Association between rates of caesarean section and maternal and neonatal mortality in the 21st century: a worldwide population-based ecological study with longitudinal data

At any cost: a paradigm shift in the culture of caesarean section rate monitoring in the United Kingdom

Recent reviews into maternity safety in the United Kingdom (UK) have led to a paradigm shift in culture and policy around caesarean section (CS) rate monitoring. CS rates in the UK have risen considerably over the last few decades and, in this time, there has been national effort at the level of government to kerb such rises due to concerns about the associated morbidity, and the medicalisation of birth. However, recent findings from two landmark reviews raise concerns that the pursuit of low CS rates may have caused harm to patients in some instances, and this has led the UK government to recommend cessation of the use of total CS rates as performance metric for maternity services. Instead, it is proposed that such data be collected with use of the Robson classification. Ongoing appraisal of maternity safety will be required to evaluate the effect of these changes in future.

Comparison of Breastfeeding Success by Mode of Delivery

OBJECTIVE

This article identifies how mode of delivery and the presence of labor affect the initiation and effectiveness of breastfeeding.

STUDY DESIGN

This is a retrospective cohort study of breastfeeding success after vaginal delivery, cesarean section after labor, and scheduled cesarean section in term, singleton deliveries in nulliparous patients at a large academic institution from 2017 to 2018. Exclusion criteria included major postpartum complications requiring admission to the surgical intensive care unit or neonatal intensive care unit, general anesthesia, and major fetal anomalies. Breastfeeding success in the immediate postpartum period, defined as the first 2 to 3 days postpartum prior to hospital discharge, was measured by the presence of breastfeeding, the need for formula supplementation, the average number of breastfeeding sessions per day, the average amount of time spent at each breastfeeding session, the average number of newborn stools and wet diapers produced daily, and the neonatal percentage in weight loss over the first 2 to 3 days of life. Multivariable linear and logistic regression were used to assess the association between mode of delivery and markers of breastfeeding success after adjusting for potential confounders. A Tukey's post hoc analysis with pairwise comparisons was performed to assess differences in breastfeeding outcomes between vaginal delivery, scheduled cesarean section, and cesarean section after labor.

RESULTS

A total of 2,966 women met inclusion criteria during the study period, 1,936 (65.3%) of whom underwent spontaneous vaginal delivery, 415 (14.0%) of whom delivered by scheduled cesarean section, and 615 (20.7%) of whom underwent cesarean section after labor. There were significant differences in maternal age, obesity, race/ethnicity, insurance status, gestational age at delivery, birth weight, and 1-minute Apgar's score less than 7 between vaginal delivery, scheduled cesarean section, and cesarean section after labor. There were also significant differences between indication for oxytocin, type of anesthesia, and postpartum hemorrhage between the three groups. After controlling for these factors, women who underwent vaginal delivery were more likely to have infants with decreased need for formula supplementation (adjusted odds ratio [aOR] = 1.71, 95% confidence interval [CI]: 1.52-1.93) and were less likely to switch from breast to formula feeding (aOR = 1.71, 95% CI: 1.04-1.31) in comparison to women who delivered via cesarean section in labor or scheduled cesarean section. The infants of these women also had an increased number of breastfeeding sessions on average (β = 0.06, p = 0.002), required fewer number of daily formula feedings (β = 0.14, p < 0.001), and experienced a smaller percentage in neonatal weight loss over the first 2 to 3 days of life (β = 0.18, p < 0.001) compared to those born after cesarean section and cesarean section after labor. These women comparatively required less time at each breastfeeding session (β = 0.06, p = 0.005), and produced fewer wet diapers and stools on average (β = 0.12, p < 0.001 and β = 0.12, p < 0.001, respectively). On post hoc analysis with pairwise comparisons, and on separate sensitivity analysis of only women who underwent cesarean delivery, there was no difference in breastfeeding outcome measures between scheduled cesarean section and cesarean section in labor.

CONCLUSION

Women who deliver by cesarean section, despite the presence or absence of labor, are less likely to maintain exclusive breastfeeding postpartum and are more likely to require formula supplementation. These women may need more support with breastfeeding after surgery in order to experience similar benefits for neonatal growth and weight gain.

KEY POINTS

· Women who deliver by cesarean section are less likely to maintain exclusive breastfeeding.. · Women who deliver by cesarean section are more likely to require formula supplementation.. · Women may need more support with breastfeeding after cesarean delivery..

Equivalence between physicians and associate clinicians in the frequency of iatrogenic urogenital fistula following cesarean section in Tanzania and Malawi

BACKGROUND

Physicians and associate (non-physician) clinicians conduct cesarean sections in Tanzania and Malawi. Urogenital fistulas may occur as complications of cesarean section. Location and circumstances can indicate iatrogenic origin as opposed to ischemic injury following prolonged, obstructed labor.

METHODS

This retrospective review assessed the frequency of iatrogenic urogenital fistulas following cesarean sections conducted by either associate clinicians or physicians in Tanzania and Malawi. It focuses on 325 women with iatrogenic fistulas among 1290 women who had fistulas after cesarean birth in Tanzania and Malawi between 1994 and 2017. An equivalence test compared the proportion of iatrogenic fistulas after cesarean sections performed by associate clinicians and physicians (equivalence margin = 0.135). Logistic regression was used to model the occurrence of iatrogenic fistula after cesarean section, controlling for cadre, date, maternal age, previous abdominal surgery and parity.

RESULTS

Associate clinicians attended 1119/1290 (86.7%) cesarean births leading to fistulas, while physicians attended 171/1290 (13.3%). Iatrogenic fistulas occurred in 275/1119 (24.6%) cesarean births by associate clinicians and in 50/171 (29.2%) cesarean births by physicians. The risk difference and 90% confidence interval were entirely contained within an equivalence margin of 13.5%, supporting a conclusion of equivalence between the two cadres. The odds of iatrogenic fistula after cesarean section were not statistically significantly different between associate clinicians and physicians (aOR 0.90; 95% CI 0.61-1.33).

CONCLUSIONS

Associate clinicians appear equivalent to physicians performing cesarean sections in terms of iatrogenic fistula risk. Lower iatrogenic proportions for associate clinicians could reflect different caseloads. The occurrence of iatrogenic fistulas illustrates the importance of appropriate labor management and cesarean section decision-making, irrespective of health provider cadre. Given the noninferior performance and lower costs of employing associate clinicians, other countries with insufficient and/or unequally distributed health workforces could consider task-shifting cesarean sections to associate clinicians.

Using Robson classification to analyze cesarean section and induction rates in relation to changes in the standards of perinatal care in one hospital in Poland

BACKGROUND

Poland has one of the highest cesarean birth (CB) rates in Europe. For this study, we used the Robson Ten-Group Classification System (TGCS) to analyze trends in the induction and CB rates in one hospital in Poland over a period of 11 years. We compare these trends with changes in National Legislative and Medical Guidelines introduced during this time that were aimed at lowering rates of unnecessary medical interventions.

METHODS

We conducted a retrospective study including all births after 24 weeks' gestation between 2010 and 2020 from one tertiary hospital (n = 66,716 births). After the deletion of records with missing data, 66,678 births were included in the analysis. All births were classified according to the Robson TGCS. The size, CB rate, and contribution of each group for every year were calculated. Linear regression analyses were used to analyze trends over time.

RESULTS

The total CB rate varied from 29.6% to 33.0% during the study period, with a linear increase of 0.045 percentage points annually (R2 = 0.021; F(1) = 0.189; p = 0.674). This study was considerably lower than the total CB rate for Poland, which rose from 33.9% in 2010 to 45.1% in 2020, increasing at a rate of 1.13 percentage points per year (R2 = 0.93; F(1) = 61.88; p < 0.001). Induction rates among both nulliparous (R1 + R2) and multiparous (R3 + R4) women at term also increased. Study groups R5 (previous cesarean birth), R2 (nulliparous in induced or prelabor cesarean delivery), and R1 (nulliparous women at term with single cephalic pregnancy in spontaneous labor) were the highest contributors to the overall CB rate. The greatest decrease in the CB rate was detected in group R5b (more than one previous CB). None of the groups showed statistically significant increases in CB rates over the study period.

CONCLUSIONS

The CB rate in the hospital where the study was conducted was considerably lower than the total CB rate in Poland. When compared with countries with similar CB rates, group R2b (women with nulliparous, prelabor cesarean birth) in our study was considerably larger. More comparisons across different hospital settings in Poland are needed. However, as hospitals are not encouraged to routinely collect the data needed to construct TGCS, such comparisons are very difficult to conduct.

Caesarean delivery and neonatal mortality: evidence from selected slums in and around Dhaka city, Bangladesh- A prospective cohort study

BACKGROUND

This study examined the neonatal mortality for newborn of women who delivered by caesarean section or vaginally using a prospective cohort.

METHODS

A total of 6,989 live births registered from 2016 to 2018, were followed for neonatal survival from the selected slums of Dhaka (North and South) and Gazipur city corporations, where icddr,b maintained the Health and Demographic Surveillance System (HDSS). Neonatal mortality was compared by maternal and newborn characteristics and mode of delivery using z-test. Logistic regression model performed for neonatal mortality by mode of delivery controlling selected covariates and reported adjusted odd ratios (aOR) with 95% confidence interval (CI).

RESULTS

Out of 6,989 live births registered, 27.7% were caesarean and the rest were vaginal delivery; of these births, 265 neonatal deaths occurred during the follow-up. The neonatal mortality rate was 2.7 times higher (46 vs. 17 per 1,000 births) for vaginal than caesarean delivered. Until 3rd day of life, the mortality rate was very high for both vaginal and caesarean delivered newborn; however, the rate was 24.8 for vaginal and 6.3 per 1,000 live births for caesarean delivered on the 1st day of life. After adjusting the covariates, the odds of neonatal mortality were higher for vaginal than caesarean delivered (aOR: 2.63; 95% CI: 1.82, 3.85). Additionally, the odds were higher for adolescent than elderly adult mother (aOR: 1.60; 95% CI: 1.03, 2.48), for multiple than singleton birth (aOR: 5.40; 95% CI: 2.82, 10.33), for very/moderate (aOR: 5.13; 95% CI: 3.68, 7.15), and late preterm birth (aOR: 1.48; 95% CI: 1.05, 2.08) than term birth; while the odds were lower for girl than boy (aOR: 0.74; 95% CI: 0.58, 0.96), and for 5th wealth quintile than 1st quintile (aOR: 0.59, 95% CI: 0.38, 0.91).

