The Effect of the No Pain Labor & Delivery-Global Health Initiative on Cesarean Delivery and Neonatal Outcomes in China: An Interrupted Time-Series Analysis

Labor Neuraxial Analgesia and Its Association With Perinatal Outcomes in China in 2015-2016: A Propensity Score-Matched Analysis

BACKGROUND

The use of labor neuraxial analgesia (NA) in China has increased significantly in the past decade, and the current rate of use is unknown. This study aimed to describe the epidemiology of NA based on a large multicenter cross-sectional survey, the China Labor and Delivery Survey (CLDS) (2015-2016), and to evaluate the association between NA and intrapartum caesarean delivery (CD) and maternal and neonatal outcomes.

METHODS

The CLDS was a facility-based cross-sectional investigation with a cluster random sampling scheme conducted from 2015 to 2016. A specific weight was assigned to each individual based on the sampling frame. Logistic regression was adopted to analyze the factors associated with the use of NA. A propensity score matching scheme was used to analyze the associations between NA and intrapartum CD and perinatal outcomes.

RESULTS

A total of 51,488 vaginal deliveries or intrapartum CD were included in our study, excluding prelabor CDs. The weighted NA rate was 17.3% (95% confidence interval [CI], 16.6-18.0) in this survey population. Nulliparous, previous CD, hypertensive disorders, and labor augmentation were associated with higher use of NA. In the propensity score-matched analysis, NA was associated with reduced risks of intrapartum CD, especially intrapartum CD by maternal request (adjusted odds ratio [aOR], 0.68; 95% CI, 0.60-0.78 and aOR, 0.48; 95% CI, 0.30-0.76, respectively), 3rd or 4th degree perineal laceration (aOR, 0.36; 95% CI, 0.15-0.89), and 5-minute Apgar score ≤3 (aOR, 0.15; 95% CI, 0.03-0.66).

CONCLUSIONS

The use of NA may be associated with improved obstetric outcomes, including fewer intrapartum CD, less birth canal trauma, and better neonatal outcomes in China.

Impact of the COVID-19 Pandemic on the Provision of Dialysis Service and Mortality in Veterans Receiving Maintenance Hemodialysis in the VA: An Interrupted Time-Series Analysis

INTRODUCTION

According to the US Renal Data System (USRDS), patients with end-stage kidney disease (ESKD) on maintenance dialysis had higher mortality during early COVID-19 pandemic. Less is known about the effect of the pandemic on the delivery of outpatient maintenance hemodialysis and its impact on death. We examined the effect of pandemic-related disruption on the delivery of dialysis treatment and mortality in patients with ESKD receiving maintenance hemodialysis in the Veterans Health Administration (VHA) facilities, the largest integrated national healthcare system in the USA.

METHODS

Using national VHA electronic health records data, we identified 7,302 Veterans with ESKD who received outpatient maintenance hemodialysis in VHA healthcare facilities during the COVID-19 pandemic (February 1, 2020, to December 31, 2021). We estimated the average change in the number of hemodialysis treatments received and deaths per 1,000 patients per month during the pandemic by conducting interrupted time-series analyses. We used seasonal autoregressive moving average (SARMA) models, in which February 2020 was used as the conditional intercept and months thereafter as conditional slope. The models were adjusted for seasonal variations and trends in rates during the pre-pandemic period (January 1, 2007, to January 31, 2020).

RESULTS

The number (95% CI) of hemodialysis treatments received per 1,000 patients per month during the pre-pandemic and pandemic periods were 12,670 (12,525-12,796) and 12,865 (12,729-13,002), respectively. Respective all-cause mortality rates (95% CI) were 17.1 (16.7-17.5) and 19.6 (18.5-20.7) per 1,000 patients per month. Findings from SARMA models demonstrate that there was no reduction in the dialysis treatments delivered during the pandemic (rate ratio: 0.999; 95% CI: 0.998-1.001), but there was a 2.3% (95% CI: 1.5-3.1%) increase in mortality. During the pandemic, the non-COVID hospitalization rate was 146 (95% CI: 143-149) per 1,000 patients per month, which was lower than the pre-pandemic rate of 175 (95% CI: 173-176). In contrast, there was evidence of higher use of telephone encounters during the pandemic (3,023; 95% CI: 2,957-3,089), compared with the pre-pandemic rate (1,282; 95% CI: 1,241-1,324).

