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Bartels HC, Downey P, Brennan DJ. Looking back to look forward: Has the time arrived for active management of obstetricians in placenta accreta spectrum? Int J Gynaecol Obstet 2024. [PMID: 39045676 DOI: 10.1002/ijgo.15826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Revised: 07/10/2024] [Accepted: 07/15/2024] [Indexed: 07/25/2024]
Abstract
Placenta accreta spectrum (PAS) is a relatively new obstetric condition which, until recently, was poorly understood. The true incidence is unknown because of the poor quality and heterogeneous diagnostic criteria. Classification systems have attempted to provide clarity on how to grade and diagnose PAS, but these are no longer reflective of our current understanding of PAS. This is particularly true for placenta percreta, which referred to extrauterine disease, as recent studies have demonstrated that placental villi associated with PAS have minimal potential to invade beyond the uterine serosa. It is accepted that PAS is a direct consequence of previous iatrogenic uterine injury, most commonly a previous cesarean section. Here, we "look back to look forwards"-starting with the primary predisposing factor for PAS, an iatrogenic uterine injury and subsequent wound healing. We then consider the evolution of definitions and diagnostic criteria of PAS from its first description over a century ago to current classifications. Finally, we discuss why modifications to the current classifications are needed to allow accurate diagnosis of this rare but life-threatening complication, while avoiding overdiagnosis and potential patient harm.
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Affiliation(s)
- Helena C Bartels
- Department of University College Dublin Obstetrics and Gynaecology, School of Medicine, National Maternity Hospital, Dublin, Ireland
| | - Paul Downey
- Department of Histopathology, National Maternity Hospital, Dublin, Ireland
| | - Donal J Brennan
- University College Dublin Gynaecological Oncology Group (UCD-GOG), Mater Misericordiae University Hospital and St Vincent's University Hospital, Dublin, Ireland
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2
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Al Khalaf SY, Heazell AEP, Kublickas M, Kublickiene K, Khashan AS. Risk of stillbirth after a previous caesarean delivery: A Swedish nationwide cohort study. BJOG 2024; 131:1054-1061. [PMID: 38287170 DOI: 10.1111/1471-0528.17760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 12/19/2023] [Accepted: 12/30/2023] [Indexed: 01/31/2024]
Abstract
OBJECTIVES To investigate the risk of stillbirth in relation to (1) a previous caesarean delivery (CD) compared with those following a vaginal birth (VB); and (2) vaginal birth after caesarean (VBAC) compared with a repeat CD. DESIGN Population-based cohort study. SETTING The Swedish Medical Birth registry. POPULATION Women with their first and second singletons between 1982 and 2012. METHODS Multivariable logistic regression models were performed to estimate adjusted odds ratios (aOR) and 95% confidence intervals (CI) of the association between CD in the first pregnancy and stillbirth in the second pregnancy and the association between VBAC and stillbirth. Sub-group analyses were performed by types of CD and timing of stillbirth (antepartum and intrapartum). MAIN OUTCOME MEASURES Stillbirth (antepartum and intrapartum fetal death). RESULTS Of the 1 771 700 singleton births from 885 850 women, 117 114 (13.2%) women had a CD in the first pregnancy, and 51 755 had VBAC in the second pregnancy. We found a 37% increased odds of stillbirth (aOR 1.37; 95% CI 1.23-1.52) in women with a previous CD compared with VB. The odds of intrapartum stillbirth were higher in the previous pre-labour CD group (aOR 2.72; 95% CI 1.51-4.91) and in the previous in-labour CD group (aOR 1.35; 95% CI 0.76-2.40), although not statistically significant in the latter case. No increased odds were found for intrapartum stillbirth in women who had VBAC (aOR 0.99; 95% CI 0.48-2.06) compared with women who had a repeat CD. CONCLUSIONS This study confirms that a CD is associated with an increased risk of subsequent stillbirth, with a greater risk among pre-labour CD. This association is not solely mediated by increases in intrapartum asphyxia, uterine rupture or attempted VBAC. Further research is needed to understand this association, but these findings might help healthcare providers to reach optimal decisions regarding mode of birth, particularly when CD is unnecessary.
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Affiliation(s)
| | - Alexander E P Heazell
- Maternal and Fetal Health Research Centre, School of Medical Sciences, Medical and Health, University of Manchester, Manchester, UK
| | - Marius Kublickas
- Department of Obstetrics & Gynaecology, Unit of Fetal Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Karolina Kublickiene
- Department of Clinical Intervention, Science and Technology (CLINTEC), Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Ali S Khashan
- School of Public Health, University College Cork, Cork, Ireland
- INFANT Research Centre, University College Cork, Cork, Ireland
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3
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Sima YT, Magnus MC, Kvalvik LG, Morken NH, Klungsøyr K, Skjærven R, Sørbye LM. The relationship between cesarean delivery and fecundability: a population-based cohort study. Am J Obstet Gynecol 2024; 230:667.e1-667.e21. [PMID: 37863159 DOI: 10.1016/j.ajog.2023.10.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 10/09/2023] [Accepted: 10/15/2023] [Indexed: 10/22/2023]
Abstract
BACKGROUND Previous studies have found that women who undergo cesarean delivery have fewer pregnancies. Cesarean delivery is also more common among women with lower fecundability. The potential role of cesarean delivery in reduced fecundability is not known. OBJECTIVE This study aimed to assess the bidirectional relationship between cesarean delivery and fecundability. STUDY DESIGN This was a prospective cohort study based on data from the Norwegian Mother, Father, and Child Cohort study linked with the Medical Birth Registry of Norway. We estimated the fecundability ratio (per cycle probability of pregnancy) and relative risk of infertility (time to pregnancy ≥12 months) by mode of delivery in the previous delivery among 42,379 women. For the reverse association, we estimated the relative risk of having a cesarean delivery by fecundability (the number of cycles women needed to conceive) among 74,024 women. RESULTS The proportion of women with infertility was 7.3% (2707/37,226) among women with a previous vaginal delivery and 9.9% (508/5153) among women with a previous cesarean delivery, yielding an adjusted relative risk of 1.21 (95% confidence interval, 1.10-1.33). Women with a previous cesarean delivery also had a lower fecundability ratio (0.90; 95% confidence interval, 0.88-0.93) than women with a previous vaginal delivery. When assessing the reverse association between fecundability and cesarean delivery, we found that women who did not conceive within 12 or more cycles had a higher risk for cesarean delivery (adjusted relative risk, 1.57; 95% confidence interval, 1.48-1.66) than women who conceived within the first 2 cycles. The associations remained after controlling for sociodemographic and clinical risk factors and were observed across parity groups. CONCLUSION Among women with more than 1 child, those who had a previous cesarean delivery subsequently had a lower fecundability ratio and an increased infertility risk than those who had a vaginal delivery. However, women who needed a longer time to conceive were also more prone to be delivered by cesarean delivery, indicating a bidirectional relationship between cesarean delivery and fecundability. This could suggest a common underlying explanatory mechanism and that the surgical procedure itself may not or only partly directly influence fecundability.
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Affiliation(s)
- Yeneabeba Tilahun Sima
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.
| | | | - Liv Grimstvedt Kvalvik
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Nils-Halvdan Morken
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway; Department of Clinical Science, University of Bergen, Bergen, Norway; Department of Obstetrics and Gynecology, Haukeland University Hospital, Bergen, Norway
| | - Kari Klungsøyr
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway; Division of Mental and Physical Health, Norwegian Institute of Public Health, Bergen, Norway
| | - Rolv Skjærven
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway; Centre for Fertility and Health, Norwegian Institute of Public Health, Oslo, Norway
| | - Linn Marie Sørbye
- Department of Obstetrics and Gynecology, Haukeland University Hospital, Bergen, Norway; Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway; Norwegian Research Centre for Women's Health, Oslo University Hospital, Rikshospitalet, Oslo, Norway
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Gutiérrez-Martínez S, Fernández-Martínez MN, Adánez-García JM, Fernández-Fernández C, Pérez-Prieto B, García-Gallego A, Gómez-Salgado J, Medina-Díaz M, Fernández-García D. Applying the Modified Ten-Group Robson Classification in a Spanish Tertiary Hospital. J Clin Med 2023; 13:252. [PMID: 38202259 PMCID: PMC10780088 DOI: 10.3390/jcm13010252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 12/23/2023] [Accepted: 12/29/2023] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND Caesarean section is necessary to save the lives of mothers and newborns at times, but it is important to perform it only when it is essential due to all the risks involved. This study aimed to examine the rate of caesarean sections performed at a tertiary hospital using the Robson classification to detect methods for the detection of and/or reduction in these caesarean section rates. METHODS A descriptive, cross-sectional study of a retrospective database was carried out. RESULTS A total of 10,317 births were assessed. The Robson classification was used to assess these interventions and verify whether the indication for performed caesarean sections was appropriate. In total, 2036 births by caesarean section were performed in the whole sample. The annual caesarean section rate varied between 18.67% and 21.18%. CONCLUSIONS Caesarean sections increased by about 20% in 2021 compared to 2020 even though the trend over the years of study was decreasing. Vaginal delivery after caesarean section is a reasonable and safe option. Caesarean section rates could be improved, mostly in Robson's Group 2. The Robson classification facilitated progress in the implementation of measures aimed at improving care and adjusting caesarean section rates.
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Affiliation(s)
- Serena Gutiérrez-Martínez
- Department of Gynecology and Obstetrics, University Hospital of León, 24071 León, Spain; (S.G.-M.); (C.F.-F.)
| | - María Nélida Fernández-Martínez
- Department of Biomedical Sciences, Institute of Biomedicine (IBIOMED), Faculty of Veterinary, University of León, 24071 León, Spain
| | - José Manuel Adánez-García
- Department of Gynecology and Obstetrics, University Hospital of Oviedo, 33011 Oviedo, Spain; (J.M.A.-G.); (M.M.-D.)
| | - Camino Fernández-Fernández
- Department of Gynecology and Obstetrics, University Hospital of León, 24071 León, Spain; (S.G.-M.); (C.F.-F.)
| | - Beatriz Pérez-Prieto
- Department of Gynecology and Obstetrics, University Hospital of León, 24071 León, Spain; (S.G.-M.); (C.F.-F.)
| | - Ana García-Gallego
- Department of Statistics and Operations Research, University of Leon, 24071 León, Spain
| | - Juan Gómez-Salgado
- Department of Sociology, Social Work and Public Health, Faculty of Labour Sciences, University of Huelva, 21071 Huelva, Spain
- Safety and Health Postgraduate Program, Universidad Espíritu Santo, Guayaquil 092301, Ecuador
| | - María Medina-Díaz
- Department of Gynecology and Obstetrics, University Hospital of Oviedo, 33011 Oviedo, Spain; (J.M.A.-G.); (M.M.-D.)
| | - Daniel Fernández-García
- Health Research Nursing Group (GREIS), Department of Nursing and Physioterapy, University of León, 24071 León, Spain
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Kapali A, Daltveit AK, Myhr KM, Bjornevik K, Baldin E, Pugliatti M, Riise T, Cortese M. Childbirth delivery mode and the risk of multiple sclerosis: a prospective population-based study. J Neurol Neurosurg Psychiatry 2023; 95:8-13. [PMID: 37479464 DOI: 10.1136/jnnp-2023-331241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 06/20/2023] [Indexed: 07/23/2023]
Abstract
BACKGROUND Caesarean section (CS) may affect the risk of developing multiple sclerosis (MS) in the offspring, possibly through changes in gut microbiota composition, but findings from previous studies are inconsistent. We investigated whether birth by CS was associated with the risk of adult-onset MS. METHODS We conducted a prospective population-based cohort study, including all individuals born in Norway between 1967 and 2003, using the Medical Birth Registry of Norway linked with the Norwegian Multiple Sclerosis Registry and Biobank. The follow-up was until 2021. We used multivariable Cox models to estimate HRs for MS risk with 95% CIs. RESULTS Among 2 046 637 individuals in the cohort, 4954 MS cases were identified. Being born by CS was associated with a modest increase in MS risk (HR=1.18, 95% CI 1.05 to 1.32). In the sibling-matched analysis, we found no association between CS and MS risk. We found an interaction between CS and gestational age (p=0.03): CS was associated with an increased risk of MS in individuals born preterm (HR=1.62, 95% CI 1.18 to 2.24), whereas there was no association in individuals born at term (HR=1.13, 95% CI 0.99 to 1.27). In a subgroup analysis of individuals born in 1988 and onwards, emergency CS was related to an elevated MS risk (HR=1.40, 95% CI 1.07 to 1.83), whereas planned CS was not (HR: 1.10, 95% CI 0.77 to 1.58). CONCLUSIONS CS was associated with a modestly higher risk of developing MS. However, the stronger associations seen in subgroups who likely experienced a more complicated pregnancy/delivery may point to confounding underlying these associations.
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Affiliation(s)
- Akash Kapali
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Anne Kjersti Daltveit
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- Department of Health Registry Research and Development, Norwegian Institute of Public Health, Bergen, Norway
| | - Kjell-Morten Myhr
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Kjetil Bjornevik
- Department of Epidemiology, Harvard T H Chan School of Public Health, Boston, Massachusetts, USA
- Department of Nutrition, Harvard T H Chan School of Public Health, Boston, Massachusetts, USA
| | - Elisa Baldin
- Epidemiology and Biostatistics Unit, IRCCS Istituto Delle Scienze Neurologiche di Bologna, Bologna, Emilia-Romagna, Italy
| | - Maura Pugliatti
- Department of Neuroscience and Rehabilitation, University of Ferrara, Ferrara, Italy
- Department of Medicine, McGill University, Montreal, Québec, Canada
| | - Trond Riise
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Marianna Cortese
- Department of Nutrition, Harvard T H Chan School of Public Health, Boston, Massachusetts, USA
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Racene L, Rostoka Z, Kise L, Kacerauskiene J, Rezeberga D. In-Depth Analysis of Caesarean Section Rate in the Largest Secondary Care-Level Maternity Hospital in Latvia. J Clin Med 2023; 12:6426. [PMID: 37835069 PMCID: PMC10573868 DOI: 10.3390/jcm12196426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 10/01/2023] [Accepted: 10/03/2023] [Indexed: 10/15/2023] Open
Abstract
There is no surgical intervention without risk. A high rate of caesarean sections (CSs) impacts on maternal and newborn mortality and morbidity. For optimisation of the CS rate, regular monitoring is necessary. In 2015, the World Health Organization recommended the Robson classification as a global standard for assessing, monitoring, and comparing CS rates. We analysed all births in 2019 in the Riga Maternity Hospital-a secondary-level monodisciplinary perinatal care hospital in Latvia-according to the Robson classification, seeking to identify which groups make the biggest contribution to the overall CS rate. In total, 5835 women were included. The overall CS rate was 21.5%. In our study, the largest contributors to the overall CS rate were as follows: Group 5 (33.3%); Group 2 (20.8%); and Group 1 (15.6%). The results of our deeper analysis of individual groups (Group 1 and 5) from our study may help to develop targeted interventions for specific subgroups of the obstetric population, effectively reducing both the overall rate of CS and the number of unnecessary CSs performed. The CS rate reduction strategy should be based on decreasing CSs in Group 1 and encouraging VBAC, thus decreasing the number of women undergoing two or more CSs in future.
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Affiliation(s)
- Laura Racene
- Department of Obstetrics and Gynaecology, Rīga Stradiņš University, LV-1007 Riga, Latvia; (Z.R.); (L.K.); (D.R.)
- Riga Maternity Hospital, LV-1013 Riga, Latvia
| | - Zane Rostoka
- Department of Obstetrics and Gynaecology, Rīga Stradiņš University, LV-1007 Riga, Latvia; (Z.R.); (L.K.); (D.R.)
- Riga Maternity Hospital, LV-1013 Riga, Latvia
| | - Liva Kise
- Department of Obstetrics and Gynaecology, Rīga Stradiņš University, LV-1007 Riga, Latvia; (Z.R.); (L.K.); (D.R.)
- Riga Maternity Hospital, LV-1013 Riga, Latvia
| | - Justina Kacerauskiene
- Department of Obstetrics and Gynaecology, Lithuanian University of Health Sciences, 50167 Kaunas, Lithuania;
| | - Dace Rezeberga
- Department of Obstetrics and Gynaecology, Rīga Stradiņš University, LV-1007 Riga, Latvia; (Z.R.); (L.K.); (D.R.)
