Ipek Gurol-Urganci

Variation in rates of caesarean section among English NHS trusts after accounting for maternal and clinical risk: cross sectional study.

Objective To determine whether the variation in unadjusted rates of caesarean section derived from routine data in NHS trusts in England can be explained by maternal characteristics and clinical risk factors. Design A cross sectional analysis using routinely collected hospital episode statistics was performed. A multiple logistic regression model was used to estimate the likelihood of women having a caesarean section given their maternal characteristics (age, ethnicity, parity, and socioeconomic deprivation) and clinical risk factors (previous caesarean section, breech presentation, and fetal distress). Adjusted rates of caesarean section for each NHS trust were produced from this model. Setting 146 English NHS trusts. Population Women aged between 15 and 44 years with a singleton birth between 1 January and 31 December 2008. Main outcome measure Rate of caesarean sections per 100 births (live or stillborn). Results Among 620 604 singleton births, 147 726 (23.8%) were delivered by caesarean section. Women were more likely to have a caesarean section if they had had one previously (70.8%) or had a baby with breech presentation (89.8%). Unadjusted rates of caesarean section among the NHS trusts ranged from 13.6% to 31.9%. Trusts differed in their patient populations, but adjusted rates still ranged from 14.9% to 32.1%. Rates of emergency caesarean section varied between trusts more than rates of elective caesarean section. Conclusion Characteristics of women delivering at NHS trusts differ, and comparing unadjusted rates of caesarean section should be avoided. Adjusted rates of caesarean section still vary considerably and attempts to reduce this variation should examine issues linked to emergency caesarean section.

Third- and fourth-degree perineal tears among primiparous women in England between 2000 and 2012: time trends and risk factors.

To describe the trends of severe perineal tears in England and to investigate to what extent the changes in related risk factors could explain the observed trends.

Risk of placenta previa in second birth after first birth cesarean section: a population-based study and meta-analysis

BackgroundObjective: To compare the risk of placenta previa at second birth among women who had a cesarean section (CS) at first birth with women who delivered vaginally.MethodsRetrospective cohort study of 399,674 women who gave birth to a singleton first and second baby between April 2000 and February 2009 in England. Multiple logistic regression was used to adjust the estimates for maternal age, ethnicity, deprivation, placenta previa at first birth, inter-birth interval and pregnancy complications. In addition, we conducted a meta-analysis of the reported results in peer-reviewed articles since 1980.ResultsThe rate of placenta previa at second birth for women with vaginal first births was 4.4 per 1000 births, compared to 8.7 per 1000 births for women with CS at first birth. After adjustment, CS at first birth remained associated with an increased risk of placenta previa (odds ratio = 1.60; 95% CI 1.44 to 1.76). In the meta-analysis of 37 previously published studies from 21 countries, the overall pooled random effects odds ratio was 2.20 (95% CI 1.96-2.46). Our results from the current study is consistent with those of the meta-analysis as the pooled odds ratio for the six population-based cohort studies that analyzed second births only was 1.51 (95% CI 1.39-1.65).ConclusionsThere is an increased risk of placenta previa in the subsequent pregnancy after CS delivery at first birth, but the risk is lower than previously estimated. Given the placenta previa rate in England and the adjusted effect of previous CS, 359 deliveries by CS at first birth would result in one additional case of placenta previa in the next pregnancy.

Vaginal birth after caesarean section: a cohort study investigating factors associated with its uptake and success

To investigate the demographic and obstetric factors associated with the uptake and success rate of vaginal birth after caesarean section (VBAC).

Impact of Caesarean section on subsequent fertility: a systematic review and meta-analysis

