Interrelations between four antepartum obstetric interventions and cesarean delivery in women at low risk: a systematic review and modeling of the cascade of interventions

Basic psychological needs: A framework for understanding childbirth satisfaction

Women often report being dissatisfied with their childbirth experience, which in turn predicts negative outcomes for themselves and their children. Currently, there is no consensus as to what constitutes a satisfying or positive birth experience. We posit that a useful framework for addressing this question already exists in the form of Basic Psychological Needs Theory, a subtheory of Self-Determination Theory (Deci & Ryan, Can. Psychol., 49, 2008, 182). Specifically, we argue that the degree to which maternity care practitioners support or frustrate women's needs for relatedness, competence, and autonomy predicts their childbirth satisfaction. Using this framework provides a potentially powerful lens to better understand and improve the well-being of new mothers and their infants.

A comparison of the rates of and indications for cesarean delivery between Syrian refugee women and Turkish women

OBJECTIVE

The aim of this study was to compare the rates of and indications for cesarean delivery among Syrian refugee women and local Turkish women.

METHODS

The study included 74,864 pregnant women, of whom 52,145 were Turkish and 22,719 were Syrian refugee women and who gave birth at our hospital between January 2013 and December 2021. In this study, the pregnant women were divided into two groups: Syrian refugee women and Turkish women, and primary cesarean delivery rates were calculated separately for each group. Cesarean delivery rates for Syrian refugee women and Turkish women were compared separately for each year. Indications for cesarean delivery were determined separately for each group and compared between the groups.

RESULTS

The overall cesarean delivery rate was 56% among Turkish women and 32% among Syrian women (p<0.05). The primary cesarean delivery rate was 18.4% for local Turkish women versus 10.7% among Syrian refugee women (p<0.05). The most common indication for cesarean delivery among both Syrian refugee women and local Turkish women was previous cesarean delivery, followed by acute fetal distress and cephalopelvic disproportion.

CONCLUSION

Indications for cesarean delivery were similar for Syrian refugee women and local Turkish women, but both overall and primary cesarean delivery rates were higher among local Turkish women compared with Syrian refugee women.

Role of Intrapartum Social Support in Preventing Postpartum Depression

A cross-sectional, multicenter study examined the role of intrapartum social support (SS) on postpartum depression (PPD), using survey data that covered eight of the 25 PPD risk factors identified by a recent umbrella review. A total of 204 women participated at an average of 1.26 months after birth. An existing U.S. Listening to Mothers-II/Postpartum survey questionnaire was translated, culturally adapted, and validated. Multiple linear regression found four statistically significant independent variables. A path analysis determined that prenatal depression, pregnancy and childbirth complications, intrapartum SS from healthcare providers and partners, and postpartum SS from husbands and others were significant predictors of PPD, while intrapartum and postpartum SS were intercorrelated. In conclusion, intrapartum companionship is as important as postpartum SS in preventing PPD.

Planned hospital birth compared with planned home birth for pregnant women at low risk of complications

BACKGROUND

Observational studies of increasingly better quality and in different settings suggest that planned hospital birth in many places does not reduce mortality and morbidity but increases the frequency of interventions and complications. Euro-Peristat (part of the European Union's Health Monitoring Programme) has raised concerns about iatrogenic effects of obstetric interventions, and the World Health Organization (WHO) has raised concern that the increasing medicalisation of childbirth tends to undermine women's own capability to give birth and negatively impacts their childbirth experience. This is an update of a Cochrane Review first published in 1998, and previously updated in 2012.

OBJECTIVES

To compare the effects of planned hospital birth with planned home birth attended by a midwife or others with midwifery skills and backed up by a modern hospital system in case a transfer to hospital should turn out to be necessary. The primary focus is on women with an uncomplicated pregnancy and low risk of medical intervention during birth.  SEARCH METHODS: For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register (which includes trials from CENTRAL, MEDLINE, Embase, CINAHL, WHO ICTRP, and conference proceedings), ClinicalTrials.gov (16 July 2021), and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing planned hospital birth with planned home birth in low-risk women as described in the objectives. Cluster-randomised trials, quasi-randomised trials, and trials published only as an abstract were also eligible.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data, and checked the data for accuracy. We contacted study authors for additional information. We assessed the certainty of the evidence using the GRADE approach.  MAIN RESULTS: We included one trial involving 11 participants. This was a small feasibility study to show that well-informed women - contrary to common beliefs - were prepared to be randomised. This update did not identify any additional studies for inclusion, but excluded one study that had been awaiting assessment. The included study was at high risk of bias for three out of seven risk of bias domains. The trial did not report on five of the seven primary outcomes, and reported zero events for one primary outcome (caesarean section), and non-zero events for the remaining primary outcome (baby not breastfed). Maternal mortality, perinatal mortality (non-malformed), Apgar < 7 at 5 minutes, transfer to neonatal intensive care unit, and maternal satisfaction were not reported. The overall certainty of the evidence for the two reported primary outcomes was very low according to our GRADE assessment (downgraded two levels for high overall risk of bias (due to high risk of bias arising from lack of blinding, high risk of selective reporting and lack of ability to check for publication bias) and two levels for very serious imprecision (single study with few events)).   AUTHORS' CONCLUSIONS: This review shows that for selected, low-risk pregnant women, the evidence from randomised trials to support that planned hospital birth reduces maternal or perinatal mortality, morbidity, or any other critical outcome is uncertain. As the quality of evidence in favour of home birth from observational studies seems to be steadily increasing, it might be just as important to prepare a regularly updated systematic review including observational studies as described in the Cochrane Handbook for Systematic Reviews of Interventions as to attempt to set up new RCTs. As women and healthcare practitioners may be aware of evidence from observational studies, and as the International Federation of Gynecology and Obstetrics and the International Confederation of Midwives collaboratively conclude that there is strong evidence that out-of-hospital birth supported by a registered midwife is safe, equipoise may no longer exist, and randomised trials may now thus be considered unethical or hardly feasible.

