Dear Editor,
As you are aware, cesarean delivery is the most commonly performed surgery in the world, and rates are rising, in part because elective repeat cesarean birth in women who have had a prior cesarean birth has become more frequent [1]. For appropriately selected women, a trial of labor, which is an attempt at vaginal birth, is a safe alternative to elective repeat cesarean birth [2]. However, a complicated or failed trial of labor can be associated with increased frequency of maternal and neonatal complications compared to elective repeat cesarean delivery [2].
Rates of cesarean birth have been increasing in a rural region of Southwest Guatemala, paralleling global trends, with about 20 % of cesareans being performed for a history of prior cesarean birth (RR 4.8, CI [3.4,6.9]) [3]. Since October 1, 2018, we have begun collecting additional data on cesarean birth (whether it was performed before the onset or during the course of labor) in order to better understand mode of delivery among women with a history of cesarean birth. Table 1 describes observed mode of delivery in the past year (through October 1, 2019) in this population.
Table 1.
Mode of delivery among women with a history of prior cesarean birth between October 1, 2018 and October 1, 2019 in the Southwest Trifinio, Guatemala.
| Total Population (n = 35) |
Vaginal Birth After Cesarean (n = 10, 28.6 %) |
Elective Repeat Cesarean Birth, Pre-labor (n = 22, 62.9%) |
Repeat Cesarean Birth, Intrapartum (n = 3, 8.6%) |
P-value | |
|---|---|---|---|---|---|
| Sociodemographic Characteristics | |||||
| 0 % missing | 0 % missing | ||||
| Age in years (median, IQR) | 22.9 [21.1,28.4] | 25.5 [22.7,28.2] | 22.6 [20.9,29.6] | 22.6 [21.3,23.0] | 0.69a |
| 0 % missing | 0 % missing | ||||
| Education | 1.0 | ||||
| None | 4 (11.4 %) | 1 (10.0 %) | 3 (13.6 %) | 0 (0.0 %) | |
| Any | 31 (88.6 %) | 9 (90.0 %) | 19 (86.4 %) | 3 (100.0 %) | |
| 0 % missing | 0 % missing | ||||
| Not Employed | 35 (100 %) | 10 (100 %) | 22 (100 %) | 3 (100 %) | - |
| 0 % missing | 0 % missing | ||||
| Not Single (Marital Status) | 33 (94.3 %) | 9 (90.0 %) | 21 (95.5 %) | 3 (100.0 %) | 0.61 |
| n = 33, 5.7 % missing | n = 33, 5.7 % missing | ||||
| Weekly Income (Quetzales) | 0.33 | ||||
| 0 - 500 | 28 (84.9 %) | 7 (70.0 %) | 18 (90.0 %) | 3 (100.0 %) | |
| 500 - 1000 | 5 (15.2 %) | 3 (30.0 %) | 2 (10.0 %) | 0 (0.0 %) | |
| 0 % missing | 0 % missing | ||||
| Community | + | 0.24 | |||
| 1 | 2 (5.7 %) | 0 (10.0 %) | 2 (9.1 %) | 0 (0.0 %) | |
| 2 | 2 (5.7 %) | 2 (20.0 %) | 0 (0.0 %) | 0 (0.0 %) | |
| 3 | 6 (17.1 %) | 1 (10.0 %) | 5 (22.7 %) | 0 (0.0 %) | |
| 4 | 3 (8.6 %) | 0 (0.0 %) | 3 (13.6 %) | 0 (0.0 %) | |
| 5 | 5 (14.3 %) | 2 (20.0 %) | 2 (9.1 %) | 1 (33.3 %) | |
| 6 | 0 (0.0 %) | 0 (0.0 %) | 0 (0.0 %) | 0 (0.0 %) | |
| 7 | 1 (2.9 %) | 1 (10.0 %) | 0 (0.0 %) | 0 (0.0 %) | |
| 8 | 8 (22.9 %) | 4 (40.0 %) | 3 (13.6 %) | 1 (33.3 %) | |
| 9 | 0 (0.0 %) | 0 (0.0 %) | 0 (0.0 %) | 0 (0.0 %) | |
| 10 | 2 (5.7 %) | 0 (0.0 %) | 2 (9.1 %) | 0 (0.0 %) | |
