Racial disparities in low-risk cesarean birth rates across hospitals.

BACKGROUND: We compared low-risk cesarean birth rates for Black and White women across hospitals serving increasing proportions of Black women and identified hospitals where Black women had low-risk cesarean rates less than or equal to White women. METHODS: In this cross-sectional analysis of secondary data from four states, we categorized hospitals by their proportion of Black women giving birth from "low" to "high". We analyzed the odds of low-risk cesarean for Black and White women across hospital categories. RESULTS: Our sample comprised 493 hospitals and the 65,524 Black and 251,426 White women at low risk for cesarean who birthed in them. The mean low-risk cesarean rate was significantly higher for Black, compared with White, women in the low (20.1% vs. 15.9%) and medium (18.1% vs. 16.9%) hospital categories. In regression models, no hospital structural characteristics were significantly associated with the odds of a Black woman having a low-risk cesarean. For White women, birthing in a hospital serving the highest proportion of Black women was associated with a 21% (95% CI: 1.01-1.44) increase in the odds of having a low-risk cesarean. DISCUSSION: Black women had higher odds of a low-risk cesarean than White women and were more likely to access care in hospitals with higher low-risk cesarean rates. The existence of hospitals where low-risk cesarean rates for Black women were less than or equal to those of White women was notable, given a predominant focus on hospitals where Black women have poorer outcomes. Efforts to decrease the low-risk cesarean rate should focus on (1) improving intrapartum care for Black women and (2) identifying differentiating organizational factors in hospitals where cesarean birth rates are optimally low and equivalent among racial groups as a basis for system-level policy efforts to improve equity and reduce cesarean birth rates.

Is Birth Method Associated with Sensory Hyperreactivity in Children 3-4 Years in an Upper-Middle-Income Country?

Background: Research has shown that pressure in the vaginal birth process aids the infant's neurophysiological adaption to extrauterine life, including their ability to regulate their responses to diverse sensory stimuli. As pressure is absent in elective caesarean section births, we hypothesised that these children may be at higher risk for developing sensory hyperreactivity (SHR), a sensory modulation difficulty which negatively impacts on the child's engagement in their occupations. This paper reports on a study which investigated associations between birth method and SHR. Method: In this cross-sectional study, 91 children aged three and four years from various language, cultural, and socioeconomic groups were recruited and categorised based on birth method (caesarean section or vaginal birth). Caregivers of each child completed the Short Sensory Profile-2 and a demographic questionnaire. The prevalence of SHR between the birth method groups was compared. Results: The prevalence of SHR was greater in the vaginal birth group (29%) than the caesarean section group (9%). Mothers in the vaginal birth group were younger (p ≤ 0.001), of lower-income level (p = 0.003), and more likely to be single (p = 0.037). During data collection with the vaginal birth group, comprehensibility of certain items in the Short Sensory Profile-2 proved challenging for many caregivers. Conclusion: The statistically significant higher prevalence of SHR in the vaginal birth group supported a null hypothesis. However, the results are questioned due to the challenges related to data collection. Given this, the study supports the need for further investigation of how sociocultural and socioeconomic factors influence the assessment of SHR in the South African context.

Stress Response Assessment between First and Second Elective Caesarean Sections by Comparing Cortisol Levels.

OBJECTIVES: The aim of this study was to compare the stress response produced during elective CS for the first and second time. For that goal, cortisol blood levels before, during and after childbirth were measured. MATERIALS AND METHODS: We performed this prospective observational study during the period of September 2020 to September 2021. Blood samples were taken from all participants at three different stages. A statistical analysis was performed to compare the CS1 (first elective Caesarean) and CS2 (second elective Caesarean) groups. RESULTS: At every stage, the levels of cortisol were statistically higher in the CS1 group than in the CS2 group. Therefore, CS2 generates a significantly less stressful response than CS1. Between stages, in CS2 cortisol was lowered at a faster rate than in CS1, meaning the stress response initiated was present for a longer time period in the CS1 group. CONCLUSION: A second elective caesarean section is a safe procedure that does not place an unnecessary burden upon the mother. This is an important fact that practitioners can rely upon while designing the ideal management of a pregnant woman for the stressful environment of birth.

Topics in the routine assessment of newborn kitten vitality: Apgar score, reflexes and complementary assessments.