Navigating intensive altered states of consciousness: How can the set and setting key parameters promote the science of human birth?

The subjective childbirth experience is crucial from a public health standpoint. There is a correlation between a negative childbirth experience and a poor mental state after birth, with effects that go far beyond the postpartum (PP) period. This paper offers a new approach as to how birthing experiences, and birth in general, can be navigated. The theory of set and setting proves that psychedelic experiences are shaped, first and foremost, by the mindset of an individual entering a psychedelic experience (set) and by the surroundings in which the experience happens (setting). In research on altered states of consciousness during psychedelic experiences, this theory explains how the same substance can lead to a positive and life-changing experience or to a traumatic and frightening experience. Because recent studies suggest that birthing women enter an altered state of consciousness during physiological birth ("birthing consciousness"), I suggest analyzing the typical modern birthing experience in terms of set and setting theory. I argue that the set and setting key parameters can help design, navigate, and explain many psychological and physiological elements of the human birth process. Thus, an operative conclusion that emerges from the theoretical analysis presented in this paper is that framing and characterizing the birth environment and birth preparations in terms of set and setting is a central tool that could be used to promote physiological births as well as subjective positive birthing experiences, which is currently a primary, yet unreached goal, in modern obstetrics and public health.

Giving birth in rural Arctic Greenland results from an Eastern Greenlandic birth cohort

Eastern Greenland is one of the most remote areas in the world. Approximately 3,500 people lives in two small towns and five villages. There is limited information on birth outcomes in Eastern Greenland. A cohort of all birthing women from Eastern Greenland from 2000 to 2017 was established and pregnancy, birth, and neonatal outcomes were described. A total of 1,344 women and 1,355 children were included in the cohort where 14.5% of the women were 18 years or younger, and 36.2% were single parents. Most women, 84.8% gave birth in East Greenland and 92.9%, experienced a vaginal, non-instrumental birth. The overall caesarean section rate was 6.5%. The rate of premature births was 10.1% and 2.2% of the children were born with malformations. The rate of premature births was high, preventive initiatives such as midwifery-led continuity of care including a stronger focus on the pregnant woman’s social and mental life situation may be recommended. Organisation of maternity services in East Greenland may benefit from a strong focus on public health, culture, and setting specific challenges, including the birth traditions of the society.

Path analysis model of epidural/spinal anesthesia on breastfeeding among healthy nulliparous women: Secondary analysis of the United States Certificate of Live Births 2016

BACKGROUND

The effect of epidural/spinal anesthesia during labor on breastfeeding is unclear. Few studies had assessed whether or how medically assisted delivery (operative vaginal delivery or unscheduled cesarean birth) plays a mediating role. We aimed to examine whether the relationship between using epidural/spinal anesthesia and breastfeeding is mediated by increased medically assisted delivery among healthy nulliparous women.

METHODS

A secondary, cross-sectional analysis was conducted using US birth certificate data from 2016 (n = 381 199). Logistic regression was used to examine associations between factors. Structural equation modeling (SEM) was used to analyze the model fit of the path models and to quantify the direct, indirect, and total effect of anesthesia on breastfeeding at discharge, considering medically assisted delivery as a mediator.

RESULTS

Women who were administered epidural/spinal anesthesia were more likely to experience medically assisted delivery (adjusted odds ratio [AOR]: 95% confidence interval [CI] 3.01 (2.91-3.12)) and less likely to be breastfeeding at discharge (0.95 [0.92-0.98]). Operative vaginal and unscheduled cesarean deliveries were significantly associated with nonbreastfeeding at discharge (0.81 [0.77-0.84] and 0.81 [0.79-0.84], respectively). SEM revealed excellent model fit for our model. The indirect effect was significant (β = -0.038; 95% CI, -0.043 to -0.033), as was the total effect (β = -0.038; 95% CI, -0.043 to -0.033).

CONCLUSIONS

Epidural/spinal anesthesia is associated with nonbreastfeeding at discharge, mediated through medically assisted delivery. Health care providers should consider these risks and provide adequate support to help all parents attain their breastfeeding goals.

Can a simple assessment of fear of childbirth in pregnant women predict requests and use of non-urgent obstetric interventions during labour?

OBJECTIVE

To examine whether the Wijma Delivery Expectation Questionnaire (W-DEQ-A) and the one-item Fear of Childbirth-Postpartum-Visual Analogue Scale (FOCP-VAS) - measuring high FOC - are useful tools in predicting requested and received non-urgent obstetric interventions in pregnant women.

DESIGN

A prospective cohort study.

POPULATION AND SETTING

Self-selected pregnant women from midwifery care settings (n=401).

METHODS

W-DEQ-A and FOCP-VAS were assessed at two timepoints in pregnancy. Measures of non-urgent obstetric interventions which were derived from medical files were: induction of labour, epidural analgesia, augmentation with oxytocin due to failure to progress and self-requested caesarean section. Hierarchical logistics regression models were used.

MAIN OUTCOME MEASURES

The change in the Nagelkerke R² was examined for three models predicting two outcome measures: (1) explicitly requested non-urgent obstetric interventions during pregnancy and (2) received non-urgent obstetric interventions during labour. The first model only included participants' characteristics, the second model also included FOCP-VAS ≥5, and in the third model the W-DEQ-A ≥66 was added.

RESULTS

High FOC measured with FOCP-VAS≥5 predicted requested (pseudo-R²=0.33, X²=59.82, P<0.001) and received non-urgent obstetric interventions (pseudo-R²=0.19, X²=32.81, P<0.001) better than high FOC measured with W-DEQ-A≥66.

CONCLUSION

This study is the first evaluating self-reported FOC and postpartum based on VAS (subjective outcome) in relation to actual pregnancy and childbirth outcomes derived from medical files (objective outcome). Non-urgent obstetric interventions could already be predicted in the first half of pregnancy by means of a simple FOC assessment with the one-item FOCP-VAS. Implementing this easy to use one-item screening tool in midwifery care is suggested.

