A systematic review and time-response meta-analysis of the optimal timing of elective caesarean sections for best maternal and neonatal health outcomes.
Cesarean Section
/ statistics & numerical data
Elective Surgical Procedures
/ statistics & numerical data
Female
Gestational Age
Humans
Infant, Newborn
Intensive Care Units, Neonatal
/ statistics & numerical data
Maternal Mortality
Outcome Assessment, Health Care
/ statistics & numerical data
Perinatal Mortality
Pregnancy
Elective caesarean section
Gestational age
Maternal morbidity
Neonatal intensive care unit
Neonatal morbidity
Term birth
Time-response meta-analysis
Journal
BMC pregnancy and childbirth
ISSN: 1471-2393
Titre abrégé: BMC Pregnancy Childbirth
Pays: England
ID NLM: 100967799
Informations de publication
Date de publication:
08 Jul 2020
08 Jul 2020
Historique:
received:
18
10
2019
accepted:
26
05
2020
entrez:
10
7
2020
pubmed:
10
7
2020
medline:
17
2
2021
Statut:
epublish
Résumé
The rate of caesarean sections (CS) has increased in the last decades to about 30% of births in high income countries. Many CSs are electively planned without an urgent medical reason for mother or child. An early CS though may harm the newborn. Our aim was to evaluate the gestational time point after the 37 + 0 week of gestation (WG) (after prematurity = term) of performing an elective CS with the lowest morbidity for mother and child by assessing the time course from 37 + 0 to 42+ 6 WG. We performed a systematic literature search in MEDLINE, EMBASE, CENTRAL and CINAHL in November 2018. We included studies that compared different time points of elective CS at term no matter the reason for elective CS. Our primary outcomes were the rate of admissions to the neonatal intensive care unit (NICU), neonatal death and maternal death in early versus late term elective CS. Various binary and dose response random effects meta-analyses were performed. We identified 35 studies including 982,749 women. Except one randomised controlled trial, all studies were cohort studies. We performed a linear time-response meta-analysis on the primary outcome NICU admission on 14 studies resulting in a decrease of the relative risk (RR) to 0.63 (95% CI 0.56, 0.71) from 37 + 0 to 39 + 6 WG. RR for neonatal death showed a decrease to 39 + (0-6) WG (RR 0.59 95% CI 0.43 to 0.83) and increase from then on (RR 2.09 95% CI 1.18 to 3.70) assuming a U-shape course and using a cubic spline model for meta-analysis of four studies. We only identified one study analyzing maternal death resulting in RR of 0.38 (95% CI 0.04 to 3.40) for 37 + 0 + 38 + 6 WG versus ≥39 + 0 WG. Our systematic review showed that elective CS (primary and repeated) before the 39 + 0 WG lead to more NICU admissions and neonatal deaths, although death is rare and increases again after 39 + 6 WG. We did not find enough evidence on maternal outcomes. There is a need for more research, considering maternal outcomes to provide a balanced decision between neonatal and maternal health. Registered in PROSPERO (CRD42017078231).
Sections du résumé
BACKGROUND
BACKGROUND
The rate of caesarean sections (CS) has increased in the last decades to about 30% of births in high income countries. Many CSs are electively planned without an urgent medical reason for mother or child. An early CS though may harm the newborn. Our aim was to evaluate the gestational time point after the 37 + 0 week of gestation (WG) (after prematurity = term) of performing an elective CS with the lowest morbidity for mother and child by assessing the time course from 37 + 0 to 42+ 6 WG.
METHODS
METHODS
We performed a systematic literature search in MEDLINE, EMBASE, CENTRAL and CINAHL in November 2018. We included studies that compared different time points of elective CS at term no matter the reason for elective CS. Our primary outcomes were the rate of admissions to the neonatal intensive care unit (NICU), neonatal death and maternal death in early versus late term elective CS. Various binary and dose response random effects meta-analyses were performed.
