Parir después de los 50 años. Estudio piloto observacional / Birth over 50: A pilot observational study

Objetivos: Evaluar si existe una mayor tasa de resultados obstétricos adversos, incontinencia urinaria posparto y problemas sexuales entre las mujeres que dan a luz después de los 50 años.Material y métodos: Estudio observacional ambispectivo de un solo centro. Se registraron la tasa de parto por cesárea, la diabetes gestacional, la preeclampsia, la restricción del crecimiento intrauterino (RCIU), la prematuridad, la incontinencia urinaria (Cuestionario de incontinencia en formato corto [ICIQ-SF]) y la disfunción sexual (índice de función sexual femenina [FSFI-6]). Resultados: Veinticinco (0,06%) de 38.510 nacimientos ocurrieron en mujeres mayores de 50 años durante el período de estudio en nuestro centro. Hubo 16 (64%) partos por cesárea. Siete (28%) mujeres padecieron diabetes gestacional. Se diagnosticó preeclampsia en 3 (12%) mujeres. Hubo 5 (20%) casos de RCIU. Hubo 5 (20%) partos prematuros. Las diferencias en la tasa de parto por cesárea, diabetes gestacional y RCIU entre el grupo de estudio y la población total fueron estadísticamente significativas. Los resultados de los cuestionarios ICIQ-SF y FSFI-6 se obtuvieron de 17 mujeres. Se encontró algún grado de incontinencia urinaria en 7 (41,1%) y disfunción sexual en 9 (52,9%) mujeres. Conclusiones: Los embarazos en mujeres mayores de 50 años parecen estar asociados con una mayor tasa de diabetes gestacional, RCIU y preeclampsia. Hay una alta prevalencia de incontinencia urinaria y problemas sexuales entre estas mujeres.(AU)

Objectives: To assess whether there is a higher rate of adverse obstetric outcomes, postpartum urinary incontinence, and sexual problems among women who give birth over 50. Material and methods: A single-center ambispective observational study. Rate of cesarean birth, gestational diabetes, preeclampsia, intrauterine growth restriction (IUGR), prematurity, urinary incontinence (Incontinence Questionnaire Short Form [ICIQ-SF]), and sexual dysfunction (Female Sexual Function Index [FSFI-6]) were recorded. Results: Twenty-five (0.06%) of 38,510 births occurred in women over 50 during the study period. There were 16 (64%) cesarean births. Seven (28%) women had gestational diabetes. Preeclampsia was diagnosed in 3 (12%) women. There were 5 (20%) cases of IUGR. There were 5 (20%) preterm births. The differences in the rate of cesarean birth, gestational diabetes, and IUGR between the study group and the total population were statistically significant. The results of the ICIQ-SF and FSFI-6 questionnaires were obtained from 17 women. Some degree of urinary incontinence was found in 7 (41.1%) and sexual dysfunction in 9 (52.9%) women. Conclusions: Pregnancies in women over 50 may be associated with a higher rate of gestational diabetes, IUGR, and preeclampsia. There is a high prevalence of urinary incontinence and sexual problems among these women.(AU)

Trends in Cesarean Delivery in Puerto Rico, 2018-2022.

Cesarean delivery is major surgery associated with higher costs and adverse outcomes, such as surgical complications, compared with vaginal delivery (1-3). The cesarean delivery rate in Puerto Rico rose from just over 30% in the early to mid-1990s to over 40% by the early 2000s (4,5). During this time, cesarean delivery rates in Puerto Rico were 40%-70% higher than rates in the U.S. mainland and up to 78% higher than rates for Hispanic women in the U.S. mainland (4,5). This report describes trends in Puerto Rico's cesarean delivery rate from 2010 to 2022 and explores changes by maternal age, gestational age, and municipality from 2018 to 2022.

Minority-Serving Hospitals Are Associated With Low Within-Hospital Disparity.

BACKGROUND: Disparities in obstetric care have been well documented, but disparities in the within-hospital population have not been as extensively explored. The objective is to assess cesarean delivery rate disparities at the hospital level in a nationally recognized low risk of cesarean delivery group. METHODS: An observational study using a national population-based database, Nationwide Inpatient Sample, from 2008 to 2011 was conducted. All patients with nulliparous, term, singleton, vertex pregnancies from Black and White patients were included. The primary outcome was delivery mode (cesarean vs vaginal). The primary independent variable was race (Black vs White). RESULTS: A total of 1,064,351 patients were included and the overall nulliparous, term, singleton, and vertex pregnancies cesarean delivery rate was 14.1%. The within-hospital disparities of cesarean delivery rates were lower in minority-serving hospitals (OR: 1.20 95% CI: 1.12-1.28), rural hospitals (OR 1.11 95% CI: 1.02-1.20), and the South (OR 1.24 95% CI 1.19-1.30) compared to their respective counterparts. Non-minority serving hospitals (OR: 1.20 95% CI 0.12-1.25), and urban hospitals (OR1.32 95% CI 1.28-1.37), the Northeast (OR 1.41 95% CI 1.30-1.53) or West (OR 1.52 95% CI 1.38-1.67), had higher within-hospital racial disparities of cesarean delivery rates. The odds ratios reported are comparing within-hospital cesarean delivery rates in Black and White patients. DISCUSSION: Significant within-hospital disparities of cesarean delivery rates across hospitals highlight the importance of facility-level factors. Policies aimed at advancing health equity must address hospital-level drivers of disparities in addition to structural racism.

