Variation in the rates of operative delivery in the United States

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.

The influence of detailed maternal ethnicity on cesarean delivery: findings from the U.S. birth certificate in the State of Massachusetts

BACKGROUND

Our objective was to examine the likelihood of primary cesarean delivery for women at low risk for the procedure in Massachusetts.

METHODS

Birth certificate data for all births from 1996 to 2010 that were nulliparous, term, singleton, and vertex (NTSV; N = 427,393) were used to conduct logistic regression models to assess the likelihood of a cesarean delivery for each of the 31 ethnic groups relative to self-identified "American" mothers. The results were compared with broad classifications of race/ethnicity more commonly employed in research.

RESULTS

While 23.3 percent of American women had primary cesarean deliveries, cesarean delivery rates varied from 12.9 percent for Cambodian to 32.4 percent for Nigerian women. Women from 21 of 30 ethnic groups had higher odds of a primary cesarean (range of adjusted odds ratios [AORs] 1.09-1.77), while only Chinese, Cambodian, and Japanese women had lower odds (range of AORs 0.66-0.92), compared with self-identified "Americans." Using broad race/ethnicity categories, Non-Hispanic black, Hispanic, and "Other" women had higher odds of cesarean delivery relative to Non-Hispanic white women (range of AORs 1.12-1.47), while there were no differences for Asian or Pacific Islander women.

CONCLUSIONS

Detailed maternal ethnicity explains the variation in NTSV cesarean delivery rates better than broad race/ethnicity categories. Different patterns of cesarean delivery between ethnic groups suggest cultural specificity related to birth culture.

Mode of delivery and the probability of subsequent childbearing: a population-based register study

OBJECTIVE

To investigate the relationship between mode of first delivery and probability of subsequent childbearing.

DESIGN

Population-based study.

SETTING

Nationwide study in Sweden.

POPULATION

A cohort of 771 690 women who delivered their first singleton infant in Sweden between 1992 and 2010.

METHODS

Using Cox's proportional-hazards regression models, risks of subsequent childbearing were compared across four modes of delivery. Hazard ratios (HRs) were calculated, using 95% confidence intervals (95% CIs).

MAIN OUTCOME MEASURES

Probability of having a second and third child; interpregnancy interval.

RESULTS

Compared with women who had a spontaneous vaginal first delivery, women who delivered by vacuum extraction were less likely to have a second pregnancy (HR 0.96, 95% CI 0.95-0.97), and the probabilities of a second childbirth were substantially lower among women with a previous emergency caesarean section (HR 0.85, 95% CI 0.84-0.86) or an elective caesarean section (HR 0.82, 95% CI 0.80-0.83). There were no clinically important differences in the median time between first and second pregnancy by mode of first delivery. Compared with women younger than 30 years of age, older women were more negatively affected by a vacuum extraction with respect to the probability of having a second child. A primary vacuum extraction decreased the probability of having a third child by 4%, but having two consecutive vacuum extraction deliveries did not further alter the probability.

CONCLUSIONS

A first delivery by vacuum extraction does not reduce the probability of subsequent childbearing to the same extent as a first delivery by emergency or elective caesarean section.

Analyzing support of postnatal transition in term infants after c-section

Background

Whereas good data are available on the resuscitation of infants, little is known regarding support of postnatal transition in low-risk term infants after c-section. The present study was performed to describe current delivery room (DR) management of term infants born by c-section in our institution by analyzing videos that were recorded within a quality assurance program.

Methods

DR- management is routinely recorded within a quality assurance program. Cross-sectional study of videos of term infants born by c-section. Videos were analyzed with respect to time point, duration and number of all medical interventions. Study period was between January and December 2012.

Results

186 videos were analyzed. The majority of infants (73%) were without support of postnatal transition. In infants with support of transition, majority of infants received respiratory support, starting in median after 3.4 minutes (range 0.4-14.2) and lasting for 8.8 (1.5-28.5) minutes. Only 33% of infants with support had to be admitted to the NICU, the remaining infants were returned to the mother after a median of 13.5 (8-42) minutes. A great inter- and intra-individual variation with respect to the sequence of interventions was found.

