Long-term risks and benefits associated with cesarean delivery for mother, baby, and subsequent pregnancies: Systematic review and meta-analysis

Second-trimester anthropometric estimators of cesarean section: the agreement between body roundness index, body mass index, body fat percentage, and waist circumference

PURPOSE

To explore the relationships between second-trimester anthropometric obesity indicators and cesarean section (CS).

METHODS

A retrospective study was conducted at West China Second University Hospital, utilizing electronic health records from 15,304 pregnant women who received routine prenatal care and delivered between January 2021 and June 2022. Second-trimester anthropometric indicators, including body roundness index (BRI), body mass index (BMI), body fat percentage (BFP), and waist circumference (WC), were measured using bioelectrical impedance analysis (BIA). Logistic regression models were employed to assess the associations between these indicators and CS risk, with additional subgroup analyses based on maternal age and fetal sex.

RESULTS

The mean maternal age was 30.13 years. After adjusting for covariates, BRI (OR 1.22, 95%CI 1.15-1.30), BMI (OR 1.07, 95%CI 1.05-1.08), BFP (OR 1.03, 95%CI 1.02-1.04), and WC (OR 1.02, 95%CI 1.01-1.03) were all significantly associated with CS. Stratified analyses based on maternal age and fetal sex further confirmed these independent associations.

CONCLUSION

Second-trimester BRI, BMI, BFP, and WC were all significantly associated with CS risk, with BRI potentially demonstrating the strongest independent correlation. An integrated approach incorporating BMI and WC is recommended for CS risk, particularly in time-sensitive or resource-limited settings. The effect of anthropometric changes during pregnancy on CS may be explored in the future.

Can Birth Hospital Explain Racial/Ethnic Differences in Cesarean Birth Among Low-Risk Births? An Analysis of California Data, 2007-2018

BACKGROUND

In the US, there is substantial variability in low-risk cesarean birth rate by hospitals and race/ethnicity. The contribution of inequitable hospital quality to disparities in low-risk cesarean births is uncertain. We examine the contribution of birth hospital to racial/ethnic disparities in low-risk cesarean births.

METHODS

We used vital records linked with maternal birth hospitalization data (California, 2007-18). We examined self-reported race/ethnicity and low-risk cesarean birth, i.e., nulliparous, term, singleton, and vertex (NTSV) births. Poisson regression models with a mixed effect for hospital and bootstrapped errors were used to compare racial/ethnic differences in cesarean prevalence, adjusted for maternal and hospital characteristics. We used G-computation to assess how the prevalence of cesarean section by racial/ethnic group would change if all births occurred at the same distribution of hospitals as births to White individuals.

RESULTS

Among 1,594,277 NTSV births at 212 hospitals, 26.9% were cesarean. After adjustment for hospital characteristics, risk ratios for cesarean birth ranged from 1.05 for foreign-born Hispanic (95% CI 1.02-1.09) to 1.28 for Black (95% CI 1.22-1.33) individuals, relative to White individuals. In the G-computation substitution, cesarean prevalence among NTSV births was reduced for some race/ethnicities and increased for others, ranging from 87 excess events (0.3% increase) in Black populations to 6473 avoided events (5.6% decrease) among US-born Hispanic populations.

CONCLUSIONS

Racial/ethnic disparities in cesarean prevalence among low-risk births in California are not explained by individual-level maternal or hospital characteristics.

Association between gestational age and severe maternal morbidity in preterm delivery: A nationwide population-based cohort study

OBJECTIVE

This study investigates whether early gestational age (GA) at delivery is associated with an increased risk for severe maternal morbidity (SMM) in women with preterm delivery.

METHODS

This retrospective national cohort study based on the Programme de Médicalisation des Systèmes d'Information database included mothers who gave birth between 22 and 37 weeks in metropolitan France in 2019 (in utero deaths and medical terminations of pregnancies were excluded). SMM was defined as a composite criterion consisting of the occurrence of at least one of the following events: death, severe preeclampsia, obstetric surgical complications, severe maternal diseases, and admission to the intensive care unit. The association between GA as a categorical variable (22-24 weeks, 24-26 weeks, 26-28 weeks, 28-32 weeks, 32-34 weeks, and >34 weeks) and SMM was assessed by performing multivariate logistic regressions. Interaction tests were performed to identify factors that might influence the association between SMM and GA.

RESULTS

Among the 42 821 women who gave birth prematurely in metropolitan France in 2019 (6.2% of all parturients), 6249 (1.6%) presented with an SMM event (mostly severe preeclampsia, at 74.3%). GA was associated with SMM (adjusted odds ratio ranging from 1.83 between 32 and 34 weeks to 2.67 between 22 and 24 weeks compared to the reference group of 34-37 weeks, P < 0.001). The evolution of the risk of SMM according to GA appeared linear.

CONCLUSION

Early GA at delivery was associated with an increased risk of SMM in women with preterm delivery. This study showed that SMM is also increased in cases of spontaneous prematurity and vaginal delivery.

Seeding microbes in defined early-life windows to fight diabetes

Establishment of the early-life gut microbiome, coinciding with the host development, predisposes to long-term disease risk if disrupted. Recently, Hill et al. precisely delineated a critical early-life window in humans and mice during which specific fungi and bacteria play indispensable roles in β-cell development, thereby regulating lifelong metabolic homeostasis.

Intervention using the Robson classification as a tool to reduce cesarean section rates in six public hospitals in Brazil

OBJECTIVES

To analyze the effectiveness and safety of a multifaceted intervention to reduce cesarean section (CS) rates.

METHODS

This interrupted time series study involved six public hospitals with pre-intervention CS rates>35 %. We collected monthly data on overall and Robson group CS rates of 37,031 women who gave birth at the six hospitals during 30 months in the pre-intervention (12 months, n=14,836 women), intervention (6 months, n=6,431 women), and post-intervention (12 months, n=15,764 women) study periods. The intervention bundle included six components: audit and feedback using the Robson classification, goal setting for overall CS rate, distribution of evidence-based guidelines, informative meetings with hospital coordinators, newsletters, and inter-hospital mentoring.

RESULTS

There were no significant changes in mean overall CS rates between the three periods. However, five of the six hospitals had a significant decrease in CS rates in at least one Robson group during the study period: groups 1 and 5a (2 hospitals), group 2a (1 hospital), groups 4 and 4a (1 hospital), and group 5b (1 hospital). There were no significant increases in adverse events (maternal and perinatal mortality, neonatal asphyxia) in any of the hospitals with reductions in CS rates.

CONCLUSIONS

The multifaceted intervention did not significantly reduce the overall CS rate in the participating hospitals. However, five of the six hospitals had significant reductions in CS rates in at least one Robson group, without increasing adverse maternal or perinatal outcomes.

Guidelines for antenatal and preoperative care in cesarean delivery: Enhanced Recovery After Surgery Society recommendations (part 1)-2025 update

BACKGROUND

Enhanced recovery after cesarean delivery protocols include evidence-based interventions designed to improve patient experience, pregnancy, and neonatal outcomes while reducing healthcare-related costs. This is the first update of the Enhanced Recovery After Surgery Society guidelines for antenatal and preoperative care before cesarean delivery after the original publication in 2018.

METHODS

Interventions were selected based on expert consensus using the Delphi method. An updated literature search was conducted in September 2024 using the Embase, PubMed, MEDLINE, EBSCO CINAHL (Cumulative Index of Nursing and Allied Health Literature), Scopus, and Web of Science databases. Targeted searches were performed by a medical librarian to identify relevant articles published since the 2018 Enhanced Recovery After Surgery Society guidelines publication, which evaluated each antenatal and preoperative enhanced recovery after cesarean delivery intervention, focusing on randomized clinical trials and large observational studies (≥800 patients) to maximize search feasibility and relevance. Following a review of the evidence, a consensus was reached regarding the quality of evidence and the strength of recommendation for each proposed intervention according to the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system.

RESULTS

The 6 recommended enhanced recovery after cesarean delivery interventions are (1) antenatal pathway patient education for scheduled caesarean delivery (evidence low to very low, recommendation strong); (2) multidisciplinary medical and surgical staff education regarding enhanced recovery after cesarean delivery support, intervention implementation, and measurement (evidence low, recommendation strong); (3) optimization of the medical care for pregnant patients with comorbid conditions, such as anemia, obesity, hypertension, prepregnancy and gestational diabetes, smoking (tobacco, cannabis, vaping), congenital heart disease, epilepsy, autoimmune disease, and asthma (evidence moderate, recommendation strong); (4) abdominal skin preparation with chlorhexidine gluconate impregnated cloth (evening before scheduled cesarean delivery) (evidence moderate; recommendation weak); (5) the duration of preoperative fasting based on the content intake (evidence low, recommendation weak); (6) the use of a preoperative, nonparticulate carbohydrate drink (evidence low-moderate, recommendation strong).

CONCLUSION

The first 3 recommendations are for use in the antenatal period (10-38 weeks of gestation), which allow for the optimization of patient comorbidities, whereas the remaining 3 recommendations are for preoperative interventions (skin preparation, preoperative fasting directives, and preoperative carbohydrate supplementation). Educational tools for cesarean delivery with well-designed shared decision-making focus on comorbidity management should be developed. These management tasks are viewed as routine care; however, the measurable success and impact have clinical variance. The enhanced recovery after cesarean delivery goal for patients who are undergoing a scheduled caesarean delivery is to maximize the quality of the pregnant patient's recovery and the fetal-neonatal outcome.

Prediction models for intrapartum fetal hypoxia: A systematic review

BACKGROUND

Intrapartum fetal hypoxia (IFH) occurs infrequently and many cases occur unexpectedly, highlighting the importance of identifying at-risk fetuses to prevent hypoxic injury during birth.

OBJECTIVES

This systematic review aims to evaluate existing prediction models for IFH and ascertain the predictor variables that were incorporated into most models.

SEARCH STRATEGY

We searched MEDLINE and EMBASE databases from inception to December 2023 for synonyms of fetal distress, operative birth and neonatal asphyxia, with a filter for prediction models.

SELECTION CRITERIA

Prediction models for IFH were included. IFH was defined as evidence of hypoxia or operative intervention for suspected fetal distress.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted information on study design, outcome definition and validation. We evaluated study quality using the PROBAST tool. The number of models in which each predictor variable significantly contributed to the risk of IFH was quantified.

MAIN RESULTS

From 874 articles, 23 publications reported on 41 eligible prediction models. 32 models reported on model development only, while seven models across three studies included both development and internal validation. Of these, two models were also externally validated and refit to the validation data, but investigated fetuses with antenatally-suspected growth restriction, limiting generalisability. Frequently reported predictor variables included parity (13 studies), cerebroplacental ratio (10 studies) and oxytocin use (6 studies).

CONCLUSIONS

No prediction models for IFH applicable to the general population are currently ready for clinical application. External validation of existing models or development of new, reliable models applicable to all pregnant women is needed.