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.

Análisis de la tasa de cesáreas en el Hospital Universitario Materno-Infantil La Paz de Madrid (2010-2018) a través de la clasificación de Robson / Analysis of the Caesarean section rate at the La Paz Maternal-Child University Hospital in Madrid (2010–2018) through the Robson classification

Introducción: La necesidad de racionalizar y optimizar el uso de las cesáreas es un reto internacional en salud pública. Para ello, la OMS recomienda el uso de la clasificación Robson, que permite comparar las tasas de cesárea en función del perfil materno-fetal. El objetivo de este trabajo es evaluar la tasa de cesárea en el Hospital Universitario Materno-Infantil La Paz de Madrid entre 2010 y 2018 por medio de la clasificación Robson. Material y métodos: La población analizada corresponde a los datos de los 41.037 partos registrados en el programa Obstetricia del Hospital Universitario Materno-Infantil La Paz de Madrid de 2010 a 2018. Por medio del programa SPSS, se evalúa el cambio temporal en a) el porcentaje de partos (vaginales y por cesárea) respecto al total de nacimientos, b) la tasa de cesárea respecto a los partos vaginales y c) la contribución relativa a la tasa global de cesárea. Resultados: Las más elevadas contribuciones parciales a la tasa global de cesárea correspondieron a nulíparas con parto inducido, con cesárea previa, nulíparas con parto espontáneo y con gestaciones múltiples. El grupo de las nulíparas con parto inducido fue el único que registró un aumento significativo de su contribución a la tasa total de cesárea (30,4% en 2018). Conclusiones: Los resultados de este trabajo indican que el reto en salud pública es seguir evaluando la relación entre inducción del parto y riesgo de cesárea intraparto, particularmente en mujeres nulíparas, el grupo que registra la más alta tasa relativa de cesárea y en aumento significativo.(AU)

Introduction: The need to rationalise and optimise the use of caesarean sections is an international public health challenge. To this end, the WHO recommends the use of the Robson classification, which allows comparison of caesarean section rates according to the maternal-fetal profile. The aim of this study is to evaluate the rate of caesarean section in the Hospital Universitario Materno-Infantil La Paz in Madrid between 2010 and 2018 using the Robson classification. Material and methods: The population analysed corresponds to data from the 41,037 deliveries registered in the Obstetrics programme of the Hospital Universitario Materno-Infantil La Paz of Madrid from 2010 to 2018. Using SPSS software, the temporal change in (a) the percentage of deliveries (vaginal and caesarean) with respect to total births, (b) the caesarean rate with respect to vaginal deliveries and (c) the relative contribution to the overall caesarean rate is evaluated. Results: The highest partial contributions to the overall caesarean section rate were made by nulliparous women with induced labour, previous caesarean section, nulliparous women with spontaneous labour and multiple gestations. The group of nulliparous with induced labour was the only one with a significant increase in its contribution to the overall caesarean section rate (30.4% in 2018). Conclusions: The results of this work indicate that the challenge in public health is to further assess the relationship between induction of labour and risk of intrapartum caesarean section, particularly in nulliparous women, the group with the highest and significantly increasing relative caesarean section rate.(AU)

Evolución del parto por cesárea en la provincia del Neuquén, 2000-2020 / Caesarean section rate evolution in Neuquén province, 2000 to 2020

RESUMEN INTRODUCCIÓN: El nacimiento por cesárea se encuentra en aumento en todo el mundo, con diferencias significativas entre regiones. El objetivo fue determinar la situación del porcentaje de cesárea en mujeres con parto en la provincia del Neuquén en 2000-2020, buscando diferencias entre subsectores, zonas sanitarias, localidades e instituciones de salud . MÉTODOS: Se analizaron las estadísticas del Sistema Informático Perinatal referentes a vía de parto, recién nacidos y mujeres con partos entre 2000 y 2020. Se realizó un análisis estratificado del porcentaje de cesáreas, describiendo medidas de tendencia central, de dispersión y velocidad promedio de incremento anual . RESULTADOS: Las características sociodemográficas de madres gestantes se han modificado, con un descenso del embarazo adolescente y un aumento de madres de más de 35 años. Se observó un mayor porcentaje de bajo peso al nacer en el subsector privado y una importante disminución de la tasa bruta de natalidad, con mayor descenso en el interior provincial. Se encontró un aumento sostenido, así como diferencias crecientes y muy significativas entre subsectores (y dentro de estos entre las distintas instituciones) . DISCUSIÓN: Existen diferencias muy significativas en los resultados si se comparan los diferentes subsectores e instituciones respecto al nacimiento por cesárea. Estos resultados son un aporte para la construcción de políticas acordes a la realidad epidemiológica de la provincia y de cada institución de salud.

