Trial of labor after caesarean section in low risk pregnancies: is it risky?

PURPOSE: To evaluate the influence of a previous caesarean section on adverse composite maternal and perinatal outcome in women who attempted a trial of labor. METHODS: This historical cohort study analyzed maternal and perinatal outcome in women with otherwise low risk pregnancies at term who underwent a trial of labor after a caesarean section (TOLAC). The primary outcome measure was the adverse composite outcome. Secondary outcome measures were amongst others the caesarean section rate and the mode of vaginal delivery. RESULTS: The adverse composite outcome was more frequently in the previous caesarean section group compared to women with no previous caesarean Sect. (22.3% vs. 15.6%, p < 0.0001). The percentage of caesarean Sect. (15.4% vs. 8.2%, p < 0,0001), uterine rupture (1.0% vs. 0.02%, p < 0.0001), placental abruption (1.1% vs. 0.3%, p = 0.0014), vaginal operative delivery (16.0% vs. 8.6%, p < 0.0001), pH < 7.10 (3.7% vs. 2.5%, p = 0.0151), base excess < -12 (3.2% vs. 2.2%, p = 0.0297), abnormal cardiotocography (22.5% vs. 13.9%, p < 0,0001) and fetal blood analysis (6.2% vs. 2.6%, p < 0.0001) was significantly higher in women with a previous caesarean section. Taking the parity into account, these differences could only been seen in women without a previous vaginal delivery. In parous women with a previous vaginal delivery and a caesarean section in history, the adverse composite did not differ between the groups. Only the rate of pH < 7.1 was higher in women after a caesarean Sect. (4.5% vs. 1.8%, p = 0.0436). CONCLUSION: Trial of labor after caesarean in otherwise low risk pregnancies is associated with a higher rate of complications especially if there is no history of vaginal delivery.

A global study of the association of cesarean rate and the role of socioeconomic status in neonatal mortality rate in the current century.

INTRODUCTION: Caesarean section (C/S) rates have significantly increased across the world over the past decades. In the present population-based study, we sought to evaluate the association between C/S and neonatal mortality rates. MATERIAL AND METHODS: This retrospective ecological study included longitudinal data of 166 countries from 2000 to 2015. We evaluated the association between C/S rates and neonatal mortality rate (NMR), adjusting for total fertility rate, human development index (HDI), gross domestic product (GDP) percentage, and maternal age at first childbearing. The examinations were also performed considering different geographical regions as well as regions with different income levels. RESULTS: The C/S rate and NMR in the 166 included countries were 19.97% ± 10.56% and 10 ± 10.27 per 1000 live birth, respectively. After adjustment for confounding variables, C/S rate and NMR were found correlated (r = -1.1, p < 0.001). Examination of the relationship between C/S rate and NMR in each WHO region resulted in an inverse correlation in Africa (r = -0.75, p = 0.005), Europe (r = -0.12, p < 0.001), South-East Asia (r = -0.41, p = 0.01), and Western Pacific (r = -0.13, p = 0.02), a direct correlation in America (r = 0.06, p = 0.04), and no correlation in Eastern Mediterranean (r = 0.01, p = 0.88). Meanwhile, C/S rate and NMR were inversely associated in regions with upper-middle (r = -0.15, p < 0.001) and lower-middle (r = -0.24, p < 0.001) income levels, directly associated in high-income regions (r = 0.02, p = 0.001), and not associated in low-income regions (p = 0.13). In countries with HDI below the centralized value of 1 (the real value of 0.9), the correlation between C/S rate and NMR was negative while it was found positive in countries with HDI higher than the mentioned cut-off. CONCLUSIONS: This study indicated that NMR associated with C/S is dependent on various socioeconomic factors such as total fertility rate, HDI, GDP percentage, and maternal age at first childbearing. Further attentions to the socioeconomic status are warranted to minimize the NMR by modifying the C/S rate to the optimum cut-off.

Variation of caesarean section rates in Palestinian governmental hospitals.

