Women's experiences of VBAC in Cyprus: a qualitative study.

BACKGROUND AND AIM: In 21st century, there has been an increasing interest in vaginal birth after previous caesarean section (VBAC) in Cyprus, a country with a very high operative birth rate. Research-based evidence of women's VBAC experiences in Cyprus is non-existent, despite its significance for the well-being of mothers and families. The aim of this study is to gain insight into the women's lived experience of VBAC in Cyprus. In this study women's experiences of VBAC are explored for the first time in Cyprus. METHOD: The study is qualitative and exploratory in nature. Data were collected through semi-structured interviews with 10 women, who experienced vaginal birth after a previous caesarean section (VBAC) in Cyprus. A descriptive phenomenological approach was employed for the analysis of data. RESULTS: Analysis of data yielded four major themes: (a) medicalization of childbirth, (b) preparing for a VBAC, (c) birth environment, and (d) healing through VBAC. On the whole, the women interviewed described their previous experience of CS as traumatic, in contrast to vaginal childbirth. VBAC was considered an utterly positive experience that made the women feel empowered and proud of themselves. CONCLUSION: This study offers valuable insight into a newly researched subject in Cyprus, which is necessary for advancing perinatal care in Cyprus. The findings indicate that women need evidence-based information, guidelines on birthing options, good preparation with tailored information and personalized care for a successful vaginal birth after a previous caesarean section. Proper, non-biased, consultations are a main factor that affects women's choice of mode of birth. The introduction of new, women-friendly perinatal strategies that respect and promote childbirth rights is imperative in the case of Cyprus. All women have the right to exercise informed choice and the choice to alternative birthing options.

An epidemic of avoidable caesarean deliveries in the private sector in India: Is physician-induced demand at play?

PURPOSE AND SETTING OF RESEARCH: Caesarean section (C-section) rates of over 15% suggest overuse of the surgery which may be difficult to justify on medical grounds. One important contributor to the rise in Csection rates is the rapid expansion of unregulated private-sector providers in number of settings. This study analyses the contribution of private sector in the rapid rise in Csection deliveries in India and the extent to which these can be justified on medical grounds. METHODS: This is a cross sectional study design using National Family Health Surveys. Logistic regression and propensity score matching (PSM) analyses are performed. The main outcome measured is avoidable C-sections in the private sector. PRINCIPAL FINDINGS: Our findings suggest that the rising trend in C-section rates in the private sector cannot be explained by medical reasons alone. The odds of C-section among women who chose to deliver in private was over 4 times higher than women who chose to delivery in public facilities. Despite, controlling for medical complications, women's characteristics and preferences, our PSM analysis suggest that the public-private gap has doubled over the years and that the difference cannot be explained by known determinants of C-section. Over supply of avoidable C-section to the extent of 21%, as a result of physician induced demand and perverse financial incentives was observed in the private sector. CONCLUSIONS: This paper attempts to understand the reason for the high C-section rates in the private sector in India and the extent to which these are avoidable. Our analysis supports the assumption that physician induced demand as a result of perverse financial incentives in the private sector is at play.

Pattern of live births in Rio de Janeiro State, Brazil, according to Robson groups and the Kotelchuck index classification - 2015/2016 / Padrão de nascidos vivos no estado do Rio de Janeiro, Brasil, segundo os grupos Robson e a classificação do índice Kotelchuck - 2015/2016

