Search

Background: Poland has one of the highest cesarean birth (CB) rates in Europe. For this study, we used the Robson Ten‐Group Classification System (TGCS) to analyze trends in the induction and CB rates in one hospital in Poland over a period of 11 years. We compare these trends with changes in National Legislative and Medical Guidelines introduced during this time that were aimed at lowering rates of unnecessary medical interventions. Methods: We conducted a retrospective study including all births after 24 weeks' gestation between 2010 and 2020 from one tertiary hospital (n = 66,716 births). After the deletion of records with missing data, 66,678 births were included in the analysis. All births were classified according to the Robson TGCS. The size, CB rate, and contribution of each group for every year were calculated. Linear regression analyses were used to analyze trends over time. Results: The total CB rate varied from 29.6% to 33.0% during the study period, with a linear increase of 0.045 percentage points annually (R2 = 0.021; F(1) = 0.189; p = 0.674). This study was considerably lower than the total CB rate for Poland, which rose from 33.9% in 2010 to 45.1% in 2020, increasing at a rate of 1.13 percentage points per year (R2 = 0.93; F(1) = 61.88; p < 0.001). Induction rates among both nulliparous (R1 + R2) and multiparous (R3 + R4) women at term also increased. Study groups R5 (previous cesarean birth), R2 (nulliparous in induced or prelabor cesarean delivery), and R1 (nulliparous women at term with single cephalic pregnancy in spontaneous labor) were the highest contributors to the overall CB rate. The greatest decrease in the CB rate was detected in group R5b (more than one previous CB). None of the groups showed statistically significant increases in CB rates over the study period. Conclusions: The CB rate in the hospital where the study was conducted was considerably lower than the total CB rate in Poland. When compared with countries with similar CB rates, group R2b (women with nulliparous, prelabor cesarean birth) in our study was considerably larger. More comparisons across different hospital settings in Poland are needed. However, as hospitals are not encouraged to routinely collect the data needed to construct TGCS, such comparisons are very difficult to conduct. [ABSTRACT FROM AUTHOR]

Purpose: The association between birth order and adverse perinatal outcomes has been well studied in twin pregnancies. However, little is known about the differences in immediate perinatal outcomes as well as long‐term hospitalization of the offspring in triplet pregnancies according to their birth order. As such, we aimed to assess the differences in immediate perinatal outcomes and long‐term hospitalizations among triplets by their birth order. Methods: In a retrospective hospital‐based cohort study, immediate perinatal outcomes and long‐term hospitalizations were compared among triplet siblings according to their birth order. Deliveries occurred between the years 1991 and 2021 in a tertiary medical center. The study groups were followed until 18 years of age for cardiovascular, respiratory, neurological, and infection‐related hospitalizations. Generalized estimation equation (GEE) models were used to control for confounders. Kaplan–Meier survival curves were used to compare cumulative long‐term hospitalization incidences and Cox proportional hazards models were performed to control for confounders. Results: The study included 117 triplet deliveries. Rates of small for gestational age (SGA) infants increased linearly by birth order (6.0%, 7.7%, and 15.4% for the first, second, and third siblings, respectively; p‐value for trends = 0.035). Using a GEE model controlling for maternal age, being born third in a triplet pregnancy was independently associated with SGA (third vs. first sibling, adjusted OR 3.0, 95% CI 1.38–6.59, p = 0.005). No significant differences in cardiovascular, respiratory, neurological, and infection‐related hospitalizations were noted among the first, second, and third siblings. Likewise, using Kaplan–Meier survival analyses, no significant differences in the cumulative incidence of long‐term pediatric hospitalizations were noted between the siblings. In Cox proportional hazards models, controlling for weight and gender, birth order in a triplet pregnancy did not exhibit an association with long‐term hospitalizations of the offspring. Conclusion: Despite the association between birth order and SGA, birth order in triplets does not seem to have an impact on the risk for long‐term offspring hospitalization. [ABSTRACT FROM AUTHOR]

Background: In 2014, the National University Hospital of Iceland (NUHI) merged a mixed‐risk birth unit and a midwifery‐led low‐risk unit into one mixed‐risk unit. Interprofessional preventative and mitigating measures were implemented since there was a known threat of cultural contamination between mixed‐risk and low‐risk birth environments. The aim of the study was to assess whether the NUHI's goal of protecting the rates of birth without intervention had been achieved and to support further development of labor services. Methods: A retrospective cohort study of all women who had singleton births at NUHI birth units in two 2‐year periods, 2012–2013 and 2015–2016. The primary outcome variables, birth without intervention, with or without artificial rupture of membranes (AROM), were adjusted for confounding variables using logistic regression analysis. Secondary outcome variables (individual interventions and maternal and neonatal complications) were analyzed using descriptive statistics, t test, and Chi‐square test. Results: The rate of births without interventions, both with and without AROM, increased significantly after the unit merger and accompanying preventative measures. The rates of AROM, oxytocin augmentation, episiotomies, and epidural analgesia decreased significantly. The rate of induction increased significantly. There were no significant differences in maternal or neonatal complication rates. Conclusions: Interprofessional preventative measures, implemented alongside a mixed‐risk and low‐risk birth unit merger, can increase rates of births without interventions in a mixed‐risk hospital setting. However, it is necessary to maintain awareness of the possible effects of a mixed‐risk birth environment on the use of childbirth interventions and examine the long‐term effects of preventative measures. [ABSTRACT FROM AUTHOR]