Multi-level factors influencing caesarean section preferences among women in low- and middle- income countries: A systematic review

BACKGROUND

Women's preferences regarding caesarean section (CS) are a significant contributing factor to the increasing and widely varying rates of this procedure across countries and regions. This trend is particularly pronounced in low- and middle-income countries (LMICs), where both overuse and underuse of CS can pose significant health risks. Understanding the multi-level factors influencing CS preferences is essential for promoting the appropriate use of this procedure and ensuring optimal maternal and neonatal health outcomes.

AIM

To systematically review literature examining multi-level factors influencing CS preferences among women in LMICs through ecological systems and exploring the prevalence of CS preferences.

METHODS

A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). Six electronic databases were searched: Academic Search Ultimate (EBSCO), MEDLINE (EBSCO), Nursing & Allied Health Premium (ProQuest), PubMed, ScienceDirect, and Scopus. The search included studies published from January 2014 to August 2024. The quality of each article was assessed using the Joanna Briggs Institute's critical appraisal tool.

FINDINGS

A total of 17 studies were included in this review. The proportion of CS preferences varied significantly, ranging from 8.8 % to 58 % in LMICs. The multi-level factors influencing CS preferences were summarized across four levels, based on ecological systems: microsystem level (sociodemographic factors, reproductive factors, psychological factors, and literacy-related factors), mesosystem level (healthcare influence, family and relative influence), exosystem level (healthcare environment and social media influence), and macrosystem level (socio-cultural factors).

CONCLUSION

Factors within the microsystem, mesosystem, and macrosystem levels displayed the substantial influence aligned with ecological systems. To reduce unnecessary CS, future research should comprehensively explore multi-level factors. Policymakers should implement prominent factors across the system.

Prevalence of successful vaginal birth after caesarean section and its associated factors among women delivered in the university of Gondar comprehensive specialized referral hospital, Northwest Ethiopia

INTRODUCTION

Caesarean section (CS) is an essential, life-saving surgical intervention used to address obstetric complications. Nonetheless, its excessive use has raised global concerns. In low- and middle-income countries (LMICs) like Ethiopia, the challenges of repeat CS and the limited success of VBAC are particularly problematic. Despite this, there is a significant gap in knowledge regarding vaginal births following a cesarean delivery in Ethiopia, especially in the specific study area.

OBJECTIVES

To determine the prevalence and associated factors of successful vaginal birth after one caesarean section in the University of Gondar Comprehensive Specialized Hospital.

METHODS

Institutional based cross-sectional study was conducted among 409 women who were randomly selected and had one previous caesarean section delivery and underwent a trial of labor. Data were analyzed and computed using Stata version 14 Software. Multivariable logistic regression analysis was performed to identify the factors associated with successful vaginal birth after caesarean section. A crude and adjusted odds ratio with a 95% confidence interval was used to interpret the results. A P value of < 0.05 indicated statistically significant results.

RESULTS

Of 385 completed charts reviewed, the success rate of vaginal birth after caesarean section was 38.2%,( 95%CI;33.3-43.1%).The factors associated with successful vaginal birth after cesarean section were: prior history of spontaneous vaginal delivery at any point time (AOR = 1.84,95% CI;1.02-3.33), prior history of successful vaginal birth after previous cesarean section (AOR = 2.12, 95%CI;0.97-4.64), no history of stillbirth (AOR = 1.78, 95% CI;1.03-3.07), cervical dilation on admission ≥ 3 cm (AOR = 2.22, 95% CI; 1.14-4.35), station on admission ≥ 0(AOR = 1.94, 95% CI; 1.12-3.37), and Antenatal care follow-up (AOR = 2.48,95%CI;1.26-4.88).

CONCLUSIONS

Our study demonstrated a low prevalence of successful VBAC, highlighting that factors such as a prior history of VBAC, spontaneous vaginal delivery at any time, cervical dilatation at admission, history of stillbirth, ANC follow-up, and fetal station at admission are significantly associated with positive outcomes. This evidence clearly indicates that targeted, evidence-based interventions are urgently needed to improve VBAC success rates. Therefore; the Federal Ministry of Health (FMOH), policymakers, and relevant stakeholders should collaborate to develop, implement, and continuously review comprehensive policies and guidelines that support these targeted interventions.

Variations in caesarean section outcome reporting in low- and middle-income countries: A systematic review

OBJECTIVE

To explore the variation and quality of the outcomes reported using descriptive analysis and interactive network visualisation of CS outcomes of comparative studies conducted in low-and middle-income settings.

STUDY DESIGN

Systematic review of comparative studies to reduce caesarean section complications in low- and middle-income countries and outcome assessment using the modified Harman questionnaire, assessing for the presence of a clear primary outcome, an explanation of how the outcomes were analysed and a description of the methods used to enhance the quality of these measures.

RESULTS

102 comparative studies were included. Studies of interventions to improve maternal and perinatal outcomes after caesarean section reported 466 outcomes with 15 % of these outcomes appearing only once across the outcomes reviewed (n = 73). The most common outcome categories reported were maternal death, disability and bleeding. Psychological and injury outcomes were less commonly reported. The overall quality of outcome reporting varied between studies but was particularly low for reporting on methods to improve outcome measures. Very few outcomes scored a maximum of three points when assessed according to the modified Harman score, with only 15 of the primary outcomes (16 %) achieving 3 points and 40 of the secondary outcomes (11 %) achieving 3 points. The median quality of reporting was 2 (range 0, 3) for all outcomes, for a maximum score of 3. Quality of outcome reporting was associated with the type of outcome (primary or secondary), the region in which the study was conducted in, and journal characteristics such as impact factor and journal type.

CONCLUSIONS

There was wide variability in both the outcomes reported and the frequency in which they were reported. Overall, very few primary and secondary outcomes achieved the maximum score of three on the modified Harman score, highlighting the need for a core outcome set for caesarean section intervention trials to improve the consistency and synergy of future research outcome definition, measurement and synthesis.

TRIAL REGISTRATION

The protocol was registered (PROSPERO CRD42022353939).

Optimizing maternal recovery: insights into enhanced recovery after Cesarean delivery

Enhanced recovery after surgery (ERAS) is an innovative perioperative management approach designed to shorten the recovery time, improve patient safety and quality of care, and enhance overall satisfaction. Successful implementation of ERAS requires active collaboration between healthcare providers and patients to facilitate a timely return to daily activities. The ERAS protocol, originally developed for colorectal surgery, has gradually been expanded and adapted to other major surgeries, and more recently, to Cesarean deliveries. Enhanced recovery after Cesarean delivery (ERAC) presents unique challenges due to its distinct patient population, comprising relatively young women. Its dual focus on maternal recovery and neonatal well-being sets it apart from conventional ERAS protocols. Several components of the ERAC protocol have been adapted from the ERAS recommendations; however, supporting evidence remains limited. This review examines the current ERAC protocol and considers the types of research needed to establish an evidence-based ERAC protocol in the future.

Racial inequities in cesarean use among high- and low-risk deliveries: An analysis of childbirth hospitalizations in New Jersey from 2000 to 2015

OBJECTIVE

To examine racial inequities in low-risk and high-risk (or "medically appropriate") cesarean delivery rates in New Jersey during the era surrounding the United States cesarean surge and peak.

STUDY SETTING AND DESIGN

This retrospective repeated cross-sectional study examined the universe of childbirth hospitalizations in New Jersey from January 1, 2000 through September 30, 2015. We estimate the likelihood of cesarean delivery by maternal race and ethnicity, with mixed-level logistic regression models, stratified by cesarean risk level designated by the Society of Maternal Fetal Medicine (SMFM).

DATA SOURCES AND ANALYTIC SAMPLE

We used all-payer hospital discharge data from the Healthcare Cost and Utilization Project's State Inpatient Discharge Database and linked this data to the American Hospital Association Annual Survey. ZIP-code Tabulation Area (ZCTA)-level racialized economic segregation index data were from the 2007-2011 American Community Survey. We identified 1,604,976 statewide childbirth hospitalizations using International Classification of Diseases-9-CM (ICD-9) diagnosis and procedure codes and Diagnosis-Related Group codes, and created an indicator of cesarean delivery using ICD-9 codes.

PRINCIPAL FINDINGS

Among low-risk deliveries, Black patients, particularly those in the age group of 35-39 years, had higher predicted probabilities of giving birth via cesarean than White people in the same age categories (Black-adjusted predicted probability = 24.0%; vs. White-adjusted predicted probability = 17.3%). Among high-risk deliveries, Black patients aged 35 to 39 years had a lower predicted probability (by 2.7 percentage points) of giving birth via cesarean compared with their White counterparts.

CONCLUSIONS

This study uncovered a lack of medically appropriate cesarean delivery for Black patients, with low-risk Black patients at higher odds of cesarean delivery and high-risk Black patients at lower odds of cesarean than their White counterparts. The significant Black-White inequities highlight the need to address misalignment of evidence-based cesarean delivery practice in the efforts to improve maternal health equity. Quality metrics that track whether cesareans are provided when medically needed may contribute to clinical and policy efforts to prevent disproportionate maternal morbidity and mortality among Black patients.

Unintended Upper Uterine Wall Extensions at the Time of Cesarean Delivery: Risk Factors and Associated Adverse Maternal and Neonatal Outcomes

This study aims to estimate the frequency of unintended upper uterine wall extensions during cesarean delivery (CD) and identify associated risk factors and adverse outcomes.A multicenter retrospective cohort study was conducted, including patients who underwent CD between 2005 and 2021. Demographic factors, obstetric history, CD indications, delivery and surgical characteristics, adverse maternal and neonatal outcomes were compared between those with unintended upper uterine wall extensions during CD and those without extensions. Crude and adjusted estimates (odds ratios [ORs] and 95% confidence intervals [CIs]) were used.Among 30,517 patients meeting inclusion criteria, 117 (0.4%) had an unintended upper uterine wall extension. In univariate analysis, upper uterine wall extensions were associated with higher rates of intrapartum CD, second-stage CD, unplanned or emergency CD, CD following failed vacuum delivery or trial of labor after CD, chorioamnionitis, prolonged labor, increased vaginal exams, lower fetal head station, and higher birth weight. During surgery, higher rates of general anesthesia, significant intraperitoneal adhesion, fetal malpresentation, and fetal extraction by the leg were observed. Multivariable analysis identified fetal extraction not by head (adjusted OR [aOR]: 9.17, 95% CI: 5.35-15.73), vertex fetal presentation (aOR: 3.65, 95% CI: 1.81-7.35), second-stage CD (aOR: 3.07, 95% CI: 1.24-7.59), and trial of labor after cesarean (aOR: 2.04, 95% CI: 1.08-3.84) as significant risk factors for unintended upper uterine wall extensions. Additionally, upper uterine wall extensions were associated with higher rates of maternal and neonatal complications, including longer operating times, excessive bleeding, postpartum hemorrhage, intraperitoneal drainage, blood product transfusion, puerperal fever, paralytic ileus, Apgar score < 7 at 1 and 5 minutes, and fetal intracranial hemorrhage.Our study identifies risk factors for unintended upper uterine wall extensions during CD. While these extensions are infrequent, their occurrence is associated with increased maternal and neonatal morbidity. · Unintended upper uterine wall extensions occur in 0.4% of cesarean deliveries.. · Significant risk factors include fetal extraction not by head and second-stage CD.. · Extensions are associated with increased maternal complications like excessive bleeding and prolonged surgery.. · Neonatal complications include lower Apgar scores and intracranial hemorrhage.. · Awareness of these risks is critical for improving cesarean delivery outcomes..