OBJECTIVES: The aim of this study was to perform neonatal clinical assessments at birth to identify newborn kittens at risk according to type of delivery, thus allowing immediate intervention and increasing their chances of survival. METHODS: This study compared Apgar scores, reflexes and clinical parameters (temperature, weight, blood glucose and peripheral oxygen saturation [SpO2]) between eutocic neonates and those delivered by emergency cesarean section. The animals were evaluated at birth and after 10 and 60 mins. RESULTS: Thirty-two neonates were evaluated, with 19 animals in the eutocic group (EG) and 13 animals in the cesarean group (CG). When comparing groups, CG neonates had significantly lower Apgar scores (P <0.0001), lower SpO2 (P = 0.0535), higher blood glucose (P = 0.0009), reduced reflexes (P <0.0001) and lower respiratory rates (P <0.0001) at birth and after 10 and 60 mins than EG neonates. Apgar scores positively correlated with parameters such as heart rate, reflex score, SpO2 and weight. The mortality rate in evaluated newborns was 15.6% (5/32). The early mortality rate (0-2 days old) was 80% (4/5) and the late mortality rate (3-30 days old) was 20% (1/5). CONCLUSIONS AND RELEVANCE: This study showed lower vitality in cats delivered by emergency cesarean section than in those delivered through eutocic birth. In general, neonates delivered by cesarean section have greater depression and low vitality at birth and may require advanced resuscitation procedures. The evaluations carried out in this study identified newborns with low vitality and those requiring advanced resuscitation, thus allowing immediate intervention. Apgar and reflex scores for feline neonates were suggested. Newborn-specific clinical assessment with these feline vitality scores allows the identification of at-risk neonates. Care immediately after birth increases the chance of survival among these patients.

A national Israeli survey of neuraxial anesthesia for cesarean delivery: pre-operative block assessment and intra-operative pain management.

BACKGROUND: Neuraxial protocols for cesarean delivery differ among institutions, with various means of assessing the block prior to incision and managing breakthrough intra-operative pain. The different approaches used to deal with these issues in Israel have not been assessed. METHODS: Questionnaires were distributed to all anesthesiologists working in obstetric units in Israeli hospitals. The survey included several non-identifying respondent details intended to allow a description of the study population as a whole and multiple-choice questions addressing neuraxial techniques, method of pre-operative block assessment and medications used to treat intra-operative pain. RESULTS: Three hundred and sixty-one doctors completed the survey in 24 medical centers, an 81.1% response rate. Thirteen different protocols for spinal anesthesia and 20 different protocols for epidural anesthesia were described. Nine different protocols for assessment of the block prior to incision were identified, with significant inter-institutional differences (P <0.001). For treatment of intra-operative pain prior to delivery, 35.7% of spinals given and 40% of epidurals given were converted to general anesthesia whereas, after delivery, conversion of spinal to general anesthesia was 18% and epidural to general anesthesia was 18.6%. CONCLUSIONS: There were a variety of spinal and epidural regimens used as well as different methods for assessing the block and managing intra-operative pain. Further studies should be performed to identify optimal techniques for neuraxial anesthesia for pre-operative block assessment and for management of intra-operative pain.

The clinical evaluation of IIA balloon occlusion in caesarean delivery for patients with PAS: a retrospective study.

OBJECTIVE: The aim of this study is the clinical evaluation of IIA balloon occlusion in the caesarean delivery in patients with a diagnosis of placenta accreta spectrum. BACKGROUND: High incidence of cesarean section leads to the increasing incidence of placenta accreta spectrum (PAS), which contributes to serious consequences such as severe obstetric postpartum hemorrhage or even maternal mortality. METHODS: Fifty-eight patients with a diagnosis of PAS were retrospectively reviewed. The balloon group consisted of 23 patients, who underwent a caesarean delivery with internal iliac artery occlusion. 35 patients were in the control group, who had a standard caesarean delivery. The primary outcomes were estimated blood loss (EBL). The secondary outcomes were cesarean hysterectomy, blood transferring volume, operating time, intraoperative hemostatic approaches, surgical complications, balloon catheter-related complications, length of maternal stay, cost of hospitalization, and neonatal outcomes. RESULTS: No difference was observed in estimated blood loss (EBL), blood transferring percentages and volume, additional measures to secure hemostasis, surgical complications, hospital stay postoperatively and newborn outcomes. More than 40% of the balloon group underwent hysterectomy because of uncontrollable postpartum bleeding (10 [43.48%] vs. 11 [31.43%], P=0.350). Complications related to occlusion of IIA did not occur. The duration of the surgery of the balloon group was significantly longer than that of the control group (123.52 min±74.76 versus 89.17±48.68, P=0.038), and the total hospitalization cost was also significantly higher than that of the control group (45116.67±9358.67 yuan versus 30615.41±11587.44 yuan, P=0.000). CONCLUSION: It does not permit to draw final conclusions for us on the effectiveness of the balloons IIA given the heterogeneity of selection of cases undergoing the procedures in the retrospective design. However, it is possible that IIA balloon occlusion may contribute to limiting intraoperative blood loss in more severe cases, particularly those undergoing peripartum hysterectomy.

