Cesarean delivery rates for overall and multiple pregnancies in Japan: A descriptive study using nationwide health insurance claims data

Quantitative and calculated estimated blood loss in cesarean deliveries for twin and singleton pregnancies: a retrospective analysis

PURPOSE

This study retrospectively assessed blood loss during cesarean deliveries for twin and singleton pregnancies using two distinct methods, quantitative estimation measured during cesarean sections and hematocrit-based calculated estimation.

METHODS

We included scheduled cesarean deliveries for twin or singleton pregnancies at ≥ 34 weeks of gestation. Quantitative blood loss was recorded based on the blood volume in the graduated collector bottle and by weighing the blood-soaked textiles during cesarean sections. The blood loss was calculated using the change in hematocrit levels before and after the cesarean delivery.

RESULTS

We evaluated 403 cases including 44 twins and 359 singletons. Quantitative blood loss during cesarean section was significantly higher in twin pregnancies than that in singleton pregnancies (1117 [440] vs 698 [378] mL; p < 0.001). However, no significant differences were observed in the calculated blood loss between the two groups on the day after delivery (487 mL [692 mL] vs 507 mL [522 mL]; p = 0.861). On post-delivery days 4-5, twin pregnancies were associated with a significantly higher calculated blood loss than singleton pregnancies (725 [868] mL vs 444 [565] mL, p = 0.041). Although a significant moderate correlation between quantitative and calculated blood loss was observed in singleton pregnancies (r = 0.473, p < 0.001), no significant correlation was observed between twin pregnancies (r = 0.053, p = 0.735).

CONCLUSION

Quantitative blood loss measurements during cesarean section may be clinically insufficient in twin pregnancies. Incorporating blood tests and continuous assessments are warranted for enhanced blood loss evaluation, especially in twin pregnancies, owing to the risk of persistent bleeding.

Annual numbers of diagnoses and medical expenses for obstetric diseases in Japan: A report from the National Database of Health Insurance Claims

AIM

The present study aimed to estimate the total numbers of obstetric diseases diagnosed, total amounts of medical expenses claimed for obstetric diseases, their averages per livebirth, and yearly trends in Japan.

METHODS

This is a secondary analysis of the National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB) (data from 2015 to 2019). The target population was women of reproductive age (15-49 years old) with diseases in pregnancy, childbirth, and the puerperium, defined by having O codes according to the International Classification of Diseases 10th Revision. We calculated the numbers of obstetric diseases diagnosed, amounts of medical expenses claimed for obstetric diseases marked with the "main injury/disease decision flag," and the totals divided by the annual numbers of livebirths, by year and women's age group.

RESULTS

From 2015 to 2019, both the numbers of obstetric diseases diagnosed and amounts of medical expenses claimed for obstetric diseases per livebirth were on an upward trend, whereas the total numbers of obstetric diseases diagnosed were decreased. Women in advanced age groups had a higher number of diagnoses and a higher amount of medical expenses for obstetric diseases per livebirth. "Preterm labour without delivery" had the highest amounts of medical expenses claimed for and the second highest numbers of diagnoses throughout the study period.

CONCLUSIONS

This study suggests that pregnant women in Japan would have an increasing number of obstetric complications and necessary medical expenses year by year. Further study is warranted to elucidate these trends and identify possible mitigation measures.

Anesthesia practice for Cesarean delivery in Japan: a retrospective cohort study

PURPOSE

General anesthesia for Cesarean delivery affects maternal and neonatal outcomes. We aimed to evaluate temporal trends in anesthesia management for Cesarean deliveries over 16 years and analyze interinstitutional variations in general anesthesia use in Japan.

METHODS

In this retrospective cohort study, we obtained patient data from the nationwide health insurance claims database containing data for ten million individuals. We included patients who underwent Cesarean delivery between 1 January 2005 and 31 August 2021. The primary outcome was the use of general anesthesia. We evaluated institutional variations in general anesthesia use in medical facilities using two-level hierarchical logistic regression analyses with median odds ratios and intraclass correlation coefficients.

RESULTS

The cohort included 86,793 patients who underwent 102,617 Cesarean deliveries at 2,496 institutions. General anesthesia was used in 3.7% (95% confidence interval [CI], 3.6 to 3.9) of all Cesarean deliveries. The temporal trend in the use of general anesthesia decreased gradually from 10.8% in 2005 to 2.9% in 2021 (P for trend < 0.001). The adjusted median odds ratio for medical facilities was 6.1 (95% CI, 5.9 to 6.7), and the intraclass correlation coefficient was 0.52 (95% CI, 0.51 to 0.55).

