C. Prunet

Variations in rates of severe perineal tears and episiotomies in 20 European countries: a study based on routine national data in Euro-Peristat Project

Rates of severe perineal tears and episiotomies are indicators of obstetrical quality of care, but their use for international comparisons is complicated by difficulties with accurate ascertainment of tears and uncertainties regarding the optimal rate of episiotomies. We compared rates of severe perineal tears and episiotomies in European countries and analysed the association between these two indicators.

A global reference for caesarean section rates (C‐Model): a multicountry cross‐sectional study

To generate a global reference for caesarean section (CS) rates at health facilities.

Risk factors of preterm birth in France in 2010 and changes since 1995: Results from the French National Perinatal Surveys

OBJECTIVES To investigate risk factors of total, spontaneous and induced preterm birth in 2010 and differences between 1995 and 2010. MATERIAL AND METHODS The national perinatal surveys are based on a representative sample of births in France. We selected live-born singletons (n=14,326 in 2010 and 12,885 in 1995) and used multiple regression analyses to calculate adjusted odds ratios (aOR) for maternal sociodemographic characteristics, obstetric history, prenatal care and smoking. RESULTS The main risk factors in 2010 were parity 1 compared to parity 2 (aOR=1.9 [95% CI 1.5-1.3]), previous preterm delivery (aOR=6.6 [5.0-8.7]), pre-pregnancy body mass index<18.5 compared to 18.5-24.9kg/m2 (aOR=1.7 [1.4-2.2]), level of education completed: high school or less, inadequate prenatal care and cannabis use. Most risk factors of spontaneous and induced preterm births were similar. Compared to 1995, maternal age≥35 years and previous induced abortion were no longer associated with preterm birth in 2010. CONCLUSION Identified risk factors for preterm birth in France in 2010 agree with the literature. Increases in baseline rates for maternal age and medically induced abortions may explain changes in certain preterm birth risk factors.OBJECTIVES To investigate risk factors of total, spontaneous and induced preterm birth in 2010 and differences between 1995 and 2010. MATERIAL AND METHODS The national perinatal surveys are based on a representative sample of births in France. We selected live-born singletons (n=14,326 in 2010 and 12,885 in 1995) and used multiple regression analyses to calculate adjusted odds ratios (aOR) for maternal sociodemographic characteristics, obstetric history, prenatal care and smoking. RESULTS The main risk factors in 2010 were parity 1 compared to parity 2 (aOR=1.9 [95% CI 1.5-1.3]), previous preterm delivery (aOR=6.6 [5.0-8.7]), pre-pregnancy body mass index<18.5 compared to 18.5-24.9kg/m2 (aOR=1.7 [1.4-2.2]), level of education completed: high school or less, inadequate prenatal care and cannabis use. Most risk factors of spontaneous and induced preterm births were similar. Compared to 1995, maternal age≥35 years and previous induced abortion were no longer associated with preterm birth in 2010. CONCLUSION Identified risk factors for preterm birth in France in 2010 agree with the literature. Increases in baseline rates for maternal age and medically induced abortions may explain changes in certain preterm birth risk factors.

A global reference for caesarean section rates (C-Model): a multicountry cross-sectional study

To generate a global reference for caesarean section (CS) rates at health facilities.

Classification de Robson : un outil d’évaluation des pratiques de césarienne en France

OBJECTIVE To give a description of caesarean rates in France in 2010 using Robson classification, to assess practices according to the level of care of the maternity units. MATERIALS AND METHODS The study population was the sample of the French National Perinatal Survey in 2010 (n=14,165). Data were stratified by the level of care of the maternity unit (1, 2 or 3). Women were classified in 12 groups according to Robson classification, using maternal characteristics and obstetrical history. In each level of care, we calculated for each group, its relative size, its crude caesarean rate and its contribution to the overall caesarean rate. RESULTS The overall rate of caesarean in 2010 in France was 20.8% in level 1, 21.1% in level 2 and 20.0% in level 3 maternity units. In the three levels, the main contributors to the overall caesarean rate were primiparous women in spontaneous labour (group 1; contribution: 3.5% in level 1 units, 2.2% in level 2 units, 2.7% in level 3 units) or with induced labour (group 2a; contribution: 2.9, 2.5 and 3.0%, respectively) and multiparous women with previous caesarean (group 5; contribution: 5.8, 5.3 and 6.0%, respectively). Premature singletons (group 10) contributed to 0.8% to the overall caesarean rate in level 1 units, 1.4% in level 2 units and 3.5% in level 3 units. CONCLUSION The Robson classification is easy to use. Each maternity unit can compare its rates with those of units with similar level, to find whether some groups of women have very high rates of caesarean sections.

