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The decreasing trend in early-term repeat cesarean deliveries in the United States: 2005 through 2014

Published:November 03, 2016DOI:https://doi.org/10.1016/j.ajog.2016.10.039

      Objective

      Several studies in 2009, including a large cohort study from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Maternal-Fetal Medicine Units Network, found that early term delivery (37 0/7-38 6/7 weeks’ gestation) was associated with increased neonatal and infant morbidity and mortality compared to deliveries at ≥39 weeks.
      • Clark S.L.
      • Miller D.D.
      • Belfort M.A.
      • Dildy G.A.
      • Frye D.L.
      • Meyers J.A.
      Neonatal and maternal outcomes associated with elective term delivery.
      • Oshiro B.T.
      • Henry E.
      • Wilson J.
      • Branch D.W.
      • Varner M.W.
      Decreasing elective deliveries before 39 weeks of gestation in an integrated healthcare system.
      • Tita A.T.
      • Landon M.B.
      • Spong C.Y.
      • et al.
      Timing of elective repeat cesarean delivery at term and neonatal outcomes. Eunice Kennedy Shriver NICHD Maternal-Fetal Medicine Units Network.
      • Zhang X.
      • Kramer M.S.
      Variations in mortality and morbidity by gestational age among infants born at term.
      The NICHD study also found that over one third of nonmedically indicated cesarean deliveries occurred <39 weeks.
      • Tita A.T.
      • Landon M.B.
      • Spong C.Y.
      • et al.
      Timing of elective repeat cesarean delivery at term and neonatal outcomes. Eunice Kennedy Shriver NICHD Maternal-Fetal Medicine Units Network.
      Subsequently, in August 2009, the American Congress of Obstetricians and Gynecologists (ACOG)
      American College of Obstetricians and Gynecologists
      Induction of labor. ACOG Practice bulletin no. 107.
      and later the Society for Maternal-Fetal Medicine (SMFM) published guidelines to discourage delivery <39 weeks’ gestation without a medical indication.
      American College of Obstetricians and Gynecologists
      Nonmedically indicated early-term deliveries. ACOG Committee opinion no. 561; 2013, reaffirmed in 2015.
      Given that nearly one third of cesarean deliveries are done in the absence of labor or other recognized medical or obstetrical indications,
      • Tita A.T.
      • Landon M.B.
      • Spong C.Y.
      • et al.
      Timing of elective repeat cesarean delivery at term and neonatal outcomes. Eunice Kennedy Shriver NICHD Maternal-Fetal Medicine Units Network.
      this presented clinicians with an opportunity to change clinical practice and improve neonatal outcomes. Our objective was to examine the trend in early term repeat cesarean delivery rates from 2005 through 2014, before and after the publication of these recommendations.

      Study Design

      This is a study of the trend in timing of term repeat cesarean delivery in the United States from 2005 through 2014. We calculated the distribution of deliveries for each week of gestation between 35-41 weeks for total and repeat cesarean deliveries for 3 one-year time periods preceding (2005), coinciding with (2010), and following (2014) implementation of new guidelines using the National Vital Statistics System birth certificate data set. Because this study analyzes nonidentified data, it was deemed exempt from review by the Weill Cornell Investigation Review Board.

      Results

      The study population consisted of 8,667,268 total deliveries of which 1,099,783 were repeat cesarean deliveries. The proportion of repeat cesarean deliveries at 38 weeks decreased from 28.7% in 2005 to 18.5% in 2014 (55.1% decrease; P < .001) and increased at 39 weeks from 30.5% in 2005 to 43.5% in 2014 (42.6% increase; P < .001) (Figure). The proportion of all deliveries at 38 weeks decreased from 19.7% in 2005 to 16.8% in 2014 (17.3% decrease; P < .001) and increased at 39 weeks from 26.7% in 2005 to 31.8% in 2014 (16% increase; P < .001). There were no significant changes from 2005 through 2014 in the proportion of deliveries between 35-37 weeks and 40-41 weeks.
      Figure thumbnail gr1
      FigureRepeat cesarean deliveries: distribution by weeks gestation
      Razavi. Decreasing trend in early-term repeat cesarean deliveries. Am J Obstet Gynecol 2017.

      Conclusion

      Our study confirms a significant decrease in the rate of early term deliveries at 38 weeks in the years following the early term birth guidelines published by ACOG and SMFM. We present evidence to support that this decrease was in large part due to a decrease in repeat cesarean deliveries.
      Ohio Perinatal Quality Collaborative Writing Committee
      A statewide initiative to reduce inappropriate scheduled births at 360/7-386/7 weeks’ gestation.
      • Zanardo V.
      • Simbi A.K.
      • Franoi M.
      • Solda G.
      • Salvadori A.
      • Trevisanuto D.
      Neonatal respiratory morbidity risk and mode of delivery at term: influence of timing of elective cesarean delivery.
      While our study is the first to analyze national data of trends in early term deliveries, similar results have been published on a local and statewide level.
      Ohio Perinatal Quality Collaborative Writing Committee
      A statewide initiative to reduce inappropriate scheduled births at 360/7-386/7 weeks’ gestation.
      • Ehrenthal D.B.
      • Hoffman M.K.
      • Jiang X.
      • Ostrum G.
      Neonatal outcomes after implementation of guidelines limiting elective delivery before 39 weeks gestation.
      An investigation of neonatal intensive care unit admission, respiratory morbidity, stillbirth, and other outcomes is needed to fully evaluate the impact of this change on neonatal outcome. This information could provide further encouragement for a national commitment to improve obstetric practice and optimize neonatal outcomes by delivering babies at ≥39 weeks unless otherwise medically indicated.

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