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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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He X, Dai Q, Wu X, Zhou J, Li J. Outcomes and risk factors for failed trial of labor after cesarean delivery (TOLAC) in women with one previous cesarean section: a Chinese population-based study. BMC Pregnancy Childbirth 2022; 22:676. [PMID: 36057560 PMCID: PMC9440562 DOI: 10.1186/s12884-022-05005-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 08/26/2022] [Indexed: 11/17/2022] Open
Abstract
Objective To evaluate the outcomes and risk factors for trial of labor after cesarean delivery (TOLAC) failure in patients in China. Methods Consecutive patients who had a previous cesarean delivery (CD) and attempted TOLAC were included from 2014 to 2020. Patients who successfully delivered were classified into the TOLAC success group. Patients who attempted TOLAC but had a repeat CD due to medical issues were classified into the TOLAC failure group. Multiple logistic regression analyses were performed to examine the risk factors for TOLAC failure. Results In total, 720 women who had a previous CD and attempted TOLAC were identified and included. The success rate of TOLAC was 84.2%(606/720). Seven patients were diagnosed with uterine rupture, none of whom underwent hysterectomy. Multiple logistic regression analysis showed that the induction of labor (OR = 2.843, 95% CI: 1.571–5.145, P < 0.001) was positively associated with TOLAC failure, but the thickness of the lower uterine segment (LUS) (OR = 0.215, 95% CI: 0.103–0.448, P < 0.001) was negatively associated with TOLAC failure. Conclusions This study suggested that TOLAC was effective in decreasing CD rates in the Chinese population. The induction of labor was positively associated with TOLAC failure, but the thickness of the LUS was negatively associated with TOLAC failure. Our findings need to be confirmed in larger samples with patients of different ethnicities.
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Affiliation(s)
- Xiaobo He
- Department of Obstetrics, Ningbo Women and Children's Hospital, Ningbo, 315012, Zhejiang, China
| | - Qiaona Dai
- Department of Obstetrics, Ningbo Women and Children's Hospital, Ningbo, 315012, Zhejiang, China
| | - Xiaoli Wu
- Department of Obstetrics, Ningbo Women and Children's Hospital, Ningbo, 315012, Zhejiang, China
| | - Junjun Zhou
- Department of Obstetrics, Ningbo Women and Children's Hospital, Ningbo, 315012, Zhejiang, China
| | - Jie Li
- Department of Obstetrics, Ningbo Women and Children's Hospital, Ningbo, 315012, Zhejiang, China.
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Ji YJ, Wang HB, Bai Z, Long DJ, Ma K, Yan J, Li YX, Wu YF, Yang H. Achieving WHO's Goal for Reducing Cesarean Section Rate in a Chinese Hospital. Front Med (Lausanne) 2021; 8:774487. [PMID: 34881268 PMCID: PMC8645788 DOI: 10.3389/fmed.2021.774487] [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: 09/12/2021] [Accepted: 10/15/2021] [Indexed: 11/13/2022] Open
Abstract
Background: To address the worldwide dramatically increased Cesarean section (CS) rate in the past decades, WHO has recommended the CS rate should not be higher than 10-15%. Whether it is achievable remains unknown. Methods: We collected the data of delivery from 2008 to 2017 in two typical regional hospitals in China: Longhua Hospital (national policies rigorously implemented) and Dongguan Hospital (national policies not rigorously implemented). We compared between the two hospitals the 10 years trend in annual rate of CS, standardized by age, education level, parity, and CS history, against the time of issuing relevant national, local, and hospital policies. Results: In 10 years, 42,441 women in Longhua and 36,935 women in Dongguan have given birth. China's first national policy on CS reduction was issued in 2010 and the formal relaxation of one-child policy was issued in 2015-2016. In Longhua, the standardized annual CS rate was around 35% in 2008-2009, which declined sharply since 2010 down to 13.1% in 2016 (p < 0.001) and then leveled off. In contrast, in Dongguan, the rate stayed around 25% at the beginning, increased to 36% in 2011, decreased sharply to 27% in 2012, and leveled off until 2015 (p < 0.001), and then bounced back to 35% in 2017. The proportion of women with the history of CS increased significantly in the two hospitals (both roughly from 6% before 2010 to 20% after 2015). Analyses stratified by modified Robson classification showed that CS rates reduced in all risk classes of delivery women in Longhua but only in the Robson class 2 group in Dongguan. Major complications did not differ by hospital. Conclusion: With vigorously implementing national policies at micro levels, the WHO-recommended CS rate could be achieved without increase in major complications.
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Affiliation(s)
- Yan-Jie Ji
- The First Dongguan Affiliated Hospital of Guangdong Medical University, Dongguan, China
| | - Hai-Bo Wang
- Peking University Clinical Research Institute, Peking University First Hospital, Beijing, China
| | - Zhi Bai
- The First Dongguan Affiliated Hospital of Guangdong Medical University, Dongguan, China
| | - Da-Jian Long
- The First Dongguan Affiliated Hospital of Guangdong Medical University, Dongguan, China
| | - Kaidong Ma
- Shenzhen Longhua District Central Hospital, Shenzhen, China
| | - Jie Yan
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
| | - Yun-Xiu Li
- Shenzhen Longhua District Central Hospital, Shenzhen, China
| | - Yang-Feng Wu
- Peking University Clinical Research Institute, Peking University First Hospital, Beijing, China
| | - Huixia Yang
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
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Xu C, Bao Y, Zuo J, Li Y, Tang Y, Qu X, Ying H. Maternal chronic hepatitis B virus infection and the risk of preterm birth: A retrospective cohort analysis in Chinese women. J Viral Hepat 2021; 28:1422-1430. [PMID: 34342096 DOI: 10.1111/jvh.13585] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 07/23/2021] [Indexed: 01/05/2023]
Abstract
The association between different clinical states of chronic HBV infection and preterm birth (PTB) is still controversial. A retrospective cohort study among 57,386 pregnant women was conducted to examine the impact of chronic HBsAg positive, both HBsAg and HBeAg positive, and chronic active hepatitis on pregnancy complications related to the overall PTB and its subtypes (spontaneous and iatrogenic). A total of 54,245 pregnancies were included in the final study cohort, among which 2,151(4.0%) pregnant women were HBsAg positive. The PTB rate was 6.0% (129/2151) for HBV-infected women while 4.5% (2319/52094) for those not. Compared with women not infected with HBV, multivariable-adjusted analyses showed HBV-infected women had a 33% higher risk of overall PTB (aRR 1.33 95%CI, 1.11-1.60), a 27% higher risk of spontaneous PTB (aRR 1.27, 95% CI, 1.02-1.57) and a 50% higher risk of iatrogenic PTB (aRR 1.50, 95%CI, 1.07-2.11). The PTB rate was 8.9% (35/395) for both HBsAg and HBeAg-positive women and 16.2% (22/136) for women with active chronic hepatitis. Multivariable-adjusted analyses showed women who were both HBsAg and HBeAg positive had a 47% higher risk of overall PTB (aRR 1.47, 95%CI, 1.04-2.09), a 2.03 times higher risk of spontaneous PTB (aRR 2.03, 95%CI, 1.38-2.99) and a 32% higher risk of iatrogenic PTB (aRR 1.32, 95%CI, 0.62-2.81), while women with chronic active hepatitis had a 3.84 times higher risk of overall PTB (aRR 3.84, 95%CI, 2.42-6.10), a 3.88 times higher risk of spontaneous PTB (aRR 3.88, 95%CI, 2.32-6.45) and a 3.01 times higher risk of iatrogenic PTB (aRR 3.01, 95%CI, 1.22-7.44). Different maternal clinical states of chronic HBV infection are independently associated with an increased risk of overall PTB and its subtypes (spontaneous and iatrogenic).