Abstract Objective To investigate the patterns of hospital births in the state of Rio de Janeiro (RJ), Brazil, between 2015 and 2016; considering the classification of obstetric characteristics proposed by Robson and the prenatal care index proposed by Kotelchuck. Methods Data obtained from the Information System on Live Births of the Informatics Department of the Brazilian Unified Health System (SINASC/DATASUS, in the Portuguese acronym) databases were used to group pregnant women relatively to the Robson classification. A descriptive analysis was performed for each Robson group, considering the variables: maternal age, marital status, schooling, parity, Kotelchuck prenatal adequacy index and gestational age. A logistic model estimated odds ratios (ORs) for cesarean sections (C-sections), considering the aforementioned variables. Results Out of the 456,089 live births in Rio de Janeiro state between 2015 and 2016, 391,961 records were retained, 60.3% of which were C-sections. Most pregnant women (58.6%) were classified in groups 5, 2 or 3. The percentage of C-sections in the Robson groups 1, 2, 3, 4, 5 and 8 was much higher than expected. Prenatal care proved to be inadequate for women who subsequently had a vaginal delivery, had an unfavorable family structure and a lower socioeconomic status (mothers without partners and with lower schooling), compared with those undergoing cesarean delivery. For a sameRobson group, the chance of C-section increases when maternal age rises (OR = 3.33 for 41-45 years old), there is the presence of a partner (OR = 1.81) and prenatal care improves (OR = 3.19 for "adequate plus"). Conclusion There are indications that in the state of RJ, from 2015 to 2016, many cesarean deliveries were performed due to nonclinical factors.

Resumo Objetivo Investigar os padrões dos partos hospitalares no estado do Rio de Janeiro (RJ), Brasil, entre 2015 e 2016, considerando a classificação de características obstétricas de Robson e a dos cuidados pré-natais proposta por Kotelchuck. Métodos Dados sistema de informações sobre nascidos vivos (SINASC) do departamento de informática do sistema único de saúde (DATASUS) foram utilizados para agrupar gestantes relativamente à classificação de Robson. Foi efetuada uma análise descritiva para cada grupo de Robson, considerando-se as variáveis idade materna, estado civil, escolaridade, paridade, o índice de Kotelchuck de adequação do pré-natal e a idade gestacional. Também foi realizado o cálculo de razão de chances (RC) para parto cesáreo, considerando-se um modelo logístico. Resultados Dos 456.089 nascimentos vivos ocorridos no RJ de 2015 a 2016, foram incluídos 391.961 registros, sendo 60,3% cesáreas, com maioria de gestantes (58,6%) nos grupos 5, 2 ou 3. O percentual de cesáreas nos grupos 1, 2, 3, 4, 5 e 8 foi bem superior ao sugerido pela literatura. Para gestantes de um mesmo grupo (controladas as demais características), a chance de cesárea se eleva quando aumenta a idade materna (RC = 3,33 para 41-45 anos), existe a presença de um companheiro (RC = 1,81), o nível de escolaridade é maior (RC = 3,11 para ≥ 12 anos) e o pré-natal é mais cuidadoso (RC= 3,19 para "adequado plus"). Conclusão Há indícios que no RJ, de 2015 a 2016, muitos partos cesáreos foram realizados sob influência de fatores extraclínicos.

The strange case of less C-sections: Hospital ownership, market concentration, and DRG-tariff regulation.

We evaluate the relationship between hospital ownership and responses to a policy providing large financial incentives for vaginal deliveries and financial disincentives for C-sections. We compare for-profit, nonprofit, and public hospitals operating in a public health care system organized according to the quasi-market model. We first theoretically show that hospital ownership matters insofar different hospitals are characterized by different ethical preferences. We also show that competition makes ownership less important. We then consider the case study of Lombardy in Italy. We exploit spatial variation in hospital ownership and in market concentration at the local level to evaluate the relationship between ownership and the probability of C-section. According to theory, empirical results strongly suggest that competitive pressures from alternative providers tend to homogenize behaviors. However, in local monopolies, in presence of a strong monetary incentive toward vaginal deliveries, we do observe less C-section from private for-profit hospitals than from public and private nonprofit hospitals, especially when C-sections are medically appropriate.

Demanda de atención obstétrica y densidad de recursos en salud para mujeres mexicanas en edad fértil / Demand for obstetric care and density of health resources for childbearing age Mexican women

Resumen Introducción: México registra aumento de las cesáreas e inequidad y desigualdad en la distribución de recursos para la atención obstétrica. Objetivo: Identificar las entidades y municipios en México que concentran la demanda de atención obstétrica y tasas de cesáreas y su relación con los recursos en salud y mujeres en edad fértil (MEF). Método: Se registraron los nacimientos del periodo 2008-2017, agrupados en cinco estratos municipales, y los recursos en salud y MEF de 2017. Resultados: La tasa nacional de cesáreas 2008-2017 fue de 45.3/100 nacimientos; 95 y 97 % de los nacimientos y cesáreas se concentraron en el estrato “muy alto” (470 municipios), en el cual se utilizó 80 % o más de los recursos en salud y destacó la sobreutilización. La densidad de recursos en salud destinados a las MEF reflejó inequidad y desigualdad. Conclusiones: La alta concentración de la demanda obstétrica y oferta de los recursos en salud pudiera conllevar mayor recurrencia a la cesárea. En las políticas de reducción de cesáreas es necesario considerar la organización y administración adecuadas de los recursos en salud.

