Differences in caesarean rates across women's socio-economic status by diverse obstetric indications: Cross-sectional study

Sociodemographic inequities in food allergy: Insights on food allergy from birth cohorts

A large and growing corpus of epidemiologic studies suggests that the population-level burden of pediatric FA is not equitably distributed across major sociodemographic groups, including race, ethnicity, household income, parental educational attainment, and sex. As is the case for more extensively studied allergic disease states such as asthma and atopic dermatitis epidemiologic data suggest that FA may be more prevalent among certain populations experiencing lower socioeconomic status (SES), particularly those with specific racial and ethnic minority backgrounds living in highly urbanized regions. Emerging data also indicate that these patients may also experience more severe FA-related physical health, psychosocial, and economic outcomes relating to chronic disease management. However, many studies that have identified sociodemographic inequities in FA burden are limited by cross-sectional designs that are subject to numerous biases. Compared with cross-sectional study designs or cohorts established later in life, birth cohorts offer advantages relative to other study designs when investigators seek to understand causal relationships between exposures occurring during the prenatal or postnatal period and the atopic disease status of individuals later in life. Numerous birth cohorts have been established across recent decades, which include evaluation of food allergy-related outcomes, and a subset of these also have measured sociodemographic variables that, together, have the potential to shed light on the existence and possible etiology of sociodemographic inequities in food allergy. This manuscript reports the findings of a comprehensive survey of the current state of this birth cohort literature and draws insights into what is currently known, and what further information can potentially be gleaned from thoughtful examination and further follow-up of ongoing birth cohorts across the globe.

How does high socioeconomic status affect maternal and neonatal pregnancy outcomes? A population-based study among American women

Objectives

The purpose of this study was to evaluate the effect of high SES on multiple pregnancy outcomes, while controlling for confounding factors.

Methods

Using the Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP-NIS), the largest American medical database including 20 % of annual hospital admissions, we studied the years 2004-2014 inclusively. We conducted a population-based retrospective cohort study consisting of women from different median household income quartiles throughout the United States. Women in the highest household income quartile were compared to those in all other lower income quartiles combined. Chi-square and Fischer exact tests were used to compare demographic and baseline characteristics. Univariate and multivariate regression analyses were carried to adjust for confounding factors, including ethnicity, pre-existing conditions, smoking status, obesity, illicit drug use and insurance type.

Results

Among 5,448,255 deliveries during the study period with income data, 1,218,989 deliveries were to women from the wealthiest median household income. These women were more likely to be older, Caucasian, and have private medical insurance (P < 0.05, all). They were less likely to smoke, have chronic hypertension, pre-gestational diabetes, and use illicit drugs (P < 0.05, all). They were less likely to develop complications including gestational hypertension (aOR 0.87 95 %CI 0.85-0.88), preeclampsia (aOR 0.88 95 %CI 0.86-0.89), eclampsia (aOR 0.81 95 %CI 0.66-0.99), gestational diabetes (aOR 0.91 95 %CI 0.89-0.92), preterm premature rupture of membranes (PPROM) (aOR 0.92 95 %CI 0.88-0.96), preterm birth (aOR 0.90 95 %CI 0.89-0.92), and placental abruption (aOR 0.89 95 %CI 0.85-0.93). They were less likely to have an intra-uterine fetal death (IUFD) (aOR 0.80 95 %CI 0.74-0.86), but more likely to deliver neonates with congenital anomalies (aOR 1.10 95 %CI 1.04-1.20).

Conclusions

Higher SES predisposes to better pregnancy outcomes, even when controlled for confounding factors such as ethnicity and underlying baseline health status. Efforts are required in order to eliminate health disparities in pregnancy.

Inequalities in cesarean births between American Indian & Alaska Native people and White people

OBJECTIVE

To explore population-level American Indian & Alaska Native-White inequalities in cesarean birth incidence after accounting for differences in cesarean indication, age, and other individual-level risk factors.

DATA SOURCES AND STUDY SETTING

We used birth certificate data inclusive of all live births within the United States between January 1 and December 31, 2017.