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Affiliation(s)
- Chuanlu Xu
- Shanghai Key Laboratory of maternal fetal medicine, Department of Obstetrics, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Yirong Bao
- Shanghai Key Laboratory of maternal fetal medicine, Department of Obstetrics, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Jia Zuo
- Shanghai Key Laboratory of maternal fetal medicine, Department of Obstetrics, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Yuhong Li
- Shanghai Key Laboratory of maternal fetal medicine, Department of Obstetrics, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Yuping Tang
- Shanghai Key Laboratory of maternal fetal medicine, Department of Obstetrics, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Xiaoxian Qu
- Shanghai Key Laboratory of maternal fetal medicine, Department of Obstetrics, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Hao Ying
- Shanghai Key Laboratory of maternal fetal medicine, Department of Obstetrics, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, China
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Liu X, Huang D, Landon MB, Cheng W, Chen Y. Trends in Cesarean Delivery Rate after Cessation of the One-Child Policy in China. Am J Perinatol 2021; 38:e84-e91. [PMID: 32198746 DOI: 10.1055/s-0040-1705176] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE We aimed to describe changes in cesarean delivery (CD) rates after the change of the one-child policy in China by using the Robson classification in a large Chinese population. STUDY DESIGN This retrospective cohort study included 91,015 women who delivered at ≥24 weeks of gestation at a large tertiary obstetric center in Shanghai, China from 2011 to 2016. We analyzed CD rate trend and CD contribution trend in each Robson group. Logistic regression was used to calculate the odds of CD while adjusting for confounding variables. RESULTS The overall CD rate decreased from 49.0% in 2011 to 40.6% in 2016. In nulliparous women with singleton cephalic term pregnancy and planned CD, the CD contribution rate was reduced significantly from 29.3% in 2011 to 16.4% in 2016 (p < 0.001). In multiparous with a scarred uterus, the CD contribution rate began to increase from 3.8% in 2011 to 9.1% in 2016 (p < 0.001). Compared with delivery in 2011, delivery in 2016 was associated with a 37% (adjusted odds ratio [aOR]: 0.63; 95% confidence interval [CI]: 0.60-0.66) reduction in CD. This reduction was observed in both nulliparous women with singleton cephalic term pregnancy (aOR: 0.57; 95% CI: 0.54-0.60), and multiparous women with singleton cephalic term pregnancy without scar (aOR: 0.41; 95% CI: 0.30-0.55). CONCLUSION The rate of cesarean delivery in our Chinese population has declined significantly in the past few years.
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Affiliation(s)
- Xiaohua Liu
- Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, People's Republic of China
| | - Ding Huang
- Department of Obstetrics, International Peace Maternity & Child Health Hospital, Shanghai Jiaotong University Medical School, Shanghai, People's Republic of China
| | - Mark B Landon
- Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, The Ohio State University College of Medicine, Columbus, Ohio
| | - Weiwei Cheng
- Department of Obstetrics, International Peace Maternity & Child Health Hospital, Shanghai Jiaotong University Medical School, Shanghai, People's Republic of China
| | - Yan Chen
- Department of Obstetrics, International Peace Maternity & Child Health Hospital, Shanghai Jiaotong University Medical School, Shanghai, People's Republic of China.,Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, The Ohio State University College of Medicine, Columbus, Ohio
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Liu Y, Li T, Guo N, Jiang H, Li Y, Xu C, Yao X. Women's experience and satisfaction with midwife-led maternity care: a cross-sectional survey in China. BMC Pregnancy Childbirth 2021; 21:151. [PMID: 33607963 PMCID: PMC7893951 DOI: 10.1186/s12884-021-03638-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 02/11/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Low risk pregnancy ending in a vaginal birth is best served and guided by a midwife. Utilizing a midwife in such cases offers many emotional and economic advantages and does not increase the risks for mother or neonate. However, women's experience and satisfaction of midwife-led maternity care is rarely reported in China. The primary objective of this study is to describe the experience of Chinese women receiving midwife-led maternity care, and to report their satisfaction level of the experience. METHODS The study is a cross-sectional survey of 4192 women who had natural birth from March-June 2019 in a maternity care center, Shanghai, China. We used a self-administered questionnaire addressing items related to women's experience during childbirth, as well as their satisfaction with midwife-led maternity care. We also included demographic and perinatal characteristics of each participant. Descriptive statistics and correlations analysis between groups of different experience and satisfaction were used. RESULTS In this sample, 87.7% of women had a Doula and a family member present during childbirth. Epidural anesthesia was used in 75.6% and episiotomy was needed in 23.2%. Free positioning during the first stage of labor and free positioning during the second stage of labor and delivery were adopted in 84.3 and 67.9% of the cases, respectively. Moderate to severe perineal pain and moderate to severe perineal edema were reported in 43.1 and 12.2% of the participants, respectively. High satisfaction level was found when there was midwife-led prenatal counseling and presence of Doula and family member, Lamaze breathing techniques, warm perineal compresses, epidural anesthesia, free positioning during the first stage of labor, and midwifes' postpartum guidance. Negative satisfaction was seen with perineal pain and edema. CONCLUSION Women in this survey generally had high satisfaction with midwife-led maternity care. This satisfaction is probably felt because of the prenatal counseling by the midwife and allowing a Doula and a family member in the room during childbirth. Other intangible factors to improve the satisfaction level were Lamaze breathing techniques, warm perineal compresses, epidural anesthesia, free positioning during first stage of labor, and early skin to skin contact.