Infrared thermographic assessment of spinal anaesthesia-related cutaneous temperature changes during caesarean section.

INTRODUCTION: Assessment of adequacy of spinal anaesthesia, prior to obstetric surgery is extremely important but can be problematic because currently available clinical assessment methods are indirect and subjective. As the sympathectomy associated with spinal anaesthesia is known to cause vasodilation and heat redistribution, we sought to assess whether spinal anaesthesia led to significant and consistent cutaneous temperature changes as measured by infrared thermography. METHODS: Following ethics committee approval, this observational study was conducted in a tertiary level obstetric centre. Participants included women undergoing elective caesarean section under spinal anaesthesia. Following consent, a Flir T540 infrared camera captured thermographic images over the feet, patella, buttock, iliac crests, xiphisternum and axilla. Temperature was measured prior to spinal needle insertion (T0) and following clinical assessment when the block was deemed adequate. RESULTS: Thirty patients were included. Baseline temperature varied considerable by site. Spinal anaesthesia altered skin temperature in all areas of interest: right and left hallux (mean of differences (MD) +4.0°C and 5.2°C respectively, P <0.0001), right and left plantar (MD +6.1°C and 6.8°C respectively, P <0.0001), patella (MD -0.33°C, P=0.0445), buttock (MD -0.5°C, P=0.009), iliac crest (MD -0.7°C, P=0.0004), xiphisternum (MD -0.95°C, P <0.0001) and axilla (MD -0.71°C, P=0.0002). CONCLUSIONS: Following spinal anaesthesia thermographic imaging identified different patterns of skin temperature changes, with pronounced temperature increases measured in the feet and cooling of a lesser amplitude in the thoracic and lumbar dermatomes. Infrared thermography has the potential to provide objective measurement of sympathectomy.

Effect of prophylactic balloon occlusion of internal iliac artery in pregnancies complicated by placenta previa and accreta.

BACKGROUND: Placenta previa and accreta are serious obstetric conditions that are associated with a high risk of intraoperative massive hemorrhage, the prophylactic intravascular balloon occlusion technique is increasingly used in managing uncontrolled hemorrhage in cesarean section (CS). We aim to examine the clinical effectiveness of prophylactic balloon occlusion of the internal iliac artery (PBOIIA) during CS in improving maternal outcomes for patients with placenta previa and accreta. METHODS: A total of 420 women with placenta previa and accreta who underwent CS from January 2014 to December 2018 were included retrospectively. Patients were divided into balloon group in which patients had PBOIIA (n = 248) and the control group in which patients did not have PBOIIA (n = 172). Meanwhile, we performed a subgroup analysis in whether taking parallel transverse uterine incision (PTUI) surgery. Information on conditions of patients and newborns, perioperative blood indicators, surgical outcomes were collected. RESULTS: Median estimated blood loss (mEBL) was 2200 mL in the balloon group and 2150 mL in the control group respectively, there was no significant difference between two-groups comparison (P > 0.05), and the rate of patients with hysterectomy was also has no difference between the two groups (36.3% verus 35.5%, P > 0.05), while there is a significant difference between two groups in the amount of PRBCs transfused [3 (0-31.5) verus 3 (0-39), P <0.05], moreover, the proportion of PRBCS> 8 units in the balloon group is significantly lower than that in control group (11.29% verus 23.26%, P <0.05).. However, the total hospitalization costs (45,624.4 ± 11,061.9 verus 37,523.1 ± 14,662.2, CYN) and surgery costs (19,910.6 ± 2622.6 verus 11,850.5 ± 3146.1, CYN) in balloon group were significantly higher than those in control group (P < 0.05). Subgroup analysis showed PTUI surgery had no significant differences in EBL (P >0.05), but it could significantly decrease hysterectomy rates (P <0.05). CONCLUSIONS: PBOIIA has no significant effect on reducing intraoperative EBL and hysterectomy rate in patients with placenta previa and accreta. and although it could reduce the intraoperative PRBCs in patients with massive hemorrhage, it significantly increases the financial cost for patients. Therefore, PBOIIA should not be routinely recommended to patients with placenta previa and accreta.

