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Association of late-preterm and
early-term delivery with Cesarean
delivery in low-risk Florida
women: The role of parity?
Dave Goodman, MS PhD
William Sappenfield, MD MPH
Dan Thompson, MPH
Division of Family Health Services, Florida Department of Health
Charles Mahan, MD
University of South Florida, College of Public Health
Lori Reeves, MPH
March of Dimes, Florida Chapter
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Association of late-preterm and early-term
delivery with Cesarean delivery in low-risk
Florida women: The role of parity?
Florida DOH
Infant, Maternal, and Reproductive Health
Planning, Evaluation, and Data Analysis
Dr. John Middaugh, State Epidemiologist
Florida Partners
March of Dimes Preterm Birth Prevention Statewide
Workgroup
Lawton Rhea Chiles Center for Healthy Mothers and Babies
National Partners
Michael Kogan, HRSA, MCHB
Carol Sakala and Maureen Corry, Childbirth Connection
Eugene DeClercq, Boston University
Charles Denk, New Jersey Department of Health
Joann Petrini, National Chapter March of Dimes 2
Introduction
Preterm and Late Preterm Birth: Florida and U.S. 1995-2006
15
Preterm
*
12
Late Preterm
Percentage of Births
*
9
6
Florida
U.S.
3
0
1995 2000 2006
Birth Year
Data Source, Florida: Final Birth Data, 1995-2006. 3
Data Source, U.S.: NCHS Final Natality Data, 1995-2004. * Preliminary Natality Data, 2005.
Introduction
40 Cesarean Delivery: Florida and U.S. 1995-2006
Overall
35
30
*
Percentage of Births
25
Without Labor
20
15
With Labor
Florida
10
U.S.
5
0
1995 2000 2006
Birth Year
Data Source, Florida: Final Birth Data, 1995-2006. 4
Data Source, U.S.: NCHS Final Natality Data, 1995-2004. * Preliminary Natality Data, 2005.
Public Health Importance
Cesarean delivery in FL is associated with
the increasing preterm birth rate among
singletons (1995-2003)
The preterm birth increase among
singletons solely because of increasing
late preterm births (1995-2003)
Persistent disparities in who is delivering
by Cesarean (2004-2006; Yesterdays
Presentation in Session B4)
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Methods: Data
Data
Florida 2004* – 2006 birth file
Study Population
● Resident in-state births (n=644,329)
● 34-41 weeks (n=572,829)
● Singleton gestations (n=557,976)
● No previous Cesarean (n=489,514)
● Low-documented risk (n=361,770)
* Excludes 1st 2-months (old birth cert)
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Methods: Definitions
Definitions
Cesarean with Labor:
● Attempted vaginal delivery that ends in
cesarean
Check box
Induction or Augmentation indicated
Vacuum or Forceps use indicated
Low-Documented Risk:
● None of 18 medical factors associated with
Cesarean
● Not intensive prenatal care usage (GINDEX)
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Low Documented Risk for
Cesarean Delivery
None of the following are documented using the birth certificate:
• Hypertension prepregnancy (Chronic)
• Hypertension gestational (PIH, Preeclampsia)
• Hypertension - Eclampsia
• Diabetes Prepregnancy (Diagnosis prior to the pregnancy)
• Gestational Diabetes (Diagnosis in this pregnancy)
• Prolonged labor (≥ 20 hours)
• Moderate/Heavy meconium staining of the amniotic fluid
• Fetal intolerance of labor (such that in-utero resuscitative measures and/or further fetal
assessment and/or operative delivery actions are taken)
• Clinical Chorioamnionitis diagnosed during labor or maternal temperature >38ºC
• Non-vertex presentation
• Fetal presentation at birth other than cephalic
• A birth weight greater than 4,500-g
• Any of these congenital anomalies:
Anencephaly
Congenital diaphragmatic hernia
Meningomyelocele/Spina bifida
Omphalocele
Cyanotic congenital heart disease
Gastroschisis
• Modified GINDEX indicates intensive prenatal care use 8
Methods: Analysis
Analysis
Outcomes:
● Late Preterm (34-36 weeks)
● Early Term (37-38 weeks)
Association of interest
●Cesarean with labor
●Cesarean without labor
9
Methods: Analysis
Analysis
Multinomial logistic regression
● Term deliveries are reference for both
outcomes
Adjusted for:
● Delivery pay source, Race, Ethnicity, Age, BMI,
Gestational weight gain, Smoking, Education,
Marital status, Adequacy of prenatal care,
Infertility treatment, Delivery year, Delivery day
of week
STATA 9.2 SE
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Results: Regression
Adjusted (AOR) Odds of Late Preterm Among Florida Resident
Singleton Births, 34-41 Weeks Gestational Age, No Previous
Cesarean, and Low Documented Risk for Cesarean Delivery
(N=311,926). 2004-2006.
