Difference In Caesarean Section Rates Research Articles

Castor oil, bath and/or enema for cervical priming and induction of labour.

Castor oil, a potent cathartic, is derived from the bean of the castor plant. Anecdotal reports, which date back to ancient Egypt have suggested the use of castor oil to stimulate labour. Castor oil has been widely used as a traditional method of initiating labour in midwifery practice. Its role in the initiation of labour is poorly understood and data examining its efficacy within a clinical trial are limited. This is one of a series of reviews of methods of cervical ripening and labour induction using standardised methodology. To determine the effects of castor oil or enemas for third trimester cervical ripening or induction of labour in comparison with other methods of cervical ripening or induction of labour. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 April 2013) and bibliographies of relevant papers. Clinical trials comparing castor oil, bath or enemas used for third trimester cervical ripening or labour induction with placebo/no treatment or other methods listed above it on a predefined list of labour induction methods. A strategy was developed to deal with the large volume and complexity of trial data relating to labour induction. This involved a two-stage method of data extraction. Three trials, involving 233 women, are included. There was no evidence of differences in caesarean section rates between the two interventions in the two trials reporting this outcome (risk ratio (RR) 2.04, 95% confidence interval (CI) 0.92 to 4.55). There were no data presented on neonatal or maternal mortality or morbidity.There was no evidence of a difference between castor oil and placebo/no treatment for the rate of instrumental delivery, meconium-stained liquor, or Apgar score less than seven at five minutes. The number of participants was too small to detect all but large differences in outcome. All women who ingested castor oil felt nauseous (RR 59.92, 95% CI 8.46 to 424.52). The three trials included in the review contain small numbers of women. All three studies used single doses of castor oil. The results from these studies should be interpreted with caution due to the risk of bias introduced due to poor methodological quality. Further research is needed to attempt to quantify the efficacy of castor oil as an cervical priming and induction agent.

A mixed-method study of factors associated with differences in caesarean section rates at community level: The case of rural China

Objectiveto assess population-based caesarean section (CS) rates in rural China and explore determinants and reasons for choosing a CS. Designcross-sectional study, quantitative and qualitative methods, statistical modelling. Settingtwo rural counties in Anhui province, China. Participants(a) household survey participants: 2326 women who gave birth in the two counties from January 2005 to December 2006; (b) qualitative study participants: health providers at township and village level and maternal health-care providers (N=58). Measurements and findingsthe household survey were conducted among 2326 women, collecting data on socio-economic and health status and utilisation of maternal health services. Eleven Focus Group Discussions with health-care providers and users to explore perceptions surrounding CS.the CS rate in the two areas were 46.0% and 64.7%. There were complex and different interactions among social-economic and clinical determinants associated with differences in CS rates. The main determinants that emerged were maternal age, maternal education, yearly income, primiparity, uptake of antenatal care and recorded obstetric complications with complex and differing interactions for each county. Maternal fear of pain, worry about mothers' and infants' safety, not satisfied with doctors' competences and physicians' low confidence in vaginal delivery, and absence of a strong midwifery cadre together contributed to final determination of CS. Key conclusionsthe CS rates were extremely high in the two counties in rural China. Maternal socio-economic, clinic characteristics and health providers' preference contributed together to the high rates of CS. Implications for practiceevidence-based knowledge and methods to reduce unnecessary CS should be communicated to medical professionals and women. Greater comprehensive attention needs to be paid to a complex pattern of medical, socio-cultural, political and economic contexts of maternity care.

Ethnicity and risk of caesarean section in a term, nulliparous New Zealand obstetric cohort

One in four New Zealand (NZ) women undergo caesarean section (CS); however, little is understood about how ethnicity influences CS rates. Previous NZ studies do not include many of NZ's ethnic groups and have been unable to account comprehensively for clinical risk factors. To investigate ethnicity as an independent risk factor for elective and emergency CS in nulliparous women at term. We hypothesised that compared with European, Māori and Pacific women would have a lower risk of elective CS, but there would be no ethnic differences in emergency CS. This was a retrospective cohort analysis of prospectively recorded maternity data at National Women's Health, Auckland, NZ from 2006 to 2009. The study population was 11848 singleton, nulliparous, term births. Multivariable logistic regression analysis was performed for elective and emergency CS, accounting for comprehensive confounding factors. The overall CS rate was 31.2% (elective 7.8%, n=923 and emergency 23.4%, n=2770). Compared with European ethnicity, Pacific and Chinese women had a reduced odds of elective CS (adjusted odds ratios, aOR 0.42, [95% CI 0.24-0.73] and 0.68, [0.49-0.94], respectively), while Indian women had an increased odds of emergency CS (aOR 1.54, [1.26-1.88]). Rates of elective or emergency CS for other ethnicities were similar to European. After adjustment for confounding, we report ethnic differences in elective and emergency CS rates, which may be related to patient and/or care provider factors. Further prospective research is recommended to examine reasons for these ethnic differences in CS rates.