Multi-Institutional Practice-Patterns in Fetal Congenital Heart Disease Following Implementation of a Standardized Clinical Assessment and Management Plan.

Background Prenatal diagnosis of congenital heart disease has been associated with early-term delivery and cesarean delivery (CD). We implemented a multi-institutional standardized clinical assessment and management plan (SCAMP) through the University of California Fetal-Maternal Consortium. Our objective was to decrease early-term (37-39 weeks) delivery and CD in pregnancies complicated by fetal congenital heart disease using a SCAMP methodology to improve practice in a high-risk and clinically complex setting. Methods and Results University of California Fetal-Maternal Consortium site-specific management decisions were queried following SCAMP implementation. This contemporary intervention group was compared with a University of California Fetal-Maternal Consortium historical cohort. Primary outcomes were early-term delivery and CD. A total of 496 maternal-fetal dyads with prenatally diagnosed congenital heart disease were identified, 185 and 311 in the historical and intervention cohorts, respectively. Recommendation for later delivery resulted in a later gestational age at delivery (38.9 versus 38.1 weeks, P=0.01). After adjusting for maternal age and site, historical controls were more likely to have a CD (odds ratio [OR],1.8; 95% CI, 2.1-2.8; P=0.004) and more likely (OR, 2.1; 95% CI, 1.4-3.3) to have an early-term delivery than the intervention group. Vaginal delivery was recommended in 77% of the cohort, resulting in 61% vaginal deliveries versus 50% in the control cohort (P=0.03). Among pregnancies with major cardiac lesions (n=373), vaginal birth increased from 51% to 64% (P=0.008) and deliveries ≥39 weeks increased from 33% to 48% (P=0.004). Conclusions Implementation of a SCAMP decreased the rate of early-term deliveries and CD for prenatal congenital heart disease. Development of clinical pathways may help standardize care, decrease maternal risk secondary to CD, improve neonatal outcomes, and reduce healthcare costs.

Single-center task analysis and user-centered assessment of physical space impacts on emergency Cesarean delivery.

OBJECTIVE: This study aimed to begin to address this gap using validated techniques in human factors to perform a participatory user-centered analysis of physical space during emergency Cesarean. METHODS: This study employed a mixed-methods design. Focus group interviews and surveys were administered to a convenience sample (n = 34) of multidisciplinary obstetric teams. Data collected from focus group interviews were used to perform a task and equipment analysis. Survey data were coded and mapped by specialty to identify reported areas of congestion and time spent, and to identify themes related to physical space of the OR and labor and delivery unit. RESULTS: Task analysis revealed complex interdependencies between specialties. Thirty task groupings requiring over 20 pieces of equipment were identified. Perceived areas of congestion and areas of time spent in the OR varied by clinical specialty. The following categories emerged as main challenges encountered during an emergency Cesarean: 1) size of physical space and equipment, 2) layout and orientation, and 3) patient transport. CONCLUSION: User insights on physical space and workflow processes during emergency Cesarean section at the institution studied revealed challenges related to getting the patients into the OR expediently and having space to perform tasks without crowding or staff injury. By utilizing human factors techniques, other institutions may build upon our findings to improve safety during emergency situations on labor and delivery.

The impact of opportunistic salpingectomy on ovarian cancer mortality and healthcare costs: a call for universal insurance coverage.

