Higher Rates Of Cesarean Delivery Research Articles

Cesarean delivery after non-medically indicated induction of labor: A population-based study using different definitions of expectant management.

Most observational studies found that non-medically indicated induction of labor (IOL) is not associated with an increased risk of cesarean delivery compared with expectant management, defined as all births at a later gestation. However, given the higher rate of cesarean delivery at late term, this definition of the expectant management group might bias the results of observational studies in favor of IOL at early or full term when estimating the risk of short-term (eg up to 1week) expectant management. We conducted a retrospective cohort study including 447066 singleton term and post-term hospital births that occurred in Austria between 2008 and 2016. Multivariate logistic regression was used to test the association of IOL and cesarean delivery at each week of gestation from 37-41. Expectant management was either defined as all births at "next week or beyond" or "at next week". Non-medically indicated IOL was associated with increased odds for cesarean delivery at 37 and 38weeks, and reduced odds at 40 and 41weeks. At 39weeks, IOL resulted in comparable cesarean rates compared with expectant management defined as "next week or beyond" (17.2% vs 16.2%; adjusted odds ratio [OR] 0.93; 95% confidence interval [CI] 0.86-1.00; P=.059). However, when defined as births "at the next week", expectant management was associated with significantly reduced odds for cesarean delivery (13.6%; adjusted OR 0.76; 95% CI 0.70-0.82; P<.001). Comparison of the cesarean delivery rates for the two definitions of expectant management showed that the "next week and beyond" model underestimates the benefit of short-term expectant management by up to 1week, particularly for IOL at weeks 38 and 39. Our findings demonstrate that the definition of the expectant management group has a significant impact when analyzing the outcome of IOL in retrospective cohort studies. Non-medically indicated IOL is not an all-or-none choice between "elective" induction and indefinite expectant management. Thus, to define the control group as all births at the next week could be useful for clinical decision-making, as it allows to estimate the risks of expectant management until the next appointment compared with immediate IOL.

The effect of polyhydramnios on the success of trial of labor after cesarean delivery (TOLAC): A retrospective cohort

ObjectivePrediction of success of trial of labor after cesarean delivery (TOLAC) is of major importance. We investigated the impact of polyhydramnios on the success rate of TOLAC. Study designA retrospective cohort study of all women with singleton pregnancies ≥ 34th weeks of gestation who underwent TOLAC after one previous cesarean delivery, between 2011 and 2016 in a single tertiary care center. Polyhydramnios was defined as amniotic fluid index ≥ 240 mm.Primary outcome was defined as the rate of successful TOLAC. Results31,245 women gave birth during the study period, of them 1637 (5.3 %) women underwent TOLAC and met inclusion criteria. 39 (2.4 %) women with polyhydramnios were compared to a control group of 1598 (97.6 %) women with amniotic fluid index < 240 mm.Polyhydramnios significantly reduced the rate of successful TOLAC: 69.2 % (27/39) in the study group compared to 85.8 % (1371/1598) in the control group (P = 0.009). In a subgroup analysis based on amniotic fluid index, women with AFI > 270 mm had substantially lower TOLAC success rate [9/19 (47.4 %) vs 18/20 (90 %); P = 0.006]. There was no difference in the rate of uterine rupture between the groups (0/39 (o%) vs 9/1598 (0.56 %); P = 0.64).Logistic regression analysis revealed that polyhydramnios remained significantly associated with higher rates of cesarean delivery [OR 3.09 (95 % CI, 1.37−6.98)] after adjustment for confounding factors. ConclusionPolyhydramnios was associated with significantly reduced TOLAC success rate with no statistical difference in the rate of uterine rupture. This information should be considered in physician counseling.

Use of the Robson Classification System to Assess Cesarean Delivery Rate in a Tertiary Hospital in the Basque Country

