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Association between provider type and cesarean birth in healthy nulliparous laboring women: A retrospective cohort study.

ABSTRACT: BACKGROUND:Term nulliparous women have the greatest variation across hospitals and providers in cesarean rates and therefore present an opportunity to improve quality through optimal care. We evaluated associations between provider type and mode of birth, including examination of intrapartum management in healthy, laboring nulliparous women. METHODS:Retrospective cohort study using prospectively collected perinatal data from a United States academic medical center (2005-2012). The sample included healthy nulliparous women with spontaneous labor onset and term, singleton, vertex fetus managed by either obstetricians or certified nurse-midwives. Univariate and multivariate logistic regression was used to compare labor interventions and mode of birth by provider type. RESULTS:A total of 1339 women received care by an obstetrician (n = 749) or nurse-midwife (n = 590). The cesarean rate was 13.4% (179/1339). Adjusting for maternal and pregnancy characteristics, care by obstetricians was associated with an increased risk of unplanned cesarean birth (adjusted odds ratio [aOR] 1.48 [95% confidence interval {CI} 1.04-2.12]) compared with care by midwives. Obstetricians more frequently used oxytocin augmentation (aOR 1.41 [95% CI 1.10-1.80]), neuraxial anesthesia (aOR 1.69 [95% CI 1.29-2.23]), and operative vaginal delivery with forceps or vacuum (aOR 2.79 [95% CI 1.75-4.44]). Adverse maternal or neonatal outcomes were not different by provider type across all modes of birth, but were more frequent in women with cesarean than vaginal births. DISCUSSION:In low-risk nulliparous laboring women, care by obstetricians compared with nurse-midwives was associated with increased risk of labor interventions and operative birth. Changes in labor management or increased use of nurse-midwives could decrease the rate of a first cesarean in low-risk laboring women.

SUBMITTER: Carlson NS

PROVIDER: S-EPMC5980660 | biostudies-literature | 2018 Jun

REPOSITORIES: biostudies-literature

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Association between provider type and cesarean birth in healthy nulliparous laboring women: A retrospective cohort study.

Carlson Nicole S NS Corwin Elizabeth J EJ Hernandez Teri L TL Holt Elizabeth E Lowe Nancy K NK Hurt K Joseph KJ

Birth (Berkeley, Calif.) 20180131 2

<h4>Background</h4>Term nulliparous women have the greatest variation across hospitals and providers in cesarean rates and therefore present an opportunity to improve quality through optimal care. We evaluated associations between provider type and mode of birth, including examination of intrapartum management in healthy, laboring nulliparous women.<h4>Methods</h4>Retrospective cohort study using prospectively collected perinatal data from a United States academic medical center (2005-2012). The ...[more]

PMID: 29388247

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Project description:ImportanceCesarean birth rate among nulliparous, term, singleton, vertex (NTSV) pregnancies is a standard quality measure in obstetrical care. There are limited data on how the number and type of preexisting conditions affect mode of delivery among primigravidae, and it is also uncertain how maternal comorbidity burden differs across racial and ethnic groups and whether this helps to explain disparities in the NTSV cesarean birth rate.ObjectiveTo determine the association between obstetric comorbidity index (OB-CMI) score and cesarean delivery among NTSV pregnancies and to evaluate whether disparities in mode of delivery exist based on race and ethnicity group after adjusting for covariate factors.Design, setting, and participantsThis cross-sectional study of deliveries between January 2019 and December 2021 took place across 7 hospitals within a large academic health system in New York and included all NTSV pregnancies identified in the electronic medical record system. Exclusion criteria were fetal demise and contraindication to labor.ExposureThe OB-CMI score. Covariate factors assessed included race and ethnicity group (American Indian or Alaska Native, Asian or Pacific Islander, Hispanic, non-Hispanic Black, non-Hispanic White, other or multiracial, and declined or unknown), public health insurance, and preferred language.Main outcome and measuresCesarean delivery.ResultsA total of 30 253 patients (mean [SD] age, 29.8 [5.4] years; 100% female) were included. Non-Hispanic White patients constituted the largest race and ethnicity group (43.7%), followed by Hispanic patients (16.2%), Asian or Pacific Islander patients (14.6%), and non-Hispanic Black patients (12.2%). The overall NTSV cesarean birth rate was 28.5% (n = 8632); the rate increased from 22.1% among patients with an OB-CMI score of 0 to greater than 55.0% when OB-CMI scores were 7 or higher. On multivariable mixed-effects logistic regression modeling, there was a statistically significant association between OB-CMI score group and cesarean delivery; each successive OB-CMI score group had an increased risk. Patients with an OB-CMI score of 4 or higher had more than 3 times greater odds of a cesarean birth (adjusted odds ratio, 3.14; 95% CI, 2.90-3.40) than those with an OB-CMI score of 0. Compared with non-Hispanic White patients, nearly all other race and ethnicity groups were at increased risk for cesarean delivery, and non-Hispanic Black patients were at highest risk (adjusted odds ratio, 1.43; 95% CI, 1.31-1.55).Conclusions and relevanceIn this cross-sectional study of patients with NTSV pregnancies, OB-CMI score was positively associated with cesarean birth. Racial and ethnic disparities in this metric were observed. Although differences in the prevalence of preexisting conditions were seen across groups, this did not fully explain variation in cesarean delivery rates, suggesting that unmeasured clinical or nonclinical factors may have influenced the outcome.