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Affiliation(s)
- Ying Liu
- Nursing Department, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, No.2699, West Gaoke Road, Pudong New Area, Shanghai, 201204, China
| | - Tengteng Li
- Nursing Department, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, No.2699, West Gaoke Road, Pudong New Area, Shanghai, 201204, China
| | - Nafei Guo
- Nursing Department, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, No.2699, West Gaoke Road, Pudong New Area, Shanghai, 201204, China
| | - Hui Jiang
- Nursing Department, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, No.2699, West Gaoke Road, Pudong New Area, Shanghai, 201204, China.
| | - Yuehong Li
- Delivery Room, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, No.2699, West Gaoke Road, Pudong New Area, Shanghai, 201204, China
| | - Chenying Xu
- Delivery Room, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, No.2699, West Gaoke Road, Pudong New Area, Shanghai, 201204, China
| | - Xiao Yao
- Delivery Room, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, No.2699, West Gaoke Road, Pudong New Area, Shanghai, 201204, China
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Song C, Xu Y, Ding Y, Zhang Y, Liu N, Li L, Li Z, Du J, You H, Ma H, Jin G, Wang X, Shen H, Lin Y, Jiang X, Hu Z. The rates and medical necessity of cesarean delivery in China, 2012-2019: an inspiration from Jiangsu. BMC Med 2021; 19:14. [PMID: 33487165 PMCID: PMC7831243 DOI: 10.1186/s12916-020-01890-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 12/15/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The World Health Organization (WHO) in 2015 stated that every effort should be made to provide cesarean delivery (CD) for women in need. In China, the two-child policy largely prompts the number of advanced age childbirth, which raises the possibility of an increasing number of women who need a c-section. The aim of this study was to assess the trends in the overall and medical indication-classified CD rates in the era of the two-child policy in Jiangsu, China. METHODS A retrospective cross-sectional study of 291,448 women who delivered in 11 hospitals in Jiangsu province between 2012 and 2019 was conducted. Medical cesarean indication for each woman was ascertained by manually reviewing the medical records. The 291,448 women were divided into two subgroups according to the presence of the indications: the indicated group (7.80%) and the non-indicated group (92.20%). We then fitted joinpoint regression and log-binomial regression models to estimate trends in the CD rates across the study period. RESULTS The overall CD rate was observed with a declining trend from 52.51% in 2012-2015 to 49.76% in 2016-2019 (adjusted RR, 0.92; 95% CI, 0.91-0.93; P < 0.001), along with an annual percentage change (APC) to be - 1.0 (95% CI, - 2.1 to 0.0) across the period. The participants were then divided into two subgroups according to the presence of medical CD indications: the indicated group (7.80%) and the non-indicated group (92.20%).We found the declining trend was most pronounced in the non-indicated group, with the CD rates decreased from 50.02% in 2012-2015 to 46.27% in 2016-2019 (adjusted RR, 0.90; 95% CI, 0.89-0.90; P < 0.001). By contrast, we observed a steady trend in the CD rate of the indicated group, which maintained from 87.47% in 2012-2015 to 86.57% in 2016-2019 (P = 0.448). In the indicated group, a higher risk of adverse pregnancy outcomes was revealed for those women who delivered vaginally as compared with those who received c-section. We further investigated that women with following specific indications had a higher proportion of vaginal delivery, i.e., pregnancy complications, fetal macrosomia, and pregnancy complicated with tumor (34.70%, 10.84%, and 16.34%, respectively). Women with the above 3 indications were observed with a higher risk of adverse pregnancy outcomes if delivered vaginally. The incidence rates of the medical indications among the general population increased considerably over the 8-year period (P < 0.001). CONCLUSIONS Although the overall CD rate apparently decreased in the recent years, along with the decline of the unnecessary CD rate, a considerable proportion of indicated women were not provided with CD service in Jiangsu, China. Instead of targeting the overall CD rate, we need to take actions to reduce unnecessary CD rate and provide adequate c-section service for women with indications, particularly for those with underlying diseases and suspected fetal macrosomia.
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Affiliation(s)
- Ci Song
- State Key Laboratory of Reproductive Medicine, Nanjing Medical University, Nanjing, 211166, China.,Department of Epidemiology, School of Public Health, Nanjing Medical University, Nanjing, 211166, China
| | - Yan Xu
- Department of Maternal and Child Health, Jiangsu Commission of Health, Nanjing, 210008, China
| | - Yuqing Ding
- State Key Laboratory of Reproductive Medicine, Nanjing Medical University, Nanjing, 211166, China.,Department of Epidemiology, School of Public Health, Nanjing Medical University, Nanjing, 211166, China
| | - Yanfang Zhang
- Department of Group Health, Women and Children Branch Hospital of Jiangsu Province Hospital/Jiangsu Women and Children Health Hospital, Nanjing Medical University, Nanjing, 210036, China
| | - Na Liu
- Department of Group Health, Women and Children Branch Hospital of Jiangsu Province Hospital/Jiangsu Women and Children Health Hospital, Nanjing Medical University, Nanjing, 210036, China
| | - Lin Li
- Department of Group Health, Women and Children Branch Hospital of Jiangsu Province Hospital/Jiangsu Women and Children Health Hospital, Nanjing Medical University, Nanjing, 210036, China
| | - Zhun Li
- Department of Group Health, Women and Children Branch Hospital of Jiangsu Province Hospital/Jiangsu Women and Children Health Hospital, Nanjing Medical University, Nanjing, 210036, China
| | - Jiangbo Du
- State Key Laboratory of Reproductive Medicine, Nanjing Medical University, Nanjing, 211166, China.,Department of Epidemiology, School of Public Health, Nanjing Medical University, Nanjing, 211166, China
| | - Hua You
- Department of Social Medicine & Health Education, Nanjing Medical University, Nanjing, 211166, China
| | - Hongxia Ma
- State Key Laboratory of Reproductive Medicine, Nanjing Medical University, Nanjing, 211166, China.,Department of Epidemiology, School of Public Health, Nanjing Medical University, Nanjing, 211166, China
| | - Guangfu Jin
- Department of Epidemiology, School of Public Health, Nanjing Medical University, Nanjing, 211166, China
| | - Xudong Wang
- Department of Group Health, Women and Children Branch Hospital of Jiangsu Province Hospital/Jiangsu Women and Children Health Hospital, Nanjing Medical University, Nanjing, 210036, China
| | - Hongbing Shen
- State Key Laboratory of Reproductive Medicine, Nanjing Medical University, Nanjing, 211166, China.,Department of Epidemiology, School of Public Health, Nanjing Medical University, Nanjing, 211166, China
| | - Yuan Lin
- Department of Maternal, Child and Adolescent Health, School of Public Health, Nanjing Medical University, Nanjing, 211166, China.
| | - Xiaoqing Jiang
- Department of Group Health, Women and Children Branch Hospital of Jiangsu Province Hospital/Jiangsu Women and Children Health Hospital, Nanjing Medical University, Nanjing, 210036, China.
| | - Zhibin Hu
- State Key Laboratory of Reproductive Medicine, Nanjing Medical University, Nanjing, 211166, China. .,Department of Epidemiology, School of Public Health, Nanjing Medical University, Nanjing, 211166, China.