Cesarean section rate differences by migration indicators

To answer the question: are there differences in cesarean section rates among childbearing women in Canada according to selected migration indicators? Secondary analyses of 3,500 low-risk women who had given birth between January 2003 and April 2004 in one of ten hospitals in the major Canadian migrant-receiving cities (Montreal, Toronto, Vancouver) were conducted. Women were categorized as non-refugee immigrant, asylum seeker, refugee, or Canadian-born and by source country world region. Stratified analyses were performed. Cesarean section rates differed by migration status for women from two source regions: South East and Central Asia (non-refugee immigrants 26.0 %, asylum seekers 28.6 %, refugees 56.7 %, p = 0.001) and Latin America (non-refugee immigrants 37.7 %, asylum seekers 25.6 %, refugees 10.5 %, p = 0.05). Of these, low-risk refugee women who had migrated to Canada from South East and Central Asia experienced excess cesarean sections, while refugees from Latin America experienced fewer, compared to Canadian-born (25.4 %, 95 % CI 23.8-27.3). Cesarean section rates of African women were consistently high (31-33 %) irrespective of their migration status but were not statistically different from Canadian-born women. Although it did not reach statistical significance, risk for cesarean sections also differed by time since migration (≤2 years 29.8 %, >2 years 47.2 %). Migration status, source region, and time since migration are informative migration indicators for cesarean section risk.

Outcomes of planned home births and planned hospital births in low-risk women in Norway between 1990 and 2007: A retrospective cohort study

BackgroundThe safety of planned home births remains controversial in Western countries. The aim of the present study was to compare outcomes in women who planned, and were selected to, home birth at the onset of labor with women who planned for a hospital birth. MethodsData from 1631 planned home births between 1990 and 2007 were compared with a random sample of 16,310 low-risk women with planned hospital births. The primary outcomes were intrapartum intervention rates and complications. Secondary outcomes were perinatal and neonatal death rates. ResultsPrimiparas who planned home births had reduced risks for assisted vaginal delivery (OR 0.32; 95% CI 0.20–0.48), epidural analgesia (OR 0.21; CI 0.14–0.33) and dystocia (OR 0.40; CI 0.27–0.59). Multiparas who planned home births had reduced risks for operative vaginal delivery (OR 0.26; CI 0.12–0.56), epidural analgesia (OR 0.08; CI 0.04–0.16), episiotomy (OR 0.48; CI 0.31–0.75), anal sphincter tears (OR 0.29; CI 0.12–0.70), dystocia (OR 0.10; CI 0.06–0.17) and postpartum hemorrhage (OR 0.27; CI 0.17–0.41). We found no differences in cesarean section rate. Perinatal mortality rate was 0.6/1000 (CI 0–3.4) and neonatal mortality rate 0.6/1000 (CI 0–3.4) in the home birth cohort. In the hospital birth cohort, the rates were 0.6/1000 (CI 0.3–1.1) and 0.9/1000 (CI 0.5–1.5) respectively. ConclusionsPlanning for home births was associated with reduced risk of interventions and complications. The study is too small to make statistical comparisons of perinatal and neonatal mortality.

Does ultrasonographic foetal head position prior to induction of labour predict the outcome of delivery?

