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Maternal Outcomes When a Primary Cesarean is the Only Indication for a Repeat Cesarean

Maternal Outcomes When a Primary Cesarean is the Only Indication for a Repeat Cesarean. Jessica A. Taubner, Eugene Declercq, PhD, Mary Barger, CNM, MPH, Howard Cabral, PhD, MPH, Stephen R. Evans, MPH, Milton Kotelchuck, PhD, MPH, Judith Weiss, ScD APHA 134 th Annual Meeting

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Maternal Outcomes When a Primary Cesarean is the Only Indication for a Repeat Cesarean

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  1. Maternal Outcomes When a Primary Cesarean is the Only Indication for a Repeat Cesarean Jessica A. Taubner, Eugene Declercq, PhD, Mary Barger, CNM, MPH, Howard Cabral, PhD, MPH, Stephen R. Evans, MPH, Milton Kotelchuck, PhD, MPH, Judith Weiss, ScD APHA 134th Annual Meeting Boston, MA ~ November 6, 2006

  2. Overall Vaginal Birth After Cesarean (VBAC) Rates* 1989-2004 U.S. & Massachusetts % *Vaginal births after cesareans/VBACs + Repeat Cesareans Sources: Martin JA, et.al. S. Births: final data for 2004. Natl Vit Stat Rep. 2006;55(1):1-102. MassChip v.3.0, Natality file.

  3. Context • Between 1996-2004, the rate of vaginal birth after cesarean (VBAC) in the U.S. decreased by 67%, while in Massachusetts it decreased by 68%1 • In 1998, 1999, and 2004 ACOG released practice guidelines calling for VBACs to be limited to facilities capable of 24 hour coverage for an emergency cesarean.2-4 • As a result, a prior cesarean has become an indication for a repeat cesarean without any other medical indications 1. Martin JA, et.al. S. Births: final data for 2004. Natl Vit Stat Rep. 2006;55(1):1-102. MassChip v.3.0, Natality file. 2. ACOG practice bulletin. Vaginal birth after previous cesarean delivery. # 2, 10/98. IJGO. 1999;64(2):201-8 3. ACOG practice bulletin. Vaginal birth after previous cesarean delivery. # 5 7/99 IJGO 1999;66(2):197-204. 4. ACOG Practice Bulletin #54: Vaginal birth after previous cesarean. Obstet Gynecol. 2004 Jul;104(2):203-12.

  4. Objective • No studies to date have examined postpartum or financial outcomes related to repeat cesareans that are not medically indicated • This study analyzes postpartum rehospitalization rates and associated costs for women who had: • A planned repeat cesarean with no other medical indications • A planned VBAC

  5. Methods • Data was obtained from the Pregnancy to Early Life Longitudinal (PELL) Data System • PELL links birth & fetal death certificates* to mother’s birth related hospital discharge records^ • Subsequent maternal post-birth hospital discharge records up to 1 year postpartum are linked to the mother’s delivery record * Vital records from MA Dept. of Public Health, Registry of Vital Records & Statistics ^ Hospital Discharge Data from Division of Health Care Finance and Policy

  6. Methods (cont’d) • For this study we used data from the 470,857 linked records for births that occurred to MA residents in MA hospitals from 1/1/1998 through 12/31/2003 • We identified mothers who approached labor with no documented medical risk (NDR) prior to delivery • Women were then assigned to 2 study groups based on labor associated complications during delivery

  7. Total linked Mass. births to Mass. residents, 1998-003 470,857 Prior Cesarean, singleton, vertex, 37-41 weeks Gestation 46,674 Birth Certificate 37,494 Hospital Discharge 40,849 Alternate measures of No Documented Prior Risk Combined BC/HD 33,664 Mothers with no documented risk (NDR) prior to delivery Stratifying mothers with & w/out labor associated complications VBACs w/ Doc. Risk 2,189 Unplanned Repeat Cesareans 4,826 No Doc. Labor Risk VBACs 8,321 Final Study Groups:Mothers with Planned VBACs & Planned Repeat Cesareans Planned Repeat Cesareans 18,328 Planned VBACs 15,336 Source: PELL Data System

