Brazilian women and physicians' viewpoints on their preferred route of delivery

OBJECTIVE: To describe women's preferred route of delivery and physicians' viewpoint on that. METHODS: A total of 656 women who gave birth in the National Health System hospitals of the state of S?o Paulo and Pernambuco and were enrolled in the Latin American Cesarean Section Study (ELAC) were interviewed. Of them, 230 women were selected from three intervention hospitals where patients routinely sought a second opinion when faced with the decision of undergoing a cesarean section, and 426 women were selected from control hospitals. Also, 72 physicians in the intervention hospitals and 70 in the control hospitals filled out a self-administered structured questionnaire. Data analysis was carried out using Mantel-Haenszel's chi-square test, Yates' test and Fischer's exact test. RESULTS: The majority of women reported preferring vaginal delivery than a cesarean section in both groups of hospitals. This preference was significantly higher among women who had had both vaginal delivery and cesarean section (nearly 90% in both groups of hospitals) compared to those who had cesarean sections only (72.8% in intervention hospitals and 77.8% in control hospitals). According to 45% physicians from intervention hospitals and 55% from control hospitals, most women who underwent cesarean sections are satisfied with that; 81% and 85% physicians from intervention and control hospitals, respectively, believed women prefer a cesarean sections out of fear of vaginal deliveries. CONCLUSIONS: The belief that the main reason for increasing cesarean section rates is fulfilling women's desire by their doctors seems to have no support. Better communication between physicians and pregnant women could possibly contribute to improve the current situation.     

The making of a medical tradition: vaginal birth after cesarean

By 1982, both the National Institutes of Health (NIH) and the American College of Obstetricians and Gynecologists had recommended that hospitals adopt policies favoring vaginal birth after cesarean (VBAC). Yet VBAC has since made only small inroads against repeat cesarean section and is primarily popular among progressive obstetricians and middle-class women wanting to experience natural childbirth and to avoid surgery. This study was undertaken to learn why, in hospitals permitting and ostensibly encouraging VBAC, some obstetrical patients choose 'trial of labor' for vaginal delivery, and others choose elective repeat cesarean section. Interviews with 100 women showed that the choice of a delivery method was largely influenced by the respondents' interactions with physicians, their reconstructions of the meanings of the previous cesarean section, and their personal ideologies about reproduction and motherhood. Ethnic minority women exhibited a greater preference for elective repeat cesarean than did white women. Caution is nevertheless urged in overinterpreting the significance of patient ethnicity for the continued popularity of elective repeat cesarean surgery.     

Mode of Childbirth in Low-Risk Pregnancies: Nicaraguan Physicians’ Viewpoints

To explore attitudes of physicians attending births in the public and private sectors and at the managerial level toward cesarean birth in Nicaragua. A qualitative study was conducted consisting of four focus groups with 17 physicians and nine in-depth interviews with decision-makers. Although study participants listed many advantages of vaginal birth and disadvantages of cesarean birth, they perceived that the increase in the cesarean birth rate in Nicaragua has resulted in a reduction in perinatal morbidity and mortality. They ascribed high cesarean birth rates to a web of interrelated provider, patient, and health system factors. They identified five actions that would facilitate a reduction in the number of unnecessary cesarean operations: establishing standards and protocols; preparing women and their families for labor and childbirth; incorporating cesarean birth rate monitoring and audit systems into quality assurance activities at the facility level; strengthening the movement to humanize birth; and promoting community-based interventions to educate women and families about the benefits of vaginal birth. Study participants believe that by performing cesarean operations they are providing the best quality of care feasible within their context. They do not perceive problems with their current practice. The identified causes of unnecessary cesarean operations in Nicaragua are multifactorial, so it appears that a multi-layered strategy is needed to safely reduce cesarean birth rates. The recent Nicaraguan Ministry of Health guidance to promote parto humanizado (“humanization of childbirth”) could serve as the basis for a collaborative effort among health care professionals, government, and consumer advocates to reduce the number of unnecessary cesarean births in Nicaragua.     

Variation in cesarean section rates among hospitals in Washington State.

