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Psenkova P, Tedla M, Minarcinova L, Zahumensky J. Application of a specific clinical pathway can affect the choice of trial of labor in patients with a history of cesarean delivery. BMC Pregnancy Childbirth 2024; 24:292. [PMID: 38641800 PMCID: PMC11027349 DOI: 10.1186/s12884-024-06429-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 03/15/2024] [Indexed: 04/21/2024] Open
Abstract
BACKGROUND Mode of delivery in women with previous history of cesarean delivery (CD) is highly modifiable by the practices of the delivery unit. Vaginal birth after a cesarean (VBAC) delivery is a safe and preferred alternative in most cases. The aim of this study was to assess the impact of adopting a complex set of measures aimed at the mode of delivery in this group. METHODS This was a retrospective observational study comparing two birth cohorts before and after the implementation of a series of quality improvement (QI) interventions. The study cohorts comprised women with a history of cesarean delivery who gave birth in the period before (January 2013 - December 2015) and after (January 2018 - December 2020) the adoption of the QI measures. The measures were focused on singleton term cephalic pregnancies with a low transverse incision in the uterus. Measures included approval of all planned CDs by a senior obstetrician, re-training staff on the use of the FIGO classification for intrapartum fetal cardiotocogram, establishing VBAC management guidelines, encouraging epidural analgesia during trial of labor after cesarean (TOLAC), establishing a labor ward team and introducing a monthly maternity audit. RESULTS Term singleton cephalic pregnancies with previous history of CD accounted for 12.55% of all births in the pre-intervention period and 12.01% in the post-intervention period. The frequency of cesarean deliveries decreased from 89.94% in the pre-intervention period to 64.47% in the post-intervention period (p < 0.0001). We observed a significant increase in TOLAC from 13.18 to 42.12% (p<0.0001) and also an increase in successful VBAC from 76.27 to 84.35% (p < 0.0001). All changes occurred without statistically significant change in overall perinatal mortality. CONCLUSIONS This study demonstrates the feasibility to safely increase trial of labor and vaginal birth after cesarean delivery by implementing a series of quality improvement interventions and clinical pathway changes.
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Affiliation(s)
- Petra Psenkova
- 2nd Department of Gynecology and Obstetrics, University Hospital Bratislava and Comenius University, Ruzinovska 6, Bratislava, 82106, Slovakia
| | - Miroslav Tedla
- Department of Otorhinolaryngology - Head and Neck Surgery, University Hospital Bratislava and Comenius University, Antolská 11, Bratislava, 851 07, Slovakia
| | - Lenka Minarcinova
- 2nd Department of Gynecology and Obstetrics, University Hospital Bratislava and Comenius University, Ruzinovska 6, Bratislava, 82106, Slovakia.
| | - Jozef Zahumensky
- 2nd Department of Gynecology and Obstetrics, University Hospital Bratislava and Comenius University, Ruzinovska 6, Bratislava, 82106, Slovakia
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Rao J, Fan D, Lu D, Liu Y, Guo X, Liu Z. Preferences of pregnant individuals to undergo labor after one cesarean in southern China. Birth 2023; 50:988-995. [PMID: 37496210 DOI: 10.1111/birt.12743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 04/27/2023] [Accepted: 06/09/2023] [Indexed: 07/28/2023]
Abstract
BACKGROUND Labor after cesarean (LAC) remains an optional delivery method among healthy pregnant individuals. Exploring women's attitudes, preferences, reasons for previous cesarean delivery, and the incentives underlying pregnant individuals' preferences could help us understand their choice of delivery mode. In this study we evaluated the preferences and attitudes of eligible pregnant women regarding participation in a LAC in Foshan, China. METHODS A cross-sectional survey was conducted among 438 pregnant individuals with one prior cesarean delivery (CD) who attended their antenatal examination at a tertiary hospital in southern China, between November 1, 2018, and October 31, 2019. Information on demographic characteristics, obstetric data, preferences for LAC, and incentives for LAC were analyzed. RESULTS Overall, 85.4% (374/438) of women preferred LAC if they did not have contraindications before delivery, whereas 12.3% (54/438) refused and 2.3% (10/438) were unsure. Participants reported that the most important factors affecting their willingness to undergo LAC were safety indicators (i.e., "ability of hospitals to perform emergency cesarean delivery" [score of 9.28 ± 1.86]), followed by accessibility indicators (i.e., "priority bed arrangements" [score of 9.17 ± 1.84]). Logistic regression analysis indicated that neonatal wellbeing with the prior CD was an independent influencing factor (OR = 2.235 [95%CI: 1.115-4.845], p = 0.024) affecting willingness to access LAC in the subsequent pregnancy. CONCLUSIONS We found a high preference for LAC among pregnant individuals without contraindications before delivery in southern China. Healthcare providers need to ensure access to LAC and increase pregnant individuals' LAC willingness through high-quality shared decsision-making in alignment with patient preferences.
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Affiliation(s)
- Jiaming Rao
- Foshan Fetal Medicine Institute, Affiliated Foshan Maternity and Child Healthcare Hospital, Southern Medical University (Foshan Maternity and Child Healthcare Hospital), Foshan, China
| | - Dazhi Fan
- Foshan Fetal Medicine Institute, Affiliated Foshan Maternity and Child Healthcare Hospital, Southern Medical University (Foshan Maternity and Child Healthcare Hospital), Foshan, China
| | - Demei Lu
- Foshan Fetal Medicine Institute, Affiliated Foshan Maternity and Child Healthcare Hospital, Southern Medical University (Foshan Maternity and Child Healthcare Hospital), Foshan, China
- Department of Obstetrics, Affiliated Foshan Maternity and Child Healthcare Hospital, Southern Medical University (Foshan Maternity and Child Healthcare Hospital), Foshan, China
| | - Yan Liu
- Department of Obstetrics, Affiliated Foshan Maternity and Child Healthcare Hospital, Southern Medical University (Foshan Maternity and Child Healthcare Hospital), Foshan, China
| | - Xiaoling Guo
- Department of Obstetrics, Affiliated Foshan Maternity and Child Healthcare Hospital, Southern Medical University (Foshan Maternity and Child Healthcare Hospital), Foshan, China
| | - Zhengping Liu
- Foshan Fetal Medicine Institute, Affiliated Foshan Maternity and Child Healthcare Hospital, Southern Medical University (Foshan Maternity and Child Healthcare Hospital), Foshan, China
- Department of Obstetrics, Affiliated Foshan Maternity and Child Healthcare Hospital, Southern Medical University (Foshan Maternity and Child Healthcare Hospital), Foshan, China
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Rubashkin N. Epistemic Silences and Experiential Knowledge in Decisions After a First Cesarean: The case of a vaginal birth after cesarean calculator. Med Anthropol Q 2023; 37:341-353. [PMID: 37459454 PMCID: PMC10993819 DOI: 10.1111/maq.12784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Accepted: 05/01/2023] [Indexed: 12/02/2023]
Abstract
Evidence-based obstetrics can employ statistical models to justify greater use of cesareans, sometimes excluding experiential elements from informed decision making. Over the past decade, prenatal providers adopted a vaginal birth after cesarean (VBAC) calculator designed to support patients in making informed decisions about their births by estimating their probability for a VBAC. Among other factors, the calculator used race and ethnicity to make its estimate, assigning lower probabilities for a successful VBAC to Black and Hispanic patients. I analyze how a diverse group of women and their providers engaged with the VBAC calculator. Some providers used low calculator scores to remove a shared decision-making model by prescriptively counseling Black and Hispanic women who desired a VBAC into undergoing repeat cesareans. Consequently, women racialized by the calculator as Black or Hispanic used experiential knowledge to challenge the calculator's assessment of their supposed lesser ability to give birth vaginally.
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Affiliation(s)
- Nicholas Rubashkin
- Department of Obstetrics, Gynecology, & Reproductive Sciences, University of California at San Francisco, San Francisco, United States
- Institute for Global Health Sciences, University of California at San Francisco, San Francisco, United States
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Eggen MB, Petrey J, Roberson P, Curnutte M, Jennings JC. An exploration of barriers to access to trial of labor and vaginal birth after cesarean in the United States: a scoping review. J Perinat Med 2023; 51:981-991. [PMID: 37067843 DOI: 10.1515/jpm-2022-0364] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 03/06/2023] [Indexed: 04/18/2023]
Abstract
INTRODUCTION Increasing the number of vaginal birth after cesarean (VBAC) deliveries is one strategy to reduce the cesarean rate in the United States. Despite evidence of its safety, access to trial of labor after cesarean (TOLAC) and VBAC are limited by many clinical and non-clinical factors. We used a scoping review methodology to identify barriers to access of TOLAC and VBAC in the United States and extract potential leverage points from the literature. CONTENT We searched PubMed, Embase, Cochrane, and CINAHL for peer-reviewed, English-language studies published after 1990, focusing on access to TOLAC and/or VBAC in the United States. Themes and potential leverage points were mapped onto the Minority Health and Health Disparities Research Framework. The search yielded 21 peer-reviewed papers. SUMMARY Barriers varied across levels of influence and included factors related to restrictive clinical guidelines, provider reluctance, geographic disparities, and midwifery scopes of practice. While barriers varied in levels of influence, the majority were related to systemic and interpersonal factors. OUTLOOK Barriers to TOLAC and VBAC exist at many levels and are both clinical and non-clinical in nature. The existing body of literature can benefit from more research examining the impact of recent revisions to clinical guidelines related to VBAC as well as additional qualitative studies to more deeply understand the complexity of provider reluctance.
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Affiliation(s)
- Melissa B Eggen
- Department of Health Management and Systems Sciences, University of Louisville, School of Public Health and Information Sciences, Louisville, KY, USA
| | - Jessica Petrey
- Department of Health Management and Systems Sciences, University of Louisville, School of Public Health and Information Sciences, Louisville, KY, USA
| | - Paige Roberson
- Department of Health Management and Systems Sciences, University of Louisville, School of Public Health and Information Sciences, Louisville, KY, USA
| | - Mary Curnutte
- Department of Health Management and Systems Sciences, University of Louisville, School of Public Health and Information Sciences, Louisville, KY, USA
| | - J'Aime C Jennings
- Department of Health Management and Systems Sciences, University of Louisville, School of Public Health and Information Sciences, Louisville, KY, USA
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Elaraby S, Altieri E, Downe S, Erdman J, Mannava S, Moncrieff G, Shamanna BR, Torloni MR, Betran AP. Behavioural factors associated with fear of litigation as a driver for the increased use of caesarean sections: a scoping review. BMJ Open 2023; 13:e070454. [PMID: 37076154 PMCID: PMC10124311 DOI: 10.1136/bmjopen-2022-070454] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 04/04/2023] [Indexed: 04/21/2023] Open
Abstract
OBJECTIVE To explore the behavioural drivers of fear of litigation among healthcare providers influencing caesarean section (CS) rates. DESIGN Scoping review. DATA SOURCES We searched MEDLINE, Scopus and WHO Global Index (1 January 2001 to 9 March 2022). DATA EXTRACTION AND SYNTHESIS Data were extracted using a form specifically designed for this review and we conducted content analysis using textual coding for relevant themes. We used the WHO principles for the adoption of a behavioural science perspective in public health developed by the WHO Technical Advisory Group for Behavioural Sciences and Insights to organise and analyse the findings. We used a narrative approach to summarise the findings. RESULTS We screened 2968 citations and 56 were included. Reviewed articles did not use a standard measure of influence of fear of litigation on provider's behaviour. None of the studies used a clear theoretical framework to discuss the behavioural drivers of fear of litigation. We identified 12 drivers under the three domains of the WHO principles: (1) cognitive drivers: availability bias, ambiguity aversion, relative risk bias, commission bias and loss aversion bias; (2) social and cultural drivers: patient pressure, social norms and blame culture and (3) environmental drivers: legal, insurance, medical and professional, and media. Cognitive biases were the most discussed drivers of fear of litigation, followed by legal environment and patient pressure. CONCLUSIONS Despite the lack of consensus on a definition or measurement, we found that fear of litigation as a driver for rising CS rates results from a complex interaction between cognitive, social and environmental drivers. Many of our findings were transferable across geographical and practice settings. Behavioural interventions that consider these drivers are crucial to address the fear of litigation as part of strategies to reduce CS.
