The use of a quality indicator to reduce elective repeat Caesarean section for low-risk women before 39 weeks' gestation: the Eastern Ontario experience

OBJECTIVE

Elective repeat Caesarean section (ERCS) for low-risk women at < 39 weeks' gestation has consistently been associated with increased risks to the neonate, including respiratory morbidity, NICU admission, and lengthier hospital stays than ERCS at 39 to 40 weeks' gestation. The objective of this quality improvement project was to reduce high rates of ERCS < 39 weeks across the Eastern Ontario region.

METHODS

All hospitals within the region providing care during labour and birth (n = 10) were asked to participate. Representatives from each hospital received information about their site-specific rates and knowledge-translation resources to assist them with the project. A benchmark rate for ERCS < 39 weeks was set at 30%. The rates of ERCS < 39 weeks were calculated for two different times (the 2009-2010 and 2010-2011 fiscal years) and the relative difference and 95% confidence intervals were calculated to quantify the magnitude and statistical significance of any change. Qualitative interviews were completed with key informants from each hospital.

RESULTS

The proportion of ERCS at < 39 weeks' gestation across the region in the fiscal year 2010-2011 (n = 197/497; 39.6%) was significantly decreased (relative difference: -21%; 95% CI -31% to -8%, P = 0.002) from the previous fiscal year 2009-2010 (n = 229/459; 49.9%). A number of barriers to, and facilitators of, practice change were identified.

CONCLUSION

A reduction in the rate of ERCS < 39 weeks among low-risk women was achieved across the region. Awareness of the issue, possession of site-specific data, and agreement about the evidence and the need for change are critical first steps to improving practice.

Perinatal Outcome in Women with a Vietnamese Migration Background - Retrospective Comparative Data Analysis of 3000 Deliveries

Introduction

Perinatal data of women with a Vietnamese migration background have not been systematically studied in Germany to date. Numerous details of important maternal and child outcomes were compared and analysed. The studyʼs primary parameters were the frequency of and indication for c-section.

Methodology

The perinatal data from a Berlin hospital were analysed retrospectively. The women (Vietnamese migration background vs. autochthonous) were grouped using name analysis. Datasets of 3002 women giving birth, including 999 women with a Vietnamese migration background, were included. The associations between primary or secondary cesarean delivery and different child outcomes depending on the migration background (exposure) were studied using logistical regression analysis.

Results

Women with a Vietnamese migration background have a lower c-section rate of 8.0% for primary and 12.6% for secondary c-section than women without a migration background (11.1% primary and 16.4% secondary c-section respectively). Regression analysis shows that the odds that women with a Vietnamese migration background will have a primary (OR 0.75; p = 0.0884) or secondary c-section (OR 0.82; p = 0.1137) are not significantly lower. A Vietnamese migration background was associated with higher odds for an episiotomy but not for a grade 3 – 4 perineal tear. A Vietnamese migration background does not have a significant influence on poor 5-min Apgar scores ≤ 7 and low umbilical cord arterial pH values ≤ 7.10. Newborns of mothers with a Vietnamese migration background have higher odds of a relatively higher birth weight (> 3110 g).

Summary

There was no evidence that women with a Vietnamese migration background are delivered more often by caesarean section. There were also no differences as regards important child outcome data from women in the comparator group. Overall, the results do not provide any evidence for poorer quality of care of women with a Vietnamese migration background in Berlin despite the cultural and communication barriers in the reality of care provision.

A Retrospective Perinatal Data Analysis of Immigrant and German Women from Representative Birth Cohorts at the Virchow Hospital, Berlin

Introduction: The aim of this study was to define and characterise differences in the level of obstetric care provided to immigrant and German women. Materials and Methods: An analysis of the Virchow Hospital's birth registers was conducted for the years 1974, 1984 and 1994. The study population of 5445 patients was grouped according to ancestry/family origin on the basis of a name analysis, and subsequently also according to parity (primiparous or multiparous). On name analysis 2741 women were defined as German, 1598 were grouped as women of Turkish origin and 810 as immigrants of other origin. χ² tests and Fisher's exact test were used for significance testing (significance level p < 0.05), and a logistic regression analysis was performed. Results: Rates of caesarean section, episiotomy, higher grade perineal tears and severe postpartum haemorrhage did not differ between the groups. There were however significant differences in the use of uterine stimulants, analgesics in labour and both local and regional anaesthesia, with women of Turkish origin and other immigrants receiving anaesthesia less, but oxytocin more often. Rooming-in was more common among German primipara and multipara from 1984 onwards. Discussion: This retrospective analysis of three historical birth cohorts showed significant differences in perinatal care between German and immigrant women, presumably reflecting deficits in care. It seems remarkable that this trend has not changed over a time span of three decades despite a continuous increase in immigration and acculturation. A "research paradox", however, remains: Despite these increasing rates, there are no current or older, prospective or systematic studies of obstetric care in immigrants.