RESULTS
RESULTS
We identified 35 studies including 982,749 women. Except one randomised controlled trial, all studies were cohort studies. We performed a linear time-response meta-analysis on the primary outcome NICU admission on 14 studies resulting in a decrease of the relative risk (RR) to 0.63 (95% CI 0.56, 0.71) from 37 + 0 to 39 + 6 WG. RR for neonatal death showed a decrease to 39 + (0-6) WG (RR 0.59 95% CI 0.43 to 0.83) and increase from then on (RR 2.09 95% CI 1.18 to 3.70) assuming a U-shape course and using a cubic spline model for meta-analysis of four studies. We only identified one study analyzing maternal death resulting in RR of 0.38 (95% CI 0.04 to 3.40) for 37 + 0 + 38 + 6 WG versus ≥39 + 0 WG.
CONCLUSION
CONCLUSIONS
Our systematic review showed that elective CS (primary and repeated) before the 39 + 0 WG lead to more NICU admissions and neonatal deaths, although death is rare and increases again after 39 + 6 WG. We did not find enough evidence on maternal outcomes. There is a need for more research, considering maternal outcomes to provide a balanced decision between neonatal and maternal health.
SYSTEMATIC REVIEW REGISTRATION
BACKGROUND
Registered in PROSPERO (CRD42017078231).
Identifiants
pubmed: 32641019
doi: 10.1186/s12884-020-03036-1
pii: 10.1186/s12884-020-03036-1
pmc: PMC7341650
doi:
Types de publication
Journal Article
Meta-Analysis
Systematic Review
Langues
eng
Sous-ensembles de citation
IM
Pagination
395Subventions
Organisme : Bundesministerium für Gesundheit
ID : GE 20160425
Références
Lancet. 2018 Oct 13;392(10155):1341-1348
pubmed: 30322584
Arch Gynecol Obstet. 2016 Jul;294(1):77-81
pubmed: 26590575
Paediatr Perinat Epidemiol. 2007 Mar;21(2):98-113
pubmed: 17302638
J Matern Fetal Neonatal Med. 2019 Jan;32(2):193-197
pubmed: 28854840
Tohoku J Exp Med. 2014;233(4):243-8
pubmed: 25078250
Lancet. 2016 Jan 30;387(10017):462-74
pubmed: 26584737
Stat Med. 2002 Jun 15;21(11):1539-58
pubmed: 12111919
Lancet. 1985 Aug 24;2(8452):436-7
pubmed: 2863457
Fetal Diagn Ther. 2004 May-Jun;19(3):228-31
pubmed: 15067232
Res Synth Methods. 2016 Mar;7(1):55-79
pubmed: 26332144
Am J Obstet Gynecol. 2010 Mar;202(3):245.e1-245.e12
pubmed: 20207242
Am J Obstet Gynecol. 2009 Feb;200(2):156.e1-4
pubmed: 19110225
Evid Based Ment Health. 2019 Nov;22(4):153-160
pubmed: 31563865
J Pediatr Endocrinol Metab. 2002 Mar;15(3):319-24
pubmed: 11924935
J Pediatr. 2007 Mar;150(3):252-5
pubmed: 17307540
J Nippon Med Sch. 2014;81(4):285-8
pubmed: 25186583
Biometrics. 1994 Dec;50(4):1088-101
pubmed: 7786990
Curr Opin Obstet Gynecol. 2015 Apr;27(2):121-7
pubmed: 25689238
BMJ. 2008 Jan 12;336(7635):85-7