ABSTRACT INTRODUCTION: Cesarean delivery is increasing all over the world, with significant differences between regions. The aim was to determine the cesarean section rate in women giving birth between 2000 and 2020 in Neuquén province, seeking for differences between sub-sectors, health zones, cities and health institutions . METHODS: Statistics from the Perinatal Information System were analyzed regarding type of delivery, newborns and women delivering between 2000 and 2020. A stratified analysis of the cesarean section rate was conducted, describing central tendency and dispersion measures, and the average annual rate of increase . RESULTS: Maternal sociodemographic characteristics have changed, with adolescent pregnancy decrease and a higher number of mothers older than 35 years of age. The percentage of low birth weight was higher in the private sub-sector, with a significant decrease of gross birth rate, mainly inside the province. There was a steady increase as well as growing and very significant differences between sub-sectors (and within them between the different institutions) . DISCUSSION: The results show very significant differences when comparing sub-sectors and institutions regarding cesarean birth, and contribute to building policies tailored to the epidemiological situation of the province and each health institution.

Decision and economic analysis of hostile abortion laws compared with supportive abortion laws.

BACKGROUND: On June 24, 2022, the US Supreme Court overturned Roe v Wade in Dobbs v Jackson Women's Health Organization. Therefore, several states banned abortion, and other states are considering more hostile abortion laws. OBJECTIVE: This study aimed to assess the incidence of adverse maternal and neonatal outcomes in the hypothetical cohort where all states have hostile abortion laws compared with the pre-Dobbs v Jackson cohort (supportive abortion laws cohort) and examine the cost-effectiveness of these policies. STUDY DESIGN: This study developed a decision and economic analysis model comparing the hostile abortion laws cohort with the supportive abortion laws cohort in a sample of 5.3 million pregnancies. Cost (inflated to 2022 US dollars) estimates were from a healthcare provider's perspective, including immediate and long-term costs. The time horizon was set to a lifetime. Probabilities, costs, and utilities were derived from the literature. The cost-effectiveness threshold was set to be at $100,000 per quality-adjusted life year. Probabilistic sensitivity analyses using the Monte Carlo simulation with 10,000 simulations were performed to assess the robustness of our results. The primary outcomes included maternal mortality and an incremental cost-effectiveness ratio. The secondary outcomes included hysterectomy, cesarean delivery, hospital readmission, neonatal intensive care unit admission, neonatal mortality, profound neurodevelopmental disability, and incremental cost and effectiveness. RESULTS: In the base case analysis, the hostile abortion laws cohort had 12,911 more maternal mortalities, 7518 more hysterectomies, 234,376 more cesarean deliveries, 102,712 more hospital readmissions, 83,911 more neonatal intensive care unit admissions, 3311 more neonatal mortalities, and 904 more cases of profound neurodevelopmental disability than the supportive abortion laws cohort. The hostile abortion laws cohort was associated with more cost ($109.8 billion [hostile abortion laws cohort] vs $75.6 billion [supportive abortion laws cohort]) and 120,749,900 fewer quality-adjusted life years with an incremental cost-effectiveness ratio of negative $140,687.60 than the supportive abortion laws cohort. Probabilistic sensitivity analyses suggested that the chance of the supportive abortion laws cohort being the preferred strategy was more than 95%. CONCLUSION: When states consider enacting hostile abortion laws, legislators should consider an increase in the incidence of adverse maternal and neonatal outcomes.

Robson classification of caesarean births: implications for reducing caesarean section rate in a private tertiary hospital in Nigeria.

BACKGROUND: Caesarean section (CS) is a potentially lifesaving obstetric procedure. However, there are concerns about the rising CS rate in many countries of the world including Nigeria. The Ten-Group Robson classification system is presently recommended as an effective monitoring tool for comparing CS rates and identifying target groups for intervention aimed at reducing the rates. The aim of this study was to evaluate the cesarean section rate and the groups with the highest risk of CS at the obstetric unit of Babcock University Teaching Hospital (BUTH), using the Robson classification system. METHODS: A cross-sectional study involving 447 women who gave birth at the obstetric unit of BUTH between August 2020 and February 2022. Relevant information was retrieved from the delivery records of the study participants. Data were analyzed using the IBM-SPSS Statistics for Windows version 23.0 (IBM Corp., Armonk, NY, USA). RESULTS: The overall CS rate was 51.2%. Multiparous women with previous CS, single, cephalic, term (group 5); nulliparous women, single cephalic, term, with induced labour or pre-labour CS (group 2); women with preterm single cephalic, term (group 10); and single cephalic term multiparous women in spontaneous labour (group 3) were the largest contributors to CS rate accounting for 34.5%, 14.0%, 12.6%, and 10.0% respectively. The commonest indication for CS was previous CS (87; 38.0%), followed by poor progress in labour (24; 10.5%). CONCLUSIONS: The CS rate in BUTH is high and Robson groups 5, 2 10 and 3 were the major contributors to this high rate. Interventions directed at reducing the first CS by improving management of spontaneous and induced labours; and strengthening clinical practice around encouraging vaginal birth after CS will have the most significant effect on reducing CS rate.

