Maternal clinical diagnoses and hospital variation in the risk of cesarean delivery: analyses of a National US Hospital Discharge Database

Breastfeeding Intention and Breastfeeding Postpartum Outcomes between High-Risk and Low-Risk Pregnant Women: A Greek Prospective Cohort Study

BACKGROUND

This prospective cohort study, conducted from pregnancy to six months postpartum and grounded in STROBE methodology, quantitatively explores the relationship between antenatal breastfeeding intentions and subsequent breastfeeding outcomes among high-risk pregnant women, compared to a low-risk pregnancy group.

METHODS

The study was conducted in one of the largest public hospitals in Attica that provides care to pregnant women, enrolling 380 participants divided into high-risk (n = 200) and low-risk (n = 180) cohorts. Data were collected over 20 months (starting from the end of May 2020 until January 2022), spanning from pregnancy to six months postpartum, via comprehensive questionnaires.

RESULTS

Statistical analysis revealed a pronounced correlation between prenatal breastfeeding intentions and actual breastfeeding behaviors across both groups. Specifically, 81.1% of women in the high-risk group and 82.5% in the low-risk group expressed intentions of exclusively breastfeeding during pregnancy. By six months postpartum, 54.9% of the high-risk and 64.3% of the low-risk pregnancy group managed to sustain breastfeeding. Extended antenatal hospitalization emerged as a statistically significant factor (p = 0.045) negatively impacting exclusive breastfeeding intentions among high-risk pregnancies.

CONCLUSION

The findings illuminate the critical influence of antenatal intentions on breastfeeding outcomes, particularly among high-risk pregnancies. Moreover, the study identifies the detrimental effect of prolonged hospital stays on breastfeeding aspirations. These insights underscore the necessity for nuanced, supportive interventions aimed at bolstering breastfeeding rates, thereby advancing maternal and neonatal health objectives aligned with World Health Organization recommendations.

Reducing inpatient opioid consumption after caesarean delivery: effects of an opioid stewardship programme and racial impact in a community hospital

Caesarean section is the most common inpatient surgery in the USA, with more than 1.1 million procedures in 2020. Similar to other surgical procedures, healthcare providers rely on opioids for postoperative pain management. However, current evidence shows that postpartum patients usually experience less pain due to pregnancy-related physiological changes. Owing to the current opioid crisis, public health agencies urge providers to provide rational opioid prescriptions. In addition, a personalised postoperative opioid prescription may benefit racial minorities since research shows that this population receives fewer opioids despite greater pain levels. Our project aimed to reduce inpatient opioid consumption after caesarean delivery within 6 months of the implementation of an opioid stewardship programme.A retrospective analysis of inpatient opioid consumption after caesarean delivery was conducted to determine the baseline, design the opioid stewardship programme and set goals. The plan-do-study-act method was used to implement the programme, and the results were analysed using a controlled interrupted time-series method.After implementing the opioid stewardship programme, we observed an average of 80% reduction (ratio of geometric means 0.2; 95% CI 0.2 to 0.3; p<0.001) in inpatient opioid consumption. The institution designated as control did not experience relevant changes in inpatient opioid prescriptions during the study period. In addition, the hospital where the programme was implemented was unable to reduce the difference in inpatient opioid demand between African Americans and Caucasians.Our project showed that an opioid stewardship programme for patients undergoing caesarean delivery can effectively reduce inpatient opioid use. PDSA, as a quality improvement method, is essential to address the problem, measure the results and adjust the programme to achieve goals.

Minority-Serving Hospitals Are Associated With Low Within-Hospital Disparity

BACKGROUND

Disparities in obstetric care have been well documented, but disparities in the within-hospital population have not been as extensively explored. The objective is to assess cesarean delivery rate disparities at the hospital level in a nationally recognized low risk of cesarean delivery group.

METHODS

An observational study using a national population-based database, Nationwide Inpatient Sample, from 2008 to 2011 was conducted. All patients with nulliparous, term, singleton, vertex pregnancies from Black and White patients were included. The primary outcome was delivery mode (cesarean vs vaginal). The primary independent variable was race (Black vs White).

RESULTS

A total of 1,064,351 patients were included and the overall nulliparous, term, singleton, and vertex pregnancies cesarean delivery rate was 14.1%. The within-hospital disparities of cesarean delivery rates were lower in minority-serving hospitals (OR: 1.20 95% CI: 1.12-1.28), rural hospitals (OR 1.11 95% CI: 1.02-1.20), and the South (OR 1.24 95% CI 1.19-1.30) compared to their respective counterparts. Non-minority serving hospitals (OR: 1.20 95% CI 0.12-1.25), and urban hospitals (OR1.32 95% CI 1.28-1.37), the Northeast (OR 1.41 95% CI 1.30-1.53) or West (OR 1.52 95% CI 1.38-1.67), had higher within-hospital racial disparities of cesarean delivery rates. The odds ratios reported are comparing within-hospital cesarean delivery rates in Black and White patients.

DISCUSSION

Significant within-hospital disparities of cesarean delivery rates across hospitals highlight the importance of facility-level factors. Policies aimed at advancing health equity must address hospital-level drivers of disparities in addition to structural racism.

Comparing Cesarean Birth Utilization Between US Hospitals: A Demonstration of the Robson Ten-Group Classification System for Use in Quality Improvement and Benchmarking

BACKGROUND

The World Health Organization-endorsed Robson Ten-Group Classification System (TGCS) is a standard reporting mechanism for cesarean birth, yet this approach is not widely adopted in the United States.

OBJECTIVE

To describe the application and utility of the TGCS to compare hospital-level cesarean births rates, for use in quality improvement and benchmarking.

METHODS

We conducted a descriptive, secondary data analysis of the Consortium on Safe Labor dataset using data from 228 438 women's births, from 2002 to 2008, in 12 sites across the United States. We stratified births into 10 mutually exclusive groups and calculated within-group proportions of group size and cesarean birth rates for between-hospital comparisons of cesarean birth, trial of labor after cesarean (TOLAC), and labor induction utilization.

RESULTS

There is variation in use of cesarean birth, labor induction, and TOLAC across the 12 sites.

CONCLUSION

The TGCS provides a method for between-hospital comparisons, particularly for revealing usage patterns of labor induction, TOLAC, and cesarean birth. Adoption of the TGCS in the United States would provide organizations and quality improvement leaders with an effective benchmarking tool to assist in reducing the use of cesarean birth and increasing the support of TOLAC.

Outcomes of Childbirth Education for Women With Pregnancy Complications

The purpose of this study was to examine associations between pregnancy outcomes and childbirth education, identifying any outcomes moderated by pregnancy complications. This was a secondary analysis of the Pregnancy Risk Assessment Monitoring System, Phase 8 data for four states. Logistic regression models compared outcomes with childbirth education for three subgroups: women with no pregnancy complications, women with gestational diabetes, and women with gestational hypertension. Women with pregnancy complications do not receive the same benefit from attending childbirth education as women with no pregnancy complications. Women with gestational diabetes who attended childbirth education were more likely to have a cesarean birth. The childbirth education curriculum may need to be altered to provide maximum benefits for women with pregnancy complications.

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

OBJECTIVE

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

DATA SOURCES AND STUDY SETTING

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

STUDY DESIGN

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

DATA COLLECTION/EXTRACTION METHODS

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

PRINCIPAL FINDINGS

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

CONCLUSIONS

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

Birth equity on the front lines: Impact of a community-based doula program in Brooklyn, NY

BACKGROUND

We assessed whether participation in Healthy Start Brooklyn's By My Side Birth Support Program-a maternal-health program providing community-based doula support during pregnancy, labor and delivery, and the early postpartum period-was associated with improved birth outcomes. By My Side takes a strength-based approach that aligns with the doula principles of respecting the client's autonomy, providing culturally appropriate care without judgment or conditions, and promoting informed decision making.

METHODS

Using a matched cohort design, birth certificate records for By My Side participants from 2010 through 2017 (n = 603) were each matched to three controls who also lived in the program area (n = 1809). Controls were matched on maternal age, race/ethnicity, education level, and trimester of prenatal-care initiation, using the simple random sampling method. The sample was restricted to singleton births. The odds of preterm birth, low birthweight, and cesarean birth were estimated, using conditional logistic regression.

RESULTS

By My Side participants had lower odds of having a preterm birth (5.6% vs 11.9%, P < .0001) or a low-birthweight baby (5.8% vs 9.7%, P = .0031) than controls. There was no statistically significant difference in the odds of cesarean delivery.

CONCLUSION

Participation in the By My Side Birth Support Program was associated with lower odds of preterm birth and low birthweight for participants, who were predominantly Black and Hispanic. Investing in doula services is an important way to address birth inequities among higher risk populations such as birthing people of color and those living in poverty. It could also help shape a new vision of the maternal-health system, placing the needs and well-being of birthing people at the center.

