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Tsamantioti E, Sandström A, Muraca GM, Joseph KS, Remaeus K, Razaz N. Severe maternal morbidity surveillance, temporal trends and regional variation: A population-based cohort study. BJOG 2024; 131:811-822. [PMID: 37798853 DOI: 10.1111/1471-0528.17686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 09/12/2023] [Accepted: 09/18/2023] [Indexed: 10/07/2023]
Abstract
OBJECTIVE To quantify temporal trends and regional variation in severe maternal morbidity (SMM) in Sweden. DESIGN Cohort study. POPULATION Live birth and stillbirth deliveries in Sweden, 1999-2019. METHODS Types and subtypes of SMM were identified, based on a standard list (modified for Swedish clinical setting after considering the frequency and validity of each indicator) using diagnoses and procedure codes, among all deliveries at ≥22 weeks of gestation (including complications within 42 days of delivery). Contrasts between regions were quantified using rate ratios (RRs) and 95% confidence intervals (95% CIs). Temporal changes in SMM types and subtypes were described. MAIN OUTCOME MEASURES Types and subtypes of SMM. RESULTS There were 59 789 SMM cases among 2 212 576 deliveries, corresponding to 270.2 (95% CI 268.1-272.4) per 10 000 deliveries. Composite SMM rates increased from 236.6 per 10 000 deliveries in 1999 to 307.3 per 10 000 deliveries in 2006, before declining to 253.8 per 10 000 deliveries in 2019. Changes in composite SMM corresponded with temporal changes in severe haemorrhage rates, which increased from 94.9 per 10 000 deliveries in 1999 to 169.3 per 10 000 deliveries in 2006, before declining to 111.2 per 10 000 deliveries in 2019. Severe pre-eclampsia, eclampsia and HELLP (haemolysis, elevated liver enzymes and low platelet count) syndrome (103.8 per 10 000 deliveries), severe haemorrhage (133.7 per 10 000 deliveries), sepsis, embolism, disseminated intravascular coagulation, shock and severe mental health disorders were the most common SMM types. Rates of embolism, disseminated intravascular coagulation and shock, acute renal failure, cardiac complications, sepsis and assisted ventilation increased, whereas rates of surgical complications, severe uterine rupture and anaesthesia complications declined. CONCLUSIONS The observed spatiotemporal variations in composite SMM and SMM types provide substantive insights and highlight regional priorities for improving maternal health.
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Affiliation(s)
- Eleni Tsamantioti
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Anna Sandström
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Giulia M Muraca
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Obstetrics and Gynaecology, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - K S Joseph
- Department of Obstetrics and Gynaecology, University of British Columbia and the Children's and Women's Hospital and Health Centre of British Columbia, Vancouver, British Columbia, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Katarina Remaeus
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Neda Razaz
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
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Joseph KS, Lisonkova S, Boutin A, Muraca GM, Razaz N, John S, Sabr Y, Chan WS, Mehrabadi A, Brandt JS, Schisterman EF, Ananth CV. Maternal mortality in the United States: are the high and rising rates due to changes in obstetrical factors, maternal medical conditions, or maternal mortality surveillance? Am J Obstet Gynecol 2024; 230:440.e1-440.e13. [PMID: 38480029 DOI: 10.1016/j.ajog.2023.12.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 11/30/2023] [Accepted: 12/21/2023] [Indexed: 04/05/2024]
Abstract
BACKGROUND National Vital Statistics System reports show that maternal mortality rates in the United States have nearly doubled, from 17.4 in 2018 to 32.9 per 100,000 live births in 2021. However, these high and rising rates could reflect issues unrelated to obstetrical factors, such as changes in maternal medical conditions or maternal mortality surveillance (eg, due to introduction of the pregnancy checkbox). OBJECTIVE This study aimed to assess if the high and rising rates of maternal mortality in the United States reflect changes in obstetrical factors, maternal medical conditions, or maternal mortality surveillance. STUDY DESIGN The study was based on all deaths in the United States from 1999 to 2021. Maternal deaths were identified using the following 2 approaches: (1) per National Vital Statistics System methodology, as deaths in pregnancy or in the postpartum period, including deaths identified solely because of a positive pregnancy checkbox, and (2) under an alternative formulation, as deaths in pregnancy or in the postpartum period, with at least 1 mention of pregnancy among the multiple causes of death on the death certificate. The frequencies of major cause-of-death categories among deaths of female patients aged 15 to 44 years, maternal deaths, deaths due to obstetrical causes (ie, direct obstetrical deaths), and deaths due to maternal medical conditions aggravated by pregnancy or its management (ie, indirect obstetrical deaths) were quantified. RESULTS Maternal deaths, per National Vital Statistics System methodology, increased by 144% (95% confidence interval, 130-159) from 9.65 in 1999-2002 (n=1550) to 23.6 per 100,000 live births in 2018-2021 (n=3489), with increases occurring among all race and ethnicity groups. Direct obstetrical deaths increased from 8.41 in 1999-2002 to 14.1 per 100,000 live births in 2018-2021, whereas indirect obstetrical deaths increased from 1.24 to 9.41 per 100,000 live births: 38% of direct obstetrical deaths and 87% of indirect obstetrical deaths in 2018-2021 were identified because of a positive pregnancy checkbox. The pregnancy checkbox was associated with increases in less specific and incidental causes of death. For example, maternal deaths with malignant neoplasms listed as a multiple cause of death increased 46-fold from 0.03 in 1999-2002 to 1.42 per 100,000 live births in 2018-2021. Under the alternative formulation, the maternal mortality rate was 10.2 in 1999-2002 and 10.4 per 100,000 live births in 2018-2021; deaths from direct obstetrical causes decreased from 7.05 to 5.82 per 100,000 live births. Deaths due to preeclampsia, eclampsia, postpartum hemorrhage, puerperal sepsis, venous complications, and embolism decreased, whereas deaths due to adherent placenta, renal and unspecified causes, cardiomyopathy, and preexisting hypertension increased. Maternal mortality increased among non-Hispanic White women and decreased among non-Hispanic Black and Hispanic women. However, rates were disproportionately higher among non-Hispanic Black women, with large disparities evident in several causes of death (eg, cardiomyopathy). CONCLUSION The high and rising rates of maternal mortality in the United States are a consequence of changes in maternal mortality surveillance, with reliance on the pregnancy checkbox leading to an increase in misclassified maternal deaths. Identifying maternal deaths by requiring mention of pregnancy among the multiple causes of death shows lower, stable maternal mortality rates and declines in maternal deaths from direct obstetrical causes.
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Affiliation(s)
- K S Joseph
- Department of Obstetrics and Gynaecology, University of British Columbia, BC Children's and Women's Hospital and Health Centre, Vancouver, Canada; School of Population and Public Health, University of British Columbia, Vancouver, Canada.
| | - Sarka Lisonkova
- Department of Obstetrics and Gynaecology, University of British Columbia, BC Children's and Women's Hospital and Health Centre, Vancouver, Canada; School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Amélie Boutin
- Department of Pediatrics, Faculty of Medicine, Université Laval, CHU de Québec-Université Laval Research Center, Québec City, Canada
| | - Giulia M Muraca
- Department of Obstetrics and Gynecology and Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Neda Razaz
- Division of Clinical Epidemiology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Sid John
- Department of Obstetrics and Gynaecology, University of British Columbia, BC Children's and Women's Hospital and Health Centre, Vancouver, Canada
| | - Yasser Sabr
- Department of Obstetrics and Gynecology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Wee-Shian Chan
- Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Azar Mehrabadi
- Perinatal Epidemiology Research Unit, Department of Obstetrics and Gynaecology and Department of Pediatrics, Dalhousie University, Halifax, Canada
| | - Justin S Brandt
- Department of Obstetrics, Gynecology and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ; Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, NYU Grossman School of Medicine, New York, NY
| | - Enrique F Schisterman
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Cande V Ananth
- Division of Epidemiology and Biostatistics, Department of Obstetrics, Gynecology and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ; Cardiovascular Research Institute, Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ; Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ; Environmental and Occupational Health Sciences Institute, Rutgers Robert Wood Johnson Medical School, Piscataway, NJ
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Wang LQ, Bone JN, Muraca GM, Razaz N, Joseph KS, Lisonkova S. Prepregnancy body mass index and other risk factors for early-onset and late-onset haemolysis, elevated liver enzymes and low platelets (HELLP) syndrome: a population-based retrospective cohort study in British Columbia, Canada. BMJ Open 2024; 14:e079131. [PMID: 38521522 PMCID: PMC10961512 DOI: 10.1136/bmjopen-2023-079131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 03/01/2024] [Indexed: 03/25/2024] Open
Abstract
BACKGROUND Obesity increases risk of pre-eclampsia, but the association with haemolysis, elevated liver enzymes and low platelets (HELLP) syndrome is understudied. OBJECTIVE To examine the association between prepregnancy body mass index (BMI) and HELLP syndrome, including early-onset versus late-onset disease. STUDY DESIGN A retrospective cohort study using population-based data. SETTING British Columbia, Canada, 2008/2009-2019/2020. POPULATION All pregnancies resulting in live births or stillbirths at ≥20 weeks' gestation. METHODS BMI categories (kg/m2) included underweight (<18.5), normal (18.5-24.9), overweight (25.0-29.9) and obese (≥30.0). Rates of early-onset and late-onset HELLP syndrome (<34 vs ≥34 weeks, respectively) were calculated per 1000 ongoing pregnancies at 20 and 34 weeks' gestation, respectively. Cox regression was used to assess the associations between risk factors (eg, BMI, maternal age and parity) and early-onset versus late-onset HELLP syndrome. MAIN OUTCOME MEASURES Early-onset and late-onset HELLP syndrome. RESULTS The rates of HELLP syndrome per 1000 women were 2.8 overall (1116 cases among 391 941 women), and 1.9, 2.5, 3.2 and 4.0 in underweight, normal BMI, overweight and obese categories, respectively. Overall, gestational age-specific rates of HELLP syndrome increased with prepregnancy BMI. Obesity (compared with normal BMI) was more strongly associated with early-onset HELLP syndrome (adjusted HR (AHR) 2.24 (95% CI 1.65 to 3.04) than with late-onset HELLP syndrome (AHR 1.48, 95% CI 1.23 to 1.80) (p value for interaction 0.025). Chronic hypertension, multiple gestation, bleeding (<20 weeks' gestation and antepartum) also showed differing AHRs between early-onset versus late-onset HELLP syndrome. CONCLUSIONS Prepregnancy BMI is positively associated with HELLP syndrome and the association is stronger with early-onset HELLP syndrome. Associations with early-onset and late-onset HELLP syndrome differed for some risk factors, suggesting possible differences in aetiological mechanisms.
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Affiliation(s)
- Li Qing Wang
- Department of Obstetrics and Gynaecology, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
- BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Jeffrey N Bone
- Research Informatics, BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Giulia M Muraca
- Department of Obstetrics and Gynecology, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institute, Stockholm, Sweden
| | - Neda Razaz
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institute, Stockholm, Sweden
| | - K S Joseph
- BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
- Department of Obstetrics and Gynaecology, School of Population and Public Health, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Sarka Lisonkova
- BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
- Department of Obstetrics and Gynaecology, School of Population and Public Health, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
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Muraca GM, Peled T, Kirubarajan A, Weiss A, Sela HY, Grisaru-Granovsky S, Rottenstreich M. The association between unintended hysterotomy extensions with cesarean delivery and subsequent preterm birth. Am J Obstet Gynecol MFM 2024; 6:101326. [PMID: 38447679 DOI: 10.1016/j.ajogmf.2024.101326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Revised: 02/18/2024] [Accepted: 02/27/2024] [Indexed: 03/08/2024]
Abstract
BACKGROUND An increased risk for preterm birth has been observed among individuals with a previous second stage cesarean delivery when compared with those with a previous vaginal delivery. One mechanism that may contribute to the increased risk for preterm birth following a second stage cesarean delivery is the increased risk for cervical injury because of extension of the uterine incision (hysterotomy) into the cervix. The contribution of hysterotomy extension to the rate of preterm birth in a subsequent pregnancy has not been investigated and may shed light on the mechanism underlying the observed relationship between the mode of delivery and subsequent preterm birth. OBJECTIVE We aimed to quantify the association between unintended hysterotomy extension and preterm birth in a subsequent delivery. STUDY DESIGN We performed a retrospective cohort study using electronic perinatal data collected from 2 university-affiliated obstetrical centers. The study included patients with a primary cesarean delivery of a term, singleton live birth and a subsequent singleton birth in the same catchment (2005-2021). The primary outcome was subsequent preterm birth <37 weeks' gestation; secondary outcomes included subsequent preterm birth at <34, <32, and <28 weeks' gestation. We assessed crude and adjusted associations between unintended hysterotomy extensions and subsequent preterm birth with log binomial regression models using rate ratios and 95% confidence intervals. Adjusted models included several characteristics of the primary cesarean delivery such as maternal age, length of active labor, indication for cesarean delivery, chorioamnionitis, and maternal comorbidity. RESULTS A total 4797 patients met the study inclusion criteria. The overall rate of unintended hysterotomy extension in the primary cesarean delivery was 6.0% and the total rate of preterm birth in the subsequent pregnancy was 4.8%. Patients with an unintended hysterotomy extension were more likely to have a longer duration of active labor, chorioamnionitis, failed vacuum delivery attempt, second stage cesarean delivery, and persistent occiput posterior position of the fetal head in the primary cesarean delivery and higher rates of smoking in the subsequent pregnancy. Multivariable analyses that controlled for several confounders showed that a history of hysterotomy extension was not associated with a higher risk for preterm birth <37 weeks' gestation (adjusted rate ratio, 1.55; 95% confidence interval, 0.98-2.47), but it was associated with preterm birth <34 weeks' gestation (adjusted rate ratio, 2.49; 95% confidence interval, 1.06-5.42). CONCLUSION Patients with a uterine incision extension have a 2.5 times higher rate of preterm birth <34 weeks' gestation when compared with patients who did not have this injury. This association was not observed for preterm birth <37 weeks' gestation. Future research should aim to replicate our analyses with incorporation of additional data to minimize the potential for residual confounding.
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Affiliation(s)
- Giulia M Muraca
- Department of Obstetrics and Gynecology, Faculty of Health Sciences, McMaster University (Drs Muraca, Kirubarajan, and Rottenstreich), Hamilton, Canada; Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University (Dr Muraca), Hamilton, Canada; Clinical Epidemiology Unit, Department of Medicine, Solna, Karolinska Institutet (Dr Muraca), Stockholm, Sweden.
| | - Tzuria Peled
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, Hebrew University School of Medicine (Drs Peled, Weiss, Sela, Grisaru-Granovsky, and Rottenstreich), Jerusalem, Israel
| | - Abirami Kirubarajan
- Department of Obstetrics and Gynecology, Faculty of Health Sciences, McMaster University (Drs Muraca, Kirubarajan, and Rottenstreich), Hamilton, Canada
| | - Ari Weiss
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, Hebrew University School of Medicine (Drs Peled, Weiss, Sela, Grisaru-Granovsky, and Rottenstreich), Jerusalem, Israel
| | - Hen Y Sela
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, Hebrew University School of Medicine (Drs Peled, Weiss, Sela, Grisaru-Granovsky, and Rottenstreich), Jerusalem, Israel
| | - Sorina Grisaru-Granovsky
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, Hebrew University School of Medicine (Drs Peled, Weiss, Sela, Grisaru-Granovsky, and Rottenstreich), Jerusalem, Israel
| | - Misgav Rottenstreich
- Department of Obstetrics and Gynecology, Faculty of Health Sciences, McMaster University (Drs Muraca, Kirubarajan, and Rottenstreich), Hamilton, Canada; Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, Hebrew University School of Medicine (Drs Peled, Weiss, Sela, Grisaru-Granovsky, and Rottenstreich), Jerusalem, Israel
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Lisonkova S, Bone JN, Wen Q, Muraca GM, Ting JY, Razaz N, Joseph KS. COVID-19 Pandemic-Related Changes in Rates of Neonatal Abstinence Syndrome. JAMA Netw Open 2024; 7:e241651. [PMID: 38457184 PMCID: PMC10924237 DOI: 10.1001/jamanetworkopen.2024.1651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2024] Open
Abstract
This cross-sectional study examines COVID-19 pandemic–related changes in rates of neonatal abstinence syndrome (NAS) and whether infants in urban or rural areas and those with low socioeconomic status were disproportionately affected.
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Affiliation(s)
- Sarka Lisonkova
- Department of Obstetrics and Gynaecology, University of British Columbia and the Children's and Women's Hospital and Health Centre of British Columbia, Vancouver, British Columbia, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jeffrey N Bone
- Department of Obstetrics and Gynaecology, University of British Columbia and the Children's and Women's Hospital and Health Centre of British Columbia, Vancouver, British Columbia, Canada
- Division of Biostatistics, British Columbia Children's Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Qi Wen
- Department of Obstetrics and Gynaecology, University of British Columbia and the Children's and Women's Hospital and Health Centre of British Columbia, Vancouver, British Columbia, Canada
| | - Giulia M Muraca
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
| | - Joseph Y Ting
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Neda Razaz
- Clinical Epidemiology Division, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - K S Joseph
- Department of Obstetrics and Gynaecology, University of British Columbia and the Children's and Women's Hospital and Health Centre of British Columbia, Vancouver, British Columbia, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
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Kirubarajan A, Thangavelu N, Rottenstreich M, Muraca GM. Operative delivery in the second stage of labor and preterm birth in a subsequent pregnancy: a systematic review and meta-analysis. Am J Obstet Gynecol 2024; 230:295-307.e2. [PMID: 37673234 DOI: 10.1016/j.ajog.2023.08.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 08/18/2023] [Accepted: 08/28/2023] [Indexed: 09/08/2023]
Abstract
OBJECTIVE This study aimed to quantify the association between mode of operative delivery in the second stage of labor (cesarean delivery vs operative vaginal delivery) and spontaneous preterm birth in a subsequent pregnancy. DATA SOURCES MEDLINE, Embase, EmCare, CINAHL, the Cochrane Library, Web of Science: Core Collection, and Scopus were searched from database inception to April 1, 2023. STUDY ELIGIBILITY CRITERIA All retrospective cohort studies with participants who had a second-stage cesarean delivery (defined as intrapartum cesarean delivery at full cervical dilation) or operative vaginal delivery (including forceps- and/or vacuum-assisted delivery) and that reported the rate of preterm birth (either spontaneous or not specified) in subsequent pregnancy were included. METHODS Both a descriptive analysis and a meta-analysis were performed. A meta-analysis was performed for dichotomous data using the Mantel-Haenszel random-effects model and used the odds ratio as an effect measure with 95% confidence intervals. The risk of bias was assessed using Cochrane's 2022 Risk Of Bias In Non-randomized Studies of Exposure tool. RESULTS After screening 2671 articles from 7 databases, a total of 18 retrospective cohort studies encompassing 605,138 patients were included. The pooled rates of spontaneous preterm birth in a subsequent pregnancy were 6.9% (12 studies) after second-stage cesarean delivery and 2.6% (8 studies) after operative vaginal delivery. A total of 7 studies encompassing 75,460 patients compared the primary outcome of spontaneous preterm birth after second-stage cesarean delivery vs operative vaginal delivery in an index pregnancy with an odds ratio of 2.01 (95% confidence interval, 1.57-2.58) in favor of operative vaginal delivery. However, most studies did not include important confounding factors, did not address exposure misclassification because of failed operative vaginal delivery, and considered operative vaginal delivery as a homogeneous category with no distinction between forceps- and vacuum-assisted deliveries. CONCLUSION Although a synthesis of the existing literature suggests that the risk of spontaneous preterm birth is higher in those with a previous second-stage cesarean delivery than in those with operative vaginal delivery, the risk of bias in these studies is very high. Findings should be interpreted with caution.
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Affiliation(s)
- Abirami Kirubarajan
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Canada.
| | - Nila Thangavelu
- Bachelor of Health Sciences Program, McMaster University, Hamilton, Canada
| | - Misgav Rottenstreich
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Canada; Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, affiliated with the Hebrew University School of Medicine, Jerusalem, Israel
| | - Giulia M Muraca
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Canada; Faculty of Health Sciences, Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada; Clinical Epidemiology Unit, Department of Medicine, Solna, Karolinska Institute, Stockholm Sweden
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Muraca GM, Desai A, Hébert V, Mann GK, Park M, Lisonkova S, Joseph KS. Variation in Episiotomy Use Among Nulliparous Individuals by Maternity Care Provider and Associated Rates of Obstetric Anal Sphincter Injury. J Obstet Gynaecol Can 2024; 46:102415. [PMID: 38387834 DOI: 10.1016/j.jogc.2024.102415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 01/30/2024] [Accepted: 01/31/2024] [Indexed: 02/24/2024]
Abstract
OBJECTIVES To quantify variation in the association between episiotomy and obstetric anal sphincter injury (OASI) by maternity care provider in spontaneous and operative vaginal deliveries (SVDs and OVDs). METHODS Population-based retrospective cohort study of vaginal, term deliveries among nullipara in Canada (2004-2015). Adjusted rate ratios (ARRs) and 95% CIs were estimated using log-binomial regression to quantify the associations between episiotomy and OASI, stratified by care provider (obstetrician [OB], family physician [FP], or registered midwife [RM]) while adjusting for potential confounders. RESULTS The study included 631 642 deliveries. Episiotomy use varied by provider: among SVDs, the episiotomy rate was 19.6%, 14.4%, and 8.4% in the OB, FP, and RM groups, respectively. The rate of OASI was higher among SVDs with versus without episiotomy (5.8% vs 4.6%). Conversely, OASI occurred less frequently in operative vaginal deliveries with episiotomy (15.3%) compared with those without (16.7%). In all provider groups, the ARR for OASI was increased with episiotomy in SVD and decreased with episiotomy with forceps delivery. No differences in these associations were observed by provider except among vacuum delivery (ARR with episiotomy vs. without, OB: 0.88, 95% CI 0.84-0.92; FP: 0.89, 95% CI 0.83-0.96, RM: 1.22, 95% CI 1.02-1.48). CONCLUSIONS In nullipara, irrespective of maternity care provider, there is a positive association between episiotomy and OASI among SVDs and an inverse association between episiotomy and deliveries with forceps. The relationship between episiotomy and OASI is modified by maternity care providers among vacuum deliveries.