CONCLUSION

Although the rate of general anesthesia use for Cesarean delivery in Japan decreased gradually from 2005 to 2021, general anesthesia was used in 3.7% of all Cesarean deliveries. The use of general anesthesia varied significantly across institutions, and 52% of the overall variations in general anesthesia practice can be explained by differences between facilities.

Influence of Cesarean Section on Postpartum Fertility and Dysmenorrhea: A Retrospective Cohort Study in Japan

Objective

To investigate the association between cesarean section (CS) and postpartum fertility and dysmenorrhea using data from a Japanese insurance registry.

Methods

This retrospective cohort study used a data set of patients registered between 2007 and 2021 in an insurance registry comprising specific employee-based health insurance companies in Japan. Of those data sets, we included data from participants who had their first recorded childbirth between 2014 and 2018. The exclusion criteria were any prior deliveries, dysmenorrhea, or complications that would affect the next pregnancy or postpartum dysmenorrhea since 2007. The occurrence of subsequent childbirth and postpartum dysmenorrhea until 2021 was compared between the CS and vaginal delivery (VD) groups using the log-rank test and Cox proportional hazards model with stratification according to age and age matching.

Results

This study included 25,984 (5,926 after age matching) and 5,926 participants in the VD and CS groups, respectively. After age matching, the rate of subsequent childbirth was 18.3% and 16.3%, and the rate of postpartum dysmenorrhea was 6.5% and 7.8% in the VD and CS groups, respectively. There were fewer subsequent childbirths in the CS group than in the VD group after age matching in the stratified Cox proportional hazards model (hazard ratio [HR] 95% confidence interval [CI]: 0.86 [0.79-0.94]). The CS group had a significantly higher risk of dysmenorrhea (HR [95% CI]: 1.18 [1.03-1.36]).

Conclusions

Although confounding might be existing, our study suggests that CS might be associated with decreased postpartum fertility and increased dysmenorrhea. The medical indications for CS should be carefully determined; post-CS women should be meticulously followed up.

Translation and validation of the Japanese version of the Birth Satisfaction Scale-Revised

AIM

This study aimed to develop a Japanese version of the Birth Satisfaction Scale-Revised and evaluate its reliability and validity.

METHODS

After translating the Birth Satisfaction Scale-Revised into Japanese, we conducted an Internet-based cross-sectional study with 445 Japanese-speaking women within 2 months of childbirth. Of these, 98 participated in the retest 1 month later. Data were analyzed using the COSMIN study design checklist for patient-reported outcome measurement instruments. Content validity was evaluated through cognitive debriefing during the translation process into Japanese. Confirmatory factor analysis was conducted to verify structural and cross-cultural validities. For hypothesis testing, we tested correlations with existing measures for convergent and divergent validities, and for known-group discriminant validity, we made comparisons between types of childbirth. Internal consistency was calculated using Cronbach's α, and test-retest reliability was evaluated using the intraclass correlation coefficient.

RESULTS

For the Japanese-Birth Satisfaction Scale-Revised, the established three-factor model fit poorly, whereas the four-factor model fit better. Full metric invariance was observed in both the nulliparous and multiparous groups. Good convergent, divergent, and known-group discriminant validities and test-retest reliability were established. Internal consistency observations were suboptimal; however for vaginal childbirth, the Cronbach's α of the total score was .71.

CONCLUSIONS

The Japanese-Birth Satisfaction Scale-Revised is a valid and reliable scale, with the exception of internal consistency that requires further investigation. If limited to vaginal childbirth, research, clinical applications, and international comparisons can be drawn.

Ultrasonographic cervical length screening at 20-24 weeks of gestation in twin pregnancies for prediction of spontaneous preterm birth: A 10-year Taiwanese cohort

BACKGROUND

Shortened cervical length is one of the primary predictors for spontaneous preterm deliveries in twin pregnancies. However, there is lack of consensus regarding cut-off values. Recent evidence highlights that established cut-offs for cervical length screening might not always apply across different populations. This study aims to present the distribution of cervical length in Taiwanese twin pregnancies and to assess its predictive value for spontaneous preterm birth during mid-trimester screening.

