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Objective: To examine the association between county-level caesarean delivery (CD) rates among women at low risk and morbidity among term newborns., Design: Cross-sectional study., Setting: Population-based study of US county-level birth data from 2015 to 2017., Population: Nulliparous women with term, singleton, vertex-presenting infants (NTSV) at low risk for morbidity., Methods: The primary exposure was county-level CD rates., Main Outcome Measures: The outcome was morbidity among the low-risk NTSV cohort, categorised as severe (5-minute Apgar score of ≤3, assisted ventilation for ≥6 hours, severe neurologic injury or seizure, transfer or death) or moderate (5-minute Apgar score of <7 but >3, administration of antibiotics or assisted ventilation at delivery). We used linear regression models to determine the association between county NTSV CD and neonatal morbidity rates with cluster robust standard errors., Results: The analysis included data from 2 753 522 births in 952 counties from all 48 states. The mean NTSV CD rate was 23.6% (standard deviation 4.8%). The median severe and moderate neonatal morbidity rates were 15.2 (interquartile range, IQR 9.4-23.6) and 52.5 (IQR 33.4-75.7) per 1000 births, respectively. In the unadjusted analysis using the risk-adjusted exposure and outcome, every percentage point increase in the CD rate of a county was associated with 0.6 (95% CI -0.9, -0.3) and 2.3 fewer (95% CI -3.4, -1.1) cases of severe and moderate neonatal morbidity per 1000 live births. After adjustment for other county factors, the relationships remained significant. These findings were tested in multiple sensitivity analyses., Conclusions: Lower county-level NTSV CD rates were associated with a small increase in morbidity among term newborns in the USA., Tweetable Abstract: Lower county-level caesarean delivery rates were associated with an increase in morbidity among term newborns in the USA., (© 2021 John Wiley & Sons Ltd.)

Background: Although there are many indications for a cesarean delivery, the "optimal" cesarean delivery rate is unknown. Neonatal and maternal morbidity have largely not been considered in the generation of hospital-level cesarean delivery rate targets., Objective: We sought to examine if the widely adopted and reported markers of maternal and neonatal morbidity were associated with hospital cesarean delivery rates to provide context for potential comparison and consideration for defining cesarean delivery rate targets. We hypothesized that hospitals with higher cesarean delivery rates would have increased rates of severe maternal morbidity, though we were less certain of the associations of the cesarean delivery rates with unexpected newborn complications., Study Design: This is a cross-sectional, ecological study using data from the 2016 Nationwide Readmission Database of hospitals with at least 100 deliveries per year. The exposure of interest was hospital cesarean delivery rate. The outcomes were (1) severe maternal morbidity with and without transfusion-in accordance with the Centers for Disease Control and Prevention's definition, and (2) neonatal morbidity-defined using The Joint Commission's Perinatal Quality metric of moderate and severe unexpected newborn complications among term, singleton, and nonanomalous neonates. Before assuming a single linear relationship to model the associations between morbidity and cesarean delivery rates, the Joinpoint Regression Analysis program was used to examine for potential splines in the relationships with both severe maternal morbidity (with and without transfusion) and severe and moderate unexpected newborn complications. Poisson regression model was then used to determine the association between morbidity and cesarean delivery rates., Results: The analysis included 831,111 deliveries from 621 hospitals. The mean cesarean delivery rate was 30.5%. The median severe maternal morbidity rate was 1.40 per 100 deliveries (interquartile range, 0.71-2.21 per 1000 deliveries). Excluding transfusion, the median severe maternal morbidity rate was 0.47 per 100 deliveries (interquartile range, 0.22-0.73 per 100 deliveries). The median rate of severe and moderate unexpected newborn complications was 1.01 per 100 low-risk newborns (interquartile range, 0.64-1.69 per 100 low-risk newborns) and 1.79 per 1000 low-risk newborns (interquartile range, 0.94-2.93 per 100 low-risk newborns), respectively. In the unadjusted analysis, every percentage point increase in a hospital's cesarean delivery rate was associated with a 3.4% (95% confidence interval, 2.3%-4.4%) and a 2.3% (95% confidence interval, 1.0%-3.5%) increase in severe maternal morbidity including and excluding transfusion, respectively. After adjustment for the case mix and hospital factors, only the relationship with severe maternal morbidity including transfusion remained significant: 3.3% (95% confidence interval, 1.7%-4.9%) increase in severe maternal morbidity per 1 percentage point increase in the cesarean delivery rate. There was no observed association between cesarean delivery rates and unexpected newborn complications CONCLUSION: Severe maternal morbidity and unexpected newborn complications occur in fewer than 5 in 100 births. Findings from this analysis of hospitals with cesarean delivery rates ranging from 6.8%-56.3% suggest that those with lower cesarean delivery rates have lower severe maternal morbidity (which includes transfusion) and similar unexpected newborn complications compared with hospitals with higher cesarean delivery rates. This work may provide a helpful context to providers, hospitals, and policymakers who are measuring and reporting outcomes. Regarding neonatal morbidity in particular, the Joint Commission manual notes that the unexpected newborn complication metric was specifically designed to be compared against maternal-focused metrics such as cesarean delivery rates. More work is needed to define and identify appropriate measures of maternal and neonatal morbidity for these types of comparisons., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: We sought to determine if hospital delivery volume was associated with a patient's risk for cesarean delivery in low-risk women., Study Design: This study retrospectively examines a cohort of 1 657 495 deliveries identified in the 2013 Nationwide Readmissions Database. Hospitals were stratified by delivery volume quartiles. Low-risk patients were identified using the Society for Maternal-Fetal Medicine definition (n=845 056). A multivariable logistic regression accounting for hospital-level clustering was constructed to assess the factors affecting a patient's odds for cesarean delivery., Results: The range of cesarean delivery rates was 2.4-51.2% among low-risk patients, and the median was 16.5% (IQR 12.8-20.5%). The cesarean delivery rate was higher in the top two-volume-quartile hospitals (17.4 and 18.2%) compared to the bottom quartiles (16.4 and 16.3%) (P<0.001). Hospital volume was not associated with a patient's odds for cesarean delivery after adjusting for patient and other hospital characteristics (P=0.188)., Conclusion: Hospital delivery volume is not an independent predictor of cesarean delivery in this population.