BACKGROUND: Globally, the increased use of cesarean sections has become prevalent in high-income and low and middle-income countries. In Palestine, the rate had risen from 20.3% in 2014 to 25.1% in 2018. We have rates as high as 35.8% in some governmental hospitals and some as low as 15%. This study aimed to understand better why there is a variation in cesarean rates in governmental hospitals that use the same guidelines. METHODS: A qualitative and quantitative research approach was used. In-depth interviews were conducted with 27 specialists, obstetrics and gynecologists, and midwives in five government hospitals. The hospitals were selected based on the 2017 Annual Health Report reported cesarean section rates. The interview guide was created with the support of specialists and researchers and was piloted. Questions focused mainly on adherence to the obstetric guidelines and barriers to the use, sources of information, training for healthcare providers, the hospital system, and the factors that affect decision-making. Each hospital's delivery records for one month were analyzed to determine the reason for each cesarean section. RESULTS: The results indicated that each governmental hospital at the system level had a different policy on cesarean sections. The National Guidelines were found to be interpreted differently among hospitals. One obstetrician-gynecologist decided on a cesarean section at high-rate hospitals, while low-rate hospitals used collective decision-making with empowered midwives. At the professional level, all hospitals urged the importance of a continuous training program to refresh the medical team knowledge, in-house training of new members joining the hospital, and discussion of cases subjective to obstetrician-gynecologists interpretations. CONCLUSION: Several institutional factors were identified to strengthen the implementation of the national obstetric guidelines. For example, encouraging collective decision-making between obstetrician-gynecologists and midwives, promoting the use of a second opinion, and mandatory training.

Association between migration status and caesarean section delivery based on a modified Robson classification in China.

BACKGROUND: China has one of the highest caesarean section (C-Section) rates in the world. In recent years, China has been experiencing a massive flow of migration due to rapid urbanization. In this study, we aimed to differentiate the rates of C-Section between migrants and residents, and explore any possible factors which may moderate the association between migrant status and C-Section rates. METHODS: We conducted a retrospective cohort study in Shanghai, China. All deliveries were classified using the modified Robson Classification. The association between women's migrant status and C-Section rates was assessed using the Poisson regression of sandwich estimation, after adjusting for possible factors. RESULTS: Of the 40,621 women included in the study, 66.9% were residents and 33.1% were internal migrants. The rate of C-Section in migrants was lower than that of residents in all subjects (39.9 and 47.7%) and in group 1 subjects (based on the Robson Classification) using a modified Robson Classification. There was an association between migrant status and caesarean delivery on maternal request that was statistically significant (RR = 0.664, p < 0.001), but the association was weakened after adjusting for such factors as maternal age at delivery (aRR = 0.774, p = 0.02), ethnicity (aRR = 0.753, p < 0.001), health insurance (aRR = 0.755, p < 0.001), and occupation (aRR = 0.747, p = 0.004), but had no significant changes when adjusting for health conditions (aRR = 0.668, p = 0.001) and all considering variables (aRR = 0.697, p = 0.002). In group 1 subjects, the effect of migrant status on maternal requested intrapartum C-Section was also statistically significant (RR = 0.742, p = 0.004). CONCLUSION: C-Section rates are lower among migrant women than residents, especially on maternal request. The medical practitioners should further reinforce the management of elective C-Section in resident women.

Impact of maternal nationality on caesarean section rate variation in a high-income country.

BACKGROUND: Caesarean section (CS) rates have been reported to differ between immigrants and native-born women in high-income countries. OBJECTIVE: We assessed the CS rate and its relationship with the CS rate in country of nationality and other explanatory factors among women of different nationalities including Qatari women who underwent deliveries at our hospital to generate evidence that will quantify and help explain the observed CS rates in our hospital. METHODS: In this retrospective cross-sectional study conducted at the second-largest public maternity hospital in Qatar, Al-Wakra Hospital (AWH), data for all births delivered in 2019 were retrieved from the hospital's electronic medical records. The CS rates and the crude and adjusted risks of Caesarean delivery for mothers from each nationality were determined, and the common indications for CS were analyzed based on nationality. The association between nationality and Caesarean delivery was examined using binomial logistic regression analysis, with Qatari women as the reference group. The correlation between CS rate in country of nationality and observed CS rates in Qatar was also examined using Pearson's correlation. RESULTS: The study population consisted of 4816 births by women of 68 nationalities, of which 4513 births were by women from 25 countries. The highest proportion of deliveries (n-1247, 25.9%) was by Indian women. The frequency of CS was the highest and lowest among Egyptian (49.6%) and Yemeni women (17.9%), respectively. Elective CS was predominantly performed in women of Arab nationalities; the most common indication was a history of previous multiple CSs. Emergency CS was primarily performed in women of Asian and Sub-Saharan African nationalities; the most common indications were failure to progress and fetal distress. For most nationalities, the CS rate in Qatar was associated with those of the countries of nationality. CONCLUSIONS: The observed CS rates varied widely among women of different nationalities. The variation was influenced by maternal factors and medical indications as well as the CS rates in the country of nationality. We posit that cultural preferences, acculturation, and patient expectations influenced observed findings. More efforts are required to reduce primary CS rates and to help women make the most informed decisions regarding modes of delivery. Key Message: CS rates varied widely among women of different nationalities. The variation was influenced by medical indications, maternal preferences, and CS rate in countries of nationality. The solution to reducing CS rates should be a culturally informed response.