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Liu L, Drzymalski D, Xu W, Zhang W, Wang L, Xiao F. Dose dependent reduction in median effective concentration (EC 50) of ropivacaine with adjuvant dexmedetomidine in labor epidural analgesia: An up-down sequential allocation study. J Clin Anesth 2020; 68:110115. [PMID: 33142249 DOI: 10.1016/j.jclinane.2020.110115] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Revised: 10/17/2020] [Accepted: 10/24/2020] [Indexed: 11/18/2022]
Abstract
STUDY OBJECTIVE Adjuvant dexmedetomidine can be used to reduce the required concentration of ropivacaine for labor epidural analgesia. However, the potency of dexmedetomidine has not been fully studied. The purpose of this study was to determine the median effective concentration (EC50) of ropivacaine with adjuvant dexmedetomidine. DESIGN Prospective, double-blind, up-down sequential allocation study. SETTING Academic medical center specializing in the care of women and children. PATIENTS One hundred and fifty healthy, term parturients requesting labor epidural analgesia were randomly assigned to 1 of 5 different concentrations of dexmedetomidine: 0 μg/ml, 0.3 μg/ml, 0.4 μg/ml, 0.5 μg/ml, or 0.6 μg/ml. INTERVENTIONS The study solution for the first patient in each group included the randomly assigned concentration of dexmedetomidine in 0.1% ropivacaine. Subsequent patients in each randomization group received the assigned concentration of dexmedetomidine in a new concentration of ropivacaine as determined by the up-down allocation methodology. Effective analgesia was defined as pain on the visual analogue scale of<3 at30 min after administration of local anesthetic. The up-down sequential allocation method and probit regression were used to calculate the EC50 of epidural ropivacaine. MEASUREMENTS The primary outcome was pain 30 min after administration of local anesthetic via epidural catheter. Exploratory outcomes included side effects, neonatal outcomes, and obstetric outcomes. MAIN RESULTS The EC50 values for ropivacaine in dexmedetomidine 0.4 μg/ml, 0.5 μg/ml, and 0.6 μg/ml (0.044% [95% CI 0.036% to 0.045%], 0.035% [95% CI 0.031% to 0.041%], and 0.039% [95% CI 0.034% to 0.045%], respectively) were lower compared to ropivacaine in dexmedetomidine 0 μg/ml and 0.3 μg/ml (0.086% [95% CI 0.081% to 0.092%], and, 0.069% [95% CI 0.056% to 0.076%], respectively). Differences between EC50 values for ropivacaine in dexmedetomidine 0.4 μg/ml, 0.5 μg/ml, and 0.6 μg/ml were not statistically significant. Results of our exploratory analyses did not reveal differences in side effects, neonatal outcomes, or obstetric outcomes. CONCLUSIONS In this study, the lowest concentration of dexmedetomidine in ropivacaine with the greatest clinical effect was 0.4 μg/ml, which is important because there may be no additional analgesic benefit of dexmedetomidine greater than 0.4 μg/ml.
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Affiliation(s)
- Lin Liu
- Department of Anesthesia, Jiaxing University Affiliated Women and Children Hospital, Jiaxing Maternity and Child Care Hospital, Jiaxing City, China
| | - Dan Drzymalski
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, MA, USA
| | - Wenping Xu
- Department of Anesthesia, Jiaxing University Affiliated Women and Children Hospital, Jiaxing Maternity and Child Care Hospital, Jiaxing City, China
| | - Wangping Zhang
- Department of Anesthesia, Jiaxing University Affiliated Women and Children Hospital, Jiaxing Maternity and Child Care Hospital, Jiaxing City, China
| | - Lizhong Wang
- Department of Anesthesia, Jiaxing University Affiliated Women and Children Hospital, Jiaxing Maternity and Child Care Hospital, Jiaxing City, China
| | - Fei Xiao
- Department of Anesthesia, Jiaxing University Affiliated Women and Children Hospital, Jiaxing Maternity and Child Care Hospital, Jiaxing City, China.
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9
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van der Spek L, Sanglier S, Mabeya HM, van den Akker T, Mertens PLJM, Houweling TAJ. Socioeconomic differences in caesarean section - are they explained by medical need? An analysis of patient record data of a large Kenyan hospital. Int J Equity Health 2020; 19:117. [PMID: 32641057 PMCID: PMC7341621 DOI: 10.1186/s12939-020-01215-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 06/10/2020] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Caesarean section (C-section) rates are often low among the poor and very high among the better-off in low- and middle-income countries. We examined to what extent these differences are explained by medical need in an African context. METHODS We analyzed electronic records of 12,209 women who gave birth in a teaching hospital in Kenya in 2014. C-section rates were calculated by socioeconomic position (SEP), using maternal occupation (professional, small business, housewife, student) as indicator. We assessed if women had documented clinical indications according to hospital guidelines and if socioeconomic differences in C-section rates were explained by indication. RESULTS Indication for C-section according to hospital guidelines was more prevalent among professionals than housewives (16% vs. 9% of all births). The C-section rate was also higher among professionals than housewives (21.1% vs. 15.8% [OR 1.43; 95%CI 1.23-1.65]). This C-section rate difference was largely explained by indication (4.7 of the 5.3 percentage point difference between professionals and housewives concerned indicated C-sections, often with previous C-section as indication). Repeat C-sections were near-universal (99%). 43% of primary C-sections had no documented indication. Over-use was somewhat higher among professionals than housewives (C-section rate among women without indication: 6.6 and 5.5% respectively), which partly explained socioeconomic differences in primary C-section rate. CONCLUSIONS Socioeconomic differences in C-section rates can be largely explained by unnecessary primary C-sections and higher supposed need due to previous C-section. Prevention of unnecessary primary C-sections and promoting safe trial of labor should be priorities in addressing C-section over-use and reducing inequalities. Unnecessary primary C-sections and ubiquitous repeat C-sections drive overall C-section rates and C-section inequalities.
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Affiliation(s)
- Lisa van der Spek
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Sterre Sanglier
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Hillary M Mabeya
- Department of Reproductive Health, Moi University School of Medicine and Gynocare Womens and Fistula Hospital, Eldoret, Kenya
| | - Thomas van den Akker
- Department of Obstetrics and Gynaecology, Leiden University Medical Center, Leiden, The Netherlands
- Athena Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Paul L J M Mertens
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- School of Public Health, Moi University, Eldoret, Kenya
| | - Tanja A J Houweling
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.