Maternal and Infant Morbidity and Mortality in Relation to Delivery Mode in a Large U.S. Health Care Claims Database in 2019 and 2020

This study aimed to provide contemporary data on maternal and infant outcomes after delivery to better understand risks of cesarean section (CS).Data for deliveries in 2019 and 2020 were obtained from a large U.S. commercial health care claims database. Maternal morbidity measures included 20 severe maternal morbidity (SMM) outcomes and seven additional obstetric and mental health outcomes. Infant morbidity measures included eight outcomes related to respiratory health, digestive health, atopic dermatitis, and birth trauma. Outcome prevalence was ascertained at 42 days (maternal only) and 360 days after delivery. Logistic regression was used to estimate the odds ratio (OR) and 95% confidence interval (CI) for prevalence adjusted for risk factors for delivery mode and each outcome. Analyses were conducted for 2019 and 2020 to assess the influence of the coronavirus disease 2019 pandemic.A total of 436,991 deliveries were identified (145,061 CS; 291,930 vaginal). The prevalence of SMM was 3.3% at 42 days and 4.1% at 360 days. The covariate-adjusted odds of SMM were higher among CS than vaginal deliveries at 42 days (OR: 2.0, 95% CI: 1.9, 2.1) and 360 days (OR: 1.7, 95% CI: 1.7, 1.8). There were 226,983 infants available for analysis of outcomes at 360 days. Most adverse infant outcomes were more prevalent at 360 days among CS than vaginal deliveries, and the covariate-adjusted odds of any adverse infant outcome at 360 days were higher among CS than vaginal deliveries (OR: 1.2; 95% CI: 1.1, 1.3). Respiratory morbidity was most affected by delivery mode. Maternal and infant mortality up to 360 days was rare. Similar trends were observed in the 2019 and 2020 cohorts.This observational study, performed using recent data obtained from a large U.S. commercial claims database, provides contemporary evidence of risks to mothers and infants of CS relative to vaginal delivery. · In a large commercially insured population, one-third of deliveries were by CS.. · Most maternal and infant outcomes were more prevalent among CS deliveries than vaginal deliveries.. · Respiratory conditions were most strongly related to delivery mode among infants.. · Maternal and infant mortality up to 360 days was rare in this population.. · Results were similar in 2019 and 2020, indicating a small impact of the COVID-19 pandemic..

Health outcomes up to 5 years in children born as a second child after a previous caesarean section in a first pregnancy: a Swedish population-based register study between 1999 and 2015

OBJECTIVE

To explore health outcomes up to 5 years of age, according to mode of birth, in a large cohort of Swedish children who were born as a second child to women who had a caesarean section (CS) in their first pregnancy.

DESIGN

Retrospective population-based register study.

POPULATION

All children (n=94 498) who were born as a second child (or children in cases of twins or higher-order multiple births) during 1999-2015 in Sweden in women who had a CS first birth. The children were followed up to 5 years of age. For inclusion, both births must have occurred in Sweden.

METHODS

A nationwide cohort study using follow-up data up to 5 years of age. Maternal factors, including age, smoking, diabetes, obesity (body mass index ≥30), mental illness, pre-eclampsia, education, income, country of birth and the neonatal factors of being a singleton and prematurity (up to week 36+6) were adjusted for in regression models.

MAIN OUTCOME MEASURES

Developmental problems, asthma, allergy, hospital care and death within 5 years of age.

RESULTS

A total of 94 498 children were included in the study. Risk for developmental problems, asthma and allergy was increased after repeat CS but not after vaginal birth. The need for hospital care was increased in all other birth modes compared with spontaneous vaginal birth. The risk of death within 5 years increased after instrumental vaginal birth and emergency repeat CS.

CONCLUSIONS

All repeat CS compared with spontaneous vaginal birth was related to increased risks for developmental problems, asthma, allergy and hospital stay, and emergency repeat CS was associated with an increased risk of death within 5 years. The results of the present study support vaginal birth as the optimal mode of birth after previous CS for longer-term child health outcomes.

Prevalence and factors associated with caesarean delivery on maternal request and its effect on maternal and foetal outcomes in selected tertiary care hospital, Odisha, Southeastern India

Background

Caesarean delivery is now predominantly performed in response to the mother's request, often without medical indications, commonly referred to as caesarean delivery on maternal request (CDMR). The rise in CDMR has become a significant issue in maternal and newborn health. We aimed to explore the factors influencing CDMR and its effect on maternal and foetal outcomes.

Methods

We used a prospective cohort design approach to recruit 413 participants and a consecutive sampling technique to select the participants. Those who fulfilled the inclusion criteria were taken during the six-month data collection period from October 2023 to March 2024. We used a structured interview method for data collection. We utilised inferential statistics, such as Fisher exact and χ2 tests for univariate analysis and a logistic regression model in the multivariate analysis, to investigate the relationship between factors and mode of delivery.

Results

The multivariate regression analysis revealed that the CDMR rate was higher among the women who preferred caesarean delivery before giving birth (odds ratio (OR) = 6.295; 95% confidence interval (CI) = 1.468-26.995, P < 0.05). Additionally, women with a history of previous caesarean delivery were more inclined to choose CDMR in the subsequent pregnancy (OR = 25.642; 95% CI = 1.199-548.221, P < 0.05). The likelihood of experiencing wound pain (OR = 42.374; 95% CI = 14.612-122.887, P < 0.05), encountering breastfeeding difficulties (OR = 11.469; 95% CI = 2.91-45.2, P < 0.05), and neonatal intensive care unit admissions (OR = 0.268; 95% CI = 0.076-0.95, P < 0.05) was significantly higher in CDMR compared to normal vaginal delivery.

Conclusions

The prevalence of CDMR was 21.35%, which was relatively higher than the World Health Organization's recommended guidelines. The previous mode of delivery and maternal preference for caesarean birth were the factors that influenced CDMR. It is necessary to make childbirth readiness counselling a regular practice to assist women in selecting the best delivery method.

Mutual Interactions Between Microbiota and the Human Immune System During the First 1000 Days of Life

The development of the human immune system starts during the fetal period in a largely, but probably not completely, sterile environment. During and after birth, the immune system is exposed to an increasingly complex microbiota. The first microbiota encountered during passage through the birth canal colonize the infant gut and induce the tolerance of the immune system. Transplacentally derived maternal IgG as well as IgA from breast milk protect the infant from infections during the first 100 days, during which the immune system further develops and immunological memory is formed. The Weaning and introduction of solid food expose the immune system to novel (food) antigens and allow for other microbiota to colonize. The cells and molecules involved in the mutual and intricate interactions between microbiota and the developing immune system are now beginning to be recognized. These include bacterial components such as polysaccharide A from Bacteroides fragilis, as well as bacterial metabolites such as the short-chain fatty acid butyrate, indole-3-aldehyde, and indole-3-propionic acid. All these, and probably more, bacterial metabolites have specific immunoregulatory functions which shape the development of the human immune system during the first 1000 days of life.

Mode of delivery among preterm twins and offspring health, a retrospective cohort study

Although cesarean delivery (CD) has been linked to long-term health risks in singleton infants, the impact of delivery mode on long-term health outcomes in preterm twins remains underexplored. A retrospective cohort study was conducted at a tertiary medical center in Israel from 1991 to 2021, comparing preterm twins vaginally delivered (VD) versus cesarean section, excluding cases with congenital malformations or perinatal deaths. Kaplan-Meier survival curves were used to compare the cumulative incidence, and Cox proportional hazards models were applied to adjust for potential confounders. Four thousand twenty-eight preterm twin offspring were included, with 1703 (42%) VD and 2325 (58%) by CD. Preterm twins delivered by CD had a higher incidence of respiratory morbidities (42% vs. 35% in the VD group, p < 0.001), with an adjusted Hazard Ratio (aHR) of 1.15 (95%CI 1.02-1.30). CD was associated with an increased incidence of neurologic morbidities (22% vs. 17% in the VD group, p < 0.001), with an aHR of 1.16 (95%CI 1.02-1.36). CD was associated with a higher incidence of infectious morbidities (69% vs. 62%, p < 0.001), with an aHR of 1.10 (95%CI 1.01-1.21). Gastrointestinal morbidities were more pronounced in the CD group (29% vs. 25%, p < 0.001), but the multivariable analysis did not reach significance (aHR = 1.10, 95%CI 0.95-1.27). Sub-analyses of elective-uncomplicated deliveries showed consistent results for most morbidities.

CONCLUSIONS

Cesarean delivery in preterm twins is associated with long-term respiratory, neurologic, infectious and gastrointestinal morbidities of the offspring. The findings suggest the potential benefits of vaginal over cesarean deliveries regarding offspring long-term health complications.

WHAT IS KNOWN

• Studies on singleton births show that cesarean delivery may increase respiratory, infectious, neurological and gastrointestinal outcomes remains inconsistent across term and preterm deliveries. • Cesarean delivery rates remain high despite recommendations to reduce their frequency, yet data on the association between cesarean delivery and morbidity among twins, particularly in small for gestational age twins, is limited.

WHAT IS NEW

• This is the first large-scale study demonstrating that cesarean delivery in preterm twins increases the odds of respiratory, neurologic, infectious and gastrointestinal long-term morbidities up to age 18. • The higher rates of respiratory, neurologic, infectious, and gastrointestinal complications persist even in uncomplicated cesarean deliveries.

Prepartum working conditions predict mental health symptoms 14 months postpartum in first-time mothers and their partners - results of the prospective cohort study "DREAM"

BACKGROUND

During the vulnerable transition to parenthood, (expectant) parents may be particularly susceptible to the negative effects of adverse working conditions. However, research on the influence of work-related factors on peripartum mental health issues is scarce. This study aims to enhance our understanding of work-related risk factors for the adjustment of parents in the transition to parenthood by investigating the role of prepartum precarious employment, abusive supervision, job insecurity, and job demand on postpartum mental health symptoms in first-time mothers and their partners.

