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Winner RM, Graves J, Jarvis K, Beckman D, Youkilis BB, Monroe M, Davies CC. Relationships Among Mode of Birth, Onset of Labor, and Bishop Score. J Obstet Gynecol Neonatal Nurs 2024:S0884-2175(24)00069-8. [PMID: 38782048 DOI: 10.1016/j.jogn.2024.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 04/10/2024] [Accepted: 04/12/2024] [Indexed: 05/25/2024] Open
Abstract
OBJECTIVE To investigate mode of birth in relation to onset of labor and Bishop score. DESIGN Retrospective observational cohort design. SETTING A 434-bed Magnet e-designated community hospital. PARTICIPANTS Nulliparous women, 18 years of age or older, who gave birth at 37 to 41 weeks gestation to live, singleton fetuses in the vertex presentation (N = 701). METHODS We conducted a retrospective chart review and used chi-square analysis to measure the associations among mode of birth, onset of labor, and Bishop score. We used logistic regression to test the probability of cesarean birth for women undergoing elective induction of labor. RESULTS Most participants (n = 531, 75.7%) gave birth vaginally. Significant findings included the following relationships: spontaneous onset of labor and vaginal birth (χ2 = 22.2, Ø = 0.18, p < .001) and Bishop score of greater than or equal to 8 and vaginal birth (χ2 = 4.9, Ø = .14, p = .028). Induction of labor was a significant predictor in cesarean birth when controlling for age and body mass index (OR = 2.1, 95% confidence interval [1.5, 3.1], p < .01). CONCLUSION Reducing elective induction of labor in women with low-risk pregnancies may help lower the risk of cesarean birth. Clinically, Bishop score and mode of birth have a weak association, particularly when induction includes cervical ripening.
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Allen C, Taylor I, Ushry A. Alliance for Innovation on Maternal Health: Evolution of a program to address maternal morbidity and mortality. Semin Perinatol 2024; 48:151903. [PMID: 38688743 DOI: 10.1016/j.semperi.2024.151903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
The Alliance for Innovation on Maternal Health program is a national investment in promoting safe care for every birth in the United States and lowering rates of preventable maternal mortality and severe maternal morbidity. Through its work with state and jurisdiction-based teams on patient safety bundle implementation, the program supports data-driven quality improvement. This paper details key aspects of the Alliance for Innovation on Maternal Health including patient safety bundles, technical assistance, implementation resource development, data support, and partnerships while providing an overview of the program's evolution, reach, impact, and future opportunities.
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Affiliation(s)
- Christie Allen
- American College of Obstetricians and Gynecologists, USA
| | - Isabel Taylor
- American College of Obstetricians and Gynecologists, USA
| | - Amy Ushry
- American College of Obstetricians and Gynecologists, USA.
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Hussaini KS, Galang R, Li R. Differences in Cesarean Rates for Nulliparous, Term, Singleton, Vertex Births Among Racial and Ethnic Groups and States Before and After Stay-at-Home Orders During the COVID-19 Pandemic, United States, 2017-2021. Public Health Rep 2024:333549241236629. [PMID: 38504483 DOI: 10.1177/00333549241236629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2024] Open
Abstract
OBJECTIVES Evidence is limited on differences in cesarean rates for nulliparous, term, singleton, vertex (NTSV) births across racial and ethnic groups at the national and state level during the COVID-19 pandemic. We assessed changes in levels and trends of NTSV cesarean rates before and after stay-at-home orders (SAHOs) were implemented in the United States (1) overall, (2) by racial and ethnic groups, and (3) by 50 US states from January 2017 through December 2021. METHODS We used birth certificate data from 2017 through 2021, restricted to hospital births, to calculate monthly NTSV cesarean rates for the United States and for racial and ethnic groups and to calculate quarterly NTSV cesarean rates for the 50 states. We used interrupted time-series analysis to measure changes in NTSV cesarean rates before and after implementation of SAHOs (March 1 through May 31, 2020). RESULTS Of 6 022 552 NTSV hospital births, 1 579 645 (26.2%) were cesarean births. Before implementation of SAHOs, NTSV cesarean rates were declining in the United States overall; were declining among births to non-Hispanic Asian, non-Hispanic Black, Hispanic, and non-Hispanic White women; and were declining in 6 states. During the first month of implementation of SAHOs in May 2020, monthly NTSV rates increased in the United States by 0.55%. Monthly NTSV rates increased by 1.20% among non-Hispanic Black women, 0.90% among Hispanic women, and 0.28% among non-Hispanic White women; quarterly NTSV rates increased in 6 states. CONCLUSION In addition to emergency preparedness planning, hospital monitoring, and reporting of NTSV cesarean rates to increase provider awareness, reallocation and prioritization of resources may help to identify potential strains on health care systems during public health emergencies such as the COVID-19 pandemic.
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Affiliation(s)
- Khaleel S Hussaini
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
- Division of Public Health, Delaware Department of Health and Social Services, Dover, DE, USA
| | - Romeo Galang
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Rui Li
- Office of Epidemiology and Research, Maternal and Child Health Bureau, Division of Research, Health Resources and Services Administration, US Department of Health and Human Services, Rockville, MD, USA
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Clark RRS, Peele ME, Srinivas S, Lake ET. Racial disparities in low-risk cesarean birth rates across hospitals. Birth 2024; 51:176-185. [PMID: 37800376 PMCID: PMC10922231 DOI: 10.1111/birt.12778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 07/24/2023] [Accepted: 09/12/2023] [Indexed: 10/07/2023]
Abstract
BACKGROUND We compared low-risk cesarean birth rates for Black and White women across hospitals serving increasing proportions of Black women and identified hospitals where Black women had low-risk cesarean rates less than or equal to White women. METHODS In this cross-sectional analysis of secondary data from four states, we categorized hospitals by their proportion of Black women giving birth from "low" to "high". We analyzed the odds of low-risk cesarean for Black and White women across hospital categories. RESULTS Our sample comprised 493 hospitals and the 65,524 Black and 251,426 White women at low risk for cesarean who birthed in them. The mean low-risk cesarean rate was significantly higher for Black, compared with White, women in the low (20.1% vs. 15.9%) and medium (18.1% vs. 16.9%) hospital categories. In regression models, no hospital structural characteristics were significantly associated with the odds of a Black woman having a low-risk cesarean. For White women, birthing in a hospital serving the highest proportion of Black women was associated with a 21% (95% CI: 1.01-1.44) increase in the odds of having a low-risk cesarean. DISCUSSION Black women had higher odds of a low-risk cesarean than White women and were more likely to access care in hospitals with higher low-risk cesarean rates. The existence of hospitals where low-risk cesarean rates for Black women were less than or equal to those of White women was notable, given a predominant focus on hospitals where Black women have poorer outcomes. Efforts to decrease the low-risk cesarean rate should focus on (1) improving intrapartum care for Black women and (2) identifying differentiating organizational factors in hospitals where cesarean birth rates are optimally low and equivalent among racial groups as a basis for system-level policy efforts to improve equity and reduce cesarean birth rates.
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Affiliation(s)
- Rebecca R. S. Clark
- Pennsylvania Hospital, Philadelphia, Pennsylvania, USA
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania, USA
| | - Morgan E. Peele
- University of Pennsylvania Population Studies Center, Philadelphia, Pennsylvania, USA
| | - Sindhu Srinivas
- Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania, USA
- Dulles 5-Dept OBGYN, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Eileen T. Lake
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania, USA
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Combs CA, Kern-Goldberger A, Bauer ST. Society for Maternal-Fetal Medicine Special Statement: Clinical quality measures in obstetrics. Am J Obstet Gynecol 2024; 230:B2-B17. [PMID: 37939984 DOI: 10.1016/j.ajog.2023.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2023]
Abstract
This article provides an updated overview and critique of clinical quality measures relevant to obstetrical care. The history of the quality movement in the United States and the proliferation of quality metrics over the past quarter-century are reviewed. Common uses of quality measures are summarized: payment programs, accreditation, public reporting, and quality improvement projects. We present listings of metrics that are reported by physicians or hospitals, either voluntarily or by mandate, to government agencies, payers, "watchdog" ratings organizations, and other entities. The costs and other burdens of extracting data and reporting metrics are summarized. The potential for unintended adverse consequences of the use of quality metrics is discussed along with approaches to mitigating adverse consequences. Finally, some recent attempts to develop simplified core measure sets are presented, with the promise that the complex and burdensome quality-metric enterprise may improve in the near future.