MATERIALS AND METHODS

This retrospective analysis of cervical length screening in Taiwan evaluated 469 twin pregnancies between 20-24 weeks of gestation. Outcome data were obtained directly from the medical records of the delivery hospital. The study explored the predictive value of cervical length screening for spontaneous preterm birth and the characteristics of cervical length distribution in Taiwanese twin pregnancies.

RESULTS

The average gestational age at screening was 22.7 weeks. Cervical length values displayed a non-normal distribution (p-value <0.001). The median, 5th and 95th centiles were 37.5 mm 25.1 mm, and 47.9 mm, respectively. Various cut-off values were assessed using different methods, yielding positive [negative] likelihood ratios for spontaneous preterm births between 32-37 weeks of gestational age (GA) (1.3-30.1 and [0.51-0.92]) and for very preterm births between 28-32 weeks GA (5.6-51.1 and [0.45-0.64]).

CONCLUSIONS

The findings from our analysis of Taiwanese twin pregnancies uphold the moderate predictive potential of cervical length screening, consistent with prior investigations. The presented likelihood ratios for predicting preterm birth at different gestational ages equip clinicians with valuable tools to enhance their diagnostic rationale and resource utilization. By fine-tuning screening parameters according to the spontaneous preterm birth prevalence and clinical priorities of the particular population, healthcare providers can enhance patient care. Our data implies that a cervical length below 20 mm might provide an optimal balance between minimizing false negatives and managing false positives when predicting spontaneous preterm birth.

A Retrospective Comparative Study of the Effect of Controlled-Release Dinoprostone Vaginal Delivery System (Propess®) and Mechanical Methods for Cervical Ripening in Nulliparous Women in Late-Term Pregnancy

OBJECTIVE

The effects of the controlled-release dinoprostone vaginal delivery system (Propess®) and mechanical methods for cervical ripening in nulliparous women in late-term pregnancy were compared retrospectively.

METHODS

This retrospective comparative study included 46 nulliparous pregnant women (24 in the Propess® group and 22 in the mechanical methods groups) with a low Bishop score (≤1) who needed labor induction at 41 weeks of gestation. The primary outcome was the success rate of cervical ripening (= Bishop score >6 or vaginal delivery) by the next day following the insertion of Propess® only or mechanical cervical dilation only. In the cases in which cervical ripening was unsuccessful, other methods were performed, and the success rate of cervical ripening the day after was compared as the secondary outcome.

RESULTS

As the primary outcome, there was not a significant difference in the success rate of cervical ripening between the Propess® and mechanical methods groups (21 vs. 22%, p = 0.88). As for the secondary outcomes, there was not a significant difference in the total success rate of cervical ripening between the two groups (75 (5+13/24) vs. 73 (5+11/22)%, p = 0.86)). Of the unsuccessful cervical ripening cases as secondary outcomes, the Bishop score of all was ≤2 on the second day of hospitalization.

CONCLUSION

The combined use of Propess® and mechanical methods was effective for cervical ripening in nulliparous women with a low Bishop score in late-term pregnancy, regardless of order.

Prevalence, definition, and etiology of cesarean scar defect and treatment of cesarean scar disorder: A narrative review

Background

Cesarean scar defects (CSD) are caused by cesarean sections and cause various symptoms. Although there has been no previous consensus on the name of this condition for a long time, it has been named cesarean scar disorder (CSDi).

Methods

This review summarizes the definition, prevalence, and etiology of CSD, as well as the pathophysiology and treatment of CSDi. We focused on surgical therapy and examined the effects and procedures of laparoscopy, hysteroscopy, and transvaginal surgery.

Main findings

The definition of CSD was proposed as an anechoic lesion with a depth of at least 2 mm because of the varied prevalence, owing to the lack of consensus. CSD incidence depends on the number of times, procedure, and situation of cesarean sections. Histopathological findings in CSD are fibrosis and adenomyosis, and chronic inflammation in the uterine and pelvic cavities decreases fertility in women with CSDi. Although the surgical procedures are not standardized, laparoscopic, hysteroscopic, and transvaginal surgeries are effective.

Conclusion

The cause and pathology of CSDi are becoming clear. However, there is variability in the prevalence and treatment strategies. Therefore, it is necessary to conduct further studies using the same definitions.

