Difference In Caesarean Section Rates Research Articles

Are differences in caesarean section rates between countries in Europe decreasing or increasing?

Abstract Objective Caesarean section (CS) rates differ greatly between European countries, but whether these variations in practices between countries are increasing or decreasing has not been investigated. Improved scientific evidence to underpin CS indications as well as common trends in maternal characteristics could lead to convergence of rates. This study aimed to analyse trends in CS rates between 2004 and 2020 for all births and for specific risk sub-groups. Methods The study uses data from the Euro-Peristat network which collected national-level routine data on CS overall and by sub-group using a standardised protocol on births in 2004, 2010 and 2015-2020. Sub-groups were: parity (nulliparous, multiparous), multiplicity (singleton, multiple), previous CS (yes/no), breech (yes/no) and preterm/term. 25 countries had data at all time points. We divided countries into terciles based on 2004 rates and analysed trajectories in these three groups. Results The CS rate ranged from 14.4% to 37.8% in 2004 and from 16.2% to 44.8% in 2020. Cutoffs for the terciles in 2004 were 19% et 25%. Countries in the first tercile (low rates, 9 countries) continued to have low rates with flat or mildly increasing trajectories. In the second tercile, there were two trajectories - flat or mildly increasing (3 countries) or sharper increases over time (4 countries). Countries in the highest tercile had increasing rates (8 countries). These patterns were observed most clearly in singleton and nulliparous pregnancies. For sub-group analyses, patterns varied, with some low CS countries having high CS rates for breech or preterm births, but practices within sub-groups were relatively stable over time. Conclusions Differences in overall CS rates between European countries over time have widened with more marked clustering into high and low CS groups. These analyses suggest a lack of progress in developing an evidence-base that would lead to standardisation of practice.

Effect of the smartphone application on caesarean section in women with overweight and obesity: a randomized controlled trial in China

BackgroundThe rate of caesarean section (CS) is increasing worldwide. While a CS can be life-saving when medically indicated, it can cause adverse health effects for both women and children. This trial aims to evaluate the effect of the smartphone application, which aims to control the gestational weight gain, on the rate of CS in overweight and obese women.MethodsOverweight and obese primiparas (BMI ≥ 24 kg/m2) with age between 20 and 40 years old were recruited at Beijing Obstetrics and Gynecology Hospital, and randomly assigned into the intervention group (143 cases) and the control group (138 cases). The intervention group applied the smartphone application (App) to control gestational weight gain in addition to the usual care, and the control group received the usual care. Primary outcome was cesarean section (CS) rate. Secondary outcomes included gestational hypertension, preeclampsia and eclampsia, gestational diabetes mellitus, postpartum hemorrhage, neonatal asphyxia, and macrosomia.ResultsThere was a significant difference in CS rate, with 53.3% in the intervention group and 65.4% in the control group (P = 0.044). The difference still exists in the overweight subgroup (32.6% vs. 55.6%, P = 0.04), but disappears in the obesity subgroup (63.0% vs. 69.1%, P = 0.381). The median of gestational weight gain (GWG) of the intervention group is 8.5 kg (IQR 5.5, 11.0), which is significantly less than that of the control group (median 10.0 kg, IQR [6.0, 14.0], P = 0.008). The intervention group has significantly lower rate of postpartum hemorrhage (5.19%) than the control group (12%) (P = 0.045). There were no significant differences between the groups in gestational hypertension, gestational diabetes mellitus, neonatal asphyxia, and macrosomia.ConclusionThe smartphone assisted weight control may help reduce CS rate. The effects of the smartphone application might be via the management of gestational weight gain.Trail registrationThis trial was registered at Chinese Clinical Trial Registry. Registration number is ChiCTR2300068845 (retrospectively registered, 01/03/2023).

