Outcomes of planned home births with certified professional midwives: large prospective study in North America

Objective To evaluate the safety of home births in North America involving direct entry midwives, in jurisdictions where the practice is not well integrated into the healthcare system.Design Prospective cohort study.Setting All home births involving certified professional midwives across the United States (98% of cohort) and Canada, 2000.Participants All 5418 women expecting to deliver in 2000 supported by midwives with a common certification and who planned to deliver at home when labour began.Main outcome measures Intrapartum and neonatal mortality, perinatal transfer to hospital care, medical intervention during labour, breast feeding, and maternal satisfaction.Results 655 (12.1%) women who intended to deliver at home when labour began were transferred to hospital. Medical intervention rates included epidural (4.7%), episiotomy (2.1%), forceps (1.0%), vacuum extraction (0.6%), and caesarean section (3.7%); these rates were substantially lower than for low risk US women having hospital births. The intrapartum and neonatal mortality among women considered at low risk at start of labour, excluding deaths concerning life threatening congenital anomalies, was 1.7 deaths per 1000 planned home births, similar to risks in other studies of low risk home and hospital births in North America. No mothers died. No discrepancies were found for perinatal outcomes independently validated.Conclusions Planned home birth for low risk women in North America using certified professional midwives was associated with lower rates of medical intervention but similar intrapartum and neonatal mortality to that of low risk hospital births in the United States.     

Measures of performance in Scottish maternity hospitals.

OBJECTIVE--To develop measures of hospital performance over time with particular reference to maternal and neonatal care by controlling for case mix. DESIGN--Analysis of computerised records of births. SETTING--Scotland, 1980-7. SUBJECTS--Over half a million singleton live births and stillbirths. MAIN OUTCOME MEASURES--Numbers of perinatal deaths and caesarean sections. RESULTS--Scottish maternity hospitals perform more or less equally with regard to perinatal mortality. When caesarean sections are considered, there is evidence that hospitals differ in their treatment of different groups of women; in two examples one hospital had an increased rate among women of parity 2 or more and another had a reduced rate of repeat caesarean section. CONCLUSIONS--Developing measures of performance over time by controlling for case mix is a valid system for monitoring hospital outcomes and activity, and allows comparison either between hospitals or with data for all Scottish maternity hospitals. Hospital profiles permit identification of differences for particular patient groups after allowance is made for other case mix variables.     

Home versus hospital deliveries: follow up study of matched pairs for procedures and outcome. Zurich Study Team.

OBJECTIVE: To assess procedures and outcomes in deliveries planned at home versus those planned in hospital among women choosing the place of delivery. DESIGN: Follow up study of matched pairs. SETTING: Antenatal clinics and reference hospitals in Zurich between 1989 and 1992. SUBJECTS: 489 women opting for home delivery and 385 opting for hospital delivery; the women comprised all those attending members of the study team for antenatal care and those attending the reference hospital for antenatal care who could be matched with the women planning home confinement. MAIN OUTCOME MEASURES: Need for medication and incidence of interventions during delivery (caesarean section, forceps, vacuum extraction, episiotomy), duration of labour, occurrence of severe perineal lesions, maternal blood loss, and perinatal morbidity and death. RESULTS: All women were followed up from their first antenatal visit till three months after delivery. Referrals during pregnancy (n = 37) and labour (70), changes of mind (15 home to hospital, eight hospital to home), and 17 miscarriages resulted in 369 births occurring at home and 486 in hospital. During delivery the home birth group needed significantly less medication and fewer interventions whereas no differences were found in durations of labour, occurrence of severe perineal lesions, and maternal blood loss. Perinatal death was recorded in one planned hospital delivery and one planned home delivery (overall perinatal mortality 2.3/1000). There was no difference between home and hospital delivered babies in birth weight, gestational age, or clinical condition. Apgar scores were slightly higher and umbilical cord pH lower in home births, but these differences may have been due to differences in clamping and the time of transportation. CONCLUSION: Healthy low risk women who wish to deliver at home have no increased risk either to themselves or to their babies.     

