Melissa G. Rosenstein

Maternal Mortality in Argentina: A Closer Look at Women Who Die Outside of the Health System

Objectives To assess maternal mortality among women who died outside health institutions. To use the technique of verbal autopsy to identify maternal deaths and to obtain qualitative information about the determinants of maternal death using the “three delays” model. Methods Subjects were women aged 10–49 who died outside of a health institution during 2002 in five Argentine provinces with maternal mortality ratios above the national average. Cases were identified through the national and provincial registries, and data were collected using verbal autopsies, where the relatives of the deceased are interviewed. Results Of 252 completed verbal autopsies, 15 maternal deaths and five late maternal deaths were found. Hemorrhage was the most common cause of maternal death. Seventy-nine percentage of women who died of maternal causes experienced at least one delay in accessing care, with delays in seeking assistance as the most common, followed by delays in accessing and receiving quality care. Conclusions Maternal causes of death are equally prevalent among women who die outside the health system as among those who die within it, but avoidable deaths are still a problem. Interventions to improve understanding of “alarm signals” (serious symptoms) and improved access and quality of care are necessary to reduce maternal mortality.

The Association of Expanded Access to a Collaborative Midwifery and Laborist Model With Cesarean Delivery Rates.

OBJECTIVE: To examine the association between expanded access to collaborative midwifery and laborist services and cesarean delivery rates. METHODS: This was a prospective cohort study at a community hospital between 2005 and 2014. In 2011, privately insured women changed from a private practice model to one that included 24-hour midwifery and laborist coverage. Primary cesarean delivery rates among nulliparous, term, singleton, vertex women and vaginal birth after cesarean delivery (VBAC) rates among women with prior cesarean delivery were compared before and after the change. Multivariable logistic regression models estimated the effects of the change on the odds of primary cesarean delivery and VBAC; an interrupted time-series analysis estimated the annual rates before and after the expansion. RESULTS: There were 3,560 nulliparous term singleton vertex deliveries and 1,324 deliveries with prior cesarean delivery during the study period; 45% were among privately insured women whose care model changed. The primary cesarean delivery rate among these privately insured women decreased after the change, from 31.7% to 25.0% (P=.005, adjusted odds ratio [OR] 0.56, 95% confidence interval [CI] 0.39–0.81). The interrupted time-series analysis estimated a 7% drop in the primary cesarean delivery rate in the year after the expansion and a decrease of 1.7% per year thereafter. The VBAC rate increased from 13.3% before to 22.4% afterward (adjusted OR 2.03, 95% CI 1.08–3.80). CONCLUSION: The change from a private practice to a collaborative midwifery–laborist model was associated with a decrease in primary cesarean rates and an increase in VBAC rates. LEVEL OF EVIDENCE: II

Association between vaginal birth after cesarean delivery and primary cesarean delivery rates.

OBJECTIVE: To estimate the association between vaginal birth after cesarean delivery (VBAC) rates and primary cesarean delivery rates in California hospitals. METHODS: Hospital VBAC rates were calculated using birth certificate and discharge data from 2009, and hospitals were categorized by quartile of VBAC rate. Multivariable logistic regression analysis was performed to estimate the odds of cesarean delivery among low-risk nulliparous women with singleton pregnancies at term in vertex presentation (nulliparous term singleton vertex) by hospital VBAC quartile while controlling for many patient-level and hospital-level confounders. RESULTS: There were 468,789 term singleton births in California in 2009 at 255 hospitals, 125,471 of which were low-risk nulliparous term singleton vertex. Vaginal birth after cesarean delivery rates varied between hospitals, with a range of 0–44.6%. Rates of cesarean delivery among low-risk nulliparous term singleton vertex women declined significantly with increasing VBAC rate. When adjusted for maternal and hospital characteristics, low-risk nulliparous term singleton vertex women who gave birth in hospitals in the highest VBAC quartile had an odds ratio of 0.55 (95% confidence interval 0.46–0.66) of cesarean delivery compared with women at hospitals with the lowest VBAC rates. Each percentage point increase in a hospitals VBAC rate was associated with a 0.65% decrease in the low-risk nulliparous term singleton vertex cesarean delivery rate. CONCLUSION: Hospitals with higher rates of VBAC have lower rates of primary cesarean delivery among low-risk nulliparous women with singleton pregnancies at term in vertex presentation. LEVEL OF EVIDENCE: II

