How do pregnant women's perceptions of obstetric forceps change according to their demographic background: a cross sectional study.

BACKGROUND: Women's attitudes towards obstetric forceps likely contribute to declining use and opportunities for residency training, but formal documentation of women's attitudes towards obstetric forceps is currently limited. A clearer understanding should help guide our attempts to preserve its use in modern obstetrics and to improve residency training. Our objective is to document women's attitudes towards obstetric forceps and the influence basic demographic variables have on those attitudes. METHODS: A cross sectional study was performed. We developed a one-time anonymous structured 5-question survey that was given to all women with low-risk pregnancies presenting to our medical center for prenatal care between October 2018-December 2018. The questionnaire asked for the woman's self-reported age, race, education level and insurance type. The five questions were as follows: (1) Do you think forceps should be used to deliver babies, (2) Is forceps safe for the baby, (3) Is forceps safe for the mother, (4) Do you think forceps can help to lower the cesarean section rate, (5) Do you think physicians in training should learn to place forceps on a real patient. We calculated means and proportions for the responses according to the overall group and various subgroups. Statistical analysis included Kruskall-Wallis or Mann-Whitney tests as appropriate. Results were also adjusted by regression using a Generalized Linear Model. Power calculation showed sample size of 384 was required. RESULTS: A total of 499 women returned the questionnaire. Response rate was 56.8% (499/878). The findings suggest that women's perceptions towards forceps are generally negative. Women with white ethnicity, college education or higher and private insurance did have more favorable views than their counterparts, but the majority still had unfavorable views. Age was not shown to have a significant effect on maternal attitude. CONCLUSION: Women's views towards forceps use in the University of Kansas Medical Center are negative and may be contributing to the decline of its use. Improving women's perceptions of forceps would require multiple different strategies rather than a single focused easily-implemented message. If forceps training continues, such training will rely on a minority of women who will accept forceps use in childbirth.

Perinatal outcomes among singletons after assisted reproductive technology with single-embryo or double-embryo transfer versus no assisted reproductive technology.

OBJECTIVE: To examine outcomes of singleton pregnancies conceived without assisted reproductive technology (non-ART) compared with singletons conceived with ART by elective single-embryo transfer (eSET), nonelective single-embryo transfer (non-eSET), and double-embryo transfer with the establishment of 1 (DET -1) or ≥2 (DET ≥2) early fetal heartbeats. DESIGN: Retrospective cohort using linked ART surveillance data and vital records from Florida, Massachusetts, Michigan, and Connecticut. SETTING: Not applicable. PATIENT(S): Singleton live-born infants. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Preterm birth (PTB <37 weeks), very preterm birth (VPTB <32 weeks), small for gestational age birth weight (<10th percentile), low birth weight (LBW <2,500 g), very low birth weight (VLBW <1,500 g), 5-minute Apgar score <7, and neonatal intensive care unit (NICU) admission. RESULT(S): After controlling for maternal characteristics and employing a weighted propensity score approach, we found that singletons conceived after eSET were less likely to have a 5-minute Apgar <7 (adjusted odds ratio [aOR] 0.33; 95% CI, 0.15-0.69) compared with non-ART singletons. There were no differences among outcomes between non-ART and non-eSET infants. We found that PTB, VPTB, LBW, and VLBW were more likely among DET -1 and DET ≥2 compared with non-ART infants, with the odds being higher for DET ≥2 (PTB aOR 1.58; 95% CI, 1.09-2.29; VPTB aOR 2.46; 95% CI, 1.20-5.04; LBW aOR 2.17; 95% CI, 1.24-3.79; VLBW aOR 3.67; 95% CI, 1.38-9.77). CONCLUSION(S): Compared with non-ART singletons, singletons born after eSET and non-eSET did not have increased risks whereas DET -1 and DET ≥2 singletons were more likely to have adverse perinatal outcomes.

Risk of Preeclampsia in Pregnancies After Assisted Reproductive Technology and Ovarian Stimulation.

Objective To compare the risk of preeclampsia among spontaneously conceived pregnancies to those after hyperestrogenic ovarian stimulation (hyperestrogenic OS) with and without assisted reproductive technology (ART), and stimulation with non-hyperestrogenic aromatase inhibitor stimulation (non-hyperestrogenic OS). Methods Live-born singleton deliveries among women 20-49 years were identified in the 2004-2012 Truven Health MarketScan Commercial Claims and Encounters Databases using ICD-9 and CPT codes. Maternal characteristics were compared using Chi squared and Fisher exact tests. We performed multilevel multivariable logistic regression, controlling for maternal age, parity, comorbid conditions, and region of delivery, and calculated adjusted odds ratios (aOR) and 95 % confidence intervals for mild and severe preeclampsia. Results 1,014,526 spontaneously conceived, 6881 hyperestrogenic OS with ART, 27,516 hyperestrogenic OS without ART, and 2117 non-hyperestrogenic OS pregnancies were identified. The adjusted odds of developing preeclampsia were increased for deliveries after hyperestrogenic OS with ART (mild preeclampsia aOR 1.42, 1.24-1.62; severe preeclampsia aOR 1.83, 1.59-2.11) and without ART (mild preeclampsia aOR 1.32, 1.24-1.42; severe preeclampsia aOR 1.53, 1.41-1.66). Adjusted odds of preeclampsia were similar between spontaneously conceived and non-hyperestrogenic OS pregnancies. Conclusions for Practice Risk of preeclampsia after ART may in part be related to supraphysiologic estrogen associated with hyperestrogenic OS.