Background: Late preterm and full‐term infants comprise the majority of births in our hospital which serves a multicultural lower socioeconomic community. Patients give birth vaginally (normal birth, NB) or by cesarean birth (CB), and the majority of neonates are exclusively breastmilk fed until discharge. In this study we examined what factors within these two birth modes and feeding regimes of exclusive breast milk were associated with early postnatal readmission. Ideally, findings will aid initiatives to decrease readmission rates. Methods: A retrospective cohort study was performed on maternal–infant pairs. All neonates from 2016 to 2018, exclusively breastmilk fed at discharge, born by NB (n = 4245) or CB (n = 1691), were grouped as non‐Readmitted (Reference) or Readmitted within 30 days of discharge. Readmission reason was determined, and potential associations were identified using univariate analysis and multivariable logistic regression. Results: Rates of readmission were similar for both NB and CB infants (6.8% vs. 7.3%). In order, NB concerns were jaundice, infection, and feeding—this was reversed for the CB Group. NB readmission bilirubin levels were higher (293 ± 75 vs. 236 ± 112, μmol/L, NB:CB, p < 0.001). Factors associated with readmission for both groups were similar to previously published studies. Edinburgh Postnatal Depression Score (EPDS) was higher for Readmitted infant mothers. Importantly, for non‐jaundice readmission EDPS categories indicated that both CB and NB mothers were more likely to have depression. Conclusion: Early readmission of exclusively breastmilk‐fed infants born by means of NB or CB is multifactorial. Early pregnancy mental health issues are associated with readmission, highlighting the potential effects of perinatal depression on neonatal health. [ABSTRACT FROM AUTHOR]

Background: In the United States, there are significant health inequities in perinatal care. This study examined differences in perinatal care provided to women based on the birthing person's designated race, within a large and diverse cohort of women. Methods: This retrospective electronic medical record review identified patients receiving perinatal care within a large hospital system between January 2012 and September 2018 and examined associations between maternal designated race/ethnicity (Hispanic or non‐Hispanic [NH] Black, Asian or White) and various provider treatment decisions. Results: The study sample (N = 7056) was comprised of 36% Hispanic, 34% NH White, 21% NH Black, and 4% NH Asian women, aged 29.7 ± 6.3 years; 53% of the sample had private insurance, and 45% had Medicaid. Few differences by race were seen in perinatal care based on guidelines or expert recommendations (nondiscretionary care). Discretionary care, however, varied by race: Compared with NH White women, NH Black women were less likely to receive a prenatal depression screen (OR 0.8 [95% CI: 0.7, 0.9]) and more likely to have a urine drug test when denying drug use (OR 1.6 [95% CI 1.3, 2.0]), whereas Hispanic (OR 0.6 [95% CI: 0.5, 0.8]) and NH Asian (0.4 [95% CI 0.2, 0.9]) women were less likely to have a urine drug test completed when denying drug use. Discussion: Perinatal care differs by maternal race/ethnicity, particularly when guidelines or expert recommendations are absent. Greater efforts need to be made to identify and mitigate providers' implicit and explicit biases; expanded professional guidelines may offer some protections against inequitable, discretionary care. [ABSTRACT FROM AUTHOR]

Background: The Perinatal Integrated Psychosocial Assessment (PIPA) tool screens for anxiety, depression, and psychosocial factors in pregnancy. We aimed to assess the association between PIPA‐determined psychosocial risk and obstetric and neonatal outcomes. Methods: Cohort study of all pregnant women who gave birth at ≥20 weeks of gestation in 2017‐2019 at a tertiary maternity hospital in, Sydney, Australia. Women completed PIPA at their first antenatal visit and were assigned a PIPA risk category. At‐risk women were reviewed and referred for support. The association between PIPA risk category and obstetric and neonatal outcomes was evaluated using multivariable logistic regression adjusting for sociodemographic and pregnancy factors. Results: In all, 5969 women completed PIPA; 71.4% were assessed no/low risk, 17.5% medium risk, and 11.1% medium‐high/high risk. Compared with no/low‐risk women, medium‐high/high‐risk women were more likely to remain in hospital for >72 hours (aOR 1.47 [95% CI 1.33‐1.64]); to not be breastfeeding at discharge (aOR 1.77 [95% CI 1.20‐2.61]); to have their infants experience birth complications (aOR 1.24 [95% CI 1.03‐1.50]); and to be admitted to the NICU (aOR 1.63 [95% CI 1.26‐2.11]). There was a modest increase in odds of cesarean birth (aOR 1.12 [95% CI 1.00‐1.27]), and no association with preterm birth or low birthweight. The risk of adverse outcomes disappeared for medium‐high/high‐risk women referred for support. Conclusions: The PIPA tool identified one in 10 women at high psychosocial risk with increased risk of adverse obstetric and neonatal outcomes. Adverse outcomes were attenuated for high‐risk women who were referred for extra support, suggesting that psychosocial review and referral for high‐risk women may reduce the risk of adverse obstetric and neonatal outcomes. [ABSTRACT FROM AUTHOR]

