INTRODUCTION Little is known about the relationship between disability and mode of delivery. Prior research has indicated elevated risk of cesarean delivery among women with certain disabilities, but has not examined patterns across multiple types of disability or by parity. OBJECTIVE To determine whether physical, sensory, or intellectual and developmental disabilities are independently associated with primary cesarean delivery. METHODS We conducted a retrospective cohort study of all deliveries in California 2000–2010 using linked birth certificate and hospital discharge data. We identified physical, sensory, and intellectual and developmental disabilities using ICD-9 codes. We used logistic regression to examine the association of these disabilities and primary cesarean delivery, controlling for socio-demographic characteristics and co-morbidities and stratified by parity. RESULTS In our sample, 0.45% (20,894/4,610,955) of deliveries were to women with disabilities. A larger proportion of women with disabilities were nulliparous, had public insurance, and had co-morbidities (e.g., gestational diabetes) compared with women without disabilities (p<0.001 for all). The proportion of primary cesarean in women with disabilities was twice that in women without disabilities (32.7% versus 16.3%, p<0.001; aOR = 2.05; 95% CI = 1.94–2.17). The proportion of deliveries by cesarean was highest among women with physical disabilities due to injuries compared with women without disabilities (57.8% versus 16.3%, p<0.001; aOR = 6.83; 95%CI = 5.46–8.53). CONCLUSION Women across disability subgroups have higher odds of cesarean delivery, and there is heterogeneity by disability type. More attention is needed to this population to ensure better understanding of care practices that may impact maternal and perinatal outcomes.

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Background Although it is likely that childbearing among women with disabilities is increasing, no empirical data have been published on changes over time in the numbers of women with disabilities giving birth. Further, while it is known that women with disabilities are at increased risk of cesarean delivery, temporal trends in cesarean deliveries among women with disabilities have not been examined. Objective To assess time trends in births by any mode and in primary cesarean deliveries among women with physical, sensory, or intellectual/developmental disabilities. Methods We conducted a retrospective cohort study using linked vital records and hospital discharge data from all deliveries in California, 2000–2010 (n=4,605,061). We identified women with potential disabilities using ICD-9 codes. We used descriptive statistics and visualizations to examine time patterns. Logistic regression analyses assessed the association between disability and primary cesarean delivery, stratified by year. Results Among all women giving birth, the proportion with a disability increased from 0.27% in 2000 to 0.80% in 2010. Women with disabilities had significantly elevated odds of primary cesarean delivery in each year, but the magnitude of the odds ratio decreased over time from 2.60 (95% CI=2.25=2.99) in 2000 to 1.66 (95% CI=1.51–1.81) in 2010. Conclusions Adequate clinician training is needed to address the perinatal care needs of the increasing numbers of women with disabilities giving birth. Continued efforts to understand cesarean delivery patterns and reasons for cesarean deliveries may help guide further reductions in proportions of cesarean deliveries among women with disabilities relative to women without disabilities.

Introduction: Prior studies have found that women with disabilities are less likely to receive adequate prenatal care than women without disabilities. However, little is known about differences in patterns of prenatal care by type of disability. Therefore, this study examined timing and frequency of prenatal care among women with physical, sensory, or intellectual/developmental disabilities compared with women without disabilities. Methods: This was a retrospective cohort study using linked maternal and infant hospital discharge and birth certificate data for all births in California in 2000-2012 (N=6,745,201). Analyses were conducted in 2017-2018. Modified Poisson regression analyses compared women with each type of disability with women without disabilities on trimester of prenatal care initiation and number of prenatal care visits. Results: Women with intellectual/developmental disabilities or with limited hearing had significantly higher RR of delaying prenatal care initiation until the second or third trimester (intellectual/developmental disabilities: adjusted RR=1.21, 95% CI=1.09, 1.33; hearing: adjusted RR=1.11, 95% CI=1.02, 1.21), whereas women with physical disabilities and limited vision had lower risk of delaying care (physical: adjusted RR=0.91, 95% CI=0.88, 0.94; vision: adjusted RR=0.85, 95% CI=0.73, 0.99). Women with limited hearing or vision or intellectual/ developmental disabilities had higher risk of receiving fewer prenatal visits than recommended, compared with women without disabilities. Women with physical disabilities or intellectual/ developmental disabilities had higher RR of receiving more than the typical number of visits. Conclusions: There were key differences in prenatal care utilization by disability type, reflective of particularly pronounced disparities for women with intellectual/developmental disabilities and women with limited hearing.

Background: Prior research has found that women with disabilities are more likely to deliver by cesarean than are women without disabilities. It is not clear whether all of the cesarean deliveries among women with disabilities are medically necessary.Objectives: To examine the associations between maternal disability status and type, mode of delivery, and medical indications for cesarean delivery in California deliveries. Study design:Retrospective cohort study of all nulliparous births in California between 2000 and 2012. We classified births as to whether or not women underwent a trial of labor, and determined if medical indications for cesarean delivery were present. Multivariable logistic regression models examined the association of disability with trial of labor and indications for cesarean delivery.Results: Women with disabilities had lower odds of having a labored delivery, compared to women without disabilities (adjusted odds ratio (aOR) = 0.45, 95% confidence interval (CI) 0.41 -0.49). In the sample of women who labored (90.5% of total), women with disabilities were more Corresponding Author, 707 SW Gaines Street, Portland, Oregon 97239, (phone)