Outcomes of Childbirth Education in PRAMS, Phase 8

OBJECTIVE

To determine if childbirth education is associated with improved outcomes for national maternal child health goals in the United States.

METHODS

This was a secondary analysis of PRAMS data. The sample was limited to survey respondents who answered a question "During your most recent pregnancy, did you take a class or classes to prepare for childbirth and learn what to expect during labor and delivery?" The outcomes included nine national objectives from Title V and Healthy People. Logistic regression models were built with control for characteristics associated with attending childbirth education. Odds ratios were converted to adjusted risk ratios for interpretation. Stratification by maternal race/ethnicity and use of Medicaid identified opportunities for improvement in childbirth education.

RESULTS

Of the 2,256 eligible respondents, 936 (41.5%) attended childbirth education. Attending childbirth education was associated with reduced likelihood of primary cesarean (ARR 0.79), increased attendance at postpartum visit (ARR 1.06), use of birth control (ARR 1.07), safe infant sleep (Back to Sleep ARR 1.04; Sleep on Own 1.12), and breastfeeding (Ever breastfeed ARR 1.08; still breastfeeding ARR 1.15). No association was found for LARC use or postpartum depression. Not all benefits of childbirth education were apparent for all racial/ethnic groups, nor for those with Medicaid insurance.

CONCLUSIONS FOR PRACTICE

Childbirth education is a community intervention that may help achieve population maternal and child health goals.

Cesarean delivery using an ERAS-CD process for nonopioid anesthesia and analgesia drug/medication management

Cesarean delivery (CD) is a surgical delivery of a neonate with surgical access through the maternal abdominal and uterine structures. The Enhanced Recovery After Surgery (ERAS) protocol is a standardized perioperative care program and surgery quality improvement process that has had global spread across numerous surgical disciplines. The medical and surgical use of opioids for pain management and the nonmedical opioid use, over the last three decades, have significantly increased the prevalence of abuse and addiction to opioids. This review summarizes pain, pregnancy substance use, and ERAS-directed analgesia and anesthesia for opioid use reduction or elimination in the operative and postoperative periods. Enhanced recovery (quality and safety) in the surgical CD context requires collaboration, consensus, and appropriate clinical prioritization to allow for the identification of 'the right patient, in the right clinical situation, with the right informed consent, and the right clinical care team and health system'.

Improving communication and teamwork during labor: A feasibility, acceptability, and safety study

BACKGROUND

TeamBirth was designed to promote best practices in shared decision making (SDM) among care teams for people giving birth. Although leading health organizations recommend SDM to address gaps in quality of care, these recommendations are not consistently implemented in labor and delivery.

METHODS

We conducted a mixed-methods trial of TeamBirth among eligible laboring patients and all clinicians (nurses, midwives, and obstetricians) at four high-volume hospitals during April 2018 to September 2019. We used patient and clinician surveys, abstracted clinical data, and administrative claims to evaluate the feasibility, acceptability, and safety of TeamBirth.

RESULTS

A total of 2,669 patients (approximately 28% of eligible delivery volume) and 375 clinicians (78% response rate) responded to surveys on their experiences with TeamBirth. Among patients surveyed, 89% reported experiencing at least one structured full care team conversation ("huddle") during labor and 77% reported experiencing multiple huddles. There was a significant relationship between the number of reported huddles and patient acceptability (P < 0.001), suggestive of a dose response. Among clinicians surveyed, 90% would recommend TeamBirth for use in other labor and delivery units. There were no significant changes in maternal and newborn safety measures.

CONCLUSIONS

Implementing a care process that aims to improve communication and teamwork during labor with high fidelity is feasible. The process is acceptable to patients and clinicians and shows no negative effects on patient safety. Future work should evaluate the effectiveness of TeamBirth in improving care experience and health outcomes.

Impact of an educational program and decision tool on choice of maternity hospital: the delivery decisions randomized clinical trial

Background

Reducing cesarean rates is a public health priority. To help pregnant people select hospitals with lower cesarean rates, numerous organizations publish publically hospital cesarean rate data. Few pregnant people use these data when deciding where to deliver. We sought to determine whether making cesarean rate data more accessible and understandable increases the likelihood of pregnant people selecting low-cesarean rate hospitals.

Methods

We conducted a 1:1 randomized controlled trial in 2019–2021 among users of a fertility and pregnancy mobile application. Eligible participants were trying to conceive for fewer than five months or were 28–104 days into their pregnancies. Of 189,456 participants approached and enrolled, 120,621 participants met entry criteria and were included in analyses. The intervention group was offered an educational program explaining the importance of hospital cesarean rates and an interactive tool presenting hospital cesarean rates as 1-to-5-star ratings. Control group users were offered an educational program about hospital choice and a hospital choice tool without cesarean rate data. The primary outcome was the star rating of the hospital selected by each patient during pregnancy. Secondary outcomes were the importance of cesarean rates in choosing a hospital and delivery method (post-hoc secondary outcome).

Results

Of 120,621 participants (mean [SD] age, 27.8 [7.9]), 12,284 (10.2%) reported their choice of hospital during pregnancy, with similar reporting rates in the intervention and control groups. Intervention group participants selected hospitals with higher star ratings (2.52 vs 2.16; difference, 0.37 [95% CI, 0.32 to 0.43] p < 0.001) and were more likely to believe that the hospitals they chose would impact their chances of having cesarean deliveries (38.5% vs 33.1%, p < 0.001) but did not assign higher priority to cesarean delivery rates when choosing their hospitals (76.2% vs 74.3%, p = 0.05). There was no difference in self-reported cesarean rates between the intervention and control groups (31.4% vs 31.4%, p = 0.98).

Conclusion

People offered an educational program and interactive tool to compare hospital cesarean rates were more likely to use cesarean data in selecting a hospital and selected hospitals with lower cesarean rates but were not less likely to have a cesarean.

Clinical Trial Registration

Registered December 9, 2016 at clinicaltrials.gov, First enrollment November 2019. ID NCT02987803, https://clinicaltrials.gov/ct2/show/NCT02987803

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-05087-y.

Implementation strategies within a complex environment: A qualitative study of a shared decision-making intervention during childbirth

BACKGROUND

Shared decision-making (SDM) may improve communication, teamwork, patient experience, respectful maternity care, and safety during childbirth. Despite these benefits, SDM is not widely implemented, and strategies for implementing SDM interventions are not well described. We assessed the acceptability and feasibility of TeamBirth, an SDM solution that centers the birthing person in decision-making through simple tools that structure communication among the care team. We identified and described implementation strategies that bridge the gap between knowledge and practice.

METHODS

We conducted a qualitative study among four hospitals in the United States to understand the acceptability and feasibility of TeamBirth. We interviewed 103 clinicians and conducted 16 focus group discussions with 52 implementers between June 2018 and October 2019. We drew on the Consolidated Framework for Implementation Research to understand acceptability and feasibility, and to identify and describe the underlying contextual factors that affected implementation.

RESULTS

We found that clinicians and implementers valued TeamBirth for promoting clarity about care plans among the direct care team and for centering the birthing person in decision-making. Contextual factors that affected implementation included strength of leadership, physician practice models, and quality improvement culture. Effective implementation strategies included regular data feedback and adapting "flexible" components of TeamBirth to the local context.

DISCUSSION

By identifying and describing TeamBirth's contextual factors and implementation strategies, our findings can help bridge the implementation gap of SDM interventions. Our in-depth analysis offers tangible lessons for other labor and delivery unit leaders as they seek to integrate SDM practices in their own settings.

Timing of Maternal Discharge after Cesarean Delivery and Risk of Maternal Readmission

OBJECTIVE

Despite legislation and hospital policies (present in some institutions) mandating a minimum length of stay in an effort to decrease the frequency of hospital readmissions, the effectiveness of this approach remains uncertain.We hypothesized that following cesarean delivery (CD), the rates of maternal readmission or unscheduled health care visits are lower in patients discharged on postoperative day (POD) 3 or ≥4 as compared with those discharged earlier on POD 2.

METHODS

This is a secondary analysis of a multicenter randomized trial comparing adjunctive azithromycin for unscheduled CD to prevent infection. Groups were compared based on the duration of hospitalization measured in days from delivery (POD 0) to day of discharge and categorized as POD 2, 3, and ≥4. The primary outcome was the composite of any maternal postpartum readmission, unscheduled clinic, or emergency room (ER) visit, within 6 weeks of delivery. Secondary outcomes included components of the primary outcome and neonatal readmissions. We excluded women with hypertensive disorders of pregnancy and infections diagnosed prior to POD 2.