- Riga Maternity Hospital, LV-1013 Riga, Latvia
- Riga East Clinical University Hospital, LV-1038 Riga, Latvia
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Karampas G, Witkowski M, Metallinou D, Steinwall M, Matsas A, Panoskaltsis T, Christopoulos P. Delivery Progress, Labor Interventions and Perinatal Outcome in Spontaneous Vaginal Delivery of Singleton Pregnancies between Nulliparous and Primiparous Women with One Previous Elective Cesarean Section: A Retrospective Comparative Study. Life (Basel) 2023; 13:2016. [PMID: 37895398 PMCID: PMC10608638 DOI: 10.3390/life13102016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 09/25/2023] [Accepted: 09/26/2023] [Indexed: 10/29/2023] Open
Abstract
Trial of labor after cesarean (TOLAC) is an alternative to repeated cesarean for women with singleton pregnancy and one previous transverse lower segment cesarean section (LSCS), resulting in most cases being a successful vaginal birth after cesarean section (VBAC). The primary objective of this study was to examine if the progress and the duration of the active first stage and the second stage of labor in nulliparous women with singleton pregnancy, spontaneous start of labor and vaginal birth differ from primiparous women succeeding VBAC after one previous elective LSCS in a country with a low cesarean section and high VBAC rate. Secondary objectives were to compare labor interventions and maternal-neonatal outcomes between the two groups. METHODS This is a retrospective comparative study. Data were collected in a four-year period at the departments of Obstetrics and Gynecology at Kristianstad and Ystad hospitals in Sweden. Out of 14,925 deliveries, 106 primipara women with one previous elective LSCS and a spontaneous labor onset in the subsequent singleton pregnancy were identified. Of these women, 94 (88.7%) delivered vaginally and were included in the study (VBAC group). The comparison group included 212 randomly selected nulliparous women that had a normal singleton pregnancy, spontaneous labor onset and delivered vaginally. RESULTS The rate of cervical dilation during the active first stage of labor as well as the duration of the second stage did not differ between the two groups. When adjusting for cervical dilation at admission, there was no significant difference between the two groups regarding the duration of the active phase of the first stage of labor. No significant differences were found in maternal-neonatal outcomes between the two groups except for higher birth weight in the VBAC group. The use of epidural analgesia was associated with slower dilation rhythm over the duration of the active phase and second stage of labor, need for labor augmentation, postpartum bleeding and need for transfusion at higher rates, irrespective of parity when epidural was used. CONCLUSIONS Our study provides evidence that in women with one previous elective LSCS undergoing TOLAC in the subsequent pregnancy resulting in vaginal birth, the progress and duration of labor are not different from those in nulliparous women when labor is spontaneous and the it is a singleton pregnancy. The use of epidural was associated with prolonged labor, need for labor augmentation and higher postpartum bleeding, irrespective of parity. This information may be useful in patient counseling and labor management in TOLAC.
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Affiliation(s)
- Grigorios Karampas
- Department of Obstetrics and Gynecology, Skånes University Hospital, 21428 Malmö-Lund, Sweden
- Second Department of Obstetrics & Gynecology, Medical School, University of Athens “Aretaieion” Hospital, 11528 Athens, Greece
| | - Martin Witkowski
- Department of Obstetrics and Gynecology, Kristianstad/Ystad Community Hospitals, 27133 Ystad, Sweden
| | - Dimitra Metallinou
- Department of Midwifery, University of West Attica, 12243 Athens, Greece
| | - Margareta Steinwall
- Department of Obstetrics and Gynecology, Kristianstad/Ystad Community Hospitals, 27133 Ystad, Sweden
| | - Alkis Matsas
- Second Department of Obstetrics & Gynecology, Medical School, University of Athens “Aretaieion” Hospital, 11528 Athens, Greece
| | - Theodoros Panoskaltsis
- Second Department of Obstetrics & Gynecology, Medical School, University of Athens “Aretaieion” Hospital, 11528 Athens, Greece
| | - Panagiotis Christopoulos
- Second Department of Obstetrics & Gynecology, Medical School, University of Athens “Aretaieion” Hospital, 11528 Athens, Greece
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Ontiveros J, Gunnarsdóttir J, Guðnadóttir SA, Aspelund T, Einarsdóttir K. Twin birth rates and obstetric interventions in Iceland: A nationwide study from 1997 to 2018. Int J Gynaecol Obstet 2023; 163:226-233. [PMID: 37128945 DOI: 10.1002/ijgo.14817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 03/29/2023] [Accepted: 04/12/2023] [Indexed: 05/03/2023]
Abstract
OBJECTIVE Twin pregnancies are associated with increased antepartum and intrapartum risks. Limited multiple embryo transfers are associated with decreased twin birth rates. We aimed to study the effect of 2009 Icelandic regulations on twin birth rates and examine obstetric intervention rates for twin births during the study period. METHODS The study included all births (N = 94 028) in Iceland during 1997-2018. Twin birth rates and obstetric intervention rates were compared over birth year periods using modified Poisson regression adjusted for confounders. RESULTS An observed decrease in the twin birth rate trend was most notable from 2006 until 2009. Twin birth decreased in 2009-2013 (prevalence ratio [PR] 0.74, 95% confidence interval [CI] 0.64-0.86) and in 2014-2018 (PR 0.74, 95% CI 0.64-0.86) compared with 1997-2002. This decrease was only evident for women aged 30+ years in stratified analysis. Induction of labor rates increased from 26% in 1997-2002 to 44% in 2014-2018 (adjusted rate ratio [ARR] 2.10, 95% CI 1.72-2.57) whereas elective cesarean section (ARR 0.80, 95% CI 0.59-1.07) and urgent cesarean section (ARR 0.79, 95% CI 0.63-1.00) rates appeared to decline. CONCLUSION Twin births decreased during the study period. International guidelines published before the Icelandic regulations may have affected twin birth rates in Iceland. Induction of labor rates for twins increased while cesarean section rates decreased.
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Affiliation(s)
- Jamie Ontiveros
- Centre of Public Health Sciences, Faculty of Medicine, University of Iceland, Reykjavík, Iceland
| | - Jóhanna Gunnarsdóttir
- Centre of Public Health Sciences, Faculty of Medicine, University of Iceland, Reykjavík, Iceland
- Department of Obstetrics and Gynecology, Landspítali The National University Hospital of Iceland, Reykjavík, Iceland
| | | | - Thor Aspelund
- Centre of Public Health Sciences, Faculty of Medicine, University of Iceland, Reykjavík, Iceland
| | - Kristjana Einarsdóttir
- Centre of Public Health Sciences, Faculty of Medicine, University of Iceland, Reykjavík, Iceland
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9
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Götestam Skorpen C, Lydersen S, Salvesen KÅ, Wallenius M. A population-based study of caesarean section in women with juvenile idiopathic arthritis. Rheumatol Adv Pract 2023; 7:rkad062. [PMID: 37600477 PMCID: PMC10435369 DOI: 10.1093/rap/rkad062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 06/19/2023] [Indexed: 08/22/2023] Open
Abstract
Objectives The literature on delivery methods in women with JIA is limited. Active inflammation is a risk factor for caesarean section (CS) in other arthritic diseases. A CS entails a higher risk for complications than vaginal delivery and restricted physical activity in the first weeks after birth. Our objective was to explore a possible association of inflammatory active disease and the proportion of CS in women with JIA. Methods Data from the Norwegian nationwide observational register RevNatus were linked with data from the Medical Birth Registry of Norway (MBRN). Cases comprised singleton births in women with JIA (n = 196) included in RevNatus from 2010 to 2019. Singleton births registered in the MBRN during the same period of time, excluding births in mothers with rheumatic inflammatory diseases, served as population controls (n = 575 798). Results CS was more frequent in women with JIA (20.4%) and in the subgroup of women with inflammatory active JIA (30.0%) than in population controls (15.6%). Women with active JIA had a risk for elective CS similar to population controls [risk difference 2.3% (95% CI -2.5, 12.9)] and a higher risk for emergency CS [risk difference 14.0% (95% CI 4.3, 27.4)] compared with population controls. Conclusion Women with active JIA had a higher risk for emergency CS, but not elective CS, compared with population controls.
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Affiliation(s)
- Carina Götestam Skorpen
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Rheumatology Ålesund, Helse More og Romsdal HF, Ålesund, Norway
| | - Stian Lydersen
- Department of Mental Health, Regional Center for Child and Youth Mental Health and Child Welfare, Norwegian University of Science and Technology, Trondheim, Norway
| | - Kjell Å Salvesen
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Obstetrics and Gynecology, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Marianne Wallenius
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway
- Norwegian National Advisory Unit on Pregnancy and Rheumatic Diseases, Department of Rheumatology, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
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10
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Campos ASDQ, Rattner D, Diniz CSG. Achievement of appropriate cesarean rates using Robson's 10-Group classification system in Brazilian private practice. BMC Pregnancy Childbirth 2023; 23:504. [PMID: 37430192 PMCID: PMC10332037 DOI: 10.1186/s12884-023-05803-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 06/21/2023] [Indexed: 07/12/2023] Open
Abstract
BACKGROUND Increasing cesarean section (CS) rates are a global concern because they are related to higher maternal and neonatal complication rates and do not provide positive childbirth experiences. In 2019, Brazil ranked second globally, given its overall CS rate of 57%. According to the World Health Organization (WHO), populational CS rates of 10-15% are associated with decreased maternal, neonatal, and infant mortality rates. This study aimed to investigate whether multidisciplinary care following evidence-based protocols associated with a high motivation of both women and professionals for a vaginal birth leads to less overuse of CS in a Brazilian private practice (PP). METHODS This cross-sectional study evaluated CS rates by Robson group for women who sought vaginal birth in a private practice in Brazil comparing with Swedish data. Collaborative care of midwives and obstetricians who adopted evidence-based guidelines was offered. CS rates, overall and by Robson group, contribution of each Robson group to the overall CS rate, clinical and nonclinical interventions, vaginal birth, pre-labor CS, and intrapartum CS proportions were estimated. The expected CS rate was calculated using the World Health Organization C-model tool. The analysis used Microsoft Excel and R Studio (version 1.2.1335. 2009-2019). RESULTS The PP overall CS rate was 15.1% (95%CI, 13.4-17.1%) versus the 19.8% (95%CI, 14.8-24.7%) rate expected by the WHO C-model tool. The population included 43.7% women in Robson Group 1 (nulliparous, single, cephalic, at term, spontaneous labor), 11.4% in Group 2 (nulliparous, single, cephalic, at term, induced labor or CS before labor), and 14.9% in Group 5 (multiparous women with previous CS), the greatest contributors to higher CS rates (75.4% of them). The Swedish overall CS rate was 17.9% (95%CI, 17.6-18.1%) in a population of 27% women in Robson Group 1, 10.7% in Group 2, and 9.2% in Group 5. CONCLUSIONS Multidisciplinary care following evidence-based protocols, associated with high motivation of both women and professionals for vaginal birth, may lead to a significant and safe reduction of CS rates even in contexts such as Brazil, with high medicalization of obstetric care and excess CS.
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Affiliation(s)
- Andrea Silveira de Queiroz Campos
- Faculdade de Saúde Pública, Universidade de São Paulo, Av. Doutor Arnaldo, 715, 2º andar, Cerqueira César, São Paulo, 01246904 SP Brasil
| | - Daphne Rattner
- Faculdade de Ciências da Saúde, Universidade de Brasília, Campus Universitário Darcy Ribeiro, Asa Norte, Brasília, 70910900 DF Brasil
| | - Carmen Simone Grilo Diniz
- Faculdade de Saúde Pública, Universidade de São Paulo, Av. Doutor Arnaldo, 715, 2º andar, Cerqueira César, São Paulo, 01246904 SP Brasil
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Abdallah W, Abi Tayeh G, Kesrouani A, Nassar M, Finan R, Mansour F, Attieh E, Suidan J, Bou Saba C, El Kassis N, Yaghi N, Aouad N, Atallah D. The rate of cesarean delivery changes after internal audit based on the Robson Ten Group Classification System in Lebanon. Int J Gynaecol Obstet 2023; 161:314-319. [PMID: 36479965 DOI: 10.1002/ijgo.14610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 10/06/2022] [Accepted: 10/28/2022] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To evaluate the efficiency of the Robson classification as an internal clinical audit and feedback of the high rate of cesarean delivery at Hotel Dieu de France, a tertiary referral hospital. METHODS A pre-post study was conducted, with a retrospective approach in 2018 and 2019, identified as the pre-period (before the implementation of the Robson classification), and with a prospective approach in 2020 and 2021, labeled the post-period. RESULTS The total number of deliveries during the study period was 2560; 1305 patients were included in the pre-period and 1255 patients delivered in the post-period. No significant differences between the two groups were found. No significant difference was found in the overall rate of cesarean delivery between the first and second periods (57.86% vs 56.72%; P = 0.2). However, a significant decrease in the absolute contribution of groups 3 and 4 (multiparous women without a previous uterine scar with a single cephalic pregnancy, ≥37 weeks of gestation, with spontaneous labor or induced labor) in the overall rate of cesarean delivery was remarked (P = 0.02 and 0.01, respectively). CONCLUSION The Robson classification seems to be appropriate to monitor and audit the rate of cesarean delivery, but not sufficient to decrease the rate and change the practice.
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Affiliation(s)
- Wael Abdallah
- Department of Obstetrics and Gynecology, Hôtel-Dieu de France University Hospital, Saint Joseph University, Beirut, Lebanon
| | - Georges Abi Tayeh
- Department of Obstetrics and Gynecology, Hôtel-Dieu de France University Hospital, Saint Joseph University, Beirut, Lebanon
| | - Assaad Kesrouani
- Department of Obstetrics and Gynecology, Hôtel-Dieu de France University Hospital, Saint Joseph University, Beirut, Lebanon
| | - Malek Nassar
- Department of Obstetrics and Gynecology, Hôtel-Dieu de France University Hospital, Saint Joseph University, Beirut, Lebanon
| | - Ramzi Finan
- Department of Obstetrics and Gynecology, Hôtel-Dieu de France University Hospital, Saint Joseph University, Beirut, Lebanon
| | - Fersan Mansour
- Department of Obstetrics and Gynecology, Hôtel-Dieu de France University Hospital, Saint Joseph University, Beirut, Lebanon
| | - Elie Attieh
- Department of Obstetrics and Gynecology, Hôtel-Dieu de France University Hospital, Saint Joseph University, Beirut, Lebanon
| | - Joe Suidan
- Department of Obstetrics and Gynecology, Hôtel-Dieu de France University Hospital, Saint Joseph University, Beirut, Lebanon
| | - Camille Bou Saba
- Department of Obstetrics and Gynecology, Hôtel-Dieu de France University Hospital, Saint Joseph University, Beirut, Lebanon
| | - Nadine El Kassis
- Department of Obstetrics and Gynecology, Hôtel-Dieu de France University Hospital, Saint Joseph University, Beirut, Lebanon
| | - Nancy Yaghi
- Department of Obstetrics and Gynecology, Hôtel-Dieu de France University Hospital, Saint Joseph University, Beirut, Lebanon
| | - Norma Aouad
- Department of Obstetrics and Gynecology, Hôtel-Dieu de France University Hospital, Saint Joseph University, Beirut, Lebanon
| | - David Atallah
- Department of Obstetrics and Gynecology, Hôtel-Dieu de France University Hospital, Saint Joseph University, Beirut, Lebanon
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Golbasi C, Golbasi H, Bayraktar B, Omeroglu I, Vural T, Sahingoz Yildirim AG, Ekin A. Cesarean delivery rates based on time and indication using the Robson Ten-Group Classification System: Assessment at a Turkish tertiary center. J Obstet Gynaecol Res 2023; 49:883-892. [PMID: 36502809 DOI: 10.1111/jog.15522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Accepted: 11/29/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE This study aimed to evaluate increasing cesarean delivery (CD) rates, their causes, and changes over the years in a Turkish tertiary center using the Robson Ten-Group Classification System (RTGCS). METHODS Data of deliveries involving birth weight of ≥500 g or ≥24 weeks of gestation period from 2013 to 2020 were retrospectively collected and classified from the hospital digital record system using obstetric concepts and parameters described in the RTGCS. RESULTS The overall CD rate for all births (69051) from 2013 to 2020 was 55.5%. Groups 3, 5, and 1 were the most represented groups (29.1%, 23.9%, and 19.4%, respectively). The major contributors to the overall CD rate were Groups 5, 2, and 10 (23.8%, 9.9%, and 5.6%, respectively). Groups 2 and 4 (nullipara, multipara, single cephalic at term) had high CD rates associated with high rates of pre-labor CD (88.9% and 73.3%, respectively). The CD rate was 99.7% in Group 5, which showed recurrent CD, and 67.2% in Group 10. The overall CD rate was 60.8% in 2020 owing to the significant increase in the contributions by Groups 5, 8, and 10. The most common indication for CD was previous CD (46.1%), fetal distress (13.2%), and cephalopelvic disproportion (CPD) (8%). CONCLUSION Groups 1, 2, 5, and 10 were the major contributors to the overall CD rate at this tertiary center. To reduce overall CD rates, policies that reduce primary CD and support vaginal delivery after cesarean section should be established.
