Risk of severe maternal morbidity associated with cesarean delivery and the role of maternal age: a population-based propensity score analysis

Abstract

esarean delivery is a useful intervention for mothers and newborns in many situations. Nonetheless, its rates have soared over the past 20 years in most developed countries, where more than 1 out of 5 women deliver by cesarean. 1 The range of indications for cesarean delivery appears to have broadened considerably, with more cesarean deliveries likely to be performed for questionable medical indications. 2-7 This increase requires evaluation of its potential adverse consequences on maternal and neonatal health. The long-term obstetric risks associated with the presence of a scarred uterus in future pregnancies are well recognized, primarily uterine rupture and abnormal placentation. 8-13 Conversely, conclusions about the comparative short-term maternal risks of cesarean and vaginal delivery remain unclear. A randomized controlled trial among women with no medical indication for cesarean delivery is, at best, ethically questionable. Observational studies can provide relevant information to address this, but their conclusions are likely to be limited owing to confounding by indication. That is, the fact that maternal morbidity may be a result of the condition indicating or justifying the cesarean delivery rather than to the surgical procedure itself can produce an apparent association between cesarean delivery and maternal morbidity. Earlier studies of the association between maternal mortality and mode of delivery have shown a higher risk of maternal mortality associated with cesarean versus vaginal deliveries. 14,15 These studies, however, were limited by their retrospective design, the rarity of maternal deaths and insufficient consideration of this confounding by indication. Over the past 10 years, numerous observational studies have reported discordant results about the association between cesarean and severe maternal morbidity, and their conclusions too are limited by several methodological flaws: insufficient control for confounding by indication, inappropriate definition of severe acute maternal morbidity, retrospective designs limiting quality and availability RESEARCH HEALTH SERVICES CPD Risk of severe maternal morbidity associated with cesarean delivery and the role of maternal age: a population-based propensity score analysis

Severe maternal morbidity by mode of delivery in women with twin pregnancy and planned vaginal delivery

“…The definitions of infection and postpartum hemorrhage used in previous studies, which did not focus on severe cases, may explain this difference. The increased risk of severe postpartum hemorrhage observed in our study is consistent with results in singleton pregnancies [17][18][19] . The higher risk in singletons is especially marked for cesareans during labor and for cesareans during the second stage of labor 19,20 -both conditions met by cesareans for second twins.…”

Time Series Analysis and Forecasting of Caesarian Section Births in Ghana

“…Although postpartum pain is common among women who deliver babies either by vaginal or ceasarian modes, it has been reported in many studies that postpartum pain is rampantly observed within an extended period of time among women who have undergone ceasarian birth delivery [1,2]. CS delivery had also been associated with higher risk of severe acute maternal morbidity (SAMM) than vaginal delivery particularly in women who are 35 years or older [3]. Studies recommend the control of the CS through the use of Robson classification or policy instruments at the health system level [4].…”

Delivery options and risk of severe acute maternal morbidity

“…Instead, two management options are available: planned cesarean and planned vaginal delivery. [2][3][4] There fore, the only clinically relevant finding in this study 1 is that there was no signifi cant increase in the risk of SAMM after planned cesarean delivery (adjusted odds ratio 1.09, 95% confidence interval 0.85-1.41).…”

“…3,4 Neither the Term Breech Trial (n = 2088) 3 nor the Twin Births Study (n = 2804) 4 showed any association between planned cesarean delivery and SAMM. Although these trials were limited in size (given the low frequency of SAMM), their findings (and those of less valid, nonexperimental studies) 1,6 are consistent with a nearzero rate difference in SAMM between planned cesarean and planned vaginal delivery.…”