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Affiliation(s)
- Giulia M Muraca
- Department of Obstetrics and Gynecology, Faculty of Health Sciences, McMaster University, Hamilton, ON; Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, ON; Clinical Epidemiology Unit, Department of Medicine, Karolinska Institutet, Solna, Sweden.
| | - Anvi Desai
- Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, ON
| | - Vanessa Hébert
- Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, ON
| | - Gurkiran K Mann
- Department of Obstetrics and Gynecology, Faculty of Health Sciences, McMaster University, Hamilton, ON
| | - Meejin Park
- Department of Global Health, Faculty of Health Sciences, McMaster University, Hamilton, ON
| | - Sarka Lisonkova
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada; School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - K S Joseph
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada; School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
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Park M, Wanigaratne S, D'Souza R, Geoffrion R, Williams S, Muraca GM. Asian-White disparities in obstetric anal sphincter injury: a systematic review and meta-analysis. AJOG Glob Rep 2024; 4:100296. [PMID: 38283323 PMCID: PMC10820309 DOI: 10.1016/j.xagr.2023.100296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2024] Open
Abstract
OBJECTIVE Obstetrical anal sphincter injury describes a severe injury to the perineum and perianal muscles after birth. Obstetrical anal sphincter injury occurs in approximately 4.4% of vaginal births in the United States; however, racial and ethnic inequities in the incidence of obstetrical anal sphincter injury have been shown in several high-income countries. Specifically, an increased risk of obstetrical anal sphincter injury in individuals who identify as Asian vs those who identify as White has been documented among residents of the United States, Australia, Canada, Western Europe, and the Scandinavian countries. The high rates of obstetrical anal sphincter injury among the Asian diaspora in these countries are higher than obstetrical anal sphincter injury rates reported among Asian populations residing in Asia. A systematic review and meta-analysis of studies in high-income, non-Asian countries was conducted to further evaluate this relationship. DATA SOURCES MEDLINE, Ovid, Embase, EmCare, and the Cochrane databases were searched from inception to March 2023 for original research studies. STUDY ELIGIBILITY CRITERIA Observational studies using keywords and controlled vocabulary terms related to race, ethnicity and obstetrical anal sphincter injury. All observational studies, including cross-sectional, case-control, and cohort were included. 2 reviewers followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and the Meta-analysis of Observational Studies in Epidemiology recommendations. METHODS Meta-analysis was performed using RevMan (version 5.4; Cochrane Collaboration, London, United Kingdom) for dichotomous data using the random effects model and the odds ratios as effect measures with 95% confidence intervals. Subgroup analysis was performed among Asian subgroups. The risk of bias was assessed using the Joanna Briggs Institute Critical Appraisal tools. Meta-regression was used to determine sources of between-study heterogeneity. Results A total of 27 studies conducted in 7 countries met the inclusion criteria encompassing 2,337,803 individuals. The pooled incidence of obstetrical anal sphincter injury was higher among Asian individuals than White individuals (pooled odds ratio, 1.64; 95% confidence interval, 1.48-1.80). Subgroup analyses showed that obstetrical anal sphincter injury rates were highest among South Asians and among population-based vs hospital-based studies. Meta-regression showed that moderate heterogeneity remained even after accounting for differences in studies by types of Asian subgroups included, study year, mode of delivery included, and study setting. Conclusion Obstetrical anal sphincter injury is more frequent among Asian versus white birthing individuals in multiple high-income, non-Asian countries. Qualitative and quantitative research to elucidate underlying causal mechanisms responsible for this relationship are warranted.
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Affiliation(s)
- Meejin Park
- Faculty of Health Sciences, Department of Global Health, McMaster University, Hamilton, Ontario, Canada (Ms Park)
| | - Susitha Wanigaratne
- Edwin S.H. Leong Centre for Healthy Children, SickKids Research Institute, Toronto, Ontario, Canada (Dr Wanigaratne)
| | - Rohan D'Souza
- Faculty of Health Sciences, Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada (Drs D'Souza and Muraca)
- Faculty of Health Sciences, Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada (Drs D'Souza and Muraca)
| | - Roxana Geoffrion
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, British Columbia, Canada (Dr Geoffrion)
| | - Sarah Williams
- Department of Anthropology, University of Connecticut, Mansfield, CT (Dr Williams)
| | - Giulia M. Muraca
- Faculty of Health Sciences, Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada (Drs D'Souza and Muraca)
- Faculty of Health Sciences, Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada (Drs D'Souza and Muraca)
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden (Dr Muraca)
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Peled T, Muraca GM, Ratner M, Sela HY, Kirubarajan A, Weiss A, Grisaru-Granovsky S, Rottenstreich M. Impacted fetal head extraction methods at second stage cesarean and subsequent preterm delivery: A multicenter study. Int J Gynaecol Obstet 2024. [PMID: 38235842 DOI: 10.1002/ijgo.15383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 12/22/2023] [Accepted: 01/02/2024] [Indexed: 01/19/2024]
Abstract
OBJECTIVE Second-stage cesarean delivery (CD) is associated with subsequent preterm birth (PTB). It has been suggested that an increased risk of PTB after second-stage cesarean delivery could be linked to a higher chance of cervical injury due to the extension of the uterine incision. Previous studies have shown that reverse breech extraction is associated with lower rates of uterine incision extensions compared to the "push" method. We aimed to investigate the association between the method of fetal extraction during second-stage CD and the rate of spontaneous PTB (sPTB), as well as other maternal and neonatal outcomes during the subsequent pregnancy. METHODS This was a multicenter retrospective cohort study. The study population included women in their first subsequent singleton delivery following a second-stage CD between 2004 and 2021. The main exposure of interest was the method of fetal extraction in the index CD ("push" method vs. reverse breech extraction). The primary outcome of this study was sPTB <37 weeks in the subsequent pregnancy. Secondary outcomes were overall PTB, trial of labor, and other adverse maternal and neonatal outcomes. Univariate analysis was followed by multiple logistic regression modeling. RESULTS During the study period, 2969 index CD during second stage were performed, of those 583 met the inclusion criteria, of whom 234 (40.1%) had fetal extraction using the reverse breech extraction method, while 349 (59.9%) had the "push" method for extraction. In univariate analysis, women in those two groups had statistically similar rates of sPTB (3.7% vs. 3.0%; odds ratio [OR] 1.25, 95% CI: 0.49-3.19) and overall PTB (<37, <34 and <32 weeks), as well as other maternal, neonatal, and trial of labor outcomes. This was confirmed by multivariate analyses with an adjusted OR of 1.27 (95% CI: 0.43-3.71) for sPTB. CONCLUSION Among women with a previous second-stage CD, no significant difference was observed in PTB rates in the subsequent pregnancies following the "push" method compared to the reverse breech extraction method.
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Affiliation(s)
- Tzuria Peled
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, affiliated with the Hebrew University School of Medicine, Jerusalem, Israel
| | - Giulia M Muraca
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
- Clinical Epidemiology Unit, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Miri Ratner
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, affiliated with the Hebrew University School of Medicine, Jerusalem, Israel
| | - Hen Y Sela
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, affiliated with the Hebrew University School of Medicine, Jerusalem, Israel
| | - Abirami Kirubarajan
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
| | - Ari Weiss
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, affiliated with the Hebrew University School of Medicine, Jerusalem, Israel
| | - Sorina Grisaru-Granovsky
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, affiliated with the Hebrew University School of Medicine, Jerusalem, Israel
| | - Misgav Rottenstreich
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, affiliated with the Hebrew University School of Medicine, Jerusalem, Israel
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
- Department of Nursing, Jerusalem College of Technology, Jerusalem, Israel
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10
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Joseph KS, Lisonkova S, Simon S, John S, Razaz N, Muraca GM, Boutin A, Bedaiwy MA, Brandt JS, Ananth CV. Effect of the COVID-19 Pandemic on Stillbirths in Canada and the United States. J Obstet Gynaecol Can 2023:102338. [PMID: 38160796 DOI: 10.1016/j.jogc.2023.102338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 12/08/2023] [Accepted: 12/13/2023] [Indexed: 01/03/2024]
Abstract
OBJECTIVE There is uncertainty regarding the effect of the COVID-19 pandemic on population rates of stillbirth. We quantified pandemic-associated changes in stillbirth rates in Canada and the United States. METHODS We carried out a retrospective study that included all live births and stillbirths in Canada and the United States from 2015 to 2020. The primary analysis was based on all stillbirths and live births at ≥20 weeks gestation. Stillbirth rates were analyzed by month, with March 2020 considered to be the month of pandemic onset. Interrupted time series analyses were used to determine pandemic effects. RESULTS The study population included 18,475 stillbirths and 2,244,240 live births in Canada and 134,883 stillbirths and 22,963,356 live births in the United States (8.2 and 5.8 stillbirths per 1,000 total births, respectively). In Canada, pandemic onset was associated with an increase in stillbirths at ≥20 weeks gestation of 1.01 (95% confidence interval [CI] 0.56-1.46) per 1,000 total births and an increase in stillbirths at ≥28 weeks gestation of 0.35 (95% CI 0.16-0.54) per 1,000 total births. In the United States, pandemic onset was associated with an increase in stillbirths at ≥20 weeks gestation of 0.48 (95% CI 0.22-0.75) per 1,000 total births and an increase in stillbirths at ≥28 weeks gestation of 0.22 (95% CI 0.12-0.32) per 1,000 total births. The increase in stillbirths at pandemic onset returned to pre-pandemic levels in subsequent months. CONCLUSION The COVID-19 pandemic's onset was associated with a transitory increase in stillbirth rates in Canada and the United States.
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Affiliation(s)
- K S Joseph
- Department of Obstetrics and Gynaecology, University of British Columbia and the Children's and Women's Hospital and Health Centre of British Columbia, Vancouver, Canada; School of Population and Public Health, University of British Columbia, Vancouver, Canada.
| | - Sarka Lisonkova
- Department of Obstetrics and Gynaecology, University of British Columbia and the Children's and Women's Hospital and Health Centre of British Columbia, Vancouver, Canada; School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Sophie Simon
- Department of Obstetrics and Gynaecology, University of British Columbia and the Children's and Women's Hospital and Health Centre of British Columbia, Vancouver, Canada
| | - Sid John
- Department of Obstetrics and Gynaecology, University of British Columbia and the Children's and Women's Hospital and Health Centre of British Columbia, Vancouver, Canada
| | - Neda Razaz
- Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Giulia M Muraca
- Departments of Obstetrics and Gynecology, and Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Amélie Boutin
- Department of Pediatrics, Faculty of Medicine, Université Laval and CHU de Québec-Université Laval Research Center, Québec City, Canada
| | - Mohamed A Bedaiwy
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynaecology, University of British Columbia and the Children's and Women's Hospital and Health Centre of British Columbia, Vancouver, Canada
| | - Justin S Brandt
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, NYU Grossman School of Medicine, New York, New York, USA
| | - Cande V Ananth
- Division of Epidemiology and Biostatistics, Department of Obstetrics, Gynecology, and Reproductive Sciences; Cardiovascular Institute of New Jersey; Department of Medicine; Department of Biostatistics and Epidemiology; Environmental and Occupational Health Sciences Institute, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
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11
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Affiliation(s)
- Giulia M Muraca
- Departments of Obstetrics and Gynecology and Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - K S Joseph
- Department of Obstetrics and Gynaecology and School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
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12
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Simon S, John S, Lisonkova S, Razaz N, Muraca GM, Boutin A, Bedaiwy MA, Brandt JS, Ananth CV, Joseph KS. Obstetric Intervention and Perinatal Outcomes During the Coronavirus Disease 2019 (COVID-19) Pandemic. Obstet Gynecol 2023; 142:1405-1415. [PMID: 37826851 PMCID: PMC10642704 DOI: 10.1097/aog.0000000000005412] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Revised: 08/07/2023] [Accepted: 08/17/2023] [Indexed: 10/14/2023]
Abstract
OBJECTIVE To quantify pandemic-related changes in obstetric intervention and perinatal outcomes in the United States. METHODS We carried out a retrospective study of all live births and fetal deaths in the United States, 2015-2021, with data obtained from the natality, fetal death, and linked live birth-infant death files of the National Center for Health Statistics. Analyses were carried out among all singletons; singletons of patients with prepregnancy diabetes, prepregnancy hypertension, and hypertensive disorders of pregnancy; and twins. Outcomes of interest included preterm birth, preterm labor induction or preterm cesarean delivery, macrosomia, postterm birth, and perinatal death. Interrupted time series analyses were used to estimate changes in the prepandemic period (January 2015-February 2020), at pandemic onset (March 2020), and in the pandemic period (March 2020-December 2021). RESULTS The study population included 26,604,392 live births and 155,214 stillbirths. The prepandemic period was characterized by temporal increases in preterm birth and preterm labor induction or cesarean delivery rates and temporal reductions in macrosomia, postterm birth, and perinatal mortality. Pandemic onset was associated with absolute decreases in preterm birth (decrease of 0.322/100 live births, 95% CI 0.506-0.139) and preterm labor induction or cesarean delivery (decrease of 0.190/100 live births, 95% CI 0.334-0.047) and absolute increases in macrosomia (increase of 0.046/100 live births), postterm birth (increase of 0.015/100 live births), and perinatal death (increase of 0.501/1,000 total births, 95% CI 0.220-0.783). These changes were larger in subpopulations at high risk (eg, among singletons of patients with prepregnancy diabetes). Among singletons of patients with prepregnancy diabetes, pandemic onset was associated with a decrease in preterm birth (decrease of 1.634/100 live births) and preterm labor induction or cesarean delivery (decrease of 1.521/100 live births) and increases in macrosomia (increase of 0.328/100 live births) and perinatal death (increase of 9.840/1,000 total births, 95% CI 3.933-15.75). Most changes were reversed in the months after pandemic onset. CONCLUSION The onset of the coronavirus disease 2019 (COVID-19) pandemic was associated with a transient decrease in obstetric intervention (especially preterm labor induction or cesarean delivery) and a transient increase in perinatal mortality.
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Affiliation(s)
- Sophie Simon
- Department of Obstetrics and Gynaecology, the Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynaecology, and the School of Population and Public Health, University of British Columbia, and the Children's and Women's Hospital and Health Centre of British Columbia, Vancouver, British Columbia, the Departments of Obstetrics and Gynecology and Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, and the Department of Pediatrics, Faculty of Medicine, Université Laval and CHU de Québec-Université Laval Research Center, Québec City, Québec, Canada; the Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden; the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, NYU Grossman School of Medicine, New York, New York; and the Division of Epidemiology and Biostatistics, Department of Obstetrics, Gynecology, and Reproductive Sciences, the Cardiovascular Institute of New Jersey, and the Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, and the Department of Biostatistics and Epidemiology, Rutgers School of Public Health, and the Environmental and Occupational Health Sciences Institute, Rutgers Robert Wood Johnson Medical School, Piscataway, New Jersey
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13
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Palumbo AM, Kirkwood D, Borkhoff CM, Keown-Stoneman CDG, Muraca GM, Fuller A, Birken CS, Maguire JL, Brown HK, Anderson LN. Validation of Parent-reported Gestational Age Categories for Children Less Than 6 Years of Age. Epidemiology 2023; 34:767-773. [PMID: 37757868 DOI: 10.1097/ede.0000000000001645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2023]
Abstract
BACKGROUND Preterm birth is an important outcome or exposure in epidemiologic research. When administrative data on measured gestational age is not available, parent-reported gestational age can be obtained from questionnaires, which is subject to potential bias. To our knowledge, few studies have assessed the validity of parent-reported gestational age categories, including commonly defined categories of preterm birth. METHODS We used linked data from primarily healthy children <6 years of age in TARGet Kids! in Toronto, Canada, and ICES administrative healthcare data from April 2011 to March 2020. We assessed the criterion validity of questionnaire-based parent-reported gestational age by calculating sensitivity and specificity for term (≥37 weeks), late preterm (34-36 weeks), and moderately preterm (32-33 weeks) gestational age categories, using administrative healthcare records of gestational age as the criterion standard. We conducted subgroup analyses for various parent and socioeconomic factors that may influence recall. RESULTS Of the 4684 participants, 97.3% correctly classified the gestational age category according to administrative healthcare data. Parent-reported gestational age sensitivity ranged from 83.7% to 98.5% and specificity ranged from 88.3% to 99.8%, depending on category. For each subgroup characteristic, sensitivity and specificity were all ≥70%. Lower educational attainment, lower family income, father reporting, ≥1 year since birth, ≥2 children, lower parent age, and reported gestational diabetes and/or hypertension were associated with slightly lower sensitivity and/or specificity. CONCLUSIONS In this linked cohort, parent-reported gestational age categories had high accuracy. Criterion validity varied minimally among some parent and socioeconomic factors. Our findings can inform future quantitative bias analyses.
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Affiliation(s)
- Alexandra M Palumbo
- From the Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | | | - Cornelia M Borkhoff
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
- Division of Pediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Charles D G Keown-Stoneman
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Applied Health Research Centre, Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, Ontario
| | - Giulia M Muraca
- From the Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Obstetrics and Gynecology, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
- Clinical Epidemiology Unit, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Anne Fuller
- From the Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Paediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Catherine S Birken
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
- Division of Pediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jonathon L Maguire
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Division of Pediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Applied Health Research Centre, Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, Ontario
- Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Pediatrics, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Hilary K Brown
- ICES, McMaster University, Hamilton, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Department of Health & Society, University of Toronto Scarborough, Toronto, Ontario, Canada
| | - Laura N Anderson
- From the Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
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14
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Muraca GM, Ralph LE, Christensen P, D'Souza R, Geoffrion R, Lisonkova S, Joseph KS. Maternal and neonatal trauma during forceps and vacuum delivery must not be overlooked. BMJ 2023; 383:e073991. [PMID: 37857419 PMCID: PMC10585424 DOI: 10.1136/bmj-2022-073991] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Affiliation(s)
- Giulia M Muraca
- Departments of Obstetrics and Gynecology and Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
- Clinical Epidemiology Unit, Department of Medicine, Solna, Karolinska Institutet, Sweden
| | | | - Penny Christensen
- Public representative, Birth Trauma Canada, Saint John, New Brunswick, Canada
| | - Rohan D'Souza
- Departments of Obstetrics and Gynecology and Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Roxana Geoffrion
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sarka Lisonkova
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, British Columbia, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - K S Joseph
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, British Columbia, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
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15
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Park M, Wanigaratne S, D’Souza R, Geoffrion R, Williams SA, Muraca GM. Asian-white disparities in obstetric anal sphincter injury: Protocol for a systematic review and meta-analysis. PLoS One 2023; 18:e0291174. [PMID: 37682913 PMCID: PMC10490831 DOI: 10.1371/journal.pone.0291174] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 08/08/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND Obstetric anal sphincter injury (OASI) describes severe injury to the perineum and perineum and perianal muscles following birth and occurs in 4.4% to 6.0% of vaginal births in Canada. Studies from high-income countries have identified an increased risk of OASI in individuals who identify as Asian race versus those who identify as white. This protocol outlines a systematic review and meta-analysis which aims to determine the incidence of OASI in individuals living in high-income countries who identify as Asian versus those of white race/ethnicity. We hypothesize that the pooled incidence of OASI will be higher in Asian versus white birthing individuals. METHODS We will search MEDLINE, OVID, Embase, Emcare and Cochrane databases from inception to 2022 for observational studies using keywords and controlled vocabulary terms related to race, ethnicity and OASI. Two reviewers will follow the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines and Meta-analysis of Observational Studies (MOOSE) recommendations. Meta-analysis will be performed using RevMan for dichotomous data using the random effects model and the odds ratio (OR) as effect measure with a 95% confidence interval (CI). Subgroup analysis will be performed based on Asian subgroups (e.g., South Asian, Filipino, Chinese, Japanese individuals). Study quality assessment will be performed using The Joanna Briggs Institute Critical Appraisal tools. DISCUSSION The systematic review and meta-analysis that this protocol outlines will synthesize the extant literature to better estimate the rates of OASI in Asian and white populations in non-Asian, high-income settings and the relative risk of OASI between these two groups. This systematic summary of the evidence will inform the discrepancy in health outcomes experienced by Asian and white birthing individuals. If these findings suggest a disproportionate burden among Asians, they will be used to advocate for future studies to explore the causal mechanisms underlying this relationship, such as differential care provision, barriers to accessing care, and social and institutional racism. Ultimately, the findings of this review can be used to frame obstetric care guidelines and inform healthcare practices to ensure care that is equitable and accessible to diverse populations.