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Main EK, Chang SC, Tucker CM, Sakowski C, Leonard SA, Rosenstein MG. Hospital-level variation in racial disparities in low-risk nulliparous cesarean delivery rates. Am J Obstet Gynecol MFM 2023; 5:101145. [PMID: 37648109 PMCID: PMC10873027 DOI: 10.1016/j.ajogmf.2023.101145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 08/24/2023] [Indexed: 09/01/2023]
Abstract
BACKGROUND Nationally, rates of cesarean delivery are highest among Black patients compared with other racial/ethnic groups. These observed inequities are a relatively new phenomenon (in the 1980s, cesarean delivery rates among Black patients were lower than average), indicating an opportunity to narrow the gap. Cesarean delivery rates vary greatly among hospitals, masking racial disparities that are unseen when rates are reported in aggregate. OBJECTIVE This study aimed to explore reasons for the current large Black-White disparity in first-birth cesarean delivery rates by first examining the hospital-level variation in first-birth cesarean delivery rates among different racial/ethnic groups. We then identified hospitals that had low first-birth cesarean delivery rates among Black patients and compared them with hospitals with high rates. We sought to identify differences in facility or patient characteristics that could explain the racial disparity. STUDY DESIGN A population cross-sectional study was performed on 1,267,493 California live births from 2018 through 2020 using birth certificate data linked with maternal patient discharge records. Annual nulliparous term singleton vertex cesarean delivery (first-birth) rates were calculated for the most common racial/ethnic groups statewide and for each hospital. Self-identified race/ethnicity categories as selected on the birth certificate were used. Relative risk and 95% confidence intervals for first-birth cesarean delivery comparing 2019 with 2015 were estimated using a log-binomial model for each racial/ethnic group. Patient and hospital characteristics were compared between hospitals with first-birth cesarean delivery rates <23.9% for Black patients and hospitals with rates ≥23.9% for Black patients. RESULTS Hospitals with at least 30 nulliparous term singleton vertex Asian, Black, Hispanic, and White patients each were identified. Black patients had a very different distribution, with a significantly higher rate (28.4%) and wider standard deviation (7.1) and interquartile range (6.5) than other racial groups (P<.01). A total of 29 hospitals with a low first-birth cesarean delivery rate among Black patients were identified using the Healthy People 2020 target of 23.9% and compared with 106 hospitals with higher rates. The low-rate group had a cesarean delivery rate of 19.9%, as opposed to 30.7% in the higher-rate group. There were no significant differences between the groups in hospital characteristics (ownership, delivery volume, neonatal level of care, proportion of midwife deliveries) or patient characteristics (age, education, insurance, onset of prenatal care, body mass index, hypertension, diabetes mellitus). Among the 106 hospitals that did not meet the target for Black patients, 63 met it for White patients with a mean rate of 21.4%. In the same hospitals, the mean rate for Black patients was 29.5%. Among Black patients in the group that did not meet the 23.9% target, there were significantly higher rates of all cesarean delivery indications: labor dystocia, fetal concern (spontaneous labor), and no labor (eg, macrosomia), which are all indications with a high degree of subjectivity. CONCLUSION The statewide cesarean delivery rate of Black patients is significantly higher and has substantially greater hospital variation compared with other racial or ethnic groups. The lack of difference in facility or patient characteristics between hospitals with low cesarean delivery rates among Black patients and those with high rates suggests that unconscious bias and structural racism potentially play important roles in creating these racial differences.
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Affiliation(s)
- Elliott K Main
- California Maternal Quality Care Collaborative, Stanford, CA (Drs Main and Chang, Ms Sakowski, and Drs Leonard and Rosenstein); Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA (Drs Main and Leonard).
| | - Shen-Chih Chang
- California Maternal Quality Care Collaborative, Stanford, CA (Drs Main and Chang, Ms Sakowski, and Drs Leonard and Rosenstein); Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA (Drs Chang and Tucker and Ms Sakowski)
| | - Curisa M Tucker
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA (Drs Chang and Tucker and Ms Sakowski)
| | - Christa Sakowski
- California Maternal Quality Care Collaborative, Stanford, CA (Drs Main and Chang, Ms Sakowski, and Drs Leonard and Rosenstein); Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA (Drs Chang and Tucker and Ms Sakowski)
| | - Stephanie A Leonard
- California Maternal Quality Care Collaborative, Stanford, CA (Drs Main and Chang, Ms Sakowski, and Drs Leonard and Rosenstein); Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA (Drs Main and Leonard)
| | - Melissa G Rosenstein
- California Maternal Quality Care Collaborative, Stanford, CA (Drs Main and Chang, Ms Sakowski, and Drs Leonard and Rosenstein); Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, California, CA (Dr Rosenstein)
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Guo Y, Ding X, Wang S, Wang F, Zheng Z, Zou L. Analgesic Effect of Esketamine Combined with Tramadol for Patient-Controlled Intravenous Analgesia After Cesarean Section: A Randomized Controlled Trial. J Pain Res 2023; 16:3519-3528. [PMID: 37881234 PMCID: PMC10595208 DOI: 10.2147/jpr.s427702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 09/26/2023] [Indexed: 10/27/2023] Open
Abstract
Purpose High rate of cesarean section (CS) bring challenges to analgesic management after CS. Previous studies state that adjuvant treatment with a low dose of esketamine intraoperatively could reduce postoperative pain and opioid consumption, and even prevent postpartum depression. However, few researches involve in patient-controlled intravenous analgesia (PCIA) with esketamine after CS. In this trial, we explored a new combination of esketamine with tramadol for PCIA after CS with the aim to provide a better analgesic regimen for use in the clinic. Patients and Methods 170 puerperae undergoing CS were recruited for this trial and randomly assigned into 2 groups (1:1): The control group received a formula of PCIA with butorphanol 0.1mg/kg and tramadol 400mg postoperatively, while the intervention group received a formula of PCIA with esketamine 1mg/kg and tramadol 400mg. The primary outcome was the mean numerical rating scale (NRS) scores at rest, sitting, and uterine contraction at 6 hours postoperatively. The second outcomes included the mean NRS scores at rest, sitting, and uterine contraction at 12, 24, and 48 hours postoperatively. The incidence of adverse events, postoperative sedation, postoperative sleep quality, maternal satisfaction regarding postoperative analgesia and the Edinburgh postnatal depression scale (EPDS) score were also be evaluated. Results The mean (SD) of the mean NRS scores at rest, sitting, and during uterine contraction at 6 hours postoperatively were 4.8 (0.7) points in the intervention group and 5.3 (0.5) points in the control group. The estimated mean difference between the two groups at 6 hours postoperatively was -0.5 points (95% confidence interval [CI], -0.7 to -0.3; P < 0.001). Compared with the control group, the patients in the intervention group had a significantly lower mean pain intensity at 12 and 24 hours postoperatively (-0.5 points [95% CI, -0.6 to -0.3]; P < 0.001 and -0.2 points [95% CI, -0.4 to 0]; P = 0.019 respectively). Otherwise, differences at 48 hours after surgery between the two groups were nonsignificant (0 points [95% CI, -0.2 to 0.2]; P = 0.802). The incidence of adverse events in the intervention group (11.8%) was significantly lower than in the control group (24.7%) (ratio difference -12.9, [95% CI, -24.3 to -1.5]; P = 0.029). No difference was found in postoperative sleep quality (P = 0.765), analgesic satisfaction (P= 0.818) and EPDS scores (P = 0.154) between the two groups. Conclusion In this trial, among patients undergoing CS, esketamine combined with tramadol by PCIA improved pain intensity 6 hours postoperatively compared with butorphanol combined with tramadol.
