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Objective: This study aimed to develop and validate a machine learning (ML) model to predict the probability of a vaginal delivery (Partometer) using data iteratively obtained during labor from the electronic health record., Study Design: A retrospective cohort study of deliveries at an academic, tertiary care hospital was conducted from 2013 to 2019 who had at least two cervical examinations. The population was divided into those delivered by physicians with nulliparous term singleton vertex (NTSV) cesarean delivery rates <23.9% (Partometer cohort) and the remainder (control cohort). The cesarean rate among this population of lower risk patients is a standard metric by which to compare provider rates; <23.9% was the Healthy People 2020 goal. A supervised automated ML approach was applied to generate a model for each population. The primary outcome was accuracy of the model developed on the Partometer cohort at 4 hours from admission to labor and delivery. Secondary outcomes included discrimination ability (receiver operating characteristics-area under the curve [ROC-AUC]), precision-recall AUC, and calibration of the Partometer. To assess generalizability, we compared the performance and clinical predictors identified by the Partometer to the control model., Results: There were 37,932 deliveries during the study period; after exclusions, 9,385 deliveries were included in the Partometer cohort and 19,683 in the control cohort. Accuracy of predicting vaginal delivery at 4 hours was 87.1% for the Partometer (ROC-AUC: 0.82). Clinical predictors of greatest importance in the stacked Intrapartum Partometer Model included the Admission Model prediction and ongoing measures of dilatation and station which mirrored those found in the control population., Conclusion: Using automated ML and intrapartum factors improved the accuracy of prediction of probability of a vaginal delivery over both previously published models based on logistic regression. Harnessing real-time data and ML could represent the bridge to generating a truly prescriptive tool to augment clinical decision-making, predict labor outcomes, and reduce maternal and neonatal morbidity., Key Points: · Our ML-based model yielded accurate predictions of mode of delivery early in labor.. · Predictors for models created on populations with high and low cesarean rates were the same.. · A ML-based model may provide meaningful guidance to clinicians managing labor.., Competing Interests: None declared., (Thieme. All rights reserved.)

Strategies to safely reduce the rate of nulliparous, term, singleton, vertex (NTSV) cesarean deliveries have thus far largely ignored the contribution that labor and delivery nurses make to the delivery mode. We used a recently developed method to calculate nurse-specific cesarean delivery rates and provide these to labor and delivery nursing leadership, who shared the rates with labor and delivery nurses beginning in September 2020. We performed a 3-year interrupted time series analysis comparing our NTSV cesarean delivery rates before and after nurse-specific rates were released. On release of nurse-specific rates, our labor and delivery unit's NTSV cesarean delivery rate declined from 25.7% to 22.0%. Further work to find strategies to sustain nurse engagement is warranted., Competing Interests: Financial Disclosure Kimberly D. Gregory reports money paid to her institution from PCORI, NIH, and CA Department Public Health Service. The other authors did not report any potential conflicts of interest., (Copyright © 2022 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To examine whether the presence of a birth plan was associated with mode of delivery, obstetrical interventions, and patient satisfaction., Methods: This was a prospective cohort study of singleton pregnancies greater than 34 weeks' gestation powered to evaluate a difference in mode of delivery. Maternal characteristics, antenatal factors, neonatal characteristics, and patient satisfaction measures were compared between groups. Differences between groups were analyzed using chi-squared for categorical variables, Fisher exact test for dichotomous variables, and Wilcoxon rank sum test for continuous or ordinal variables., Results: Three hundred women were recruited: 143 (48%) had a birth plan. There was no significant difference in the risk of cesarean delivery for women with a birth plan compared with those without a birth plan (21% vs 16%, adjusted odds ratio [adjOR] 1.11 [95% confidence interval (CI) 0.61-2.04]). Women with a birth plan were 28% less likely to receive oxytocin (P < .01), 29% less likely to undergo artificial rupture of membranes (P < .01), and 31% less likely to have an epidural (P < .01). There was no difference in the length of labor (P = .12). Women with a birth plan were less satisfied (P < .01) and felt less in control (P < .01) of their birth experience than those without a birth plan., Conclusion: Women with and without a birth plan had similar odds of cesarean delivery. Though they had fewer obstetrical interventions, they were less satisfied with their birth experience, compared with women without birth plans. Further research is needed to understand how to improve childbirth-related patient satisfaction., (© 2017 Wiley Periodicals, Inc.)

