The influence of obstetric intervention on trends in twin stillbirths: United States, 1989–99

Objective: Although twin stillbirth rates have declined substantially over the past two decades, the contribution of changes in obstetric interventions to reducing twin stillbirths has not been quantified.

Methods: We carried out a retrospective cohort study of twin live births and stillbirths in the United States between 1989 and 1999 (n?=?1?102?212). Changes in the rate of stillbirth (???22 weeks) before and after adjustment for changes in labor induction, Cesarean delivery and sociodemographic factors were estimated through ecological logistic regression analysis. This analysis was based on aggregating data by each state within the United States.

Results: Between 1989 and 1999, rates of labor induction and Cesarean delivery among twin live births increased by 138% (from 5.8% to 13.8%) and 15% (from 48.3% to 55.6%), respectively. These changes were accompanied by a 43% decline in the stillbirth rate between 1989 and 1999 (from 24.4 to 13.9 per 1000 fetuses at risk). After excluding births weighing <?500?g, rates of labor induction among twins at 22–27 weeks', 28–33 weeks' and ??34 weeks' gestation increased by 95%, 131% and 127%, respectively, between 1989 and 1999. Cesarean delivery rates also increased by 55%, 29% and 2% in these same gestational age categories. The 48% (relative risk (RR) 0.52, 95% confidence interval (CI) 0.49–0.55) decline in stillbirth rate between 1989–91 and 1997–99 was reduced to a 25% (RR 0.75, 95% CI 0.72–0.79) decline after adjustment for changes in labor induction and Cesarean delivery. The decline in the rate of twin stillbirths was larger at later gestational ages (at ??32 and ??34 weeks) where the largest absolute increases in labor induction rates were observed.

Conclusions: The use of Cesarean delivery and especially labor induction for twin pregnancies has increased substantially in the United States over the last decade and these changes have been associated with a large decline in the rate of stillbirth among twins.     

Trends in twin neonatal mortality rates in the United States, 1989 through 1999: influence of birth registration and obstetric intervention

OBJECTIVE: We sought to evaluate the contributions of changes in birth registration, labor induction, and cesarean delivery on trends in twin neonatal mortality rates. STUDY DESIGN: We conducted a population-based, retrospective cohort study of twin live births, using linked birth-infant death data in the United States (1989-1999). Relative risks and 95% confidence intervals that quantified changes in neonatal (0-27 days) mortality rates were derived from ecologic logistic regression models that were fit after aggregation of the data by each state in the United States. RESULTS: The frequency of live born twins who weighed <500 g increased 72%, from 0.7% in 1989 to 1.2% in 1999, of live born twins who weighed 500 to 749 g and 750 to 999 g increased by 55% and 28%, respectively, between 1989 and 1999. Preterm birth rates increased by 19%, from 46.2% in 1989 to 57.2% in 1999. The rate of labor induction increased from 5.8% to 13.9%, and the cesarean delivery rate increased from 49.8% to 56.3%. Between 1989 to 1991 and 1997 to 1999, the crude neonatal mortality rates among twins who weighed >or=500 g declined by 37% (95% CI, 35%-40%) from 21.5 to 13.6 per 1000 twin live births. Adjustments for preterm labor induction, preterm cesarean delivery, term labor induction, term cesarean delivery, and sociodemographic factors had little influence on neonatal mortality rate trends. CONCLUSION: Increases in preterm birth because of obstetric intervention among twins have not led to increases in twin neonatal mortality rates in the United States.     

Causes and consequences of recent increases in preterm birth among twins.

OBJECTIVE: To examine the causes and consequences of the recent increase in preterm birth among twins. METHODS: We studied all twin births among residents of the province of Nova Scotia, Canada, between 1988 and 1997. Rates of preterm birth, preterm labor induction, preterm cesarean, small-for-gestational age (SGA), respiratory distress syndrome (RDS), stillbirth, perinatal mortality, and infant mortality were compared between past and more recent years. Changes in perinatal mortality were examined using logistic regression to adjust for the effects of other determinants. RESULTS: The study included 2516 twin births (73 stillbirths and 2443 live births). The rate of preterm birth increased from 42.3% in 1988-1992 to 48.2% of twin live births in 1993-1997 (14% increase, P =.04). Twin live births born after preterm labor induction increased from 3.5% in 1988-1989 to 8.6% in 1996-1997 (P for trend =.007). Of live births between 34 and 36 weeks' gestation, the proportion born SGA decreased from 17.5% in 1988-1992 to 9.2% in 1993-1997 (P =.005). Over the same period, rates of prophylactic maternal steroid therapy increased substantially and rates of RDS declined. Perinatal mortality rates among pregnancies reaching 34 weeks decreased from 12.9 per 1000 total births in 1988-1992 to 4.2 per 1000 total births in 1993-1997 (P =.05). CONCLUSION: Increases in preterm labor induction appear to be responsible for the recent increase in preterm birth among twins. These changes have been accompanied by decreases in perinatal morbidity and mortality among twin pregnancies that reach 34 weeks' gestation.     