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Affiliation(s)
- Meejin Park
- Faculty of Health Sciences, Department of Global Health, McMaster University, Hamilton, ON, Canada
| | - Susitha Wanigaratne
- Sick Kids Research Institute, Edwin S.H. Leong Centre for Healthy Children, Toronto, ON, Canada
| | - Rohan D’Souza
- Faculty of Health Science, Department of Obstetrics and Gynecology, McMaster University, Hamilton, ON, Canada
- Faculty of Health Sciences, Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Roxana Geoffrion
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada
| | - Sarah A. Williams
- Department of Anthropology, Brown University, Providence, RI, United States of America
| | - Giulia M. Muraca
- Faculty of Health Science, Department of Obstetrics and Gynecology, McMaster University, Hamilton, ON, Canada
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada
- Department of Medicine, Clinical Epidemiology Division, Solna, Karolinska Institutet, Stockholm, Sweden
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16
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Lisonkova S, Bone JN, Muraca GM, Razaz N, Boutin A, Brandt JS, Bedaiwy MA, Ananth CV, Joseph KS. Response to the Commentary 'Causes of ART-related outcomes in the COVID-19 era'. Paediatr Perinat Epidemiol 2023; 37:566-568. [PMID: 37185987 DOI: 10.1111/ppe.12980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 04/05/2023] [Indexed: 05/17/2023]
Affiliation(s)
- Sarka Lisonkova
- Department of Obstetrics and Gynaecology, University of British Columbia and the Children's and Women's Hospital and Health Centre of British Columbia, Vancouver, British Columbia, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jeffrey N Bone
- Department of Obstetrics and Gynaecology, University of British Columbia and the Children's and Women's Hospital and Health Centre of British Columbia, Vancouver, British Columbia, Canada
| | - Giulia M Muraca
- Departments of Obstetrics and Gynecology and Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Neda Razaz
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Amelie Boutin
- Department of Pediatrics, Faculty of Medicine, Université Laval, Quebec City, Quebec, Canada
- Reproduction, Mother and Youth Health and Population Health and Optimal Health Practices Units, CHU de Québec-Université Laval Research Center, Quebec City, Quebec, Canada
| | - Justin S Brandt
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, NYU Grossman School of Medicine, New York, USA
| | - Mohamed A Bedaiwy
- Department of Obstetrics and Gynaecology, University of British Columbia and the Children's and Women's Hospital and Health Centre of British Columbia, Vancouver, British Columbia, Canada
| | - Cande V Ananth
- Division of Epidemiology and Biostatistics, Department of Obstetrics, Gynecology and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
- Cardiovascular Institute of New Jersey and Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, New Jersey, USA
- Environmental and Occupational Health Sciences Institute, Rutgers Robert Wood Johnson Medical School, Piscataway, New Jersey, USA
| | - K S Joseph
- Department of Obstetrics and Gynaecology, University of British Columbia and the Children's and Women's Hospital and Health Centre of British Columbia, Vancouver, British Columbia, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
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Yearwood L, Bone JN, Wen Q, Muraca GM, Lyons J, Razaz N, Joseph K, Lisonkova S. The association between maternal stature and adverse birth outcomes and the modifying effect of race and ethnicity: a population-based retrospective cohort study. AJOG Glob Rep 2023; 3:100184. [PMID: 36941862 PMCID: PMC10024135 DOI: 10.1016/j.xagr.2023.100184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023] Open
Abstract
BACKGROUND There are known differences in the risk of perinatal and maternal birth outcomes because of maternal factors, such as body mass index and maternal race. However, the association of maternal height with adverse birth outcomes and the potential differences in this relationship by race and ethnicity have been understudied. OBJECTIVE This study aimed to examine the association between maternal stature and adverse perinatal outcomes and the potential modification of the association by race and ethnicity. STUDY DESIGN This retrospective cohort study was conducted using data on all singleton births in the United States in 2016 and 2017 (N=7,361,713) obtained from the National Center for Health Statistics. Short and tall stature were defined as <10th and >90th percentiles of the maternal height distribution (<154.9 and >172.7 cm, respectively). Race and ethnicity categories included non-Hispanic White, non-Hispanic Black, American Indian or Alaskan Native Asian or Pacific Islander, and Hispanic. The primary outcomes were preterm birth (<37 weeks of gestation), perinatal death, and composite perinatal death or severe neonatal morbidity. Logistic regression was used to obtain adjusted odds ratios and 95% confidence intervals with adjustment for confounding by maternal age, body mass index, and other factors. Multiplicative and additive effect modifications by race and ethnicity were assessed. RESULTS The study population included 7,361,713 women with a singleton stillbirth or live birth. Short women had an increased risk of adverse outcomes, whereas tall women had a decreased risk relative to average-stature women. Short women had an increased risk of perinatal death and composite perinatal death or severe neonatal morbidity (adjusted odds ratios, 1.14 [95% confidence interval, 1.10-1.17] and 1.21 [95% confidence interval, 1.19-1.23], respectively). The association between short stature and perinatal death was attenuated in non-Hispanic Black women compared with non-Hispanic White women (adjusted odds ratio, 1.10 [95% confidence interval, 1.03-1.17] vs 1.26 [95% confidence interval, 1.19-1.33]). Compared with average-stature women, tall non-Hispanic White women had lower rates of preterm birth, perinatal death, and composite perinatal death or severe neonatal morbidity (adjusted odds ratios, 0.82 [95% confidence interval, 0.81-0.83], 0.95 [95% confidence interval, 0.91-1.00], and 0.90 [95% confidence interval, 0.88-0.93], respectively). The association between tall and average stature with perinatal death was reversed in Hispanic women (adjusted odds ratio, 1.27; 95% confidence interval, 1.12-1.44). Compared with average-stature women, all tall women had lower rates of preterm birth, particularly among non-Hispanic Black and Hispanic women. CONCLUSION Relative to average-stature women, short women have an increased risk of adverse perinatal outcomes across all race and ethnicity groups; these associations were attenuated in Hispanic women and for some adverse outcomes in non-Hispanic Black and Asian women. Tall mothers have a lower risk of preterm birth in all racial and ethnic groups, whereas tall non-Hispanic White mothers have a lower risk of perinatal death or severe neonatal morbidity compared with average-stature women.
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Affiliation(s)
- Lauren Yearwood
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, British Columbia, Canada (XX Yearwood, XX Bone, Ms Wen, XX Lyons, XX Joseph, and Dr Lisonkova)
| | - Jeffrey N. Bone
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, British Columbia, Canada (XX Yearwood, XX Bone, Ms Wen, XX Lyons, XX Joseph, and Dr Lisonkova)
- Children's and Women's Hospital and Health Centre of British Columbia, Vancouver, British Columbia, Canada (XX Bone, XX Joseph, and Dr Lisonkova)
| | - Qi Wen
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, British Columbia, Canada (XX Yearwood, XX Bone, Ms Wen, XX Lyons, XX Joseph, and Dr Lisonkova)
| | - Giulia M. Muraca
- Department of Obstetrics and Gynecology and Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada (XX Muraca)
- Clinical Epidemiology Unit, Department of Medicine, Solna, Karolinska University Hospital, Karolinska Institutet, Solna, Sweden (XX Muraca and XX Razaz)
| | - Janet Lyons
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, British Columbia, Canada (XX Yearwood, XX Bone, Ms Wen, XX Lyons, XX Joseph, and Dr Lisonkova)
| | - Neda Razaz
- Clinical Epidemiology Unit, Department of Medicine, Solna, Karolinska University Hospital, Karolinska Institutet, Solna, Sweden (XX Muraca and XX Razaz)
| | - K.S. Joseph
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, British Columbia, Canada (XX Yearwood, XX Bone, Ms Wen, XX Lyons, XX Joseph, and Dr Lisonkova)
- Children's and Women's Hospital and Health Centre of British Columbia, Vancouver, British Columbia, Canada (XX Bone, XX Joseph, and Dr Lisonkova)
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada (XX Joseph and Dr Lisonkova)
| | - Sarka Lisonkova
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, British Columbia, Canada (XX Yearwood, XX Bone, Ms Wen, XX Lyons, XX Joseph, and Dr Lisonkova)
- Children's and Women's Hospital and Health Centre of British Columbia, Vancouver, British Columbia, Canada (XX Bone, XX Joseph, and Dr Lisonkova)
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada (XX Joseph and Dr Lisonkova)
- Corresponding author: Sarka Lisonkova, MD, PhD.
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Yearwood L, Bone JN, Wen Q, Muraca GM, Lyons J, Razaz N, Joseph KS, Lisonkova S. Does maternal stature modify the association between infants who are small or large for gestational age and adverse perinatal outcomes? A retrospective cohort study. BJOG 2023; 130:464-475. [PMID: 36424901 DOI: 10.1111/1471-0528.17350] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 08/26/2022] [Accepted: 09/09/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To investigate the effect of maternal stature on adverse birth outcomes and quantify perinatal risks associated with small- and large-for-gestational age infants (SGA and LGA, respectively) born to mothers of short, average, and tall stature. DESIGN Retrospective cohort study. SETTING USA, 2016-2017. POPULATION Women with a singleton live birth (N = 7 325 741). METHODS Using data from the National Center for Health Statistics, short and tall stature were defined as <10th and >90th centile of the maternal height distribution. Modified Poisson regression was used to estimate adjusted risk ratios (aRRs) and 95% confidence intervals (95% CIs). MAIN OUTCOME MEASURES Preterm birth (<37 weeks of gestation), neonatal intensive care unit (NICU) admission and severe neonatal morbidity/mortality (SNMM). RESULTS With increased maternal height, the risk of adverse outcomes increased in SGA infants and decreased in LGA infants compared with infants appropriate-for-gestational age (AGA) (p < 0.001). Infants who were SGA born to women of tall stature had the highest risk of NICU admission (aRR 1.98, 95% CI 1.91-2.05; p < 0.001), whereas LGA infants born to women of tall stature had the lowest risk (aRR 0.85, 95% CI 0.82-0.88; p < 0.001), compared with AGA infants born to women of average stature. LGA infants born to women of short stature had an increased risk of NICU admission and SNMM, compared with AGA infants born to women of average stature (aRR 1.32, 95% CI 1.27-1.38; aRR 1.21, 95% CI 1.13-1.29, respectively). CONCLUSIONS Maternal height modifies the association between SGA and LGA status at birth and neonatal outcomes. This quantification of risk can assist healthcare providers in monitoring fetal growth, and optimising neonatal care and follow-up.
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Affiliation(s)
- Lauren Yearwood
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jeffrey N Bone
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, British Columbia, Canada.,Children's and Women's Hospital and Health Centre of British Columbia, Vancouver, British Columbia, Canada
| | - Qi Wen
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Giulia M Muraca
- Department of Obstetrics & Gynecology and Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Ontario, Canada.,Clinical Epidemiology Unit, Department of Medicine, Solna, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Janet Lyons
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Neda Razaz
- Clinical Epidemiology Unit, Department of Medicine, Solna, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - K S Joseph
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, British Columbia, Canada.,Children's and Women's Hospital and Health Centre of British Columbia, Vancouver, British Columbia, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sarka Lisonkova
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, British Columbia, Canada.,Children's and Women's Hospital and Health Centre of British Columbia, Vancouver, British Columbia, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
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19
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Joseph KS, Young CB, Muraca GM, Boutin A, Razaz N, John S, Lisonkova S, Wilson RD. Hospital factors associated with maternal and neonatal outcomes of deliveries to patients with a previous cesarean delivery: an ecological study. CMAJ 2023; 195:E178-E186. [PMID: 36746486 PMCID: PMC9904811 DOI: 10.1503/cmaj.220928] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/25/2022] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Recommendations for deliveries of pregnant patients with a previous cesarean delivery and the type of hospitals deemed safe for these deliveries have evolved in recent years, although no studies have examined hospital factors and associated safety. We sought to evaluate maternal and neonatal outcomes among patients with a previous cesarean delivery by hospital tier and volume. METHODS We carried out an ecological study of singleton live births delivered at term gestation to patients with a previous cesarean delivery in all Canadian hospitals (excluding Quebec), 2013-2019. We obtained data from the Discharge Abstract Database of the Canadian Institute for Health Information. The primary outcomes were severe maternal morbidity or mortality (SMMM), and serious neonatal morbidity or mortality (SNMM). We used regression modelling to examine hospital tier (tier 4 hospitals being those that provide the highest level of care) and volume; we also identified hospitals with high rates of SMMM and SNMM using within-tier comparisons and comparisons with the overall rate. RESULTS We included 235 442 deliveries to patients with a previous cesarean delivery; SMMM and SNMM rates were 14.6 per 1000 deliveries and 4.6 per 1000 live births, respectively. Among patients with a parity of 1, SMMM rates were lower in tier 1 hospitals (adjusted incidence rate ratio [IRR] 0.68, 95% confidence interval [CI] 0.52-0.89) and higher in tier 4 hospitals (adjusted IRR 1.41, 95% CI 1.05-1.91) than in tier 2 hospitals; SNMM rates did not differ by hospital tier. Rates of SNMM increased with increasing hospital volume (adjusted IRR 1.02, 95% CI 1.00-1.04) and increasing rates of vaginal birth after cesarean delivery (adjusted IRR 1.02, 95% CI 1.01-1.04). Most hospitals had relatively low SMMM and SNMM rates, although a few hospitals in each tier and volume category had significantly higher rates than others. INTERPRETATION Adverse maternal and neonatal outcomes among patients with a previous cesarean delivery showed no clear pattern of decreasing SMMM and SNMM with increasing tiers of service and hospital volume. All hospitals, irrespective of tier or size, should continually review their rates of adverse maternal and neonatal outcomes.
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Affiliation(s)
- K S Joseph
- Department of Obstetrics and Gynaecology (Joseph, John, Lisonkova), University of British Columbia; Children's and Women's Hospital (Joseph, John, Lisonkova), Health Centre of British Columbia; School of Population and Public Health (Joseph, Lisonkova), University of British Columbia, Vancouver, BC; Department of Obstetrics and Gynecology (Young), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Departments of Obstetrics and Gynecology, and Health Research Methods, Evidence, and Impact (Muraca), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; Department of Pediatrics (Boutin), Faculty of Medicine, Université Laval and CHU de Québec-Université Laval Research Center, Québec, Que.; Division of Clinical Epidemiology (Razaz), Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden; Department of Obstetrics and Gynecology (Wilson), Cumming School of Medicine, University of Calgary, Calgary, Alta.
| | - Carmen B Young
- Department of Obstetrics and Gynaecology (Joseph, John, Lisonkova), University of British Columbia; Children's and Women's Hospital (Joseph, John, Lisonkova), Health Centre of British Columbia; School of Population and Public Health (Joseph, Lisonkova), University of British Columbia, Vancouver, BC; Department of Obstetrics and Gynecology (Young), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Departments of Obstetrics and Gynecology, and Health Research Methods, Evidence, and Impact (Muraca), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; Department of Pediatrics (Boutin), Faculty of Medicine, Université Laval and CHU de Québec-Université Laval Research Center, Québec, Que.; Division of Clinical Epidemiology (Razaz), Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden; Department of Obstetrics and Gynecology (Wilson), Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Giulia M Muraca
- Department of Obstetrics and Gynaecology (Joseph, John, Lisonkova), University of British Columbia; Children's and Women's Hospital (Joseph, John, Lisonkova), Health Centre of British Columbia; School of Population and Public Health (Joseph, Lisonkova), University of British Columbia, Vancouver, BC; Department of Obstetrics and Gynecology (Young), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Departments of Obstetrics and Gynecology, and Health Research Methods, Evidence, and Impact (Muraca), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; Department of Pediatrics (Boutin), Faculty of Medicine, Université Laval and CHU de Québec-Université Laval Research Center, Québec, Que.; Division of Clinical Epidemiology (Razaz), Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden; Department of Obstetrics and Gynecology (Wilson), Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Amélie Boutin
- Department of Obstetrics and Gynaecology (Joseph, John, Lisonkova), University of British Columbia; Children's and Women's Hospital (Joseph, John, Lisonkova), Health Centre of British Columbia; School of Population and Public Health (Joseph, Lisonkova), University of British Columbia, Vancouver, BC; Department of Obstetrics and Gynecology (Young), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Departments of Obstetrics and Gynecology, and Health Research Methods, Evidence, and Impact (Muraca), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; Department of Pediatrics (Boutin), Faculty of Medicine, Université Laval and CHU de Québec-Université Laval Research Center, Québec, Que.; Division of Clinical Epidemiology (Razaz), Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden; Department of Obstetrics and Gynecology (Wilson), Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Neda Razaz
- Department of Obstetrics and Gynaecology (Joseph, John, Lisonkova), University of British Columbia; Children's and Women's Hospital (Joseph, John, Lisonkova), Health Centre of British Columbia; School of Population and Public Health (Joseph, Lisonkova), University of British Columbia, Vancouver, BC; Department of Obstetrics and Gynecology (Young), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Departments of Obstetrics and Gynecology, and Health Research Methods, Evidence, and Impact (Muraca), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; Department of Pediatrics (Boutin), Faculty of Medicine, Université Laval and CHU de Québec-Université Laval Research Center, Québec, Que.; Division of Clinical Epidemiology (Razaz), Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden; Department of Obstetrics and Gynecology (Wilson), Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Sid John
- Department of Obstetrics and Gynaecology (Joseph, John, Lisonkova), University of British Columbia; Children's and Women's Hospital (Joseph, John, Lisonkova), Health Centre of British Columbia; School of Population and Public Health (Joseph, Lisonkova), University of British Columbia, Vancouver, BC; Department of Obstetrics and Gynecology (Young), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Departments of Obstetrics and Gynecology, and Health Research Methods, Evidence, and Impact (Muraca), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; Department of Pediatrics (Boutin), Faculty of Medicine, Université Laval and CHU de Québec-Université Laval Research Center, Québec, Que.; Division of Clinical Epidemiology (Razaz), Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden; Department of Obstetrics and Gynecology (Wilson), Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Sarka Lisonkova
- Department of Obstetrics and Gynaecology (Joseph, John, Lisonkova), University of British Columbia; Children's and Women's Hospital (Joseph, John, Lisonkova), Health Centre of British Columbia; School of Population and Public Health (Joseph, Lisonkova), University of British Columbia, Vancouver, BC; Department of Obstetrics and Gynecology (Young), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Departments of Obstetrics and Gynecology, and Health Research Methods, Evidence, and Impact (Muraca), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; Department of Pediatrics (Boutin), Faculty of Medicine, Université Laval and CHU de Québec-Université Laval Research Center, Québec, Que.; Division of Clinical Epidemiology (Razaz), Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden; Department of Obstetrics and Gynecology (Wilson), Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - R Douglas Wilson
- Department of Obstetrics and Gynaecology (Joseph, John, Lisonkova), University of British Columbia; Children's and Women's Hospital (Joseph, John, Lisonkova), Health Centre of British Columbia; School of Population and Public Health (Joseph, Lisonkova), University of British Columbia, Vancouver, BC; Department of Obstetrics and Gynecology (Young), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Departments of Obstetrics and Gynecology, and Health Research Methods, Evidence, and Impact (Muraca), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; Department of Pediatrics (Boutin), Faculty of Medicine, Université Laval and CHU de Québec-Université Laval Research Center, Québec, Que.; Division of Clinical Epidemiology (Razaz), Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden; Department of Obstetrics and Gynecology (Wilson), Cumming School of Medicine, University of Calgary, Calgary, Alta
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Lisonkova S, Bone JN, Muraca GM, Razaz N, Boutin A, Brandt JS, Bedaiwy MA, Ananth CV, Joseph KS. Early coronavirus disease 2019 restrictive measures and changes in maternal characteristics, use of assisted reproductive technology, and stillbirth. Paediatr Perinat Epidemiol 2023; 37:117-127. [PMID: 36038519 PMCID: PMC9539106 DOI: 10.1111/ppe.12925] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 07/29/2022] [Accepted: 08/14/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND The initial COVID-19 pandemic response-related effects on conceptions following the use of assisted reproductive technologies (ART), and on changes in the maternal characteristics of women who conceived during the early vs. pre-pandemic period, have been understudied. OBJECTIVES To examine the effects of ART clinic closures in the United States (US) in March 2020 on the frequency of ART-conceived live births, multiple births and stillbirths; and to describe changes in the characteristics of women who conceived in the early pandemic period. METHODS Population-based cohort study including all births in the US from January 2015 to December 2020 (22,907,688 live births; 134,537 stillbirths). Interrupted time series (ITS) methodology was used to estimate rate ratios (RR) of expected versus observed rates in December 2020 (i.e., among births conceived mainly in March 2020). Demographic and clinical characteristics were compared between mothers who conceived in March 2020 versus March 2015-2019. RESULTS Overall, 1.1% of live births and 1.7% of stillbirths were conceived by ART. ART-conceived live births decreased by 57.0% in December 2020 (observed vs. expected RR 0.43, 95% confidence interval [CI] 0.40, 0.45), and these declines occurred in all subgroups of women. Multiple births also declined in December 2020. Stillbirth rates increased in December 2020 in ART-conceived births (RR 2.55, 95% CI 1.63, 3.92) but remained unchanged in the non-ART group. Maternal characteristics of women who conceived in the early pandemic versus pre-pandemic period differed and included an increased prevalence of pre-pregnancy obesity class 3 and chronic hypertension. CONCLUSIONS The early pandemic closure of ART clinics resulted in a substantial decline in ART-conceived live births and multiple births in December 2020 and an increase in the proportion of stillbirths among ART-conceived births. Women who conceived in the early pandemic period also had an increased prevalence of obesity and chronic hypertension.