Objective: The objective of the study was to assess women's preferences for vaginal vs cesarean delivery in 4 contexts: prior cesarean delivery, twins, breech presentation, and absent indication for cesarean., Study Design: This was a cross-sectional study of pregnant women at 24-40 weeks' gestation. After assessing stated preferences for vaginal or cesarean delivery, we used the standard gamble metric to measure the strength of these preferences and the time tradeoff metric to determine how women value the potential processes and outcomes associated with these 2 delivery approaches., Results: Among the 240 participants, 90.8% had a stated preference for vaginal delivery. Across the 4 contexts, these women indicated that, on average, they would accept a 59-75% chance of an attempted vaginal birth ending in a cesarean delivery before choosing a planned cesarean delivery, indicating strong preferences for spontaneous, uncomplicated vaginal delivery. Variations in preferences for labor processes emerged. Although uncomplicated labor ending in vaginal birth was assigned mean utilities of 0.993 or higher (on a 0-1 scale, with higher scores indicating more preferred outcomes), the need for oxytocin, antibiotics, or operative vaginal delivery resulted in lower mean scores, comparable with those assigned to uncomplicated cesarean delivery. Substantially lower scores (ranging from 0.432 to 0.598) were obtained for scenarios ending in severe maternal or neonatal morbidity., Conclusion: Although most women expressed strong preferences for vaginal delivery, their preferences regarding interventions frequently used to achieve that goal varied. These data underscore the importance of educating patients about the process of labor and delivery to facilitate incorporation of informed patient preferences in shared decision making regarding delivery approach., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Primary cesarean delivery requires both the clinical assessment and judgment of the provider performing the procedure and the consent of the patient. The interaction between patient and provider and the relative weight and influence of patient preferences and provider recommendations may vary depending on whether a cesarean delivery is planned or unplanned, elective or indicated; understanding the range of contexts in which decision making takes place and the interplay of patient and provider factors in each of these situations is crucial to identifying ways to impact the cesarean rate that are safe and acceptable to both patients and providers. We conducted a review of the literature on patient and provider preferences and obstetrical decision making in the context of primary cesarean delivery, and offer recommendations for future research directions, including potential interventions that may impact the patient and provider factors affecting the primary cesarean rate., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Objective: To determine the optimal gestational age of delivery for women with placenta previa by accounting for both neonatal and maternal outcomes., Study Design: A decision-analytic model was designed comparing total maternal and neonatal quality-adjusted life years for delivery of women with previa at gestational ages from 34 to 38 weeks. At each week, we allowed for four different delivery strategies: (1) immediate delivery, without amniocentesis or steroids; (2) delivery 48 hours after steroid administration (without amniocentesis); (3) amniocentesis with delivery if fetal lung maturity (FLM) positive or retesting in one week if FLM negative; (4) amniocentesis with delivery if FLM testing is positive or administration of steroids if FLM negative., Results: Delivery at 36 weeks, 48 hours after steroids, for women with previa optimizes maternal and neonatal outcomes. In sensitivity analyses, these results were robust to a wide range of variation in input assumptions. If it is assumed that steroids offer no neonatal benefit at this gestational age, outright delivery at 36 weeks' gestation is the best strategy., Conclusion: Steroid administration at 35 weeks and 5 days followed by delivery at 36 weeks for women with placenta previa optimizes maternal and neonatal outcomes.