Obstetric intervention,stillbirth, and preterm birth

Despite widespread recognition that preventing preterm birth is the most important perinatal challenge facing industrialized countries, preterm birth has increased steadily in recent years. This article examines the relation between trends in preterm birth, preterm labor induction/cesarean delivery, stillbirth, and infant mortality. The recent rise in preterm birth in the United States and Canada has been mainly due to increases in mild preterm birth (34-36 weeks). Live births at 34 to 36 weeks' gestation have increased largely as a consequence of increases in preterm induction and preterm cesarean delivery among women at high risk for adverse pregnancy outcomes. Increased obstetric intervention at 34 to 36 weeks' gestation appears to have led to larger-than-expected temporal declines in stillbirth rates at this gestation. Infant mortality rates have declined overall and also among live births at 34 to 36 weeks' gestation. Obstetric intervention at preterm gestation, when indicated, can prevent stillbirth and reduce infant morbidity and mortality despite the increasing rates of preterm delivery.     

Trends in twin births in New South Wales, Australia, 1990-1999.

OBJECTIVE: To examine trends in gestational age and the mode of delivery of twins. METHOD: All twin births in New South Wales, Australia from 1990 through 1999 were analyzed. RESULTS: Twin births increased from 1922 (2.2%) in 1990 to 2522 (2.9%) in 1999. Twins born preterm (<37 weeks) increased from 40.8 to 48.8%. The increase in preterm twin births was associated with increases in induction of labor and cesareans before labor at 32-36 weeks. The rate of fetal deaths decreased by 49% and Apgar scores <4 at 5 min by 28%. CONCLUSIONS: A greater than expected increase in preterm twins was largely explained by an increase in elective deliveries at 35-36 weeks' gestation. Increasing maternal age does not appear to have contributed to the increase in preterm twin births. Lower rates of fetal death and low Apgar scores were achieved seemingly at the price of delivering more infants before term.     

The impact of route of delivery and presentation on twin neonatal and infant mortality: a population-based study in the USA, 1995-97.

OBJECTIVE: We examined whether the route of delivery for near-term (> or = 34 weeks' gestation) twins, as candidates for vaginal delivery, affected neonatal and infant mortality rates. We further evaluated whether these mortality rates were modified by fetal presentation. METHODS: A population-based retrospective cohort study based on the matched multiple births data in the USA (1995-97) was performed. Analyses were restricted to non-malformed liveborn twins delivered at (> or = 34 weeks' gestation. Twins with breech-breech and breech-vertex presentations were excluded, since they are not candidates for vaginal delivery. Neonatal mortality rates (death within the first 27 days) and post-neonatal mortality rates (death between 28 and 365 days) per 1000 twin live births, by route of delivery and fetal presentation, were derived. The associations between neonatal mortality, post-neonatal mortality and the route of delivery for vertex-breech versus vertex-vertex presentations were expressed based on relative risks (RR) and 95% confidence intervals (CI) derived from logistic regression models based on the method of generalized estimating equations. RESULTS: Of the 177,622 twins analyzed, 87% (n = 154,531) presented as vertex-vertex. Fifty-five per cent (n = 97,692) of twins were both delivered vaginally, 41% (n = 72,825) were both delivered by Cesarean section and, of the remaining 4% (n = 7,105), the first twin was delivered vaginally and the second by Cesarean section. Twins with vertex-breech presentations delivered by Cesarean-cesarean sections, as well as those with vertex-vertex presentations delivered vaginally, had the lowest neonatal mortality rate (1.6 per 1000 live births). The highest neonatal mortality rate in the vertex-breech pairs occurred with vaginal-Cesarean deliveries (2.7 per 1000 live births). Among twins with vertex-vertex presentations, twins delivered via the vaginal-Cesarean route experienced the highest neonatal mortality (3.8 per 1000 live births). The RR for neonatal mortality in this group was 2.24 (95% CI 1.35, 3.72) compared with twins both delivered vaginally. CONCLUSION: Route of delivery and fetal presentation both confer an impact on twin infant mortality rates. Strategies to reduce discordant routes in complicated vaginal deliveries may lead to improved neonatal survival.     