Objective To test the hypothesis that maternal height is associated with adverse perinatal outcomes, controlling for and stratified by maternal body mass index (BMI). Study Design This was a retrospective cohort study of all births in California between 2007 and 2010 (n = 1,775,984). Maternal height was categorized into quintiles, with lowest quintile (≤20%) representing shorter stature and the uppermost quintile (≥80%) representing taller stature. Outcomes included gestational diabetes mellitus (GDM), preeclampsia, cesarean, preterm birth (PTB), macrosomia, and low birth weight (LBW). We calculated height/outcome associations among BMI categories, and BMI/outcome associations among height categories, using various multivariable logistic regression models. Results Taller women were less likely to have GDM, nulliparous cesarean, PTB, and LBW; these associations were similar across maternal BMI categories and persisted after multivariable adjustment. In contrast, when stratified by maternal height, the associations between maternal BMI and birth outcomes varied by specific outcomes, for example, the association between morbid obesity (compared with normal or overweight) and the risk of GDM was weaker among shorter women (adjusted odds ratio [aOR], 95% confidence interval [CI]: 3.48, 3.28–3.69) than taller women (aOR, 95% CI: 4.42, 4.19–4.66). Conclusion Maternal height is strongly associated with altered perinatal risk even after accounting for variations in complications by BMI.

Background Women seeking VBAC may find limited in-hospital options. Increasing numbers of US women are delivering by VBAC out-of-hospital. Little is known about neonatal outcomes among those delivering by VBAC in vs. out-of-hospital. Objective(s) To compare neonatal outcomes between women delivering via VBAC in hospital vs. out-of-hospital (home and freestanding birth center). Study Design Retrospective cohort study using 2007-2010 linked US birth and death records to compare singleton, term, vertex, non-anomalous, live born neonates who delivered by VBAC in or out-of-hospital. Descriptive statistics and multivariate regression analyses were conducted to estimate unadjusted, absolute, and relative birth setting risk differences. Stratification by parity and history of vaginal birth examined association between birth setting and each outcome. Sensitivity analyses involving three transfer status scenarios were conducted. Results A small proportion of the total number of US women with a history of cesarean (n = 1,138,813) delivered by VBAC (n = 109,970, 9.65%) with a large majority of these delivering in-hospital (n = 106,823, 97.14%). The proportion of home VBAC births increased from 1.78% to 2.45%. A pattern of increased neonatal morbidity was noted in unadjusted analysis (neonatal seizures, Apgar score <7 or <4, neonatal seizures), with higher morbidity noted in the out-of-hospital setting (neonatal seizures: 23 (0.02%) vs. 6 (0.19%), p <0.001; Apgar score <7: 2859 (2.68%) vs. 139 (4.42%), p <0.001; Apgar score <4: 431 (0.4%) vs. 23 (0.73), p = 0.01). A similar, but non-significant, pattern of increased risk was observed for neonatal death and ventilator support among those born in the out-of-hospital setting. Multivariate regression estimated that neonates born out-of-hospital had higher odds of poor outcomes (neonatal seizures (adjusted odds ratio [aOR] 8.53, 95% confidence interval [CI] 2.87-25.4); Apgar <7 (aOR, 1.62; 95% CI, 1.35-1.96); Apgar <4 (aOR 1.77, CI 1.12-2.79)). While odds of neonatal death (aOR, 2.1; CI 0.73-6.05, p = 0.18) and ventilator support (aOR 1.36, CI 0.75-2.46) appeared to be increased in out-of-hospital settings, findings did not reach statistical significance. Women birthing their second child by VBAC in out-of-hospital settings had higher odds of neonatal morbidity and mortality compared to women of higher parity. Women without a history of vaginal birth prior to out-of-hospital VBAC delivery had higher odds of neonatal morbidity and mortality compared to those with a history of vaginal birth. Sensitivity analyses generated distributions of plausible alternative estimates by outcome Conclusions Fewer than 1 in 10 US women with a prior CD delivered by VBAC in any setting and increasing proportions of these women delivered out-of-hospital. Adverse outcomes were more frequent for neonates born out-of-hospital, with risk concentrated among women birthing their second child and women without a history of vaginal birth. This information urgently signals the need to increase availa...

Background There is an evidence gap regarding the use of regional anaesthesia (epidural, spinal, or combined epidural/spinal anaesthesia) and associated complications by maternal body mass index (BMI). We examine associations between regional anaesthesia, mode of delivery, and regional anaesthesia complications by pre-pregnancy BMI categories among term deliveries. Methods Retrospective cohort study of births in California, 2007–2010, utilizing linked birth certificate data and patient discharge data. Outcomes were mode of delivery (among laboured deliveries) and select regional anaesthesia complications. Multivariable Poisson regression was used to adjust for maternal characteristics. Results In women undergoing labour (i.e., laboured delivery), women with higher BMI categories were more likely to receive regional analgesia in a dose-response fashion (adjusted risk ratio [aRR] for primiparous women with category I obesity, 1.10, 95% confidence interval [CI] 1.10, 1.11), and in those receiving regional anaesthesia, were less likely to deliver vaginally (e.g., aRR 0.85, 95% CI 0.84, 0.85 for the same category of women). Regional anaesthesia complications displayed a complex relationship with maternal BMI, with women in intermediate obesity categories having decreased odds as compared to normal-weight women, and women in the highest BMI category having a twofold increased risk of complications (aRR for primiparous women 2.34, 95% CI 1.37, 4.02). Conclusion Labouring women in higher BMI categories were more likely to receive regional anaesthesia and more likely to deliver via caesarean compared to normal weight women and women without regional anaesthesia. Rates of anaesthesia complications were highest among women in the highest BMI category.