Abstract Introduction: In Mexico, there is an increase in the number of C-sections, as well as inequity and inequality in the distribution of resources for obstetric care. Objective: To identify the states and municipalities in Mexico that concentrate the demand for obstetric care and the C-section rates and their relationship with health resources and women of childbearing age (WCBA). Method: Births of the 2008-2017 period were recorded, grouped into five municipal strata, as well as 2017 health resources and WCBA. Results: The 2008-2017 national rate of C-sections was 45.3/100 births; 95 and 97 % of births and C-sections were concentrated in the “very high” stratum, where 80 % or more of health resources were used, with overuse standing out. The density of health resources assigned to WCBAs reflected inequity and inequality Conclusions: The high concentration of obstetric demand and health resources supply could entail a higher recurrence of C-sections. Policies for C-section reduction should consider proper organization and administration of health resources.

Challenges to achieving appropriate and equitable access to Caesarean section: ethnographic insights from rural Pakistan.

Access to Caesarean section (C-section) remains inadequate for some groups of women while others have worryingly high rates. Understanding differential receipt demands exploration of the socio-cultural, and political economic, characteristics of the health systems that produce them. This extensive institutional ethnography investigated under- and over-receipt of C-section in two rural districts in Pakistan - Jhelum and Layyah. Data were collected between November and July 2013 using semi-structured interviews from a randomly selected sample of 11 physicians, 38 community midwives, 18 Lady Health Visitors and nurses and 15 Traditional Birth Attendants. In addition, 78 mothers, 35 husbands and 23 older women were interviewed. The understandings of birth by C-section held by women and their family members were heavily shaped by gendered constructions of womanhood, patient-provider power differentials and financial constraints. They considered C-section an expensive and risky procedure, which often lacked medical justification, and was instead driven by profit motive. Physicians saw C-section as symbolizing obstetric skill and status and a source of legitimate income. Physician views and practices were also shaped by the wider health care system characterized by private practice, competition between providers and a lack of regulation and supervision. These multi-layered factors have resulted in both unnecessary intervention, and missed opportunities for appropriate C-sections. The data indicate a need for synergistic action at patient, provider and system levels. Recommendations include: improving physician communication with patients and family so that the need for C-section is better understood as a life-saving procedure, challenging negative attitudes and promoting informed decision-making by mothers and their families, holding physicians accountable for their practice and introducing price caps and regulations to limit financial incentives associated with C-sections. The current push for privatization of health care in low-income countries also needs scrutiny given its potential to encourage unnecessary intervention.

What Are Optimal Cesarean Section Rates in the U.S. and How Do We Get There? A Review of Evidence-Based Recommendations and Interventions.

Cesarean sections (CSs) are the most commonly performed surgical procedures in the world today. Global epidemiological studies from the last decade suggest that the optimal CS rates in developed countries exist somewhere between 15% and 19%. Despite these findings, CS rates in the United States have remained stable at slightly over 32% over the past 10 years. Using primary and secondary literature published from 2010 to 2015, this review discusses how optimal CS rates were developed. In addition, we define a category of potentially avoidable CS (i.e., those conducted on nulliparous low-risk women who present with vertex infants at term) and explore how CS in this population appear to be one of the main drivers of high CS rates overall. The institutional, provider, and patient-related factors, which may be related to higher-than-recommended rates of CS, particularly those conducted in low-risk women, will be discussed. This review will then delve into clinician and patient-oriented interventions that have been shown to effectively reduce the rate of potentially avoidable CS. Our analysis showed that large-scale, multifaceted interventions that include audit and feedback cycles as well as peer review strategies were the most effective in decreasing rates of potentially avoidable CS. This review concludes with an agenda for future research into interventions that aim to achieve optimal CS rates.