Background: Hospitals quickly adapted perinatal care to mitigate SARS‐CoV‐2 transmission at the onset of the COVID‐19 pandemic. The objective of this study was to estimate the impact of pandemic‐related hospital policy changes on perinatal care and outcomes in one region of the United States. Methods: This interrupted time series analysis used retrospective data from consecutive singleton births at 15 hospitals in the Pacific Northwest from 2017 to 2020. The primary outcomes were those hypothesized to be affected by pandemic‐related hospital policies and included labor induction, epidural use, oxytocin augmentation, mode of delivery, and early discharge (<48 hours after cesarean and <24 hours after vaginal births). Secondary outcomes included preterm birth, severe maternal morbidity, low 5‐minute Apgar score, neonatal intensive care unit (NICU) admission, and 30‐day readmission. Segmented Poisson regression models estimated the outcome level shift changes after the pandemic onset, controlling for underlying trends, seasonality, and stratifying by parity. Results: No statistically significant changes were detected in intrapartum interventions or mode of delivery after onset of the pandemic. Early discharge increased for all births following cesarean and vaginal birth. Newborn readmission rates increased but only among nulliparas (aRR: 1.49, 95%CI: 1.17, 1.91). Among multiparas, decreases were observed in preterm birth (aRR: 0.90, 95%CI: 0.84, 0.96), low 5‐minute Apgar score (aRR: 0.75, 95%CI: 0.68, 0.81), and term NICU admission rates (aRR: 0.85, 95%CI: 0.80, 0.91). Conclusions: Increases in early discharge and newborn readmission rates among nulliparas suggest a need for more postpartum support during the pandemic. Decreases in preterm birth and term NICU admission among multiparas may have implications beyond the pandemic and deserve further study. [ABSTRACT FROM AUTHOR]

Background: This study aimed to analyze perinatal outcomes and adverse events during the COVID‐19 pandemic's first wave to help direct decision making in future waves. Methods: This study was an epidemiological cohort study analyzing comprehensive birth registry data among all 80 obstetric departments in Austria. Out of 469 771 records, 468 348 were considered eligible, whereof those with preterm delivery, birthweight <500 g, multiple fetuses, fetal malformations and chromosomal anomalies, intrauterine fetal death, maternal cancer, HIV infection, and/or inter‐hospital transfers were excluded. Women who delivered between January and June 2020 were then classified as cases, whereas those who delivered between January and June 2015‐2019 were classified as controls. Perinatal outcomes, postpartum hospitalization, and adverse events served as outcome measures. Results: Of 33 198 cases and 188 225 controls, data analysis showed significantly increased rates of labor induction, instrumental delivery, obstetric anesthesia, NICU transfer, and 5‐min Apgar score below 7 during the COVID‐19 period. There was a significantly shorter length of postpartum hospitalization during the COVID‐19 period compared with the non‐COVID‐19 period (3.1 ± 1.4 vs 3.5 ± 1.5 days; P <.001). Significantly more women opted for short‐stay delivery during the COVID‐19 period (3.7% vs 2.4%; P <.001). Those who delivered during the COVID‐19 period were also more likely to experience postpartum adverse events (3.0% vs 2.6%; P <.001), which was confirmed in the logistic regression model (odds ratio, 2.137; 95% confidence interval, 1.805‐2.530; P <.001). Conclusions: Perinatal and postpartum care during the first wave of the COVID‐19 pandemic differed significantly from that provided before. Increased rates of adverse events underline the need to ensure access to high‐quality obstetric care to prevent collateral damage. [ABSTRACT FROM AUTHOR]

Background: Centers for Medicare & Medicaid Services (CMS) funded 182 US health care sites to reduce preterm birth rates by enhancing prenatal care for at‐risk women. As a funded site, the enhanced prenatal care maternity care home (MCH) model was implemented from 2013 to 2018 for 1042 Medicaid‐eligible pregnant women. Methods: This retrospective study evaluated the impact of enhanced services on preterm birth risk reduction. Certified community health workers provided enhanced services from enrollment through six weeks postpartum. Participants attending enhanced intake and third‐trimester prenatal visits comprised the Active Group (N = 632). Participants missing third‐trimester visits, but participating in enhanced intake and postpartum visits, comprised the Inactive Group (N = 128). Lost Group participants attended only intake visits (N = 282). Data were collected through CMS‐developed intake, third‐trimester, postpartum, and exit forms. Descriptive analysis, analysis of variance, and the chi‐square tests analyzed the impact of risk factors, participant characteristics, and program participation on birth outcomes. Results: Active Group compared with Inactive and Lost Group participants experienced significantly lower preterm birth rates (7.64% vs 22.48% and 15.82%, P < 0.001) and therefore a significantly lower NICU admission rate compared with Inactive and Lost Groups (2.82% vs 11.85% and 5.47%, P < 0.001). Conclusions: The MCH model of enhanced prenatal care reduced preterm birth and NICU admission rates for Active Group participants. The Black Active Group participant preterm birth rate was not significantly different than other Active Group rates, but was lower than Black Inactive and Lost Group rates. [ABSTRACT FROM AUTHOR]