To assess the rate of cesarean delivery at Basurto University Hospital (Bilbao, Spain) between 2015 and 2017 and to determine the cause of an increase in this rate during 2017. We retrospectively reviewed 6975 deliveries between 2015 and 2017, classifying women using the Robson classification. We analyzed extended perinatal mortality and perinatal outcomes during the study period and performed a comparative analysis of cesarean deliveries by year and Robson group. Comparisons were made with analysis of variance and χ2 or Fisher's exact tests. During the study period, 928 cesarean deliveries (13.3%) were performed. Extended perinatal mortality in this period was 7.0%. We detected an increase in the rate of cesarean delivery in 2017 in Group 1 women (P = 0.0224), with significant differences in the homogeneity of the distribution of cesarean deliveries performed for fetal distress between years in this group (P = 0.0093). Auditing the cases of cesareans performed for fetal distress in Group 1 in 2017, we found that the indication was appropriate in all cases, but in 39.4%, the management of uterine contractions during labour was considered suboptimal. Classifying cesarean deliveries using the Robson classification allows us to compare cesarean rates in different years and analyze any increases in these rates. Increases are sometimes attributed to changes in the obstetric population, but when investigated may be found to be related to potentially correctable problems. It is not necessary to have a high rate of cesarean delivery to warrant internal audit.

Uterine fibroids and preterm birth risk: A systematic review and meta-analysis.

This study explored the association between the presence of uterine fibroids (UF), as determined by ultrasound, and preterm birth (PB) risk. Medline, Embase, Cochrane, Scopus and Web of Science databases. Studies reporting women with and without UF demonstrated by an ultrasound exam. The primary outcome was the risk of PB < 37 weeks of gestation in pregnancies with UF diagnosed by an obstetric ultrasound exam. Effects for dichotomous and continuous outcomes are, respectively, reported as risk ratios (RR) or mean differences and their 95% confidence intervals (CI). Eighteen studies were included comprising 276 172 pregnancies to whom obstetric ultrasound assessment was performed for the presence/absence of UF. Women with UF were older (mean difference = 2.40 years, 95% CI 0.94-3.85) and were at higher risk of PB before 37 (RR = 1.43, 95% CI 1.27-1.60), 34 (RR = 1.79, 95% CI 1.32-2.42), 32 (RR = 1.94, 95% CI 1.33-2.85) and 28 (RR = 2.17, 95% CI 1.48-3.17) weeks as compared to those without UF (P < 0.01). In addition, women with UF were at higher risk of threatened preterm labor, preterm premature rupture of membranes, fetal malpresentation, placental abruption, lower gestational age and birthweight at delivery and a higher cesarean delivery rate. Pregnant women with UF are at increased risk of PB and other adverse obstetric outcomes.

Prevalence of calcium and vitamin D deficiency and their association with feto-maternal outcomes in a sample of Iranian pregnant women.

Calcium and vitamin D deficiency is common among Iranian women of childbearing age and poses adverse effects on pregnancy outcomes. The aim of the current study was to determine the prevalence of vitamin D and calcium in a sample of Iranian pregnant women and to assess its correlation with the feto-maternal outcomes. In this prospective cross-sectional study, a sample of pregnant women between 15 to 45 years who were in the third trimester were recruited from a number of hospitals in Tehran. Data were collected by the means of a self-developed questionnaire, interviews, physical examination, and paraclinical tests including measuring the serum level of calcium, vitamin D, parathormone (PTH) and phosphorous (Pi). The questionnaire obtained information on age, level of education, socio-economic status, parity, gravidity, calcium intake during pregnancy, as well as feto-maternal outcomes. We included a total number of 233 singleton pregnancies. Most of the subjects (58.4%) had vitamin D deficiency and 12.0% suffered from severe vitamin D deficiency. Vitamin D deficiency was adversely associated with the years of education (p= 0.007), serum level of parathormone (p< 0.001). The Metabolic Equivalent of Task (MET) (p< 0.001), the exercise sequence per week (p< 0.001), sun exposure (p< 0.001), higher rate of sunscreen usage (p= 0.011) and higher BMI (p= 0.005). VitaminD deficiency was associated with higher rate of cesarean delivery (p= 0.024), higher rate of diastolic hypertension (p= 0.019), higher rate of neonatal jaundice (p= 0.009) and higher rate of neonatal respiratory infections (p< 0.001). Serum level of PTH was a significant risk factor for severe vitamin D deficiency while calcium D supplementation, MET and sunscreen were significant protective factors. The prevalence of vitamin D deficiency during pregnancy among Iranian women is extremely high and is associated with adverse pregnancy outcomes including cesarean delivery, neonatal jaundice and neonatal respiratory infections. Low vitamin D supplementation and sun exposure, lack of physical activity and high BMI are the etiologies. Increasing the knowledge along with vitamin D supplementation during the pregnancy is recommended in Iranian population.