Background: To determine whether the mode of delivery was different between women who attended childbirth education (CBE) class, had a birth plan, or both compared with those who did not attend CBE class or have a birth plan., Methods: This is a retrospective cross-sectional study of women who delivered singleton gestations > 24 weeks at our institution between August 2011 and June 2014. Based on a self-report at the time of admission for labor, women were stratified into four categories: those who attended a CBE class, those with a birth plan, both, and those with neither CBE or birth plan. The primary outcome was the mode of delivery. Multivariate logistic regression analyses adjusting for clinical covariates were performed., Results: In this study, 14,630 deliveries met the inclusion criteria: 31.9 percent of the women attended CBE class, 12.0 percent had a birth plan, and 8.8 percent had both. Women who attended CBE or had a birth plan were older (p < 0.001), more likely to be nulliparous (p < 0.001), had a lower body mass index (p < 0.001), and were less likely to be African-American (p < 0.001). After adjusting for significant covariates, women who participated in either option or both had higher odds of a vaginal delivery (CBE: OR 1.26 [95% CI 1.15-1.39]; birth plan: OR 1.98 [95% CI 1.56-2.51]; and both: OR 1.69 [95% CI 1.46-1.95]) compared with controls., Conclusion: Attending CBE class and/or having a birth plan were associated with a vaginal delivery. These findings suggest that patient education and birth preparation may influence the mode of delivery. CBE and birth plans could be used as quality improvement tools to potentially decrease cesarean rates., (© 2016 Wiley Periodicals, Inc.)

Objective: Measures of maternal mortality and severe maternal morbidity have risen in the United States, sparking national interest regarding hospitals' ability to provide maternal risk-appropriate care. We examined the extent to which hospitals could be classified by increasingly sophisticated maternal levels of care., Study Design: We performed a cross-sectional survey to identify hospital-specific resources and classify hospitals by criteria for basic, intermediate, and regional maternal levels of care in all nonmilitary childbirth hospitals in California. We measured hospital compliance with maternal level of care criteria that were produced via consensus based on professional standards at 2 regional summits funded by the March of Dimes through a cooperative agreement with the Community Perinatal Network in 2007 (California Perinatal Summit on Risk-Appropriate Care)., Results: The response rate was 96% (239 of 248 hospitals). Only 82 hospitals (34%) were classifiable under these criteria (35 basic, 42 intermediate, and 5 regional) because most (157 [66%]) did not meet the required set of basic criteria. The unmet criteria preventing assignment into the basic category included the ability to perform a cesarean delivery within 30 minutes 100% of the time (only 64% met), pediatrician availability day and night (only 56% met), and radiology department ultrasound capability within 12 hours (only 83% met). Only 29 of classified hospitals (35%) had a nursery or neonatal intensive care unit level that matched the maternal level of care, and for most remaining hospitals (52 of 53), the neonatal intensive care unit level was higher than the maternal care level., Conclusion: Childbirth services varied widely across California hospitals, and most hospitals did not fit easily into proposed levels. Cognizance of this existing variation is critical to determining the optimal configuration of services for basic, intermediate, and regional maternal levels of care., (Copyright © 2015 Elsevier Inc. All rights reserved.)

The tracking of elective deliveries (ED) prior to 39 gestational weeks has become a mandatory requirement for all hospitals with ≥1,100 deliveries for accreditation by The Joint Commission (TJC); however, the feasibility and accuracy of monitoring efforts remain problematic for many hospitals. Here, we evaluated the feasibility of three operational approaches to tracking ED. We used mixed methods to evaluate the feasibility of 3 different approaches to tracking ED: (1) using administrative data, (2) using electronic medical record (EMR) data, and (3) using targeted data collection in a county-wide quality improvement (QI) effort. For (1), we analyzed data from the California 2009 linked birth cohort dataset, and calculated hospital rates of ED using TJC technical specifications. For (2), we performed a case study of a project that recruited hospitals to provide EMR data for the TJC measure calculation. For (3), we performed a case study of a project that recruited hospitals to prospectively track elective inductions of labor. For (1), hospital discharge data were insufficient without supplementation from the EMR or birth certificate. For (2), legal and operational issues surrounding data sharing, and non-standardized data elements prohibited hospital participation. For (3), the QI approach successfully established policies and data collection systems yet lacked infrastructure to assure sustainability at a hospital or regional level. In summary, ED tracking required the coordination and support of multiple resources to enable hospitals to satisfactorily report on this measure.