COVID-19 and Cesarean Section Rates

Objective: This study aimed to evaluate the effect of COVID-19 infection on the rate and indications for cesarean section (CS) according to Robson's Ten-Group Classification system. Methodology: Our study was a 6-month retrospective observational study at the Maternal and Child Health Wing where every antenatal woman who was admitted irrespective of gestational age and whether in labor or not was customarily screened for COVID-19 infection. Based on the mode of delivery, all delivered women were classified into two groups: vaginal or cesarean, and the information was then further classified according to Robson's classification. Data collected were analyzed using Excel sheets, and Chi-square test was applied to evaluate if the difference in CS rates was statistically significant. Results: During COVID months, a total number of confinements were 877, among which the cesarean section were 381, contributing to a rate of 43.4%. The total COVID-19-positive confinements during the same period were 68. Group 2 formed the vast majority of CSs, followed by Group 1 and 5. During the post-COVID months, summation of confinements was 1443, among which the CS were 580, thereby contributing to a rate of 40.1%. In contrast to COVID time, Group 5 formed the greatest chunk contributing to CS rate, followed by Group 2 and 1. There was a statistically significant difference among confinements during COVID and post-COVID period and between CS rates among COVID-19 positive and negative women. Conclusion: During the COVID pandemic, there was a decrease in the number of confinement in our hospital. However, the CS rate increased and according to Robson's classification Group 1 and 2 made greatest contribution to CSs due to changed dynamics.

Interstate differences in institutional delivery and Caesarean section rates in India

In the last two decades, India witnessed a steep rise in institutional delivery (ID) rates and some increase in Caesarean section (CS) rates. Analysis of raw data from three major surveys was undertaken with the objective of identifying factors associated with both low and high institutional deliveries and Caesarean rates so that appropriate locale specific corrective interventions can be initiated. The raw data from NFHS4, AHS and DLHS4 were analysed to assess urban-rural and interstate differences in ID and CS rates in government and private institutions and CS rates in relation to sociodemographic and obstetric profile of the woman.At national level 3/4 of women had ID. There were substantial interstate variations (50·4% to 99·8%). ID rates were higher in urban areas and in DLHS4 states. CS rate in ID at the national level was 18·5%; CS rates in ID were higher in urban areas, in DLHS4 states and in private institutions in all states. Interstate differences in CS rate were high (2·4% in government institutions in Bihar to 69·2% in private institutions in West Bengal. CS rates were higher in urban, educated women from higher SLI group delivering in private institutions.National surveys help in identifying the states and institutions with lower ID rates and higher CS rates and enable the initiation of appropriate interventions to strengthen institutions. Awareness generation about adverse consequences of home deliveries and CS without obstetric indications will hasten the progress towards universal institutional delivery and optimal CS rates.

O-058 Obstetric outcomes of twin gestation after In-Vitro Fertilization and Embryo Transfer (IVT-ET) treatment in patients who underwent hysteroscopic septoplasty for subseptate uterus

