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Cesarean Delivery and Vaginal Birth After Cesarean Delivery Rates in a First Nations Community-Based Obstetrical Program in Northwestern Ontario

Published:January 24, 2020DOI:https://doi.org/10.1016/j.jogc.2019.08.024

      Abstract

      Objective

      To examine rates of cesarean delivery (CD) and vaginal birth after cesarean delivery (VBAC) and the patient profile in a community-based obstetrical practice.

      Methods

      Retrospective data from 2012 to 2017 for the Sioux Lookout Meno Ya Win Health Centre (SLMHC) were compared to data from the 30 hospitals providing the same level of services (Maternity 1b: maternity care by family physicians/midwives with CD and VBAC capacity) and Ontario. SLMHC VBAC patients were then compared to the general SLMC obstetrical population. Data included maternal age, parity, comorbidities, CD, VBAC, neonatal birth weight, and Apgar scores.

      Results

      The SLMHC obstetrical population differed from comparable obstetrical programs, with significantly higher rates of alcohol, tobacco, and opioid use and a higher prevalence of diabetes. CD rates were significantly lower (25% vs. 28%), and women delivering at SLMHC chose a trial of labour after CD almost twice as often (46% vs. 27%), resulting in a significantly higher VBAC rate (31% vs. 16%). Patients in the VBAC population differed from the general SLMHC obstetrical population, being older (7 years) and of greater parity. The neonates of VBAC patients had equivalent Apgar scores but lower rates of macrosomia and lower birth weights, although the average VBAC birth weight at 3346 g was equivalent to the provincial average.

      Conclusion

      The SLMHC obstetrical program has lower CD and higher VBAC rates than expected, despite prevalent risk factors typically associated with CD. Our study demonstrates that VBAC can be safely performed in well-screened and monitored patients in a rural setting with emergency CD capacity.

      Résumé

      Objectif

      Examiner les taux de césarienne et d'accouchement vaginal après césarienne (AVAC) ainsi que le profil des patientes dans le cadre d'une pratique obstétricale communautaire.

      Méthodologie

      Les auteurs ont comparé les données rétrospectives du Sioux Lookout Meno Ya Win Health Centre (SLMHC) de 2012 à 2017 aux données tirées de 30 hôpitaux qui offrent le même niveau de services (niveau 1b : soins de maternité prodigués par des médecins de famille et sages-femmes, dans un établissement où il est possible de réaliser des AVAC et césariennes) en Ontario. Les patientes ayant eu un AVAC au SLMHC ont ensuite été comparées à la population obstétricale générale du même établissement. Les données comprenaient l'âge maternel, la parité, les comorbidités, la césarienne, l'AVAC, le poids à la naissance et l'indice d'Apgar.

      Résultats

      La population obstétricale du SLMHC différait des populations de programmes obstétricaux comparables; elle présentait des taux considérablement plus élevés de tabagisme et de consommation d'alcool et d'opioïdes, ainsi qu'une prévalence accrue de diabète et un taux de césarienne significativement inférieur (25 % c. 28 %). Les femmes ayant accouché au SLMHC ont choisi presque deux fois plus souvent de se soumettre à une épreuve de travail après la césarienne que les femmes des autres populations (46 % c. 27 %), ce qui a donné lieu à un taux d'AVAC considérablement supérieur (31 % c. 16 %). Les patientes de la population ayant eu un AVAC étaient plus âgées de 7 ans en moyenne et avaient donné naissance à un plus grand nombre d'enfants que les femmes de la population obstétricale générale du SLMHC. Les nouveau-nés des patientes ayant subi un AVAC avaient un indice d'Apgar égal à celui des autres populations, mais présentaient un taux inférieur de macrosomie et un plus petit poids à la naissance, même si le poids à la naissance moyen des bébés nés par AVAC, qui s'élevait à 3 346 g, équivalait à la moyenne provinciale.

      Conclusion

      Le programme obstétrical du SLMHC présente un taux de césarienne inférieur et un taux d'AVAC supérieur aux attentes, en dépit des facteurs de risque généralement associés à la césarienne. L'étude indique que l'AVAC peut être réalisé de manière sécuritaire chez des patientes dont l'état de santé a été bien évalué et qui demeurent sous surveillance, dans un établissement en milieu rural doté de la capacité de pratiquer des césariennes d'urgence.

      Keywords

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