Objective: We sought to determine the impact of the laborist staffing model on cesarean rates and maternal morbidity in California community hospitals., Study Design: This is a cross-sectional study comparing cesarean rates, vaginal birth after cesarean rates, composite maternal morbidity, and severe maternal morbidity for laboring women in California community hospitals with and without laborists. We conducted interviews with nurse managers to obtain data regarding hospital policies, practices, and the presence of laborists, and linked this information with patient-level hospital discharge data for all deliveries in 2012., Results: Of 248 childbirth hospitals, 239 (96.4%) participated; 182 community hospitals were studied, and these hospitals provided 221,247 deliveries for analysis. Hospitals with laborists (n = 43, 23.6%) were busier, had more clinical resources, and cared for higher-risk patients. There was no difference in the unadjusted primary cesarean rate for laborist vs nonlaborist hospitals (11.3% vs 11.7%; P = .382) but there was a higher maternal composite morbidity rate (14.4% vs 12.0%; P = .0006). After adjusting for patient and hospital characteristics, there were no differences in laborist vs nonlaborist hospitals for any of the specified outcomes. Hospitals with laborists had higher attempted trial of labor after cesarean rates, and lower repeat cesarean rates (90.9% vs 95.9%; P < .0001). However, among women attempting trial of labor after cesarean, there was no difference in the vaginal birth after cesarean success rate., Conclusion: We were unable to demonstrate differences in cesarean and maternal childbirth complication rates in community hospitals with and without laborists. Further efforts are needed to understand how the laborist staffing model contributes to neonatal outcomes, cost and efficiency of care, and patient and physician satisfaction., (Copyright © 2015 Elsevier Inc. All rights reserved.)

To review management strategies associated with lower risk for cesarean delivery. Targeted literature review for labor interventions during the first stage of labor. There is evidence that policies regarding labor admission criteria, standardized policies regarding labor management including judicious use of oxytocin, standardized terminology and treatment for electronic fetal monitoring, standardized criteria for dystocia, and systematic implementation of policies that incorporate continuous supportive care during labor are associated with lower risk for cesarean. Evidence regarding use of amniotomy is conflicting. Management of the first stage of labor can affect the risk for cesarean delivery.

This report presents recent findings for 2013 on four maternal morbidities associated with labor and delivery-maternal transfusion, ruptured uterus, unplanned hysterectomy, and intensive care unit (ICU) admission-that are collected on birth certificates for a 41-state and District of Columbia reporting area, which represents 90% of all births in the United States., (All material appearing in this report is in the public domain and may be reproduced or copied without permission; citation as to source, however, is appreciated.)