| 11 | 1 (2.9 %) | 0 (0.0 %) | 1 (4.6 %) | 0 (0.0 %) | |
| 12 | 5 (14.3 %) | 0 (0.0 %) | 4 (18.2 %) | 1 (33.3 %) | |
| Obstetric and Antepartum Characteristics | |||||
| n = 32, 8.6 % missing | n = 32, 8.6 % missing | ||||
| Interpregnancy Interval in months (median, IQR) | 32.7 [18.7,45.8] | 45.5 [30.9,49.5] | 26.7 [13.8,36.0] | 36.5 [34.2,63.2] | 0.06a |
| 0 % missing | 0 % missing | ||||
| Parity at Enrollment | 0.004 | ||||
| 1 | 16 (45.7 %) | 1 (10.0 %) | 12 (54.6 %) | 3 (100.0 %) | |
| 2+ | 19 (54.3 %) | 9 (90.0 %) | 10 (45.5 %) | 0 (0.0 %) | |
| 0 % missing | 0 % missing | ||||
| Number of Prior Cesarean Births | 0.53 | ||||
| 1 | 25 (71.4 %) | 6 (60.0 %) | 16 (72.7 %) | 3 (100 %) | |
| 2 | 10 (28.6 %) | 4 (40.0 %) | 6 (27.3 %) | 0 (0.0 %) | |
| 0 % missing | 0 % missing | ||||
| Trimester mother entered care | 0.29 | ||||
| First | 7 (14.3 %) | 0 (0.0 %) | 6 (27.3 %) | 1 (33.3 %) | |
| Second | 20 (40.0 %) | 7 (70.0 %) | 12 (54.6 %) | 1 (33.3 %) | |
| Third | 8 (45.7 %) | 3 (30.0 %) | 4 (18.2 %) | 1 (33.3 %) | |
| 0 % missing | 0 % missing | ||||
| Number of Madres Sanas PNVs* | |||||
| <4 | 7 (74.3 %) | 4 (40.0 %) | 3 (13.6 %) | 0 (0.0 %) | 0.24 |
| 4+ | 28 (25.7 %) | 6 (60.0 %) | 19 (86.4 %) | 3 (100.0 %) | |
| Delivery Characteristics | |||||
| n = 34, 2.9 % missing | n = 34, 2.9 % missing | ||||
| Location of Delivery | <0.001** | ||||
| Home or Other | 6 (17.7 %) | 6 (60.0 %) | 0 (0.0 %) | 0 (0.0 %) | |
| Facility | 28 (82.4 %) | 4 (40.0 %) | 21 (100 %) | 3 (100 %) | |
| 0 % missing | 0 % missing | ||||
| Birth Attendant | 0.002** | ||||
| Comadrona (TBA) or Family | 5 (14.3 %) | 5 (50.0 %) | 0 (0.0 %) | 0 (0.0 %) | |
| Nurse or Physician | 30 (85.7 %) | 5 (50.0 %) | 22 (100 %) | 3 (100 %) | |
| 0 % missing | 0 % missing | ||||
| Infant Sex | 0.26 | ||||
| Male | 17 (48.6 %) | 6 (60.0 %) | 11 (50.0 %) | 0 (0.0 %) | |
| Female | 18 (51.4 %) | 4 (40.0 %) | 11 (50.0 %) | 3 (100 %) | |
| 0 % missing | 0 % missing | ||||
| Gestational Age | 0.49 | ||||
| Preterm (< 37 + 0) | 3 (8.6 %) | 2 (20.0 %) | 1 (4.6 %) | 0 (0.0 %) | |
| Term (37 + 0–40 + 6) | 13 (37.1 %) | 3 (30.0 %) | 8 (36.4 %) | 2 (66.7 %) | |
| Late Term (41 + 0–41 + 6) | 9 (25.7 %) | 1(10.0 %) | 7 (31.8 %) | 1 (33.3 %) | |
| Postterm (≥ 42 + 0) | 10 (29.6 %) | 4 (40.0 %) | 6 (27.3 %) | 0 (0.0 %) | |
| 0 % missing | 0 % missing | ||||
| Birthweight at Delivery in grams (mean, SD) | 2940 ± 497 | 3008 ± 633 | 2921 ± 480 | 2872 ± 130 | 0.64b |
| 0 % missing | 0 % missing | ||||
| Antepartum or Intrapartum Obstetric/Maternal Complication | 19 (54.3 %) | 3 (30.0 %) | 14 (63.6 %) | 2 (66.7 %) | 0.39c |
| 0 % missing | 0 % missing | ||||
| Skin-to-Skin | 13 (37.1 %) | 6 (60.0 %) | 5 (22.7 %) | 2 (66.7 %) | 0.07 |
| 0 % missing | 0 % missing | ||||
| Breastfed Within 1 Hour of Birth | 11 (31.4 %) | 4 (40.0 %) | 7 (31.8 %) | 0 (0.0 %) | 0.54 |
PNVs: prenatal visits, TBA: traditional birth attendant.
Note: p-value is the result of Fisher’s exact testing unless otherwise noted.