Fetal head malposition and epidural analgesia in labor: a case-control study

BACKGROUND

The fetal head malposition in labor leads to prolonged labor, cesarean delivery and increased perinatal morbidity. Epidural analgesia has been associated with fetal head malposition, but it remains unknown if this relation is causal.

OBJECTIVE

To compare the incidence of fetal malposition during labor and maternal/fetal outcomes, between women who received epidural analgesia with those who did not use the analgesic method.

STUDY DESIGN

Case control study including 500 women with a single fetus in vertex position who gave birth at term at the Policlinic Hospital of Modena between May 2019 and July 2019. Two-hundred and fifty women belonged to the epidural analgesia (EA) group and 250 to the control group.

RESULTS

The rate of posterior occiput positions occurred 4 times more frequently in the EA group than in the control group (8.8% vs 2.2%, p = .004). Cesarean sections were significantly higher in the EA group (11.6% vs 1.6%, p < .0000) as well as the need for augmentation with oxytocin (20% vs 8%, p = .0001) compared to the control group, in which spontaneous delivery prevailed instead. Women with epidural had labors that lasted on average 7.0 h against the 3.30 h of controls (p < .0000). The length of 2nd stage of labor was 55 vs 30 min (p = .009), respectively. No differences in blood loss and Apgar score between groups. Early breastfeeding was significantly higher among controls (82% vs 92.8%, p = .0004).

CONCLUSIONS

Women receiving epidural analgesia in labor have higher rate of fetal malposition, prolonged labors, and more cesarean sections than controls. However, further studies are required to confirm a causal association between EA and fetal head malposition.

Swedish midwives' experiences and views of amniotomy: An interview study

OBJECTIVE

To explore midwives' experiences and views of amniotomy.

DESIGN

A qualitative inductive design was used. Data were collected using interviews and analysed with content analysis carried out with NVivo 12.

SETTING AND PARTICIPANTS

Sixteen midwives working at delivery wards at three hospitals in the south of Sweden.

FINDINGS

Three categories emerged: "Promote, protect and support the physiological process of labour", "To make the decision -to do or not to do" and "Unpredictable response". The overall theme linking the three categories was "We become our decisions", portraying how midwives carry the responsibility in the decision-making and represent themselves in their handling of amniotomy.

CONCLUSIONS

Amniotomy was experienced and viewed as both simple and complex, safe and risky, and deciding on it sometimes implied balancing contradicting perspectives. By using midwifery skills in the decision-making for an amniotomy, the midwives tried to predict the response, purposing to support physiological labour and promote health for women and babies.

Disruption of physiological labour; - A population register-based study among nulliparous women at term

OBJECTIVES

Current labour practices have seen an acceleration in interventions to either initiate, monitor, accelerate, or terminate the physiological process of pregnancy and childbirth. This study aimed to describe and analyse the use of interventions in childbirth in Denmark over almost two decades (2000-2017). We also examined the extent to which contemporary care adheres to current international recommendations towards restricted use of interventions.

STUDY DESIGN

A national retrospective Danish register-based cohort study including all nulliparous women with term births with singleton pregnancy and a foetus in cephalic between the years 2000 and 2017 (n = 380,326 births). Multivariate regression analyses with adjustment for change in population were performed.

MAIN OUTCOME MEASURES

Induction of labour, epidural analgesia, and augmentation of labour.

RESULTS

Between 2000/2001 and 2016/2017, the prevalence increased for induction of labour from 5.1% to 22.8%, AOR 4.84, 95% CI [4.61-5.10], epidural analgesia from 10.5% to 34.3% (AOR 4.10, 95% CI [3.95-4.26]), and augmentation of labour decreased slightly from 40.1% to 39.3% (AOR 0.84, 95% CI [0.81-0.86]). Having more than one of the three mentioned interventions increased from 12.8% in to 30.9%.

CONCLUSIONS

The number of interventions increased during the study period as well as the number of interventions in each woman. As interventions may interfere in physiological labour and carry the risk of potential short- and long-term consequences, the findings call for a careful re-evaluation of contemporary maternity care with a "first, do no harm" perspective.

The AEDUCATE Collaboration. Comprehensive antenatal education birth preparation programmes to reduce the rates of caesarean section in nulliparous women. Protocol for an individual participant data prospective meta-analysis

INTRODUCTION

Rates of medical interventions in normal labour and birth are increasing. This prospective meta-analysis (PMA) proposes to assess whether the addition of a comprehensive multicomponent birth preparation programme reduces caesarean section (CS) in nulliparous women compared with standard hospital care. Additionally, do participant characteristics, intervention components or hospital characteristics modify the effectiveness of the programme? METHODS AND ANALYSIS: Population: women with singleton vertex pregnancies, no planned caesarean section (CS) or epidural.Intervention: in addition to hospital-based standard care, a comprehensive antenatal education programme that includes multiple components for birth preparation, addressing the three objectives: preparing women and their birth partner/support person for childbirth through education on physiological/hormonal birth (knowledge and understanding); building women's confidence through psychological preparation (positive mindset) and support their ability to birth without pain relief using evidence-based tools (tools and techniques). The intervention could occur in a hospital-based or community setting.Comparator: standard care alone in hospital-based maternity units.

OUTCOMES

Primary: CS.Secondary: epidural analgesia, mode of birth, perineal trauma, postpartum haemorrhage, newborn resuscitation, psychosocial well-being.Subgroup analysis: parity, model of care, maternal risk status, maternal education, maternal socio-economic status, intervention components.

STUDY DESIGN

An individual participant data (IPD) prospective meta-analysis (PMA) of randomised controlled trials, including cluster design. Each trial is conducted independently but share core protocol elements to contribute data to the PMA. Participating trials are deemed eligible for the PMA if their results are not yet known outside their Data Monitoring Committees.