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Affiliation(s)
- Sarah Elaraby
- Community Medicine Department, Alexandria University Faculty of Medicine, Alexandria, Egypt
- Behavioural Insights Unit, World Health Organization, Geneve, Switzerland
| | - Elena Altieri
- Behavioural Insights Unit, World Health Organization, Geneve, Switzerland
| | - Soo Downe
- School of Community Health & Midwifery, University of Central Lancashire, Preston, UK
| | - Joanna Erdman
- Schulich School of Law, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Sunny Mannava
- School of Medical Sciences, University of Hyderabad, Hyderabad, India
| | - Gill Moncrieff
- School of Community Health & Midwifery, University of Central Lancashire, Preston, UK
| | - B R Shamanna
- School of Medical Sciences, University of Hyderabad, Hyderabad, India
| | | | - Ana Pilar Betran
- UNDP/UNFPA/UNICEF/World Bank Special Program of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
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Thornton PD. VBAC calculator 2.0: Recent evidence. Birth 2023; 50:120-126. [PMID: 36639832 DOI: 10.1111/birt.12705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 07/07/2022] [Accepted: 12/16/2022] [Indexed: 01/15/2023]
Abstract
Following criticism for the use of race as a biological predictor of vaginal birth after cesarean (VBAC), an updated version of the Society for Maternal-Fetal Medicine (SMFM) VBAC calculator has been published. The variable "African American" or "Hispanic" (yes/no), which produced systematically lower chances of VBAC for nonwhites has been replaced with "chronic hypertension requiring treatment" (yes/no). Although there are no published external validation studies to date, developers report accuracy (area under the curve and calibration) nearly identical to the original calculator and it is published online for immediate use. This review examines the history of the calculator, measures of its validity, and recent studies measuring its performance among Hispanics, Blacks, Asians, and others with lower range scores. Underprediction of successful VBAC is evident in the original calculator, especially as predicted VBAC decreases. These studies raise a concern about the use of calculator scores in clinical management, that is, discouraging or restricting access to labor after cesarean (LAC) for parents with lower calculator scores. This raises special concern for minority populations who experience increased cesarean-related morbidity, face obstacles accessing LAC care, and who may benefit disproportionately from increased LAC uptake. Although calculator developers have discouraged using calculator scores to restrict access to LAC, such uses are documented. It is not clear what effect the removal of race will have on calculator performance, and further study is required before calculator scores are used in counseling. This includes studies that include large numbers of low scoring and minority patients.
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Affiliation(s)
- Patrick D Thornton
- College of Nursing, Department of Human Development Nursing Science, University of Illinois Chicago, Chicago, Illinois, USA
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Basile Ibrahim B, Kozhimannil KB. Racial Disparities in Respectful Maternity Care During Pregnancy and Birth After Cesarean in Rural United States. J Obstet Gynecol Neonatal Nurs 2023; 52:36-49. [PMID: 36400125 PMCID: PMC9839498 DOI: 10.1016/j.jogn.2022.10.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 10/24/2022] [Accepted: 10/26/2022] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To describe the experiences of pregnancy and birth after cesarean of women who live in rural areas of the United States, including access to vaginal birth after cesarean (VBAC), type of maternity care provider, travel times, autonomy in decision making, and respectful maternity care. DESIGN Retrospective observational study. SETTING Online questionnaire of women who gave birth in the United States. PARTICIPANTS Women (N = 1,711) with histories of cesarean and subsequent births within 5 years of participating. METHODS We calculated descriptive and bivariate statistics by identified areas of residence and stratified measures of autonomy and respectful maternity care by self-identification as a member of a racialized group. We applied qualitative descriptive analysis to responses to an open-ended survey question. RESULTS A total of 299 (17.5%) participants identified their areas of residence as rural. Similar percentages of rural and metropolitan participants were able to plan VBAC (p = .88). More rural participants than metropolitan participants reported travel times of more than 60 minutes to give birth (p < .001), and fewer had obstetricians (p = .002) or doulas (p = .03). Rural participants from racialized groups experienced significantly less respectful maternity care than White, non-Hispanic rural participants and all metropolitan participants (p = .04). Qualitative data illustrating the main findings are included. CONCLUSIONS Our findings highlight challenges faced by rural residents accessing VBAC and help explain why rates of VBAC in rural areas remain low. We suggest a range of clinical and policy strategies to improve access to VBAC in rural areas and to improve the quality of maternity care for racialized women who live in rural areas.
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8
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Attanasio LB, Paterno MT, Kjerulff KH. Factors associated with labor after cesarean in a prospective cohort. Birth 2022; 49:833-842. [PMID: 35608986 PMCID: PMC9649839 DOI: 10.1111/birt.12656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 04/08/2022] [Accepted: 05/11/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND The goals of this study were (a) to determine how experiences in the first perinatal period shape birth mode preference among individuals with a first birth by cesarean; and (b) to examine the relationship between birth mode preference and other factors and subsequent labor after cesarean (LAC). METHODS Data are from the First Baby Study, a prospective cohort of 3006 primiparous individuals. The analytic sample includes individuals with a first cesarean birth and a second birth during the 5-year follow-up period (n = 394). We used multivariable logistic regression to examine the relationship between experiences in the first perinatal period and subsequent preference for vaginal birth, and between preference for vaginal birth and LAC in the second birth. RESULTS About a third of the sample preferred vaginal birth in a future birth, and 20% had LAC. Factors associated with higher odds of future vaginal birth preference were favorable prenatal attitude toward vaginal birth, lower perceived maternal-infant bonding at 1 month after the first birth, post-traumatic stress symptoms after the first birth, and desiring more than 1 additional child after the first birth. Odds of LAC were nearly 8 times higher among those who preferred vaginal birth (AOR = 7.69, P < .001). Fatigue after the first birth, post-traumatic stress symptoms after the first birth, and having higher predicted chances of vaginal birth after cesarean were also associated with higher odds of LAC. CONCLUSIONS Our findings suggest that the formation of preferences around vaginal birth may present a modifiable target for future counseling and shared decision-making interventions.
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Affiliation(s)
- Laura B Attanasio
- Department of Health Promotion and Policy, School of Public Health and Health Sciences, University of Massachusetts Amherst, Amherst, MA, USA
| | - Mary T Paterno
- Midwifery Services at Cooley Dickinson ObGyn & Midwifery, Cooley Dickinson Medical Group, Northampton, MA, USA
| | - Kristen H Kjerulff
- Department of Public Health Sciences, College of Medicine, Penn State University, Hershey, PA, USA
- Department of Obstetrics and Gynecology, College of Medicine, Hershey, PA, USA
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Thornton PD, Liese K, Adlam K, Erbe K, McFarlin BL. Barriers to labor after cesarean: A survey of United States midwives. Birth 2022; 49:675-686. [PMID: 35460106 DOI: 10.1111/birt.12633] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 10/31/2021] [Accepted: 03/08/2022] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Despite calls for increased vaginal birth after cesarean (VBAC), <14% of candidates have VBAC. Requirements for documentation of scar type, and prohibitions on induction or augmentation of labor are not supported by evidence but may be widespread. The purpose of this study was to document midwives' perceptions of barriers to labor after cesarean (LAC) and their effects on midwives' ability to accommodate patient desires for LAC. METHODS Midwives certified by the American Midwifery Certification Board (AMCB) were surveyed in 2019. Multiple option and open-ended text responses were analyzed using quantitative statistics and thematic content analysis. Select barriers to LAC, ability to accommodate LAC, and supportiveness of collaborators among midwives offering LAC were explored. RESULTS Responses from 1398 midwives were analyzed. Eighty-four percent felt able to accommodate LAC "most of the time," and 39% reported one or more barriers to LAC. Barriers decreased ability to accommodate LAC by as much as 80%. Analysis of text responses revealed specific themes. CONCLUSIONS Thirty-nine percent of midwives reported their practice was limited by one or more barriers that were inconsistent with professional guidelines. Imposition of barriers was driven primarily by collaborating physicians, and superceded supportive practices of midwives, nurses, and system administrators. Affected midwives were significantly less able to accommodate patient requests for LAC than those not affected. Midwives also reported pride in providing VBAC care, restrictions specific to midwifery scope of practice, and variation in physician support for LAC within practices affecting their ability to provide care.
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Affiliation(s)
- Patrick D Thornton
- Department of Human Development Nursing Science, College of Nursing, University of Illinois Chicago, Chicago, Illinois, USA
| | - Kylea Liese
- Department of Human Development Nursing Science, College of Nursing, University of Illinois Chicago, Chicago, Illinois, USA
| | - Kirby Adlam
- Department of Human Development Nursing Science, College of Nursing, University of Illinois Chicago, Chicago, Illinois, USA
| | | | - Barbara L McFarlin
- Department of Human Development Nursing Science, University of Illinois Chicago, Chicago, Illinois, USA
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MacDorman MF, Barnard-Mayers R, Declercq E. United States community births increased by 20% from 2019 to 2020. Birth 2022; 49:559-568. [PMID: 35218065 DOI: 10.1111/birt.12627] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 02/05/2022] [Accepted: 02/08/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND Anecdotal and emerging evidence suggested that the 2020 COVID-19 pandemic may have influenced women's attitudes toward community birth. Our purpose was to examine trends in community births from 2019 to 2020, and the risk profile of these births. METHODS Recently released 2020 birth certificate data were compared with prior years' data to analyze trends in community births by socio-demographic and medical characteristics. RESULTS In 2020, there were 71 870 community births in the United States, including 45 646 home births and 21 884 birth center births. Community births increased by 19.5% from 2019 to 2020. Planned home births increased by 23.3%, while birth center births increased by 13.2%. Increases occurred in every US state, and for all racial and ethnic groups, particularly non-Hispanic Black mothers (29.7%), although not all increases were statistically significant. In 2020, 1 of every 50 births in the United States was a community birth (2.0%). Women with planned home and birth center births were less likely than women with hospital births to have several characteristics associated with poor pregnancy outcomes, including teen births, smoking during pregnancy, obesity, and preterm, low birthweight, and multiple births. More than two-thirds of planned home births were self-paid, compared with one-third of birth center and just 3% of hospital births. CONCLUSIONS It is to the great credit of United States midwives working in home and birth center settings that they were able to substantially expand their services during a worldwide pandemic without compromising standards in triaging women to optimal settings for safe birth.
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Affiliation(s)
- Marian F MacDorman
- Maryland Population Research Center, University of Maryland, College Park, Maryland, USA
| | | | - Eugene Declercq
- Boston University School of Public Health, Boston, Massachusetts, USA
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11
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African American Women's Experiences with Birth After a Prior Cesarean Section. Matern Child Health J 2021; 26:806-813. [PMID: 34731358 DOI: 10.1007/s10995-021-03277-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVES Women who have had a cesarean section (C-section) and become pregnant again may choose to have a planned repeat cesarean delivery (RCD) or vaginal birth after a cesarean (VBAC). This study aimed to characterize the pregnancy and birth experiences of African American (AA) women who had a successful VBAC, failed VBAC, or RCD. METHODS Eligible participants (N = 25) self-identified as AA, had a C-section and a subsequent birth(s) in the past 12 years, and were educated past high school. Each participant was individually interviewed via phone call. The Sort and Sift, Think and Shift method was used to evaluate interview transcripts to minimize researcher bias and emphasize the voices of the participants. RESULTS The resulting themes included the impact of providers on pregnancy and childbirth satisfaction, the value of autonomy in maternal health decision-making, and the role that racism plays in AA women's birth experiences. Although some participants recalled a positive experience, the presence of limited autonomy, lack of support, and negative experiences with providers indicate that birth after a prior C-section for AA women can be improved. CONCLUSIONS Providers should address their own racial biases and utilize the shared decision-making approach when their patients decide between a VBAC and RCD to improve patient satisfaction.