Objective: To determine whether there are differences in adverse pregnancy outcomes in very advanced maternal age (vAMA) women who conceived with assisted reproductive technologies (ART) compared with spontaneous conceptions., Design: Retrospective cohort study., Setting: Academic tertiary care medical center., Patient(s): A total of 472 women aged ≥45 years who delivered at one institution., Intervention(s): Mode of conception., Main Outcome Measure(s): Maternal and neonatal outcomes., Result(s): For singleton pregnancies, vAMA women who conceived with ART were significantly older (47.0 ± 2.3 vs. 45.6 ± 0.1 years), more likely to be white (88.1% vs. 75.6%), and less parous (0.4 ± 0.9 vs. 1.2 ± 1.8) than vAMA women who conceived spontaneously. They were at significantly increased risk for cesarean delivery (CD) (75.1% vs. 49.7%) and were more likely to undergo elective primary CD without labor (25.4% vs. 9.4%). Risk of retained placenta was also significantly higher (2.7% vs. 0%). Rates of other maternal complications and neonatal outcomes were similar. Subgroup analysis of ART singleton pregnancies did not demonstrate differences in women using autologous oocytes versus donor oocytes., Conclusion(s): Very advanced maternal age women who conceive after ART are more likely to be white, older, primiparous, and are more likely to proceed with an elective CD compared with vAMA women who conceive spontaneously. The increased risk of retained placenta in women who conceive with ART may indicate an underlying risk for placentation defects., (Copyright © 2015 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: Cesarean is the single most common operation in United States and has reached epidemic proportions in recent decades. Our objective was to study the effect of nonclinical parameters on primary cesarean rates in a large contemporary population., Study Design: We designed a retrospective multicenter study using data obtained from electronic medical records from 19 U.S. hospitals between 2005 and 2007 (Consortium on Safe Labor Database), which included 145,764 term, singleton, nonanomalous, vertex, live births that included labor. The impact of nonclinical parameters (patient and provider characteristics, time of delivery, institutional policies, and insurance type) was investigated using modified Poisson regression methodology and classification and regression tree analysis., Results: There were 125,517 vaginal and 20,247 cesarean deliveries. Using the multivariable model, the nonclinical parameters with statistical significance for primary cesarean were delivery during evening hours, a male provider, public insurance, and nonwhite race (p < 0.001)., Conclusions: Cesarean rates are associated with several nonclinical factors. Further investigation into these factors might help to develop strategies to reduce their influence and hence the rates of cesarean., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Objective: Cesarean delivery rates are on the rise in many countries, including the United States. There is mounting evidence that cesarean delivery is associated with adverse reproductive outcomes in subsequent pregnancies. The purpose of this article is to review those outcomes in a well-defined cohort of pregnant women., Study Design: In a cohort of primigravid women from the Danish National Birth Cohort with known baseline exposure characteristics, we stratified women by method of first delivery, vaginal or cesarean, and evaluated for appearance of adverse reproductive events in subsequent pregnancies., Results: After adjusting for age, body mass index, alcohol, smoking, and socioeconomic status, women who underwent cesarean delivery at first birth were at increased risk in their subsequent pregnancy for anemia (odds ratio [OR], 2.8; 95% confidence interval [CI], 2.3-3.4), placental abruption (OR, 2.3; 95% CI, 1.5-3.6), uterine rupture (OR, 268; 95% CI, 65.6-999), and hysterectomy (OR, 28.8; 95% CI, 3.1-263.8)., Conclusion: Women who deliver their first baby with a cesarean are at increased risk of adverse reproductive outcomes in subsequent pregnancies and should be counseled accordingly., (Copyright © 2012 Mosby, Inc. All rights reserved.)

Objective: To describe contemporary cesarean delivery practice in the United States., Study Design: Consortium on Safe Labor collected detailed labor and delivery information from 228,668 electronic medical records from 19 hospitals across the United States, 2002-2008., Results: The overall cesarean delivery rate was 30.5%. The 31.2% of nulliparous women were delivered by cesarean section. Prelabor repeat cesarean delivery due to a previous uterine scar contributed 30.9% of all cesarean sections. The 28.8% of women with a uterine scar had a trial of labor and the success rate was 57.1%. The 43.8% women attempting vaginal delivery had induction. Half of cesarean for dystocia in induced labor were performed before 6 cm of cervical dilation., Conclusion: To decrease cesarean delivery rate in the United States, reducing primary cesarean delivery is the key. Increasing vaginal birth after previous cesarean rate is urgently needed. Cesarean section for dystocia should be avoided before the active phase is established, particularly in nulliparous women and in induced labor., (Published by Mosby, Inc.)

Objective: We sought to assess body mass index (BMI) effect on cesarean risk during labor., Study Design: The Consortium on Safe Labor collected electronic data from 228,668 deliveries. Women with singletons > or = 37 weeks and known BMI at labor admission were analyzed in this cohort study. Regression analysis generated relative risks for cesarean stratifying for parity and prior cesarean while controlling for covariates., Results: Of the 124,389 women, 14.0% had cesareans. Cesareans increased with increasing BMI for nulliparas and multiparas with and without a prior cesarean. Repeat cesareans were performed in > 50% of laboring women with a BMI > 40 kg/m(2). The risk for cesarean increased as BMI increased for all subgroups, P < .001. The risk for cesarean increased by 5%, 2%, and 5% for nulliparas and multiparas with and without a prior cesarean, respectively, for each 1-kg/m(2) increase in BMI., Conclusion: Admission BMI is significantly associated with delivery route in term laboring women. Parity and prior cesarean are other important predictors., (Copyright 2010 Mosby, Inc. All rights reserved.)