ETHICS AND DISSEMINATION

Participants in the individual trials will consent to participation, with respective trials receiving ethical approval by their local Human Research Ethics Committees. Individual datasets remain the property of trialists, and can be published prior to the publication of final PMA results. The overall data for meta-analysis will be held, analysed and published by the collaborative group, led by the Cochrane PMA group.

TRIAL REGISTRATION NUMBER

CRD42020103857.

Variation of intrapartum care and cesarean rates among practitioners attending births of low-risk, nulliparous women

BACKGROUND

Variation in hospital cesarean birth rates across the United States is likely because of differences in practitioner practice patterns. Yet, few studies conducted in the last twenty years have examined the relationships between practitioner characteristics and the use of intrapartum interventions and cesarean birth. The objective of this study was to examine associations among practitioner characteristics and the use of amniotomy, epidural, oxytocin augmentation, and cesarean birth in low-risk women with spontaneous onset of labor.

METHODS

A secondary analysis was performed using data collected by the Consortium on Safe Labor. The sample included nulliparous term singleton vertex (NTSV) births with spontaneous onset of labor (n = 13 196) from 2002 to 2007 across eight hospitals. Generalized linear mixed models were conducted to examine outcomes.

RESULTS

The cesarean birth rate ranged from 7.2% to 18.9% across hospitals and from 0% to 53.3% across physicians. Practice type (P < .05) and specialty type (P < .0001) were associated with physician cesarean birth rates. Compared with obstetrician/gynecologists, midwives were nearly twice as likely to use no intrapartum interventions (relative risk 1.80 [CI 95 1.45-2.24]) and 26% less likely to use amniotomy-epidural-oxytocin (0.74 [0.62-0.89]). Family practice physicians had a 21% lower likelihood of using amniotomy-epidural-oxytocin (0.79 [0.67-0.94]) and a 53% lower likelihood of performing cesarean births (0.47 [0.35-0.63]).

CONCLUSIONS

Wide variation in hospital and physician cesarean birth rates was observed in this sample of low-risk, nulliparous women. Practitioner practice type and specialty were significantly associated with the use of intrapartum interventions. Interprofessional practitioner education could be one strategy to reduce variation of intrapartum care and cesarean birth.

WHEN LESS IS MORE: SHIFTING RISK MANAGEMENT IN AMERICAN CHILDBIRTH

As maternal mortality increases in the United States, birth providers and policymakers are seeking new solutions to address what scholars have called the "C-section epidemic." Hospital cesarean rates vary tremendously, from 7 to 70 percent of all births. Based on in-depth, semi-structured interviews with 47 obstetricians and family physicians in the United States, I explore one reason for this variation: differences in how physicians perceive and manage risk in American obstetrics. While the dominant model of risk management encourages high levels of intervention and monitoring, I argue that a significant portion of physicians are concerned about high intervention rates in childbirth and are working to reduce cesarean rates and/or the use of monitoring technologies like continuous fetal heart rate monitors. Unlike prior theories of biomedicalization, which suggest that health risks are managed through increased monitoring and intervention, I find that many physicians are resisting this model of risk management by ordering fewer interventions and collecting less information about their patients. These providers acknowledge that interventions designed to mitigate risks may only provide an illusion of control, rather than an actual mastery of risks. By limiting interventions, providers may lose this illusion of control but also mitigate the iatrogenic effects of intervention and continuous monitoring. This alternative approach to risk management is growing in many medical fields and deserves more attention from medical sociologists.

Associations Among Intrapartum Interventions and Cesarean Birth in Low-Risk Nulliparous Women with Spontaneous Onset of Labor

INTRODUCTION

Cesarean birth rates vary widely across hospitals in the United States, even among women who are considered low-risk for the procedure. This variation has been attributed to differences in health care provider practice, but few studies have explored patterns of labor management in relation to cesarean birth.

METHODS

This was a retrospective observational study of 26,259 nulliparous, term, singleton gestation, vertex presentation births following spontaneous onset of labor. Births occurred from 2002 to 2007 in 11 hospitals in the Consortium on Safe Labor. Generalized linear mixed modeling was used to examine the relationship between intrapartum interventions (amniotomy, epidural analgesia, oxytocin augmentation) used individually and in combination and the outcome of cesarean birth.

RESULTS

More than 90% of the women in this low-risk sample received at least one intervention regardless of mode of birth. Epidural analgesia was the most frequently applied intervention, both when used as a single intervention (18.7%) and in combination with other interventions (79.9%). The strongest associations between these interventions and cesarean birth were observed when 2 or 3 interventions were applied during labor. Compared with women who received no interventions, the strongest association was observed among women who received amniotomy-oxytocin augmentation (adjusted odds ratio [aOR], 1.89; 95% CI, 1.36-2.62). The use of all 3 interventions (amniotomy-epidural analgesia-oxytocin augmentation) showed a similar positive association with cesarean birth (aOR 1.83; 95% CI, 1.50-2.21).

DISCUSSION

Findings show that the combined use of amniotomy, epidural analgesia, and oxytocin augmentation is positively associated with cesarean birth. Additional research is needed to examine the timing and sequence of interventions as well as whether a causal relationship exists between combinations of interventions and cesarean birth in low-risk nulliparous women.

Associations among cervical dilatation at admission, intrapartum care, and birth mode in low-risk, nulliparous women

BACKGROUND

Admission in early labor is associated with increased likelihood of cesarean birth, but the context in which this occurs is unclear. Previous research has explored the relationship between dilatation at admission and the use of single intrapartum interventions; however, the majority of women in the United States receive multiple intrapartum interventions. The objective of this study was to examine the associations among cervical dilatation at admission, intrapartum care, and birth mode in low-risk, nulliparous women with spontaneous onset of labor.

METHODS

This was a cross-sectional, observational study of 21 858 nulliparous, singleton, term vertex births that occurred from 2002 to 2007 across nine hospitals in the Consortium on Safe Labor. Outcome measures included the individual and combined use of intrapartum interventions (amniotomy, epidural anesthesia, oxytocin augmentation) and birth mode.