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Zhang Y, Betran AP, Li X, Liu D, Yuan N, Shang L, Lin W, Tu S, Wang L, Wu X, Zhu T, Zhang Y, Lu Z, Zheng L, Gu C, Fang J, Liu Z, Ma L, Cai Z, Yang X, Li H, Zhang H, Zhao X, Yan L, Wang L, Sun X, Luo Q, Liu L, Zhu J, Qin W, Yao Q, Dong S, Yang Y, Cui Z, He Y, Feng X, He L, Zhang H, Zhang L, Wang X, Souza JP, Qi H, Duan T, Zhang J. What is an appropriate caesarean delivery rate for China: a multicentre survey. BJOG 2021; 129:138-147. [PMID: 34559941 PMCID: PMC9297886 DOI: 10.1111/1471-0528.16951] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2021] [Indexed: 11/30/2022]
Abstract
Objective To assess the current status of caesarean delivery (CD) in China, propose reference CD rates for China overall, and by regions, investigate the main indications for CDs and identify possible areas for safe reduction. Design A multicentre cross‐sectional study. Setting A total of 94 hospitals across 23 provinces in China. Population A total of 73 977 randomly selected deliveries. Methods We used a modified Robson classification to characterise CDs in subgroups and by regions, and the World Health Organization (WHO) C‐Model to calculate reference CD rates. Main outcome measures CD rates in China. Results In 2015–2016, the overall CD rate in China was 38.9% (95% CI 38.6–39.3%). Considering the obstetric characteristics of the population, the multivariable model‐based reference CD rate was estimated at 28.5% (95% CI 28.3–28.8%). Accordingly, an absolute reduction of 10.4% (or 26.7% relative reduction) may be considered. The CD rate varied substantially by region. Previous CD was the most common indication in all regions, accounting for 38.2% of all CDs, followed by maternal request (9.8%), labour dystocia (8.3%), fetal distress (7.7%) and malpresentation (7.6%). Overall, 12.7% of women had prelabour CDs, contributing to 32.8% of the total CDs. Conclusions Nearly 39% of births were delivered by caesarean in China but a reduction of this rate by a quarter may be considered attainable. Repeat CD contributed more than one‐third of the total CDs. Given the large variation in maternal characteristics, region‐specific or even hospital‐specific reference CD rates are needed for precision management of CD. Tweetable abstract The caesarean rate in 2015–2016 in China was 38.9%, whereas the reference rate was 28.5%. The caesarean rate in 2015–2016 in China was 38.9%, whereas the reference rate was 28.5%. Linked article This article is commented on by M Varner, p. 148 in this issue. To view this mini commentary visit https://doi.org/10.1111/1471-0528.16953.
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Affiliation(s)
- Y Zhang
- Ministry of Education - Shanghai Key Laboratory of Children's Environmental Health, School of Public Health, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - A P Betran
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, World Health Organization (WHO), Geneva, Switzerland
| | - X Li
- Obstetrics and Gynaecology Hospital of Fudan University, Shanghai, China
| | - D Liu
- Dongguan City Maternal and Child Health Hospital, Southern Medical University, Guangdong, China
| | - N Yuan
- Department of Obstetrics and Gynaecology, The Second Hospital Affiliated to Shaanxi University of Chinese Medicine, Shaanxi, China
| | - L Shang
- Department of Obstetrics, The Maternal and Child Health Hospital of Xinxiang, Henan, China
| | - W Lin
- Department of Obstetrics, The Maternal and Child Health Hospital of Dalian, Liaoning, China
| | - S Tu
- Department of Obstetrics and Gynaecology, Southwest Medical University, Sichuan, China
| | - L Wang
- Department of Obstetrics and Gynaecology, The First Hospital Affiliated to Kunming Medical University, Yunnan, China
| | - X Wu
- Department of Obstetrics, Jiangsu Women and Child Health Hospital, Jiangsu, China
| | - T Zhu
- The First People's Hospital of Zhaotong, Kunming Medical University, Yunnan, China
| | - Y Zhang
- Department of Obstetrics, The Maternal and Child Health Hospital of Qujing, Yunnan, China
| | - Z Lu
- Suining Central Hospital, Chongqing Medical University, Sichuan, China
| | - L Zheng
- Taizhou Hospital of Zhejiang Province, Zhejiang, China
| | - C Gu
- Yangzhou Maternal and Child Care Service Centre, Jiangsu, China
| | - J Fang
- Qingdao Chengyang People's Hospital, Shandong First Medical University, Shandong, China
| | - Z Liu
- Department of Obstetrics, The Maternal and Child Health Hospital of Baoji, Shaanxi, China
| | - L Ma
- Yanshi City People's Hospital, Henan, China
| | - Z Cai
- Department of Obstetrics and Gynaecology, Aviation Hospital of Beijing, China Medical University, Beijing, China
| | - X Yang
- Department of Obstetrics, The Maternal and Child Health Hospital of Luohu District, Shenzhen, China
| | - H Li
- Yanan University Affiliated Hospital, Shaanxi, China
| | - H Zhang
- Haikou Hospital of the Maternal and Child Health, Hainan, China
| | - X Zhao
- The First People's Hospital of Taizhou, Wenzhou Medical University, Zhejiang, China
| | - L Yan
- The Second Affiliated Hospital of Hebei North University, Hebei, China
| | - L Wang
- Department of Obstetrics and Gynaecology, The 174th Hospital of the Chinese People's Liberation Army, Xiamen University, Fujian, China
| | - X Sun
- Puyang Maternal and Child Care Centres, Henan, China
| | - Q Luo
- Luzhou People's Hospital, Sichuan, China
| | - L Liu
- Affiliated Hospital of Jiangsu University, Jiangsu, China
| | - J Zhu
- The Second People's Hospital of Tongxiang, Zhejiang, China
| | - W Qin
- Department of Obstetrics and Gynaecology, Aviation Hospital of Beijing, China Medical University, Beijing, China
| | - Q Yao
- The Central Hospital of Shaoyang, University of South China, Hunan, China
| | - S Dong
- Affiliated Hospital of Zunyi Medical University, Guizhou, China
| | - Y Yang
- The First Affiliated Hospital of Anhui Medical University, Anhui, China
| | - Z Cui
- Department of Obstetrics, The Maternal and Child Health Hospital of Cangzhou, Hebei, China
| | - Y He
- The Second People's Hospital of Qingyuan City, Guangdong, China
| | - X Feng
- Department of Obstetrics and Gynaecology, Fujian Medical University Union Hospital, Fujian Medical University, Fujian, China
| | - L He
- The People's Hospital of Pengzhou, Sichuan, China
| | - H Zhang
- Department of Obstetrics, Eastern District of the Fourth Hospital of Hebei Medical University, Hebei, China
| | - L Zhang
- Ministry of Education - Shanghai Key Laboratory of Children's Environmental Health, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - X Wang
- Department of Obstetrics and Gynaecology, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - J P Souza
- Department of Social Medicine, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, São Paulo, Brazil
| | - H Qi
- Department of Obstetrics and Gynaecology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - T Duan
- Department of Obstetrics, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China
| | - J Zhang
- Ministry of Education - Shanghai Key Laboratory of Children's Environmental Health, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Basile Ibrahim B, Kennedy HP, Holland ML. Demographic, Socioeconomic, Health Systems, and Geographic Factors Associated with Vaginal Birth After Cesarean: An Analysis of 2017 U.S. Birth Certificate Data. Matern Child Health J 2021; 25:1069-1080. [PMID: 33201453 PMCID: PMC8126565 DOI: 10.1007/s10995-020-03066-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVES In order to better understand the current rates of vaginal birth after cesarean (VBAC) in the United States, 2017 U.S. birth certificate data were used to examine sociodemographic and geographic factors associated with the outcome of a VBAC. METHODS The 2017 Natality Limited Geography Dataset and block sequential logistic regression were used to examine sociodemographic and geographic factors associated with subsequent births in 2017 in the United States to women with a history of 1 or 2 cesareans (N = 540,711). RESULTS The adjusted odds of VBAC were 6% higher for Black women (1.06; 95% CI: 1.04, 1.08) and 18% higher for American Indian/Alaska Native women (aOR 1.18; 95% CI: 1.10, 1.27) relative to white women. Asian/Pacific Islander women were 9% less likely to have a VBAC (aOR 0.91; 95% CI: 0.88, 0.94) than similar white women with a history of cesarean delivery. Latina women had a 10% less likelihood of a VBAC (aOR 0.90; 95% CI: 0.88, 0.92) when compared with non-Latina women. Women with a high school education (aOR 0.85; 95% CI: 0.83, 0.88) or some college (aOR 0.85; 95% CI: 0.84, 0.87) were less likely to have a VBAC than women educated at a baccalaureate level or higher. Women whose births were paid for by Medicaid had a 5% increased likelihood of VBAC over women with private insurance (aOR 1.05, 95% CI: 1.03, 1.07). Women who self-pay have twice the likelihood of VBAC (aOR 1.99; 95% CI: 1.92, 2.07) compared to women with private insurance. The adjusted odds of VBAC were lowest for women giving birth in Southern states (aOR 0.72; 95% CI: 0.71, 0.74) and highest for women giving birth in the Midwest (aOR 1.19; 95% CI: 1.16, 1.22) relative to women in the Northeastern U.S. Thirteen percent (13%) of women who had a VBAC had a certified nurse-midwife (CNM) birth attendant, which is 44% higher than the national CNM-attended birth rate. CONCLUSIONS FOR PRACTICE Significant variation exists in VBAC rates based on a number of sociodemographic and geographic factors, likely reflecting disparities in access to vaginal birth after cesarean and differences in preference regarding mode of birth after cesarean. Further research is recommended to better understand and address these disparities to improve maternity care.
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Affiliation(s)
| | - Holly Powell Kennedy
- Yale University School of Nursing, 400 West Campus Drive, Orange, CT, 06477, USA
| | - Margaret L Holland
- Yale University School of Nursing, 400 West Campus Drive, Orange, CT, 06477, USA
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Davidson C, Walker CH, Sangi-Haghpeykar H. A regional survey evaluating patient experience seeking trial of labor after cesarean. J Matern Fetal Neonatal Med 2021; 35:7924-7928. [PMID: 34134585 DOI: 10.1080/14767058.2021.1938529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To evaluate access to trial of labor after cesarean (TOLAC) in a large metropolitan city. STUDY DESIGN In 2012, a public tertiary care hospital in Houston, TX promoted its TOLAC services on social media, resulting in a surge of self-referrals. In 2018, an electronic survey was distributed by email to 200 women who had previously contacted the hospital regarding TOLAC and posted on 2 local social media TOLAC sites. Women were asked to participate if they ever sought TOLAC in the Houston area. Data were analyzed for trends in patient experience seeking TOLAC and comparisons were made based on number of prior cesarean deliveries (CD) and race/ethnicity. RESULTS The survey was open for responses for 1 month, with 128 completed surveys by the end of the study time period. Of the respondents, most (64%) had 1 prior CD and identified as White (63%). Most (60%) of all women reported contacting ≥3 providers before finding one that offered TOLAC, with no difference reported for women with 1 vs 2 prior CD (p = .2). Over half (52%) reported their experience seeking TOLAC to be difficult with more difficulty noted by those with 2 vs 1 prior CD, (61.8% vs 42.7%,) but not statistically significant (p = .06). White women were more likely to report an easier experience seeking TOLAC compared to Black women (55.6% vs 30%, p = .04).Overall, 37% attempted TOLAC at the reference hospital. Black (50%) and Hispanic (68.2%) women were significantly more likely to have delivered at the reference hospital than White women (24%) (p < .05). CONCLUSION Our results suggest that women seeking TOLAC have difficulty finding providers who offer the service. This may be especially true for Black and Hispanic women and women with >1 prior CD. Women may utilize social media forums for resources and recommendations and such platforms may represent an underutilized opportunity to identify regional TOLAC services.