To examine the capacity of pre-induction sonographic assessment of occipital position of the foetal head to predict the outcome of delivery, and to assess whether sonographic foetal head position before induction of labour is related to foetal presentation at delivery. A prospective cohort study was conducted in the Máxima Medical Centre, The Netherlands. We included consecutive women in whom labour was induced. Immediately prior to induction a transabdominal ultrasound was performed to determine the position of the foetal occiput. The primary outcome was mode of delivery. We recorded maternal demographics, labour and delivery characteristics, maternal and neonatal outcomes. The association between position of the foetal head before induction of labour and the occurrence of caesarean section was addressed using univariable and logistic regression analysis. From the 50 of the 183 foetuses that started labour in occipitoposterior position, 11 persisted in occipitoposterior position until birth, whereas from the 120 foetuses that were in occipitoanterior position before induction, three children were born in an occipitoposterior position. Although we found a difference in caesarean section rate between OP position and OA position of the foetal head at sonography prior to induction, this was not statistically significant (14% versus 6.7%, OR 2.3, 95% CI 0.78-6.7). Our study demonstrates that OP position prior to labour induction does not affect mode of delivery. Sonographic assessment of the position of the foetal head prior to labour induction should not be introduced in clinical practice.

Impact of Morbid Obesity on the Mode of Delivery and Obstetric Outcome in Nulliparous Singleton Pregnancy and the Implications for Rural Maternity Services

Obesity represents a rapidly emerging epidemic amongst pregnant women. Our study looks at the impact of morbid obesity on pregnant singleton nulliparous women in comparison with normal body mass index women. We conclude that morbid obesity is associated with a significantly higher risk of pre-existing medical conditions, developing antenatal complications, induction of labour, caesarean section and greater birth weight. However, there was no significant difference in caesarean section rates when adjusted for induction of labour. We also found no significant difference in length of hospital stay, postnatal complications and neonatal morbidity.

A randomised controlled trial of caseload midwifery care: M@NGO (Midwives @ New Group practice Options)

BackgroundAustralia has an enviable record of safety for women in childbirth. There is nevertheless growing concern at the increasing level of intervention and consequent morbidity amongst childbearing women. Not only do interventions impact on the cost of services, they carry with them the potential for serious morbidities for mother and infant.Models of midwifery have proliferated in an attempt to offer women less fragmented hospital care. One of these models that is gaining widespread consumer, disciplinary and political support is caseload midwifery care. Caseload midwives manage the care of approximately 35-40 a year within a small Midwifery Group Practice (usually 4-6 midwives who plan their on call and leave within the Group Practice.) We propose to compare the outcomes and costs of caseload midwifery care compared to standard or routine hospital care through a randomised controlled trial.Methods/designA two-arm RCT design will be used. Women will be recruited from tertiary women's hospitals in Sydney and Brisbane, Australia. Women allocated to the caseload intervention will receive care from a named caseload midwife within a Midwifery Group Practice. Control women will be allocated to standard or routine hospital care. Women allocated to standard care will receive their care from hospital rostered midwives, public hospital obstetric care and community based general medical practitioner care. All midwives will collaborate with obstetricians and other health professionals as necessary according to the woman's needs.DiscussionData will be collected at recruitment, 36 weeks antenatally, six weeks and six months postpartum by web based or postal survey. With 750 women or more in each of the intervention and control arms the study is powered (based on 80% power; alpha 0.05) to detect a difference in caesarean section rates of 29.4 to 22.9%; instrumental birth rates from 11.0% to 6.8%; and rates of admission to neonatal intensive care of all neonates from 9.9% to 5.8% (requires 721 in each arm). The study is not powered to detect infant or maternal mortality, however all deaths will be reported. Other significant findings will be reported, including a comprehensive process and economic evaluation.Trial registrationAustralian New Zealand Clinical Trials Registry ACTRN12609000349246

Impact of morbid obesity on the mode of delivery and obstetric outcome in nulliparous singleton pregnancy and the implications for rural maternity services

Obesity represents a rapidly emerging epidemic amongst pregnant women. Our study looks at the impact of morbid obesity on pregnant singleton nulliparous women in comparison with normal body mass index women. We conclude that morbid obesity is associated with a significantly higher risk of pre-existing medical conditions, developing antenatal complications, induction of labour, caesarean section and greater birth weight. However, there was no significant difference in caesarean section rates when adjusted for induction of labour. We also found no significant difference in length of hospital stay, postnatal complications and neonatal morbidity.

