Practice variation of vaginal birth after cesarean and the influence of risk factors at patient level: a retrospective cohort study

Nationwide implementation of a decision aid on vaginal birth after cesarean: a before and after cohort study

OBJECTIVES

Woman with a history of a previous cesarean section (CS) can choose between an elective repeat CS (ERCS) and a trial of labor (TOL), which can end in a vaginal birth after cesarean (VBAC) or an unplanned CS. Guidelines describe women's rights to make an informed decision between an ERCS or a TOL. However, the rates of TOL and vaginal birth after CS varies greatly between and within countries. The objective of this study is to asses nation-wide implementation of counselling with a decision aid (DA) including a prediction model, on intended delivery compared to care as usual. We hypothesize that this may result in a reduction in practice variation without an increase in cesarean rates or complications.

METHODS

In a multicenter controlled before and after cohort study we evaluate the effect of nation-wide implementation of a DA. Practice variation was defined as the standard deviation (SD) of TOL percentages.

RESULTS

A total of 27 hospitals and 1,364 women were included. A significant decrease was found in practice variation (SD TOL rates: 0.17 control group vs. 0.10 intervention group following decision aid implementation, p=0.011). There was no significant difference in the ERCS rate or overall CS rates. A 21% reduction in the combined maternal and perinatal adverse outcomes was seen.

CONCLUSIONS

Nationwide implementation of the DA showed a significant reduction in practice variation without an increase in the rate of cesarean section or complications, suggesting an improvement in equality of care.

Methodology for sampling women at high maternal risk in administrative data

Background

In population level studies, the conventional practice of categorizing women into low and high maternal risk samples relies upon ascertaining the presence of various comorbid conditions in administrative data. Two problems with the conventional method include variability in the recommended comorbidities to consider and inability to distinguish between maternal and fetal risks. High maternal risk sample selection may be improved by using the Obstetric Comorbidity Index (OCI), a system of risk scoring based on weighting comorbidities associated with maternal end organ damage. The purpose of this study was to compare the net benefit of using OCI risk scoring vs the conventional risk identification method to identify a sample of women at high maternal risk in administrative data.

Methods

This was a net benefit analysis using linked delivery hospitalization discharge and vital records data for women experiencing singleton births in Georgia from 2008 to 2012. We compared the value identifying a sample of women at high maternal risk using the OCI score to the conventional method of dichotomous identification of any comorbidities. Value was measured by the ability to select a sample of women designated as high maternal risk who experienced severe maternal morbidity or mortality.

Results

The high maternal risk sample created with the OCI had a small but positive net benefit (+ 0.6), while the conventionally derived sample had a negative net benefit indicating the sample selection performed worse than identifying no woman as high maternal risk.

Conclusions

The OCI can be used to select women at high maternal risk in administrative data. The OCI provides a consistent method of identification for women at risk of maternal morbidity and mortality and avoids confounding all obstetric risk factors with specific maternal risk factors. Using the OCI may help reduce misclassification as high maternal risk and improve the consistency in identifying women at high maternal risk in administrative data.

The effect of the use of a decision aid with individual risk estimation on the mode of delivery after a caesarean section: A prospective cohort study

OBJECTIVE

After one previous caesarean section (CS), pregnant women can deliver by elective repeat CS or have a trial of labor which can end in a vaginal birth after caesarean (VBAC) or an unplanned CS. Despite guidelines describing women's rights to make an informed choice, trial of labor and VBAC rates vary greatly worldwide. Many women are inadequately informed due to caregivers' fear of an increase in CS rates in a high VBAC rate setting. We compared counseling with a decision aid (DA) including a prediction model on VBAC to care as usual. We hypothesize that counselling with the DA does not decrease VBAC rates. In addition, we aimed to study the effects on unplanned CS rate, patient involvement in decision-making and elective repeat CS rates.

METHODS

We performed a prospective cohort study. From 2012 to 2014, 483 women in six hospitals, where the DA was used (intervention group), were compared with 441 women in six matched hospitals (control group). Women with one previous CS, pregnant of a singleton in cephalic presentation, delivering after 37 weeks 0 days were eligible for inclusion.

RESULTS

There was no significant difference in VBAC rates between the intervention (45%) and control group (46%) (adjusted odds ratio 0,92 (95% Confidence interval 0.69-1.23)). In the intervention group more women (42%) chose an elective repeat CS compared to the control group (31%) (adjusted odds ratio 1.6 (95% Confidence interval 1.18-2.17)). Of women choosing trial of labor, in the intervention group 77% delivered vaginally compared to 67% in the control group, resulting in an unplanned CS adjusted odds ratio of 0,57 (0.40-0.82) in the intervention group. In the intervention group, more women reported to be involved in decision-making (98% vs. 68%, P< 0.001).

CONCLUSIONS

Implementing a decision aid with a prediction model for risk selection suggests unchanged VBAC rates, but 40% reduction in unplanned CS rates, increase in elective repeat CS and improved patient involvement in decision-making.