Late Preterm Early Term
Delivery Route AOR (95% CI) AOR (95% CI)
Cesarean with labor 0.76 (0.72-0.81) 0.83 (0.80-0.86)
Cesarean without labor 1.53 (1.44-1.62) 1.53 (1.49-1.58)
Adjusted for:
Delivery pay source Race
Ethnicity Age
Body Mass Index Gestational weight gain
Smoking Education
Marital status Adequacy of prenatal care
Infertility treatment Delivery year
Delivery day of week Parity
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Data Source: Florida Final Birth Data, 1995-2006.
Results: Regression
Adjusted (AOR) Odds of Late Preterm Among Florida Resident
Singleton Births, 34-41 Weeks Gestational Age, No Previous
Cesarean, and Low Documented Risk for Cesarean Delivery.
2004-2006. By Parity.
Late Preterm (34-36 weeks)
Delivery Route New mom Experienced mom
AOR (95% CI) AOR (95% CI)
Cesarean with labor 0.70 (0.64-0.75) 0.93 (0.83-1.04)
Cesarean without labor 1.28 (1.17-1.40) 1.74 (1.62-1.88)
Adjusted for:
Delivery pay source Race
Ethnicity Age
Body Mass Index Gestational weight gain
Smoking Education
Marital status Adequacy of prenatal care
Infertility treatment Delivery year
Delivery day of week 12
Data Source: Florida Final Birth Data, 1995-2006.
Results: Regression
Adjusted (AOR) Odds of Late Preterm Among Florida Resident
Singleton Births, 34-41 Weeks Gestational Age, No Previous
Cesarean, and Low Documented Risk for Cesarean Delivery.
2004-2006. By Parity.
Late Preterm (34-36 weeks) Early Term (37-38 weeks)
Delivery Route New mom Experienced mom New mom Experienced mom
AOR (95% CI) AOR (95% CI) AOR (95% CI) AOR (95% CI)
Cesarean L+ 0.70 (0.64-0.75) 0.93 (0.83-1.04) 0.78 (0.75-0.81) 0.97 (0.92-1.04)
Cesarean L - 1.28 (1.17-1.40) 1.74 (1.62-1.88) 1.34 (1.28-1.40) 1.71 (1.64-1.79)
Adjusted for:
Delivery pay source Race
Ethnicity Age
Body Mass Index Gestational weight gain
Smoking Education
Marital status Adequacy of prenatal care
Infertility treatment Delivery year
Delivery day of week 13
Data Source: Florida Final Birth Data, 1995-2006.
Limitations
Limited to birth certificate data
Misclassification
● Gestational age
● Delivery route
● Medical Risk Factors
● Labor
Labor categorized as no labor
Differentiate emergency from scheduled Cesareans
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Day of the Week: Delivery Route
Index of Occurrence of Delivery Route: Florida 2004-2006
Singletons, 34-41 Weeks, No Previous Cesarean, Low Documented Risk, and No Medical
Induction (N=263,326)
140
120
Index of Occurrence
100
80
Vaginal
Cesarean with labor
60
Cesarean without labor
40
20
Sun Mon Tue Wed Thu Fri Sat
Day of Week
15
Data Source: 2004-2006, Final Birth File.
Hour of Day: Delivery Route
Index of Occurrence of Delivery Route: Florida 2004-2006
Singletons, 34-41 Weeks, No Previous Cesarean, Low Documented Risk, and No Medical
Induction (N=260,023)
Vaginal
300
Cesarean with labor
Index of Occurrence
Cesarean without labor
200
100
0
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
Hour of Day
16
Data Source: 2004-2006, Final Birth File.
Summary
Among this low-risk group, Cesarean
without labor:
Associated with increased risk of
early delivery.
The association with early delivery is
significantly greater among
experienced moms than new moms.
17
Implications
Experienced moms are at increased
risk of Cesarean delivery that leads
to earlier delivery,
or
We are missing risk factors
associated with Cesarean delivery,
which leads to higher rates of early
delivery
18
Current Activities
March of Dimes Preterm Birth Prevention Statewide
Workgroup
Florida Obstetric and Gynecologic Society (FOGS) – Dept. of
Health Informal Study Group
● Review evidence-base
● Develop recommendations on next steps
● 2 Meetings completed!
Qualitative Cesarean focus groups (Healthy Start Coalition
of Pinellas)
Awaiting (and planning for) PRAMS Phase 6
● New Standard questions about why and when of Cesarean
delivery
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End
dave_goodman@doh.state.fl.us
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