Potential of Standard Perinatal Data for Measuring Violation of Birth Integrity

Background: Measuring the phenomenon of violation of birth integrity (vBI) (e.g., obstetric violence) relies in part on the availability and content of maternity care providers' data. The population coverage and linkage possibilities that these data provide make for a yet untapped potential. Although vBI is a complex phenomenon best measured with dedicated instruments, we argue that maternity care providers' data could contribute to enhance our knowledge of the manifestations and frequency of vBI, and allow for analyses across different sub-groups of the population. Looking into the German standardized perinatal data, we investigate which variables are relevant to vBI-related research, and how complete their reporting is.

Methods: First, we analyse state-of-the-art frameworks and recommendations, and, for each vBI-related domain, we search for and list corresponding variables in the perinatal data which could contribute to a better understanding of vBI issues. Second, we use an example and analyse the content of perinatal data obtained between 2013 and 2016 in the context of the BaBi birth cohort study set in Bielefeld, Germany. We use descriptive statistics to assess the completeness of the data.

Results: The vBI-related variables can be classified in three main categories: discrimination based on specific patient socio-demographic attributes (e.g., height and weight to calculate BMI before pregnancy, foreign origin), indication for medical interventions (i.e., medicalization-related variables: indication for cesarean sections and induction), and supportive care, in particular the mobilization dimension (e.g., continuous fetal heartbeat monitoring). The data analyses included 876 births, of which 601 were vaginal birth. We found poor reporting on demographic variables in terms of completeness. Medicalization and mobilization variables are better documented, although limited in scope.

Conclusions: Putting more emphasis on the completeness of standardized data could increase their potential for vBI-related research. Perinatal data alone are insufficient to assess vBI, but a broader, theory-informed discussion of indicators to be included in standardized datasets would contribute to capturing the different aspects of integrity violation in a more systematic way and expand the evidence-base on different types of vBI.

Fewer Preterm Births in the First COVID-19 Pandemic Year? An Evaluation of the Berlin Perinatal Data for the Years 2017 to 2020

Introduction The study analyzes and interprets possible effects of the COVID-19 pandemic on the preterm birth rate. Research questions included: were there fewer preterm births in Berlin in 2020, the first year of the pandemic, compared to the three years before the pandemic? Were there differences in preterm birth rates grouped according to weeks of gestation? Method The perinatal data of all singleton pregnancies were evaluated with regard to birth rates in Berlin, and the numbers of preterm neonates born in the three pre-pandemic years from 2017 to 2019 were compared to the rate for 2020, the first year of the pandemic. Results The overall number of singleton pregnancies born in maternity hospitals and labor wards in Berlin decreased in the first year of the pandemic. The percentage of preterm neonates born before 37 + 0 weeks of gestation (GW) was significantly lower in 2020 compared to the three previous years, with significantly more preterm neonates born before 28 + 0 GW and significantly fewer preterm neonates born between 28 + 0 to 35 + 0 GW. In 2020, significantly fewer neonates born before 37 + 0 weeks of gestation were delivered by primary caesarean section. The incidence of induced births was approximately the same. Conclusions In the first year of the pandemic, a range of social, iatrogenic, and biological factors may have had an impact on preterm birth rates. A Germany-wide evaluation of perinatal data across different German federal states for the period 2020 to 2022 would offer the opportunity to identify the causes of this lower rate of preterm births and determine whether conclusions can be drawn from this which would affect future strategies to reduce preterm birth rates.

Do the Antenatal Care and Perinatal Outcomes of Women with a Vietnamese Migration Background Differ from Those of Other Women?: A Retrospective Analysis

Introduction

In Germany, 0.25% of the total population are persons with a Vietnamese migration background. There are almost no studies on this particular group of immigrants. We compared the perinatal data of women with a Vietnamese migration background with the pregnancy outcomes of non-Vietnamese women also living in Germany.

Methods

After using name analysis to allocate women into different groups, the perinatal data of women with a Vietnamese migration background who gave birth between 1.1.2016 and 31.12.2019 in Campus Charité Mitte in Berlin were retrospectively evaluated. These data were compared in a 3:1 ratio with the data of women of non-Vietnamese origin and the same age and parity. Multivariate regression analysis was used to determine factors which influenced caesarean section rates, the transfer rates of neonates to the neonatal department, and the rates of higher degree perineal tears.

Results

The perinatal data of 470 women with a Vietnamese migration background, 209 (44.5%) of whom were registered as living in a refugee shelter, were compared with those of 1410 controls. An "ideal pregnancy outcome," which included giving birth after 37 + 0 weeks of gestation, a 5-minute Apgar score ≥ 8, arterial cord blood pH ≥ 7.20, no transfer of the newborn to the neonatal department, and spontaneous birth or vacuum extraction without a higher degree perineal tear, was recorded for 44.5% of women with and 38.1% of women without a Vietnamese migration background (p = 0.1), despite the lower attendance rates at antenatal screening appointments of Vietnamese women. Accommodation in a shelter for refugees was a protective factor against caesarean section (OR 0.5, 95% CI: 0.36-0.73) and transfer of the newborn to the neonatal department (OR 0.45, 95% CI: 0.23-0.89). A Vietnamese migration background was a risk factor for a third-degree perineal tear (OR 5.4, 95% CI: 1.4-21.30).

Conclusion

Despite lower levels of antenatal care, women with a Vietnamese migration background did not have poorer pregnancy outcomes.