Caesarean section in uninsured women in the USA: systematic review and meta-analysis

OBJECTIVE

The aim of this study is to assess the odds of caesarean section (CS) for uninsured women in the USA and understand the underlying mechanisms as well as consequences of lower use.

STUDY DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed, Embase, the Cochrane Library and CINAHL from the first year of records to April 2018.

ELIGIBILITY CRITERIA

We included studies that reported data to allow the calculation of ORs of CS of uninsured as compared with insured women.

OUTCOMES

The prespecified primary outcome was the adjusted OR of deliveries by CS of uninsured women as compared with privately or publicly insured women. The prespecified secondary outcome was the crude OR of deliveries by CS of uninsured women as compared with insured women.

RESULTS

12 articles describing 16 separate studies involving more than 8.8 million women were included in this study. We found: 0.70 times lower odds of CS in uninsured as compared with privately insured women (95% CI 0.63 to 0.78), with no relevant heterogeneity between studies (τ2=0.01); and 0.92 times lower odds for CS in uninsured as compared with publicly insured women (95% CI 0.80 to 1.07), with no relevant heterogeneity between studies (τ2=0.02). We found 0.70 times lower odds in uninsured as compared with privately and publicly insured women (95% CI 0.69 to 0.72).

CONCLUSIONS

CSs are less likely to be performed in uninsured women as compared with insured women. While the higher rates for CS among privately insured women can be explained with financial incentives associated with private insurance, the lower odds among uninsured women draw attention at barriers to access for delivery care. In many regions, the rates for uninsured women are above, close or below the benchmarks for appropriate CS rates and could imply both, underuse and overuse.

Decision-making during trial of labour after caesarean; a qualitative study with gynaecologists

OBJECTIVE

The attempt of a woman to deliver vaginally after having had a caesarean in a previous pregnancy is increasingly common in current obstetric practice. During a trial of labour after caesarean, gynaecologists consider whether continuing vaginal birth is safe or, alternately, whether a repeat caesarean is advised. There is large variation in the success rates of women with comparable medical risk factors, requiring better insight in how this assessment is made. As a window of opportunity to intervene in this unexplained variation in practice in specific, and in the globally rising caesarean rate in general, our aim was to increase understanding of gynaecologists' decision-making during trial of labour.

STUDY DESIGN

We conducted a constructivist grounded theory study, interviewing Dutch gynaecologists. Data collection and analysis were performed concurrently. Initial convenience sampling shifted to theoretical sampling as the study progressed. Data collection continued until theoretical sufficiency was reached. We applied open and axial codes to transcripts of the interviews, and then assembled the axial codes into themes that built up to an emerging theoretical framework.

RESULTS

Nine gynaecologists were interviewed. Data indicated they continuously weighed the chance of a successful outcome of trial of labour against the likelihood of adversities. Patients' opinions, aspects of progress of labour and gynaecologists' personal stances regarding trial of labour played a role in the decision-making process; these factors are influenced by organisational affordances and culture. Variation in the assessment of individuals' chances of success and variable thresholds for a repeat caesarean added to the complexity of the decision-making.

CONCLUSION

This study pieced together patient-, delivery-, physician- and society-related factors that result in vitally important decisions during trial of labour after caesarean; it reveals the complexity as well as the repetitive patterns involved in this process. Exposing these factors offers opportunities to incorporate the decision-making process in targeted educational interventions, with the aim of modifying the underlying assumptions and concepts in order to reduce practice variation.

Frequency and evaluation of the perceptions towards caesarean section among pregnant women attending public hospitals in Pakistan and the implications

OBJECTIVES

There is increasing prevalence of caesarean sections (CS) worldwide; however, there are concerns about their rates in some countries, including potential fears among mothers. Consequently, we aimed to determine the frequency of CS, and explore patient's perception towards CS attending public hospitals in Pakistan, to provide future guidance.

METHODS

A two-phased study design (retrospective and cross sectional) was adopted. A retrospective study was conducted to assess the frequency of CS over one year among four public hospitals. A cross sectional study was subsequently conducted to determine patients' perception towards CS attending the four tertiary care public hospitals in Quetta city, Pakistan, which is where most births take place.

RESULTS

Overall prevalence of CS was 13.1% across the four hospitals. 728 patients were approached and 717 responded to the survey. Although 78.8% perceived CS as dangerous, influenced by education (p = 0.004), locality (p = 0.001) and employment status (p = 0.001), 74.5% of patients were in agreement that this is the best approach to save mother's and baby's lives if needed. 62% of respondents reported they would like to avoid CS if they could due to post-operative pain, and 58.9% preferred a normal delivery. There was also a significant association with education (p = 0.001) and locality (p = 0.001) where respondents considered normal vaginal delivery as painful.

CONCLUSION

The overall frequency of CS approximates to WHO recommendations, although there is appreciable variation among the four hospitals. When it comes to perception towards CS, women had limited information. There is a need to provide mothers with education during the antenatal period, especially those with limited education, to accept CS where needed.