CONCLUSION

Our study found that caesarean delivered babies had significantly lower neonatal mortality than vaginal delivered. Therefore, a comprehensive delivery and postnatal care for vaginal births needed a special attention for the slum mothers to ensure the reduction of neonatal mortality.

Caesarean section delivery rates and associated factors in a faith-based referral hospital in Ghana: A retrospective analysis

INTRODUCTION

The global incidence of caesarean section (CS) deliveries has exceeded the recommended threshold set by the World Health Organization. This development is a matter of public health concern due to the cost involved and the potential health risk to the mother and the neonate. We sought to investigate the prevalence, indications, maternal and neonatal outcomes and determinants of CS in private health facilities in Ghana.

METHOD

A retrospective cross-sectional analysis was conducted using data from women who delivered at the Holy Family Hospital from January to February 2020 using descriptive and inferential statistics, with a significance level set at p<0.05.

RESULTS

The prevalence of CS was 28.70%. The primary indications of C/S include previous C/S, foetal distress, breech presentation, pathological CTG and failed induction. Significant associations were found between CS and breech presentation (AOR = 4.60; 95%CI: 1.22-17.38) p<0.024, previous CS history (AOR = 51.72, 95% CI: 11.59-230.70) p<0.00, and neonates referred to NICU (AOR = 3.67, 95% CI: 2.10-6.42) p<0.00.

CONCLUSION

The prevalence of caesarean section (CS) deliveries was higher than the WHO-recommended threshold. Major indications for CS included previous CS, fetal distress, and failed induction. Significant risk factors for CS were previous CS history, breech presentation, and neonates referred to NICU.

An implementation analysis of a quality improvement project to reduce cesarean section in Brazilian private hospitals

BACKGROUND

Brazil has one of the highest prevalence of cesarean sections in the world. The private health system is responsible for carrying out most of these surgical procedures. A quality improvement project called Adequate Childbirth Project ("Projeto Parto Adequado"- PPA) was developed to identify models of care for labor and childbirth, which place value on vaginal birth and reduce the frequency of cesarean sections without a clinical indication. This research aims to evaluate the implementation of PPA in private hospitals in Brazil.

METHOD

Evaluative hospital-based survey, carried out in 2017, in 12 private hospitals, including 4,322 women. We used a Bayesian network strategy to develop a theoretical model for implementation analysis. We estimated and compared the degree of implementation of two major driving components of PPA-"Participation of women" and "Reorganization of care" - among the 12 hospitals and according to type of hospital (belonging to a health insurance company or not). To assess whether the degree of implementation was correlated with the rate of vaginal birth data we used the Bayesian Network and compared the difference between the group "Exposed to the PPA model of care" and the group "Standard of care model".

RESULTS

PPA had a low degree of implementation in both components "Reorganization of Care" (0.17 - 0.32) and "Participation of Women" (0.21 - 0.34). The combined implementation score was 0.39-0.64 and was higher in hospitals that belonged to a health insurance company. The vaginal birth rate was higher in hospitals with a higher degree of implementation of PPA.

CONCLUSION

The degree of implementation of PPA was low, which reflects the difficulties in changing childbirth care practices. Nevertheless, PPA increased vaginal birth rates in private hospitals with higher implementation scores. PPA is an ongoing quality improvement project and these results demonstrate the need for changes in the involvement of women and the care offered by the provider.

An Analysis of the Mode of Delivery, Risk Factors, and Subgroups with High Caesarean Birth Rates Using Robson Classification System

OBJECTIVE

We aimed to understand the utilization of the mode of delivery and related risk factors. Further aimed to apply the Robson classification system to evaluate the data quality and analyze the CS rates in subgroups.

METHODS

We conducted a retrospective descriptive study by reviewing the medical records of all women who delivered at the State Hospital in 2019. A proforma was developed for extracting data from patient records. All women with six obstetric parameters were categorized into Robson groups to determine the absolute and relative contributions of each group to the overall CS rate.

RESULTS

Of 797 deliveries, 401 (50.2%) were CSs. Being older, being Turkish Cypriot, having preterm births, previous CS, multiple fetuses, and having breech or transverse fetal presentations were related to having higher risks of CS. The most common medical indication for CSs (52.3%) was a history of previous CSs. Robson Group 5 contributed the most (50.7%) to the overall CS rate, with the highest absolute contribution of 21.8%. Group 10 and Group 8 were the second and third highest contributors to the overall CS rate, with relative contributions of 25.3% and 9.0%, respectively.

CONCLUSIONS

Findings revealed the substandard quality of obstetric data and a noticeably high overall CS rate. The top priority should be given to improving the quality of medical records. It underscored the necessity of implementing the Robson classification system as a standard clinical practice to enhance data quality, which helps to effectively evaluate and monitor the CS rates in obstetric populations.

Effect of prior cesarean delivery on the outcomes of intracytoplasmic sperm injection

OBJECTIVE

This study was conducted to investigate the impact of previous delivery mode on pregnancy outcomes in patients with secondary infertility after frozen-thawed embryo transfer.

METHODS

This prospective observational study included 140 patients experiencing secondary infertility. Of these, 70 patients had a previous cesarean delivery (CD), while the remaining 70 patients had a previous normal vaginal delivery (NVD). The primary outcome was the implantation rate. The secondary outcomes included rates of clinical pregnancy, chemical pregnancy, miscarriage, and ectopic pregnancy.

RESULTS

The comparison of all fertility outcomes between the two groups revealed no statistically significant differences. The implantation rate was 40.4% in the CD group and 41.7% in the NVD group (p=0.842). The clinical pregnancy rate was 50% in the CD group and 49.3% in the NVD group (p=0.932), while the chemical pregnancy rate was 14.6% in the CD group and 19% in the NVD group (p=0.591). The miscarriage rates in the CD and NVD groups were 20% and 17.6%, respectively (p=0.803). One case of tubal ectopic pregnancy occurred in the NVD group (1.4%).

CONCLUSION

The mode of prior delivery did not significantly impact pregnancy outcomes following frozen-thawed embryo transfer.

The RETHINK Study: Could pain catastrophising explain why some women are more likely to attend hospital during the latent phase of labour

OBJECTIVE

To examine the prevalence of pain catastrophising and identify whether it impacts on the timing of hospital admission when in labour.

METHODS

A longitudinal cohort study. Nulliparous women, experiencing an uncomplicated pregnancy in England, were recruited between 25 and 33 weeks gestation. Participants completed two online questionnaires, (1) on recruitment, including the Pain Catastrophizing Scale (PCS) and the Wijma Delivery Expectancy Questionnaire (WDEQ-A) (2) at three weeks postnatal.

RESULTS

A total of 389 eligible participants entered the study. The percentage of women who were pain catastrophisers (PCS ≥ 20) was 28.1 %, while 7.6 % had a high pain catastrophising score (PCS ≥ 30). There was no association between pain catastrophising and the timing of hospital admission. The percentage of women reporting fear of childbirth (WDEQ-A score of ≥ 85) was 10.6 %. Fear of childbirth was highly associated with PCS scores (p <.001) at both the lower (≥20) and higher (≥30) thresholds.

CONCLUSION

Although not statistically significant, there was a tendency for women who pain catastrophise to present to hospital in the latent phase. The highly significant association between PCS and WDEQ-A scores has implications for the identification of these women and suggests that the PCS can be used as a screening tool to identify those women who have heightened fear around pain and who may also go on to develop clinically relevant fear of childbirth. Further studies are needed to confirm the acceptability of the PCS as a screening tool with women.

EUROPEAN ASSOCIATION OF PERINATAL MEDICINE (EAPM) EUROPEAN MIDWIVES ASSOCIATION (EMA) Joint position statement: Caesarean delivery rates at a country level should be in the 15-20 % range

While cesarean deliveries performed for health indications can save lives, unnecessary cesareans cause unjustifiable health risks for the mother, newborn, and for future pregnancies. Previous recommendations for cesarean delivery rates at a country level in the 10-15% range are currently unrealistic, and the proposed concept that striving to achieve specific rates is not important has resulted in a confusing message reaching healthcare professionals and the public. It is important to have a clear understanding of when cesarean delivery rates are deviating from internationally acceptable ranges, to trigger the implementation of healthcare policies needed to correct this problem. Based on currently existing scientific evidence, we recommend that cesarean delivery rates at a country level should be in the 15-20% range. This advice is based on the demonstration of decreased maternal and neonatal mortalities when national cesarean delivery rates rise to circa 15%, but values exceeding 20% are not associated with further benefits. It is also based on real-world experiences from northern European countries, where cesarean delivery rates in the 15-20% range are associated with some of the best maternal and perinatal quality indicators in the world. With the increase in cesarean delivery rates projected for the coming years, experience in provision of intrapartum care may come under threat in many hospitals, and recovering from this situation is likely to be a major challenge. Professional and scientific societies, together with healthcare authorities and governments need to prioritize actions to reverse the upward trend in cesarean delivery rates observed in many countries, and to strive to achieve values as close as possible to the recommended range.

Maternal health surveillance panel: a tool for expanding epidemiological surveillance of women's health and its determinants

OBJECTIVE

To present the methodology used in the development of two products for maternal health surveillance and its determinants and discuss their possible uses.

METHODS

Based on a theoretical model of the determinants of maternal death and databases of Brazilian health information systems, two free products were developed: an interactive panel "surveillance of maternal health" and an educational material "Aparecida: a story about the vulnerability of Brazilian women to maternal death", both available on the website of the Brazilian Obstetric Observatory.