Trend in neuraxial morphine use and postoperative analgesia after cesarean delivery in Japan from 2005 to 2020

The increasing rate of cesarean deliveries warrants obstetric anesthesiologists to deliver high-quality post-cesarean delivery analgesia. The aim of this study was to evaluate the temporal trends in the use of neuraxial morphine for cesarean deliveries and to describe the current postoperative analgesia practices. A retrospective cohort study using nationwide health insurance claims databases was conducted from 2005 to 2020 in Japan. Pregnant women who had undergone cesarean deliveries were included. The annual rate of neuraxial morphine use was extracted and analyzed. Additionally, we explored the patient- and facility-level factors associated with neuraxial morphine use through a multilevel logistic regression analysis. The cohort included 65,208 cesarean delivery cases from 2275 institutions. The prevalence of neuraxial morphine use was 16.0% (95% confidence interval [CI], 15.8-16.3) in the overall cohort. Intrathecal morphine was used in 20.6% (95% CI, 20.2-21.0) of spinal anesthesia cases. The trend in neuraxial morphine use steadily increased from 2005 to 2020. The significant predictors of neuraxial morphine use included spinal anesthesia, recent surgery, large medical facilities, and academic hospitals. Variations in the utilization of postoperative analgesia were observed. Our study described the current trend of neuraxial morphine use and the variation in postoperative analgesia practice in Japan.

Current Epidemiology of the General Anesthesia Practice for Cesarean Delivery Using a Nationwide Claims Database in Japan: A Descriptive Study

The current status of general anesthesia practice for cesarean delivery in Japan remains unknown. Therefore, using a nationwide claims database, we aimed to investigate general anesthesia use for cesarean delivery over a period of 15 years, and to analyze the general anesthesia practice in Japan. Patients who claimed the Japanese general anesthesia claim code (L008) for cesarean delivery between 1 January 2005, and 31 March 2020, were analyzed. Primary endpoint was the prevalence of general anesthesia use. We used two definitions of general anesthesia: L008 code only (insurance definition) and combination of the L008 code with muscle relaxant use (clinical definition). The general anesthesia claim cohort (L008) included 10,972 cesarean deliveries at 1111 institutions from 2005 to 2020. Muscle relaxants were used in 27.3% of L008 claims cases. The rate of general anesthesia use for cesarean delivery ranged from 3.9% in clinical definition to 14.4% in insurance definition of all cesarean deliveries. We observed a temporal trend of gradual decrease in general anesthesia use, regardless of its definition (p for trend < 0.001). We recommend the clinical definition of general anesthesia as the combination of L008 code and muscle relaxant use in a claims-based approach.

Cesarean delivery on maternal request and its influencing factors in Chongqing, China

BACKGROUND

A high rate of cesarean delivery has become a cause of global concern. Although the rate of cesarean delivery has declined over recent years, it remains at a high level largely because of cesarean delivery on maternal request (CDMR). Unnecessary cesarean delivery has limited significance in benefiting maternal and infant physical health; in some ways, it might pose potential risks instead. With the implementation of the "Two-child Policy" in China, an increasing number of women plan to have a second child. Accordingly, how to handle the CDMR rate in China remains an important issue.

METHODS

Data were collected from a longitudinal follow-up study conducted in Chongqing, China, from 2018 to 2019. A structured questionnaire was administered to subjects for data collection. Basic information, including demographic characteristics, living habits, medical history, and follow-up data of pregnant women, as well as their families and society, was collected. Additionally, delivery outcomes were recorded. Logistic regression was performed to analyze the factors influencing CDMR.

RESULTS

The rate of cesarean delivery in Chongqing, China was 36.01 %, and the CDMR rate was 8.42 %. Maternal request (23.38 %), fetal distress (22.73 %), and pregnancy complications (9.96 %) were the top three indications for cesarean delivery. Logistic regression analysis showed that older age (OR = 4.292, 95 % CI: 1.984-9.283) and being a primiparous woman (OR = 6.792, 95 % CI: 3.230-14.281) were risk factors for CDMR. In addition, CDMR was also associated with factors such as the tendency to choose cesarean delivery during late pregnancy (OR = 5.525, 95 % CI: 2.116-14.431), frequent contact with mothers who had undergone vaginal deliveries (OR = 0.547, 95 % CI: 0.311-0.961), and the recommendation of cesarean delivery by doctors (OR = 4.071, 95 % CI: 1.007-16.455).

CONCLUSIONS

"Maternal request" has become the primary indication for cesarean delivery. The occurrence of CDMR is related to both the personal factors of women during pregnancy and others. Medical institutions and obstetricians should continue popularizing delivery knowledge among pregnant women, enhancing their own professional knowledge about delivery, adhering to the standard indications for cesarean delivery, and providing pregnant women with adequate opportunities for attempting vaginal delivery.