Interventions to reduce unnecessary caesarean sections in healthy women and babies

Optimising the use of caesarean section (CS) is of global concern. Underuse leads to maternal and perinatal mortality and morbidity. Conversely, overuse of CS has not shown benefits and can create harm. Worldwide, the frequency of CS continues to increase, and interventions to reduce unnecessary CSs have shown little success. Identifying the underlying factors for the continuing increase in CS use could improve the efficacy of interventions. In this Series paper, we describe the factors for CS use that are associated with women, families, health professionals, and health-care organisations and systems, and we examine behavioural, psychosocial, health system, and financial factors. We also outline the type and effects of interventions to reduce CS use that have been investigated. Clinical interventions, such as external cephalic version for breech delivery at term, vaginal breech delivery in appropriately selected women, and vaginal birth after CS, could reduce the frequency of CS use. Approaches such as labour companionship and midwife-led care have been associated with higher proportions of physiological births, safer outcomes, and lower health-care costs relative to control groups without these interventions, and with positive maternal experiences, in high-income countries. Such approaches need to be assessed in middle-income and low-income countries. Educational interventions for women should be complemented with meaningful dialogue with health professionals and effective emotional support for women and families. Investing in the training of health professionals, eliminating financial incentives for CS use, and reducing fear of litigation is fundamental. Safe, private, welcoming, and adequately resourced facilities are needed. At the country level, effective medical leadership is essential to ensure CS is used only when indicated. We conclude that interventions to reduce overuse must be multicomponent and locally tailored, addressing women’s and health professionals’ concerns, as well as health system and financial factors

Adherence to guidelines and suboptimal practice in term breech delivery with perinatal death- a population-based case-control study in Norway

Background In a recent population-based study we reported excess risk of neonatal mortality associated with vaginal breech delivery. In this case-control study we examine whether deviations from Norwegian guidelines are more common in breech deliveries resulting in intrapartum or neonatal deaths than in breech deliveries where the offspring survives, and if these deaths are potentially avoidable. Material and methods Case-control study completed as a perinatal audit including term breech deliveries of singleton without congenital anomalies in Norway from 1999 to 2015. Deliveries where the child died intrapartum or in the neonatal period were case deliveries. For each case, two control deliveries who survived were identified. All the included deliveries were reviewed by four obstetricians independently assessing if the deaths in the case group might have been avoided and if the management of the deviations from Norwegian guidelines were more common in case than in control deliveries. Results Thirty-one case and 62 control deliveries were identified by the Medical Birth Registry of Norway. After exclusion of non-eligible deliveries, 22 case and 31 control deliveries were studied. Three case and two control deliveries were unplanned home deliveries, while all in-hospital deliveries were in line with national guidelines. Antenatal care and/or management of in-hospital deliveries was assessed as suboptimal in seven (37%) case and two (7%) control deliveries (p = 0.020). Three case deliveries were completed as planned caesarean delivery and 12 (75%) of the remaining 16 deaths were considered potentially avoidable had planned caesarean delivery been done. In seven of these 16 deliveries, death was associated with cord prolapse or difficult delivery of the head. Conclusion All in-hospital breech deliveries were in line with Norwegian guidelines. Seven of twelve potentially avoidable deaths were associated with birth complications related to breech presentation. However, suboptimal care was more common in case than control deliveries. Further improvement of intrapartum care may be obtained through continuous rigorous training and feedback from repeated perinatal audits

Incidence of invasive Group B Streptococcal infection and the risk of infant death and cerebral palsy: a Norwegian Cohort Study

Background Group B Streptococcus (GBS) is the leading cause of invasive neonatal infection worldwide. In high-income countries mortality rates are 4–10%, and among survivors of GBS meningitis 30–50% have neurodevelopmental impairments. We hypothesized that invasive GBS infection was associated with increased risk of infant mortality and cerebral palsy (CP). Methods All children born alive in Norway during 1996–2012 were included. Data were collected from three national registers. Invasive GBS infection during infancy was categorized into early-onset disease (EOD), late-onset disease (LOD), and very late-onset disease (VLOD). Primary outcomes were infant mortality and CP. Results Invasive GBS infection was diagnosed in 625 children (incidence: 0.62 per 1000 live births; 95% confidence interval (CI): 0.57–0.67). The incidence of EOD was 0.41 (0.37–0.45), of LOD 0.20 (0.17–0.23), and of VLOD 0.012 (0.007–0.021). The annual incidence of LOD increased slightly. Among infected infants, 44 (7%) died (odds ratio (OR): 24.5; 95% CI: 18.0–33.3 compared with the background population). Among survivors, 24 (4.1%) children were later diagnosed with CP, compared with 1887 (0.19%) in the background population (OR: 22.9; 95% CI: 15.1–34.5). Conclusion Despite a relatively low incidence of invasive GBS infection in Norway, the risk of death and CP remains high. Improvements in prevention strategies are needed. Impact During the first decade of the twenty-first century, invasive GBS disease in infancy is still associated with high mortality. Despite the overall low incidence of invasive GBS disease, the incidence of LOD increased during the study period. The finding that invasive GBS infection in the neonatal period or during infancy is associated with an excess risk of CP, comparable to the risk following moderate preterm birth and moderate low Apgar scores, adds to the existing literature. The results of this study emphasize the importance of adhering to guidelines and the need for better prevention strategies