BACKGROUND: Opportunistic salpingectomy at the time of hysterectomy or as an alternative to bilateral tubal ligation may reduce the incidence of ovarian cancer, because it has been demonstrated that most serous ovarian cancers begin in the fallopian tubes. However, salpingectomy at the time of sterilization is not always financially covered by third-party payers, and this represents a barrier to adoption. Routine salpingectomy has become more common but is not always practiced at the time of hysterectomy. OBJECTIVE: This study aimed to determine the impact of opportunistic salpingectomy as an alternative tubal ligation and routine salpingectomy at the time of hysterectomy on ovarian cancer mortality and overall cost. STUDY DESIGN: An 8-state Markov state transition model was constructed, including hysterectomy, tubal ligation, and ovarian cancer. Transition probabilities were informed by previously reported population data and include age-adjusted rates of elective sterilization and hysterectomy. This model was used to predict ovarian cancer incidence and the cost effectiveness of opportunistic salpingectomy. Testing of this model suggested that it accurately predicted overall life expectancy and closely predicted the rate of hysterectomy in the population. The model may underestimate the rate of tubal sterilization, making it conservative with respect to the benefits of salpingectomy. RESULTS: The recursive Markov model was run from ages 20 to 85 years in 1-year intervals with a half step correction and included age-adjusted rates of tubal ligation, hysterectomy (with and without oophorectomy), and ovarian cancer. The model predicts that opportunistic salpingectomy at the time of tubal ligation will reduce ovarian cancer mortality by 8.13%. Opportunistic salpingectomy at the time of hysterectomy will reduce ovarian cancer mortality by 6.34% for a combined decrease of 14.5%. Both strategies are cost effective when considering only the cost of the opportunistic salpingectomy. The excess cost of opportunistic salpingectomy at the time of tubal ligation was $433.91 with an incremental cost-effective ratio of $6401 per life-year and $5469 per quality-adjusted life year gained when adjusting for ovarian cancer with a utility of 0.64. The incremental cost-effective ratio for opportunistic salpingectomy during hysterectomy at a cost of $124.70 was $2006 per life-year and $1667 per quality-adjusted life year. When considering the impact of ovarian cancer prevention with respect to the cost of ovarian cancer treatment, opportunistic salpingectomy may produce a substantial healthcare savings. Utilizing a 3% discount rate, it is estimated that the total savings for universal salpingectomy could be as high as $445 million annually in the United States. A sensitivity analysis around the benefit of opportunistic salpingectomy suggests that this procedure will be cost effective even if salpingectomy provides only a modest reduction in the risk of ovarian cancer. CONCLUSION: It is estimated that universal opportunistic salpingectomy may prevent 1854 deaths per year from ovarian cancer and may reduce healthcare costs. Given these data, universal opportunistic salpingectomy should be considered at the time of tubal ligation and hysterectomy and covered by third-party payers.

Value-based care in obstetrics: comparison between vaginal birth and caesarean section.

BACKGROUND: Healthcare costs have substantially increased in recent years, threatening the population health. Obstetric care is a significant contributor to this scenario since it represents 20% of healthcare. The rate of cesarean sections (C-sections) has escalated worldwide. Evidence shows that cesarean delivery is not only more expensive, but it is also linked to poorer maternal and neonatal outcomes. This study assesses which type of delivery is associated with a higher healthcare value in low-risk pregnancies. RESULTS: A total of 9345 deliveries were analyzed. The C-section group had significantly worse rates of breastfeeding in the first hour after delivery (92.57% vs 88.43%, p < 0.001), a higher rate of intensive unit care (ICU) admission both for the mother and the newborn (0.8% vs 0.3%, p = 0.001; 6.7% vs 4.5%, p = 0.0078 respectively), and a higher average cost of hospitalization (BRL14,342.04 vs BRL12,230.03 considering mothers and babies). CONCLUSION: Cesarean deliveries in low-risk pregnancies were associated with a lower value delivery because in addition to being more expensive, they had worse perinatal outcomes.

Indications and outcomes of emergency obstetric hysterectomy; a 5-year review at the Bafoussam Regional Hospital, Cameroon.