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Affiliation(s)
- Ceren Golbasi
- Department of Obstetrics and Gynecology, Izmir Tinaztepe University Faculty of Medicine, Izmir, Turkey
| | - Hakan Golbasi
- Department of Obstetrics and Gynecology Division of Perinatology, University of Health Sciences Tepecik Training and Research Hospital, Izmir, Turkey
| | - Burak Bayraktar
- Department of Obstetrics and Gynecology, University of Health Sciences Tepecik Training and Research Hospital, Izmir, Turkey
| | - Ibrahim Omeroglu
- Department of Obstetrics and Gynecology Division of Perinatology, University of Health Sciences Tepecik Training and Research Hospital, Izmir, Turkey
| | - Tayfun Vural
- Department of Obstetrics and Gynecology, University of Health Sciences Tepecik Training and Research Hospital, Izmir, Turkey
| | - Alkim Gulsah Sahingoz Yildirim
- Department of Obstetrics and Gynecology Division of Perinatology, University of Health Sciences Tepecik Training and Research Hospital, Izmir, Turkey
| | - Atalay Ekin
- Department of Obstetrics and Gynecology Division of Perinatology, University of Health Sciences Tepecik Training and Research Hospital, Izmir, Turkey
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Trial of labor after cesarean in women with hypertensive disorders and no prior vaginal delivery. Arch Gynecol Obstet 2023; 307:771-777. [PMID: 35578135 DOI: 10.1007/s00404-022-06601-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 04/27/2022] [Indexed: 11/02/2022]
Abstract
KEY MESSAGE Trial of labor among women who never delivered vaginally with hypertensive disorder is associated with nearly half the success rate of the general population. PURPOSE To study the trial of labor after cesarean (TOLAC) among women with hypertensive disorders and no prior vaginal delivery. METHODS A retrospective cohort study was conducted including women with no prior vaginal delivery undergoing TOLAC during 2010-2020. Women with hypertensive disorder were compared to those without. RESULTS A total of 54/2,144 (2.5%) TOLACs had a hypertensive disorder: 32 (59%) had gestational hypertension, 16 (30%) had chronic hypertension and 6 (11%) had preeclampsia. Women with hypertensive disorders had higher BMI and higher proportion of diabetic disorders. TOLAC success rate was lower among hypertensive mothers: 32 (59%) vs. 1,605 (76.8%), p=0.003 odds ratio (OR), 95% confidence interval (CI) 0.44 (0.25-0.76). The rate of uterine rupture was 23/2,144 (1.1%). In a multivariable logistic regression analysis, hypertensive disorder was independently negatively associated with TOLAC success, adjusted OR (95% CI) 0.47 (0.26-0.85). Other factors negatively independently associated with TOLAC failure were maternal age, predelivery body mass index, dystocia at primary CD, gestational age at TOLAC, induction of labor and birth weight. Epidural was independently positively associated with TOLAC success, adjusted OR (95% CI) 1.54 (1.18-1.99). CONCLUSION TOLAC in hypertensive women with no prior vaginal delivery is safe. Success rate is impaired in comparison to non-hypertensive women.
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Paz LDC, Banegas RC, Luz AG, Costa ML. Robson's Ten Group Classification System to Evaluate Cesarean Section Rates in Honduras: The Relevance of Labor Induction. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2022; 44:830-837. [PMID: 36216268 PMCID: PMC9948060 DOI: 10.1055/s-0042-1753547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023] Open
Abstract
OBJECTIVE To use the Robson Ten Group Classification (RTGC) to analyze cesarean section (CS) rates in a Honduran maternity hospital, with focus in groups that consider induction of labor. METHODS Cross-sectional study. Women admitted for childbirth (August 2017 to October 2018) were classified according to the RTGC. The CS rate for each group and the contribution to the overall CS rate was calculated, with further analyses of the induction of labor among term primiparous (group 2a), term multiparous (group 4a), and cases with one previous CS (group 5.1). RESULTS A total of 4,356 women were considered, with an overall CS rate of 26.1%. Group 3 was the largest group, with 38.6% (1,682/4,356) of the cases, followed by Group 1, with 30.8% (1,342/4,356), and Group 5, with 10.3% (450/4,356). Considering the contribution to overall CS rates per group, Group 5 contributed with 30.4% (345/1,136) of the CSs and within this group, 286/345 (82.9%) had 1 previous CS, with a CS rate > 70%. Groups 1 and 3, with 26.6% (291/1,136) and 13.5% (153/1,136), respectively, were the second and third larger contributors to the CS rate. Groups 2a and 4a had high induction success, with low CS rates (18.4 and 16.9%, respectively). CONCLUSION The RTGC is a useful tool to assess CS rates in different healthcare facilities. Groups 5, 1, and 3 were the main contributors to the CS rate, and groups 2 and 4 showed the impact and importance of induction of labor. These findings may support future interventions to reduce unnecessary CS, especially among primiparous and in women with previous CS.
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Affiliation(s)
| | | | - Adriana Gomes Luz
- Department of Obstetrics, University of Campinas, Campinas, SP, Brazil
| | - Maria Laura Costa
- Department of Obstetrics, University of Campinas, Campinas, SP, Brazil
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Muraca GM, Joseph K, Razaz N, Ladfors LV, Lisonkova S, Stephansson O. Crude and adjusted comparisons of cesarean delivery rates using the Robson classification: A population-based cohort study in Canada and Sweden, 2004 to 2016. PLoS Med 2022; 19:e1004077. [PMID: 35913981 PMCID: PMC9377587 DOI: 10.1371/journal.pmed.1004077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 08/15/2022] [Accepted: 07/15/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The Robson classification has become a global standard for comparing and monitoring cesarean delivery (CD) rates across populations and over time; however, this classification does not account for differences in important maternal, fetal, and obstetric practice factors known to impact CD rates. The objectives of our study were to identify subgroups of women contributing to differences in the CD rate in Sweden and British Columbia (BC), Canada using the Robson classification and to estimate the contribution of maternal, fetal/infant, and obstetric practice factors to differences in CD rates between countries and over time. METHODS AND FINDINGS We conducted a population-based cohort study of deliveries in Sweden (January 1, 2004 to December 31, 2016; n = 1,392,779) and BC (March 1, 2004 to April 31, 2017; n = 559,205). Deliveries were stratified into Robson categories and the CD rate, relative size of each group and its contribution to the overall CD rate were compared between the Swedish and the Canadian cohorts. Poisson and log-binomial regression were used to assess the contribution of maternal, fetal, and obstetric practice factors to spatiotemporal differences in Robson group-specific CD rates between Sweden and BC. Nulliparous women comprised 44.8% of the study population, while women of advanced maternal age (≥35 years) and women with overweight/obesity (≥25 kg/m2) constituted 23.5% and 32.4% of the study population, respectively. The CD rate in Sweden was stable at approximately 17.0% from 2004 to 2016 (p for trend = 0.10), while the CD rate increased in BC from 29.4% to 33.9% (p for trend < 0.001). Differences in CD rates between Sweden and BC varied by Robson group, for example, in Group 1 (nullipara with a term, single, cephalic fetus with spontaneous labor), the CD rate was 8.1% in Sweden and 20.4% in BC (rate ratio [RR] for BC versus Sweden = 2.52, 95% confidence interval [CI] 2.49 to 2.56, p < 0.001) and in Group 2 (nullipara, single, cephalic fetus, term gestation with induction of labor or prelabor CD), the rate of CD was 37.3% in Sweden and 45.9% in BC (RR = 1.23, 95% CI 1.22 to 1.25, p < 0.001). The effect of adjustment for maternal characteristics (e.g., age, body mass index), maternal comorbidity (e.g., preeclampsia), fetal characteristics (e.g., head position), and obstetric practice factors (e.g., epidural) ranged from no effect (e.g., among breech deliveries; Groups 6 and 7) to explaining up to 5.2% of the absolute difference in the CD rate (Group 2: adjusted CD rate in BC 40.7%, adjusted RR = 1.09, 95% CI 1.08 to 1.12, p < 0.001). Adjustment also explained a substantial fraction of the temporal change in CD rates among some Robson groups in BC. Limitations of the study include a lack of information on intrapartum details, such as labor duration as well as maternal and perinatal outcomes associated with the observed differences in CD rates. CONCLUSIONS In this study, we found that several factors not included in the Robson classification explain a significant proportion of the spatiotemporal difference in CD rates in some Robson groups. These findings suggest that incorporating these factors into explanatory models using the Robson classification may be useful for ensuring that public health initiatives regarding CD rates are evidence informed.
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Affiliation(s)
- Giulia M. Muraca
- Clinical Epidemiology Unit, Department of Medicine, Solna, Karolinska University Hospital, Karolinska Institutet, Eugeniahemmet, Stockholm, Sweden
- Department of Obstetrics and Gynaecology, University of British Columbia and the Children’s and Women’s Hospital and Health Centre of British Columbia, Vancouver, British Columbia, Canada
- Departments of Obstetrics and Gynecology and Health Research Methods, Evidence & Impact, Faculty of Health Sciences, McMaster University, Ontario, Canada
- * E-mail:
| | - K.S. Joseph
- Department of Obstetrics and Gynaecology, University of British Columbia and the Children’s and Women’s Hospital and Health Centre of British Columbia, Vancouver, British Columbia, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Neda Razaz
- Clinical Epidemiology Unit, Department of Medicine, Solna, Karolinska University Hospital, Karolinska Institutet, Eugeniahemmet, Stockholm, Sweden
| | - Linnea V. Ladfors
- Clinical Epidemiology Unit, Department of Medicine, Solna, Karolinska University Hospital, Karolinska Institutet, Eugeniahemmet, Stockholm, Sweden
| | - Sarka Lisonkova
- Department of Obstetrics and Gynaecology, University of British Columbia and the Children’s and Women’s Hospital and Health Centre of British Columbia, Vancouver, British Columbia, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Olof Stephansson
- Clinical Epidemiology Unit, Department of Medicine, Solna, Karolinska University Hospital, Karolinska Institutet, Eugeniahemmet, Stockholm, Sweden
- Division of Women’s Health, Department of Obstetrics, Karolinska University Hospital, Stockholm, Sweden
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Dias BAS, Leal MDC, Esteves-Pereira AP, Nakamura-Pereira M. Variations in cesarean and repeated cesarean section rates in Brazil according to gestational age at birth and type of hospital. CAD SAUDE PUBLICA 2022; 38:e00073621. [PMID: 35857919 DOI: 10.1590/0102-311xpt073621] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 04/14/2022] [Indexed: 11/21/2022] Open
Abstract
This study aimed to describe cesarean and repeated cesarean section rates in Brazil according to gestational age (GA) at birth and type of hospital. This is an ecologic study using data from the Brazilian Information System on Live Births and the 2017 National Registry of Health Facilities. Overall and repeated cesarean section rates were calculated and analyzed according to GA, region of residence, and type of hospital. Spearman correlations were performed between cesarean and repeated cesarean section rates by GA subgroups at birth (≤ 33, 34-36, 37-38, 39-41, and ≥ 42 weeks) and analyzed according to the type of hospital. Overall and repeated cesarean section rates were 55.1% and 85.3%, respectively. More than 60% of newborns between 37-38 weeks were delivered via cesarean section. Private hospitals in all regions showed the highest cesarean section rates, especially those in the Central-West Region, with more than 80% at all GAs. The overall cesarean section rate was highly correlated with all cesarean section rates of GA subgroups (r > 0.7, p < 0.01). Regarding repeated cesarean sections, the overall rate was strongly correlated with the rates of 37-38 and 39-41 weeks in public/mixed hospitals, differing from private hospitals, which showed moderate correlations. This finding indicates the decision for cesarean section is not based on clinical factors, which can cause unnecessary damage to the health of both the mother and the baby. Then, changes in the delivery care model, strengthening public policies, and encouragement of vaginal delivery after a cesarean section in subsequent pregnancies are important strategies to reduce cesarean section rates in Brazil.
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Affiliation(s)
| | - Maria do Carmo Leal
- Vice-Presidência de Ensino, Informação e Comunicação, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil
| | | | - Marcos Nakamura-Pereira
- Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil
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Khowaja BMH, Shahil Feroz A, Saleem S. Factors influencing utilisation of services provided by community midwives and their non-retention in district Thatta, Pakistan: a qualitative study protocol. BMJ Open 2022; 12:e052323. [PMID: 35863826 PMCID: PMC9310158 DOI: 10.1136/bmjopen-2021-052323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Drawing on the well-acknowledged evidence of community midwives services to address the issue of high maternal mortality, the Government of Pakistan initiated the Community Midwifery (CMW) programme in 2006 to provide skilled birth attendance to pregnant women living in rural areas. Despite a large investment in CMW programme, the availability of community midwives in rural areas following their training is a constant struggle. The concerns related to the training, support and acceptability of community midwives need to be studied in order to identify gaps in the provision of skilled maternal and newborn healthcare. Therefore, this study aims to explore factors influencing the utilisation of services provided by community midwives and their non-retention in district Thatta, Pakistan. METHODS AND ANALYSIS The study will use a qualitative exploratory research design. The data will be collected through semistructured interviews and an approach of purposive sampling for the selection of participants for interviews. The study will be conducted in one of the rural districts Thatta of Province Sindh, Pakistan. The data will be collected through key informant interviews (KIIs) and in-depth interviews (IDIs). The KIIs will be conducted with officials of the health department (Thatta), the provincial maternal and newborn child health programme, and the Midwifery Association of Pakistan. The IDIs will be conducted with midwifery students, community midwives working and not working in the district, and community women of district Thatta. Data will be analysed through qualitative data analysis software NVivo V.10 and the thematic analysis approach. ETHICS AND DISSEMINATION Ethical approval for this study has been obtained from the Aga Khan University Ethical Review Committee (2020-3391-11138). The results of the study will be disseminated to the scientific community, to policy-makers involved in CMW programme training and implementation, and to the research subjects participating in the study.
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Affiliation(s)
| | | | - Sarah Saleem
- Community Health Sciences, Aga Khan University, Karachi, Pakistan
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Wängberg Nordborg J, Svanberg T, Strandell A, Carlsson Y. Term breech presentation-Intended cesarean section versus intended vaginal delivery-A systematic review and meta-analysis. Acta Obstet Gynecol Scand 2022; 101:564-576. [PMID: 35633052 DOI: 10.1111/aogs.14333] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 12/24/2021] [Accepted: 01/07/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Three per cent of all infants are born in breech presentation, still the preferred way to deliver them remains controversial. The objective of this systematic review was to assess the safety for the mother and child depending on intended mode of delivery when the baby is in breech position at term. MATERIAL AND METHODS The population (P) was pregnant women with a child in breech presentation, from gestational week 34+0 . The intervention (I) was the intention to deliver by cesarean section, the comparison (C) was the intention to deliver vaginally. Outcomes (O) were perinatal mortality, perinatal morbidity, maternal mortality, maternal morbidity, conversion of delivery mode, and the mother's experience. Systematic literature searches were performed. We included randomized trials, cohort studies with more than 500 women/group and case series for more than 15 000 women published between 1990 and October 2021, written in English or the Nordic languages. The certainty of evidence was assessed using the GRADE approach and data were pooled in meta-analyses. PROSPERO registration number: CRD42020209546. RESULTS Thirty-two articles were included (with 530 604 women). The certainty of evidence was moderate or low because the study designs were mostly retrospective cohort studies. The only randomized trial showed reduced risk of perinatal mortality for planned cesarean section, risk ratio (RR) 0.27 (95% confidence interval [CI] 0.08-0.97, 2078 women, low certainty of evidence), stillbirths excluded. A meta-analysis of cohort studies resulted in a similar estimate, RR 0.36 (95% CI 0.25-0.51, 21 studies, 388 714 women, low certainty of evidence). We also found reduced risk for outcomes representing perinatal morbidity 0-28 days: 5-min Apgar score less than 7 in one randomized controlled trial: RR 0.27 (95% CI 0.12-0.58, 2033 women, moderate certainty of evidence), and in a meta-analysis: RR 0.1 (95% CI 0.14-0.26, 18 studies, 217 024 women, moderate certainty of evidence); APGAR score less than 4 at 5 min: RR 0.39 (95% CI 0.19-0.81, five studies, 44 498 women, low certainty of evidence); and pH less than 7.0: RR 0.23 (95% CI 0.12-0.43, four studies, 13 440 women, low certainty of evidence). Outcomes for the mother were similar in the groups except for reduced risk for experience of urinary incontinence in the group of planned cesarean section: RR 0.62 (95% CI 0.41-0.93, one study, 1940 women, low certainty of evidence). The conversion rate from planned vaginal delivery to emergency cesarean section ranged from 16% to 51% (median 41.8%, 10 studies, 50 763 women, moderate certainty of evidence). CONCLUSIONS Intended cesarean section may reduce the risk of perinatal mortality and perinatal as well as some maternal morbidity compared with intended vaginal delivery. It is uncertain whether there is any difference in maternal mortality. The conversion rate from intended vaginal delivery to emergency cesarean section is high.
