Abstract
ObjectiveTo examine whether changing to a midwifery-led maternity service model was associated with a lower national rate of cesarean delivery. MethodsWe analyzed trends in the rate of cesarean delivery per 1000 live births between 1996 and 2010 in New Zealand. Estimates of relative increases in rate were calculated via Poisson regression for several maternal age groups over the study period. ResultsRates of cesarean delivery increased over the study period, from 156.9 per 1000 live births in 1996 to 235 per 1000 in 2010: a crude increase of 49.8%. Increasing trends were apparent in each age group, with the largest increases occurring before 2003 and relatively stable rates in the subsequent period. The smoothed estimate showed that the increase in cesarean rate across all age groups was 43.7% (95% confidence interval, 41.6–45.8) over the 15-year period. ConclusionA national midwifery-led care model was not associated with a decreased rate of cesarean delivery but, instead, with an increase similar to that in other high-resource countries. This indicates that other factors may account for the increase. Further research is needed to examine maternity outcomes associated with different models of maternity care.
Highlights
Rising rates of cesarean delivery are a cause for global concern [1]
The steepest increase was among women aged 40–54 years; increases in cesarean rates occurred across all age groups in the study period
The introduction of independent midwifery care in New Zealand was not associated with decreased cesarean rates
Summary
Rising rates of cesarean delivery are a cause for global concern [1]. The US rate increased from 205 per 1000 live births in 1996 to 328 per 1000 in 2009: an increase of 60% [2,3]. The UK reported a 52% increase in cesarean rate between 1996 and 2010 (163 and 248 per 1000 live births, respectively) [4]. Cesarean delivery is associated with increased maternal morbidity, longer maternal hospital stays, and greater complications in subsequent pregnancies—including uterine rupture and placental implantation problems—as well as respiratory problems for infants [5,6]. Possible contributing factors are increasing comorbidities associated with advanced maternal age, maternal choice, and changes in practice such as cesarean delivery for breech presentation and decreased trial of labor after cesarean [5,7]. The type of provider may influence cesarean rates, with midwives less likely than obstetricians to favor interventions such as induction and cesarean delivery [8,9]
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