In Denmark, the cesarean section rate has increased by 49% between 1998 and 2015 and accounts for 21% of all births. Cesarean sections may cause short- as well as long-term consequences for both the ...mother and the child and impose further risks in future pregnancies. Delaying pregnancy until advanced maternal age at childbirth has been suggested as contributing to the increase. The proportion of women giving birth at 35 years or above increased from 15% (1998) to 21% (2015). Advanced maternal age at childbirth has been found to be related to increased pre-pregnancy morbidity and associated risk factors that may contribute to an increased risk of cesarean section. The aim of this study was to examine the association between advanced maternal age and cesarean section in a Danish population and the influence of demographic, anthropometric, health, and obstetric factors on this association.
This study draws on a national population-based cohort study of all Danish births between 1998 and 2015 (N = 1,122,964). Maternal age less than 30 years serves as reference with the following age categories: (30-34 years); (35-39 years), and (40 years and above). The primary outcome was a cesarean section. Multivariate regression models with adjustment for demographic, health, pregnancy, fetal, and obstetric characteristics were performed with the results further stratified by parity.
In general, a positive association between advanced maternal age and cesarean section was found. Only minor changes in the risk estimate occurred after adjustment for relevant confounders. In comparison with the reference category, nulliparous women aged 35-39- years had twice the risk for cesarean section (adjusted odds ratio (AOR) 2.18, 95% confidence interval (CI) 2.11-2.26) whereas for women of 40 years or above, the risk was more than tripled (AOR 3.64, 95% CI 3.41-3.90). For multiparous women aged 35-39-years the risk was more moderate, but still with an AOR of 1.56, 95% CI 1.53-1.60, and for those 40 years and above, the AOR was 2.02, 95% CI 1.92-2.09.
Overall, cesarean section increased with increasing maternal age. Adjustment for maternal and obstetric risk factors had only a minor influence on the association. The association was stronger in nulliparous women compared to multiparous women. Given the lack of impact of demographic and health risks on the relationship between maternal age and cesarean section, the authors suggest obstetric culture could be added to the list of risk factors for a cesarean. Future research on obstetric culture is recommended as are studies on a possible age-related decrease in the ability to maintain the progression of labor.
The study uses depersonalized register data and has been approved by the Danish Data Protection Agency (2015-41-4168).
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Variations in intervention rates, without subsequent reductions in adverse outcomes, can indicate overuse. We studied variations in and associations between commonly used childbirth interventions and ...adverse outcomes, adjusted for population characteristics.
In this multinational cross-sectional study, existing data on 4,729,307 singleton births at ≥37 weeks in 2013 from Finland, Sweden, Norway, Denmark, Iceland, Ireland, England, the Netherlands, Belgium, Germany (Hesse), Malta, the United States, and Chile were used to describe variations in childbirth interventions and outcomes. Numbers of births ranged from 3,987 for Iceland to 3,500,397 for the USA. Crude data were analysed in the Netherlands, or analysed data were shared with the principal investigator. Strict variable definitions were used and information on data quality was collected. Intervention rates were described for each country and stratified by parity. Uni- and multivariable analyses were performed, adjusted for population characteristics, and associations between rates of interventions, population characteristics, and outcomes were assessed using Spearman's rank correlation coefficients. Considerable intercountry variations were found for all interventions, despite adjustments for population characteristics. Adjustments for ethnicity and body mass index changed odds ratios for augmentation of labour and episiotomy. Largest variations were found for augmentation of labour, pain relief, episiotomy, instrumental birth, and cesarean section (CS). Percentages of births at ≥42 weeks varied from 0.1% to 6.7%. Rates among nulliparous versus multiparous women varied from 56% to 80% versus 51% to 82% for spontaneous onset of labour; 14% to 36% versus 8% to 28% for induction of labour; 3% to 13% versus 7% to 26% for prelabour CS; 16% to 48% versus 12% to 50% for overall CS; 22% to 71% versus 7% to 38% for augmentation of labour; 50% to 93% versus 25% to 86% for any intrapartum pain relief, 19% to 83% versus 10% to 64% for epidural anaesthesia; 6% to 