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Affiliation(s)
- Julia Wängberg Nordborg
- Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Therese Svanberg
- HTA-centrum, Sahlgrenska University Hospital, Gothenburg, Sweden.,Medical Library, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Annika Strandell
- Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Sweden.,HTA-centrum, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Obstetrics and Gynecology, Gothenburg Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden
| | - Ylva Carlsson
- Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Obstetrics and Gynecology, Gothenburg Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden
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Sima YT, Skjærven R, Kvalvik LG, Morken NH, Klungsøyr K, Sørbye LM. Cesarean delivery in Norwegian nulliparous women with singleton cephalic term births, 1967-2020: a population-based study. BMC Pregnancy Childbirth 2022; 22:419. [PMID: 35585522 PMCID: PMC9118652 DOI: 10.1186/s12884-022-04755-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 05/10/2022] [Indexed: 11/26/2022] Open
Abstract
Background Nulliparous women contribute to increasing cesarean delivery in the Nordic countries and advanced maternal age has been suggested as responsible for rise in cesarean delivery rates in many developed countries. The aim was to describe changes in cesarean delivery rates among nulliparous women with singleton, cephalic, term births by change in sociodemographic factors across 50 years in Norway. Methods We used data from the Medical Birth Registry of Norway and included 1 067 356 women delivering their first, singleton, cephalic, term birth between 1967 and 2020. Cesarean delivery was described by maternal age (5-year groups), onset of labor (spontaneous, induced and pre-labor CD), and time periods: 1967–1982, 1983–1998 and 1999–2020. We combined women’s age, onset of labor and time period into a compound variable, using women of 20–24 years, with spontaneous labor onset during 1967–1982 as reference. Multivariable regression models were used to estimate adjusted relative risk (ARR) of cesarean delivery with 95% confidence interval (CI). Results Overall cesarean delivery increased both in women with and without spontaneous onset of labor, with a slight decline in recent years. The increase was mainly found among women < 35 years while it was stable or decreased in women > = 35 years. In women with spontaneous onset of labor, the ARR of CD in women > = 40 years decreased from 14.2 (95% CI 12.4–16.3) in 1967–82 to 6.7 (95% CI 6.2–7.4) in 1999–2020 and from 7.0 (95% CI 6.4–7.8) to 5.0 (95% CI 4.7–5.2) in women aged 35–39 years, compared to the reference population. Despite the rise in induced onset of labor over time, the ARR of CD declined in induced women > = 40 years from 17.6 (95% CI 14.4–21.4) to 13.4 (95% CI 12.5–14.3) while it was stable in women 35–39 years. Conclusion Despite growing number of Norwegian women having their first birth at a higher age, the increase in cesarean delivery was found among women < 35 years, while it was stable or decreased in older women. The increase in cesarean delivery cannot be solely explained by the shift to an older population of first-time mothers. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-022-04755-3.
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Affiliation(s)
- Yeneabeba Tilahun Sima
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.
| | - Rolv Skjærven
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Liv Grimstvedt Kvalvik
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | | | - Kari Klungsøyr
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Linn Marie Sørbye
- Norwegian Research Centre for Women's Health, Oslo University Hospital, Rikshospitalet, Oslo, Norway
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Richmond E, Ray JG, Pudwell J, Djerboua M, Gaudet L, Walker M, Smith GN, Velez MP. Caesarean birth in women with infertility: population-based cohort study. BJOG 2022; 129:908-916. [PMID: 34797929 PMCID: PMC9300122 DOI: 10.1111/1471-0528.17019] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/20/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Caesarean section (CS) is more common following infertility treatment (IT) but the reasons why remain unclear and confounded. The Robson 10-Group Classification System (TGCS) may further explain variation in CS rates. We assessed the association between mode of conception and CS across Robson groups. DESIGN Population-based cohort study. SETTING Ontario, Canada, in a public healthcare system. POPULATION 921 023 births, 2006-2014. METHODS Modified Poisson regression produced relative risks (RR) and 95% confidence intervals, comparing the risk of CS among women with (1) subfertility without IT, (2) non-invasive IT (OI, IUI) or (3) invasive IT (IVF)-each relative to (4) spontaneous conception (SC). MAIN OUTCOME MEASURES CS rate according to one of four modes of conception, overall and stratified by each of the TGCS groups. RESULTS Relative to SC (26.9%), the risk of CS increased in those with subfertility without IT (RR 1.17, 95% CI 1.16-1.18), non-invasive IT (RR 1.21, 95% CI 1.18-1.24) and invasive IT (RR 1.39, 95% CI 1.36-1.42). Within each Robson group, similar patterns of RRs were seen, but with markedly differing rates. For example, in Group 1 (nulliparous, singleton, cephalic at ≥37 weeks, with spontaneous labour), the respective rates were 15.0, 19.4, 18.7 and 21.9%; in Group 2 (nulliparous, singleton, cephalic at ≥37 weeks, without spontaneous labour), the rates were 35.9, 44.4, 43.2 and 54.1%; and in Group 8 (multiple pregnancy), they were 55.9, 67.5, 65.0 and 69.3%, respectively. CONCLUSIONS CS is relatively more common in women with subfertility and those receiving IT, an effect that persists across Robson groups. TWEETABLE ABSTRACT Caesarean delivery is more common in women with infertility independent of demographics and prenatal conditions.
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Affiliation(s)
- E Richmond
- Department of Obstetrics & GynaecologyKingston General HospitalQueen’s UniversityKingstonONCanada
| | - JG Ray
- ICESTorontoONCanada
- Department of MedicineSt. Michael’s HospitalUniversity of TorontoTorontoONCanada
| | - J Pudwell
- Department of Obstetrics & GynaecologyKingston General HospitalQueen’s UniversityKingstonONCanada
| | | | - L Gaudet
- Department of Obstetrics & GynaecologyKingston General HospitalQueen’s UniversityKingstonONCanada
| | - M Walker
- Department of Obstetrics, Gynaecology & Newborn CareUniversity of OttawaOttawaONCanada
| | - GN Smith
- Department of Obstetrics & GynaecologyKingston General HospitalQueen’s UniversityKingstonONCanada
| | - MP Velez
- Department of Obstetrics & GynaecologyKingston General HospitalQueen’s UniversityKingstonONCanada
- ICESTorontoONCanada
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Pourshirazi M, Heidarzadeh M, Taheri M, Esmaily H, Babaey F, Talkhi N, Gholizadeh L. Cesarean delivery in Iran: a population-based analysis using the Robson classification system. BMC Pregnancy Childbirth 2022; 22:185. [PMID: 35260106 PMCID: PMC8903666 DOI: 10.1186/s12884-022-04517-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 02/25/2022] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND The rise of Cesarean Sections (CS) is a global concern. In Iran, the rate of CS increased from 40.7% in 2005 to 53% in 2014. This figure is even higher in the private sector. OBJECTIVE To analyze the CS rates in the last 2 years using the Robson Classification System in Iran. METHODS A retrospective analysis of all in-hospital electronically recorded deliveries in Iran was conducted using the Robson classification. Comparisons were made in terms of the type of hospital, CS rate, and obstetric population, and contributions of each group to the overall cesarean deliveries were reported. RESULTS Two million three hundred twenty-two thousand five hundred women gave birth, 53.6% delivered through CS. Robson group 5 was the largest contributing group to the overall number of cesarean deliveries (47.1%) at a CS rate of 98.4%. Group 2 and 1 ranked the second and third largest contributing groups to overall CSs (20.6 and 10.8%, respectively). The latter groups had CS rates much higher than the WHO recommendation of 67.2 and 33.1%, respectively. "Fetal Distress" and "Undefined Indications" were the most common reasons for cesarean deliveries at CS rates of 13.6 and 13.4%, respectively. There was a significant variation in CS rate among the three types of hospitals for Robson groups 1, 2, 3, 4, and 10. CONCLUSION The study revealed significant variations in CS rate by hospital peer-group, especially for the private maternity units, suggesting the need for further attention and audit of the Robson groups that significantly influence the overall CS rate. The study results will help policymakers identify effective strategies to reduce the CS rate in Iran, providing appropriate benchmarking to compare obstetric care with other countries that have better maternal and perinatal outcomes.
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Affiliation(s)
- Maryam Pourshirazi
- Department of Hospital Management and Clinical Services Excellence, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mohammad Heidarzadeh
- Neonatal Health Office, Ministry of Health and Medical Education, Tehran, Iran.
- Department of Neonatology, Tabriz University of Medical Sciences, Tabriz, Iran.
| | - Mahshid Taheri
- Department of Hospital Management and Clinical Services Excellence, Ministry of Health and Medical Education, Tehran, Iran
| | - Habibollah Esmaily
- Social Determinants of Health Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Farah Babaey
- Department of Hospital Management and Clinical Services Excellence, Ministry of Health and Medical Education, Tehran, Iran
| | - Nasrin Talkhi
- Department of biostatistics, School of Health, Mashhad university of Medical Sciences, Mashhad, Iran
| | - Leila Gholizadeh
- Faculty of Health, University of Technology, Sydney, NSW, Australia
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Dias BAS, Leal MDC, Esteves-Pereira AP, Nakamura-Pereira M. Variations in cesarean and repeated cesarean section rates in Brazil according to gestational age at birth and type of hospital. CAD SAUDE PUBLICA 2022. [DOI: 10.1590/0102-311xen073621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2024] Open
Abstract
This study aimed to describe cesarean and repeated cesarean section rates in Brazil according to gestational age (GA) at birth and type of hospital. This is an ecologic study using data from the Brazilian Information System on Live Births and the 2017 National Registry of Health Facilities. Overall and repeated cesarean section rates were calculated and analyzed according to GA, region of residence, and type of hospital. Spearman correlations were performed between cesarean and repeated cesarean section rates by GA subgroups at birth (≤ 33, 34-36, 37-38, 39-41, and ≥ 42 weeks) and analyzed according to the type of hospital. Overall and repeated cesarean section rates were 55.1% and 85.3%, respectively. More than 60% of newborns between 37-38 weeks were delivered via cesarean section. Private hospitals in all regions showed the highest cesarean section rates, especially those in the Central-West Region, with more than 80% at all GAs. The overall cesarean section rate was highly correlated with all cesarean section rates of GA subgroups (r > 0.7, p < 0.01). Regarding repeated cesarean sections, the overall rate was strongly correlated with the rates of 37-38 and 39-41 weeks in public/mixed hospitals, differing from private hospitals, which showed moderate correlations. This finding indicates the decision for cesarean section is not based on clinical factors, which can cause unnecessary damage to the health of both the mother and the baby. Then, changes in the delivery care model, strengthening public policies, and encouragement of vaginal delivery after a cesarean section in subsequent pregnancies are important strategies to reduce cesarean section rates in Brazil.
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Shittu S, Alansari L, Nattouf F, Olukade T, Abdallah N. Impact of maternal nationality on caesarean section rate variation in a high-income country. Qatar Med J 2021; 2021:69. [PMID: 34888204 PMCID: PMC8628854 DOI: 10.5339/qmj.2021.69] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 11/01/2021] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Caesarean section (CS) rates have been reported to differ between immigrants and native-born women in high-income countries. OBJECTIVE We assessed the CS rate and its relationship with the CS rate in country of nationality and other explanatory factors among women of different nationalities including Qatari women who underwent deliveries at our hospital to generate evidence that will quantify and help explain the observed CS rates in our hospital. METHODS In this retrospective cross-sectional study conducted at the second-largest public maternity hospital in Qatar, Al-Wakra Hospital (AWH), data for all births delivered in 2019 were retrieved from the hospital's electronic medical records. The CS rates and the crude and adjusted risks of Caesarean delivery for mothers from each nationality were determined, and the common indications for CS were analyzed based on nationality. The association between nationality and Caesarean delivery was examined using binomial logistic regression analysis, with Qatari women as the reference group. The correlation between CS rate in country of nationality and observed CS rates in Qatar was also examined using Pearson's correlation. RESULTS The study population consisted of 4816 births by women of 68 nationalities, of which 4513 births were by women from 25 countries. The highest proportion of deliveries (n-1247, 25.9%) was by Indian women. The frequency of CS was the highest and lowest among Egyptian (49.6%) and Yemeni women (17.9%), respectively. Elective CS was predominantly performed in women of Arab nationalities; the most common indication was a history of previous multiple CSs. Emergency CS was primarily performed in women of Asian and Sub-Saharan African nationalities; the most common indications were failure to progress and fetal distress. For most nationalities, the CS rate in Qatar was associated with those of the countries of nationality. CONCLUSIONS The observed CS rates varied widely among women of different nationalities. The variation was influenced by maternal factors and medical indications as well as the CS rates in the country of nationality. We posit that cultural preferences, acculturation, and patient expectations influenced observed findings. More efforts are required to reduce primary CS rates and to help women make the most informed decisions regarding modes of delivery. Key Message: CS rates varied widely among women of different nationalities. The variation was influenced by medical indications, maternal preferences, and CS rate in countries of nationality. The solution to reducing CS rates should be a culturally informed response.
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Affiliation(s)
- Saheed Shittu
- Department of Obstetrics and Gynaecology, Al-Wakra Hospital, Hamad Medical Corporation, Qatar E-mail:
| | - Lolwa Alansari
- Department of Obstetrics and Gynaecology, Al-Wakra Hospital, Hamad Medical Corporation, Qatar E-mail:
| | - Fahed Nattouf
- Department of Obstetrics and Gynaecology, Al-Wakra Hospital, Hamad Medical Corporation, Qatar E-mail:
| | - Tawa Olukade
- Department of Paediatrics, Hamad General Hospital, Hamad Medical Corporation, Qatar
| | - Naji Abdallah
- Department of Obstetrics and Gynaecology, Al-Wakra Hospital, Hamad Medical Corporation, Qatar E-mail:
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Gunnarsdóttir J, Swift EM, Jakobsdóttir J, Smárason A, Thorkelsson T, Einarsdóttir K. Cesarean birth, obstetric emergencies, and adverse neonatal outcomes in Iceland during a period of increasing labor induction. Birth 2021; 48:493-500. [PMID: 34132423 DOI: 10.1111/birt.12564] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 06/02/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND The rate of labor induction has risen steeply throughout the world. This project aimed to estimate changes in the rates of adverse maternal and neonatal outcomes in Iceland between 1997 and 2018, and to assess whether the changes can be explained by an increased rate of labor induction. METHODS Singleton live births, occurring between 1997 and 2018, that did not start by prelabor cesarean, were identified from the Icelandic Medical Birth Register (n = 85 971). Rates of intrapartum cesarean birth (CB), obstetric emergencies, and neonatal outcomes were calculated, and adjusted risk ratios (aRRs) and 95% confidence intervals (CIs) were estimated with log-binomial regression (reference: 1997-2001). Adjustments were made for: (a) maternal characteristics, and (b) labor induction and gestational age. RESULTS The rate of labor induction increased from 13.6% in the period 1997-2001 to 28.1% in the period 2014-2018. The rate of intrapartum CB decreased between the periods of 1997-2001 and 2014-2018 for both primiparous (aRR 0.76, 95% CI: 0.69 to 0.84) and multiparous women (aRR 0.55, 95% CI: 0.49 to 0.63). The rate of obstetric emergencies and adverse neonatal outcomes also decreased between these time periods. Adjusting for labor induction did not attenuate these associations. CONCLUSIONS The rates of adverse maternal outcomes and adverse neonatal outcomes decreased over the study period. However, there was no evidence that this decrease could be explained by the increased rate of labor induction.
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Affiliation(s)
- Jóhanna Gunnarsdóttir
- Centre of Public Health Sciences, Faculty of Medicine, University of Iceland, Reykjavik, Iceland.,Department of Obstetrics and Gynecology, Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland
| | - Emma M Swift
- Centre of Public Health Sciences, Faculty of Medicine, University of Iceland, Reykjavik, Iceland.,Faculty of Nursing - Department of Midwifery, University of Iceland, Reykjavik, Iceland
| | - Jóhanna Jakobsdóttir
- Centre of Public Health Sciences, Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Alexander Smárason
- Institution of Health Science Research, University of Akureyri and Akureyri Hospital, Akureyri, Iceland
| | - Thordur Thorkelsson
- Division of Neonatal Intensive Care, Children's Medical Center, Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland
| | - Kristjana Einarsdóttir
- Centre of Public Health Sciences, Faculty of Medicine, University of Iceland, Reykjavik, Iceland
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Pulvermacher C, Van de Vondel P, Gerzen L, Gembruch U, Welchowski T, Schmid M, Merz WM. Analysis of cesarean section rates in two German hospitals applying the 10-Group Classification System. J Perinat Med 2021; 49:818-829. [PMID: 33827151 DOI: 10.1515/jpm-2020-0505] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Accepted: 03/18/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES In Germany, cesarean section (CS) rates more than doubled within the past two decades. For analysis, auditing and inter-hospital comparison, the 10-Group Classification System (TGCS) is recommended. We used the TGCS to analyze CS rates in two German hospitals of different levels of care. METHODS From October 2017 to September 2018, data were prospectively collected. Unit A is a level three university hospital, unit B a level one district hospital. The German birth registry was used for comparison with national data. We performed two-sample Z tests and bootstrapping to compare aggregated (unit A + B) with national data and unit A with unit B. RESULTS In both datasets (national data and aggregated data unit A + B), Robson group (RG) 5 was the largest contributor to the overall CS rate. Compared to national data, group sizes in RG 1 and 3 were significantly smaller in the units under investigation, RG 8 and 10 significantly larger. Total CS rates between the two units differed (40.7 vs. 28.4%, p<0.001). The CS rate in RG 5 and RG 10 was different (p<0.01 for both). The most relative frequent RG in both units consisted of group 5, followed by group 10 and 2a. CONCLUSIONS The analysis allowed us to explain different CS rates with differences in the study population and with differences in the clinical practice. These results serve as a starting point for audits, inter-hospital comparisons and for interventions aiming to reduce CS rates.