RESULTS

In this sample, 92.0% of women received at least one intrapartum intervention and 22.7% received all three interventions. After propensity score adjustment, women were more than twice as likely to receive the combination of amniotomy-epidural-oxytocin when admitted at 0-3 cm (RR 2.83 [95% CI 2.45-3.27]) and 4-5 cm (2.49 [2.15-2.89]) compared to 6-10 cm. Adjusted likelihood of cesarean birth was five times greater for women admitted at 0-3 cm (5.26 [4.36-6.34]) and two times greater for women admitted at 4-5 cm (2.27 [1.86-2.77]) compared to 6-10 cm.

CONCLUSIONS

To promote normal physiologic birth, low-risk, nulliparous women should be engaged in shared decision-making about timing of admission after spontaneous onset of labor.

Cesarean section on a rise-Does advanced maternal age explain the increase? A population register-based study

Background

In Denmark, the cesarean section rate has increased by 49% between 1998 and 2015 and accounts for 21% of all births. Cesarean sections may cause short- as well as long-term consequences for both the mother and the child and impose further risks in future pregnancies. Delaying pregnancy until advanced maternal age at childbirth has been suggested as contributing to the increase. The proportion of women giving birth at 35 years or above increased from 15% (1998) to 21% (2015). Advanced maternal age at childbirth has been found to be related to increased pre-pregnancy morbidity and associated risk factors that may contribute to an increased risk of cesarean section. The aim of this study was to examine the association between advanced maternal age and cesarean section in a Danish population and the influence of demographic, anthropometric, health, and obstetric factors on this association.

Methods

This study draws on a national population-based cohort study of all Danish births between 1998 and 2015 (N = 1,122,964). Maternal age less than 30 years serves as reference with the following age categories: (30–34 years); (35–39 years), and (40 years and above). The primary outcome was a cesarean section. Multivariate regression models with adjustment for demographic, health, pregnancy, fetal, and obstetric characteristics were performed with the results further stratified by parity.

Results

In general, a positive association between advanced maternal age and cesarean section was found. Only minor changes in the risk estimate occurred after adjustment for relevant confounders. In comparison with the reference category, nulliparous women aged 35-39- years had twice the risk for cesarean section (adjusted odds ratio (AOR) 2.18, 95% confidence interval (CI) [2.11–2.26]) whereas for women of 40 years or above, the risk was more than tripled (AOR 3.64, 95% CI [3.41–3.90]). For multiparous women aged 35-39-years the risk was more moderate, but still with an AOR of 1.56, 95% CI [1.53–1.60], and for those 40 years and above, the AOR was 2.02, 95% CI [1.92–2.09].

Conclusions

Overall, cesarean section increased with increasing maternal age. Adjustment for maternal and obstetric risk factors had only a minor influence on the association. The association was stronger in nulliparous women compared to multiparous women. Given the lack of impact of demographic and health risks on the relationship between maternal age and cesarean section, the authors suggest obstetric culture could be added to the list of risk factors for a cesarean. Future research on obstetric culture is recommended as are studies on a possible age-related decrease in the ability to maintain the progression of labor.

Trial registration

The study uses depersonalized register data and has been approved by the Danish Data Protection Agency (2015-41-4168).

Interventions to reduce unnecessary caesarean sections in healthy women and babies

Optimising the use of caesarean section (CS) is of global concern. Underuse leads to maternal and perinatal mortality and morbidity. Conversely, overuse of CS has not shown benefits and can create harm. Worldwide, the frequency of CS continues to increase, and interventions to reduce unnecessary CSs have shown little success. Identifying the underlying factors for the continuing increase in CS use could improve the efficacy of interventions. In this Series paper, we describe the factors for CS use that are associated with women, families, health professionals, and health-care organisations and systems, and we examine behavioural, psychosocial, health system, and financial factors. We also outline the type and effects of interventions to reduce CS use that have been investigated. Clinical interventions, such as external cephalic version for breech delivery at term, vaginal breech delivery in appropriately selected women, and vaginal birth after CS, could reduce the frequency of CS use. Approaches such as labour companionship and midwife-led care have been associated with higher proportions of physiological births, safer outcomes, and lower health-care costs relative to control groups without these interventions, and with positive maternal experiences, in high-income countries. Such approaches need to be assessed in middle-income and low-income countries. Educational interventions for women should be complemented with meaningful dialogue with health professionals and effective emotional support for women and families. Investing in the training of health professionals, eliminating financial incentives for CS use, and reducing fear of litigation is fundamental. Safe, private, welcoming, and adequately resourced facilities are needed. At the country level, effective medical leadership is essential to ensure CS is used only when indicated. We conclude that interventions to reduce overuse must be multicomponent and locally tailored, addressing women's and health professionals' concerns, as well as health system and financial factors.

'I felt like I could do anything!' Writing the phenomenon of 'transcendent birth' through autoethnography

OBJECTIVE

To discuss the concept of 'transcendent birth', an as yet poorly articulated and under recognised psychosocial wellness phenomenon of childbirth.

DESIGN

an auto-ethnographical examination of the primary authors' journaled experiences as a student midwife and childbearing woman.

SETTING

three maternity care units in South Eastern Australia as well as the home of the primary author.

FINDINGS

The phenomenon of transcendent birth is linked with physiologic birth. Maternity care can hinder or facilitate physiologic birth, and therefore transcendent birth.

KEY CONCLUSIONS

Transcendent birth is more likely in maternity care models which value the childbearing woman and physiologic birth.

IMPLICATIONS FOR PRACTICE

Women's access to transcendent birth is demarcated by women's position in society, cultural knowledge of transcendent birth and the valuing of transcendent birth as a maternity care outcome.

Barriers and facilitators to birth without epidural in a tertiary obstetric referral center: Perspectives of health care professionals and patients

BACKGROUND

Epidural rates are high in tertiary obstetric referral centers, even though many patients in tertiary settings might not want or need epidural analgesia. Epidural rates are influenced by factors including labor support and routine medical intervention. This study aimed to identify barriers and facilitators to birth without epidural in a Canadian tertiary center, from the perspectives of doctors, nurses, and patients.