OBJECTIVES. This study examined hospital characteristics and hospital population risk factors and their associations with hospital-specific cesarean section rates in Washington State. METHODS. Data were obtained from 1987 birth certificates. The study population included all hospitals that had 12 or more singleton live births. RESULTS. Hospital-specific cesarean section rates varied from 0% to 43% and were positively associated with proprietary ownership, size of delivery service, and the proportions of women who had complications or high-birthweight infants. The proportion of women who had late prenatal care was inversely associated with cesarean section rates. Although proprietary hospitals had higher cesarean section rates, their patient populations were lower risk than patients of public or teaching hospitals. CONCLUSIONS. Variation in cesarean section rates among hospitals cannot be fully explained by either hospital or patient population characteristics. A combined strategy may be necessary to lower unjustifiably high cesarean section rates.     

Effect of hospital volume on maternal outcomes in women with prior cesarean delivery undergoing trial of labor

The authors examined the association between hospital volume of vaginal birth after cesarean section (VBAC) and VBAC failure, uterine rupture, and maternal morbidity. This was a secondary analysis of data from a retrospective cohort study carried out from 1995 to 2000. Trained nurses extracted detailed information from the medical records of more than 25,000 women with a prior cesarean delivery from 17 community and tertiary-care hospitals in the northeastern United States. The study sample included 12,844 women with prior cesarean section who attempted vaginal delivery with a singleton birth. Annual hospital VBAC volume was divided into tertiles. Primary outcomes included VBAC failure, uterine rupture, and a composite measure of maternal morbidity. The authors used multivariable logistic regression to assess the association between hospital VBAC volume and adverse VBAC outcomes after controlling for confounders. The authors did not find evidence of an association between hospital VBAC volume and the likelihood of adverse outcomes in VBAC after adjustment for patient mix. Other risk factors consistent with prior research were identified, including induction of labor, >/=2 prior cesarean deliveries, preeclampsia, diabetes mellitus, and high birth weight. Prior vaginal delivery was protective against adverse VBAC outcomes. The risk of an adverse VBAC outcome in low-volume hospitals was comparable to that in high-volume hospitals.     

Transvaginal ultrasonographic assessment of the expulsion rate of intrauterine devices inserted in the immediate postpartum period: a pilot study

OBJECTIVE: To compare the expulsion rates of intrauterine devices (IUDs) inserted in the immediate postpartum after vaginal birth and cesarean section. METHODS: Nineteen patients who had a vaginal birth and 19 patients who had a cesarean section at Hospital de Clínicas de Porto Alegre, Brazil, were selected for copper T 380A IUD insertion. With the aim of detecting clinically unnoticed dislodged devices, ultrasound examinations were performed at 1 month and between 3 and 12 months after delivery. The IUDs were considered completely expelled when found outside the endometrial cavity (e.g., in the cervical canal) or outside the uterus (in the vagina). RESULTS: Expulsion rates were statistically different between the two groups: after a vaginal birth, 50% (ultrasound only) + 27.8% (clinical examination); and post-cesarean section, 0% (p < .001; OR 5.75, 95% CI 2.36-14.01). CONCLUSION: Considering that the contraceptive efficacy of IUDs is associated with their intrauterine location, the high expulsion rates seen when they are inserted immediately after vaginal delivery contraindicate their use in this setting. The use of IUDs immediately after a cesarean section is still a reasonable alternative because its expulsion rate was zero. Ultrasound assessment of IUD positioning performed better than clinical examination, which failed to detect expulsion after postpartum insertion in 75% of the cases (9 from 12 cases).     

An Examination of Cesarean and Vaginal Birth Histories Among Hispanic Women Entering Prenatal Care in Two California Counties with Large Immigrant Populations

Repeat cesarean delivery (CD) rates among US Hispanic women are the highest of all racial/ethnic groups (90%). Vaginal birth after cesarean (VBAC) is an alternative delivery method, but requires medical records documentation of a non-vertical incision and favorable conditions in the current pregnancy. VBAC rates for Hispanic women are extremely low. This study explores the birth histories and medical records access among Hispanic women in California, taking into account the potential role of immigration on access to VBAC. Study aims are to describe for a sample of Hispanic women: (1) CD and VBAC histories as well as history of vaginal delivery preceding CD; and (2) medical records access, among women who had previous births in Mexico. Chart review was conducted for prenatal patients from three safety net clinics in two California counties with large Mexican migrant populations between August, 2003 and February 2004—during which VBAC was widely available in these two counties to determine: obstetric histories, CD details, birthplace and whether or not medical records had been requested/obtained for CD. 355 multiparous Hispanic women were included. Thirty-three percent had a previous CD, almost two-thirds (64%) had only one CD. Over half of the women (55%) with 2+ births and CD history also reported a vaginal birth history. Medical records for CD were infrequently requested (29%). Of those requested, records were received for 77% of women with a US CD, compared with 13% of women with Mexican CD histories. Policies to address: (1) VBAC opportunities for low risk women, such as those with prior vaginal births and one CD, and (2) overcoming limited medical records access, could mitigate against unnecessary CD and associated medical expenditures and risks for future complications.     