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Affiliation(s)
- Sarka Lisonkova
- Department of Obstetrics and GynaecologyUniversity of British Columbia and the Children's and Women's Hospital and Health Centre of British ColumbiaVancouverBritish ColumbiaCanada
- School of Population and Public HealthUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Jeffrey N. Bone
- Department of Obstetrics and GynaecologyUniversity of British Columbia and the Children's and Women's Hospital and Health Centre of British ColumbiaVancouverBritish ColumbiaCanada
| | - Giulia M. Muraca
- Department of Obstetrics and Gynecology, Evidence and ImpactMcMaster UniversityHamiltonOntarioCanada
- Department of Health Research Methods, Evidence and ImpactMcMaster UniversityHamiltonOntarioCanada
- Clinical Epidemiology Division, Department of MedicineSolna, Karolinska InstitutetStockholmSweden
| | - Neda Razaz
- Clinical Epidemiology Division, Department of MedicineSolna, Karolinska InstitutetStockholmSweden
| | - Amelie Boutin
- Department of Pediatrics, Faculty of MedicineUniversité LavalQuebec CityQuebecCanada
- Reproduction, Mother and Youth Health and Population Health and Optimal Health Practices UnitsCHU de Québec‐Université Laval Research CenterQuebec CityQuebecCanada
| | - Justin S. Brandt
- Division of Maternal‐Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive SciencesRutgers Robert Wood Johnson Medical SchoolNew BrunswickNew JerseyUSA
| | - Mohamed A. Bedaiwy
- Department of Obstetrics and GynaecologyUniversity of British Columbia and the Children's and Women's Hospital and Health Centre of British ColumbiaVancouverBritish ColumbiaCanada
| | - Cande V. Ananth
- Division of Epidemiology and Biostatistics, Department of Obstetrics, Gynecology and Reproductive SciencesRutgers Robert Wood Johnson Medical SchoolNew BrunswickNew JerseyUSA
- Cardiovascular Institute of New Jersey and Department of MedicineRutgers Robert Wood Johnson Medical SchoolNew BrunswickNew JerseyUSA
- Department of Biostatistics and EpidemiologyRutgers School of Public HealthPiscatawayNew JerseyUSA
- Environmental and Occupational Health Sciences InstituteRutgers Robert Wood Johnson Medical SchoolPiscatawayNew JerseyUSA
| | - K. S. Joseph
- Department of Obstetrics and GynaecologyUniversity of British Columbia and the Children's and Women's Hospital and Health Centre of British ColumbiaVancouverBritish ColumbiaCanada
- School of Population and Public HealthUniversity of British ColumbiaVancouverBritish ColumbiaCanada
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Bone JN, Joseph K, Magee LA, Muraca GM, Razaz N, Mayer C, Lisonkova S. Pre-pregnancy body mass index and adverse perinatal outcomes in the presence of other maternal risk factors. AJOG Global Reports 2023; 3:100175. [PMID: 36970645 PMCID: PMC10034503 DOI: 10.1016/j.xagr.2023.100175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023] Open
Abstract
BACKGROUND High prepregnancy body mass index is one of the most common risk factors for adverse perinatal events. OBJECTIVE This study aimed to assess whether the association between maternal body mass index and adverse perinatal outcome is modified by other concomitant maternal risk factors. STUDY DESIGN This was a retrospective cohort study of all singleton live births and stillbirths in the United States from 2016 to 2017, using data from the National Center for Health Statistics. Logistic regression was used to estimate the adjusted odds ratios and 95% confidence intervals between prepregnancy body mass index and a composite outcome of stillbirth, neonatal death, and severe neonatal morbidity. Modification of this association by maternal age, nulliparity, chronic hypertension, and prepregnancy diabetes mellitus was assessed on both multiplicative and additive scales. RESULTS The study population included 7,576,417 women with singleton pregnancy; 254,225 (3.5%) were underweight, 3,220,432 (43.9%) had normal body mass index, 1,918,480 (26.1%) were overweight, and 1,062,177 (14.4%), 516,693 (7.0%), and 365,357 (5.0%) had class I, II, and III obesity, respectively. Rates of the composite outcome increased with increasing body mass index above normal values, compared with women with normal body mass index. Nulliparity (289,776; 38.6%), chronic hypertension (135,328; 1.8%), and prepregnancy diabetes mellitus (67,744; 0.89%) modified the association between body mass index and the composite perinatal outcome on both the additive and multiplicative scales. Nulliparous (vs parous) women had a higher rate of increase in adverse outcomes with increasing body mass index. For example, in nulliparous women, class III obesity was associated with 1.8-fold higher odds compared with normal body mass index (adjusted odds ratio, 1.77; 95% confidence interval, 1.73-1.83), whereas in parous women, the adjusted odds ratio was 1.35 (95% confidence interval, 1.32-1.39). Women with chronic hypertension or prepregnancy diabetes mellitus had higher outcome rates overall; however, the dose-response relationship with increasing body mass index was absent. Although the composite outcome rates increased with maternal age, the risk curves were relatively similar across obesity classes in all maternal age groups. Overall, underweight women had 7% higher odds of the composite outcome, and this increased to 21% in parous women. CONCLUSION Women with elevated prepregnancy body mass index are at increased risk of adverse perinatal outcomes, and the magnitude of these risks differs by concomitant risk factors, including prepregnancy diabetes mellitus, chronic hypertension, and nulliparity. In particular, in woman with chronic hypertension or prepregnancy diabetes mellitus, there is no impact of increasing body mass index on adverse perinatal outcomes. However, overall rates remain high, and prepregnancy prevention of hypertension and diabetes mellitus should be emphasized among all women irrespective of body mass index.
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Affiliation(s)
- Jeffrey N. Bone
- Department of Obstetrics and Gynaecology, The University of British Columbia and the Children's and Women's Hospital and Health Centre of British Columbia, Vancouver, Canada (Mr Bone and Drs Joseph, Mayer, and Lisonkova)
- Biostatistics, Research Informatics, British Columbia Children's Hospital Research Institute, Vancouver, Canada (Mr Bone)
- Corresponding author: Jeffrey N. Bone, MSc.
| | - K.S. Joseph
- Department of Obstetrics and Gynaecology, The University of British Columbia and the Children's and Women's Hospital and Health Centre of British Columbia, Vancouver, Canada (Mr Bone and Drs Joseph, Mayer, and Lisonkova)
- School of Population and Public Health, The University of British Columbia, Vancouver, Canada (Drs Joseph and Lisonkova)
| | - Laura A. Magee
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom (Dr Magee)
| | - Giulia M. Muraca
- Departments of Obstetrics and Gynecology and Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada (Dr Muraca)
- Division of Clinical Epidemiology, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden (Drs Muraca and Razaz)
| | - Neda Razaz
- Division of Clinical Epidemiology, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden (Drs Muraca and Razaz)
| | - Chantal Mayer
- Department of Obstetrics and Gynaecology, The University of British Columbia and the Children's and Women's Hospital and Health Centre of British Columbia, Vancouver, Canada (Mr Bone and Drs Joseph, Mayer, and Lisonkova)
| | - Sarka Lisonkova
- Department of Obstetrics and Gynaecology, The University of British Columbia and the Children's and Women's Hospital and Health Centre of British Columbia, Vancouver, Canada (Mr Bone and Drs Joseph, Mayer, and Lisonkova)
- School of Population and Public Health, The University of British Columbia, Vancouver, Canada (Drs Joseph and Lisonkova)
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Lisonkova S, Ukah UV, John S, Yearwood L, Muraca GM, Razaz N, Sabr Y, Yong PJ, Bedaiwy MA. Racial and Ethnic Disparities in the Perinatal Health of Infants Conceived by ART. Pediatrics 2022; 150:189747. [PMID: 36258133 DOI: 10.1542/peds.2021-055855] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/03/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Although racial and ethnic disparities in adverse birth outcomes have been well documented, it is unknown whether such disparities diminish in women who use medically assisted reproduction (MAR). We examined differences in the association between maternal race and ethnicity and adverse birth outcomes among women who conceived spontaneously and those who used MAR, including assisted reproduction technology (ART), eg, in-vitro fertilization, and also non-ART MAR, eg, fertility drugs. METHODS We conducted a population-based retrospective cohort study using data on all singleton births (N = 7 545 805) in the United States from 2016 to 2017. The outcomes included neonatal and fetal death, preterm birth, and serious neonatal morbidity, among others. Modified Poisson regression was used to estimate adjusted rate ratios (aRR) and 95% confidence intervals (CI) and to assess the interactions between race and ethnicity and mode of conception. RESULTS Overall, 93 469 (1.3%) singletons were conceived by MAR. Neonatal mortality was twofold higher among infants of non-Hispanic Black versus non-Hispanic White women in the spontaneous-conception group (aRR = 1.9, 95% CI: 1.8-1.9), whereas in the ART-conception group, neonatal mortality was more than fourfold higher in infants of non-Hispanic Black women (aRR = 4.1, 95% CI: 2.9-5.9). Racial and ethnic disparities between Hispanic versus non-Hispanic White women were also significantly larger among women who conceived using MAR with regard to preterm birth (<34 weeks) and perinatal mortality. CONCLUSIONS Compared to women who conceived spontaneously, racial and ethnic disparities in adverse perinatal outcomes were larger in women who used MAR. More research is needed to identify preventive measures for reducing risks among vulnerable women who use medically assisted reproduction.
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Affiliation(s)
- Sarka Lisonkova
- Department of Obstetrics and Gynaecology, University of British Columbia and the Children's and Women's Hospital and Health Centre of British Columbia, Vancouver, British Columbia, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Ugochinyere Vivian Ukah
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada.,HealthPartners Institute, Minneapolis, Minnesota
| | - Sid John
- Department of Obstetrics and Gynaecology, University of British Columbia and the Children's and Women's Hospital and Health Centre of British Columbia, Vancouver, British Columbia, Canada
| | - Lauren Yearwood
- Department of Obstetrics and Gynaecology, University of British Columbia and the Children's and Women's Hospital and Health Centre of British Columbia, Vancouver, British Columbia, Canada
| | - Giulia M Muraca
- Departments of Obstetrics and Gynecology and Health Research Methods, Evidence & Impact, Faculty of Health Sciences, McMaster University, Ontario, Canada.,Clinical Epidemiology Unit, Department of Medicine, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Neda Razaz
- Clinical Epidemiology Unit, Department of Medicine, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Yasser Sabr
- College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Paul J Yong
- Department of Obstetrics and Gynaecology, University of British Columbia and the Children's and Women's Hospital and Health Centre of British Columbia, Vancouver, British Columbia, Canada
| | - Mohamed A Bedaiwy
- Department of Obstetrics and Gynaecology, University of British Columbia and the Children's and Women's Hospital and Health Centre of British Columbia, Vancouver, British Columbia, Canada
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Muraca GM, Lisonkova S, Joseph KS. The authors reply regarding transparency, balance and perspective on intervention at full dilation. CMAJ 2022; 194:E1174. [PMID: 36265063 PMCID: PMC9448420 DOI: 10.1503/cmaj.147016-l] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Giulia M Muraca
- Assistant professor, Department of Obstetrics and Gynecology, and of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ont.; Clinical Epidemiology Unit, Department of Medicine, Solna, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Sarka Lisonkova
- Assistant professor, Department of Obstetrics and Gynaecology, University of British Columbia and the Children's and Women's Hospital and Health Centre of British Columbia; School of Population and Public Health, University of British Columbia, Vancouver, BC
| | - K S Joseph
- Professor, Department of Obstetrics and Gynaecology, University of British Columbia and the Children's and Women's Hospital and Health Centre of British Columbia; School of Population and Public Health, University of British Columbia, Vancouver, BC
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Muraca GM, Joseph K, Razaz N, Ladfors LV, Lisonkova S, Stephansson O. Crude and adjusted comparisons of cesarean delivery rates using the Robson classification: A population-based cohort study in Canada and Sweden, 2004 to 2016. PLoS Med 2022; 19:e1004077. [PMID: 35913981 PMCID: PMC9377587 DOI: 10.1371/journal.pmed.1004077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 08/15/2022] [Accepted: 07/15/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The Robson classification has become a global standard for comparing and monitoring cesarean delivery (CD) rates across populations and over time; however, this classification does not account for differences in important maternal, fetal, and obstetric practice factors known to impact CD rates. The objectives of our study were to identify subgroups of women contributing to differences in the CD rate in Sweden and British Columbia (BC), Canada using the Robson classification and to estimate the contribution of maternal, fetal/infant, and obstetric practice factors to differences in CD rates between countries and over time. METHODS AND FINDINGS We conducted a population-based cohort study of deliveries in Sweden (January 1, 2004 to December 31, 2016; n = 1,392,779) and BC (March 1, 2004 to April 31, 2017; n = 559,205). Deliveries were stratified into Robson categories and the CD rate, relative size of each group and its contribution to the overall CD rate were compared between the Swedish and the Canadian cohorts. Poisson and log-binomial regression were used to assess the contribution of maternal, fetal, and obstetric practice factors to spatiotemporal differences in Robson group-specific CD rates between Sweden and BC. Nulliparous women comprised 44.8% of the study population, while women of advanced maternal age (≥35 years) and women with overweight/obesity (≥25 kg/m2) constituted 23.5% and 32.4% of the study population, respectively. The CD rate in Sweden was stable at approximately 17.0% from 2004 to 2016 (p for trend = 0.10), while the CD rate increased in BC from 29.4% to 33.9% (p for trend < 0.001). Differences in CD rates between Sweden and BC varied by Robson group, for example, in Group 1 (nullipara with a term, single, cephalic fetus with spontaneous labor), the CD rate was 8.1% in Sweden and 20.4% in BC (rate ratio [RR] for BC versus Sweden = 2.52, 95% confidence interval [CI] 2.49 to 2.56, p < 0.001) and in Group 2 (nullipara, single, cephalic fetus, term gestation with induction of labor or prelabor CD), the rate of CD was 37.3% in Sweden and 45.9% in BC (RR = 1.23, 95% CI 1.22 to 1.25, p < 0.001). The effect of adjustment for maternal characteristics (e.g., age, body mass index), maternal comorbidity (e.g., preeclampsia), fetal characteristics (e.g., head position), and obstetric practice factors (e.g., epidural) ranged from no effect (e.g., among breech deliveries; Groups 6 and 7) to explaining up to 5.2% of the absolute difference in the CD rate (Group 2: adjusted CD rate in BC 40.7%, adjusted RR = 1.09, 95% CI 1.08 to 1.12, p < 0.001). Adjustment also explained a substantial fraction of the temporal change in CD rates among some Robson groups in BC. Limitations of the study include a lack of information on intrapartum details, such as labor duration as well as maternal and perinatal outcomes associated with the observed differences in CD rates. CONCLUSIONS In this study, we found that several factors not included in the Robson classification explain a significant proportion of the spatiotemporal difference in CD rates in some Robson groups. These findings suggest that incorporating these factors into explanatory models using the Robson classification may be useful for ensuring that public health initiatives regarding CD rates are evidence informed.
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Affiliation(s)
- Giulia M. Muraca
- Clinical Epidemiology Unit, Department of Medicine, Solna, Karolinska University Hospital, Karolinska Institutet, Eugeniahemmet, Stockholm, Sweden
- Department of Obstetrics and Gynaecology, University of British Columbia and the Children’s and Women’s Hospital and Health Centre of British Columbia, Vancouver, British Columbia, Canada
- Departments of Obstetrics and Gynecology and Health Research Methods, Evidence & Impact, Faculty of Health Sciences, McMaster University, Ontario, Canada
- * E-mail:
| | - K.S. Joseph
- Department of Obstetrics and Gynaecology, University of British Columbia and the Children’s and Women’s Hospital and Health Centre of British Columbia, Vancouver, British Columbia, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Neda Razaz
- Clinical Epidemiology Unit, Department of Medicine, Solna, Karolinska University Hospital, Karolinska Institutet, Eugeniahemmet, Stockholm, Sweden
| | - Linnea V. Ladfors
- Clinical Epidemiology Unit, Department of Medicine, Solna, Karolinska University Hospital, Karolinska Institutet, Eugeniahemmet, Stockholm, Sweden
| | - Sarka Lisonkova
- Department of Obstetrics and Gynaecology, University of British Columbia and the Children’s and Women’s Hospital and Health Centre of British Columbia, Vancouver, British Columbia, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Olof Stephansson
- Clinical Epidemiology Unit, Department of Medicine, Solna, Karolinska University Hospital, Karolinska Institutet, Eugeniahemmet, Stockholm, Sweden
- Division of Women’s Health, Department of Obstetrics, Karolinska University Hospital, Stockholm, Sweden
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Razaz N, Muraca GM, Fink K, Boutin A, John S, Lisonkova S, Stephansson O, Cnattingius S, Joseph K. Time of delivery among low-risk women at 37-42 weeks of gestation and risks of stillbirth and infant mortality, and long-term neurological morbidity. Paediatr Perinat Epidemiol 2022; 36:577-587. [PMID: 35244233 PMCID: PMC9314589 DOI: 10.1111/ppe.12868] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 01/18/2022] [Accepted: 01/18/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND The most important knowledge gap in connection with obstetric management for time of delivery in term low-risk pregnancies relates to the absence of information on long-term neurodevelopmental outcomes. OBJECTIVES We examined risks of stillbirth, infant mortality, cerebral palsy (CP) and epilepsy among low-risk pregnancies. METHODS In this population-based Swedish study, we identified, from 1998 to 2019, 1,773,269 singleton infants born between 37 and 42 completed weeks in women with low-risk pregnancies. Poisson log-linear regression models were used to examine the association between gestational age at delivery and stillbirth, infant mortality, CP and epilepsy. Adjusted rate ratios (RR) and 95% confidence intervals expressing the effect of birth at a particular gestational week compared with birth at a later gestational week were estimated. RESULTS Compared with those born at a later gestation, RRs for stillbirth and infant mortality were higher among births at 37 weeks' and 38 weeks' gestation. The RRs for infant mortality were approximately 20% and 25% lower among births at 40 or 41 weeks compared with those born at later gestation, respectively. Infants born at 37 and 38 weeks also had higher RRs for CP (vs infants born at ≥38 and ≥39 weeks, respectively), while those born at 39 gestation had similar RRs (vs infants born at ≥40 weeks); infants born at 40 and 41 weeks had lower RRs of CP (vs those born at ≥41 and 42 weeks, respectively). The RRs for epilepsy were higher in those born at 37 and 38 weeks compared with those born at later gestation. CONCLUSIONS Among low-risk pregnancies, birth at 37 or 38 completed weeks' gestation is associated with increased risks of stillbirth, infant mortality and neurological morbidity, while birth at 39-40 completed weeks is associated with reduced risks compared with births at later gestation.