  8. Identifying Women with No Documented Prior Risk: Total linked Mass. births to Mass. residents, 1998-003 470,857 Prior Cesarean, singleton, vertex, 37-41 weeks gestation 46,674 Birth Certificate (BC)* 37,494 Hospital Discharge (HD)* 40,849 Alternate measures of no documented prior risk (NDPR): OR Mothers with no documented risk prior to delivery Combined BC/HD 33,664 Source: PELL Data System

  9. Defining Planned Repeat Cesareans & Planned VBACs: No Documented Risk Prior to Labor on BC or HD 33,664 Repeat Cesareans with Labor* Complications 4,826 VBACs w/ No Labor Complications 8,321 VBACs with Labor Complications 2,189 Planned Repeat Cesareans 18,328 Planned VBACs 15,336 Source: PELL Data System

  10. Percent of Planned Repeat Cesareans & Planned VBACs with No Documented Prior Risk by Year, MA 1998-2003 90% Increase 51% Decrease Source: PELL Data System

  11. Percent of Planned Repeat Cesareans of all NDPR Births by Maternal Characteristics, MA 1998-2003 Source: PELL Data System

  12. Postpartum (PP) Rehospitalization Rates and Odds Ratios, Planned VBACs vs. Planned Repeat Cesareans, MA 1998-2003 * Adjusted for age, race/ethnicity, and parity. Source: PELL Data System

  13. Reasons for Postpartum Rehospitalization ^ ICD-9-CM Primary & Secondary Diagnosis Codes * Includes cellulitis and abscess of trunk †p=<0.0001 Source: PELL Data System

  14. Average Hospital Length of Stay and Costs 32% Difference 25% Difference 19% Difference 34% Difference * Charge data adjusted by cost to charge ratios obtained from the MA Div. of Healthcare Finance and Policy and adjusted for inflation to reflect 2003 dollars. Source: PELL Data System

  15. Summary of Findings • Between 1998 and 2003 repeat cesareans with no medical indication increased rapidly in Massachusetts (90%) • The likelihood of having a planned repeat cesarean vs. a planned VBAC increases with maternal age

  16. Summary of Findings (cont’d) • Compared with women who have a planned VBAC, women who have a planned repeat cesarean: • Are 34% more likely to be rehospitalized in the first month • Have a 32% longer initial hospital length of stay that is 25% more costly • Who are rehospitalized in 12 months postpartum, have a 19% longer hospital stay that is 34% more costly

  17. Conclusions • Obstetric providers, policy makers, and women should consider the benefits and risks of both repeat cesareans and VBACs

  18. anemia cardiac disease acute or chronic lung disease diabetes genital herpes hydramnios or oligohydramnios hemoglobinopathy chronic hypertension pregnancy associated hypertension eclampsia incompetent cervix prior infant w/ birth defects prior infant 4000+ grams prior preterm / SGA infant renal disease Rh sensitization uterine bleeding placenta previa Birth Certificate Medical Risk Factors* Declercq E, Menacker F, MacDorman M. Rise in “no indicated risk” primary caesareans in the United States, 1991-2001. BMJ 2005; 330:71-2.

  19. antepartum bleeding or placental abruption herpes severe hypertension eclampsia or severe pre-eclampsia hypertension, other prior uterine scar unrelated to cesarean delivery maternal soft tissue disorder multiple gestation preterm gestation unengaged fetal head macrosomia congenital fetal CNS or chromosomal abnormality malpresentation cephalic version Hospital Discharge Medical Risk Factors* Menacker F, Curtin S. Trends in cesarean birth and vaginal birth after previous cesarean, 1991-1999. National Vital Statistics Reports. Vol 49, No 13. Hyattsville, MD.: National Center for Health Statistics, 2001

  20. Birth Certificate febrile meconium mod/heavy premature rupture of membranes abruptio placenta or other excessive bleeding seizures during labor precipitous labor prolonged labor dysfunctional labor cephalopelvic disproportion cord prolapse anesthetic complication fetal distress Hospital Discharge disproportion fetal distress failed mechanical induction unspecified induction obstructed labor abnormality of forces of labor long labor umbilical cord complications Labor & Delivery Complications*

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