Differences Among Obstetricians in Caesarean Section Rates

EDITORIAL COMMENT: The editor was once engaged in what was said to be the longest ever running case of medical investigation in Australia against an obstetrician whose Caesarean section rate was claimed to be excessive. The leading expert witnesses on both sides of the case were required to table the Caesarean section rates in their private practices. Who will be surprised to learn that both, including the editor, reported a rate above 20%. We are all charitable to ourselves when relating the high-risk nature of our private practices, with many women referred with previous Caesarean section or poor perinatal result. This paper is carefully restricted to low-risk nulliparas. In Melbourne, for a time, it was practice to notify each consultant of his/her Caesarean section rate and each was provided with an anonymous list of his/her colleagues' rates. In the Mc Bride case referred to above, the Judge asked the expert witness - 'do not the doctors in your institution with notification of low Caesarean rates fear accusation of malpractice?'
Summary: This retrospective study examined the Caesarean section rates of 15 obstetricians at 1 hospital delivering 5,559 nulliparas with a single cephalic baby of birth-weight ≥ 2,500 g. There was a wide variation in obstetricians' Caesarean rates, whether considering all their deliveries (5.5% to 20.1%), deliveries of their own patients (8.9% to 28.2%), or deliveries of their colleagues' patients (4.5% to 17.9%). There was no relation between Caesarean rates and perinatal outcome. The different Caesarean section rates among the obstetricians could not be explained by institutional factors, physician convenience, patient differences, or self-serving economic incentives.     

Depressive Symptoms and Birth Outcomes among Pregnant Teenagers

Study ObjectiveFew studies have examined the effects of maternal depressive symptoms among adolescent women. The purpose of this study was to investigate the impact of depressive symptoms on birth outcomes of infants born to adolescent mothers.DesignThe medical records of pregnant adolescent patients were examined. Information about maternal depressive symptoms and birth outcomes was collected.SettingData were collected at Washington Hospital Center, a nonprofit, community-based hospital that serves residents throughout the Washington, DC area.ParticipantsParticipants were 294 African-American and Latina adolescent mothers. Mean age was 16.2 years (standard deviation [SD] 1.4). Based on self-reports of depressive symptoms, adolescents were categorized by the following: no reported symptoms, depressive symptoms without SI/SA (suicidal ideation or attempt), and depressive symptoms with SI/SA.Main Outcome MeasuresInfant birth weight and gestational age at delivery.ResultsOver one-quarter of pregnant adolescents in this study reported symptoms of depression. Adolescents reporting depressive symptoms with SI/SA delivered babies that weighed 239.5 grams (98.3% confidence interval [CI] 3.9 to 475.1) less than babies born to mothers reporting depressive symptoms without SI/SA. There was no association between reported symptoms and gestational age.ConclusionsResults suggest that compared to nonpregnant teens and adults, pregnant teens may have an increased risk for depression. Additionally, pregnant adolescents with suicidal ideation are at greater risk for delivering infants of lower birth weight compared with teens reporting depressive symptoms without SI/SA and teens reporting no symptoms. This study supports the need for early screening and treatment of depression for young pregnant women.     

Hmong Women: Characteristics and Birth Outcomes, 1990

ABSTRACT: Current demographic characteristics and pregnancy outcomes of immigrant Hmong women in a small town in southeastern United States were documented in a retrospective study. Interviews and review of existing records were used to determine prenatal practices and perceived problems. Sixteen health professionals and two women from the community were interviewed, and the labor and delivery records from 1985 to 1990 were reviewed for parity, child spacing, and health status of the women and newborns. The greatest concerns voiced by health caregivers were multiparity and the need for contraceptive compliance. Seventy-eight full-term infants were born to 64 women in five years, with 2 stillbirths. No eclampsia, diabetes, or Rh incompatibilities were noted. Evidence is limited that birth frequency or outcome for Hmong women is a problem. Their perinatal difficulties were thought to be sociocultural rather than medical. Further study of the effects of acculturation on maternal family position, perinatal risks, and birth outcomes is imperative as lifestyle and environment change for these immigrant women.     