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Affiliation(s)
- Neda Razaz
- Clinical Epidemiology DivisionDepartment of Medicine SolnaKarolinska InstitutetStockholmSweden
| | - Giulia M. Muraca
- Clinical Epidemiology DivisionDepartment of Medicine SolnaKarolinska InstitutetStockholmSweden,Department of Obstetrics and GynaecologyBC Children’s and Women’s Hospital and Health Centre and the University of British ColumbiaVancouverBCCanada
| | - Katharina Fink
- Department of Clinical NeuroscienceKarolinska InstitutetStockholmSweden,Centrum for NeurologyAcademical Specialist CenterStockholmSweden
| | - Amélie Boutin
- Department of Obstetrics and GynaecologyBC Children’s and Women’s Hospital and Health Centre and the University of British ColumbiaVancouverBCCanada
| | - Sid John
- Department of Obstetrics and GynaecologyBC Children’s and Women’s Hospital and Health Centre and the University of British ColumbiaVancouverBCCanada
| | - Sarka Lisonkova
- Department of Obstetrics and GynaecologyBC Children’s and Women’s Hospital and Health Centre and the University of British ColumbiaVancouverBCCanada,School of Population and Public HealthUniversity of British ColumbiaVancouverBCCanada
| | - Olof Stephansson
- Clinical Epidemiology DivisionDepartment of Medicine SolnaKarolinska InstitutetStockholmSweden,Department of Women’s HealthKarolinska University HospitalStockholmSweden
| | - Sven Cnattingius
- Clinical Epidemiology DivisionDepartment of Medicine SolnaKarolinska InstitutetStockholmSweden
| | - K. S. Joseph
- Department of Obstetrics and GynaecologyBC Children’s and Women’s Hospital and Health Centre and the University of British ColumbiaVancouverBCCanada,School of Population and Public HealthUniversity of British ColumbiaVancouverBCCanada
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Ladfors LV, Muraca GM, Zetterqvist J, Butwick AJ, Stephansson O. Authors reply re: The Ten Group Classification System - First Things First. BJOG 2022; 129:1171-1173. [PMID: 34985182 DOI: 10.1111/1471-0528.17057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Accepted: 12/09/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Linnea V Ladfors
- Clinical Epidemiology Division, Department of Medicine - Solna, Karolinska Institutet, Stockholm, Sweden
| | - Giulia M Muraca
- Clinical Epidemiology Division, Department of Medicine - Solna, Karolinska Institutet, Stockholm, Sweden.,Department of Obstetrics and Gynaecology and Health Research Methods, Evidence & Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Johan Zetterqvist
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
| | - Alexander J Butwick
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Olof Stephansson
- Clinical Epidemiology Division, Department of Medicine - Solna, Karolinska Institutet, Stockholm, Sweden
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Muraca GM, Boutin A, Razaz N, Lisonkova S, John S, Ting JY, Scott H, Kramer MS, Joseph KS. Maternal and neonatal trauma following operative vaginal delivery. CMAJ 2022; 194:E1-E12. [PMID: 35012946 PMCID: PMC8800478 DOI: 10.1503/cmaj.210841] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2021] [Indexed: 12/31/2022] Open
Abstract
Background: Operative vaginal delivery (OVD) is considered safe if carried out by trained personnel. However, opportunities for training in OVD have declined and, given these shifts in practice, the safety of OVD is unknown. We estimated incidence rates of trauma following OVD in Canada, and quantified variation in trauma rates by instrument, region, level of obstetric care and institutional OVD volume. Methods: We conducted a cohort study of all singleton, term deliveries in Canada between April 2013 and March 2019, excluding Quebec. Our main outcome measures were maternal trauma (e.g., obstetric anal sphincter injury, high vaginal lacerations) and neonatal trauma (e.g., subgaleal hemorrhage, brachial plexus injury). We calculated adjusted and stabilized rates of trauma using mixed-effects logistic regression. Results: Of 1 326 191 deliveries, 38 500 (2.9%) were attempted forceps deliveries and 110 987 (8.4%) were attempted vacuum deliveries. The maternal trauma rate following forceps delivery was 25.3% (95% confidence interval [CI] 24.8%–25.7%) and the neonatal trauma rate was 9.6 (95% CI 8.6–10.6) per 1000 live births. Maternal and neonatal trauma rates following vacuum delivery were 13.2% (95% CI 13.0%–13.4%) and 9.6 (95% CI 9.0–10.2) per 1000 live births, respectively. Maternal trauma rates remained higher with forceps than with vacuum after adjustment for confounders (adjusted rate ratio 1.70, 95% CI 1.65–1.75) and varied by region, but not by level of obstetric care. Interpretation: In Canada, rates of trauma following OVD are higher than previously reported, irrespective of region, level of obstetric care and volume of OVD among hospitals. These results support a reassessment of OVD safety in Canada.
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Affiliation(s)
- Giulia M Muraca
- Department of Obstetrics and Gynaecology (Muraca, Boutin, Lisonkova, John, Joseph), University of British Columbia, Vancouver, BC; Clinical Epidemiology Unit, Department of Medicine (Muraca, Razaz), Solna, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden; Department of Pediatrics (Boutin), Université Laval, Québec City, Quebec; School of Population and Public Health (Lisonkova, Joseph); Division of Neonatology, Department of Pediatrics (Ting), University of British Columbia, Vancouver, BC; Department of Obstetrics and Gynaecology (Scott), Dalhousie University and the IWK Health Centre, Halifax, NS; Departments of Epidemiology and Occupation Health and of Pediatrics (Kramer), McGill University, Montréal, Que.
| | - Amélie Boutin
- Department of Obstetrics and Gynaecology (Muraca, Boutin, Lisonkova, John, Joseph), University of British Columbia, Vancouver, BC; Clinical Epidemiology Unit, Department of Medicine (Muraca, Razaz), Solna, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden; Department of Pediatrics (Boutin), Université Laval, Québec City, Quebec; School of Population and Public Health (Lisonkova, Joseph); Division of Neonatology, Department of Pediatrics (Ting), University of British Columbia, Vancouver, BC; Department of Obstetrics and Gynaecology (Scott), Dalhousie University and the IWK Health Centre, Halifax, NS; Departments of Epidemiology and Occupation Health and of Pediatrics (Kramer), McGill University, Montréal, Que
| | - Neda Razaz
- Department of Obstetrics and Gynaecology (Muraca, Boutin, Lisonkova, John, Joseph), University of British Columbia, Vancouver, BC; Clinical Epidemiology Unit, Department of Medicine (Muraca, Razaz), Solna, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden; Department of Pediatrics (Boutin), Université Laval, Québec City, Quebec; School of Population and Public Health (Lisonkova, Joseph); Division of Neonatology, Department of Pediatrics (Ting), University of British Columbia, Vancouver, BC; Department of Obstetrics and Gynaecology (Scott), Dalhousie University and the IWK Health Centre, Halifax, NS; Departments of Epidemiology and Occupation Health and of Pediatrics (Kramer), McGill University, Montréal, Que
| | - Sarka Lisonkova
- Department of Obstetrics and Gynaecology (Muraca, Boutin, Lisonkova, John, Joseph), University of British Columbia, Vancouver, BC; Clinical Epidemiology Unit, Department of Medicine (Muraca, Razaz), Solna, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden; Department of Pediatrics (Boutin), Université Laval, Québec City, Quebec; School of Population and Public Health (Lisonkova, Joseph); Division of Neonatology, Department of Pediatrics (Ting), University of British Columbia, Vancouver, BC; Department of Obstetrics and Gynaecology (Scott), Dalhousie University and the IWK Health Centre, Halifax, NS; Departments of Epidemiology and Occupation Health and of Pediatrics (Kramer), McGill University, Montréal, Que
| | - Sid John
- Department of Obstetrics and Gynaecology (Muraca, Boutin, Lisonkova, John, Joseph), University of British Columbia, Vancouver, BC; Clinical Epidemiology Unit, Department of Medicine (Muraca, Razaz), Solna, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden; Department of Pediatrics (Boutin), Université Laval, Québec City, Quebec; School of Population and Public Health (Lisonkova, Joseph); Division of Neonatology, Department of Pediatrics (Ting), University of British Columbia, Vancouver, BC; Department of Obstetrics and Gynaecology (Scott), Dalhousie University and the IWK Health Centre, Halifax, NS; Departments of Epidemiology and Occupation Health and of Pediatrics (Kramer), McGill University, Montréal, Que
| | - Joseph Y Ting
- Department of Obstetrics and Gynaecology (Muraca, Boutin, Lisonkova, John, Joseph), University of British Columbia, Vancouver, BC; Clinical Epidemiology Unit, Department of Medicine (Muraca, Razaz), Solna, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden; Department of Pediatrics (Boutin), Université Laval, Québec City, Quebec; School of Population and Public Health (Lisonkova, Joseph); Division of Neonatology, Department of Pediatrics (Ting), University of British Columbia, Vancouver, BC; Department of Obstetrics and Gynaecology (Scott), Dalhousie University and the IWK Health Centre, Halifax, NS; Departments of Epidemiology and Occupation Health and of Pediatrics (Kramer), McGill University, Montréal, Que
| | - Heather Scott
- Department of Obstetrics and Gynaecology (Muraca, Boutin, Lisonkova, John, Joseph), University of British Columbia, Vancouver, BC; Clinical Epidemiology Unit, Department of Medicine (Muraca, Razaz), Solna, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden; Department of Pediatrics (Boutin), Université Laval, Québec City, Quebec; School of Population and Public Health (Lisonkova, Joseph); Division of Neonatology, Department of Pediatrics (Ting), University of British Columbia, Vancouver, BC; Department of Obstetrics and Gynaecology (Scott), Dalhousie University and the IWK Health Centre, Halifax, NS; Departments of Epidemiology and Occupation Health and of Pediatrics (Kramer), McGill University, Montréal, Que
| | - Michael S Kramer
- Department of Obstetrics and Gynaecology (Muraca, Boutin, Lisonkova, John, Joseph), University of British Columbia, Vancouver, BC; Clinical Epidemiology Unit, Department of Medicine (Muraca, Razaz), Solna, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden; Department of Pediatrics (Boutin), Université Laval, Québec City, Quebec; School of Population and Public Health (Lisonkova, Joseph); Division of Neonatology, Department of Pediatrics (Ting), University of British Columbia, Vancouver, BC; Department of Obstetrics and Gynaecology (Scott), Dalhousie University and the IWK Health Centre, Halifax, NS; Departments of Epidemiology and Occupation Health and of Pediatrics (Kramer), McGill University, Montréal, Que
| | - K S Joseph
- Department of Obstetrics and Gynaecology (Muraca, Boutin, Lisonkova, John, Joseph), University of British Columbia, Vancouver, BC; Clinical Epidemiology Unit, Department of Medicine (Muraca, Razaz), Solna, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden; Department of Pediatrics (Boutin), Université Laval, Québec City, Quebec; School of Population and Public Health (Lisonkova, Joseph); Division of Neonatology, Department of Pediatrics (Ting), University of British Columbia, Vancouver, BC; Department of Obstetrics and Gynaecology (Scott), Dalhousie University and the IWK Health Centre, Halifax, NS; Departments of Epidemiology and Occupation Health and of Pediatrics (Kramer), McGill University, Montréal, Que
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Lisonkova S, Bone JN, Muraca GM, Razaz N, Wang LQ, Sabr Y, Boutin A, Mayer C, Joseph K. Incidence and risk factors for severe preeclampsia, hemolysis, elevated liver enzymes, and low platelet count syndrome, and eclampsia at preterm and term gestation: a population-based study. Am J Obstet Gynecol 2021; 225:538.e1-538.e19. [PMID: 33974902 DOI: 10.1016/j.ajog.2021.04.261] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 04/22/2021] [Accepted: 04/29/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND The majority of previous studies on severe preeclampsia, eclampsia, and hemolysis, elevated liver enzymes, and low platelet count syndrome were hospital-based or included a relatively small number of women. Large, population-based studies examining gestational age-specific incidence patterns and risk factors for these severe pregnancy complications are lacking. OBJECTIVE This study aimed to assess the gestational age-specific incidence rates and risk factors for severe preeclampsia, hemolysis, elevated liver enzymes, and low platelet count syndrome, and eclampsia. STUDY DESIGN We carried out a retrospective, population-based cohort study that included all women with a singleton hospital birth in Canada (excluding Quebec) from 2012 to 2016 (N=1,078,323). Data on the primary outcomes (ie, severe preeclampsia, hemolysis, elevated liver enzymes, and low platelet count syndrome, and eclampsia) were obtained from delivery hospitalization records abstracted by the Canadian Institute for Health Information. A Cox regression was used to assess independent risk factors (eg, maternal age and chronic comorbidity) for each primary outcome and to assess differences in the effects at preterm vs term gestation (<37 vs ≥37 weeks). RESULTS The rates of severe preeclampsia (n=2533), hemolysis, elevated liver enzymes, and low platelet count syndrome (n=2663), and eclampsia (n=465) were 2.35, 2.47, and 0.43 per 1000 singleton pregnancies, respectively. The cumulative incidence of term-onset severe preeclampsia was lower than that of preterm-onset severe preeclampsia (0.87 vs 1.54 per 1000; rate ratio, 0.57; 95% confidence intervals, 0.53-0.62), the rates of hemolysis, elevated liver enzymes, and low platelet count syndrome were similar (1.32 vs 1.23 per 1000; rate ratio, 0.93; 95% confidence interval, 0.86-1.00), and the preterm-onset eclampsia rate was lower than the term-onset rate (0.12 vs 0.33 per 1000; rate ratio, 2.64; 95% confidence interval, 2.16-3.23). For each primary outcome, chronic comorbidity and congenital anomalies were stronger risk factors for preterm- vs term-onset disease. Younger mothers (aged <25 years) were at higher risk for severe preeclampsia at term and for eclampsia at all gestational ages, whereas older mothers (aged ≥35 years) had elevated risks for severe preeclampsia and hemolysis, elevated liver enzymes, and low platelet count syndrome. Regardless of gestational age, nulliparity was a risk factor for all outcomes, whereas socioeconomic status was inversely associated with severe preeclampsia. CONCLUSION The risk for severe preeclampsia declined at term, eclampsia risk increased at term, and hemolysis, elevated liver enzymes, and low platelet count syndrome risk was similar for preterm and term gestation. Young maternal age was associated with an increased risk for eclampsia and term-onset severe preeclampsia. Prepregnancy comorbidity and fetal congenital anomalies were more strongly associated with severe preeclampsia, hemolysis, elevated liver enzymes, and low platelet count syndrome, and eclampsia at preterm gestation.
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Ladfors LV, Muraca GM, Zetterqvist J, Butwick AJ, Stephansson O. Postpartum haemorrhage trends in Sweden using the Robson ten group classification system: a population-based cohort study. BJOG 2021; 129:562-571. [PMID: 34536326 DOI: 10.1111/1471-0528.16931] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 07/09/2021] [Accepted: 07/15/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To examine postpartum haemorrhage (PPH) trends in Sweden using the Robson classification system. DESIGN Population-based cohort study. SETTING Sweden. POPULATION Deliveries in 2000-2016, classified as Robson groups 1-5 (singleton pregnancies in vertex presentation, from gestational weeks 37+0; n = 1 590 178). METHODS We examined temporal trends in PPH between 2000 and 2016 overall, and within each Robson group, and performed logistic regression to examine the influence of changes in risk factors (maternal, comorbidity, obstetric practice and infant factors) over time. MAIN OUTCOME MEASURES Postpartum haemorrhage, defined as an estimated blood loss of >1000 ml. RESULTS The overall PPH rate increased from 5.4 to 7.3%, corresponding to a 37% (OR 1.37, 95% CI 1.32-1.42) increase over time. Rates varied between Robson groups, ranging from 4.5% in group 3 to 14.3% in group 4b. Increasing trends in PPH were found in all Robson groups except for groups 2b and 4b (prelabour caesarean deliveries). In the unstratified analysis, adjusting for maternal, comorbidity and obstetric practice factors slightly attenuated the risk of PPH in the later period (2013-2016), compared with the reference period (2000-2004; crude OR 1.26, 95% CI 1.24-1.29, adjusted OR 1.22, 95% CI 1.20-1.25). Within individual Robson groups, changes in risk factors did not explain increasing rates of PPH. CONCLUSIONS Postpartum haemorrhage rates varied between Robson groups. Changes in risk factors could not explain the 37% increase in PPH for women in Robson groups 1-5 in Sweden, 2000-2016. TWEETABLE ABSTRACT Changes in risk factors could not explain the increasing trend of PPH in Sweden, and rates of PPH varied widely between Robson groups.
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Affiliation(s)
- L V Ladfors
- Clinical Epidemiology Division, Department of Medicine - Solna, Karolinska Institutet, Stockholm, Sweden
| | - G M Muraca
- Clinical Epidemiology Division, Department of Medicine - Solna, Karolinska Institutet, Stockholm, Sweden.,Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada
| | - J Zetterqvist
- Clinical Epidemiology Division, Department of Medicine - Solna, Karolinska Institutet, Stockholm, Sweden
| | - A J Butwick
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - O Stephansson
- Clinical Epidemiology Division, Department of Medicine - Solna, Karolinska Institutet, Stockholm, Sweden
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Boutin A, Lisonkova S, Muraca GM, Razaz N, Liu S, Kramer MS, Joseph KS. Bias in comparisons of mortality among very preterm births: A cohort study. PLoS One 2021; 16:e0253931. [PMID: 34191860 PMCID: PMC8244917 DOI: 10.1371/journal.pone.0253931] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Accepted: 06/15/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Several studies of prenatal determinants and neonatal morbidity and mortality among very preterm births have resulted in unexpected and paradoxical findings. We aimed to compare perinatal death rates among cohorts of very preterm births (24-31 weeks) with rates among all births in these groups (≥24 weeks), using births-based and fetuses-at-risk formulations. METHODS We conducted a cohort study of singleton live births and stillbirths ≥24 weeks' gestation using population-based data from the United States and Canada (2006-2015). We contrasted rates of perinatal death between women with or without hypertensive disorders, between maternal races, and between births in Canada vs the United States. RESULTS Births-based perinatal death rates at 24-31 weeks were lower among hypertensive than among non-hypertensive women (rate ratio [RR] 0.67, 95% CI 0.65-0.68), among Black mothers compared with White mothers (RR 0.94, 95%CI 0.92-0.95) and among births in the United States compared with Canada (RR 0.74, 95%CI 0.71-0.75). However, overall (≥24 weeks) perinatal death rates were higher among births to hypertensive vs non-hypertensive women (RR 2.14, 95%CI 2.10-2.17), Black vs White mothers (RR 1.86, 95%CI 184-1.88;) and births in the United States vs Canada (RR 1.08, 95%CI 1.05-1.10), as were perinatal death rates based on fetuses-at-risk at 24-31 weeks (RR for hypertensive disorders: 2.58, 95%CI 2.53-2.63; RR for Black vs White ethnicity: 2.29, 95%CI 2.25-2.32; RR for United States vs Canada: 1.27, 95%CI 1.22-1.30). CONCLUSION Studies of prenatal risk factors and between-centre or between-country comparisons of perinatal mortality bias causal inferences when restricted to truncated cohorts of very preterm births.
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Affiliation(s)
- Amélie Boutin
- Department of Obstetrics and Gynaecology, BC Children’s and Women’s Hospital and Health Centre, and the University of British Columbia, Vancouver, British Columbia, Canada
| | - Sarka Lisonkova
- Department of Obstetrics and Gynaecology, BC Children’s and Women’s Hospital and Health Centre, and the University of British Columbia, Vancouver, British Columbia, Canada
| | - Giulia M. Muraca
- Department of Obstetrics and Gynaecology, BC Children’s and Women’s Hospital and Health Centre, and the University of British Columbia, Vancouver, British Columbia, Canada
- Clinical Epidemiology Unit, Karolinska Institutet, Stockholm, Sweden
| | - Neda Razaz
- Clinical Epidemiology Unit, Karolinska Institutet, Stockholm, Sweden
| | - Shiliang Liu
- Maternal and Infant Health Section, Public Health Agency of Canada, Ottawa, Ontario, Canada
| | - Michael S. Kramer
- Departments of Pediatrics and of Epidemiology and Biostatistics, McGill University, Montreal, Quebec, Canada
| | - K. S. Joseph
- Department of Obstetrics and Gynaecology, BC Children’s and Women’s Hospital and Health Centre, and the University of British Columbia, Vancouver, British Columbia, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
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Ladfors LV, Muraca GM, Butwick A, Edgren G, Stephansson O. Accuracy of postpartum hemorrhage coding in the Swedish Pregnancy Register. Acta Obstet Gynecol Scand 2020; 100:322-330. [PMID: 32956490 PMCID: PMC7891624 DOI: 10.1111/aogs.13994] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 08/31/2020] [Accepted: 09/10/2020] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Postpartum hemorrhage (PPH) is recognized as a leading cause of obstetric morbidity and mortality. Population-wide studies have used International Classification of Diseases (ICD) diagnostic codes to track and report the prevalence of PPH. Although the 10th revision (ICD-10) was introduced in Sweden in 1997, the accuracy of ICD-10 codes for PPH is not known. Thus, the aim was to determine the accuracy of diagnostic coding for PPH in the Swedish Pregnancy Register. MATERIAL AND METHODS We performed a retrospective cohort study of 609 807 deliveries in Sweden between 2014 and 2019. Information on ICD-10 codes for PPH and estimated blood loss were extracted from the Swedish Pregnancy Register. Using an estimated blood loss >1000 mL as the reference standard, we evaluated the diagnostic accuracy of ICD-10 codes for PPH by estimating sensitivity, specificity, positive predictive value and negative predictive value with exact binomial 95% confidence intervals (CIs). In our secondary analysis, we assessed the ICD-10 coding accuracy for severe PPH, defined as an estimated blood loss >1000 mL and transfusion of at least 1 unit of red blood cells registered in the Scandinavian Donations and Transfusion database. RESULTS Of the 609 807 deliveries, 43 312 (7.1%) had an ICD-10 code for PPH and 45 071 (7.4%) had an estimated blood loss >1000 mL. The ICD codes had a sensitivity of 88.5% (95% CI 88.2-88.7), specificity of 99.4% (95% CI 99.4-99.4), positive predictive value of 92.0% (95% CI 91.8-92.3) and negative predictive value of 99.1% (95% CI 99.1-99.1). In our secondary analysis, on deliveries with severe PPH, the sensitivity for an ICD code was 91.3% (95% CI 90.7-91.9), whereas specificity was 83.5% (95% CI 82.3-84.6). CONCLUSIONS Our findings indicate that ICD-10 codes for PPH in Sweden have moderately high sensitivity and excellent specificity. These results suggest that PPH diagnostic codes in medical records and linked pregnancy and birth registers can be used for research, quality improvement and reporting PPH prevalence in Sweden.