Análise das indicações de cesáreas com base na classificação de Robson em uma maternidade brasileira de risco habitual / Cesarean section indication analysis in a habitual-risk maternity hospital in Brazil according to Robson classification system

Objetivo: Avaliar a taxa de cesáreas e suas principais indicações com base na classificação de Robson na Maternidade Municipal de São Vicente em 2020, um hospital público de risco habitual. Métodos: Trata-se de um estudo transversal observacional. Foram efetuadas revisão, correção e análise retrospectiva e documental da classificação de Robson na Maternidade Municipal de São Vicente. Foram analisados partos de janeiro a dezembro de 2020, dos quais foram coletadas e ordenadas as informações mais relevantes para a pesquisa. Resultados: Uma amostra de 1.627 partos foi encontrada. A taxa geral de cesáreas encontrada foi de 46,3%. A contribuição relativa dos grupos 1, 2 e 5 para a taxa de cesáreas foi de 16,8%, 13,3% e 46,8%, respectivamente, enquanto a contribuição relativa das indicações de cesáreas foi de 25,5% para parto cesáreo anterior e de 21,5% para sofrimento fetal agudo. Conclusão: Foi evidenciada alta taxa de cesáreas, e as principais indicações foram cesárea prévia e sofrimento fetal agudo. Os grupos 1, 2 e 5 da classificação de Robson foram os que mais contribuíram para essa taxa.

Objective: To evaluate the cesarean section rate and the cesarean indication rate based on Robson Classification during 2020 in Sã o Vicente's Municipal Maternity, a habitual-risk public hospital. Methods: This is a cross-sectional observational study. We have reviewed, corrected, analyzed retrospectively and documented Robson Classification in Sã o Vicente's Municipal Maternity. Births from January to December 2020 were analyzed, from which the main data for the research was collected and organized. Results: A sample of 1,627 births was found. The overall rate of cesarean section was 46.3%. The relative contribution of groups 1, 2 and 5 to the cesarean rate was 16.8%, 13.3% and 46.8%, respectively. While the cesarean indication relative contribution was 25.5% for previous cesarean and 21.5% for fetal distress. Conclusion: We found a high cesarean rate and the main indications were previous cesarean and fetal distress. Robson classification groups 1, 2 and 5 contributed the most to this rate.

Racial and Ethnic Disparities in Cesarean Morbidity.

OBJECTIVE: Maternal race and ethnicity have been identified as significant independent predictors of obstetric morbidity and mortality in the United States. An appreciation of the clinical contexts in which maternal racial and ethnic disparities are most pronounced can better target efforts to alleviate these disparities and improve outcomes. It remains unknown whether cesarean delivery precipitates these divergent outcomes. This study assessed the association between maternal race and ethnicity and cesarean complications. STUDY DESIGN: We conducted a retrospective cohort study from a multicenter observational cohort of women undergoing cesarean delivery. Nulliparous women with non-anomalous singleton gestations who underwent primary cesarean section were included. Race/ethnicity was categorized as non-Hispanic White, non-Hispanic Black, Hispanic, Asian, Native American, or unknown. The primary outcome was a composite of maternal cesarean complications including hysterectomy, uterine atony, blood transfusion, surgical injury, arterial ligation, infection, wound complication, and ileus. A composite of neonatal morbidity was evaluated as a secondary outcome. We created a multivariable logistic regression model adjusting for selected demographic and obstetric variables that may influence the likelihood of the primary outcome. RESULTS: A total of 14,570 women in the parent trial met inclusion criteria with an 18.8% incidence of the primary outcome (2,742 women). After adjusting for potential confounding variables, maternal surgical morbidity was found to be significantly higher for non-Hispanic Black (adjusted odds ratios [aORs] 1.96, 95% confidence intervals [CIs] 1.63-2.35) and Hispanic (aOR 1.66, 95% CI 1.37-2.01) women as compared with non-Hispanic white women. Neonatal morbidity was similarly found to be significantly associated with the Black race and Hispanic ethnicity. CONCLUSION: In this cohort, the odds of cesarean-related maternal and neonatal morbidity were significantly higher for non-Hispanic Black and Hispanic women. These findings suggest race as a distinct risk factor for cesarean complications, and efforts to alleviate disparities should highlight cesarean section as an opportunity for improvement in outcomes. KEY POINTS: · Non-Hispanic Black and Hispanic women experienced more cesarean complications than non-Hispanic White women.. · These findings suggest that disparities in maternal and neonatal outcomes exist specifically following cesarean section.. · Efforts to alleviate disparities in obstetrics should highlight cesarean section as an opportunity for improvement..

Twin Vaginal Deliveries in Labor Rooms: A Cost-Effectiveness Analysis.