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Affiliation(s)
- Yihui Guo
- Department of Anesthesiology, The People’s Hospital of Pizhou, Xuzhou, Jiangsu, People’s Republic of China
- Department of Anesthesiology, Pizhou Hospital Affiliated to Xuzhou Medical University, Xuzhou, Jiangsu, People’s Republic of China
| | - Xue Ding
- Department of Anesthesiology, The People’s Hospital of Pizhou, Xuzhou, Jiangsu, People’s Republic of China
- Department of Anesthesiology, Pizhou Hospital Affiliated to Xuzhou Medical University, Xuzhou, Jiangsu, People’s Republic of China
| | - Sheng Wang
- Department of Anesthesiology, The People’s Hospital of Pizhou, Xuzhou, Jiangsu, People’s Republic of China
- Department of Anesthesiology, Pizhou Hospital Affiliated to Xuzhou Medical University, Xuzhou, Jiangsu, People’s Republic of China
| | - Fei Wang
- Department of Anesthesiology, The People’s Hospital of Pizhou, Xuzhou, Jiangsu, People’s Republic of China
- Department of Anesthesiology, Pizhou Hospital Affiliated to Xuzhou Medical University, Xuzhou, Jiangsu, People’s Republic of China
| | - Zhongyi Zheng
- Department of Anesthesiology, The People’s Hospital of Pizhou, Xuzhou, Jiangsu, People’s Republic of China
- Department of Anesthesiology, Pizhou Hospital Affiliated to Xuzhou Medical University, Xuzhou, Jiangsu, People’s Republic of China
| | - Lifeng Zou
- Department of Anesthesiology, The People’s Hospital of Pizhou, Xuzhou, Jiangsu, People’s Republic of China
- Department of Anesthesiology, Pizhou Hospital Affiliated to Xuzhou Medical University, Xuzhou, Jiangsu, People’s Republic of China
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Wetcher CS, Kirshenbaum RL, Alvarez A, Gerber RP, Pachtman Shetty SL, De Four Jones M, Suarez F, Combs A, Nimaroff M, Lewis D, Blitz MJ. Association of Maternal Comorbidity Burden With Cesarean Birth Rate Among Nulliparous, Term, Singleton, Vertex Pregnancies. JAMA Netw Open 2023; 6:e2338604. [PMID: 37856118 PMCID: PMC10587795 DOI: 10.1001/jamanetworkopen.2023.38604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 09/01/2023] [Indexed: 10/20/2023] Open
Abstract
IMPORTANCE Cesarean birth rate among nulliparous, term, singleton, vertex (NTSV) pregnancies is a standard quality measure in obstetrical care. There are limited data on how the number and type of preexisting conditions affect mode of delivery among primigravidae, and it is also uncertain how maternal comorbidity burden differs across racial and ethnic groups and whether this helps to explain disparities in the NTSV cesarean birth rate. OBJECTIVE To determine the association between obstetric comorbidity index (OB-CMI) score and cesarean delivery among NTSV pregnancies and to evaluate whether disparities in mode of delivery exist based on race and ethnicity group after adjusting for covariate factors. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study of deliveries between January 2019 and December 2021 took place across 7 hospitals within a large academic health system in New York and included all NTSV pregnancies identified in the electronic medical record system. Exclusion criteria were fetal demise and contraindication to labor. EXPOSURE The OB-CMI score. Covariate factors assessed included race and ethnicity group (American Indian or Alaska Native, Asian or Pacific Islander, Hispanic, non-Hispanic Black, non-Hispanic White, other or multiracial, and declined or unknown), public health insurance, and preferred language. MAIN OUTCOME AND MEASURES Cesarean delivery. RESULTS A total of 30 253 patients (mean [SD] age, 29.8 [5.4] years; 100% female) were included. Non-Hispanic White patients constituted the largest race and ethnicity group (43.7%), followed by Hispanic patients (16.2%), Asian or Pacific Islander patients (14.6%), and non-Hispanic Black patients (12.2%). The overall NTSV cesarean birth rate was 28.5% (n = 8632); the rate increased from 22.1% among patients with an OB-CMI score of 0 to greater than 55.0% when OB-CMI scores were 7 or higher. On multivariable mixed-effects logistic regression modeling, there was a statistically significant association between OB-CMI score group and cesarean delivery; each successive OB-CMI score group had an increased risk. Patients with an OB-CMI score of 4 or higher had more than 3 times greater odds of a cesarean birth (adjusted odds ratio, 3.14; 95% CI, 2.90-3.40) than those with an OB-CMI score of 0. Compared with non-Hispanic White patients, nearly all other race and ethnicity groups were at increased risk for cesarean delivery, and non-Hispanic Black patients were at highest risk (adjusted odds ratio, 1.43; 95% CI, 1.31-1.55). CONCLUSIONS AND RELEVANCE In this cross-sectional study of patients with NTSV pregnancies, OB-CMI score was positively associated with cesarean birth. Racial and ethnic disparities in this metric were observed. Although differences in the prevalence of preexisting conditions were seen across groups, this did not fully explain variation in cesarean delivery rates, suggesting that unmeasured clinical or nonclinical factors may have influenced the outcome.
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Affiliation(s)
- Cara S. Wetcher
- Department of Obstetrics and Gynecology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Rachel L. Kirshenbaum
- Department of Obstetrics and Gynecology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Alejandro Alvarez
- Biostatistics Unit, Office of Academic Affairs, Northwell Health, New Hyde Park, New York
| | - Rachel P. Gerber
- Department of Obstetrics and Gynecology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Sarah L. Pachtman Shetty
- Department of Obstetrics and Gynecology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
- Katz Institute for Women’s Health, Northwell Health, New York, New York
| | - Monique De Four Jones
- Department of Obstetrics and Gynecology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
- Katz Institute for Women’s Health, Northwell Health, New York, New York
| | - Fernando Suarez
- Department of Obstetrics and Gynecology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Adriann Combs
- Department of Obstetrics and Gynecology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
- Katz Institute for Women’s Health, Northwell Health, New York, New York
| | - Michael Nimaroff
- Department of Obstetrics and Gynecology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
- Katz Institute for Women’s Health, Northwell Health, New York, New York
| | - Dawnette Lewis
- Department of Obstetrics and Gynecology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
- Katz Institute for Women’s Health, Northwell Health, New York, New York
| | - Matthew J. Blitz
- Department of Obstetrics and Gynecology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
- Katz Institute for Women’s Health, Northwell Health, New York, New York
- Institute of Health Systems Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York
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Visser GHA, Ubom AE, Neji K, Nassar A, Jacobsson B, Nicholson W. FIGO opinion paper: Drivers and solutions to the cesarean delivery epidemic with emphasis on the increasing rates in Africa and Southeastern Europe. Int J Gynaecol Obstet 2023; 163 Suppl 2:5-9. [PMID: 37807592 DOI: 10.1002/ijgo.15111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
Cesarean delivery rates are rapidly increasing in Southeastern Europe (to more than 60%), North Africa (with a rate as high as 72% in Egypt), and in urban areas in Southern Africa (a rate of over 50% in Lagos, Nigeria). Data on the background to these increases are scarce, but likely to include poor birthing facilities in general hospitals, convenience for the doctor, private medicine, fear of litigation, socioeconomic status, shortage of midwives and nurses, and disappearance of vaginal instrumental deliveries. Options to reverse cesarean delivery trends are discussed. In this context there is a need to be better informed about how women are being counseled regarding vaginal or cesarean delivery. The long-term consequences in subsequent pregnancies for mothers and children may well be largely ignored, while these risks are highest in LMICs where higher birth numbers are desired. FIGO has begun discussions with obstetric and gynecologic societies, healthcare bodies, and governments in several countries discussed in this article, to find ways to lower the cesarean delivery rate. The requests came from the countries themselves, which may prove beneficial in helping advance progress.
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Affiliation(s)
- Gerard H A Visser
- Department of Obstetrics, University Medical Center, Utrecht, The Netherlands
| | - Akaninyene Eseme Ubom
- Department of Obstetrics, Gynecology and Perinatology, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria
| | - Khaled Neji
- Tunis Maternity Center (La Rabta), Medical Faculty, Tunis, Tunisia
| | - Anwar Nassar
- Department of Obstetrics and Gynecology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Bo Jacobsson
- Department of Obstetrics and Gynecology, University of Gothenburg/Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Wanda Nicholson
- George Washington University Milken Institute of Public Health, Washington, District of Columbia, USA
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Lin R, DiCenzo N, Rosen T. Cesarean scar ectopic pregnancy: nuances in diagnosis and treatment. Fertil Steril 2023; 120:563-572. [PMID: 37506758 DOI: 10.1016/j.fertnstert.2023.07.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 07/24/2023] [Accepted: 07/24/2023] [Indexed: 07/30/2023]
Abstract
A cesarean scar ectopic pregnancy (CSEP) occurs when the embryo implants on the scar of a previous cesarean delivery. The number of births delivered by cesarean section has climbed by 50% over the last decade, from a nadir of 20.7% in 1996 to 32.1% in 2021. As a result, the incidence of CSEP has also increased. Because CSEP may cause serious morbidity such as life-threatening hemorrhage, uterine rupture, placental accreta spectrum, hysterectomy, and even mortality, accurate diagnosis and appropriate management of this condition are essential. This review focuses on the etiology, incidence, clinical diagnosis, and management of CSEPs.