Is vaginal breech delivery associated with higher risk for perinatal death and cerebral palsy compared with vaginal cephalic birth? Registry-based cohort study in Norway

Objective: This paper aims to study if vaginal breech delivery is associated with increased risk for neonatal mortality (NNM) or cerebral palsy (CP) in Norway where vaginal delivery accounts for 1/3 of all breech deliveries. Design: Cohort study using information from the national Medical BirthRegister and Cerebral Palsy Register. Setting: Births in Norway 1999–2009. Participants: 520 047 term-born singletons without congenital malformations. Main outcome measures: NNM, CP and a composite outcome of these and death during birth. Results: Compared with cephalic births, breech births had substantially increased risk for NNM but not for CP. Vaginal delivery was planned for 7917 of 16 700 fetuses in breech, while 5561 actually delivered vaginally. Among these, NNM was 0.9 per 1000 compared with 0.3 per 1000 in vaginal cephalic delivery, and 0.8 per 1000 in those actually born by caesarean delivery (CD) in breech. Compared with planned cephalic delivery, planned vaginal delivery was associated with excess risk for NNM (OR 2.4; 95% CI 1.2 to 4.9), while the OR associated with planned breech CD was 1.6 (95% CI 0.7 to 3.7). These risks were attenuated when NNM was substituted by the composite outcome. Vaginal breech delivery was not associated with excess risk for CP compared with vaginal cephalic delivery. Conclusion: Vaginal breech delivery, regardless of whether planned or actual, and actual breech CD were associated with excess risk for NNM compared with vaginal cephalic delivery, but not with CP. The risk for NNM and CP in planned breech CD did not differ significantly from planned vaginal cephalic delivery. However, the absolute risk for these outcomes was low, and taking into consideration potential long-term adverse consequences of CD for the child and later deliveries, we therefore conclude that vaginal breech delivery may be recommended, provided competent obstetric care and strict criteria for selection to vaginal delivery

Prelabor rupture of membranes and the association with cerebral palsy in term born children: A national registry-based cohort study.

Background Guidelines regarding management of prelabor rupture of membranes (PROM) at term vary between immediate induction and expectant management. A long interval between PROM and delivery increases the risk for perinatal infections. Severe perinatal infections are associated with excess risk for cerebral palsy (CP) and perinatal death. We investigated if increasing intervals between PROM and delivery were associated with perinatal death or CP. Methods Eligible to participate in this population-based cohort-study were term born singletons without congenital malformations born in Norway during 1999–2009. Data was retrieved from the Medical Birth Registry of Norway (MBRN) and the Cerebral Palsy Register of Norway. In line with the registration in the MBRN, intervals between PROM and delivery of more than 24 h was defined as ‘prolonged’ and intervals between 12 and 24 h as ‘intermediate’. Outcomes were stillbirth, death during delivery, neonatal mortality and CP. Logistic regression was used to calculate odds ratio (OR) with 95% confidence intervals (CI) for adverse outcomes in children born after prolonged and intermediate intervals, compared with a reference group comprising all children born less than 12 h after PROM or without PROM. Results Among 559,972 births, 34,759 children were born after intermediate and 30,332 were born after prolonged intervals. There was no association between increasing intervals and death during delivery or in the neonatal period, while the prevalence of stillbirths decreased with increasing intervals. Among children born after intermediate intervals 38 (0.11%) had CP, while among those born after prolonged intervals 46 (0.15%) had CP. Compared with the reference group, the OR for CP was 1.16 (CI; 0.83 to 1.61) after intermediate and 1.61 (CI; 1.19 to 2.18) after prolonged intervals. Adjusting for antenatal factors did not affect these associations. Among children with CP the proportion with diffuse cortical injury and basal ganglia pathology on cerebral MRI, consistent with hypoxic-ischemic injuries, increased with increasing intervals. Conclusion Intervals between PROM and delivery of more than 24 h were associated with CP, but not with neonatal mortality or death during delivery. The inverse association with stillbirth is probably due to reverse causality

Cell-Type-Specific Transcription of Innate Immune Regulators in response to HMPV Infection