OBJECTIVE: Twin vaginal deliveries (VDs) are often performed in the operating room (OR) given the theoretical risk of conversion to cesarean delivery (CD) for the aftercoming twin. We aim to evaluate the cost-effectiveness of performing VDs for twin gestations in the labor and delivery room (LDR) versus OR. STUDY DESIGN: We conducted a cost-effectiveness analysis using a decision-analysis model that compared the costs and effectiveness of two strategies of twin deliveries undergoing a trial of labor: (1) intended delivery in the LDR and 2) delivery in the OR. Sensitivity analyses were performed to assess strength and validity of the model. Primary outcome was incremental cost-effectiveness ratio (ICER) defined as cost needed to gain 1 quality-adjusted life year (QALY). RESULTS: In the base-case scenario, where 7% of deliveries resulted in conversion to CD for twin B, attempting to deliver twins in the LDR was the most cost-effective strategy. For every QALY gained by delivering in the OR, 243,335 USD would need to be spent (ICER). In univariate sensitivity analyses, the most cost-effective strategy shifted to delivering in the OR when the following was true: (1) probability of successful VD was less than 86%, (2) probability of neonatal morbidity after emergent CD exceeded 3.5%, (3) cost of VD in an LDR exceeded 10,500 USD, (4) cost of CD was less than 10,000 USD, or (5) probability of neonatal death from emergent CD exceeded 2.8%. Assuming a willingness to pay of 100,000 USD per neonatal QALY gained, attempted VD in the LDR was cost effective in 51% of simulations in the Monte Carlo analysis. CONCLUSION: Twin VDs in the LDR are cost effective based on current neonatal outcome data, taking into account gestational age and associated morbidity. Further investigation is needed to elucidate impact of cost and outcomes on optimal utilization of resources. KEY POINTS: · Cost effectiveness of twin VDs in the LDR versus OR was assessed.. · Twin VDs in the LDR are cost effective based on current neonatal outcome data.. · Attempted VD in the LDR was cost effective in 51% of simulations in the Monte Carlo analysis..

The rate of cesarean delivery changes after internal audit based on the Robson Ten Group Classification System in Lebanon.

OBJECTIVE: To evaluate the efficiency of the Robson classification as an internal clinical audit and feedback of the high rate of cesarean delivery at Hotel Dieu de France, a tertiary referral hospital. METHODS: A pre-post study was conducted, with a retrospective approach in 2018 and 2019, identified as the pre-period (before the implementation of the Robson classification), and with a prospective approach in 2020 and 2021, labeled the post-period. RESULTS: The total number of deliveries during the study period was 2560; 1305 patients were included in the pre-period and 1255 patients delivered in the post-period. No significant differences between the two groups were found. No significant difference was found in the overall rate of cesarean delivery between the first and second periods (57.86% vs 56.72%; P = 0.2). However, a significant decrease in the absolute contribution of groups 3 and 4 (multiparous women without a previous uterine scar with a single cephalic pregnancy, ≥37 weeks of gestation, with spontaneous labor or induced labor) in the overall rate of cesarean delivery was remarked (P = 0.02 and 0.01, respectively). CONCLUSION: The Robson classification seems to be appropriate to monitor and audit the rate of cesarean delivery, but not sufficient to decrease the rate and change the practice.

Inequalities in cesarean births between American Indian & Alaska Native people and White people.

OBJECTIVE: To explore population-level American Indian & Alaska Native-White inequalities in cesarean birth incidence after accounting for differences in cesarean indication, age, and other individual-level risk factors. DATA SOURCES AND STUDY SETTING: We used birth certificate data inclusive of all live births within the United States between January 1 and December 31, 2017. STUDY DESIGN: We calculated propensity score weights that simultaneously incorporate age, cesarean indication, and clinical and obstetric risk factors to estimate the American Indian and Alaska Native-White inequality. DATA COLLECTION/EXTRACTION METHODS: Births to individuals identified as American Indian, Alaska Native, or White, and residing in one of the 50 US states or the District of Columbia were included. Births were excluded if missing maternal race/ethnicity or any other covariate. PRINCIPAL FINDINGS: After weighing the American Indian and Alaska Native obstetric population to be comparable to the distribution of cesarean indication, age, and clinical and obstetric risk factors of the White population, the cesarean incidence among American Indian and Alaska Natives increased to 33.4% (95% CI: 32.0-34.8), 3.2 percentage points (95% CI: 1.8-4.7) higher than the observed White incidence. After adjustment, cesarean birth incidence remained higher and increased in magnitude among American Indian and Alaska Natives in Robson groups 1 (low risk, primary), 6 (nulliparous, breech presentation), and 9 (transverse/oblique lie). CONCLUSIONS: The unadjusted lower cesarean birth incidence observed among American Indian and Alaska Native individuals compared to White individuals may be related to their younger mean age at birth. After adjusting for this demographic difference, we demonstrate that American Indian and Alaska Native individuals undergo cesarean birth more frequently than White individuals with similar risk profiles, particularly within the low-risk Robson group 1 and those with non-cephalic presentations (Robson groups 6 and 9). Racism and bias in clinical decision making, structural racism, colonialism, or other unidentified factors may contribute to this inequality.

Breech delivery in low-income settings: A systematic review of perinatal and maternal outcomes in vaginal versus cesarean breech deliveries.