Background: In Canada, as is found globally, women of reproductive age are a growing demographic of persons living with HIV. Combination antiretroviral therapy (cART) treatment enables women living with HIV (WLWH) to become pregnant without perinatal transmission, and they are increasingly planning to become pregnant. Since 2014, Canadian guidelines no longer recommend routine elective cesarean birth (CB) for women who are virally suppressed and receiving cART. It is unknown whether their obstetric care has changed since this update. Our objective was to describe trends in cesarean births among WLWH in Ontario, Canada, over a 12‐year period. Methods: Our research is co‐led and codesigned with WLWH. We conducted a retrospective population‐level cohort study using linked health administrative databases at ICES (formally, the Institute for Clinical and Evaluative Sciences). Participants were all women who gave birth in Ontario, between 2006/07 and 2017/18. We assessed their intrapartum characteristics and used multivariable regression to determine an association between HIV status and CB, controlling for sociodemographic and clinical variables. Results: Since 2014, the overall proportion of CB among WLWH remained stable and was higher than among women without HIV (39.9% vs 29.0%, P < 0.001). In addition, the proportion of primary CB decreased between 2006 and 2010 and between 2014 and 2018 (28.5%‐19.3%), whereas the proportion of repeat CB increased (13.1%‐20.5%, P = 0.013). Conclusions: Because of decreasing HIV‐related indications for CB, more practitioners may be following the guidelines for first‐time mothers. Currently, no guidelines exist for care of WLWH with a previous CB, and opportunities for vaginal birth may be missed in this population. [ABSTRACT FROM AUTHOR]

Background: One approach to decreasing the cesarean birth rate in the United States is to increase the availability of birth attendants, including certified nurse‐midwives (CNMs), who offer trial of labor after cesarean (TOLAC). We examined associations between provider type and mode of birth for women attempting vaginal birth after cesarean (VBAC). Methods: We performed a retrospective cohort study at a United States academic medical center using prospectively‐collected data (2005‐2012). We included healthy women with term singleton vertex pregnancies after one or two prior cesareans who were managed by obstetricians or CNMs. We assessed unplanned cesarean birth by provider type using univariate and logistic regression and examined labor interventions and predicted VBAC success. Results: Overall VBAC success was 88% for 502 included patients. Unplanned cesarean rates were similar by provider type. Black race, no prior VBAC, recurring clinical indication for cesarean, labor augmentation/induction, and any Pitocin use were associated with increased unplanned cesarean. Higher parity and early‐term gestational age at delivery were associated with decreased unplanned cesarean. Postpartum hemorrhage and composite maternal morbidity were increased with unplanned cesarean, but there was no difference in neonatal outcome by mode of delivery or provider type. Obstetricians had slightly higher composite adverse maternal outcomes. Nomogram‐predicted VBAC success but not provider type was associated with unplanned cesarean. Conclusions: Unplanned cesarean was similar for patients attempting labor after cesarean managed by midwives or obstetricians. Increasing the number of CNMs who manage TOLAC may help decrease the high rate of cesareans. [ABSTRACT FROM AUTHOR]

Background: Few studies have evaluated the impact of Baby Friendly Hospital Initiative (BFHI) implementation on underserved populations in the United States. We undertook this study in New Mexico, a large southwestern state with a diverse population and limited health care access. Methods: A quasi‐experimental, retrospective cohort design was used to compare short‐term breastfeeding duration between a pre‐BFHI and a post‐BFHI cohort. Among the post‐BFHI cohort, logistic regression models were fitted to predict short‐term breastfeeding duration from both individual and cumulative exposure to inpatient maternity care practices (Steps 4 to 9). Results: Implementation of the BFHI and cumulative exposure to the Ten Steps increased short‐term duration of any breastfeeding and exclusive breastfeeding at 2‐6 weeks postpartum. Exposure to all six of the inpatient Ten Steps increased the odds of any breastfeeding by 34 times and exclusive breastfeeding by 24 times. Exposure to Step 9 ("Give no pacifiers or artificial nipples") uniquely increased the likelihood of any breastfeeding at 2‐6 weeks postpartum by 5.7 times, whereas Step 6 ("Give infants no food or drink other than breastmilk") increased the rate of exclusive breastfeeding by 4.4 times at 2‐6 weeks postpartum. Conclusion: These findings demonstrate that the Baby Friendly Hospital Initiative can have a positive impact on breastfeeding among underserved populations. [ABSTRACT FROM AUTHOR]