Caesarean Section Frequency among Immigrants,Second- and Third-Generation Women,and Non-Immigrants: Prospective Study in Berlin/Germany

ObjectiveThe frequency of caesarean section delivery varies between countries and social groups. Among other factors, it is determined by the quality of obstetrics care. Rates of elective (planned) and emergency (in-labor) caesareans may also vary between immigrants (first generation), their offspring (second- and third-generation women), and non-immigrants because of access and language barriers. Other important points to be considered are whether caesarean section indications and the neonatal outcomes differ in babies delivered by caesarean between immigrants, their offspring, and non-immigrants.MethodsA standardized interview on admission to delivery wards at three Berlin obstetric hospitals was performed in a 12-month period in 2011/2012. Questions on socio-demographic and care aspects and on migration (immigrated herself vs. second- and third-generation women vs. non-immigrant) and acculturation status were included. Data was linked with information from the expectant mothers’ antenatal records and with perinatal data routinely documented in the hospital. Regression modeling was used to adjust for age, parity and socio-economic status.ResultsThe caesarean section rates for immigrants, second- and third-generation women, and non-immigrant women were similar. Neither indications for caesarean section delivery nor neonatal outcomes showed statistically significant differences. The only difference found was a somewhat higher rate of crash caesarean sections per 100 births among first generation immigrants compared to non-immigrants.ConclusionUnlike earlier German studies and current studies from other European countries, this study did not find an increased rate of caesarean sections among immigrants, as well as second- and third-generation women, with the possible exception of a small high-risk group. This indicates an equally high quality of perinatal care for women with and without a migration history.     

Epidural anaesthesia and long term backache after childbirth.

OBJECTIVE--To examine the relation between epidural anaesthesia and long term backache after childbirth. DESIGN--Data from postal questionnaire on morbidity after childbirth sent to women who had delivered in one maternity hospital between 1978 and 1985 were linked to maternity case notes for each woman. SETTING--Maternity hospital in Birmingham. SUBJECTS--11,701 Women who had delivered their most recent baby at the maternity hospital during the defined period and who returned their completed questionnaires. MAIN OUTCOME MEASURES AND RESULTS--Of the 1634 women who reported backache, 1132 (69%) had had it for over a year. A significant association was found between backache and epidural anaesthesia (relative risk = 1.8); 903 of 4766 women (18.9%) who had had epidural anaesthesia reported this symptom, compared with 731 of the 6935 women (10.5%) who had not had epidural anaesthesia. This association was consistent in both "normal" and "abnormal" deliveries, the only exception being after an elective caesarean section when no excess backache occurred after epidural anaesthesia. CONCLUSIONS--The relation between backache and epidural anaesthesia is probably causal. It seems to result from a combination of effective analgesia and stressed posture during labour. Further investigations on the mechanisms causing backache after epidural anaesthesia are required.     

Relation between private health insurance and high rates of caesarean section in Chile: qualitative and quantitative study

ObjectivesTo explore the circumstances and factors that explain the association between private health insurance cover and a high rate of caesarean sections in Chile.DesignQualitative analysis of audiotaped in-depth interviews with obstetricians and pregnant women; quantitative analysis of data from face to face semistructured interview survey conducted postnatally (with women who had given birth in the previous 24-72 hours), and of a review of medical notes at a public hospital, a university hospital, and a private clinic.SettingSantiago, Chile.ParticipantsQualitative arm: 22 obstetricians, 21 pregnant women; quantitative arm: 540 postnatal women.ResultsPrivate health insurance cover requires the primary maternity care provider to be an obstetrician. In the postnatal survey, women with private obstetricians showed consistently higher rates of caesarean section (range 57-83%) than those cared for by midwives or doctors on duty in public or university hospitals (range 27-28%). Only a minority of women receiving private care reported that they had wanted this method of delivery (range 6-32%). With the diversification in the healthcare market, most obstetricians now have demanding peripatetic work schedules. Private maternity patients are a lucrative source of income. The obstetrician is committed to attend these private births in person, and the “programming” (or scheduling) of births is a common time management strategy. The rate of elective caesarean sections was 30-68% in women with private obstetricians and 12-14% in women not attended by private obstetricians.ConclusionsPolicies on healthcare financing can influence maternity care management and outcomes in unforeseen ways. The prevailing business ethos in health care encourages such pragmatism among those doctors who do not have a moral objection to non-medical caesarean section.     

