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Maternal and Fetal Morbidity in the setting of a Recent Governmental Regulation in Brazil to Decrease the Cesarean Delivery Rate
Abstract Number: F1A-2
Abstract Type: Original Research
Introduction: Though the optimal cesarean delivery (CD) rate is unknown, recent studies suggest rates above 20% may increase maternal or fetal risk without clear benefit. In Brazil, 88% of births in private and 43% in public hospitals were via CD. In January 2015, the Brazilian government’s “Resolution Normativa 368” was implemented to decrease the CD rate. We hypothesized that rapid increase in vaginal delivery (VD) rates without sufficient education or training could paradoxically increase maternal and fetal morbidity.
Methods: We retrospective reviewed paper and electronic records from 50,540 deliveries at a private maternity hospital in Brazil from 2013- 2017 to determine rates of maternal hemorrhage requiring transfusion, unplanned ICU admissions, and neonatal hypoxia. Multivariable analyses using linear or logistic regression were performed, with unadjusted and adjusted rates reported (using alpha 0.05 and two tailed tests).
Results: There were statistically significant but not clinically meaningful differences in many patient characteristics pre- vs. post-mandate (Table). VD rates increased by 32% (8.4% vs. 11.2%, p <0.001) and elective CD prior to labor decreased by 11.7% (77.9% vs. 68.8%, p<0.001). After multivariable adjustment, there was a highly significant, 4.4-fold increased odds of neonatal hypoxia and a trend toward increased odds of maternal hemorrhage requiring transfusion post mandate. There was an increase in the odds of maternal hemorrhage requiring transfusion (OR 1.50, 95%CI 1.11- 2.03, p= 0.009) and of neonatal hypoxia (OR 3.29, 95%CI 1.28- 8.44, p= 0.013) in VD vs. CD over the entire study period.
Discussion: In this single center study, a government mandate successfully decreased the CD rate and increased the VD rates but was associated with an increase in the odds of neonatal harm, and a trend toward maternal harm. VDs were associated with increased odds of maternal and fetal harm regardless of the timing of the mandate. Because VD may require different resources and training from elective CD (e.g., fetal monitoring, 24/7 personnel availability, and decision tools for conversion to CD) efforts focused on increasing its use may benefit from increased resource allocation and/or incremental implementation. Although causality cannot be inferred from these data, the increased maternal and fetal morbidity associated with VD requires further study.