Most studies comparing vaginal breech delivery (VBD) with cesarean breech delivery (CBD) have been conducted in high-income settings. It is uncertain whether these results are applicable in a low-income setting. To assess the neonatal and maternal mortality and morbidity for singleton VBD compared to CBD in low- and lower-middle-income settings,the PubMed database was searched from January 1, 2000, to January 23, 2020 (updated April 21, 2021). Randomized controlled trials (RCTs) and non-RCTs comparing singleton VBD with singleton CBD in low- and lower-middle-income settings reporting infant mortality were selected. Two authors independently assessed papers for eligibility and risk of bias. The primary outcome was relative risk of perinatal mortality. Meta-analysis was conducted on applicable outcomes. Eight studies (one RCT, seven observational) (12 510 deliveries) were included. VBD increased perinatal mortality (relative risk [RR] 2.67, 95% confidence interval [CI] 1.82-3.91; one RCT, five observational studies, 3289 women) and risk of 5-minute Apgar score below 7 (RR 3.91, 95% CI 1.90-8.04; three observational studies, 430 women) compared to CBD. There was a higher risk of hospitalization and postpartum bleeding in CBD. Most of the studies were deemed to have moderate or serious risk of bias. CBD decreases risk of perinatal mortality but increases risk of bleeding and hospitalization.

Characteristics of women who underwent one or more previous cesarean sections according to Nascer no Brasil / Características de mulheres com uma ou mais cesáreas anteriores no nascer no Brasil

ABSTRACT OBJECTIVE To descriptively analyze Brazilian parturient women who underwent previous cesarean section and point out the factors associated with Vaginal Birth After Cesarean (VBAC) in Brazil. METHODS The study used data from women with one, two, or three or more cesarean sections from the survey Nascer no Brasil (Birth in Brazil). Differences between categories were assessed through the chi-square test (χ2). Variables with significant differences (p < 0.05) were incorporated into logistic regression. FINDINGS Out of the total of 23,894 women, 20.9% had undergone a previous cesarean section. The majority (85.1%) underwent another cesarean section, with 75.5% occurring before the onset of labor. The rate of Vaginal Birth After Cesarean (VBAC) was 14.9%, with a success rate of 60.8%. Women who underwent three or more cesarean sections displayed greater social vulnerability. The chances of VBAC were higher among those who opted for a vaginal birth towards the end of gestation, had a prior vaginal birth, underwent labor induction, were admitted with over 4 centimeters of dilation, and without partner. Receiving care from the private health care system, having two or more prior cesarean sections, obstetric complications, and deciding on cesarean delivery late in gestation reduced the chances of VBAC. Age group, educational background, prenatal care adequacy, and the reason for the previous cesarean section did not result in significant differences. CONCLUSION The majority of women who underwent a previous cesarean section in Brazil are directed towards another surgery, and a higher number of cesarean sections is linked to greater social inequality. Factors associated with VBAC included choosing vaginal birth towards the end of gestation, having had a previous vaginal birth, higher cervical dilation upon admission, induction, assistance from the public health care system, absence of obstetric complications, and without a partner. Efforts to promote VBAC are necessary to reduce overall cesarean rates and their repercussions on maternal and child health.

RESUMO OBJETIVO Analisar descritivamente as parturientes brasileiras com cesariana anterior e apontar os fatores associados ao parto vaginal após cesárea (Vaginal Birht After Cesarean- VBAC) no Brasil. MÉTODOS Foram utilizados dados de mulheres com uma, duas ou três e mais cesáreas da pesquisa Nascer no Brasil. As diferenças entre categorias foram avaliadas pelo teste de qui-quadrado (χ2). As variáveis que apresentaram diferença significativa (< 0,05) foram incluídas em regressão logística. RESULTADOS Do total de 23.894 mulheres, 20,9% tinham cesárea anterior. A maior parte (85,1%) foi submetida a outra cesárea, 75,5% antes do início do trabalho de parto. A porcentagem de VBAC foi de 14,9%, uma taxa de sucesso de 60,8%. Mulheres com três cesáreas ou mais apresentaram maior vulnerabilidade social. As chances de VBAC foram maiores entre aquelas decididas pelo parto vaginal no fim da gestação, com parto vaginal anterior, indução de parto, admitidas com mais de 4 centímetros de dilatação e sem companheiro. Assistência no sistema privado, ter duas cesáreas ou mais, complicações obstétricas e decisão por cesariana no final da gestação diminuíram as chances de VBAC. Faixa etária, escolaridade, adequação do pré-natal e razão da cesárea anterior não apresentaram diferença significativa. CONCLUSÃO A maior parte das mulheres com cesárea anterior no Brasil é encaminhada para uma nova cirurgia, e o maior número de cesáreas está associado à maior iniquidade social. Os fatores associados ao VBAC foram decisão pelo parto vaginal no fim da gestação, parto vaginal anterior, maior dilatação cervical na internação, indução, atendimento no sistema público de saúde, ausência de complicações obstétricas e ausência de companheiro. São necessárias ações de estímulo ao VBAC, visando reduzir taxas globais de cesarianas e suas consequências para a saúde materno-infantil.

Evaluation on the information about absolute and relative indications of cesarean sections available on popular websites / Avaliação das informações sobre indicações absolutas e relativas de cesarianas disponíveis em sites populares

Abstract Objectives: to evaluate the reliability of information available on popular websites, in other words, websites aimed lay pregnant women, about absolute and relative indications for cesarean sections. Methods: this was a descriptive/comparative study based on the popular websites most likely to be visited by lay pregnant women and that contained information about indications for absolute and relative cesarean sections. Cohen's Kappa index of agreement was used to analyze the reliability degree on the indications for cesarean sections presented on the websites and the scientific evidence. Results: there was a higher prevalence (62.63%) of information on the indications for cesarean sections that did not mention whether the indication was absolute or relative, and of these indications, 40.74% were not indications for cesarean sections. Low agreement was also observed among websites and the scientific evidence when the website mentioned the indication for cesarean section was absolute or relative. Conclusion: this study showed that the reliability of the information on absolute and relative indications for cesarean sections available in popular websites is questionable.