BACKGROUND: Emergency Obstetric Hysterectomy (EOH) is removal of the uterus due to life threatening conditions within the puerperium. This life saving intervention is associated with life threatening complications. In our setting, little is known on EOH. OBJECTIVES: To determine the prevalence, indications and outcomes of emergency obstetric hysterectomy while comparing both postpartum hysterectomy and caesarean hysterectomy. METHODS: A 5-year hospital-based retrospective cohort study involving medical records of patients who underwent emergency obstetric hysterectomies between 1st January 2015 and 31st December 2019, was carried out at the Bafoussam Regional Hospital (BRH) from 1st February 2020 to 30th April 2020. Cases were classified as caesarean hysterectomy (CH) or postpartum hysterectomy (PH). Epidemiological data, indications, and complications of EOH were collected and analyzed in EPI-INFO 7.2.2.1. The chi-squared test was used to compare the two groups, and bivariate analysis was used to identify indicators of adverse outcomes of EOH. Statistical significance was set at p < 0.05. RESULTS: There were 30 cases of emergency obstetric hysterectomy (24 caesarean hysterectomies and 6 postpartum hysterectomies), giving a prevalence rate of 3.75 per 1000 deliveries. The most common indication for CH, was intractable postpartum haemorrhage and uterine rupture (33.33% each), while abnormal placentation (50%) was commonly indicated for PH. Anaemia (both groups) (p = 0.013) and sepsis (PH group only, 33.33%) (p = 0.03) were the most statistically significant complications of EOH respectively. Absence of blood transfusion prior to surgery (p = 0.013) and prolonged surgery lasting 2 or more hours (p = 0.04), were significantly associated with a negative clinical outcome. CONCLUSION: The prevalence of EOH is high. There were no differences in the sociodemographic profile, risk factors and indications of both groups. PH group was more likely to develop sepsis as complication. Lack of blood transfusion prior to surgery and prolonged surgeries were significantly associated to complication. Meticulous care and timely recognition of negative prognostic factors of delivery as well as those of EOH will help improve maternal outcomes of pregnancy.

Two- and three-dimensional transvaginal ultrasound in assessment of the impact of selected obstetric risk factors on cesarean scar niche formation: the case-controlled study.

OBJECTIVES: Incomplete healing of the uterine scar after cesarean section may result in formation of a niche. The aim of this study is to identify the potential risk factors for the improper uterine healing after cesarean section in women with single layer, full thickness uterine closure with the use of two- and three-dimensional transvaginal ultrasonography. MATERIAL AND METHODS: 204 women with a history of at least one low transverse cesarean section (CS) with a single layer uterine closure participated in the study. Residual myometrial thickness (RMT), adjacent myometrial thickness (AMT), width (W), depth (D) and volume of the niche, RMT/AMT, RMT/D, RMT/W ratio and clinical characteristics were analyzed. RESULTS: A niche after cesarean section was found in 153 cases. However only five patients had a RMT < 2.2 mm, and 35 had an RMT/AMT ratio ≤ 0.5. The RMT and RMT/AMT ratio among women who had undergone more than one cesarean section was lower than among women who underwent the first cesarean section. No statistically significant relationship was found between the incidence of niche, its parameters and cervical dilation, uterine contractions, cesarean section in the second stage of labor, type of uterus incision expansion and flexion, operator's experience. CONCLUSION: Healing of the uterine cesarean section scar in women with single-layer continuous suture covering the entire thickness of the myometrium, excluding the decidua is not affected by the mode of caesarean section, type of uterine incision expansion and flexion, operator's experience, stage of labor at the time of caesarean section.

Maternal near miss among women admitted in major private hospitals in eastern Ethiopia: a retrospective study.