Objective: We sought to determine maternal and neonatal outcomes by labor onset type and gestational age., Study Design: We used electronic medical records data from 10 US institutions in the Consortium on Safe Labor on 115,528 deliveries from 2002 through 2008. Deliveries were divided by labor onset type (spontaneous, elective induction, indicated induction, unlabored cesarean). Neonatal and maternal outcomes were calculated by labor onset type and gestational age., Results: Neonatal intensive care unit admissions and sepsis improved with each week of gestational age until 39 weeks (P < .001). After adjusting for complications, elective induction of labor was associated with a lower risk of ventilator use (odds ratio [OR], 0.38; 95% confidence interval [CI], 0.28-0.53), sepsis (OR, 0.36; 95% CI, 0.26-0.49), and neonatal intensive care unit admissions (OR, 0.52; 95% CI, 0.48-0.57) compared to spontaneous labor. The relative risk of hysterectomy at term was 3.21 (95% CI, 1.08-9.54) with elective induction, 1.16 (95% CI, 0.24-5.58) with indicated induction, and 6.57 (95% CI, 1.78-24.30) with cesarean without labor compared to spontaneous labor., Conclusion: Some neonatal outcomes improved until 39 weeks. Babies born with elective induction are associated with better neonatal outcomes compared to spontaneous labor. Elective induction may be associated with an increased hysterectomy risk., (Copyright 2010 Mosby, Inc. All rights reserved.)

Background: The cesarean rate has served an integral role in the monitoring of obstetrical care, and in 2002, the national rate reached 26.1%, the highest ever reported., Objective: We sought to describe the effect of clinical complications on hospital cesarean rates., Research Design: This was a population-based cohort study., Subjects: All laboring women without a previous cesarean who delivered in California in 1995 as reported through public-use hospital discharge data were included., Measures: Women with and without maternal, fetal, or placental complications were compared with respect to cesarean use. Using recursive partitioning algorithms, women with complications were stratified into clinically homogeneous categories, which were analyzed separately with respect to cesarean use., Results: The 443,532 women delivered at 288 hospitals and included 116,170 women (26.2%) in the complicated group (cesarean rate 22.6%); and 327,362 women (73.8%) in the uncomplicated group (cesarean rate 6.7%). At the hospital level, the cesarean rates among the complicated and uncomplicated patients respectively were: median 23.5% (range, 2.2-9.9%); and median 6.5% (range, 1.8-18.2%). Recursive partitioning algorithms suggested 16 distinct clinical categories, with cesarean rates varying from 8.9% for women with asthma to 84.5% for women with an unengaged fetal head., Conclusions: Cesarean rates varied widely across complication types, and complication-specific rates varied widely among hospitals. Although the presence of pregnancy complications upon hospital admission comprised the strongest factor affecting first-time cesarean use among laboring women, the importance and interdependence of these clinical conditions has yet to be incorporated into commonly used models for cesarean rate comparisons.

The caesarean delivery rate has become a commonly used measure intended to reflect the quality of obstetric care. At least 25% of all primary caesarean deliveries occur electively, i.e. to women who are not in labour. This study is intended to validate a previously published model designed to use ICD-9-CM codes to identify and categorise cases of elective primary caesarean delivery by their indication. ICD-9-CM codes were compared with diagnoses written in the medical record for all women without a prior caesarean who delivered in the same month in a single hospital to examine the accuracy of the codes for 12 potential elective primary caesarean indications derived by the published model: malpresentation; bleeding; genital herpes; severe hypertension; uterine scar; multiple gestation; macrosomia; unengaged fetus; maternal soft tissue conditions; other hypertensive conditions; prematurity; and chromosomal anomalies. Of 440 eligible women, a total of 26 (5.9%) had an elective primary caesarean by medical record review vs. [27] (6.1%) by administrative data. Using medical record data as the gold standard, the sensitivity, specificity, and accuracy of administrative data for the identification of elective primary caesarean delivery were 73.1%, 98.1%, and 96.6%, respectively. Administrative coding for all of the 12 conditions was highly specific, although wide variability existed in its sensitivity; its accuracy ranged between 83.9% and 100%. These results suggest that, despite widespread use of caesarean delivery rates obtained through administrative data, more experience is needed to determine which obstetric codes may be sufficiently specific, sensitive, or prevalent to serve a monitoring or surveillance function reflecting the quality of obstetrical care. The results support continued efforts to use administrative data to monitor elective primary caesarean delivery.