Variability and consistency of rates of primary and repeat cesarean sections among hospitals in two states.

Hospitals in New York and Illinois have wide variations in their primary and repeat cesarean section rates. A number of factors account for these differences. To investigate whether hospitals with higher or lower rates tend to continue these patterns over time, their rates in 1988 were compared with those in 1983. It was found that a hospital''s cesarean section rate was consistent, but some regression to the mean process did occur. By 1988, teaching hospitals had lower rates than nonteaching hospitals; this difference is likely due to the greater response to calls for increasing trials of vaginal birth after a previous cesarean section by teaching hospitals. Over time this should contribute to further moderating of the rates. Data were from the Illinois and New York State Departments of Health.     

剖宫产术后阴道分娩成功因素及母婴结局的临床研究

目的探讨影响剖宫产术后阴道分娩成功的因素以及母婴结局。方法回顾性分析2013~2016年深圳市龙华新区人民医院收治的1 638名剖宫产术后阴道试产孕妇,根据阴道试产成功与否分为阴道分娩成功组(1 038名)和阴道试产失败组(600名)。对比两组的产后出血率、子宫破裂率以及新生儿窒息率,总结影响剖宫产术后阴道分娩相关因素,影响母婴结局的相关因子。结果孕妇剖宫产术后阴道分娩情况与年龄、产前体质量指数(body mass index,BMI)、入院宫口的扩张情况、上次剖宫产手术时间、是否紧急入院及有无阴道分娩史之间有关联;两组孕妇的产后出血率、子宫破裂率及新生儿窒息率比较差异均有统计学意义(P0.05)。结论剖宫产术后阴道分娩成功与孕妇年龄≤35岁、产前BMI30 kg/m~2、距离上次剖宫产手术时间10年、有阴道分娩史、紧急入院以及入院时宫口扩张≥6 cm密切相关。     

Uterine scars and subsequent vaginal birth: follow-up of 73 parturients in the Central Maternity Hospital of Bangui (Central African Republic)

Uterine rupture is a threat during vaginal deliveries of women with uterine scars from previous caesarean deliveries or other surgery. Special prudence among this group has resulted in a rise of cesarean rates in developed countries but also in Africa. The lack of available data in this domain in our country led us to conduct this preliminary study, with the objectives of: determining the frequency of deliveries among these patients and of the complications associated with them; identifying some of the risk factors and assessing maternal and fetal prognosis. This should facilitate further studies to determine the management attitudes most appropriate to the realities of our health system. We conducted a cross-sectional study during the last six months of 1999 at the central maternity hospital in Bangui. We included in this study only women with previous caesarean scars giving birth again during the study period. We followed them from admission to the labour room until discharge, without intervening in their delivery. Structured questionnaires enabled us to collect data on clinical, social and demographic variables. We recorded 74 births, including one set of twins, among the 73 parturient subjects. Vaginal delivery occurred in 45 cases (60.8%), and caesarean in 29. Women with a single uterine scar gave birth by vaginal delivery significantly more often than they had caesareans. We recorded 7 cases of uterine rupture, most often associated with a birth interval less than 2 years. One uterine rupture led to the mother's death. Perinatal mortality was 10.8%: no newborn survived these uterine ruptures. Vaginal delivery remains possible for women with uterine scars when adequate monitoring of a trial of labor is available and on condition that the pelvis is normal and the birth interval exceeds two years.     

The decision of women for cesarean birth: a case study in two units of the supplementary health care system of the State of Rio de Janeiro

Cesarean section rates are very high in Brazil mainly in private hospitals, probably due to socioeconomic and cultural factors. The objective of this study was to describe socioeconomic, demographic, cultural and reproductive characteristics of women in the postpartum period and the factors that had determined their decision for caesarean section in two units of the supplementary health care system of the State of Rio de Janeiro. The study population was composed of 437 women that had vaginal or caesarean childbirths in the two selected units. Data were collected by means of interviews with mothers and consultation of hospital records. The factors associated with the decision for cesarean section as mode of delivery were evaluated using non-conditional logistic regression analysis and following the hierarchic models established at three definite moments. Although 70% of the women had no initial preference for cesarean section, 90% of them had this mode of birth. It was verified that, despite their initial desire, the interaction with the health services resulted in cesarean section as mode of birth. Educative actions directed to pregnant women and to the public at large as well as changes in the childbirth care model can be promising strategies for reverting this picture.     