STUDY DESIGN

We calculated propensity score weights that simultaneously incorporate age, cesarean indication, and clinical and obstetric risk factors to estimate the American Indian and Alaska Native-White inequality.

DATA COLLECTION/EXTRACTION METHODS

Births to individuals identified as American Indian, Alaska Native, or White, and residing in one of the 50 US states or the District of Columbia were included. Births were excluded if missing maternal race/ethnicity or any other covariate.

PRINCIPAL FINDINGS

After weighing the American Indian and Alaska Native obstetric population to be comparable to the distribution of cesarean indication, age, and clinical and obstetric risk factors of the White population, the cesarean incidence among American Indian and Alaska Natives increased to 33.4% (95% CI: 32.0-34.8), 3.2 percentage points (95% CI: 1.8-4.7) higher than the observed White incidence. After adjustment, cesarean birth incidence remained higher and increased in magnitude among American Indian and Alaska Natives in Robson groups 1 (low risk, primary), 6 (nulliparous, breech presentation), and 9 (transverse/oblique lie).

CONCLUSIONS

The unadjusted lower cesarean birth incidence observed among American Indian and Alaska Native individuals compared to White individuals may be related to their younger mean age at birth. After adjusting for this demographic difference, we demonstrate that American Indian and Alaska Native individuals undergo cesarean birth more frequently than White individuals with similar risk profiles, particularly within the low-risk Robson group 1 and those with non-cephalic presentations (Robson groups 6 and 9). Racism and bias in clinical decision making, structural racism, colonialism, or other unidentified factors may contribute to this inequality.

Estimating the differences in Caesarean section (C-section) rates between public and privately insured mothers in Florida: A decomposition approach

BACKGROUND

Caesarean section (C-sections) is a medically critical and often life-saving procedure for prevention of childbirth complications. However, there are reports of its overuse, especially in women covered by private insurance as compared to public insurance. This study evaluates the difference in C-Section rates among nulliparous women in Florida hospitals across insurance groups and quantifies the contribution of maternal and hospital factors in explaining the difference in rates.

METHODS

We used Florida's inpatient data provided by the Florida Agency for HealthCare Administration (FLAHCA) and focused on low-risk births that occurred between January 1, 2010, and September 30, 2015. A Fairlie decomposition method was performed on cross-sectional data to decompose the difference in C-Section rates between insurance groups into the proportion explained versus unexplained by the differences in observable maternal and hospital factors.

RESULTS

Of the 386,612 NTSV low-risk births, 72,984 were delivered via C-Section (18.87%). Higher prevalence of C-section at maternal level was associated with diabetes, hypertension, and the expectant mother being over 35 years old. Higher prevalence of C-section at the hospital level was associated with lower occupancy rate, presence of neonatal ICU (NICU) unit and higher obstetrics care level in the hospital. Private insurance coverage in expectant mothers is associated with C-section rates that were 4.4 percentage points higher as compared to that of public insurance. Just over 33.7% of the 4.4 percentage point difference in C-section rates between the two insurance groups can be accounted for by maternal and hospital factors.

CONCLUSIONS

The study identifies that the prevalence of C-sections in expectant mothers covered by private insurance is higher compared to mothers covered by public insurance. Although, majority of the difference in C-Section rates across insurance groups remains unexplained (around 66.3%), the main contributor that explains the other 33.7% is advancing maternal age and socioeconomic status of the expectant mother. Further investigation to explore additional factors that explain the difference needs to be done if United States wants to target specific policies to lower overall C-Section rate.

Cesarean Deliveries Among Immigrant and Canadian-Born Women in a Representative Community Population in Canada: A Retrospective Cohort Study

OBJECTIVE

To examine differences in the rate of cesarean delivery between Canadian-born women and immigrants to Canada and by duration of time in Canada and rate of cesarean delivery in their country-of-origin.