Reducing caesarean section rate in an urban hospital serving women attending privately in India - a quality improvement initiative.

BACKGROUND: In line with global trends, India has witnessed a sharp rise in caesarean section (CS) deliveries, especially in the private sector. Despite the urgent need for change, there are few published examples of private hospitals that have successfully lowered their CS rates. Our hospital, serving private patients too, had a CS rate of 79% in 2001. Care was provided by fee-for-service visiting consultant obstetricians without uniform clinical protocols and little clinical governance. Consultants attributed high CS rate to case-mix and maternal demand and showed little inclination for change. We attempted to reduce this rate with the objective of improving the quality of our care and demonstrating that CS could be safely lowered in the private urban Indian healthcare setting. METHODS: We hired full-time salaried consultants and began regular audit of CS cases. When this proved inadequate, we joined an improvement collaborative in 2011 and dedicated resources for quality improvement. We adopted practice guidelines, monitored outcomes by consultant, improved labour ward support, strengthened antenatal preparation, and moved to group practice among consultants. RESULTS: Guidelines ensured admissions in active labour and reduced CS (2011 to 2016) for foetal heart rate abnormalities (23 to 5%; p < 0.001) and delayed progress (19 to 6%; p < 0.001) in low-risk first-birth women. Antenatal preparation increased trial of labour, even among women with prior CS (28 to 79%; p < 0.001). Group practice reduced time pressure and stress, with a decline in CS (52 to 18%; p < 0.001) and low-risk first-birth CS (48 to 12%; p < 0.001). Similar CS rates were maintained in 2017 and 2018. Measures of perinatal harm including post-partum haemorrhage, 3rd-4th degree tears, shoulder dystocia, and Apgar < 7 at 5 min were within acceptable ranges (13, 3, 2% and 3 per thousand respectively in 2016-18,). CONCLUSIONS: It is feasible to substantially reduce CS rate in private healthcare setting of a middle-income country like India. Ideas such as moving to full-time attachment of consultants, joining a collaborative, improving labour ward support, providing resources for data collection, and perseverance could be adopted by other hospitals in their own journey of moving towards a medically justifiable CS rate.

Association between maternal mortality and caesarean section in Ethiopia: a national cross-sectional study.

BACKGROUND: Several studies concluded that there is a reduction of maternal deaths with improved access to caesarean section, while other studies showed the existence of a direct association between the two variables. In Ethiopia, literature about the association between maternal mortality and caesarean section is scarce. This study was aimed to assess the association between maternal mortality ratios and caesarean section rates in hospitals in Ethiopia. METHODS: Analysis was done of a national maternal health dataset of 293 hospitals that accessed from the Ethiopian Public Health Institute. Hospital specific characteristics, maternal mortality ratios and caesarean section rates were described. Pearson's correlation coefficient was used to determine the direction of association between maternal mortality ratios and caesarean section rate, taking regions into consideration. Presence of a linear association between these variables was declared statistically significant at p-value < 0.05. RESULTS: The overall maternal mortality ratio in Ethiopian hospitals was 149 (95% CI: 136-162) per 100,000 livebirths. There was significant regional variation in maternal mortality ratios, ranging from 74 (95% CI: 51-104) per 100,000 livebirths in Tigray region to 548 (95% CI: 251-1,037) in Afar region. The average annual caesarean section rate in hospitals was 20.3% (95% CI: 20.2-20.5). The highest caesarean section rate of 38.5% (95% CI: 38.1-38.9) was observed in Addis Ababa, while the lowest rate of 5.7% (95% CI: 5.2-6.2) occurred in Somali region. At national level, a statistically non-significant inverse association was observed between maternal mortality ratios and caesarean section rates. Similarly, unlike in other regions, there were inverse associations between maternal mortality ratios and caesarean section rates in Addis Ababa, Afar Oromia and Somali, although associations were not statistically significant. CONCLUSIONS: At national level, a statistically non-significant inverse association was observed between maternal mortality ratios and caesarean section rates in hospitals, although there were regional variations. Additional studies with a stronger design should be conducted to assess the association between population-based maternal mortality ratios and caesarean section rates.

