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Persistent Cesarean Delivery Risk Among Florida Women: Who’s Next?

Persistent Cesarean Delivery Risk Among Florida Women: Who’s Next?. Dave Goodman, MS PhD William Sappenfield, MD MPH Dan Thompson, MPH Division of Family Health Services, Florida Department of Health Charles Mahan, MD University of South Florida, College of Public Health Lori Reeves, MPH

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Persistent Cesarean Delivery Risk Among Florida Women: Who’s Next?

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  1. Persistent Cesarean Delivery Risk Among Florida Women:Who’s Next? Dave Goodman, MS PhD William Sappenfield, MD MPH Dan Thompson, MPH Division of Family Health Services, Florida Department of Health Charles Mahan, MD University of South Florida, College of Public Health Lori Reeves, MPH March of Dimes, Florida Chapter

  2. Persistent Cesarean Delivery Risk Among Florida Women:Who’s Next? Florida DOH • Infant, Maternal, and Reproductive Health • Planning, Evaluation, and Data Analysis • Dr. John Middaugh, State Epidemiologist Florida Partners • March of Dimes Preterm Birth Prevention Statewide Workgroup • Lawton Rhea Chiles Center for Healthy Mothers and Babies National Partners • Michael Kogan, HRSA, MCHB • Carol Sakala and Maureen Corry, Childbirth Connection • Eugene DeClercq, Boston University • Charles Denk, New Jersey Department of Health • Joann Petrini, National Chapter March of Dimes

  3. * Introduction Cesarean Delivery: Florida and U.S. 1995-2006 40 Overall 35 30 * 25 Without Labor 20 Percentage of Births 15 With Labor Florida 10 U.S. 5 0 1995 2006 2000 Birth Year Data Source, Florida: Final Birth Data, 1995-2006. Data Source, U.S.: NCHS Final Natality Data, 1995-2004. Preliminary Natality Data.

  4. * Introduction Cesarean Delivery: Florida and U.S. 1995-2006 40 Overall 35 30 * 25 Without Labor Range for Florida hospitals with > 2,000 births per year: 21 – 60% Data Source: AHCA. Cesarean Rates 1998-2006. http://www.floridahealthfinder.gov/researchers/QuickStat/cesarean-buffer.shtml 20 Percentage of Births 15 With Labor Florida 10 U.S. 5 0 1995 2006 2000 Birth Year Data Source, Florida: Final Birth Data, 1995-2006. Data Source, U.S.: NCHS Final Natality Data, 1995-2004. Preliminary Natality Data.

  5. Public Health Importance Cesarean in FL associated with: • Increase in preterm birth rate • Singletons • 1995-2003 • Increased risk of late preterm birth • Singletons • 2004-2006 • Low-risk cohort • Session C5, Tomorrow morning

  6. Methods: Data Data • Florida 2004*– 2006 birth file • Study Population • Resident in-state births • 34-41 weeks • Singleton gestations * Excludes 1st quarter (old birth cert)

  7. Methods: Definitions Definitions • Cesarean with labor • Attempted vaginal delivery that ends in cesarean • Check box • Induction or Augmentation indicated • Vacuum or Forceps use indicated • Low-Documented Risk • None of 18 medical factors associated with Cesarean • Not intensive prenatal care usage (GINDEX)

  8. Low Documented Risk for Cesarean Delivery • None of the following are documented using the birth certificate: • Hypertension prepregnancy (Chronic) • Hypertension gestational (PIH, Preeclampsia) • Hypertension - Eclampsia • Diabetes Prepregnancy (Diagnosis prior to the pregnancy) • Gestational Diabetes (Diagnosis in this pregnancy) • Prolonged labor (≥ 20 hours) • Moderate/Heavy meconium staining of the amniotic fluid • Fetal intolerance of labor (such that in-utero resuscitative measures and/or further fetal assessment and/or operative delivery actions are taken) • Clinical Chorioamnionitis diagnosed during labor or maternal temperature >38ºC • Non-vertex presentation • Fetal presentation at birth other than cephalic • A birth weight greater than 4,500-g • Any of these congenital anomalies: • Anencephaly • Congenital diaphragmatic hernia • Meningomyelocele/Spina bifida • Omphalocele • Cyanotic congenital heart disease • Gastroschisis • Modified GINDEX indicates intensive prenatal care use