Resumo Objetivos: avaliar a confiabilidade das informações disponíveis em sites populares, ou seja, sites voltados para gestantes leigas, sobre indicações absolutas e relativas de cesarianas. Métodos: estudo descritivo/comparativo, baseado nos sites populares mais prováveis de serem visitados por gestantes leigas e que traziam informações sobre as indicações de cesarianas absolutas e relativas. Para analisar o grau de confiabilidade das indicações de cesarianas apresentadas pelos sites e a evidência cientifica, foi realizado o índice de concordância de Kappa de Cohen. Resultados: houve maior prevalência (62,63%) de informações de indicações de cesarianas que não mencionavam se a indicação apresentada era absoluta ou relativa, sendo que destas, 40,74% não eram indicações de cesarianas. Observou-se, concordância baixa entre os sites e a evidência cientifica quando o site mencionava que a indicação de cesariana era absoluta ou relativa. Conclusão: este estudo demonstrou que a confiabilidade das informações acerca das indicações absolutas e relativas de cesarianas disponíveis em sites populares é questionável

Robson Classification for cesarean section in a Public Hospital in Distrito Federal / Classificação de Robson para cesárea em um Hospital Público do Distrito Federal

Abstract Objectives: to evaluate cesarean taxes by looking at Robson classification on 10 groups (G) and the principal indications at the prevalent groups and at G10. Methods: cross-sectional, observational, retrospective study, including all deliveries performed in a public hospital in Distrito Federal in 2019. Data were collected from medical records and pregnant women were classified in 10 groups. Pearson's chi-squared test was used to calculate the p-value. The risk estimate for cesarean was defined by common odds ratio of Mantel-Haenszel, with calculation of odds ratio (OR) and 95% confidence interval (CI95%). Results: there were 2,205 deliveries, 1,084 (49.1%) of which were cesarean and 1,121 (50.9%) vaginal deliveries. The principal factors for cesarean were G5 (39.3%), G2 (21.2%) and G1 (13.6%). At G10, cesarean had 51.5% of births, not differing statistically from the other groups (p>0.05). Considering all preterm births, G6 to G10 and the other groups, there is a bigger chance of cesarean happening in relation to normal labor (OR=1.4; CI95%= 1.011-2.094; p=0.042). Dystocia remained at G1 and G2, previous cesarean at G5 and hypertensive syndrome at G10. Conclusion: cesarean was most prevalent delivery route, showing elevated rates even in primiparous and preterm births. Preponderance of dystocia and acute fetal distress suggests better evaluation of the diagnostic criteria, mainly in G1, G2 and G10.

Resumo Objetivos: avaliar as taxas de cesárea pela classificação de Robson em 10 grupos (G) e as principais indicações nos grupos prevalentes e no G10. Métodos: estudo transversal, observacional, retrospectivo, incluindo todos os nascimentos em um hospital público do Distrito Federal em 2019. Dados coletados de prontuários eletrônicos e as parturientes categorizadas em dez grupos. Teste qui-quadrado de Pearson para o valor de p e razão de chances comum de Mantel-Haenszel para estimativa de risco, com OR e IC95%. Resultados: ocorreram 2.205 nascimentos, 1.084 (49,1%) cesáreas e 1.121 (50,9%) partos normais. Os principais contribuintes para a cesárea foram G5 (39,3%), G2 (21,2%) e G1 (13,6%). No G10, cesárea teve 51,5% dos nascimentos, não diferindo estatisticamente dos demais grupos (p>0,05). Considerando todos os prematuros, G6 ao G10 e demais grupos, há maior chance de cesárea em relação ao parto normal (OR=1,4; IC95%= 1.011-2.094; p=0,042). Distócia prevaleceu nos G1 e G2, Cesárea prévia no G5 e Síndromes hipertensivas no G10. Conclusão: a cesárea mostrou taxas elevadas inclusive nas primíparas e nos prematuros. Predomínio de Distócia e Sofrimento fetal sugerem melhor avaliação destes critérios diagnósticos, principalmente em G1, G2 e G10.