METHODS

We used linked data from hospitalization records and the Canadian Community Health Survey for all deliveries after 20 weeks gestation between 2002 and 2017 in Canada (excluding Québec). Odds of cesarean delivery in recent immigrants (<5 y in Canada) and non-recent immigrants (≥5 y in Canada) were compared with those of Canadian-born women using multivariable logistic regression. Immigrants were further categorized using the cesarean delivery rate in their country-of-origin as low (<10%), medium (≥10 to <35%), or high (≥35%).

RESULTS

Of the 53 505 women included, 89% were Canadian-born, 4% were recent immigrants and 7% were non-recent immigrants. Overall, 28.6% of women had a cesarean delivery. After adjusting for medical and socio-economic factors, the odds of cesarean delivery among recent immigrants (OR 1.12; 95% CI 0.95-1.34) and non-recent immigrants (OR 1.11; 95% CI 0.98-1.25) did not differ statistically from those of Canadian-born women. Recent immigrants from countries with lower caesarean delivery rates had higher odds of cesarean delivery (OR 1.34; 95% CI 1.05-1.70), whereas the odds of caesarean for recent immigrants from medium- and high-rate countries did not differ from those of Canadian-born women.

CONCLUSION

After accounting for demographic and medical factors, few differences remained in cesarean delivery rates between immigrants and Canadian-born women. Country-of-origin practices are unlikely to reflect preferences for cesarean delivery in immigrant women in Canada.

The association of birth by caesarean section and cognitive outcomes in offspring: a systematic review

PURPOSE

Studies have reported children born by caesarean section are more likely to have lower cognitive outcomes compared to those born by vaginal delivery. This paper reviews the literature examining caesarean birth and offspring cognitive outcomes.

METHODS

A systematic search for observational studies or case-control studies that compared cognitive outcomes of people born by caesarean section with those born by vaginal delivery was conducted in six databases (Medline, PubMed, EMBASE, PsychInfo, CINAHL, Web of Science) from inception until December 2019 according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies were assessed for quality and a narrative synthesis was undertaken considering the evidence for a causal relationship according to the Bradford Hill Criteria.

RESULTS

A total of seven studies were identified. Of these, four found a significant association between elective and emergency caesarean birth and reduction in offspring cognitive performance as measured by school performance or validated cognitive testing. Three studies found no association. There was variability in the quality of the studies, assessment of the reason for caesarean section (emergency vs elective), measurement of outcomes and adjustment for confounding factors.

CONCLUSION

The evidence of an association between CS birth and lower offspring cognitive functioning is inconsistent. Based on currently available data, there is no evidence that a causal association exists. To better examine this association, future studies should (a) distinguish elective and emergency caesareans, (b) adequately adjust for confounding variables and (c) have valid outcome measures of cognition.

Using Robson's Ten-Group Classification System for comparing caesarean section rates in Europe: an analysis of routine data from the Euro-Peristat study

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.

Women's experience of agency and respect in maternity care by type of insurance in California

OBJECTIVE

Public insurance (Medicaid) covered 42% of all U.S. births in 2018. This paper describes and analyzes the self-reported experiences of women with Medicaid versus commercial insurance relating to autonomy, control and respectful treatment in maternity care.

METHODS

The sampling frame for the Listening to Mothers in California survey was drawn from 2016 California birth certificate files. The 30-minute survey had a 55% response rate. A secondary multivariable analysis of results from the survey included 2,318 women with commercial private insurance (1,087) or public (Medi-Cal) (1,231) coverage. Results were weighted and were representative of all births in 2016 in California. The multivariable analysis of variables related to maternal agency included engagement in decision making regarding interventions such as vaginal birth after cesarean and episiotomy, feeling pressured to have interventions and sense of fair treatment. We examined their relationship to insurance status adjusted for maternal age, race/ethnicity, education, nativity and attitude toward birth as well as type of prenatal provider, type of birth attendant and pregnancy complications.