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Affiliation(s)
- Christina Davidson
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - Caroline Haley Walker
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - Haleh Sangi-Haghpeykar
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
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15
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Munro S, Wilcox ES, Lambert LK, Norena M, Kaufman S, Encinger J, Kendall T, Thompson R. A survey of health care practitioners' attitudes toward shared decision-making for choice of next birth after cesarean. Birth 2021; 48:194-208. [PMID: 33538001 DOI: 10.1111/birt.12529] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 01/04/2021] [Accepted: 01/05/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Patients with a history of cesarean may benefit from shared decision-making (SDM) interventions, such as patient decision aids, that provide individualized clinical information and help to clarify personal preferences. We sought to understand the factors that influence how care practitioners support choices for mode of birth and what individual and health system factors influence uptake of SDM in routine care. METHODS We conducted a cross-sectional survey of health care practitioners in British Columbia, Canada (2016-2017). Participants included family physicians, midwives, obstetricians, and registered nurses. We conducted descriptive and inferential analyses of quantitative data and subjected the open-ended survey responses to thematic analysis. RESULTS Analysis of survey responses (n = 307) suggested there was no significant association between the size of the participant hospital and their medico-legal concerns about mode of birth. Environmental factors that may influence the use of SDM included the length of time it takes to initiate an emergency cesarean and the timing of when the SDM intervention is introduced to the patient. No participants reported protocols prohibiting VBAC at their hospital. Participants preferred an SDM approach where the pregnant person is involved in making the final decision for mode of birth. CONCLUSIONS Although maternity care practitioners express attitudes and behaviors that may support SDM for mode of birth after cesarean, implementing SDM using a patient decision aid alone may be challenging because of environmental factors. Our study demonstrates how survey data can aid in identifying how, when, where, for whom, and why an SDM intervention could be implemented.
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Affiliation(s)
- Sarah Munro
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada
| | - Elizabeth S Wilcox
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Leah K Lambert
- School of Nursing, University of British Columbia, Vancouver, BC, Canada
| | - Monica Norena
- Centre for Health Evaluation and Outcome Sciences, Providence Health Care Research Institute, Vancouver, BC, Canada
| | - Sarah Kaufman
- Clinical Nurse Specialist, Fraser Health Authority, Surrey, BC, Canada
| | - Jana Encinger
- Clinical Quality and Systems Improvement, Perinatal Services BC, Provincial Health Services Authority, Vancouver, BC, Canada
| | - Tamil Kendall
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Rachel Thompson
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia
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16
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Attanasio LB, Paterno MT. Racial/Ethnic Differences in Socioeconomic Status and Medical Correlates of Trial of Labor After Cesarean and Vaginal Birth After Cesarean. J Womens Health (Larchmt) 2021; 30:1788-1794. [PMID: 33719567 DOI: 10.1089/jwh.2020.8801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Objectives: Black and Latinx women have higher rates of trial of labor after cesarean (TOLAC) compared with White women, but lower rates of vaginal birth after cesarean (VBAC). This study examined potential racial/ethnic differences in correlates of TOLAC and VBAC. Materials and Methods: The analytic sample includes term, singleton hospital births to women with one prior cesarean in birth certificate data for 2016. We estimated associations between medical factors (diabetes, hypertension, and prepregnancy obesity) and socioeconomic status (education level and insurance type) and TOLAC and VBAC using logistic regression, stratifying by race/ethnicity and testing whether coefficients differed across models. Results: Hypertension and obesity were more strongly related to reduced chances of TOLAC among White women than among women of color. For example, having a body mass index (BMI) between 30 and 39 (vs. normal BMI) was associated with a 6.3 percentage-point (pp) lower probability of TOLAC for White women, a 5.9 pp lower probability for Black women, and 2.9 pp lower probability for Latinx women. Paying out-of-pocket for birth was associated with a 5.5 pp increase in the probability of TOLAC among White women, versus a 3.2 pp decrease among Black women. Overweight and obesity were associated with lower probability of VBAC, but the magnitude of this association was smaller for Black and Latinx women than for White women. Conclusions: More research is needed to elucidate the underlying decision-making processes that lead to these associations. Future work should focus on ensuring equity in access to VBAC-supportive providers and hospitals and fostering informed decision-making after a prior cesarean.
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Affiliation(s)
- Laura B Attanasio
- Department of Health Promotion and Policy, University of Massachusetts Amherst School of Public Health and Health Sciences, Amherst, Massachusetts, USA
| | - Mary T Paterno
- Cooley Dickinson Women's Health, Northampton, Massachusetts, USA
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17
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Dissanayake MV, Bovbjerg ML, Tilden EL, Snowden JM. The Association between Hospital Frequency of Labor after Cesarean and Outcomes in California. Womens Health Issues 2020; 30:453-461. [PMID: 32859469 DOI: 10.1016/j.whi.2020.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Revised: 07/09/2020] [Accepted: 07/24/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Labor after cesarean (LAC) is an alternative to planned repeat cesarean delivery. The effect of hospital-level factors on LAC frequency and vaginal birth after cesarean (VBAC) has been relatively understudied. It was our goal to determine if hospital frequency of LAC (number of women undergoing LAC/number of women with previous uterine scars) is associated with increased VBAC and associated outcomes among women undergoing LAC. METHODS We analyzed 43,331 term, singleton births to women who experienced LAC in California from 2007 to 2010. We conducted multivariable logistic regressions of infant and maternal outcomes for women at hospitals with high LAC frequency (≥median) compared with low LAC frequency (<median), adjusting for maternal and hospital characteristics. We stratified analyses by overall hospital birth volume (categories 1, low; 2, medium; 3, high). RESULTS We did not observe an association between high LAC frequency and VBAC in any category of hospital birth volume in regression models. We found that women in hospitals with high LAC frequency had higher odds of infection in category 1 (low) and 2 (medium) hospitals (category 1 hospitals adjusted odds ratio [aOR], 1.61; 95% confidence interval [CI], 1.04-2.48; category 2 hospitals, aOR, 2.12; 95% CI, 1.34-3.35) and postpartum hemorrhage in category 2 and 3 hospitals (category 2 hospitals: aOR, 2.49; 95% CI, 1.57-3.94; category 3 hospitals: aOR, 1.83; 95% CI, 1.24-2.70). We observed that high LAC frequency was associated with more adverse outcomes (e.g., infection, severe perineal lacerations, decreased Apgar scores) in category 2 than in category 1 and 3 hospitals. CONCLUSIONS We did not find that high LAC frequency was associated with more VBAC, nor with many perinatal complications in category 1 and 3 hospitals. The associations between high LAC frequency and both infection and postpartum hemorrhage are concerning and require further investigation. There may be a sensitive balance between increasing LAC access and determining appropriate LAC candidate selection.
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Affiliation(s)
- Mekhala V Dissanayake
- Department of Obstetrics & Gynecology, Oregon Health and Science University, Portland, Oregon.
| | - Marit L Bovbjerg
- College of Public Health & Human Sciences, Oregon State University, Corvallis, Oregon
| | - Ellen L Tilden
- Department of Obstetrics & Gynecology, Oregon Health and Science University, Portland, Oregon; Department of Nurse-Midwifery, Oregon Health & Science University School of Nursing, Portland, Oregon
| | - Jonathan M Snowden
- Department of Obstetrics & Gynecology, Oregon Health and Science University, Portland, Oregon; School of Public Health, Oregon Health and Science University/Portland State University, Portland, Oregon
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18
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Kurtz Landy C, Sword W, Kathnelson JC, McDonald S, Biringer A, Heaman M, Angle P. Factors obstetricians, family physicians and midwives consider when counselling women about a trial of labour after caesarean and planned repeat caesarean: a qualitative descriptive study. BMC Pregnancy Childbirth 2020; 20:367. [PMID: 32552758 PMCID: PMC7301440 DOI: 10.1186/s12884-020-03052-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 06/09/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Repeat caesarean sections (CSs) are major contributors to the high rate of CS in Canada and globally. Women's decisions to have a planned repeat CS (PRCS) or a trial of labour after CS (TOLAC) are influenced by their maternity care providers. This study explored factors maternity care providers consider when counselling pregnant women with a previous CS, eligible for a TOLAC, about delivery method. METHODS A qualitative descriptive design was implemented. Semi-structured, one-to-one in-depth telephone interviews were conducted with 39 maternity care providers in Ontario, Canada. Participants were recruited at 2 maternity care conferences and with the use of snowball sampling. Interviews were audio recorded and transcribed verbatim. Data were uploaded into the data management software, NVIVO 10.0 and analyzed using qualitative content analysis. RESULTS Participants consisted of 12 obstetricians, 13 family physicians and 14 midwives. Emergent themes, reflecting the factors maternity care providers considered when counselling on mode of delivery, were organized under the categories clinical/patient factors, health system factors and provider preferences. Maternity care providers considered clinical/patient factors, including women's choice … with conditions, their assessment of women's chances of a successful TOLAC, their perception of women's risk tolerance, women's preferred delivery method, and their perception of women's beliefs and attitudes about childbirth. Additionally, providers considered health system factors which included colleague support for TOLAC and time needed to mount an emergency CS. Finally, provider factors emerged as considerations when counselling. They included provider preference for PRCS or TOLAC, provider scope of practice, financial incentives and convenience related to PRCS, past experiences with TOLAC and PRCS and providers' perspectives on risk of TOLAC. CONCLUSION The findings highlight the multiplicity of factors maternity care providers consider when counselling women. Effectively addressing clinical, health care system and personal factors that influence counselling may help decrease non-medically indicated PRCS.
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Affiliation(s)
- Christine Kurtz Landy
- Faculty of Health, School of Nursing, York University, HNES 312A, 4700 Keele Street, Toronto, Ontario, M3J 1P3, Canada.
| | - Wendy Sword
- McMaster University, 1280 Main Street West, Hamilton, Ontario, L8S 4L8, Canada
| | - Jackie Cramp Kathnelson
- Faculty of Health, York University, HNES 312A, 4700 Keele Street, Toronto, Ontario, M3J 1P3, Canada
| | - Sarah McDonald
- Department of Obstetrics and Gynecology, McMaster University, 1280 Main Street West, Hamilton, Ontario, L8S 4K1, Canada
| | - Anne Biringer
- Department of Family and Community Medicine, University of Toronto, Ada Slaight and Slaight Family director of Family Medicine Maternity Care, Toronto, Canada
- Ray D Wolfe Department of Family Medicine, Sinai Health System, 60 Murray St, Toronto, Ontario, M5T 1L9, Canada
| | - Maureen Heaman
- College of Nursing, Rady Faculty of Health Sciences, Helen Glass Centre for Nursing, University of Manitoba, 89 Curry Place, Winnipeg, MB, R3T 2N2, Canada
| | - Pam Angle
- Sunnybrook Research Institute, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada
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Clarke M, Devane D, Gross MM, Morano S, Lundgren I, Sinclair M, Putman K, Beech B, Vehviläinen-Julkunen K, Nieuwenhuijze M, Wiseman H, Smith V, Daly D, Savage G, Newell J, Simpkin A, Grylka-Baeschlin S, Healy P, Nicoletti J, Lalor J, Carroll M, van Limbeek E, Nilsson C, Stockdale J, Fobelets M, Begley C. OptiBIRTH: a cluster randomised trial of a complex intervention to increase vaginal birth after caesarean section. BMC Pregnancy Childbirth 2020; 20:143. [PMID: 32138712 PMCID: PMC7059398 DOI: 10.1186/s12884-020-2829-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 02/20/2020] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Despite evidence supporting the safety of vaginal birth after caesarean section (VBAC), rates are low in many countries. METHODS OptiBIRTH investigated the effects of a woman-centred intervention designed to increase VBAC rates through an unblinded cluster randomised trial in 15 maternity units with VBAC rates < 35% in Germany, Ireland and Italy. Sites were matched in pairs or triplets based on annual birth numbers and VBAC rate, and randomised, 1:1 or 2:1, intervention versus control, following trial registration. The intervention involved evidence-based education of clinicians and women with one previous caesarean section (CS), appointment of opinion leaders, audit/peer review, and joint discussions by women and clinicians. Control sites provided usual care. Primary outcome was annual hospital-level VBAC rates before the trial (2012) versus final year of the trial (2016). Between April 2014 and October 2015, 2002 women were recruited (intervention 1195, control 807), with mode-of-birth data available for 1940 women. RESULTS The OptiBIRTH intervention was feasible and safe across hospital settings in three countries. There was no statistically significant difference in the change in the proportion of women having a VBAC between intervention sites (25.6% in 2012 to 25.1% in 2016) and control sites (18.3 to 22.3%) (odds ratio adjusted for differences between intervention and control groups (2012) and for homogeneity in VBAC rates at sites in the countries: 0.87, 95% CI: 0.67, 1.14, p = 0.32 based on 5674 women (2012) and 5284 (2016) with outcome data. Among recruited women with birth data, 4/1147 perinatal deaths > 24 weeks gestation occurred in the intervention group (0.34%) and 4/782 in the control group (0.51%), and two uterine ruptures (one per group), a rate of 1:1000. CONCLUSIONS Changing clinical practice takes time. As elective repeat CS is the most common reason for CS in multiparous women, interventions that are feasible and safe and that have been shown to lead to decreasing repeat CS, should be promoted. Continued research to refine the best way of promoting VBAC is essential. This may best be done using an implementation science approach that can modify evidence-based interventions in response to changing clinical circumstances. TRIAL REGISTRATION The OptiBIRTH trial was registered on 3/4/2013. Trial registration number ISRCTN10612254.