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10
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Ma Y, Zhang L, Wang X, Qiu L, Hesketh T, Wang X. Low Incidence of Maternal Near-Miss in Zhejiang, a Developed Chinese Province: A Cross-Sectional Study Using the WHO Approach. Clin Epidemiol 2020; 12:405-414. [PMID: 32425608 PMCID: PMC7196796 DOI: 10.2147/clep.s243414] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 04/01/2020] [Indexed: 12/02/2022] Open
Abstract
Background and Aim Maternal near-miss (MNM) surveillance has been developed to identify severe complications in pregnancy since 2011 in China. However, very little is known about MNM in China. This study aims to explore the prevalence of MNM, the risk factors, and perinatal outcomes using the WHO near-miss approach in a developed Chinese province. Materials and Methods We used data from China’s National Maternity Near Miss Obstetrics Surveillance System for the period 2012 to 2017, which included 18 hospitals in Zhejiang Province. Chi-squared tests were used to compare the socio-demographic factors, obstetric complications and perinatal outcomes between women with and without MNM. Logistic regression was used to examine the independent risk factors for MNM. Results A total of 612,264 pregnant women were recruited. There were 3208 MNM cases and 34 maternal deaths. The MNM incidence ratio was low at 5.9 per 1,000 live births, with an MNM mortality ratio of 98:1 and mortality index of 1.1%. Among 3208 women with MNM, postpartum hemorrhage was the commonest cause at 76.3% followed by severe anemia at 23.7% and placenta previa at 23.0%. Embolism was identified as having the highest risk for MNM (AOR 46.0; 95% CI 19.1–110.7), followed by postpartum hemorrhage (AOR 41.0; 95% CI 35.7–47.0), and severe anemia (AOR 36.6; 95% CI 16.0–84.1). MNM cases were significantly associated with severe perinatal outcome, including premature birth, low birth weight, multiple fetuses, stillbirth rates and neonatal mortality. Conclusion Overall near-miss indicators suggested a relatively high quality of maternal health care in a developed province of China. The identified risk factors may be helpful in developing targeted interventions for improving maternal safety.
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Affiliation(s)
- YuanYing Ma
- Department of Women's Healthcare, Women's Hospital, Zhejiang University School of Medicine, Zhejiang Province, People's Republic of China
| | - LiSan Zhang
- Department of Neurology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Zhejiang Province, People's Republic of China
| | - Xian Wang
- Department of Big Data Analysis, Hangzhou Maicim Medical Technology Co., Ltd, Zhejiang Province, People's Republic of China
| | - Liqian Qiu
- Department of Women's Healthcare, Women's Hospital, Zhejiang University School of Medicine, Zhejiang Province, People's Republic of China
| | - Therese Hesketh
- Centre for Global Health, Zhejiang University, Zhejiang Province, People's Republic of China.,Institute for Global Health, University College London; London, UK
| | - Xinyu Wang
- Department of Obstetrics and Gynaecology, Women's Hospital, Zhejiang University School of Medicine, People's Republic of China
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11
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Zhang L, Zhang L, Li M, Xi J, Zhang X, Meng Z, Wang Y, Li H, Liu X, Ju F, Lu Y, Tang H, Qin X, Ming Y, Huang R, Li G, Dai H, Zhang R, Qin M, Zhu L, Zhang J. A cluster-randomized field trial to reduce cesarean section rates with a multifaceted intervention in Shanghai, China. BMC Med 2020; 18:27. [PMID: 32054535 PMCID: PMC7020498 DOI: 10.1186/s12916-020-1491-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 01/07/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cesarean section (CS) rate has risen dramatically and stayed at a very high level in China over the past two to three decades. Given the short- and long-term adverse effects of CS, effective strategies are needed to reduce unnecessary CS. We aimed to evaluate whether a multifaceted intervention would decrease the CS rate in China. METHODS We carried out a cluster-randomized field trial with a multifaceted intervention in Shanghai, China, from 2015 to 2017. A total of 20 hospitals were randomly allocated into an intervention or a control group. The intervention consisted of more targeted health education to pregnant women, improved hospital CS policy, and training of midwives/doulas for 8 months. The study included a baseline survey, the intervention, and an evaluation survey. The primary outcome was the changes of overall CS rate from the pre-intervention to the post-intervention period. A subgroup analysis stratified by the Robson classification was also conducted to examine the CS change among women with various obstetric characteristics. RESULTS A total of 10,752 deliveries were randomly selected from the pre-intervention period and 10,521 from the post-intervention period. The baseline CS rates were 42.5% and 41.5% in the intervention and control groups, respectively, while the post-intervention CS rates were 43.4% and 42.4%, respectively. Compared with the control group, the intervention did not significantly reduce the CS rate (adjusted OR = 0.92; 95% CI 0.73, 1.15). Similar results were obtained in subgroup analyses stratified by the risk level of pregnancy, maternal age, number of previous CS, or parity. Scarred uterus and maternal request remained the primary reasons for CS after the interventions in both groups. The intervention did not alter the perinatal outcomes (adjusted change of risk score = - 0.06; 95%CI - 0.43, 0.31). CONCLUSIONS A multifaceted intervention including more targeted prenatal health education, improved hospital CS policy, and training of midwives/doulas, did not significantly reduce the CS rate in Shanghai, China. However, our experience in implementing a multifaceted intervention may provide useful information to other similar areas with high CS use. TRIAL REGISTRATION This trial was registered at the Chinese Clinical Trial Registry (www.chictr.org.cn) (ChiCTR-IOR-16009041) on 17 August 2016.
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Affiliation(s)
- Lulu Zhang
- Ministry of Education-Shanghai Key Laboratory of Children's Environmental Health, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lin Zhang
- Department of Obstetrics and Gynecology, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Meng Li
- Ministry of Education-Shanghai Key Laboratory of Children's Environmental Health, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Shanghai Jiao Tong University School of Public Health, Shanghai, China
| | - Jie Xi
- Department of Obstetrics, Jiading District Maternal and Child Health Hospital, Shanghai, China
| | - Xiaohua Zhang
- Department of Maternal Health Care, Minhang District Maternal and Child Health Hospital, Shanghai, China
| | - Zhenni Meng
- Department of Obstetrics, First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China
| | - Ying Wang
- Department of Obstetrics, Songjiang District Maternal and Child Health Hospital, Shanghai, China
| | - Huaping Li
- Department of Obstetrics and Gynecology, Sixth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaohua Liu
- Department of Obstetrics, First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China.,Department of Obstetrics, China Welfare Association International Peace Maternal and Child Health Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Feihua Ju
- Department of Obstetrics and Gynecology, Pudong New District Maternal and Child Health Hospital, Shanghai, China
| | - Yuping Lu
- Department of Obstetrics and Gynecology, Pudong New Area People's Hospital, Shanghai, China
| | - Huijun Tang
- Department of Obstetrics, Putuo District Maternal and Child Health Hospital, Shanghai, China
| | - Xianju Qin
- Department of General Surgery, Eighth People's Hospital, Shanghai, China
| | - Yanhong Ming
- Ministry of Education-Shanghai Key Laboratory of Children's Environmental Health, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Rong Huang
- Ministry of Education-Shanghai Key Laboratory of Children's Environmental Health, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Guohong Li
- Shanghai Jiao Tong University School of Public Health, Shanghai, China.,Center for HTA, China Hospital Development Institute, Shanghai Jiao Tong University, Shanghai, China
| | - Hongying Dai
- Nursing College, Shanghai University of Medicine & Health Sciences, Shanghai, China
| | - Rong Zhang
- Shanghai Maternal and Child Health Center, Shanghai, China
| | - Min Qin
- Shanghai Maternal and Child Health Center, Shanghai, China.
| | - Liping Zhu
- Shanghai Maternal and Child Health Center, Shanghai, China.
