A Comparison of Obstetric Morbidity and Management Between Clinic and Private Patients

The patterns of morbidity and management among clinic and private patients in a teaching hospital were compared by an audit of computerized case records. The clinic patients were more likely to have a poor obstetric history and antenatal complications, and the private patients were managed more actively. Perinatal mortality in the clinic patients was higher and was related to the higher frequency of low birth weight babies.     

Robotic Transabdominal Cerclage vs Laparotomy: A Comparison of Obstetric and Surgical Outcomes

Study ObjectiveTo compare obstetric and surgical outcomes of transabdominal cerclage (TAC) via laparotomy (TAC-LAP) versus robotic-assisted (TAC-RA) approaches.DesignRetrospective cohort study.SettingAn academic medical center.PatientsSixty-nine women with acquired or congenital cervical insufficiency.InterventionsAll women underwent TAC either by laparotomy or robotic-assisted approaches by 2 primary surgeons between January 2003 and July 2018. Women with a preconceptional TAC without a subsequent pregnancy were excluded.Measurements and Main ResultsA total of 69 women met inclusion criteria in the 15-year study period with 40 in the historical TAC-LAP group and 29 in the TAC-RA group. Gestational age at delivery was similar in the 2 groups (36 weeks 3 days vs 37 weeks; median difference −1 day, 95% confidence interval [CI] −6 to 2, p = .36). There were no differences in birth weight, Apgar scores, neonatal intensive care unit admission, or neonatal survival. Estimated blood loss and length of stay were significantly greater in the TAC-LAP group (50 mL vs 20 mL; median difference 25, 95% CI 5–40, p = .007 and 76 hours vs 3 hours; median difference 71, 95% CI 65–75, p <.001, respectively). Operative time was significantly shorter in the TAC-LAP group (65 minutes vs 132 minutes; median difference −64.7, 95% CI −79 to −49, p <.001). There was one intra-operative complication and 4 minor postoperative complications in the TAC-LAP group and none observed in the TAC-RA group. All outcomes were similar when comparing postconceptional TAC alone, except there was no longer a difference in blood loss. When comparing pre- versus postconceptional robotic TAC, there were no differences in surgical outcomes.ConclusionRobotic TAC has similar favorable obstetric outcomes to traditional laparotomy and is associated with reduced blood loss and shorter hospital stays. Despite longer operative times, the robotic group did not experience any intra-operative or postoperative complications, which speaks to the benefits of this minimally invasive approach to TAC.     

Impact of Provider Payment Structure on Obstetric Interventions and Outcomes: A Difference-in-Differences Analysis

ObjectiveTraditionally, Canadian physicians provide care on a fee-for-service (FFS) basis; however, this model has been criticized as it incentivizes quantity of care over quality of care. Consequently, all Canadian provinces and territories have implemented some form of alternative payment plan. Evaluation of the impact of these policy changes, however, has typically focused on family physicians as opposed to specialists.MethodsOn January 1, 2004, obstetricians at the Medicine Hat Regional Hospital (MHRH) transitioned from FFS to salary. A difference-in-differences analysis was used to examine the impact of changes in obstetrician payment structure on the use of obstetric interventions and neonatal outcomes controlling for temporal trends at MHRH (intervention group) and the Chinook Regional Hospital (CRH; comparison group) from 2002 to 2005.ResultsBetween the pre-intervention period (2002-2003) and the post-intervention period (2004-2005), the rate of cesarean delivery increased significantly at both sites. Following adjustment for time of day, day of week, and antepartum risk score, the difference-in-difference estimator demonstrated a 5.8% (95% CI 1.5–10.0) increase in cesarean deliveries performed by obstetricians at MHRH compared with cesarean deliveries done at CRH after accounting for baseline differences and temporal trends. No significant differences were observed for family physicians. No significant differences were observed for other obstetric interventions or neonatal outcomes.ConclusionUnder an FFS model, obstetricians are incentivized to cesarean delivery due to the increased reimbursement rate; however, the increase in cesarean deliveries at MHRH following the transition to a salary model was unexpected. This finding suggests that, in Canada, financial incentives are not a factor that explains the increasing rate of cesarean delivery.     