Conclusions

The study provides data for an internal quality improvement program and supports the benefit of using routine video recording of DR-management. Furthermore, data can be used for benchmarking with current practice in other centers.

Maternal mortality in the United States: predictability and the impact of protocols on fatal postcesarean pulmonary embolism and hypertension-related intracranial hemorrhage

OBJECTIVE

The purpose of this study was to examine the efficacy of specific protocols that have been developed in response to a previous analysis of maternal deaths in a large hospital system. We also analyzed the theoretic impact of an ideal system of maternal triage and transport on maternal deaths and the relative performance of cause of death determination from chart review compared with a review of discharge coding data.

STUDY DESIGN

We conducted a retrospective evaluation of maternal deaths from 2007-2012 after the introduction of disease-specific protocols that were based on 2000-2006 data.

RESULTS

Our maternal mortality rate was 6.4 of 100,000 births in just >1.2 million deliveries. A policy of universal use of pneumatic compression devices for all women who underwent cesarean delivery resulted in a decrease in postoperative pulmonary embolism deaths from 7 of 458,097 cesarean births to 1 of 465,880 births (P = .038). A policy that involved automatic and rapid antihypertensive therapy for defined blood pressure thresholds eliminated deaths from in-hospital intracranial hemorrhage and reduced overall deaths from preeclampsia from 15-3 (P = .02.) From 1-3 deaths were related causally to cesarean delivery. Only 7% of deaths were potentially preventable with an ideal system of admission triage and transport. Cause of death analysis with the use of discharge coding data was correct in 52% of cases.

CONCLUSION

Disease-specific protocols are beneficial in the reduction of maternal death because of hypertensive disease and postoperative pulmonary embolism. From 2-6 women die annually in the United States because of cesarean delivery itself. A reduction in deaths from postpartum hemorrhage should be the priority for maternal death prevention efforts in coming years in the United States.

Clinical indications associated with primary cesarean birth

Cesarean birth is the most common surgical procedure in the United States and is associated with increased morbidity and mortality when compared to vaginal birth. Of the more than 4 million births a year, one in three is now a cesarean. A better understanding of the clinical indications contributing to the current prevalence in primary cesarean rates can inform prevention strategies. This column takes a second look at two recent studies in which researchers evaluated the clinical indications associated with primary cesarean birth rates.

Cesarean delivery rates vary tenfold among US hospitals; reducing variation may address quality and cost issues

Cesarean delivery is the most commonly performed surgical procedure in the United States, and cesarean rates are increasing. Working with 2009 data from 593 US hospitals nationwide, we found that cesarean rates varied tenfold across hospitals, from 7.1 percent to 69.9 percent. Even for women with lower-risk pregnancies, in which more limited variation might be expected, cesarean rates varied fifteenfold, from 2.4 percent to 36.5 percent. Thus, vast differences in practice patterns are likely to be driving the costly overuse of cesarean delivery in many US hospitals. Because Medicaid pays for nearly half of US births, government efforts to decrease variation are warranted. We focus on four promising directions for reducing these variations, including better coordinating maternity care, collecting and measuring more data, tying Medicaid payment to quality improvement, and enhancing patient-centered decision making through public reporting.

Racial and ethnic differences in primary, unscheduled cesarean deliveries among low-risk primiparous women at an academic medical center: a retrospective cohort study

Background

Cesarean sections are the most common surgical procedure for women in the United States. Of the over 4 million births a year, one in three are now delivered in this manner and the risk adjusted prevalence rates appear to vary by race and ethnicity. However, data from individual studies provides limited or contradictory information on race and ethnicity as an independent predictor of delivery mode, precluding accurate generalizations. This study sought to assess the extent to which primary, unscheduled cesarean deliveries and their indications vary by race/ethnicity in one academic medical center.