Objectives: Our aim was to compare maternal and neonatal outcomes of women with a low‐risk pregnancy attending the "Cocoon," an alongside midwifery‐led birth center and care pathway, with women with a low‐risk pregnancy attending the traditional care pathway in a tertiary care hospital in Belgium. Methods: We performed a retrospective cohort study of maternal and neonatal outcomes of women with a low‐risk pregnancy who chose to adhere to the Cocoon pathway of care (n = 590) and women with a low‐risk pregnancy who chose the traditional pathway of care (n = 394) from March 1, 2014, to February 29, 2016. We performed all analyses using an intention‐to‐treat approach. Results: In this setting, the cesarean birth rate was 10.3% compared with 16.0% in the traditional care pathway (adjusted odds ratios [aOR] 0.42 [95% CI 0.25‐0.69]), the induction rate was 16.3% compared with 30.5% (0.46 [0.30‐0.69]), the epidural analgesia rate was 24.9% compared with 59.1% (0.15 [0.09‐0.22]), and the episiotomy rate was 6.8% compared with 14.5% (0.31 [0.17‐0.56]). There was no increase in adverse neonatal outcomes. Intrapartum and postpartum transfer rates to the traditional pathway of care were 21.1% and 7.1%, respectively. Conclusions: Women planning their births in the midwifery‐led unit, the Cocoon, experienced fewer interventions with no increase in adverse neonatal outcomes. Our study gives initial support for the introduction of similar midwifery‐led care pathways in other hospitals in Belgium. [ABSTRACT FROM AUTHOR]

Background: External cephalic version (ECV) is a common procedure for women carrying a breech‐presenting fetus, in an effort to avoid a cesarean birth. The benefit of immediate labor induction after ECV vs. expectant management is undetermined. We aimed to evaluate whether induction of labor immediately after a successful ECV improves the chances of a vaginal delivery compared with expectant management. Methods: Retrospective analysis of 296 women who underwent successful ECV performed in term singleton gestations (2007‐2018) in the Rabin Medical Center. Mode of delivery and other obstetrical and neonatal outcomes were compared between women undergoing immediate labor induction after ECV and those managed expectantly. Results: Of 296 women after successful ECVs, 54 (18.2%) underwent immediate labor induction and 242 (81.8%) were managed expectantly. Immediate induction was associated with higher parity (2.4 vs 1.7, P = .03) and lower mean birthweight (3128 vs 3346 g, P < .01). Mode of delivery was similar between groups, and no other significant differences in obstetrical and neonatal adverse outcomes were noted. Discussion: In our cohort, immediate labor induction after successful ECV apparently had no benefits in terms of obstetrical or neonatal complications, and did not reduce the risk of cesarean birth. Therefore, expectant management seems reasonable and safe. [ABSTRACT FROM AUTHOR]

Background: External cephalic version (ECV) should be offered for patients presenting with a noncephalic pregnancy that are willing to deliver vaginally. Various reports have evaluated predictors for successful ECV. Yet, none have reported a single‐operator large cohort experience. We aim to analyze the outcome of referrals for ECV. Methods: We conducted a retrospective cohort study of prospectively collected data. We performed a multivariate analysis of data with respect to ECV procedures performed by a single operator in a 6‐year period. Maternal and fetal characteristics were compared between ECV success and failure groups. Results: Six hundred and two women underwent ECV. Of them, ECV was successful in 432 (71.7%). A multivariate binary logistic regression model demonstrated that high liquor volume was a predictor of ECV success (Adj OR 1.17 [95% CI 1.09‐1.26]). Failure of ECV was correlated with anterior placenta (0.44 [0.56‐0.76]) and nulliparity (0.21 [0.11‐0.36]). Adverse events were rare and mostly minor, occurring in 1% of procedures. Conclusions: ECV has a high success rate and a low complication rate, enabling vaginal birth and avoiding cesarean. The role of manipulation of modifiable determinants such as liquor volume should be further assessed in future studies. [ABSTRACT FROM AUTHOR]