Peripartum interventions resulting in reduced perinatal mortality rates, and birth asphyxia rates, over 18 years in a tertiary centre in South India: a retrospective study.

OBJECTIVE: To study the changes in the rates of perinatal mortality, birth asphyxia, and caesarean sections in relation to interventions implemented over the past 18 years, in a tertiary centre in South India. DESIGN: Retrospective study. SETTING: Labour and maternity unit of a tertiary centre in South India. POPULATION OR SAMPLE: Women who gave birth between 2000 and 2018. METHODS: Information from perinatal audits, chart reviews, and data retrieved from the electronic database were used. Interventions implemented during this time period were audits and training, obstetric re-organisation, and minor changes in staffing and infrastructure. MAIN OUTCOME MEASURES: Main outcome measures were perinatal mortality rate, birth asphyxia rate, and caesarean section rate. RESULTS: Perinatal mortality rate decreased from 44 per 1000 births in 2000 to 16.4 per 1000 births in 2018 (P < 0.001). The rates of babies born with birth asphyxia requiring admission to the neonatal unit decreased from 24 per 1000 births in 2001 to 0.7 per 1000 births in 2018 (P < 0.00001). The overall caesarean section rate was maintained close to 30%. CONCLUSION: In a large tertiary hospital in South India, with 14 000 deliveries per year, a policy of rigorous audits of stillbirths and birth asphyxia, electronic fetal monitoring, and the introduction of standardised criteria for trial of scar, reduced the perinatal mortality and the rate of babies born with birth asphyxia over the past 18 years, without an increase in the caesarean section rate. TWEETABLE ABSTRACT: Rigorous perinatal audits with training in fetal cardiotocography, decreased birth asphyxia, without a major increase in caesarean rates.

The effectiveness of financial intervention strategies for reducing caesarean section rates: a systematic review.

BACKGROUND: The increasing trend of Caesarean section (CS) in childbirth has become a global public health challenge. Previous studies have proposed financial intervention strategies for reducing CS rates by limiting caesarean delivery on maternal request (CDMR). This study synthesizes such strategies while evaluating their effectiveness. METHODS: The sources of data for this study are Cochrane Library, PubMed, EMBASE, and CINAHL. The publication period included in this study is from January 1991 to November 2018. The financial intervention strategies are divide into two categories: healthcare provider interventions and patient interventions. Risk of Bias in Non-randomized Studies - of Interventions (ROBINS-I) was employed to assess the risk of bias of included studies. The outcome of each study was evaluated with Grades of Recommendation, Assessment, Development and Evaluation (GRADE) through the GRADEpro Guideline Development Tool software. RESULTS: Nine studies were included in this systematic review: five with high certainty evidence (HCE), three with moderate certainty evidence (MCE), and one with low certainty evidence (LCE). Of the nine studies, seven are centered on the effect of provider-side interventions. Three of the HCE studies found that the diagnosis-related group payment system, risk-adjusted capitation, and equalizing fee for both facilities and physicians were effective intervention strategies. One HCE and one MCE study showed that only equalizing facility fees between vaginal and CS deliveries in healthcare service settings had no significant effect on reducing the CS rate. The MCE study showed that case payment had a negative effect on reducing the CS rates. One LCE study revealed that the effect of a global budget system was uncertain, and one HCE and one MCE study focused on combining both provider and patient-side interventions. However, equalizing fees for vaginal and CS deliveries and a co-payment policy for CDMRs failed to reduce the CS rate. CONCLUSIONS: The effectiveness of risk-adjusted payment methods appears promising and should be the subject of further research. Financial interventions should consider stakeholders' characteristics, especially the personal interests of doctors. Finally, high-quality randomized control trials and comparative studies on different financial intervention methods are needed to confirm or refute previous studies' outcomes.

Caesarean section rate and cost control effectiveness of case payment reform in the new cooperative medical scheme for delivery: evidence from Xi County, China.