Computerized Physician Order Entry Reduces Medication Turnaround Time of Labor Induction Agents

We sought to determine whether computerized physician order entry (CPOE) improves the induction agent turnaround time on the labor and delivery unit (L&D) compared with paper-based order entry (PBOE). We conducted a retrospective study of singleton, term pregnancies admitted to L&D for induction of labor. Outcomes of women who delivered 3 months before or 3 months after universal CPOE implementation were compared including induction agent turnaround time. The induction agent turnaround time was significantly shorter in the CPOE group ( N = 83) compared with PBOE group ( N = 71) [71 (range 8 to 411) versus 100 (2 to 442) minutes, P = 0.004]. There were no differences in cesarean section rate or length of hospital stay. After controlling for time of day of induction, induction agent, and type of order entry, CPOE continued to significantly decrease the induction agent turnaround time by 25 minutes ( P = 0.042). CPOE improved the process of induction of labor and efficiency of care of pregnant women.

P32.12: Interobserver repeatability of ultrasound 3D volume cervix in post‐term pregnancies

Results: 101 and 67 patients were enrolled in group A and group B, respectively. For each patient a median of 2.9 evaluations (group A = 2.1, group B = 3.7; P = n.s.) was performed. The indications of hospital admission were: decreased volumes of amniotic fluid (AFI <50 mm) in 34 cases, abnormal cardiotocography in 19 cases, pregnancy after 41 weeks + 5 days in 11 cases, and spontaneous labor in the other 104 cases. The difference in caesarean section rate between the two groups such as neonatal outcome, birth weight, Apgar score, pH and neonatal intensive care unit admission was not stastically significant. Conclusions: Our experience suggest that the management of postterm pregnancies might be performed until 41+5 gestational weeks in outpatients’ department, according to patients’ characteristics, with a clinical and ultrasound evaluation of fetal conditions.

A randomized controlled trial of 24‐hour vaginal dinoprostone pessary compared to gel for induction of labor in term pregnancies with a Bishop score ≤ 4

To compare 24-hour controlled-release vaginal dinoprostone pessary vs. gel for induction of labor at term in women with an unfavorable cervix. Randomized controlled trial. University hospital. A total of 133 women with singleton pregnancies, fetal cephalic presentation, Bishop score < or = 4, gestational age of 37-42 weeks, no previous cesarean section and intact membranes admitted for induction of labor. Random allocation to either 24-hour 10-mg controlled-release vaginal dinoprostone pessary or repeat doses of 2 mg vaginal dinoprostone gel. Rate of spontaneous vaginal, operative vaginal and cesarean delivery. The rate of spontaneous vaginal delivery was significantly higher in the pessary group (72%) than in the gel group (54%), paralleled by a lower rate of operative vaginal deliveries (3 vs. 15%). The difference in cesarean section rate (25 vs. 31%) did not reach statistical significance. Both methods of induction of labor appeared to be safe, with no cases of 5-minute Apgar scores < 7 or episodes of uterine hyperstimulation in either group. The medication cost was lower in the pessary group, with a median saving of 50.20 euro compared to the gel group. Both the 24-hour dinoprostone vaginal pessary and the vaginal gel appear to be safe for labor induction. In women induced at term with a Bishop score < or = 4 the pessary achieved a significantly higher rate of spontaneous vaginal delivery.

Understanding the factors associated with differences in caesarean section rates at hospital level: the case of Latin America

As in many other regions of the world, caesarean section (CS) rates in Latin America are increasing. Studies elsewhere have shown that providing feedback to caregivers regarding their own performance relative to their peers can significantly reduce the rates. Our objectives are to calculate risk-adjusted CS rates for hospitals in Latin America and to identify factors associated with differences among risk-adjusted rates. We included 120 randomly selected institutions in eight countries of Latin America, representing 97 095 pregnancies. We used random-effects models to calculate a risk-adjusted rate for each hospital and to identify hospitals significantly higher or lower than a benchmark rate. We conducted a regression analysis to identify characteristics of hospitals associated with differences among risk-adjusted rates. The overall CS rate was 35%, ranging from 0% to 85%. Risk-adjusted CS rates ranged from 11% to 78%. Three-quarters of hospitals had risk-adjusted rates significantly above the previously identified benchmark of 20%. Characteristics of institutions explained 48% of the variability among risk-adjusted rates, including being a private as opposed to a public institution, having some economic incentive for CS as opposed to no incentive, and having > or = 50 maternity beds. Strategies to halt further increases in CS rates and reduce rates to levels that reflect the best quality of care, are urgently needed worldwide. The involvement of local quality control departments is an essential component in achieving success. Our results can be used to identify institutions that can be targets for further interventions to reduce CS rates.