Abstract Study question Is there an associated increased risk of preterm birth (PTB) in patients who underwent hysteroscopic septoplasty for subseptate uterus (SSU) with twin gestation through IVF-ET? Summary answer This study suggests an increased risk of PTB in patients, who underwent hysteroscopic septoplasty for SSU, and subsequently conceived twins after IVF-ET treatment. What is known already In general, the incidence of PTB is higher after IVF-ET treatment. In addition, Müllerian uterine anomalies, such as unicornuate uterus, are considered risk factors for PTB, even with singleton pregnancy. Furthermore, historical data suggest that some patients with uterine anomaly may have cervical incompetence. Twin gestation is associated with PTB in approximately 50% of cases. It is assumed that the obstetric outcome of twin gestation after successful septoplasty should be no different from those with normal uterine cavity. The impact of previous septoplasty for SSU on the obstetric outcomes of twin gestation after IVF-ET treatment has not been adequately studied. Study design, size, duration This retrospective cohort study included 377 fertility patients who received treatment between 2006-2019. The study group included 162 patients who underwent hysteroscopic septoplasty for SSU and subsequently conceived dichorionic-diamniotic (DI-DI) twins after IVF-ET treatment (Group 1). The control group included 215 patients who had normal endometrial cavity on hysteroscopy (#109) or Transvaginal 3D ultrasound scan with saline sonohysterogram (#106) and subsequently conceived DI-DI twins after IVF-ET treatment (Group 2). Participants/materials, setting, methods This study was conducted at an infertility clinic affiliated with an academic hospital. Demographic, clinical, and obstetric outcome data were collected for both groups and compared using appropriate statistical methods. PTB, severe PTB, extreme PTB, and peri-viable birth were defined as < 37 weeks, <32 weeks, <28 weeks and between 20 weeks-25 weeks 6 days gestation respectively. Main results and the role of chance There was no significant difference in mean age, BMI and infertility duration or in the incidence of smoking, primary infertility, tubal factors and unexplained infertility between the two groups. There was significantly lower mean baseline FSH levels (p < 0.01), lower incidence of male infertility (p < 0.001) and higher incidence of ovulatory disorders (p < 0.001) and endometriosis (p < 0.05) in Group 1 compared to Group 2. As expected, there was past history of lower parity rate (p < 0.01) and higher miscarriage rate (p < 0.001) in Group 1 compared to Group 2 prior to septum division. There was significantly higher incidence of PTB (72.8% vs 56.3%, p < 0.01), severe PTB (20.3% vs 8.2%, p < 0.01), extreme PTB (8.3% vs 3.9%, p < 0.05), and peri-viable birth (6.3% vs 1.9%, p < 0.05) in Group 1 compared to Group 2. There was no significant difference in cesarean section rate (82.8% vs 87.5%, p = 0.349) between Group1 and Group 2 respectively. There was significantly lower gestational age at birth in weeks (34.0 + 4.0 vs 35.6 + 3.0, p < 0.001), birth weight of the first newborn (2180.5 + 717.9 vs 2436.4 + 606.6, p < 0.001), and the second newborn (2235.2 + 674.2 vs 2398.0 + 537.9, p < 0.05) in grams in Group 1 compared to Group 2. Limitations, reasons for caution Our study has limitations being retrospective in nature. Data on cervical length measurements via ultrasound, if performed, was not available. However, recall bias was prevented by retrieving data from that submitted to the Society of Assisted Reproductive Technology. Additionally, procedural variation was reduced as this was a single-center study. Wider implications of the findings Our study suggests that twin gestation after IVF-ET in patients who underwent successful hysteroscopic septoplasty for SSU may increase the likelihood of PTB. Such patients may require increased surveillance with ultrasound cervical length and signs for preterm labor. Future research should focus on measures to reduce PTB in such patients. Trial registration number Not Applicable

COVID-19 and clinical outcomes of pregnancy: a comparative study

Background A series of changes in maternity care provision were implemented internationally in response to the COVID-19 pandemic. This study aimed to assess the impact of COVID-19 on maternal clinical outcomes, resulting from these changes to care provision. Methods A before and during comparative study of maternal pregnancy, childbirth, and postpartum clinical outcomes was conducted at a maternity hospital in Ireland. Inferential statistics were used to compare datasets with significance set at P<0.05. Results Overall, no difference in caesarean section rates between the two study periods was observed, although more caesarean sections were observed in multiparous women during the pandemic (30% vs 35%, P=0.01). The rate of elective compared to emergency caesarean section was also higher during the pandemic, from a proportionate difference of 3.6% pre-pandemic to 13.6% during the pandemic. Rates of induction of labour for post-dates (post-maturity induction) were also increased during the pandemic. Conclusions The changes to maternity care because of the COVID-19 pandemic appear to have affected some maternal clinical outcomes, and thus, potentially, women's overall intrapartum and postnatal health and wellbeing.

Misoprostol for labour induction.

Oral and vaginal misoprostol are effective induction methods, but there is a delicate balance between a quicker labour and avoiding side effects. In randomised comparisons with balloon catheters, oral misoprostol resulted in more vaginal births in the first 24h as well as fewer caesarean sections without an increase in hyperstimulation events. Vaginal misoprostol was most effective when used concurrently with a balloon catheter. In comparison with dinoprostone, oral misoprostol had lower rates of caesarean section and uterine hyperstimulation with foetal heart rate changes, but fewer babies were born vaginally within 24h. In contrast, vaginal misoprostol resulted in more vaginal births within 24h, with no significant differences in caesarean section rates. There were no differences in perinatal adverse events with either route. When oral and vaginal misoprostol were compared, vaginal misoprostol resulted in more vaginal births in the first 24h, but with more maternal and neonatal complications.