BACKGROUND: In China, increases in both the caesarean section (CS) rates and delivery costs have raised questions regarding the reform of the medical insurance payment system. Case payment is useful for regulating the behaviour of health providers and for controlling the CS rates and excessive increases in medical expenses. New Cooperative Medical Scheme (NCMS) agencies in Xi County in Henan Province piloted a case payment reform (CPR) in delivery for inpatients. We aimed to observe the changes in the CS rates, compare the changes in delivery-related variables, and identify variables related to delivery costs before and after the CPR in Xi County. METHODS: Overall, 28,314 cases were selected from the Xi County NCMS agency from 2009 to 2010 and from 2014 to 2015. One-way ANOVA and chi-square tests were used to compare the distributions of CS and vaginal delivery (VD) before and after the CPR under different indicators. We applied multivariate linear regressions for the total medical cost of the VD and CS groups and total samples to identify the relationships between medical expenses and variables. RESULTS: The CS rates in Xi County increased from 26.1% to 32.5% after the CPR. The length of stay (LOS), total medical cost, and proportion of county hospitals increased in the CS and VD groups after the CPR, which had significant differences. The total medical cost in the CS and VD groups as well as the total samples was significantly influenced by inpatient age, LOS, and hospital type, and had a significant correlation with the CPR in the VD group and the total samples. CONCLUSION: The CPR might fail to control the growth of unreasonable medical expenses and regulate the behaviour of providers, which possibly resulted from the unreasonable compensation standard of case payments, prolonged LOS, and the increasing proportion of county hospitals. The NCMS should modify the case payment standard of delivery to inhibit providers' motivation to render CS services. The LOS should be controlled by implementing clinical guidelines, and a reference system should be established to guide patients in choosing reasonable hospitals.

Association between rates of caesarean section and maternal and neonatal mortality in the 21st century: a worldwide population-based ecological study with longitudinal data.

OBJECTIVE: Caesarean section was initially performed to save the lives of the mother and/or her baby. Caesarean section rates have risen substantially worldwide over the past decades. In this study, we set out to compile all available caesarean section rates worldwide at the country level, and to identify the appropriate caesarean section rate at the population level associated with the minimal maternal and neonatal mortality. DESIGN: Ecological study using longitudinal data. SETTING: Worldwide country-level data. POPULATION: A total of 159 countries were included in the analyses, representing 98.0% of global live births (2005). METHODS: Nationally representative caesarean section rates from 2000 to 2012 were compiled. We assessed the relationship between caesarean section rates and mortality outcomes, adjusting for socio-economic development by means of human development index (HDI) using fractional polynomial regression models. MAIN OUTCOME MEASURES: Maternal mortality ratio and neonatal mortality rate. RESULTS: Most countries have experienced increases in caesarean section rate during the study period. In the unadjusted analysis, there was a negative association between caesarean section rates and mortality outcomes for low caesarean section rates, especially among the least developed countries. After adjusting for HDI, this effect was much smaller and was only observed below a caesarean section rate of 5-10%. No important association between the caesarean section rate and maternal and neonatal mortality was observed when the caesarean section rate exceeded 10%. CONCLUSIONS: Although caesarean section is an effective intervention to save maternal and infant lives, based on the available ecological evidence, caesarean section rates higher than around 10% at the population level are not associated with decreases in maternal and neonatal mortality rates, and thus may not be necessary to achieve the lowest maternal and neonatal mortality. TWEETABLE ABSTRACT: The caesarean section rate of around 10% may be the optimal rate to achieve the lowest mortality.

Study of Caesarean Section Births in a Tertiary Care Hospital in Mumbai Using Robson Classification System.

