Infectious Disease Department, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom.
Center for Data and Knowledge Integration for Health, Oswaldo Cruz Foundation, Salvador, Brazil.
PLoS Med. 2021 Oct 12;18(10):e1003791. doi: 10.1371/journal.pmed.1003791. eCollection 2021 Oct.
There is an increasing use of cesarean delivery (CD) based on preference rather than on medical indication. However, the extent to which nonmedically indicated CD benefits or harms child survival remains unclear. Our hypothesis was that in groups with a low indication for CD, this procedure would be associated with higher child mortality and in groups with a clear medical indication CD would be associated with improved child survival chances.
We conducted a population-based cohort study in Brazil by linking routine data on live births between January 1, 2012 and December 31, 2018 and assessing mortality up to 5 years of age. Women with a live birth who contributed records during this period were classified into one of 10 Robson groups based on their pregnancy and delivery characteristics. We used propensity scores to match CD with vaginal deliveries (1:1) and prelabor CD with unscheduled CD (1:1) and estimated associations with child mortality using Cox regressions. A total of 17,838,115 live births were analyzed. After propensity score matching (PSM), we found that live births to women in groups with low expected frequencies of CD (Robson groups 1 to 4) had a higher death rate up to age 5 years if they were born via CD compared with vaginal deliveries (HR = 1.25, 95% CI: 1.22 to 1.28; p < 0.001). The relative rate was greatest in the neonatal period (HR = 1.39, 95% CI: 1.34 to 1.45; p < 0.001). There was no difference in mortality rate when comparing offspring born by a prelabor CD to those born by unscheduled CD. For the live births to women with a CD in a prior pregnancy (Robson group 5), the relative rates for child mortality were similar for those born by CD compared with vaginal deliveries (HR = 1.05, 95% CI: 1.00 to 1.10; p = 0.024). In contrast, for live births to women in groups with high expected rates of CD (Robson groups 6 to 10), the child mortality rate was lower for CD than for vaginal deliveries (HR = 0.90, 95% CI: 0.89 to 0.91; p < 0.001), particularly in the neonatal period (HR = 0.84, 95% CI: 0.83 to 0.85; p < 0.001). Our results should be interpreted with caution in clinical practice, since relevant clinical data on CD indication were not available.
In this study, we observed that in Robson groups with low expected frequencies of CD, this procedure was associated with a 25% increase in child mortality. However, in groups with high expected frequencies of CD, the findings suggest that clinically indicated CD is associated with a reduction in child mortality.
基于偏好而非医学指征，剖宫产的应用日益增多。然而，非医学指征剖宫产对儿童生存有益还是有害尚不清楚。我们的假设是，在剖宫产指征较低的组中，该手术与较高的儿童死亡率相关，而在有明确医学指征的组中，剖宫产与改善儿童生存机会相关。
我们在巴西进行了一项基于人群的队列研究，通过链接 2012 年 1 月 1 日至 2018 年 12 月 31 日期间的活产记录，并评估了 5 岁以下儿童的死亡率。在此期间有活产记录的妇女根据其妊娠和分娩特征分为 10 个 Robson 组之一。我们使用倾向得分匹配（PSM）将剖宫产与阴道分娩（1:1）和计划性剖宫产与非计划性剖宫产（1:1）进行匹配，并使用 Cox 回归估计与儿童死亡率的关联。共分析了 17838115 例活产。在 PSM 后，我们发现，如果在 Robson 1 至 4 组中低预期剖宫产频率的妇女通过剖宫产分娩，其 5 岁以下儿童的死亡率更高（HR = 1.25，95%CI：1.22 至 1.28；p < 0.001）。在新生儿期，相对风险最高（HR = 1.39，95%CI：1.34 至 1.45；p < 0.001）。计划性剖宫产与非计划性剖宫产分娩的婴儿死亡率没有差异。对于既往妊娠行剖宫产的妇女的活产儿（Robson 组 5），与阴道分娩相比，行剖宫产分娩的儿童死亡率相似（HR = 1.05，95%CI：1.00 至 1.10；p = 0.024）。相比之下，在高预期剖宫产频率的组（Robson 组 6 至 10）中，剖宫产的儿童死亡率低于阴道分娩（HR = 0.90，95%CI：0.89 至 0.91；p < 0.001），尤其是在新生儿期（HR = 0.84，95%CI：0.83 至 0.85；p < 0.001）。由于没有剖宫产指征的相关临床数据，因此在临床实践中应谨慎解释这些结果。
在本研究中，我们观察到在剖宫产预期频率较低的 Robson 组中，该手术与儿童死亡率增加 25%相关。然而，在预期剖宫产频率较高的组中，研究结果表明，临床指征明确的剖宫产与儿童死亡率降低相关。
