Twin deliveries and place of birth in NSW 2001-2005

Hospital case volume and maternal adverse events following abnormal deliveries: Analysis using a Japanese national in-patient database

OBJECTIVE

To clarify the relationship between the number of deliveries and maternal outcomes in Japan, considering the declining birth rate and the evidence that hospitals with few deliveries have medical safety issues.

METHODS

Hospitalizations for deliveries were analyzed using the Diagnosis Procedure Combination database from April 2014 to March 2019, after which maternal comorbidities, maternal end-organ injury, medical treatment during hospitalization, and hemorrhage volume during delivery were compared. Hospitals were divided into four groups based on the number of deliveries per month.

RESULTS

A total of 792 379 women were included in the analysis, among whom 35 152 (4.4%) received blood transfusions, with a median blood loss of 1450 mL during delivery. Regarding complications, pulmonary embolism was significantly more frequent in hospitals with the lowest number of deliveries.

CONCLUSION

Using a Japanese administrative database, this study suggests an association between hospital case volume and the occurrence of preventable complications, such as pulmonary embolisms.

Twin pregnancies complicated by gestational diabetes mellitus: a single centre cohort study

AIMS

In women with a twin pregnancy, to determine the incidence of, risk factors for and outcomes of women with gestational diabetes mellitus, and assess how these have changed with a change in gestational diabetes screening.

METHODS

Retrospective cohort study of women with a twin pregnancy attending an Australian tertiary hospital, 2002-2013. Information on gestational diabetes status, gestational diabetes risk factors and pregnancy outcomes was ascertained. Pregnancy outcomes included hypertensive disorders, twin birthweight centile and a composite adverse pregnancy outcome. Analysis was stratified pre/post screening protocol change (epoch 1: 2002-2009, epoch 2: 2010-2013) and by gestational diabetes status.

RESULTS

Gestational diabetes was diagnosed in 86/982 (8.8%) women, increasing from 4.4% to 14.7% between epochs (P = 0.0001). The proportion of women with hypertensive disorders increased (11.7% vs. 13.4%, P = 0.009), but the proportion of infant's birthweight > 90th centile decreased (11.0% vs. 7.6%, P = 0.02) between epochs. Overall, 33.6% of women had ≥ 1 risk factors for gestational diabetes. Three-quarters (73.7%) of women overall had an adverse pregnancy outcome, with a slightly higher proportion in women with gestational diabetes compared with those with no gestational diabetes (79.7% vs. 73.1%, P = 0.06). The rate of the adverse pregnancy outcome did not change by epoch, after adjusting for maternal and pregnancy risk factors (adjusted odds ratio = 0.96, 95% confidence interval 0.73-1.26).

CONCLUSIONS

Almost 1 in 10 women with a twin pregnancy were diagnosed with gestational diabetes, with the incidence of gestational diabetes increasing threefold with a new screening protocol. The pregnancy outcomes of women with a twin pregnancy did not change with increased detection and treatment for gestational diabetes.

Association of prelabor cesarean delivery with reduced mortality in twins born near term

OBJECTIVE

To examine short-term and longer-term outcomes for twins born at or near term, comparing prelabor cesarean delivery with birth after a trial of labor.

METHODS

This study was conducted on a retrospective cohort of twin pregnancies delivered at 36 weeks of gestation or greater from 2000 to 2009. Pregnancies with an antenatal death, lethal anomaly, birth weight discordance 25% or more, or birth weight less than 2,000 g or more than 4,000 g were excluded. Outcomes included severe hypoxia, stillbirth and neonatal death, and hospital admissions or death during the first 5 years of life.

RESULTS

Approximately 45% of 7,099 twin pregnancies were delivered by prelabor cesarean delivery. Compared with delivery after labor, prelabor cesarean delivery was associated with significantly reduced risks of adverse neonatal and child outcomes including severe birth hypoxia (0.08% compared with 0.75%, relative risk 0.10, 95% confidence interval [CI] 0.04-0.26), neonatal death (0.00% compared with 0.15%, relative risk 0.05, 95% CI 0.00-0.82), and death up to 5 years of age (0.16% compared with 0.40%, relative risk 0.41, 95% CI 0.20-0.85). Whereas total mortality for first twins was similar after labor (0.15%) compared with prelabor cesarean delivery (0.16%), total mortality was four times more common in second twins born after labor (0.64%) compared with second twins born after prelabor cesarean delivery (0.16%).