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Affiliation(s)
- Mike Clarke
- Queen's University Belfast, Belfast, Northern Ireland, UK
| | - Declan Devane
- National University of Ireland Galway, Galway, Ireland
| | | | | | | | | | - Koen Putman
- Department of Public Health, Interuniversity Centre for Health Economics Research (I-CHER), Vrije Universiteit Brussel, Brussels, Belgium
| | - Beverley Beech
- Association for Improvements in the Maternity Services, Surrey, UK
| | | | | | | | | | | | - Gerard Savage
- Queen's University Belfast, Belfast, Northern Ireland, UK
| | - John Newell
- National University of Ireland Galway, Galway, Ireland
| | | | | | | | | | | | | | | | | | | | - Maaike Fobelets
- Department of Public Health, Interuniversity Centre for Health Economics Research (I-CHER), Vrije Universiteit Brussel, Brussels, Belgium
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Fore MS, Allshouse AA, Carlson NS, Hurt KJ. Outcomes of trial of labor after cesarean birth by provider type in low-risk women. Birth 2020; 47:123-134. [PMID: 31823421 PMCID: PMC7047558 DOI: 10.1111/birt.12474] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 11/16/2019] [Accepted: 11/16/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND One approach to decreasing the cesarean birth rate in the United States is to increase the availability of birth attendants, including certified nurse-midwives (CNMs), who offer trial of labor after cesarean (TOLAC). We examined associations between provider type and mode of birth for women attempting vaginal birth after cesarean (VBAC). METHODS We performed a retrospective cohort study at a United States academic medical center using prospectively-collected data (2005-2012). We included healthy women with term singleton vertex pregnancies after one or two prior cesareans who were managed by obstetricians or CNMs. We assessed unplanned cesarean birth by provider type using univariate and logistic regression and examined labor interventions and predicted VBAC success. RESULTS Overall VBAC success was 88% for 502 included patients. Unplanned cesarean rates were similar by provider type. Black race, no prior VBAC, recurring clinical indication for cesarean, labor augmentation/induction, and any Pitocin use were associated with increased unplanned cesarean. Higher parity and early-term gestational age at delivery were associated with decreased unplanned cesarean. Postpartum hemorrhage and composite maternal morbidity were increased with unplanned cesarean, but there was no difference in neonatal outcome by mode of delivery or provider type. Obstetricians had slightly higher composite adverse maternal outcomes. Nomogram-predicted VBAC success but not provider type was associated with unplanned cesarean. CONCLUSIONS Unplanned cesarean was similar for patients attempting labor after cesarean managed by midwives or obstetricians. Increasing the number of CNMs who manage TOLAC may help decrease the high rate of cesareans.
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Affiliation(s)
- Matthew S. Fore
- Penn State Health Milton S. Hershey Medical Center, Obstetrics and Gynecology, 500 University Drive, Hershey PA 17033
| | - Amanda A. Allshouse
- University of Utah School of Medicine, Obstetrics and Gynecology, Maternal Fetal Medicine, 30 N. 1900 E, Salt Lake City Utah 84132
| | - Nicole S. Carlson
- Emory University Nell Hodgson Woodruff School of Nursing, 1520 Clifton Road NE, Atlanta GA 30322
| | - K. Joseph Hurt
- University of Colorado School of Medicine, Obstetrics and Gynecology, Maternal Fetal Medicine & Reproductive Sciences, 12700 East 19 Avenue, MS 8613, Aurora CO 80045
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Carlson NS, Breman R, Neal JL, Phillippi JC. Preventing Cesarean Birth in Women with Obesity: Influence of Unit-Level Midwifery Presence on Use of Cesarean among Women in the Consortium on Safe Labor Data Set. J Midwifery Womens Health 2020; 65:22-32. [PMID: 31464045 PMCID: PMC7021572 DOI: 10.1111/jmwh.13022] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 06/10/2019] [Accepted: 06/15/2019] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Maternal obesity is associated with slow labor progression and unplanned cesarean birth. Midwives use fewer medical interventions during labor, and the women they care for have lower cesarean birth rates, compared with low-risk, matched groups of women cared for by physicians. The primary aim of this study was to examine associations between midwifery unit-level presence and unplanned cesarean birth in women with different body mass index (BMI) ranges. Unit-level presence of midwives was analyzed as a representation of a unique set of care practices that exist in settings where midwives work. METHODS A retrospective cohort study was conducted using Consortium on Safe Labor data from low-risk, healthy women who labored and gave birth in medical centers with (n = 9795) or without (n = 13,398) the unit-level presence of midwives. Regression models were used to evaluate for associations between unit-level midwifery presence and 1) the incidence of unplanned cesarean birth and 2) in-hospital labor durations with stratification by maternal BMI and adjustment for maternal demographic and pregnancy factors. RESULTS The odds of unplanned cesarean birth among women who gave birth in centers with midwives were 16% lower than the odds of cesarean birth among similar women at who gave birth at centers without midwives (adjusted odds ratio, 0.84; 95% CI, 0.77-0.93). However, women whose BMI was above 35.00 kg/m2 at labor admission had similar odds of cesarean birth, regardless of unit-level midwifery presence. In-hospital labor duration prior to unplanned cesarean was no different by unit-level midwifery presence in nulliparous women whose BMI was above 35.00 kg/m2 . DISCUSSION Although integration of midwives into the caregiving environment of medical centers in the United States was associated with overall decrease in the incidence of cesarean birth, increased maternal BMI nevertheless remained positively associated with these outcomes.
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Affiliation(s)
- Nicole S Carlson
- Emory University Nell Hodgson Woodruff School of Nursing, Atlanta, Georgia
| | - Rachel Breman
- University of Maryland School of Nursing, Baltimore, Maryland
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Rosenstein MG, Norrell L, Altshuler A, Grobman W, Kaimal A, Kuppermann M. Hospital bans on trial of labor after cesarean and antepartum transfer of care. Birth 2019; 46:574-582. [PMID: 31691369 PMCID: PMC9536508 DOI: 10.1111/birt.12460] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 09/25/2019] [Accepted: 09/25/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND Hospital policies restricting access to trial of labor after cesarean (TOLAC) are prevalent. Many women with a previous cesarean birth are affected by these bans, but there are limited data on the effect of these bans and whether women would consider changing delivery hospitals in the setting of a real or hypothetical TOLAC ban. METHODS This was a survey of TOLAC-eligible women receiving prenatal care at four hospitals where TOLAC is available, and 1 non-TOLAC site. Participants were asked about their likelihood of switching hospitals to pursue TOLAC if it were unavailable. Women at the non-TOLAC site had their medical records reviewed to ascertain final location and approach to delivery. RESULTS A total of 297 women were interviewed, 48 from the non-TOLAC site. 162 (54%) participants indicated they would transfer care if TOLAC were unavailable. Among women at the non-TOLAC site, 57% who indicated an intention to switch hospitals did so. In a multivariable logistic regression model, variables associated with transferring care included race/ethnicity other than Latina (aOR 25.20 [95% CI 2.23-284.26]), being unaware of the TOLAC ban (19.81 [1.99-196.64]), and perceiving that a close friend/relative thought they should undergo TOLAC (17.31 [1.70-176.06]). CONCLUSIONS More than half of women with prior cesarean would consider transferring care if TOLAC became unavailable, and more than 1 of 3 of women at a non-TOLAC site transferred care. More research is needed on the impact of TOLAC bans and how to facilitate transfer for those who desire TOLAC.
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Affiliation(s)
- Melissa G. Rosenstein
- Assistant Professor, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco
| | | | - Anna Altshuler
- Obstetrician/Gynecologist, California Pacific Medical Center
| | - William Grobman
- Professor of Obstetrics and Gynecology (Maternal-Fetal Medicine) and Preventative Medicine, Northwestern University
| | - Anjali Kaimal
- Associate Professor of Obstetrics, Gynecology and Reproductive Biology, Massachusetts General Hospital
| | - Miriam Kuppermann
- Assistant Professor, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco
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Abstract
Trial of labor after cesarean delivery (TOLAC) refers to a planned attempt to deliver vaginally by a woman who has had a previous cesarean delivery, regardless of the outcome. This method provides women who desire a vaginal delivery the possibility of achieving that goal-a vaginal birth after cesarean delivery (VBAC). In addition to fulfilling a patient's preference for vaginal delivery, at an individual level, VBAC is associated with decreased maternal morbidity and a decreased risk of complications in future pregnancies as well as a decrease in the overall cesarean delivery rate at the population level (). However, although TOLAC is appropriate for many women, several factors increase the likelihood of a failed trial of labor, which in turn is associated with increased maternal and perinatal morbidity when compared with a successful trial of labor (ie, VBAC) and elective repeat cesarean delivery (). Therefore, assessing the likelihood of VBAC as well as the individual risks is important when determining who is an appropriate candidate for TOLAC. Thus, the purpose of this document is to review the risks and benefits of TOLAC in various clinical situations and to provide practical guidelines for counseling and management of patients who will attempt to give birth vaginally after a previous cesarean delivery.
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MacDorman MF, Declercq E. Trends and state variations in out-of-hospital births in the United States, 2004-2017. Birth 2019; 46:279-288. [PMID: 30537156 PMCID: PMC6642827 DOI: 10.1111/birt.12411] [Citation(s) in RCA: 124] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 10/30/2018] [Accepted: 11/12/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Out-of-hospital births have been increasing in the United States, although past studies have found wide variations between states. Our purpose was to examine trends in out-of-hospital births, the risk profile of these births, and state differences in women's access to these births. METHODS National birth certificate data from 2004 to 2017 were analyzed. Newly available national data on method of payment for the delivery (private insurance, Medicaid, self-pay) were used to measure access to out-of-hospital birth options. RESULTS After a gradual decline from 1990 to 2004, the number of out-of-hospital births increased from 35 578 in 2004 to 62 228 in 2017. In 2017, 1 of every 62 births in the United States was an out-of-hospital birth (1.61%). Home births increased by 77% from 2004 to 2017, whereas birth center births more than doubled. Out-of-hospital births were more common in the Pacific Northwest and less common in the southeastern states such as Alabama, Louisiana, and Mississippi. Women with planned home and birth center births were less likely to have a number of population characteristics associated with poor pregnancy outcomes, including teen births, smoking during pregnancy, obesity, and preterm, low birthweight, and multiple births. More than 2/3 of planned home births were self-paid, compared with 1/3 of birth center and just 3% of hospital births, with large variations by state. CONCLUSIONS Lack of insurance or Medicaid coverage is an important limiting factor for women desiring out-of-hospital birth in most states. Recent increases in out-of-hospital births despite important limiting factors highlight the strong motivation of some women to choose out-of-hospital birth.