68% versus 2% to 30% for episiotomy in vaginal births; 3% to 30% versus 1% to 7% for instrumental vaginal births; and 42% to 70% versus 50% to 84% for spontaneous vaginal births. Countries with higher rates of births at ≥42 weeks had higher rates of births with a spontaneous onset (rho = 0.82 for nulliparous/rho = 0.83 for multiparous women) and instrumental (rho = 0.67) and spontaneous (rho = 0.66) vaginal births among multiparous women and lower rates of induction of labour (rho = -0.71/-0.66), prelabour CS (rho = -0.61/-0.65), overall CS (rho = -0.61/-0.67), and episiotomy (multiparous: rho = -0.67). Variation in CS rates was mainly due to prelabour CS (rho = 0.96). Countries with higher rates of births with a spontaneous onset had lower rates of emergency CS (nulliparous: rho = -0.62) and higher rates of spontaneous vaginal births (multiparous: rho = 0.70). Prelabour and emergency CS were positively correlated (nulliparous: rho = 0.74). Higher rates of obstetric anal sphincter injury following vaginal birth were found in countries with higher rates of spontaneous birth (nulliparous: rho = 0.65). In countries with higher rates of epidural anaesthesia (nulliparous) and spontaneous births (multiparous), higher rates of Apgar score < 7 were found (rhos = 0.64). No statistically significant variation was found for perinatal mortality. Main limitations were varying quality of data and missing information.
Considerable intercountry variations were found for all interventions, even after adjusting for population characteristics, indicating overuse of interventions in some countries. Multivariable analyses are essential when comparing intercountry rates. Implementation of evidence-based guidelines is crucial in optimising intervention use and improving quality of maternity care worldwide.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Uterine rupture without a former history of cesarean delivery or uterine scarring is an exceedingly rare complication in pregnancy and labor. Misoprostol is widely used to induce labor but there is a ...lack of knowledge about serious adverse effects. It is especially challenging to collect reports on side effects because misoprostol is not a registered drug. We report a case of a woman induced by one dose 25μg misoprostol vaginally. Her pregnancy was uncomplicated and she had an unscarred uterus. Her labor progressed rapidly and she experienced hyperstimulation, meconium stained amniotic fluid, uterine rupture, and excessive blood loss of approximately 14l. The child survived but is diagnosed with cerebral palsy. The case was never reported as an adverse event. This case questions the safety of misoprostol even in low dosage. It also underlines the need to report side effects to national reporting systems.
•Low dose misoprostol can cause uterine rupture in unscarred uterus.•It is important to report adverse effects, especially medication used off-label.•There is a lack of knowledge about adverse events of misoprostol.•The reporting system is insufficient in relation to off-label use.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
ObjectivesFor many years, routine elective induction of labour at gestational week (GW) 42+0 has been recommended in Denmark. In 2011, a more proactive protocol was introduced aimed at reducing ...stillbirths, and practice changed into earlier routine induction, i.e. between 41+3 and 41+5 GW. The present study evaluates a national change in induction of labour regime. The trend of maternal and neonatal consequences are monitored in the preintervention period (2000–2010) compared with the postintervention period (2012–2016).DesignA national retrospective register-based cohort study.SettingDenmark.ParticipantsAll births in Denmark 41+3 to 45+0 GWs between 2000 and 2016 (N = 152 887).Outcome measuresPrimary outcomes: stillbirths, perinatal death, and low Apgar scores. Additional outcomes: birth interventions and maternal outcomes.ResultsFor the primary outcomes, no differences in stillbirths, perinatal death, and low Apgar scores were found comparing the preintervention and postintervention period. Of additional outcomes, the trend changed significantly postintervention concerning use of augmentation of labour, epidural analgesia, induction of labour and uterine rupture (all p<0.05). There was no significant change in the trend for caesarean section and instrumental birth. Most notable for clinical practice was the increase in induction of labour from 41% to 65% (p<0.01) at 41+3 weeks during 2011 as well as the rare occurrence of uterine ruptures (from 2.6 to 4.2 per thousand, p<0.02).ConclusionsEvaluation of a more proactive regimen recommending induction of labour from GW 41+3 compared with 42+0 using national register data found no differences in neonatal outcomes including stillbirth. The number of women with induced labour increased significantly.