Attendant and hospital were highly correlated with pearson’s coefficient of 0.88.
NOTE: too much missing data on: neonatal outcomes (22.9 % missing).
Kruskal-Wallis test.
ANOVA test.
Maternal/obstetric complications included obstructed labor, hemorrhage (antepartum, intrapartum, postpartum), uterine rupture, hypertensive disease/pre-eclampsia, chorioamnionitis, endometritis, maternal death, blood transfusion, surgical management of hemorrhage (hysterectomy, dilation & curettage, iliac artery), antibiotics, magnesium sulfate, medical treatment of hypertension, postpartum uterotonics.
Of 35 women, 10 (28.6 %) delivered vaginally, 22 (62.9 %) by elective repeat cesarean birth, and 3 (8.6 %) by intrapartum repeat cesarean birth. These groups differed by parity at enrollment (para 1 10.0 % vs 54.6 % vs 100.0 %, p = 0.004), delivery in a healthcare facility (40.0 % vs 100 % vs 100 %, p < 0.001), and birth attendant (50 % of vaginal birth after cesarean by the traditional birth attendant vs 100 % skilled attendants for all cesareans, p = 0.002).
This descriptive analysis is limited by its observational design, that data were collected by maternal self-report, and by the small convenience sample, which precludes more complex analyses [3]. However, it is notable that 60.0 % of women (n = 6 of 10) achieving successful vaginal birth after cesarean did so at home with traditional birth attendants attending (n = 5 of the 6 women who delivered at home). Given the potential for catastrophic maternal and neonatal complications in the setting of trial of labor after cesarean (although there was no statistical difference in rate of maternal complications per Table 1 and too much missing data to observe neonatal complications in this cohort), this finding deserves further exploration [2]. Accordingly, we are planning a qualitative study to analyze attitudes and beliefs about mode of delivery, including delivery setting, among about 20 women (or until we reach thematic saturation) with a history of prior cesarean in February 2020.
We feel that it is important for your readers to be aware that women with a history of cesarean birth are pursuing multiple modes of birth in multiple settings around the world. We feel it is of great interest to understand the knowledge and attitudes of women regarding mode of delivery after cesarean birth, and it is of great importance to study how shared decision making and informed consent regarding mode of delivery in these populations is or is not occurring around the world. We feel this brief commentary contributes to the building literature around these issues,
Synopsis/precis.
Women who delivered by vaginal birth after cesarean, pre-labor elective repeat cesarean, and intrapartum repeat cesarean differed by parity, location of delivery, and attendant.
Acknowledgements
We want to thank all the women and men involved in collection of the data analyzed in this work and all the women who participate in the community-based maternal healthcare program–their health, well-being, and successful pregnancy outcomes are the motivation for performing this work.
Funding
Funding for this project comes from the Eunice Kennedy Shriver National Institutes of Child Health and Human Development Women’s Reproductive Health Research K12 award (5K12HD001271) and the Doris Duke Charitable Foundation.
Footnotes
Ethical statement
The Colorado Multiple Institutional Review Board approved this de-identified secondary analysis of data prospectively collected as part of a quality improvement database (COMIRB # 15-0909).
Declaration of Competing Interest
The authors have no relationships to disclose that may be deemed to influence the objectivity of this paper and its review. The authors report no commercial associations, either directly or through immediate family, in areas such as expert testimony, consulting, honoraria, stock holdings, equity interest, ownership, patent-licensing situations or employment that might pose a conflict of interest to this analysis. Additionally, the authors have no conflicts such as personal relationships or academic competition to disclose. The findings presented in this paper represent the views of the named authors only, and not the views of their institutions or organizations.
Contributor Information
Margo S. Harrison, University of Colorado School of Medicine, Department of Obstetrics and Gynecology, United States.
Saskia Bunge Montes, Fundacion Integral por la Salud de los Guatemaltecos, Center for Human Development, United States.
Claudia Rivera, Fundacion Integral por la Salud de los Guatemaltecos, Center for Human Development, United States.
Amy Nacht, University of Colorado School of Medicine, Department of Obstetrics and Gynecology, United States.
Andrea Jimenez Zambrano, University of Colorado School of Public Health, Center for Global Health, United States.
Molly Lamb, University of Colorado School of Public Health, Center for Global Health, United States.
Antonio Bolanos, Fundacion Integral por la Salud de los Guatemaltecos, Center for Human Development, United States.
Edwin Asturias, University of Colorado School of Public Health, Center for Global Health, United States.
Stephen Berman, University of Colorado School of Public Health, Center for Global Health, United States.
Gretchen Heinrichs, Denver Health, Department of Obstetrics & Gynecology, United States.
References
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