Background: The presence of midwives in a health system may affect perinatal outcomes but has been inadequately described in United States settings. Our objective was to compare labor processes and outcomes for low‐risk nulliparous women birthing in United States medical centers with interprofessional care (midwives and physicians) versus noninterprofessional care (physicians only). Methods: We conducted a retrospective cohort study using Consortium on Safe Labor data from low‐risk nulliparous women who birthed in interprofessional (n = 7393) or noninterprofessional centers (n = 6982). Unadjusted, adjusted (age, race, health insurance type), propensity‐adjusted, and propensity‐matched logistic regression models were used to compare outcomes. Results: There was concordance across logistic regression models, the most restrictive and conservative of which were propensity‐matched models. With this approach, women at interprofessional medical centers, compared with women at noninterprofessional centers, were 74% less likely to undergo labor induction (risk ratio [RR] 0.26; 95% CI 0.24‐0.29) and 75% less likely to have oxytocin augmentation (RR 0.25; 95% CI 0.22‐0.29). The cesarean birth rate was 12% lower at interprofessional centers (RR 0.88; 95% CI 0.79‐0.98). Adverse neonatal outcomes occurred in only 0.3% of births and were thus too rare to be modeled. Conclusions: The care processes and birth outcomes at interprofessional and noninterprofessional medical centers differed significantly. Nulliparous women receiving care at interprofessional centers were less likely to experience induction, oxytocin augmentation, and cesarean than women at noninterprofessional centers. Labor care and birth outcome differences between interprofessional and noninterprofessional centers may be the result of the presence of midwives and interprofessional collaboration, organizational culture, or both. [ABSTRACT FROM AUTHOR]

Background: The timing of hospital admission for women with spontaneous labor onset and the criteria used to assess active labor progress and diagnose labor dystocia may significantly influence women's risk for primary cesarean birth. Our aims were to assess associations of labor status at admission (i.e., preactive or active) and active labor progress (i.e., dystocic or physiologic) with oxytocin augmentation, cesarean birth, and adverse neonatal outcome rates. Methods: A sample of low‐risk, nulliparous women admitted to hospitals for spontaneous labor onset was extracted from the Consortium on Safe Labor (n = 27 077). Binomial logistic regression was used to assess associations between labor classifications and outcomes. Results: At admission, 68.0% of women were in preactive labor and 32.0% were in active labor. Cesarean rates for these groups were 18.0% and 7.2%, respectively (adjusted odds ratio [AOR] 2.69; 95% CI 2.45‐2.96). Oxytocin augmentation and adverse neonatal outcomes were more likely for women admitted in preactive labor. Among women admitted in active labor, 9.3% experienced labor dystocia and 90.7% progressed physiologically. Cesarean rates for these groups were 20.4% and 5.9%, respectively (AOR 3.02; 95% CI 2.45‐3.73). Nearly half of the cesareans performed for dystocia among women admitted in active labor occurred when cervical dilation was physiologic. Oxytocin augmentation and adverse neonatal outcomes were more likely when active labor was dystocic. Conclusions: Adoption of evidence‐based, standardized approaches for diagnosing active labor onset, assessing labor progress, and diagnosing dystocia may safely decrease oxytocin augmentation and cesarean birth rates in the United States. [ABSTRACT FROM AUTHOR]

Background: In view of the reported increase in obstetric anal sphincter injuries, the objective of this study was to evaluate the incidence of such injuries over time and the associated risk and protective factors. Methods: This was a retrospective cohort study from a national database of 168 137 primiparous women with term, singleton, cephalic, vaginal delivery between 2008 and 2014. The main outcome measure was obstetric anal sphincter injury. A multivariate regression model was used to identify risk and protective factors. Results: Age >19 years, birthweight >4000 g, and operative vaginal delivery were independent risk factors for obstetric anal sphincter injuries. Mediolateral episiotomy increased the risk for obstetric anal sphincter injuries in spontaneous vaginal birth (number needed to harm 333), whereas it was protective in vacuum delivery (number needed to treat 50). From 2008 to 2014, there was an increase in the rate of obstetric anal sphincter injuries (2.1% vs 3.1%, P < .01), vacuum deliveries (12.1% vs 12.8%, P < .01), and cesarean delivery after labor (17.1% vs 19.4%, P < .01), while forceps deliveries (0.4% vs 0.1%, P < .01) and episiotomy rate decreased (35.9% vs 26.4%, P < .01). Conclusions: Episiotomy may be a risk or protective factor depending on the type of episiotomy and the clinical setting in which it is used. Our study supports a restrictive use of mediolateral episiotomy in spontaneous vaginal deliveries. In vacuum deliveries mediolateral episiotomy may help prevent obstetric anal sphincter injuries. [ABSTRACT FROM AUTHOR]

Background Cesarean delivery is one of the most widely used surgical interventions in Latin America and in many cases it is performed with no clear medical indication. Our objective was to analyze the relationship between reported indications for a cesarean and support for that indication in the clinical record in four Mexican hospitals, during the 2006-2007 period. Methods The data are from 604 (37.1%) women from a total of 1,625 who were admitted to the hospital in labor, and who gave birth through cesarean. Multivariate logistical regression analysis was used to explore the association between indications for clinically justified or unjustified surgery and other clinical and sociodemographic variables. Results Supporting clinical information for indications of cesarean delivery were found in only 45 percent of the cases considered. The adjusted statistical analysis showed that the variables associated with an unjustified indication for cesarean were: not having had a prior birth ( OR 1.84 [95% CI 1.16-2.89]), having a maximum cervical dilation of 4 centimeters or less at time of cesarean ( OR 2.44 [95% CI 1.53-3.87]), and having received care in a private hospital ( OR 6.11 [95% CI 1.90-19.57]). Discussion The indications for cesarean related to labor dynamics were those least supported. Not having had a prior birth poses the greatest risk of having a poorly supported indication for a cesarean delivery. It would be prudent to institute audits, and greater requirements for and surveillance of documentation for cesarean delivery indications. [ABSTRACT FROM AUTHOR]