Factors Influencing the Caesarean Section Rates in German Hospitals in the Years 2015-2017: An Ecological Study

Studies in various other countries have shown that there are urban-rural differences in caesarean section rates. Most urban areas showed higher caesarean section rates. The aim of this study was to compare the caesarean section rates between hospitals in urban and rural areas in Germany, and to identify other factors affecting the caesarean section rate. A secondary data analysis was carried out to investigate the present research topic. The years 2015-2017 were considered, using as data sources the quality reports of the hospitals. Using the statistical program SPSS, mean value comparisons and multiple linear regressions were conducted. The mean value analysis showed no significant differences in caesarean section rate between urban and rural hospitals (2015: urban hospitals=31.87% vs. rural hospitals=31.6%, 2016: urban hospitals=31.09% vs. rural hospitals=31.04%, 2017: urban hospitals=31.26% vs. rural hospitals: 31.03%). The multiple linear regression showed that the variables "number of beds" (2015: b=0.005, 2016: b=0.007, 2017: b=0.006), "teaching activity" (2015: b=- 1.42, 2016: b=- 1.351, 2017: b=- 1.823), "number of gynaecologists per 100,000 inhabitants" (2015: b=0.198, 2016: b=0.241, 2017: b=0.254) and the "percentage of the population with a college/university degree" (2015: b=- 0.45, 2016: b=- 0.507, 2017: b=- 0.392) were significant predictors of the caesarean section rate in all years of the study. The study was able to identify hospital characteristics as well as population- and care-specific characteristics that have an influence on the caesarean section rate in a hospital. The average level of education in the district where the hospital was located was particularly relevant. Thus, caesarean section rates seem to be influenced less by population density than by the regional level of education.

Clinical analysis of pregnancy with cardiovascular diseases for a decade of Beijing Anzhen Hospital

Objective: To analyze the clinical data of pregnant women complicated with cardiovascular disease in our center in the past 10 years, and to explore the trend of incidence, clinical diagnosis, and treatment of the disease. Methods: Clinical data of pregnant women with cardiovascular disease who delivered in Beijing Anzhen Hospital, Capital Medical University from 2010 to 2019 were collected and analyzed retrospectively. According to the time of the establishment of multidisciplinary team (MDT) in the center, the pregnant women were divided into the first 5-year group (2010-2014) and the second 5-year group (2015-2019). The general data, the composition of pregnancy complicated with cardiovascular disease and the changes of maternal and infant outcomes of the two groups were analyzed. Results: (1) During 2010-2019, there were 2 267 cases of pregnancy complicated with cardiovascular disease (836 cases in the first 5-year group and 1 431 cases in the second 5-year group), with a total incidence of 10.2% (2 267/22 334). Among all kinds of cardiovascular diseases, arrhythmia (41.0%, 930/2 267) and congenital heart disease (38.2%, 865/2 267) were more common. (2) There were 212 cases (25.4%, 212/836) and 426 cases (29.8%, 426/1 431) classified as Ⅲ or Ⅳ by modified WHO cardiovascular risk classification in the first 5-year group and the second 5-year group, respectively, and the difference was statistically significant (χ²=5.076,P=0.024). Among all kinds of cardiovascular diseases, there were 111 cases (13.3%, 111/836) and 159 cases (11.1%, 159/1 431) with valvular disease in the first 5-year group and the second 5-year group, respectively. The change of the component ratio was -16.5% (the difference was significant when the absolute value of change>10%), showing a significant decreasing trend. Aortic disease was found in 16 cases (1.9%, 16/836) and 56 cases (3.9%, 56/1 431), respectively, with a significant upward trend of 105.3%. (3) The mortality rate of pregnant women with cardiovascular disease was 1.0% (22/2 267), and 1.2% (10/836) and 0.8% (12/1 431) in the first 5-year grouop and the second 5-year group, respectively. There was no significant difference between the two groups (χ²=0.702,P=0.402). ICU occupancy rates in the first 5-year group and the second 5-year group were 25.6% (214/836) and 20.7% (296/1 431), respectively, and the difference between the two groups was statistically significant (χ²=7.306,P=0.007). There were no significant differences in cesarean section rate, mortality rate and incidence of adverse events between the two groups of pregnant women, and there were no significant differences in birth weight, preterm birth rate, mortality rate and asphyxia rate between the two groups of newborns (all P>0.05). Conclusions: Pregnancy complicated with cardiovascular disease is a common cause of adverse obstetric outcomes. There are various types of specific cardiovascular diseases, and the prognosis varies greatly. In recent years, the disease composition ratio has changed, and the severity and complexity of diseases have increased. Hierarchical management, MDT and individual management could improve the treatment level and reduce adverse outcomes.