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Affiliation(s)
- Ruby Lin
- Department of Obstetrics and Gynecology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey.
| | - Natalie DiCenzo
- Department of Obstetrics and Gynecology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Todd Rosen
- Department of Obstetrics and Gynecology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
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Hamm RF, Moniz MH, Wahid I, Breman RB, Callaghan-Koru JA. Implementation research priorities for addressing the maternal health crisis in the USA: results from a modified Delphi study among researchers. Implement Sci Commun 2023; 4:83. [PMID: 37480135 PMCID: PMC10360260 DOI: 10.1186/s43058-023-00461-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 06/21/2023] [Indexed: 07/23/2023] Open
Abstract
BACKGROUND Maternal health outcomes in the USA are far worse than in peer nations. Increasing implementation research in maternity care is critical to addressing quality gaps and unwarranted variations in care. Implementation research priorities have not yet been defined or well represented in the plans for maternal health research investments in the USA. METHODS This descriptive study used a modified Delphi method to solicit and rank research priorities at the intersection of implementation science and maternal health through two sequential web-based surveys. A purposeful, yet broad sample of researchers with relevant subject matter knowledge was identified through searches of published articles and grant databases. The surveys addressed five implementation research areas in maternal health: (1) practices to prioritize for broader implementation, (2) practices to prioritize for de-implementation, (3) research questions about implementation determinants, (4) research questions about implementation strategies, and (5) research questions about methods/measures. RESULTS Of 160 eligible researchers, 82 (51.2%) agreed to participate. Participants were predominantly female (90%) and White (75%). Sixty completed at least one of two surveys. The practices that participants prioritized for broader implementation were improved postpartum care, perinatal and postpartum mood disorder screening and management, and standardized management of hypertensive disorders of pregnancy. For de-implementation, practices believed to be most impactful if removed from or reduced in maternity care were cesarean delivery for low-risk patients and routine discontinuation of all psychiatric medications during pregnancy. The top methodological priorities of participants were improving the extent to which implementation science frameworks and measures address equity and developing approaches for involving patients in implementation research. CONCLUSIONS Through a web-based Delphi exercise, we identified implementation research priorities that researchers consider to have the greatest potential to improve the quality of maternity care in the USA. This study also demonstrates the feasibility of using modified Delphi approaches to engage researchers in setting implementation research priorities within a clinical area.
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Affiliation(s)
- Rebecca F Hamm
- Maternal and Child Health Research Center, Department of Obstetrics & Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Michelle H Moniz
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Inaya Wahid
- Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, PA, USA
| | - Rachel Blankstein Breman
- Department of Partnerships, Professional Education and Practice, School of Nursing, University of Maryland, Baltimore, MD, USA
| | - Jennifer A Callaghan-Koru
- Office of Community Health and Research, University of Arkansas for Medical Sciences, Springdale, AR, USA.
- Department of Obstetrics & Gynecology, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
- Center for Implementation Research, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
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Cheng PJ, Cheng YH, Shaw SSW, Jang HC. Reducing primary cesarean delivery rate through implementation of a smart intrapartum surveillance system. NPJ Digit Med 2023; 6:126. [PMID: 37433963 DOI: 10.1038/s41746-023-00867-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 06/26/2023] [Indexed: 07/13/2023] Open
Abstract
The rapid changes in clinical maternity situations that occur in a labor and delivery unit can lead to unpredictable maternal and newborn morbidities. Cesarean section (CS) rate is a key indicator of the accessibility and quality of a labor and delivery unit. This retrospective cross-sectional study assesses the nulliparous, term, singleton, vertex (NTSV) cesarean delivery rates before and after the implementation of a smart intrapartum surveillance system. Research data were collected from the electronic medical records of a labor and delivery unit. The primary outcome was the CS rate of the NTSV population. The data of 3648 women admitted for delivery were analyzed. Of the studied deliveries, 1760 and 1888 occurred during the preimplementation and postimplementation periods, respectively. The CS rate for the NTSV population was 31.0% and 23.3% during the preimplementation and postimplementation periods, respectively, indicating a significant 24.7% (p = 0.014) reduction in CS rate after the implementation of the smart intrapartum surveillance system (relative risk, 0.75; 95% confidence interval, 0.71-0.80). In the NTSV population, the vaginal and CS birth groups, no significant difference in terms of newborn weight, neonatal Apgar scores, composite neonatal adverse outcome indicator, and the occurrence of the following: neonatal intensive care unit admission, neonatal meconium aspiration, chorioamnionitis, shoulder dystocia, perineal laceration, placental abruption, postpartum hemorrhage, maternal blood transfusion, and hysterectomy before and after the implementation of the smart intrapartum surveillance system. This study reveals that the use of the smart intrapartum surveillance system can effectively reduce the primary CS rate for low-risk NTSV pregnancies without significantly affecting perinatal outcomes.
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Affiliation(s)
- Po Jen Cheng
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital-Linkou Medical Center, Chang Gung University College of Medicine, Taoyuan, Taiwan.
- College of Medicine, Chang Gung University, Taoyuan, Taiwan.
| | - You Hung Cheng
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Bone and Joint Research Center, Department of Orthopaedic Surgery, Chang Gung Memorial Hospital-Linkou, Taoyuan, Taiwan
- Graduate Institute of Biomedical Electronics and Bioinformatics College of Electrical Engineering and Computer Science National Taiwan University, Taipei, Taiwan
| | - Steven S W Shaw
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital-Linkou Medical Center, Chang Gung University College of Medicine, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Hung Chi Jang
- Hongchi Women & Children's Hospital, Taoyuan, Taiwan
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13
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Stierman EK, O'Brien BT, Stagg J, Ouk E, Alon N, Engineer LD, Fabiyi CA, Liu TM, Chew E, Benishek LE, Harding B, Terhorst RG, Latif A, Berenholtz SM, Mistry KB, Creanga AA. Statewide Perinatal Quality Improvement, Teamwork, and Communication Activities in Oklahoma and Texas. Qual Manag Health Care 2023; 32:177-188. [PMID: 36913770 PMCID: PMC10290572 DOI: 10.1097/qmh.0000000000000407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/15/2023]
Abstract
BACKGROUND AND OBJECTIVE The purpose of this study was to describe statewide perinatal quality improvement (QI) activities, specifically implementation of Alliance for Innovation on Maternal Health (AIM) patient safety bundles and use of teamwork and communication tools in obstetric units in Oklahoma and Texas. METHODS In January-February 2020, we conducted a survey of AIM-enrolled hospitals in Oklahoma (n = 35) and Texas (n = 120) to gather data on obstetric unit organization and QI processes. Data were linked to hospital characteristics information from the 2019 American Hospital Association survey and hospitals' maternity levels of care from state agencies. We generated descriptive statistics for each state and created an index to summarize adoption of QI processes. We fitted linear regression models to examine how this index varied by hospital characteristics and self-reported ratings for patient safety and AIM bundle implementation. RESULTS Most obstetric units had standardized clinical processes for obstetric hemorrhage (94% Oklahoma; 97% Texas), massive transfusion (94% Oklahoma; 97% Texas), and severe hypertension in pregnancy (97% Oklahoma; 80% Texas); regularly conducted simulation drills for obstetric emergencies (89% Oklahoma; 92% Texas); had multidisciplinary QI committees (61% Oklahoma; 83% Texas); and conducted debriefs after major obstetric complications (45% Oklahoma; 86% Texas). Few obstetric units offered recent staff training on teamwork and communication to their staff (6% Oklahoma; 22% Texas); those who did were more likely to employ specific strategies to facilitate communication, escalate concerns, and manage staff conflicts. Overall, adoption of QI processes was significantly higher in hospitals in urban than rural areas, teaching than nonteaching, offering higher levels of maternity care, with more staff per shift, and greater delivery volume (all P < .05). The QI adoption index scores were strongly associated with respondents' ratings for patient safety and implementation of maternal safety bundles (both P < .001). CONCLUSIONS Adoption of QI processes varies across obstetric units in Oklahoma and Texas, with implications for implementing future perinatal QI initiatives. Notably, findings highlight the need to reinforce support for rural obstetric units, which often face greater barriers to implementing patient safety and QI processes than urban units.