Objective: To examine the association between active phase arrest and perinatal outcomes., Methods: This was a retrospective cohort study of women with term, singleton, cephalic gestations diagnosed with active phase arrest of labor, defined as no cervical change for 2 hours despite adequate uterine contractions. Women with active phase arrest who underwent a cesarean delivery were compared with those who delivered vaginally, and women who delivered vaginally with active phase arrest were compared with those without active phase arrest. The association between active phase arrest, mode of delivery, and perinatal outcomes was evaluated using univariable and multivariable logistic regression models., Results: We identified 1,014 women with active phase arrest: 33% (335) went on to deliver vaginally, and the rest had cesarean deliveries. Cesarean delivery was associated with an increased risk of chorioamnionitis (adjusted odds ratio [aOR] 3.37, 95% confidence interval [CI] 2.21-5.15), endomyometritis (aOR 48.41, 95% CI 6.61-354), postpartum hemorrhage (aOR 5.18, 95% CI 3.42-7.85), and severe postpartum hemorrhage (aOR 14.97, 95% CI 1.77-126). There were no differences in adverse neonatal outcomes. Among women who delivered vaginally, women with active phase arrest had significantly increased odds of chorioamnionitis (aOR 2.70, 95% CI 1.22-2.36) and shoulder dystocia (aOR 2.37, 95% CI 1.33-4.25). However, there were no differences in the serious sequelae associated with these outcomes, including neonatal sepsis or Erb's palsy., Conclusion: Efforts to achieve vaginal delivery in the setting of active phase arrest may reduce the maternal risks associated with cesarean delivery without additional risk to the neonate., Level of Evidence: II.

Objective: The purpose of this study was to examine the effect of a change in policy regarding the timing of antibiotic administration on the rates of postcesarean delivery surgical-site infections (SSI)., Study Design: This was a retrospective cohort study of 1316 term, singleton cesarean deliveries at 1 institution. A policy change was instituted wherein prophylactic antibiotics were given before skin incision rather than after cord clamp. The primary outcome that was examined was SSI; secondary outcomes were the rates of endometritis and cellulitis. Multivariable regression was performed to control for potential confounders., Results: The overall rate of SSI fell from 6.4-2.5% (P = .002). When we controlled for potential confounders, there was a decline in overall SSI with an adjusted odds ratio (aOR) of 0.33 (95% CI, 0.14,0.76), a decrease in endometritis (aOR, 0.34; 95% CI, 0.13,0.92), and a trend towards a decrease in cellulitis (aOR, 0.22; 95% CI, 0.05,1.22)., Conclusion: At our institution, a change in policy to administer prophylactic antibiotics before skin incision led to a significant decline in postcesarean delivery SSIs.

Objective: To examine the association between county‐level caesarean delivery (CD) rates among women at low risk and morbidity among term newborns. Design: Cross‐sectional study. Setting: Population‐based study of US county‐level birth data from 2015 to 2017. Population: Nulliparous women with term, singleton, vertex‐presenting infants (NTSV) at low risk for morbidity. Methods: The primary exposure was county‐level CD rates. Main outcome measures: The outcome was morbidity among the low‐risk NTSV cohort, categorised as severe (5‐minute Apgar score of ≤3, assisted ventilation for ≥6 hours, severe neurologic injury or seizure, transfer or death) or moderate (5‐minute Apgar score of <7 but >3, administration of antibiotics or assisted ventilation at delivery). We used linear regression models to determine the association between county NTSV CD and neonatal morbidity rates with cluster robust standard errors. Results: The analysis included data from 2 753 522 births in 952 counties from all 48 states. The mean NTSV CD rate was 23.6% (standard deviation 4.8%). The median severe and moderate neonatal morbidity rates were 15.2 (interquartile range, IQR 9.4–23.6) and 52.5 (IQR 33.4–75.7) per 1000 births, respectively. In the unadjusted analysis using the risk‐adjusted exposure and outcome, every percentage point increase in the CD rate of a county was associated with 0.6 (95% CI −0.9, −0.3) and 2.3 fewer (95% CI −3.4, −1.1) cases of severe and moderate neonatal morbidity per 1000 live births. After adjustment for other county factors, the relationships remained significant. These findings were tested in multiple sensitivity analyses. Conclusions: Lower county‐level NTSV CD rates were associated with a small increase in morbidity among term newborns in the USA. Lower county‐level caesarean delivery rates were associated with an increase in morbidity among term newborns in the USA. Lower county‐level caesarean delivery rates were associated with an increase in morbidity among term newborns in the USA. [ABSTRACT FROM AUTHOR]