BackgroundIn Denmark, the cesarean section rate has increased by 49% between 1998 and 2015 and accounts for 21% of all births. Cesarean sections may cause short- as well as long-term consequences for both the mother and the child and impose further risks in future pregnancies. Delaying pregnancy until advanced maternal age at childbirth has been suggested as contributing to the increase. The proportion of women giving birth at 35 years or above increased from 15% (1998) to 21% (2015). Advanced maternal age at childbirth has been found to be related to increased pre-pregnancy morbidity and associated risk factors that may contribute to an increased risk of cesarean section. The aim of this study was to examine the association between advanced maternal age and cesarean section in a Danish population and the influence of demographic, anthropometric, health, and obstetric factors on this association.MethodsThis study draws on a national population-based cohort study of all Danish births between 1998 and 2015 (N = 1,122,964). Maternal age less than 30 years serves as reference with the following age categories: (30–34 years); (35–39 years), and (40 years and above). The primary outcome was a cesarean section. Multivariate regression models with adjustment for demographic, health, pregnancy, fetal, and obstetric characteristics were performed with the results further stratified by parity.ResultsIn general, a positive association between advanced maternal age and cesarean section was found. Only minor changes in the risk estimate occurred after adjustment for relevant confounders. In comparison with the reference category, nulliparous women aged 35-39- years had twice the risk for cesarean section (adjusted odds ratio (AOR) 2.18, 95% confidence interval (CI) [2.11–2.26]) whereas for women of 40 years or above, the risk was more than tripled (AOR 3.64, 95% CI [3.41–3.90]). For multiparous women aged 35-39-years the risk was more moderate, but still with an AOR of 1.56, 95% CI [1.53–1.60], and for those 40 years and above, the AOR was 2.02, 95% CI [1.92–2.09].ConclusionsOverall, cesarean section increased with increasing maternal age. Adjustment for maternal and obstetric risk factors had only a minor influence on the association. The association was stronger in nulliparous women compared to multiparous women. Given the lack of impact of demographic and health risks on the relationship between maternal age and cesarean section, the authors suggest obstetric culture could be added to the list of risk factors for a cesarean. Future research on obstetric culture is recommended as are studies on a possible age-related decrease in the ability to maintain the progression of labor.Trial registrationThe study uses depersonalized register data and has been approved by the Danish Data Protection Agency (2015-41-4168).

Background Variations in intervention rates, without subsequent reductions in adverse outcomes, can indicate overuse. We studied variations in and associations between commonly used childbirth interventions and adverse outcomes, adjusted for population characteristics. Methods and findings In this multinational cross-sectional study, existing data on 4,729,307 singleton births at �37 weeks in 2013 from Finland,

Objective: The objective of this review was to identify, assess and synthesize the best available evidence on the effects of induction prior to post-term on the mother and fetus. Maternal and fetal outcomes after routine labor induction in low-risk pregnancies at 41+0 to 41+6 gestational weeks (prior to post-term) were compared to routine labor induction at 42+0 to 42+6 gestational weeks (post-term). Introduction: Induction of labor when a pregnancy exceeds 14 days past the estimated due date has long been used as an intervention to prevent adverse fetal and maternal outcomes. Over the last decade, clinical procedures have changed in many countries towards earlier induction. A shift towards earlier inductions may lead to 15–20% more inductions. Given the fact that induction as an intervention can cause harm to both mother and child, it is essential to ensure that the benefits of the change in clinical practice outweigh the harms. Inclusion criteria: This review included studies with participants with expected low-risk deliveries, where both fetus and mother were considered healthy at inclusion and with no known risks besides the potential risk of the ongoing pregnancy. Included studies evaluated induction at 41+1–6 gestational weeks compared to 42+1–6 gestational weeks. Randomized control trials (n = 2), quasi-experimental trials (n = 2), and cohort studies (n = 3) were included. The primary outcomes of interest were cesarean section, instrumental vaginal delivery, low Apgar score (≤ 7/5 min.), and low pH (< 7.10). Secondary outcomes included additional indicators of fetal or maternal wellbeing related to prolonged pregnancy or induction. Methods: The following information sources were searched for published and unpublished studies: PubMed, CINAHL, Embase, Scopus, Swemed+, POPLINE; Cochrane, TRIP; Current Controlled Trials; Web of Science, and, for gray literature: MedNar; Google Scholar, ProQuest Nursing & Allied Health Source, and guidelines from the Royal College of Obstetricians and Gynaecologists, and American College of Obstetricians and Gynecologists, according to the published protocol. In addition, OpenGrey and guidelines from the National Institute for Health and Care Excellence, World Health Organization, and Society of Obstetricians and Gynaecologists of Canada were sought. Included papers were assessed by all three reviewers independently using the Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information (JBI SUMARI). The standardized data extraction tool from JBI SUMARI was used. Data were pooled in a statistical meta-analysis model using RevMan 5, when the criteria for meta-analysis were met. Non-pooled results were presented separately. Results: Induction at 41+0–6 gestational weeks compared to 42+0–6 gestational weeks was found to be associated with an increased risk of overall cesarean section (relative ris...