Differences Between Adnexal Torsion in Pregnant and Nonpregnant Women

Study ObjectiveTo compare the clinical manifestation, management, and outcome of adnexal torsion in pregnant and nonpregnant women.DesignRetrospective case-control study (Canadian Task Force classification II-3).SettingTertiary care university hospital.PatientsSixty-four pregnant women and 198 nonpregnant women with episodes of adnexal torsion.InterventionsSurgery to treat proved adnexal torsion.Measurements and Main ResultsThe mean (SD) gestational age in the pregnant group was 11.5 (7.7) weeks. Thirty six episodes of adnexal torsion in the pregnant group (56%) developed after treatment for infertility, compared with only 14 such episodes (7%) in the nonpregnant group (p < .001). A repeated episode of torsion occurred more frequently in the pregnant group (14% vs 4%; p = .03). Sonographic demonstration of multicystic ovaries was more common in pregnant women with recurrent torsion than in women with a single episode of torsion (86% vs 31%; p = .009). Tissue preservation was achieved more frequently in pregnant than in nonpregnant patients (95% vs 77%; p < .001), and the duration of surgery was 15 minutes shorter in the pregnant women (p < .001).ConclusionPregnancy after treatment for infertility is a risk factor for adnexal torsion. Recurrence of ovarian torsion occurs more frequently in pregnant patients, and in particular in enlarged multicystic ovaries.     

50例Rh阴性血型孕妇的妊娠结局分析

目的:探讨Rh阴性血型孕妇孕期处理、妊娠结局及其影响因素.方法:对住院分娩的50例Rh阴性孕妇进行回顾性分析,观察其临床特点、孕期处理及妊娠结局,并随机抽取同期分娩的50例Rh阳性孕妇作为对照组.结果:Rh阴性孕妇早产、新生儿高胆红素血症发生率均高于对照组,差异有高度统计学意义及统计学意义(P＜0.01,＜0.05);随孕产次增加围生儿溶血病发生率增高,差异有统计学意义(P＜0.05);ABO血型相合者较不相合者Rh血型抗体产生率要高,差异有统计学意义(P＜0.05);血浆置换、人血丙种免疫球蛋白及宫内输血可明显改善胎儿及新生儿溶血情况.结论:对Rh阴性妇女加强孕期监护,必要时抽脐血检查并积极给予血浆置换、宫内输血等综合治疗,可延长胎龄,提高围生儿的存活率和生存质量.     

Rh阴性孕妇妊娠结局的Meta分析

目的：分析Rh阴性孕妇的妊娠结局。方法：计算机检索中国知网、维普、万方、PubMed和Embase数据库，搜集有关Rh阴性孕妇妊娠结局的相关研究，检索时间均为1980年1月1日—2018年1月30日。由2名研究者按照纳入与排除标准筛选文献、提取资料和评价纳入研究的质量，采用RevMan 5.3软件进行Meta分析。结果：共纳入9篇文献，共4 122例研究对象，其中Rh阴性孕妇组679例，Rh阳性孕妇组3 443例。Meta分析结果显示，Rh阴性孕妇组新生儿高胆红素血症（RR=6.29，95%CI：3.64～10.85，P＜0.000 01）和早产（RR=3.05，95%CI：1.80～5.15，P＜0.000 1）的发生率均高于Rh阳性孕妇组。结论：Rh阴性孕妇发生新生儿高胆红素血症和早产的风险较高。因此，对Rh阴性孕妇要加强孕期监护，定期监测Rh抗体，以降低围生儿的各种并发症。     

Birth Outcomes Associated with Receipt of Group Prenatal Care Among Low‐Income Hispanic Women

Introduction: Although Hispanic women in the United States have preterm birth and low‐birth‐weight rates comparable to non‐Hispanic white women, their rates fall short of 2010 Healthy People goals, with variability found across states. This study examined the effectiveness of the CenteringPregnancy group prenatal care model in reducing preterm birth and low‐birth‐weight rates for Hispanic women. Methods: Pregnant Hispanic women at less than or equal to 20 weeks, gestation initiating prenatal care between January 2008 to July 2009 at 2 Palm Beach County, Florida, public health clinics selected either group or traditional prenatal care. Data on neonatal birth weight and gestational age were obtained through abstraction of Palm Beach County Health Department medical records. Records were abstracted for 97% of CenteringPregnancy (n = 150) and 94% of traditional care (n = 66) participants. Results: A statistically significant difference was found in the percentage of women giving birth to preterm neonates (5% group prenatal care vs 13% traditional care; P= .04). There were no statistically significant differences in the percentage of women having a low‐birth‐weight neonate when group and traditional care participants were compared. Discussion: The CenteringPregnancy model holds promise for improving the birth outcomes of Hispanic women. Future research should be conducted with larger sample sizes to replicate study findings using experimental designs and incorporating formal cost‐effectiveness analyses.     