Introduction Many birth units use central fetal monitoring ( CFM) under the assumption that greater surveillance improves perinatal outcomes. The unexpected loss of the CFM system at a tertiary unit provided a unique opportunity to evaluate outcomes and staff attitudes toward CFM. Methods This retrospective cohort study compared patient data from 2,855 electronically monitored women delivering over a 12-month period, where CFM was available for the first 6 months but unavailable for the following 6 months. Primary outcomes relating to neonatal morbidity and secondary outcomes relating to intrapartum interventions were examined. Additionally, birth unit staff members were surveyed about aspects of care related to CFM. Results There were no significant differences in perinatal outcomes between the cohorts. While unadjusted analysis suggested a lower spontaneous vaginal birth rate (55.4% vs 60.3%) and a higher cesarean delivery rate (25.1% vs 22.0%, p = 0.026), together with higher epidural (53.0% vs 49.2%, p = 0.04) and fetal blood sampling (11.8% vs 9.4%, p = 0.03) rates in the presence of CFM, these differences were lost when adjusted for prostaglandin ripening. Over half of the staff (56.0% of midwives, 54.0% of obstetricians) reported spending more time with the laboring woman in the period without CFM. Conclusions This single institution's experience indicates that in birth units staffed for one-to-one care in labor, central fetal monitoring does not appear to be associated with either a benefit on perinatal outcomes or an increase in cesarean delivery and other interventions. However, it is associated with a reduction in the time a midwife spends with the laboring woman. [ABSTRACT FROM AUTHOR]

Background: In the Dutch maternity care system, primary care midwives provide care to low-risk women and refer to obstetricians if risks or complications occur. We examined reasons for referral, management of labor, and maternal and neonatal outcomes among women who were referred during labor. Methods: In a retrospective cohort study, descriptive analyses were performed on data obtained from patient records. Six purposively chosen hospitals in The Netherlands participated in the study from June 2011 to February 2012. The study population included 600 pregnant women who were referred during labor from primary to secondary care. Main outcome measures: Reasons for referral, interventions after referral, mode of delivery, and maternal and neonatal outcomes. Results: Of women who were referred during labor, three out of four women were referred for moderate risk indications: request for pain relief (30.5%), meconium-stained liquor (25.3%), failure to progress during first stage of labor (14.0%), and prolonged ruptured membranes without contractions (12.5%). Of all women, 65.7 percent had a spontaneous vaginal delivery and 59.7 percent received some kind of pain relief. Acute referral, meaning fetal distress, occurred in 5.5 percent. Of the newborns, 2.7 percent had an Apgar score of 7 or less after 5 minutes and 1.2 percent had an umbilical cord pH < 7.05. Postpartum complications occurred among 11.0 percent of women. Conclusion: Women who are referred during labor have a high probability of spontaneous vaginal delivery. To improve continuity of care and satisfaction for this group of women, management of labor could be continued by trained primary care midwives. [ABSTRACT FROM AUTHOR]

Background: The relationship between migration and pregnancy outcomes is complex, with little insight into whether women of refugee background have greater risks of adverse pregnancy outcomes than other migrant women. This study aimed to describe maternal health, pregnancy care, and pregnancy outcomes among migrant women from humanitarian and nonhumanitarian source countries. Methods: Retrospective, observational study of singleton births, at a single maternity service in Australia 2002-2011, to migrant women born in humanitarian source countries (HSCs, n = 2,713) and non-HSCs (n = 10,606). Multivariable regression analysis assessed associations between maternal HSC-birth and pregnancy outcomes. Results: Compared with women from non-HSCs, the following were more common in women from HSCs: age < 20 years (0.6 vs 2.9% p < 0.001), multiparity (51 vs 76% p < 0.001), body mass index (BMI) > 25 (38 vs 50% p < 0.001), anemia (3.2 vs 5.9% p < 0.001), tuberculosis (0.1 vs 0.4% p = 0.001), and syphilis (0.4 vs 2.5% p < 0.001). Maternal HSC-birth was independently associated with poor or no pregnancy care attendance (OR 2.5 [95% CI 1.8-3.6]), late first pregnancy care visit (OR 1.3 [95% CI 1.1-1.5]), and postterm birth (> 41 weeks gestation) (OR 2.5 [95% CI 1.9-3.4]). Stillbirth (0.8 vs 1.2% p = 0.04, OR 1.5 [95% CI 1.0-2.4]) and unplanned birth before arrival at the hospital (0.6 vs 1.2% p < 0.001, OR 1.3 [95% CI 0.8-2.1]) were more common in HSC-born women but not independently associated with maternal HSC-birth after adjusting for age, parity, BMI and relative socioeconomic disadvantage. Conclusions: These findings suggest areas where women from HSCs may have additional needs in pregnancy compared with women from non-HSCs. Refugee-focused strategies to support engagement in pregnancy care and address maternal health needs would be expected to improve health outcomes in resettlement countries. [ABSTRACT FROM AUTHOR]