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Affiliation(s)
| | | | - Lydia Gerzen
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, Bonn, Germany
| | - Ulrich Gembruch
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, Bonn, Germany
| | - Thomas Welchowski
- Department of Medical Biometry, Informatics and Epidemiology, Faculty of Medicine, University of Bonn, Bonn, Germany
| | - Matthias Schmid
- Department of Medical Biometry, Informatics and Epidemiology, Faculty of Medicine, University of Bonn, Bonn, Germany
| | - Waltraut M Merz
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, Bonn, Germany
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Changes in maternal risk factors and their association with changes in cesarean sections in Norway between 1999 and 2016: A descriptive population-based registry study. PLoS Med 2021; 18:e1003764. [PMID: 34478464 PMCID: PMC8452082 DOI: 10.1371/journal.pmed.1003764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 09/20/2021] [Accepted: 08/11/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Increases in the proportion of the population with increased likelihood of cesarean section (CS) have been postulated as a driving force behind the rise in CS rates worldwide. The aim of the study was to assess if changes in selected maternal risk factors for CS are associated with changes in CS births from 1999 to 2016 in Norway. METHODS AND FINDINGS This national population-based registry study utilizes data from 1,055,006 births registered in the Norwegian Medical Birth Registry from 1999 to 2016. The following maternal risk factors for CS were included: nulliparous/≥35 years, multiparous/≥35 years, pregestational diabetes, gestational diabetes, hypertensive disorders, previous CS, assisted reproductive technology, and multiple births. The proportion of CS births in 1999 was used to predict the number of CS births in 2016. The observed and predicted numbers of CS births were compared to determine the number of excess CS births, before and after considering the selected risk factors, for all births, and for births stratified by 0, 1, or >1 of the selected risk factors. The proportion of CS births increased from 12.9% to 16.1% (+24.8%) during the study period. The proportion of births with 1 selected risk factor increased from 21.3% to 26.3% (+23.5%), while the proportion with >1 risk factor increased from 4.5% to 8.8% (+95.6%). Stratification by the presence of selected risk factors reduced the number of excess CS births observed in 2016 compared to 1999 by 67.9%. Study limitations include lack of access to other important maternal risk factors and only comparing the first and the last year of the study period. CONCLUSIONS In this study, we observed that after an initial increase, proportions of CS births remained stable from 2005 to 2016. Instead, both the size of the risk population and the mean number of risk factors per birth continued to increase. We observed a possible association between the increase in size of risk population and the additional CS births observed in 2016 compared to 1999. The increase in size of risk population and the stable CS rate from 2005 and onward may indicate consistent adherence to obstetric evidence-based practice in Norway.
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Kvalvik SA, Rasmussen S, Thornhill HF, Baghestan E. Risk factors for surgical site infection following cesarean delivery: A hospital-based case-control study. Acta Obstet Gynecol Scand 2021; 100:2167-2175. [PMID: 34309849 DOI: 10.1111/aogs.14235] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 06/28/2021] [Accepted: 07/19/2021] [Indexed: 02/01/2023]
Abstract
INTRODUCTION Cesarean section is the single most important risk factor for postpartum infection. Where the rest of the world shows increasing trends, the cesarean section rates are low in Norway and risk factors for infection after cesarean section may differ in high and low cesarean section settings. The goal of this study was to examine independent risk factors for surgical site infection after cesarean delivery in a setting of low cesarean section rates. MATERIAL AND METHODS We conducted a hospital-based case-control study at Haukeland University Hospital. We included women who presented to our hospital with surgical site infection after cesarean section during the years 2014-2016 (n = 75). Controls were selected at a ratio of 2:1 (n = 148). Cases and controls were compared with respect to maternal and pregnancy characteristics using uni- and multivariable logistic regression models. Main outcome measures were anticipated risk factors for surgical site infection. RESULTS The occurrence of surgical site infection was 0.4% and 5.4% after elective and emergency cesarean section, respectively. Compared to women without surgical site infection, women with surgical site infection were almost thrice more obese before pregnancy (OR 2.8, 95% CI 1.2-7.0), four times more likely to have preexisting psychiatric conditions (OR 4.4, 95% CI 1.1-17.6), and five times more likely to receive blood transfusion (OR 5.1, 95% CI 1.4-18.8). Signs of infection during labor was a marginally significant risk factor for surgical site infection (OR 2.0, 95% CI 1.0-5.4). CONCLUSIONS Emergency cesarean section was a significant risk factor for surgical site infection. Pregestational obesity, preexisting psychiatric conditions, and blood transfusion during or following delivery, were independent risk factors for surgical site infection. Signs of infection during labor was a marginally significant risk factor. Women with either of these risk factors should be carefully monitored and evaluated for signs of infection in the postpartum period.
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Affiliation(s)
- Sedina Atic Kvalvik
- Department of Obstetrics and Gynecology, Haukeland University Hospital, Bergen, Norway
| | - Svein Rasmussen
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | | | - Elham Baghestan
- Department of Obstetrics and Gynecology, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
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Abstract
Background Between 5% and 14% of women suffer from fear of childbirth (FOC) which is associated with difficulties during birth and in postnatal psychological adjustment. Therefore, effective interventions are needed to improve outcomes for women. A systematic review and meta-analysis was used to identify effective interventions for treating women with FOC. Methods Literature searches were undertaken on online databases. Hand searches of reference lists were also carried out. Studies were included in the review if they recruited women with FOC and aimed to reduce FOC and/or improve birth outcomes. Data were synthesised qualitatively and quantitatively using meta-analysis. The literature searches provided a total of 4474 citations. Results After removing duplicates and screening through abstracts, titles and full texts, 66 papers from 48 studies were identified for inclusion in the review. Methodological quality was mixed with 30 out of 48 studies having a medium risk of bias. Interventions were categorised into six broad groups: cognitive behavioural therapy, other talking therapies, antenatal education, enhanced midwifery care, alternative interventions and interventions during labour. Results from the meta-analysis showed that most interventions reduced FOC, regardless of the approach (mean effect size = −1.27; z = −4.53, p < 0.0001) and that other talking therapies may reduce caesarean section rates (OR 0.48, 95% CI 0.48–0.90). Conclusions Poor methodological quality of studies limits conclusions that can be drawn; however, evidence suggests that most interventions investigated reduce FOC. Future high-quality randomised controlled trials are needed so that clear conclusions can be made.
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Stålberg V, Josefsson A, Bladh M, Lilliecreutz C. The risk of postpartum hemorrhage when lowering the oxytocin dose in planned cesarean section, a pilot study. SEXUAL & REPRODUCTIVE HEALTHCARE 2021; 29:100641. [PMID: 34174496 DOI: 10.1016/j.srhc.2021.100641] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 05/17/2021] [Accepted: 06/01/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Oxytocin is the drug of choice in preventing postpartum hemorrhage (PPH). The aim was to compare the peroperative- and total blood loss within two hours and PPH after planned cesarean section (CS) when receiving 2.5 IU vs 5.0 IU of oxytocin in different risk groups for PPH. STUDY DESIGN A pilot study including 927 women undergoing planned CS where women receiving 2.5 IU of oxytocin were compared to women receiving 5.0 IU of oxytocin. MAIN OUTCOME MEASURES Data comparing peroperative blood loss, total blood loss within two hours and PPH were analyzed. RESULTS The women receiving 2.5 IU of oxytocin had a slightly higher peroperative blood loss, compared to the 5.0 IU group (476 ml vs 426 ml, p = 0.029). The total blood loss two hours after surgery showed no significant difference between the groups (626 ml vs 595 ml, p = 0.230). In the 2.5 IU group 13% had a blood loss ≥ 1000 ml vs 10% in the 5 IU group (aOR 1.64, 95% CI = 1.05-2.56). When the women considered to be at high risk for postpartum hemorrhage were excluded, we found no difference in the likelihood for postpartum hemorrhage between the groups (aOR 1.13, 95% CI = 0.64-1.99). CONCLUSIONS Women undergoing planned CS and receiving 2.5 IU of oxytocin had a slightly higher risk for postpartum hemorrhage in this study. However, a lower dose of 2.5 IU of oxytocin seems to be a safe option in planned CS for women without known risk factors for postpartum hemorrhage, but further research is needed to confirm these findings.
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Affiliation(s)
- Valerie Stålberg
- Department of Obstetrics and Gynecology in Norrköping and Division of Children's and Women's Health, Department of Biomedical and Clinical Sciences, Faculty of Medicine and Health Sciences, Linköping University, Sweden
| | - Ann Josefsson
- Department of Obstetrics and Gynecology in Linköping and Division of Children's and Women's Health, Department of Biomedical and Clinical Sciences, Faculty of Medicine and Health Sciences, Linköping University, Sweden
| | - Marie Bladh
- Department of Obstetrics and Gynecology in Linköping and Division of Children's and Women's Health, Department of Biomedical and Clinical Sciences, Faculty of Medicine and Health Sciences, Linköping University, Sweden
| | - Caroline Lilliecreutz
- Department of Obstetrics and Gynecology in Linköping and Division of Children's and Women's Health, Department of Biomedical and Clinical Sciences, Faculty of Medicine and Health Sciences, Linköping University, Sweden.
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Abstract
OBJECTIVES The objective of this study is to explore the association of health financing indicators with the proportion of births by caesarean section (CS) across countries. DESIGN Ecological cross-country study. SETTING This study examines CS proportions across 172 countries. MAIN OUTCOME MEASURES The primary outcome was the percentage excess of CS proportion, defined as CS proportions above the global target of 19%. We also analysed continuous CS proportions, as well as excess proportion with a more restrictive 9% global target. Multivariable linear regressions were performed to test the association of health financing factors with the percentage excess proportions of CS. The health financing factors considered were total available health system resources (as percentage of gross domestic product), total contributions from private households (out-of-pocket, compulsory and voluntary health insurance contributions) and total national income. RESULTS We estimate that in 2018 there were a total of 8.8 million unnecessary CS globally, roughly two-thirds of which occurred in upper middle-income countries. Private health financing was positively associated with percentage excess CS proportion. In models adjusted for income and total health resources as well as human resources, each 10 per cent increase in out-of-pocket expenditure was associated with a 0.7 per cent increase in excess CS proportions. A 10 per cent increase in voluntary health insurance was associated with a 4 per cent increase in excess CS proportions. CONCLUSIONS We have found that health system finance features are associated with CS use across countries. Further monitoring of these indicators, within countries and between countries will be needed to understand the effect of financial arrangements in the provision of CS.
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Affiliation(s)
- Ilir Hoxha
- Kolegji Heimerer, Pristina, Kosovo
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire, USA
| | - Günther Fink
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzlerland
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Hjartardóttir H, Lund SH, Benediktsdóttir S, Geirsson RT, Eggebø TM. Fetal descent in nulliparous women assessed by ultrasound: a longitudinal study. Am J Obstet Gynecol 2021; 224:378.e1-378.e15. [PMID: 33039395 DOI: 10.1016/j.ajog.2020.10.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 09/25/2020] [Accepted: 10/02/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Ultrasound measurements offer objective and reproducible methods to measure the fetal head station. Before these methods can be applied to assess labor progression, the fetal head descent needs to be evaluated longitudinally in well-defined populations and compared with the existing data derived from clinical examinations. OBJECTIVE This study aimed to use ultrasound measurements to describe the fetal head descent longitudinally as labor progressed through the active phase in nulliparous women with spontaneous onset of labor. STUDY DESIGN This was a single center, prospective cohort study at the Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland, from January 2016 to April 2018. Nulliparous women with a single fetus in cephalic presentation and spontaneous labor onset at a gestational age of ≥37 weeks, were eligible. Participant inclusion occurred during admission for women with an established active phase of labor or at the start of the active phase for women admitted during the latent phase. The active phase was defined as an effaced cervix dilated to at least 4 cm in women with regular contractions. According to the clinical protocol, vaginal examinations were done at entry and subsequently throughout labor, paired each time with a transperineal ultrasound examination by a separate examiner, with both examiners being blinded to the other's results. The measurements used to assess the fetal head station were the head-perineum distance and angle of progression. Cervical dilatation was examined clinically. RESULTS The study population comprised 99 women. The labor patterns for the head-perineum distance, angle of progression, and cervical dilatation differentiated the participants into 75 with spontaneous deliveries, 16 with instrumental vaginal deliveries, and 8 cesarean deliveries. At the inclusion stage, the cervix was dilated 4 cm in 26 of the women, 5 cm in 30 of the women, and ≥6 cm in 43 women. One cesarean and 1 ventouse delivery were performed for fetal distress, whereas the remaining cesarean deliveries were conducted because of a failure to progress. The total number of examinations conducted throughout the study was 345, with an average of 3.6 per woman. The ultrasound-measured fetal head station both at the first and last examination were associated with the delivery mode and remaining time of labor. In spontaneous deliveries, rapid head descent started around 4 hours before birth, the descent being more gradual in instrumental deliveries and absent in cesarean deliveries. A head-perineum distance of 30 mm and angle of progression of 125° separately predicted delivery within 3.0 hours (95% confidence interval, 2.5-3.8 hours and 2.4-3.7 hours, respectively) in women delivering vaginally. Although the head-perineum distance and angle of progression are independent methods, both methods gave similar mirror image patterns. The fetal head station at the first examination was highest for the fetuses in occiput posterior position, but the pattern of rapid descent was similar for all initial positions in spontaneously delivering women. Oxytocin augmentation was used in 41% of women; in these labors a slower descent was noted. Descent was only slightly slower in the 62% of women who received epidural analgesia. A nonlinear relationship was observed between the fetal head station and dilatation. CONCLUSION We have established the ultrasound-measured descent patterns for nulliparous women in spontaneous labor. The patterns resemble previously published patterns based on clinical vaginal examinations. The ultrasound-measured fetal head station was associated with the delivery mode and remaining time of labor.
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Could Subtle Obstetrical Brachial Plexus Palsy Be Related to Unilateral B Glenoid Osteoarthritis? J Clin Med 2021; 10:jcm10061196. [PMID: 33809287 PMCID: PMC7999215 DOI: 10.3390/jcm10061196] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 03/04/2021] [Accepted: 03/04/2021] [Indexed: 02/06/2023] Open
Abstract
Background: Several factors associated with B glenoid are also linked with obstetrical brachial plexus palsy (OBPP). The purpose of this observational study was to determine the incidence of OBPP risk factors in type B patients. Methods: A cohort of 154 patients (68% men, 187 shoulders) aged 63 ± 17 years with type B glenoids completed a questionnaire comprising history of perinatal characteristics related to OBPP. A literature review was performed following the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) to estimate the incidence of OBPP risk factors in the general population. Results: Twenty-seven patients (18%) reported one or more perinatal OBPP risk factors, including shoulder dystocia (n = 4, 2.6%), macrosomia >4 kg (n = 5, 3.2%), breech delivery (n = 6, 3.9%), fetal distress (n = 8, 5.2%), maternal diabetes (n = 2, 1.3%), clavicular fracture (n = 2, 1.3%), and forceps delivery (n = 4, 2.6%). The comparison with the recent literature suggested that most perinatal OBPP risk factors were within the normal range, although the incidence of shoulder dystocia, forceps and vaginal breech deliveries exceeded the average rates. Conclusion: Perinatal factors related to OBPP did not occur in a higher frequency in patients with Walch type B OA compared to the general population, although some of them were in the high normal range.
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Kayem G, Seco A, Beucher G, Dupont C, Branger B, Crenn Hebert C, Huissoud C, Fresson J, Winer N, Langer B, Rozenberg P, Morel O, Bonnet MP, Perrotin F, Azria E, Carbillon L, Chiesa C, Raynal P, Rudigoz RC, Dreyfus M, Vendittelli F, Patrier S, Deneux-Tharaux C, Sentilhes L. Clinical profiles of placenta accreta spectrum: the PACCRETA population-based study. BJOG 2021; 128:1646-1655. [PMID: 33393174 DOI: 10.1111/1471-0528.16647] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/29/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To describe and compare the characteristics of women with placenta accreta spectrum (PAS) and their pregnancy outcomes according to the presence of placenta praevia and a prior caesarean section. DESIGN Prospective population-based study. SETTING All 176 maternity hospitals of eight French regions. POPULATION Two hundred and forty-nine women with PAS, from a source population of 520 114 deliveries. METHODS Women with PAS were classified into two risk-profile groups, with or without the high-risk combination of placenta praevia (or an anterior low-lying placenta) and at least one prior caesarean. These two groups were described and compared. MAIN OUTCOME MEASURES Population-based incidence of PAS, characteristics of women, pregnancies, deliveries and pregnancy outcomes. RESULTS The PAS population-based incidence was 4.8/10 000 (95% CI 4.2-5.4/10 000). After exclusion of women lost to follow up from the analysis, the group with placenta praevia and a prior caesarean included 115 (48%) women and the group without this combination included 127 (52%). In the group with both factors, PAS was more often suspected antenatally (77% versus 17%; P < 0.001) and more often percreta (38% versus 5%; P < 0.001). This group also had more hysterectomies (53% versus 21%, P < 0.001) and higher rates of blood product transfusions, maternal complications, preterm births and neonatal intensive care unit admissions. Sensitivity analysis showed similar results after exclusion of women who delivered vaginally. CONCLUSION More than half the cases of PAS occurred in women without the combination of placenta praevia and a prior caesarean delivery, and these women had better maternal and neonatal outcomes. We cannot completely rule out that some of the women who delivered vaginally had placental retention rather than PAS; however, we found similar results among women who delivered by caesarean. TWEETABLE ABSTRACT Half the women with PAS do not have both placenta praevia and a prior caesarean delivery, and they have better maternal outcomes.