Antenatal Hospitalizations Among Pregnancies Conceived With and Without Assisted Reproductive Technology.

OBJECTIVE: To describe the prevalence of antenatal hospitalizations, compare characteristics of women with and without antenatal hospitalizations, and compare timing, length of stay, and reason for hospitalization among pregnancies conceived with and without assisted reproductive technology (ART). METHODS: We performed a retrospective cohort analysis using linked ART surveillance, vital records, and hospital discharge data from Michigan to calculate the hospitalization ratio as the number of antenatal admissions per 100 live birth deliveries for ART and non-ART deliveries during 2004-2012 and compare trends by ART status. We then restricted analysis to 2008-2012 and used logistic, multinomial, and Poisson regression analysis to model antenatal admissions, trimester of admission, and length of stay, respectively, for ART compared with non-ART deliveries. We examined reason for hospitalization by ART status. RESULTS: Between 2004 and 2012, the hospitalization ratio for ART deliveries decreased from 14.6 to 12.3 per 100 deliveries (P<.001). Of 557,708 live deliveries during 2008-2012, 22,763 (4.1%) had an antenatal hospitalization. Assisted reproductive technology was a risk factor for having any antenatal admission (singletons adjusted risk ratio [RR] 1.63, 95% confidence interval [CI] 1.43-1.83; multiples adjusted RR 1.24, 95% CI 1.12-1.38) and two or more admissions (singletons adjusted RR 1.86, 95% CI 1.25-2.75; multiples adjusted RR 1.33, 95% CI 1.14-1.54). The percent of time (days) hospitalized during the antenatal period was greater for ART deliveries than non-ART deliveries (singleton adjusted RR 1.28, 95% CI 1.09-1.51; multiples adjusted RR 1.14, 95% CI 1.01-1.29). The most common reason for antenatal admission was preterm labor among all non-ART and multiple gestation deliveries and vaginal bleeding among ART singleton gestations. CONCLUSION: Deliveries after ART were associated with increased risk of antenatal admissions and longer hospitalizations compared with non-ART deliveries.

Trends in Severe Maternal Morbidity After Assisted Reproductive Technology in the United States, 2008-2012.

OBJECTIVE: To examine trends in severe maternal morbidity from 2008 to 2012 in delivery and postpartum hospitalizations among pregnancies conceived with or without assisted reproductive technology (ART). METHODS: In this retrospective cohort study, deliveries were identified in the 2008-2012 Truven Health MarketScan Commercial Claims and Encounters Databases. Severe maternal morbidity was identified using International Classification of Diseases, 9th Revision, Clinical Modification diagnosis codes and Current Procedural Terminology codes. Rate of severe maternal morbidity was calculated for ART and non-ART pregnancies. We performed multivariable logistic regression, controlling for maternal characteristics, and calculated adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for severe morbidity. Additionally, a propensity score analysis was performed between ART and non-ART deliveries. RESULTS: Of 1,016,618 deliveries, 14,761 (1.5%) were identified as pregnancies conceived with ART. Blood transfusion was the most common severe morbidity indicator for ART and non-ART pregnancies. For every 10,000 singleton deliveries, there were 273 ART deliveries or postpartum hospitalizations with severe maternal morbidity compared with 126 for non-ART (P<.001). For ART singleton deliveries, the rate of severe morbidity decreased from 369 per 10,000 deliveries in 2008 to 219 per 10,000 deliveries in 2012 (P=.025). Odds of severe morbidity were increased for ART compared with non-ART singletons (adjusted OR 1.84, 95% CI 1.63-2.08). Among multiple gestations, there was no significant difference between ART and non-ART pregnancies (rate of severe morbidity for ART 604/10,000 and non-ART 539/10,000 deliveries, P=.089; adjusted OR 1.04, 95% CI 0.91-1.20). Propensity score matching agreed with these results. CONCLUSION: Singleton pregnancies conceived with ART are at increased risk for severe maternal morbidity; however, the rate has been decreasing since 2008. Multiple gestations have increased risk regardless of ART status.