Significant differences in cesarean section rates between a private and a public hospital in Brazil

This paper evaluates the association of maternal variables and of variables related to prenatal and delivery care with cesarean sections at a public and at a private maternity. A retrospective cross-sectional study was performed at a public maternity clinic (2,889 deliveries) and at a private maternity clinic (2,911 deliveries) in the city of Ribeirão Preto, São Paulo State, Brazil. The prevalence of cesarean sections was 18.9% at the public maternity clinic and 84.3% at the private one. The factors associated with cesarean sections at both hospitals were: mothers from other cities, aged > or =25 years and with hypertension. Having more than one child was a protective factor. At the public hospital, cesarean sections were more frequent on Wednesdays and from 12:00 to 23:59 hours of any day of the week, whereas at the private hospital they occurred on any day, though were less common on Sundays, and at any time except in the early morning. At the private hospital, cesarean sections were more frequent when performed by the doctor who had provided the prenatal care. Non-medical factors were more associated with cesarean sections in the private maternity clinic than biological or clinical factors related to pregnancy.

Screening for inter-hospital differences in cesarean section rates in low-risk deliveries using administrative data: An initiative to improve the quality of care

BackgroundRising national cesarean section rates (CSRs) and unexplained inter-hospital differences in CSRs, led national and international bodies to select CSR as a quality indicator. Using hospital discharge abstracts, we aimed to document in Belgium (1) inter-hospital differences in CSRs among low risk deliveries, (2) a national upward CSR trend, (3) lack of better neonatal outcomes in hospitals with high CSRs, and (4) possible under-use of CS.MethodsWe defined a population of low risk deliveries (singleton, vertex, full-term, live born, <4500 g, >2499 g). Using multivariable logistic regression techniques, we provided degrees of evidence regarding the observed departure ([relative risk-1]*100) of each hospital (N = 107) from the national CSR and its trend. To determine a benchmark, we defined three CSR groups (high, average and low) and compared them regarding 1 minute Apgar scores and other neonatal endpoints. An anonymous feedback is provided to the hospitals, the College of Physicians (with voluntary disclosure of the outlying hospitals for quality improvement purposes) and to the policy makers.ResultsCompared with available information, the completeness and accuracy of the data, regarding the variables selected to determine our study population, showed adequate. Important inter-hospital differences were found. Departures ranged from -65% up to +75%, and 9 "high CSR" and 13 "low CSR" outlying hospitals were identified. We observed a national increasing trend of 1.019 (95%CI [1.015; 1.022]) per semester, adjusted for age groups. In the "high CSR" group 1 minute Apgar scores < 4 were over-represented in the subgroup of vaginal deliveries, suggesting CSs not carried out for medical reasons. Under-use of CS was also observed. Given their questionable completeness, except Apgar scores, our neonatal results, showing a significant association of CS with adverse neonatal endpoints, are to be cautiously interpreted. Taking the available evidence into account, the "Average CSR" group seemed to be the best benchmark candidate.ConclusionRather than firm statements about quality of care, our results are to be considered a useful screening. The inter-hospital differences in CSR, the national CS upward trend, the indications of over-use and under-use, the geographically different obstetric patterns and the admission day-related concentration of deliveries, whether or not by CS, may trigger initiatives aiming at improving quality of care.

Which factors could explain the low birth weight paradox?

Low birth weight children are unusual among well-off families. However, in Brazil, low birth weight rate was higher in a more developed city than in a less developed one. The study objective was to find out the reasons to explain this paradox. A study was carried out in two municipalities, Ribeirão Preto (Southeastern Brazil) and São Luís (Northeastern Brazil), which low birth weight rates were 10.7% and 7.6% respectively. Data from two birth cohorts were analyzed: 2,839 newborns in Ribeirão Preto in 1994 and 2,439 births in São Luís in 1997-1998. Multiple logistic regression analysis was performed, adjusted for confounders. Low birth weight risk factors in São Luís were primiparity, maternal smoking and maternal age less than 18 years. In Ribeirão Preto, the associated variables were family income between one and three minimum wages, maternal age less than 18 and equal to or more than 35 years, maternal smoking and cesarean section. In a combined model including both cohorts, Ribeirão Preto presented a 45% higher risk of low birth weight than São Luís. When adjusted for maternal smoking habit, the excess risk for low birth weight in Ribeirão Preto compared to São Luís was reduced by 49%, but the confidence interval was marginally significant. Differences in cesarean section rates between both cities contributed to partially explain the paradox. Maternal smoking was the most important risk factor for explaining the difference in low birth weight between both cities. The other factors contributed little to explain the difference in low birth weight rates.

