Better Outcomes Registry & Network Ontario (Guo, Erwin, Corsi, Walker); OMNI Research Group (Guo, Murphy, Erwin, Fakhraei, Corsi, White, Harvey, Walker, Wen, El-Chaâr), Clinical Epidemiology Program, Ottawa Hospital Research Institute; Children's Hospital of Eastern Ontario Research Institute (Guo, Fakhraei, Corsi); Department of Obstetrics, Gynecology and Newborn Care (White, Wen, Walker, El-Chaâr), The Ottawa Hospital, Ottawa, Ont.; Department of Obstetrics and Gynecology (Gaudet), Kingston Health Sciences Centre; Department of Obstetrics and Gynecology (Gaudet), Queen's University, Kingston, Ont.
CMAJ. 2021 May 3;193(18):E634-E644. doi: 10.1503/cmaj.202262.
Data on the effect of cesarean delivery on maternal request (CDMR) on maternal and neonatal outcomes are inconsistent and often limited by inadequate case definitions and other methodological issues. Our objective was to evaluate the trends, determinants and outcomes of CDMR using an intent-to-treat approach.
We designed a population-based retrospective cohort study using data on low-risk pregnancies in Ontario, Canada (April 2012-March 2018). We assessed temporal trends and determinants of CDMR. We estimated the relative risks for component and composite outcomes used in the Adverse Outcome Index (AOI) related to planned CDMR compared with planned vaginal delivery using generalized estimating equation models. We compared the Weighted Adverse Outcome Score (WAOS) and the Severity Index (SI) across planned modes of delivery using analysis of variance.
Of 422 210 women, 0.4% ( = 1827) had a planned CDMR and 99.6% ( = 420 383) had a planned vaginal delivery. The prevalence of CDMR remained stable over time at 3.9% of all cesarean deliveries. Factors associated with CDMR included late maternal age, higher education, conception via in vitro fertilization, anxiety, nulliparity, being White, delivery at a hospital providing higher levels of maternal care and obstetrician-based antenatal care. Women who planned CDMR had a lower risk of adverse outcomes than women who planned vaginal delivery (adjusted relative risk 0.42, 95% confidence interval [CI] 0.33 to 0.53). The WAOS was lower for planned CDMR than planned vaginal delivery (mean difference -1.28, 95% CI -2.02 to -0.55). The SI was not statistically different between groups (mean difference 3.6, 95% CI -7.4 to 14.5).
Rates of CDMR have not increased in Ontario. Planned CDMR is associated with a decreased risk of short-term adverse outcomes compared with planned vaginal delivery. Investigation into the long-term implications of CDMR is warranted.
关于因产妇要求行剖宫产（CDMR）对母婴结局影响的数据不一致，且往往受到不充分的病例定义和其他方法学问题的限制。我们的目的是采用意向治疗方法评估 CDMR 的趋势、决定因素和结局。
我们使用加拿大安大略省的低危妊娠数据（2012 年 4 月至 2018 年 3 月）设计了一项基于人群的回顾性队列研究。我们评估了 CDMR 的时间趋势和决定因素。我们使用广义估计方程模型，针对与计划行剖宫产相比计划行阴道分娩的相关不良结局指数（AOI），估计了各组成部分和复合结局的相对风险。我们使用方差分析比较了不同计划分娩方式的加权不良结局评分（WAOS）和严重度指数（SI）。
在 422210 名女性中，有 0.4%（=1827）为计划行 CDMR，99.6%（=420383）为计划行阴道分娩。CDMR 的发生率在所有剖宫产中保持稳定，为 3.9%。与 CDMR 相关的因素包括母亲年龄较大、较高的教育程度、体外受精受孕、焦虑、初产妇、为白人、在提供较高水平产妇护理的医院分娩以及由产科医生进行的产前护理。与计划行阴道分娩的女性相比，计划行 CDMR 的女性不良结局的风险较低（校正后的相对风险 0.42，95%置信区间[CI]0.33 至 0.53）。计划行 CDMR 的 WAOS 低于计划行阴道分娩（平均差值-1.28，95%CI-2.02 至-0.55）。两组间 SI 无统计学差异（平均差值 3.6，95%CI-7.4 至 14.5）。
在安大略省，CDMR 的发生率没有增加。与计划行阴道分娩相比，计划行 CDMR 与短期不良结局风险降低相关。需要对 CDMR 的长期影响进行调查。