A Controlled Study of the Effect of Prepared Childbirth Classes on Obstetric Outcomes

ABSTRACT: After the development and initiation of prepared childbirth classes in a large, inner-city hospital, a case-controlled study was designed to assess their impact on obstetric outcomes. Prepared couples were matched with nonattenders on six variables: race, patient status (clinic or private), parity, marital status, age, and socioeconomic status. Statistically significant differences between the groups were found. Prepared couples were more likely to receive little or no pain medication and less conduction anesthesia than controls. Consequently, 79 percent of their deliveries were spontaneous, compared to 51 percent for controls (P < 0.001). Despite the increased pushing ability of the class attenders, over 80 percent of women in both groups had an episiotomy, which was, in turn, significantly associated with a second-, third-, or fourth-degree laceration, thus bringing into question its routine use. Further studies to identify additional factors associated with positive obstetric outcomes are warranted.     

Adverse Obstetric Outcomes at Term after Hysteroscopic Metroplasty

Study ObjectiveTo estimate obstetrical complications at term after hysteroscopic metroplasty for septate uterus.DesignA retrospective comparative study (Canadian Task Force classification II-2).SettingLa Conception Hospital, Department of Obstetrics and Gynecology, Marseille, France.Patients and InterventionsThirty-one women who had a term pregnancy from January 1996 through December 2004 after hysteroscopic metroplasty for septate uterus (group A) were studied retrospectively. A control group (group B) of 62 women was selected from the same database who had term pregnancies and no history of hysteroscopic metroplasty.Measurements and Main ResultsObstetric complications at term and neonatal outcomes after hysteroscopic metroplasty were compared between 2 groups. The rate of fetal malpresentation was significantly higher in group A versus group B (11/31 [35.5%] vs 0/62, p < .001). Mean birth weight was significantly lower in group A versus group B (2940 g ± 52 vs 3266 g ± 456, p =.002). The rate of caesarean section was significantly higher in group A versus group B (19/31 [61.3%] vs 4/62 [6.4%], p < .001).ConclusionThe results of this study suggest that patients with a previous hysteroscopic metroplasty for septate uterus are at increased risk for fetal malpresentation at term, low birth weight infants, and delivery by caesarean section and should therefore be informed of these risks before delivery.     

How Well Does Epidemiological Evidence Hold For The Relationship Between Smoking and Adverse Obstetric Outcomes in New South Wales?

Summary: This study examines whether the established epidemiological relationships between cigarette-smoking exposure in pregnancy and adverse obstetric outcomes are confirmed in Australian data from the NSW Midwives Data Collection (MDC). These data were analysed to compare the obstetric complications and pregnancy outcomes between smoking and nonsmoking women confined in 1994. Results showed that smoking mothers had higher rates of antepartum haemorrhage due to placental abruption and placenta praevia. They were also at higher risk of giving birth to low birth-weight babies and preterm delivery. Infants born to smoking mothers were 17% more likely to be admitted to hospital special care nurseries or neonatal intensive care units. Moreover, the risk of reported perinatal death among babies of smoking mothers was 20% higher than babies of nonsmoking mothers. However, smoking during pregnancy was found to confer a protective effect against the development of pregnancy-induced hypertension. These results were compared with existing evidence from the literature. Published research reports on the corresponding smoking effects were identified to assess the consistency of evidence and typical risk ratios. Findings from the literature search showed a near-perfect concordance with the associations in the NSW MDC data. The paper documents the likely complications which might be prevented if smoking in pregnancy were eliminated. There remains a real need for effective programmes to reduce smoking prevalence in pregnancy.     