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Affiliation(s)
- G Kayem
- Trousseau Hospital, APHP, Sorbonne University, Paris, France.,CRESS U1153, INSERM, Obstetrical, Perinatal and Paediatric Epidemiology (EPOPé) Research Team, Université de Paris, Paris, France
| | - A Seco
- CRESS U1153, INSERM, Obstetrical, Perinatal and Paediatric Epidemiology (EPOPé) Research Team, Université de Paris, Paris, France.,Clinical Research Unit Necker Cochin, APHP, Paris, France
| | - G Beucher
- Service de Gynécologie Obstétrique et Médecine de la Reproduction, CHU de Caen, Caen Cedex, France
| | - C Dupont
- Réseau Périnatal Aurore, Hospices Civils de Lyon, Hôpital de la Croix Rousse, Lyon, France.,Health Services and Performance Research HESPER EA 7425, Université de Lyon, University Claude Bernard Lyon 1, Lyon, France
| | - B Branger
- Réseau « Sécurité Naissance - Naître ensemble » des Pays-de-la-Loire, France
| | - C Crenn Hebert
- Louis Mourier University Hospital, APHP, Colombes, France.,Réseau Périnatal des Hauts de Seine, PERINAT92, Issy-les-Moulineaux, France
| | - C Huissoud
- Health Services and Performance Research HESPER EA 7425, Université de Lyon, University Claude Bernard Lyon 1, Lyon, France.,Maternité de la Croix Rousse, Lyon, France
| | - J Fresson
- CRESS U1153, INSERM, Obstetrical, Perinatal and Paediatric Epidemiology (EPOPé) Research Team, Université de Paris, Paris, France.,CHRU Nancy, Réseau Périnatal Lorrain, France
| | - N Winer
- Service de Gynécologie Obstétrique HME Université de Nantes, NUN, INRA, UMR 1280, Phan, Université de Nantes, Nantes, France
| | - B Langer
- CHU de Strasbourg, Strasbourg, France
| | | | - O Morel
- CHRU de Nancy, Nancy, France
| | - M P Bonnet
- Anaesthesia and Critical Care department, Trousseau Hospital, APHP, Sorbonne University, Paris, France
| | | | - E Azria
- CRESS U1153, INSERM, Obstetrical, Perinatal and Paediatric Epidemiology (EPOPé) Research Team, Université de Paris, Paris, France.,Maternity Unit, Paris Saint Joseph Hospital, DHU Risks in Pregnancy, Paris Descartes University, Paris, France
| | - L Carbillon
- Réseau Périnatal NEF Naître dans l'Est Francilien, Paris 13 University, France
| | - C Chiesa
- CRESS U1153, INSERM, Obstetrical, Perinatal and Paediatric Epidemiology (EPOPé) Research Team, Université de Paris, Paris, France
| | - P Raynal
- CH de Versailles, Site Andre Mignot, Versailles, France
| | - R C Rudigoz
- Health Services and Performance Research HESPER EA 7425, Université de Lyon, University Claude Bernard Lyon 1, Lyon, France.,Maternité de la Croix Rousse, Lyon, France
| | - M Dreyfus
- Service de Gynécologie Obstétrique et Médecine de la Reproduction, CHU de Caen, Caen Cedex, France
| | - F Vendittelli
- Réseau de Santé en Périnatalité d'Auvergne, CHU de Clermont-Ferrand, France.,CNRS, SIGMA Clermont, Institut Pascal, CHU Clermont-Ferrand, Université Clermont Auvergne, Clermont-Ferrand, France
| | | | - C Deneux-Tharaux
- CRESS U1153, INSERM, Obstetrical, Perinatal and Paediatric Epidemiology (EPOPé) Research Team, Université de Paris, Paris, France
| | - L Sentilhes
- Department of Obstetrics and Gynaecology, Bordeaux University Hospital, Bordeaux, France
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Zeitlin J, Durox M, Macfarlane A, Alexander S, Heller G, Loghi M, Nijhuis J, Sól Ólafsdóttir H, Mierzejewska E, Gissler M, Blondel B. Using Robson's Ten-Group Classification System for comparing caesarean section rates in Europe: an analysis of routine data from the Euro-Peristat study. BJOG 2021; 128:1444-1453. [PMID: 33338307 PMCID: PMC8359161 DOI: 10.1111/1471-0528.16634] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/11/2020] [Indexed: 12/04/2022]
Abstract
Objective Robson's Ten Group Classification System (TGCS) creates clinically relevant sub‐groups for monitoring caesarean birth rates. This study assesses whether this classification can be derived from routine data in Europe and uses it to analyse national caesarean rates. Design Observational study using routine data. Setting Twenty‐seven EU member states plus Iceland, Norway, Switzerland and the UK. Population All births at ≥22 weeks of gestational age in 2015. Methods National statistical offices and medical birth registers derived numbers of caesarean births in TGCS groups. Main outcome measures Overall caesarean rate, prevalence and caesarean rates in each of the TGCS groups. Results Of 31 countries, 18 were able to provide data on the TGCS groups, with UK data available only from Northern Ireland. Caesarean birth rates ranged from 16.1 to 56.9%. Countries providing TGCS data had lower caesarean rates than countries without data (25.8% versus 32.9%, P = 0.04). Countries with higher caesarean rates tended to have higher rates in all TGCS groups. Substantial heterogeneity was observed, however, especially for groups 5 (previous caesarean section), 6, 7 (nulliparous/multiparous breech) and 10 (singleton cephalic preterm). The differences in percentages of abnormal lies, group 9, illustrate potential misclassification arising from unstandardised definitions. Conclusions Although further validation of data quality is needed, using TGCS in Europe provides valuable comparator and baseline data for benchmarking and surveillance. Higher caesarean rates in countries unable to construct the TGCS suggest that effective routine information systems may be an indicator of a country's investment in implementing evidence‐based caesarean policies. Tweetable abstract Many European countries can provide Robson's Ten‐Group Classification to improve caesarean rate comparisons. Many European countries can provide Robson's Ten‐Group Classification to improve caesarean rate comparisons.
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Affiliation(s)
- J Zeitlin
- CRESS, Obstetrical Perinatal and Paediatric Epidemiology Research Team, EPOPe, INSERM, INRA, Universite de Paris, Paris, France
| | - M Durox
- CRESS, Obstetrical Perinatal and Paediatric Epidemiology Research Team, EPOPe, INSERM, INRA, Universite de Paris, Paris, France
| | - A Macfarlane
- Centre for Maternal and Child Health Research, School of Health Sciences, City, University of London, London, UK
| | - S Alexander
- Perinatal Epidemiology and Reproductive Health Unit, CR2, School of Public Health, ULB, Brussels, Belgium
| | - G Heller
- Institute for Quality Assurance and Transparency in Health Care, Berlin, Germany
| | - M Loghi
- Directorate for Social Statistics and Welfare, Italian Statistical Institute (ISTAT), Rome, Italy
| | - J Nijhuis
- Department of Obstetrics & Gynaecology, Maastricht University Medical Centre, MUMC+, Maastricht, The Netherlands
| | - H Sól Ólafsdóttir
- Department of Obstetrics and Gynaecology, Landspitali University Hospital, Reykjavik, Iceland
| | - E Mierzejewska
- Department of Epidemiology and Biostatistics, National Research Institute of Mother and Child, Warsaw, Poland
| | - M Gissler
- Department of Epidemiology and Biostatistics, National Research Institute of Mother and Child, Warsaw, Poland
| | - B Blondel
- THL Finnish Institute for Health and Welfare, Helsinki, Finland.,Karolinska Institute, Stockholm, Sweden
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Zhang H, Liu H, Luo S, Gu W. Oxytocin use in trial of labor after cesarean and its relationship with risk of uterine rupture in women with one previous cesarean section: a meta-analysis of observational studies. BMC Pregnancy Childbirth 2021; 21:11. [PMID: 33407241 PMCID: PMC7786988 DOI: 10.1186/s12884-020-03440-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Accepted: 11/18/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Trial of labor after a previous cesarean delivery (TOLAC) has reduced the rate of cesarean sections (CS). Nevertheless, the widespread use of TOLAC has been limited by an increase in adverse outcomes, the most serious one being the risk of symptomatic uterine rupture, which is possibly associated with oxytocin. In this meta-analysis, we explored the risk association between oxytocin use and uterine rupture in TOLAC. METHODS Multiple electronic databases (PubMed, Embase, Web of Science, and Google Scholar) were searched for cross-sectional studies reporting on TOLAC, oxytocin and uterine rupture, which were published between January 1986 and October 2019. The bias-corrected Hedge's g was calculated as the effect size using the random-effects model. A two-sample Z test was used to compare the differences in synthetic rates between groups. The Newcastle-Ottawa Scale (NOS) was used to evaluate the risk of bias. Quality of the evidence was assessed with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) certainty ratings system. RESULTS A total of 14 studies, which included 48,457 women who underwent TOLAC, met the inclusion criteria. The pooled rate of vaginal birth after a cesarean section (VBAC) and the rate of uterine rupture in spontaneous labor were 74.3 and 0.7%, respectively. In addition, the pooled rate of VBAC and the rate of uterine rupture in the induction labor group was 60.7 and 2.2%, respectively. The women who had spontaneous labor had a significantly higher rate of VBAC (p = 0.001) and a lower rate of uterine rupture (p = 0.0003) compared to induced labor. The pooled rates of uterine rupture in women using oxytocin and women not using oxytocin in TOLAC were 1.4% and 0.5%, respectively, and the difference was significant (p = 0.0002). Also, the synthetic rate of uterine rupture in oxytocin augmentation among women with spontaneous labor and women who had a successful induction of labor were 1.7% and 2.2%, respectively, without significant difference (p = 0.443). CONCLUSIONS Women with induced labor had a higher risk of uterine rupture compared to women with spontaneous labor following TOLAC. Oxytocin use may increase this risk, which could be influenced by the process of induction or individual cervix condition. Consequently, simplified and standardized intrapartum management, precise protocol, and cautious monitoring of oxytocin use in TOLAC are necessary.
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Affiliation(s)
- Huan Zhang
- Department of Obstetrics and Gynecology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, 200011, China
| | - Haiyan Liu
- Department of Obstetrics and Gynecology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, 200011, China
| | - Shouling Luo
- Department of Obstetrics and Gynecology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, 200011, China
| | - Weirong Gu
- Department of Obstetrics and Gynecology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, 200011, China.
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Ochieng Arunda M, Agardh A, Asamoah BO. Cesarean delivery and associated socioeconomic factors and neonatal survival outcome in Kenya and Tanzania: analysis of national survey data. Glob Health Action 2020; 13:1748403. [PMID: 32345146 PMCID: PMC7241493 DOI: 10.1080/16549716.2020.1748403] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 03/24/2020] [Indexed: 01/06/2023] Open
Abstract
Background: The increasing trends in cesarean delivery are globally acknowledged. However, in many low-resource countries, socioeconomic disparities have created a pattern of underuse and overuse among lower and higher socioeconomic groups. The impact of rising cesarean delivery rates on neonatal survival is also unclear.Objective: To examine cesarean delivery and its associated socioeconomic patterns and neonatal survival outcome in Kenya and Tanzania.Methods: We employed binary logistic regression to analyze cross-sectional demographic and health survey data on neonates born in health facilities in Kenya (2014) and Tanzania (2016).Results: Cesarean delivery rates ranged from 5% among uneducated, rural Tanzanian women to 26% among educated urban women in Kenya to 37.5% among managers in urban Tanzania. Overall findings indicated higher odds of cesarean delivery among mothers from richest households, adjusted odds ratio (aOR) 1.4 (95% CI 1.2-1.8), those insured, aOR 1.6 (95% CI 1.3-1.9), highly educated, aOR 1.6 (95% CI 1.2-2.0) and managers aOR 1.7 (95% CI 1.3-2.2), compared to middle class, no insurance, primary education and unemployed, respectively. Overall, compared to normal births and while adjusting for maternal risk factors, cesarean delivery was significantly associated with neonatal mortality in Kenya and Tanzania, overall aOR 1.7 (95% CI 1.2-2.7). However, statistical significance ceased when fetal risk factors and number of antenatal care visits were further controlled for, aOR 1.6 (95% CI 0.9-2.6).Conclusion: Disproportionate access to cesarean delivery has widened in Kenya and Tanzania. Higher risks of cesarean-related neonatal deaths exist. Medically indicated or not, the safety and/or choice of cesarean delivery is best addressed on individual basis at the health-facility level. However, policy initiatives to eliminate incentives, improve equitable access and accountability to reduce unnecessary cesarean deliveries through well-informed decisions are needed. Efforts to prevent unintended pregnancies among adolescents as well as training of health workers and continuous research to improve neonatal outcomes are vital.
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Affiliation(s)
- Malachi Ochieng Arunda
- Social Medicine and Global Health, Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Anette Agardh
- Social Medicine and Global Health, Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Benedict Oppong Asamoah
- Social Medicine and Global Health, Department of Clinical Sciences, Lund University, Malmö, Sweden
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First stage progression in women with spontaneous onset of labor: A large population-based cohort study. PLoS One 2020; 15:e0239724. [PMID: 32976520 PMCID: PMC7518577 DOI: 10.1371/journal.pone.0239724] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 09/13/2020] [Indexed: 11/19/2022] Open
Abstract
Objective To describe the duration, progression and patterns of first stage of labor among Swedish women. Design Population-based cohort study. Population Data from Stockholm-Gotland Obstetric Cohort 2008–2014 including ¼ of all births in Sweden, the final sample involved a total of 85,408 women with term, singleton, vertex, live fetuses experiencing spontaneous labor onset and vaginal delivery with normal neonatal outcomes. Main outcome measures Time to progress during first stage of labor using three approaches: 1) Traverse time in hours to progress centimeter to centimeter, 5th, 50th (and 95th percentile); 2) Dilation curves for different percentiles, and; 3) Cumulative duration for the 95th percentile by parity and dilation at admission. Results Variation in both the total duration and the trajectory of cervical change over time is large. Similar to the general held view, the rate of cervical dilation accelerates at 5–6 centimeters. Among nulliparous women, the median time found in our population was faster than their counterparts in studies conducted on American and African cohorts. Among nulliparous and multiparous women our data suggest that the median cervical change over time is faster than 1 cm per hour during the first stage of labor. However, traverse time of cervical change at and beyond the 95th percentile is longer than 1 cm per hour. Conclusions Labor progression varies widely and labors experiencing a prolonged first stage can still result in normal outcomes. The assumption of 1 cm per hour cervical dilation rate for the first stage of labor may not be universally meaningful. There are differences in progression for women during first stage of labor in different populations. For prolonged labor progression to be more clinically meaningful, the association with adverse birth outcomes needs to be further investigated in specific populations.
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Knobel R, Lopes TJP, Menezes MDO, Andreucci CB, Gieburowski JT, Takemoto MLS. Cesarean-section Rates in Brazil from 2014 to 2016: Cross-sectional Analysis Using the Robson Classification. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2020; 42:522-528. [PMID: 32559791 PMCID: PMC10309242 DOI: 10.1055/s-0040-1712134] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
OBJECTIVE To obtain cesarean-section (CS) rates according to the Robson Group Classification in five different regions of Brazil. METHODS A descriptive epidemiological study using data from secondary birth records from the Computer Science Department of the Brazilian Unified Health System (Datasus, in Portuguese) between January 1st, 2014, and December 31st, 2016, including all live births in Brazil. RESULTS The overall rate of CS was of 56%. The sample was divided into 11 groups, and vaginal births were more frequent in groups 1 (53.6%), 3 (80.0%) and 4 (55.1%). The highest CS rates were found in groups 5 (85.7%), 6 (89.5%), 7 (85.2%) and 9 (97.0%). The overall CS rate per region varied from 46.2% in the North to 62.1% in the Midwest. Group 5 was the largest obstetric population in the South, Southeast and Midwest, and group 3 was the largest in the North and Northeast. Group 5 contributed the most to the overall CS rate, accounting for 30.8% of CSs. CONCLUSION Over half of the births in Brazil were cesarean sections. The Midwest had the highest CS rates, while the North had the lowest. The largest obstetric population in the North and in the Northeast was composed of women in group 3, while in the South, Southeast and Midwest it was group 5. Among all regions, the largest contribution to the overall CS rate was from group 5.