RESULTS

A total of 1,391 patients were included. The rate of the primary outcome of any readmission increased with POD at discharge: 5.9% for POD 2, 9.4% for POD 3, and 10.9% for POD ≥4 group (trend for p = 0.03). The primary outcome increased with later discharge (POD ≥4 when compared with POD 2). Among components of the composite, ER and unscheduled clinic visits, but not maternal readmissions, increased with the timing of discharge for patients discharged on POD ≥4 when compared with POD 2. Using logistic regression, discharge on POD 3 and on POD ≥4 was significantly associated with the composite (adjusted odds ratios [aOR] 2.6, 95% confidence interval [CI] [1.3-5.3]; aOR 2.9, 95% CI [1.3-6.4], respectively) compared with POD 2.

CONCLUSION

The risk of maternal readmission composite following uncomplicated but unscheduled CD was not lower in patients discharged home on POD 3 or ≥4 compared with patients discharged earlier (POD 2).

KEY POINTS

· Risk of maternal readmission is higher in patients discharged on POD 3 or 4 compared with POD 2.. · No significant differences by the timing of discharge were observed for any neonatal readmissions.. · Timing of discharge should include an individualized approach with the option of discharge by POD 2..

Variation and racial/ethnic disparities in Caesarean delivery at New York City hospitals: The contribution of hospital-level factors

PURPOSE

We aimed to quantify general and specific contextual effects associated with Caesarean delivery at New York City (NYC) hospitals, overall and by maternal race/ethnicity.

METHODS

Among 127,449 singleton, nulliparous births at NYC hospitals from 2015 to 2017, we used multilevel logistic regression to examine the association of hospital characteristics (public/private ownership, teaching status and delivery caseloads) with Caesarean delivery, overall, and by maternal race/ethnicity. We estimated the intra-class correlation (ICC) to examine general contextual effects and 80% interval odds ratios (IOR) and percentage of opposed odds ratios (POOR) to examine specific contextual effects.

RESULTS

Overall, 27.8% of births were Caesareans. The general contextual (hospital) effect on Caesarean delivery was small (ICC: 1.8%). Hospital characteristics associated with Caesarean delivery differed by maternal race/ethnicity, with delivery in teaching hospitals reducing the odds of Caesarean delivery among White (IOR: 0.31, 0.86; POOR: 4.7%) and Asian women (IOR: 0.41, 0.95; POOR: 7.3%), but not among Black (IOR: 0.51, 1.34; POOR: 30.7%) or Hispanic women (IOR: 0.44, 1.24; POOR: 22.6%). Hospital ownership and caseloads were not associated with Caesarean delivery for any group.

CONCLUSION

There is little within-hospital clustering of Caesarean delivery, suggesting that Caesarean disparities may not be explained by hospital of delivery.

Development and Validation of a Nomogram to Estimate Risk of Cesarean After Induction of Labor in Term Pregnancies with an Unfavorable Cervix in Iran

This study aimed to develop and validate a labor induction nomogram for nulliparous and multiparous women who were 38 weeks pregnant or more and had their labor induced by an unfavorable cervix. This prospective study was conducted on 300 individuals (200 for nomogram development and 100 for nomogram validation). Height, body mass index at delivery, parity, gestational age, adjusted bishop score, and cesarean section risk assessment were all recorded on a checklist. Participants were followed until they gave birth, and the type of delivery was noted in the checklist. Out of 300 labor inductions, 80 (26.7%) underwent a cesarean section. Cesarean risk estimation was the only predictor of delivery type based on multivariate logistic regression. The AUC (Area Under the Curve) in development group was 0.68 and in validation group was 0.71. The developed nomogram for predicting of cesarean section risk following labor induction has a relatively good predictive value among women.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Predictors of planned caesarean section births in a sample of Romanian women

OBJECTIVES

Romania has one of the highest incidences of births by caesarean section (CS) in the European Union (EU). The present study aims to identify the possible predictors of planned caesarean section (PCS) in a convenience sample of Romanian women.

METHODS

This is a secondary analysis of the cross-sectional data collected as part of the EU-level Babies Born Better online survey from 1908 Romanian women who gave birth between 2013 and 2018. Univariable and multivariable logistic regression models were performed to identify the potential individual and health system-level predictors of PCS.

RESULTS

PCS was reported by 36.7% (n = 657) of the women. In the multivariable regression model, older maternal age (aOR: 1.10, 95% CI: 1.07-1.14) and presence of medical or non-medical problems during pregnancy (adjusted odds ratio [aOR]: 1.67, 95% CI: 1.31-2.12) were significantly associated with PCS. Conversely, birth at a very high level of competence hospital was inversely associated with PCS (aOR: 0.48, 95% CI: 0.30-0.76).

CONCLUSIONS

Our findings indicate that PCS may be associated with both individual and health system-level variables. Our results are significant because they could be used to inform decision-making processes aimed at lowering PCS incidence.

Racial and Ethnic Inequities in Cesarean Birth and Maternal Morbidity in a Low-Risk, Nulliparous Cohort

OBJECTIVE

To evaluate race and ethnicity differences in cesarean birth and maternal morbidity in low-risk nulliparous people at term.

METHODS

We conducted a secondary analysis of a randomized trial of expectant management compared with induction of labor in low-risk nulliparous people at term. The primary outcome was cesarean birth. Secondary outcome was maternal morbidity, defined as: transfusion of 4 or more units of red blood cells, any transfusion of other products, postpartum infection, intensive care unit admission, hysterectomy, venous thromboembolism, or maternal death. Multivariable modified Poisson regression was used to evaluate associations between race and ethnicity, cesarean birth, and maternal morbidity. Indication for cesarean birth was assessed using multivariable multinomial logistic regression. A mediation model was used to estimate the portion of maternal morbidity attributable to cesarean birth by race and ethnicity.

RESULTS

Of 5,759 included participants, 1,158 (20.1%) underwent cesarean birth; 1,404 (24.3%) identified as non-Hispanic Black, 1,670 (29.0%) as Hispanic, and 2,685 (46.6%) as non-Hispanic White. Adjusted models showed increased relative risk of cesarean birth among non-Hispanic Black (adjusted relative risk [aRR] 1.21, 95% CI 1.03-1.42) and Hispanic (aRR 1.26, 95% CI 1.08-1.46) people compared with non-Hispanic White people. Maternal morbidity affected 132 (2.3%) individuals, and was increased among non-Hispanic Black (aRR 2.05, 95% CI 1.21-3.47) and Hispanic (aRR 1.92, 95% CI 1.17-3.14) people compared with non-Hispanic White people. Cesarean birth accounted for an estimated 15.8% (95% CI 2.1-48.7%) and 16.5% (95% CI 4.0-44.0%) of excess maternal morbidity among non-Hispanic Black and Hispanic people, respectively.

CONCLUSION

Non-Hispanic Black and Hispanic nulliparous people who are low-risk at term undergo cesarean birth more frequently than low-risk non-Hispanic White nulliparous people. This difference accounts for a modest portion of excess maternal morbidity.

Maternal perceptions of cesarean birth care: A qualitative study to inform ERAS guideline development

BACKGROUND

Cesarean birth (CB) is the most common inpatient surgical procedure, and until recently, there were no internationally accepted, standardized clinical guidelines available. The Enhanced Recovery After Surgery (ERAS^® ) program aims to improve outcomes through the development of international guidelines (IGs). As an ERAS IG for CB was being developed, this qualitative study was conducted to explore and consolidate women's experiences with CB.

METHODS

Qualitative methods were used to assess the patient experience with current evidence-based CB protocols across operative phases. Twelve women who experienced CB at a single center in Canada were interviewed using an open-ended, semi-structured interview guide at six weeks postpartum. Two researchers coded the emerging themes separately and compared findings.

RESULTS

Women described feeling informed, but felt they did not have a choice. Presurgery, women wanted more information about the risks of CB. Preoperatively, women expressed confusion with the procedures, but felt informed about local anesthesia and thermoregulation. Post-CB, women felt informed about pain and nausea control; however, urinary catheter removal was delayed when compared to the ERAS recommendations. Information about postpartum infant care was not well communicated, as many women were uninformed about delayed cord clamping and infant thermoregulation.

CONCLUSIONS

This qualitative study provides opportunities to improve communication, the patient-practitioner relationship, and the overall satisfaction throughout the CB process. The findings support the implementation of patient decision aids and training with the shared decision model. The improved procedures recommended in the ERAS IG for CB have the potential to deliver significant improvements to patient care and patient satisfaction.

Assessing Preparedness of Labor and Delivery Personnel in Transferring to a New Unit

OBJECTIVES

This case study intends to examine how staff characteristics, training methods, and duration of training impact overall staff preparedness and comfortability when transitioning to a new Labor and Delivery.

BACKGROUND

A new medical facility offers an opportunity for greater capacity and expanding services, but it also poses new challenges for staff. Success in this transition depends on how quickly the staff can adapt to their new environment and how prepared they are to deliver high-quality care to patients.

METHODS

An optional survey was conducted to determine the staff's confidence in their training using a 5-point Likert-type scale.

RESULTS

After responses were collected, a paired samples two-sided t test revealed that there was no statistically significant change in the confidence and preparedness for staff.