Application of remote fetal heart rate monitoring during the pandemic of COVID‑19

Objective: To explore the application of remote fetal heart rate monitoring during the pandemic of COVID‑19. Methods: The rate of cesarean section, the incidence of neonatal asphyxia, the times of self‑care, the false positive rate, and the degree of anxiety were compared between the remote fetal heart rate monitoring group and control group. Results: There was no significant difference in cesarean section rate and neonatal asphyxia rate between the two groups( P >0.05). The frequency of self‑care and the incidence of false positive in the remote fetal heart monitoring group were better than in control group( P <0.01). Compared with the remote fetal heart rate monitoring group, the control group were more likely to be anxious( P <0.01). Conclusion: Remote fetal heart rate monitoring is suitable as an effective supplement for hospital prenatal examination during the epidemic period, and it has good application prospects. © 2021, Editorial Board of Medical Journal of Wuhan University. All right reserved.

The timing of initiation of pharmacotherapy for women with gestational diabetes mellitus

BackgroundThe decision to initiate pharmacotherapy is integral in the care for pregnant women with gestational diabetes mellitus (GDM). We sought to compare pregnancy outcomes between two threshold percentages of elevated glucose values prior to initiation of pharmacotherapy for GDM. We hypothesized that a lower threshold at pharmacotherapy initiation will be associated with lower rates of adverse perinatal outcomes.MethodsThis was a retrospective cohort study of women with GDM delivering in a single tertiary care center. Pregnancy outcomes were compared using bivariable and multivariable analyses between women who started pharmacotherapy (insulin or oral hypoglycemic agent) after a failed trial of dietary modifications at two different ranges of elevated capillary blood glucose (CBG) values: Group 1 when 20–39% CBG values were above goal; Group 2 when ≥40% CBG values were above goal. The primary outcome was a composite GDM-associated neonatal adverse outcome that included: macrosomia, large for gestational age (LGA), shoulder dystocia, hypoglycemia, hyperbilirubinemia requiring phototherapy, respiratory distress syndrome, stillbirth, and neonatal demise. Secondary outcomes included cesarean delivery, preterm birth (< 37 weeks), neonatal intensive care unit (NICU) admission, and small for gestational age (SGA).ResultsA total of 417 women were included in the study. In univariable analysis, the composite neonatal outcome was statistically significantly higher in Group 2 compared to Group 1 (47.9% vs. 31.4%, p = 0.001). In addition, rates of preterm birth (15.7% vs 7.4%, p = 0.011), NICU admission (11.7% vs 4.0%, p = 0.006), and LGA (21.2% vs 9.1% p = 0.001) were higher in Group 2. In contrast, higher rates of SGA were noted in Group 1 (8.0% vs. 2.9%, p = 0.019). There was no difference in cesarean section rates. These findings persisted in multivariable analysis after adjusting for confounding factors (composite neonatal outcome aOR = 0.50, 95%CI [0.31–0.78]).ConclusionsInitiation of pharmacotherapy for GDM when 20–39% of CBG values are above goal, compared to ≥40%, was associated with decreased rates of adverse neonatal outcomes attributable to GDM. This was accompanied by higher rates of SGA among women receiving pharmacotherapy at the lower threshold. Additional studies are required to identify the optimal threshold of abnormal CBG values to initiate pharmacotherapy for GDM.

Provider Specific Nulliparous, Singleton, Vertex, Term Cesarean Rates Impact on Maternal and Neonatal Outcomes [33L

INTRODUCTION: Recent national initiatives have proposed to reduce cesarean delivery rates. Institutions have reported increased neonatal and maternal morbidity secondary to these initiatives. This study evaluated the impact of provider level nulliparous, singleton, vertex, term cesarean section rates on maternal and neonatal outcomes for all laboring patients. METHODS: This was an IRB approved retrospective study of deliveries at a tertiary healthcare system over four years from January 1, 2015 to December 31, 2018. Nulliparous, singleton, vertex, term cesarean rates were calculated for each provider. Providers that were one standard deviation above and below the mean were grouped into high NSVT providers and low NSVT providers. All laboring patients of these two provider groups were then compared for maternal and neonatal outcomes. RESULTS: Of the 5465 deliveries, there were significant differences in cesarean section rates among high NSVT providers and low NSVT providers, 22.5% vs 6.0%, P&lt;.0001. High NSVT providers had higher rates of maternal fever, 6.1% vs 4.2% (P=.0018 OR 1.47 CI 1.16-1.88), and maternal readmission, 1.6% vs 0.9% (P=.0268 OR 1.73 CI 1.07-2.83). High NSVT providers had lower rates of 3rd or 4th degree lacerations, 1.6% vs 2.4% (P=.0326 OR 0.65 CI 0.44-0.97), shoulder dystocia, 1.8% vs 2.6% (P=.0289 OR 0.66 CI 0.46-0.96), and fetal macrosomia, 0.7% vs 1.3% (P=.0250 OR 0.52 CI 0.29-0.92). All other measures were not significant. CONCLUSION: Providers with relatively high and low primary cesarean section rates exhibit different risk profiles for maternal and neonatal morbidity when examining all their laboring patients.