Methods

A retrospective, cross-sectional cohort study was conducted of 4,483 nulliparous women with term, singleton, and vertex presentation deliveries at a major academic medical center between 2006–2011. Cases with medical conditions, risk factors, or pregnancy complications that can contribute to increased cesarean risk or contraindicate vaginal birth were excluded. Multinomial logistic regression analysis was used to evaluate differences in delivery mode and caesarean indications among racial and ethnic groups.

Results

The overall rate of cesarean delivery in our cohort was 16.7%. Compared to White women, Black and Asian women had higher rates of cesarean delivery than spontaneous vaginal delivery, (adjusted odds ratio {AOR}: 1.43; 95% CI: 1.07, 1.91, and AOR: 1.49; 95% CI: 1.02, 2.17, respectively). Black women were also more likely, compared to White women, to undergo cesarean for fetal distress and indications diagnosed in the first stage as compared to the second stage of labor.

Conclusions

Racial and ethnic differences in delivery mode and indications for cesareans exist among low-risk nulliparas at our institution. These differences may be best explained by examining the variation in clinical decisions that indicate fetal distress and failure to progress at the hospital-level.

Intrapartum management of category II fetal heart rate tracings: towards standardization of care

There is currently no standard national approach to the management of category II fetal heart rate (FHR) patterns, yet such patterns occur in the majority of fetuses in labor. Under such circumstances, it would be difficult to demonstrate the clinical efficacy of FHR monitoring even if this technique had immense intrinsic value, since there has never been a standard hypothesis to test dealing with interpretation and management of these abnormal patterns. We present an algorithm for the management of category II FHR patterns that reflects a synthesis of available evidence and current scientific thought. Use of this algorithm represents one way for the clinician to comply with the standard of care, and may enhance our overall ability to define the benefits of intrapartum FHR monitoring.

Hospital differences in cesarean deliveries in Massachusetts (US) 2004-2006: the case against case-mix artifact

Objective

We examined the extent to which differences in hospital-level cesarean delivery rates in Massachusetts were attributable to hospital-level, rather than maternal, characteristics.

Methods

Birth certificate and maternal in-patient hospital discharge records for 2004–06 in Massachusetts were linked. The study population was nulliparous, term, singleton, and vertex births (NTSV) (n = 80,371) in 49 hospitals. Covariates included mother's age, race/ethnicity, education, infant birth weight, gestational age, labor induction (yes/no), hospital shift at time of birth, and preexisting health conditions. We estimated multilevel logistic regression models to assess the likelihood of a cesarean delivery

Results

Overall, among women with NTSV births, 26.5% births were cesarean, with a range of 14% to 38.3% across hospitals. In unadjusted models, the between-hospital variance was 0.103 (SE 0.022); adjusting for demographic, socioeconomic and preexisting medical conditions did not reduce any hospital-level variation 0.108 (SE 0.023).

Conclusion

Even after adjusting for both socio-demographic and clinical factors, the chance of a cesarean delivery for NTSV pregnancies varied according to hospital, suggesting the importance of hospital practices and culture in determining a hospital's cesarean rate.

Maternity care and liability: most promising policy strategies for improvement

BACKGROUND

The present liability system is not serving well childbearing women and newborns, maternity care clinicians, or maternity care payers. Examination of evidence about the impact of this system on maternity care led us to identify seven aims for a high-functioning liability system in this clinical context. Herein, we identify policy strategies that are most likely to meet these aims and contribute to needed improvements. A companion paper considers strategies that hold little promise.

METHODS

We considered whether 25 strategies that have been used or proposed for improvement have met or could meet the seven aims. We used a best available evidence approach and drew on more recent empirical legal studies and health services research about maternity care and liability when available, and considered other studies when unavailable.

FINDINGS

Ten strategies seem to have potential to improve liability matters in maternity care across multiple aims. The most promising strategy--implementing rigorous maternity care quality improvement (QI) programs--has led to better quality and outcomes of care, and impressive declines in liability claims, payouts, and premium levels.