Life-table analysis of the risk of perinatal death at term and post term in singleton pregnancies

OBJECTIVE: This study was undertaken to estimate the cumulative risk of perinatal death associated with delivery at each gestational week both at term and post term. STUDY DESIGN: The numbers of antepartum stillbirths, intrapartum stillbirths, neonatal deaths, and surviving neonates delivered at between 37 and 43 weeks' gestation in Scotland, 1985-1996, were obtained from national databases (n = 700,878) after exclusion of multiple pregnancies and deaths caused by congenital abnormality. The numbers of deaths at each gestational week were related to appropriate denominators: antepartum stillbirths were related to ongoing pregnancies, intrapartum stillbirths were related to all births (excluding antepartum stillbirths), and neonatal deaths were related to live births. The cumulative probability of perinatal death associated with delivery at each gestational week was estimated by means of life-table analysis. RESULTS: The gestational week of delivery associated with the lowest cumulative risk of perinatal death was 38 weeks' gestation, whereas the perinatal mortality rate was lowest at 41 weeks' gestation. The risk of death increased more sharply among primigravid women after 38 weeks' gestation because of a greater risk of antepartum stillbirth. The relationships between risk of death and gestational age were similar for the periods 1985-1990 and 1991-1996. CONCLUSION: Delivery at 38 weeks' gestation was associated with the lowest risk of perinatal death.     

Prospective risk of stillbirth.

Some fraction of any cohort of fetuses alive at a given gestational age will ultimately die before birth. The residual prospective risk of stillbirth as a function of gestational age was calculated from records of the New York City Department of Health covering 370,051 reported births between 1987-1989, including 2454 stillbirths. In the general population, the prospective risk of stillbirth at 26 weeks was one in 150 and, because the time distributions of live births and stillbirths were not proportionate, the risk changed with gestational age. By 40 weeks' gestation, it was one in 475, rising progressively thereafter to one in 375 at 43 weeks. The prospective risk of stillbirth was elevated in certain ethnic groups and increased significantly with advanced maternal age, multiple gestation, and lack of prenatal care. The prospective risk of stillbirth is an important consideration in decisions regarding timing of delivery.     

Seventy-one quadruplet pregnancies: management and outcome

This article reviews the epidemiology, management, and outcome of 71 quadruplet pregnancies that occurred between 1980 and 1989. A study of detailed medical questionnaires and medical records revealed that 67 (94%) of the pregnancies followed ovulation induction therapy. A majority of the pregnancies were diagnosed by 9.3 weeks' gestation and bed rest was instituted by 16.7 weeks; 14% of women had cervical cerclages. Tocolytic agents were used in 59 (83%) of the group beginning at 24.5 weeks' gestation. The mean gestational age at delivery was 31.4 weeks and the mean birth weight was 1482 gm. Cesarean sections were performed in 89% of the cases. The average maternal weight gain was 45.8 pounds. Of the 284 fetuses, there were six first-trimester losses (including one ectopic pregnancy), 10 stillbirths and 33 neonatal deaths, resulting in a stillbirth rate of 29 per 1000, and corrected neonatal and perinatal mortality rates of 37 per 1000 and 67 per 1000, respectively. Other than premature labor, the most common maternal complications were first-trimester bleeding (35%), toxemia (32%), and anemia (25%). The quadruplet fetal growth curve parallels the singleton 25th percentile until 34 weeks, when it drops below the 10th percentile. These data suggest that a majority of quadruplets are delivered after 28 weeks and a viable outcome is expected. Because of retarded growth after 34 weeks, delivery should be considered at 34 weeks in most cases.     

Recent trends and patterns in cesarean and vaginal birth after cesarean (VBAC) deliveries in the United States

Cesarean delivery is the most common major surgical procedure for women in the United States, with 1.4 million surgeries annually. In 2008, nearly one-third (32.3%) of US births were by cesarean delivery. Cesarean delivery rates have increased rapidly in the United States in recent years because of an increasing primary cesarean delivery rate and a declining vaginal birth after cesarean (VBAC) rate. In 2007, the VBAC rate was 8.3% in a 22-state reporting area. The US VBAC rate was lowest among 14 industrialized countries; 3 countries had VBAC rates greater than 50%.     

