Pregnancy-related death and health care services

doi:10.1016/S0029-7844(03)00408-3

Obstetrics & Gynecology

Volume 102, Issue 2, August 2003, Pages 273-278

https://doi.org/10.1016/S0029-7844(03)00408-3 Get rights and content

Abstract

Objective

To examine the association between health care services variables and pregnancy-related death using a contemporary geographically defined population and enhanced methods for case identification.

Methods

This is a population-based, case-control study from North Carolina for the 7-year period 1992–1998. Pregnancy-related deaths after a live birth (n = 118) were identified after review of pregnancy-associated deaths (n = 400) ascertained from death certificate codes and linkage of birth and death files. Controls (n = 3697) were randomly selected from all registered live births for the same 7-year period and were not matched with cases. This sample size was sufficient to ensure that the standard errors for subgroup prevalences were less than 1%. The associations between pregnancy-related death and health care services were explored with univariate and multivariable regression analysis.

Results

Neither maternity care coordination nor nutritional services were protective. There was no association with source of care, private versus public. The adjusted odds ratio (OR) for pregnancy-related death associated with cesarean delivery was 3.9 (95% confidence interval [CI] 2.5, 6.1). The adjusted OR for pregnancy-related death associated with the receipt of prenatal care was 0.2 (95% CI 0.1, 0.6).

Conclusion

Removing barriers to and actively promoting use of prenatal care services and decreasing the rate of cesarean deliveries could decrease the number of pregnancy-related deaths.

Section snippets

Materials and methods

North Carolina uses a comprehensive approach to identify potential pregnancy-related deaths. This surveillance system identifies all death certificates with any mentioned cause of death related to a pregnancy complication (International Classification of Diseases, 9th Revision, codes 630–676) or with any other indication that the decedent was currently or recently pregnant. In addition, records of all deaths occurring in females between the ages of 10 and 50 are electronically matched with

Results

For the population during this 7-year period, the pregnancy-associated mortality ratio was 54.7 deaths per 100,000 live births. The pregnancy-related mortality ratio was 20.7 deaths per 100,000 live births.

The distribution of primary predictor variables among cases and controls is shown in Table 1. The crude and adjusted ORs for pregnancy-related death associated with each of these variables are shown in Table 2. There was no association between Maternity Care Coordination or Women, Infants,

Discussion

This study is unique in several respects. It comes from a contemporary and geographically defined population and is one of the few case–control studies examining the associations between pregnancy-related death and multiple health care services factors. Cases were identified using three methods, including electronic linkage of birth and death files. All pregnancy-related deaths were validated by an expert panel. Adjustments were made for confounders in the analysis.