CONCLUSIONS

A number of promising strategies warrant demonstration and evaluation at the level of states, health systems, or other appropriate entities. Rigorous QI programs have a growing track record of contributing to diverse aims of a high-functioning liability system and seem to be a win-win-win prevention strategy for childbearing families, maternity care providers, and payers. Effective strategies are also needed to assist families when women and newborns are injured.

Regional variation in late preterm births in North Carolina

Late preterm (LPT) neonates (34 0/7th-36 6/7th weeks' gestation) account for 70% of all premature births in the United States. LPT neonates have a higher morbidity and mortality risk than term neonates. LPT birth rates vary across geographic regions. Unwarranted variation is variation in medical care that cannot be explained by sociodemographic or medical risk factors; it represents differences in health system performance, including provider practice variation. The purpose of this study is to identify regional variation in LPT births in North Carolina that cannot be explained by sociodemographic or medical/obstetric risk factors. We searched the NC State Center for Health Statistics linked birth-death certificate database for all singleton term and LPT neonates born between 1999 and 2006. We used multivariable logistic regression analysis to control for socio-demographic and medical/obstetric risk factors. The main outcome was the percent of LPT birth in each of the six perinatal regions in North Carolina. We identified 884,304 neonates; 66,218 (7.5%) were LPT. After multivariable logistic regression, regions 2 (7.0%) and 6 (6.6%) had the highest adjusted percent of LPT birth. Analysis of a statewide birth cohort demonstrates regional variation in the incidence of LPT births among NC's perinatal regions after adjustment for sociodemographic and medical risk factors. We speculate that provider practice variation might explain some of the remaining difference. This is an area where policy changes and quality improvement efforts can help reduce variation, and potentially decrease LPT births.

A systematic approach to the identification and classification of near-miss events on labor and delivery in a large, national health care system

We describe a systematic approach to the identification and classification of near-miss events on labor and delivery in a large, national health care system. Voluntary reports of near-miss events were prospectively collected during 2010 in 203,708 deliveries. These reports were analyzed according to frequency and potential severity. Near-miss events were reported in 0.69% of deliveries. Medication and patient identification errors were the most common near-miss events. However, existing barriers were found to be highly effective in preventing such errors from reaching the patient. Errors with the greatest potential for causing harm involved physician response and decision making. Fewer and less effective existing barriers between these errors and potential patient harm were identified. Use of a comprehensive system for identification of near-miss events on labor and delivery units have proven useful in allowing us to focus patient safety efforts on areas of greatest need.

Adoption of diagnostic technology and variation in caesarean section rates: a test of the practice style hypothesis in Norway

OBJECTIVE

To examine whether the introduction of advanced diagnostic technology in maternity care has led to less variation in type of delivery between hospitals in Norway.

DATA SOURCES

The Medical Birth Registry of Norway provided detailed medical information for 1.7 million deliveries from 1967 to 2005. Information about diagnostic technology was collected directly from the maternity units.

STUDY DESIGN

The data were analyzed using a two-level binary logistic model with Caesarean section as the outcome measure. Level one contained variables that characterized the health status of the mother and child. Hospitals are level two. A heterogeneous variance structure was specified for the hospital level, where the error variance was allowed to vary according to the following types of diagnostic technology: two-dimensional ultrasound, cardiotocography, ST waveform analysis, and fetal blood analyses.

PRINCIPAL FINDING

There was a marked variation in Caesarean section rates between hospitals up to 1973. After this the variation diminished markedly. This was due to the introduction of ultrasound and cardiotocography.

CONCLUSION

Diagnostic technology reduced clinical uncertainty about the diagnosis of risk factors of the mother and child during delivery, and variation in type of delivery between hospitals was reduced accordingly. The results support the practice style hypothesis.

Preventing primary cesarean sections: intrapartum care

Some intrapartum care practices promote vaginal birth, whereas others may increase the risk for cesarean section. Electronic fetal monitoring and use of the Friedman graph to plot and monitor labor progress are associated with increasing the cesarean section rate. Continuous one-to-one support and midwifery management are associated with lower cesarean section rates. This article reviews the evidence that links specific intrapartum care practices to cesarean section. Strategies that can be implemented in the current social and cultural setting of obstetrics today are recommended.

