2.1%; P<.001). There was no change in neonatal intensive care unit admission, stillbirth, or assisted ventilation prepolicy and postpolicy, but chorioamnionitis did increase (from 1.2% to 2.2%, P<.001; adjusted odds ratio 1.94, 95% confidence interval 1.80-2.09).

CONCLUSIONS

Oregon's statewide policy to limit elective early-term delivery was associated with a reduction in elective early-term deliveries, but no improvement in maternal or neonatal outcomes.

Racial and Ethnic Disparities in the Quality of Health Care

The annual National Healthcare Quality and Disparities Reports document widespread and persistent racial and ethnic disparities. These disparities result from complex interactions between patient factors related to social disadvantage, clinicians, and organizational and health care system factors. Separate and unequal systems of health care between states, between health care systems, and between clinicians constrain the resources that are available to meet the needs of disadvantaged groups, contribute to unequal outcomes, and reinforce implicit bias. Recent data suggest slow progress in many areas but have documented a few notable successes in eliminating these disparities. To eliminate these disparities, continued progress will require a collective national will to ensure health care equity through expanded health insurance coverage, support for primary care, and public accountability based on progress toward defined, time-limited objectives using evidence-based, sufficiently resourced, multilevel quality improvement strategies that engage patients, clinicians, health care organizations, and communities.

Mode of Delivery among HIV-Infected Pregnant Women in Philadelphia, 2005-2013

Objective

Current guidelines call for HIV-infected women to deliver via scheduled Caesarean when the maternal HIV viral load (VL) is >1,000 copies/ml. We describe the mode of delivery among HIV-infected women and evaluate adherence to relevant recommendations.

Study Design

We performed a population-based surveillance analysis of HIV-infected pregnant women in Philadelphia from 2005 to 2013, comparing mode of delivery (vaginal, scheduled Caesarean, or emergent Caesarean) by VL during pregnancy, closest to the time of delivery (≤1,000 copies/ml versus an unknown VL or VL >1,000 copies/ml) and associated factors in multivariable analysis.

Results

Our cohort included 824 deliveries from 648 HIV-infected women, of whom 69.4% had a VL ≤1,000 copies/ml and 30.6% lacked a VL or had a VL >1,000 copies/ml during pregnancy, closest to the time of delivery. Mode of delivery varied by VL: 56.6% of births were vaginal, 30.1% scheduled Caesarean, and 13.3% emergent Caesarean when the VL was ≤1,000 copies/ml; when the VL was unknown or >1,000 copies/ml, 32.9% of births were vaginal, 49.9% scheduled Caesarean and 17.5% emergent Caesarean. In multivariable analyses, Hispanic women (adjusted odds ratio (AOR) 0.17, 95% Confidence Interval (CI) 0.04–0.76) and non-Hispanic black women (AOR 0.27, 95% CI 0.10–0.77) were less to likely to deliver via scheduled Caesarean compared to non-Hispanic white women. Women who delivered prior to 38 weeks’ gestation (AOR 0.37, 95% CI 0.18–0.76) were also less likely to deliver via scheduled Caesarean compared to women who delivered after 38 weeks’ gestation. An interaction term for race and gestational age at delivery was significant in multivariable analysis. Non-Hispanic black (AOR 0.06, 95% CI 0.01–0.36) and Hispanic women (AOR 0.03, 95% CI 0.00–0.59) were more likely to deliver prematurely and less likely to deliver via scheduled C-section compared to non-Hispanic white women. Having a previous Caesarean (AOR 27.77, 95% CI 8.94–86.18) increased the odds of scheduled Caesarean delivery.

Conclusions

Only half of deliveries for women with an unknown VL or VL >1,000 copies/ml occurred via scheduled Caesarean. Delivery prior to 38 weeks, particularly among minority women, resulted in a missed opportunity to receive a scheduled Caesarean. However, even when delivering at or after 38 weeks’ gestation, a significant proportion of women did not get a scheduled Caesarean when indicated, suggesting a need for focused public health interventions to increase the proportion of women achieving viral suppression during pregnancy and delivering via scheduled Caesarean when indicated.