Objective: To develop a methodology to identify indications and normative rates for elective primary cesarean delivery using administrative data., Data Sources/study Setting: All delivery discharges in 1995, as reported to the California Office of Statewide Health Planning and Development (secondary data)., Study Design: Retrospective population based study., Data Collection/extraction: Data were entered into a recursive partitioning algorithm to develop a hierarchy of conditions by which patients with multiple conditions could be sorted with respect to the binary outcome of labor or elective primary cesarean without labor. This hierarchy was examined for its clinical consistency, validated on a second sample, and compared with results obtained from logistic regression., Principal Findings: Four percent (19,664) of delivery discharges in 1995 underwent elective primary cesarean. Twelve clinical conditions contributed to the hierarchy, and accounted for 92.9 percent of all women experiencing elective primary cesarean delivery. The remaining 7.1 percent of the elective primary cesarean cases were classified as "unspecified.", Conclusions: A standardized methodology (utilizing recursive partitioning algorithms) for assigning indications for elective primary cesarean is presented. This methodology relies on administrative data, classifies women with complex comorbidity patterns into clinically relevant subpopulations, and can be used to establish normative rates for benchmarking specific indications for cesarean delivery.

Background: The low-risk cesarean delivery (CD) rate is an established performance indicator for providers in maternity care for quality improvement purposes. Purpose: Our objectives were to assess nurse performance using adjusted nurse-level CD rates and to compare methods of identifying nurse outliers. Methods: We conducted a retrospective, cohort study of 6970 births attended by 181 registered nurses in one hospital's maternity unit. Adjusted and unadjusted nurse-level CD rates were compared and agreement between 3 definitions (statistical, top decile, over a benchmark) of outliers calculated. Results: Adjusted nurse-level CD rates varied from 5.5% to 53.2%, and the unadjusted rates varied from 5% to 50%. Risk adjustment had little impact on the ranking of nurses, and outliers were consistently identified by 3 definitions. Conclusions: Trade-offs between statistical certainty and feasibility need to be considered when classifying nurse outliers. Findings can help target interventions to improve nurse performance. [ABSTRACT FROM AUTHOR]

Objective  To evaluate whether prophylactic antibiotics at the time of placement of an intrauterine balloon tamponade (IBT) is associated with a reduction in postpartum endometritis. Study Design  Retrospective cohort study of patients who received an IBT from January 1, 2012, to December 12, 2016. Patients were included if the IBT remained in place at least 2 hours and excluded if chorioamnionitis was present. Patients who received prophylactic antibiotics at the time of IBT placement were compared with those who did not. Results  A total of 149 subjects received an IBT; 36 were excluded due to early removal or chorioamnionitis. Of the remaining, 59 received prophylactic antibiotics and 54 did not. Baseline characteristics were similar between the groups except mode of delivery. The majority (65%) of those who did not receive prophylactic antibiotics had a cesarean delivery (p  = 0.03). The overall incidence of endometritis was 15%. The incidence of endometritis was greater among those patients who did not receive prophylactic antibiotics compared with those who did (5 vs. 26%; p  < 0.002; odds ratio [OR]: 6.53; 95% confidence interval [CI]: 1.76–24.25). This association remained after adjustment for mode of delivery and receiving group B Streptococcus antibiotics prior to delivery (adjusted OR: 5.9; 95% CI: 1.58–22.35). Conclusion  Prophylactic antibiotics were associated with a reduction in postpartum endometritis among patients receiving an IBT. [ABSTRACT FROM AUTHOR]

