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      Effects of continuity of care by a primary midwife (caseload midwifery) on caesarean section rates in women of low obstetric risk: the COSMOS randomised controlled trial : Effects of caseload midwifery on caesarean section rates

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          Abstract

          To determine whether primary midwife care (caseload midwifery) decreases the caesarean section rate compared with standard maternity care. Randomised controlled trial. Tertiary-care women's hospital in Melbourne, Australia. A total of 2314 low-risk pregnant women. Women randomised to caseload received antenatal, intrapartum and postpartum care from a primary midwife with some care by 'back-up' midwives. Women randomised to standard care received either midwifery or obstetric-trainee care with varying levels of continuity, or community-based general practitioner care. caesarean birth. Secondary outcomes included instrumental vaginal births, analgesia, perineal trauma, induction of labour, infant admission to special/neonatal intensive care, gestational age, Apgar scores and birthweight. In total 2314 women were randomised-1156 to caseload and 1158 to standard care. Women allocated to caseload were less likely to have a caesarean section (19.4% versus 24.9%; risk ratio [RR] 0.78; 95% CI 0.67-0.91; P = 0.001); more likely to have a spontaneous vaginal birth (63.0% versus 55.7%; RR 1.13; 95% CI 1.06-1.21; P < 0.001); less likely to have epidural analgesia (30.5% versus 34.6%; RR 0.88; 95% CI 0.79-0.996; P = 0.04) and less likely to have an episiotomy (23.1% versus 29.4%; RR 0.79; 95% CI 0.67-0.92; P = 0.003). Infants of women allocated to caseload were less likely to be admitted to special or neonatal intensive care (4.0% versus 6.4%; RR 0.63; 95% CI 0.44-0.90; P = 0.01). No infant outcomes favoured standard care. In settings with a relatively high baseline caesarean section rate, caseload midwifery for women at low obstetric risk in early pregnancy shows promise for reducing caesarean births. © 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology © 2012 RCOG.

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          Most cited references21

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          Caesarean section is associated with an increased risk of childhood-onset type 1 diabetes mellitus: a meta-analysis of observational studies.

          The aim of this study was to investigate the evidence of an increased risk of childhood-onset type 1 diabetes in children born by Caesarean section by systematically reviewing the published literature and performing a meta-analysis with adjustment for recognised confounders. After MEDLINE, Web of Science and EMBASE searches, crude ORs and 95% CIs for type 1 diabetes in children born by Caesarean section were calculated from the data reported in each study. Authors were contacted to facilitate adjustments for potential confounders, either by supplying raw data or calculating adjusted estimates. Meta-analysis techniques were then used to derive combined ORs and to investigate heterogeneity between studies. Twenty studies were identified. Overall, there was a significant increase in the risk of type 1 diabetes in children born by Caesarean section (OR 1.23, 95% CI 1.15-1.32, p < 0.001). There was little evidence of heterogeneity between studies (p = 0.54). Seventeen authors provided raw data or adjusted estimates to facilitate adjustments for potential confounders. In these studies, there was evidence of an increase in diabetes risk with greater birthweight, shorter gestation and greater maternal age. The increased risk of type 1 diabetes after Caesarean section was little altered after adjustment for gestational age, birth weight, maternal age, birth order, breast-feeding and maternal diabetes (adjusted OR 1.19, 95% CI 1.04-1.36, p = 0.01). This analysis demonstrates a 20% increase in the risk of childhood-onset type 1 diabetes after Caesarean section delivery that cannot be explained by known confounders.
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            Caesarean section and risk of unexplained stillbirth in subsequent pregnancy.

            Caesarean section is associated with an increased risk of disorders of placentation in subsequent pregnancies, but effects on the rate of antepartum stillbirth are unknown. We aimed to establish whether previous caesarean delivery is associated with an increased risk of antepartum stillbirth. We linked pregnancy discharge data from the Scottish Morbidity Record (1980-98) and the Scottish Stillbirth and Infant Death Enquiry (1985-98). We estimated the relative risk of antepartum stillbirth in second pregnancies using time-to-event analyses. For 120633 singleton second births, there were 68 antepartum stillbirths in 17754 women previously delivered by caesarean section (2.39 per 10000 women per week) and 244 in 102879 women previously delivered vaginally (1.44; p<0.001). Risk of unexplained stillbirth associated with previous caesarean delivery differed significantly with gestational age (p=0.04); the excess risk was apparent from 34 weeks (hazard ratio 2.23 [95% CI 1.48-3.36]). Risk was not attenuated by adjustment for maternal characteristics or outcome of the first pregnancy (2.74 [1.74-4.30]). The absolute risk of unexplained stillbirth at or after 39 weeks' gestation was 1.1 per 1000 women who had had a previous caesarean section and 0.5 per 1000 in those who had not. The difference was due mostly to an excess of unexplained stillbirths among women previously delivered by caesarean section. Delivery by caesarean section in the first pregnancy could increase the risk of unexplained stillbirth in the second. In women with one previous caesarean delivery, the risk of unexplained antepartum stillbirth at or after 39 weeks' gestation is about double the risk of stillbirth or neonatal death from intrapartum uterine rupture.
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              Risks of adverse outcomes in the next birth after a first cesarean delivery.

              To estimate the risks of cesarean first birth, compared with vaginal first birth, for adverse obstetric and perinatal outcomes in the second birth. Population-based retrospective cohort study of all singleton, second births in the South Australian perinatal data collection 1998 to 2003 comparing outcomes for 8,725 women who underwent a cesarean delivery for their first birth with 27,313 women who underwent a vaginal first birth. Predictor variables include age, indigenous status, smoking, pregnancy interval, medical and obstetric complications, gestation, patient type, hospital category, and history of ectopic pregnancy, miscarriage, stillbirth or termination of pregnancy. The cesarean delivery cohort had increased risks for malpresentation (odds ratio [OR] 1.84, 95% confidence interval [CI] 1.65-2.06), placenta previa (OR 1.66, 95% CI 1.30-2.11), antepartum hemorrhage (OR 1.23, 95% CI 1.08-1.41), placenta accreta (OR 18.79, 95% CI 2.28-864.6), prolonged labor (OR 5.89, 95% CI 3.91-8.89), emergency cesarean (relative risk 9.37, 95% CI 8.98-9.76) and uterine rupture (OR 84.42, 95% CI 14.64-infinity), preterm birth (OR 1.17, 95% CI 1.04-1.31), low birth weight (OR 1.30, 95% CI 1.14-1.48), small for gestational age (OR 1.12, 95% CI 1.02-1.23), stillbirth (OR 1.56, 95% CI 1.04-2.32), and unexplained stillbirth (OR 2.34, 95% CI 1.26-4.37). The range of the number of primary cesarean deliveries needed to harm included 134 for one additional preterm birth, up to 1,536 for one additional placenta accreta. Cesarean delivery is associated with increased risks for adverse obstetric and perinatal outcomes in the subsequent birth. However, some risks may be due to confounding factors related to the indication for the first cesarean. II.
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                Author and article information

                Journal
                BJOG: An International Journal of Obstetrics & Gynaecology
                Wiley
                14700328
                November 2012
                November 2012
                July 25 2012
                : 119
                : 12
                : 1483-1492
                Article
                10.1111/j.1471-0528.2012.03446.x
                22830446
                2617e7d5-f5ec-4890-a3e2-2d2a77301fd2
                © 2012

                http://doi.wiley.com/10.1002/tdm_license_1.1

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