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Affiliation(s)
- Linnea V Ladfors
- Clinical Epidemiology Division, Department of Medicine - Solna, Karolinska Institutet, Stockholm, Sweden
| | - Giulia M Muraca
- Clinical Epidemiology Division, Department of Medicine - Solna, Karolinska Institutet, Stockholm, Sweden.,Department of Obstetrics and gynecology, University of British Columbia, Children's and Women's Hospital and Health Centre of British Columbia, Vancouver, Canada
| | - Alexander Butwick
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Gustaf Edgren
- Clinical Epidemiology Division, Department of Medicine - Solna, Karolinska Institutet, Stockholm, Sweden
| | - Olof Stephansson
- Clinical Epidemiology Division, Department of Medicine - Solna, Karolinska Institutet, Stockholm, Sweden
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Razaz N, Villamor E, Muraca GM, Bonamy AKE, Cnattingius S. Maternal obesity and risk of cardiovascular diseases in offspring: a population-based cohort and sibling-controlled study. Lancet Diabetes Endocrinol 2020; 8:572-581. [PMID: 32559473 DOI: 10.1016/s2213-8587(20)30151-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 04/09/2020] [Accepted: 04/12/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND Maternal overweight and obesity might increase risks of adiposity and cardiovascular and metabolic diseases in offspring. We examined associations between maternal overweight and obesity severity and risk of cardiovascular diseases in young offspring. METHODS In this population-based cohort study, we used data from live singleton births recorded in the Swedish Medical Birth Register. We calculated maternal BMI in early pregnancy from self-reported height and weight measurements at the first prenatal visit. We used multivariable Cox proportional hazards regression to estimate adjusted hazard ratios (HRs) and 95% CIs. We calculated the proportion of the associations mediated through known consequences of obesity that also predicted cardiovascular diseases and did family case-control analyses. FINDINGS We identified 2 230 115 live singleton infants (without congenital malformations) in Sweden registered between Jan 1, 1992, and Dec 31, 2016. Overall, 1741 (0·08%) offspring were diagnosed with a cardiovascular disease between ages 1 and 25 years. Cardiovascular disease rates by maternal BMI categories were 0·57 per 10 000 child-years (BMI 18·5-24·9 kg/m2; normal weight), 0·61 per 10 000 child-years (25·0-29·9 kg/m2; overweight), 0·67 per 10 000 child-years (30·0-34·9 kg/m2; obesity grade I), 1·02 per 10 000 child-years (35·0-39·9 kg/m2; obesity grade II), and 1·38 per 10 000 child-years (≥40·0 kg/m2; obesity grade III). Compared with offspring of mothers with normal BMI, HRs of cardiovascular diseases were 1·10 (95% CI 0·97-1·25) for overweight, 1·16 (0·95-1·43) for obesity grade I, 1·84 (1·36-2·49) for obesity grade II, and 2·51 (1·60-3·92) for obesity grade III. Risks of cerebrovascular diseases increased with maternal obesity severity and were partly mediated through asphyxia-related neonatal complications. The sibling-cohort analysis also indicated a positive trend between maternal BMI and cardiovascular disease rates. INTERPRETATIONS Our findings indicate that maternal obesity might be a risk factor for cardiovascular diseases in childhood and early adulthood. These results need to be replicated and possible underlying mechanisms identified. FUNDING Swedish Research Council for Health, Working Life and Welfare.
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Affiliation(s)
- Neda Razaz
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden.
| | - Eduardo Villamor
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Giulia M Muraca
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Anna-Karin Edstedt Bonamy
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden; Sachs' Children's and Youth Hospital, Södersjukhuset, Stockholm, Sweden
| | - Sven Cnattingius
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
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Muraca GM, Liu S, Sabr Y, Lisonkova S, Skoll A, Brant R, Cundiff GW, Stephansson O, Razaz N, Joseph KS. Episiotomy use among vaginal deliveries and the association with anal sphincter injury: a population-based retrospective cohort study. CMAJ 2020; 191:E1149-E1158. [PMID: 31636163 DOI: 10.1503/cmaj.190366] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/16/2019] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND The rate of obstetric anal sphincter injury has increased in recent years, particularly among operative vaginal deliveries. We sought to characterize temporal trends in episiotomy use and to quantify the association between episiotomy and obstetric anal sphincter injury. METHODS Using a population-based retrospective cohort study design of hospital data from 2004 to 2017, we studied all vaginal deliveries of singleton infants at term gestation in Canada (excluding Quebec). Rates of obstetric anal sphincter injury were contrasted between women who had an episiotomy and those who did not. Log-binomial regression was used to estimate the association between episiotomy and obstetric anal sphincter injury among women with spontaneous and operative vaginal deliveries after controlling for confounders. RESULTS The study population included 2 570 847 deliveries. Episiotomy use declined significantly among operative vaginal deliveries (53.1% in 2004 to 43.2% in 2017, p < 0.0001) and spontaneous vaginal deliveries (13.5% in 2004 to 6.5% in 2017, p < 0.0001). Episiotomy was associated with higher rates of obstetric anal sphincter injury among spontaneous vaginal deliveries (4.8 with episiotomy v. 2.4% without; adjusted rate ratio [RR] 2.06, 95% confidence interval [CI] 2.00-2.11) and this association remained after stratification by parity and obstetric history. In contrast, episiotomy was associated with lower rates of obstetric anal sphincter injury among forceps deliveries in nulliparous women (adjusted RR 0.63, 95% CI 0.61-0.66), and women with vaginal birth after cesarean (adjusted RR 0.71, 95% CI 0.60-0.85), but not among parous women without a previous cesarean (adjusted RR 1.16, 95% CI 1.00-1.34). INTERPRETATION Episiotomy use has declined in Canada for all vaginal deliveries. The protective association between episiotomy and obstetric anal sphincter injury among women who gave birth by operative vaginal delivery (especially forceps) warrants reconsideration of clinical practice among nulliparous women and those attempting vaginal birth after cesarean.
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Affiliation(s)
- Giulia M Muraca
- Clinical Epidemiology Unit, Department of Medicine (Muraca, Stephansson, Razaz), Solna, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden; Department of Obstetrics & Gynaecology (Muraca, Sabr, Lisonkova, Skoll, Cundiff, Joseph), University of British Columbia, Vancouver, BC; Maternal, Child and Youth Health Division (Liu), Centre for Surveillance and Applied Research, Public Health Agency of Canada, Ottawa, Ont.; Department of Obstetrics and Gynaecology (Sabr), King Saud University, Riyadh, Saudi Arabia; School of Population and Public Health (Lisonkova, Joseph); Department of Statistics (Brant), University of British Columbia, Vancouver, BC; Department of Women's and Children's Health, Division of Obstetrics and Gynaecology (Stephansson), Karolinska Institutet, Stockholm, Sweden
| | - Shiliang Liu
- Clinical Epidemiology Unit, Department of Medicine (Muraca, Stephansson, Razaz), Solna, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden; Department of Obstetrics & Gynaecology (Muraca, Sabr, Lisonkova, Skoll, Cundiff, Joseph), University of British Columbia, Vancouver, BC; Maternal, Child and Youth Health Division (Liu), Centre for Surveillance and Applied Research, Public Health Agency of Canada, Ottawa, Ont.; Department of Obstetrics and Gynaecology (Sabr), King Saud University, Riyadh, Saudi Arabia; School of Population and Public Health (Lisonkova, Joseph); Department of Statistics (Brant), University of British Columbia, Vancouver, BC; Department of Women's and Children's Health, Division of Obstetrics and Gynaecology (Stephansson), Karolinska Institutet, Stockholm, Sweden
| | - Yasser Sabr
- Clinical Epidemiology Unit, Department of Medicine (Muraca, Stephansson, Razaz), Solna, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden; Department of Obstetrics & Gynaecology (Muraca, Sabr, Lisonkova, Skoll, Cundiff, Joseph), University of British Columbia, Vancouver, BC; Maternal, Child and Youth Health Division (Liu), Centre for Surveillance and Applied Research, Public Health Agency of Canada, Ottawa, Ont.; Department of Obstetrics and Gynaecology (Sabr), King Saud University, Riyadh, Saudi Arabia; School of Population and Public Health (Lisonkova, Joseph); Department of Statistics (Brant), University of British Columbia, Vancouver, BC; Department of Women's and Children's Health, Division of Obstetrics and Gynaecology (Stephansson), Karolinska Institutet, Stockholm, Sweden
| | - Sarka Lisonkova
- Clinical Epidemiology Unit, Department of Medicine (Muraca, Stephansson, Razaz), Solna, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden; Department of Obstetrics & Gynaecology (Muraca, Sabr, Lisonkova, Skoll, Cundiff, Joseph), University of British Columbia, Vancouver, BC; Maternal, Child and Youth Health Division (Liu), Centre for Surveillance and Applied Research, Public Health Agency of Canada, Ottawa, Ont.; Department of Obstetrics and Gynaecology (Sabr), King Saud University, Riyadh, Saudi Arabia; School of Population and Public Health (Lisonkova, Joseph); Department of Statistics (Brant), University of British Columbia, Vancouver, BC; Department of Women's and Children's Health, Division of Obstetrics and Gynaecology (Stephansson), Karolinska Institutet, Stockholm, Sweden
| | - Amanda Skoll
- Clinical Epidemiology Unit, Department of Medicine (Muraca, Stephansson, Razaz), Solna, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden; Department of Obstetrics & Gynaecology (Muraca, Sabr, Lisonkova, Skoll, Cundiff, Joseph), University of British Columbia, Vancouver, BC; Maternal, Child and Youth Health Division (Liu), Centre for Surveillance and Applied Research, Public Health Agency of Canada, Ottawa, Ont.; Department of Obstetrics and Gynaecology (Sabr), King Saud University, Riyadh, Saudi Arabia; School of Population and Public Health (Lisonkova, Joseph); Department of Statistics (Brant), University of British Columbia, Vancouver, BC; Department of Women's and Children's Health, Division of Obstetrics and Gynaecology (Stephansson), Karolinska Institutet, Stockholm, Sweden
| | - Rollin Brant
- Clinical Epidemiology Unit, Department of Medicine (Muraca, Stephansson, Razaz), Solna, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden; Department of Obstetrics & Gynaecology (Muraca, Sabr, Lisonkova, Skoll, Cundiff, Joseph), University of British Columbia, Vancouver, BC; Maternal, Child and Youth Health Division (Liu), Centre for Surveillance and Applied Research, Public Health Agency of Canada, Ottawa, Ont.; Department of Obstetrics and Gynaecology (Sabr), King Saud University, Riyadh, Saudi Arabia; School of Population and Public Health (Lisonkova, Joseph); Department of Statistics (Brant), University of British Columbia, Vancouver, BC; Department of Women's and Children's Health, Division of Obstetrics and Gynaecology (Stephansson), Karolinska Institutet, Stockholm, Sweden
| | - Geoffrey W Cundiff
- Clinical Epidemiology Unit, Department of Medicine (Muraca, Stephansson, Razaz), Solna, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden; Department of Obstetrics & Gynaecology (Muraca, Sabr, Lisonkova, Skoll, Cundiff, Joseph), University of British Columbia, Vancouver, BC; Maternal, Child and Youth Health Division (Liu), Centre for Surveillance and Applied Research, Public Health Agency of Canada, Ottawa, Ont.; Department of Obstetrics and Gynaecology (Sabr), King Saud University, Riyadh, Saudi Arabia; School of Population and Public Health (Lisonkova, Joseph); Department of Statistics (Brant), University of British Columbia, Vancouver, BC; Department of Women's and Children's Health, Division of Obstetrics and Gynaecology (Stephansson), Karolinska Institutet, Stockholm, Sweden
| | - Olof Stephansson
- Clinical Epidemiology Unit, Department of Medicine (Muraca, Stephansson, Razaz), Solna, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden; Department of Obstetrics & Gynaecology (Muraca, Sabr, Lisonkova, Skoll, Cundiff, Joseph), University of British Columbia, Vancouver, BC; Maternal, Child and Youth Health Division (Liu), Centre for Surveillance and Applied Research, Public Health Agency of Canada, Ottawa, Ont.; Department of Obstetrics and Gynaecology (Sabr), King Saud University, Riyadh, Saudi Arabia; School of Population and Public Health (Lisonkova, Joseph); Department of Statistics (Brant), University of British Columbia, Vancouver, BC; Department of Women's and Children's Health, Division of Obstetrics and Gynaecology (Stephansson), Karolinska Institutet, Stockholm, Sweden
| | - Neda Razaz
- Clinical Epidemiology Unit, Department of Medicine (Muraca, Stephansson, Razaz), Solna, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden; Department of Obstetrics & Gynaecology (Muraca, Sabr, Lisonkova, Skoll, Cundiff, Joseph), University of British Columbia, Vancouver, BC; Maternal, Child and Youth Health Division (Liu), Centre for Surveillance and Applied Research, Public Health Agency of Canada, Ottawa, Ont.; Department of Obstetrics and Gynaecology (Sabr), King Saud University, Riyadh, Saudi Arabia; School of Population and Public Health (Lisonkova, Joseph); Department of Statistics (Brant), University of British Columbia, Vancouver, BC; Department of Women's and Children's Health, Division of Obstetrics and Gynaecology (Stephansson), Karolinska Institutet, Stockholm, Sweden
| | - K S Joseph
- Clinical Epidemiology Unit, Department of Medicine (Muraca, Stephansson, Razaz), Solna, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden; Department of Obstetrics & Gynaecology (Muraca, Sabr, Lisonkova, Skoll, Cundiff, Joseph), University of British Columbia, Vancouver, BC; Maternal, Child and Youth Health Division (Liu), Centre for Surveillance and Applied Research, Public Health Agency of Canada, Ottawa, Ont.; Department of Obstetrics and Gynaecology (Sabr), King Saud University, Riyadh, Saudi Arabia; School of Population and Public Health (Lisonkova, Joseph); Department of Statistics (Brant), University of British Columbia, Vancouver, BC; Department of Women's and Children's Health, Division of Obstetrics and Gynaecology (Stephansson), Karolinska Institutet, Stockholm, Sweden
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Lisonkova S, Razaz N, Sabr Y, Muraca GM, Boutin A, Mayer C, Joseph KS, Kramer MS. Maternal risk factors and adverse birth outcomes associated with HELLP syndrome: a population-based study. BJOG 2020; 127:1189-1198. [PMID: 32189413 DOI: 10.1111/1471-0528.16225] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVES We assessed the incidence, risk factors and adverse birth outcomes associated with elevated liver enzymes and low platelets (HELLP) syndrome. DESIGN A retrospective population-based cohort study. SETTING Canada (excluding Quebec), 2012/2013-2015/2016. POPULATION Mothers with a singleton hospital live birth or stillbirth at ≥24 weeks' gestation (n = 1 078 323). METHODS HELLP syndrome was identified using ICD-10-CA diagnostic code from delivery hospitalisation data. We used logistic regression to identify independent risk factors for HELLP syndrome by obtaining adjusted odds ratios (AOR) and 95% confidence intervals (CI), and to assess the associations with adverse outcomes. MAIN OUTCOME MEASURES Adverse maternal (e.g. eclampsia) and fetal/neonatal outcomes (e.g. intraventricular haemorrhage, perinatal death). RESULTS The incidence of HELLP syndrome was 2.5 per 1000 singleton deliveries (n = 2663). Risk factors included: age ≥35 years, rural residence, nulliparity, parity ≥4, pre-pregnancy and gestational hypertension and diabetes, assisted reproduction, chronic cardiac conditions, systemic lupus erythematosus, obesity, chronic hepatic conditions, placental disorders (e.g. fetomaternal transfusion) and congenital anomalies. PROM and age <25 years were inversely associated with HELLP syndrome (P-values <0.05). Women with the syndrome had a 10-fold higher maternal mortality (95% CI 1.6-84.3) and elevated severe maternal morbidity (9.6 versus 121.7 per 1000; AOR 12.5, 95% CI 11.1-14.1); and higher perinatal mortality (4.3 versus 21.0 per 1000; AOR 4.5, 95% CI 3.5-5.9) and perinatal mortality/severe neonatal morbidity (21.2 versus 202.4 per 1000; AOR 10.7, 95% CI 9.7-11.8). CONCLUSION HELLP syndrome is associated with specific pre-pregnancy and pregnancy risk factors, higher rates of maternal death, and substantially higher severe maternal morbidity, perinatal mortality and severe neonatal morbidity. TWEETABLE ABSTRACT HELLP syndrome is associated with higher maternal death rate, and substantially higher severe maternal and neonatal morbidity, and perinatal mortality.
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Affiliation(s)
- S Lisonkova
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada.,Children's and Women's Hospital and Health Centre of British Columbia, Vancouver, BC, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - N Razaz
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Y Sabr
- Department of Obstetrics and Gynaecology, King Saud University, Riyadh, Saudi Arabia
| | - G M Muraca
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - A Boutin
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada.,Children's and Women's Hospital and Health Centre of British Columbia, Vancouver, BC, Canada
| | - C Mayer
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada.,Children's and Women's Hospital and Health Centre of British Columbia, Vancouver, BC, Canada
| | - K S Joseph
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada.,Children's and Women's Hospital and Health Centre of British Columbia, Vancouver, BC, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - M S Kramer
- Departments of Paediatrics and of Epidemiology, Biostatistics and Occupational Health, McGill University Faculty of Medicine, Montreal, QC, Canada
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Lisonkova S, Geoffrion R, Sanaee M, Muraca GM, Wen Q, Yong PJ, Larouche M, Cundiff GW. Regional Variation and Temporal Trends in Surgery for Pelvic Organ Prolapse in Canada, 2004-2014. J Obstet Gynaecol Can 2020; 42:846-852.e5. [PMID: 32173237 DOI: 10.1016/j.jogc.2019.12.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 12/20/2019] [Accepted: 12/23/2019] [Indexed: 11/16/2022]
Abstract
OBJECTIVES We sought to examine temporal trends in pelvic organ prolapse (POP) surgery in Canada. METHODS In this observational cross-sectional study, we used diagnostic and procedure codes from all hospitalizations and outpatient clinic visits in Canada (excluding Québec) from 2004 to 2014 to identify and analyze data on POP surgery. RESULTS There were 204 301 POP surgery visits from 2004 to 2014, and the rate of POP surgery declined from 19.3 to 16.0 per 10 000 women during this period. The rates of "native tissue reconstructive repair" and "hysterectomy without other procedure" declined from 15.0 to 12.8 per 10 000 women and 2.6 to 1.6 per 10 000 women, respectively. The rate of obliteration increased from 0.1 to 0.3 per 10 000 women (all P values for trend <0.01). Mesh procedures increased from 1.6 per 10 000 women in 2004 to 2.4 per 10 000 women in 2007 and 2008, and then declined to 1.3 per 10 000 women in 2014. Reconstructive mesh surgery using an abdominal open approach declined, while laparoscopic procedures increased over the period examined. CONCLUSION The rates of POP surgery declined in Canada between 2004 and 2014. An increase was observed in obliteration procedures and in laparoscopic vaginal suspension and fixation with mesh.