We used birth certificate

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The positive association between cesarean section and maternal mortality in Latin America found in this review is consistent with previous studies from other geographical regions (Rubin 1981; Hall and Bewley 1999; Harper 2003; Deneux-Tharaux et al., 2006; Khan et al., 2006; Clark et al., 2008; Kamilya et al., 2010; Lumbiganon et al., 2010; Souza et al., 2010). In general, evidences from other regions showed that women who underwent cesarean section had a higher risk of severe maternal morbidity and mortality than women who underwent vaginal birth, independent of geographical area and clinical characteristics (Rubin 1981; Hall and Bewley 1999; Harper 2003; Deneux-Tharaux et al., 2006; Khan et al., 2006; Clark et al., 2008; Kamilya et al., 2010; Lumbiganon et al., 2010; Souza et al., 2010). Kamilya et al. (2010), in India, showed that cesarean section was associated with a 3.01-fold increase in the risk of maternal mortality compared with vaginal birth.
it is critically important to explore a possible relationship between cesarean section and maternal mortality in Latin America, where the highest cesarean section rates in the world are found. Our aim was to conduct a systematic literature review on the relationship between maternal death and caesarean section in Latin America.
we undertook a systematic review through six electronic databases. Studies that reported any association analysis between maternal mortality and the mode of delivery in Latin America were included. Papers that fulfilled the inclusion criteria were then read fully, and a quality assessment was conducted with the PROMPT tool.
seven articles were identified for final analysis, all of which were observational studies. Most of the studies were retrospective (6) and one was prospective. Of the retrospective studies, 3 were case control and 3 were cross-sectional. Most of the publications on this topic suggest that there may be an increased risk of maternal mortality with cesarean section compared with vaginal birth (odds ratio ranging from 1.6 to 7.08). However, it is evident that there is a lack of studies with this subject, especially those that take into account the differences in risk between women delivered by cesarean section or by vaginal birth.
most of the articles showed that there may be an increased risk of maternal mortality with cesarean section compared with vaginal birth. However, it is clear that there is a limited number of studies published on this issue. Additional studies with a better methodological design should be conducted.
Evidence-Based Labor and Delivery Management: Can We Safely Reduce the Cesarean Rate?
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As noted, the increase in cesarean deliveries from 1996 to 2009 pushed the overall cesarean rate in the United States well above the 15% to 20% threshold for benefit that has been identified and recommended. In addition to no improvements in maternal or neonatal mortality, there are potential morbidities from cesarean delivery, including higher risks of maternal hemorrhage and infection.22 Additionally, there are risks from a cesarean delivery on outcomes in future pregnancies.
What is the optimal gestational age for women with gestational diabetes type A1 to deliver?
2014, American Journal of Obstetrics and Gynecology
Type A1 gestational diabetes mellitus (A1GDM), also known as diet-controlled gestational diabetes, is associated with an increase in adverse perinatal outcomes such as macrosomia and Erb palsy. However, it remains unclear when to deliver these women because optimal timing of delivery requires balancing neonatal morbidities from early term delivery against the risk of intrauterine fetal demise (IUFD). We sought to determine the optimal gestational age (GA) for women with A1GDM to deliver.
A decision-analytic model was built to compare the outcomes of delivery at 37-41 weeks in a theoretical cohort of 100,000 women with A1GDM. Strategies involving expectant management until a later GA accounted for probabilities of spontaneous delivery, indicated delivery, and IUFD during each week. GA-associated risks of neonatal complications included cerebral palsy, infant death, and Erb palsy. Probabilities were derived from the literature, and total quality-adjusted life years were calculated. Sensitivity analyses were used to investigate the robustness of the baseline assumptions.
Our model showed that induction at 38 weeks maximized quality-adjusted life years. Within our cohort, delivery at 38 weeks would prevent 48 stillbirths but lead to 12 more infant deaths compared to 39 weeks. Sensitivity analysis revealed that 38 weeks remains the optimal timing of delivery until IUFD rates fall <0.3-fold of our baseline assumption, at which point expectant management until 39 weeks is optimal.
By weighing the risks of IUFD against infant deaths and neonatal morbidities from early term delivery, we determined that the ideal GA for women with A1GDM to deliver is 38 weeks.
US nulliparas' perceptions of roles and of the birth experience as predictors of their delivery preferences
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Citation Excerpt :
Caesarean rates substantially higher than 15% are associated with risks to reproductive health that outweigh the intended benefits (Betrán et al., 2007). Consequences of the overuse of caesarean section include increased maternal morbidity and mortality (Harper et al., 2003; Deneux-Tharaux et al., 2006; Liu et al., 2007), neonatal morbidity and mortality (Laubereau et al., 2004; Hansen et al., 2007; MacDorman et al., 2008), disruption of the attachment and breast-feeding process (Rowe-Murray and Fisher, 2001, 2002; Pérez-Ríos et al., 2008; Zanardo et al., 2010) and an increased financial burden to the health-care system (Sakala and Corry, 2008). The problem of high caesarean rates is multifaceted and complex.