Background Disparities exist in pregnancy and birth outcomes between Australian Aboriginal women and their non-Aboriginal counterparts. Understanding patterns of health service use by Aboriginal women is critical. This study describes the use of maternal health services by remote dwelling Aboriginal women in northern Australia during pregnancy, birth and the postpartum period and their burden of disease. Methods A retrospective cohort study of maternity care for all 412 maternity cases from two remote Aboriginal communities in the Northern Territory of Australia, 2004-2006. Primary endpoints were the number and type of maternal health-related complications and service episodes at the health centers and regional hospital during pregnancy, birth, and the first 6 months postpartum. Results Ninety-three percent of women attended antenatal care. This often commenced late in pregnancy. High levels of complications were identified and 23 percent of all women required antenatal hospitalization. Birth occurred within the regional hospital for 90 percent of women. By 6 months postpartum, 45 percent of women had documented postnatal morbidities and 8 percent required hospital admission. The majority of women accessed remote health services at least once; however, only one third had a record of a postnatal care within 2 months of giving birth. Conclusion Maternal health outcomes were poor despite frequent service use throughout pregnancy, birth, and the first 6 months postpartum suggesting quality of care rather than access issues. These findings reflect outcomes that are more aligned with the developing rather than developed world and have significant implications for future planning of maternity services that must be urgently addressed. [ABSTRACT FROM AUTHOR]

Background The Inuulitsivik midwifery service is a community-based, Inuit-led initiative serving the Hudson coast of the Nunavik region of northern Québec. This study of outcomes for the Inuulitsivik birth centers, aims to improve understanding of maternity services in remote communities. Methods We used a retrospective review of perinatal outcome data collected at each birth at the Inuulitsivik birth centers to examine outcomes for 1,372 labors and 1,382 babies from 2000 to 2007. Data were incomplete for some indicators, particularly for transfers to Montreal. Results Findings revealed low rates of intervention with safe outcomes in this young, largely multiparous 'all risk' Inuit population. Ninety-seven percent of births were documented as spontaneous vaginal deliveries, and 85 percent of births were attended by midwives. Eighty-six percent of the labors occurred in Nunavik, whereas 13.7 percent occurred outside Nunavik. The preterm birth rate was found to be 10.6 percent. Postpartum hemorrhage was documented in 15.4 percent of women; of these cases, 6.9 percent had blood loss greater than 1,000 mL. Four fetal deaths (2.9 per 1,000) and five neonatal deaths (< 3.6 per 1,000) were documented. Nine percent (9%) of births involved urgent transfers of mother or baby. The most common reasons for medical evacuation were preterm labor and preeclampsia, and preterm birth was the most common reason for urgent neonatal transfer. Conclusions The success of the Innulitsivik midwifery service rests on the knowledge and skills of the Inuit midwives, and support of an interprofessional health team. Our study points to the potential for safe, culturally competent local care in remote communities without cesarean section capacity. Our findings support recommendations for integration of midwifery services and Aboriginal midwifery education programs in remote communities. ( BIRTH 39:3 September 2012) [ABSTRACT FROM AUTHOR]

Background Primary postpartum hemorrhage is a leading cause of maternal mortality and morbidity internationally. Research comparing physiological (expectant) and active management of the third stage of labor favors active management, although studies to date have focused on childbirth within hospital settings, and the skill levels of birth attendants in facilitating physiological third stage of labor have been questioned. The aim of this study was to investigate the effect of place of birth on the risk of postpartum hemorrhage and the effect of mode of management of the third stage of labor on severe postpartum hemorrhage. Methods Data for 16,210 low-risk women giving birth in 2006 and 2007 were extracted from the New Zealand College of Midwives research database. Modes of third stage management and volume of blood lost were compared with results adjusted for age, parity, ethnicity, smoking, length of labor, mode of birth, episiotomy, perineal trauma, and newborn birthweight greater than 4,000 g. Results In total, 1.32 percent of this low-risk cohort experienced an estimated blood loss greater than 1,000 mL. Place of birth was not found to be associated with risk of blood loss greater than 1,000 mL. More women experienced blood loss greater than 1,000 mL in the active management of labor group for all planned birth places. In this low-risk cohort, those women receiving active management of third stage of labor had a twofold risk (RR: 2.12, 95% CI: 1.39-3.22) of losing more than 1,000 mL blood compared with those expelling their placenta physiologically. Conclusions Planned place of birth does not influence the risk of blood loss greater than 1,000 mL. In this low-risk group active management of labor was associated with a twofold increase in blood loss greater than 1,000 mL compared with physiological management. ( BIRTH 39:2 June 2012) [ABSTRACT FROM AUTHOR]