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Affiliation(s)
- Sarka Lisonkova
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC; Children's and Women's Hospital and Health Centre of British Columbia, Vancouver, BC; School of Population and Public Health, University of British Columbia, Vancouver, BC.
| | - Roxana Geoffrion
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC
| | - May Sanaee
- Department of Obstetrics and Gynaecology, University of Alberta, Edmonton, AB
| | - Giulia M Muraca
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC; Children's and Women's Hospital and Health Centre of British Columbia, Vancouver, BC
| | - Qi Wen
- Department of Statistics and Actuarial Sciences, Simon Fraser University, Burnaby, BC
| | - Paul J Yong
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC; Children's and Women's Hospital and Health Centre of British Columbia, Vancouver, BC
| | - Maryse Larouche
- St. Mary's Research Center, Montreal, QC; Department of Obstetrics and Gynecology, McGill University, Montreal, QC
| | - Geoffrey W Cundiff
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC
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Muraca GM, Joseph KS. The authors respond to "Routine use of episiotomy with forceps should not be encouraged". CMAJ 2020; 192:E191-E192. [PMID: 32094271 PMCID: PMC7043826 DOI: 10.1503/cmaj.74565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Giulia M Muraca
- Postdoctoral fellow, Clinical Epidemiology Unit, Department of Medicine, Solna Karolinska Institutet, Stockholm, Sweden, and Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC
| | - K S Joseph
- Professor, Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC
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Muraca GM, Razaz N. Key considerations when comparing outcomes by mode of delivery raise questions about study validity and clinical relevance. CMAJ 2019; 191:E923. [PMID: 31427360 DOI: 10.1503/cmaj.72687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Giulia M Muraca
- Postdoctoral fellow, Clinical Epidemiology Unit, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Neda Razaz
- Postdoctoral fellow, Clinical Epidemiology Unit, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
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Lisonkova S, Richter LL, Ting J, Muraca GM, Wen Q, Mehrabadi A, Mitchell-Foster S, Oviedo-Joekes E, Lyons J. Neonatal Abstinence Syndrome and Associated Neonatal and Maternal Mortality and Morbidity. Pediatrics 2019; 144:peds.2018-3664. [PMID: 31300529 DOI: 10.1542/peds.2018-3664] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/15/2019] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES We examined demographic characteristics and birth outcomes of infants with neonatal abstinence syndrome (NAS) and their mothers in Canada. METHODS This retrospective, population-based, descriptive cross-sectional study of mother-infant dyads included all singleton live births in Canada (excluding Quebec), from 2005-2006 to 2015-2016 (N = 2 881 789). Demographic characteristics, NAS, and neonatal and maternal morbidities were identified from delivery hospitalization data (including diagnostic codes). The main composite outcomes were maternal and neonatal mortality and/or severe morbidity, including death and potentially life-threatening conditions in the mother and the infant, respectively. Logistic regression yielded adjusted odds ratios (aORs) and 95% confidence intervals (CIs). RESULTS The study included 10 027 mother-infant dyads with NAS. The incidence of NAS increased from 0.20% to 0.51%. Maternal mortality was 1.99 vs 0.31 per 10 000 women in the NAS group versus the comparison group (aOR = 6.53; 95% CI: 1.59 to 26.74), and maternal mortality and/or severe morbidity rates were 3.10% vs 1.35% (aOR = 2.21; 95% CI: 1.97 to 2.49). Neonatal mortality was 0.12% vs 0.19% (aOR = 0.28; 95% CI: 0.15 to 0.53), and neonatal mortality and/or severe morbidity rates were 6.36% vs 1.73% (aOR = 2.27; 95% CI: 2.06 to 2.50) among infants with NAS versus without NAS. CONCLUSIONS NAS incidence increased notably in Canada between 2005-2006 and 2015-2016. Infants with NAS had elevated severe morbidity, and their mothers had elevated mortality and severe morbidity. These results highlight the importance of implementing integrated care services to support the mother-infant dyad during childbirth and in the postpartum period.
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Affiliation(s)
- Sarka Lisonkova
- Departments of Obstetrics and Gynecology and .,School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Joseph Ting
- Pediatrics, University of British Columbia and the British Columbia Women's Hospital and Health Center, Vancouver, British Columbia, Canada
| | | | - Qi Wen
- Department of Statistics and Actuarial Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Azar Mehrabadi
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Sheona Mitchell-Foster
- Departments of Obstetrics and Gynecology and.,Northern Medical Program, University of British Columbia, Prince George, British Columbia, Canada; and
| | - Eugenia Oviedo-Joekes
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada.,Centre for Health Evaluation and Outcome Sciences, Providence Health Care, St Paul's Hospital, Vancouver, Canada
| | - Janet Lyons
- Departments of Obstetrics and Gynecology and
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Richter LL, Ting J, Muraca GM, Synnes A, Lim KI, Lisonkova S. Temporal trends in neonatal mortality and morbidity following spontaneous and clinician-initiated preterm birth in Washington State, USA: a population-based study. BMJ Open 2019; 9:e023004. [PMID: 30782691 PMCID: PMC6361413 DOI: 10.1136/bmjopen-2018-023004] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 12/04/2018] [Accepted: 12/13/2018] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE After a decade of increase, the preterm birth (PTB) rate has declined in the USA since 2006, with the largest decline at late preterm (34-36 weeks). We described concomitant changes in gestational age-specific rates of neonatal mortality and morbidity following spontaneous and clinician-initiated PTB among singleton infants. DESIGN, SETTING AND PARTICIPANTS This retrospective population-based study included 754 763 singleton births in Washington State, USA, 2004-2013, using data from birth certificates and hospitalisation records. PTB subtypes included preterm premature rupture of membranes (PPROM), spontaneous onset of labour and clinician-initiated delivery. OUTCOME MEASURES The primary outcomes were neonatal mortality and a composite outcome including death or severe neonatal morbidity. Temporal trends in the outcomes and individual morbidities were assessed by PTB subtype. Logistic regression yielded adjusted odds ratios (AOR) per 1 year change in outcome and 95% CI. RESULTS The rate of PTB following PPROM and spontaneous labour declined, while clinician-initiated PTB increased (all p<0.01). Overall neonatal mortality remained unchanged (1.3%; AOR 0.99, CI 0.95 to 1.02), though gestational age-specific mortality following clinician-initiated PTB declined at 32-33 weeks (AOR 0.85, CI 0.74 to 0.97) and increased at 34-36 weeks (AOR 1.10, CI 1.01 to 1.20). The overall rate of the composite outcome increased (from 7.9% to 11.9%; AOR 1.06, CI 1.05 to 1.08). Among late preterm infants, combined mortality or severe morbidity increased following PPROM (AOR 1.13, CI 1.08 to 1.18), spontaneous labour (AOR 1.09, CI 1.06 to 1.13) and clinician-initiated delivery (AOR 1.10, CI 1.07 to 1.13). Neonatal sepsis rates increased among all preterm infants (AOR 1.09, CI 1.08 to 1.11). CONCLUSIONS Timing of obstetric interventions is associated with infant health outcomes at preterm. The temporal decline in late PTB among singleton infants was associated with increased mortality among late preterm infants born following clinician-initiated delivery and increased combined mortality or severe morbidity among all late preterm infants, mainly due to increased rate of sepsis.
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Affiliation(s)
- Lindsay L Richter
- Department of Obstetrics and Gynaecology, University of British Columbia and the Children’s and Women’s Hospital and Health Centre of British Columbia, Vancouver, British Columbia, Canada
| | - Joseph Ting
- Department of Pediatrics, University of British Columbia and the Children’s and Women’s Hospital and Health Centre of British Columbia, Vancouver, British Columbia, Canada
| | - Giulia M Muraca
- Department of Obstetrics and Gynaecology, University of British Columbia and the Children’s and Women’s Hospital and Health Centre of British Columbia, Vancouver, British Columbia, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Anne Synnes
- Department of Pediatrics, University of British Columbia and the Children’s and Women’s Hospital and Health Centre of British Columbia, Vancouver, British Columbia, Canada
| | - Kenneth I Lim
- Department of Obstetrics and Gynaecology, University of British Columbia and the Children’s and Women’s Hospital and Health Centre of British Columbia, Vancouver, British Columbia, Canada
| | - Sarka Lisonkova
- Department of Obstetrics and Gynaecology, University of British Columbia and the Children’s and Women’s Hospital and Health Centre of British Columbia, Vancouver, British Columbia, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
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Muraca GM, Skoll A, Lisonkova S, Sabr Y, Brant R, Cundiff GW, Joseph KS. Authors/ reply re: Perinatal and maternal morbidity and mortality among term singletons following mid cavity operative vaginal delivery versus caesarean delivery. BJOG 2018; 125:1492. [PMID: 30069997 DOI: 10.1111/1471-0528.15391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/25/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Giulia M Muraca
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada.,Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada.,BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Amanda Skoll
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada.,BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Sarka Lisonkova
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada.,Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada.,BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Yasser Sabr
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada.,Department of Obstetrics and Gynaecology, King Saud University, King Khalid University Hospital, Riyadh, Saudi Arabia
| | - Rollin Brant
- BC Children's Hospital Research Institute, Vancouver, BC, Canada.,Department of Statistics, University of British Columbia, Vancouver, BC, Canada
| | - Geoffrey W Cundiff
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada.,BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | - K S Joseph
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada.,Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada.,BC Children's Hospital Research Institute, Vancouver, BC, Canada
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Muraca GM, Lisonkova S, Skoll A, Brant R, Cundiff GW, Sabr Y, Joseph KS. Ecological association between operative vaginal delivery and obstetric and birth trauma. CMAJ 2018; 190:E734-E741. [PMID: 29914910 PMCID: PMC6008188 DOI: 10.1503/cmaj.171076] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/07/2018] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Increased use of operative vaginal delivery (use of forceps, vacuum or other device) has been recommended to address high rates of cesarean delivery. We sought to determine the association between rates of operative vaginal delivery and obstetric trauma and severe birth trauma. METHODS We carried out an ecological analysis of term, singleton deliveries in 4 Canadian provinces (2004-2014) using data from the Canadian Institute for Health Information. The primary exposure was mode of delivery. The primary outcomes were obstetric trauma and severe birth trauma. RESULTS Data on 1 938 913 deliveries were analyzed. The rate of obstetric trauma was 7.2% in nulliparous women, and 2.2% and 2.7% among parous women without and with a previous cesarean delivery, respectively, and rates of severe birth trauma were 2.1, 1.7 and 0.7 per 1000, respectively. Each 1% absolute increase in rates of operative vaginal delivery was associated with a higher frequency of obstetric trauma among nulliparous women (adjusted rate ratio [ARR] 1.06, 95% confidence interval [CI] 1.05-1.06), parous women without a previous cesarean delivery (ARR 1.10, 95% CI 1.08-1.13) and parous women with a previous cesarean delivery (ARR 1.11, 95% CI 1.07-1.16). Operative vaginal delivery was associated with more frequent severe birth trauma, but only in nulliparous women (ARR 1.05, 95% CI 1.03-1.07). In nulliparous women, sequential vacuum and forceps instrumentation was associated with the largest increase in obstetric trauma (ARR 1.44, 95% CI 1.35-1.55) and birth trauma (ARR 1.53, 95% CI 1.03-2.27). INTERPRETATION Increases in population rates of operative vaginal delivery are associated with higher population rates of obstetric trauma, and in nulliparous women with severe birth trauma.
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Affiliation(s)
- Giulia M Muraca
- School of Population and Public Health (Muraca, Lisonkova, Joseph); Department of Obstetrics & Gynaecology (Muraca, Lisonkova, Skoll, Cundiff, Sabr, Joseph), University of British Columbia; BC Children's and Women's Hospital and Health Centre (Muraca, Lisonkova, Skoll, Brant, Cundiff, Joseph); Department of Statistics (Brant), University of British Columbia, Vancouver, BC; Department of Obstetrics and Gynaecology (Sabr), King Saud University, King Khalid University Hospital, Riyadh, Saudi Arabia
| | - Sarka Lisonkova
- School of Population and Public Health (Muraca, Lisonkova, Joseph); Department of Obstetrics & Gynaecology (Muraca, Lisonkova, Skoll, Cundiff, Sabr, Joseph), University of British Columbia; BC Children's and Women's Hospital and Health Centre (Muraca, Lisonkova, Skoll, Brant, Cundiff, Joseph); Department of Statistics (Brant), University of British Columbia, Vancouver, BC; Department of Obstetrics and Gynaecology (Sabr), King Saud University, King Khalid University Hospital, Riyadh, Saudi Arabia
| | - Amanda Skoll
- School of Population and Public Health (Muraca, Lisonkova, Joseph); Department of Obstetrics & Gynaecology (Muraca, Lisonkova, Skoll, Cundiff, Sabr, Joseph), University of British Columbia; BC Children's and Women's Hospital and Health Centre (Muraca, Lisonkova, Skoll, Brant, Cundiff, Joseph); Department of Statistics (Brant), University of British Columbia, Vancouver, BC; Department of Obstetrics and Gynaecology (Sabr), King Saud University, King Khalid University Hospital, Riyadh, Saudi Arabia
| | - Rollin Brant
- School of Population and Public Health (Muraca, Lisonkova, Joseph); Department of Obstetrics & Gynaecology (Muraca, Lisonkova, Skoll, Cundiff, Sabr, Joseph), University of British Columbia; BC Children's and Women's Hospital and Health Centre (Muraca, Lisonkova, Skoll, Brant, Cundiff, Joseph); Department of Statistics (Brant), University of British Columbia, Vancouver, BC; Department of Obstetrics and Gynaecology (Sabr), King Saud University, King Khalid University Hospital, Riyadh, Saudi Arabia
| | - Geoffrey W Cundiff
- School of Population and Public Health (Muraca, Lisonkova, Joseph); Department of Obstetrics & Gynaecology (Muraca, Lisonkova, Skoll, Cundiff, Sabr, Joseph), University of British Columbia; BC Children's and Women's Hospital and Health Centre (Muraca, Lisonkova, Skoll, Brant, Cundiff, Joseph); Department of Statistics (Brant), University of British Columbia, Vancouver, BC; Department of Obstetrics and Gynaecology (Sabr), King Saud University, King Khalid University Hospital, Riyadh, Saudi Arabia
| | - Yasser Sabr
- School of Population and Public Health (Muraca, Lisonkova, Joseph); Department of Obstetrics & Gynaecology (Muraca, Lisonkova, Skoll, Cundiff, Sabr, Joseph), University of British Columbia; BC Children's and Women's Hospital and Health Centre (Muraca, Lisonkova, Skoll, Brant, Cundiff, Joseph); Department of Statistics (Brant), University of British Columbia, Vancouver, BC; Department of Obstetrics and Gynaecology (Sabr), King Saud University, King Khalid University Hospital, Riyadh, Saudi Arabia
| | - K S Joseph
- School of Population and Public Health (Muraca, Lisonkova, Joseph); Department of Obstetrics & Gynaecology (Muraca, Lisonkova, Skoll, Cundiff, Sabr, Joseph), University of British Columbia; BC Children's and Women's Hospital and Health Centre (Muraca, Lisonkova, Skoll, Brant, Cundiff, Joseph); Department of Statistics (Brant), University of British Columbia, Vancouver, BC; Department of Obstetrics and Gynaecology (Sabr), King Saud University, King Khalid University Hospital, Riyadh, Saudi Arabia
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Young CB, Liu S, Muraca GM, Sabr Y, Pressey T, Liston RM, Joseph KS. Mode of delivery after a previous cesarean birth, and associated maternal and neonatal morbidity. CMAJ 2018; 190:E556-E564. [PMID: 29735533 PMCID: PMC5940456 DOI: 10.1503/cmaj.170371] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2018] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND The mode of delivery for women with a previous cesarean delivery remains contentious. We conducted a study comparing maternal and infant outcomes after attempted vaginal birth after cesarean delivery versus elective repeat cesarean delivery. METHODS We used data from the Discharge Abstract Database that includes all hospital deliveries in Canada (excluding Quebec). In our analysis, we included singleton deliveries to women between 37 and 43 weeks gestation who had a single prior cesarean delivery between April 2003 and March 2015. The primary outcomes were severe maternal morbidity and mortality, and serious neonatal morbidity and mortality. We used logistic regression to estimate adjusted rate ratios (RRs) and 95% confidence intervals (CIs). RESULTS Absolute rates of severe maternal morbidity and mortality were low but significantly higher after attempted vaginal birth after cesarean delivery compared with elective repeat cesarean delivery (10.7 v. 5.65 per 1000 deliveries, respectively; adjusted RR 1.96, 95% CI 1.76 to 2.19). Adjusted rate differences in severe maternal morbidity and mortality, and serious neonatal morbidity and mortality were small (5.42 and 7.09 per 1000 deliveries, respectively; number needed to treat 184 and 141, respectively). The association between vaginal birth after cesarean delivery, and serious neonatal morbidity and mortality showed a temporal worsening (adjusted RR 0.94, 95% CI 0.77 to 1.15 in 2003-2005; adjusted RR 2.07, 95% CI 1.83 to 2.35 in 2012-2014). INTERPRETATION Although absolute rates of adverse outcomes are low, attempted vaginal birth after cesarean delivery continues to be associated with higher relative rates of severe morbidity and mortality in mothers and infants. Temporal worsening of infant outcomes after attempted vaginal birth after cesarean delivery highlights the need for greater care in selecting candidates, and more careful monitoring of labour and delivery.
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Affiliation(s)
- Carmen B Young
- Department of Obstetrics and Gynecology (Young), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta; Maternal, Child and Youth Health Division (Liu), Centre for Surveillance and Applied Research, Public Health Agency of Canada, Ottawa, Ont.; Department of Obstetrics and Gynaecology (Muraca, Sabr, Pressey, Liston and Joseph), Faculty of Medicine; School of Population and Public Health (Muraca, Joseph), University of British Columbia; Children and Women's Health Centre of British Columbia (Muraca, Sabr, Pressey, Liston and Joseph), Vancouver, BC; Department of Obstetrics and Gynaecology, College of Medicine, King Saud University, Riyadh, Saudi Arabia (Sabr).
| | - Shiliang Liu
- Department of Obstetrics and Gynecology (Young), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta; Maternal, Child and Youth Health Division (Liu), Centre for Surveillance and Applied Research, Public Health Agency of Canada, Ottawa, Ont.; Department of Obstetrics and Gynaecology (Muraca, Sabr, Pressey, Liston and Joseph), Faculty of Medicine; School of Population and Public Health (Muraca, Joseph), University of British Columbia; Children and Women's Health Centre of British Columbia (Muraca, Sabr, Pressey, Liston and Joseph), Vancouver, BC; Department of Obstetrics and Gynaecology, College of Medicine, King Saud University, Riyadh, Saudi Arabia (Sabr)
| | - Giulia M Muraca
- Department of Obstetrics and Gynecology (Young), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta; Maternal, Child and Youth Health Division (Liu), Centre for Surveillance and Applied Research, Public Health Agency of Canada, Ottawa, Ont.; Department of Obstetrics and Gynaecology (Muraca, Sabr, Pressey, Liston and Joseph), Faculty of Medicine; School of Population and Public Health (Muraca, Joseph), University of British Columbia; Children and Women's Health Centre of British Columbia (Muraca, Sabr, Pressey, Liston and Joseph), Vancouver, BC; Department of Obstetrics and Gynaecology, College of Medicine, King Saud University, Riyadh, Saudi Arabia (Sabr)
| | - Yasser Sabr
- Department of Obstetrics and Gynecology (Young), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta; Maternal, Child and Youth Health Division (Liu), Centre for Surveillance and Applied Research, Public Health Agency of Canada, Ottawa, Ont.; Department of Obstetrics and Gynaecology (Muraca, Sabr, Pressey, Liston and Joseph), Faculty of Medicine; School of Population and Public Health (Muraca, Joseph), University of British Columbia; Children and Women's Health Centre of British Columbia (Muraca, Sabr, Pressey, Liston and Joseph), Vancouver, BC; Department of Obstetrics and Gynaecology, College of Medicine, King Saud University, Riyadh, Saudi Arabia (Sabr)
| | - Tracy Pressey
- Department of Obstetrics and Gynecology (Young), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta; Maternal, Child and Youth Health Division (Liu), Centre for Surveillance and Applied Research, Public Health Agency of Canada, Ottawa, Ont.; Department of Obstetrics and Gynaecology (Muraca, Sabr, Pressey, Liston and Joseph), Faculty of Medicine; School of Population and Public Health (Muraca, Joseph), University of British Columbia; Children and Women's Health Centre of British Columbia (Muraca, Sabr, Pressey, Liston and Joseph), Vancouver, BC; Department of Obstetrics and Gynaecology, College of Medicine, King Saud University, Riyadh, Saudi Arabia (Sabr)
| | - Robert M Liston
- Department of Obstetrics and Gynecology (Young), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta; Maternal, Child and Youth Health Division (Liu), Centre for Surveillance and Applied Research, Public Health Agency of Canada, Ottawa, Ont.; Department of Obstetrics and Gynaecology (Muraca, Sabr, Pressey, Liston and Joseph), Faculty of Medicine; School of Population and Public Health (Muraca, Joseph), University of British Columbia; Children and Women's Health Centre of British Columbia (Muraca, Sabr, Pressey, Liston and Joseph), Vancouver, BC; Department of Obstetrics and Gynaecology, College of Medicine, King Saud University, Riyadh, Saudi Arabia (Sabr)
| | - K S Joseph
- Department of Obstetrics and Gynecology (Young), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta; Maternal, Child and Youth Health Division (Liu), Centre for Surveillance and Applied Research, Public Health Agency of Canada, Ottawa, Ont.; Department of Obstetrics and Gynaecology (Muraca, Sabr, Pressey, Liston and Joseph), Faculty of Medicine; School of Population and Public Health (Muraca, Joseph), University of British Columbia; Children and Women's Health Centre of British Columbia (Muraca, Sabr, Pressey, Liston and Joseph), Vancouver, BC; Department of Obstetrics and Gynaecology, College of Medicine, King Saud University, Riyadh, Saudi Arabia (Sabr)
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Wen Q, Muraca GM, Ting J, Coad S, Lim KI, Lisonkova S. Temporal trends in severe maternal and neonatal trauma during childbirth: a population-based observational study. BMJ Open 2018; 8:e020578. [PMID: 29500215 PMCID: PMC5855201 DOI: 10.1136/bmjopen-2017-020578] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Revised: 01/08/2018] [Accepted: 01/31/2018] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Instrumental vaginal delivery is associated with birth trauma to infant and obstetric trauma to mother. As caesarean delivery rates increased during the past decades, the rate of instrumental vaginal delivery declined. We examined concomitant temporal changes in the rates of severe birth trauma and maternal obstetric trauma. DESIGN A retrospective observational study. SETTINGS AND PARTICIPANTS All hospital singleton live births in Washington State, USA, 2004-2013, excluding breech delivery. Severe birth trauma (brain, nerve injury, fractures and other severe birth trauma) and obstetric trauma (third/fourth degree perineal lacerations, cervical/high vaginal lacerations) were identified from hospitalisation data. Pregnancy and delivery characteristics were obtained from birth certificates. Temporal trends were assessed by the Cochran-Armitage test. Logistic regression was used to obtain adjusted ORs (AORs) and 95% CI. RESULTS Overall, 732 818 live births were included. The rate of severe birth trauma declined from 5.3 in 2004 to 4.5 per 1000 live births in 2013 (P<0.001). The decline was observed only in spontaneous vaginal delivery, the rates of fractures and other severe birth trauma declined by 5% and 4% per year, respectively (AOR: 0.95, 95% CI 0.94 to 0.97 and AOR: 0.96, 95% CI 0.93 to 0.99; respectively). The rate of third/fourth degree lacerations declined in spontaneous vaginal delivery from 3.5% to 2.3% (AOR: 0.95; 95% CI 0.94 to 0.95) and in vacuum delivery from 17.3% to 14.5% (AOR: 0.97, 95% CI 0.96 to 0.98). Among women with forceps delivery, these rates declined from 29.8% to 23.4% (AOR: 0.98, 95% CI 0.96 to 1.00). CONCLUSION While the rates of fractures and other birth trauma declined among infants delivered by spontaneous vaginal delivery, the rate of birth trauma remained unchanged in instrumental vaginal delivery and caesarean delivery. Among mothers, the rates of severe perineal lacerations declined, except for women with forceps delivery.