RESULTS

More than 30 indicators were calculated for the period 2012-2020, containing information on socioeconomic conditions and access to health services, reproductive planning, prenatal care, delivery care, conditions of birth and maternal mortality and morbidity. The indicators related to severe maternal morbidity in public hospitalizations stand out, calculated for the first time for the country. The panel allows analysis by municipality or aggregated by health region, state, macro-region and country; historical series analysis; and comparisons across locations and with benchmarks. Information quality data are presented and discussed in an integrated manner with the indicators. In the educational material, visualizations with national and international data are presented, aiming to help in the understanding of the determinants of maternal death and facilitate the interpretation of the indicators.

CONCLUSION

It is expected that the two products have the potential to expand epidemiological surveillance of maternal health and its determinants, contributing to the formulation of health policies and actions that promote women's health and reduce maternal mortality.

The impact of a trial of labor after cesarean versus elective repeat cesarean delivery: A meta-analysis

BACKGROUND

The increasing global incidence of cesarean section has prompted efforts to reduce cesarean delivery rates. A trial of labor after cesarean (TOLAC) has emerged as an alternative to elective repeat cesarean delivery (ERCD) for women with a prior cesarean delivery. However, the available evidence on the comparative outcomes of these 2 options remains inconsistent, primarily due to varying advantages and risks associated with each. Our meta-analysis aims to compare the maternal-neonatal results in TOLAC and ERCD in women with prior cesarean deliveries.

METHODS

A comprehensive search was performed in PubMed, Embase, Cochrane library databases up to September,2022 to identity studies evaluating perinatal outcomes in women who underwent TOLAC compared to ERCD following a previous cesarean delivery. The included studies were subjected to meta-analysis using RevMan 5.3 software to assess the overall findings.

RESULTS

A total of 13 articles were included in this meta-analysis. Statistically significant differences were identified in the rate of uterine rupture (OR = 2.01,95%CI = 1.48-2.74, P < .00001) and APGAR score < 7 at 5 minutes (OR = 2.17,95%CI = 1.69-2.77, P < .00001) between the TOLAC and ERCD groups. However, no significant differences were observed in the rates of hysterectomy, maternal blood transfusion, postpartum infection, postpartum hemorrhage and neonatal intensive care unit (P ≥ .05) admission between the 2 groups.

CONCLUSIONS

Our analysis revealed that TOLAC is associated with a higher risk of uterine rupture and lower incidence APGAR score < 7 at 5 minutes compared to ERCD. It is vital to consider predictive factors when determining the appropriate mode of delivery in order to ensure optimal pregnancy outcomes. Efforts should be made to identify the underlying causes of adverse outcomes and implement safety precautions to select suitable participants and create safe environments for TOLAC.

To Determine the Quality of Life in Indian Women After Peripartum Hysterectomy Using a Hindi Version of the SF-36 Questionnaire

Objective

The objective of the study was to determine the quality of life in women after peripartum hysterectomy using a Hindi version of the SF-36 questionnaire.

Background

There are long-term effects on quality of life in women after peripartum hysterectomy. The effects on physical, mental, and social functioning have a prolonged recovery. No studies have been done in Indian women after peripartum hysterectomy to evaluate quality of life.

Methods

Patients who underwent peripartum hysterectomy from January 2017 to May 2021 were contacted to participate in the study. To determine the quality of life post-surgery, a Hindi version of the 36-item Short-Form Health Survey (SF-36) was used for a face-to-face personal interview-based assessment. The participants were divided into two groups based on the duration between surgery and the interview. The aggregate scores for the eight components of SF-36 were calculated, and responses were analyzed.

Results

Out of the 138 post-hysterectomy women, 118 were enrolled in the study. Women who could not be contacted [14 (10.14%)] and those who died post-procedure [6 (4.35%)] were excluded. Out of the total, 43 assessed participants were within 2 years of surgery, and 75 were after 2 years of surgery. The group that was assessed after 2 years of surgery had a significantly lower quality of life in six, out of the eight aspects of SF-36 domains.

Conclusion

Women after peripartum hysterectomy undergo a prolonged recovery phase with effects on physical, mental, and social functioning. A multi-disciplinary long-term follow-up including physiotherapy and psychotherapy is required and that should be guided by a dedicated clinical team.

Inequalities in use of hospitals for childbirth among rural women in sub-Saharan Africa: a comparative analysis of 18 countries using Demographic and Health Survey data

INTRODUCTION

Rising facility births in sub-Saharan Africa (SSA) mask inequalities in higher-level emergency care-typically in hospitals. Limited research has addressed hospital use in women at risk of or with complications, such as high parity, linked to poverty and rurality, for whom hospital care is essential. We aimed to address this gap, by comparatively assessing hospital use in rural SSA by wealth and parity.

METHODS

Countries in SSA with a Demographic and Health Survey since 2015 were included. We assessed rural hospital childbirth stratifying by wealth (wealthier/poorer) and parity (nulliparity/high parity≥5), and their combination. We computed percentages, 95% CIs and percentage-point differences, by stratifier level. To compare hospital use across countries, we produced a composite index, including six utilisation and equality indicators.

RESULTS

This cross-sectional study included 18 countries. In all, a minority of rural women used hospitals for childbirth (2%-29%). There were disparities by wealth and parity, and poorer, high-parity women used hospitals least. The poorer/wealthier difference in utilisation among high-parity women ranged between 1.3% (Mali) and 13.2% (Rwanda). We found use and equality of hospitals in rural settings were greater in Malawi and Liberia, followed by Zimbabwe, the Gambia and Rwanda.

DISCUSSION

Inequalities identified across 18 countries in rural SSA indicate poor, higher-risk women of high parity had lower use of hospitals for childbirth. Specific policy attention is urgently needed for this group where disadvantage accumulates.

How does hospital organisation influence the use of caesarean sections in low- and middle-income countries? A cross-sectional survey in Argentina, Burkina Faso, Thailand and Vietnam for the QUALI-DEC project

BACKGROUND

Improving the understanding of non-clinical factors that lead to the increasing caesarean section (CS) rates in many low- and middle-income countries is currently necessary to meet the challenge of implementing effective interventions in hospitals to reverse the trend. The objective of this study was to study the influence of organizational factors on the CS use in Argentina, Vietnam, Thailand and Burkina Faso.

METHODS

A cross-sectional hospital-based postpartum survey was conducted in 32 hospitals (8 per country). We selected women with no potential medical need for CS among a random sample of women who delivered at each of the participating facilities during the data collection period. We used multilevel multivariable logistic regression to analyse the association between CS use and organizational factors, adjusted on women's characteristics.

RESULTS

A total of 2,092 low-risk women who had given birth in the participating hospitals were included. The overall CS rate was 24.1%, including 4.9% of pre-labour CS and 19.3% of intra-partum CS. Pre-labour CS was significantly associated with a 24-hour anaesthetist dedicated to the delivery ward (ORa = 3.70 [1.41; 9.72]) and with the possibility to have an individual room during labour and delivery (ORa = 0.28 [0.09; 0.87]). Intra-partum CS was significantly associated with a higher bed occupancy level (ORa = 1.45 [1.09; 1.93]): intrapartum CS rate would increase of 6.3% points if the average number of births per delivery bed per day increased by 10%.

CONCLUSION

Our results suggest that organisational norms and convenience associated with inadequate use of favourable resources, as well as the lack of privacy favouring women's preference for CS, and the excessive workload of healthcare providers drive the CS overuse in these hospitals. It is also crucial to enhance human and physical resources in delivery rooms and the organisation of intrapartum care to improve the birth experience and the working environment for those providing care.

TRIAL REGISTRATION

The QUALI-DEC trial is registered on the Current Controlled Trials website ( https://www.isrctn.com/ ) under the number ISRCTN67214403.

Cesarean section rate: navigating the gap between WHO recommended range and current obstetrical challenges

The cesarean section (CS) rate is very heterogeneous all over the world, reflecting the differences in the access to healthcare services. In higher-income countries, changes observed in the obstetrical population brought to an increased rate of cesarean section for maternal request. Besides, clinicians are facing an increasing number of induction of labor, with the consequent risk of CS if the management is inappropriate. Analyzing the rate of primary CS, the interpretation of intrapartum CTG and a tailored management of labor are also red flags that must be considered. In this optic, the implementation of obstetrics training and simulation programs and the improvement of clinical protocols with the latest evidence can lead to the reduction of unnecessary CS.

Making the cut on caesarean section: a logistic regression analysis on factors favouring caesarean sections without medical indication in comparison to spontaneous vaginal birth

BACKGROUND

In the absence of medical necessity, opting for caesarean sections exposes mothers and neonates to increased risks of enduring long-term health problems and mortality. This ultimately results in greater economic burden when compared to the outcomes of spontaneous vaginal births. In Switzerland around 33% of all births are by caesarean section. However, the rate of caesarean sections without medical indication is still unknown. Therefore, we devise an identification strategy to differentiate caesarean sections without medical indication using routine data. In addition, we aim to categorize the influencing factors for women who undergo spontaneous vaginal births as opposed to those with caesarean sections without medical indication.

METHOD

We use Swiss Federal Statistics data including 98.3% of all women giving birth from 2014 to 2018. To determine non-medically indicated caesarean sections in our dataset, we base our identification strategy on diagnosis-related groups, diagnosis codes, and procedure classifications. Subsequently, we compare characteristics of women who give birth by non-medically CS and external factors such as the density of practicing midwives to women with spontaneous vaginal birth. Logistic regression analysis measures the effect of factors, such as age, insurance class, income, or density of practicing midwives on non-medically indicated caesarean sections.

RESULTS

Around 8% of all Swiss caesarean sections have no medical indication. The regression analysis shows that higher age, supplemental insurance, higher income, and living in urban areas are associated with non-medically indicated caesarean sections, whereas a higher density of midwives decreases the likelihood of caesarean sections without medical indication.