Association of Maternal Vitamin D Status with Glucose Tolerance and Caesarean Section in a Multi-Ethnic Asian Cohort: The Growing Up in Singapore Towards Healthy Outcomes Study

Objective

Epidemiological studies relating maternal 25-hydroxyvitamin D (25OHD) with gestational diabetes mellitus (GDM) and mode of delivery have shown controversial results. We examined if maternal 25OHD status was associated with plasma glucose concentrations, risks of GDM and caesarean section in the Growing Up in Singapore Towards healthy Outcomes (GUSTO) study.

Methods

Plasma 25OHD concentrations, fasting glucose (FG) and 2-hour postprandial glucose (2HPPG) concentrations were measured in 940 women from a Singapore mother-offspring cohort study at 26–28 weeks’ gestation. 25OHD inadequacy and adequacy were defined based on concentrations of 25OHD ≤75nmol/l and >75nmol/l respectively. Mode of delivery was obtained from hospital records. Multiple linear regression was performed to examine the association between 25OHD status and glucose concentrations, while multiple logistic regression was performed to examine the association of 25OHD status with risks of GDM and caesarean section.

Results

In total, 388 (41.3%) women had 25OHD inadequacy. Of these, 131 (33.8%), 155 (39.9%) and 102 (26.3%) were Chinese, Malay and Indian respectively. After adjustment for confounders, maternal 25OHD inadequacy was associated with higher FG concentrations (β = 0.08mmol/l, 95% Confidence Interval (CI) = 0.01, 0.14), but not 2HPPG concentrations and risk of GDM. A trend between 25OHD inadequacy and higher likelihood of emergency caesarean section (Odds Ratio (OR) = 1.39, 95% CI = 0.95, 2.05) was observed. On stratification by ethnicity, the association with higher FG concentrations was significant in Malay women (β = 0.19mmol/l, 95% CI = 0.04, 0.33), while risk of emergency caesarean section was greater in Chinese (OR = 1.90, 95% CI = 1.06, 3.43) and Indian women (OR = 2.41, 95% CI = 1.01, 5.73).

Conclusions

25OHD inadequacy is prevalent in pregnant Singaporean women, particularly among the Malay and Indian women. This is associated with higher FG concentrations in Malay women, and increased risk of emergency caesarean section in Chinese and Indian women.     

The role of oral glucose intolerance test in reducing pregnancy complications

The influence of glucose monitoring during pregnancy on newborn body weight, and complications during pregnancy and labor was assessed. We performed a retrospective analysis of macrosomal children, fetal growth, caesarean sections, malformations, still-births and the number of oral glucose tolerance test (OGTT) carried out in a five-year period. The proportion of women participating in OGTT tests increased from 20% to 40% (p<0.05) between 2000 and 2004. Gestation diabetes mellitus (GDM) proportions among pregnant women seen at the Department of Obstetrics and Gynecology at Slavonski Brod General Hospital, Croatia increased from 1% to 6.7% (p < 0. 05) during the observed period. Proportion of births identified as macrosomal decreased from 13.3% to 12.2% (p<0.05). Additionally, infant mortality and still-births along with other fetal and maternal complications declined during the same period. These results suggest that regular measurements of glucose tolerance during pregnancy may prevent preterm birth, decrease the proportion of macrosomal newborns, lower mortality and decrease fetal and maternal complication incidence during pregnancy and delivery.     