Maternal-fetal medicine subspecialists' provision of second-trimester termination services

OBJECTIVE Most abortions for pregnancy complications occur in the second trimester. Little is known about whether maternal-fetal medicine subspecialists (MFMs) perform terminations for these women. STUDY DESIGN We surveyed all members of Society of Maternal Fetal Medicine by e-mail or mail regarding second-trimester abortion provision. We conducted analyses of whether MFMs perform abortions, by what method, and how frequently. RESULTS Our response rate was 32.4% (689/2,125). Over two-thirds of respondents perform either dilation and evacuation (D&E) or induction; 31% perform D&Es. Male gender, frequent chorionic villus sampling provision, and being trained in D&E during fellowship are associated with performing D&Es. Nonprovision of any second-trimester abortion is significantly associated with age over 50, nonacademic practice setting, and less supportive abortion attitudes (p < 0.001). A nonsignificant trend toward association between south/southeast region and nonprovision of any second-trimester abortion is seen (p = 0.09). CONCLUSION Many MFMs include D&E and induction termination services in their practice. Supporting current D&E providers and expanding training options for MFMs may optimize care for women diagnosed with serious pregnancy complications.

Effect of stage of initial labor dystocia on vaginal birth after cesarean success

OBJECTIVE The objective of the study was to examine whether the stage of labor dystocia causing a primary cesarean delivery (CD) affects a trial of labor after cesarean (TOLAC) success. STUDY DESIGN This was a retrospective cohort study of women who had primary CD of singleton pregnancies for first- or second-stage labor dystocia and attempted TOLAC at a single hospital between 2002 and 2014. We compared TOLAC success rates between women whose primary CD was for first- vs second-stage labor dystocia and investigated whether the effect of prior dystocia stage on TOLAC success was modified by previous vaginal delivery (VD). RESULTS A total of 238 women were included; nearly half (49%) achieved vaginal birth after cesarean (VBAC). Women with a history of second-stage labor dystocia were more likely to have VBAC compared with those with first-stage dystocia, although this trend was not statistically significant among the general population (55% vs 45%, adjusted odds ratio, 1.4, 95% confidence interval, 0.8-2.5]). However, among women without a prior VD, those with a history of second-stage dystocia did have statistically higher odds of achieving VBAC than those with prior first-stage dystocia (54% vs 38%, adjusted odds ratio, 1.8 [95% confidence interval, 1.0-3.3], P for interaction = .043). CONCLUSION Nearly half of women with a history of primary CD for labor dystocia will achieve VBAC. Women with a history of second-stage labor dystocia have a slightly higher VBAC rate, seen to a statistically significant degree in those without a history of prior VD. TOLAC should be offered to all eligible women and should not be discouraged in women with a prior second-stage arrest.

Ultrasound-guided instrumental removal of the retained placenta after vaginal delivery.

The standard treatment for retained placenta is manual extraction, in which a hand is introduced inside the uterus to cleave a plane between the placenta and the uterine wall. For women without an epidural, the procedure is extremely uncomfortable and may require additional measures such as intravenous narcotics or regional anesthesia. Although ultrasound-guided instrumental removal of the placenta is standard practice as part of second-trimester abortion by dilation and evacuation and may be done at many institutions, especially after failed manual extraction, it has not yet been described in the literature as a technique following vaginal birth. Our experience with this technique is that it causes less discomfort to the patient than a traditional manual extraction, because the instrument entering the uterus is much narrower than a hand. With the patient in dorsal lithotomy, we locate the cervix and stabilize it either with fingers or a ring forceps on the anterior lip. We introduce Bierer ovum forceps into the uterus under direct ultrasound guidance. The Bierer forceps are preferred because of their long length, large head, and serrated teeth that allow for a firm, secure grip on the placenta. We grasp the placental tissue with the forceps and apply slow, gentle traction in short strokes, regrasping increasingly more distal areas of placenta as necessary to tease out the placenta. After 1-2 minutes, the placenta separates and can be pulled out of the uterus, usually intact. Our experience suggests that this technique is a well-tolerated option for women without an epidural who have a retained placenta. Further study is needed to quantify the amount of discomfort and anesthesia that can be avoided with this technique, as well as whether there is any change in the frequency of infectious complications or the necessity of postremoval curettage.