Differences in Cesarean section rates by fetal sex among Chinese women in the United States: Does Chinese culture play a role?

To investigate whether elements of Chinese culture, such as son preference, influence women’s mode of child delivery, this paper analyzes how fetal sex affects C-section rates among Chinese mothers compared with Japanese mothers in the United States. It uses birth certificate data from 1990 to 2000, a period when women were routinely able to learn the sex of the fetus during pregnancy. Compared with Japanese mothers, Chinese mothers were 1 percentage point more likely to undergo C-section when giving birth to boys than when giving birth to girls. This result is robust to the addition of a rich set of controls and the restriction of the sample to infants without congenital diseases or anomalies at birth. The effects are concentrated in subgroups that are more likely to prefer sons—specifically, where both parents are Asian or where mothers are first-generation immigrants. The findings offer valuable insights for health professionals into culturally driven pregnancy behaviors among Chinese women, potentially enabling them to offer more culturally appropriate healthcare as they support women in making a healthy transition to motherhood.

Double balloon catheter for labour induction at term after previous cesarean: a retrospective clinical research

Objective To determine the safety and effectiveness of double balloon catheter for labor induction in women with previous cesarean section. Methods This was a retrospective case-control study. Data from Shenzhen maternal and child healthcare hospital and Shenzhen Longgang District Maternal and Child Healthcare Hospital between 2015.01.01 to 2018.12.31 were used. A total of 156 term pregnant women, with previous one low segment cesarean section (CS) and balloon catheter for labour induction were included as case group. A total of 156 term pregnant women with previous one low segment CS and spontaneous onset of labor were included as control group. The vaginal delivery rate and maternal and infant outcomes were compared between the two groups. Results There was no significant difference in CS rate, vaginal assisted rate and vaginal spontaneous rate between the two groups (20.51% vs 15.38%, 8.97% vs 5.77%, 70.51% vs 78.85% respectively, P>0.05). And there were no significant difference in the rates of intrauterine infection, uterine rupture, postpartum hemorrhage, blood transfusion, maternal and infant mortality and neonatal transfer between the two groups. Conclusions Our study indicates that induction of labor with double balloon catheter is effective and safe in term pregnant women with previous one low segment CS. Women with previous CS and indications for labour induction should be informed about vaginal birth success rates and the alternative of elective repeat CS needs to be discussed. Key words: Labor, induced; Vaginal birth after cesarean; Catheterization

Neighborhood Income and Caesarean Section Rates at a Tertiary Care Center in Canada [23A

INTRODUCTION: With rising rates of caesarean section (CS) in Canada and worldwide, non-clinical factors for CS warrant consideration. Our objective was to determine the association between a primigravid woman's neighborhood income and rates of CS. METHODS: A retrospective cohort study was conducted at an Ontario tertiary care center from January 2003 to December 2013. Rates of CS were determined using data collected from the Discharge Abstract Database. Women with singleton live births were included. The main exposure variable was neighborhood income quintile. A multivariable model was used to adjust for covariates and provide an estimate of the independent effect of neighborhood income on CS rate. RESULTS: The study cohort comprised 32,714 women. Compared with the lowest quintile, women in the highest quintile had increased rates of CS (Relative Risk (RR) 1.06, 95% Confidence Interval (CI) [1.02, 1.11]). Following adjustment for important confounders, there was no longer an association between neighborhood income and CS rate (adjusted RR 1.00, 95% CI [0.99-1.01]). Women in the highest quintile were more likely to have greater maternal age (P<0.001). CONCLUSION: Although differences in CS rates are seen by neighborhood income quintile, they appear to be related to maternal and infant clinical factors. Neighborhood income does not appear to be an independent predictor of CS.