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Affiliation(s)
- Marian F MacDorman
- Maryland Population Research Center, University of Maryland, College Park, Maryland
| | - Eugene Declercq
- Community Health Sciences Department, Boston University School of Public Health, Boston, Massachusetts
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Sargent JA, Savitsky LM, Dissanayake MV, Lo JO, Cheng YW, Caughey AB. Gestational Weight Gain during Pregnancy as an Important Factor Influencing a Successful Trial of Labor following Two Previous Cesareans. Am J Perinatol 2019; 36:588-593. [PMID: 30231273 PMCID: PMC7138436 DOI: 10.1055/s-0038-1670679] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
OBJECTIVE We sought to identify factors associated with a successful trial of labor (TOL) following two cesarean deliveries (CDs) in a contemporary North American cohort. STUDY DESIGN This is a retrospective cohort study of term, nonanomalous, singleton, vertex pregnancies attempting a vaginal birth after cesarean (VBAC) following a history of two previous CDs in the United States from 2012 to 2014. Maternal and intrapartum factors were analyzed using chi-square tests and multivariable logistic regression. RESULTS A total of 22,762 women met the inclusion criteria and underwent TOL. Of these, 12,192 (53.6%) had a VBAC. Using multivariate logistic regression, previous vaginal delivery and delivery at 40 to 41 weeks' gestation were associated with VBAC; maternal age, education, Medicaid insurance, non-Caucasian race/ethnicity, weight (overweight or obese), and gestational weight gain above the Institute of Medicine guidelines (adjusted odds ratio: 0.88; 95% confidence interval: 0.81-0.95) were associated with CD. Induction of labor did not affect the VBAC rate. CONCLUSION For those desiring a TOL after two previous CDs, prospective studies are needed to assess interventions that limit gestational weight gain as well as the safety and optimal timing of an induction of labor. The decision to attempt a TOL should be guided by counseling regarding the risks, benefits, and chances of a successful TOL.
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Affiliation(s)
- James A. Sargent
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon
| | - Leah M. Savitsky
- Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington
| | - Mekhala V. Dissanayake
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon
| | - Jamie O. Lo
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon
| | - Yvonne W. Cheng
- Department of Obstetrics and Gynecology, California Pacific Medical Center, San Francisco, California
| | - Aaron B. Caughey
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon
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Attanasio LB, Paterno MT. Correlates of Trial of Labor and Vaginal Birth After Cesarean in the United States. J Womens Health (Larchmt) 2019; 28:1302-1312. [PMID: 30864889 DOI: 10.1089/jwh.2018.7270] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
Background: Little is known about trial of labor after cesarean (TOLAC) uptake and vaginal birth after cesarean (VBAC) success on the national level, which is important as national-level data may help shape future clinical guidelines. This study examined correlates of trial of labor and successful VBAC among women with one prior cesarean in the United States in 2016. Materials and Methods: We used publically available birth certificate data for 2016. Outcomes were TOLAC among women with one prior cesarean (N = 338,311) and VBAC among women with a TOLAC (N = 76,688). We used logistic regression to assess the association between the outcomes and the following categories of independent variables: social determinants of health, demographic and medical factors impacting birth, behavioral factors, and geographic access. Results: About 23% of women had a TOLAC, and 74% of women with a TOLAC gave birth vaginally. Black women had higher odds of TOLAC relative to White women, but lower odds of successful VBAC. Women without a high school degree had higher odds of TOLAC and of successful VBAC compared to women who completed high school or beyond, as did women with inadequate prenatal care utilization. Conclusions: Understanding correlates of TOLAC and successful VBAC at the population level is important for developing national guidelines that can be considered and individualized at the patient/provider level.
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Affiliation(s)
- Laura B Attanasio
- Department of Health Promotion and Policy, School of Public Health and Health Sciences, University of Massachusetts Amherst, Amherst, Massachusetts
| | - Mary T Paterno
- College of Nursing, University of Massachusetts Amherst, Amherst, Massachusetts
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Attanasio LB, Kozhimannil KB, Kjerulff KH. Women's preference for vaginal birth after a first delivery by cesarean. Birth 2019; 46:51-60. [PMID: 30051510 PMCID: PMC6348143 DOI: 10.1111/birt.12386] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 06/28/2018] [Accepted: 06/28/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Nearly 90% of United States pregnant women with a prior cesarean give birth by repeat cesarean. Public health goals encourage greater use of vaginal birth after cesarean (VBAC), but there is little prospective data on predictors of women's preference for VBAC. We characterized predictors of women's preferred mode of delivery after a first cesarean and thematically categorized reasons for their preference. METHODS Data were from a cohort of 3006 women whose first childbirth was in Pennsylvania in 2009-2011. The analytic sample included women who had their first birth by cesarean and reported mode of delivery preference for their next delivery at 12 months postpartum (n = 616). Associations with future birth mode preference were assessed using multivariate logistic regression, and reasons for preference were categorized using content analysis. RESULTS At 12 months postpartum, 45% of women who delivered by cesarean in their first birth wanted to have their next delivery vaginally. Independent predictors of VBAC preference were Black race/ethnicity, nonrecurrent indication for the first cesarean, planning three or more additional children, and difficulty recovering from the first cesarean. The most common reason for preferring a vaginal birth was wanting the experience of vaginal birth; the most common reason for preferring cesarean birth was that the first birth was by cesarean. CONCLUSION Nearly half of respondents preferred VBAC in future births, but national estimates indicate that only about 12% of women with prior cesareans have a VBAC. This suggests a need to ensure greater access to VBAC for women who want it.
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Affiliation(s)
- Laura B. Attanasio
- Assistant Professor in the Department of Health Promotion and Policy, University of Massachusetts Amherst School of Public Health and Health Sciences, Amherst, MA
| | - Katy B. Kozhimannil
- Associate Professor in the Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN
| | - Kristen H. Kjerulff
- Professor in the Department of Public Health Sciences and Department of Obstetrics and Gynecology, College of Medicine, Penn State University, Hershey, PA
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Basinger M, Ballas J, Davidson C. A national survey evaluating obstetric providers' attitudes and regional trends of trial of labor after cesarean. J Matern Fetal Neonatal Med 2019; 33:2872-2876. [PMID: 30621483 DOI: 10.1080/14767058.2018.1562543] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Objective: To evaluate trends amongst residency programs offering trial of labor after cesarean delivery (TOLAC).Methods: An electronic survey was sent to Program Directors of every obstetrics and gynecology residency program accredited by the Accreditation Council for Graduate Medical Education (ACGME) in the USA and Puerto Rico via publicly available e-mail address for 249 of the 249 programs. The Program Directors were asked to forward the e-mail to all of the current residents in their respective program to complete a similar version of the survey.Results: Seventy-nine Program Directors (33%) and 243 residents responded. All programs offered TOLAC to patients with one prior cesarean. University programs were more likely to offer TOLAC to women with two prior cesareans compared to non-university programs (85 versus 65%; p < .01). Overall, Program Directors and residents were comfortable counseling and managing TOLACs (99 and 95%, respectively). This confidence was associated with advancing years in residency. Residents attending university programs report they are more likely to offer TOLAC to women with 1 prior cesarean (98.1 versus 91.2%, p = .02) and willing to induce TOLAC with favorable cervix (95.2 versus 88.2%; p = .03) post-residency when compared to non-university trained residents. There is an association between region and whether TOLAC is offered to women with two or more prior cesareans, without prior vaginal delivery, and women with twins. Specifically, those in the Mid-Atlantic region are less likely to offer TOLAC to women with two prior cesareans (68 versus 86%; p < .01) and those with unknown type of previous uterine incision (51 versus 74%; p < .01).Conclusion: Offering TOLAC to women with one prior cesarean appears universally acceptable amongst residency programs in the USA. Significant differences arise between types of programs and region of the country in regards to offering TOLAC to women with more complicated obstetrical histories.
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Affiliation(s)
- Monica Basinger
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Jerasimos Ballas
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Christina Davidson
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Baylor College of Medicine, Houston, TX, USA
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Xu X, Lee HC, Lin H, Lundsberg LS, Campbell KH, Lipkind HS, Pettker CM, Illuzzi JL. Hospital variation in utilization and success of trial of labor after a prior cesarean. Am J Obstet Gynecol 2019; 220:98.e1-98.e14. [PMID: 30278176 DOI: 10.1016/j.ajog.2018.09.034] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 09/20/2018] [Accepted: 09/24/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Trial of labor after cesarean delivery is an effective and safe option for women without contraindications. OBJECTIVES The objective of the study was to examine hospital variation in utilization and success of trial of labor after cesarean delivery and identify associated institutional characteristics and patient outcomes. STUDY DESIGN Using linked maternal and newborn hospital discharge records and birth certificate data in 2010-2012 from the state of California, we identified 146,185 term singleton mothers with 1 prior cesarean delivery and no congenital anomalies or clear contraindications for trial of labor at 249 hospitals. Risk-standardized utilization and success rates of trial of labor after cesarean delivery were estimated for each hospital after accounting for differences in patient case mix. Risk for severe maternal and newborn morbidities, as well as maternal and newborn length of stay, were compared between hospitals with high utilization and high success rates of trial of labor after cesarean delivery and other hospitals. Bivariate analysis was also conducted to examine the association of various institutional characteristics with hospitals' utilization and success rates of trial of labor after cesarean delivery. RESULTS In the overall sample, 12.5% of women delivered vaginally. After adjusting for patient clinical risk factors, utilization and success rates of trial of labor after cesarean delivery varied considerably across hospitals, with a median of 35.2% (10th to 90th percentile range: 10.2-67.1%) and 40.5% (10th to 90th percentile range: 8.5-81.1%), respectively. Risk-standardized utilization and success rates of trial of labor after cesarean delivery demonstrated an inverted U-shaped relationship such that low or excessively high use of trial of labor after cesarean delivery was associated with lower success rate. Compared with other births, those delivered at hospitals with above-the-median utilization and success rates of trial of labor after cesarean delivery had a higher risk for uterine rupture (adjusted risk ratio, 2.74, P < .001), severe newborn respiratory complications (adjusted risk ratio, 1.46, P < .001), and severe newborn neurological complications/trauma (adjusted risk ratio, 2.48, P < .001), but they had a lower risk for severe newborn infection (adjusted risk ratio, 0.80, P = .003) and overall severe unexpected newborn complications (adjusted risk ratio, 0.86, P < .001) as well as shorter length of stays (adjusted mean ratio, 0.948 for mothers and 0.924 for newborns, P < .001 for both). Teaching status, system affiliation, larger volume, higher neonatal care capacity, anesthesia availability, higher proportion of midwife-attended births, and lower proportion of Medicaid or uninsured patients were positively associated with both utilization and success of trial of labor after cesarean delivery. However, rural location and higher local malpractice insurance premium were negatively associated with the utilization of trial of labor after cesarean delivery, whereas for-profit ownership was associated with lower success rate. CONCLUSION Utilization and success rates of trial of labor after cesarean delivery varied considerably across hospitals. Strategies to promote vaginal birth should be tailored to hospital needs and characteristics (eg, increase availability of trial of labor after cesarean delivery at hospitals with low utilization rates while being more selective at hospitals with high utilization rates, and targeted support for lower capacity hospitals).