METHODS

In the prospective-longitudinal cohort study "DREAM", N = 1,259 mothers and N = 811 male and female partners were asked about their working conditions during pregnancy and their mental health 14 months postpartum. We conducted several hierarchical multiple regression analyses with prepartum precarious employment, abusive supervision, job insecurity, and job demand (the latter three in joint regression analyses) as predictors of postpartum symptoms of depression, somatization, obsessive-compulsiveness, anxiety, and anger/hostility. In Model 1 we controlled for sociodemographic variables, and in Model 2 we also controlled for pre-existing symptoms of the respective mental health variable during pregnancy. Separate analyses were calculated for mothers and partners, and each mental health outcome.

RESULTS

Multiple regression analyses revealed that prepartum precarious employment and abusive supervision predicted mothers' and partners' mental health symptoms 14 months postpartum even after controlling for pre-existing symptoms. Prepartum job insecurity and job demand also predicted mental health symptoms 14 months postpartum but were no longer significant predictors in most models after controlling for pre-existing mental health symptoms. There were only minor differences regarding the considered mental health outcomes and between mothers' and partners' results.

CONCLUSIONS

Our study demonstrates that adverse working conditions are important risk factors for the adjustment of parents in the transition to parenthood, requiring more attention from research and practice. Precarious employment and abusive supervision appear to be particularly important factors affecting new parents' mental health. Future research should investigate the mechanisms behind these variables, including comparisons between mothers and their partners, and the role of stress-related biomarkers. Additionally, developing screening methods for clinical use to facilitate targeted preventive interventions is essential.

Preference of mode of delivery and associated factors among mothers in East Africa: systematic review and meta-analysis

INTRODUCTION

Preference of mode of delivery refers to the expectant mother's personal choice or preference for the method by which she would like to have her baby delivered. Although there are many fragmented primary studies on the preference of mode of delivery among women in East Africa, the pooled preference rate is unknown. In addition, those studies disagreed on reporting the associated factors. Therefore, this study was intended to determine the pooled preference for mode of delivery and its associated factors among women in East Africa.

METHOD

We searched studies using PubMed, Scopus, Embase, Science Direct, and Google Scholar that were published between March 01/2014 and March 31/2024. This study used the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. The quality of studies was evaluated using the modified Newcastle-Ottawa quality assessment tool. The data were extracted by two authors independently using Microsoft Excel and analyzed by Stata version 17. A random effects model was applied to calculate the pooled preference for mode of delivery and its associated factors. The PROSPERO registration number for the review was CRD42024541921.

RESULTS

A total of 14 studies comprising 47,561 participants were involved in this meta-analysis. The pooled preference of vaginal delivery and cesarean delivery were 75% ((95% C.I = 67 - 83%) and 25% (95% C.I = 17 - 34%), [Formula: see text]respectively. This study showed that ANC-follow (OR= 1.11; 95% CI=0.67-1.82), previous intrapartum satisfaction (OR= 2.69; 95% CI = 0.53-13.64), place of residence (OR= 1.10; 95% CI = 0.86-1.42), occupation (P=0.000; OR= 0.97; 95% CI=0.67-1.42), planned pregnancy (OR= 1.89; 95% CI=1.26-2.82), previous history of spontaneous abortion (OR= 2.30; 95% CI=0.71-7.44), current pregnancy related problem (OR= 3.86; 95% CI=1.37-10.84), discussion with a partner (OR= 0.67; 95% CI=0.35-1.27), types of the hospital (OR= 1.13; 95% CI = 0.65-1.94) were significant factors associated with preference of mode of delivery.

CONCLUSION

The preference for vaginal delivery was higher than for cesarean delivery. Factors such as antenatal care follow-up, previous intrapartum satisfaction, place of residence, occupation, planned pregnancy, prior history of spontaneous abortion, maternal education, current pregnancy-related problems, discussion with partner, and types of hospital were significantly associated. The findings of this study imply a multifaceted approach is required.

Maternal demography, clinical characteristics, & outcomes at an obstetric intensive care unit of a tertiary-care teaching maternity hospital in the Kashmir Valley

Background & objectives Obstetric patients often need admission to intensive care units (ICUs). The data on these patients are scarce and heterogeneous. We studied the profile of obstetric patients admitted to our ICU. Methods The records of obstetric patients admitted to the ICU at the Government Lalla Ded Hospital, Srinagar, Jammu and Kashmir, India, dedicated to obstetrics and gynaecology patients, were analysed retrospectively from March 2022 to February 2023.This included demography, co-morbidities, pre-admission surgeries/procedures, clinical characteristics, and outcomes (death/discharge/transfer). Results Out of 525 obstetric ICU patients, the majority were admitted for obstetric causes (94.66%) and after surgery (84.38%), mostly (66.59%) after caesarean section (CS). Hypertension (35.23%) and anaemia (32.76%) were the most common co-morbidities. The majority were admitted for hypertensive disorders of pregnancy (HDP; 34.47%) or post-partum haemorrhage (PPH; 24.71%) or complications. Only two per cent of CS and one per cent of vaginal delivery (VD) patients needed ICU admission. The maternal ICU mortality rate was 6.53 per cent (0.15% of total deliveries). Only 6.66 per cent needed transfer to non-obstetric or multi-specialty care. Admission with heart disease [Hazard ratio; HR=8.26, 95% Confidence interval (CI)=0.01-67.17,P<0.05], after intra-uterine foetal death (IUFD; HR=5.17, 95% CI=1-26.75, P<0.05), or after laparotomy for ectopic pregnancy (EP; HR=50.2, CI=1.43-1766.87, P<0.05) and need for invasive mechanical ventilation (IMV; HR=35.5, CI=3.14-401.75, P<0.05) or inotropic support (IS; HR=12.06, CI=1.96-74.19, P<0.05) increased while admission after VD (HR=0.10, CI=0.01-0.73, P<0.05) decreased mortality risk. Interpretation & conclusions HDP and PPH were the most common maternal presentations in obstetric ICUs. Maternal mortality was low. Patients with heart diseases, IMV/IS requirement, and those admitted after IUFD or laparotomy for EP had increased, while patients admitted after VD had decreased mortality risk in the ICU.

Relationship between nurse staffing during labor and cesarean birth rates in U.S. hospitals

BACKGROUND

Cesarean birth increases risk of maternal morbidity and mortality.

PURPOSE

Examine the relationship between labor and delivery staffing and hospital cesarean and vaginal birth after cesarean (VBAC) rates.

METHODS

Survey of U.S. labor nurses in 2018 and 2019 on adherence to AWHONN nurse staffing standards with data linked to American Hospital Association Survey data, patient discharge data, and cesarean birth and VBAC rates.

FINDINGS

In total, 2,786 nurses from 193 hospitals in 23 states were included. Mean cesarean rate was 27.3% (SD 5.9, range 11.7%-47.2%); median VBAC rate 11.1% (IQR 1.78%-20.2%; range 0%-40.1%). There was relatively high adherence to staffing standards (mean, 3.12 of possible 1-4 score). After adjusting for hospital characteristics, nurse staffing was an independent predictor of hospital-level cesarean and VBAC rates (IRR 0.89, 95% CI 0.84-0.95 and IRR 1.58, 95% CI 1.25-1.99, respectively).

DISCUSSION

Better nurse staffing predicted lower cesarean birth rates and higher VBAC rates.

CONCLUSION

Hospitals should be accountable for providing adequate nurse staffing during childbirth.

Cesarean Section, Childhood Health, and Schooling: Quasi-Experimental Evidence From Denmark, Norway and Sweden

Despite being one of the most common surgical procedures in industrialized countries, there is limited causal evidence on the long-term consequences of Cesarean section (CS). We study the impacts of CS on health during ages 1-12 years and human capital outcomes at age 16 years, using exogenous variation in the probability of receiving a CS for breech births at term-a group with high CS risk. We use administrative data from Denmark, Norway, and Sweden to show that preventing complicated vaginal births benefits health at birth and reduces the number of all-cause hospital nights during childhood. Our findings for childhood diagnoses for asthma, allergies, diabetes mellitus type 1, and school outcomes are imprecise and do thus not lend strong support for prominent hypotheses on CS causing long-term immune dysfunction disorders and, thereby, worse human capital outcomes.

Preterm Cesarean Delivery and Safety of Subsequent Delivery: Risk of Uterine Rupture and Other Maternal and Neonatal Outcomes-Multicenter Retrospective Cohort Study

Background/Objectives: The safety of trial of labor after cesarean (TOLAC) following prior preterm low-segment transverse cesarean delivery (pCD) was compared to that following term low-segment transverse cesarean delivery (tCD) in terms of the rate of uterine rupture (UR) and adverse maternal and neonatal outcomes. Methods: A multicenter retrospective cohort study evaluated the delivery outcomes among women with a prior primary pCD and those with a primary tCD. The primary outcome was UR, defined as a full-thickness uterine wall defect. The secondary outcomes included maternal and neonatal morbidities. Chi-square, Fisher's exact test, and Mann-Whitney tests, with the results reported as means ± SDs or medians + interquartile ranges (IQRs), were employed. Results: The cohort comprised 5340 women, including 186 with a prior pCD and 5154 with a prior tCD. The median gestational age at pCD was 28 weeks, compared to 39 weeks for tCD. Women in the pCD group had higher rates of hypertensive disorders (20.4% vs. 2.5%; p < 0.001). No significant difference in UR incidence was observed at subsequent delivery (0% vs. 0.6%; p = 0.3). However, the pCD group had higher rates of subsequent preterm delivery (19.9% vs. 4.7%; p < 0.01) and vaginal birth after cesarean (VBAC) success (86.1% vs. 77.3%; p = 0.015). Adjusted analyses showed no significant association between pCD and composite adverse neonatal outcomes (OR = 0.796, 95% CI [0.487-1.301]; p = 0.363). Conclusions: This study underscores the safety of trial of labor after a primary preterm cesarean delivery, indicating no increased risk of uterine rupture compared to term cesarean deliveries. Care should be directed toward lowering subsequent preterm delivery and its associated risks.

Immediate Changes in the Elasticity of Tissue and the Pain Pressure Threshold in Cesarean Scar Tissue After a Vacuum Intervention: An Open Clinical Trial

Background/Objectives: Cesarean section (C-section) scars are commonly linked to reduced tissue elasticity and increased pain due to adhesion formation. Addressing these concerns is essential to improving patient comfort and functional outcomes. This study aimed to assess the immediate effects of vacuum therapy on skin elasticity and pain sensitivity in C-section scar tissue. Methods: Thirty-one women with C-section scars older than six months and less than two years participated in an open clinical trial. The skin elasticity was assessed using the Adheremeter, and the pain sensitivity was measured through the Pressure Pain Threshold (PPT) using algometry. The intervention consisted of a 15 min vacuum therapy session using the AeroFlow® device that targeted the scar and surrounding areas. Results: The vacuum therapy intervention resulted in significant improvements in the skin elasticity at multiple assessment points, particularly in regions with fascial restrictions (p < 0.05). Concurrently, the PPT values decreased, indicating a reduction in pain sensitivity around the scar area (p < 0.05). These findings suggest that vacuum therapy may enhance tissue flexibility and alleviate pain in adherent C-section scars. Conclusions: This study demonstrated the potential of vacuum therapy as an effective intervention to improve skin elasticity and reduce pain sensitivity in C-section scars. The Adheremeter-based assessment provided valuable insights into the biomechanical properties of scar tissue and supported its use in scar management protocols. This approach offers a promising, non-invasive strategy for personalized scar treatment, ultimately aiming to enhance patient outcomes and quality of life.