BACKGROUND: Since maternal mortality is a rare event, maternal near miss has been used as a proxy indicator for measuring maternal health. Maternal near miss (MNM) refers to a woman who nearly died but survived of complications during pregnancy, childbirth or within 42 days of termination of pregnancy. Although study of MNM in Ethiopia is becoming common, it is limited to public facilities leaving private facilities aside. The objective of this study was to assess MNM among women admitted in major private hospitals in eastern Ethiopia. METHODS: An institution based retrospective study was conducted from March 05 to 31, 2020 in two major private hospitals in Harar and Dire Dawa, eastern Ethiopia. The records of all women who were admitted during pregnancy, delivery or within 42 days of termination of pregnancy was reviewed for the presence of MNM criteria as per the sub-Saharan African MNM criteria. Descriptive analysis was done by computing proportion, ratio and means. Factors associated with MNM were assessed using binary logistic regression with adjusted odds ratio (aOR) along with its 95% confidence interval (CI). RESULTS: Of 1214 pregnant or postpartum women receiving care between January 09, 2019 and February 08, 2020, 111 women developed life-threatening conditions: 108 MNM and 3 maternal deaths. In the same period, 1173 live births were registered, resulting in an MNM ratio of 92.1 per 1000 live births. Anemia in the index pregnancy (aOR: 5.03; 95%CI: 3.12-8.13), having chronic hypertension (aOR: 3.13; 95% CI: 1.57-6.26), no antenatal care (aOR: 3.04; 95% CI: 1.58-5.83), being > 35 years old (aOR: 2.29; 95%CI: 1.22-4.29), and previous cesarean section (aOR: 4.48; 95% CI: 2.67-7.53) were significantly associated with MNM. CONCLUSIONS: Close to a tenth of women admitted to major private hospitals in eastern Ethiopia developed MNM. Women with anemia, history of cesarean section, and old age should be prioritized for preventing and managing MNM. Strengthening antenatal care and early screening of chronic conditions including hypertension is essential for preventing MNM.

Rationalisation of the caesarean section rate in a tertiary referral hospital using the Robson classification.

The aim of this study was to implement the Robson Ten Groups Classification System (RTGCS) to identify the main contributors to the caesarean section (CS) rate and to evaluate whether the introduction of a plan of obstetrical interventions reduced this rate. An observational retrospective cross-sectional study was conducted during two time periods at Alicante University General Hospital. In the pre-implementation period (2009-2012), RTGCS was applied to identify the main groups contributing to the overall CS rate. In the post-implementation period (2013-2017), RTGCS was applied again to identify changing trends in CS rates. In all, 11,034 deliveries during the pre-intervention period and 11,453 during the post-intervention period were analysed. The overall CS rate was 23.9% and 20.9%, respectively. There were no changes in perinatal outcomes. In the post-intervention period, there was a significant decrease of the CS rate in the groups of targeted interventions 1, 2, 3, 4, 5, and 8B.Impact statementWhat is already known on this subject? High CS rates are becoming a public health problem because of risks, costs, excessive medicalisation, and abuse of resources. RTGCS provides a framework for auditing and analysing CS rates.What do the results of this study add? RTGCS can identify the groups that have the greatest impact on the CS rate and monitor changes in it consequent to policy changes.What are the implications of these findings for clinical practice? The introduction of a strategic plan with evidence-based clinical interventions may have a greater effect on the CS rate than other features justifying the increase in the incidence of CS.

Economic evaluation of elective cesarean versus vaginal delivery on cost of future pelvic floor disorders in the United States.

AIM: To analyze the cost impact of cesarean versus vaginal delivery in the United States on the development of stress urinary incontinence (SUI) and pelvic organ prolapse (POP). METHODS: We compared average cost of delivery method to the lifetime risk and cost of pelvic floor disorders (PFDs) in women < 65 years. Costs of maternal care, obtained from the MarketScan® database, included those incurred at delivery and 3 months post-partum. Future costs of PFDs included those incurred after delivery up to 65 years. Previously reported data on the prevalence of POP and SUI following cesarean and vaginal delivery was used to calculate attributable risk. An incremental cost of illness model was used to estimate costs for SUI. Direct surgical and ambulatory care costs were used to determine cost of POP. RESULTS: Average estimated cost was $7089 for vaginal delivery and $9905 for cesarean delivery. The absolute risks for SUI and POP were estimated as 7% and 5%, respectively, following cesarean delivery, and 13% and 14%, respectively, following vaginal delivery. For SUI, average direct cost was $5642, indirect cost was $4208, and personal cost was $750. Average direct cost of POP surgery was $4658, and nonsurgical cost was $2220. The potential savings for reduced prevalence of SUI and POP in women who underwent cesarean delivery is estimated at $1255, but they incur an additional $2816 maternal care cost over vaginal delivery. CONCLUSIONS: Although elective cesarean is associated with reduced prevalence of PFDs, the increased initial cost of cesarean delivery does not offset future cost savings.

The shifting demographics of birth-related brachial plexus injury: The impact of socio-economic status and ethnic groups.

