How to Stop the Relentless Rise in Cesarean Deliveries

Deputy Editor John T. Queenan, MD, is the Deputy Editor of Obstetrics & Gynecology
Obstetrics and Gynecology (Impact Factor: 4.37). 08/2011; 118(2 Pt 1):199-200. DOI: 10.1097/AOG.0b013e3182266682
Source: PubMed
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    ABSTRACT: Cesarean delivery is the most common inpatient surgery in the United States, where 1.3 million cesarean sections occur annually, and rates vary widely by hospital. Identifying sources of variation in cesarean use is crucial to improving the consistency and quality of obstetric care. We used hospital discharge records to examine the extent to which variability in the likelihood of cesarean section across US hospitals was attributable to individual women's clinical diagnoses.
    PLoS Medicine 10/2014; 11(10):e1001745. DOI:10.1371/journal.pmed.1001745 · 15.25 Impact Factor
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    ABSTRACT: Recent literature on the effect of induction of labour (compared with expectant management) has provided conflicting results. Reviews of observational studies generally report an increase in the rate of caesarean section, whereas reviews of post-dates and term prelabour rupture of membrane (PROM trials suggest either no difference or a reduction in risk. To evaluate with a systematic review and meta-analysis of randomised controlled trials (RCTs) whether or not the induction of labour increases the risk of caesarean section in women with intact membranes. Literature search using electronic databases: MEDLINE, EMBASE, and the Cochrane Database of Clinical Trials. RCTs comparing a policy of induction of labour with expectant management in women with intact membranes. A total of 37 trials were identified and reviewed. Quantitative analyses with fixed- and random-effects models were performed with revman 5.1. Of the 37 RCTs, 27 were trials of uncomplicated pregnancies at 37-42 weeks of gestation. The remaining ten evaluated induction versus expectant management in pregnancies with suspected macrosomia (two), diabetes in pregnancy (one), oligohydramnios (one), twins (two), intrauterine growth restriction (IUGR) (two), mild pregnancy-induced hypertension (PIH) (one), and women with a high-risk score for caesarean section (one). Meta-analysis of 31 trials determined that a policy of induction was associated with a reduction in the risk of caesarean section compared with expectant management (OR 0.83, 95% CI 0.76-0.92). Induction of labour in women with intact membranes reduces the risk of caesarean section. Review of the trials suggests that this effect may arise from non-treatment effects, and that additional trials are needed.
    BJOG An International Journal of Obstetrics & Gynaecology 07/2013; 121(6). DOI:10.1111/1471-0528.12328 · 3.86 Impact Factor
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    ABSTRACT: Approximately 15% of the 4 million annual US births occur in rural hospitals. To (1) measure differences in obstetric care in rural and urban hospitals, and to (2) examine whether trends over time differ by rural-urban hospital location. This was a retrospective analysis of hospital discharge records for all births in the 2002-2010 Nationwide Inpatient Sample, which constitutes 20% sample of US hospitals (N=7,188,972 births: 6,316,743 in urban hospitals, 837,772 in rural hospitals). Rates of low-risk cesarean (full-term, singleton, vertex pregnancies; no prior cesarean), vaginal birth after cesarean (VBAC), nonindicated cesarean, and nonindicated labor induction were estimated. In 2010, low-risk cesarean rates in rural and urban hospitals were 15.5% and 16.1%, respectively, and nonindicated cesarean rates were 16.9% and 17.8%, respectively. VBAC rates were 5.0% in rural and 10.0% in urban hospitals in 2010. Between 2002 and 2010, rates of low-risk cesarean and nonindicated cesarean increased, and VBAC rates decreased in both rural and urban hospitals. Nonindicated labor induction was less frequent in rural versus urban hospitals in 2002 [adjusted odds ratio=0.79 (0.78-0.81)], but increased more rapidly in rural hospitals from 2002 to 2010 [adjusted odds ratio=1.05 (1.05-1.06)]. In 2010, 16.5% of rural births were induced without indication (12.0% of urban births). From 2002 to 2010, cesarean rates rose and VBAC rates fell in both rural and urban hospitals. Nonindicated labor induction rates rose disproportionately faster in rural versus urban settings. Tailored clinical and policy tools are required to address differences between rural and urban hospitals.
    Medical care 01/2014; 52(1):4-9. DOI:10.1097/MLR.0000000000000016 · 2.94 Impact Factor