Factors affecting the success of labor in twin pregnancies: A retrospective study on maternal and fetal outcomes

OBJECTIVE

To explore the relevant factors associated with successful labor in twin pregnancies and investigate maternal and fetal outcomes in the group with failed labor.

METHODS

A retrospective analysis was conducted on twin pregnancies that underwent labor in our hospital from July 2016 to June 2023. A total of 519 cases were divided into two groups: the successful labor group (450 cases with vaginal delivery of both fetuses) and the failed labor group (69 cases with cesarean delivery of one or two fetuses). The relevant factors of the labor, as well as the maternal and fetal outcomes, were analyzed between these two groups.

RESULTS

Multivariate analysis indicated that advanced maternal age (odds ratio [OR] 1.13, 95% confidence interval [CI] 1.05-1.22), high pre-delivery body mass index (OR 1.11, 95% CI 1.04-1.19), and vertex/transverse twins (OR 3.75, 95% CI 1.35-10.40) were risk factors for the failure of vaginal labor. Multiparity (OR 0.15, 95% CI 0.08-0.29), premature birth (OR 0.43, 95% CI 0.24-0.78), and neuraxial analgesia (OR 0.37, 95% CI 0.20-0.72) were protective factors for the failure of delivery. There were no statistically significant differences (P > 0.05) in decreased hemoglobin and neonatal outcomes between the two groups. The postpartum hospitalization time in the successful labor group was shorter than that in the failed labor group (P < 0.05).

CONCLUSIONS

Labor in twin pregnancies is generally safe. Factors such as multiparity, previous premature birth, and neuraxial analgesia can significantly enhance the likelihood of a successful vaginal delivery.

Development and validation of a risk prediction model for caesarean delivery among multiparous women

While caesarean risk prediction models exist for nulliparous and high-risk pregnancies, there is a lack of models that predict the risk of caesarean delivery among multiparous women. This study aimed to develop and validate a risk prediction model for caesarean delivery and assess its clinical utility among multiparous women. Using data from 460 participants, a prediction model was developed to predict the risk of caesarean delivery. The model performance was evaluated using the area under the receiver operating characteristic curve (AUC) and calibration plot, and the model was internally validated using bootstrapping technique. A simplified risk score was calculated, and a nomogram was developed for the individual caesarean delivery risk guide. Additionally, a decision curve analysis was performed to assess the clinical utility of the model. The final model included four predictors: maternal age, previous caesarean delivery, pregnancy-induced hypertension, and antepartum hemorrhage. The model had an AUC of 78.0% (95% CI 71.1-84.8), indicating good discrimination capacity. The model also exhibited good calibration and a low overoptimism coefficient, indicating minimal risk of overfitting. The risk prediction model has good clinical utility for discriminating multiparous women at risk of caesarean delivery. The tool can guide clinicians in estimating the risk of caesarean delivery among multiparous women that could lead to improved maternal and neonatal outcomes, ultimately enhancing the quality of care delivered in low-resource settings.

Geographically weighted regression analysis of cesarean delivery using the Ethiopian Mini Demographic and Health Survey 2019

A justified cesarean delivery plays a major role in reducing maternal and neonatal death in Ethiopia. However, inequalities exist in access to cesarean delivery within the country. Therefore, this study aimed to assess the geographic variations and predictors of cesarean delivery hotspots in Ethiopia using geographically weighted regression analysis. For this study, data from the 2019 Ethiopian Mini Demographic and Health Survey were utilized. Moran's I and Getis-OrdGi* statistics were used to assess the geographical disparities in the occurrence of cesarean deliveries. Subsequently, spatial regression was performed using ordinary least squares regression and geographically weighted regression to predict hotspot areas of cesarean delivery. The prevalence of cesarean delivery in Ethiopia was 6.07% (95% CI: 5.602, 6.538). In this study, Dire Dawa, Hareri, and the southeastern region of Somali were the hotspot areas for cesarean delivery. A higher level of education, multiple births, five or more antenatal care visits, and delivery in private health institutions were statistically significant predictors of cesarean delivery hotspots in Ethiopia. Cesarean delivery in Ethiopia is still underutilized, despite the presence of hotspot areas. Region-specific interventions are necessary, particularly in hotspot areas. Ensuring accessible and equitable cesarean delivery services is crucial, especially in cold spot areas.

Cesarean section and the gestational duration of subsequent pregnancies: A nationwide register-based cohort study

INTRODUCTION

Preterm delivery risk is increased for women with a previous cesarean section, which are becoming more common worldwide. However, this risk is based on studies which have not fully accounted for selection bias, and the studied outcomes have been limited to the study of early deliveries. This study aimed to determine the impact of previous delivery modes on the incidence of deviant duration of subsequent pregnancies.

MATERIAL AND METHODS

This retrospective cohort study used clinical data registered in the Swedish Medical Birth Register. 612 935 women with their first two pregnancies and 157 581 women with their first three pregnancies were included. The outcome was the gestational duration of the last pregnancy of the series, depending on previous delivery modes. The associations were analysed with multivariable logistic regression (with the gestational duration categorised) and survival models including Cox regression analyses.

RESULTS

When using standard logistic regression, previous cesarean section was associated with an increased risk of both spontaneous preterm birth (adjusted odds ratio [aOR] 1.67, 95% CI 1.57-1.77) and postterm birth (aOR 1.55, 95% CI 1.49-1.62). However, the more appropriate survival models only showed an association between cesarean section and longer gestational duration of the subsequent pregnancy (adjusted hazard ratio 0.72, 95% CI 0.71-0.73).

CONCLUSIONS

The survival model handles bias related to management differences between the exposure and reference groups better than standard logistic regression, making it the statistical method of choice when conducting studies on this research topic. This study shows that the main association between cesarean section and the gestational duration of the subsequent pregnancy is the prolonging of it, which stands in contrast with previous research on the topic.

Health care provider's perceived factors for the increased practice of caesarean delivery in North West Amhara referral hospitals, Ethiopia, 2022: a qualitative study

Background

Caesarean delivery is an essential obstetric intervention to reduce maternal and newborn mortality in emergencies. However, in Ethiopia, there is a high prevalence of caesarean deliveries. Therefore, this study aimed to explore the factors perceived by healthcare providers that contribute to the excessive rates of caesarean deliveries in North West Amhara referral hospitals, Ethiopia, in 2022.

Methods

A phenomenological study design was employed, utilizing semi-structured interview guide for data collection. Fifteen healthcare providers working in referral hospitals in the north-western region of Amhara were interviewed using a heterogeneous purposive sampling approach until data was saturated. Transcribed interviews were translated coded and finally thematic analyses were employed using Open Code 4.0 software.

Results

Healthcare providers observed a significant increase in the frequency of caesarean deliveries. Multiple factors were identified as contributing to this rise, including the involvement of medical students, the use of cardiotocography, a decline in instrumental deliveries, inadequate trial of labor after previous caesarean deliveries, and the absence of clear indications for performing caesarean deliveries for social or maternal requests. Notably, patients who had received care in private clinics were more likely to undergo caesarean deliveries.

Conclusion

Caesarean deliveries were observed to be performed based on subjective or approximate indications, rather than clear obstetric indications. Encouraging greater emphasis on trial of labor, instrumental delivery, and performing caesarean deliveries only when there are definitive obstetric indications, rather than for social or maternal requests, can contribute to reducing the prevalence of caesarean delivery rates.

The effect of propranolol on cesarean section rate in prolonged labor: a systematic review and meta-analysis

Background

Propranolol is widely recognized as a nonselective β-adrenergic receptor blocker known to enhance uterine activity in both pregnant and non-pregnant women. Prolonged labor and serious concerns about maternal and neonatal health prompted us to investigate medical issues. The aim of this systematic review and meta-analysis was to assess the effect of propranolol on cesarean deliveries during prolonged labor.

Methods

A systematic search was conducted in databases including PubMed, Cochrane CENTRAL, Science Direct, Google Scholar, Embase, and Web of Science from inception to 1 November 2023. We included randomized clinical trials that evaluated maternal and neonatal outcomes in patients receiving intrapartum propranolol during prolonged labor. Unadjusted risk ratios with 95% confidence intervals were calculated using a fixed-effects model. The I2 statistic was used to measure and assess heterogeneity. The primary outcome was cesarean delivery rate, and secondary outcomes included Apgar score, cord arterial pH, neonatal birth weight, neonatal intensive care unit admission, postpartum hemorrhage, and composite maternal and neonatal morbidity.

Results

Of the 704 identified articles, six were included in the meta-analyses. There was a significant difference in cesarean deliveries between propranolol and placebo (RR 0.80, 95% confidence interval 0.59-1.09, P = 0.02). In addition, there was no significant difference between study groups in secondary outcomes.

Conclusion

In this meta-analysis, a notable reduction in cesarean rates was observed when propranolol was given to women in prolonged labor. The results of this meta-analysis show that the use of propranolol safely reduces the need for cesarean deliveries due to labor arrest disorders.

"It's a breech, and what now?": A decision-aid tool to help clinicians counsel women with breech presentation near term

OBJECTIVE

Management options for breech presentation near term include vaginal breech delivery, cesarean delivery, and external cephalic version. Shared decision-making in this context involves conveying detailed information about each procedure, including success rates, potential discomforts, risks, recovery periods, and necessary follow-up. The complexity of this information can make discussions challenging. Our goal was to develop a decision aid tool specifically for clinicians, aimed at facilitating shared decision-making with pregnant women who have breech presentations near term.

METHODS

The decision aid tool was developed following a thorough literature review, and incorporated input from three clinical experts and a clinical communication psychologist. The document then underwent a two-round Delphi evaluation involving 18 experienced obstetricians from different hospitals, using a 5-point Likert scale ("strongly disagree" to "strongly agree"). Consensus was defined as more than 75% of participants responding "agree" or "strongly agree".

RESULTS

A comprehensive tool providing information on clinical aspects derived from the most robust evidence, along with guidance on the steps involved in shared decision-making was constructed. The percent agreement in classes 4 ("agree") and 5 ("strongly agree") was 100 %, with a kappa of 1 (95 % CI, 1-1).

CONCLUSION

An innovative tool aimed at clinicians was developed to facilitate shared decision-making with pregnant women who have breech presentations near term. A strong consensus on the document́ content was achieved using the Delphi technique.

SYNOPSIS

An innovative tool aimed at clinicians was developed to facilitate shared decision-making with pregnant women who have breech presentations near term.