Maternal and neonatal individual risks and benefits associated with caesarean delivery: multicentre prospective study

Objective To assess the risks and benefits associated with caesarean delivery compared with vaginal delivery.Design Prospective cohort study within the 2005 WHO global survey on maternal and perinatal health.Setting 410 health facilities in 24 areas in eight randomly selected Latin American countries; 123 were randomly selected and 120 participated and provided dataParticipants 106 546 deliveries reported during the three month study period, with data available for 97 095 (91% coverage).Main outcome measures Maternal, fetal, and neonatal morbidity and mortality associated with intrapartum or elective caesarean delivery, adjusted for clinical, demographic, pregnancy, and institutional characteristics.Results Women undergoing caesarean delivery had an increased risk of severe maternal morbidity compared with women undergoing vaginal delivery (odds ratio 2.0 (95% confidence interval 1.6 to 2.5) for intrapartum caesarean and 2.3 (1.7 to 3.1) for elective caesarean). The risk of antibiotic treatment after delivery for women having either type of caesarean was five times that of women having vaginal deliveries. With cephalic presentation, there was a trend towards a reduced odds ratio for fetal death with elective caesarean, after adjustment for possible confounding variables and gestational age (0.7, 0.4 to 1.0). With breech presentation, caesarean delivery had a large protective effect for fetal death. With cephalic presentation, however, independent of possible confounding variables and gestational age, intrapartum and elective caesarean increased the risk for a stay of seven or more days in neonatal intensive care (2.1 (1.8 to 2.6) and 1.9 (1.6 to 2.3), respectively) and the risk of neonatal mortality up to hospital discharge (1.7 (1.3 to 2.2) and 1.9 (1.5 to 2.6), respectively), which remained higher even after exclusion of all caesarean deliveries for fetal distress. Such increased risk was not seen for breech presentation. Lack of labour was a risk factor for a stay of seven or more days in neonatal intensive care and neonatal mortality up to hospital discharge for babies delivered by elective caesarean delivery, but rupturing of membranes may be protective.Conclusions Caesarean delivery independently reduces overall risk in breech presentations and risk of intrapartum fetal death in cephalic presentations but increases the risk of severe maternal and neonatal morbidity and mortality in cephalic presentations.     

Maternal and Perinatal Mortality Associated with Cesarean Section in Alberta (1955-1959)

A province-wide study of perinatal mortality was initiated in Alberta (population 1,283,000) in 1955. The period 1955-1959 covered 182,028 total births and 4219 perinatal deaths of which 260 were from 3813 Cesarean sections.The perinatal mortality rate in Cesarean-section births in rural hospitals (101.4 per thousand Cesarean births) was compared with that for urban hospitals (55.7 per thousand).Examination of the indications for primary Cesarean section in which a perinatal death occurred showed that hemorrhage accounted for 54 out of 85 of these deaths in rural hospitals, and 49 out of 110 similar urban deaths. Of 33 perinatal deaths associated with elective repeat sections, 17 were of premature babies.Eleven of the 85 maternal deaths during 1955-1959 were associated with Cesarean section, a maternal mortality rate of 28.8 per 10,000 Cesarean section births. Preventable factors were present in 8 of the 11 cases. Hemorrhage was the primary cause of death.     

