A global reference for caesarean section rates (C-Model): a multicountry cross-sectional study

Objective

To generate a global reference for caesarean section (CS) rates at health facilities.

Design

Cross‐sectional study.

Setting

Health facilities from 43 countries.

Population/Sample

Thirty eight thousand three hundred and twenty‐four women giving birth from 22 countries for model building and 10 045 875 women giving birth from 43 countries for model testing.

Methods

We hypothesised that mathematical models could determine the relationship between clinical‐obstetric characteristics and CS. These models generated probabilities of CS that could be compared with the observed CS rates. We devised a three‐step approach to generate the global benchmark of CS rates at health facilities: creation of a multi‐country reference population, building mathematical models, and testing these models.

Main outcome measures

Area under the ROC curves, diagnostic odds ratio, expected CS rate, observed CS rate.

Results

According to the different versions of the model, areas under the ROC curves suggested a good discriminatory capacity of C‐Model, with summary estimates ranging from 0.832 to 0.844. The C‐Model was able to generate expected CS rates adjusted for the case‐mix of the obstetric population. We have also prepared an e‐calculator to facilitate use of C‐Model (www.who.int/reproductivehealth/publications/maternal_perinatal_health/c-model/en/).

Conclusions

This article describes the development of a global reference for CS rates. Based on maternal characteristics, this tool was able to generate an individualised expected CS rate for health facilities or groups of health facilities. With C‐Model, obstetric teams, health system managers, health facilities, health insurance companies, and governments can produce a customised reference CS rate for assessing use (and overuse) of CS.

Tweetable abstract

The C‐Model provides a customized benchmark for caesarean section rates in health facilities and systems.

The C‐Model provides a customized benchmark for caesarean section rates in health facilities and systems.

[Robson classification: A tool for assessment of caesarean practices in France]

OBJECTIVE

To give a description of caesarean rates in France in 2010 using Robson classification, to assess practices according to the level of care of the maternity units.

MATERIALS AND METHODS

The study population was the sample of the French National Perinatal Survey in 2010 (n=14,165). Data were stratified by the level of care of the maternity unit (1, 2 or 3). Women were classified in 12 groups according to Robson classification, using maternal characteristics and obstetrical history. In each level of care, we calculated for each group, its relative size, its crude caesarean rate and its contribution to the overall caesarean rate.

RESULTS

The overall rate of caesarean in 2010 in France was 20.8% in level 1, 21.1% in level 2 and 20.0% in level 3 maternity units. In the three levels, the main contributors to the overall caesarean rate were primiparous women in spontaneous labour (group 1; contribution: 3.5% in level 1 units, 2.2% in level 2 units, 2.7% in level 3 units) or with induced labour (group 2a; contribution: 2.9, 2.5 and 3.0%, respectively) and multiparous women with previous caesarean (group 5; contribution: 5.8, 5.3 and 6.0%, respectively). Premature singletons (group 10) contributed to 0.8% to the overall caesarean rate in level 1 units, 1.4% in level 2 units and 3.5% in level 3 units.

CONCLUSION

The Robson classification is easy to use. Each maternity unit can compare its rates with those of units with similar level, to find whether some groups of women have very high rates of caesarean sections.

Cannabis use during pregnancy in France in 2010

OBJECTIVE

The aim was to estimate the proportion of women who reported cannabis use during pregnancy, to analyse the demographic and social characteristics of users, and the link between cannabis use and either preterm or small-for-gestational-age birth.

DESIGN

Data were obtained from interviews of a representative sample of women giving birth in France in 2010 in the days after delivery, and from their medical records.

SETTING

All maternity units in France.

SAMPLE

The analysis includes women with live singleton births in metropolitan France who responded to the question about cannabis use during pregnancy: in total, 13 545 women.

METHODS

The percentage of cannabis users during pregnancy was estimated, and variations according to social characteristics were described. Logistic regression analyses were used to investigate any associations between cannabis use and preterm birth or small-for-gestational-age status.

MAIN OUTCOME MEASURES

Percentage of cannabis use, preterm birth rate, and small-for-gestational-age rate.