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Affiliation(s)
- Elizabeth K Stierman
- Departments of International Health (Drs Stierman and Creanga) and Health Policy and Management (Drs Engineer and Berenholtz), Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Oklahoma Perinatal Quality Improvement Collaborative, Oklahoma City, (Mss O'Brien and Ouk); The University of Oklahoma Health Sciences Center, Oklahoma City (Mss O'Brien and Ouk); Community Health Improvement Division, Texas Department of State Health Services, Austin (Ms Stagg); Alliance for Innovation on Maternal Health, American College of Obstetricians and Gynecologists, Washington, District of Columbia (Ms Alon); Armstrong Institute for Patient Safety and Quality, Johns Hopkins School of Medicine, Baltimore, Maryland (Drs Engineer, Benishek, Latif, and Berenholtz, Ms Liu, and Mr Terhorst); Departments of Anesthesiology and Critical Care Medicine (Drs Engineer, Benishek, Latif, and Berenholtz) and Gynecology and Obstetrics (Dr Creanga), Johns Hopkins School of Medicine, Baltimore, Maryland; and Agency for Healthcare Research and Quality, Rockville, Maryland (Drs Fabiyi and Mistry and Mss Chew and Harding)
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14
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Panelli DM, Leonard SA, Joudi N, Judy AE, Bianco K, Gilbert WM, Main EK, El-Sayed YY, Lyell DJ. Clinical and Physician Factors Associated With Failed Operative Vaginal Delivery. Obstet Gynecol 2023; 141:1181-1189. [PMID: 37141591 PMCID: PMC10440297 DOI: 10.1097/aog.0000000000005181] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 03/02/2023] [Indexed: 05/06/2023]
Abstract
OBJECTIVE To examine clinical and physician factors associated with failed operative vaginal delivery among individuals with nulliparous, term, singleton, vertex (NTSV) births. METHODS This was a retrospective cohort study of individuals with NTSV live births with an attempted operative vaginal delivery by a physician between 2016 and 2020 in California. The primary outcome was cesarean birth after failed operative vaginal delivery, identified using linked diagnosis codes, birth certificates, and physician licensing board data stratified by device type (vacuum or forceps). Clinical and physician-level exposures were selected a priori, defined using validated indices, and compared between successful and failed operative vaginal delivery attempts. Physician experience with operative vaginal delivery was estimated by calculating the number of operative vaginal delivery attempts made per physician during the study period. Multivariable mixed effects Poisson regression models with robust standard errors were used to estimate risk ratios of failed operative vaginal delivery for each exposure, adjusted for potential confounders. RESULTS Of 47,973 eligible operative vaginal delivery attempts, 93.2% used vacuum and 6.8% used forceps. Of all operative vaginal delivery attempts, 1,820 (3.8%) failed; the success rate was 97.3% for vacuum attempts and 82.4% for forceps attempts. Failed operative vaginal deliveries were more likely with older patient age, higher body mass index, obstructed labor, and neonatal birth weight more than 4,000 g. Between 2016 and 2020, physicians who attempted more operative vaginal deliveries were less likely to fail. When vacuum attempts were successful, physicians who conducted them had a median of 45 vacuum attempts during the study period, compared with 27 attempts when vacuum attempts were unsuccessful (adjusted risk ratio [aRR] 0.95, 95% CI 0.93-0.96). When forceps attempts were successful, physicians who conducted them had a median of 19 forceps attempts, compared with 11 attempts when forceps attempts were unsuccessful (aRR 0.76, 95% CI 0.64-0.91). CONCLUSION In this large, contemporary cohort with NTSV births, several clinical factors were associated with operative vaginal delivery failure. Physician experience was associated with operative vaginal delivery success, more notably for forceps attempts. These results may provide guidance for physician training in maintenance of operative vaginal delivery skills.
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Affiliation(s)
- Danielle M Panelli
- Division of Maternal-Fetal Medicine and Obstetrics, Department of Obstetrics and Gynecology, Stanford University, Stanford, the Department of Obstetrics and Gynecology, Sutter Medical Center, Sacramento, and the California Maternal Quality Care Collaborative, Palo Alto, California
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15
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White VanGompel E, Carlock F, Singh L, Keer E, Brown J, Kane Low L. Attitudes of Clinicians and Patient Safety Culture Before and After the ARRIVE Trial. J Obstet Gynecol Neonatal Nurs 2023; 52:211-222. [PMID: 36720433 PMCID: PMC10544748 DOI: 10.1016/j.jogn.2022.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 12/20/2022] [Accepted: 12/21/2022] [Indexed: 01/30/2023] Open
Abstract
OBJECTIVE To assess the attitudes of intrapartum clinicians about elective induction of labor before and after A Randomized Trial of Induction Versus Expectant Management (ARRIVE) and to assess the effect of different attitudes on patient safety culture. DESIGN Repeated cross-sectional design. SETTING Online surveys. PARTICIPANTS Clinicians (883 nurses and 201 physicians in the before-ARRIVE group and 1,741 nurses and 574 physicians in the after-ARRIVE group) who provided intrapartum care at 35 hospitals in California in 2017 and 57 hospitals in Michigan in 2020 and participated in statewide quality improvement efforts to reduce use of cesarean. METHODS We used annual nulliparous, term, singleton, vertex cesarean rates to stratify hospitals into performance quartiles. We used cumulative proportional odds logistic regression to examine induction attitudes before and after ARRIVE by role and hospital performance quartile as well as induction attitudes and patient safety culture among clinicians. We used content analysis to examine qualitative data. RESULTS After ARRIVE, physicians' attitudes shifted in favor of induction at hospitals within the top three performance categories (top quartile: M = 3.48 vs. 2.81, p < .0001), whereas nurses' attitudes did not change (p = .388). After ARRIVE, attitudes among clinicians were more aligned at hospitals with stronger patient safety cultures. Qualitative themes included The Timing of Induction is Important, Who Should Have Inductions, Need for Clear Protocols and More Staff, and Ideas to Improve the Induction of Labor Process. CONCLUSION Physician attitudes about induction were significantly different before versus after ARRIVE, whereas nurse attitudes were not. Differences in attitudes may erode the quality of team-based care; intentional interdisciplinary engagement is essential when implementing ARRIVE findings.
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16
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The active phase of labor. Am J Obstet Gynecol 2023; 228:S1037-S1049. [PMID: 36997397 DOI: 10.1016/j.ajog.2021.12.269] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 12/27/2021] [Accepted: 12/28/2021] [Indexed: 03/17/2023]
Abstract
The active phase of labor begins at various degrees of dilatation when the rate of dilatation transitions from the relatively flat slope of the latent phase to a more rapid slope. No diagnostic manifestations demarcate its onset, other than accelerating dilatation. It ends with apparent slowing of dilatation, a deceleration phase, which is usually short in duration and frequently undetected. Several aberrant labor patterns can be detected during the active phase, including protracted dilatation, arrest of dilatation, prolonged deceleration phase and failure of descent. Underlying factors may include cephalopelvic disproportion, excessive neuraxial block, poor uterine contractility, fetal malpositions, malpresentations, uterine infection, maternal obesity, advanced maternal age and previous cesarean delivery. When an active-phase disorder is identified, cesarean delivery is justifiable if there is compelling clinical evidence of disproportion. A prolonged deceleration disorder is strongly associated with disproportion and second stage abnormalities. Shoulder dystocia may occur if vaginal delivery eventuates. This review discusses several issues raised by the introduction of new clinical practice guidelines for labor management.