Placental pouch closure

<strong>Background:</strong> Placenta accreta spectrum (PAS) has become a global problem secondary to the high rate of cesarean delivery (CD). The current study presents an effective surgical procedure (placental pouch closure) for uterine preservation in patients with PAS. <strong>Methods</strong>: We applied this procedure in sixty cases at a tertiary university hospital between September 2017 and January 2019. We included women who were diagnosed as PAS based on preoperative ultrasound and Doppler evaluation, and who had the desire for uterine preservation. <strong>Results:</strong> The procedure was successful in almost all cases; the uterus was conserved 98.33 % of participants, with no associated severe maternal morbidities or mortality. In all cases, no additional surgical procedures were needed. The mean blood loss was 1263 ml, and the mean number of units of blood required for transfusion was 2.31 units. <strong>Conclusion:</strong> Identifying and meticulously closing the placental pouch is a novel surgical procedure for conservative management of PAS. In well-selected cases with the availability of facilities and expertise, the technique could have a place as a safe and effective surgical technique in women presenting with placenta accreta who desire uterine preservation. <strong>Trial registration number:</strong> NCT03241849. Registered on August 8, 2017

Reduced fetal movements at term, low-risk pregnancies: is it associated with adverse pregnancy outcomes? Ten years of experience from a single tertiary center.

We aimed to assess the outcomes of low-risk pregnancies complicated by isolated reduced fetal movements (RFM) at term. The study population were patients at term, with singleton, low-risk, pregnancies who presented to our obstetric-triage and delivered during the subsequent 2 weeks. The study group included patients with an isolated complaint of RFM (RFM group). The control group included patients without history of RFM (control group). The pregnancy, delivery, and neonatal outcomes were compared between the groups. Severe and mild composites of adverse neonatal outcomes were defined. Multivariate regression analyses were performed to identify independent association with adverse neonatal outcomes. Among the 13,338 pregnant women, 2762 (20.7%) were included in the RFM group and 10,576 (79.3%) in the control group. The RFM group had higher rates of nulliparity (p < 0.001), and smoking (p < 0.001). At admission, the RFM group had higher rates of IUFD (p < 0.001). The RFM group had higher rates of Cesarean delivery due to non-reassuring fetal monitor (p < 0.001), and mild adverse neonatal outcomes (p = 0.001). RFM was associated with mild adverse outcome independent of background confounders (aOR = 1.4, 95% CI 1.2-2.6, p < 0.001). Patients presented with isolated RFM at term had higher rates of IUFD at presentation and significant adverse outcomes at delivery.

Risk Factors Associated With Cesarean Delivery After Induction of Labor in Women With Class III Obesity.

To assess the risk factors associated with cesarean delivery in women with class III obesity (body mass index [BMI, calculated as weight in kilograms divided by height in meters squared] 40 or higher) who are undergoing induction of labor. This was a retrospective cohort of obese women with a BMI of 40 or higher and singleton pregnancy of 34 weeks of gestation or longer who underwent induction of labor at two large teaching institutions from January 2013 to December 2015. The primary outcome was cesarean delivery. Secondary outcomes included maternal and neonatal composite morbidity. We then assessed the applicability of using a previously developed calculator to predict the risk of cesarean delivery. The area under the receiver operating characteristic (ROC) curve was used as a measure of the ability of the calculator to discriminate between women who underwent cesarean compared with vaginal delivery. There were 485 women with class III obesity who underwent induction during the study period. Of the 428 women who met inclusion criteria, 81.8% had a BMI of 40-50, 14.5% had a BMI of 50-60, and 3.7% had a BMI higher than 60. The overall cesarean delivery rate was 49.1% (46% with BMI 40-50, 63% with BMI 50-60, and 69% with BMI higher than 60, P=.012). Of the 428 women studied, 77.6% were black and 55% were nulliparous. Nulliparity, height, initial cervical dilation, and modified Bishop score were associated with a higher rate of cesarean delivery in multivariable models. Maternal and neonatal composite morbidity was higher in obese women who underwent cesarean delivery, compared with those who delivered vaginally. The performance of a previously developed induction calculator applied to this cohort had an area under the ROC curve of 75% (95% CI 0.70-0.79). In women with class III obesity who underwent labor induction, the cesarean delivery rate approaches 50%. Nulliparity, height, and unfavorable cervical examination were the most significant risk factors for cesarean delivery. This information can be used to augment counseling for the obese patient who is undergoing induction.

Obstetric anesthesia in China: associated challenges and long-term goals.