Introduction: Robson ten-group classification system is recommended by WHO (World health organization) as a global standard for assessment and monitoring caesarean section (CS) rates. This classification is simple and robust. It is prospective, easily reproducible and clinically relevant. Methodology: We conducted a prospective observational study of CS births at a tertiary care institute. Caesarean births in a tertiary care hospital were classified using Robson classification system as recommended by WHO. The study was conducted for period of 6 months duration. The ethics committee of the institute approved this study. We enrolled 4771 consecutive women who delivered during this study period. We included patients who had vaginal delivery as well as those who had delivery by CS. Both live births and stillbirths (of at least 500-g birth weight or at least 22 weeks gestation (according to WHO recommendations) were included in this study. Results: During this study period, we had 4771 deliveries, out of which 2231 pregnant women (46.76%) were delivered by CS as compared to 2540 vaginal deliveries. Women with previous CS (term with single cephalic pregnancy) were included in Robson group 5. Group 5 had the highest CS rate (13.41%). Robson group 5, 1 and 10 were the largest contributors to the high CS rates at our institute. Conclusion: In our study, 4771 deliveries were conducted during this study period (6 months). Out of 4771 deliveries, CS was done in 2231 pregnant women (46.76%). 2540 women had vaginal deliveries. Group 5 (13.41%) which comprised of women with previous CS had the highest CS rate followed by group 1 and group 10. The second largest contribution was from Group 1 with CS rate of 9.01%. Robson Group 1 included nulliparous term women with single cephalic pregnancy in spontaneous labour. Group 10 was the third largest contributor to the overall CS. Group 10 included women who delivered preterm (single cephalic presentation). Group 10 contributed to 8.09% of overall CS rate. We should make every effort to provide CS for women requiring this procedure, rather than work towards achieving a specific rate for CS.

Feto-maternal outcomes of caesarean delivery in Federal Medical Centre, Asaba: a two year review.

Background: The upward trend of caesarean section and its associated morbidity/mortality especially in low and middle income areas makes regular appraisal of the procedure necessary. Objective: To evaluate caesarean section; its rate, indications, and maternal and fetal outcomes in Asaba. Methods: A retrospective study of all caesarean sections carried out at the obstetrics unit of the Federal Medical Centre, Asaba, between July 1, 2018 and June 31, 2020. Data was analyzed using SPSS version 20. Results: There were 2778 deliveries during the period, out of which 705 had caesarean sections, giving an overall caesarean section rate of 25.4%.There were 456 (64.7%) emergency caesarean sections. The commonest indication for caesarean section was repeat caesarean section 196 (27.8%), while cephalo-pelvic disproportion 87 (12.3%) was the commonest indication for emergency caesarean section. Majority of the babies had low APGAR score at 1min and 5mins, 126 (27.6%) and 50 (11.0%) from emergency than elective caesarean section 16 (6.4%) and 5 (2.0%) at 1min and 5mins respectively (x2=17.963, P<0.001). There were 31 (4.2%) perinatal deaths out of which majority 28 (6.1%) were from emergency caesarean sections (x2=9.412 P=0.002). The commonest post-operative complication was postpartum anaemia (140 (19.9%) while caesarean section case fatality was 0.6%. Conclusion: This study showed a caesarean section rate of 25.4% with repeat caesarean section and Cephalopelvic disproportion being the most common indication for elective and emergency caesarean section respectively. Emergency caesarean section accounted for most of the cases and is associated with a higher risk of maternal and perinatal morbidity and mortality.

Promotion of Pre-natal Education Courses Is Associated With Reducing the Rates of Caesarean Section: A Case-Control Study.

Objective: The number of women having a caesarean section has significantly increased worldwide, in particular in China. Maternal requestion makes a moderate contribution to this increased rate in China. Reducing the caesarean section rate is now becoming a big challenge to midwives and obstetricians as well as health policymakers in China. Our recent survey found that pre-natal education course had some positive effects on the reduction of caesarean section on maternal request. However, pre-natal education course is relatively new in China. In this study, we investigated whether pre-natal education course influences delivery mode in the largest tertiary women's hospital in China. Methods: In this retrospective study, during the study period, 644 pregnant women attended a pre-natal education course and 4,134 pregnant women did not. Data on maternal age, parity, gravida, delivery mode, delivery weeks, birthweight, gestational age at attending pre-natal education course and maternal body mass index before pregnancy were collected and analysed. Results: The numbers of women who attempted vaginal delivery were significantly higher in women who attended a pre-natal education course, compared to women who did not (87 vs. 60%). In addition, the rate of caesarean section on maternal request was 23% in women who attended a pre-natal education course. Conclusion: Attendance of a pre-natal education course influences the mode of delivery and reduces the unnecessary caesarean section in China. Our findings suggest that the promotion of pre-natal education courses is important to reduce the higher caesarean section rate in China, by midwives or obstetricians or health policy-makers as part of China's strategy.

A Quasi-Experimental Study to Compare the Effect of Respectful Maternity Care Using Intrapartum Birth Companion of Her Choice on Maternal and Newborn Outcome in Tertiary Care Centre.