The association between hospital obstetrical volume and maternal postpartum complications

OBJECTIVE

The purpose of this study was to examine the relationship between delivery volume and maternal complications.

STUDY DESIGN

We used administrative data to identify women who had been admitted for childbirth in 2006. Hospitals were stratified into deciles that were based on delivery volume. We compared composite complication rates across deciles.

RESULTS

We evaluated 1,683,754 childbirths in 1045 hospitals. Decile 1 and 2 hospitals had significantly higher rates of composite complications than decile 10 (11.8% and 10.1% vs 8.5%, respectively; P < .0001). Decile 9 and 10 hospitals had modestly higher composite complications as compared with decile 6 (8.8% and 8.5% vs 7.6%, respectively; P < .0001). Sixty percent of decile 1 and 2 hospitals were located within 25 miles of the nearest greater volume hospital.

CONCLUSION

Women who deliver at very low-volume hospitals have higher complication rates, as do women who deliver at exceedingly high-volume hospitals. Most women who deliver in extremely low-volume hospitals have a higher volume hospital located within 25 miles.

Operative vaginal deliveries: practical aspects

Forceps, vacuum, and cesarean sections are relatively recent additions to the obstetrician's armamentarium. The art of modern obstetrics is one that mandates from obstetricians the attentive vigilance of the development of natural processes and an active intervention when such processes fall outside normally accepted standards. What constitutes the "normal process" and the "accepted standard" is subject to discussion, and international variations in obstetric practice are in part the reflection of such controversies. This article presents a practical approach to the contemporary issue of instrumental deliveries, outlining supporting evidence (when available) and the most current position of professional colleges in obstetrics and gynecology.

Patient safety in obstetrics--the Hospital Corporation of America experience

We report an update on obstetric patient safety efforts and results in the nation's largest obstetric health care delivery system. The application of principles advocated by the Institute of Medicine a decade ago has resulted in reduced adverse outcomes, as reflected by claims experience. Particular progress has been made in standardization and documentation of critical processes, establishment of national quality benchmarks, reduction in elective deliveries <39 weeks' gestation, and reduction in fatal postcesarean pulmonary embolism. Our experience provides a useful blueprint for similar progress in other health care systems.

Reduction in elective delivery at <39 weeks of gestation: comparative effectiveness of 3 approaches to change and the impact on neonatal intensive care admission and stillbirth

OBJECTIVE

No studies exist that have examined the effectiveness of different approaches to a reduction in elective early term deliveries or the effect of such policies on newborn intensive care admissions and stillbirth rates.

STUDY DESIGN

We conducted a retrospective cohort study of prospectively collected data and examined outcomes in 27 hospitals before and after implementation of 1 of 3 strategies for the reduction of elective early term deliveries.

RESULTS

Elective early term delivery was reduced from 9.6-4.3% of deliveries, and the rate of term neonatal intensive care admissions fell by 16%. We observed no increase in still births. The greatest improvement was seen when elective deliveries at <39 weeks were not allowed by hospital personnel.

CONCLUSION

Physician education and the adoption of policies backed only by peer review are less effective than "hard stop" hospital policies to prevent this practice. A 5% rate of elective early term delivery would be reasonable as a national quality benchmark.

Surfactant use for premature infants with respiratory distress syndrome in three New York city hospitals: discordance of practice from a community clinician consensus standard

OBJECTIVE

To assess concordance with a locally developed standard of care for premature infants with respiratory distress syndrome (RDS) for whom the standard recommends surfactant treatment within 2 h of birth, and to examine the association between clinical, demographic, and hospital characteristics with discordance from the standard.

STUDY DESIGN

Retrospective cohort study of 773 infants weighing < or =1750 g born in any of the three New York City hospitals between 1999 and 2002.

