Why women with previous caesarean and eligible for a trial of labour have an elective repeat caesarean delivery? A national study in France

Abstract

Objective To identify the characteristics of women and maternity units associated with elective repeat caesarean delivery (ERCD) in women eligible for trial of labour after caesarean (TOLAC).Design Cross-sectional study.Setting France.Population and sample Using data from the 2010 French National Perinatal Survey, a representative sample of births in France (n = 14 681 women), we studied two groups of women with prior caesarean section: (i) women eligible for TOLAC according to guidelines (n = 1179) and (ii) a subgroup of these women without any medical characteristics that might indicate ERCD (n = 575).Methods Associations were analysed by multilevel logistic regression.Main outcome measures Adjusted odds ratios.Results Among the 1584 women with a previous caesarean, 1179 (74.4%) were eligible for TOLAC according to guidelines (group 1); 490 (41.6%) had ERCD. Risk of ERCD increased with increasing maternal age and body mass index, pre-existing condition and suspected macrosomia and decreased with previous vaginal deliveries. Among the unit characteristics, private status (aOR = 2.3, 95% CI 1.3-4.1) and low level of care (aOR = 2.5, 95% CI 1.4-4.5]) were independently associated with a higher risk of ERCD after adjustment on patient/pregnancy characteristics. The variability of ERCD rate between hospitals was mainly (78%) explained by the status and level of care, and not (0%) by patient/ pregnancy characteristics. Associations with unit characteristics were similar for group 2.Conclusion For women eligible for TOLAC, the rate of ERCD is high and not in agreement with guidelines. Some characteristics of women are associated with ERCD, but the main determinants are at the unit level, which suggests that non-medical reasons are involved in the decision process.Keywords Caesarean delivery, determinants, previous caesarean, repeat caesarean section, route of delivery.Tweetable abstract Elective repeat caesarean in women eligible for trial of labour mainly depends on maternity unit characteristics.

Elective repeat cesarean delivery in women eligible for trial of labor in Brazil

“…As expected, a previous vaginal delivery had a strong protective effect against ERCD, a finding that is in agreement with previous reports . In the present study, a previous vaginal delivery was strongly correlated with a preference for a vaginal delivery at the beginning of the index pregnancy (data not shown); however, regardless of this preference, a previous vaginal delivery had an independent protective effect on ERCD.…”

“…However, both overall CD and ERCD rates are still higher than those reported for all women with a previous CD in Finland (47%) and Norway (54%) . A similar study in France showed an ERCD rate of 41.6% across the entire population and 28.4% among women without any characteristic that might indicate a repeat CD . Given the Brazilian recommendations for VBAC do not differ much from those in high‐income countries, it is likely that nonclinical factors, such as hospital policy, liability concerns, or provider preference, had a role in the decision to perform an ERCD, even within the public sector.…”

“…Three hospital characteristics (location in a noncapital city, mixed hospital, and fewer than 1500 deliveries per year) were associated with an increased risk for ERCD. Many studies have shown that hospital factors have an important effect on the planned CD rate and the repeat CD rate . Bartolo et al .…”

“…Many studies have shown that hospital factors have an important effect on the planned CD rate and the repeat CD rate . Bartolo et al . found that maternity unit characteristics were the main determinants of the planned mode of delivery and explained 78% of the variation in ERCD rates in France.…”

“…15 A similar study in France showed an ERCD rate of 41.6% across the entire population and 28.4% among women without any characteristic that might indicate a repeat CD. 2…”