PURPOSE OF THE STUDY: Traditionally during labour woman is supported by another woman. However, in hospitals, continuous support during labour has often become the exception rather than the routine. Worldwide, there is a growing concern about the disrespect and abuse of women seeking maternity care. This prompted us to decide to change the obstetric care practices by providing a birth companion of her choice to women during labour and compare their maternal and newborn outcomes with the data from the same institute before intervention. METHODS: This was a quasi-experimental study conducted in the Department of OBGY, GMCH, Aurangabad for 20 months and compared with the previous data from the same institute before implementation of the birth companion policy. The impact of this intervention was evaluated by caesarean section rate, episiotomy rates and admission to neonatal intensive care units, and data was analysed by an appropriate statistical test. RESULTS: The rate of caesarean Section (20%) and episiotomy (8.57%) was significantly lower in the intervention group than in the control group. The rate of NICU admission and time required for initiation of breastfeeding was significantly lower in the intervention than in the control group. Around 86.6% of women from the intervention group were fully satisfied with the role of birth companion and 13.4% were partially satisfied. CONCLUSION: Our study demonstrated that the use of an intrapartum birth companion of her choice helped us improve maternal and newborn outcomes without any harm. We recommend generalizing the policy of use of the trained birth companion of her choice in the private as well as the public sector.

Cesarean rate in selected hospital network of private sector: A retrospective study.

INTRODUCTION: In Spain over the last two decades, cesarean section (CS) rates have increased from 15 to 25% in the Public Health Sector and from 28 to 38% in the private sector. There are multiples causes for this rise, which are often unclear. The aim of our study is to collect and analyze all the CS rates data from a hospital network of the 42 Quirónsalud Hospitals (private sector) and to assess its distribution regarding the different types of hospitals and patient characteristics. MATERIAL AND METHODS: An observational retrospective study between 2017 and 2018 was performed. Hospitals are classified into three groups: large hospitals (11), medium hospitals (17) and small hospitals (14). The cesarean section rate was measured by patient categorization into three groups: total deliveries, low risk cesarean sections and low risk cesarean sections without previous cesarean delivery. RESULTS: We analyzed 62,685 deliveries: 42,987 were vaginal deliveries (68.6%) and 19,698 CS (31.4%). The mean age for the total number of deliveries was 34.18 years old, whilst the mean age for the low-risk group was 34.12. Of the 19,698 CS, 18.36% (3618) were in high-risk population and 81.63% (16,080) in low risk population. 69.54% (11,183) of the low-risk CS were in patients without a previous CS. CONCLUSIONS: The overall rate of CS in the Quirónsalud group is slightly higher than the one from the Public Healthcare. The older maternal age as well as the hospital resources involved in the delivery attendance can explain this difference.

Analysis of the caesarean section rate using the 10-Group Robson classification at Benha University Hospital, Egypt.

BACKGROUND: Egypt has the third highest caesarean section rate (54%) in the world and lacks a standard classification system to analyse caesarean section rates. The World Health Organization (WHO) recommends the Robson classification as an effective caesarean section analysis and monitoring tool. AIM: To analyse the caesarean section rate of Benha University Hospital, Egypt using the standard 10-Group Robson classification system. METHOD: A prospective, cross-sectional study was conducted at the Benha University Hospital from 1 April to 30 June 2018. All women admitted for childbirth were categorised into Robson groups to determine the absolute and relative contribution made by each group to the overall caesarean section rate. Epi Data V.3.1 software programme was used to analyse the data. FINDINGS: 850 women gave birth during the study period, 466 (55%) by caesarean section (CS). Robson Group 5 (multiparous, term, cephalic presentation and previous caesarean section) contributed the most (36%) to the overall CS rate. 175/308 (56%) women in this group had previously undergone one caesarean section. Group 6 (all nulliparous women with single breech pregnancy) and Group10 (cephalic preterm pregnancies) were the second and the third greatest contributors toward the overall CS rate, with 4.6% and 2.8% respectively. CONCLUSIONS: In keeping with other studies, Groups 5, 6, and 10 were the main contributors to the overall caesarean section rate. We found Robson classification to be clinically relevant and an effective tool to analyse the caesarean section rate even in settings with limited resources.

Prostaglandin E2 induction of labor and cervical ripening for term isolated oligohydramnios in pregnant women with Bishop score ≤ 5.