| | - Jun Zhang
- Ministry of Education-Shanghai Key Laboratory of Children's Environmental Health, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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12
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13
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Li YX, Bai Z, Long DJ, Wang HB, Wu YF, Reilly KH, Huang SR, Ji YJ. Predicting the success of vaginal birth after caesarean delivery: a retrospective cohort study in China. BMJ Open 2019; 9:e027807. [PMID: 31129593 PMCID: PMC6538023 DOI: 10.1136/bmjopen-2018-027807] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES To develop a nomogram to predict the likelihood of vaginal birth after caesarean section (VBAC) among women after a previous caesarean section (CS). DESIGN A retrospective cohort study. SETTING Two secondary hospitals in Guangdong Province, China. PARTICIPANTS Inclusion criteria were as follows: pregnant women with singleton fetus, age ≥18 years, had a history of previous CS and scheduled for trial of labour after caesarean delivery (TOLAC). Patients with any of the following were excluded from the study: preterm labour (gestational age <37 weeks), two or more CSs, contradictions for vaginal birth, history of other uterine incision such as myomectomy, and incomplete medical records. PRIMARY OUTCOME MEASURE The primary outcome was VBAC, which was retrospectively abstracted from computerised medical records by clinical staff. RESULTS Of the women who planned for TOLAC, 84.0% (1686/2006) had VBAC. Gestational age, history of vaginal delivery, estimated birth weight, body mass index, spontaneous onset of labour, cervix Bishop score and rupture of membranes were independently associated with VBAC. An area under the receiver operating characteristic curve (AUC) in the prediction model was 0.77 (95% CI 0.73 to 0.81) in the training cohort. The validation set showed good discrimination with an AUC of 0.70 (95% CI 0.60 to 0.79). CONCLUSIONS TOLAC may be a potential strategy for decreasing the CS rate in China. The validated nomogram to predict success of VBAC could be a potential tool for VBAC counselling.
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Affiliation(s)
- Yun-Xiu Li
- Shenzhen Longhua District Central Hospital, Shenzhen, P.R. China
| | - Zhi Bai
- Dongguan Tangxia Hospital, Dongguan, P.R. China
| | | | - Hai-Bo Wang
- Project development and management, Peking University Clinical Research Institute, Beijing, P.R. China
| | - Yang-Feng Wu
- Project development and management, Peking University Clinical Research Institute, Beijing, P.R. China
| | - Kathleen H Reilly
- Independent Consultant, New York City, New York, USA
- National Center for AIDS/STD Prevention and Control, Chinese Center for Disease Control and Prevention, Beijing, P.R. China
| | - Su-Ran Huang
- Dongguan People’s Hospital, Dongguan, P.R. China
| | - Yan-Jie Ji
- Dongguan Tangxia Hospital, Dongguan, P.R. China
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14
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Increased pregnancy complications following frozen-thawed embryo transfer during an artificial cycle. J Assist Reprod Genet 2019; 36:925-933. [PMID: 30924053 DOI: 10.1007/s10815-019-01420-1] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 02/07/2019] [Indexed: 12/13/2022] Open
Abstract
PURPOSE This study aimed to clarify the risks of adverse pregnancy outcomes in patients and their offspring after frozen embryo transfer (FET) during an artificial cycle (AC). METHODS We conducted a retrospective cohort study that included all FET cycles and subsequent deliveries in a single centre between August 2013 and March 2016. Pregnancy, obstetric and neonatal outcomes were compared among patients treated during an AC or a natural cycle with luteal phase support (NC-LPS). Multivariate logistic regression was performed to evaluate the relationship between endometrial preparation schemes and pregnancy, obstetric and neonatal outcomes. RESULTS AC-FET was not a significant risk factor for clinical pregnancy rate, multiple birth rate or miscarriage rate after adjusting for potential confounders. However, AC-FET was a significant risk factor for ectopic pregnancy rate (adjusted odds ratio (AOR), 1.738; 95% confidence interval (CI), 1.086-2.781) and live birth rate (AOR, 0.709; 95% CI, 0.626-0.802). Regarding obstetric outcomes, AC-FET was found to be associated with an increased risk for hypertension disorder (AOR, 1.780; 95% CI, 1.262-2.510) and caesarean section (AOR, 1.507; 95% CI, 1.195-1.900). In multiples, birth weight (2550 g (2150-2900 g) in AC-FET vs. 2600 g (2350-2900 g) in NC-LPS; P = 0.023), gestational age (36.6 weeks (35.3-37.6 weeks) vs. 37.1 weeks (36.1-37.9 weeks); P < 0.001), and z-score (- 0.5 (- 1.1, - 0.0) vs. - 0.4 (- 1.0, 0.2); P = 0.009) were higher in the NC-LPS group than in the AC-FET group, although there were no differences in these variables among singletons. CONCLUSION Compared with NC-LPS, AC-FET seemed to have a negative effect on obstetric outcomes.
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15
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Visser GHA, Ayres-de-Campos D, Barnea ER, de Bernis L, Di Renzo GC, Vidarte MFE, Lloyd I, Nassar AH, Nicholson W, Shah PK, Stones W, Sun L, Theron GB, Walani S. FIGO position paper: how to stop the caesarean section epidemic. Lancet 2018; 392:1286-1287. [PMID: 30322563 DOI: 10.1016/s0140-6736(18)32113-5] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 08/29/2018] [Indexed: 11/17/2022]
Affiliation(s)
- Gerard H A Visser
- Department of Obstetrics, University Medical Center, Utrecht, Netherlands.