RESULTS

In all, 1.2% of women reported having used cannabis during pregnancy. This percentage was higher among younger women, women living alone, or women who had a low level of education or low income. It was also associated with tobacco use and drinking alcohol. Cannabis users had higher rates of spontaneous preterm births: 6.4 versus 2.8%, for an adjusted odds ratio (aOR) of 2.15 (95% CI 1.10-4.18). The corresponding aOR was 2.64 (95% CI 1.12-6.22) among tobacco smokers and 1.22 (95% CI 0.29-5.06) among non-tobacco smokers.

CONCLUSIONS

Although the reported rate of cannabis use during pregnancy in France is low, efforts should be continued to inform women and healthcare providers about the potential consequences of its use.

[Medical care organization in analgesia, anaesthesia and intensive care in maternity units: results from the National Perinatal Surveys in 2003 and 2010]

OBJECTIVE

The equipment and practices in obstetric analgesia, anaesthesia and intensive care, as well as their evolution between 2003 and 2010 in metropolitan France, were described.

POPULATION AND METHODS

Data were derived from two representative samples of births in 2003 and 2010, based on all births in France during one week. The sample included 534 maternity units and 14,903 births in 2010 and 618 maternity units and 14,737 births in 2003.

RESULTS

The caesarean operating room was adjacent or inside the labour ward in 66% of maternity units in 2010 vs 56% in 2003. An anaesthetist was appointed permanently to the labour ward in 38.9% of maternity units in 2010 vs 21.5% in 2003. Locoregional analgesia or anaesthesia rate increased significantly: 81.5% in 2010 compared to 74.9% in 2003. Almost all operative vaginal deliveries were performed under epidural anesthesia in 2010. Patient controlled epidural analgesia (PCEA) was available in 58% of the units in 2010 but only 34.2% of women had PCEA. Newborn's resuscitations were performed mainly by paediatricians in 2010, but 11.4% of children were resuscitated by an anaesthetist in level 1 maternity units.

CONCLUSION

The conditions required to ensure anaesthetic care safety in maternity units has improved since 2003. Improvements in quality of care are still possible.

Comparison of the cytotoxic, pro-oxidant and pro-inflammatory characteristics of different oxysterols

Oxidized low-density lipoproteins play important roles in the development of atherosclerosis and contain several lipid-derived, bioactive molecules which are believed to contribute to atherogenesis. Of these, some cholesterol oxidation products, referred to as oxysterols, are suspected to favor the formation of atherosclerotic plaques involving cytotoxic, pro-oxidant and pro-inflammatory processes. Ten commonly occurring oxysterols (7alpha-, 7beta-hydroxycholesterol, 7-ketocholesterol, 19-hydroxycholesterol, cholesterol-5alpha,6alpha-epoxide, cholesterol-5beta,6beta-epoxide, 22R-, 22S-, 25-, and 27-hydroxycholesterol) were studied for both their cytotoxicity and their ability to induce superoxide anion production (O2*-) and IL-8 secretion in U937 human promonocytic leukemia cells. Cytotoxic effects (phosphatidylserine externalization, loss of mitochondrial potential, increased permeability to propidium iodide, and occurrence of cells with swollen, fragmented and/or condensed nuclei) were only identified with 7beta-hydroxycholesterol, 7-ketocholesterol and cholesterol-5beta,6beta-epoxide, which also induce lysosomal destabilization associated or not associated with the formation of monodansylcadaverine-positive cytoplasmic structures. No relationship between oxysterol-induced cytotoxicity and HMG-CoA reductase activity was found. In addition, the highest O2*- overproduction quantified with hydroethidine was identified with 7beta-hydroxycholesterol, 7-ketocholesterol and cholesterol-5beta,6beta-epoxide, with cholesterol-5alpha, 6alpha-epoxide and 25-hydroxycholesterol. The highest capacity to simultaneously stimulate IL-8 secretion (quantified by ELISA and by using a multiplexed, particle-based flow cytometric assay) and enhance IL-8 mRNA levels (determined by RT-PCR) was observed with 7beta-hydroxycholesterol and 25-hydroxycholesterol. None of the effects observed for the oxysterols were detected for cholesterol. Therefore, oxysterols may have cytotoxic, oxidative, and/or inflammatory effects, or none whatsoever.