Female genital mutilation: Obstetric outcomes in metropolitan Sydney.

Female genital mutilation (FGM) and its impact on women's health are becoming relevant in Australia due to increases in numbers of refugees and migrants from affected countries. Notwithstanding the psychological trauma from FGM, there is a broad range of sequelae relevant to obstetrics and gynaecology, particularly related to maternal morbidity from labour and delivery. To assess the prevalence of FGM in our unit and document its effect on maternal and neonatal outcomes. Retrospective cohort study of women affected by FGM who delivered at a metropolitan hospital in Sydney over a five-year period. The primary outcome was mode of delivery and secondary outcomes addressed maternal morbidity and neonatal nursery admission compared with women unaffected by FGM. A full data set was available for 141/142 women affected by FGM. The overall prevalence of FGM was 1.64%. The majority of women affected by FGM were documented to have FGM 3 (41.1%). There was no difference in caesarean section rate. Women with FGM were less likely to be delivered by vacuum or forceps (11.1% vs 2.8%; P=0.0009). There was no difference in perineal trauma, postpartum haemorrhage and neonatal nursery admission. Women with FGM 3 were more likely to have an episiotomy (4.8% vs 25.9%; P=0.0007) without an increase in anal sphincter injury (P=0.7). Documentation complying with local policy and guidelines was poor. FGM is increasingly common in Australia. This study adds to the Australian literature quantifying the effects on obstetric outcomes in these high-risk women.

Delivery Profile and indications of Cesarean Section in a rural referral Hospital: what could be the implications?

Introduction: There is huge difference in cesarean section rate between rural (3.5%) and urban (15%) areas of Nepal. The national CS rate is around 5% whereas global CS rate is 26%. The objective of this study is to find out the delivery profile and rate and indications of CS in a rural university hospital.&#x0D; Methodology: This is a three -year’s retrospective cross-sectional study done from January 2016 to January 2019 (Magh 2072 to Poush 2075) at Karnali Academy of Health Sciences, Jumla. The data was retrieved from hospital birth profile records and analyzed using SPSS 20. Permission was taken from Institutional review committee (IRC) to conduct the study.&#x0D; Results: Total number of delivery during this period was 1841 out of which 172 were Cesarean delivery giving a CS rate of 9.3%. The most common indication of CS were fetal distress (33.7%), previous CS (9.3%), failed induction of labor (9.3%). Non progress of Labor (8.1%) and post term pregnancy (8.1%). Majority of the CS were done as an emergency procedure.&#x0D; Conclusion: The CS rate at KAHS teaching hospital was within WHO recommendation of between 5-15% and was very low in comparison to other centers situated in urban areas of the country. The indications of CS was also similar to the other national and international statistics.

Caesarean section in Palestine using the Robson Ten Group Classification System: a population-based birth cohort study

ObjectiveTo analyse the current situation of caesarean section in Palestine using the Robson Ten Group Classification System (TGCS).DesignA population-based birth cohort study.SettingObstetrical departments in three governmental hospitals in Gaza.ParticipantsAll women...

Non-clinical interventions for reducing unnecessary caesarean section.