High prevalence of NTDs in Shanxi Province: a combined epidemiological approach

BACKGROUND: Shanxi Province has historically reported a high prevalence of NTDs. In order to establish baseline rates for NTDs and discuss the risk factors associated with sociodemographic, maternal characteristics, and geographic factors, we performed the present study using an approach combining population and hospital-based methodologies. METHODS: We used chi(2) and Fisher's exact tests to evaluate variation in the prevalence by selected covariates and computed crude ORs and 95% CIs. Adjusted odds ratios (AORs) were performed using logistic regression with all the covariates included in the model. RESULTS: The overall NTD prevalence during the 3 year study period was 199.38 per 10,000 births, with a higher NTD prevalence clustered in 46 villages within this geographic area. However, no statistical significance was found between NTD prevalence and the elevation of the villages or their distance from coal plants. AORs revealed women aged 20 and above had a lower risk of NTDs compared to those younger than 20 (AOR range 0.4-0.5). A higher risk of NTDs was observed among female infants (AOR 1.50; 95% CI: 1.04-2.17), women with four or more previous births (AOR 2.80; 95% CI: 1.20-6.52), and a previous history of birth defects (AOR 3.23; 95% CI: 1.46-7.12). CONCLUSIONS: This study has documented a high prevalence of NTDs in Shanxi. Similar variations to other reports were found in the risk of NTDs by maternal demographic characteristics and a clustering of NTDs in certain villages that require further exploration.     

Caesarean Section in Peru: Analysis of Trends Using the Robson Classification System

Introduction

Cesarean section rates continue to increase worldwide while the reasons appear to be multiple, complex and, in many cases, country specific. Over the last decades, several classification systems for caesarean section have been created and proposed to monitor and compare caesarean section rates in a standardized, reliable, consistent and action-oriented manner with the aim to understand the drivers and contributors of this trend. The aims of the present study were to conduct an analysis in the three Peruvian geographical regions to assess levels and trends of delivery by caesarean section using the Robson classification for caesarean section, identify the groups of women with highest caesarean section rates and assess variation of maternal and perinatal outcomes according to caesarean section levels in each group over time.

Material and Methods

Data from 549,681 pregnant women included in the Peruvian Perinatal Information System database from 43 maternal facilities in three Peruvian geographical regions from 2000 and 2010 were studied. The data were analyzed using the Robson classification and women were studied in the ten groups in the classification. Cochran-Armitage test was used to evaluate time trends in the rates of caesarean section rates and; logistic regression was used to evaluate risk for each classification.

Results

The caesarean section rate was 27% and a yearly increase in the overall caesarean section rates from 2000 to 2010 from 23.5% to 30% (time trend p<0.001) was observed. Robson groups 1, 3 (nulliparous and multiparas, respectively, with a single cephalic term pregnancy in spontaneous labour), 5 (multiparas with a previous uterine scar with a single, cephalic, term pregnancy) and 7 (multiparas with a single breech pregnancy with or without previous scars) showed an increase in the caesarean section rates over time. Robson groups 1 and 3 were significantly associated with stillbirths (OR 1.43, CI95% 1.17–1.72; OR 3.53, CI95% 2.95–4.2) and maternal mortality (OR 3.39, CI95% 1.59–7.22; OR 8.05, CI95% 3.34–19.41).

Discussion

The caesarean section rates increased in the last years as result of increased CS in groups with spontaneous labor and in-group of multiparas with a scarred uterus. Women included in groups 1 y 3 were associated to maternal perinatal complications. Women with previous cesarean section constitute the most important determinant of overall cesarean section rates. The use of Robson classification becomes an useful tool for monitoring cesarean section in low human development index countries.     

Factors associated with unfavourable birth outcomes in Kenya

Studies addressing factors associated with adverse birth outcomes have almost exclusively been based on hospital statistics. This is a serious limitation in developing countries where the majority of births do not occur within health facilities. This paper examines factors associated with premature deliveries, small baby's size at birth and Caesarean section deliveries in Kenya based on the 1993 Kenya Demographic and Health Survey data. Due to the hierarchical nature of the data, the analysis uses multilevel logistic regression models to take into account the family and community effects. The results show that the odds of unfavourable birth outcomes are significantly higher for first births than for higher order births. Furthermore, antenatal care (measured by frequency of antenatal care visits and tetanus toxoid injection) is observed to have a negative association with the incidence of premature births. For the baby's size at birth, maternal nutritional status is observed to be a predominant factor. Short maternal stature is confirmed as a significant risk factor for Caesarean section deliveries. The observed higher odds of Caesarean section deliveries among women from households of high socioeconomic status are attributed to the expected association between socioeconomic status and the use of appropriate maternal health care services. The odds of unfavourable birth outcomes vary significantly between women. In addition, the odds of Caesarean section deliveries vary between districts, after taking into account the individual-level characteristics of the woman.     