Financial incentives, timing of births, and infant health: a closer look into the delivery room.

As a result of strong financial incentives created by the German parental leave reform on January 1, 2007, some 1000 births have been shifted from the last days of 2006 to the first days of 2007, especially by working mothers. This fact is already described in the literature, yet there is no evidence as to the mechanisms and only scarce evidence regarding the effects on newborn health. I use new data to study the timing of C-sections and the induction of births around the day the reform took effect. I estimate that postponed C-sections and inductions account for nearly 80 % of the pre-reform shortfall and nearly 90 % of the post-reform excess number of births. Despite concerns voiced by doctors before the reform, hardly any evidence can be found for detrimental health effects of those shifts, as measured by changes in gestational age, birth weight, APGAR scores, neonatal mortality, or hospitalization.

Does Experience Rating Improve Obstetric Practices? Evidence from Italy.

Using inpatient discharge records from the Italian region of Piedmont, we estimate the impact of an increase in malpractice pressure brought about by experience-rated liability insurance on obstetric practices. Our identification strategy exploits the exogenous location of public hospitals in court districts with and without schedules for noneconomic damages. We perform difference-in-differences analysis on the entire sample and on a subsample which only considers the nearest hospitals in the neighborhood of court district boundaries. We find that the increase in medical malpractice pressure is associated with a decrease in the probability of performing a C-section from 2.3 to 3.7 percentage points (7-11.6%) with no consequences for medical complications or neonatal outcomes. The impact can be explained by a reduction in the discretion of obstetric decision-making rather than by patient cream skimming.

The impact of non-economic damages caps on obstetrics: incentives versus practice style.

This paper uses 1989-2010 county-level data to reexamine the effect of non-economic damages caps on the field of obstetrics. Previous literature found that caps on damages lead to both changes in the number of physicians and changes in treatment patterns. This paper investigates whether the changes in procedures are attributable to changes in incentives or to selection when new entrants could have a different practice style than incumbents. First, I find that the relationship between non-economic damages caps and the number of physicians and procedures identified in previous literature is not robust to the inclusion of the newer policy changes. Second, over the period when such changes were observed, the impact on procedures is concentrated in areas with the greatest changes in the number of obstetricians/gynecologists per capita, suggesting that most of the effect on procedures is driven by differences in practice style between entrants and incumbents.

A Clincal Study on Anesthetic Induction with a Thiopental and Ketamine Combination during C-Section / 대한마취과학회지

The incidence of C-sections has increased up to 15~20% and general anesthesia of C-sections is usually induced with thiopental or ketamin. Thiopental can produce significant fetal depression in doses higher than 4mg/kg and ketamine can cause dysphoria. The purpose of this study was to evaluate the possibility of minimizing untoward effects of both drugs by combination of the two. Sixty four pregnant women who underwent general anesthesia and C-section received thiopental 5 mg/kg(n=24); ketamine 1mg/kg(n=19); or a combination of thiopental 2.5mg/kg and ketamine 0.5mg/kg(n=21). The results were as follows: 1. At endotracheal intubation, mean arterial pressure, pulse rate, systolic blood pressure, and rate pressure product were increased from the values before anesthetic induction but there was no statistical significance among groups(p>0.05). 2. The patient's movement to the strong stimulus of skin incision and intraoperative awareness were lower in the ketamine group and higher in the combined group. 3. The induction delivery interval and uterine incision delivery interval did not differ significantly among groups. 4. The incidence of 1 and 5 min Apgar scores below 7 was highest in the thiopental group and lowest in the ketamine group. 5. Postoperative recalling of intraoperative awareness occurred in two patients only in the combined group. 6. PAR scores in the recovery room did not differ significantly among 3 groups. From the above results, the combination of thiopental and ketamine appeared to offer little advantage over thiopental or ketamine. ketamine(1mg/kg) was though to be appropriate for the induction of anesthesia for C-section with respect to the incidence of intraoperative awareness, patient's movemnet to surgical stimuli, and neonatal Apgar scores.