METHODS

In this qualitative exploratory study, individual, semi-structured interviews were conducted in 2016 with 5 doctors, 5 nurses, and 4 patients who intended to birth without epidural. Interviews were audio-recorded, transcribed, and analyzed using inductive qualitative thematic analysis.

RESULTS

Several contextual factors in the tertiary center facilitated or were barriers to birth without epidural. The following themes emerged: (1) differing perceptions of pain, (2) being ready for things to go wrong, (3) labor support is more labor intensive, and (4) having insufficient resources for birth without epidural.

CONCLUSIONS

Reconciling patient birth goals with staff focus on patient safety is challenging in the tertiary context. Discrepancies between health care professional and patient attitudes about childbirth pain may influence decision-making about epidural use. Maintaining labor support skills is challenging for health care professionals who have limited exposure to birth without epidural. There is a need to allocate dedicated resources to better support birth without epidural. Specifically, support could be improved through the implementation of guidelines for assessment and management of labor pain, provision of a variety of pain management options, and labor support training for health care professionals.

Variations in childbirth interventions in high-income countries: protocol for a multinational cross-sectional study

INTRODUCTION

There are growing concerns about the increase in rates of commonly used childbirth interventions. When indicated, childbirth interventions are crucial for preventing maternal and perinatal morbidity and mortality, but their routine use in healthy women and children leads to avoidable maternal and neonatal harm. Establishing ideal rates of interventions can be challenging. This study aims to describe the range of variations in the use of commonly used childbirth interventions in high-income countries around the world, and in outcomes in nulliparous and multiparous women.

METHODS AND ANALYSIS

This multinational cross-sectional study will use data from births in 2013 with national population data or representative samples of the population of pregnant women in high-income countries. Data from women who gave birth to a single child from 37 weeks gestation onwards will be included and the results will be presented for nulliparous and multiparous women separately. Anonymised individual level data will be analysed. Primary outcomes are rates of commonly used childbirth interventions, including induction and/or augmentation of labour, intrapartum antibiotics, epidural and pharmacological pain relief, episiotomy in vaginal births, instrument-assisted birth (vacuum or forceps), caesarean section and use of oxytocin postpartum. Secondary outcomes are maternal and perinatal mortality, Apgar score below 7 at 5 min, postpartum haemorrhage and obstetric anal sphincter injury. Univariable and multivariable logistic regression analyses will be conducted to investigate variations among countries, adjusted for maternal age, body mass index, gestational weight gain, ethnic background, socioeconomic status and infant birth weight. The overall mean rates will be considered as a reference category, weighted for the size of the study population per country.

ETHICS AND DISSEMINATION

The Medical Ethics Review Committee of VU University Medical Center Amsterdam confirmed that an official approval of this study was not required. Results will be disseminated at national and international conferences and published in peer-reviewed journals.

Route of birth delivery preferred by mothers and their motivations

Abstract Objective: Identify the route of birth delivery preferred by mothers and their motivations. Method: Cross-sectional study with 361 mothers from a university hospital. Data were obtained using a structured questionnaire from February to April 2013. Descriptive analysis was performed and the Chi-square test was used to verify association among the variables. Results: 77.6% of the women preferred vaginal delivery and the reason reported by 81.8% of them was easier recovery postpartum; 20.5% believed they took part in the decision-making concerning the type of delivery; 64.5% believed the type of delivery they experienced did not involve risk for themselves, while 21.9% believed it involved risk for the newborn. Statistical association was found between number of deliveries and type of previous delivery with the preferred route of delivery. Conclusion: Women did not have adequate knowledge regarding the risks and benefits of different types of delivery and for this reason were not empowered to exert their autonomy in regard to this decision.

Timing of hospital admission in labour: latent versus active phase, mode of birth and intrapartum interventions. A correlational study

BACKGROUND

Hospitalization of women in latent labour often leads to a cascade of unnecessary intrapartum interventions, to avoid potential disadvantages the recommendation should be to stay at home to improve women's experience and perinatal outcomes.

AIM

The primary aim of this study was to investigate the association between hospital admission diagnosis (latent vs active phase) and mode of birth. The secondary aim was to explore the relationship between hospital admission diagnosis, intrapartum intervention rates and maternal/neonatal outcomes.

METHODS

A correlational study was conducted in a large Italian maternity hospital. Data from January 2013 to December 2014 were collected from the hospital electronic records. 1.446 records of low risk women were selected. These were dichotomized into two groups based on admission diagnosis: 'latent phase' or 'active phase' of labour.

FINDINGS

52.7% of women were admitted in active labour and 47.3% in the latent phase. Women in the latent phase group were more likely to experience a caesarean section or an instrumental birth, artificial rupture of membranes, oxytocin augmentation and epidural analgesia. Admission in the latent phase was associated with higher intrapartum interventions, which were statistically correlated to the mode of birth.

CONCLUSIONS

Women admitted in the latent phase were more likely to experience intrapartum interventions, which increase the probability of caesarean section. Maternity services should be organized around women and families needs, providing early labour support, to enable women to feel reassured facilitating their admission in labour to avoid the cascade of intrapartum interventions which increases the risk of caesarean section.

What Are Optimal Cesarean Section Rates in the U.S. and How Do We Get There? A Review of Evidence-Based Recommendations and Interventions

Cesarean sections (CSs) are the most commonly performed surgical procedures in the world today. Global epidemiological studies from the last decade suggest that the optimal CS rates in developed countries exist somewhere between 15% and 19%. Despite these findings, CS rates in the United States have remained stable at slightly over 32% over the past 10 years. Using primary and secondary literature published from 2010 to 2015, this review discusses how optimal CS rates were developed. In addition, we define a category of potentially avoidable CS (i.e., those conducted on nulliparous low-risk women who present with vertex infants at term) and explore how CS in this population appear to be one of the main drivers of high CS rates overall. The institutional, provider, and patient-related factors, which may be related to higher-than-recommended rates of CS, particularly those conducted in low-risk women, will be discussed. This review will then delve into clinician and patient-oriented interventions that have been shown to effectively reduce the rate of potentially avoidable CS. Our analysis showed that large-scale, multifaceted interventions that include audit and feedback cycles as well as peer review strategies were the most effective in decreasing rates of potentially avoidable CS. This review concludes with an agenda for future research into interventions that aim to achieve optimal CS rates.