RESULTS

Women with Medi-Cal had a demographic profile distinct from those with commercial insurance. In multivariable analysis, women with Medi-Cal reported less control over their maternity care experience than women with commercial insurance, including less choice of prenatal provider (AOR 1.61 95%C.I. 1.20, 2.17), or a vaginal birth after cesarean (AOR 2.93 95%C.I. 1.49, 5.73). Mothers on Medi-Cal were also less likely to be consulted before experiencing an episiotomy (AOR 0.30 95%C.I. 0.09, 0.94). They were more likely to report feeling pressure to have a primary cesarean (AOR 2.54 95%C.I. 1.55, 4.16) and less likely to be encouraged by staff to make their own decisions (AOR 0.63 95%C.I. 0.47, 0.85).

CONCLUSIONS

Childbearing women with public insurance in California clearly and consistently reported less opportunity to choose their care than women with private insurance. These inequities are a call to action for increased accountability and quality improvement relating to care of the many childbearing women with Medicaid coverage.

Associations of area-level deprivation with adverse obstetric and perinatal outcomes in Bavaria, Germany: Results from a cross-sectional study

Background

We investigated associations of area-level deprivation with obstetric and perinatal outcomes in a large population-based routine dataset.

Methods

We used the data of n = 827,105 deliveries who were born in hospitals between 2009 to 2016 in Bavaria, Germany. The Bavarian Index of Multiple Deprivation (BIMD) on district level was assigned to each mother by the zip code of her residential address. We calculated odds ratios (ORs) with 95% confidence intervals (CIs) for preterm deliveries, Caesarian sections (CS), stillbirths, small for gestational age (SGA) births and low 5-minute Apgar scores by BIMD quintiles with and without adjustment for potential confounders.

Results

We observed a significantly increased risk for preterm deliveries in mothers from the most deprived compared to the least deprived districts (e.g. OR [95% CI] for highest compared to lowest deprivation quintile: 1.06 [1.03, 1.09]) in adjusted analyses. Increased deprivation was also associated with higher SGA and secondary CS rates, but with lower proportions of stillbirths, primary CS and low Apgar scores. When one large clinic with an unusually high stillbirth rate was excluded, the association of BIMD with stillbirths was attenuated and almost disappeared.

Conclusions

We found that area-level deprivation in Bavaria was positively associated with preterm and SGA births, confirming previous studies. In contrast, the finding of an inverse association between deprivation and both stillbirth rates and low Apgar score came somewhat surprising. However, we conclude that the stillbirths finding is spurious and reflects regional bias due to a clinic which seems to specialize in termination of pregnancies.

Implementation of the WHO manual for Robson classification: an example from Sri Lanka using a local database for developing quality improvement recommendations

OBJECTIVES

This study aimed at describing the use of a prospective database on hospital deliveries for analysing caesarean section (CS) practices according to the WHO manual for Robson classification, and for developing recommendations for improving the quality of care (QoC).

DESIGN

Observational study.

SETTING

University Obstetric Unit at De Soysa Hospital for Women, the largest maternity unit in Sri Lanka.

DATA COLLECTION AND ANALYSIS

For each childbirth, 150 variables were routinely collected in a standardised form and entered into a database. Data were routinely monitored for ensuring quality. Information on deliveries occurring from July 2015 to June 2017 were analysed according the WHO Robson classification manual. Findings were discussed internally to develop quality improvement recommendations.

RESULTS

7504 women delivered in the hospital during the study period and at least one maternal or fetal pathological condition was reported in 2845 (37.9%). The CS rate was 30.0%, with 11.9% CS being performed prelabour. According to the Robson classification, Group 3 and Group 1 were the most represented groups (27.0% and 23.1% of population, respectively). The major contributors to the CS rate were group 5 (29.6%), group 1 (14.0%), group 2a (13.3%) and group 10 (11.5%). The most commonly reported indications for CS included abnormal cardiotocography/suspected fetal distress, past CS and failed progress of labour or failed induction. These suggested the need for further discussion on CS practices. Overall, 18 recommendations were agreed on. Besides updating protocols and hands-on training, activities agreed on included monitoring and supervision, criterion-based audits, risk management meetings and appropriate information for patients, and recommendations to further improve the quality of data.

CONCLUSIONS

This study provides an example on how the WHO manual for Robson classification can be used in an action-oriented manner for developing recommendations for improving the QoC, and the quality of data collected.