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Affiliation(s)
- Roxana Knobel
- Department of Gynecology and Obstetrics, Universidade Federal de Santa Catarina, Florianópolis, Santa Catarina, Brazil
| | - Thiago Jose Pinheiro Lopes
- Department of Gynecology and Obstetrics, Universidade Federal de Santa Catarina, Florianópolis, Santa Catarina, Brazil
| | - Mariane de Oliveira Menezes
- Postgraduate Program in Tocogynecology, Faculty of Medicine, Universidade Estadual Paulista, Botucatu, SP, Brazil
| | | | - Juliana Toledo Gieburowski
- Department of Gynecology and Obstetrics, Universidade Federal de Santa Catarina, Florianópolis, Santa Catarina, Brazil
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Carrillo-Aguirre G, Dalmau-Bueno A, Campillo-Artero C, García-Altés A. Caesarean section trends in Catalonia between 2013 and 2017 based on the Robson classification system: A cross-sectional study. PLoS One 2020; 15:e0234727. [PMID: 32544171 PMCID: PMC7297373 DOI: 10.1371/journal.pone.0234727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 06/01/2020] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION In Catalonia caesarean rates have always been analysed as a single percentage. The objective is to estimate caesarean section rates using the Robson classification in publicly funded hospitals in Catalonia between 2013 and 2017, considering sociodemographic, institutional and obstetric characteristics. MATERIALS AND METHODS Cross-sectional population-based study in Catalonia including all women delivering within publicly funded hospitals between 2013-2017 (n = 210 020). The modified Robson classification distribution was estimated, the caesarean rate and the overall contribution, analysed for each year, and by confounders, through logistic regression models. RESULTS CS rates decreased steadily between 2013 and 2017 in Catalonia within publicly funded hospitals from 24.3% to 22.8% (cOR 0.92, 95% CI; 0.89 to 0.95). Once adjusted for changes in sociodemographic, institutional and obstetric characteristics the observed decline was even more pronounced (aOR 0.87, 95% CI; 0.84 to 0.90). Within the different groups of Robson once adjusted for confounders, groups 1+2 (aOR 0.88, 95% CI; 0.83 to 0.93), 3+4 (aOR 0.83, 95% CI; 0.78 to 0.89) and 10 (aOR 0.78, 95% CI; 0.68 to 0.90) presented a reduction in caesarean section rates, whereas group 5 showed no significant decrease (aOR 0.95, 95% CI; 0.87 to 1.03%). CONCLUSIONS The decrease in caesarean section rates in Catalonia is more pronounced when adjusted for known confounders, suggesting retrospective overutilization of caesarean section and percentages of (in)adequacy in the past. In any case, it remains above the recommended by experts. Further efforts should be made to achieve optimum rates, including improvement on obstetric data collection.
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Affiliation(s)
- Garazi Carrillo-Aguirre
- Master’s Degree Public Health, Pompeu Fabra University (UPF), Barcelona, Spain
- Department of Health, Health Evaluation and Quality Agency of Catalonia (AQuAS), Government of Catalonia, Barcelona, Catalonia, Spain
| | - Albert Dalmau-Bueno
- Department of Health, Health Evaluation and Quality Agency of Catalonia (AQuAS), Government of Catalonia, Barcelona, Catalonia, Spain
| | - Carlos Campillo-Artero
- Center for Research in Health and Economics, Pompeu Fabra University, IB-Salut, Barcelona, Spain
| | - Anna García-Altés
- Department of Health, Health Evaluation and Quality Agency of Catalonia (AQuAS), Government of Catalonia, Barcelona, Catalonia, Spain
- Biomedical Research Networking Center for Epidemiology and Public Health (CIBERESP), Madrid, Spain
- Sant Pau Biomedical Research Institute (IIB Sant Pau), Barcelona, Spain
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Rudey EL, Leal MDC, Rego G. Cesarean section rates in Brazil: Trend analysis using the Robson classification system. Medicine (Baltimore) 2020; 99:e19880. [PMID: 32332659 PMCID: PMC7220553 DOI: 10.1097/md.0000000000019880] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 03/09/2020] [Accepted: 03/10/2020] [Indexed: 11/26/2022] Open
Abstract
Cesarean section (CS) is a surgical procedure used to deliver babies that is medically indicated to prevent maternal and neonatal mortality. However, it is associated with short- and long-term risks. CS rates have increased, and efforts are being made to ensure that CS is performed only when necessary. The Robson classification system is considered useful for studying, evaluating, monitoring, and comparing CS rates within and between healthcare facilities. In Brazil, there are few studies on this subject, and no large epidemiological studies on this topic utilizing the Robson classification have been reported. This study aimed to report and analyze CS rates in Brazil using the Robson classification system, and subsequently suggest possible measures to address it.Data were collected from the Brazilian Live Birth Information System (Sistema de Informações sobre Nascidos Vivos) that contains data of the entire obstetric population, from 2014 to 2017. All births in the country during this period were analyzed according to the Robson classification.A total of 11,774,665 live births were reported in Brazil during 2014 to 2017, most of which were mostly via CS (55.8%). Regions with high human development indexes had significantly higher CS rates than those with low human development indexes. The Robson group (RG) 1 to 4 accounts for 60.2% of live births and 47.1% of all CSs. RG5 was larger than all the other groups and contributed to the highest global rate of CS (31.3%), in addition to being the group who presented the largest growth.Although RG 1 to 4 present favorable initial conditions for vaginal delivery, CS accounted for almost half of births in these groups. The size of RG1 and RG2 in Brazil was comparable to that in countries with low CS rates; however, CS rates in these groups were 3 times higher in Brazil. Nulliparous women in RG1 and RG2 who undergo CS are subsequently categorized into RG5, increasing the global CS rate by 1% annually.We suggest the implementation of health policies to avoid the unnecessary performance of CS in RG1 and RG2 to decrease the CS rates in Brazil.
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Palacios-Marques AM, Quijada-Cazorla MA, Marcos-Sanmartin J, Garcia-Villalba A, Perez-Silvestre L, Jimenez-Martinez MD, Martinez-Escoriza JC. Rationalisation of the caesarean section rate in a tertiary referral hospital using the Robson classification. J OBSTET GYNAECOL 2020; 41:200-206. [PMID: 32172631 DOI: 10.1080/01443615.2020.1718625] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The aim of this study was to implement the Robson Ten Groups Classification System (RTGCS) to identify the main contributors to the caesarean section (CS) rate and to evaluate whether the introduction of a plan of obstetrical interventions reduced this rate. An observational retrospective cross-sectional study was conducted during two time periods at Alicante University General Hospital. In the pre-implementation period (2009-2012), RTGCS was applied to identify the main groups contributing to the overall CS rate. In the post-implementation period (2013-2017), RTGCS was applied again to identify changing trends in CS rates. In all, 11,034 deliveries during the pre-intervention period and 11,453 during the post-intervention period were analysed. The overall CS rate was 23.9% and 20.9%, respectively. There were no changes in perinatal outcomes. In the post-intervention period, there was a significant decrease of the CS rate in the groups of targeted interventions 1, 2, 3, 4, 5, and 8B.Impact statementWhat is already known on this subject? High CS rates are becoming a public health problem because of risks, costs, excessive medicalisation, and abuse of resources. RTGCS provides a framework for auditing and analysing CS rates.What do the results of this study add? RTGCS can identify the groups that have the greatest impact on the CS rate and monitor changes in it consequent to policy changes.What are the implications of these findings for clinical practice? The introduction of a strategic plan with evidence-based clinical interventions may have a greater effect on the CS rate than other features justifying the increase in the incidence of CS.
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Affiliation(s)
- Ana Maria Palacios-Marques
- Obstetrics and Gynecology Department, Alicante University General Hospital, Alicante, Spain.,Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain.,Department of Public Health, History of Science and Gynecology, Miguel Hernández University of Elche, Campus of San Juan, Alicante, Spain
| | - Maria Asunción Quijada-Cazorla
- Obstetrics and Gynecology Department, Alicante University General Hospital, Alicante, Spain.,Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
| | - Josefa Marcos-Sanmartin
- Obstetrics and Gynecology Department, Alicante University General Hospital, Alicante, Spain.,Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain.,Department of Public Health, History of Science and Gynecology, Miguel Hernández University of Elche, Campus of San Juan, Alicante, Spain
| | - Alejandra Garcia-Villalba
- Obstetrics and Gynecology Department, Alicante University General Hospital, Alicante, Spain.,Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
| | - Lucia Perez-Silvestre
- Obstetrics and Gynecology Department, Alicante University General Hospital, Alicante, Spain.,Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
| | - Maria Dolores Jimenez-Martinez
- Obstetrics and Gynecology Department, Alicante University General Hospital, Alicante, Spain.,Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
| | - Juan Carlos Martinez-Escoriza
- Obstetrics and Gynecology Department, Alicante University General Hospital, Alicante, Spain.,Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain.,Department of Public Health, History of Science and Gynecology, Miguel Hernández University of Elche, Campus of San Juan, Alicante, Spain
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Fischer MB, Vestgaard M, Ásbjörnsdóttir B, Mathiesen ER, Damm P. Predictors of emergency cesarean section in women with preexisting diabetes. Eur J Obstet Gynecol Reprod Biol 2020; 248:50-57. [PMID: 32179286 DOI: 10.1016/j.ejogrb.2020.03.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 02/19/2020] [Accepted: 03/05/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Preexisting diabetes in pregnancy is associated with a high risk of emergency cesarean section (CS), which is associated with increased risk of maternal and neonatal complications. Thus, the aim of this study was to identify possible predictors of emergency CS in women with preexisting diabetes. STUDY DESIGN This is a secondary analysis of a prospective observational study of 204 women with preexisting diabetes (118 with type 1 diabetes and 86 with type 2) with singleton pregnancies recruited at Rigshospitalet, Copenhagen, Denmark from August 2015 to February 2018. Mode of delivery (trial of labor or planned CS) was individually planned in late pregnancy based on clinical variables reflecting maternal and fetal health including glycemic control and ultrasonically estimated fetal weight. Univariate and multivariable analyses were performed to identify possible predictors of in labor emergency CS. RESULTS Trial of labor was planned in 79 % (n = 162) of the women of whom 65 % (n = 105) were delivered vaginally and 35 % (n = 57) by an emergency CS, while the remaining 21 % (n = 42) were offered a planned CS. Nulliparity (adjusted odds ratio (aOR) 5.6 95 % CI 1.7-18.8), presence of a hypertensive disorder (aOR 2.8, 95 % CI 1.2-6.7) and previous CS (aOR 6.7, 95 % CI 1.5-28.9) were independently associated with an emergency CS. Maternal height was inversely associated with emergency CS (aOR 0.6 95 %, CI 0.5-0.9 per 5 cm decrease). Neither maternal HbA1c nor ultrasonically estimated fetal size in late pregnancy were associated with emergency CS. Women scheduled for a planned CS were characterized by poorer glycemic control and higher estimated fetal size than those offered a trial of labor. CONCLUSION Nulliparity, presence of a hypertensive disorder, previous CS and shorter maternal height were predictors of emergency CS in women with a planned trial of labor, whereas this not was the case for late pregnancy maternal Hba1c or fetal size estimated by ultrasound.
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Affiliation(s)
- Margit B Fischer
- Center for Pregnant Women With Diabetes, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen O, Denmark; Department of Endocrinology, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen O, Denmark.
| | - Marianne Vestgaard
- Center for Pregnant Women With Diabetes, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen O, Denmark; Department of Endocrinology, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen O, Denmark; Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen N, Denmark.
| | - Björg Ásbjörnsdóttir
- Center for Pregnant Women With Diabetes, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen O, Denmark; Department of Endocrinology, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen O, Denmark; Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen N, Denmark.
| | - Elisabeth R Mathiesen
- Center for Pregnant Women With Diabetes, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen O, Denmark; Department of Endocrinology, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen O, Denmark; Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen N, Denmark.
| | - Peter Damm
- Center for Pregnant Women With Diabetes, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen O, Denmark; Department of Obstetrics, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen O, Denmark; Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen N, Denmark.
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Van Den Berg K, Dijksman LM, Keus SHJ, Scheele F, Van Pampus MG. Value-based health care in obstetrics. J Eval Clin Pract 2020; 26:101-108. [PMID: 31197893 DOI: 10.1111/jep.13208] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 05/08/2019] [Accepted: 05/13/2019] [Indexed: 11/27/2022]
Abstract
RATIONALE, AIMS, AND OBJECTIVES We strive to maximize outcomes that are relevant to the women who deliver in our hospital. We demonstrate a practical method of using value-based health care (VBHC) concepts to analyse how care can be improved. METHOD Using International Consortium of Health Outcome Measurements (ICHOM) set, a practical outcome set was constructed for women who go into spontaneous labour at term of a singleton in cephalic presentation and used for benchmarking. We included data on interventions that are major drivers of outcomes. Data from two hospitals in Amsterdam and for The Netherlands for 2011 to 2015 were collected. RESULTS Benchmarking of readily available data helped identify a number of statistically significant and clinically relevant differences in obstetric outcomes. Caesarean section rate was significantly different at 13.7% in hospital 2 compared with 11.5% in hospital 1 with similar neonatal outcomes. Third and fourth degree tearing rates were significantly higher for hospital 1 at 5.5% compared with 3.6% for hospital 2 and the national average of 3.5%. On the basis of the guidelines, literature, and discussion, initiatives on how to improve these outcomes were then identified. These include caesarean section audit and guidelines regarding caesarean section decision making. In order to reduce the rate of third and fourth degree tearing, routine episiotomy on vaginal operative deliveries was introduced, and a training programme was set up to make care providers more aware of risk factors and potential preventive measures. CONCLUSION Defining, measuring, and comparing relevant outcomes enable care providers to identify improvements. Collection and comparison of readily available data can provide insights in where care can be improved. Insights from literature and comparison of care practices and processes can lead to how care can be improved. Continuous monitoring of outcomes and expanding the set of outcomes that is readily available are key in the process towards value-based care provision.
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Affiliation(s)
- Kim Van Den Berg
- Department of Obstetrics and Gynecology, OLVG, Amsterdam, The Netherlands
| | - Lea Magdalena Dijksman
- Department of Quality and Improvement, St. Antonius Hospital, Utrecht, /Nieuwegein, The Netherlands
| | | | - Fedde Scheele
- Department of Obstetrics and Gynecology, OLVG, Amsterdam, The Netherlands.,Amsterdam University Medical Center, Amsterdam, The Netherlands
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Association of Oxytocin Use and Artificial Rupture of Membranes With Cesarean Delivery in France. Obstet Gynecol 2020; 135:436-443. [DOI: 10.1097/aog.0000000000003618] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Cegolon L, Mastrangelo G, Maso G, Dal Pozzo G, Ronfani L, Cegolon A, Heymann WC, Barbone F. Understanding Factors Leading to Primary Cesarean Section and Vaginal Birth After Cesarean Delivery in the Friuli-Venezia Giulia Region (North-Eastern Italy), 2005-2015. Sci Rep 2020; 10:380. [PMID: 31941963 PMCID: PMC6962159 DOI: 10.1038/s41598-019-57037-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 12/22/2019] [Indexed: 01/21/2023] Open
Abstract
Although there is no evidence that elevated rates of cesarean sections (CS) translate into reduced maternal/child perinatal morbidity or mortality, CS have been increasingly overused almost everywhere, both in high and low-income countries. The primary cesarean section (PCS) has become a major driver of the overall CS (OCS) rate, since it carries intrinsic risk of repeat CS (RCS) in future pregnancies. In our study we examined patterns of PCS, pl compared with planned TOLAC anned PCS (PPCS), vaginal birth after 1 previous CS (VBAC-1) and associated factors in Friuli Venezia Giulia (FVG), a region of North-Eastern Italy, collecting data from its 11 maternity centres (coded from A to K) during 2005-2015. By fitting three multiple logistic regression models (one for each delivery mode), we calculated the adjusted rates of PCS and PPCS among women without history of CS, whilst the calculation of the VBAC rate was restricted to women with just one previous CS (VBAC-1). Results, expressed as odds ratio (OR) with 95% confidence interval (95%CI), were controlled for the effect of hospital, calendar year as well as several factors related to the clinical and obstetric conditions of the mothers and the newborn, the obstetric history and socio-demographic background. In FVG during 2005-2015 there were 24,467 OCS (rate of 24.2%), 19,565 PCS (19.6%), 7,736 PPCS (7.7%) and 2,303 VBAC-1 (28.4%). We found high variability of delivery mode (DM) at hospital level, especially for PCS and PPCS. Breech presentation was the strongest determinant for PCS as well as PPCS. Leaving aside placenta previa/abuptio placenta/ante-partum hemorrhage, further significant factors, more importantly associated with PCS than PPCS were non-reassuring fetal status and obstructed labour, followed by (in order of statistical significance): multiple birth; eclampsia/pre-eclampsia; maternal age 40-44 years; placental weight 600-99 g; oligohydramios; pre-delivery LoS 3-5 days; maternal age 35-39 years; placenta weight 1,000-1,500 g; birthweight < 2,000 g; maternal age ≥ 45 years; pre-delivery LoS ≥ 6 days; mother's age 30-34 years; low birthweight (2,000-2,500 g); polyhydramnions; cord prolaspe; ≥6 US scas performed during pregnancy and pre-term gestations (33-36 weeks). Significant factors for PPCS were (in order of statistical significance): breech presentation; placenta previa/abruptio placenta/ante-partum haemorrhage; multiple birth; pre-delivery LoS ≥ 3 days; placental weight ≥ 600 g; maternal age 40-44 years; ≥6 US scans performed in pregnancy; maternal age ≥ 45 and 35-39 years; oligohydramnios; eclampsia/pre-eclampsia; mother's age 30-34 years; birthweight <2,000 g; polyhydramnios and pre-term gestation (33-36 weeks). VBAC-1 were more likely with gestation ≥ 41 weeks, placental weight <500 g and especially labour analgesia. During 2005-2015 the overall rate of PCS in FVG (19.6%) was substantially lower than the corresponding figure reported in 2010 for the entire Italy (29%) and still slightly under the most recent national PCS rate for 2017 (22.2%). The VBAC-1 rate on women with history of one previous CS in FVG was 28.4% (25.3% considering VBAC on all women with at least 1 previous CS), roughly three times the Italian national rate of 9% reported for 2017. The discrepancy between the OCS rate at country level (38.1%) and FVG's (24.2%) is therefore mainly attributable to RCS. Although there was a marginal decrease of PCS and PPCS crudes rates over time in the whole region, accompained by a progressive enhancement of the crude VBAC rate, we found remarkable variability of DM across hospitals. To further contain the number of unnecessary PCS and promote VBAC where appropriate, standardized obstetric protocols should be introduced and enforced at hospital level. Decision-making on PCS should be carefully scrutinized, introducing a diagnostic second opinion for all PCS, particularly for term singleton pregancies with cephalic presentation and in case of obstructed labour as well as non-reassuring fetal status, grey areas potentially affected by subjective clinical assessment. This process of change could be facilitated with education of staff/patients by opinion leaders and prenatal counseling for women and partners, although clinical audits, financial penalties and rewards to efficient maternity centres could also be considered.