How does the first index mode of birth in public or private hospitals predict subsequent births? A 16-year Australian population-based linked data study

OBJECTIVES

In this descriptive study, we aimed to assess how the index mode of birth and subsequent birth modes vary over time for public and private hospital maternity care funding models. The second aim was to determine to what extent the index mode of birth predicts subsequent birth modes in general and whether this differs in public versus private hospital maternity care funding models. With our aim, we have an innovative approach, specifically the women's life course approach, which is hypothesis-generating and can be assessed in future studies.

DESIGN, SETTING AND PARTICIPANTS

New South Wales population-linked data of low-risk women were analysed (2001-2016). Demographics and public/private care were recorded. Modes of the index birth and subsequent modes of second and third births (ie, spontaneous vaginal, instrumental vaginal elective/emergency caesarean birth) were registered. For those with 2 births and 3 births, 16 and 64 subsequent births patterns were created.

PRIMARY AND SECONDARY OUTCOME MEASURES

Trend of index modes of birth and subsequent modes of birth over time and the prediction of subsequent birth modes based on the index birth. These outcomes were stratified for the initial maternity care funding model.

RESULTS

In total, 172 041 low-risk nulliparous women were included in the initial cohort, 54.1% had a spontaneous index vaginal birth and 71% had their index birth in public hospitals. During the study period, 131 675 women had 2 births and 44 677 of these women had 3 births, respectively. Among women birthing in public hospitals, higher proportions of index and subsequent vaginal births were observed than in private hospitals, with fewer instrumental vaginal births and caesarean sections. Large differences were observed for birth patterns: vaginal-vaginal (public 55.8% vs private 36.8%) and vaginal-vaginal-vaginal (public 57.2% vs private 38.8%). Women with an index spontaneous vaginal birth showed a high probability (91.3%) of subsequent spontaneous vaginal births. When stratified by maternity care funding model, the probabilities were similar: 91.6% in public hospitals and 90.2% in private hospitals.

CONCLUSIONS

Our study of low-risk Australian women (2001-2011) found that those giving birth in public hospitals had higher proportions of spontaneous vaginal births compared with private hospitals, where caesarean sections were more common. Women with an index spontaneous vaginal birth had a very high probability to have subsequent vaginal births. These findings suggest that index mode of birth may be a predictor for subsequent modes of birth.

Novel Insights into the Pathogenesis of Inflammatory Bowel Diseases

Inflammatory bowel diseases (IBDs), encompassing Crohn's disease and ulcerative colitis, are complex chronic disorders characterized by an intricate interplay between genetic predisposition, immune dysregulation, gut microbiota alterations, and environmental exposures. This review aims to synthesize recent advances in IBD pathogenesis, exploring key mechanisms and potential avenues for prevention and personalized therapy. A comprehensive literature search was conducted across major bibliographic databases, selecting the most recent and impactful studies on IBD pathogenesis. The review integrates findings from multi-omics analyses, single-cell transcriptomics, and longitudinal cohort studies, focusing on immune regulation, gut microbiota dynamics, and environmental factors influencing disease onset and progression. Immune dysregulation, including macrophage polarization (M1 vs. M2) and Th17 activation, emerges as a cornerstone of IBD pathogenesis. Dysbiosis, as a result of reduced alpha and beta diversity and overgrowth of harmful taxa, is one of the main contributing factors in causing inflammation in IBD. Environmental factors, including air and water pollutants, maternal smoking, and antibiotic exposure during pregnancy and infancy, significantly modulate IBD risk through epigenetic and microbiota-mediated mechanisms. While recent advances have supported the development of new therapeutic strategies, deeply understanding the complex dynamics of IBD pathogenesis remains challenging. Future efforts should aim to reduce the burden of disease with precise, personalized treatments and lower the incidence of IBD through early-life prevention and targeted interventions addressing modifiable risk factors.

Obstetric and pregnancy-related factors associated with caesarean delivery in Bangladesh: a survey in Rajshahi district

OBJECTIVES

Caesarean section (CS) delivery is the most common operative obstetric procedure globally. The increasing trend of CS deliveries poses a significant threat to both child and maternal health. The adverse maternal outcomes associated with caesarean delivery represent a substantial public health concern worldwide. This study aimed to identify emerging obstetric and pregnancy risk factors and maternal outcomes associated with CS delivery among women in Rajshahi district, Bangladesh.

DESIGN

This was a cross-sectional study.

SETTING

Data were collected from 9 Upazilas with 233 community clinics of Rajshahi district, Bangladesh.

PARTICIPANTS

Multistage sampling technique was utilised for selecting sample from the population. A total of 540 mothers with a live infant were enrolled in the study. Descriptive statistics, χ2 test, logistic regression and ROC curve were used to analyse the data.

RESULTS

The mean age of respondents was 26.28 years (SD 4.96); among them, the proportion of CS was 34.44%, with a higher proportion occurring in private clinics (82.8%) compared with public hospitals (17.2%). The likelihood of having a CS increased with factors such as insufficient sleep duration (p=0.002), oedema problems (p=0.014), inadequate supplements of micronutrients (p=0.009), severe headaches with blurred vision (p=0.028) and inadequate food consumption during pregnancy (p=0.032). The probability of experiencing obstetric fistula or postpartum anaemia (p=0.049) was higher among mothers who had a CS in their most recent live birth than mothers who had a vaginal birth.

CONCLUSION

The study found that having a CS increases the risk of maternal complications like an obstetric fistula or postpartum anaemia. Considering these results, it is recommended to urgently introduce carefully evaluated clinical practices to assess if vaginal delivery is possible. Counselling women about the delivery method is important to decrease unnecessary CS in Bangladesh.

Shaping oral and intestinal microbiota and the immune system during the first 1,000 days of life

The first 1, 000 days of life, from the fetal stage of a woman's pregnancy to 2 years of age after the baby is born, is a critical period for microbial colonization of the body and development of the immune system. The immune system and microbiota exhibit great plasticity at this stage and play a crucial role in subsequent development and future health. Two-way communication and interaction between immune system and microbiota is helpful to maintain human microecological balance and immune homeostasis. Currently, there is a growing interest in the important role of the microbiota in the newborn, and it is believed that the absence or dysbiosis of human commensal microbiota early in life can have lasting health consequences. Thus, this paper summarizes research advances in the establishment of the oral and intestinal microbiome and immune system in early life, emphasizing the substantial impact of microbiota diversity in the prenatal and early postnatal periods, and summarizes that maternal microbes, mode of delivery, feeding practices, antibiotics, probiotics, and the environment shape the oral and intestinal microbiota of infants in the first 1, 000 days of life and their association with the immune system.

Cesarean delivery on child health and development in Japanese nationwide birth cohort

The long-term effects of cesarean delivery (CD) on child health and development remain controversial. This study aimed to investigate these effects using an outcome-wide approach in a Japanese context, where perinatal mortality rates are among the world's lowest. We analyzed data from 2,114 children in a nationwide Japanese birth cohort, linking the 21st Century Longitudinal Survey of Newborns with the Perinatal Research Network database. We examined associations between CD and various health and developmental outcomes up to 9 years of age, including hospitalizations, obesity, and developmental milestones. After adjusting for potential confounders, CD was not significantly associated with most outcomes, including all-cause hospitalization (adjusted risk ratio 1.25, 95% CI 0.997-1.56), obesity at 5.5 and 9 years, and various developmental milestones. Subgroup analyses for multiple births and preterm infants showed some differences in point estimates, but were limited by small sample sizes. CD was not significantly associated with adverse long-term child health or developmental outcomes in this Japanese cohort. These findings provide reassurance regarding CD safety when medically indicated in advanced perinatal care settings. Further research with larger samples and longer follow-up is needed, especially for specific subgroups.

Clinical implications of maternal multikingdom transmissions and early-life microbiota

Mother-to-infant transmission of the bacteriome, virome, mycobiome, archaeome, and their mobile genetic elements has been recognised in nature as an important step for the infant to acquire and maintain a healthy early-life (from birth till age 3 years) microbiota. A comprehensive overview of other maternal multikingdom transmissions remains unavailable, except for that of the bacteriome. Associations between microorganisms and diseases throughout the human life span have been gradually discovered; however, whether these microorganisms are maternally derived and how they concomitantly interact with other microbial counterparts remain poorly understood. This Review first discusses the current understanding of maternal multikingdom transmissions, their contributions to the development of early-life microbiota, and the primary factors that influence the transmission processes. The clinical implications of the inherited microbiota on human health in early life have been emphasised upon next, along with highlighting of knowledge gaps that should be addressed in future research. Finally, interventions to restore typical vertical transmission or disturbed early-life microbiota have been discussed as potential therapeutic approaches.

Socioeconomic disadvantage and racial/ethnic disparities in low-risk cesarean birth in California

Our objective was to assess the relationship of socioeconomic disadvantage and race/ethnicity with low-risk cesarean birth. We examined birth certificates (2007-2018) linked with maternal hospitalization data from California; the outcome was cesarean birth among low-risk deliveries (ie, nulliparous, term, singleton, vertex [NTSV]). We used generalized estimation equation Poisson regression with an interaction term for race/ethnicity (n = 7 groups) and a measure of socioeconomic disadvantage (census tract-level neighborhood deprivation index, education, or insurance). Among 1 815 933 NTSV births, 26.6% were by cesarean section. When assessing the joint effect of race/ethnicity and socioeconomic disadvantage among low-risk births, risk of cesarean birth increased with socioeconomic disadvantage for most racial/ethnic groups, and disadvantaged Black individuals had the highest risks. For example, Black individuals with a high school education or less had a risk ratio of 1.49 (95% CI, 1.45-1.53) relative to White individuals with a college degree. The disparity in risk of cesarean birth between Black and White individuals was observed across all strata of socioeconomic disadvantage. Asian American and Hispanic individuals had higher risks than White individuals at lower socioeconomic disadvantage; this disparity was not observed at higher levels of disadvantage. Black individuals have a persistent, elevated risk of cesarean birth relative to White individuals, regardless of socioeconomic disadvantage.

Obstetric Outcomes by Hospital Volume of Operative Vaginal Delivery

Importance

Characterizing hospital-level factors associated with adverse outcomes following operative vaginal delivery (OVD) is crucial for optimizing obstetric care.

Objective

To assess the association between hospital OVD volume and adverse outcomes.

Design, Setting, and Participants

This was a retrospective cohort study of OVDs in California between 2008 and 2020. OVD was determined using birth certificate and International Classification of Diseases, Ninth Revision, Clinical Modification or International Statistical Classification of Diseases, Tenth Revision, Clinical Modification codes. This study used linked vital statistics and hospital discharge data from California. The study included singleton, nonanomalous, full-term deliveries with vertex presentation. Data analysis was performed between June 10 and October 23, 2024.