CONCLUSIONS

With this overall outcome, medical facilities will have more discernment on ways to improve their employees' trust and confidence in performing their tasks and providing care while in a new environment. This will then be reflected in the care given toward patients in the future.

Cesarean delivery rates by hospital type among nulliparous and multiparous patients

BACKGROUND

Cesarean delivery rates continue to remain high despite recent attempts to decrease these rates. Prior data suggest that there is great variation in cesarean rates by hospital.

OBJECTIVE

The intent of this study is to examine the association of several hospital characteristics and cesarean delivery rates in California.

METHODS

We performed a retrospective study of singleton, non-anomalous, term (37-42 week) deliveries in California. We excluded hospitals with <50 deliveries per year and missing hospital information. We separated hospitals by volume based on previously published categories: low-volume (<1200 deliveries/year), medium-volume (1200-2399 deliveries/year), and medium-high-volume (2400-3599 deliveries/year, and high-volume (3600 deliveries/year). We also evaluated rural versus urban and non-teaching versus teaching hospitals. We examined overall cesarean rates as well as stratified by parity and with and without prior cesarean. We analyzed data with chi-square tests and multivariable logistic regression models.

RESULTS

In a total of 2,545,464 pregnancies, 772,539 (30.35%) resulted in cesarean deliveries. After controlling for race/ethnicity, age, body mass index, education, and insurance, rates of cesarean delivery were higher in low-volume hospitals (aOR: 1.07; 95% CI: 1.0-1.08) and lower in medium-high-volume hospitals (aOR: 0.97; 95% CI: 0.96-0.98) as compared to high-volume hospitals. Rural hospitals had higher rates of cesarean delivery (aOR: 1.08; 95% CI: 1.06-1.10) as compared to urban hospitals while non-teaching hospitals had higher odds of cesarean deliveries (aOR: 1.27; 95% CI: 1.25-1.28) as compared with teaching hospitals. Among nulliparous patients, medium- and medium-high-volume hospitals had lower rates of cesarean deliveries (aOR: 0.95; 95% CI: 0.93-0.96; aOR: 0.93; 95% CI: 0.91-0.94) as compared to high-volume hospitals, while non-teaching hospitals had higher rates of cesarean deliveries than teaching hospitals (aOR: 1.11; 95% CI: 1.10-1.13). Multiparous patients without prior cesarean had higher rates of cesarean delivery at low-volume hospitals and lower rates of cesarean delivery at medium-high-volumes (aOR: 1.07; 95% CI: 1.05-1.10; aOR: 0.96; 95% CI: 0.94-0.098) as compared to high-volume hospitals. Additionally, multiparous patients without prior cesarean had higher rates of cesarean delivery at non-teaching hospitals than teaching hospitals (aOR: 1.16; 95% CI: 1.13-1.19). Multiparous patients with prior cesarean had high rates of cesarean delivery at all volume hospitals with the highest odds at low-volume hospitals (aOR: 1.81; 95% CI: 1.74, 1.89) as well as at rural and non-teaching hospitals.

CONCLUSION

Cesarean delivery rates were higher at low and high-volume hospitals for nulliparous and multiparous patients without prior cesarean, but increased with decreasing hospital volume for multiparous patients with prior cesarean. Additionally, cesarean delivery was more likely at rural and non-teaching hospitals. Our results suggest that further investigation is necessary to determine the structural and mechanistic causes of the differences in practice by hospital type in order to identify targets for approaches in reducing cesarean deliveries.

Evaluating the impact of a standardized induction protocol to reduce adverse perinatal outcomes: a prospective cohort study

OBJECTIVE

Our objective was to evaluate the impact of a standardized induction protocol on reducing maternal and neonatal morbidity in women undergoing an induction with an unfavorable cervix.

STUDY DESIGN

We performed a prospective cohort study of women undergoing an induction from May 2013 to June 2015. Women who were ≥18 years, ≥37 weeks with intact membranes and an unfavorable cervix (Bishop score of ≤6 and cervical dilation ≤2 cm) with no prior cesarean were included. We compared the following outcomes between women managed with the labor protocol versus women in an observation group, managed at the discretion of the provider: Labor length, cesarean delivery, maternal and neonatal morbidity, and neonatal intensive care unit admission for >48 hours. Multivariable models incorporated confounders specific to each outcome.

RESULTS

855 women were included (491: labor protocol group; 364: observational group). Women in the labor protocol group had a shorter time to delivery (15.7 hours vs. 18.0 hours, p < .001), a decrease in maternal morbidity (7.3% vs. 11.5%, p = .04), lower rates of NICU admission >48 hours (3.5% vs 8%, p = .005), and a lower neonatal morbidity (3.0% vs. 7.7%, p = .003) compared to women in the observational group. There was no difference in rate of cesarean between the labor protocol and observational groups (27.7% vs. 32.7%, p = .13). When adjusting for confounders, women in the labor protocol group had a 60% reduction in NICU admission >48 hours (RR: 0.41, 95% CI: 0.22-0.76) and a 70% reduction in neonatal morbidity (RR: 0.31, 95% CI: 0.13-0.70). Time to delivery and maternal morbidity were not significantly different in adjusted models.

CONCLUSION

Utilization of a standardized induction protocol was associated with a significant reduction in neonatal morbidity without increasing the risk of cesarean or maternal morbidity.

Term Singleton Vertex Cesarean Birth Rates in the Military Health System

Cesarean births have increased in the United States, accounting for approximately one-third of all births. There is concern that cesarean birth is overused, due to the wide variation in rates geographically and at different institutions within the same region. Despite the rising rate, there has not been an improvement in maternal or neonatal outcomes. Consequently, the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine published recommendations aimed at the safe prevention of primary cesarean births in 2014. The purpose of this project was to identify the term singleton vertex cesarean birth rates in the Military Health System's hospitals; to compare the Military Health System's rate of term singleton vertex cesarean birth to published benchmarks; and to compare term singleton vertex cesarean birth rates over time and among facilities within the Military Health System to determine whether variation existed. This was a retrospective review of aggregate data reported by the National Perinatal Information Center. Data were analyzed over 9 years at 2-year intervals from 2011 through 2019 inclusively. The Military Health System exceeded national benchmarks for term singleton vertex cesarean birth rates and had less variation over time and among facilities.

Variation in use of Caesarean section in Norway: An application of spatio-temporal Gaussian random fields

Aims:

Caesarean section (CS) is a medical intervention performed in Norway when a surgical delivery is considered more beneficial than a vaginal. Because deliveries with higher risk are centralized to larger hospitals, use of CS varies considerably between hospitals. We describe how the use of CS varies geographically by municipality. Since indications for CS should have little variation across the relatively homogenous population of Norway, we expect fair use of CS to be evenly distributed across the municipalities.

Methods:

Data from the Medical Birth Registry of Norway were used in our analyses (810,914 total deliveries, 133,746 CSs, 440 municipalities). We propose a spatial correlation model that takes the location into account to describe the variation in use of CS across the municipalities. The R packages R-INLA and TMB are used to estimate the yearly municipal CS rate and the spatial correlation between the municipalities. We also apply stratified models for different categories of delivering women (Robson groups). Estimated rates are displayed in maps and model parameters are shown in tables.

Results:

The CS rate varies substantially between the different municipalities. As expected, there was strong correlation between neighbouring municipalities. Similar results were found for different Robson groups.

Conclusions:

The substantial difference in CS use across municipalities in Norway is not likely to be due to specific medical reasons, but rather to hospitals’ different policies towards the use of CS. The policy to be either more or less restrictive to CS was not specific to any category of deliveries.

Population risk factors for nulliparous, term, singleton, vertex caesarean birth: a national cross-sectional study

OBJECTIVE

To characterise medical, obstetric and demographic risk factors associated with nulliparous, term, singleton, vertex (NTSV) caesarean birth.

STUDY DESIGN

Cross-sectional study.

SETTING

United States delivery hospitalisations.

POPULATION

NTSV births in 2016-18 US natality data.

METHODS

This study analysed a national sample of natality data generated by the United States National Vital Statistics System. NTSV deliveries were identified. The primary outcome was caesarean birth. Risk factors including maternal age, body mass index (BMI) and pregestational diabetes were analysed. Multivariable log-linear regression models analysed factors associated with NTSV caesarean with adjusted risk ratios (aRR) as measures of effect.