Frecuencia de y cesáreas en establecimientos públicos y privados de la Provincia de Concepción, Chile, 2001-2019 / Caesareans section frequency in public and private establishments of the Province of Concepción, Chile, 2001-2019

Introducción: El porcentaje nacional de cesárea supera las recomendaciones internacionales, alcanzando altos niveles, con consecuencias significativas en la salud de la mujer. Por esta razón es un problema necesario de analizar. Objetivo: Describir la situación epidemiológica de las cesáreas en la Provincia de Concepción, periodo 2001-2019, según establecimiento y previsión. Material y métodos: Estudio observacional, descriptivo, ecológico, transversal. Incluye universo de partos en la Provincia de Concepción 2001-2019, datos del Departamento de Estadísticas e Información de Salud (DEIS). Recopilación y análisis según técnicas descriptivas en Microsoft Excel® Resultados: En establecimientos públicos, el número de partos disminuyó un 60.6%. En establecimientos privados aumentó 4.8 veces, junto al 39% de incremento en las cesáreas. Las pacientes pertenecientes al grupo A de menores ingresos de la aseguradora de salud pública, Fondo Nacional de Salud (FONASA), presentaron un porcentaje estable de cesáreas, en torno al 25%, mientras que el grupo D (de mayores ingresos) aumentó un 47.8% entre los años 2005 y 2009. Entre 2002 y 2019 el porcentaje promedio de cesáreas de pacientes pertenecientes a las aseguradoras privadas, Instituciones de Salud Previsional (ISAPRE), fue del 66.5%. Conclusiones: Se observó un aumento de cesáreas muy especialmente en recintos privados. La previsión de salud es un factor que considerar, particularmente el grupo FONASA-D, que presentó la mayor alza en las cesáreas, incluso más que las gestantes de ISAPRE. El porcentaje alarmante de cesáreas, especialmente en establecimientos privados, debe ser preocupación prioritaria para nuestro sistema de salud.

Introduction: The national caesarean section rate exceeds international recommendations, reaching elevated levels, with significant consequences on women's health. For this reason it is a necessary problem to analyze. Objective: To describe the epidemiological situation of caesarean sections in the Province of Concepción, period 2001-2019, according to establishment and forecast. Material and methods: Observational, descriptive, ecological, longitudinal study. Includes universe of births in the Province of Concepción 2001-2019, data from the Department of Statistics and Health Information (DEIS). Collection and analysis according to descriptive techniques in Microsoft Excel®. Results: In public establishments, the number of deliveries decreased by 60.6%. In private establishments it increased 4.8 times, together with the 39% increase in cesarean sections. Patients belonging to group A with the lowest income of the public health insurer, National Health Fund (FONASA), presented a stable percentage of caesarean sections, around 25%, while group D (with the highest income) increased 47.8% between 2005 and 2009. Between 2002 and 2019, the average percentage of caesarean sections of patients belonging to private insurers, Institutions of Social Security (ISAPRE), was 66.5%. Conclusions: An increase in caesarean sections was observed, especially in private facilities. Health insurance is a factor to consider, particularly the FONASA-D group, which presented the highest increase in cesarean sections, even more than ISAPRE pregnant women. The alarming percentage of caesarean sections, especially in private establishments, should be a priority concern for our health system.

Buprenorphine versus Methadone for Opioid Use Disorder in Pregnancy.

BACKGROUND: Opioid agonist therapy is strongly recommended for pregnant persons with opioid use disorder. Buprenorphine may be associated with more favorable neonatal and maternal outcomes than methadone, but existing data are limited. METHODS: We conducted a cohort study involving pregnant persons who were enrolled in public insurance programs in the United States during the period from 2000 through 2018 in which we examined outcomes among those who received buprenorphine as compared with those who received methadone. Exposure to the two medications was assessed in early pregnancy (through gestational week 19), late pregnancy (gestational week 20 through the day before delivery), and the 30 days before delivery. Risk ratios for neonatal and maternal outcomes were adjusted for confounders with the use of propensity-score overlap weights. RESULTS: The data source for the study consisted of 2,548,372 pregnancies that ended in live births. In early pregnancy, 10,704 pregnant persons were exposed to buprenorphine and 4387 to methadone. In late pregnancy, 11,272 were exposed to buprenorphine and 5056 to methadone (9976 and 4597, respectively, in the 30 days before delivery). Neonatal abstinence syndrome occurred in 52.0% of the infants who were exposed to buprenorphine in the 30 days before delivery as compared with 69.2% of those exposed to methadone (adjusted relative risk, 0.73; 95% confidence interval [CI], 0.71 to 0.75). Preterm birth occurred in 14.4% of infants exposed to buprenorphine in early pregnancy and in 24.9% of those exposed to methadone (adjusted relative risk, 0.58; 95% CI, 0.53 to 0.62); small size for gestational age in 12.1% and 15.3%, respectively (adjusted relative risk, 0.72; 95% CI, 0.66 to 0.80); and low birth weight in 8.3% and 14.9% (adjusted relative risk, 0.56; 95% CI, 0.50 to 0.63). Delivery by cesarean section occurred in 33.6% of pregnant persons exposed to buprenorphine in early pregnancy and 33.1% of those exposed to methadone (adjusted relative risk, 1.02; 95% CI, 0.97 to 1.08), and severe maternal complications developed in 3.3% and 3.5%, respectively (adjusted relative risk, 0.91; 95% CI, 0.74 to 1.13). Results of exposure in late pregnancy were consistent with results of exposure in early pregnancy. CONCLUSIONS: The use of buprenorphine in pregnancy was associated with a lower risk of adverse neonatal outcomes than methadone use; however, the risk of adverse maternal outcomes was similar among persons who received buprenorphine and those who received methadone. (Funded by the National Institute on Drug Abuse.).