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17
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Frappaolo AM, Logue TC, Goffman D, Nathan LM, Sheen JJ, Andrikopoulou M, Wen T, D'Alton ME, Friedman AM. Cesarean Delivery Trends Among Patients at Low Risk for Cesarean Delivery in the US, 2000-2019. JAMA Netw Open 2023; 6:e235428. [PMID: 36988955 PMCID: PMC10061237 DOI: 10.1001/jamanetworkopen.2023.5428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/30/2023] Open
Abstract
Importance Reducing rates of unnecessary cesarean deliveries is both a national and a global health objective. However, there are limited national US data on trends in indications for low-risk cesarean delivery. Objective To determine temporal trends in and indications for cesarean delivery among patients at low risk for the procedure over a 20-year period. Design, Setting, and Participants This cross-sectional study analyzed 2000 to 2019 delivery hospitalizations using the National Inpatient Sample. Births at low risk for cesarean delivery were identified using a definition from the Society for Maternal-Fetal Medicine and additional criteria. Temporal trends in cesarean birth were analyzed using joinpoint regression to estimate the average annual percentage change (AAPC) with 95% CIs. Data analysis was performed from August 2022 to January 2023. Exposure This analysis evaluated cesarean birth trends in a population at low risk for this procedure over a 20-year period. Main Outcomes and Measures In addition to overall cesarean birth risk, cesarean deliveries for nonreassuring fetal status and labor arrest were individually analyzed. Results Of an estimated 76.7 million delivery hospitalizations, 21.5 million were excluded according to the Society for Maternal-Fetal Medicine definition, and 14.7 million were excluded according to additional criteria. Of the estimated 40 517 867 deliveries included, 12.1% (4 885 716 deliveries) were by cesarean delivery. Cesarean deliveries among patients at low risk for the procedure increased from 9.7% to 13.9% between 2000 and 2009, plateaued, and then decreased from 13.0% to 11.1% between 2012 and 2019. The AAPC for cesarean delivery was 6.4% (95% CI, 5.2% to 7.6%) from 2000 to 2005, 1.2% from 2005 to 2009 (95% CI, -1.2% to 3.7%), and -2.2% from 2009 to 2019 (95% CI, -2.7% to -1.8%). Cesarean delivery for nonreassuring fetal status increased from 3.4% of all deliveries in 2000 to 5.1% in 2019 (AAPC, 2.1%; 95% CI, 1.7% to 2.5%). Cesarean delivery for labor arrest increased from 3.6% in 2000 to a peak of 4.8% in 2009 before decreasing to 2.7% in 2019. Cesarean deliveries for labor arrest increased during the first half of the study (2000-2009) for the active phase (from 1.5% to 2.1%), latent phase (from 1.1% to 1.5%), and second stage (from 0.9% to 1.3%) and then decreased from 2010 to 2019, from 2.1% to 1.7% for the active phase, from 1.5% to 1.2% for the latent phase, and from 1.2% to 0.9% for the second stage. Conclusions and Relevance Cesarean deliveries among patients at low risk for cesarean birth appeared to decrease over the latter years of the study period, with cesarean deliveries for labor arrest becoming less common.
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Affiliation(s)
- Anna M Frappaolo
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, New York
| | - Teresa C Logue
- Department of Obstetrics and Gynecology, Christiana Care Health System, Newark, Delaware
| | - Dena Goffman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, New York
| | - Lisa M Nathan
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, New York
| | - Jean-Ju Sheen
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, New York
| | - Maria Andrikopoulou
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, New York
| | - Timothy Wen
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco
| | - Mary E D'Alton
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, New York
| | - Alexander M Friedman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, New York
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18
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Teitler JO, Chegwin V, Li L, Liu K, Bearman PS, Gorney-Daley MA, Reichman NE. Trends in Elective Deliveries in California and New Jersey. AJPM FOCUS 2023; 2:100052. [PMID: 37789944 PMCID: PMC10546565 DOI: 10.1016/j.focus.2022.100052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
Introduction Cesarean section deliveries in the U.S. increased from 5% of births in 1970 to 32% in 2020. Little is known about trends in cesarean sections and inductions in low-risk pregnancies (i.e., those for which interventions would not be medically necessary). This study addresses the following questions: (1) what is the prevalence of elective deliveries at the population level?, (2) how has that changed over time?, and (3) to what extent do the rates of elective deliveries vary across the population? Methods We first documented long-term trends in cesarean sections in the U.S., California, and New Jersey. We then used linked birth and hospital discharge records and an algorithm based on Joint Commission guidelines to identify low-risk pregnancies and document trends in cesarean sections and inductions in low-risk pregnancies in California and New Jersey over a recent 2-decade period, overall and by maternal characteristics and gestational age. Results In low-risk pregnancies in California and New Jersey, rates of cesarean sections and inductions increased sharply from the early 1990s through the mid-2000s, peaked at 33% in California and 41% in New Jersey in 2007, and then declined somewhat, and the proportions of inductions that were followed by cesarean sections increased from fewer than 1 in 5 to about 1 in 4. More education, non-Hispanic White race/ethnicity, U.S.-born status, and non-Medicaid were associated with higher rates of interventions. Trends were similar across all socioeconomic groups, but differences have been narrowing in California. Among early-term (gestational age of 37-38 weeks) births in low-risk pregnancies, the rates of elective deliveries increased substantially in both states until the mid/late-2000s, peaked at about 35% in California and over 40% in New Jersey, and then decreased in both states to about 20%. Conclusions Given established health risks of nonmedically necessary cesarean sections, that a nontrivial share of induced deliveries in low-risk pregnancies result in cesarean sections, and that interventions in low-risk pregnancies have not substantially declined since their peak in the mid-2000s, the trends documented in this paper suggest that sustained, even increased, public health attention is needed to address the still-too-high rates of cesarean sections and inductions in the U.S.
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Affiliation(s)
| | | | - Linda Li
- School of Social Work, Columbia University, New York, New York
| | - Kayuet Liu
- Department of Sociology, University of California, Los Angeles, Los Angeles, California
- RIKEN Center for Brain Science (CBS), Wako-shi, Japan
| | - Peter S. Bearman
- Department of Sociology, Columbia University, New York, New York
| | | | - Nancy E. Reichman
- Rutgers, Robert Wood Johnson Medical School, The State University of New Jersey, New Brunswick, New Jersey
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Federspiel JJ, Kucirka LM, Mallampati DP, Wheeler SM, Menard MK, Hughes BL, Quist-Nelson J, Meng ML. For better care we need better data: towards a national obstetrics registry. Am J Obstet Gynecol MFM 2023; 5:100787. [PMID: 36404523 PMCID: PMC10065844 DOI: 10.1016/j.ajogmf.2022.100787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 09/29/2022] [Accepted: 10/20/2022] [Indexed: 11/05/2022]
Abstract
Unacceptably high rates of severe maternal morbidity and mortality in the United States and stark racial disparities in outcomes are generating efforts to improve both research capacity and quality improvement in obstetrical care. Comprehensive, high-quality datasets on which to build these efforts are crucial to the success of obstetrical quality improvement efforts. However, existing data sources in obstetrics have notable limitations. Other medical and surgical specialties have addressed similar challenges through the creation of national registries, and we argue that obstetrics must take the same approach to improve outcomes. In this article, we summarized the current availability and limitations of large-scale data in obstetrics research and compared the data with registries developed in other specialties. Moreover, we have outlined the guiding principles for the development of a national obstetrics registry and have proposed future directions.
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Affiliation(s)
- Jerome J Federspiel
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, NC (Drs Federspiel, Wheeler, and Hughes).
| | - Lauren M Kucirka
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina, Durham, NC (Drs Kucirka, Mallampati, Menard, and Quist-Nelson)
| | - Divya P Mallampati
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina, Durham, NC (Drs Kucirka, Mallampati, Menard, and Quist-Nelson)
| | - Sarahn M Wheeler
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, NC (Drs Federspiel, Wheeler, and Hughes)
| | - M Kathyrn Menard
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina, Durham, NC (Drs Kucirka, Mallampati, Menard, and Quist-Nelson)
| | - Brenna L Hughes
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, NC (Drs Federspiel, Wheeler, and Hughes)
| | - Johanna Quist-Nelson
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina, Durham, NC (Drs Kucirka, Mallampati, Menard, and Quist-Nelson)
| | - Marie-Louise Meng
- Division of Women's Anesthesiology, Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina, USA (Dr Meng)
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20
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High Primary Cesarean Section Rates: Strategies for Improvement. Jt Comm J Qual Patient Saf 2022; 48:617-624. [PMID: 36050212 DOI: 10.1016/j.jcjq.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 07/27/2022] [Accepted: 07/29/2022] [Indexed: 12/30/2022]
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21
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Rahman M, Chen L, Daw J, Wright JD, D’Alton ME, Wen T, Friedman AM. Pregnancy costs with commercial insurance. J Matern Fetal Neonatal Med 2022; 35:10143-10151. [DOI: 10.1080/14767058.2022.2122037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Affiliation(s)
| | - Ling Chen
- Department of Obstetrics and Gynecology, Columbia University, New York, NY, USA
| | - Jamie Daw
- Department of Health Policy and Management, Columbia Mailman School of Public Health, New York, New York, USA
| | - Jason D. Wright
- Department of Obstetrics and Gynecology, Columbia University, New York, NY, USA
| | - Mary E. D’Alton
- Department of Obstetrics and Gynecology, Columbia University, New York, NY, USA
| | - Timothy Wen
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California-San Francisco, San Francisco, CA, USA
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22
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Pre and Post-Lockdown Cesarean Deliveries and Perinatal Quality Indicators During the COVID-19 Pandemic. Dela J Public Health 2022; 8:108-112. [PMID: 36177166 PMCID: PMC9495475 DOI: 10.32481/djph.2022.08.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Gurol‐Urganci I, Jardine J, Carroll F, Frémeaux A, Muller P, Relph S, Waite L, Webster K, Oddie S, Hawdon J, Harris T, Khalil A, van der Meulen J. Use of induction of labour and emergency caesarean section and perinatal outcomes in English maternity services: a national hospital-level study. BJOG 2022; 129:1899-1906. [PMID: 35445784 PMCID: PMC9543153 DOI: 10.1111/1471-0528.17193] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 03/29/2022] [Accepted: 04/07/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To assess the association between hospital-level rates of induction of labour and emergency caesarean section, as measures of "practice style", and rates of adverse perinatal outcomes. DESIGN National study using electronic maternity records. SETTING English National Health Service. PARTICIPANTS Hospitals providing maternity care to women between April 2015 and March 2017. MAIN OUTCOME MEASURES Stillbirth, admission to a neonatal unit, and babies receiving mechanical ventilation. RESULTS Among singleton term births, the risk of stillbirth was 0.15%; of admission to a neonatal unit 5.4%; and of mechanical ventilation 0.54%. There was considerable between-hospital variation in the induction of labour rate (minimum 17.5%, maximum 40.7%) and the emergency caesarean section rate (minimum 5.6%, maximum 17.1%). Women who gave birth in hospitals with a higher induction of labour rate had better perinatal outcomes. For each 5%-point increase in induction, there was a decrease in the risk of term stillbirth by 9% (OR 0.91; 95% CI 0.85 to 0.97) and mechanical ventilation by 14% (OR 0.86; 95% CI 0.79 to 0.94). There was no significant association between hospital-level induction of labour rates and neonatal unit admission at term (p>0.05). There was no significant association between hospital-level emergency caesarean section rates and adverse perinatal outcomes (p always >0.05). CONCLUSIONS There is considerable between-hospital variation in the use of induction of labour and emergency caesarean section. Hospitals with a higher induction rate had a lower risk of adverse birth outcomes. A similar association was not found for caesarean section.