CONCLUSIONS

By identifying non-medically indicated caesarean sections using routine data, it becomes feasible to gain insights into the characteristics of impacted mothers as well as the external factors involved. Illustrating these results, our recommendation is to revise the incentive policies directed towards healthcare professionals. Among others, future research may investigate the potential of midwife-assisted pregnancy programs on strengthening spontaneous vaginal births in absence of medical complications.

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.

A bit of medical paternalism? A qualitative study on power relations between women and healthcare providers when deciding on mode of birth in five public maternity wards of Argentina

BACKGROUND

Whether women should be able to decide on mode of birth in healthcare settings has been a topic of debate in the last few decades. In the context of a marked increase in global caesarean section rates, a central dilemma is whether pregnant women should be able to request this procedure without medical indication. Since 2015, Law 25,929 of Humanised Birth is in place in Argentina. This study aims at understanding the power relations between healthcare providers, pregnant women, and labour companions regarding decision-making on mode of birth in this new legal context. To do so, central concepts of power theory are used.

METHODS

This study uses a qualitative design. Twenty-six semi-structured interviews with healthcare providers were conducted in five maternity wards in different regions of Argentina. Participants were purposively selected using heterogeneity sampling and included obstetrician/gynaecologists (heads of department, specialists working in 24-h shifts, and residents) and midwives where available. Reflexive thematic analysis was used to inductively develop themes and categories.

RESULTS

Three themes were developed: (1) Healthcare providers reconceptualize decision-making processes of mode of birth to make women's voices matter; (2) Healthcare providers feel powerless against women's request to choose mode of birth; (3) Healthcare providers struggle to redirect women's decision regarding mode of birth. An overarching theme was built to explain the power relations between healthcare providers, women and labour companions: Healthcare providers' loss of beneficial power in decision-making on mode of birth.

CONCLUSIONS

Our analysis highlights the complexity of the healthcare provider-woman interaction in a context in which women are, in practice, allowed to choose mode of birth. Even though healthcare providers claim to welcome women being an active part of the decision-making processes, they feel powerless when women make autonomous decisions regarding mode of birth. They perceive themselves to be losing beneficial power in the eyes of patients and consider fruitful communication on risks and benefits of each mode of birth to not always be possible. At the same time, providers perform an increasing number of CSs without medical indication when it is convenient for them, which suggests that paternalistic practices are still in place.

Determinants of Neonatal Mortality in the United States

Introduction Despite a notable reduction in infant mortality over recent decades, the United States, with a rate of 5.8 deaths per 1,000 live births, still ranks unfavorably compared to other developed countries. This improvement appears inadequate when contrasted with the country's healthcare spending, the highest among developed nations. A significant proportion of this infant mortality rate can be attributed to neonatal fatalities. Objective The present study aimed to determine the risk factors associated with neonatal deaths in the United States. Method Using the United States Vital Statistics records, we conducted a retrospective study on childbirths between 2015 and 2019 to identify risk factors for neonatal mortality. Our final multivariate analysis included maternal parameters like age, insurance type, education level, cesarean section rate, pregnancy inductions and augmentations, weight gain during pregnancy, birth weight, number of prenatal visits, pre-existing conditions like chronic hypertension and prediabetes, and pregnancy complications like gestational diabetes mellitus (GDM). These variables were incorporated to enhance our model's sensitivity and specificity. Result There were 51,174 neonatal mortalities. Mothers with augmentation of labor had a 25% reduction in neonatal mortalities (NM) (OR=0.75; 95% CI 0.72-0.79), while labor induction was associated with a 31% reduction in NM (OR=0.69; 95% CI 0.66-0.72). Women above 40 years had a 29% increase in NM rate (OR=1.29;95% CI 1.15-1.44). Women without prenatal care have a 22% increase in the risk of NM (OR=1.22; 95% CI 1.14-1.30). The present model has a 60.7% sensitivity and a 99.9% specificity. Conclusion In the present study, significant interventions such as labor induction, augmentation, and prenatal care were associated with improved neonatal outcomes. These findings could serve as an algorithm for improving neonatal outcomes in the United States.

Can the Day of the Week and the Time of Birth Predict the Mode of Delivery According to Robson Classification?

Worldwide, the cesarean section rate has steadily increased from 6.7% in 1990 to 21.1% in 2018 and is expected to rise even more. The World Health Organization propose the adoption of the Robson classification system as a global standard for monitoring, evaluating, and comparing delivery rates. The purpose of the current study is to use the Robson classification system to investigate how, independently of medical factors, the day of the week and time of delivery may be related to the mode of birth. In the sample analysis, we included the records of 8572 women giving birth in one private health facility in Greece. Over 60% of deliveries during the study period were performed by cesarean section, 30.6% by vaginal delivery, and 8.5% of deliveries were performed by operative vaginal delivery. The results of this study indicate that the lowest birth rates are observed on Monday, Saturday, and Sunday. Nulliparous women with no previous cesarean delivery, with a singleton in cephalic presentation ≥37 weeks with spontaneous labor (group 1) are 73% more likely to deliver by cesarean section between 08:00 A.M. and 03:59 P.M. compared to those who give birth between 12:00 A.M. and 07:59 A.M. Also, multiparous women with a single cephalic term pregnancy and one previous cesarean section (group 5.1) are 16.7 times more likely to deliver by cesarean section in the morning compared to overnight deliveries. These results point out two non-clinical variables that influences the CS rate. The Robson classification system was a useful tool for the above comparisons.

Spatial distribution of caesarean deliveries and their determinants in Bangladesh: evidence from linked data of population and health facility survey

Background

Health facility-level factors play a crucial role in women's access to and use of caesarean section (CS) services, but lacks relevant evidence. The study aimed to understand the effects of health facility-level factors on CS delivery in Bangladesh.

Methods

The 2017-18 Bangladesh Demographic and Health Survey (2017-18 BDHS) and the 2017 Bangladesh Health Facility Survey (2017 BHFS) were linked and analysed in this study. The sample comprised of 4954 women gave at least one live birth within three years preceding the survey. The outcome variable was delivery through CS (yes, no) and the explanatory variables were health facility-level, individual-level, household-level, and community-level factors. Moran's I and Getis-Ord General G statistic were used to identify the hotspots of delivery through CS. Mixed-effect multilevel logistic regression was used to examine the association of the outcome variable with explanatory variables.

Findings

Around 33% of women in Bangladesh underwent CS in their most recent pregnancies. The hotspots of delivery through CS are located primarily in Rajshahi, Dhaka, and Khulna divisions. The likelihood of delivered through CS increased with the rising scores of the management (Adjusted Odds Ratio (AOR), 1.83; 95% CI 1.04-2.07) and infrastructure (AOR, 3.14; 95% CI 1.40-5.12) of the nearest health facility. The readiness of health facilities to provide comprehensive obstetric care was significantly associated with an increased likelihood of delivery through CS (AOR, 2.18; 95% CI 1.15-3.28). These relationships were strong for private than non-government and government health facilities.

Interpretation

The proximity of comprehensive obstetric care facilities to women's residences and their readiness to provide services play critical roles in the access to and use of CS in Bangladesh. The findings highlight the importance of necessary healthcare personnel, including midwives, availability of government hospitals where undue CS are avoided, and awareness-building programmes about the adverse effects of CS delivery.

Funding

None.

Machine learning applied in maternal and fetal health: a narrative review focused on pregnancy diseases and complications

Introduction

Machine learning (ML) corresponds to a wide variety of methods that use mathematics, statistics and computational science to learn from multiple variables simultaneously. By means of pattern recognition, ML methods are able to find hidden correlations and accomplish accurate predictions regarding different conditions. ML has been successfully used to solve varied problems in different areas of science, such as psychology, economics, biology and chemistry. Therefore, we wondered how far it has penetrated into the field of obstetrics and gynecology.

Aim

To describe the state of art regarding the use of ML in the context of pregnancy diseases and complications.

Methodology

Publications were searched in PubMed, Web of Science and Google Scholar. Seven subjects of interest were considered: gestational diabetes mellitus, preeclampsia, perinatal death, spontaneous abortion, preterm birth, cesarean section, and fetal malformations.

Current state

ML has been widely applied in all the included subjects. Its uses are varied, the most common being the prediction of perinatal disorders. Other ML applications include (but are not restricted to) biomarker discovery, risk estimation, correlation assessment, pharmacological treatment prediction, drug screening, data acquisition and data extraction. Most of the reviewed articles were published in the last five years. The most employed ML methods in the field are non-linear. Except for logistic regression, linear methods are rarely used.

Future challenges

To improve data recording, storage and update in medical and research settings from different realities. To develop more accurate and understandable ML models using data from cutting-edge instruments. To carry out validation and impact analysis studies of currently existing high-accuracy ML models.

Conclusion

The use of ML in pregnancy diseases and complications is quite recent, and has increased over the last few years. The applications are varied and point not only to the diagnosis, but also to the management, treatment, and pathophysiological understanding of perinatal alterations. Facing the challenges that come with working with different types of data, the handling of increasingly large amounts of information, the development of emerging technologies, and the need of translational studies, it is expected that the use of ML continue growing in the field of obstetrics and gynecology.

Mise à jour technique N° 436 : Classification des césariennes au Canada : Critères de Robson modifiés

OBJECTIF

Décrire et promouvoir l'utilisation d'un système de classification universel de la césarienne au Canada.