to develop a model for understanding predictors of nulliparas' delivery preferences: provider type, setting, mode of delivery and the use/avoidance of pain medication.
a cross-sectional, descriptive, self-administered, web-based survey. The sample was composed of nulliparous women aged 18–40, living in the US and pregnant at 20 or fewer weeks' gestation (n=344). Data were analysed using structural equation modelling.
women who regard their active participation as effective and essential to the childbearing process are more likely to prefer the care of a midwife, the home as the birth setting, vaginal delivery and the avoidance of pain medication compared to women who see their role as a passive one. When women perceive their provider's role to be more central to the delivery process than their own, they are likely to prefer the care of a physician and the hospital setting. If the provider's role is seen as a collaborative one, women are likelier to prefer midwifery care and planned home birth. The more painful and fearful a woman expects the delivery experience to be, the more likely she is to prefer a caesarean delivery to vaginal birth.
women's perceptions of (a) their role in pregnancy and delivery, (b) their providers' role in assisting them and (c) the nature of the delivery experience are effective predictors of their delivery preferences.
providers can help ensure that the informational resources that influence women's perceptions about delivery are factual and evidence-based.
Cost-effectiveness of elective induction of labor at 41 weeks in nulliparous women
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To investigate the cost-effectiveness of elective induction of labor at 41 weeks in nulliparous women.
A decision analytic model comparing induction of labor at 41 weeks vs expectant management with antenatal testing until 42 weeks in nulliparas was designed. Baseline assumptions were derived from the literature as well as from analysis of the National Birth Cohort dataset and included an intrauterine fetal demise rate of 0.12% in the 41st week and a cesarean rate of 27% in women induced at 41 weeks. One-way and multiway sensitivity analyses were conducted to examine the robustness of the findings.
Compared with expectant management, induction of labor is cost-effective with an incremental cost of $10,945 per quality-adjusted life year gained. Induction of labor at 41 weeks also resulted in a lower rate of adverse obstetric outcomes, including neonatal demise, shoulder dystocia, meconium aspiration syndrome, and severe perineal lacerations.
Elective induction of labor at 41 weeks is cost-effective and improves outcomes.
Short-term and long-term effects of caesarean section on the health of women and children
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Planned CS confers a lower risk of mortality compared with emergency, intrapartum CS. Although still a rare event, studies19–21 have estimated the risk of death from an emergency intrapartum CS to be up to four times higher than from vaginal birth. Further, the risk of maternal death during birth is increased in pregnancies after a CS, due to an increased risk of uterine rupture and abnormal placentation.
A caesarean section (CS) can be a life-saving intervention when medically indicated, but this procedure can also lead to short-term and long-term health effects for women and children. Given the increasing use of CS, particularly without medical indication, an increased understanding of its health effects on women and children has become crucial, which we discuss in this Series paper. The prevalence of maternal mortality and maternal morbidity is higher after CS than after vaginal birth. CS is associated with an increased risk of uterine rupture, abnormal placentation, ectopic pregnancy, stillbirth, and preterm birth, and these risks increase in a dose–response manner. There is emerging evidence that babies born by CS have different hormonal, physical, bacterial, and medical exposures, and that these exposures can subtly alter neonatal physiology. Short-term risks of CS include altered immune development, an increased likelihood of allergy, atopy, and asthma, and reduced intestinal gut microbiome diversity. The persistence of these risks into later life is less well investigated, although an association between CS use and greater incidence of late childhood obesity and asthma are frequently reported. There are few studies that focus on the effects of CS on cognitive and educational outcomes. Understanding potential mechanisms that link CS with childhood outcomes, such as the role of the developing neonatal microbiome, has potential to inform novel strategies and research for optimising CS use and promote optimal physiological processes and development.

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^☆: Supported by grant TS-437 from the Association of Teachers of Preventive Medicine and grant 5K12HD01267 from the NICHD Women’s Reproductive Health Career Development Award.

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Pregnancy-related death and health care services☆

Abstract

Objective

Methods

Results

Conclusion

Section snippets

Materials and methods

Results

Discussion

Obstet Gynecol

Obstet Gynecol

Am J Obstet Gynecol

Maternal mortality—United States, 1982–1996

MMWR Morb Mortal Wkly Rep

WHO revised 1990 estimates of maternal mortality: A new approach by WHO and UNICEF

Healthy People 2010: Understanding and improving health

Enhanced maternal mortality surveillance—North Carolina, 1988 and 1989

MMWR Morb Mortal Wkly Rep

Maternal mortality in United StatesReport from the maternal mortality collaborative

Obstet Gynecol