CONCLUSIONS

We found no evidence that there was a disruption in the delivery of outpatient maintenance hemodialysis treatment in VHA facilities during the COVID-19 pandemic and that the modest rise in deaths during the pandemic is unlikely to be due to missed dialysis.

The effectiveness of auricular acupressure on pain management during labor: A systematic review and meta-analysis of randomized controlled trials

AIM

This meta-analysis aimed to systematically evaluate the effectiveness of auricular acupressure on pain management during labor.

METHODS

Six English and three Chinese electronic databases were comprehensively searched from inception to 6 November 2021. The PRISMA checklist was followed. The methodological quality of the included studies was assessed with the Cochrane Collaboration Bias Risk Assessment Tool. The meta-analysis was performed using Review Manager 5.3 software. Heterogeneity between studies was calculated using I² .

RESULTS

Five studies comprising 312 participants were included. The labor pain scores of the auricular acupressure group were significantly lower than those of the usual care group at cervix dilations of 6, 8, and 10 cm, with mean differences (95% confidence intervals) of -1.05 (-1.41, -0.69), -1.44 (-2.07, -0.82), and -1.96 (-3.30, -0.61), respectively. Auricular acupressure can thus effectively improve the labor pain perception at cervix dilations of 6, 8, and 10 cm. Moreover, auricular acupressure shortened the active phase, and had the trend of shortening the second and third stages of labor. There was no evidence that auricular acupressure had an effect on the rate of cesarean section or the 1 and 5 min Apgar scores.

CONCLUSION

Effective labor pain relief, better labor pain perception, and the lack of adverse effects support the use of auricular acupressure. More high-quality and rigorous trials are needed to verify our findings before we can make strong recommendations.

Improving accuracy of American Society of Anesthesiologists Physical Status using audit and feedback and artificial intelligence: a time-series analysis

BACKGROUND

While the American Society of Anesthesiologists (ASA) Physical Status (PS) is used to adjust for greater mortality risk with higher ASA PS classification, inaccurate classification can lead to an inaccurate comparison of institutions.

OBJECTIVE

The purpose of this study was to assess the effect of audit and feedback with a rule-based artificial intelligence algorithm on the accuracy of ASA PS classification.

METHODS

We reviewed 78 121 anesthetic records from 1 January 2017 to 19 February 2020. The first intervention entailed audit and feedback emphasizing accurately documenting ASA PS classification using body mass index (BMI), while the second intervention consisted of implementing a rule-based artificial intelligence algorithm. If a patient with a BMI ≥40 kg/m2 had a documented ASA PS classification of 1 or 2, the provider was alerted to change the ASA PS classification to 3 or above. The primary outcome was the overall proportion of patients with inaccurate ASA PS classification based on BMI per month. Secondary outcomes included the proportion of patients with a BMI ≥40 or a BMI 30-39.9 who had inaccurate ASA PS classification and the proportion of patients documented as having ASA 3-5. Data were analyzed using interrupted time-series analysis.

RESULTS

For the primary outcome, the slope for ASA PS classification inaccurately incorporating BMI was unchanging before the first intervention (parameter coefficient 0.002, 95% CI -0.034 to 0.038; P = 0.911). Following the first intervention, there was an immediate level change (parameter coefficient -0.821, 95% CI -1.236 to -0.0406; P < 0.001) without significant change in slope (parameter coefficient -0.048, 95% CI -0.100 to 0.004; P = 0.067). The post-intervention slope was negative (parameter coefficient -0.046, 95% CI -0.083 to -0.009; P = 0.017). Following the second intervention, there was no level change (parameter coefficient 0.203, 95% CI -0.380 to 0.463; P = 0.839) and no significant change in slope (parameter coefficient 0.013, 95% CI -0.043 to 0.043; P = 0.641). The post-intervention slope was not significant (parameter coefficient -0.034, 95% CI -0.078 to 0.010; P = 0.121). The proportion of patients whose ASA PS classification inaccurately incorporated BMI at the first and final timepoint of the study was 2.6% and 0.8%, respectively.

