Variability in caesarean section rates for very preterm births at 28–31 weeks of gestation in 10 European regions: Results of the MOSAIC project

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Abstract

Objective

Given the continuing debate about the benefits of caesarean section for very preterm infants, we sought to describe caesarean section rates for infants between 28 and 31 weeks of gestation in European regions and their association with regional mortality and short-term morbidity.

Study design

Singletons and twins without lethal congenital anomalies alive at onset of labour from 28 to 31 weeks of gestation from the 2003 MOSAIC cohort of very preterm births in 10 European regions were analysed (N = 3310). Determinants included maternal and fetal characteristics as well as regional caesarean section rates for all births. We explored correlations between caesarean section rates and mortality and morbidity on the regional level.

Results

95% of infants from pregnancies complicated by hypertension or severe growth restriction detected antenatally were delivered by caesarean section (regional range: 90–100%) versus 55.4% (range: 29–84%) for other pregnancies. Regional caesarean section rates for births at all gestations ranged from 14% to 38% and were correlated with very preterm caesarean rates (p = 0.011). Determinants of caesarean section differed between regions with high versus low rates: multiples were more likely to be born by caesarean section in regions with high rates. There were no regional level correlations between caesarean section rates and mortality and morbidity.

Conclusions

With the exception of pregnancies with hypertension and growth restriction, there was broad variation in very preterm caesarean section rates between regions after adjustment for clinical factors. Given maternal risks associated with caesarean section, more research on its optimal use for very preterm deliveries is necessary.

Introduction

The use of caesarean section for delivery of very preterm infants (<32 weeks) has increased over the last twenty years as their survival chances have improved [1], [2], [3], [4]. The evidence about the benefits of caesarean section for these infants remains unclear, however. For fetuses with growth restriction, studies have found positive associations with survival [5], [6], [7] and fetuses in breech presentation also appear to have better survival [4], [8], [9], [10], but not consistently [11], [12]. For other very preterm births, caesarean delivery has not been associated with reduced mortality [5], [6], [7], [9], [10], [13], [14], although some studies reported reduced rates of intraventricular hemorrhage [15], [16].

A large scientific literature on term deliveries has revealed broad differences in practices between countries and has identified non-clinical factors, such as maternal social characteristics and the size and specialization of maternity units, that are associated with the probability of caesarean delivery [17], [18], [19]. We did not find any similar studies for the very preterm population.

Given the debate on these topics, our aim was to describe the variation in caesarean section rates for very preterm births in European regions, to study which maternal and organisational factors have an influence on these rates, and to explore whether short-term neonatal outcomes differ between regions with different rates. One of our research questions was also whether practices of caesarean section for the overall population of births influenced decisions about surgical delivery of very preterm babies. This analysis focuses on births between 28 and 31 weeks of gestation. Births under 28 weeks were not included because ethical decisions to withhold or withdraw care differ in Europe for this group [20], [21] and our aim was to study the use of caesarean when active intervention would be considered for all fetuses.

Section snippets

Methods

Our data come from the MOSAIC study, an observational prospective cohort study of very preterm babies in 10 European regions. This study aimed to compare the organization of care, medical practices and outcomes at discharge home from hospital of births from 22 to 31 weeks of gestation [22]. Study regions were the Eastern region of Denmark, Flanders in Belgium, 6 districts of the Ile-de-France region in France, Hesse in Germany, Lazio in Italy, the Eastern and Central regions of the Netherlands,

Results

Table 1 presents caesarean section rates for all births in 2002 and for births at 28–31 weeks in 2003 in the MOSAIC regions. Caesarean section rates for all births varied from 13.9% in the Netherlands to 38.3% in the Lazio region in Italy. For births between 28 and 31 weeks of gestation, caesarean section rates ranged from 48.7% in Eastern/Central Netherlands to 87.4% in Hesse, Germany. Ranges for prelabour caesareans were 34.2–63.0% and 10.8–27.4% for caesareans after onset of labour. Most

Comment

Most infants born between 28 and 31 weeks of gestation from pregnancies complicated by hypertension and growth restriction detected before delivery were delivered by caesarean section in the European regions in our study. For pregnancies without these complications, however, rates varied widely, from 29% to 84%. Regions with higher rates of caesarean section for all births also had higher very preterm caesarean section rates, suggesting that socio-cultural and organisational factors that play a

Acknowledgements

This project was partially funded by a grant from the European Commission Research Directorate (QLG4-CT-2001-01907) and coordinated by Assistance-Publique Hôpitaux de Paris. The authors would like to acknowledge the assistance of the personnel in the maternity and neonatal units in the regions participating in the MOSAIC project.

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    Belgium, Flanders (E. Martens, G. Martens, P. Van Reempts); Denmark, Eastern Denmark (K. Boerch, T. Weber, B. Peitersen); France, Ile-de-France (G. Bréart, JL Chabernaud, D. Delmas, PH Jarreau, E. Papiernik); Germany, Hesse (L. Gortner, W. Künzel, R.F. Maier, B. Misselwitz, S. Schmidt); Italy, Lazio (R. Agostino, D. Di Lallo, R. Paesano); Netherlands, Eastern and Central (L. den Ouden, L. Kollée, G. Visser, J. Gerrits, R. de Heus); Poland, Wielkopolska and Lubuskie (G. Breborowicz, J.Gadzinowski, J. Mazela); Portugal, Northern Region (H. Barros, I. Campos, M.Carrapato,) UK, Trent Region (E. Draper, D. Field, J. Konje); UK, Northern Region (A. Fenton, D. Milligan, S. Sturgiss); INSERM U149, Paris (G. Bréart, B. Blondel, H. Pilkington, J. Zeitlin); External contributors (M. Cuttini, S.Petrou). Steering Committee (E. Papiernik, J. Zeitlin, G. Bréart, E. Draper, L. Kollée).

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