Midwives’ perception of intrapartum risk in England, Belgium and France

The second half of the last century saw remarkable changes in the delivery of maternity care services, with the introduction of antibiotics and safe anaesthesia. This was associated with a continued decrease in maternal and perinatal mortality and some were quick to establish a cause-and-effect relationship. However, this was challenged by statisticians and technological developments have also been challenged later by some, though embraced by others. An initial study of midwives’ practice and perception of risk had demonstrated not only a slight link between higher intrapartum intervention rate and higher perception of risk but also an over-pessimistic evaluation of the chances of normal women to progress normally and an over-optimistic risk perception of the outcomes associated with interventions. Known variations in obstetric practice and caesarean section rates suggested that this study might benefit from replication in other European Union member states. The replication of the initial English study aimed at comparing the intrapartum care provided by midwives in the Belgian Flanders and the French regions of Alsace and Lorraine, as well as their intrapartum risk perception for the outcomes of spontaneous labour of nulliparous women suitable for midwifery-led care. A survey by questionnaire was administered to midwives in England, Belgium and France. In England, the midwives were selected on the basis that they worked in maternity units that made their maternity data available centrally on an annual basis. This enabled the analysis of the level of intrapartum interventions for healthy nulliparous women suitable for midwifery-led care and the subsequent comparison of the level of recommended intrapartum care and risk perception by midwives working in maternity units classified as either “lower” or “higher” intrapartum intervention units. The opportunities to replicate the study in Belgium and France were limited to the survey of midwives’ recommended intrapartum care and perception of risk, without the comparison of the actual intrapartum care and outcomes of the maternity units where they practise. All midwives working in the 11 relevant maternity units in England were surveyed. In Belgium, midwives attending the annual Flemish midwives’ conference were surveyed, whereas in France the collaboration of two midwifery schools meant that all midwives involved in intrapartum care in two regions – Alsace and Lorraine – were surveyed. The computerised St Mary’s Maternity Information System data were subjected to systematic data reduction to analyse the data of healthy Caucasian women at term of a healthy pregnancy and in spontaneous labour. The remaining data were then subjected to descriptive statistics to examine the rate of various intrapartum interventions and to establish an intrapartum score that was used to categorise maternity units as either “lower” or “higher” intrapartum intervention units (Mead and Kornbrot, Midwifery 20(1):61–71, 2004). The midwives’ surveys were subjected to descriptive statistical analysis. Major differences in midwifery practice were observed in the three countries: English midwives were more likely to monitor the maternal condition than French and Belgian midwives but less likely to use continuous electronic fetal monitoring, restrict maternal nutrition or recommend epidural analgesia. They were also generally more pessimistic about women’s ability to progress normally in labour. If the variations in methods of delivery observed in England parallel those of France and Belgium, the midwives in all three countries systematically overestimated the benefits of intrapartum intervention and, in particular, epidural analgesia. There are major differences in midwifery practice and in obstetric outcomes in these three countries. It is unlikely that the practices alone can explain the variations in outcomes and, in particular, the differences in caesarean section rates. More research is necessary to examine how the health care systems, perception of risk and attitudes to risk aversion may affect midwifery and obstetric practices and maternity services outcomes.

Does caesarean section negatively influence the post-partum prognosis of low back pain and pelvic pain during pregnancy?

Low back and pelvic pain (LBPP) is prevalent during pregnancy and also post-partum. The aetiology is poorly understood. The aim of this study was to investigate possible associations between epidural or spinal anaesthesia and caesarean section (CS) with persistent LBPP half a year after pregnancy. In a previous questionnaire study (n=891) altogether 639 (72%) women had reported LBPP during pregnancy. We sent these respondents a second questionnaire at approximately 6 months post-delivery. The response rate was 72.6% (n=464). The respondents were divided into three groups reporting 'no pain', 'recurrent pain' and 'continuous pain' in relation to LBPP 6 months after delivery. Pearson's chi-square test was used to test the difference between groups and logistic regression analysis was performed. Forty percent of the respondents had received epidural anaesthesia (EDA) or spinal anaesthesia during delivery and 18.5% of women had been delivered by CS. Epidural or spinal anaesthesia was not associated with persistent LBPP. There was no significant difference in CS rates between different sub-groups. The risk of persistent LBPP was increased three- to fourfold in women delivered by elective CS compared with women delivered by emergency CS. Epidural or spinal anaesthesia was not associated with risk of persistent LBPP. Elective CS was associated with an increased risk of persistent LBPP. However, the results must be interpreted with caution because of a relatively small study sample.