Intrapartum stillbirth in a Nigerian tertiary hospital setting

OBJECTIVE: To examine the nonmedical events contributing to intrapartum stillbirths in an African setting. METHODS: Retrospective analysis of the records of women who had intrapartum stillbirths at the University of Nigeria Teaching Hospital, Enugu, from January 1999 to December 2007. The events surrounding the delivery of these women were critically analyzed and statistically compared with those who had live births to determine the nonmedical factors contributing to the stillbirths. RESULTS: The overall stillbirth rate was 89 per 1000 births. The intrapartum stillbirth rate was 52.1 per 1000 births. Nonmedical factors contributing to stillbirths included delays in receiving appropriate management, inadequate intrapartum monitoring, inappropriate interventions, and wrong diagnosis. All 3 types of delay were significantly associated with intrapartum stillbirth (P=0.0001). CONCLUSION: Intrapartum stillbirth accounts for the majority of stillbirths in this setting. Avoidable delays, suboptimal intrapartum monitoring, and inappropriate interventions contribute to the majority of intrapartum stillbirths in Nigeria.     

Incidence of stillbirth and perinatal mortality and their associated factors among women delivering at Harare Maternity Hospital, Zimbabwe: a cross-sectional retrospective analysis

BACKGROUND: Death of an infant in utero or at birth has always been a devastating experience for the mother and of concern in clinical practice. Infant mortality remains a challenge in the care of pregnant women worldwide, but particularly for developing countries and the need to understand contributory factors is crucial for addressing appropriate perinatal health. METHODS: Using information available in obstetric records for all deliveries (17,072 births) at Harare Maternity Hospital, Zimbabwe, we conducted a cross-sectional retrospective analysis of a one-year data, (1997-1998) to assess demographic and obstetric risk factors for stillbirth and early neonatal death. We estimated risk of stillbirth and early neonatal death for each potential risk factor. RESULTS: The annual frequency of stillbirth was 56 per 1,000 total births. Women delivering stillbirths and early neonatal deaths were less likely to receive prenatal care (adjusted relative risk [RR] = 2.54; 95% confidence intervals [CI] 2.19-2.94 and RR = 2.52; 95% CI 1.63-3.91), which for combined stillbirths and early neonatal deaths increased with increasing gestational age (Hazard Ratio [HR] = 3.98, HR = 7.49 at 28 and 40 weeks of gestation, respectively). Rural residence was associated with risk of infant dying in utero, (RR = 1.33; 95% CI 1.12-1.59), and the risk of death increased with increasing gestational age (HR = 1.04, HR = 1.69, at 28 and 40 weeks of gestation, respectively). Older maternal age was associated with risk of death (HR = 1.50; 95% CI 1.21-1.84). Stillbirths were less likely to be delivered by Cesarean section (RR = 0.64; 95% CI 0.51-0.79), but more likely to be delivered as breech (RR = 4.65; 95% CI 3.88-5.57, as were early neonatal deaths (RR = 3.38; 95% CI 1.64-6.96). CONCLUSION: The frequency of stillbirth, especially macerated, is high, 27 per 1000 total births. Early prenatal care could help reduce perinatal death linking the woman to the health care system, increasing the probability that she would seek timely emergency care that would reduce the likelihood of death of her infant in utero. Improved quality of obstetric care during labor and delivery may help reduce the number of fresh stillbirths and early neonatal deaths.     

The changing epidemiology of multiple births in the United States

OBJECTIVE: To describe changes in the epidemiology of multiple births in the United States from 1980 to 1999 by race, maternal age, and region; and to examine the impact of these changes on birth weight-specific infant mortality rates for singleton and multiple births. METHODS: Retrospective univariate and multivariable analyses were conducted using vital statistics data from the National Center for Health Statistics. RESULTS: Between 1980 and 1999, the overall multiple birth ratio increased 59% (from 19.3 to 30.7 multiple births per 1000 live births, P <.001), with rates among whites increasing more rapidly than among blacks. Women of advanced maternal age, especially those aged 30-34, 35-39, and 40-44 experienced the greatest increases (62%, 81%, and 110%, respectively). Although all regions of the United States experienced increases in multiple birth ratios between 1991 and 1999, the Northeast had the highest twin (33.9 per 1000 live births) and higher order birth ratios (280.5 per 100,000 live births), even after adjusting for maternal age and race. Between 1989 and 1999, multiple births experienced greater declines in infant mortality than singletons in all birth weight categories. Consequently, very low birth weight and moderately low birth weight infant mortality rates among multiples were lower than among singletons. CONCLUSION: It is important to understand the changing epidemiology of multiple births, especially for women at highest risk (advanced maternal age, white race, Northeast residents). The attribution of infertility management requires further study. The differential birth weight-specific infant mortality for singletons and multiples demonstrates the importance of stratifying by plurality when assessing perinatal outcomes.     