POPULATION CIBLE

Les femmes enceintes devant subir une césarienne. BéNéFICES, RISQUES ET COûTS: L'utilisation d'un système de classification normalisé de la césarienne permet de comparer les taux de césariennes et tendances aux échelles locale, régionale, nationale et internationale. Le système inclusif et simple à mettre en œuvre repose sur des bases de données existantes. DONNéES PROBANTES: La revue exhaustive de la littérature a été mise à jour pour tenir compte des articles publiés jusqu'en avril 2022; les articles ont été répertoriés à partir de mots clés et de termes MeSH (cesarean section, classification, taxonomy, nomenclature, terminology) dans les bases de données PubMed-Medline et Embase. Seuls les résultats de revues systématiques, d'essais cliniques randomisés, d'essais cliniques et d'études observationnelles ont été retenus. D'autres publications ont été répertoriées par consultation des références d'articles intégraux pertinents. La littérature grise a été examinée en recherchant sur les sites Web d'organismes de santé. MéTHODES DE VALIDATION: Les auteures ont évalué la qualité des données probantes et la force des recommandations en utilisant le cadre méthodologique GRADE (Grading of Recommendations, Assessment, Development, and Evaluation). Voir l'annexe A en ligne (tableau A1 pour les définitions et tableau A2 pour l'interprétation des recommandations fortes et conditionnelles [faibles]). Le conseil d'administration de la SOGC a approuvé la version définitive aux fins de publication. PROFESSIONNELS CONCERNéS: Fournisseurs de soins obstétricaux, administrateurs des services de santé, épidémiologistes.

RECOMMANDATIONS

Technical Update No. 436: Classification of Cesarean Deliveries in Canada: The Modified Robson Criteria

OBJECTIVE

To describe and advocate for the use of a common classification system for cesarean delivery in Canada.

TARGET POPULATION

Pregnant individuals undergoing cesarean delivery.

BENEFITS, HARMS, COSTS

Use of a standardized classification system for cesarean delivery allows for local, regional, national, and international comparison of cesarean delivery rates and trends. The system is inclusive and simple to implement, based on existing databases.

EVIDENCE

A comprehensive literature review was updated to April 2022 with medical subject headings (MeSH) and keywords (cesarean section, classification, taxonomy, nomenclature, terminology) in MEDLINE/PubMed and Embase databases. Results were restricted to systematic reviews, randomized controlled trials and clinical trials, and observational studies. Additional literature was identified by backward citation tracking using relevant full-text articles. The grey literature was reviewed by searching websites of health agencies.

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendation using the Grade of Recommendations, Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretation of strong and conditional [weak] recommendations).The Board of the SOGC approved the final draft for publication.

INTENDED AUDIENCE

Obstetric care providers, health care administrators, epidemiologists.

RECOMMENDATIONS

Global increased cesarean section rates and public health implications: A call to action

Over the years; global caesarian section (CS) rates have significantly increased from around 7% in 1990 to 21% today surpassing the ideal acceptable CS rate which is around 10%-15% according to the WHO. However, currently, not all CS are done for medical reasons with rapidly increasing rate of nonmedically indicated CS and the so-called "caesarian on maternal request." These trends are projected to continue increasing over this current decade where both unmet needs and overuse are expected to coexist with the projected global rate of 29% by 2030. CS reduces both maternal and neonatal morbidity and mortality significantly when it is done under proper indications while at the same time, it can be of harm to the mother and the child when performed contrary. The later exposes both the mother and the baby to a number of unnecessary short and long-term complications and increase the chances of developing different noncommunicable diseases and immune-related conditions among babies later in life. The implications of lowering SC rate will ultimately lower healthcare expenditures. This challenge can be addressed by several ways including provision of intensive public health education regarding public health implications of increased CS rate. Assisted vaginal delivery approaches like the use of vacuum and forceps and other methods should be considered and encouraged during delivery as long as their indications for implementation are met. Conducting frequent external review and audits to the health facilities and providing feedback regarding the rates of CS deliveries can help to keep in check the rising CS trends as well as identifying the settings with unmet surgical needs. Moreover, the public especially expectant mothers during clinic visits and clinicians should be educated and be informed on the WHO recommendations on nonclinical interventions towards reduction of unnecessary CS procedures.

The Pathophysiology of Labor Dystocia: Theme with Variations

Abnormally prolonged labor, or labor dystocia, is a common complication of parturition. It is the indication for about half of unplanned cesarean deliveries in low-risk nulliparous women. Reducing the rate of unplanned cesarean birth in the USA has been a public health priority over the last two decades with limited success. Labor dystocia is a complex disorder due to multiple causes with a common clinical outcome of slow cervical dilation and fetal descent. A better understanding of the pathophysiologic mechanisms of labor dystocia could lead to new clinical opportunities to increase the rate of normal vaginal delivery, reduce cesarean birth rates, and improve maternal and neonatal health. We conducted a literature review of the causes and pathophysiologic mechanisms of labor dystocia. We summarize known mechanisms supported by clinical and experimental data and newer hypotheses with less supporting evidence. We review recent data on uterine preparation for labor, uterine contractility, cervical preparation for labor, maternal obesity, cephalopelvic disproportion, fetal malposition, intrauterine infection, and maternal stress. We also describe current clinical approaches to preventing and managing labor dystocia. The variation in pathophysiologic causes of labor dystocia probably limits the utility of current general treatment options. However, treatments targeting specific underlying etiologies could be more effective. We found that the pathophysiologic basis of labor dystocia is under-researched, offering wide opportunities for translational investigation of individualized labor management, particularly regarding uterine metabolism and fetal position. More precise diagnostic tools and individualized therapies for labor dystocia might lead to better outcomes. We conclude that additional knowledge of parturition physiology coupled with rigorous clinical evaluation of novel biologically directed treatments could improve obstetric quality of care.

Alarming Trends of Cesarean Section-Time to Rethink: Evidence From a Large-Scale Cross-sectional Sample Survey in India

BACKGROUND

Cesarean section (CS) delivery rate has increased significantly both globally and in India, thereby posing a burden on overstretched health systems.

OBJECTIVE

This study plans to understand the factors associated with CS rate with an objective to (1) analyze the trends of CS delivery from 1998-99 to 2019-21 and (2) understand the proximate determinants of CS deliveries in India.

METHODS

Analysis of secondary data (National Family Health Survey) of a nationally representative sample of 230,870 women (year 2019-21) was undertaken to explore the trends, distribution, and determinants of CS deliveries in India and within states. Multivariable analyses were performed to determine the proximate variables associated with CS and elective CS. The relative interaction effect of confounding factors, such as number of antenatal care (ANC) visits, place of residence, and wealth status, on cesarean delivery was assessed. A composite index was generated using trust, support, and intimate partner violence variables (termed the partner human capital index [PHI]) to study its influence on CS deliveries, with a low PHI indicating abusive partner and a high PHI indicating supportive partner. Statewise spatial distribution of the most significantly associated factors, namely, wealth quintile and ANC checkups, were also analyzed.

RESULTS

The overall prevalence of CS was 21.50% (49,634/230,870) which had risen from 16.72% (2312/13,829) in 1998-99. The adjusted odds of CS deliveries were significantly higher among women who were highly educated (odds ratio [OR] 7.30, 95% CI 7.02-7.60; P<.001), had 4 or more ANC visits (OR 2.28, 95% CI 2.15-2.42; P<.001), belonging to the high-wealth quintile (OR 7.87, 95% CI 7.57-8.18; P<.001), and from urban regions. Increasing educational level of the head of the household (OR 3.05, 95% CI 2.94-3.16; P<.001) was also found to be a significant determinant of CS deliveries. The odds of selection of elective and emergency CS were also significantly higher among women from richer families (OR 1.66, 95% CI 1.25-2.21; P<.001) and those belonging to Christian religion (OR 1.67, 95% CI 1.14-2.43; P=.008). Adjusting the cesarean delivery by PHI, the odds of outcome were significantly higher among women with moderate and high PHI compared with those with low PHI (OR 1.46, 95% CI 1.36-1.56 and OR 1.61, 95% CI 1.49-1.74, respectively; P<.001 for both). The interaction effect result reiterates that women with more than 4 ANC checkups, high PHI, and belonging to the richer wealth quintile were more likely to undergo cesarean delivery (OR 22.22, 95% CI 14.99-32.93; P<.001) compared with those with no ANC visit, low PHI, and poorest women.

CONCLUSIONS

The increasing trend of CS deliveries across India is raising concerns. Better education, wealth, and good support from the partner have been incriminated as the contributory factors. There is a need to institute proper monitoring mechanisms to assess the need for CS, especially when performed electively.

An Analysis of the Rate, Indications, and Associated Maternal Mortality for Cesarean Sections at a Tertiary Care Hospital, First Report from Somalia

Background

There has been an increase in worldwide cesarean section rates, although they remain low in most Sub-Saharan African countries, including Somalia. The present is the first hospital-based study that analyzes the rate, indications, and associated maternal mortality of cesarean deliveries reported from Somalia.

Methods

This retrospective study reviewed data of all deliveries from 2015 to 2021 using electronic medical records in the hospital information system. Retrieved data include baseline demographic characteristics, mode of delivery, indications and the type of cesarean section, and the documented maternal mortality during the study period.

Results

During seven years, there were 12,540 total deliveries. Among these, 2703 were cesarean sections giving an overall cesarean section rate of 21.6%. The mean age of the patients was 26.7±7.3 years [14-44 years]. Multiparous mothers constituted 67.7% during the study period. According to cesarean deliveries, nulliparous mothers (55.7%) underwent the maximum number of cesarean sections. Emergency cesarean section was the predominant intervention compared to elective C-sections (59.2% vs 40.8%). Primary CS was the most common predominant, while repeat CS increased timely, 77.7% vs 22.3%, respectively. Overall, previous C-sections and fetal distress were the two most common indications for cesarean delivery (22.3% and 22.1%), respectively. C-sections were predominant in women of younger age, Primiparity, having term deliveries, and did not receive regular antenatal care. The maternal mortality rate was 1.7%, and 61% was due to direct obstetric hemorrhage, including postpartum hemorrhage, Placenta abruption, and uterine rupture.

Conclusion

The study findings showed a slight increase in cesarean delivery rates during the study period. This rate is higher than the 10-15% recommended by the WHO in developing countries. Policies and efforts to decrease unnecessary cesarean sections should be promoted and implemented at each health facility.