ObjectivesThe need for thorough patient information is increasing as maternity care becomes more medicalised. The aim was to assess the quality of written patient information on labour induction. In ...most Danish hospitals, misoprostol is the first-choice drug for induction in low-risk pregnancies. Misoprostol has been associated with adverse side effects and severe outcomes for mother and child and is not registered for obstetric use in Denmark.SettingSecondary care hospitals in Denmark.DataPatient information leaflets from all hospitals that used misoprostol as an induction agent by June 2015 (N=13).DesignPatient leaflets were evaluated according to a validated scoring tool (International Patient Decision Aid Standards instrument, IPDAS), core elements in the Danish Health Act, and items regarding off-label use and non-registered medication. Two of the authors scored all leaflets independently.Outcome measuresWomen's involvement in decision-making, information on benefits and harms associated with the treatment, other justifiable treatment options, and non-registered treatment.ResultsGenerally, the hospitals scored low on the IPDAS checklist. No hospitals encouraged women to consider their preferences. Information on side effects and adverse outcomes was poorly covered and varied substantially between hospitals. Few hospitals informed about precautions regarding outpatient inductions, and none informed about the lack of evidence on the safety of this procedure. None informed that misoprostol is not registered for induction or explained the meaning of off-label use or use of non-registered medication. Elements such as interprofessional consensus, long-term experience, and health authorities' approval were used to add credibility to the use of misoprostol.ConclusionsCentral criteria for patient involvement and informed consent were not met, and the patient leaflets did not inform according to current evidence on misoprostol-induced labour. Our findings indicate that patients receive very different, sometimes contradictory, information with potential ethical implications. Concerns should be given to outpatient inductions, where precise written information is of particular importance.
•Interventions are increasingly used among nulliparous women between 2000 and 2017.•Induction of labour and epidural raised substantially during the period.•The risk of having more than one ...intervention grew.•Overall, fetal and maternal birth outcomes were unchanged.•An evaluation of contemporary care with a “first do no harm” perspective is needed.
Current labour practices have seen an acceleration in interventions to either initiate, monitor, accelerate, or terminate the physiological process of pregnancy and childbirth. This study aimed to describe and analyse the use of interventions in childbirth in Denmark over almost two decades (2000–2017). We also examined the extent to which contemporary care adheres to current international recommendations towards restricted use of interventions.
A national retrospective Danish register-based cohort study including all nulliparous women with term births with singleton pregnancy and a foetus in cephalic between the years 2000 and 2017 (n = 380,326 births). Multivariate regression analyses with adjustment for change in population were performed.
Induction of labour, epidural analgesia, and augmentation of labour.
Between 2000/2001 and 2016/2017, the prevalence increased for induction of labour from 5.1% to 22.8%, AOR 4.84, 95% CI 4.61–5.10, epidural analgesia from 10.5% to 34.3% (AOR 4.10, 95% CI 3.95–4.26), and augmentation of labour decreased slightly from 40.1% to 39.3% (AOR 0.84, 95% CI 0.81–0.86). Having more than one of the three mentioned interventions increased from 12.8% in to 30.9%.