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Affiliation(s)
- Ipek Gurol‐Urganci
- Department of Health Services Research and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
- Royal College of Obstetricians and GynaecologistsLondonUK
| | - Jennifer Jardine
- Department of Health Services Research and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
- Royal College of Obstetricians and GynaecologistsLondonUK
| | - Fran Carroll
- Royal College of Obstetricians and GynaecologistsLondonUK
| | | | - Patrick Muller
- Royal College of Obstetricians and GynaecologistsLondonUK
| | - Sophie Relph
- Royal College of Obstetricians and GynaecologistsLondonUK
| | - Lara Waite
- Royal College of Obstetricians and GynaecologistsLondonUK
| | | | - Sam Oddie
- Bradford Teaching Hospitals NHS Foundation TrustBradfordUK
| | - Jane Hawdon
- Royal Free London NHS Foundation TrustLondonUK
| | - Tina Harris
- Centre for Reproduction Research, Faculty of Health and Life SciencesDe Montfort UniversityLeicesterUK
| | - Asma Khalil
- Fetal Medicine Unit, Department of Obstetrics and GynaecologySt George’s University Hospitals NHS Foundation TrustLondonUK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research InstituteSt George’s University of LondonLondonUK
| | - Jan van der Meulen
- Department of Health Services Research and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
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Kozhimannil KB, Interrante JD, Admon LK, Basile Ibrahim BL. Rural Hospital Administrators’ Beliefs About Safety, Financial Viability, and Community Need for Offering Obstetric Care. JAMA HEALTH FORUM 2022; 3:e220204. [PMID: 35977287 PMCID: PMC8956977 DOI: 10.1001/jamahealthforum.2022.0204] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 01/27/2022] [Indexed: 01/28/2023] Open
Affiliation(s)
- Katy B. Kozhimannil
- University of Minnesota Rural Health Research Center, Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis
| | - Julia D. Interrante
- University of Minnesota Rural Health Research Center, Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis
| | - Lindsay K. Admon
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Bridget L. Basile Ibrahim
- University of Minnesota Rural Health Research Center, Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis
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Iverson RE, Bocchino RL, Schapero MA, White KO. The association of hourly second-stage documentation with cesarean delivery and maternal blood loss. J Matern Fetal Neonatal Med 2022; 35:9511-9516. [PMID: 35236206 DOI: 10.1080/14767058.2022.2044776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE OF THE ARTICLE Cesarean rates and maternal morbidity increase with the duration of the second stage of labor. We studied the effect of hourly evaluation and documentation during the second stage of labor on maternal and fetal outcomes. MATERIALS AND METHODS We performed a retrospective cohort study of all women who delivered at our urban, tertiary care hospital and underwent a second stage of greater than 60 min between 1 June 2016 and 31 May 2019. There were 1498 patients with complete data. Four hundred forty patients had hourly evaluation and documentation throughout the second stage and 1058 did not. We performed t-tests, Chi-squared, and regression analyses to compare cesarean delivery rate, second-stage duration, quantitative blood loss, hemorrhage and blood transfusion rates, and fetal outcomes. We performed regression analyses to evaluate for independent effect of this intervention on each outcome. RESULTS Patients with hourly evaluation and documentation had a decreased likelihood of cesarean delivery (8.2% vs. 20.3%, p < .001), shorter second-stage of labor (98.1 min vs. 177.5 min, p < .001), decreased quantitative blood loss (514.4 mL vs. 667.7 mL, p < .001), and hemorrhage rate (12.5% vs. 19.9%, p < .001). Hourly evaluation was associated with decreased transfusion rates (3.2% vs. 5.6%, p = .05) but was not related to the number of units transfused. Regression analyses confirmed the impact of hourly documentation when potential confounders were included. These differences in outcomes were also noted when evaluation was performed and documented within every 75 min. Hourly second-stage evaluation and documentation did not affect other maternal or infant morbidities. CONCLUSION Hourly evaluation and documentation in the second stage was associated with decreased cesarean delivery rate, second-stage duration, quantitative blood loss, hemorrhage, and transfusion.
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Affiliation(s)
- Ronald E Iverson
- Department of Obstetrics and Gynecology, Boston University School of Medicine, Boston, MA, USA
| | - Rachel L Bocchino
- Department of Obstetrics and Gynecology, Boston Medical Center, Boston, MA, USA
| | - Melissa A Schapero
- Department of Obstetrics and Gynecology, Boston Medical Center, Boston, MA, USA
| | - Katharine O White
- Department of Obstetrics and Gynecology, Boston University School of Medicine, Boston, MA, USA
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Variations in Low-Risk Cesarean Delivery Rates in the United States Using the Society for Maternal-Fetal Medicine Definition. Obstet Gynecol 2022; 139:235-243. [DOI: 10.1097/aog.0000000000004645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 10/28/2021] [Indexed: 11/26/2022]
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Hirsh-Yechezkel G, Glasser S, Farhi A, Levitan G, Shachar Y, Zaslavsky-Paltiel I, Boyko V, Ezra Y, Lerner-Geva L. Cesarean delivery on maternal request in Israel: Maternity department policies and obstetricians’ perspectives. WOMEN'S HEALTH 2022; 18:17455057221125366. [DOI: 10.1177/17455057221125366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Objective: This study aimed to describe Israeli maternity departments’ policies regarding cesarean delivery on maternal request, and factors associated with obstetricians’ support for cesarean delivery on maternal request in specific scenarios. Methods: This multicenter cross-sectional study included 22 maternity department directors and 222 obstetricians from the majority of Israeli hospitals. Directors were interviewed and completed a questionnaire about their department’s cesarean delivery on maternal request policy, and obstetricians responded to a survey presenting case scenarios in which women requested cesarean delivery on maternal request. The scenarios represented profiles referring to the following factors: maternal age, poor obstetric history, pregnancy complications, and psychological problems. The survey also included the obstetricians’ socio-demographic information and questions about other issues associated with cesarean delivery on maternal request. The main outcome measures were department policies regarding cesarean delivery on maternal request and obstetricians’ support for cesarean delivery on maternal request in specific cases. Results: Policies were divided between allowing and prohibiting cesarean delivery on maternal request (n = 10 and 12, respectively), and varied regarding issues such as informed consent and pre-surgery consultation. Most of the obstetricians (96.5%) did not support cesarean delivery on maternal request in the “reference scenario” describing a young woman with no obstetric complications. Additional factors increased the rate of support. Support was greater among obstetricians aged > 45 (odds ratio = 2.11; 95% confidence intervals 1.33–3.36) and lower among females (odds ratio = 0.58; 95% confidence intervals 0.39–0.86). Obstetricians whose department policy was less likely to allow cesarean delivery on maternal request reported lower rates of support for cesarean delivery on maternal request in most cases. Conclusion: Policies and obstetricians’ support for cesarean delivery on maternal request vary broadly depending on clinical profiles and physician characteristics. Department policy has an impact on obstetricians’ support for cesarean delivery on maternal request. Health policy will benefit from a framework in which the organizations, physicians, and patients are consulted.
