How does the WHI study alter the risk-benefit ratio of HT?

Good clinical practice depends on knowledge of the current best medical care research evidence, but clinicians must be able to determine what is the best evidence and whether this evidence is relevant to their own patients. At the heart of evidence-based medicine is the assessment of the validity, importance, and relevance of a given study. These may be evaluated by asking key questions; here these questions are applied to the WHI study.     

Prenatal diagnosis: does it alter outcome?

The prenatal detection of urinary tract anomalies is changing paediatric practice but in many areas the impact on clinical outcome remains difficult to quantify. However it is already apparent that termination of pregnancy has reduced the numbers of infants with lethal pulmonary hypoplasia and renal dysplasia who would previously have been liveborn but destined to succumb as neonates. Similarly, referrals of major non lethal abnormalities such as bladder exstrophy are declining as parents increasingly opt for termination. Fetuses at greatest risk of early onset postnatal renal failure can now be identified with considerable accuracy on prenatal ultrasound. Termination, prompted by quality of life considerations, could result in reduced numbers of infants and young children requiring end stage renal failure treatment in the first few years of life. Pre natal detection of anomalies such as PUJ obstruction and reflux undoubtedly provides an opportunity to avert functional deterioration and minimise urinary infection. But the proportion of children who genuinely benefit has proved difficult to assess. The prenatal detection of mild dilatation is of doubtful benefit in all but a minority of cases. Clinically significant underlying pathology is rare yet this common prenatal finding often generates disproportionate parental anxiety.     

How does the WHI study alter the risk–benefit ratio of HT?

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Good clinical practice depends on knowledge of the current best medical care research evidence, but clinicians must be able to determine what is the best evidence and whether this evidence is relevant to their own patients. At the heart of evidence-based medicine is the assessment of the validity, importance, and relevance of a given study. These may be evaluated by asking key questions; here these questions are applied to the WHI study.     

Does the ARRIVE trial merit changing obstetric practice? Some reflections four-year postrelease

Background

It has been 4 years since the release of the study Labor Induction versus Expectant Management in Low-Risk Nulliparous Women, also known as the ARRIVE trial. As researchers and speakers who frequently present to the United States and international audiences about models of care and strategies to support normal physiologic labor and birth, we have had ample opportunity to engage with practitioners who consistently ask about our perspectives on the ARRIVE trial's findings and methods. Many note the marked increase in pressure they feel to induce at 39 weeks since the study's publication in 2018.

Methods

In this commentary, we discuss some of the concerns that have been brought up during these conversations.

Results/Conclusion

We focus on the trial's key findings and reflect on factors critical to consider as translation into clinical practice is negotiated.     

Can obstetric complications explain the high levels of obstetric interventions and maternity service use among older women? A retrospective analysis of routinely collected data

Objective To determine whether the higher levels of obstetric intervention and maternity service use among older women can be explained by obstetric complications.Design A retrospective analysis of routinely collected data from the Aberdeen Maternity and Neonatal Databank.Participants All residents of Aberdeen city district delivering singleton infants at the Maternity Hospital 1988-1997 (28,484 deliveries).Main outcome measures Odds ratios for each intervention in older maternal age groups compared with women aged 20-29. Interventions considered include obstetric interventions (induction of labour, augmentation, epidural use, assisted delivery, caesarean section) and raised maternity service use (more than two prenatal scans, amniocentesis, antenatal admission to hospital, admission at delivery of more than five days, infant resuscitation, and admission to the neonatal unit).Methods Logistic regression was used to investigate the association between maternal age and the incidence of interventions. The odds ratios for each intervention were then adjusted for relevant obstetric complications and maternal socio-demographic characteristics.Results Levels of amniocentesis, caesarean section, assisted delivery, induction, and augmentation (in primiparae) are all higher among older women. Maternity service use also increases significantly with age: older women are more likely to have an antenatal admission, more than two scans, a hospital stay at delivery of more than five days, and have their baby admitted to a neonatal unit. Controlling for relevant obstetric complications reveals several examples of effect modification, but does not eliminate the age effect for most interventions in most groups of women.Conclusions Higher levels of intervention among older women are not explained by the obstetric complications we considered.     

Can obstetric complications explain the high levels of obstetric interventions and maternity service use among older women? A retrospective analysis of routinely collected data

Objective To determine whether the higher levels of obstetric intervention and maternity service use among older women can be explained by obstetric complications.
Design A retrospective analysis of routinely collected data from the Aberdeen Maternity and Neonatal Databank.
Participants All residents of Aberdeen city district delivering singleton infants at the Maternity Hospital 1988-1997 (28,484 deliveries).
Main outcome measures Odds ratios for each intervention in older maternal age groups compared with women aged 20-29. Interventions considered include obstetric interventions (induction of labour, augmentation, epidural use, assisted delivery, caesarean section) and raised maternity service use (more than two prenatal scans, amniocentesis, antenatal admission to hospital, admission at delivery of more than five days, infant resuscitation, and admission to the neonatal unit).
Methods Logistic regression was used to investigate the association between maternal age and the incidence of interventions. The odds ratios for each intervention were then adjusted for relevant obstetric complications and maternal socio-demographic characteristics.
Results Levels of amniocentesis, caesarean section, assisted delivery, induction, and augmentation (in primiparae) are all higher among older women. Maternity service use also increases significantly with age: older women are more likely to have an antenatal admission, more than two scans, a hospital stay at delivery of more than five days, and have their baby admitted to a neonatal unit. Controlling for relevant obstetric complications reveals several examples of effect modification, but does not eliminate the age effect for most interventions in most groups of women.
Conclusions Higher levels of intervention among older women are not explained by the obstetric complications we considered.     

Maternal health in resource-poor urban settings: how does women's autonomy influence the utilization of obstetric care services?

Background

Caesarean section rates continue to increase worldwide with uncertain medical consequences. Auditing and analysing caesarean section rates and other perinatal outcomes in a reliable and continuous manner is critical for understanding reasons caesarean section changes over time.

Methods

We analyzed data on 97,095 women delivering in 120 facilities in 8 countries, collected as part of the 2004-2005 Global Survey on Maternal and Perinatal Health in Latin America. The objective of this analysis was to test if the "10-group" or "Robson" classification could help identify which groups of women are contributing most to the high caesarean section rates in Latin America, and if it could provide information useful for health care providers in monitoring and planning effective actions to reduce these rates.

Results

The overall rate of caesarean section was 35.4%. Women with single cephalic pregnancy at term without previous caesarean section who entered into labour spontaneously (groups 1 and 3) represented 60% of the total obstetric population. Although women with a term singleton cephalic pregnancy with a previous caesarean section (group 5) represented only 11.4% of the obstetric population, this group was the largest contributor to the overall caesarean section rate (26.7% of all the caesarean sections). The second and third largest contributors to the overall caesarean section rate were nulliparous women with single cephalic pregnancy at term either in spontaneous labour (group 1) or induced or delivered by caesarean section before labour (group 2), which were responsible for 18.3% and 15.3% of all caesarean deliveries, respectively.

Conclusion

The 10-group classification could be easily applied to a multicountry dataset without problems of inconsistencies or misclassification. Specific groups of women were clearly identified as the main contributors to the overall caesarean section rate. This classification could help health care providers to plan practical and effective actions targeting specific groups of women to improve maternal and perinatal care.