RESULTS

Of 11 622 400 deliveries, 3 764 707 met NTSV criteria, and their caesarean section rate was 25.9%. Maternal age 35-39 years (aRR 1.51, 95% CI 1.50-1.52) and 40-54 years (aRR 2.03, 95% 2.00-2.05) compared with age 19-34 years; BMI 25 to <30 kg/m2 (aRR 1.32, 95% CI 1.31-1.33), 30 to <35 kg/m2 (aRR 1.57 95% CI 1.56-1.58), 35 to <40 kg/m2 (aRR 1.82, 95% CI 1.80-1.83) and ≥40 kg/m2 (aRR 2.17, 95% CI 2.15-2.19) compared with BMI 18.5-24.9 kg/m2; and pregestational diabetes (aRR 1.54, 95% CI 1.51-1.57) were all associated with increased risk. Risk factors allowed stratification of patients into high-risk versus low-risk groups. The NTSV caesarean rate was 37.9% in women who had one or more of the following characteristics: age ≥35 years, BMI ≥30 kg/m2 or pregestational diabetes. In comparison, the NTSV caesarean rate was 20.8% among women without any of these three risk factors (P < 0.01).

CONCLUSION

Among NTSV births, BMI, maternal age and medical conditions are important risk factors for caesarean delivery.

Association between the type of provider and Cesarean section delivery in India: A socioeconomic analysis of the National Family Health Surveys 1999, 2006, 2016

BACKGROUND

Prevalence of Cesarean section (C-section) is unequally distributed. Since both extremely low and high levels of C-section can not only cause adverse birth outcomes but also impose a double burden of inefficiency within maternal health care, it is important to monitor the dynamics of key factors associated with the use of C-section.

OBJECTIVES

To examine the association between type of provider and C-section in India in three-time points: 1999, 2006, and 2016, and also to assess whether this association differed across maternal education and wealth level.

METHODS

Data were from three waves of cross-sectional and nationally representative Indian National Health Family Survey: Wave II (1999), III (2006), and IV (2016). Target population is women aged 15 and 49 who had an institutional delivery for the most recent live birth during the three or five years preceding the survey (depending on the survey round). Multivariate logistic regression models adjusting for state cluster effect were performed to determine the association between the type of providers and C-section. Differential association between the type of providers and C-section by maternal education and wealth level was examined by stratified analyses.

RESULTS

The prevalence of C-section among institutional delivery increased from 20.5% in 1999 to 24.8% in 2006 while it declined to 19.4% in 2016. The positive association between private providers and C-section became stronger over the study period (Odds Ratio (OR) = 1.39, 95% Confidence Interval (CI) 1.18-1.64 in 1999, OR = 3.71 95% CI 2.93-4.70 in 2016). The association was consistently significant across all states in 2016. The gap in C-section between public and private providers was greater among less-educated and poorer women. The ORs gradually increased from the poorest to the richest quintiles, and also from the least educated group (no formal education) to the most educated group (college graduate or above).

CONCLUSIONS

Our results suggest that disparity in C-section between private and public providers has increased over the last 15 years and was higher in lower SES women. The behavior of providers needs to be closely monitored to ensure that C-section is performed only when medically justified.

Spontaneous vaginal birth varies significantly across US hospitals

BACKGROUND

Birth is the most common reason for hospitalization in the United States. Hospital variation in maternal outcomes is an important indicator of health care quality. Spontaneous vaginal birth (SVB) is the most optimal birth outcome for the majority of mothers and newborns. The purpose of this study was to examine hospital-level variation in SVB overall and among low-risk women in a four-state sample representing 25% of births in the United States in 2016.

METHODS

Women giving birth in California, Pennsylvania, New Jersey, and Florida were identified in 2016 state discharge abstracts. Patient data were merged with hospital data from the American Hospital Association's (AHA) 2016 Annual Survey. Overall and low-risk SVB rates were calculated for each hospital in the sample and stratified by bed size, teaching status, rurality, birth volume, and state.

RESULTS

Our final sample included 869 681 women who gave birth in 494 hospitals. The mean overall SVB rate in the sample was 61.1%, ranging from 16.8% to 79.9%. The mean low-risk SVB rate was 78% and ranged from 34.6% to 93.3%. Variation in SVB rates cut across all the hospital structural characteristic strata.

DISCUSSION

The wide variation in SVB rates indicates significant room for improvement in this maternal quality metric. Our finding, that hospitals of all types and locations had both low and high SVB rates, suggests that excellent maternal outcomes are possible in all hospital settings. The variation in SVB rates across hospitals warrants research into modifiable hospital factors that may be influencing SVB rates.

A Simple Approach to Adjust for Case-Mix When Comparing Institutional Cesarean Birth Rates

OBJECTIVE

This study aimed to develop a validated model to predict intrapartum cesarean in nulliparous women and to use it to adjust for case-mix when comparing institutional laboring cesarean birth (CB) rates.

STUDY DESIGN

This multicenter retrospective study used chart-abstracted data on nulliparous, singleton, term births over a 7-year period. Prelabor cesareans were excluded. Logistic regression was used to predict the probability of CB for individual pregnancies. Thirty-five potential predictive variables were evaluated including maternal demographics, prepregnancy health, pregnancy characteristics, and newborn weight and gender. Models were trained on 21,017 births during 2011 to 2015 (training cohort), and accuracy assessed by prediction on 15,045 births during 2016 to 2017 (test cohort).

RESULTS

Six variables delivered predictive success equivalent to the full set of 35 variables: maternal weight, height, and age, gestation at birth, medically-indicated induction, and birth weight. Internal validation within the training cohort gave a receiver operator curve with area under the curve (ROC-AUC) of 0.722. External validation using the test cohort gave ROC-AUC of 0.722 (0.713-0.731 confidence interval). When comparing observed and predicted CB rates at 16 institutions in the test cohort, five had significantly lower than predicted rates and three had significantly higher than predicted rates.

CONCLUSION

Six routine clinical variables used to adjust for case-mix can identify outliers when comparing institutional CB rates.

Assessing the regional policies of Italian regions in managing the Cesarean delivery phenomenon: a fractal analysis

Objectives.

Assessing the 2017 administrative data on Cesareans delivery in Italy by using fractal statistic.

Methods.

2017 administrative data on Italian Cesarean deliveries are freely available as crude numbers and rates according to each Italian region, according to Italian health institute type and according to first or repeated Cesarean. As already reported, the Italian Cesarean delivery phenomenon is in relationship with hospital, regional, cultural perspectives in caring pregnancy and delivery. Fractal statistics can best assess the biocomplexity underlying the Italian Cesarean section phenomenon. Fractal shapes and self-organized criticality of the Cesarean section phenomenon for each Italian region were done. Fractal shapes were compared to find similarities by using global test of coincidence among regression lines.

Results.

In the regions where the health care institutes are more than a type, there are evanescent similar fractal shapes. Self-organized criticality assessment demonstrates that chaos is largely involved in Cesarean delivery phenomenon in all Italian regions and in Italy. The fractal images for each region are able to highlight the item causing the deviation from fractal shapes in each region.

Conclusion.

Fractal statistics could be used to compare regional or hospital policies in performing Cesareans, starting from Cesareans rates extracted from administrative data. (www.actabiomedica.it)

Gestational Risk as a Determining Factor for Cesarean Section according to the Robson Classification Groups

OBJECTIVE

 To analyze and compare the frequency of cesarean sections and vaginal deliveries through the Robson Classification in pregnant women attended at a tertiary hospital in two different periods.

METHODS

 Cross-sectional, retrospective study of birth records, comprising 4,010 women, conducted from January 2014 to December 2015 in the only public regional referral hospital for the care of high- risk pregnancies, located in Southern Brazil.

RESULTS

 The overall cesarean section rate reached 57.5% and the main indication was the existence of a previous uterine cesarean scar. Based on the Robson Classification, groups 5 (26.3%) and 10 (17.4%) were the most frequent ones. In 2015, there was a significant increase in the frequency of groups 1 and 3 (p < 0.001), when compared with the previous year, resulting in an increase in the number of vaginal deliveries (p < 0.0001) and a reduction in cesarean section rates.

CONCLUSION

 The Robson Classification proved to be a useful tool to identify the profile of parturients and the groups with the highest risk of cesarean sections in different periods in the same service. Thus, it allows monitoring in a dynamic way the indications and delivery routes and developing actions to reduce cesarean rates according to the characteristics of the pregnant women attended.

Caesarean section rates in women in the Republic of Ireland who chose to attend their obstetrician privately: a retrospective observational study

Background

Caesarean section (CS) rates are increasing and there are wide variations in rates internationally and nationally. There is evidence that women who attend their obstetrician privately have a higher incidence of CS than those who attend publicly. The purpose of this observational study was to further investigate why CS rates may be higher in women who chose to attend their obstetrician privately.

Methods

This study analysed data collected as part of the clinical records by midwives at the woman’s first antenatal appointment in a large European maternity hospital. All women who delivered between the years 2009 and 2017 were included. Data were analysed both cross-sectionally and longitudinally.