The number of interventions increased during the study period as well as the number of interventions in each woman. As interventions may interfere in physiological labour and carry the risk of potential short- and long-term consequences, the findings call for a careful re-evaluation of contemporary maternity care with a “first, do no harm” perspective.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
A traumatic upbringing increases the risks of antenatal health problems, unfavourable pregnancy outcomes, and mental disorders. Such childhood experiences may affect women’s pa-renting skills and the ...social–emotional functioning of their children. Research on screening for adverse childhood experiences in antenatal care is limited. The objective of this study was to explore pregnant women’s attitudes towards and experiences of an adverse childhood experiences questionnaire, and to assess the relevance of the questionnaire among a population of pregnant women referred to antenatal care levels one and two, targeting women who are generally not perceived to be vulnerable. Data were collected at three maternity wards and consisted of quantitative data on 1352 women’s adverse childhood experience scores, structured observations of 18 midwifery visits, and in-depth interviews with 15 pregnant women. Quantitative data were analysed by descriptive statistics, and qualitative data were analysed using systematic text condensation. The qualitative analysis revealed two main categories: “Being screened for childhood adversities” and “Having adverse childhood experiences”. In the study population, the prevalence of adverse childhood experiences was high. The women assessed the adverse childhood experiences questionnaire to be a relevant and acceptable screening method. Furthermore, women’s perceptions of their relationship with their midwife greatly impacted their attitudes towards and experiences of the questionnaire.
Adverse childhood experiences have a potential lifelong impact on health. A traumatic upbringing may increase antenatal health risks in mothers-to-be and impact child development in their offspring. ...Yet, little is known about the identification of adverse childhood experiences in antenatal care. The objective of this study was to explore the feasibility and acceptability of the adverse childhood experiences questionnaire among midwives and factors affecting its implementation. Three Danish maternity wards participated in the study. The data consisted of observations of midwifery visits and informal conversations with midwives, as well as mini group interviews and dialogue meetings with midwives. The data were analysed using systematic text condensation. Analysis of the data revealed three main categories; "Relevance of the adverse childhood experiences questionnaire", "Challenges related to use of the adverse childhood experiences questionnaire" and "Apprehensions, emotional strain, and professional support". The findings showed that the adverse childhood experiences questionnaire was feasible to implement in Danish antenatal care. Midwives' acceptability of the questionnaire was high. Training courses and dialogue meetings motivated the midwives to work with the questionnaire in practice. The main factors affecting the implementation process were time restrictions, worries of overstepping women's boundaries, and a lack of a specific intervention for women affected by their traumatic upbringing circumstances.
IntroductionThere are growing concerns about the increase in rates of commonly used childbirth interventions. When indicated, childbirth interventions are crucial for preventing maternal and ...perinatal morbidity and mortality, but their routine use in healthy women and children leads to avoidable maternal and neonatal harm. Establishing ideal rates of interventions can be challenging. This study aims to describe the range of variations in the use of commonly used childbirth interventions in high-income countries around the world, and in outcomes in nulliparous and multiparous women.Methods and analysisThis multinational cross-sectional study will use data from births in 2013 with national population data or representative samples of the population of pregnant women in high-income countries. Data from women who gave birth to a single child from 37 weeks gestation onwards will be included and the results will be presented for nulliparous and multiparous women separately. Anonymised individual level data will be analysed. Primary outcomes are rates of commonly used childbirth interventions, including induction and/or augmentation of labour, intrapartum antibiotics, epidural and pharmacological pain relief, episiotomy in vaginal births, instrument-assisted birth (vacuum or forceps), caesarean section and use of oxytocin postpartum. Secondary outcomes are maternal and perinatal mortality, Apgar score below 7 at 5 min, postpartum haemorrhage and obstetric anal sphincter injury. Univariable and multivariable logistic regression analyses will be conducted to investigate variations among countries, adjusted for maternal age, body mass index, gestational weight gain, ethnic background, socioeconomic status and infant birth weight. The overall mean rates will be considered as a reference category, weighted for the size of the study population per country.Ethics and disseminationThe Medical Ethics Review Committee of VU University Medical Center Amsterdam confirmed that an official approval of this study was not required. Results will be disseminated at national and international conferences and published in peer-reviewed journals.
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