STUDY QUESTION Is there an association between a Caesarean section and subsequent fertility? SUMMARY ANSWER Most studies report that fertility is reduced after Caesarean section compared with vaginal delivery. However, studies with a more robust design show smaller effects and it is uncertain whether the association is causal. WHAT IS KNOWN ALREADY A previous systematic review published in 1996 summarizing six studies including 85 728 women suggested that Caesarean section reduces subsequent fertility. The included studies suffer from severe methodological limitations. STUDY DESIGN, SIZE, DURATION Systematic review and meta-analysis of cohort studies comparing subsequent reproductive outcomes of women who had a Caesarean section with those who delivered vaginally. PARTICIPANTS/MATERIALS, SETTING, METHODS Searches of Cochrane Library, Medline, Embase, CINAHL Plus and Maternity and Infant Care databases were conducted in December 2011 to identify randomized and non-randomized studies that compared the subsequent fertility outcomes after a Caesarean section and after a vaginal delivery. Eighteen cohort studies including 591 850 women matched the inclusion criteria. Risk of bias was assessed by the Newcastle-Ottawa scale (NOS). Data extraction was done independently by two reviewers. The meta-analysis was based on a random-effects model. Subgroup analyses were performed to assess whether the estimated effect was influenced by parity, risk adjustment, maternal choice, cohort period, and study quality and size. MAIN RESULTS AND THE ROLE OF CHANCE The impact of Caesarean section on subsequent pregnancies could be analysed in 10 studies and on subsequent births in 16 studies. A meta-analysis suggests that patients who had undergone a Caesarean section had a 9% lower subsequent pregnancy rate [risk ratio (RR) 0.91, 95% confidence interval (CI) (0.87, 0.95)] and 11% lower birth rate [RR 0.89, 95% CI (0.87, 0.92)], compared with patients who had delivered vaginally. Studies that controlled for maternal age or specifically analysed primary elective Caesarean section for breech delivery, and those that were least prone to bias according to the NOS reported smaller effects. LIMITATIONS, REASONS FOR CAUTION There is significant variation in the design and methods of included studies. Residual bias in the adjusted results is likely as no study was able to control for a number of important maternal characteristics, such as a history of infertility or maternal obesity. WIDER IMPLICATIONS OF THE FINDINGS Further research is needed to reduce the impact of selection bias by indication through creating more comparable patient groups and applying risk adjustment.

Maternal morbidity associated with placenta praevia among women who had elective caesarean section

OBJECTIVE Estimates of the increased risk of maternal complications after caesarean section posed by placenta praevia differ between studies and may not reflect current practice. We assess the impact of placenta praevia on maternal complications after elective caesarean section (CS). STUDY DESIGN We undertook a retrospective cohort study of women who had an elective CS for a singleton at term in the English National Health Service between 1 April 2000 and 28 February 2009 using routine data from the Hospital Episode Statistics database. Multiple logistic regression was used to estimate the effect of placenta praevia on maternal complications after controlling for maternal age, parity, whether a woman had a previous CS, and gestational age. Maternal complications included postpartum haemorrhage, obstetric trauma, blood transfusion and hysterectomy. RESULTS Among 131,731 women having an elective CS for a singleton, 4,332 (3.3%) women had placenta praevia. Placenta praevia increased the risk of postpartum haemorrhage from 9.7% to 17.5% (adjusted odds ratio (OR) 1.91; 95% CI: 1.74 to 2.09), the risk of blood transfusion from 1.4% to 6.4% (OR 4.39; 3.76 to 5.12), and the risk of hysterectomy from 0.03% to 1% (OR 39.70; 22.42 to 70.30). Previous studies have estimated the rate of hysterectomy among women with placenta praevia to be 5%. CONCLUSION Placenta praevia remains a risk factor for various maternal complications, although the increased risk of hysterectomy is lower than previously reported.

UPTAKE AND DIFFUSION OF PHARMACEUTICAL INNOVATIONS IN HEALTH SYSTEMS

AbstractMultiple interacting factors influence the uptake and diffusion of medicines which are critical to improving health. However, there is a gap in our knowledge on how regulatory policies and other national health systems attributes combine to impact on the utilisation of innovative drugs, and health system goals and objectives.Our review demonstrates that strong regulation adversely affects access to innovation, reduces incentives for research-based firms to develop innovative products and leads to short- and long-term welfare losses. Short-term efficiency gains from reducing pharmaceutical expenditures may actually increase total healthcare costs, reduce user choice, and in some cases, adversely affect health outcomes.Decision makers need to adopt a holistic approach to policy making, and consider potential impact of regulations on the uptake and diffusion of innovations, innovation systems and health system goals.

Evaluating case-mix and predictive modeling measures within the British Primary care sector

Data and methods Data was obtained from three Primary Care Trusts (PCTs) within the British NHS. Four years of data were collected at two of the sites, while two years were collected at the third site. The population of the sites varied from 6,000 to 20,000 in 2005. The independent variables included age, gender and diagnostic information, in the form of Read codes. A range of variables were used to measure resource utilization.

Impact of third‐ and fourth‐degree perineal tears at first birth on subsequent pregnancy outcomes: a cohort study

To investigate, among women who have had a third‐ or fourth‐degree perineal tear, the mode of delivery in subsequent pregnancies as well as the recurrence rate of third‐ or fourth‐degree tears.

Rates of subsequent surgery following endometrial ablation among English women with menorrhagia: population‐based cohort study

To assess the risk of further surgery amongst women who had an initial endometrial ablation (EA) for the treatment of heavy menstrual bleeding (HMB).