Asthma during Pregnancy in a Population-Based Study - Pregnancy Complications and Adverse Perinatal Outcomes

Background

Asthma is one of the most common chronic diseases, and prevalence, severity and medication may have an effect on pregnancy. We examined maternal asthma, asthma severity and control in relation to pregnancy complications, labour characteristics and perinatal outcomes.

Methods

We retrieved data on all singleton births from July 1, 2006 to December 31, 2009, and prescribed drugs and physician-diagnosed asthma on the same women from multiple Swedish registers. The associations were estimated with logistic regression.

Results

In total, 266 045 women gave birth to 284 214 singletons during the study period. Maternal asthma was noted in 26 586 (9.4%) pregnancies. There was an association between maternal asthma and increased risks of pregnancy complications including preeclampsia or eclampsia (adjusted OR 1.15; 95% CI 1.06–1.24) and premature contractions (adj OR 1.52; 95% CI 1.29–1.80). There was also a significant association between maternal asthma and emergency caesarean section (adj OR 1.29; 95% CI 1.23–1.34), low birth weight, and small for gestational age (adj OR 1.23; 95% CI 1.13–1.33). The risk of adverse outcomes such as low birth weight increased with increasing asthma severity. For women with uncontrolled compared to those with controlled asthma the results for adverse outcomes were inconsistent displaying both increased and decreased OR for some outcomes.

Conclusion

Maternal asthma is associated with a number of serious pregnancy complications and adverse perinatal outcomes. Some complications are even more likely with increased asthma severity. With greater awareness and proper management, outcomes would most likely improve.     

Randomised controlled trial of midwife led debriefing to reduce maternal depression after operative childbirth

ObjectiveTo assess the effectiveness of a midwife led debriefing session during the postpartum hospital stay in reducing the prevalence of maternal depression at six months postpartum among women giving birth by caesarean section, forceps, or vacuum extraction.DesignRandomised controlled trial.SettingLarge maternity teaching hospital in Melbourne, Australia.Participants1041 women who had given birth by caesarean section (n= 624) or with the use of forceps (n= 353) or vacuum extraction (n= 64).Results917 (88%) of the women recruited responded to the outcome questionnaire. More women allocated to debriefing scored as depressed six months after birth than women allocated to usual postpartum care (81 (17%) v 65 (14%)), although this difference was not significant (odds ratio=1.24, 95% confidence interval 0.87 to 1.77). They were also more likely to report that depression had been a problem for them since the birth, but the difference was not significant (123 (28%) v 94 (22%); odds ratio=1.37, 1.00 to 1.86). Women allocated to debriefing had poorer health status on seven of the eight SF-36 subscales, although the difference was significant only for role functioning (emotional): mean scores 73.32 v 78.98, t= −2.31, 95% confidence interval −10.48 to −0.84).ConclusionsMidwife led debriefing after operative birth is ineffective in reducing maternal morbidity at six months postpartum. The possibility that debriefing contributed to emotional health problems for some women cannot be excluded.     

Consumer demand for caesarean sections in Brazil: informed decision making,patient choice,or social inequality? A population based birth cohort study linking ethnographic and epidemiological methods