Obstetric anesthesia in China: associated challenges and long-term goals.

Reduced fetal movements at term in singleton low risk pregnancies-Is there an association with placental histopathological findings?

Maternal perception of fetal movements has long been considered an indicator of fetal well-being. A sudden decrease in the number of fetal movements is suggestive of fetal compromise. We aimed to determine whether the maternal perception of reduced fetal movements (RFM) is associated with placental pathological lesions in a low-risk term population. Our study was a case-control study that was performed in a single university center. Placental histopathology, maternal demographics, labor characteristics, and neonatal outcomes of term, singleton pregnancies with maternal perception of RFM during the 2 weeks prior to delivery were collected. To isolate the effect of RFM on placental pathology, we excluded cases complicated by preterm birth, hypertensive disorders, diabetes mellitus, small-for-gestational-age and congenital/genetic anomalies. We compared pregnancy outcomes and placental pathology between the RFM group and a control group matched for gestational age and mode of delivery. Placental lesions were classified according to the "Amsterdam" criteria. Composite adverse neonatal outcome was defined as one or more of the following: sepsis, transfusion, hypoglycemia, phototherapy, respiratory morbidity, cerebral morbidity, necrotizing enterocolitis and fetal/neonatal death. Multivariable regression analysis was performed to identify independent associations with adverse neonatal outcome. We included patients who gave birth from January 2008 until May 2019. The study group included 203 term pregnancies with RFM during the 2 weeks prior to delivery, which was matched with 203 controls. The RFM group was characterized by a higher rate of placental weight <10th percentile (22.6% vs. 3.9%, P<.001), a higher rate of maternal vascular malperfusion lesions (30.5% vs. 18.7%, P=.007) and lesions of maternal inflammatory response (43.3% vs. 29.5%, P=.005). At delivery, the RFM group had higher rates of cesarean delivery due to non-reassuring fetal heart rate monitoring (P=.01), 5-minute Apgar score ≤7 (P=.03), neonatal intensive care unit admissions (P<.001) and composite adverse neonatal outcomes (P=.007). Using multivariable analysis, RFM (adjusted odds ratio [aOR]1.7, 95% confidence interval [CI]1.1-4.8), and placental maternal vascular malperfusion lesions (aOR1.2, 95% CI1.0-2.9) were independently associated with adverse neonatal outcome. After excluding important placental-related morbidities, RFM was associated with a higher rate of placental weight <10th percentile and placental maternal vascular malperfusion lesions vs. controls. This study suggests a placental involvement in the association between RFM at term and adverse pregnancy outcomes.

Maternal Characteristics and Obstetric and Neonatal Outcomes of Singleton Pregnancies Among Adolescents.

BackgroundAdolescent pregnancy remains a global public health issue with serious implications on maternal and child health, particularly in developing countries The aim of this study was to investigate maternal characteristics and obstetric and neonatal outcomes of singleton pregnancies among adolescents.Material/MethodsA total of 241 adolescent women who gave birth to singletons between January 2015 and December 2015 at our hospital were included in this descriptive cross-sectional study. Data on maternal sociodemographic and obstetric characteristics as well as neonatal outcome were recorded.ResultsPrimary school education (66.0%), lack of regular antenatal care (69.7%), religious (36.7%) and consanguineous (37.0) marriage, Southeastern Anatolia hometown (34.9%) and Eastern Anatolia hometown (21.2%) were noted in most of the adolescent pregnancies, while 95% were desired pregnancies within marriage. Pregnancy complications were noted in 19.5% (preeclampsia in 5.8%) and cesarean delivery was performed in 44.8% of adolescent pregnancies. Preterm delivery rate was 27.0% (20.3% were in >34 weeks). Overall, 13.3% of neonates were admitted to neonatal intensive care unit (NICU) in the postpartum period (prematurity in 28.1%), while 25.3% were re-admitted to NICU admission in the post-discharge 1-month (hyperbilirubinemia in 55.7%). Adolescent pregnancies were associated considerably high rates of fetal distress at birth (28.7%), preterm delivery (26.9%), and re-admission to NICU after hospital discharge (25.3%).ConclusionsIn conclusion, our findings indicate that along with considerably high rates of poor antenatal care, maternal anemia and cesarean delivery, adolescent pregnancies were also associated with high rates for fetal distress at birth, preterm delivery, and NICU re-admission within post-discharge 1-month.