Predictors of Obstetric Fistula Repair Outcomes in Lubango,Angola

ObjectiveObstetric fistulas have a significant physical and social impact on many women in Angola. The majority of the population of this sub-Saharan African nation does not have access to high-quality obstetric care, and this is associated with a risk of prolonged labour and formation of obstetric fistulas. Fistulas are challenging to correct surgically and may require repeated operations. The objective of the study was to determine predictors of successful obstetric fistula repair.MethodsIn this retrospective study, data from all recorded cases of fistula repair performed between July 2011 and December 2016 at the Centro Evangélico de Medicina do Lubango (CEML) hospital located in Lubango, Angola, were reviewed. Analysis of the data was carried out to determine factors affecting the success of fistula repair; parametric and non-parametric tests were used for group comparisons and logistic regression for outcome prediction (Canadian Task Force classification II-2).ResultsA total of 407 operations were performed on 243 women. Of these, 224 women were diagnosed with a vesicovaginal fistula and 19 with a combined vesicovaginal and rectovaginal fistula. The success rate for the attempted repairs was 42%. On multivariate analysis, the success of first surgery was negatively affected by the difficulty of repair (odds ratio 0.28; P < 0.01). For patients requiring repeat surgery, the odds of success were increased with each subsequent operation (odds ratio 5.32; P < 0.01).ConclusionAlthough fistulas rated as difficult to repair had a higher likelihood of initial failure, successive attempts at repair increased the likelihood of a successful outcome.     

Reproductive and Obstetric Outcomes After Hysteroscopic Removal of Retained Products of Conception

Study ObjectiveTo evaluate the reproductive outcomes in women treated for retained products of conception (RPOC) by hysteroscopy (morcellation vs loop resection).DesignCohort study.SettingA teaching and university hospital.PatientsPatients included in a previous randomized controlled trial on hysteroscopic removal of RPOC comparing morcellation (n = 46) with loop resection (n = 40).InterventionsHysteroscopic morcellation versus loop resection.Measurements and Main ResultsThe primary outcome measures were live birth and pregnancy complications (including abnormal placentation [placenta accreta/increta/percreta], placenta previa, vasa previa, retained placenta after delivery or incomplete expulsion with the need for manual removal or curettage, and RPOC), uterine rupture, and other complications (blood loss, preterm labor, preterm premature rupture of membranes, hypertensive disorders of pregnancy, and intrauterine growth restriction). The live birth rate was 88.9% in the morcellation group and 68.2% in the loop resection group (p = .09). Uterine rupture occurred in 1 patient in the morcellation group (4.2%) (p = 1.00). Placental complications were found in 20.8% and 22.2% of the hysteroscopic morcellation and loop resection groups, respectively (p = .33), and other pregnancy complications were seen in 33.3% and 16.6% of the 2 groups (p = .33). The secondary outcome was time to pregnancy. The median time to pregnancy was 14 weeks (interquartile range [IQR], 5–33 weeks) in the morcellation group and 15 weeks (IQR, 6–37 weeks) in the loop resection group (p = .96).ConclusionHysteroscopic removal of RPOC seems to have no detrimental effect on reproductive outcome and no significant effect on pregnancy rate.     

The Relationship Between Childbirth Education Classes and Obstetric Outcome

ABSTRACT: The records of 207 primigravid patients were reviewed over seven months to determine the relationship between childbirth education classes and the outcome of labor and delivery. Primiparous patients self-selected into two groups, attenders and nonattenders of childbirth education classes; 114 attended at least two classes and 93 attended one or no classes. A significantly higher percentage of attenders were older, better educated, or of higher socioeconomic status. There were nonsignificant trends toward longer second stage of labor, increased use of assistance at delivery (forceps or vacuum), and increased use of medication in the group that attended prenatal classes. A benefit of attendance at childbirth education classes in reducing interventions during labor and delivery was not demonstrated.     