ObjectivesFor many years, routine elective induction of labour at gestational week (GW) 42+0 has been recommended in Denmark. In 2011, a more proactive protocol was introduced aimed at reducing stillbirths, and practice changed into earlier routine induction, i.e. between 41+3 and 41+5 GW. The present study evaluates a national change in induction of labour regime. The trend of maternal and neonatal consequences are monitored in the preintervention period (2000–2010) compared with the postintervention period (2012–2016).DesignA national retrospective register-based cohort study.SettingDenmark.ParticipantsAll births in Denmark 41+3 to 45+0 GWs between 2000 and 2016 (N = 152 887).Outcome measuresPrimary outcomes: stillbirths, perinatal death, and low Apgar scores. Additional outcomes: birth interventions and maternal outcomes.ResultsFor the primary outcomes, no differences in stillbirths, perinatal death, and low Apgar scores were found comparing the preintervention and postintervention period. Of additional outcomes, the trend changed significantly postintervention concerning use of augmentation of labour, epidural analgesia, induction of labour and uterine rupture (all p<0.05). There was no significant change in the trend for caesarean section and instrumental birth. Most notable for clinical practice was the increase in induction of labour from 41% to 65% (p<0.01) at 41+3 weeks during 2011 as well as the rare occurrence of uterine ruptures (from 2.6 to 4.2 per thousand, p<0.02).ConclusionsEvaluation of a more proactive regimen recommending induction of labour from GW 41+3 compared with 42+0 using national register data found no differences in neonatal outcomes including stillbirth. The number of women with induced labour increased significantly.

ObjectivesThe need for thorough patient information is increasing as maternity care becomes more medicalised. The aim was to assess the quality of written patient information on labour induction. In most Danish hospitals, misoprostol is the first-choice drug for induction in low-risk pregnancies. Misoprostol has been associated with adverse side effects and severe outcomes for mother and child and is not registered for obstetric use in Denmark.SettingSecondary care hospitals in Denmark.DataPatient information leaflets from all hospitals that used misoprostol as an induction agent by June 2015 (N=13).DesignPatient leaflets were evaluated according to a validated scoring tool (International Patient Decision Aid Standards instrument, IPDAS), core elements in the Danish Health Act, and items regarding off-label use and non-registered medication. Two of the authors scored all leaflets independently.Outcome measuresWomen's involvement in decision-making, information on benefits and harms associated with the treatment, other justifiable treatment options, and non-registered treatment.ResultsGenerally, the hospitals scored low on the IPDAS checklist. No hospitals encouraged women to consider their preferences. Information on side effects and adverse outcomes was poorly covered and varied substantially between hospitals. Few hospitals informed about precautions regarding outpatient inductions, and none informed about the lack of evidence on the safety of this procedure. None informed that misoprostol is not registered for induction or explained the meaning of off-label use or use of non-registered medication. Elements such as interprofessional consensus, long-term experience, and health authorities' approval were used to add credibility to the use of misoprostol.ConclusionsCentral criteria for patient involvement and informed consent were not met, and the patient leaflets did not inform according to current evidence on misoprostol-induced labour. Our findings indicate that patients receive very different, sometimes contradictory, information with potential ethical implications. Concerns should be given to outpatient inductions, where precise written information is of particular importance.

IntroductionThere are growing concerns about the increase in rates of commonly used childbirth interventions. When indicated, childbirth interventions are crucial for preventing maternal and perinatal morbidity and mortality, but their routine use in healthy women and children leads to avoidable maternal and neonatal harm. Establishing ideal rates of interventions can be challenging. This study aims to describe the range of variations in the use of commonly used childbirth interventions in high-income countries around the world, and in outcomes in nulliparous and multiparous women.Methods and analysisThis multinational cross-sectional study will use data from births in 2013 with national population data or representative samples of the population of pregnant women in high-income countries. Data from women who gave birth to a single child from 37 weeks gestation onwards will be included and the results will be presented for nulliparous and multiparous women separately. Anonymised individual level data will be analysed. Primary outcomes are rates of commonly used childbirth interventions, including induction and/or augmentation of labour, intrapartum antibiotics, epidural and pharmacological pain relief, episiotomy in vaginal births, instrument-assisted birth (vacuum or forceps), caesarean section and use of oxytocin postpartum. Secondary outcomes are maternal and perinatal mortality, Apgar score below 7 at 5 min, postpartum haemorrhage and obstetric anal sphincter injury. Univariable and multivariable logistic regression analyses will be conducted to investigate variations among countries, adjusted for maternal age, body mass index, gestational weight gain, ethnic background, socioeconomic status and infant birth weight. The overall mean rates will be considered as a reference category, weighted for the size of the study population per country.Ethics and disseminationThe Medical Ethics Review Committee of VU University Medical Center Amsterdam confirmed that an official approval of this study was not required. Results will be disseminated at national and international conferences and published in peer-reviewed journals.

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