How a supply-side intervention can help to increase caesarean section rates in Burkina Faso facilities-Evidence from an interrupted time-series analysis using routine health data

OBJECTIVES

In Burkina Faso, only 2.1% of women give birth by caesarean section (CS). To improve the use of maternal health services during pregnancy and childbirth, many interventions were implemented during the 2010s including performance-based financing (PBF) and a free maternal health care policy (the gratuité). The objective of this study is to evaluate the impact of a supply-side intervention (PBF) combined with a demand-side intervention (gratuité) on institutional CS rates in Burkina Faso.

METHODS

We used routine health data from all the public health facilities in 21 districts (10 that implemented PBF and 11 that did not) from January 2013 to September 2017. We analysed CS rates as the proportion of CS performed out of all facility-based deliveries (FBD) that occurred in the district. We performed an interrupted time series (ITS) analysis to evaluate the impact of PBF alone and then in conjunction with the gratuité on institutional CS rates.

RESULTS

CS rates in Burkina Faso increased slightly between January 2013 and September 2017 in all districts. After the introduction of PBF, the increase of CS rates was higher in intervention than in non-intervention districts. However, after the introduction of the gratuité, CS rates decreased in all districts, independently of the PBF intervention.

CONCLUSION

In 2017, despite high FBD rates in Burkina Faso as well as the PBF intervention and the gratuité, less than 3% of women who gave birth in a health facility did so by CS. Our study shows that the positive PBF effects were not sustained in a context of user fee exemption.

Process of adhesion of the Adequate Childbirth Program to improve obstetric care in private hospitals in Brazil

BACKGROUND

In 2015, a quality improvement project called "Projeto Parto Adequado-PPA" was implemented in Brazilian private hospitals to reduce unnecessary high rates of cesarean sections. This study aimed to analyze the decision-making process of managers and care leaders to adhere to the PPA.

METHODS

The Healthy Birth study is evaluative research that used mixed methods to evaluate the implementation and effects of the Adequate Childbirth Program in 12 hospitals that participated in the program. Eight out of 12 hospitals were selected for a qualitative approach. We interviewed ten managers and 24 care leaders from July to October 2017. The interviews were transcripted, and data was systematized using the MaxQda software, with Thematic Content Analysis, to identify the facilitators and barriers for adherence to the Adequate Childbirth Program. We used the conceptions of the Diffusion of Innovation as an analytical reference.

RESULTS

The main reasons to adhere to the Adequate Childbirth Program were the absence of other quality improvements programs in Brazilian private services using multifaceted interventions, social and market status for participating; commitment to quality of care; and the possibility of structural reforms related to the Adequate Childbirth Program implementation. In addition, inviting hospital influencers to learn about the objectives and intentions of the project before joining was considered an important strategy to motivate hospitals.

CONCLUSION

Social, cultural, and economic constructs motivated adherence. The invitation strategy used by the Adequate Childbirth Program coordination, through socially respected members in Brazil, such as doctors, was highly valued by the leaders of the hospital team and encouraged adherence to the Program.

Trend and associated factors of cesarean section rate in Ethiopia: Evidence from 2000-2019 Ethiopia demographic and health survey data

BACKGROUND

The world health organization considers cesarean section (CS) prevalence of less than 5% suggests an unmet need. On the other hand, a prevalence of more than 15% may pose to risk to mother and child, however, access to CS in a resource-limited country like Ethiopia was much lower than the aforementioned level, Therefore, this was the first study to determine the trend of CS, and factors that influence it.

METHODS

This was done based on the five Ethiopia Demographic and Health Surveys. Trend analysis was done separately for rural and urban. The significance of the trend was assessed using the Extended Mantel-Haenszel chi-square test. The factors on CS delivery were identified based on DHS 2016 data. A multi-level logistic regression analysis technique was used to identify the factors associated with cesarean section delivery. The analysis was adjusted for the different individual- and community-level factors affecting cesarean section delivery. Data analysis was conducted using STATA 14.1 software.

RESULT

The rate of cesarean section increased from 5.1% in 1995 to 16% in 2019 in an urban area and 0.001 in 1995 to 3% in a rural area, the overall increment of CS rate was 0.7% in 1995 to 2019 at 6%. The odds of cesarean section were higher among 25-34 years (AOR = 2.79; 95% CI: 1.92, 4.07) and 34-49 years (AOR = 5.23;95% CI: 2.85,9.59), among those educated at primary school level (AOR = 1.94; 95% CI: 1.23,3.11), secondary education (AOR = 2.01; 95% CI: 1.17, 3.56) and higher education (AOR = 4.12; 95% CI: 2.33-7.29)with multiple pregnancies (AOR = 11.12; 95% CI: 5.37, 23.), with obesity (AOR = 1.73; 95% CI: 1.22, 2.45), living in an urban area (AOR = 2.28; /95% CI: 1.35-3.88), and increased with the number of ANC visit of 1-3 and 4th(AOR = 2.26; 95% CI: 1.12, 4.58), (AOR = 3.34; 95% CI: 1.12, 4.58), respectively. The odds of cesarean section are lower among parity of 2-4 children (AOR = 0.54; 95% CI: 0 .37, 0.80) and greater than four birth order (AOR = 0.42;95% CI: 0.21,0.84).

CONCLUSION

In Ethiopia, the CS rate is below the WHO recommended level in both urban and rural areas, thus, intervention efforts need to be prioritized for women living in a rural area, empowering women's education, encouraging co-services such as ANC usage could all help to address the current problem.

Why do pregnant women with fear of birth prefer vaginal birth? A qualitative study in China

Background

Fear of birth (FOB) is becoming increasingly recognized as a mental health issue that may endanger maternal and infant health and affects women's subsequent fertility desires. It has also been shown to be related to the choice of delivery mode. Given the differences in healthcare systems and policies between countries, and the gaps in the exploration of women's experience of fear of birth and its association with the delivery mode in the Chinese cultural context, this study thus attempt to understand Chinese women's experience with fear of birth and their preferences for delivery mode through a qualitative study.

Methods

A descriptive qualitative research was performed among twenty pregnant women from the obstetric outpatient of a tertiary hospital in China. Colaizzi's method was used to analyze the participants' data.

Results

We proposed three themes and nine subthemes on the participants' experience with fear of birth: (1) an invisible dilemma: trapped in lingering fear (fear of all sides, the untold loneliness, and ambivalence with mixed feelings); (2) an unexpected decision: choose to give birth naturally (initiative selection and passive acceptance); and (3) A strength to confront challenges head-on: move forward with fear (awaken of maternal spirit, hope in bloom, Chinese tolerance culture, and obstetric analgesia).

Conclusion

Fear of birth is a complex emotion, accompanied by feelings of loneliness and ambivalence in addition to fear. We found that women with fear of birth in this study prefer vaginal birth, and it was revealed to be the result of a combined action of intrinsic and extrinsic factors.

Clinicians' views of factors influencing decision-making for CS for first-time mothers-A qualitative descriptive study

Clinicians' perspectives of the reasons for performing caesarean section (CS) are fundamental to deepening knowledge and understanding of factors influencing decision-making for CS. The aim of this study was to explore midwives' and obstetricians' views of factors influencing decision-making for CS for first-time mothers. A qualitative descriptive study with semi-structured one-to-one audio-recorded interviews was used to gather data from clinicians (15 midwives and 20 senior obstetricians). Following research ethics committee approval, clinicians, who were directly involved in the decision-making process for CS during the period of data collection, were purposively selected from three maternity units in the Republic of Ireland between June 2016 to July 2017. The interviews were transcribed verbatim and analysed thematically. Three interrelated themes with several subthemes reflective of clinicians' views and experiences emerged following data analysis. These were: 'A fear factor' describing clinicians' fear of adverse outcomes and subsequent litigation, 'Personal preferences versus a threshold-clinician driven factors emphasising the influence of clinicians' personal beliefs, and 'Standardised versus individualised care-a system perspective' explaining the effects of, or lack of, organisational policy and its direct and indirect impact on the decision-making process. Findings show that decisions to perform a CS are, on occasion, based on clinicians' personal beliefs and interpretation, similar to findings from other published literature. Consideration of broader issues related to organisational, socio-cultural and political context is essential when seeking solutions to the rising CS rates. The findings will enable clinicians to reflect on their day-to-day practice, in order to look for modifiable factors that influence their decision-making, and help women understand the multitude of factors that can lead to a decision to perform a CS. Findings will also contribute to the development of the 'next step action' and assist in devising future intervention studies to reduce any unnecessary CSs.

Cervical ripening as an outpatient procedure in the pandemic - minimizing the inpatient days and lowering the socioeconomic costs

OBJECTIVES

With an increasing incidence of labor induction the socioeconomic costs are increasing and the burden on hospital capacities is rising. In addition, the worldwide SARS-CoV-2 pandemic asks for improvements in patient care during pregnancy and delivery while decreasing the patient-staff contact. Here, we are retrospectively analyzing and comparing a mechanical ripening device that is utilized as an outpatient procedure to misoprostol and dinoprostone as inpatient induction methods in a low risk cohort.

METHODS

This is a retrospective comparative analysis of obstetric data on patients who presented for cervical ripening and labor induction. Ninety-six patients received a mechanical ripening agent as an outpatient procedure. As a control group, we used 99 patients with oral misoprostol (PGE1) and 42 patients with vaginal dinoprostone (PGE2) for cervical ripening in an inpatient setting. Data from 2016 until 2020 were analysed.

RESULTS

Baseline characteristics showed no significant differences. Delivery modes were similar in all groups. The time period from patient admission to onset of labor was significantly shorter in the outpatient group (p<0.001): 10.9 h/0.5 days (±13.6/0.6) for osmotic dilator vs. 17.9 h/0.7 days (±13.1/0.5) for oral misoprostol vs. 21.8 h/0.8 days (±15.9/0.7) for vaginal dinoprostone. With 20.4 h/0.8 days (±14.3/0.6) the osmotic dilator group displayed significantly the shortest inpatient stay from admission to delivery (p=0.027). The patient subgroup of misoprostol had 25.7 h/1.1 days (±14.9/0.6) of inpatient stay from admission to delivery and the patient group of dinoprostone 27.5 h/1.1 days (±16.0/0.7). There were fewer hospital days in the outpatient group: 84.9 h/3.5 days vs. 88.9 h/3.7 days vs. 93.6 h/3.9 days (outpatient osmotic dilator vs. inpatient misoprostol and dinoprostone, respectively).