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Wingert A, Johnson C, Featherstone R, Sebastianski M, Hartling L, Douglas Wilson R. Adjunct clinical interventions that influence vaginal birth after cesarean rates: systematic review. BMC Pregnancy Childbirth 2018; 18:452. [PMID: 30463530 PMCID: PMC6249876 DOI: 10.1186/s12884-018-2065-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 10/18/2018] [Indexed: 11/30/2022] Open
Abstract
Background Rates of cesarean deliveries have been increasing, and contributes to the rising number of elective cesarean deliveries in subsequent pregnancies with associated maternal and neonatal risks. Multiple guidelines recommend that women be offered a trial of labor after a cesarean (TOLAC). The objective of the study is to systematically review the literature on adjunct clinical interventions that influence vaginal birth after cesarean (VBAC) rates. Methods We searched Ovid Medline, Ovid Embase, Wiley Cochrane Library, CINAHL via EBSCOhost; and Ovid PsycINFO. Additional studies were identified by searching for clinical trial records, conference proceedings and dissertations. Limits were applied for language (English and French) and year of publication (1985 to present). Two reviewers independently screened comparative studies (randomized or non-randomized controlled trials, and observational designs) according to a priori eligibility criteria: women with prior cesarean sections; any adjunct clinical intervention or exposure intended to increase the VBAC rate; any comparator; and, outcomes reporting changes in TOLAC or VBAC rates. One reviewer extracted data and a second reviewer verified for accuracy. Two reviewers independently conducted methodological quality assessments using the Mixed Methods Appraisal Tool (MMAT). Results Twenty-three studies of overall moderate to good methodological quality examined adjunct clinical interventions affecting TOLAC and/or VBAC rates: system-level interventions (three studies), provider-level interventions (three studies), guidelines or information for providers (seven studies), provider characteristics (four studies), and patient-level interventions (six studies). Provider-level interventions (opinion leader education, laborist, and obstetrician second opinion for cesarean sections) and provider characteristics (midwifery antenatal care, physicians on night float call schedules, and deliveries by family physicians) were associated with increased rates of VBAC. Few studies employing heterogeneous designs, sample sizes, interventions and comparators limited confidence in the effects. Studies of system-level and patient-level interventions, and guidelines/information for providers reported mixed findings. Conclusions Limited evidence indicates some provider-level interventions and provider characteristics may increase rates of attempted and successful TOLACs and/or VBACs, whereas other adjunct clinical interventions such as system-level interventions, patient-level interventions, and guidelines/information for healthcare providers show mixed findings. Electronic supplementary material The online version of this article (10.1186/s12884-018-2065-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Aireen Wingert
- Alberta Research Centre for Health Evidence, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Cydney Johnson
- Alberta Research Centre for Health Evidence, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Robin Featherstone
- Alberta Research Centre for Health Evidence, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada.,Alberta Strategy for Patient-Oriented Research (SPOR) SUPPORT Unit Knowledge Translation Platform, University of Alberta, Edmonton, AB, Canada
| | - Meghan Sebastianski
- Alberta Strategy for Patient-Oriented Research (SPOR) SUPPORT Unit Knowledge Translation Platform, University of Alberta, Edmonton, AB, Canada
| | - Lisa Hartling
- Alberta Research Centre for Health Evidence, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada.,Alberta Strategy for Patient-Oriented Research (SPOR) SUPPORT Unit Knowledge Translation Platform, University of Alberta, Edmonton, AB, Canada
| | - R Douglas Wilson
- Department of Obstetrics and Gynecology, Cumming School of Medicine, University of Calgary, 1403 - 29 Street NW, Calgary, AB, T2N 2T9, Canada.
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Lundsberg LS, Lee HC, Dueñas GV, Gregory KD, Grossetta Nardini HK, Pettker CM, Illuzzi JL, Xu X. Quality Assurance Practices in Obstetric Care: A Survey of Hospitals in California. Obstet Gynecol 2018; 131:214-223. [PMID: 29324608 PMCID: PMC7020098 DOI: 10.1097/aog.0000000000002437] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess hospital practices in obstetric quality management activities and identify institutional characteristics associated with utilization of evidence-supported practices. METHODS Data for this study came from a statewide survey of obstetric hospitals in California regarding their organization and delivery of perinatal care. We analyzed responses from 185 hospitals that completed quality assurance sections of the survey to assess their practices in a broad spectrum of quality enhancement activities. The association between institutional characteristics and adoption of evidence-supported practices (ie, those supported by prior literature or recommended by professional organizations as beneficial for improving birth outcome or patient safety) was examined using bivariate analysis and appropriate statistical tests. RESULTS Most hospitals regularly audited adherence to written protocols regarding critical areas of care; however, 77.7% and 16.8% reported not having written guidelines on diagnosis of labor arrest and management of abnormal fetal heart rate, respectively. Private nonprofit hospitals were more likely to have a written protocol for management of abnormal fetal heart rate (P=.002). One in 10 hospitals (9.7%) did not regularly review cases with significant morbidity or mortality, and only 69.0% regularly tracked indications for cesarean delivery. Moreover, 26.3%, 14.3%, and 8.7% of the hospitals reported never performing interprofessional simulations for eclampsia, shoulder dystocia, or postpartum hemorrhage, respectively. Teaching status was associated with more frequent simulations in these three areas (P≤.04 for all), while larger volume was associated with more frequent simulations for eclampsia (P=.04). CONCLUSION Hospitals in California engage in a wide range of practices to assure or improve quality of obstetric care, but substantial variation in practice exists among hospitals. There is opportunity for improvement in adoption of evidence-supported practices.
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Affiliation(s)
- Lisbet S Lundsberg
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut; the Department of Pediatrics, Division of Neonatal & Developmental Medicine, Stanford University School of Medicine, Stanford, California; the Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California; and Cushing/Whitney Medical Library, Yale University, New Haven, Connecticut
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Abstract
Trial of labor after cesarean delivery (TOLAC) refers to a planned attempt to deliver vaginally by a woman who has had a previous cesarean delivery, regardless of the outcome. This method provides women who desire a vaginal delivery the possibility of achieving that goal-a vaginal birth after cesarean delivery (VBAC). In addition to fulfilling a patient's preference for vaginal delivery, at an individual level, VBAC is associated with decreased maternal morbidity and a decreased risk of complications in future pregnancies as well as a decrease in the overall cesarean delivery rate at the population level (1-3). However, although TOLAC is appropriate for many women, several factors increase the likelihood of a failed trial of labor, which in turn is associated with increased maternal and perinatal morbidity when compared with a successful trial of labor (ie, VBAC) and elective repeat cesarean delivery (4-6). Therefore, assessing the likelihood of VBAC as well as the individual risks is important when determining who is an appropriate candidate for TOLAC. Thus, the purpose of this document is to review the risks and benefits of TOLAC in various clinical situations and to provide practical guidelines for counseling and management of patients who will attempt to give birth vaginally after a previous cesarean delivery.
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Stohl HE. When Consent Does Not Help: Challenges to Women's Access to a Vaginal Birth After Cesarean Section and the Limitations of the Informed Consent Doctrine. AMERICAN JOURNAL OF LAW & MEDICINE 2017; 43:388-425. [PMID: 29452564 DOI: 10.1177/0098858817753405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Pregnant women with a prior cesarean delivery face challenges in accessing a vaginal birth due to both hospital and provider preferences and practices. Although the doctrine of informed consent secures women's reproductive rights, it is not a viable legal remedy. Instead, women should champion increased maternity-related education and transparency as well as medical malpractice reform to increase the desired access.
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Affiliation(s)
- Hindi E Stohl
- Dr. Hindi Stohl is an Assistant Clinical Professor of Obstetrics and Gynecology at the David Geffen School of Medicine at UCLA. She is a board-certified and practicing perinatologist (high-risk obstetrician) at Harbor-UCLA Medical Center, where she is the Director of Maternal-Fetal Medicine services. Dr. Stohl has over ten years of experience in obstetrics and has cared for hundreds of women with prior cesarean deliveries. She routinely performs vaginal births after cesarean deliveries. Dr. Stohl is also a graduate of Southwestern Law School and admitted to the California State Bar
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Munro S, Kornelsen J, Corbett K, Wilcox E, Bansback N, Janssen P. Do Women Have a Choice? Care Providers' and Decision Makers' Perspectives on Barriers to Access of Health Services for Birth after a Previous Cesarean. Birth 2017; 44:153-160. [PMID: 27917532 DOI: 10.1111/birt.12270] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/27/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND Repeat cesarean delivery is the single largest contributor to the escalating cesarean rate worldwide. Approximately 80 percent of women with a past cesarean are candidates for vaginal birth after a cesarean (VBAC), but in Canada less than one-third plan VBAC. Emerging evidence suggests that these trends may be due in part to nonclinical factors, including care provider practice patterns and delays in access to surgical and anesthesia services. This study sought to explore maternity care providers' and decision makers' attitudes toward and experiences with providing and planning services for women with a previous cesarean. METHODS In-depth, semi-structured interviews were conducted with family physicians, midwives, obstetricians, nurses, anesthetists, and health service decision makers recruited from three rural and two urban Canadian communities. Constructivist grounded theory informed iterative data collection and analysis. RESULTS Analysis of interviews (n = 35) revealed that the factors influencing decisions resulted from interactions between the clinical, organizational, and policy levels of the health care system. Physicians acted as information providers of clinical risks and benefits, with limited discussion of patient preferences. Decision makers serving large hospitals revealed concerns related to liability and patient safety. These stemmed from competing access to surgical resources. CONCLUSIONS To facilitate women's increased access to planned VBAC, it is necessary to address the barriers perceived by care providers and decision makers. Strategies to mitigate concerns include initiating decision support immediately after the primary cesarean, addressing the social risks that influence women's preferences, and managing perceptions of patient and litigation risks through shared decision making.
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Affiliation(s)
- Sarah Munro
- Department of Family Practice, University of British Columbia, Vancouver, BC, Canada.,The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Hanover, NH, USA
| | - Jude Kornelsen
- Department of Family Practice, University of British Columbia, Vancouver, BC, Canada.,Centre for Rural Health Research and Applied Policy Research Unit, Vancouver, BC, Canada
| | - Kitty Corbett
- School of Public Health and Health Systems, University of Waterloo, Waterloo, ON, Canada
| | - Elizabeth Wilcox
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Nick Bansback
- University of British Columbia School of Population and Public Health, Vancouver, BC, Canada.,Centre for Health Evaluation and Outcomes Sciences, Vancouver, BC, Canada.,Centre for Clinical Epidemiology and Evaluation, Vancouver, BC, Canada
| | - Patricia Janssen
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada.,BC Children's Hospital Research Institute, Vancouver, BC, Canada
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Munro S, Janssen P, Corbett K, Wilcox E, Bansback N, Kornelsen J. Seeking control in the midst of uncertainty: Women's experiences of choosing mode of birth after caesarean. Women Birth 2016; 30:129-136. [PMID: 28029609 DOI: 10.1016/j.wombi.2016.10.005] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 09/30/2016] [Accepted: 10/14/2016] [Indexed: 11/29/2022]
Abstract
PROBLEM Clinical practice guidelines indicate that over 80% of women with a previous caesarean should be offered a planned vaginal birth after caesarean (VBAC), however only one third of eligible women choose to plan a VBAC. To support informed choices for birth after caesarean, it is necessary to understand the factors that influence women's decision-making. AIM The goal of this study was to explore attitudes towards and experiences with decision-making for mode of delivery after caesarean from the perspectives of Canadian women. METHODS In-depth, semi-structured interviews were conducted with 23 women eligible for VBAC in three rural and two urban communities in British Columbia, Canada, during summer 2015. Constructivist grounded theory informed iterative data collection and analysis. FINDINGS Women's decision-making experiences were a process of "seeking control in the midst of uncertainty." Women formed early preferences for mode of delivery after their primary caesareans and engaged in careful deliberation during their inter-pregnancy interval, consisting of: reflecting on their birth, clarifying their values, becoming informed, considering the feasibility of options, deliberating with the care team, and making an actual choice. Women struggled to make trade-offs between having a healthy baby and social attributes of delivery, such as uninterrupted bonding with their newborn. CONCLUSIONS Women begin decision-making for birth after caesarean earlier than previously reported and their choices are influenced by personal experience and psychosocial concerns. Future interventions to support choice of mode of delivery should begin early after the primary caesarean, to reflect when women begin to form preferences.