RESULT

227 of the 773 infants (29%) met criteria for treatment according to the standard. Of these, 37% received surfactant by 2 h. By 4 h, 70% of infants who met the standard received surfactant. White infants were more likely to receive surfactant by 4 h (85%) than African American (61%) or Latino infants (67%). Multivariable logistic regression revealed significant odds ratios predicting discordance from the relaxed criteria (4 h) for African American race (4.10, 95% confidence interval: 1.30 to 13.00), 100 g of birth weight (odds ratio: 1.22, 95% confidence interval: 1.10 to 1.34), and hospital of birth.

CONCLUSION

Many infants with RDS failed to receive surfactant replacement therapy at 2 and 4 h after birth. African Americans and those born larger were less likely to receive surfactant. If these data can be generalized, there is a large opportunity to reduce infant morbidity from RDS and to reduce racial/ethnic disparities in birth outcomes by increasing the rate and speed with which surfactant is delivered to these infants.

Regional variation in the cesarean delivery and assisted vaginal delivery rates

OBJECTIVE

To examine regional variations in rates of primary cesarean delivery and assisted vaginal delivery in the population of British Columbia, while adjusting for the maternal characteristics and conditions that increase the likelihood of operative delivery.

METHODS

Using data from the British Columbia Perinatal Database Registry, we studied all deliveries in British Columbia between 2004 and 2007, excluding women who had a previous cesarean delivery (n=116,839). Our primary outcome of interest was mode of delivery, further defined as delivery by cesarean or assisted vaginal delivery. We calculated crude and risk-adjusted rates of primary cesarean delivery and assisted vaginal delivery across British Columbia's 16 Health Service Delivery Areas and examined cesarean delivery rates by indication for the procedure.

RESULTS

Crude primary cesarean delivery and assisted vaginal delivery rates varied markedly across the Health Service Delivery Areas ranging from 16.1 to 27.5 per 100 deliveries, and from 8.6 to 18.6 per 100 deliveries, respectively. The most common indication for cesarean delivery was dystocia, which accounted for 30.0% of all cesarean deliveries and varied more than fivefold across regions. After controlling for maternal characteristics and conditions known to increase the likelihood of cesarean delivery and assisted vaginal delivery, adjusted cesarean delivery rates varied twofold, ranging from 14.7 to 27.6 per 100 deliveries, while adjusted assisted vaginal delivery rates varied by more than twofold, ranging from 6.5 to 15.3 per 100 deliveries.

CONCLUSION

Our results illustrate substantial regional variation in the use of cesarean delivery that cannot be explained by patient illness or preferences. This variation likely reflects differences in practitioners' approaches to medical decision-making.

LEVEL OF EVIDENCE

II.

Emergency department use during the postpartum period: implications for current management of the puerperium

OBJECTIVE

The purpose of this study was to define patterns of morbidity that are experienced by women in the postpartum period who seek care in the emergency department within 42 and 100 days of discharge.

STUDY DESIGN

We conducted a retrospective examination of discharge diagnosis codes and descriptions for emergency department visits and analyzed temporal patterns of both emergency department visits and hospital readmissions.

RESULTS

During 2007, 222,084 patients delivered in Hospital Corporation of America facilities in the United States. Among these women, there were 10,751 emergency department visits within 42 days of delivery (4.8%). Fifty-eight percent of the patients were seen for conditions that were related to pregnancy; 42% of the patients were seen for conditions unrelated to pregnancy. Fifty percent of patients in the postpartum period who were seen either in the emergency department (21,833 patients) or readmitted (5190 patients) during both 2007 and 2008 had this encounter within 10 days of discharge.

CONCLUSION

The scheduling and content of traditional postpartum education and clinical visits appear poorly suited to the prevention of puerperal morbidity.

Hospital readmission after delivery: evidence for an increased incidence of nonurogenital infection in the immediate postpartum period

OBJECTIVE

The purpose of this study was to analyze reasons for postpartum readmission.

STUDY DESIGN

We conducted a database analysis of readmissions within 6 weeks after delivery during 2007, with extended (180 day) analysis for pneumonia, appendicitis, and cholecystitis. Linear regression analysis, survival curve fitting, and Gehan-Breslow statistic with Holm-Sidak all-pairwise analysis for multiple comparisons were used. Probability values of < .05 were considered significant.