ObjectivesTo investigate why some women prefer caesarean sections and how decisions to medicalise birthing are influenced by patients, doctors, and the sociomedical environment.DesignPopulation based birth cohort study, using ethnographic and epidemiological methods.SettingEpidemiological study: women living in the urban area of Pelotas, Brazil who gave birth in hospital during the study. Ethnographic study: subsample of 80 women selected at random from the birth cohort. Nineteen medical staff were interviewed.Participants5304 women who gave birth in any of the city''s hospitals in 1993.ResultsIn both samples women from families with higher incomes and higher levels of education had caesarean sections more often than other women. Many lower to middle class women sought caesarean sections to avoid what they considered poor quality care and medical neglect, resulting from social prejudice. These women used medicalised prenatal and birthing health care to increase their chance of acquiring a caesarean section, particularly if they had social power in the home. Both social power and women''s behaviour towards seeking medicalised health care remained significantly associated with type of birth after controlling for family income and maternal education.ConclusionsFear of substandard care is behind many poor women''s preferences for a caesarean section. Variables pertaining to women''s role in the process of redefining and negotiating medical risks were much stronger correlates of caesarean section rates than income or education. The unequal distribution of medical technology has altered concepts of good and normal birthing. Arguments supporting interventionist birthing for all on the basis of equal access to health care must be reviewed.

What is already known on this topic

Women''s preferences for caesarean sections are understood to result from lack of knowledge and psychological aptitude to handle vaginal delivery and its consequencesEfforts to reduce the demand for caesarean sections have focused on providing consumers with correct information on the relative risks associated with vaginal and operative deliveries

What this study adds

In Brazil, many women prefer caesarean sections because they consider it good quality careRich women are more likely to have caesarean sections, supporting the notion that medical intervention represents superior carePoor women may implement a series of medicalised practices that justifies the need for greater medical intervention during birthInterventions for reducing caesarean sections by educating physicians and patients about risk factors associated with birthing procedures are not sufficient     

Effects on pregnancy outcome of changing partner between first two births: prospective population study

Objective To compare the effects on pregnancy outcomes of changing partner between the first two births with having the same partner for both births.Design Prospective population study.Setting Norway.Participants 31 683 women who changed partner between their first two births and 456 458 women with the same partner for both births.Results After adjustment for maternal age and education, interval between births, and decade of birth, the risk of adverse pregnancy outcomes for the second birth was higher for women who changed partner between the first two births compared with those who had the same partner for both births: preterm birth (< 37 weeks; relative risk 2.0, 95% confidence interval 1.9 to 2.1), low birth weight (< 2500 g; 2.5, 2.3 to 2.6), and infant mortality (1.8, 1.6 to 2.1). For the first birth, the risk of these adverse pregnancy outcomes was only slightly higher for mothers who subsequently had a second birth with another partner.Conclusion Women who change partner between their first two births are at an increased risk of delivering a preterm, low birthweight baby with an increased risk of infant mortality compared with women who have the same partner for both births.     

Reducing the incidence of infection after caesarean section: implications of prophylaxis with antibiotics for hospital resources.

OBJECTIVES--To estimate the cost effectiveness of giving prophylactic antibiotics routinely to reduce the incidence of wound infection after caesarean section. DESIGN--Estimation of cost effectiveness was based, firstly, on a retrospective overview of 58 controlled trials and, secondly, on evidence about costs derived from data and observations of practice. SETTING--Trials included in the overview were from obstetric units in several different countries, including the United Kingdom. The costing study was based on data referring to the John Radcliffe Maternity Hospital, Oxford. SUBJECTS--A total of 7777 women were included in the 58 controlled trials comparing the effects of giving routine prophylactic antibiotics at caesarean section with either treatment with a placebo or no treatment. Cost estimates were based on data on 486 women who had caesarean sections between January and September 1987. MAIN OUTCOME MEASURE--Cost effectiveness of prophylaxis with antibiotics. RESULTS--The odds of wound infection are likely to be reduced by between about 50 and 70% by giving antibiotics routinely at caesarean section. Forty one (8.4%) women who had caesarean section were coded by the Oxford obstetric data system as having developed wound infection. The additional average cost of hospital postnatal care for women with wound infection (compared with women who had had caesarean section and no wound infection) was estimated to be 716 pounds; introducing routine prophylaxis with antibiotics would reduce average costs of postnatal care by between 1300 pounds and 3900/100 pounds caesarean sections (at 1988 prices), depending on the cost of the antibiotic used and its effectiveness. CONCLUSIONS--The results suggest that giving antibiotics routinely at caesarean section will not only reduce rates of infection after caesarean section but also reduce costs.     