Background To determine whether the mode of delivery was different between women who attended childbirth education ( CBE) class, had a birth plan, or both compared with those who did not attend CBE class or have a birth plan. Methods This is a retrospective cross-sectional study of women who delivered singleton gestations > 24 weeks at our institution between August 2011 and June 2014. Based on a self-report at the time of admission for labor, women were stratified into four categories: those who attended a CBE class, those with a birth plan, both, and those with neither CBE or birth plan. The primary outcome was the mode of delivery. Multivariate logistic regression analyses adjusting for clinical covariates were performed. Results In this study, 14,630 deliveries met the inclusion criteria: 31.9 percent of the women attended CBE class, 12.0 percent had a birth plan, and 8.8 percent had both. Women who attended CBE or had a birth plan were older ( p < 0.001), more likely to be nulliparous ( p < 0.001), had a lower body mass index ( p < 0.001), and were less likely to be African-American ( p < 0.001). After adjusting for significant covariates, women who participated in either option or both had higher odds of a vaginal delivery ( CBE: OR 1.26 [95% CI 1.15-1.39]; birth plan: OR 1.98 [95% CI 1.56-2.51]; and both: OR 1.69 [95% CI 1.46-1.95]) compared with controls. Conclusion Attending CBE class and/or having a birth plan were associated with a vaginal delivery. These findings suggest that patient education and birth preparation may influence the mode of delivery. CBE and birth plans could be used as quality improvement tools to potentially decrease cesarean rates. [ABSTRACT FROM AUTHOR]

Background We propose a methodology for identifying and analysing 'elective' preterm births ( PTBs) using administrative data, and apply this methodology to California data with the objective of providing a framework to further explore the potential rationales for early delivery. Methods Using the California linked birth cohorts for 1999, 2002 and 2005, singleton PTBs were identified using birth certificate gestational age ≥ 24 and <37 weeks. Through a hierarchical scheme that first removed cases with standard or 'hard' indications for early delivery (e.g. severe preeclampsia, placenta previa), cases of 'elective' PTB were identified with coding for medical intervention, that is, elective caesarean or labour induction. We calculated rates of elective PTB, with subanalyses of early (<34 weeks of gestational age) and late PTB (34 to <37 weeks of gestational age) using hierarchical logistic regression models. Results Of 1 387 565 singleton deliveries, 99 614 (7.2%) were preterm. Elective PTBs increased 27.7% over the 6-year study period, with nearly all cases confined to the late PTB stratum; elective late PTB rates rose from 10.5% to 13.5% of all late PTBs ( P < 0.0001). Indications for delivery in this Elective Group ('soft indications') included prior pelvic floor repair, mental health conditions, fetal anomalies, malpresentation and oligohydramnios. Six per cent of patients with a late PTB had a medical intervention with no hard or soft indication for delivery. Conclusions Using administrative data, we developed a method for identifying and trending the proportion of PTBs that is 'elective'. This method can be used to explore and monitor potential strategies for the prevention of elective PTB. [ABSTRACT FROM AUTHOR]

We reviewed the risks and benefits of vaginal and cesarean delivery to help frame the inherent trade-offs that should be considered as part of the informed consent discussion between patients and providers. We performed a targeted literature review for common complications of childbirth. Approximately 30% of women will experience a maternal or neonatal complication during childbirth. Both cesarean and vaginal delivery is associated with well-known measurable short- and long-term maternal and neonatal complications and benefits. Childbirth is not risk free. There are data available that can guide the informed consent process with objective quantifiable data that patients and providers can use to weigh risks and benefits of delivery methods. [ABSTRACT FROM AUTHOR]

Objective: Our purpose was to describe variation in elective primary cesarean rates by nonclinical factors.Study Design: With use of California discharge data and American Hospital Association data for 1995, patients were classified into 13 mutually exclusive categories for elective primary cesarean delivery. With use of recursive partitioning algorithms, women in each category were then studied to determine whether nonclinical factors were associated with elective primary cesarean delivery.Results: A total of 463,196 women were delivered at 288 hospitals, and the elective primary cesarean delivery rate was 4.25% (19,664/463,196). Risk for elective primary cesarean delivery varied by clinical condition. The most discriminant risk factors were hospital type (malpresentation, multiple gestation, macrosomia, other hypertension), maternal age (antepartum bleeding, uterine scar, soft tissue disorder, preterm, unspecified), and teaching status (herpes, severe hypertension, unengaged head).Conclusion: This article presents methods that use administrative data to isolate and monitor the impact of nonclinical factors on the use of elective primary cesarean. [ABSTRACT FROM AUTHOR]

Focuses on the decline of cesarean rate in the U.S. for the period 1998 and 1994. Indication of primary cesarean delivery; Source of payment for the surgical operation; Percentage of caesareans attributed to dystocia and fetal distress.