Perinatal Outcomes of Women Intending to Give Birth in Birth Centers in Australia

Abstract: Background: A recent Australian study showed perinatal mortality was lower among women who gave birth in a birth center than in a comparable low‐risk group of women who gave birth in a hospital. The current study used the same large population database to investigate whether perinatal outcomes were improved for women intending to give birth in a birth center at the onset of labor, regardless of the actual place of birth. Methods: Data were obtained from the National Perinatal Data Collection (NPDC) in Australia. The study included 822,955 mothers who gave birth during the 5‐year period, 2001 to 2005, and their 836,919 babies. Of these, 22,222 women (2.7%) intended to give birth in a birth center at the onset of labor. Maternal and perinatal factors and outcomes were compared according to the intended place of birth. Data were not available on congenital anomalies, or cause, or timing of death. Results: Women intending to give birth in a birth center at the onset of labor had lower rates of intervention and of adverse perinatal outcomes compared with women intending to give birth in a hospital, including less preterm birth and low birthweight. No statistically significant difference was found in perinatal mortality for term babies of mothers intending to give birth in a birth center compared with term babies of low‐risk women intending to give birth in a hospital (1.3 per 1,000 births [99% CI = 0.66, 1.95] vs 1.7 per 1,000 births [99% CI = 1.50, 1.80], respectively). Conclusions: Term babies of women who intended to give birth in a birth center were less likely to be admitted to a neonatal intensive care unit or special care nursery, and no significant difference was found in other perinatal outcomes compared with term babies of low‐risk women who intended to give birth in a hospital labor ward. Birth center care remains a viable option for eligible women giving birth at term. (BIRTH 37:1 March 2010)     

Risk of Adverse Outcomes in Pregnant Women Exposed to Solvents

Objective: To compare maternal and live birth outcomes of women who received consultation services between 1990 and 1993 from the Wisconsin occupational reproductive health nurse consultant (76% of whom were solvent-exposed) and a sample of women and their offspring selected randomly from birth certificate records drawn from the same years.
Design: Historical cohort study.
Setting: Consultations occurred primarily through telephone contacts with pregnant women workers in Wisconsin. Birth certificate records were used to obtain additional information.
Participants: The convenience sample of largely solvent-exposed clients was compared with a random sample of women identified through birth records.
Main Outcome Measures: Relative risk (RR) estimates.
Results: Confounding by race, prenatal care, and gestational diabetes was controlled by stratification. Logistic regression was used to control for age differences. Clients had elevated RR estimates for pregnancy-induced hypertension (RR = 2.4) and hydramnios (RR = 5.2), and their offspring were more likely to have 5-minute Apgar scores less than 8 (RR = 3.6). All other outcomes thatwere examined, including prematurity, low birth weight, and birth defects, were similar between groups.
Conclusions: Most maternal and live birth outcomes were similar between the clients who sought consultation and the random sample of women. The current study supports previous research, which shows an elevated risk of pregnancy-induced hypertension associated with solvent exposure in women. The increased risk of hydramnios found in this largely solvent-exposed cohort was not found in the literature.     

A Review of Outcomes in Pregnant Women with Portal Hypertension

Background

The course of pregnancy in a woman with portal hypertension is a difficult one as it is associated with complications like variceal bleeding, splenic artery rupture and coagulopathy. All these pose a threat to a woman’s life. Although this condition is rare, every obstetrician should have a high index of suspicion when an antenatal mother presents with splenomegaly, thrombocytopenia or hematemesis. Hence, we aimed to review maternal and fetal outcomes in pregnant women with portal hypertension.

Methods

In a retrospective observational study, 41 women and 47 pregnancies were evaluated, from January 2000–December 2015 at Fernandez Hospital, a tertiary referral perinatal center. Maternal outcomes studied were variceal bleed during pregnancy, surgical procedures, morbidity and mortality. Neonatal variables were gestational age at delivery, birth weight and morbidities.