Operative and Obstetric Outcomes after Single-port Laparoscopic Myomectomy: A Retrospective Single-center Analysis of 504 Cases

Study ObjectiveTo analyze the obstetric and operative outcomes of 504 cases of single-port laparoscopic myomectomy (SPLM).DesignSingle-center retrospective study.SettingA tertiary university hospital.PatientsA total of 502 patients (504 SPLM procedures) who underwent SPLM for symptom relief or growing myomas between October 2009 and April 2020.InterventionsData on patient demographics, operative variables (estimated blood loss, hemoglobin decrease, operation time, perioperative complications, and postoperative hospital stay), and obstetric outcomes (the surgery-to-pregnancy interval and birth-related outcomes) were obtained from medical records and analyzed.Measurements and Main ResultsThe mean age of the patients was 40.6 ± 6.6 years. The patients had had an average of 2.3 ± 2.2 myomas removed; the largest myoma size was 6.8 ± 2.4 cm. The mean operation time, postoperative hemoglobin decrease, and postoperative hospital stay duration were 112.9 ± 45.3 minutes, 1.7 ± 1.1 g/dL, and 2.2 ± 1.4 days, respectively. The overall rate of postoperative complications was 7.7% (39/504), and the common complications were transfusions (16/504, 3.1%) or wound problems (15/504, 3.0%). Conversion to multiport or open myomectomy was required in 0.8% of the cases (4/504). A total of 376 women were of child-bearing age, and 56 attempted to become pregnant after surgery. The mean interval from surgery to pregnancy was 15.6 ± 12.2 months. The obstetric outcomes were pregnancy (42/56, 75.0%), live birth (39/56, 69.6%), and miscarriage (2/56, 3.6%). One pregnant woman was lost to follow-up. The 39 live births predominantly involved full-term delivery (36/39, 92.3%), mostly through cesarean section (36/39, 92.3%). No postpartum complications were reported. The 2 most common obstetric complications were preterm labor (7.6%) and gestational diabetes (5.1%).ConclusionSPLM seems to be an effective procedure with good operative and postoperative obstetric outcomes for women with myomas who require surgery and may wish to subsequently become pregnant.     

Relationship Between Obstetric Analgesia and time of Effective Breast Feeding

The Infant Breast-feeding Assessment Tool (IBFAT) was used to assess the time of effective breast feeding in 48 healthy term infants born to mothers having their first or second baby. Infants of mothers who received an analgesia (butorphanol or nalbuphine) in labor (n = 26) were compared with infants whose mothers did not receive any labor analgesia (n = 22). Timing of the administration of labor analgesia was also examined with infants whose mothers received no analgesia or analgesia within an hour of birth compared with infants whose mothers received analgesia more than one hour before birth. Infants of first-time breast-feeding mothers took longer to establish effective feeding compared with infants of second-time breast-feeding mothers. Male infants also took longer. Labor analgesia significantly affected mother-rated IBFAT scores when initiation time was considered. Infants who received analgesia within an hour of birth, or no analgesia, and who initiated breast feeding early, established effective feeding significantly earlier than infants with longer duration of analgesia and later initiation of breast feeding.     

Comparing Pregnancy in Adolescents and Adults: Obstetric Outcomes and Prevalence of Anemia

ObjectiveTo characterize the obstetric outcome and prevalence of anemia in primiparous adolescents and compare them with those in older primiparas.MethodsWe conducted a retrospective chart review of 207 adolescents (≤ 19 years old) and 415 adults (≥ 20 years old) whose prenatal care was provided by a single obstetrician in Kingston, Ontario, and who had a live singleton birth at ≥ 24 weeks’ gestation between 1996 and 2004.ResultsThe mean age of the adolescents (T) was 17.5 years and of the adults (A) 27.3 years. More than 95% of the women were Caucasian. Mean gestational age at delivery was similar in the two groups (T 39.4 weeks, A 39.6 weeks, P = 0.25). Adolescents were more likely to have a preterm delivery (T 12.6%, A 7.5%, P = 0.038), although smoking rather than young maternal age was an independent risk factor for preterm delivery (odds ratio [OR] 3.2; 95% confidence intervals [CI] 1.4–7.5). A significantly lower proportion of adolescents delivered by Caesarean section (CS) (T 12.1%, A 27.7%, P < 0.001). Older maternal age, higher pre-pregnancy BMI, increased weight gain during pregnancy, and pre-delivery anemia were all independent risk factors for CS. Smoking was the most influential factor in predicting infant birth weight. Adolescents had significantly more low birth weight infants (< 2500 g) than adults (T 10.1% vs. A 4.3%, P = 0.008). Gestational age rather than young maternal age was the most significant risk factor for low birth weight (OR 3.3; 95% CI 1.9–5.7). After controlling for smoking status, adolescents were 2.5 times more likely than adults to be anemic at 26 to 35 weeks’ gestation and pre-delivery.ConclusionOur results suggest that primiparous adolescents have significantly different obstetric outcomes from primiparous adults. Smoking and anemia are significant risk factors for poor obstetric outcomes and are potentially modifiable.     