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Affiliation(s)
- Qi Wen
- BC Children's Hospital Research Institute, Children's Hospital, Vancouver, Canada
- Department of Statistics and Actuarial Science, Simon Fraser University, Burnaby, Canada
| | - Giulia M Muraca
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, Canada
- Children's and Women's Hospital and Health Centre of British Columbia, Vancouver, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Joseph Ting
- Department of Pediatrics, University of British Columbia and the Children's and Women's Hospital and Health Centre of British Columbia, Vancouver, Canada
| | - Sarah Coad
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, Canada
- Children's and Women's Hospital and Health Centre of British Columbia, Vancouver, Canada
| | - Kenneth I Lim
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, Canada
- Children's and Women's Hospital and Health Centre of British Columbia, Vancouver, Canada
| | - Sarka Lisonkova
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, Canada
- Children's and Women's Hospital and Health Centre of British Columbia, Vancouver, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
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Lisonkova S, Muraca GM, Potts J, Liauw J, Chan WS, Skoll A, Lim KI. Association Between Prepregnancy Body Mass Index and Severe Maternal Morbidity. JAMA 2017; 318:1777-1786. [PMID: 29136442 PMCID: PMC5820710 DOI: 10.1001/jama.2017.16191] [Citation(s) in RCA: 113] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 10/04/2017] [Indexed: 11/14/2022]
Abstract
Importance Although high body mass index (BMI) is associated with adverse birth outcomes, the association with severe maternal morbidity is unclear. Objective To examine the association between prepregnancy BMI and severe maternal morbidity. Design, Setting, and Participants Retrospective population-based cohort study including all singleton hospital births in Washington State, 2004-2013. Demographic data and morbidity diagnoses were obtained from linked birth certificates and hospitalization files. Exposures Prepregnancy BMI (weight in kilograms divided by height in meters squared) categories included underweight (<18.5), normal BMI (18.5-24.9), overweight (25.0-29.9), obesity class 1 (30.0-34.9), obesity class 2 (35.0-39.9), and obesity class 3 (≥40). Main Outcomes and Measures Composite severe maternal morbidity or mortality included life-threatening conditions and conditions leading to serious sequelae (eg, amniotic fluid embolism, hysterectomy), complications requiring intensive care unit admission, and maternal death. Logistic regression was used to obtain adjusted odds ratios (ORs) and adjusted rate differences with 95% confidence intervals, adjusted for confounders (eg, maternal age and parity). Results Overall, 743 630 women were included in the study (mean age, 28.1 [SD, 6.0] years; 41.4% nulliparous). Prepregnancy BMI was distributed as follows: underweight, 3.2%; normal weight, 47.5%; overweight, 25.8%; obesity class 1, 13.1%; obesity class 2, 6.2%; and obesity class 3, 4.2%. Rates of severe maternal morbidity or mortality were 171.5, 143.2, 160.4, 167.9, 178.3 and 202.9 per 10 000 women, respectively. Adjusted ORs were 1.2 (95% CI, 1.0-1.3) for underweight women; 1.1 (95% CI, 1.1-1.2) for overweight women; 1.1 (95% CI, 1.1-1.2) for women with class 1 obesity; 1.2 (95% CI, 1.1-1.3) for women with class 2 obesity; and 1.4 (95% CI, 1.3-1.5) for women with class 3 obesity compared with women with normal BMI. Absolute risk increases (adjusted rate differences per 10 000 women, compared with women with normal BMI) were 28.8 (95% CI, 12.2-47.2) for underweight women, 17.6 (95% CI, 10.5-25.1) for overweight women, 24.9 (95% CI, 15.7-34.6) for women with class 1 obesity, 35.8 (95% CI, 23.1-49.5) for women with class 2 obesity, and 61.1 (95% CI, 44.8-78.9) for women with class 3 obesity. Conclusions and Relevance Among pregnant women in Washington State, low and high prepregnancy BMI, compared with normal BMI, were associated with a statistically significant but small absolute increase in severe maternal morbidity or mortality.
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Affiliation(s)
- Sarka Lisonkova
- Department of Obstetrics and Gynaecology, University of British Columbia and the Children’s and Women’s Hospital and Health Centre of British Columbia, Vancouver, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Giulia M. Muraca
- Department of Obstetrics and Gynaecology, University of British Columbia and the Children’s and Women’s Hospital and Health Centre of British Columbia, Vancouver, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Jayson Potts
- Department of Medicine, University of British Columbia and Women’s Hospital and Health Centre of British Columbia, Vancouver, Canada
| | - Jessica Liauw
- Department of Obstetrics and Gynaecology, University of British Columbia and the Children’s and Women’s Hospital and Health Centre of British Columbia, Vancouver, Canada
| | - Wee-Shian Chan
- Department of Medicine, University of British Columbia and Women’s Hospital and Health Centre of British Columbia, Vancouver, Canada
| | - Amanda Skoll
- Department of Obstetrics and Gynaecology, University of British Columbia and the Children’s and Women’s Hospital and Health Centre of British Columbia, Vancouver, Canada
| | - Kenneth I. Lim
- Department of Obstetrics and Gynaecology, University of British Columbia and the Children’s and Women’s Hospital and Health Centre of British Columbia, Vancouver, Canada
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Muraca GM, Skoll A, Lisonkova S, Sabr Y, Brant R, Cundiff GW, Joseph KS. Authors' reply re: Perinatal and maternal morbidity and mortality among term singletons following midcavity operative vaginal delivery versus caesarean delivery. BJOG 2017; 125:758-759. [PMID: 29131501 DOI: 10.1111/1471-0528.14980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2017] [Indexed: 12/01/2022]
Affiliation(s)
- Giulia M Muraca
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada.,Department of Obstetrics & Gynaecology, University of British Columbia, Vancouver, BC, Canada.,BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Amanda Skoll
- Department of Obstetrics & Gynaecology, University of British Columbia, Vancouver, BC, Canada.,BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Sarka Lisonkova
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada.,Department of Obstetrics & Gynaecology, University of British Columbia, Vancouver, BC, Canada.,BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Yasser Sabr
- Department of Obstetrics & Gynaecology, University of British Columbia, Vancouver, BC, Canada.,Department of Obstetrics and Gynaecology, King Saud University, King Khalid University Hospital, Riyadh, Saudi Arabia
| | - Rollin Brant
- BC Children's Hospital Research Institute, Vancouver, BC, Canada.,Department of Statistics, University of British Columbia, Vancouver, BC, Canada
| | - Geoffrey W Cundiff
- Department of Obstetrics & Gynaecology, University of British Columbia, Vancouver, BC, Canada.,BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | - K S Joseph
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada.,Department of Obstetrics & Gynaecology, University of British Columbia, Vancouver, BC, Canada.,BC Children's Hospital Research Institute, Vancouver, BC, Canada
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Muraca GM, Skoll A, Lisonkova S, Sabr Y, Brant R, Cundiff GW, Joseph KS. Authors' reply re: Perinatal and maternal morbidity and mortality among term singletons following midcavity operative vaginal delivery versus caesarean delivery. BJOG 2017; 125:760. [PMID: 29131476 DOI: 10.1111/1471-0528.14981] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2017] [Indexed: 11/28/2022]
Affiliation(s)
- G M Muraca
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada.,Department of Obstetrics & Gynaecology, University of British Columbia, Vancouver, BC, Canada.,BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | - A Skoll
- Department of Obstetrics & Gynaecology, University of British Columbia, Vancouver, BC, Canada.,BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | - S Lisonkova
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada.,Department of Obstetrics & Gynaecology, University of British Columbia, Vancouver, BC, Canada.,BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Y Sabr
- Department of Obstetrics & Gynaecology, University of British Columbia, Vancouver, BC, Canada.,Department of Obstetrics and Gynaecology, King Saud University, King Khalid University Hospital, Riyadh, Saudi Arabia
| | - R Brant
- BC Children's Hospital Research Institute, Vancouver, BC, Canada.,Department of Statistics, University of British Columbia, Vancouver, BC, Canada
| | - G W Cundiff
- Department of Obstetrics & Gynaecology, University of British Columbia, Vancouver, BC, Canada.,BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | - K S Joseph
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada.,Department of Obstetrics & Gynaecology, University of British Columbia, Vancouver, BC, Canada.,BC Children's Hospital Research Institute, Vancouver, BC, Canada
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Muraca GM, Skoll A, Lisonkova S, Sabr Y, Brant R, Cundiff GW, Joseph KS. Response to "Data limitations may affect conclusions in study of vaginal delivery at midpelvic station". CMAJ 2017; 189:E1344-E1345. [PMID: 29084763 DOI: 10.1503/cmaj.733350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Giulia M Muraca
- School of Population and Public Health, Department of Obstetrics & Gynaecology, The University of British Columbia, Vancouver, BC
| | - Amanda Skoll
- Associate Professor, School of Population and Public Health, Department of Obstetrics & Gynaecology, The University of British Columbia, Vancouver, BC
| | - Sarka Lisonkova
- Associate Professor, School of Population and Public Health, Department of Obstetrics & Gynaecology, The University of British Columbia, Vancouver, BC
| | - Yasser Sabr
- Graduate Student, Department of Obstetrics & Gynaecology, The University of British Columbia, Vancouver, BC; Assistant Professor, Department of Obstetrics and Gynaecology, King Saud University, Riyadh, Saudi Arabia
| | - Rollin Brant
- Professor, Department of Statistics, The University of British Columbia, Vancouver, BC
| | - Geoffrey W Cundiff
- Head and Professor, Department of Obstetrics & Gynaecology, The University of British Columbia, Vancouver, BC
| | - K S Joseph
- Professor, School of Population and Public Health, Department of Obstetrics & Gynaecology, The University of British Columbia, Vancouver, BC
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Muraca GM, Lisonkova S, Joseph KS, Skoll A, Cundiff GW, Brant R, Sabr Y. The authors reply to "The end of forceps deliveries?" and "Beware selection bias". CMAJ 2017; 189:E1098. [PMID: 28847784 DOI: 10.1503/cmaj.733285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Giulia M Muraca
- School of Population and Public Health, and Department of Obstetrics & Gynaecology, The University of British Columbia, Vancouver, BC
| | - Sarka Lisonkova
- School of Population and Public Health, and Department of Obstetrics & Gynaecology, The University of British Columbia, Vancouver, BC
| | - K S Joseph
- School of Population and Public Health, and Department of Obstetrics & Gynaecology, The University of British Columbia, Vancouver, BC
| | - Amanda Skoll
- Department of Obstetrics & Gynaecology, The University of British Columbia, Vancouver, BC
| | - Geoffrey W Cundiff
- Department of Obstetrics & Gynaecology, The University of British Columbia, Vancouver, BC
| | - Rollin Brant
- Department of Statistics, The University of British Columbia, Vancouver, BC
| | - Yasser Sabr
- Department of Obstetrics & Gynaecology, The University of British Columbia, Vancouver, BC, and Department of Obstetrics and Gynaecology, King Saud University, Riyadh, Saudi Arabia
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Muraca GM, Skoll A, Lisonkova S, Sabr Y, Brant R, Cundiff GW, Joseph KS. Perinatal and maternal morbidity and mortality among term singletons following midcavity operative vaginal delivery versus caesarean delivery. BJOG 2017; 125:693-702. [PMID: 28692173 PMCID: PMC5947834 DOI: 10.1111/1471-0528.14820] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2017] [Indexed: 11/30/2022]
Abstract
Objective To quantify severe perinatal and maternal morbidity/mortality associated with midcavity operative vaginal delivery compared with caesarean delivery. Design Population‐based, retrospective cohort study. Setting British Columbia, Canada. Population Term, singleton deliveries (2004–2014) by attempted midcavity operative vaginal delivery or caesarean delivery in the second stage of labour, stratified by indication for operative delivery (n = 10 901 deliveries; 5057 indicated for dystocia, 5844 for fetal distress). Methods Multinomial propensity scores and mulitvariable log‐binomial regression models were used to estimate adjusted rate ratios (ARR) and 95% confidence intervals (95% CI). Main outcome measures Composite severe perinatal morbidity/mortality (e.g. convulsions, severe birth trauma and perinatal death) and severe maternal morbidity (e.g. severe postpartum haemorrhage, shock, sepsis and cardiac complications). Results Among deliveries with dystocia, attempted midcavity operative vaginal delivery was associated with higher rates of severe perinatal morbidity/mortality compared with caesarean delivery (forceps ARR 2.11, 95% CI 1.46–3.07; vacuum ARR 2.71, 95% CI 1.49–3.15; sequential ARR 4.68, 95% CI 3.33–6.58). Rates of severe maternal morbidity/mortality were also higher following midcavity operative vaginal delivery (forceps ARR 1.57, 95% CI 1.05–2.36; vacuum ARR 2.29, 95% CI 1.57–3.36). Among deliveries with fetal distress, there were significant increases in severe perinatal morbidity/mortality following attempted midcavity vacuum (ARR 1.28, 95% CI 1.04–1.61) and in severe maternal morbidity following attempted midcavity forceps delivery (ARR 2.34, 95% CI 1.54–3.56). Conclusion Attempted midcavity operative vaginal delivery is associated with higher rates of severe perinatal morbidity/mortality and severe maternal morbidity, though these effects differ by indication and instrument. Tweetable abstract Perinatal and maternal morbidity is increased following midcavity operative vaginal delivery. Tweetable abstract Perinatal and maternal morbidity is increased following midcavity operative vaginal delivery.
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Affiliation(s)
- G M Muraca
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada.,Department of Obstetrics & Gynaecology, University of British Columbia, Vancouver, BC, Canada.,BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | - A Skoll
- Department of Obstetrics & Gynaecology, University of British Columbia, Vancouver, BC, Canada.,BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | - S Lisonkova
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada.,Department of Obstetrics & Gynaecology, University of British Columbia, Vancouver, BC, Canada.,BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Y Sabr
- Department of Obstetrics & Gynaecology, University of British Columbia, Vancouver, BC, Canada.,Department of Obstetrics and Gynaecology, King Saud University, King Khalid University Hospital, Riyadh, Saudi Arabia
| | - R Brant
- BC Children's Hospital Research Institute, Vancouver, BC, Canada.,Department of Statistics, University of British Columbia, Vancouver, BC, Canada
| | - G W Cundiff
- Department of Obstetrics & Gynaecology, University of British Columbia, Vancouver, BC, Canada.,BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | - K S Joseph
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada.,Department of Obstetrics & Gynaecology, University of British Columbia, Vancouver, BC, Canada.,BC Children's Hospital Research Institute, Vancouver, BC, Canada
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Muraca GM, Sabr Y, Lisonkova S, Skoll A, Brant R, Cundiff GW, Joseph KS. Perinatal and maternal morbidity and mortality after attempted operative vaginal delivery at midpelvic station. CMAJ 2017; 189:E764-E772. [PMID: 28584040 DOI: 10.1503/cmaj.161156] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/31/2017] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Increased use of operative vaginal delivery (i.e., forceps or vacuum application), of which 20% occurs at midpelvic station, has been advocated to reduce the rate of cesarean delivery. We aimed to quantify severe perinatal and maternal morbidity and mortality associated with attempted midpelvic operative vaginal delivery. METHODS We studied all term singleton deliveries in Canada between 2003 and 2013, by attempted midpelvic operative vaginal or cesarean delivery with labour (with and without prolonged second stage). The primary outcomes were composite severe perinatal morbidity and mortality (e.g., convulsions, assisted ventilation, severe birth trauma and perinatal death), and composite severe maternal morbidity and mortality (e.g., severe postpartum hemorrhage, shock, sepsis, cardiac complications, acute renal failure and death). RESULTS The study population included 187 234 deliveries. Among women with dystocia and prolonged second stage of labour, midpelvic operative vaginal delivery was associated with higher rates of severe perinatal morbidity and mortality compared with cesarean delivery (forceps, adjusted odds ratio [AOR] 1.81, 95% confidence interval [CI] 1.24 to 2.64; vacuum, AOR 1.81, 95% CI 1.17 to 2.80; sequential instruments, AOR 3.19, 95% CI 1.73 to 5.88), especially with higher rates of severe birth trauma. Rates of severe maternal morbidity and mortality were not significantly different after operative vaginal delivery, although rates of obstetric trauma were higher (forceps, AOR 4.51, 95% CI 4.04 to 5.02; vacuum, AOR 2.70, 95% CI 2.35 to 3.09; sequential instruments, AOR 4.24, 95% CI 3.46 to 5.19). Among women with fetal distress, similar associations were seen for severe birth trauma and obstetric trauma, although vacuum was associated with lower rates of severe maternal morbidity and mortality (AOR 0.52, 95% CI 0.33 to 0.80). Associations tended to be stronger among women without a prolonged second stage. INTERPRETATION Midpelvic operative vaginal delivery is associated with higher rates of severe birth trauma and obstetric trauma, whereas overall rates of severe perinatal and maternal morbidity and mortality vary by indication and operative instrument.
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Affiliation(s)
- Giulia M Muraca
- School of Population and Public Health (Muraca, Lisonkova, Joseph); Department of Obstetrics & Gynaecology (Muraca, Sabr, Lisonkova, Skoll, Cundiff, Joseph); Department of Statistics (Brant), The University of British Columbia, Vancouver, BC; Department of Obstetrics and Gynaecology (Sabr), King Saud University, Riyadh, Saudi Arabia
| | - Yasser Sabr
- School of Population and Public Health (Muraca, Lisonkova, Joseph); Department of Obstetrics & Gynaecology (Muraca, Sabr, Lisonkova, Skoll, Cundiff, Joseph); Department of Statistics (Brant), The University of British Columbia, Vancouver, BC; Department of Obstetrics and Gynaecology (Sabr), King Saud University, Riyadh, Saudi Arabia
| | - Sarka Lisonkova
- School of Population and Public Health (Muraca, Lisonkova, Joseph); Department of Obstetrics & Gynaecology (Muraca, Sabr, Lisonkova, Skoll, Cundiff, Joseph); Department of Statistics (Brant), The University of British Columbia, Vancouver, BC; Department of Obstetrics and Gynaecology (Sabr), King Saud University, Riyadh, Saudi Arabia
| | - Amanda Skoll
- School of Population and Public Health (Muraca, Lisonkova, Joseph); Department of Obstetrics & Gynaecology (Muraca, Sabr, Lisonkova, Skoll, Cundiff, Joseph); Department of Statistics (Brant), The University of British Columbia, Vancouver, BC; Department of Obstetrics and Gynaecology (Sabr), King Saud University, Riyadh, Saudi Arabia
| | - Rollin Brant
- School of Population and Public Health (Muraca, Lisonkova, Joseph); Department of Obstetrics & Gynaecology (Muraca, Sabr, Lisonkova, Skoll, Cundiff, Joseph); Department of Statistics (Brant), The University of British Columbia, Vancouver, BC; Department of Obstetrics and Gynaecology (Sabr), King Saud University, Riyadh, Saudi Arabia
| | - Geoffrey W Cundiff
- School of Population and Public Health (Muraca, Lisonkova, Joseph); Department of Obstetrics & Gynaecology (Muraca, Sabr, Lisonkova, Skoll, Cundiff, Joseph); Department of Statistics (Brant), The University of British Columbia, Vancouver, BC; Department of Obstetrics and Gynaecology (Sabr), King Saud University, Riyadh, Saudi Arabia
| | - K S Joseph
- School of Population and Public Health (Muraca, Lisonkova, Joseph); Department of Obstetrics & Gynaecology (Muraca, Sabr, Lisonkova, Skoll, Cundiff, Joseph); Department of Statistics (Brant), The University of British Columbia, Vancouver, BC; Department of Obstetrics and Gynaecology (Sabr), King Saud University, Riyadh, Saudi Arabia
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