Exposure

Hospital OVD volume was categorized by the proportion of OVDs performed among all deliveries, grouped into low (<5.2%), medium (5.2%-7.4%), and high (≥7.4%) volume.

Main Outcomes and Measures

Adverse outcomes for birthing individuals included obstetric anal sphincter injuries, cervical lacerations, and postpartum hemorrhage. Neonatal outcomes included shoulder dystocia, subgaleal hemorrhage, intracranial hemorrhage, facial nerve injury, and brachial plexus injury (BPI). χ2 and multivariable Poisson regression analyses were used to assess the association between hospital OVD volume and outcomes.

Results

Among 306 818 OVDs (mean [SD] birthing parent's age, 28.5 [6.2] years; 155 157 patients with public insurance [50.6%]), hospitals with low OVD volume had an increased proportion of obstetric anal sphincter injury compared with hospitals with medium and high volumes (12.16% [7444 patients] vs 11.07% [10 709 patients] vs 9.45% [14 064 patients]). Hospitals with low volume also had a higher proportion of adverse neonatal outcomes, including shoulder dystocia (3.84% [2351 patients] vs 3.50% [3386 patients] vs 2.80% [4160 patients]), subgaleal hemorrhage (0.27% [165 patients] vs 0.18% [172 patients] vs 0.10% [144 patients]), and BPI (0.41% [251 patients] vs 0.30% [291 patients] vs 0.20% [301 patients]) compared with hospitals with medium and high volume. In multivariable analyses, low OVD volume remained associated with increased risk of obstetric anal sphincter injury (adjusted risk ratio [aRR], 1.36; 95% CI, 1.14-1.62), shoulder dystocia (aRR, 1.30; 95% CI, 1.10-1.52), subgaleal hemorrhage (aRR, 2.57; 95% CI, 1.55-4.24), and BPI (aRR, 1.73; 95% CI, 1.30-2.2.29) compared with hospitals with high OVD volume. After multivariable analysis, medium OVD volume remained associated with increased risk of subgaleal hemorrhage (aRR, 1.72; 95% CI, 1.04-2.86) and BPI (aRR, 1.35; 95% CI, 1.02-1.79) compared with high OVD volume.

Conclusions and Relevance

This study found that undergoing OVD at hospitals with low OVD volume was associated with adverse perinatal outcomes compared with hospitals with medium and high OVD volumes. Further exploration of the reasons for these differences and prevention of these differences is needed to improve obstetric outcomes.

Associations between term cesarean delivery in the first pregnancy and second-pregnancy preterm delivery

INTRODUCTION

Cesarean delivery has been shown to increase the risk of preterm delivery in future pregnancies. The association could be a direct result of the procedure, or because the indications that led to the cesarean delivery also increase the risk of preterm delivery in later pregnancies.

MATERIAL AND METHODS

298 901 mothers with first and second singleton deliveries from 1999 to 2020 were investigated using data from the Medical Birth Registry of Norway linked with Statistics Norway. The mothers were categorized by mode of cesarean delivery (total, emergency and planned) and vaginal delivery at term in the first pregnancy. We used log-binomial regression models to estimate relative risks with 95% confidence intervals (CI) of iatrogenic and spontaneous preterm delivery <37 gestational weeks in the second pregnancy. Second, we explored the role of recurrent placental disease in preterm delivery by comparing estimates in mothers with placental disease in neither or both pregnancies.

RESULTS

8243 mothers (2.8%) had a preterm delivery in the second pregnancy. The adjusted relative risk (aRR) of preterm delivery was 1.24 (95% CI 1.17-1.32) after cesarean compared with vaginal delivery in the first pregnancy. The association was stronger in previous planned compared with emergency cesarean delivery (aRR 1.52, 95% CI 1.30-1.77 and aRR 1.21, 95% CI 1.14-1.29, respectively). Spontaneous preterm delivery was not associated with the previous mode of delivery; the risk was confined to iatrogenic preterm delivery after both emergency and planned cesarean delivery (aRR 1.69, 95% CI 1.52-1.87 and aRR 2.65, 95% CI 2.12-3.30, respectively). Mothers with placental disease in both pregnancies had a sixfold increased risk of preterm delivery in the second pregnancy compared with mothers with no placental disease, however, the association between mode of delivery and subsequent preterm delivery was similar in mothers with and without placental disease in the pregnancies.

CONCLUSIONS

Compared with vaginal term delivery in the first pregnancy, cesarean delivery increases the risk of iatrogenic, but not spontaneous preterm delivery in the next pregnancy. Although strongly associated with preterm delivery, placental disease had limited influence on the estimates.

Barriers and facilitators of choosing a vaginal birth after cesarean: A mixed-methods systematic review

BACKGROUND

Vaginal birth after cesarean is an effective way of reducing cesarean section rates and preventing a variety of short- and long-term complications associated with cesarean deliveries. Additionally, vaginal birth after cesarean can enhance breastfeeding rates, expedite postpartum recovery, and minimize hospitalization duration for women. Despite these benefits, the prevalence of vaginal birth after cesarean remains low in many countries, and only limited reviews have investigated the factors contributing to the low vaginal birth after cesarean rates.

OBJECTIVES

This review aims to explore the barriers and facilitators influencing decision-making during the process of vaginal birth after cesarean.

DESIGN

A mixed-methods systematic review.

METHODS

Ten electronic databases were systematically and comprehensively searched for qualitative, quantitative, and mixed-methods studies. Two reviewers critically appraised the eligible studies independently using the Joanna Briggs Institute Critical Appraisal Tool. We converted quantitative findings to narrative form and employed a convergent synthesis design to synthesize the data thematically.

RESULTS

This review included 55 studies published between 2002 and 2024. These studies originated from 19 countries and comprised 21 quantitative studies, 31 qualitative studies, and three mixed-methods studies. The methodological quality of the included studies was assessed as moderate to high. We divided the barriers and facilitators influencing vaginal birth after cesarean decision-making into four categories and nine subcategories: individual factors of pregnant women (sociodemographic characteristics, physiological factors, cognition, and psychological factors); interpersonal relationships (emotional support and communication); healthcare system factors (healthcare professionals' acceptance and commitment to action as well as healthcare facilities); and social factors (culture and ethnicity, along with law and policy).

CONCLUSIONS

This study broadens the understanding of the various factors that influence vaginal birth after cesarean decisions and may provide valuable insights for future modifications in vaginal birth after cesarean practices to enhance its availability for women. We conclude that successful implementation of vaginal birth after cesarean requires the concerted efforts of all stakeholders. Hospitals should improve the quality of care, enhance the capacity of the healthcare system to support vaginal birth after cesarean, and respect the preferences of pregnant women by providing support and encouraging their active participation in decision-making.

REGISTRATION

This systematic review was registered in PROSPERO on June 24, 2022 (CRD42022339434).

Labor Status at Delivery and Lung Function in Extremely Prematurely Born Young Adults

BACKGROUND

There has been conflicting evidence regarding the impact of mode of delivery on respiratory outcomes in later childhood and adulthood. It is possible labor status, rather than mode of delivery, influences later respiratory morbidity. We hypothesized that extremely premature infants born to mothers in labor would have better lung function at follow-up than those born to mothers not in labor.

METHODS

We reviewed data from the United Kingdom High-Frequency Oscillation Study. Lung function testing was performed on young people aged 16-18 years born before 29 weeks of gestation. Linear mixed models were used to adjust lung function for maternal and neonatal factors and for the clustering due to multiple births.

RESULTS

One hundred and fifty subjects underwent lung function testing. Young adults born to mothers in labor had better mean Forced Expiratory Flow75 (FEF75) compared to those born to mothers not in labor (adjusted difference 0.50 [95% CI: 0.02, 0.99]). Similar significant differences were noted in FEF50 (0.45 [-0.05, 0.85]), and FEF25-75 (0.53 [0.05, 1.01]).

CONCLUSION

Our study demonstrates that amongst individuals born very prematurely, those whose mothers were in labor before delivery had better small airway function at 16-19 years of age.

The effectiveness of antenatal education on improving labour and birth outcomes - A systematic review and meta-analysis

BACKGROUND

The World Health Organisation has suggested antenatal education be integrated within standard antenatal care. However, evidence for the impact of antenatal education varies. This systematic review and meta-analysis evaluated randomised controlled trial evidence regarding the influence of antenatal education on labour and birth outcomes.

METHODS

Electronic databases (CINAHL, PubMed, Embase and Scopus) were searched for randomised controlled trials published between 2011 and 2023. Primary outcomes were mode of birth, epidural analgesia use, and induction of labour. Subgroup analysis by type of education (general education, specific technique, birth plan use) was performed. Three authors reviewed studies and extracted data. Risk of bias was assessed using the Cochrane Risk of Bias 2 tool. Meta-analysis was performed using RevMan.

RESULTS

Seventeen studies (n=7260 participants) were included, most (n=10) had low risk of bias. Antenatal education was associated with decreased rates of planned caesarean sections (Relative Risk (RR) 0.87; 95 % confidence interval (CI), 0.83-0.92, I2=0 %), but not unplanned caesareans (RR 0.99; 95 % CI, 0.88-1.12, I2=0 %),as well as increased vaginal births (RR 1.14; 95 % CI 1.07-1.21, I2=79 %) and increased spontaneous onset of labour (n=10 studies, RR, 1.07; 95 % CI, 1.01-1.14, I2=0 %). Epidural analgesia use (RR, 0.88; 95 % CI, 0.88-1.00, I2=78 %) was not significantly affected. General education and birth plan care interventions were found to be more effective than specific technique care.

CONCLUSION

Antenatal education programs studied improve some labour and birth outcomes, although with substantial heterogeneity regarding mode of birth and epidural analgesia use findings. General education appeared more effective than specific technique education.

A qualitative and quantitative cross-sectional study on the past, present, and future of vaginal delivery: Turkey

OBJECTIVE

The current study focused on predicting future trends in obstetrics by examining obstetricians' approaches to specific challenging vaginal delivery that require special experience, such as breech presentation, macrosomic fetus, twin pregnancy, and vacuum use, compared with their residency training experience.

METHODS

The cross-sectional study was conducted in two phases. The first phase was qualitative and the second phase was quantitative. The "interview" and "survey" techniques served as data collection tools. In total, 20 obstetricians participated in the interviews, and 400 obstetricians took part in the survey. Data from the interviews were analyzed using the Maxqda 2020 qualitative data analysis program, and survey data were analyzed using SPSS version 25.0.

RESULTS

Over the past 2 decades, there has been a gradual shift from vaginal deliveries to cesarean deliveries in cases involving breech presentation, macrosomic fetus, twin pregnancy, and vacuum use. While medicolegal concerns are undeniable, the prevalent belief among obstetricians that cesarean delivery is safer than vaginal delivery significantly influences this trend. Comparatively, young obstetricians often complete their residency training without acquiring sufficient knowledge and skills in vaginal delivery.