BACKGROUND: We aimed to evaluate the efficacy and safety of dinoprostone for cervical ripening and labor induction in patients with term oligohydramnios and Bishop score ≤ 5. METHODS: This was a prospective case-control study, which included 104 consecutive women with a Bishop score≤5. Participants were divided into two groups. Women with term isolated oligohydramnios and Bishop score≤5 underwent induction of labor with a vaginal insert containing 10-mg timed-release dinoprostone (prostaglandin E2; Group A, n=40). The control group, Group B, consisted of 64 cases of pregnancy with normal amniotic fluid volume (amniotic fluid index≥5 cm) and Bishop score≤5, and was matched for patient's age and parity. The primary outcome was time from induction to delivery; the secondary outcomes were the caesarean section (CS) rate, uterine hyperstimulation, rate of failed induction, and neonatal complications. RESULTS: The mean time interval from induction to delivery was not different between the two groups (p=0.849), but there was a statistically significant difference between the groups in terms of the CS rate (p=0.005). There were no differences between the groups in neonatal outcome or perinatal morbidity or mortality. CONCLUSION: Dinoprostone appears to be a safe alternative for induction of labor in pregnancies with oligohydramnios. Induction of labor with dinoprostone in term pregnancies with isolated oligohydramnios is associated with increased rate of CS but there is no higher risk of perinatal complications.

Foley catheter for induction of labour filled with 30mL or 60mL: A randomized controlled trial.

OBJECTIVES: One of the methods used to induce labour is the placement of a transcervical Foley catheter (FC). The aim of this randomized controlled study was to assess in term pregnant women with an unfavourable cervix, whether there is a difference in efficacy between the two most commonly used insufflation volumes of FC (30mL and 60mL). STUDY DESIGN: Randomized controlled trial. RESULTS: Women were randomized to induction of labour with a Foley catheter filled with 30mL or with 60mL. Primary outcome was delivery within eight hours after amniotomy. Secondary outcomes included the time interval between placement of the Foley and amniotomy, the mode of delivery, complications and neonatal outcomes. In total, 174 women (87 in each arm) were randomized. The number of deliveries within eight hours after amniotomy was not significantly different between the two groups (40.7% versus 48.83%, OR=0.71(CI; 0.39-1.3)). Sub-analysis showed that more multiparous women in the 60mL group delivered within eight hours (93.10% versus 65.22%, OR=7.2 (CI; 1.35-38.37)). For the nulliparous, the 30mL Foley catheter was associated with a higher caesarean section rate (31.75% versus 15.52% (OR 2.53; CI; 1.1-6.2)). The 60mL Foley catheter was also associated with a higher chance of spontaneous labour after placement (OR 2.35; CI; 1.1-5.1), a shorter time interval for cervical ripening (OR=4.5; CI: 1.2-16.7) and less blood loss. (p=0.002). The Foley catheter ruptured twelve times in the 60mL group whereas this did not happen once in the 30mL group. One case of umbilical cord prolapse was observed in the 60mL group. No differences in neonatal outcomes and patient satisfaction were seen. CONCLUSIONS: For our primary outcome, no difference was observed between the Foley catheter balloon filled with 60mL and the one filled with 30mL. Yet, a Foley catheter filled with 60mL was associated in multiparous women with a higher rate of deliveries within eight hours after amniotomy and in nulliparous with a significantly lower caesarean section rate. These latest findings should be interpreted with cautious as underpowered.

The effect of the use of a new type of partogram on the cesarean section rates.

OBJECTIVE: To assess the contribution of a new type of partogram, used in labor monitoring, in caesarean section rates. MATERIAL AND METHODS: The study included term singleton uncomplicated pregnancies divided into two groups. Two types of partogram were used in labor monitoring. In the first group, the classical WHO partogram (A) was used. In the second group, a new type of partogram, in which cervical dilatation and the position of descending head (B) (one line) were estimated and reported, was used. The labor duration and caesarean section rates were calculated and compared in the two groups. RESULTS: A statistically significant decrease in labor duration (from the initiation of the active phase of labor to the delivery time) (dt1+dt2+dt3) (p<0.001, A: median: 318.4±10.4 min, B: 246.56±8.28 min) and in caesarean section rates was noted (p<0.001, A: 89 vs B: 49). CONCLUSION: The new type of partogram seems to have potential benefits such as reducing the incidence of prolonged labor and decreasing the caesarean section rates.