CONCLUSIONS

New approaches are required to decrease individual contacts between patients and staff while maintaining a high quality patient care in obstetrics. This analysis reveals that outpatient mechanical cervical ripening can be as safe and effective as inpatient cervical ripening with PGE1/PGE2, while lowering patient-staff contact and total hospital stays and therefore decreasing the socioeconomic costs.

Spatial and hierarchical Bayesian analysis to identify factors associated with caesarean delivery use in Ethiopia: Evidence from national population and health facility data

BACKGROUND

Caesarean section has a significant role in reducing maternal and neonatal mortality. A linked analysis of population and health facility data is valuable to map and identify caesarean section use and associated factors. This study aimed to identify geographic variation and associated factors of caesarean delivery in Ethiopia.

METHOD

Linked data analysis of the 2016 Ethiopia Demographic and Health Survey (EDHS) and the 2014 Ethiopian Service Provision Assessment Plus (ESPA+) survey was performed. Spatial analysis was conducted to identify geographic variations and factors associated with caesarean delivery. Hierarchical Bayesian analysis was also performed to identify factors associated with caesarean delivery using the SAS MCMC procedure.

RESULTS

Women's age and education, household wealth, parity, antenatal care (ANC) visits, and distance to caesarean section facility were associated with caesarean delivery use. Women who had ≥4 ANC visits were 4.67 (95% Credible Interval (CrI): 2.17, 9.43) times more likely to have caesarean delivery compared to those who had no ANC visits. Women who had education and were from rich households were also 2.80 (95% CrI: 1.83, 4.19) and 1.80 (95% CrI: 1.08, 2.84) times more likely to have caesarean deliveries relative to women who had no education and were from poor households, respectively. A one-kilometer increase in distance to a caesarean section facility was associated with an 88% reduction in the odds of caesarean delivery (Adjusted Odds Ratio (AOR) = 0.12, 95% CrI: 0.01, 0.78). Hotspots of high caesarean section rates were observed in Addis Ababa, Dire Dawa, and the Harari region. In addition, women's age at first childbirth and ≥4 ANC visits showed significant spatially varying relations between caesarean delivery use across Ethiopia.

CONCLUSION

Caesarean section is a lifesaving procedure, and it is essential to narrow disparities to reduce maternal and neonatal mortality and avoid unnecessary procedures.

A global study of the association of cesarean rate and the role of socioeconomic status in neonatal mortality rate in the current century

Introduction

Caesarean section (C/S) rates have significantly increased across the world over the past decades. In the present population-based study, we sought to evaluate the association between C/S and neonatal mortality rates.

Material and methods

This retrospective ecological study included longitudinal data of 166 countries from 2000 to 2015. We evaluated the association between C/S rates and neonatal mortality rate (NMR), adjusting for total fertility rate, human development index (HDI), gross domestic product (GDP) percentage, and maternal age at first childbearing. The examinations were also performed considering different geographical regions as well as regions with different income levels.

Results

The C/S rate and NMR in the 166 included countries were 19.97% ± 10.56% and 10 ± 10.27 per 1000 live birth, respectively. After adjustment for confounding variables, C/S rate and NMR were found correlated (r = -1.1, p < 0.001). Examination of the relationship between C/S rate and NMR in each WHO region resulted in an inverse correlation in Africa (r = -0.75, p = 0.005), Europe (r = -0.12, p < 0.001), South-East Asia (r = -0.41, p = 0.01), and Western Pacific (r = -0.13, p = 0.02), a direct correlation in America (r = 0.06, p = 0.04), and no correlation in Eastern Mediterranean (r = 0.01, p = 0.88). Meanwhile, C/S rate and NMR were inversely associated in regions with upper-middle (r = -0.15, p < 0.001) and lower-middle (r = -0.24, p < 0.001) income levels, directly associated in high-income regions (r = 0.02, p = 0.001), and not associated in low-income regions (p = 0.13). In countries with HDI below the centralized value of 1 (the real value of 0.9), the correlation between C/S rate and NMR was negative while it was found positive in countries with HDI higher than the mentioned cut-off.

Conclusions

This study indicated that NMR associated with C/S is dependent on various socioeconomic factors such as total fertility rate, HDI, GDP percentage, and maternal age at first childbearing. Further attentions to the socioeconomic status are warranted to minimize the NMR by modifying the C/S rate to the optimum cut-off.

HEALTHCARE PROFESSIONALS’ ATTITUDES TOWARDS VAGINAL BIRTH AFTER CESAREAN SECTION; İSTANBUL EXAMPLE

Rapidly increasing cesarean birth rates around the world continue to cause concern. Repeated cesarean sections are the most important causes of this increase. Vaginal birth after cesarean section (VBAC) is a good solution, but is not used widely enough in clinical practice. This cross-sectional descriptive study aimed to determine the attitudes of healthcare professionals towards VBAC and the factors that affect them. The study was conducted at a maternity hospital in Istanbul and sample included 254 healthcare professionals. The data were collected using a personal information form and the VBAC Attitudes Form. Percentages, means, Pearson’s chi-squared test, the Kruskal-Wallis H test and the Mann-Whitney U test were used. The threshold for statistical significance was p

Influence of Sonographic Fetal Weight Estimation Inaccuracies in Macrosomia on Perinatal Outcome

OBJECTIVE

 To evaluate the influence of inaccurate sonographic fetal weight estimation in macrosomia on the mode of delivery and neonatal outcome (NO).

METHODS

 In 14 633 pregnancies between 2002 and 2016, this retrospective study evaluated the association between sonographic fetal weight estimation, true birth weight (BW), mode of delivery (primary cesarean section [pCS], secondary cesarean section, vaginal delivery, and operative vaginal delivery rates) and NO parameters (5-min Apgar < 7, pH < 7.1, neonatal intensive care unit [NICU] admission, shoulder dystocia). Singleton pregnancies > 37 + 0 weeks with ultrasound-estimated fetal weight (EFW) within 7 days before delivery were included. The study population was divided into four groups: Group 1 (false-negative): EFW < 4000 g/BW ≥ 4000 g; Group 2 (true-positive): EFW ≥ 4000 g/BW ≥ 4000 g; Group 3 (false-positive): EFW ≥ 4000 g/BW < 4000 g; and Group 4 (true-negative): EFW < 4000 g/BW < 4000 g.

RESULTS

 As expected, the highest secondary cesarean section (sCS) rate was found in Group 2 (true-positive) (30.62 %), compared with only 17.68 % in Group 4 (true-negative). The sCS rate in the false-positive Group 3 was significantly higher (28.48 %) in comparison with the false-negative Group 1 (21.22 %; OR 1.48; 95 % CI, 1.16 to 1.89; P = 0.002). In comparison with the true-negative Group 4, univariate analyses showed significantly higher rates for sCS in all other groups: odds ratio (OR) 2.06 for Group 2 (95 % CI, 1.74 to 2.42; P < 0.001), 1.85 for Group 3 (95 % CI, 1.54 to 2.22, P < 0.001), and 1.25 for Group 1 (95 % CI, 1.05 to 1.49; P < 0.01). No significant differences were found for NO between Groups 1 and 3 for the parameters 5-min Apgar < 7 (P = 0.75), pH < 7.1 (P = 0.28), or NICU admission (P = 0.54). However, there was a significantly higher chance for shoulder dystocia in Group 1 compared with Group 3 (OR 4.58; 95 % CI, 1.34 to 24.30; P = 0.008).

CONCLUSION

 Sonographic EFW inaccuracies in fetal macrosomia appear to have a greater impact on the mode of delivery than birth weight itself. Underestimation of fetal weight may be associated with a higher probability of shoulder dystocia.

Rural–urban disparities in caesarean deliveries in sub-Saharan Africa: a multivariate non-linear decomposition modelling of Demographic and Health Survey data

Introduction

Globally, the rate of caesarean deliveries increased from approximately 16.0 million in 2000 to 29.7 million in 2015. In this study, we decomposed the rural–urban disparities in caesarean deliveries in sub-Saharan Africa.

Methods

Data for the study were extracted from the most recent Demographic and Health Surveys of twenty-eight countries in sub-Saharan Africa. We included 160,502 women who had delivered in health facilities within the five years preceding the survey. A multivariate non-linear decomposition model was employed to decompose the rural–urban disparities in caesarean deliveries. The results were presented using coefficients and percentages.

Results

The pooled prevalence of caesarean deliveries in the 28 countries considered in the study was 6.04% (95% CI = 5.21–6.88). Caesarean deliveries' prevalence was highest in Namibia (16.05%; 95% CI = 14.06–18.04) and lowest in Chad (1.32%; 95% CI = 0.91–1.73). For rural-urban disparities in caesarean delivery, the pooled prevalence of caesarean delivery was higher in urban areas (10.37%; 95% CI = 8.99–11.75) than rural areas (3.78%; 95% CI = 3.17-4.39) across the 28 countries. Approximately 81% of the rural–urban disparities in caesarean deliveries were attributable to the differences in child and maternal characteristics. Hence, if the child and maternal characteristics were levelled, more than half of the rural–urban inequality in caesarean deliveries would be reduced. Wealth index (39.2%), antenatal care attendance (13.4%), parity (12.8%), mother’s educational level (3.5%), and health insurance subscription (3.1%) explained approximately 72% of the rural–urban disparities in caesarean deliveries.

Conclusion

This study shows significant rural–urban disparities in caesarean deliveries, with the disparities being attributable to the differences in child and maternal characteristics: wealth index, parity, antenatal care attendance, mother’s educational level, and health insurance subscription. Policymakers in the included countries could focus and work on improving the socioeconomic status of rural-dwelling women as well as encouraging antenatal care attendance, women's education, health insurance subscription, and family planning, particularly in rural areas.

