Department of Obstetrics and Gynaecology (Joseph, John, Lisonkova), University of British Columbia; Children's and Women's Hospital (Joseph, John, Lisonkova), Health Centre of British Columbia; School of Population and Public Health (Joseph, Lisonkova), University of British Columbia, Vancouver, BC; Department of Obstetrics and Gynecology (Young), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Departments of Obstetrics and Gynecology, and Health Research Methods, Evidence, and Impact (Muraca), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; Department of Pediatrics (Boutin), Faculty of Medicine, Université Laval and CHU de Québec-Université Laval Research Center, Québec, Que.; Division of Clinical Epidemiology (Razaz), Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden; Department of Obstetrics and Gynecology (Wilson), Cumming School of Medicine, University of Calgary, Calgary, Alta.
CMAJ. 2023 Feb 6;195(5):E178-E186. doi: 10.1503/cmaj.220928.
Recommendations for deliveries of pregnant patients with a previous cesarean delivery and the type of hospitals deemed safe for these deliveries have evolved in recent years, although no studies have examined hospital factors and associated safety. We sought to evaluate maternal and neonatal outcomes among patients with a previous cesarean delivery by hospital tier and volume.
We carried out an ecological study of singleton live births delivered at term gestation to patients with a previous cesarean delivery in all Canadian hospitals (excluding Quebec), 2013-2019. We obtained data from the Discharge Abstract Database of the Canadian Institute for Health Information. The primary outcomes were severe maternal morbidity or mortality (SMMM), and serious neonatal morbidity or mortality (SNMM). We used regression modelling to examine hospital tier (tier 4 hospitals being those that provide the highest level of care) and volume; we also identified hospitals with high rates of SMMM and SNMM using within-tier comparisons and comparisons with the overall rate.
We included 235 442 deliveries to patients with a previous cesarean delivery; SMMM and SNMM rates were 14.6 per 1000 deliveries and 4.6 per 1000 live births, respectively. Among patients with a parity of 1, SMMM rates were lower in tier 1 hospitals (adjusted incidence rate ratio [IRR] 0.68, 95% confidence interval [CI] 0.52-0.89) and higher in tier 4 hospitals (adjusted IRR 1.41, 95% CI 1.05-1.91) than in tier 2 hospitals; SNMM rates did not differ by hospital tier. Rates of SNMM increased with increasing hospital volume (adjusted IRR 1.02, 95% CI 1.00-1.04) and increasing rates of vaginal birth after cesarean delivery (adjusted IRR 1.02, 95% CI 1.01-1.04). Most hospitals had relatively low SMMM and SNMM rates, although a few hospitals in each tier and volume category had significantly higher rates than others.
Adverse maternal and neonatal outcomes among patients with a previous cesarean delivery showed no clear pattern of decreasing SMMM and SNMM with increasing tiers of service and hospital volume. All hospitals, irrespective of tier or size, should continually review their rates of adverse maternal and neonatal outcomes.
近年来，对于有剖宫产史的孕妇分娩以及哪些医院适合进行此类分娩的建议已经发生了变化，尽管尚无研究探讨医院因素及其相关安全性。我们旨在评估不同层级和规模的医院中，有剖宫产史的患者的母婴结局。
我们对 2013 年至 2019 年期间在加拿大所有医院（魁北克省除外）接受足月剖宫产分娩的单胎活产患者进行了一项关于剖宫产患者的生态研究。我们从加拿大健康信息研究所的出院摘要数据库中获取了数据。主要结局是严重产妇发病率或死亡率（SMMM）和严重新生儿发病率或死亡率（SNMM）。我们使用回归模型来评估医院层级（提供最高水平护理的 4 级医院）和规模；我们还通过层级内比较和与总体比率的比较，确定 SMMM 和 SNMM 发生率较高的医院。
我们纳入了 235442 例有剖宫产史的患者分娩；SMMM 和 SNMM 的发生率分别为每 1000 例分娩 14.6 例和每 1000 例活产 4.6 例。在初产妇中，SMMM 发生率在 1 级医院较低（校正发病率比 [IRR]0.68，95%置信区间 [CI]0.52-0.89），在 4 级医院较高（校正 IRR 1.41，95% CI 1.05-1.91），而在 2 级医院则没有差异；SNMM 发生率与医院层级无关。随着医院规模的增加（校正 IRR 1.02，95% CI 1.00-1.04）和剖宫产术后阴道分娩率的增加（校正 IRR 1.02，95% CI 1.01-1.04），SNMM 发生率也随之增加。大多数医院的 SMMM 和 SNMM 发生率相对较低，但每个层级和规模类别中都有少数几家医院的发生率明显高于其他医院。
有剖宫产史的患者的母婴不良结局与服务层级和医院规模的增加没有表现出 SMMM 和 SNMM 明显降低的模式。所有医院，无论其层级或规模大小，都应不断审查其母婴不良结局的发生率。
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