Results

Overall, 73,266 women had a singleton pregnancy and 1830 had a multiple pregnancy. Of the packages of maternity care, 75.2% chose public, 10.8% chose semiprivate and 14.0% chose private. During the study, 11,991 women attended the hospital for their first and second pregnancies. Overall, women who attended privately were older and had higher proportions of infertility treatment and history of miscarriage (all p < 0.001) compared to those publicly-funded. Private patients were more likely to have a history of infertility, a history of miscarriage, a multiple pregnancy and to be ≥35 yrs. They had lower rates of obesity, smoking and illicit drug use in pregnancy (all p < 0.001). In women who chose private care, the overall rate of CS was higher compared to women choosing publicly-funded (42.7% vs 25.3%, p < 0.001) The increase was due to an increase in elective rather than emergency CS. The increase in elective CS fell after adjustment for clinical risks. In the longitudinal analysis, 89.7% chose the same package second time around. Women who changed from public to private care for the second pregnancy were more likely to have had a previous emergency CS or admission to the Neonatal Unit.

Conclusions

This study suggests that the increased CS rate in women privately insured may be attributed, in part, to the fact that women who can afford health insurance choose continuity of care from a senior obstetrician because they are risk adverse and wish to have the option of an elective CS.

Inter-hospital comparison of Cesarean delivery rates should not be considered to reflect quality of care without consideration of patient heterogeneity: An observational study

OBJECTIVE

Contemporary approaches to monitoring quality of care in obstetrics often focus on comparing Cesarean Delivery rates. Varied rates can complicate interpretation of quality of care. We previously developed a risk prediction tool for nulliparous women who may require intrapartum Cesarean delivery which identified five key predictors. Our objective with this study was to ascertain if patient heterogeneity can account for much of the observed variation in Cesarean delivery rates, thereby enabling Cesarean delivery rates to be a better marker of quality of care.

MATERIALS AND METHODS

This is a secondary analysis of the Genesis study. This was a large prospective study of 2336 nulliparous singleton pregnancies recruited at seven hospitals. A heterogeneity score was calculated for each hospital. An adjusted Cesarean delivery rate was also calculated incorporating the heterogeneous risk score.

RESULTS

A cut-off at the 90th percentile was determined for each predictive factor. Above the 90th percentile was considered to represent 'high risk' (with the exception of maternal height which identified those below the 10th percentile). The patient heterogeneous risk score was defined as the number of risk factors > 90th percentile (<10th percentile for height). An unequal distribution of high-risk patients between centers was observed (p < 0.001). The correlation between the Cesarean delivery rate and the patient heterogeneous risk score was high (0.76, p < 0.05). When adjusted for patient heterogeneity, Cesarean delivery rates became closer aligned.

CONCLUSION

Inter-institutional diversity is common. We suggest that crude comparison of Cesarean delivery rates between different hospitals as a marker of care quality is inappropriate. Allowing for marked differences in patient characteristics is essential for correct interpretation of such comparisons.

Dealing with highly skewed hospital length of stay distributions: The use of Gamma mixture models to study delivery hospitalizations

The increased focus on addressing severe maternal morbidity and maternal mortality has led to studies investigating patient and hospital characteristics associated with longer hospital stays. Length of stay (LOS) for delivery hospitalizations has a strongly skewed distribution with the vast majority of LOS lasting two to three days in the United States. Prior studies typically focused on common LOSs and dealt with the long LOS distribution tail in ways to fit conventional statistical analyses (e.g., log transformation, trimming). This study demonstrates the use of Gamma mixture models to analyze the skewed LOS distribution. Gamma mixture models are flexible and, do not require data transformation or removal of outliers to accommodate many outcome distribution shapes, these models allow for the analysis of patients staying in the hospital for a longer time, which often includes those women experiencing worse outcomes. Random effects are included in the model to account for patients being treated within the same hospitals. Further, the role and influence of differing placements of covariates on the results is discussed in the context of distinct model specifications of the Gamma mixture regression model. The application of these models shows that they are robust to the placement of covariates and random effects. Using New York State data, the models showed that longer LOS for childbirth hospitalizations were more common in hospitals designated to accept more complicated deliveries, across hospital types, and among Black women. Primary insurance also was associated with LOS. Substantial variation between hospitals suggests the need to investigate protocols to standardize evidence-based medical care.

Multi-level Drivers of Disparities in Hispanic Cesarean Delivery Rates in US-Mexico Border States

BACKGROUND

Hispanic women living along the US-Mexico border have higher cesarean delivery rates than non-Hispanic white women, African American women, and other Hispanic women in the USA. Their rates also exceed those of other Hispanic women in states that border Mexico and non-Hispanic white women along the border. Our objective was to determine the causes of the disparities in border Hispanic cesarean rates.

METHODS

Using the 2015 birth certificate file and other sources, we performed a twofold Oaxaca-Blinder decomposition analysis of the disparities in low-risk primary and repeat cesarean rates between Hispanic and non-Hispanic white women in the US-Mexico border counties and Hispanic women residing in nonborder counties of border states.

RESULTS

Rates of low-risk primary cesarean among border Hispanic, nonborder Hispanic, and border non-Hispanic white women were 21.1%, 15.0%, and 16.5%, respectively. Higher Hispanic concentration in county of residence, a larger proportion of for-profit hospital beds, and greater poverty accounted for 24.7%, 22.1%, and 11.1% of the border-nonborder Hispanic difference, respectively. No other variable explained more than 5% of the difference. Higher Hispanic concentration, more for-profit beds, less attendance by an MD, higher BMI, and greater poverty explained 60.6%, 42.4%, 42.4%, 27.4%, and 21.3%, respectively, of the Hispanic-non-Hispanic white difference. Hispanic concentration and for-profit beds were also important explanatory variables for low-risk repeat cesareans.

CONCLUSION

Efforts to address potentially unnecessary cesareans among Hispanic women on the border should recognize that community demographic and health delivery system characteristics are more influential than maternal medical risk factors.

The ARRIVE Trial: Interpretation from an Epidemiologic Perspective

The findings of the ARRIVE trial (A Randomized Trial of Induction Versus Expectant Management) were recently published. This multisite randomized trial was designed to provide evidence regarding whether labor induction or expectant management is associated with increased adverse perinatal outcomes and risk of cesarean birth among healthy nulliparous women at term. The trial reported that the primary outcome, a composite of adverse neonatal outcomes, was not significantly different between the 2 groups; the principal secondary outcome, cesarean birth, was significantly more common among women whose pregnancy was expectantly managed than among women whose labor was induced at 39 weeks. These results have the potential to change existing practice. Several aspects of the study design may influence its potential internal and external validity and should be considered in order to make sound causal inferences from this trial, which will in turn affect how its findings are translated to practice. Although chance and confounding are of minimal concern, given the sample size and randomization used in the study, selection bias may be a concern. Studies are vulnerable to selection bias when the sample population differs from eligible nonparticipants, including in randomized controlled trials. External validity is defined as the extent to which the study population and setting are representative of the larger source population the study intends to represent. External validity may be limited given the characteristics of the women enrolled in the ARRIVE trial and the practice settings where the study was conducted. This brief report provides concrete suggestions for further analyses that could help solidify conclusions from the trial, and for further research questions that will continue advancement toward answering this complex question of how best to manage labor and birth decisions at full term among low-risk women.

Associations Among Intrapartum Interventions and Cesarean Birth in Low-Risk Nulliparous Women with Spontaneous Onset of Labor

INTRODUCTION

Cesarean birth rates vary widely across hospitals in the United States, even among women who are considered low-risk for the procedure. This variation has been attributed to differences in health care provider practice, but few studies have explored patterns of labor management in relation to cesarean birth.

METHODS

This was a retrospective observational study of 26,259 nulliparous, term, singleton gestation, vertex presentation births following spontaneous onset of labor. Births occurred from 2002 to 2007 in 11 hospitals in the Consortium on Safe Labor. Generalized linear mixed modeling was used to examine the relationship between intrapartum interventions (amniotomy, epidural analgesia, oxytocin augmentation) used individually and in combination and the outcome of cesarean birth.

RESULTS

More than 90% of the women in this low-risk sample received at least one intervention regardless of mode of birth. Epidural analgesia was the most frequently applied intervention, both when used as a single intervention (18.7%) and in combination with other interventions (79.9%). The strongest associations between these interventions and cesarean birth were observed when 2 or 3 interventions were applied during labor. Compared with women who received no interventions, the strongest association was observed among women who received amniotomy-oxytocin augmentation (adjusted odds ratio [aOR], 1.89; 95% CI, 1.36-2.62). The use of all 3 interventions (amniotomy-epidural analgesia-oxytocin augmentation) showed a similar positive association with cesarean birth (aOR 1.83; 95% CI, 1.50-2.21).

DISCUSSION

Findings show that the combined use of amniotomy, epidural analgesia, and oxytocin augmentation is positively associated with cesarean birth. Additional research is needed to examine the timing and sequence of interventions as well as whether a causal relationship exists between combinations of interventions and cesarean birth in low-risk nulliparous women.