| | - Diogo Ayres-de-Campos
- Department of Obstetrics and Gynecology, Medical School-University of Lisbon, Santa Maria Hospital, Lisbon, Portugal
| | - Eytan R Barnea
- Society for the Investigation of Early Pregnancy, New York, NY, USA; BioIncept, LLC, New York, NY, USA
| | | | - Gian Carlo Di Renzo
- Department of Obstetrics and Gynecology, University of Perugia, Perugia, Italy
| | | | - Isabel Lloyd
- Ginecólogo Obstetra, Clinica Hospital San Fernando, Consultorio 6-8, Panama
| | - Anwar H Nassar
- Department of Obstetrics and Gynecology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Wanda Nicholson
- Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill School of Medicine, NC, USA
| | - P K Shah
- Department of Obstetrics and Gynecology, Seth G S Medical College and K E M Hospital, Mumbai, India
| | - William Stones
- Departments of Public Health and Obstetrics and Gynaecology, Malawi College of Medicine, Blantyre, Malawi
| | - Luming Sun
- Shanghai 1st Maternity and Infant Hospital of Tongji University, Shanghai, China
| | - Gerhard B Theron
- Department of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Salimah Walani
- Global Health Programs, March of Dimes Foundation, White Plains, NY, USA
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16
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Betrán AP, Temmerman M, Kingdon C, Mohiddin A, Opiyo N, Torloni MR, Zhang J, Musana O, Wanyonyi SZ, Gülmezoglu AM, Downe S. Interventions to reduce unnecessary caesarean sections in healthy women and babies. Lancet 2018; 392:1358-1368. [PMID: 30322586 DOI: 10.1016/s0140-6736(18)31927-5] [Citation(s) in RCA: 282] [Impact Index Per Article: 47.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 08/06/2018] [Accepted: 08/09/2018] [Indexed: 12/20/2022]
Abstract
Optimising the use of caesarean section (CS) is of global concern. Underuse leads to maternal and perinatal mortality and morbidity. Conversely, overuse of CS has not shown benefits and can create harm. Worldwide, the frequency of CS continues to increase, and interventions to reduce unnecessary CSs have shown little success. Identifying the underlying factors for the continuing increase in CS use could improve the efficacy of interventions. In this Series paper, we describe the factors for CS use that are associated with women, families, health professionals, and health-care organisations and systems, and we examine behavioural, psychosocial, health system, and financial factors. We also outline the type and effects of interventions to reduce CS use that have been investigated. Clinical interventions, such as external cephalic version for breech delivery at term, vaginal breech delivery in appropriately selected women, and vaginal birth after CS, could reduce the frequency of CS use. Approaches such as labour companionship and midwife-led care have been associated with higher proportions of physiological births, safer outcomes, and lower health-care costs relative to control groups without these interventions, and with positive maternal experiences, in high-income countries. Such approaches need to be assessed in middle-income and low-income countries. Educational interventions for women should be complemented with meaningful dialogue with health professionals and effective emotional support for women and families. Investing in the training of health professionals, eliminating financial incentives for CS use, and reducing fear of litigation is fundamental. Safe, private, welcoming, and adequately resourced facilities are needed. At the country level, effective medical leadership is essential to ensure CS is used only when indicated. We conclude that interventions to reduce overuse must be multicomponent and locally tailored, addressing women's and health professionals' concerns, as well as health system and financial factors.
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Affiliation(s)
- Ana Pilar Betrán
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland.
| | - Marleen Temmerman
- Centre of Excellence in Women and Child Health, Aga Khan University, Nairobi, Kenya; Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Carol Kingdon
- School of Community Health and Midwifery, Faculty of Health and Wellbeing, University of Central Lancashire, Preston, UK
| | - Abdu Mohiddin
- Centre of Excellence in Women and Child Health, Aga Khan University, Nairobi, Kenya
| | - Newton Opiyo
- Review Production and Quality Unit, Cochrane, London, UK
| | - Maria Regina Torloni
- Postgraduate Program on Evidence-Based Healthcare, São Paulo Federal University, São Paulo, Brazil
| | - Jun Zhang
- MOE-Shanghai Key Laboratory of Children's Environmental Health, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Othiniel Musana
- Uganda Martyrs University, St Francis Hospital Nsambya, Kampala, Uganda
| | - Sikolia Z Wanyonyi
- Centre of Excellence in Women and Child Health, Aga Khan University, Nairobi, Kenya
| | - Ahmet Metin Gülmezoglu
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Soo Downe
- School of Community Health and Midwifery, Faculty of Health and Wellbeing, University of Central Lancashire, Preston, UK
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17
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Frey HA, Liu X, Lynch CD, Musindi W, Samuels P, Rood KM, Thung SF, Bakk JM, Cheng W, Landon MB. An evaluation of fetal heart rate characteristics associated with neonatal encephalopathy: a case-control study. BJOG 2018; 125:1480-1487. [DOI: 10.1111/1471-0528.15222] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2018] [Indexed: 11/30/2022]
Affiliation(s)
- HA Frey
- Department of Obstetrics and Gynecology; The Ohio State University College of Medicine; Columbus OH USA
| | - X Liu
- Department of Obstetrics; International Peace Maternity & Child Health Hospital; Shanghai Jiao Tong University; Shanghai China
| | - CD Lynch
- Department of Obstetrics and Gynecology; The Ohio State University College of Medicine; Columbus OH USA
| | - W Musindi
- Department of Obstetrics and Gynecology; The Ohio State University College of Medicine; Columbus OH USA
| | - P Samuels
- Department of Obstetrics and Gynecology; The Ohio State University College of Medicine; Columbus OH USA
| | - KM Rood
- Department of Obstetrics and Gynecology; The Ohio State University College of Medicine; Columbus OH USA
| | - SF Thung
- Department of Obstetrics and Gynecology; The Ohio State University College of Medicine; Columbus OH USA
| | - JM Bakk
- Department of Obstetrics and Gynecology; The Ohio State University College of Medicine; Columbus OH USA
| | - W Cheng
- Department of Obstetrics; International Peace Maternity & Child Health Hospital; Shanghai Jiao Tong University; Shanghai China
| | - MB Landon
- Department of Obstetrics and Gynecology; The Ohio State University College of Medicine; Columbus OH USA
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18
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Liang J, Mu Y, Li X, Tang W, Wang Y, Liu Z, Huang X, Scherpbier RW, Guo S, Li M, Dai L, Deng K, Deng C, Li Q, Kang L, Zhu J, Ronsmans C. Relaxation of the one child policy and trends in caesarean section rates and birth outcomes in China between 2012 and 2016: observational study of nearly seven million health facility births. BMJ 2018; 360:k817. [PMID: 29506980 PMCID: PMC5836714 DOI: 10.1136/bmj.k817] [Citation(s) in RCA: 124] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/01/2018] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To examine how the relaxation of the one child policy and policies to reduce caesarean section rates might have affected trends over time in caesarean section rates and perinatal and pregnancy related mortality in China. DESIGN Observational study. SETTING China's National Maternal Near Miss Surveillance System (NMNMSS). PARTICIPANTS 6 838 582 births at 28 completed weeks or more of gestation or birth weight ≥1000 g in 438 hospitals in the NMNMSS between 2012 and 2016. MAIN OUTCOME MEASURES Obstetric risk was defined using a modified Robson classification. The main outcome measures were changes in parity and age distributions and relative frequency of each Robson group, crude and adjusted trends over time in caesarean section rates within each risk category (using Poisson regression with a robust variance estimator), and trends in perinatal and pregnancy related mortality over time. RESULTS Caesarean section rates declined steadily between 2012 and 2016 (crude relative risk 0.91, 95% confidence interval 0.89 to 0.93), reaching an overall hospital based rate of 41.1% in 2016. The relaxation of the one child policy was associated with an increase in the proportion of multiparous births (from 34.1% in 2012 to 46.7% in 2016), and births in women with a uterine scar nearly doubled (from 9.8% to 17.7% of all births). Taking account of these changes, the decline in caesarean sections was amplified over time (adjusted relative risk 0.82, 95% confidence interval 0.81 to 0.84). Caesarean sections declined noticeably in nulliparous women (0.75, 0.73 to 0.77) but also declined in multiparous women without a uterine scar (0.65, 0.62 to 0.77). The decrease in caesarean section rates was most pronounced in hospitals with the highest rates in 2012, consistent with the government's policy of targeting hospitals with the highest rates. Perinatal mortality declined from 10.1 to 7.2 per 1000 births over the same period (0.87, 0.83 to 0.91), and there was no change in pregnancy related mortality over time. CONCLUSIONS China is the only country that has succeeded in reverting the rising trends in caesarean sections. China's success is remarkable given that the changes in obstetric risk associated with the relaxation of the one child policy would have led to an increase in the need for caesarean sections. China's experience suggests that change is possible when strategies are comprehensive and deal with the system level factors that underpin overuse as well as the various incentives at work during a clinical encounter.