Maternal Clinical Diagnoses and Hospital Variation in the Risk of Cesarean Delivery: Analyses of a National US Hospital Discharge Database

Background

Cesarean delivery is the most common inpatient surgery in the United States, where 1.3 million cesarean sections occur annually, and rates vary widely by hospital. Identifying sources of variation in cesarean use is crucial to improving the consistency and quality of obstetric care. We used hospital discharge records to examine the extent to which variability in the likelihood of cesarean section across US hospitals was attributable to individual women''s clinical diagnoses.

Methods and Findings

Using data from the 2009 and 2010 Nationwide Inpatient Sample from the Healthcare Cost and Utilization Project—a 20% sample of US hospitals—we analyzed data for 1,475,457 births in 1,373 hospitals. We fitted multilevel logistic regression models (patients nested in hospitals). The outcome was cesarean (versus vaginal) delivery. Covariates included diagnosis of diabetes in pregnancy, hypertension in pregnancy, hemorrhage during pregnancy or placental complications, fetal distress, and fetal disproportion or obstructed labor; maternal age, race/ethnicity, and insurance status; and hospital size and location/teaching status.The cesarean section prevalence was 22.0% (95% confidence interval 22.0% to 22.1%) among women with no prior cesareans. In unadjusted models, the between-hospital variation in the individual risk of primary cesarean section was 0.14 (95% credible interval 0.12 to 0.15). The difference in the probability of having a cesarean delivery between hospitals was 25 percentage points. Hospital variability did not decrease after adjusting for patient diagnoses, socio-demographics, and hospital characteristics (0.16 [95% credible interval 0.14 to 0.18]). A limitation is that these data, while nationally representative, did not contain information on parity or gestational age.

Conclusions

Variability across hospitals in the individual risk of cesarean section is not decreased by accounting for differences in maternal diagnoses. These findings highlight the need for more comprehensive or linked data including parity and gestational age as well as examination of other factors—such as hospital policies, practices, and culture—in determining cesarean section use. Please see later in the article for the Editors'' Summary     

Optimal Timing of Delivery among Low-Risk Women with Prior Caesarean Section: A Secondary Analysis of the WHO Multicountry Survey on Maternal and Newborn Health

Objective

To investigate optimal timing of elective repeat caesarean section among low-risk pregnant women with prior caesarean section in a multicountry sample from largely low- and middle-income countries.

Design

Secondary analysis of a cross-sectional study.

Setting

Twenty-nine countries from the World Health Organization Multicountry Survey on Maternal and Newborn Health.

Population

29,647 women with prior caesarean section and no pregnancy complications in their current pregnancy who delivered a term singleton (live birth and stillbirth) at gestational age 37–41 weeks by pre-labour caesarean section, intra-partum caesarean section, or vaginal birth following spontaneous onset of labour.

Methods

We compared the rate of short-term adverse maternal and newborn outcomes following pre-labour caesarean section at a given gestational age, to those following ongoing pregnancies beyond that gestational age.

Main Outcome Measures

Severe maternal outcomes, neonatal morbidity, and intra-hospital early neonatal mortality.

Results

Odds of neonatal morbidity and intra-hospital early neonatal mortality were 0.48 (95% confidence interval [CI] 0.39–0.60) and 0.31 (95% CI 0.16–0.58) times lower for ongoing pregnancies compared to pre-labour caesarean section at 37 weeks. We did not find any significant change in the risk of severe maternal outcomes between pre-labour caesarean section at a given gestational age and ongoing pregnancies beyond that gestational age.

Conclusions

Elective repeat caesarean section at 37 weeks had higher risk of neonatal morbidity and mortality compared to ongoing pregnancy, however risks at later gestational ages did not differ between groups.