Project description:ObjectiveTo investigate the mode of delivery and birth outcomes in relation to the duration of the passive second stage of labour in nulliparous women.Methods and findingsA retrospective cohort study of all nulliparous women (n = 1131) at two delivery units in Sweden. Maternal and obstetric data were obtained from electronic medical records during 2019. The passive second stage was defined as the complete dilation of the cervix until the start of the active second stage. The duration of the passive second stage was categorized into three groups: 0 to 119 min (0 to <2 h), 120-239 min (2- <4h) and ≥240 min (≥4h). Differences between the groups were examined using t-test and Chi2-tests and regression analyses were used to analyse adjusted odds ratio with 95% confidence intervals. The primary outcome was mode of delivery in relation to the duration of the passive second stage and the secondary outcomes covered a series of adverse maternal and neonatal birth outcomes. The rates of instrumental and caesarean deliveries increased as the duration of the passive second stage increased. A ≥4-hour duration of the passive second stage was associated with a nine-times increased risk of caesarean section, and a four-times risk of instrumental delivery compared to a duration of <2 hours in the adjusted analyses. No differences were found in the maternal birth outcomes. The risk of a 5-minute Apgar score <7 was increased in the 2-<4h group. A longer passive second stage was not associated with an increased risk of negative birth experience.ConclusionsOur study demonstrates an increased risk of operative delivery for a longer duration (>2h) of the passive second stage in nulliparous women, although most of the women gave birth by spontaneous vaginal delivery even after ≥4 hours. There was no evidence of an increased risk of adverse maternal outcomes in a longer duration of the passive second stage but there were indications of increased adverse neonatal outcomes. Assessment of fetal well-being is important when the duration of the passive phase is prolonged.

Project description:Epidural analgesia is considered one of the most effective methods for pain relief during labor. However, it is not clear whether similar effects of epidural analgesia on the progression of labor, modes of delivery, and perinatal outcomes exist between nulliparous and multiparous women.A retrospective cohort study was conducted to analyze all deliveries after 37 weeks of gestation, with the exclusion of pregnancies complicated by multiple gestations and fetal anomalies and deliveries without trials of labor; these criteria produced a study population of n=16,852. A multivariable logistic regression model was constructed to control for confounders. In total, 7260 of 10,175 (71.4%) nulliparous and 2987 of 6677 (44.7%) multiparous parturients were administered epidural analgesia. The independent factors for intrapartum epidural analgesia included a low prepregnancy body mass index, genetic amniocentesis, group B streptococcal colonization of the genito-rectal tract, and augmentation and induction of labor. In the nulliparous women, epidural analgesia was a significant risk factor for operative vaginal delivery (adjusted odds ratio [OR] 2.14, 95% confidence interval [CI] 1.80-2.54); however, it was a protective factor against Caesarean delivery (adjusted OR 0.62, 95% CI 0.55-0.69). Epidural analgesia remained a significant risk factor for operative vaginal delivery (adjusted OR 2.17, 95% CI 1.58-2.97) but not for Caesarean delivery (adjusted OR 1.09, 95% CI 0.77-1.55) in the multiparous women. Furthermore, the women who were administered epidural analgesia during the trials of labor had similar rates of adverse perinatal outcomes compared with the women who were not administered epidural analgesia, except that a higher rate of 1-minute Apgar scores less than 7 was noted in the nulliparous women who were administered epidural analgesia.Intrapartum epidural analgesia has differential effects on the modes of delivery between nulliparous and multiparous women, and it is not associated with adverse perinatal outcomes.