Breast Stimulation for Cervical Ripening and Induction of Labour

Plain Language SummaryBreast stimulation appears beneficial in relation to the number of women not in labour after 72 hours, and reduced postpartum haemorrhage rates.Breast stimulation causes the womb to contract, though the mechanism remains unclear. It may increase levels of the hormone oxytocin, which stimulates contractions. It is a non‐medical method allowing the woman greater control over the process of attempting to induce labour. The review found insufficient research to evaluate the safety of breast stimulation in a high‐risk population and until safety issues have been fully evaluated, it should not be considered for use in this group.Abstract Background: Breast stimulation has been suggested as a means of inducing labour. It is a non‐medical intervention allowing women greater control over the induction process. This is one of a series of reviews of methods of cervical ripening and labour induction using a standardised methodology. Objectives: To determine the effectiveness of breast stimulation for third trimester cervical ripening or induction of labour in comparison with placebo/no intervention or other methods of induction of labour. Search strategy: The Cochrane Pregnancy and Childbirth Group Trials Register (March 2004) and bibliographies of relevant papers. Selection criteria: Clinical trials of breast stimulation for third trimester cervical ripening or labour induction. Data collection and analysis: A strategy was developed to deal with the large volume and complexity of trial data relating to labour induction. This involved a two‐stage method of data extraction. Main results: Six trials (719 women) were included. Analysis of trials comparing breast stimulation with no intervention found a significant reduction in the number of women not in labour at 72 hours (62.7% versus 93.6%, relative risk (RR) 0.67, 95% confidence interval (CI) 0.60 to 0.74). This result was not significant in women with an unfavourable cervix. A major reduction in the rate of postpartum haemorrhage was reported (0.7% versus 6%, RR 0.16, 95% CI 0.03 to 0.87). No significant difference was detected in the caesarean section rate (9% versus 10%, RR 0.90, 95% CI 0.38 to 2.12) or rates of meconium staining. There were no instances of uterine hyperstimulation. Three perinatal deaths were reported (1.8% versus 0%, RR 8.17, 95% CI 0.45 to 147.77).When comparing breast stimulation with oxytocin alone the analysis found no difference in caesarean section rates (28% versus 47%, RR 0.60, 95% CI 0.31 to 1.18). No difference was detected in the number of women not in labour after 72 hours (58.8% versus 25%, RR 2.35, 95% CI 1.00 to 5.54) or rates of meconium staining. There were four perinatal deaths (17.6% versus 5%, RR 3.53, 95% CI 0.40 to 30.88). Authors’ conclusions: Breast stimulation appears beneficial in relation to the number of women not in labour after 72 hours, and reduced postpartum haemorrhage rates. Until safety issues have been fully evaluated it should not be used in high‐risk women. Further research is required to evaluate its safety, and should seek data on postpartum haemorrhage rates, number of women not in labour at 72 hours and maternal satisfaction. *** The Cochrane Database of Systematic Reviews 2005 Issue 3. Copyright © 2005 The Cochrane Collaboration. Published by John Wiley &amp; Sons, Ltd. This is an abstract and plain language summary of a regularly updated, systematic review prepared and maintained by The Cochrane Collaboration. The full text of the review is available in The Cochrane Library(ISSN 1464‐780X).

Are There Socio-Economic Differences in Caesarean Section Rates in Canada?

Caesarean section rates have risen in recent years, sparking renewed debate about the circumstances under which such deliveries are being, and should be, performed. Some commentators suggest that increasing rates may, in part, be explained by women in higher-income brackets requesting elective caesareans (the so-called "too posh to push" hypothesis). After adjusting for maternal age, Canadian data do not support this theory. In fact, age-adjusted caesarean section rates were significantly lower in Canada's highest-income neighbourhoods than in the lowest-income areas in 2002-03.