Pregnancy-specific anxiety and elective cesarean section in primiparas: A cohort study in China

The purpose of this study was to investigate the association between pregnancy-specific anxiety and elective cesarean section, and identify the critical period in which pregnancy-specific anxiety will affect the elective cesarean section. Primiparous women in the 1^st trimester of pregnancy were invited to participate in the cohort. General information on maternal socio-demographic characteristics and environmental exposure were collected using questionnaires. Pregnancy-specific anxiety was assessed by using pregnancy-specific anxiety questionnaire in the 1^st, 2^nd and 3^rd trimester, respectively. Delivery modes and pregnancy complications were abstracted from medical notes. Structural equation modeling (SEM) was adopted to examine the relationship between pregnancy-specific anxiety and elective cesarean section. Results indicated the overall elective cesarean section rate in this study was 45%. Among 1 874 pregnant women, 30.9% women experienced anxiety at least once during pregnancy, and 6.9% women suffered from anxiety in all three trimesters. Anxiety in the 2^nd trimester was a significant predictor for elective cesarean section. Young maternal age and low educational level had indirect effects on women’s choice of elective caesarean section through affecting pregnancy-specific anxiety. More attention should be paid to maternal psychological problems, and professional counseling needs to be strengthened to protect women from pregnancy-specific anxiety.

Unexpected term NICU admissions: a marker of obstetrical care quality?

BACKGROUND

Unexpected admissions of term neonates to the neonatal intensive care unit and unexpected postnatal complications have been proposed as neonatal-focused quality metrics for intrapartum care. Previous studies have noted significant variation in overall hospital neonatal intensive care unit admission rates; however, little is known about the influence of obstetric practices on these rates or whether variation among unanticipated admissions in low-risk, term neonates can be attributed to systemic hospital practices.

OBJECTIVE

The objective of the study was to examine the relative effects of patient characteristics and intrapartum events on unexpected neonatal intensive care unit admissions and to quantify the between-hospital variation in neonatal intensive care unit admission rates among this group of neonates.

STUDY DESIGN

We performed a retrospective cross-sectional study using data collected as part of the Consortium for Safe Labor study. Women who delivered term (≥37 weeks), singleton, nonanomalous, liveborn infants without an a priori risk for neonatal intensive care unit admission were included. The primary outcome was neonatal intensive care unit admission among this population. Multilevel mixed-effect models were used to calculate adjusted odds ratios for demographics (age, race, insurer), pregnancy characteristics (parity, gestational age, tobacco use, birthweight), maternal comorbidities (chronic and pregnancy-induced hypertension), hospital characteristics (delivery volume, hospital and neonatal intensive care unit level, academic affiliation), and intrapartum events (prolonged second stage, induction of labor, trial of labor after cesarean delivery, chorioamnionitis, meconium-stained amniotic fluid, and abruption). Intraclass correlation coefficients were used to estimate the between-hospital variance in a series of hierarchical models.

RESULTS

Of the 143,951 infants meeting all patient and hospital inclusion criteria, 7995 (5.6%) were admitted to the neonatal intensive care unit after birth. In the fully adjusted model, the factors associated with the highest odds for neonatal intensive care unit admission included: nulliparity (adjusted odds ratio, 1.62 [95% confidence interval, 1.53-1.71]), large for gestational age (adjusted odds ratio, 1.59 [95% confidence interval, 1.47-1.71]), and small for gestational age (adjusted odds ratio, 1.60 [95% confidence interval, 1.47-1.73]). Induction of labor (adjusted odds ratio, 0.95 [95% confidence interval, 0.89-1.01]) was not associated with increased odds of neonatal intensive care unit admission compared with women who labored spontaneously. The events associated with higher odds of neonatal intensive care unit admission included: prolonged second stage (adjusted odds ratio, 1.66 [95% confidence interval, 1.51-1.83]); chorioamnionitis (adjusted odds ratio, 3.89 [95% confidence interval, 3.42-4.44]), meconium-stained amniotic fluid (adjusted odds ratio, 1.96 [95% confidence interval, 1.82-2.10]), and abruption (adjusted odds ratio, 2.64 [95% confidence interval, 2.16-.21]). Compared with women who did not labor, the odds of neonatal intensive care unit admission were lower for women who labored: adjusted odds ratio, 0.48 (95% confidence interval, 0.45-0.52) for women with no uterine scar and adjusted odds ratio, 0.83 (95% confidence interval, 0.73-0.94) for women with a uterine scar. There was significant variation in neonatal intensive care unit admission rates by hospital, ranging from 2.9% to 11.2%. After accounting for case mix and hospital characteristics, the between-hospital variance was 1.9%, suggesting that little of the variation was explained by the effect of the hospital.

CONCLUSION

This study contributes to the currently limited understanding of term, neonatal intensive care unit admission rates as a marker of obstetrical care quality. We demonstrated that significant variation exists in hospital unexpected neonatal intensive care unit admission rates and that certain intrapartum events are associated with an increased risk for neonatal intensive care unit admission after delivery. However, the between-hospital variation was low. Unmeasured confounders and extrinsic factors, such as neonatal intensive care unit bed availability, may limit the ability of unexpected term neonatal intensive care unit admissions to meaningfully reflect obstetrical care quality.

Effect of Hospital Choice on the Risk of Caesarean Delivery

OBJECTIVE

This study aimed to evaluate the variation in Caesarean delivery rate (CDR) among hospitals across the United States, its effect on maternal and neonatal outcomes, and whether differences in pregnancy and hospital characteristics can explain the higher CDRs seen in certain hospitals.

METHODS

This retrospective population-based cohort study was conducted using the 2014 Healthcare and Utilization Project Nationwide Inpatient Sample. The investigators identified all hospitals with birth admissions and compared hospitals with high CDRs with hospitals with low/mid CDRs, in terms of hospital characteristics, maternal characteristics, and maternal and neonatal outcomes. Regression analyses within multiple hospital and patient characteristic strata were used to evaluate the adjusted independent effect of the hospital on the risk of Caesarean delivery (Canadian Task Force Classification II-2).

RESULTS

In this study population, 96% of U.S. hospitals had a CDR above 20%, and 5% had a CDR >40%. High-CDR hospitals (>40%) were more often privately owned, non-teaching hospitals with an older patient population. When adjusting for baseline obstetrical and hospital characteristics, high-CDR hospitals remained independently associated with an elevated risk of Caesarean delivery. These findings persisted in stratified analyses of each hospital and patient-level characteristic. Obstetrical and neonatal outcomes were comparable in all hospitals irrespective of CDR.

CONCLUSION

Hospital characteristics and case mix do not account for the significant variation in CDRs across U.S. hospitals. Individual hospitals are in themselves independent risk factors for Caesarean delivery. Choosing to give birth in a certain hospital may put women at an increased risk of having a Caesarean delivery, without maternal or neonatal benefit.

Caesarean section in uninsured women in the USA: systematic review and meta-analysis

OBJECTIVE

The aim of this study is to assess the odds of caesarean section (CS) for uninsured women in the USA and understand the underlying mechanisms as well as consequences of lower use.

STUDY DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed, Embase, the Cochrane Library and CINAHL from the first year of records to April 2018.

ELIGIBILITY CRITERIA

We included studies that reported data to allow the calculation of ORs of CS of uninsured as compared with insured women.

OUTCOMES

The prespecified primary outcome was the adjusted OR of deliveries by CS of uninsured women as compared with privately or publicly insured women. The prespecified secondary outcome was the crude OR of deliveries by CS of uninsured women as compared with insured women.

RESULTS

12 articles describing 16 separate studies involving more than 8.8 million women were included in this study. We found: 0.70 times lower odds of CS in uninsured as compared with privately insured women (95% CI 0.63 to 0.78), with no relevant heterogeneity between studies (τ2=0.01); and 0.92 times lower odds for CS in uninsured as compared with publicly insured women (95% CI 0.80 to 1.07), with no relevant heterogeneity between studies (τ2=0.02). We found 0.70 times lower odds in uninsured as compared with privately and publicly insured women (95% CI 0.69 to 0.72).

CONCLUSIONS

CSs are less likely to be performed in uninsured women as compared with insured women. While the higher rates for CS among privately insured women can be explained with financial incentives associated with private insurance, the lower odds among uninsured women draw attention at barriers to access for delivery care. In many regions, the rates for uninsured women are above, close or below the benchmarks for appropriate CS rates and could imply both, underuse and overuse.