Trends and determinants of stillbirth in developing countries: results from the Global Network’s Population-Based Birth Registry

Background

Stillbirth rates remain high, especially in low and middle-income countries, where rates are 25 per 1000, ten-fold higher than in high-income countries. The United Nations’ Every Newborn Action Plan has set a goal of 12 stillbirths per 1000 births by 2030 for all countries.

Methods

From a population-based pregnancy outcome registry, including data from 2010 to 2016 from two sites each in Africa (Zambia and Kenya) and India (Nagpur and Belagavi), as well as sites in Pakistan and Guatemala, we evaluated the stillbirth rates and rates of annual decline as well as risk factors for 427,111 births of which 12,181 were stillbirths.

Results

The mean stillbirth rates for the sites were 21.3 per 1000 births for Africa, 25.3 per 1000 births for India, 56.9 per 1000 births for Pakistan and 19.9 per 1000 births for Guatemala. From 2010 to 2016, across all sites, the mean stillbirth rate declined from 31.7 per 1000 births to 26.4 per 1000 births for an average annual decline of 3.0%. Risk factors for stillbirth were similar across the sites and included maternal age < 20 years and age > 35 years. Compared to parity 1–2, zero parity and parity > 3 were both associated with increased stillbirth risk and compared to women with any prenatal care, women with no prenatal care had significantly increased risk of stillbirth in all sites.

Conclusions

At the current rates of decline, stillbirth rates in these sites will not reach the Every Newborn Action Plan goal of 12 per 1000 births by 2030. More attention to the risk factors and treating the causes of stillbirths will be required to reach the Every Newborn Action Plan goal of stillbirth reduction.

Trial registration

NCT01073475.

     

Labor induction for the preterm severe pre-eclamptic patient: is it worth the effort?

OBJECTIVE: The purpose of this study was to examine the success rate of labor induction in patients with severe pre-eclampsia delivered at < or = 34 weeks' gestation; to identify factors associated with its success; and to evaluate neonatal outcomes based on induction success or failure. METHODS: We identified pregnancies complicated by severe pre-eclampsia delivered at < or = 34 weeks' at our institution from 1991 to 1998. Women who underwent labor induction and had successful vaginal delivery were compared to those who underwent labor induction, but required Cesarean delivery. Multiple logistic regression analyses were performed to assess factors associated with successful induction and neonatal outcome. RESULTS: Over the 7-year study period, there were 215 patients meeting the criteria. Sixty-four (29.8%) did not undergo a labor attempt; 69 of 151 (46%) women who underwent labor induction achieved vaginal delivery. Labor induction was successful in 0%, 6.6%, 35.3% and 68.5% of cases at 24-26, 27-28, 29-31 and 32-34 weeks' gestation, respectively. By logistic regression the only factor positively associated with successful induction was gestational age at delivery (p = 0.001), while induction for non-reassuring fetal testing was inversely associated (p = 0.02). Induction attempt, failed induction and delivery mode were not associated with increased neonatal morbidity. CONCLUSIONS: In women with severe pre-eclampsia remote from term, attempted labor induction did not appear to increase neonatal morbidity, but was rarely successful at < 28 weeks.     

Epidemiology of twinning in developed countries

Twin births contribute disproportionately to the overall burden of perinatal morbidity and mortality in developed countries. Twins constitute 2%-4% of all births, and the rate of twining has increased by 76% between 1980 and 2009. The rate of preterm birth (<37 weeks) among twins is about 60%. Of all twin preterm births in the United States, roughly half are indicated, a third are due to spontaneous onset of labor, and about 10% are due to preterm premature rupture of membranes. Mortality related to preterm birth is influenced by antecedent factors and is highest when preterm delivery is the consequence of preterm premature rupture of membranes, followed by those as a result of spontaneous preterm labor and lowest among indicated preterm births. There also appears to have been a recent decline in serious neonatal morbidity (one or more of 5-minute Apgar score <4, neonatal seizures or assisted ventilation for ≥ 30 minutes) among twin gestations. Compared with twins conceived naturally, those born of assisted reproduction methods are more likely to deliver at <37 weeks. Although perinatal mortality rates have declined among twin births, the effect of preterm delivery on trends in mortality and morbidity and other long-term consequences remain issues for major concern. With the rapid increase in the liberal use of assisted reproduction methods combined with women electing to postpone their pregnancies and increased likelihood of spontaneous twins with advancing maternal age, this review underscores the need to develop priorities to understand the peripartum and long-term consequences facing twin births.     