Prediction models of vaginal birth after cesarean delivery: A systematic review

BACKGROUND

Cesarean section rates are rising in the world. Women with a history of cesarean section will select a cesarean section at the next pregnancy. An objective and accurate prediction about the success rate of vaginal delivery after cesarean section can help women to reduce the complications caused by cesarean section, shorten the time spent in the hospital, and effectively plan medical resources.

OBJECTIVE

To systematically review and critically assess the existing prediction models of vaginal delivery after cesarean section.

METHODS

Some databases (PubMed, Web of Science, EMBASE, the Cochrane Library, Cumulative Index to Nursing and Allied Health Literature) were searched from 2000 to 2021 for studies regarding the prediction model of vaginal birth after cesarean delivery. The researchers successively conducted independent literature screening, data extraction and quality evaluation of the included literature, and then utilized the Prediction model Risk of Bias Assessment Tool to assess the methodological quality of the models in the included studies.

RESULTS

A total of 33 studies were included, in which 20 prediction models were identified. Sixteen studies involved external validation of existing models (Grobman's models). In the 20 prediction models, 12 were internally validated, only three had external validation, and seven models were not explicitly reported, with the area under the curve ranging from 0.660 to 0.953; The most common predictors included in the model were body mass index and previous vaginal delivery, followed by maternal age, previous cesarean delivery indication, history of vaginal birth after cesarean, fetal weight, and Bishop's score, gestational age, history of vaginal birth after cesarean, maternal race; The prediction effect of Grobman's model was validated in multiple external populations; The majority of the studies(n = 27) had high risk of bias in the of the Prediction model Risk of Bias Assessment Tool.

CONCLUSIONS

This review provides obstetricians and midwives with important information about the prediction models of vaginal birth after cesarean section, which has been reported optimistic predictive performance and acceptable predictive power. However, the majority of the development studies have methodological limitations, which may hinder the widely application of these models by obstetricians. Further studies are supposed to develop predictive models with low risk of bias, and conduct internal and external validation, providing pragmatic and practical predictions to obstetricians.

PROSPERO REGISTRATION NUMBER

CRD42022299048.

Changes in the live birth profile in Henan, China: A hospital registry-based study

BACKGROUND

Preterm complications and neonatal asphyxia are the leading causes of death in those under 5 years of age. However, little information exists for the province of Henan, China. The purpose of this study was to explore changes in the live birth profile in a provincial hospital over the past 32 years in Henan, China.

METHODS

A retrospective analysis was conducted to reveal the characteristics of live neonates from 1987 to 2018.

RESULTS

There were 118 253 live births during the period, including 19 798 (16.74%) preterm births. The neonatal death rate was 6.45‰, and the top risk factor was preterm birth complications and birth asphyxia. Before 1998, neonatal death occurred primarily among term infants. Between 1999 and 2018, preterm infants, especially extreme and very preterm infants with very low birthweight, constituted more than half of all mortalities, and the preterm birth rate increased from 5.94% in 1999 to 16.69% in 2018. The risk factors associated with preterm birth were being male (aOR = 1.18, P < 0.001), advanced maternal age (>35 years old; aOR = 1.08, P = 0.008), gravidity ≥2 (aOR = 1.15, P < 0.001), parity ≥2 (aOR = 1.50, P < 0.001), placenta previa (aOR = 7.41, P < 0.001), twin or multiple births (aOR = 10.63, P < 0.001), hypertension (aOR = 2.08, P < 0.001), and rupture of membrane (aOR = 5.03, P < 0.001).

CONCLUSIONS

The preterm birth rate has increased over the past 32 years from 4.98% to 16.69% in a provincial hospital in China. Preterm birth was the leading reason for neonatal death, and birth asphyxia was the major risk factor for death in term infants.

Recent trends in cesarean section reduction in extreme south of Brazil: a reality only in the public sector?

This study aimed to describe changes in cesarean section (C-section) prevalence from 2007 to 2019, in public and private sectors, according to maternal characteristics. We included all puerperal women who gave birth in Rio Grande, Rio Grande do Sul, Brazil, at years 2007, 2010, 2013, 2016 and 2019. A questionnaire was applied up to 48 hours after delivery. We assessed C-section rates over time and described the prevalence according to independent variables. Poisson regression was used. A total of 12.415 puerperal women were included. The prevalence of C-section increased between 2007-2013 (from 51.2% to 61.2%) and decreased between 2013-2019 (48.9% in 2019). This decrease was observed only in the public sector and was higher among the youngest (-10.0 percentual points) and high educated women (-10.3 percentual points). While in the private sector C-section occurrence increased even more (95.7% in 2019). In the public sector, women that were older, with a partner, primiparous, who performed prenatal care in the private system and with adequate prenatal assistance presented higher prevalence of C-section. In the private sector the prevalence was high independently of the maternal characteristics. In order to reduce C-section rates, efficient delivery care policies mainly focused on the private sector are necessary.

Geospatial distribution of relative cesarean section rates within the USA

Objective

To evaluate the existence of statistically significant clusters of Cesarean section rates at the county level and assess the relationship of such clusters with previously implicated socioeconomic factors.

Results

County-level obstetrics data was extracted from March of Dimes, originally sourced from National Center for Health Statistics. County-level demographic data were extracted from the US Census Bureau. Access to obstetricians was extracted from National Provider Identifier records. Rural counties were identified using Rural Urban Commuting Area codes developed by the department of agriculture. The dataset was geospatially analyzed using Moran’s I statistic, a metric of local spatial autocorrelation, to identify clusters of increased or decreased Cesarean section rates. The American South, especially the Deep South, is a major cluster of increased Cesarean section rates. As a general but not absolute pattern, the American West and Midwest had lower Cesarean section rates than the Northeast. Focal areas of increased Cesarean section rates included the Kansas-Nebraska border, Michigan’s upper peninsula, and the New York City metropolitan area. The gross geospatial differences were not explained by rurality, obstetric access, or ethnic and racial factors alone.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13104-022-06141-w.

Benefits and risks of spontaneous pushing versus directed pushing during the second stage of labour among women without epidural analgesia: A systematic review and meta-analysis

OBJECTIVE

The aim of this systematic review and meta-analysis was to assess the benefits and risks of spontaneous pushing and directed pushing used by labouring women without epidural analgesia during the second stage labour.

DESIGN

Systematic review and meta-analysis.

METHODS

Randomised controlled trials published in PubMed/ MEDLINE, CINAHL, Web of Science, Scopus, EMBASE, psycINFO, the Cochrane Library, and four Chinese databases were systematically searched from their inception to December, 2021. Grey literature were also searched. Two authors independently screened the literature and evaluated the quality of the included studies.

RESULTS

Ten studies with a total of 1510 women were pooled. Spontaneous pushing in the second stage of labour reduced the rates of Caesarean section and extended episiotomy. The difference was significant among spontaneous pushing group and directed pushing group, with relative risk and 95% confidence intervals of 0.42 and 0.19-0.94, 0.49 and 0.29-0.82, respectively. There was no significant difference in the duration of the second stage of labour, rates of spontaneous vaginal birth and newborn outcomes.

CONCLUSION

The results of this meta-analysis demonstrate that spontaneous pushing during the second stage of labour results in at least the same maternal and newborn outcomes, lower Caesarean section rates and lower incidence of extended episiotomy.

Comparison of the effect of skin closure materials on skin closure during cesarean delivery

Objective

To compare the effect of skin closure materials on skin closure during cesarean delivery.

Methods

We searched EMBASE、PubMed、Scopus、Cochrane CENTRAL for randomized controlled trials (RCTs) on the use of closure materials for skin closing effect during cesarean delivery. The outcomes were time to skin closure of dermal and epidermal layer, skin separation rate and wound complications(wound infection, hematoma,seroma, reclosure, readmission) reported as an odds ratio (OR) and surface under the cumulative ranking curve analysis (SUCRA) score.

Results

Twenty -six RCTs met the inclusion criteria. In the network meta-analysis (NMA) for time to skin closure of dermal and epidermal layer, pooled network OR values indicated that staple (network SMD, -337.50; 95% CrI: -416.99 to -263.18) was superior to absorbable suture. In the Skin separation NMA, pooled network OR values indicated that the absorbable suture (network OR, 0.37; 95% CrI: 0.19 to 0.70) were superior to staple. In the wound complications NMA, pooled network OR values indicated that the no interventions were superior to staple.

Conclusion

In conclusion, our network meta-analysis showed that the risk of skin separation with absorbable suture after cesarean delivery was reduced compared with staple, and does not increase the risk of wound complications, but the wound closure time would slightly prolonged.

Healthcare Professionals’ Knowledge and Beliefs on Antibiotic Prophylaxis in Cesarean Section: A Mixed-Methods Study in Benin

A low adherence to recommendations on antibiotic prophylaxis has been reported worldwide. Since 2009, cesarean sections have been performed under user fee exemption in Benin with a free kit containing the required supplies and antibiotics for prophylaxis. Despite the kit, the level of antibiotic prophylaxis achievement remains low. We conducted a convergent parallel design study in 2017 using a self-administered questionnaire and interviews to assess the knowledge and explore the beliefs of healthcare professionals regarding antibiotic prophylaxis in three hospitals. Of the 35 participants, 33 filled out the questionnaire. Based on the five conventional criteria of antibiotic prophylaxis, the mean level of knowledge was 3.3 out of 5, and only 15.2% scored 5 out of 5. From the verbatim of 19 interviewees, determinants such as suboptimal patient status health, low confidence in antibiotics, some disagreement with the policy, inappropriate infrastructures and limited financial resources in hospitals, poor management of the policy in the central level, and patient refusal to buy antibiotics can explain poor practices. Because of the dysfunction at these levels, the patient becomes the major determinant of adequate antibiotic prophylaxis. Policymakers have to consider these determinants for improving antibiotic prophylaxis in a way that ensures patient safety and reduces the incidence of antimicrobial resistance.