Seeing the wood for the trees: A new way to view the human intestinal microbiome and its connection with non-communicable disease

Our paper briefly reviews the connection of the intestinal microbiome to the rise in non-communicable conditions related to atopic disease, obesity and mental health. We consider that the microbiome is best treated as if it were a single entity and have borrowed the terms semiochemical, allomone and kairomone (5) to describe interspecies relationship between the microbiome and ourselves (Fig. 1). We use the term dysbiosis to describe the breakdown of these relationships leading to disease (Fig. 2). As a result of this analysis we tentatively suggest that components of the microbiome assess microbial antigens in our food and pass this information back to our immune system via as yet undescribed chemical messengers: kairomones. We call these hypothetical microbial agents Sentinel Cells. Our suggestion is that atopic disease arises partly as a result of consuming processed food that has insufficient antigens to activate this kairomone feedback mechanism, which atrophies as a result. We note that this is potentially similar to the Old Friends concept of Rook and his co-workers (16). We suggest that obesity is a consequence of dysbiosis-induced waning of the output of allomone-like psychotropic compounds (including the known microbial metabolites dopamine and serotonin) leading to the weakening of the gut-brain axis and a negative effect on mental health. Although dysbiosis can occur in other ways, including antibiotic use and sterile caesarian section, we believe that all these problems can be overcome to provide a future free of these non-communicable diseases.

Does comparing cesarean delivery rates influence women's choice of obstetric hospital?

OBJECTIVES

Despite public reporting of wide variation in hospital cesarean delivery rates, few women access this information when deciding where to deliver. We hypothesized that making cesarean delivery rate data more easily accessible and understandable would increase the likelihood of women selecting a hospital with a low cesarean delivery rate.

STUDY DESIGN

We conducted a randomized controlled trial of 18,293 users of the Ovia Health mobile apps in 2016-2017. All enrollees were given an explanation of cesarean delivery rate data, and those randomized to the intervention group were also given an interactive tool that presented those data for the 10 closest hospitals with obstetric services. Our outcome measures were enrollees' self-reported delivery hospital and views on cesarean delivery rates.

METHODS

Intent-to-treat analysis using 2-sided Pearson's χ2 tests.

RESULTS

There was no significant difference across the experimental groups in the proportion of women who selected hospitals with low cesarean delivery rates (7.0% control vs 6.8% intervention; P = .54). Women in the intervention group were more likely to believe that hospitals in their community had differing cesarean delivery rates (66.9% vs 55.9%; P <.001) and to report that they looked at cesarean delivery rates when choosing their hospital (44.5% vs 33.9%; P <.001).

CONCLUSIONS

Providing women with an interactive tool to compare cesarean delivery rates across hospitals in their community improved women's familiarity with variation in cesarean delivery rates but did not increase their likelihood of selecting hospitals with lower rates.

Addressing unwarranted clinical variation: A rapid review of current evidence

INTRODUCTION

Unwarranted clinical variation (UCV) can be described as variation that can only be explained by differences in health system performance. There is a lack of clarity regarding how to define and identify UCV and, once identified, to determine whether it is sufficiently problematic to warrant action. As such, the implementation of systemic approaches to reducing UCV is challenging. A review of approaches to understand, identify, and address UCV was undertaken to determine how conceptual and theoretical frameworks currently attempt to define UCV, the approaches used to identify UCV, and the evidence of their effectiveness.

DESIGN

Rapid evidence assessment (REA) methodology was used.

DATA SOURCES

A range of text words, synonyms, and subject headings were developed for the major concepts of unwarranted clinical variation, standards (and deviation from these standards), and health care environment. Two electronic databases (Medline and Pubmed) were searched from January 2006 to April 2017, in addition to hand searching of relevant journals, reference lists, and grey literature.

DATA SYNTHESIS

Results were merged using reference-management software (Endnote) and duplicates removed. Inclusion criteria were independently applied to potentially relevant articles by 3 reviewers. Findings were presented in a narrative synthesis to highlight key concepts addressed in the published literature.

RESULTS

A total of 48 relevant publications were included in the review; 21 articles were identified as eligible from the database search, 4 from hand searching published work and 23 from the grey literature. The search process highlighted the voluminous literature reporting clinical variation internationally; yet, there is a dearth of evidence regarding systematic approaches to identifying or addressing UCV.

CONCLUSION

Wennberg's classification framework is commonly cited in relation to classifying variation, but no single approach is agreed upon to systematically explore and address UCV. The instances of UCV that warrant investigation and action are largely determined at a systems level currently, and stakeholder engagement in this process is limited. Lack of consensus on an evidence-based definition for UCV remains a substantial barrier to progress in this field.

Cesarean section on a rise-Does advanced maternal age explain the increase? A population register-based study

Background

In Denmark, the cesarean section rate has increased by 49% between 1998 and 2015 and accounts for 21% of all births. Cesarean sections may cause short- as well as long-term consequences for both the mother and the child and impose further risks in future pregnancies. Delaying pregnancy until advanced maternal age at childbirth has been suggested as contributing to the increase. The proportion of women giving birth at 35 years or above increased from 15% (1998) to 21% (2015). Advanced maternal age at childbirth has been found to be related to increased pre-pregnancy morbidity and associated risk factors that may contribute to an increased risk of cesarean section. The aim of this study was to examine the association between advanced maternal age and cesarean section in a Danish population and the influence of demographic, anthropometric, health, and obstetric factors on this association.

Methods

This study draws on a national population-based cohort study of all Danish births between 1998 and 2015 (N = 1,122,964). Maternal age less than 30 years serves as reference with the following age categories: (30–34 years); (35–39 years), and (40 years and above). The primary outcome was a cesarean section. Multivariate regression models with adjustment for demographic, health, pregnancy, fetal, and obstetric characteristics were performed with the results further stratified by parity.

Results

In general, a positive association between advanced maternal age and cesarean section was found. Only minor changes in the risk estimate occurred after adjustment for relevant confounders. In comparison with the reference category, nulliparous women aged 35-39- years had twice the risk for cesarean section (adjusted odds ratio (AOR) 2.18, 95% confidence interval (CI) [2.11–2.26]) whereas for women of 40 years or above, the risk was more than tripled (AOR 3.64, 95% CI [3.41–3.90]). For multiparous women aged 35-39-years the risk was more moderate, but still with an AOR of 1.56, 95% CI [1.53–1.60], and for those 40 years and above, the AOR was 2.02, 95% CI [1.92–2.09].

Conclusions

Overall, cesarean section increased with increasing maternal age. Adjustment for maternal and obstetric risk factors had only a minor influence on the association. The association was stronger in nulliparous women compared to multiparous women. Given the lack of impact of demographic and health risks on the relationship between maternal age and cesarean section, the authors suggest obstetric culture could be added to the list of risk factors for a cesarean. Future research on obstetric culture is recommended as are studies on a possible age-related decrease in the ability to maintain the progression of labor.

Trial registration

The study uses depersonalized register data and has been approved by the Danish Data Protection Agency (2015-41-4168).

Assessing the Feasibility of Measuring Variation in Facility Design Among American Childbirth Facilities

OBJECTIVE

To assess the feasibility of quantifying variation in childbirth facility design and explore the implications for childbirth service delivery across the United States.

BACKGROUND

Design has been shown to impact quality of care in childbirth. However, most prior studies use qualitative data to examine associations between the design of patient rooms and patient experience. There has been limited exploration of measures of unit design and its impact on care provision.

METHOD

We recruited 12 childbirth facilities that were diverse with regard to facility type, location, delivery volume, cesarean delivery rate, and practice model. Each facility provided annotated floor plans and participated in a site visit or telephone interview to provide information on their design and clinical practices. These data were analyzed with self-reported primary cesarean delivery rates to assess associations between design and care delivery.

RESULTS

We observed wide variation in childbirth unit design. Deliveries per labor room per year ranged from 75 to 479. The ratio of operating rooms to labor rooms ranged from 1:1 to 1:9. The average distance between labor rooms and workstations ranged from 23 to 114 ft, and the maximum distance between labor rooms ranged from 9 to 242 ft. More deliveries per room, fewer labor rooms per operating room, and longer distances between spaces were all associated with higher primary cesarean delivery rates.

CONCLUSIONS

Clinically relevant differences in design can be feasibly measured across diverse childbirth facilities. The design of these facilities may not be optimally matched to service delivery needs.

Defining the patient safety attitudes and influencing factors of health professionals working at maternity hospitals

AIM

To determine patient safety attitudes of midwives, nurses and physicians and to examine the difference or correlation in patient safety attitudes of midwives, nurses and physicians working in maternity hospitals.

BACKGROUND

It has been suggested that it is necessary to define the factors affecting patient safety attitudes of health professionals working in maternity hospitals.

METHODS

A descriptive and correlational design was employed.The sample comprised 58 midwives, 134 nurses and 63 physicians (255) in two maternity hospitals in Istanbul, Turkey. The data were collected using an 'information form' and a 'Patient Safety Attitude Questionnaire'.

RESULTS

The safety attitudes of participants were generally found to be negative. However, midwives had more positive patient safety attitudes and the age, unit, adequacy of patient safety training and the importance of patient safety were the most effective variables.

CONCLUSIONS

As health professionals working in maternity hospitals generally have negative patient safety attitudes and because patient safety training provided better attitudes among the participants, these training programmes should be developed and implemented considering the differences among age groups and units.

IMPLICATIONS FOR PRACTICE

Health professionals have different views on the patient safety culture; therefore, training needs to involve everyone to create a shared vision for patient safety.