Changes in perinatal outcomes after implementation of IADPSG criteria for screening and diagnosis of gestational diabetes mellitus: A national survey.

To compare perinatal outcomes before and after implementation of the International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria for testing of gestational diabetes mellitus (GDM). A national, perinatal, registry-based cohort study of prospectively collected data was conducted. Patients with diabetes type 1 or 2 were excluded. Outcomes of 135 786 pregnancies before (January 1, 2004 to May 31, 2010) and 140 524 after (June 1, 2011 to December 31, 2017) the introduction of IADPSG criteria were compared using Student t test and χ2 test (P<0.05 was significant). Multivariable logistic regression was used to compare outcomes controlling for potential confounders. Prevalence of GDM increased from 2.6% to 9.7% (adjusted odds ratio 3.92; 95% confidence interval 3.78-4.08). Incidence of large-for-gestational age (LGA), macrosomia (birth weight >4500g), Erb's palsy, and hypertensive disorders in pregnancy decreased despite increasing maternal age and pre-pregnancy obesity. Rates of cesarean delivery increased in both GDM and non-GDM groups, with a less pronounced increase in GDM mothers. Incidence of small-for-gestational age (SGA) increased in GDM but not in non-GDM group. Implementation of IADPSG criteria in a country with a relatively low prevalence of GDM did not result in higher rates of cesarean delivery and was associated with reductions in LGA and hypertensive disorders in pregnancy.

THE IMPACT OF ANTIEPILEPTIC TREATMENT IN PREGNANCY ON PERINATAL OUTCOME IN CROATIA - A SINGLE-CENTER STUDY.

SUMMARYPregnancy can alter the natural course of epilepsy and affect pharmacokinetic profile of antiepileptic drugs (AEDs) making therapeutic management more demanding. Since there is no relevant population-based study in Croatia to date, we conducted this research with the aim to observe antiepileptic treatment policy in pregnancy and to determine if the number of AEDs affects pregnancy outcomes. The study included all women with epilepsy with singleton pregnancy exposed to one or more AEDs divided into two groups (group 1: one AED and group 2: more than one AED used). Data were collected retrospectively at the Department of Obstetrics and Gynecology, Zagreb University Hospital Centre, Zagreb, Croatia, and included 153 women from January 2010 to December 2018. Primary outcomes included rates of preterm delivery, major fetal malformations, gestational hypertension, cesarean section rate, and appearance of seizures during pregnancy. We found higher rates of all pregnancy complications examined than in the general population, while comparison of the two study groups yielded significant differences. Preterm labor was detected in 30% of deliveries in polytherapy group compared to 16.6% in monotherapy group (p=0.03). Gestational hypertension was recorded in 20% of women in polytherapy group vs. 4.90% in monotherapy group (p=0.009). There was also a high rate of cesarean deliveries in polytherapy group (27.5%). Seizures during pregnancy occurred in 48.4% of patients in polytherapy group, which was significantly higher than the rate recorded in monotherapy group (p=0.015). In this single-center retrospective study, women with epilepsy using AEDs during pregnancy had a higher rate of gestational hypertension and preterm delivery than the general population of pregnant women. To the best of our knowledge, this is the first study in Croatia observing antiepileptic treatment policy in pregnancy with regards to AED regimen and perinatal outcome.

557: Gestational hypertension and preeclampsia - is it the same underlying placental pathology?

Gestational hypertension (GHTN) and preeclampsia (PE) share common characteristics. Yet, given the difference between the two, are there any dissimilarities in presence of multiple maternal vascular malperfusion lesions (MVM’s), which are considered a hallmark of hypertensive disorders in pregnancy? We aimed to answer this question by examining the differences between placental findings in singleton gestations complicated by GHTN and PE. A retrospective study of all women with singleton gestations and GHTN or PE, who delivered at a single, referral medical center (2001-2015) and had a placental pathology evaluation. Placental lesions were classified as MVM’s, fetal vascular malperfusion lesions, lesions associated with hemorrhage and chronic villitis. Pregnancies complicated by PE were compared to pregnancies complicated by GHTN. Overall 2,286 (4.5% of the deliveries during the study period) were complicated by GHTN/PE, out of which 913 (40.0%) had pathology data: 412 (45.1%) with GHTN and 501 (54.9%) with PE. Patient with PE were slightly younger, with lower rate of GDM, and delivered on average 5 weeks earlier with higher rate of cesarean deliveries. Neonates of parturients with PE had lower birth weight and were more prone for NICU admission (Table). Differences in placental pathology are depicted in the figure. On multivariable logistic regression model (including gestational age, maternal age, GDM and GHTN/PE), PE was associated with higher likelihood of marginal/velamentous insertion of the cord (aOR 1.9, 95% CI 1.5-2.6), and lower likelihood of ≥ 1 MVM’s (aOR 0.64, 95% CI 0.5-0.9) and chronic villitis (aOR 0.5, 95% CI 0.3-0.9). There were no significant differences in the presence of ≥ 2 or more MVM’s. Several differences exist in placental pathology between PE and GHTN.