  9. Methods: Analysis Analysis • Rates (Cesarean overall) • Multinomial logistic regression • Cesarean with labor (Cesarean Labor +) • Cesarean without labor (Cesarean Labor -) • STATA 9.2 SE

  10. Results: Cesarean DeliveryRates Singleton, 34-41 weeks (n=155,895) Overall (n=479,993) 32.5 Singletons, 34-41 weeks Delivery pay source Medicaid 30.1 Private Insurance 35.6 Self-Pay 28.3 Race White 32.8 Black 31.6 Other 31.5 Ethnicity non-Hispanic 31.2 Mexican 27.6 Puerto Rican 32.9 Cuban 47.0 Central / South American 36.9 Other / Multi-ethnic 36.0 <19 Age (Years) 21.2 19-24 26.7 25-34 34.0 35+ 44.3 1st Parity 32.9 2nd+ 32.2 <19.8 BMI 23.1 19.8-26.0 29.8 26.1-29.0 35.6 29.1+ 43.0 Gestational weight gain Recommended 28.0 Inadequate 27.9 Excessive 37.1 Significantly higher than any other category Significantly lower than any other category

  11. Results: Cesarean Delivery Rates Singleton, 34-41 weeks AND no prior Cesarean (n=155,895) (n=101,912) Overall (n=479,993) 32.5 24.2 AND no prior cesarean Delivery pay source Medicaid 30.1 22.1 Private Insurance 35.6 27.1 Self-Pay 28.3 19.2 Race White 32.8 24.5 Black 31.6 22.9 Other 31.5 24.2 Ethnicity non-Hispanic 31.2 23.2 Mexican 27.6 18.0 Puerto Rican 32.9 24.1 Cuban 47.0 38.8 Central / South American 36.9 27.7 Other / Multi-ethnic 36.0 26.9 <19 Age (Years) 21.2 19.7 19-24 26.7 20.9 25-34 34.0 24.7 35+ 44.3 32.2 1st Parity 32.9 32.8 2nd+ 32.2 16.1 <19.8 BMI 23.1 17.7 19.8-26.0 29.8 22.4 26.1-29.0 35.6 26.1 29.1+ 43.0 31.9 Gestational weight gain Recommended 28.0 20.1 27.9 18.9 Inadequate Excessive 37.1 28.9 Significantly higher than any other category Significantly lower than any other category

  12. Results: Cesarean Delivery Rates Singleton, 34-41 weeks AND no prior Cesarean AND low documented risk (n=155,895) (n=101,912) (n=53,518) Overall (n=479,993) 32.5 24.2 17.0 AND low-documented risk Delivery pay source Medicaid 30.1 22.1 15.2 Private Insurance 35.6 27.1 19.6 Self-Pay 28.3 19.2 13.5 Race White 32.8 24.5 17.2 Black 31.6 22.9 16.4 Other 31.5 24.2 17.2 Ethnicity non-Hispanic 31.2 23.2 16.3 Mexican 27.6 18.0 12.0 Puerto Rican 32.9 24.1 17.5 Cuban 47.0 38.8 28.4 Central / South American 36.9 27.7 20.2 Other / Multi-ethnic 36.0 26.9 20.1 <19 Age (Years) 21.2 19.7 13.5 19-24 26.7 20.9 14.5 25-34 34.0 24.7 17.6 35+ 44.3 32.2 23.9 Parity 1st 32.9 32.8 23.8 2nd+ 32.2 16.1 11.5 <19.8 BMI 23.1 17.7 12.0 19.8-26.0 29.8 22.4 16.0 26.1-29.0 35.6 26.1 18.9 29.1+ 43.0 31.9 23.4 Gestational weight gain Recommended 28.0 20.1 14.1 27.9 18.9 12.7 Inadequate Excessive 37.1 28.9 21.0 Significantly higher than any other category Significantly lower than any other category