CONCLUSIONS

Our quality improvement efforts successfully modified clinician behavior to accurately incorporate BMI into the ASA PS classification. By combining audit and feedback methodology with a rule-based artificial intelligence algorithm, we created a process that resulted in immediate and sustained effects. Improving ASA PS classification accuracy is important because it affects quality metrics, research design, resource allocation and workflow processes.

Why is the labor epidural rate low and cesarean delivery rate high? A survey of Chinese perinatal care providers

Objective

China has a high cesarean delivery (CD) and low labor epidural analgesia (LEA) rate. This online survey was conducted to explore the reasons behind this phenomenon and potential solutions.

Methods

A voluntary, anonymous survey was distributed via both WeChat and professional websites for 4 months amongst groups of Chinese perinatal professionals. Data was collected and analyzed using a Chi-square test and presented as percentages of respondents.

Results

1412 respondents were recorded (43% anesthesiologists, 35% obstetricians, 15.5% midwives or labor and delivery nurses, and 6.5% others), and 1320 respondents were care providers. It was found that 82.7% (1092/1320) of the provider respondents used CD per patient request in fear of lawsuits or yinao/yibao and 63.4% (837/1320) used CD for respecting superstitious culture. The number one reason (noted by 60.2% (795/1320) of all the three specialties) for low LEA use was lack of anesthesia manpower without statistical difference among specialties. The most recommended solution was increasing the anesthesia workforce, proposed by 79.8% (1053/1320) of the three specialties. However, the top solution provided by the two non-anesthesia specialties is different from the one proposed by anesthesiologists. The later (83%, 504/606) suggested increasing the incentive to provide the service is more effective. The answers to questions related to medical knowledge about CD and LEA, and unwillingness of anesthesiologists, parturients and their family members to LEA were similar for the most part, while the opinions regarding low LEA use related to poor experiences and unwillingness of obstetricians and hospital administrators were significantly divided among the three specialties. In the providers’ point of view, the unwillingness to LEA from parturient’s family members was the most salient (26.1%, 345/1320), which is more than all care providers, hospital administrators, and parturients themselves (16.8%, 222/1320).

Conclusion

The reasons for high CD rate and low LEA use are multifactorial. The sociological issues (fear of yinao/yibao and superstitious culture) were the top two contributing factors for the high CD rate in China, while lack of anesthesia manpower was the top response for the low LEA use, which contributes to its being the most recommended solution overall from the three specialties. An incentive approach to providers is a short-term solution while training more perinatal care providers (especially among anesthesiologists and midwives), improving billing systems, and reforming legal systems are 3 systemic approaches to tackling this problem in the long-term.

A retrospective review of clinical and non-clinical factors associated with unscheduled cesarean deliveries at one urban medical center

OBJECTIVE

To investigate factors associated with unscheduled cesarean delivery at one urban tertiary medical center.

METHODS

A retrospective chart review was performed on 11 162 deliveries between 2009 and 2019. The dependent variable was unscheduled cesarean delivery. Covariates examined included time of delivery, as well as several maternal and pregnancy-related factors.

RESULTS

There were a total of 7037 (63.1%) vaginal, 1133 (10.1%) elective cesarean, and 2992 (26.8%) unscheduled cesarean deliveries. Independent factors associated with increased odds for unscheduled cesarean delivery included daytime delivery (odds ratio [OR] 1.29, 95% confidence interval [CI] 1.18-1.42, P < 0.001); advanced maternal age (OR 1.40, 95% CI 1.26-1.56, P < 0.001); obesity (OR 1.04, 95% CI 1.03-1.05, P < 0.001); history of previous cesarean delivery (OR 2.77, 95% CI 1.91-4.01, P < 0.001); hypertension (OR 1.72, 95% CI 1.27-2.32, P < 0.001); multiparity (OR 3.99, 95% CI 2.82-5.64, P < 0.001); pre-eclampsia (OR 1.96, 95% CI 1.33-2.89, P = 0.001); and HELLP (hemolysis, elevated liver enzymes and low platelet count) syndrome (OR 5.45, 95% CI 1.13-26.28, P = 0.035).

CONCLUSION

Factors associated with unscheduled cesarean delivery in this study cohort included daytime delivery, advanced maternal age, obesity, hypertension, previous cesarean delivery, multiparity, preterm labor, pre-eclampsia, and HELLP syndrome.