1039: Determining the risk of cesarean delivery in the nulliparous population stratified by age and BMI

The rising cesarean delivery (CD) rate is a complex issue, particularly in a nulliparous population of advancing maternal age and increasing body mass index (BMI). The objective of this study was to stratify the CD rate in nulliparous women by age and BMI to determine if there was any significant difference within this cohort. This was a retrospective review of CD procedures of nulliparous women in Galway University Hospital, Galway and The Rotunda Hospital, Dublin, Ireland, over 4 years (from 2014 through 2017), with Institutional Review board approval from both hospitals. Data were obtained from hospital databases including details on mode of delivery, maternal age and BMI. The number of CD procedures and percentage was determined for each age and BMI category and graphed for analysis. Statistical analysis was performed using SPSS software. Sub-analysis was performed on nulliparous women in spontaneous labor (Robson Group 1). A total of n=17,474 nulliparous women were included for analysis. N=6,257 (35.8%) had CD procedures. Results are presented in Table 1. A trend can be seen emerging showing increasing CD rates for increasing age and BMI categories. Women under 20 years with a BMI of < 18.5kg/m2 had a CD rate of 9%, while those with a BMI of 30-34.9kg/m2 had a 29% CD rate. Women 35-39 years of BMI < 18.5 kg/m2 and 30-34.9kg/m2 had CD rates of 36% and 62% respectively. For women over 45 years the CD rates ranged from 80-100% in all BMI groups. The higher CD rates in women of higher BMI and advanced maternal age when compared with younger women of lower BMI was significant (P< 0.05). Similar results were obtained when analyzing the CD rates of women in Robson Group 1. We observed significant differences within the nulliparous population in the CD rates when stratified by age and BMI. The development of customized charts subdivided by age and BMI may aide to more accurately estimate a women’s risk of CD In a first pregnancy, provide a useful counseling tool to women and their clinicians and may also assist in the comparison of CD rates between obstetric units.

356: Maternal care matters: An analysis of hospital Cesarean delivery rates in Michigan

To identify factors associated with cesarean delivery (CD) and potential opportunities to reduce use of CD among the nulliparous, term, singleton, vertex (NTSV) births. We performed a retrospective cohort study of NTSV births using the birth certificate files of the Michigan Department of Health and Human Services from 2012-2017. We used bivariate analysis and effect size (ES) calculations to assess statistical and clinically meaningful differences between women that had a CD compared to those that had a VD. We developed a hierarchical model to estimate hospital risk and reliability adjusted CD rates and calculated a median odds ratio (MOR) to quantify the risk of CD from one hospital to another. Caterpillar plots of adjusted NTSV CD rates were created to identify state wide variation and outlier hospitals. We identified 185,693 NTSV births with a 28.7% CD rate (n = 53,347). Bivariate analysis revealed that nearly all factors analyzed were significantly different between women with a CD compared to those with a VD (Table 1). Effect size analysis demonstrated that only maternal BMI and infant weight at birth remained significant (ES ≥0.2). The range of risk and reliability adjusted CD rates was substantial (overall rate 28.6%, min 14.7%, max 41.5%). There were 25 hospitals with CD rate significantly above the collaborative mean (Fig 1). After controlling for maternal BMI, infant weight at birth, and clinically relevant factors, we obtained a MOR of 1.29 and a C-Statistic of 0.67. The MOR demonstrates that among women with an NTSV birth, moving from a hospital with a low CD rate to a hospital with a high CD rate increases her chance of CD by 29%. There is a nearly three-fold variation in the CD rates among NTSV births in Michigan hospitals with adjustment for clinically relevant and statistically robust risk factors. Quality improvement strategies to address hospital level variation in the NTSV CD rate should be considered. Prior to and during pregnancy, maternal BMI and fetal size could be addressed through nutritional support polices and affordable care for diabetes.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Interventions to reduce the cesarean delivery rate in a tertiary hospital in China