Objective: The aims of the study were to describe the difference in cesarean delivery rates for Medicaid patients according to hospital type and adjusted for case mix and to determine cost implications for additional cesarean deliveries.Study Design: This retrospective study used California discharge data for 92,800 patients delivered in 78 hospitals in Los Angeles County during 1991. Multivariable logistic regression was used to adjust for case mix and to calculate adjusted cesarean delivery rates according to hospital type. Cost estimates assumed $821 per day hospital reimbursement.Results: The unadjusted cesarean delivery rate in private nonteaching hospitals (reference group) was 24.5%, compared with 13.2%, 17.4%, and 16.5% in public, health maintenance organization, and private teaching hospitals, respectively. Adjustment for case mix decreased the cesarean delivery rate in public (9.0%), health maintenance organization (12.0%), and private teaching hospitals (8.0%). Cesarean deliveries performed on patients in private nonteaching hospitals result in an additional $13.6 million in Medicaid health care expenses.Conclusions: There are increased health care costs related to increased cesarean deliveries performed on Medicaid patients in private nonteaching hospitals. [ABSTRACT FROM AUTHOR]

Studies changes in indications for cesarean deliveries in the United States, for 1985 and 1994. Leading indications for cesarean delivery; Changes in the performance of cesareans attributable to dystocia, breech presentation and fetal distress; Strategies to lower cesarean rates.

Aggregate databases are increasingly being used to evaluate appropriateness of care, and, for cesarean sections, Anderson and Lomas' International Classification of Diseases, 9th Revision (ICD-9), coding hierarchy is a widely used tool. The aim of this study was to assess the validity of the hierarchy and expand its applicability to repeat cesareans. Hospital records of 1885 singleton cesareans were reviewed. Clinical indications and ICD-9 hierarchical codes were concordant for 83% of primary and 86% of repeat cesareans; modification allowed elective repeat cesareans to be distinguished from indicated procedures. The Anderson and Lomas ICD-9 hierarchy is a valid tool for assessing indications for cesarean. The current modification improves its clinical utility and expands its application to repeat procedures. [ABSTRACT FROM AUTHOR]

Providers perceive current obstetric quality measures as imperfect and insufficient. Our organizations convened a "Quality Measures in High-Risk Pregnancies Workshop." The goals were to (1) review the current landscape regarding quality measures in obstetric conditions with increased risk for adverse maternal or fetal outcomes, (2) evaluate the available evidence for management of common obstetric conditions to identify those that may drive the highest impact on outcomes, quality, and value, (3) propose measures for high-risk obstetric conditions that reflect enhanced quality and efficiency, and (4) identify current research gaps, improve methods of data collection, and recommend means of change. [ABSTRACT FROM AUTHOR]

Objective: The objective of the study was to identify vaginal birth after cesarean (VBAC) success rates and maternal and neonatal complication rates for selected antenatal conditions. Study Design: This was a population-based cohort study using administrative discharge data for women delivering in California hospitals during 2002. Results: Among 41,450 women, 29.72% (12,320 of 41,450) had maternal, fetal, or placental conditions complicating pregnancy. Attempted VBAC rates and VBAC success rates varied widely by these clinical condition, ranging from 10% to 73%. The VBAC success rate for low-risk women (no conditions) was 73.76% vs 50.31% for high-risk women (at least 1 condition), P < .0001. Absolute rates of maternal and neonatal complications were low (less than 1-2%), and the rate of adverse events was higher in the high-risk clinical group as compared with the low-risk clinical group. Conclusion: Variation in rates of VBAC success and childbirth morbidities can be partially attributed to clinical factors complicating pregnancy. Women without such conditions show improved VBAC success and fewer maternal and neonatal complications. [Copyright &y& Elsevier]