RESULTS

Of 222,751 women delivered, 2655 women (1.2%) were readmitted within 6 weeks (0.83% vaginal delivery and 1.8% cesarean section delivery; P < .001). A high percentage of these readmittances occurred within the first 6 weeks: pneumonia (84%), appendicitis (43%), or cholecystitis (46%). Cumulative readmission rates were higher in the first 6 weeks after delivery than in the next 20 weeks (pneumonia curve gradient, 3.7 vs 0.11; appendicitis curve gradient, 1.1 vs 0.36; cholecystitis curve gradient, 6.6 vs 1.7).

CONCLUSION

The cause of postpartum readmission is primarily infectious in origin. A recent pregnancy appears to increase the risk of pneumonia, appendicitis, and cholecystitis.

Cesarean delivery rates in Saudi Arabia: a ten-year review

BACKGROUND AND OBJECTIVES

In view of the global increase in the rate of cesarean deliveries (CD), with the associated higher morbidity and mortality, this study was undertaken to review CD rates and some of their determinants over a ten-year period in Saudi Arabia.

METHODS

Maternity data for Ministry of Health (MOH) hospitals across 14 administrative regions and other governmental hospitals in nine clusters were collected and the corresponding rates calculated using MOH yearly statistical books from 1997 to 2006. No private hospital data are reported.

RESULTS

The overall CD rate significantly increased by 80.2% from 10.6% in 1997 to 19.1% in 2006. The greatest increase of 265% was in the Northern region and the least of 32.8% was in the Royal Commission Hospitals. Both vaginal breech and operative vaginal deliveries showed a significant decrease of 38% and 29%, respectively. There was a significant negative correlation between the increasing CD rate and the decreasing vaginal breech and operative vaginal deliveries rates. The volume of annual deliveries did not influence the CD rate.

CONCLUSIONS

A significant increase of more than 80% in the CD rate was observed from 1997 to 2006. A national strategy to reduce the CD rate is needed and will require upgrading of the existing vital registration system. We also recommend that current national data capturing mechanisms be expanded to include private sector data and to include indications for CD.

Outcomes of obstetric hospitalizations among women with inflammatory bowel disease in the United States

BACKGROUND & AIMS

Pregnant women with Crohn's disease (CD) or ulcerative colitis (UC) are at increased risk of adverse outcomes compared with pregnant women without these disorders. We estimated the occurrence of pregnancies in women with CD and UC in the United States and compared outcomes between these patients and the non-inflammatory bowel disease (IBD) obstetric population.

METHODS

By using the 2005 Nationwide Inpatient Sample, we estimated the number of obstetric hospitalizations, deliveries, and Cesarean deliveries in women with CD, UC, and those without IBD. Outcomes included prevalences of Cesarean delivery, venous thromboembolism (VTE), blood transfusion, and malnutrition.

RESULTS

Of an estimated 4.21 million deliveries, 2372 and 1368 occurred in women with CD and UC, respectively. Compared with the non-IBD population, adjusted odds of Cesarean delivery were higher in women with CD (adjusted odds ratio [aOR], 1.72; 95% confidence interval [CI], 1.44-2.04) and UC (aOR, 1.29; 95% CI, 1.01-1.66). The risk of VTE was substantially higher in women with CD (aOR, 6.12; 95% CI, 2.91-12.9) and UC (aOR, 8.44; 95% CI, 3.71-19.2) vs the non-IBD population. Blood transfusions occurred more frequently in women with CD (aOR, 2.82; 95% CI, 1.51-5.26), whereas protein-calorie malnutrition occurred more frequently in women with CD (aOR, 20.0; 95% CI, 8.8-45.4) or UC (aOR, 60.8; 95% CI, 28.2-131.0).

CONCLUSIONS

Adverse pregnancy and maternal outcomes occur more frequently in women with IBD. Measures should be undertaken to reduce maternal complications such as VTE and malnutrition in women with these disorders.