The Effect of Epidural Analgesia Alone and in Association With Other Variables on the Risk of Cesarean Section

Introduction:

Epidural analgesia (EA) is the most widespread pharmacologic method of labor pain relief. There remains disagreement, however, regarding its adverse effects. The objective of this study was to determine the effect of EA administration on the risk of cesarean delivery and its causes (e.g., stalled labor, risk of loss of fetal well-being, among others) and the degree to which this effect may be modulated by mother-, newborn-, and labor-related variables.

Method:

A retrospective cohort observational study was conducted including all deliveries in a Spanish public hospital between March 2010 and March 2013 ( N = 2,450; EA = 562, non-EA = 1,888).

Results:

Risk of a cesarean section was significantly increased by EA administration (odds ratio [ OR] = 2.673; p < .0001). The percentage of cesarean deliveries due to the risk of loss of fetal well-being was significantly higher in the EA (47.8%) versus non-EA group (27.5%; OR = 1.739; p = 0.0012,). The EA-associated risk of cesarean section was not significantly modified as a function of maternal age or parity, fetal position, newborn weight, weeks of gestation, or sedation administration alone. However, these variables in combination may increase the risk. We present multivariate models for each group that account for these variables, allowing for estimation of the risk of a cesarean delivery if EA is administered.

Conclusion:

EA is associated with an increased risk of cesarean delivery. Other variables in combination (maternal age or parity, fetal position, newborn weight, weeks of gestation, or sedation administration) may increase this risk.

Electronic Fetal Monitoring and Cesarean Birth: A Scoping Review

BACKGROUND

In many United States hospitals, electronic fetal monitoring (EFM) is used continuously during labor for all patients regardless of risk status. Application of EFM, particularly at labor admission, may trigger a chain of interventions resulting in increased risk for cesarean birth among low-risk women. The goal of this review was to summarize evidence on use of EFM during low-risk labors and identify gaps in research.

METHODS

We conducted a scoping review of studies published in English since 1996 that addressed the relationship between EFM use and cesarean among low-risk women. We screened 57 full-text articles for appropriateness. Seven articles were included in the final review.

RESULTS

The largest study demonstrated an 81 percent increased risk of primary cesarean birth when EFM was used in labor, but did not differentiate between high- and low-risk pregnancies. Four randomized controlled trials examined the association of admission EFM with obstetric outcomes; only one considered cesarean birth as a primary outcome and found a 23 percent increase in operative birth when EFM lasted more than 1 hour. A study examining application of continuous EFM before and after 4 centimeters dilatation found no differences between groups.

CONCLUSIONS

In general, the research on this topic suggests an association between the use of EFM and cesarean birth; however, more well-designed studies are needed to examine benefits of EFM versus auscultation, determine if EFM is associated with use of other technologies that could cumulatively increase risk of cesarean birth, and understand provider motivation to use EFM over auscultation.

Patient Safety Implications of Electronic Alerts and Alarms of Maternal - Fetal Status During Labor

When nurses care for women during labor, they encounter numerous alerts and alarms from electronic fetal monitors and their surveillance systems. Notifications of values of physiologic parameters for a woman and fetus that may be outside preset limits are generated via visual and audible cues. There is no standardization of these alert and alarm parameters among electronic fetal monitoring vendors in the United States, and there are no data supporting their sensitivity and specificity. Agreement among professional organizations about physiologic parameters for alerts and alarms commonly used during labor is lacking. It is unknown if labor nurses view the alerts and alarms as helpful or a nuisance. There is no evidence that they promote or hinder patient safety. This clinical issue warrants our attention as labor nurses.

Complementary therapies for labour and birth study: a randomised controlled trial of antenatal integrative medicine for pain management in labour

OBJECTIVE

To evaluate the effect of an antenatal integrative medicine education programme in addition to usual care for nulliparous women on intrapartum epidural use.

DESIGN

Open-label, assessor blind, randomised controlled trial.

SETTING

2 public hospitals in Sydney, Australia.

POPULATION

176 nulliparous women with low-risk pregnancies, attending hospital-based antenatal clinics.

METHODS AND INTERVENTION

The Complementary Therapies for Labour and Birth protocol, based on the She Births and acupressure for labour and birth courses, incorporated 6 evidence-based complementary medicine techniques: acupressure, visualisation and relaxation, breathing, massage, yoga techniques, and facilitated partner support. Randomisation occurred at 24-36 weeks' gestation, and participants attended a 2-day antenatal education programme plus standard care, or standard care alone.

MAIN OUTCOME MEASURES

Rate of analgesic epidural use. Secondary: onset of labour, augmentation, mode of birth, newborn outcomes.

RESULTS

There was a significant difference in epidural use between the 2 groups: study group (23.9%) standard care (68.7%; risk ratio (RR) 0.37 (95% CI 0.25 to 0.55), p≤0.001). The study group participants reported a reduced rate of augmentation (RR=0.54 (95% CI 0.38 to 0.77), p<0.0001); caesarean section (RR=0.52 (95% CI 0.31 to 0.87), p=0.017); length of second stage (mean difference=-0.32 (95% CI -0.64 to 0.002), p=0.05); any perineal trauma (0.88 (95% CI 0.78 to 0.98), p=0.02) and resuscitation of the newborn (RR=0.47 (95% CI 0.25 to 0.87), p≤0.015). There were no statistically significant differences found in spontaneous onset of labour, pethidine use, rate of postpartum haemorrhage, major perineal trauma (third and fourth degree tears/episiotomy), or admission to special care nursery/neonatal intensive care unit (p=0.25).