Impact of the HealthChoice Program on Cesarean Section and Vaginal Birth after C-Section Deliveries: A Retrospective Analysis

Objective To assess the impact of the HealthChoice program in Maryland on cesarean section and vaginal birth after C-section deliveries. Study Design Pre-post design using a comparison group with Maryland State Inpatient Databases, part of the Healthcare Cost and Utilization Project, developed by the Agency for Healthcare Research and Quality. Although the combined 1995 and 2000 database contained over 1.2 million inpatient discharge records, the analysis included all hospital discharge abstracts for women in labor. To identify the delivery, Diagnoses-Related Groups (DRGs) 370–375 were used from the discharge data. Together, there were 128,743 births identified in both years. Methods Pregnant women enrolled in Medicaid managed care were compared pre-implementation and post implementation with pregnant women delivering babies under private insurance. The analysis computed difference-in-differences estimates using a logistic regression model that controlled for maternal characteristics, payment source, labor and delivery complications, and hospital characteristics. The outcome variables included Primary Cesarean, Repeat Cesarean, and Vaginal Birth after C-section. Results These results suggest that Medicaid managed care enrollees were less likely to undergo cesarean section deliveries relative to privately insured beneficiaries. Medicaid MCOs may have done a better job of limiting the growth in overused procedures than did MCOs and providers for privately insured women. Conclusion This study has shown that there has been an overall increase in the use of primary and repeat cesarean sections in Maryland hospitals. However, HealthChoice limited this increase for Medicaid enrollees relative to privately insured women. On the other hand, vaginal births after C-section have declined in Maryland.     

Vaginal birth after cesarean birth--California, 1996-2000

In 2000, of all births in the United States, 23% were cesarean, approximately 37% of which were repeat cesarean births (i.e., births to women who had a previous cesarean birth). Approximately 60% of cesarean births might be by elective repeat cesarean delivery (ERCD). Because cesarean birth is associated with higher maternal morbidity than routine vaginal birth, two of the national health objectives for 2010 are to reduce the cesarean birth rate among women at low risk to 15% of women who are giving birth for the first time (objective no. 16-9a) and to 63% of women with previous cesarean births (objective no. 16-9b). A key strategy to reduce the repeat cesarean birth rate is to promote vaginal birth after cesarean (VBAC) as an alternative to ERCD. Achieving the national health objective for 2010 will require increasing the VBAC rate to 37%. During 1989-1999, VBAC rates in the United States increased from 19% in 1989 to 28% in 1996 and then decreased to 23% in 1999. This report summarizes an analysis of California's VBAC rates during 1996-2000, which indicates that the VBAC rate in California decreased by 35%, from 23% in 1996 to 15% in 2000. Strategies to improve VBAC rates might include educating women about the risks for complications and benefits of VBAC, ensuring careful selection of VBAC candidates, developing guidelines for management of labor, and educating health-care providers about reducing VBAC risks.     

Obstetric delivery and risk of neonatal mortality in Goiânia in 2000, Brazil

OBJECTIVE: To determine factors associated to vaginal delivery and increased neonatal mortality in cohort studies of newborns. METHODS: A retrospective cohort study was carried out using linkage data from the Information System on Live Births and Mortality Data System database, which included all newborns in Goiania for the year 2000. A stratified analysis of delivery routes and maternity hospitals by risk factors of neonatal mortality was conducted through the calculation of relative risk at a 5% significance level. Statistical analyses were carried out using the Chi-square test at a 5% significance level. RESULTS: Vaginal deliveries were more commonly seen than cesarean sections in situations where there was an increased risk of neonatal mortality. Public hospitals, where vaginal deliveries predominated, were sought by the majority of those pregnant women with an increased risk of neonatal mortality. Private hospitals, not affiliated to the public-funded Brazilian Healthcare System (SUS) and where the incidence of cesarean section was as high as 84.9%, opted for vaginal delivery in situations of greater risk, such as extreme prematurity and very-low-birth-weight infants. CONCLUSIONS: The association between vaginal delivery and increase neonatal mortality resulted from a selection bias due to the distribution of pregnant women in the hospital network. In addition, this selection bias also resulted from an almost universal preference for cesarean sections in low-risk pregnancies as opposed to vaginal delivery for pregnancies with an increased risk of neonatal mortality.     