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Affiliation(s)
- Juan Liang
- National Office for Maternal and Child Health Surveillance of China, Department of Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yi Mu
- National Office for Maternal and Child Health Surveillance of China, Department of Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xiaohong Li
- National Office for Maternal and Child Health Surveillance of China, Department of Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Wen Tang
- National Office for Maternal and Child Health Surveillance of China, Department of Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yanping Wang
- National Office for Maternal and Child Health Surveillance of China, Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Zheng Liu
- National Office for Maternal and Child Health Surveillance of China, Department of Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xiaona Huang
- Health, Nutrition and Water, Sanitation & Hygiene, UNICEF China, Beijing, China
| | - Robert W Scherpbier
- Health, Nutrition and Water, Sanitation & Hygiene, UNICEF China, Beijing, China
| | - Sufang Guo
- UNICEF Regional Office for South Asia, Kathmandu, Nepal
| | - Mingrong Li
- National Office for Maternal and Child Health Surveillance of China, Department of Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Li Dai
- National Office for Maternal and Child Health Surveillance of China, Department of Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Kui Deng
- National Office for Maternal and Child Health Surveillance of China, Department of Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Changfei Deng
- National Office for Maternal and Child Health Surveillance of China, Department of Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Qi Li
- National Office for Maternal and Child Health Surveillance of China, Department of Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Leni Kang
- National Office for Maternal and Child Health Surveillance of China, Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jun Zhu
- National Office for Maternal and Child Health Surveillance of China, Department of Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Carine Ronsmans
- West China School of Public Health, Sichuan University, Chengdu, Sichuan, China
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
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Zhao J, Shan N, Yang X, Li Q, Xia Y, Zhang H, Qi H. Effect of second child intent on delivery mode after Chinese two child policy implementation: a cross sectional and prospective observational study of nulliparous women in Chongqing. BMJ Open 2017; 7:e018823. [PMID: 29282269 PMCID: PMC5770909 DOI: 10.1136/bmjopen-2017-018823] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVES To assess the influence of second child intent on the delivery preferences and final delivery modes of nulliparous women, particularly caesarean delivery on maternal request (CDMR), after implementation of China's two child policy. DESIGN Cross sectional and prospective observational study. SETTING A tertiary teaching hospital in Chongqing, China. PARTICIPANTS 1000 low risk nulliparous women were initially involved, and were divided into two groups based on their intent on having a second child. 814 women who completed all interviews were analysed. MAIN OUTCOME MEASURES Preferred mode of delivery in second trimester and at admission; final delivery mode, CDMR. RESULTS 814 women who completed all interviews were analysed, in whom 51.2% intended to have a second child. The preference for caesarean delivery (CD) at the second trimester between the intent and no intent group was 6.2% versus 17.9% (adjusted RR 0.35, 95% CI 0.20 to 0.63) and increased to 24.2% versus 37.3% (adjusted RR 0.65, 95% CI 0.45 to 0.94) at admission, respectively. The overall CD rates between the two groups were 41.0% versus 50.4% (adjusted RR 0.84, 95% CI 0.60 to 1.18), and the CDMR rates were 16.7% versus 29.0% (adjusted RR 0.56, 95% CI 0.37 to 0.86), respectively. CONCLUSIONS Women who intend to have a second child are less likely to request a CD, and high rates of CD and CDMR in nulliparous women may have decreased after implementation of China's two child policy.
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Affiliation(s)
- Jianlin Zhao
- Department of Obstetrics and Gynaecology, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Nan Shan
- Department of Obstetrics and Gynaecology, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xiaochang Yang
- Department of Obstetrics and Gynaecology, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Qin Li
- Department of Obstetrics and Gynaecology, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yinyin Xia
- School of Public Health and Management, Research Center for Medicine and Social Development, Innovation Center for Social Risk Governance in Health, Chongqing Medical University, Chongqing, China
| | - Hua Zhang
- Department of Obstetrics and Gynaecology, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Hongbo Qi
- Department of Obstetrics and Gynaecology, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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HU Y, Shen H, Landon MB, Cheng W, Liu X. Optimal timing for elective caesarean delivery in a Chinese population: a large hospital-based retrospective cohort study in Shanghai. BMJ Open 2017; 7:e014659. [PMID: 28600366 PMCID: PMC5623362 DOI: 10.1136/bmjopen-2016-014659] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To assess the relationship between the timing of antepartum elective caesarean delivery (CD) at term and perinatal outcomes in a Chinese population. METHODS We conducted a retrospective cohort study of mode of delivery at a large obstetric centre in Shanghai, China between 2007 and 2014. Eligibility criteria included: term nulliparous women with a singleton gestation undergoing antepartum elective CD. RESULTS There were 19 939 women delivered by antepartum CD without indications, with 5.9% performed at 37-37 6/7 weeks, 36.2% at 38-38 6/7 weeks, 38.4% at 39-39 6/7 weeks, 15.4% at 40-40 6/7 weeks, 4.0% at ≥41 weeks. As compared with births at 39-39 6/7 weeks, births at 37 weeks were associated with an increased odds of neonatal respiratory disease (adjusted odds ratian(aOR): 4.82; 95% CI 3.35 to 6.94), neonatal infection (aOR: 3.68; 95% CI 1.80 to 7.52), hypoglycaemia (aOR: 3.85; 95%CI 2.29 to 6.48), hyperbilirubinaemia (aOR: 3.50; 95%CI 2.12 to 5.68), neonatal intensive care admission (aOR: 3.73; 95% CI 2.84 to 4.89) and prolonged hospitalisation (aOR: 7.51; 95% CI 5.10 to 11.07). Births at 38 weeks, 40 weeks or ≥41 weeks were also associated with an increased odds of neonatal respiratory disease with corresponding aORs (95% CI) of 2.26 (1.71 to 3.00), 1.97 (1.33 to 2.94) and 2.91 (1.80 to 4.70), respectively. CONCLUSION For women undergoing elective CD, neonatal outcome data suggest that delivery at 39-39 6/7 complete weeks is optimal timing in a Chinese population.
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Affiliation(s)
- Yong HU
- Department of Neonatology, Shanghai Children’s hospital, Shanghai Jiaotong University, Shanghai, China
| | - Hong Shen
- Obstetrics Department, International Peace Maternity & Child Health Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Mark B Landon
- Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Weiwei Cheng
- Obstetrics Department, International Peace Maternity & Child Health Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Xiaohua Liu
- Obstetrics Department, International Peace Maternity & Child Health Hospital, Shanghai Jiaotong University, Shanghai, China
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