CONCLUSIONS

The Complementary Therapies for Labour and Birth study protocol significantly reduced epidural use and caesarean section. This study provides evidence for integrative medicine as an effective adjunct to antenatal education, and contributes to the body of best practice evidence.

TRIAL REGISTRATION NUMBER

ACTRN12611001126909.

Prepregnancy Obesity and Primary Cesareans among Otherwise Low-Risk Mothers in 38 U.S. States in 2012

BACKGROUND

The United States has recently experienced increases in both its rate of obesity and its cesarean rate. Our objective was to use a new item measuring prepregnancy body mass index (BMI) on the U.S. Standard Certificate of Live Birth to examine at a population level the relationship between maternal obesity and primary cesarean delivery for women at otherwise low risk for cesarean delivery.

METHODS

By 2012, 38 states with 86 percent of United States births had adopted the U.S. Standard Certificate. The sample was limited to the 2,233,144 women who had a singleton, vertex, term (37-41 weeks) birth in 2012 and no prior cesarean. We modeled the likelihood of a primary cesarean by BMI category, controlling for maternal socio-demographic and medical characteristics.

RESULTS

Overall, 46.4 percent of otherwise low-risk mothers had a prepregnancy BMI in the overweight (25.1%) or obese (21.3%) categories, with the obese category distributed as follows: obese I (BMI 30.0-34.9, 12.4%); obese II (BMI 35.0-39.9, 5.5%); and obese III (BMI 40+, 3.5%). Obesity rates were highest among American Indian and Alaska Native (32.5%) and non-Hispanic black mothers (30.5%). After adjustment for demographic and medical risks, the adjusted risk ratios (95% confidence intervals) of cesarean for low-risk primiparas were: 1.61 (1.60-1.63) for obese I, 1.86 (1.83-1.88) for obese II, and 2.21 (2.18-2.25) for obese III mothers compared with mothers in the normal weight category.

DISCUSSION

A relationship between prepregnancy obesity and primary cesarean delivery among relatively low-risk mothers remained even after controlling for social and medical risk factors.

Self-hypnosis for intrapartum pain management in pregnant nulliparous women: a randomised controlled trial of clinical effectiveness

Objective

(Primary) To establish the effect of antenatal group self-hypnosis for nulliparous women on intra-partum epidural use.

Design

Multi-method randomised control trial (RCT).

Setting

Three NHS Trusts.

Population

Nulliparous women not planning elective caesarean, without medication for hypertension and without psychological illness.

Methods

Randomisation at 28–32 weeks’ gestation to usual care, or to usual care plus brief self-hypnosis training (two × 90-minute groups at around 32 and 35 weeks’ gestation; daily audio self-hypnosis CD). Follow up at 2 and 6 weeks postnatal.

Main outcome measures

Primary: epidural analgesia. Secondary: associated clinical and psychological outcomes; cost analysis.

Results

Six hundred and eighty women were randomised. There was no statistically significant difference in epidural use: 27.9% (intervention), 30.3% (control), odds ratio (OR) 0.89 [95% confidence interval (CI): 0.64–1.24], or in 27 of 29 pre-specified secondary clinical and psychological outcomes. Women in the intervention group had lower actual than anticipated levels of fear and anxiety between baseline and 2 weeks post natal (anxiety: mean difference −0.72, 95% CI −1.16 to −0.28, P = 0.001); fear (mean difference −0.62, 95% CI −1.08 to −0.16, P = 0.009) [Correction added on 7 July 2015, after first online publication: ‘Mean difference’ replaced ‘Odds ratio (OR)’ in the preceding sentence.]. Postnatal response rates were 67% overall at 2 weeks. The additional cost in the intervention arm per woman was £4.83 (CI −£257.93 to £267.59).

Conclusions

Allocation to two-third-trimester group self-hypnosis training sessions did not significantly reduce intra-partum epidural analgesia use or a range of other clinical and psychological variables. The impact of women's anxiety and fear about childbirth needs further investigation.

Tweetable abstract

Going to 2 prenatal self-hypnosis groups didn't reduce labour epidural use but did reduce birth fear & anxiety postnatally at < £5 per woman.

Maternal age and emergency operative deliveries at term: a population-based registry study among low-risk primiparous women

OBJECTIVE

To study the association between maternal age and emergency operative delivery. The roles of in-labour indications, and birthweight ≥ 4000 g, gestational age ≥ 42 weeks, induction of labour, and epidural use, according to maternal age were explored.

DESIGN

Population-based study.

SETTING

Medical Birth Registry of Norway and Statistics Norway.

POPULATION

We studied 169 583 low-risk primiparous mothers with singleton, cephalic labours, at ≥37 weeks of gestation, from 1999 to 2009.

METHODS

The associations between maternal age and mode of delivery were analysed using multinomial regression analyses, adjusting for sociodemographic factors.

MAIN OUTCOME MEASURES

Emergency caesarean section and operative vaginal delivery.

RESULTS

Of women aged ≥40 years, 22% had emergency caesarean sections and 24% had operative vaginal deliveries, giving adjusted relative risk ratios (RRRs) of 6.60 (95% confidence interval, 95% CI 5.53-7.87) and 3.30 (95% CI 2.79-3.90), respectively, when compared with women aged 20-24 years. Adjustments for sociodemographic factors only slightly changed the estimates. Dystocia was the main indication, followed by fetal distress. All of the listed factors increased the level of emergency operative deliveries, mainly because of an increase in dystocia. The increase in risk for emergency caesarean section by all factors, and for operative vaginal deliveries by epidural, were greater in older than in younger women, but were significant for epidural only.

CONCLUSIONS

We found a close association between maternal age and emergency operative delivery in low-risk primiparas. Contributory factors increased the risk for both emergency operative delivery and epidural more in older than in younger women.