INTRODUCTION: Many of the risk factors for birth-related brachial plexus injury (BRBPI), such as maternal gestational diabetes and macrosomia, are known to vary between demographic groups. Socio-economic differences are known to influence access to healthcare, including elective caesarean section rates and access to consultant obstetricians, which could impact the rates of BRBPI. This study aims to explore whether BRBPI is affected by demographic factors. METHOD: This retrospective study compares cohorts of BRBPI patients referred to the Royal National Orthopaedic Hospital in 2004, 2014 and 2017. N = 67 in 2004, N = 61 in 2014 and N = 71 in 2017. RESULTS: The risk of BRBPI for Black patients was 6 times higher than for White patients, and 2.7 times higher for Asian patients as compared to White patients (p < 0.001). There was an unequal distribution of BRBPI occurring in patients from lower socio-economic groups based on the index of multiple deprivation, with the highest level seen in those from the second lowest quintile. Neither of these risk factors have changed within the three years that they were examined. CONCLUSION: In this sample, the risk of BRBPI varies with ethnic groups; patients from non-White backgrounds are at a higher risk overall and are disproportionately represented in the BRBPI cohort as compared to White groups. Similarly, there seems to be a trend towards greater risk for those from lower socio-economic groups. These changes are consistent each year, suggesting that these inconsistencies are yet to be addressed. Further studies are warranted to explore why these demographic factors are significantly affecting health outcomes.

Improved Outcomes With an Enhanced Recovery Approach to Cesarean Delivery.

OBJECTIVE: To examine the results of a quality-improvement study that implemented an enhanced recovery after surgery (ERAS) program for cesarean delivery. METHODS: A pre-post design was used to assess changes in opioid use, length of stay, and costs among all patients undergoing cesarean delivery before and after implementation of an evidence-based ERAS pathway for the preoperative, intraoperative, and postoperative management of patients beginning December 2018. RESULTS: A total of 3,679 cesarean deliveries (scheduled and emergent) were included from January 1, 2018, through August 31, 2019, of which 2,171 occurred before implementation on December 17, 2018, and 1,508 occurred postimplementation. Eighty-four percent of patients received opioids as inpatients after cesarean delivery during the preimplementation period, as compared with 24% in the postimplementation period (odds ratio [OR] 16.8, 95% CI 14.3-19.9). Among patients who required any opioids, the total morphine milligram equivalents also significantly decreased (median 56.5 vs 15.0, mean relative change 0.32, 95% CI 0.28-0.35). Compared with the preimplementation period, those in the postimplementation period had a shorter postcesarean length of stay (3.2 vs 2.7 days, mean relative change 0.82, 95% CI 0.80-0.83, median 3 days in both periods), lower median direct costs by $349 (mean relative change 0.93, 95% CI 0.91-0.95), and no change in the 30-day readmission rate (1.4% vs 1.7%, OR 0.83, 95% CI 0.49-1.41). CONCLUSION: An ERAS approach for the cesarean delivery population is associated with improved outcomes including decreases in opioid use, length of stay, and costs.

Cesarean section one hundred years 1920-2020: the Good, the Bad and the Ugly.

In present-day obstetrics, cesarean delivery occurs in one in three women in the United States, and in up to four of five women in some regions of the world. The history of cesarean section extends well over four centuries. Up until the end of the nineteenth century, the operation was avoided because of its high mortality rate. In 1926, the Munro Kerr low transverse uterine incision was introduced and became the standard method for the next 50 years. Since the 1970's, newer surgical techniques gradually became the most commonly used method today because of intraoperative and postpartum benefits. Concurrently, despite attempts to encourage vaginal birth after previous cesareans, the cesarean delivery rate increased steadily from 5 to 30-32% over the last 10 years, with a parallel increase in costs as well as short- and long-term maternal, neonatal and childhood complications. Attempts to reduce the rate of cesarean deliveries have been largely unsuccessful because of the perceived safety of the operation, short-term postpartum benefits, the legal climate and maternal request in the absence of indications. In the United States, as the cesarean delivery rate has increased, maternal mortality and morbidity have also risen steadily over the last three decades, disproportionately impacting black women as compared to other races. Extensive data on the prenatal diagnosis and management of cesarean-related abnormal placentation have improved outcomes of affected women. Fewer data are available however for the improvement of outcomes of cesarean-related gynecological conditions. In this review, the authors address the challenges and opportunities to research, educate and change health effects associated with cesarean delivery for all women.