Results

Mean maternal age was 26.4 years. Average gestational age at delivery was 36.5 weeks. Mean birth weight was 2507.5 g. There were three maternal deaths out of 47 deliveries, the cause of death was massive variceal bleed in one, the second one was due to cardiac arrest on MRI table, and the third death was due to splenic hilar vessel bleed. There was one stillbirth, and no neonatal deaths.

Conclusion

A multidisciplinary approach is essential to improve perinatal outcomes in pregnancy complicated by portal hypertension. Surgical measures to reduce portal venous pressure done before pregnancy or beta blockers during pregnancy might help reduce sudden variceal bleeds.

     

Prevalence of Low Birth Weight,Premature Birth,and Stillbirth Among Pregnant Adolescents in Canada: A Systematic Review and Meta-analysis

Although most studies show that adolescent pregnant women are at a higher risk for adverse birth outcomes, there has been limited research examining this relationship in Canada. This systematic review and meta-analysis investigated the prevalence of low birthweight (LBW), preterm birth (PTB), and stillbirth in Canadian adolescent women compared to adult women. Studies were included if they were primary research and included a sample of adolescent mothers (≤19 years) and adult mothers (≥20 years) who gave birth to singleton infants in Canada. Birth outcomes must have been measured consistently in at least 3 studies for inclusion. Comprehensive electronic literature searches were conducted from database inception until August 2020 in 5 databases. Random effects meta-analysis models were used to estimate pooled odds ratios (pOR) for LBW, PTB, and stillbirth between adolescent and adult pregnant women. Outcomes reported included PTB (8 studies), LBW (6 studies), and stillbirth (3 studies). Compared to adult mothers, adolescent mothers had a 56% increase in the prevalence of LBW (pOR 1.56, 95% confidence interval [CI] 1.24, 1.97), a 23% increase in PTB (pOR 1.23, 95% CI 1.06, 1.42), a 20% increase in stillbirth (pOR 1.20, 95% CI 1.05, 1.37). Heterogeneity, as assessed by I², was high for LBW and PTB and was low for stillbirth. A subgroup analysis did not remove the high heterogeneity, and some studies did not adjust for confounding variables and were missing information on sociodemographic and behavioral factors. Future research is needed to investigate the mechanisms surrounding these differences by maternal age.     

Rates of Rubella Immunity Among Immigrant and Non-immigrant Pregnant Women

ObjectiveElimination of congenital rubella syndrome depends not only on effective childhood immunization but also on the identification and immunization of susceptible women of childbearing age. Since many countries do not immunize against rubella, it is possible that some immigrant women may not be immune. Moreover, contemporary estimates of rubella immunity among Canadian-born mothers are lacking.Accordingly, we sought to compare the immunity status in pregnancy of a large number of immigrant and Canadian-born women in Toronto.MethodsWe examined data among 5783 consecutive pregnant women who gave birth at an inner city hospital in downtown Toronto between 2002 and 2007. Antenatal maternal rubella immunity status was recorded at the time of delivery, and assessed according to the mother’s birthplace. Odds ratios (OR) for rubella immunity were adjusted for maternal age, gravidity and duration of residency in Canada.ResultsRelative to a rate of 93.2% among Canadian-born mothers, the adjusted risk of being rubella immune was lowest among women from Northern Africa and the Middle East (OR 0.54, 95% CI 0.31–0.94) and China and the South Pacific (OR 0.78, 95% CI 0.59–1.03).ConclusionRates of rubella immunity are lower than desired among Canadian-born and, especially, new immigrant pregnant women. Under-immunized populations might be identified at the time of the immigration medical examination, while consideration should be given to screening for rubella immunity among all young Canadian women before puberty.     