Human metapneumovirus (HMPV) may cause severe respiratory disease. The early innate immune response to viruses like HMPV is characterized by induction of antiviral interferons (IFNs) and proinflammatory immune mediators that are essential in shaping adaptive immune responses. Although innate immune responses to HMPV have been comprehensively studied in mice and murine immune cells, there is less information on these responses in human cells, comparing different cell types infected with the same HMPV strain. The aim of this study was to characterize the HMPV-induced mRNA expression of critical innate immune mediators in human primary cells relevant for airway disease. In particular, we determined type I versus type III IFN expression in human epithelial cells and monocyte-derived macrophages (MDMs) and dendritic cells (MDDCs). In epithelial cells, HMPV induced only low levels of IFN-β mRNA, while a robust mRNA expression of IFN-λs was found in epithelial cells, MDMs, and MDDCs. In addition, we determined induction of the interferon regulatory factors (IRFs) IRF1, IRF3, and IRF7 and critical inflammatory cytokines (IL-6, IP-10, and IL-1β). Interestingly, IRF1 mRNA was predominantly induced in MDMs and MDDCs. Overall, our results suggest that for HMPV infection of MDDCs, MDMs, NECs, and A549 cells (the cell types examined), cell type is a strong determinator of the ability of HMPV to induce different innate immune mediators. HMPV induces the transcription of IFN-β and IRF1 to higher extents in MDMs and MDDCs than in A549s and NECs, whereas the induction of type III IFN-λ and IRF7 is considerable in MDMs, MDDCs, and A549 epithelial cells

Does caesarean delivery in the first pregnancy increase the risk for adverse outcome in the second? A registry-based cohort study on first and second singleton births in Norway

Objective To explore if newborns in the second pregnancy following a previous caesarean delivery (CD) have higher risk of perinatal mortality or cerebral palsy than newborns in pregnancies following a previous vaginal delivery (VD). Design Cohort study with information from the Medical Birth Registry of Norway and the Cerebral Palsy Registry of Norway. Setting Births in Norway. Participants 294 598 women with their first and second singleton delivery during 1996–2015. Main outcome measures Stillbirth, perinatal mortality, neonatal mortality and cerebral palsy. Results Among 294 598 included women, 42 962 (15%) had a CD in their first pregnancy while 251 636 (85%) had a VD. Compared with the second delivery of mothers with a previous VD, the adjusted OR (adjOR), for stillbirth in the second pregnancy following a previous CD was 1.45, 95% CI 1.22 to 1.73; for perinatal death the adjOR was 1.42 (1.22 to 1.73) and for neonatal death 1.13 (0.86 to 1.49). Among children who survived the neonatal period, the adjOR for cerebral palsy was 1.27 (0.99 to 1.64). Secondary outcomes, including small for gestational age, preterm and very preterm birth, uterine rupture and placental complications (eg, postpartum haemorrhage and pre-eclampsia) were more frequent in the subsequent pregnancy following a previous CD compared with a previous VD, in particular for uterine rupture adjOR 86.7 (48.2 to 156.1). Adjustment for potential confounders attenuated the ORs somewhat, but the excess risk in the second pregnancy persisted for all outcomes. Conclusion A previous CD was in this study associated with increased risk for stillbirth and perinatal death compared with a previous VD. Although less robust, we also found that a previous CD was associated with a slightly increased risk of cerebral palsy among children surviving the neonatal period. The aetiology behind these associations needs further investigation

Does caesarean delivery in the first pregnancy increase the risk for adverse outcome in the second? A registry-based cohort study on first and second singleton births in Norway

Objective To explore if newborns in the second pregnancy following a previous caesarean delivery (CD) have higher risk of perinatal mortality or cerebral palsy than newborns in pregnancies following a previous vaginal delivery (VD). Design Cohort study with information from the Medical Birth Registry of Norway and the Cerebral Palsy Registry of Norway. Setting Births in Norway. Participants 294 598 women with their first and second singleton delivery during 1996–2015. Main outcome measures Stillbirth, perinatal mortality, neonatal mortality and cerebral palsy. Results Among 294 598 included women, 42 962 (15%) had a CD in their first pregnancy while 251 636 (85%) had a VD. Compared with the second delivery of mothers with a previous VD, the adjusted OR (adjOR), for stillbirth in the second pregnancy following a previous CD was 1.45, 95% CI 1.22 to 1.73; for perinatal death the adjOR was 1.42 (1.22 to 1.73) and for neonatal death 1.13 (0.86 to 1.49). Among children who survived the neonatal period, the adjOR for cerebral palsy was 1.27 (0.99 to 1.64). Secondary outcomes, including small for gestational age, preterm and very preterm birth, uterine rupture and placental complications (eg, postpartum haemorrhage and pre-eclampsia) were more frequent in the subsequent pregnancy following a previous CD compared with a previous VD, in particular for uterine rupture adjOR 86.7 (48.2 to 156.1). Adjustment for potential confounders attenuated the ORs somewhat, but the excess risk in the second pregnancy persisted for all outcomes. Conclusion A previous CD was in this study associated with increased risk for stillbirth and perinatal death compared with a previous VD. Although less robust, we also found that a previous CD was associated with a slightly increased risk of cerebral palsy among children surviving the neonatal period. The aetiology behind these associations needs further investigation