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Affiliation(s)
- Sarah Munro
- Department of Family Practice, University of British Columbia, Vancouver, Canada; The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Hanover, NH, United States.
| | - Patricia Janssen
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Kitty Corbett
- School of Public Health and Health Systems, University of Waterloo, Waterloo, Canada
| | - Elizabeth Wilcox
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Nick Bansback
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Jude Kornelsen
- Department of Family Practice, University of British Columbia, Vancouver, Canada
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MacDorman MF, Declercq E. Trends and Characteristics of United States Out-of-Hospital Births 2004-2014: New Information on Risk Status and Access to Care. Birth 2016; 43:116-24. [PMID: 26991514 DOI: 10.1111/birt.12228] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/16/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Out-of-hospital births are increasing in the United States. Our purpose was to examine trends in out-of-hospital births from 2004 to 2014, and to analyze newly available data on risk status and access to care. METHODS Newly available data from the revised birth certificate for 47 states and Washington, DC, were used to examine out-of-hospital births by characteristics and to compare them with hospital births. Trends from 2004 to 2014 were also examined. RESULTS Out-of-hospital births increased by 72 percent, from 0.87 percent of United States births in 2004 to 1.50 percent in 2014. Compared with mothers who had hospital births, those with out-of-hospital births had lower prepregnancy obesity (12.5% vs 25.0%) and smoking (2.8% vs 8.5%) rates, and higher college graduation (39.3% vs 30.0%) and breastfeeding initiation (94.3% vs 80.8%) rates. Among planned home births, 67.1 percent were self-paid, compared with 31.9 percent of birth center and 3.4 percent of hospital births. Vaginal births after cesarean (VBACs) comprised 4.6 percent of planned home births and 1.6 percent of hospital and birth center births. Sociodemographic and medical risk status of out-of-hospital births improved substantially from 2004 to 2014. CONCLUSIONS Improvements in risk status of out-of-hospital births from 2004 to 2014 suggest that appropriate selection of low-risk women is improving. High rates of self-pay for the costs of out-of-hospital birth suggest serious gaps in insurance coverage, whereas higher-than-average rates of VBAC could reflect lack of access to hospital VBACs. Mandating private insurance and Medicaid coverage could substantially improve access to out-of-hospital births. Improving access to hospital VBACs might reduce the number of out-of-hospital VBACs.
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Affiliation(s)
- Marian F MacDorman
- Maryland Population Research Center, University of Maryland, College Park, MD, USA
| | - Eugene Declercq
- Community Health Sciences Department, Boston University School of Public Health, Boston, MA, USA
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Cox KJ, Bovbjerg ML, Cheyney M, Leeman LM. Planned Home VBAC in the United States, 2004-2009: Outcomes, Maternity Care Practices, and Implications for Shared Decision Making. Birth 2015; 42:299-308. [PMID: 26307086 DOI: 10.1111/birt.12188] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/07/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND In the United States, the number of planned home vaginal births after cesarean (VBACs) has increased. This study describes the maternal and neonatal outcomes for women who planned a VBAC at home with midwives who were contributing data to the Midwives Alliance of North America Statistics Project 2.0 cohort during the years 2004-2009. METHOD Two subsamples were created from the parent cohort: 12,092 multiparous women without a prior cesarean and 1,052 women with a prior cesarean. Descriptive statistics were calculated for maternal and neonatal outcomes for both groups. Sensitivity analyses comparing women with a prior vaginal birth and those who were at the lowest risk with various subgroups in the parent cohort were also conducted. RESULTS Women with a prior cesarean had a VBAC rate of 87 percent, although transfer rates were higher compared with women without a prior cesarean (18% vs 7%, p < 0.001). The most common indication for transfer was failure to progress. Women with a prior cesarean had higher proportions of blood loss, maternal postpartum infections, uterine rupture, and neonatal intensive care unit admissions than those without a prior cesarean. Five neonatal deaths (4.75/1,000) occurred in the prior cesarean group compared with 1.24/1,000 in multiparas without a history of cesarean (p = 0.015). CONCLUSION Although there is a high likelihood of a vaginal birth at home, women planning a home VBAC should be counseled regarding maternal transfer rates and potential for increased risk to the newborn, particularly if uterine rupture occurs in the home setting.
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Affiliation(s)
- Kim J Cox
- College of Nursing, University of New Mexico, Albuquerque, New Mexico, USA
| | - Marit L Bovbjerg
- College of Public Health and Human Sciences, Oregon State University, Corvallis, Oregon, USA
| | - Melissa Cheyney
- Department of Anthropology, Oregon State University, Corvallis, Oregon, USA
| | - Lawrence M Leeman
- School of Medicine, Departments of Family & Community Medicine and Obstetrics & Gynecology, University of New Mexico, Albuquerque, New Mexico, USA
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Lyndon A, Lee HC, Gay C, Gilbert WM, Gould JB, Lee KA. Effect of time of birth on maternal morbidity during childbirth hospitalization in California. Am J Obstet Gynecol 2015; 213:705.e1-11. [PMID: 26196454 PMCID: PMC4631702 DOI: 10.1016/j.ajog.2015.07.018] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2015] [Revised: 05/23/2015] [Accepted: 07/13/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE This observational study aimed to determine the relationship between time of birth and maternal morbidity during childbirth hospitalization. STUDY DESIGN Composite maternal morbidities were determined using International Classification of Diseases, Ninth Revision, Clinical Modification and vital records codes, using linked hospital discharge and vital records data for 1,475,593 singleton births in California from 2005 through 2007. Time of birth, day of week, and sociodemographic, obstetric, and hospital volume risk factors were estimated using mixed effects logistic regression models. RESULTS The odds for pelvic morbidity were lowest between 11 PM-7 AM compared to other time periods and the reference value of 7-11 AM. The odds for pelvic morbidity peaked between 11 AM-7 PM (adjusted odds ratio [AOR], 1101-1500 = 1.07; 95% confidence interval [CI], 1.06-1.09; 1501-1900 = 1.08; 95% CI, 1.06-1.10). Odds for severe morbidity were higher between 11 PM-7 AM (AOR, 2301-0300 = 1.31; 95% CI, 1.21-1.41; 0301-0700 = 1.30; 95% CI, 1.20-1.41) compared to other time periods. The adjusted odds were not statistically significant for weekend birth on pelvic morbidity (AOR, Saturday = 1.00; 95% CI, 0.98-1.02]; Sunday = 1.01; 95% CI, 0.99-1.03) or severe morbidity (AOR, Saturday = 1.09; 95% CI, 1.00-1.18; Sunday = 1.03; 95% CI, 0.94-1.13). Cesarean birth, hypertensive disorders, birthweight, and sociodemographic factors that include age, race, ethnicity, and insurance status were also significantly associated with severe morbidity. CONCLUSION Even after controlling for sociodemographic factors and known risks such as cesarean birth and pregnancy complications such as hypertensive disorders, birth between 11 PM-7 AM is a significant independent risk factor for severe maternal morbidity.
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Affiliation(s)
- Audrey Lyndon
- Department of Family Health Care Nursing, University of California, San Francisco, School of Nursing, San Francisco, CA; California Maternal Quality Care Collaborative, Stanford, CA.
| | - Henry C Lee
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University, and California Perinatal Quality Care Collaborative, Stanford, CA
| | - Caryl Gay
- Department of Family Health Care Nursing, University of California, San Francisco, School of Nursing, San Francisco, CA
| | - William M Gilbert
- California Maternal Quality Care Collaborative, Stanford, CA; Sutter Health Sacramento-Sierra Region, Sacramento, CA
| | - Jeffrey B Gould
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University, and California Perinatal Quality Care Collaborative, Stanford, CA
| | - Kathryn A Lee
- Department of Family Health Care Nursing, University of California, San Francisco, School of Nursing, San Francisco, CA
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Nijagal MA, Kuppermann M, Nakagawa S, Cheng Y. Two practice models in one labor and delivery unit: association with cesarean delivery rates. Am J Obstet Gynecol 2015; 212:491.e1-8. [PMID: 25446697 DOI: 10.1016/j.ajog.2014.11.014] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Revised: 10/11/2014] [Accepted: 11/05/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVE The objective of the study was to examine the association between labor and delivery practice model and cesarean delivery rates at a community hospital. STUDY DESGIN This was a retrospective cohort study of 9381 singleton live births at 1 community hospital, at which women were provided labor and delivery care under 1 of 2 distinct practice models: a traditional private practice model and a midwife-physician laborist practice model. Cesarean rates were compared by practice model, adjusting for potential sociodemographic and clinical confounders. Statistical comparisons were performed using the χ(2) test and multivariable logistical regression. RESULTS Compared with women managed under the midwife/laborist model, women in the private model were significantly more likely to have a cesarean delivery (31.6% vs 17.3%; P < .001; adjusted odds ratio [aOR], 2.11; 95% confidence interval [CI], 1.73-2.58). Women with nulliparous, term, singleton, vertex gestations also were more likely to have a cesarean delivery if they were cared for in the private model (29.8% vs 15.9%; P < .001; aOR, 1.86; 95% CI, 1.33-2.58) as were women who had a prior cesarean delivery (71.3% vs 41.4%; P < .001; aOR, 3.19; 95% CI, 1.74-5.88). CONCLUSION In this community hospital setting, a midwife-physician laborist practice model was associated with lower cesarean rates than a private practice model.
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King TL, Pinger W. Evidence‐Based Practice for Intrapartum Care: The Pearls of Midwifery. J Midwifery Womens Health 2014; 59:572-585. [DOI: 10.1111/jmwh.12261] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Cox KJ. Counseling women with a previous cesarean birth: toward a shared decision-making partnership. J Midwifery Womens Health 2014; 59:237-45. [PMID: 24773588 DOI: 10.1111/jmwh.12177] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Pregnant women who had a previous cesarean birth must choose whether to have a repeat cesarean or to attempt a vaginal birth. Many of these women are candidates for a trial of labor. Current practice guidelines recommend that women should be thoroughly counseled during prenatal care about the benefits and harms of both a trial of labor after cesarean (TOLAC) and an elective repeat cesarean delivery and be offered the opportunity to make an informed decision about mode of birth in collaboration with their provider. The purpose of this article is to improve the process of counseling, decision making, and informed consent by increasing health care providers' knowledge about the essential elements of shared decision making. Factors that affect the decisions to be made and concepts that are critical for effective counseling are explored, including clinical considerations, women's perspectives, decision-making models, health literacy and numeracy, communicating risk, and the use of decision aids. Issues related to birth sites for TOLAC are also discussed, including access, safety, refusal of surgery, and clinical management.
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Association between vaginal birth after cesarean delivery and primary cesarean delivery rates. Obstet Gynecol 2014; 122:1010-1017. [PMID: 24104780 DOI: 10.1097/aog.0b013e3182a91e0f] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To estimate the association between vaginal birth after cesarean delivery (VBAC) rates and primary cesarean delivery rates in California hospitals. METHODS Hospital VBAC rates were calculated using birth certificate and discharge data from 2009, and hospitals were categorized by quartile of VBAC rate. Multivariable logistic regression analysis was performed to estimate the odds of cesarean delivery among low-risk nulliparous women with singleton pregnancies at term in vertex presentation (nulliparous term singleton vertex) by hospital VBAC quartile while controlling for many patient-level and hospital-level confounders. RESULTS There were 468,789 term singleton births in California in 2009 at 255 hospitals, 125,471 of which were low-risk nulliparous term singleton vertex. Vaginal birth after cesarean delivery rates varied between hospitals, with a range of 0-44.6%. Rates of cesarean delivery among low-risk nulliparous term singleton vertex women declined significantly with increasing VBAC rate. When adjusted for maternal and hospital characteristics, low-risk nulliparous term singleton vertex women who gave birth in hospitals in the highest VBAC quartile had an odds ratio of 0.55 (95% confidence interval 0.46-0.66) of cesarean delivery compared with women at hospitals with the lowest VBAC rates. Each percentage point increase in a hospital's VBAC rate was associated with a 0.65% decrease in the low-risk nulliparous term singleton vertex cesarean delivery rate. CONCLUSION Hospitals with higher rates of VBAC have lower rates of primary cesarean delivery among low-risk nulliparous women with singleton pregnancies at term in vertex presentation. LEVEL OF EVIDENCE II.
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Scott JR. Intrapartum management of trial of labour after caesarean delivery: evidence and experience. BJOG 2013; 121:157-62. [DOI: 10.1111/1471-0528.12449] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/02/2013] [Indexed: 11/29/2022]
Affiliation(s)
- JR Scott
- Department of Obstetrics and Gynecology; University of Utah Medical Center; Salt Lake City UT USA
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