CONCLUSION

Young obstetricians currently lack adequate experience in managing vaginal deliveries for breech presentation, macrosomic fetus, twin pregnancy, and vacuum use. This experience is at risk of disappearing entirely within the next decade as senior obstetricians retire. Policymakers should take this into consideration when shaping future healthcare policies.

Care of late intrauterine fetal death and stillbirth: Green-top Guideline No. 55

A combination of mifepristone and a prostaglandin preparation should usually be recommended as the first-line intervention for induction of labour (Grade B). A single 200 milligram dose of mifepristone is appropriate for this indication, followed by: 24+0-24+6 weeks of gestation - 400 micrograms buccal/sublingual/vaginal/oral of misoprostol every 3 hours; 25+0-27+6 weeks of gestation - 200 micrograms buccal/sublingual/vaginal/oral of misoprostol every 4 hours; from 28+0 weeks of gestation - 25-50 micrograms vaginal every 4 hours, or 50-100 micrograms oral every 2 hours [Grade C]. There is insufficient evidence available to recommend a specific regimen of misoprostol for use at more than 28+0 weeks of gestation in women who have had a previous caesarean birth or transmural uterine scar [Grade D]. Women with more than two lower segment caesarean births or atypical scars should be advised that the safety of induction of labour is unknown [Grade D]. Staff should be educated in discussing mode of birth with bereaved parents. Vaginal birth is recommended for most women, but caesarean birth will need to be considered for some [Grade D]. A detailed informed discussion should be undertaken with parents of both physical and psychological aspects of a vaginal birth versus a caesarean birth [Grade C]. Parents should be cared for in an environment that provides adequate safety according to individual clinical circumstance, while meeting their needs to grieve and feel supported in doing so (GPP). Clinical and laboratory tests should be recommended to assess maternal wellbeing (including coagulopathy) and to determine the cause of fetal death, the chance of recurrence and possible means of avoiding future pregnancy complications [Grade D]. Parents should be advised that with full investigation (including postmortem and placental histology) a possible or probable cause can be found in up to three-quarters of late intrauterine fetal deaths [Grade B]. All parents should be offered cytogenetic testing of their baby, which should be performed after written consent is given (GPP). Parents should be advised that postmortem examination can provide information that can sometimes be crucial to the management of future pregnancy [Grade B].

Cesarean Delivery Upon Request in Pregnancies Following Vaginal Delivery: A Nationwide Study

BACKGROUND

The increasing rate of cesarean delivery (CD) is a significant concern in many societies worldwide. Vaginal delivery (VD) is preferred over CD for subsequent pregnancies after successful VD, for women with no specific obstetrical indications, primarily because of concerns about potential complications arising from the surgical procedure. However, the factors that influence the decision of requesting a CD have not yet been thoroughly investigated. This study aimed to examine the underlying reasons that lead mothers to choose CDs in subsequent pregnancies following a VD.

METHODS

This retrospective study included women who underwent VD in their first pregnancy between 2011 and 2020 and had a second pregnancy and childbirth within the study period. The analysis focused on women eligible for a trial of labor (TOL) in their second pregnancy, excluding those with conditions necessitating a CD. The study defined two groups: the TOL in second pregnancy (TOLS) group, consisting of women with one previous VD who attempted a VD in their subsequent pregnancy; and the CD on maternal request in second pregnancy (CDRS) group, comprising women with one past VD who opted for a CD in their second pregnancy without medical indication. The TOLS and CDRS groups were compared regarding obstetric and neonatal outcomes.

RESULTS

During the study period, 372,749 women met the inclusion criteria: 368,311 women in TOLS group and 4,438 women in CDRS group. In the regression analysis for the CDRS, several factors were identified as increasing the risk of choosing CD, including age (adjusted odds ratio [aOR], 1.06; 95% confidence interval [CI], 1.05-1.07), interval between the first and second pregnancies (aOR, 1.32; 95% CI 1.29-1.35), a history of pre-existing hypertension (aOR, 1.76; 95% CI, 1.17-2.65), gestational diabetes mellitus (GDM) during the first pregnancy (aOR, 1.19; 95% CI, 1.05-1.36), hypertensive disease during pregnancy (HDP) (aOR, 1.33; 95% CI, 1.06-1.67), preterm labor during the first pregnancy (aOR, 1.57; 95% CI, 1.32-1.86), postpartum hemorrhage (aOR, 1.33; 95% CI, 1.21-1.47), traumatic event during delivery (aOR, 1.19; 95% CI, 1.12-1.28), surgical VD (aOR, 1.29; 95% CI, 1.19-1.40), and pregnancies with abortive outcomes between the first and second pregnancies (aOR, 1.18; 95% CI, 1.08-1.29). Additionally, women with pre-existing diabetes (aOR, 1.53; 95% CI, 1.24-1.89), pre-existing hypertension (aOR, 1.69; 95% CI, 1.26-2.26), GDM (aOR, 1.23; 95% CI, 1.11-1.37), or HDP (aOR, 2.57; 95% CI, 2.24-2.94) during the second pregnancy continued to exhibit an increased risk of opting for CD even after adjustment.

CONCLUSION

CD after VD was more prevalent among women with certain demographic characteristics and obstetric histories. Investigating the factors influencing women to request CD can be helpful in making informed decisions about safe delivery methods and may also affect the CD rate.

Does caesarean section have an impact on exclusive breastfeeding? Evidence from four Southeast Asian countries

BACKGROUND

The effect of caesarean section (CS) on breastfeeding initiation has been extensively studied, but its influence on exclusive breastfeeding practices remains inconclusive. Therefore, this study aims to investigate the impact of CS on exclusive breastfeeding using evidence from four countries in the Southeast Asian region.

METHODS

This cross-sectional study used secondary data obtained from the Demographic and Health Surveys (DHS) conducted between 2016 and 2022 in four countries within the Southeast Asian Region. We included information on the youngest children aged 0-5 months living with their mothers within the DHS datasets. The association between CS and exclusive breastfeeding was determined using a simple and multiple logistic regression models. Weight factors were taken into account in all analyses for the two-stage stratified cluster sampling design.

RESULTS

Among 3420 children, nearly half (49.1%, 95%CI: 47.0, 51.2) were exclusively breastfed. Children born by CS had lower odds of being exclusively breastfed, compared to children born vaginally (aOR = 0.68, 95%CI: 0.53, 0.88). Women who were married or living with a partner (aOR = 2.19, 95%CI: 1.33, 3.60), children born at a health facility (aOR = 1.31, 95%CI: 1.00, 1.71), and girl babies (aOR = 1.24, 95%CI: 1.05, 1.48) had higher odds of exclusive breastfeeding. Furthermore, residing in rural areas was associated with an increased likelihood of exclusive breastfeeding (aOR = 1.47, 95%CI: 1.20, 1.80). Maternal age, mother's education, parity, antenatal and postnatal care taken, and mass media exposure were not associated with exclusive breastfeeding.

CONCLUSION

This study highlights a significant association between CS and reduced exclusive breastfeeding practices. The findings underscore the importance of providing adequate support and interventions to mothers who deliver by CS and their family members to ensure they can successfully achieve exclusive breastfeeding, particularly in a global context where CS rates are rising.

Twin home birth: Outcomes of 100 sets of twins in the care of a single practitioner

BACKGROUND

Research on community (home or birth center) twin birth is scarce. This study evaluates outcomes of twin pregnancies entering care with a single community practitioner.

METHODS

This is a retrospective observational cohort study of 100 consecutive twin pregnancies planning community births during a 12-year period. Outcomes measured included mode of birth; birth weights; Apgar scores; ante-, intra-, and post-partum transports; perineal integrity; birth interval; blood loss; chorionicity; weight concordance; and other maternal or neonatal morbidity.

RESULTS

31 women (31%) transferred to a hospital-based clinician prior to labor. Of the 69 pregnancies still under the obstetrician's care when labor began, 79.7% (n = 55) were Dichorionic Diamniotic and 21.3% (n = 14) were Monochorionic Diamniotic. The vaginal birth rate was 91.3% (n = 63): 77.3% for primips and functional primips (no previous vaginal births) and 97.9% for multips. Six mothers (8.7%) had in-labor cesareans (1 multip and 5 primips). Rates of vaginal birth did not vary significantly by chorionicity. There were 8 transports in labor (11.6%): 2 vaginal and 6 cesareans. Average gestational age was 39.0 weeks (range 35-42). Compared to primiparas, multiparas had less perineal trauma and higher rates of vaginal birth and spontaneous vaginal birth. One twin infant and one mother required postpartum hospital transport. Of the babies born in a community setting, there was no serious morbidity requiring hospital treatment.

CONCLUSIONS

A community birth can lead to high rates of vaginal birth and good outcomes for both mothers and babies in properly selected twin pregnancies. Community twin birth with midwifery style care under specific protocol guidelines and with a skilled practitioner may be a reasonable choice for women wishing to avoid a cesarean section-especially when there is no option of a hospital vaginal birth. Training all practitioners in vaginal twin and breech birth skills remains an imperative.

Trends and determinants of caesarean section in South Asian countries: Bangladesh, Nepal, and Pakistan

BACKGROUND

The prevalence of caesarean sections (C-sections) has remarkably increased in the past few decades worldwide, especially in the lower and middle-income countries (LMICs). To our best knowledge, no studies focused on and compared the C-section scenarios of Bangladesh, Nepal, and Pakistan based on the latest demographic and health survey (DHS) data.

OBJECTIVES

To assess the trends and factors associated with C-sections in the three South Asian countries.

STUDY POPULATION

Mothers aged 15-49 years participated in DHS 1990 to 2017-2018 and gave birth within three years of each of the surveys in Bangladesh, Nepal, and Pakistan.

MATERIALS AND METHODS

This study analyzed data from five recent DHS rounds in Bangladesh and four in Nepal and Pakistan. Multivariable logistic regression was used to assess the association between C-sections and sociodemographic characteristics.

RESULTS

The results show that institutional delivery and C-sections have increased throughout the period in all three countries. In Bangladesh, the hospital birth rate increased from 10.0% in 2004 to 49.9% in 2017, and the corresponding figures [S1 Appendix: Figure A1 and Figure A2] for C-sections increased from 3.5% to 32.8%. In Nepal, the hospital birth rate increased from 11.0% in 2001 to 58.6% in 2016, and the C-sections from 0.8% to 11.0%. Pakistan observed a sharp increase from 13.7% to 66.3% and 2.7% to 22.3% in the respective cases from 1990 to 2017. Results from regression reveal that the mother's age, place of residence, education, partner's education, wealth status, birth order, number of antenatal care visits, and body mass index are associated with C-section deliveries in all three countries.

CONCLUSIONS

Our findings regarding the association of sociodemographic factors with increased C-sections may help identify subgroups of women susceptible to C-sections and offer better support regarding C-sections plans. However, the substantial increase in C-sections across the three countries warrants further investigation to identify the reasons.