Cesarean delivery among women with low-risk pregnancies: a comparison of birth certificates and hospital discharge data

OBJECTIVE

To examine the effect of data source (birth certificate compared with hospital discharge records) and the definition of risk on the prevalence of cesarean deliveries thought to have "no indicated risk"; eg, the fetus is full-term, singleton, and in the vertex position, and the mother has no reported medical risk factors or complications of labor and/or delivery identified on the birth certificate.

METHODS

The study is based on data from 565,767 women who delivered singleton, vertex neonates with gestational ages of 37-41 weeks in Georgia hospitals between 1999 and 2004 and for whom data from birth certificates and hospital discharge records could be linked. The percentages of women with primary cesarean deliveries who did not have risk indicated on the birth certificate and on the hospital discharge record were compared. We also calculated the agreement between data sources overall and for each risk indicator.

RESULTS

Among 40,932 women with primary cesarean deliveries and no risk indicated on the birth certificate, 35,761 (87.4%) had a risk identified in the hospital discharge data. The overall agreement between data sources on the presence of any risk indicator was low (kappa=0.18). Among primary cesarean deliveries, the percentage without indicated risk was 58.3% when using birth certificate data alone and 3.9% when using hospital discharge data in combination with the birth certificate.

CONCLUSION

Using birth certificate information alone overestimated the proportion of women who had no-indicated-risk cesarean deliveries in Georgia. Evidence of many indications for cesarean delivery can be found only in the hospital discharge data. The construct of no indicated risk as determined from birth certificates should be interpreted with caution, and the use of linked data should be considered whenever possible.

LEVEL OF EVIDENCE

III.

Improved outcomes, fewer cesarean deliveries, and reduced litigation: results of a new paradigm in patient safety

In a health care delivery system with an annual delivery rate of approximately 220,000, a comprehensive redesign of patient safety process was undertaken based on the following principles: (1) uniform processes and procedure result in an improved quality; (2) every member of the obstetric team should be required to halt any process that is deemed to be dangerous; (3) cesarean delivery is best viewed as a process alternative, not an outcome or quality endpoint; (4) malpractice loss is best avoided by reduction in adverse outcomes and the development of unambiguous practice guidelines; and (5) effective peer review is essential to quality medical practice yet may be impossible to achieve at a local level in some departments. Since the inception of this program, we have seen improvements in patient outcomes, a dramatic decline in litigation claims, and a reduction in the primary cesarean delivery rate.

Maternal death in the 21st century: causes, prevention, and relationship to cesarean delivery

OBJECTIVE

We sought to examine etiology and preventability of maternal death and the causal relationship of cesarean delivery to maternal death in a series of approximately 1.5 million deliveries between 2000 and 2006.

STUDY DESIGN

This was a retrospective medical records extraction of data from all maternal deaths in this time period, augmented when necessary by interviews with involved health care providers. Cause of death, preventability, and causal relationship to mode of delivery were examined.

RESULTS

Ninety-five maternal deaths occurred in 1,461,270 pregnancies (6.5 per 100,000 pregnancies.) Leading causes of death were complications of preeclampsia, pulmonary thromboembolism, amniotic fluid embolism, obstetric hemorrhage, and cardiac disease. Only 1 death was seen from placenta accreta. Twenty-seven deaths (28%) were deemed preventable (17 by actions of health care personnel and 10 by actions of non-health care personnel). The rate of maternal death causally related to mode of delivery was 0.2 per 100,000 for vaginal birth and 2.2 per 100,0000 for cesarean delivery, suggesting that the number of annual deaths resulting causally from cesarean delivery in the United States is about 20.

CONCLUSION

Most maternal deaths are not preventable. Preventable deaths are equally likely to result from actions by nonmedical persons as from provider error. Given the diversity of causes of maternal death, no systematic reduction in maternal death rate in the United States can be expected unless all women undergoing cesarean delivery receive thromboembolism prophylaxis. Such a policy would be expected to eliminate any statistical difference in death rates caused by cesarean and vaginal delivery.