Background Caesarean section rates are steadily increasing globally. The factors contributing to these observed increases are complex. Non-clinical interventions, those applied independent of patient care in a clinical encounter, may have a role in reducing unnecessary caesarean sections. Objectives To evaluate the effectiveness and safety of non-clinical interventions for reducing unnecessary caesarean sections. Search methods We searched the following electronic databases: the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register (29 March 2010), the Cochrane Pregnancy and Childbirth Group Specialised Register (29 March 2010), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2010, Issue 2); MEDLINE (1950 to March 2010); EMBASE (1947 to March 2010) and CINAHL (1982 to March 2010). Selection criteria We included randomised controlled trials (RCTs), quasi-experimental studies, controlled clinical trials (CCTs), controlled before and after studies (CBAs) with at least two intervention and control sites, and interrupted time series analyses (ITS) where the intervention time was clearly defined and there were at least three data points before and three after the intervention. Studies evaluated non-clinical interventions to reduce unnecessary caesarean section rates. Participants included pregnant women and their families, healthcare providers who work with expectant mothers, communities and advocacy groups. Data collection and analysis Three review authors independently assessed the quality and abstracted data of all eligible studies using a standardised data extraction form, modified from the Cochrane EPOC checklists. We contacted study authors for additional information. Main results We included 16 studies in this review. Six studies specifically targeted pregnant women. Two RCTs were shown to be effective in reducing caesarean section rates: a nurse-led relaxation training programme for women with a fear or anxiety of childbirth and birth preparation sessions. However, both RCTs were small in size and targeted younger mothers with their first pregnancies. There is insufficient evidence that prenatal education and support programmes, computer patient decision-aids, decision-aid booklets and intensive group therapy are effective. Ten studies targeted health professionals. Three of these studies were effective in reducing caesarean section rates. A cluster-RCT of guideline implementation with mandatory second opinion resulted in a small, statistically significant reduction in total caesarean section rates (adjusted risk difference (RD) -1.9; 95% confidence interval (CI) -3.8 to -0.1); this reduction was predominately in intrapartum sections. An ITS study of mandatory second opinion and peer review feedback at department meetings found statistically significant results at 48 months for reducing repeat caesarean section rates (change in level was -6.4%; 95% CI -9.7% to -3.1% and change in slope -1.14%; 95% CI -1.9% to -0.3%) but not for total caesarean section rates. A cluster-RCT of guideline implementation with support from local opinion leaders increased the proportion of women with a previous caesarean section being offered a trial of labour (absolute difference 16.8%) and the number who had a vaginal birth (VBAC rates) (absolute difference 13.5%). The P values are, however, not reported due to unit of analysis errors. There was insufficient evidence that audit and feedback, training of public health nurses, insurance reform, external peer review and legislative changes are effective. Authors' conclusions Implementation of guidelines with mandatory second opinion can lead to a small reduction in caesarean section rates, predominately in intrapartum sections. Peer review, including pre-caesarean consultation, mandatory secondary opinion and postcaesarean surveillance can lead to a reduction in repeat caesarean section rates. Guidelines disseminated with endorsement and support from local opinion leaders may increase the proportion of women with previous caesarean sections being offered a trial of labour in certain settings. Nurse-led relaxation classes and birth preparation classes may reduce caesarean section rates in low-risk pregnancies.

Comparaison du pronostic obstétrical des tentatives d’accouchement par le siège : travail spontané versus déclenchement

ObjectivesDelivery mode in breech presentation (BP) is often controversial. Spontaneous labor, when vaginal birth seems safe, allows to better estimate uterus contractility, fetus’ accommodation to maternal pelvis and optimize monitoring with a partograph. Induced labor in BP was usually contra-indicated. Lack of strong scientific evidence on this matter has permitted a progressive and careful evolution in obstetrical management, with the introduction of induced labor in BP. The aim of our study is to compare vaginal birth rates when labor is induced versus when spontaneous in BP. Maternal and fetal morbidity and mortality parameters were also evaluated. MethodsIn this retrospective study were included 206 patients carrying fetuses in BP, between June 2012 and June 2017. 182 of them had spontaneous labor and 24 experienced induced labor. Inclusion criteria were singleton pregnancy, BP after 34 weeks of gestation and vaginal delivery authorized by a senior obstetrician. Multiple pregnancy, birth before 34 weeks of gestation, uterine scar, planned caesarian section for BP, intra-uterine fetal death and medical termination of pregnancy were excluded. Induction of labor was performed for medical reason on a favorable cervix. ResultsThere was no significant difference in cesarean section rates between the two “induced” and “spontaneous” labor groups in BP (OR=1.69 [CI95%: 0.71–4.04]). We observed no difference between the two groups in neither perineum trauma nor post-partum hemorrhage. No difference was found between the two groups in rates of Apgar score<7 5minutes after birth, neonatal transfer, fetal trauma and pH at birth. ConclusionDespite our small population, it seems acceptable to propose induced labor for medical reason if cervix is favorable in BP if a protocol is available stating acceptability criteria for vaginal birth. It can avoid unnecessary caesarian section and allow better obstetrical outcome. It would be interesting to study fetal and maternal morbidity and mortality criteria in induced labor versus planned cesarean section when patients could be eligible for induced labor in BP.