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Affiliation(s)
- Galit Hirsh-Yechezkel
- Women and Children’s Health Research Unit, Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center affiliated with Tel Aviv University, Ramat Gan, Israel
| | - Saralee Glasser
- Women and Children’s Health Research Unit, Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center affiliated with Tel Aviv University, Ramat Gan, Israel
| | - Adel Farhi
- Women and Children’s Health Research Unit, Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center affiliated with Tel Aviv University, Ramat Gan, Israel
| | - Gila Levitan
- Women and Children’s Health Research Unit, Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center affiliated with Tel Aviv University, Ramat Gan, Israel
| | - Yael Shachar
- Women and Children’s Health Research Unit, Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center affiliated with Tel Aviv University, Ramat Gan, Israel
| | - Inna Zaslavsky-Paltiel
- Women and Children’s Health Research Unit, Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center affiliated with Tel Aviv University, Ramat Gan, Israel
| | - Valentina Boyko
- Women and Children’s Health Research Unit, Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center affiliated with Tel Aviv University, Ramat Gan, Israel
| | - Yossef Ezra
- Department of Obstetrics and Gynaecology, Hadassah University Hospital, Jerusalem, Israel
| | - Liat Lerner-Geva
- Women and Children’s Health Research Unit, Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center affiliated with Tel Aviv University, Ramat Gan, Israel
- School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Ornaghi S, Fumagalli S, Guinea Montalvo CK, Beretta G, Invernizzi F, Nespoli A, Vergani P. Indirect impact of SARS-CoV-2 pandemic on pregnancy and childbirth outcomes: A nine-month long experience from a university center in Lombardy. Int J Gynaecol Obstet 2021; 156:466-474. [PMID: 34669973 PMCID: PMC9087530 DOI: 10.1002/ijgo.13990] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 10/19/2021] [Indexed: 01/23/2023]
Abstract
Objective To determine the impact on perinatal health of changes in social policies and obstetric care implemented to curb SARS‐CoV‐2 transmission. However, robust data on the topic are lacking since most of the studies has examined only the first few months of the outbreak. Methods A retrospective analysis of prospectively collected data on uninfected and asymptomatically infected women giving birth between March and November 2020 and in the same time frame of 2019 at our tertiary care center in Lombardy, northern Italy. Perinatal outcomes were compared according to the year (2019 versus 2020) and to the trimester (March–May, June–August, September–November) of childbirth, corresponding to the three phases of the pandemic (first wave, deceleration, second wave) and covering a 9‐month period. Results We identified increased rates of gestational diabetes mellitus, spontaneous preterm birth, and neuraxial analgesia in 2020 versus 2019, with different temporal distributions: gestational diabetes mellitus and spontaneous preterm birth were more prevalent during the deceleration and the second wave phase, whereas epidural analgesia was more prevalent during the first wave. Conclusion By assessing a prolonged time frame of the pandemic, we show that pandemic‐related control measures, as applied in Lombardy, impacted relevant perinatal outcomes of women giving birth at our center.
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Affiliation(s)
- Sara Ornaghi
- Department of Obstetrics and Gynecology, Unit of Obstetrics, MBBM Foundation Onlus at San Gerardo Hospital, Monza, Italy.,University of Milan-Bicocca School of Medicine and Surgery, Monza, Italy
| | - Simona Fumagalli
- Department of Obstetrics and Gynecology, Unit of Obstetrics, MBBM Foundation Onlus at San Gerardo Hospital, Monza, Italy.,University of Milan-Bicocca School of Medicine and Surgery, Monza, Italy
| | | | - Greta Beretta
- University of Milan-Bicocca School of Medicine and Surgery, Monza, Italy
| | - Francesca Invernizzi
- Department of Obstetrics and Gynecology, Unit of Obstetrics, MBBM Foundation Onlus at San Gerardo Hospital, Monza, Italy.,University of Milan-Bicocca School of Medicine and Surgery, Monza, Italy
| | - Antonella Nespoli
- University of Milan-Bicocca School of Medicine and Surgery, Monza, Italy
| | - Patrizia Vergani
- Department of Obstetrics and Gynecology, Unit of Obstetrics, MBBM Foundation Onlus at San Gerardo Hospital, Monza, Italy.,University of Milan-Bicocca School of Medicine and Surgery, Monza, Italy
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Reduction in Cesarean Delivery Rates Associated With a State Quality Collaborative in Maryland. Obstet Gynecol 2021; 138:583-592. [PMID: 34623072 DOI: 10.1097/aog.0000000000004540] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 06/24/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess the extent to which hospitals participating in the MDPQC (Maryland Perinatal-Neonatal Quality Care Collaborative) to reduce primary cesarean deliveries adopted policy and practice changes and the association of this adoption with state-level cesarean delivery rates. METHODS This prospective evaluation of the MDPQC includes 31 (97%) of the birthing hospitals in the state, which all voluntarily participated in the 30-month collaborative from June 2016 to December 2018. Hospital teams agreed to implement practices from the "Safe Reduction of Primary Cesarean Births" patient safety bundle, developed by the Council on Patient Safety in Women's Health Care. Each hospital's implementation of practices in the bundle was measured through surveys of team leaders at 12 months and 30 months. Half-yearly cesarean delivery rates were calculated from aggregate birth certificate data for each hospital, and differences in rates between the 6 months before the collaborative (baseline) and the 6 months afterward (endline) were tested for statistical significance. RESULTS Among the 26 bundle practices that were assessed, participating hospitals reported having a median of seven practices (range 0-23) already in place before the collaborative and implementing a median of four (range 0-17) new practices during the collaborative. Across the collaborative, the cesarean delivery rates decreased from 28.5% to 26.9% (P=.011) for all nulliparous term singleton vertex births and from 36.1% to 31.3% (P<.001) for nulliparous, term, singleton, vertex inductions. Five hospitals had a statistically significant decrease in nulliparous, term, singleton, vertex cesarean delivery rates and four had a significant increase. Nulliparous, term, singleton, vertex cesarean delivery rates were significantly lower across hospitals that implemented more practices in the "Response" domain of the bundle. CONCLUSION The MDPQC was associated with a statewide reduction in cesarean delivery rates for nulliparous, term, singleton, vertex births.
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Mollard E, Kupzyk K. Birth Satisfaction During the Early Months of the COVID-19 Pandemic in the United States. MCN Am J Matern Child Nurs 2021; 47:6-12. [PMID: 34559088 PMCID: PMC8647528 DOI: 10.1097/nmc.0000000000000777] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Purpose: The purpose of this study was to describe birth satisfaction in women who gave birth in U.S. hospitals during the earliest months of the COVID-19 pandemic (March–July 2020). Study Design and Methods: A cross-sectional survey of 747 postpartum women who gave birth in the United States during the early COVID-19 pandemic was conducted. Participants in the United were recruited via social media. They completed a questionnaire that included demographic, health, and obstetric experience questions, and the Birth Satisfaction Scale-Revised. Descriptive statistics, t-tests, analysis of variance (ANOVA) models, and nonparametric correlations were performed. Results: Higher birth satisfaction scores were associated with higher income, marriage, white race, vaginal birth, having a birth partner present, and sufficient support during birth. Factors negatively associated with birth satisfaction were separation from infant, unplanned cesarean birth, neonatal intensive care unit admission, hypertension, preeclampsia, hemorrhage, depression, and anxiety. Clinical Implications: Presence of birth partners, sufficient birth support, and minimizing separation of mother and infant improve birth satisfaction. Obstetric complications, including unplanned cesarean birth, negatively affect birth satisfaction. There are racial disparities in birth satisfaction. It is critical to develop further interventions to end racism in maternal health care. During the early months of the COVID-19 pandemic, there were many restrictive changes to childbirth practices in the inpatient setting geared toward reducing viral spread and keeping patients and health care workers safe. In this study 747 women who gave birth in the United States during the first several months of the pandemic offer their perspectives on how these changes affected their childbirth experience and overall satisfaction.
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