How do late terminations of pregnancy affect comparisons of stillbirth rates in Europe? Analyses of aggregated routine data from the Euro-Peristat Project

To describe how terminations of pregnancy at gestational ages at or above the limit for stillbirth registration are recorded in routine statistics and to assess their impact on comparability of stillbirth rates in Europe.

Anesthetic and Obstetrical Factors Associated With the Effectiveness of Epidural Analgesia for Labor Pain Relief: An Observational Population-Based Study.

Background and Objectives The effectiveness of labor epidural analgesia is difficult to explore, as it includes the maternal satisfaction with analgesia as well as the overall childbirth experience. In this population-based study, we sought to identify factors associated with the effectiveness of epidural analgesia for labor pain relief. Methods We performed a secondary analysis of the 2010 French National Perinatal Survey, a cross-sectional study of a representative sample of births in France. All participants who gave birth with an epidural analgesia were included. Effectiveness of epidural analgesia was assessed 2 to 3 days after delivery and intended to include analgesic efficacy and maternal satisfaction together. The factors analyzed were anesthetic management and maternal, obstetrical, and organizational characteristics, using a logistic regression with random effects model. Results Among the 9337 women who gave birth with an epidural analgesia and were included, 8377 (89.3%; 95% confidence interval [CI] = 88.7–89.9) considered their epidural to be very or fairly effective. In the multivariate analysis, effectiveness was significantly associated with the use of patient-controlled epidural analgesia (adjusted odds ratio [aOR] = 1.2 [1.0–1.5]; P = 0.02) and delivery in private maternity facilities (aOR = 1.3 [1.1–1.6]); it was significantly less effective in obese women (aOR = 0.6 [0.5–0.8]) and multiparous women not receiving oxytocin during labor (aOR = 0.4 [0.4–0.6]) as compared with nonobese and nulliparous women with oxytocin, respectively. Conclusions At the population level, most women found epidural analgesia effective for labor pain relief, but specific attention should be paid to obese parturients and multiparous women not receiving oxytocin. High epidural effectiveness with patient-controlled analgesia should promote an increased use of this method.

Authors' reply re: Stabilising the caesarean rate: which target population?

Sir, Our interest was drawn to the article by Le Ray et al. that confirmed the usefulness of Robson’s caesarean section (CS) classification in analysing rates. We had noted an increase in CS rate in our hospital from 26% in 2000 to 32% in 2012 despite efforts to stabilise the rate during this period. We felt that the Robson ten-group classification system (TGCS) would help to identify the groups to which interventions could be focused. Using comparator groups from the international study by Brennan et al. we found our rates in Robson group 1 (nulliparous women in spontaneous labour), group 2 (nulliparous women in induced labour or CS before labour) and group 5 (multiparous women with previous uterine scar) were significantly higher. Although these three groups constituted 48.6% of our obstetric population, they contributed to 64.8% of caesarean sections, a proportion similar to that reported by Le Ray et al. Our first action was to institute a weekly nonjudgemental review of cases to identify avoidable factors especially in the three groups identified for intervention. Our higher caesarean rate in nulliparous women in spontaneous or induced labour resulted in review of intrapartum care and increased scrutiny of indications for induction of labour. To increase the number of women with previous caesareans (Group 5) who attempted a vaginal birth, we considered establishing a specific antenatal clinic for this group of women. There are reports of such a clinic leading to an increase in the uptake of trial of labour. In our department concerns expressed on the use of the Robson classification system included a perceived shortcoming that this classification took no account of maternal factors such as age, body mass index or co-morbidities, which were considered significant risk factors in our population. We were therefore pleased to note that Le Ray et al. investigated whether maternal characteristics could explain the rising CS rates and found that the rate remained significantly higher in Group 1 after adjustment for these. We agree that Group 1 is possibly the most important category and judicious management of this group would have both short-term and long-term implications on the CS rates. As stated by Robson in his commentary and also endorsed by the World Health Organization, we believe that the TGCS is the way forward to audit and compare CS rates at all levels, to direct intervention in an attempt to curtail the ‘epidemic’ of the rising CS rates and learn lessons from each other. We found the Robson classification to be a useful tool in monitoring CS rates in our unit and have instituted a continuous surveillance process. Within a year of targeted interventions we have noticed a stabilisation of the CS rate and are hopeful that when all identified interventions are in place a reduction in CS rate will occur. We support wider use of this classification system in settings where trends of rising caesarean rates remain a concern.& References