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Affiliation(s)
- L Cegolon
- Institute for Maternal & Child Health, IRCCS "Burlo Garofolo", Trieste, Italy.
- Local Health Unit N.2 "Marca Trevigiana", Public Health Department, Treviso, Italy.
| | - G Mastrangelo
- Padua University, Department of Cardio-Thoracic & Vascular Sciences, Padua, Italy
| | - G Maso
- Institute for Maternal & Child Health, IRCCS "Burlo Garofolo", Trieste, Italy
| | - G Dal Pozzo
- Hospital "Villa Salus", Obstetric & Gynecology Unit, Venice, Italy
| | - L Ronfani
- Institute for Maternal & Child Health, IRCCS "Burlo Garofolo", Trieste, Italy
| | - A Cegolon
- University of Macerata, Department of Political Sciences, Comunication and International Relationships, Macerata, Italy
| | - W C Heymann
- Florida Department of Health, Sarasota County Health Department, Sarasota, Florida, USA
- Florida State University, College of Medicine, Department of Clinical Sciences, Sarasota, Florida, USA
| | - F Barbone
- Institute for Maternal & Child Health, IRCCS "Burlo Garofolo", Trieste, Italy
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Examining Cesarean Section Rates in Canada Using the Modified Robson Classification. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2019; 42:757-765. [PMID: 31883751 DOI: 10.1016/j.jogc.2019.09.009] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 09/06/2019] [Accepted: 09/09/2019] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Canada's cesarean delivery (CD) rate continues to increase. The Society of Obstetricians and Gynaecologists of Canada advocates the use of the modified Robson classification for comparisons. This study describes national and provincial CD rates according to this classification system. METHODS All 2016-2017 in-hospital births in Canada (outside Québec) reported to the Discharge Abstract Database were categorized using the modified Robson classification system. CD rates, group size, and contributions of each group to the overall volume of CD were reported. Rates by province and hospital peer group were also examined (Canadian Task Force Classification III). RESULTS A total of 286 201 women gave birth; among these, 83 262 (29.1%) had CDs. Robson group 5 (term singleton previous CD) had a CD rate of 80.5% and was the largest contributing group to the overall number of CD (36.6%). Women whose labour was induced (Robson group 2A) had a CD rate almost double the rate of women with spontaneous labour (Robson group 1): 33.5% versus 18.4%. These latter two groups made the next largest contributions to overall CD (15.7% and 14.1%, respectively). There were substantial variations in CD rates across provinces and among hospital peer groups. CONCLUSION The study found large variations in CD rates across provinces and hospitals within each Robson group, thus suggesting that examining variations to determine the groups contributing the most to CD rates (Robson groups 5, 2A, and 1) may provide valuable insight for reducing CD rates. This study provides a benchmark for measuring the impact of future initiatives to reduce CD rates in Canada.
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Cegolon L, Mastrangelo G, Heymann WC, Dal Pozzo G, Ronfani L, Barbone F. A Systematic Evaluation of Hospital Performance of Childbirth Delivery Modes and Associated Factors in the Friuli Venezia Giulia Region (North-Eastern Italy), 2005-2015. Sci Rep 2019; 9:19442. [PMID: 31857615 PMCID: PMC6923393 DOI: 10.1038/s41598-019-55389-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 11/18/2019] [Indexed: 12/31/2022] Open
Abstract
Cesarean sections (CS) have become increasingly common in both developed and developing countries, raising legitimate concerns regarding their appropriateness. Since improvement of obstetric care at the hospital level needs quantitative evidence, using routinely collected health data we contrasted the performance of the 11 maternity centres (coded with an alphabetic letter A to L) of an Italian region, Friuli Venezia Giulia (FVG), during 2005-15, after removing the effect of several factors associated with different delivery modes (DM): spontaneous vaginal delivery (SVD), instrumental vaginal delivery (IVD), overall CS (OCS) and urgent/emergency CS (UCS). A multivariable logistic regression model was fitted for each individual DM, using a dichotomous outcome (1 = each DM; 0 = rest of hospital births) and comparing the stratum specific estimates of every term with their respective reference categories. Results were expressed as odds ratios (OR) with 95% confidence intervals (95%CI). The Benjamini-Hochberg (BH) false discovery rates (FDR) approach was applied to control alpha error due to the large number of statistical tests performed. In the entire FVG region during 2005-2015, SVD were 75,497 (69.1% out of all births), IVD were 7,281 (6.7%), OCS were 26,467 (24.2%) and UCS were 14,106 (12.9% of all births and 53.3% out of all CS). SVD were more likely (in descending order of statistical significance) with: higher number of previous livebirths; clerk/employed occupational status of the mother; gestational age <29 weeks; placentas weighing <500 g; stillbirth; premature rupture of membranes (PROM). IVD were predominantly more likely (in descending order of statistical significance) with: obstructed labour, non-reassuring fetal status, history of CS, labour analgesia, maternal age ≥35 and gestation >40 weeks. The principal factors associated with OCS were (in descending order of statistical significance): CS history, breech presentation, non-reassuring fetal status, obstructed labour, multiple birth, placental weight ≥ 600 g, eclampsia/pre-eclampsia, maternal age ≥ 35 and oligohydramnios. The most important risk factors for UCS were (in descending order of statistical significance): placenta previa/abruptio placenta/ antepartum hemorrage; non-reassuring fetal status, obstructed labour; breech presentation; PROM, eclampsia/pre-eclampsia; gestation 33-36 weeks; gestation 41+ weeks; oligohydramnios; birthweight <2,500 g, maternal age ≥ 35 and cord prolapse. After removing the effects of all other factors, we found great variability of DM rates across hospitals. Adjusting for all risk factors, all hospitals had a OCS risk higher than the referent (hospital G). Out of these 10 hospitals with increased adjusted risk of OCS, 9 (A, B, C, D, E, F, I, J, K) performed less SVD and 5 (A, C, D, I, J) less IVD. In the above 5 centres CS was therefore probably overused. The present study shows that routinely collected administrative data provide useful information for health planning and monitoring. Although the overall CS rate in FVG during 2005-15 was 24.2%, well below the corresponding average Italian national figure (38.1%), the variability of DM rates across FVG maternity centres could be targeted by policy interventions aimed at reducing the recourse to unnecessary CS. In some clinical conditions such as obstructed labor, non-reassuring fetal status, breech presentation, history of CS, higher maternal age and multiple birth, consideration may be given to more conservative DM. The overuse of CS in nulliparas and repeat CS (RCS) should be carefully monitored and subject to audit.
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Affiliation(s)
- L Cegolon
- Local Health Unit N.2 "Marca Trevigiana", Public Health Department, Treviso, Italy.
- Institute for Maternal & Child Health, IRCCS "Burlo Garofolo", Trieste, Italy.
| | - G Mastrangelo
- Padua University, Department of Cardio-Thoracic & Vascular Sciences, Padua, Italy
| | - W C Heymann
- Florida State University, College of Medicine, Department of Clinical Sciences, Sarasota, Florida, USA
- Florida Department of Health, Sarasota County Health Department, Sarasota, Florida, USA
| | - G Dal Pozzo
- Obstetrics & Gynecology Unit, Hospital "Villa Salus", Venice, Italy
| | - L Ronfani
- Institute for Maternal & Child Health, IRCCS "Burlo Garofolo", Trieste, Italy
| | - F Barbone
- Institute for Maternal & Child Health, IRCCS "Burlo Garofolo", Trieste, Italy
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Bergholt T, Skjeldestad FE, Pyykönen A, Rasmussen SC, Tapper AM, Bjarnadóttir RI, Smárason A, Másdóttir BB, Klungsøyr K, Albrechtsen S, Källén K, Gissler M, Løkkegaard ECL. Maternal age and risk of cesarean section in women with induced labor at term-A Nordic register-based study. Acta Obstet Gynecol Scand 2019; 99:283-289. [PMID: 31583694 DOI: 10.1111/aogs.13743] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 09/26/2019] [Accepted: 09/30/2019] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Over the last decades, induction of labor has increased in many countries along with increasing maternal age. We assessed the effects of maternal age and labor induction on cesarean section at term among nulliparous and multiparous women without previous cesarean section. MATERIAL AND METHODS We performed a retrospective national registry-based study from Denmark, Finland, Iceland, Norway, and Sweden including 3 398 586 deliveries between 2000 and 2011. We investigated the impact of age on cesarean section among 196 220 nulliparous and 188 158 multiparous women whose labor was induced, had single cephalic presentation at term, and no previous cesarean section. Confounders comprised country, time-period, and gestational age. RESULTS In nulliparous women with induced labor the rate of cesarean section increased from 14.0% in women less than 20 years of age to 39.9% in women 40 years and older. Compared with women aged 25-29 years, the corresponding relative risks were 0.60 (95% confidence interval [95% CI] 0.57 to 0.64) and 1.72 (95% CI 1.66 to 1.79). In multiparous induced women the risk of cesarean section was 3.9% in women less than 20 years rising to 9.1% in women 40 years and older. Compared with women aged 25-29 years, the relative risks were 0.86 (95% CI 0.54 to 1.37) and 1.98 (95% CI 1.84 to 2.12), respectively. There were minimal confounding effects of country, time-period, and gestational age on risk for cesarean section. CONCLUSIONS Advanced maternal age is associated with increased risk of cesarean section in women undergoing labor induction with a single cephalic presentation at term without a previous cesarean section. The absolute risk of cesarean section is 3-5 times higher across 5-year age groups in nulliparous relative to multiparous women having induced labor.
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Affiliation(s)
- Thomas Bergholt
- Clinical Research Unit, Department of Obstetrics and Gynecology, North Zeeland Hospital, University of Copenhagen, Hillerød, Denmark
| | - Finn E Skjeldestad
- Department of Community Medicine, Faculty of Health Sciences, UiT the Arctic University of Norway, Tromsø, Norway
| | - Aura Pyykönen
- Department of Obstetrics and Gynecology, Helsinki University Hospital, Helsinki, Finland
| | - Steen C Rasmussen
- Clinical Research Unit, Department of Obstetrics and Gynecology, North Zeeland Hospital, University of Copenhagen, Hillerød, Denmark
| | - Anna-Maija Tapper
- Hyvinkää Hospital, Hyvinkää, Finland.,University of Helsinki, Helsinki, Finland
| | - Ragnheiður I Bjarnadóttir
- The Icelandic Birth Registry, Akureyri, Iceland.,Institute of Health Science Research, University of Akureyri, Akureyri, Iceland.,Landspitali University Hospital, Reykjavik, Iceland
| | - Alexander Smárason
- Institute of Health Science Research, University of Akureyri, Akureyri, Iceland
| | | | - Kari Klungsøyr
- Division of Mental and Physical Health, Norwegian Institute of Public Health, Bergen, Norway.,Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Susanne Albrechtsen
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.,Haukeland University Hospital, Bergen, Norway
| | - Karin Källén
- Swedish National Board of Health and Welfare, Stockholm, Sweden.,University of Lund, Lund, Sweden
| | - Mika Gissler
- Finnish Institute for Health and Welfare THL, Helsinki, Finland.,Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Stockholm, Sweden
| | - Ellen C L Løkkegaard
- Clinical Research Unit, Department of Obstetrics and Gynecology, North Zeeland Hospital, University of Copenhagen, Hillerød, Denmark
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Blanc-Petitjean P, Schmitz T, Salomé M, Goffinet F, Le Ray C. Target populations to reduce cesarean rates after induced labor: A national population-based cohort study. Acta Obstet Gynecol Scand 2019; 99:406-412. [PMID: 31628852 DOI: 10.1111/aogs.13751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 10/11/2019] [Accepted: 10/15/2019] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Great variations in cesarean rates after induction of labor exist and reasons for these disparities remain unclear. They may be explained by individual characteristics or obstetric practices. Ten-group classification systems have proved their utility to monitor cesarean rates in general population. We aimed to identify groups of women that account for most cesareans after induction of labor using the Nippita reproducible 10-group classification, specifically designed for induced population. MATERIAL AND METHODS A prospective population-based cohort study was performed in 94 French maternity units, including 3042 women undergoing induction of labor. Women were sorted according to 10 mutually exclusive groups based on parity, weeks of gestation, number of fetuses, fetal presentation and previous cesarean delivery. Relative size, cesarean delivery rate and contribution to the overall cesarean rate were described for each group. Cesarean rates were compared according to the Bishop score at the onset of labor induction. Indications for cesarean delivery were also described in the groups that contributed most to the overall cesarean rate. The MEDIP protocol was registered in ClinicalTrial (NCT02477085). RESULTS The overall cesarean rate was 21.0% among this population of induced women. Nulliparous women with a term singleton cephalic fetus (groups 1, 2 and 3; at 37-38, 39-40 and ≥41 weeks of gestation, respectively) accounted for two-thirds of the overall cesarean rate because they were the largest group (relative size of 10.6, 16.6 and 18.1%, respectively) and had higher cesarean rates (27.2, 30.9 and 33.0%, respectively). When the Bishop score was <6 (n = 2270/3042), cesarean delivery rates were higher (24.1 vs 10.7% if Bishop score ≥6, P < 0.01), in particular for group 1 (29.1 vs 12.5%, P = 0.02), and group 2 (33.3 vs 19.3%, P = 0.01). In groups 1, 2 and 3, which contributed most to the overall cesarean rate, a significant part of the cesareans were performed before 6 cm of cervical dilation for dystocia only (40.0, 16.7 and 17.6%, respectively). CONCLUSIONS Nulliparous women with a term singleton cephalic fetus and an unfavorable cervix represent the population to target for auditing induction practices. Specific actions could be implemented among this population to weigh the benefits and risks of induction and improve the management of labor induction.
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Affiliation(s)
- Pauline Blanc-Petitjean
- Center of Research in Epidemiology and Statistics (CRESS), INSERM, National Institute for Agricultural Research (INRA), Université de Paris, Paris, France.,Department of Obstetrics and Gynecology, AP-HP, Louis Mourier Hospital, Université de Paris, Colombes, France
| | - Thomas Schmitz
- Center of Research in Epidemiology and Statistics (CRESS), INSERM, National Institute for Agricultural Research (INRA), Université de Paris, Paris, France.,Department of Obstetrics and Gynecology, AP-HP, Robert Debré Hospital, Université de Paris, Paris, France
| | - Marina Salomé
- AP-HP, Cochin Hospital, Clinical Research Unit-Clinical Investigation Center (URC-CIC) Paris Descartes Necker/Cochin, Paris, France
| | - François Goffinet
- Center of Research in Epidemiology and Statistics (CRESS), INSERM, National Institute for Agricultural Research (INRA), Université de Paris, Paris, France.,AP-HP, Cochin Hospital, Port Royal Maternity Unit, Université de Paris, Paris, F-75014, France
| | - Camille Le Ray
- Center of Research in Epidemiology and Statistics (CRESS), INSERM, National Institute for Agricultural Research (INRA), Université de Paris, Paris, France.,AP-HP, Cochin Hospital, Port Royal Maternity Unit, Université de Paris, Paris, F-75014, France
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50
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Affiliation(s)
- Hildur Harðardóttir
- Department of Obstetrics and Gynecology Faculty of Medicine University of Iceland and Landspitali University Hospital Reykjavik Iceland
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