Obstetric Risks and Outcomes of Refugee Women at a Single Centre in Toronto

ObjectivesWomen who are refugees during pregnancy may be exposed to homelessness, poor nutrition, and limited access to health care, yet the pregnancy outcomes of this vulnerable population have not been systematically evaluated. We undertook a study to determine the risk of adverse obstetric and perinatal outcomes among refugee women in Toronto.MethodsUsing a retrospective cohort design, we examined pregnancy outcomes for refugee and non-refugee women delivering at St. Michael’s Hospital in Toronto, between January 1, 2008, and December 31, 2010. The primary outcome measures were preterm delivery (< 37 weeks’ gestational age), low birth weight (< 2500 g), and delivery by Caesarean section.ResultsMultiparous refugee women had a significantly higher rate of delivery by Caesarean section (36.4%), and a 1.5-fold increase in rate of low birth weight infants when compared with non-refugee women. In subgroup analysis by region of origin, women from Sub-Saharan Africa had significantly higher rates of low birth weight infants and Caesarean section than non-refugee control subjects. Further, compared with non-refugee control subjects, refugee women had significantly increased rates of prior Caesarean section, HIV-positive status, homelessness, social isolation, and delays in accessing prenatal care.ConclusionsRefugee women constitute a higher-risk population with increased rates of adverse obstetric and perinatal outcomes. These findings provide preliminary data to guide targeted public health interventions towards meeting the needs for obstetric care of this vulnerable population. Recent changes to the Interim Federal Health Program have highlighted the importance of identifying and diminishing disparities in health outcomes between refugee and non-refugee populations.     

Comparison of Costs and Associated Outcomes Between Women Choosing Newly Integrated Autonomous Midwifery Care and Matched Controls: A Pilot Study

ObjectiveIn response to consumer demand and a critical shortage of Canadian maternity care providers, provinces have integrated or are in the process of integrating midwives into their health care systems. We compared the costs and outcomes of newly integrated, autonomous midwifery care with existing health care services in the province of Alberta.MethodsAlberta Health and Wellness cost data from (1) physician fee-for-service, (2) outpatient, and (3) inpatient records, as well as outcome data from vital statistics records, were compared between participants in a midwifery integration project and individually matched women who received standard perinatal care during the same time period. Records of births occurring within the same time frame were matched according to risk score, maternal age, parity, and postal code.ResultsFor women who chose midwifery care, an average saving of $1172 per course of care was realized without adversely affecting maternal or neonatal outcomes. Cost reductions are partially realized through provision of out-of-hospital health services. Women who chose midwifery care had more prenatal visits (P < 0.01) and fewer inductions of labour (P < 0.01); their babies had greater gestational ages (P < 0.05) and higher birth weights (P < 0.05) than controls. The sample size was insufficient to compare events associated with extremely high costs, or rare or catastrophic outcomes.ConclusionRegulated and publicly funded midwifery care appears to be an effective intervention for low-risk women who make this choice. When compared with existing care, autonomous care by newly integrated midwives does not increase health care costs.