Project description:ObjectivesTo determine the rate of complicated birth at term in women classified at low risk according to the National Institute for Health and Care Excellence guideline for intrapartum care (no pre-existing medical conditions, important obstetric history, or complications during pregnancy) and to assess if the risk classification can be improved by considering parity and the number of risk factors.DesignCohort study using linked electronic maternity records.Participants276 766 women with a singleton birth at term after a trial of labour in 87 NHS hospital trusts in England between April 2015 and March 2016.Main outcome measureA composite outcome of complicated birth, defined as a birth with use of an instrument, caesarean delivery, anal sphincter injury, postpartum haemorrhage, or Apgar score of 7 or less at five minutes.ResultsMultiparous women without a history of caesarean section had the lowest rates of complicated birth, varying from 8.8% (4879 of 55 426 women, 95% confidence interval 8.6% to 9.0%) in those without specific risk factors to 21.8% (613 of 2811 women, 20.2% to 23.4%) in those with three or more. The rate of complicated birth was higher in nulliparous women, with corresponding rates varying from 43.4% (25 805 of 59 413 women, 43.0% to 43.8%) to 64.3% (364 of 566 women, 60.3% to 68.3%); and highest in multiparous women with previous caesarean section, with corresponding rates varying from 42.9% (3426 of 7993 women, 41.8% to 44.0%) to 66.3% (554 of 836 women, 63.0% to 69.5%).ConclusionsNulliparous women without risk factors have substantially higher rates of complicated birth than multiparous women without a previous caesarean section even if the latter have multiple risk factors. Grouping women first according to parity and previous mode of birth, and then within these groups according to presence of specific risk factors would provide greater and more informed choice to women, better targeting of interventions, and fewer transfers during labour than according to the presence of risk factors alone.

Project description:BackgroundNulliparous women contribute to increasing cesarean delivery in the Nordic countries and advanced maternal age has been suggested as responsible for rise in cesarean delivery rates in many developed countries. The aim was to describe changes in cesarean delivery rates among nulliparous women with singleton, cephalic, term births by change in sociodemographic factors across 50 years in Norway.MethodsWe used data from the Medical Birth Registry of Norway and included 1 067 356 women delivering their first, singleton, cephalic, term birth between 1967 and 2020. Cesarean delivery was described by maternal age (5-year groups), onset of labor (spontaneous, induced and pre-labor CD), and time periods: 1967-1982, 1983-1998 and 1999-2020. We combined women's age, onset of labor and time period into a compound variable, using women of 20-24 years, with spontaneous labor onset during 1967-1982 as reference. Multivariable regression models were used to estimate adjusted relative risk (ARR) of cesarean delivery with 95% confidence interval (CI).ResultsOverall cesarean delivery increased both in women with and without spontaneous onset of labor, with a slight decline in recent years. The increase was mainly found among women < 35 years while it was stable or decreased in women > = 35 years. In women with spontaneous onset of labor, the ARR of CD in women > = 40 years decreased from 14.2 (95% CI 12.4-16.3) in 1967-82 to 6.7 (95% CI 6.2-7.4) in 1999-2020 and from 7.0 (95% CI 6.4-7.8) to 5.0 (95% CI 4.7-5.2) in women aged 35-39 years, compared to the reference population. Despite the rise in induced onset of labor over time, the ARR of CD declined in induced women > = 40 years from 17.6 (95% CI 14.4-21.4) to 13.4 (95% CI 12.5-14.3) while it was stable in women 35-39 years.ConclusionDespite growing number of Norwegian women having their first birth at a higher age, the increase in cesarean delivery was found among women < 35 years, while it was stable or decreased in older women. The increase in cesarean delivery cannot be solely explained by the shift to an older population of first-time mothers.

Dataset Information

Association between provider type and cesarean birth in healthy nulliparous laboring women: A retrospective cohort study.

Publications

Association between provider type and cesarean birth in healthy nulliparous laboring women: A retrospective cohort study.

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