Stillbirth: a review.

Stillbirth occurs in nearly 1% of all births in the USA, and is one of the most common but least studied adverse pregnancy outcomes. The many risk factors for and causes of stillbirth are presented. Over the past several decades, the rate of stillbirth has been substantially reduced, with the reduction most apparent in those stillbirths previously occurring at term and/or in labor. Reductions have occurred because of reductions in risk factors (i.e. prevention of Rh disease and better control of diabetes), better antepartum monitoring of those with risk factors followed by early delivery for those fetuses found to be at risk (i.e. growth restriction, maternal pre-eclampsia), better intrapartum fetal monitoring, increases in Cesarean section for those at risk, and early detection of congenital anomalies followed by termination prior to the time that these early fetal deaths are classified as stillbirths. Finally, the value of using fetal autopsy and placental examination to determine the cause of death accurately, both for research purposes and for patient counseling in future pregnancies, is explored.     

Disparities in perinatal medicine: preterm birth, stillbirth, and infant mortality

Infant mortality, stillbirths, and preterm births are major public health priorities with significant disparities based on race and ethnicity. Interestingly, when evaluating the rates over the past 30 to 50 years, the disparity persists in all three and is remarkably consistent. In the United States, the infant mortality rate is 6.7 deaths per 1,000 live births, the stillbirth rate is 6.2 per 1,000 deliveries, and the preterm birth rate is 12.8% of live births. The rates among non-Hispanic African Americans are dramatically higher, nearly double the infant mortality at 13.4 infant deaths per 1,000 live births, nearly double the stillbirth rate at 11.1 stillbirths per 1,000 deliveries, and one third higher with preterm births at 18.4% of live births. Despite numerous conferences, workshops, articles, and investigators focusing on this line of work, the disparities persist and, in some cases, are growing. In this article, we summarize a Eunice Kennedy Shriver National Institute of Child Health and Human Development workshop that focused on these disparities to identify the associated factors to determine their relative contributions, identify gaps in knowledge, and develop specific strategies to address the disparities in the short-term and long-term.     

Racial and ethnic disparities in United States: stillbirth rates: trends, risk factors, and research needs

As with most adverse health outcomes, there has been long standing and persistent racial and ethnic disparity for stillbirth in the United States. In 2005, the stillbirth rate (fetal deaths ≥ 20 weeks' gestation per 1000 fetal deaths and live births) for non-Hispanic blacks was 11.13 compared with 4.79 for non-Hispanic whites. Rates were intermediate for American Indian or Alaska Natives (6.17) and Hispanics (5.44). There is racial disparity for both early (< 28 weeks' gestation) and late stillbirths. We review available data regarding risk factors for stillbirth with a focus on those factors that are more prevalent in certain racial/ethnic groups and those factors that appear to have a more profound effect in certain racial/ethnic groups. Although many factors, including genetics, environment, stress, social issues, access to and quality of medical care and behavior, contribute to racial disparity in stillbirth, the reasons for the disparity remain unclear. Knowledge gaps and recommendations for further research and interventions intended to reduce racial disparity in stillbirth are highlighted.     

Cesarean delivery outcomes from the WHO global survey on maternal and perinatal health in Africa

Objective

To assess the association between cesarean delivery rates and pregnancy outcomes in African health facilities.

Methods

Data were obtained from all births over 2-3 months in 131 facilities. Outcomes included maternal deaths, severe maternal morbidity, fresh stillbirths, and neonatal deaths and morbidity.

Results

Median cesarean delivery rate was 8.8% among 83 439 births. Cesarean deliveries were performed in only 95 (73%) facilities. Facility-specific cesarean delivery rates were influenced by previous cesarean, pre-eclampsia, induced labor, referral status, and higher health facility classification scores. Pre-eclampsia increased the risks of maternal death, fresh stillbirths, and severe neonatal morbidity. Adjusted emergency cesarean delivery rate was associated with more fresh stillbirths, neonatal deaths, and severe neonatal morbidity—probably related to prolonged labor, asphyxia, and sepsis. Adjusted elective cesarean delivery rate was associated with fewer perinatal deaths.

Conclusion

Use of cesarean delivery is limited in the African health facilities surveyed. Emergency cesareans, when performed, are often too late to reduce perinatal deaths.