CONCLUSION

Compared with prelabor cesarean delivery, twin pregnancies at and beyond 36 weeks of gestation delivered after labor have increased risks for birth outcomes associated with hypoxia, with second twins having significantly increased mortality up to 5 years of age. However, the absolute mortality rate for relatively uncomplicated twin pregnancies delivered at or near term is low and needs to be balanced against maternal morbidity.

LEVEL OF EVIDENCE

II.

Multifetal pregnancies: preterm admissions and outcomes

OBJECTIVE

To describe the rates of antenatal hospital admission during twin or higher order multifetal pregnancies, and the admission outcomes as discharge undelivered, transfer to higher care, or spontaneous or elective delivery.

METHODS

Cohort study using linked birth and hospital data. The cohort comprised women who gave birth to twins or higher order multiple infants of≥24 weeks gestation in 2001-2008 and who were admitted to hospital in weeks 20-36 of the pregnancy.

RESULTS

In 63.4% of 10 779 twin pregnancies and 99.5% of 197 triplet and quadruplet pregnancies, the woman was admitted to hospital at least once in weeks 20-36 of the pregnancy, for a total 10 985 admissions. Almost half the admissions (46.3%) ended in discharge without delivery, 10.7% in transfer to higher care, 21.1% in spontaneous labour and birth, and 21.8% in elective delivery (induction or prelabour Caesarean section). The reason for admission was preterm labour in 34.2% of admissions.

CONCLUSIONS

Hospital admission during pregnancy is common for women with multifetal pregnancies, with many of these admissions resulting in preterm birth. This is the first study to report the rate of pregnancy admissions for women with multifetal pregnancies, and provides a baseline for future studies of hospital use in this population.

Development of a maternity hospital classification for use in perinatal research

We aimed to develop a maternity hospital classification, using stable and easily available criteria, that would have wide application in maternity services research and allow comparison across state, national and international jurisdictions. A classification with 13 obstetric groupings (12 hospital groups and home births) was based on neonatal care capability, urban and rural location, annual average number of births and public/private hospital status. In a case study of early elective birth we demonstrate that neonatal morbidity differs according to the maternity hospital classification, and also that the 13 groups can be collapsed in ways that are pragmatic from a clinical and policy decision-making perspective, and are manageable for analysis.

Epidemiology and trends for Caesarean section births in New South Wales, Australia: a population-based study

Background

Caesarean section (CS) rates around the world have been increasing and in Australia have reached 30% of all births. Robson's Ten-Group Classification System (10-group classification) provides a clinically relevant classification of CS rates that provides a useful basis for international comparisons and trend analyses. This study aimed to investigate trends in CS rates in New South Wales (NSW), including trends in the components of the 10-group classification.

Methods

We undertook a cross-sectional study using data from the Midwives Data Collection, a state-wide surveillance system that monitors patterns of pregnancy care, services and pregnancy outcomes in New South Wales, Australia. The study population included all women giving birth between 1^st January 1998 and 31st December 2008. Descriptive statistics are presented including age-standardised CS rates, annual percentage change as well as regression analyses.

Results

From 1998 to 2008 the CS rate in NSW increased from 19.1 to 29.5 per 100 births. There was a significant average annual increase in primary 4.3% (95%CI 3.0-5.7%) and repeat 4.8% (95% CI 3.9-5.7%) CS rates from 1998 to 2008. After adjusting for maternal and pregnancy factors, the increase in CS delivery over time was maintained. When examining CS rates classified according to the 10-group classification, the greatest contributors to the overall CS rate and the largest annual increases occurred among nulliparae at term having elective CS and multipara having elective repeat CS.

Conclusions

Given that the increased CS rate cannot be explained by known and collected maternal or pregnancy characteristics, the increase may be related to differences in clinical decision making or maternal request. Future efforts to reduce the overall CS rate should be focussed on reducing the primary CS rate.