  13. Significantly increased risk Significantly decreased risk Results: Regression Adjusted Odds Ratio (AOR) of Cesarean Delivery Among Florida Resident Singleton Births, 34-41 Weeks Gestational Age, No Previous Cesarean, and Low Documented Risk for Cesarean Delivery (N=270,963). 2004-2006. Data Source: FL 2004-2006, Final Birth File. Adjusted for: Pay source, Adequacy of prenatal care, Infertility treatment, Parity, BMI, Gestational weight gain, Birth year, Birth day of week.

  14. Significantly increased risk Significantly decreased risk Results: Regression Adjusted Odds Ratio (AOR) of Cesarean Delivery Among Florida Resident Singleton Births, 34-41 Weeks Gestational Age, No Previous Cesarean, and Low Documented Risk for Cesarean Delivery (N=270,963). 2004-2006. Data Source: FL 2004-2006, Final Birth File. Adjusted for: Race, Ethnicity, Age, Marital Status, Smoking, Maternal Education, Birth year, Birth day of week.

  15. Significantly increased risk Significantly decreased risk Results: Regression Adjusted Odds Ratio (AOR) of Cesarean Delivery Among Florida Resident Singleton Births, 34-41 Weeks Gestational Age, No Previous Cesarean, and Low Documented Risk for Cesarean Delivery (N=270,963). 2004-2006. Data Source: FL 2004-2006, Final Birth File. Adjusted for: Race, Ethnicity, Age, Marital Status, Smoking, Maternal Education,Pay source, Adequacy of prenatal care, Infertility treatment, Parity, BMI, Gestational weight gain.

  16. Limitations Limited to birth certificate data • Misclassification • Gestational age • Delivery route • Medical Risk Factors • Labor • Labor categorized as no labor • Differentiate emergency from scheduled Cesareans

  17. Summary Persistent variability in Cesarean delivery: • Across characteristics of women • Hispanic • Older • Heavier • Across risk subsets of women • Singletons • AND No previous cesarean • AND Low-documented risk • Across Cesarean delivery types • With labor • Without labor

  18. Implications Informative to explore subgroups • Hispanic mix may be why FL Hispanics have highest rates, while nationally it is non-Hispanic Black women Gaps in intrapartum surveillance • What medical and social risk factors are we missing?

  19. Current Activities • March of Dimes Preterm Birth Prevention Statewide Workgroup • Florida Obstetric and Gynecologic Society (FOGS) – Dept. of Health Informal Study Group • Review evidence-base • Develop recommendations on next steps • 2 Meetings completed! • Qualitative Cesarean focus groups (Healthy Start Coalition of Pinellas) • Awaiting (and planning for) PRAMS Phase 6 • New Standard questions about why and when of Cesarean delivery

  20. End dave_goodman@doh.state.fl.us

  21. Day of the Week: Delivery Route Index of Occurrence of Delivery Route: Florida 2004-2006 Singletons, 34-41 Weeks, No Previous Cesarean, Low Documented Risk, and No Medical Induction (N=263,326) 140 120 100 Index of Occurrence 80 Vaginal Cesarean with labor 60 Cesarean without labor 40 20 Sun Mon Tue Wed Thu Fri Sat Day of Week Data Source: 2004-2006, Final Birth File.

  22. Hour of Day: Delivery Route Index of Occurrence of Delivery Route: Florida 2004-2006 Singletons, 34-41 Weeks, No Previous Cesarean, Low Documented Risk, and No Medical Induction (N=260,023) Vaginal 300 Cesarean with labor Cesarean without labor 200 Index of Occurrence 100 0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 Hour of Day Data Source: 2004-2006, Final Birth File.

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