Introduction High cesarean delivery rate has been a global public health concern. This study assesses the effect of medical interventions and societal changes on cesarean delivery rates in a Chinese tertiary hospital. Material and methods A retrospective study including all live births ≥34-week gestation between 2008 and 2016 from Guangzhou Women and Children’s Medical Center was divided into 5 stages: (1) no interventions; (2) patient-controlled epidural analgesia; (3) episiotomy restriction; (4) new labor management; (5) universal two-child policy. An interrupted time series design was used to measure the effect of interventions on overall cesarean rate, primary cesarean rate, maternal and neonatal outcomes. Results There were 126,609 deliveries including 49,092 cesarean deliveries and 77,517 vaginal deliveries in this period. Overall cesarean delivery rate declined after implementing patient-controlled epidural analgesia, episiotomy restriction and universal two-child policy. Primary cesarean rate decreased after implementing episiotomy restriction. Cesarean rate with previous cesarean dramatically increased, and maternal request cesarean rate decreased gradually. Low Apgar rate (score ≤7 at 5 min) increased after episiotomy restriction and maternal postpartum hemorrhage rate increased after new labor management. Conclusions Patient-controlled epidural analgesia, episiotomy restriction and the universal two-child policy showed the most significant effects to reducing the cesarean rate.

Oral glucose tolerance test for suspected late onset gestational diabetes

Background Oral glucose tolerance test is used for the diagnosis of gestational diabetes at the second trimester, however, its use at term has been questioned. Objective To compare obstetric outcomes in women with and without abnormal oral glucose tolerance test (OGTT) conducted at term due to large for gestational age (LGA) fetuses or polyhydramnios. Methods A retrospective cohort study including all women ≥37 weeks of gestation, with normal glucose challenge test (GCT), who performed 100 g OGTT at term, due to LGA fetus or polyhydramnios between January 2012 and January 2017. Abnormal OGTT was considered according to Carpenter and Coustan criteria. Data are presented as median and inter-quadrantile range (IQR). Results Database included 34,897 women, of them, 1131 (3.2%) met inclusion criteria. A total of 150 (13.2%) and 981 (86.7%) women were included in the abnormal and the normal OGTT groups, respectively. Women in the abnormal OGTT group had higher glucose levels on GCT [126 (IQR 107–137) versus 110 (IQR 91–132) mg/dL; p = .001]. The rate of cesarean deliveries was twice as high in the abnormal OGTT group [37 (24.7%) versus 103 (10.5%); p = .001]. No difference in the rate of shoulder dystocia, postpartum hemorrhage (PPH) or third and fourth-degree perineal tear was observed among women who delivered vaginally. Conclusions Abnormal OGTT at term was related to a higher rate of cesarean deliveries, with no difference in obstetrical complications among women who delivered vaginally.

Access to public health services and integral care for women during the puerperal gravid period period in Cear\xe1, Brazil

BackgroundOver time, the Brazilian health system, a growing country, has been developing to ensure good accessibility to health goods and services. This development is focusing on the principle of universality of access and completeness of health care. In this context, we aimed to evaluate the completeness of care and universality of access for women in their pregnancy and puerperal period in Ceará, Brazil.MethodsA descriptive, cross-sectional study based on a quantitative approach, using information collected from the database of the regulation system of the state of Ceará and data from the Prenatal Monitoring System. The research population comprised of 1701 women who delivered a baby in an obstetric reference unit in the Health Macro-Region of Cariri, Ceará, Brazil from January to December 2015.ResultsThere was a high rate of cesarean delivery (49.7%) and a high waiting time for access to high-risk delivery (32.6%) and neonatal intensive care unit (72.9%). There was also a low percentage (41.1%) of pregnant women undergoing an adequate number of prenatal consultations, dental care (20%), educational activities (15%), visits to the maternity ward (0.1%), laboratory tests of the third trimester (29.2%) and puerperal consultation (37.9%).ConclusionsIt was concluded that the Maternal and Child Health Policy, especially the Rede Cegonha, which is still under development, does not ensure access and completeness of care for women during the prenatal, delivery, and puerperal periods, thus violating their reproductive rights. The results of this study allow a critical analysis by the academia and health managers in search of strategies to improve the services of Rede Cegonha in Brazil.

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

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. 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. 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. 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.