Maternal Area of Residence,Socioeconomic Status,and Risk of Adverse Maternal and Birth Outcomes in Adolescent Mothers

ObjectiveAdolescent pregnancy is a significant public health issue in Canada. Current evidence highlights the individual role of social determinants of health such as maternal residence and socioeconomic status (SES) on teen pregnancy outcomes. This study evaluated the joint association between residence/SES and adverse adolescent pregnancy outcomes.MethodsThis was a population-based retrospective cohort study of all singleton, live deliveries (2010-2015) from women aged 15 to 19 who were registered in the Alberta Perinatal Health Program. Information on maternal residence and SES was extracted from the Pampalon Material Deprivation Index data set. The study categorized mothers into four risk dyads: rural/high SES, rural/low SES, urban/high SES, and urban/low SES. Adjusted odds ratios (ORs) of adverse pregnancy outcomes were calculated in logistic regression models (Canadian Task Force Classification II-2).ResultsA total of 9606 births from adolescent mothers were evaluated. Thirty percent of adolescent mothers were classified as urban/high SES; 27% were urban/low SES; 7% were rural/high SES; and 36% were placed in the rural/low SES category. Compared with urban/high SES mothers, rural/low SES mothers had increased odds of postpartum hemorrhage (OR 1.57; 95% confidence interval [CI] 1.41–1.74), operative vaginal delivery (OR 1.37; 95% CI 1.18–1.60), Caesarean section (OR 1.39; 95% CI 1.19–1.62), large for gestational age infants (OR 1.39; 95% CI 1.16–1.66), low birth weight (OR 1.11; 95% CI 1.07–1.65), and preterm birth (OR 1.48; 95% CI 1.17–1.87).ConclusionRural pregnant adolescents of low SES have the highest odds for adverse pregnancy outcomes. Social determinants of health that affect adolescent pregnancies need further examination to identify high-risk subgroups and understand pathways to health disparities in this vulnerable population.     

Transfers Among Women Intending A Birth Center Delivery in the San Diego Birth Center Study

Using data from the San Diego Birth Center Study that enrolled underserved women between 1994 and 1996, we examined demographic, sociobehavioral, and medical predictors of hospital transfer in a group of women who intended to deliver at a freestanding birth center. Of the 1808 women, 34.6% transferred to the hospital antenatally and 19.6% transferred during labor, while 45.7% delivered at the birth center. Compared with multiparous women who had never had a cesarean and never had a previous hospital delivery, nulliparous women were 2.0 times more likely (95% confidence interval [CI], 1.4–2.7), multiparous women with a previous cesarean were 2.6 times more likely (95% CI, 1.7–3.8), and women without a previous cesarean but who had a previous hospital delivery were 2.1 times more likely (95% CI, 1.5–3.0) to transfer after adjusting for other predictors of transfer. Nulliparity, cesarean history and having a previous hospital delivery were among the strongest predictors of a hospital transfer even after adjusting for demographic, sociobehavioral, and other medical conditions. Understanding predictors of transfer may assist practitioners, patients, and policy makers in considering the appropriateness of individuals for birth center delivery or to target further education to reduce nonmedical transfers.     

Neighbourhood Family Income and Adverse Birth Outcomes Among Singleton Deliveries

ObjectiveTo assess the association between neighbourhood family income and adverse birth outcomes.MethodsWe conducted a retrospective cohort study of 334 231 singleton births during 2004 and 2006 based on the Niday Perinatal Database from Ontario. Median neighbourhood family incomes from the 2001 Canadian census were linked with the Niday Perinatal Database by dissemination areas. Generalized estimating equations were applied to estimate the odds ratios of adverse birth outcomes associated with lower neighbourhood income, with adjustment for maternal confounding variables at the individual level.ResultsCompared with the highest neighbourhood income quintile, mothers from the lowest quintile were at increased risk of having small for gestational age neonates (OR 1.51; 95% CI 1.46 to 1.57), low birth weight (OR 1.43; 95% CI 1.36 to 1.50), preterm birth (OR 1.17; 95% CI 1.12 to 1.23), low Apgar score (< 7) at five minutes (OR 1.32; 95% CI 1.21 to 1.44), and stillbirth (OR 1.39; 95% CI 1.19 to 1.62). The risks of women from the lowest income quintiles delivering a macrosomic baby (OR 0.81; 95% CI 0.79 to 0.84) or a large for gestational age baby (OR 0.82; 95% CI 0.80 to 0.85) were significantly decreased. No difference in risk of congenital anomaly was found among different income quintiles.ConclusionA lower level of neighbourhood income is associated with increased risks of small for gestational age babies, low birth weight, preterm birth, low Apgar score at five minutes, and stillbirth.