High circulating levels of 7beta- and 7alpha-hydroxycholesterol and presence of apoptotic and oxidative markers in arterial lesions of normocholesterolemic atherosclerotic patients undergoing endarterectomy

In previous investigations, we found that 7beta-hydroxycholesterol had potent pro-apoptotic, and pro-oxidative properties. So, we asked whether the circulating level of this oxysterol was enhanced in atherosclerotic patients undergoing endarterectomy of the superficial femoral artery. To this end, 7beta-hydroxycholesterol serum concentrations were determined and compared with common lipid parameters in atherosclerotic patients, and in healthy subjects. 7alpha-hydroxycholesterol was simultaneously measured to evaluate the reliability of the method used for oxysterol analysis. On normal and atherosclerotic arterial fragments from patients, markers of oxidation (4-hydroxynonenal (4-HNE) adducts), and apoptosis (activated caspase-3; condensed/fragmented nuclei) were studied. Interestingly, high serum concentrations of 7beta- and 7alpha-hydroxycholesterol were found in normocholesterolemic atherosclerotic patients. However, in statin-treated patients, the circulating levels of 7beta- and 7alpha-hydroxycholesterol tend towards normal values. Therefore, 7beta- as well as 7alpha-hydroxycholesterol could be more appropriate markers of lipid metabolism disorders than cholesterol or LDL in normocholesterolemic patients with atherosclerosis of the lower limbs, and statins could normalize their serum concentrations. At the arterial level, apoptotic cells were mainly identified in low grade lesions and no statin effects were found on oxidation and apoptosis.

Involvement of a calcium-dependent dephosphorylation of BAD associated with the localization of Trpc-1 within lipid rafts in 7-ketocholesterol-induced THP-1 cell apoptosis

7-Ketocholesterol is a component of oxidized LDL, which plays a central role in atherosclerosis. It is a potent inducer of cell death towards a wide number of cells involved in atherosclerosis. In this study, it is reported that 7-ketocholesterol treatment induces an increase of cytosolic-free Ca(2+) in THP-1 monocytic cells. This increase is correlated with the induction of cytotoxicity as suggested from experiments using the Ca(2+) channel blockers verapamil and nifedipine. This 7-ketocholesterol-induced apoptosis appears to be associated with the dephosphorylation of serine 75 and serine 99 of the proapoptotic protein Bcl-2 antagonist of cell death (BAD). We demonstrated that this dephosphorylation results mainly from the activation of calcium-dependent phosphatase calcineurin by the oxysterol-induced increase in Ca(2+). Moreover, this Ca(2+) increase appears related to the incorporation of 7-ketocholesterol into lipid raft domains of the plasma membrane, followed by the translocation of transient receptor potential calcium channel 1, a component of the store operated Ca(2+) entry channel, to rafts.

[Microspheres, nanospheres and flow cytometry: from cellular to molecular analysis]

Micro- and nanospheres are tightly associated with the development of flow cytometry. They are indispensable tools to optimize diffraction and fluorescence signals as well as for fluorescence calibration and cellular purification (magnetic micro- and nanospheres). They are also usefull to evaluate phagocytosis and to detect slightly expressed antigens. Recently, developments of microspheres-based flow cytometric assays have raised to quantify soluble analytes in biological fluids, cellular and tissue samples. The technology utilizes spectrally distinct fluorescent microspheres as a solid support for a conventional immunoassay, affinity assay or DNA hybridisation assay which is subsequently analyzed on a flow cytometer. Several multiplexed bead systems are now available facilitating the development of multiplexed assays that simultaneously measure many different analytes in few microliters of sample. Some recent applications with fluorescent microspheres coated with antibodies or oligonucleotides include cytokines and PCR products quantitation and single nucleotide polymorphism genotyping. Thus, multiplex assays using microspheres and flow cytometry technologies are exciting techniques which have the potential to contribute to the development of efficient diagnostic and research methods.