瘢痕子宫再次妊娠60例的处理

目的探讨瘢痕子宫孕妇再次妊娠的临床处理方式。方法选取该院收治的瘢痕子宫再次妊娠孕妇60例,对其临床资料进行回顾性分析。结果 24例行阴道试产,其中20例成功,4例阴道试产失败后改为剖宫产。36例直接行剖宫产术,剖宫产原因包括社会因素、巨大儿、子痫前期等。阴道分娩与剖宫产新生儿Apgar评分对比差异不具有统计学意义(P>0.05),阴道分娩阴道出血量、住院时间以及住院费用均明显少于剖宫产。结论合理选择瘢痕子宫再次妊娠分娩方式对于改善的围生儿和产妇的预后具有重要作用,对于符合阴道试产条件的孕妇,可在严密监护下行阴道试产,可有效降低再次剖宫产率,利于产妇产后恢复。     

Financial incentives do not always work: an example of cesarean sections in Taiwan

OBJECTIVES: To test the hypothesis that cesarean sections are less likely to be performed after equalizing the fees for vaginal births and cesarean sections. METHODS: Population-based National Health Insurance inpatient claims in Taiwan are used. Pre-periods and post-periods are identified to investigate the impact of the policy changes. Logistic regressions are employed. RESULTS: The cesarean section rates for the first, second and higher-order births are 29, 37.4 and 39.3%, while the primary cesarean section rates are 29, 11.8 and 12.1%, respectively. After taking into consideration the case-mix and birth order, the second and higher-order births were approximately 60% less likely to be cesarean deliveries compared to the first births and the increase in the VBAC fee had an additional negative effect on them. A fee equalization policy was not found to influence the cesarean delivery. The total cesarean section rate was primarily determined by the cesarean section rate for the first birth. CONCLUSIONS: Cesarean section rates are greater for the higher-order births because of the practice "once a cesarean section, always a cesarean section". Against the background of a rapidly declining fertility rate, females play a more important role in the mode of delivery than ever before. As such, financial incentives designed specifically for obstetricians do not have the desired impact. Policies that are aimed at altering behavior should be designed within the social context.     

Changing physicians’ incentives to control the C-section rate: Evidence from a major health care reform in Iran

We evaluate the effect of a major health care policy in public hospitals which changed the demand and supply side incentives for c-section procedures in 2014 in Iran, where the c-section rate at the time was 55%. Following the reform, vaginal delivery became free for patients. The policy also introduced financial incentives to doctors for performing vaginal deliveries and set a cap on their maximum c-section rate. We show that supply side incentives had a major role in the effectiveness of the programme, after which the national rate reduced by 6 percentage points. This reduction was mainly driven by first-birth mothers. The reform also shifted doctors with high c-section rates out of public hospitals. We cannot find any adverse effect on Apgar score, hospitalisation or mortality; however, gestation length and birth weight significantly increased.     

Cesarean sections: who wants them and under what circumstances?

Brazil has extremely high cesarean rates. Among related factors, it has been suggested that a "culture of cesarean childbirth" (or a preference for this type of delivery) exists among Brazilian women. Our study investigates this notion. Data were collected from September 1998 to March 1999 in two maternity hospitals in Rio de Janeiro Interviews were conducted and hospital records analyzed for a random representative sample of 909 women who had just given birth (454 vaginal deliveries and 455 cesareans). In the interviews, when asked if they had wanted to have a cesarean, 75.5% replied in the negative, thus indicating that these women cannot be considered as adhering to a "culture of cesarean sections" The main complaints against cesareans were: slower and more difficult recovery (39.2%) and greater pain and suffering (26.8%). However, 17% of the sample had at some point requested a cesarean, 75% of whom during labor. Analysis revealed that the request for a cesarean section is directly proportional to time between admission to the hospital and delivery. This suggests that (in addition to being the usual means of access to tubal ligation) the actual circumstances of birthing are important factors in Brazilian women s requests for cesarean sections.