pubmed: 18077440
J Matern Fetal Neonatal Med. 2014 Mar;27(4):368-71
pubmed: 23796068
J Perinatol. 2018 May;38(5):557-566
pubmed: 29371628
J Matern Fetal Neonatal Med. 2016 Mar;29(6):904-10
pubmed: 25758621
Ir Med J. 2005 Jun;98(6):170-2
pubmed: 16097507
J Clin Epidemiol. 2011 Apr;64(4):380-2
pubmed: 21185693
J Matern Fetal Neonatal Med. 2014 Mar;27(5):431-8
pubmed: 23795868
PLoS Med. 2012;9(3):e1001191
pubmed: 22427748
Reprod Biol Endocrinol. 2010 Jun 21;8:68
pubmed: 20565934
Int J Gynaecol Obstet. 2008 Jan;100(1):90-1
pubmed: 17720164
BMJ. 2016 Oct 12;355:i4919
pubmed: 27733354
Acta Paediatr. 2004 May;93(5):643-7
pubmed: 15174788
Birth. 2007 Dec;34(4):301-7
pubmed: 18021145
BMJ. 1997 Sep 13;315(7109):629-34
pubmed: 9310563
J Matern Fetal Neonatal Med. 2016;29(15):2461-3
pubmed: 26444222
J Matern Fetal Neonatal Med. 2006 Feb;19(2):75-8
pubmed: 16581601
Br J Obstet Gynaecol. 1995 Feb;102(2):101-6
pubmed: 7756199
Obstet Gynecol. 2019 Feb;133(2):e156-e163
pubmed: 30681546
Birth. 2014 Sep;41(3):237-44
pubmed: 24720614
Am J Epidemiol. 1992 Jun 1;135(11):1301-9
pubmed: 1626547
Eur J Obstet Gynecol Reprod Biol. 2001 Sep;98(1):9-13
pubmed: 11516792
BMC Med Res Methodol. 2014 Feb 18;14:25
pubmed: 24548571
Pediatr Int. 2003 Aug;45(4):379-82
pubmed: 12911470
Int J Environ Res Public Health. 2018 Jan 03;15(1):
pubmed: 29301343
BMJ Open. 2016 Jul 12;6(7):e010247
pubmed: 27406637
Am J Obstet Gynecol. 2012 Dec;207(6):480.e1-7
pubmed: 23017224
N Engl J Med. 2009 Jan 8;360(2):111-20
pubmed: 19129525
BMJ. 2011 Oct 18;343:d5928
pubmed: 22008217
Pediatrics. 2000 May;105(5):1141-5
pubmed: 10790476
Aust N Z J Obstet Gynaecol. 2014 Aug;54(4):340-7
pubmed: 24836174
Curr Treat Options Pediatr. 2018 Mar;4(1):49-69
pubmed: 29881666
BMC Pregnancy Childbirth. 2011 Jun 08;11:43
pubmed: 21651785
Pediatr Crit Care Med. 2004 Nov;5(6):566-70
pubmed: 15530194
J Matern Fetal Neonatal Med. 2014 Jul;27(11):1158-62
pubmed: 24134662
Obstet Gynecol. 2008 Mar;111(3):659-66
pubmed: 18310369
Am J Epidemiol. 2004 Jun 1;159(11):1077-86
pubmed: 15155292
Clin Perinatol. 2011 Jun;38(2):179-92
pubmed: 21645788
J Perinat Educ. 2009 Summer;18(3):23-9
pubmed: 20514124
Syst Rev. 2018 Aug 16;7(1):119
pubmed: 30111372
Acta Med Port. 2015 Sep-Oct;28(5):601-7
pubmed: 26667863
J Obstet Gynaecol. 2015;35(5):455-60
pubmed: 25356739
Am J Obstet Gynecol. 2010 Mar;202(3):250.e1-8
pubmed: 20207243
West J Nurs Res. 2013 Sep;35(8):1026-42
pubmed: 23576279
Acta Obstet Gynecol Scand. 2014 Jun;93(6):603-9
pubmed: 24666278
Acta Paediatr. 2012 Oct;101(10):1054-7
pubmed: 22758608
BJOG. 2014 Jan;121(2):183-92
pubmed: 24251861
Ned Tijdschr Geneeskd. 1998 Oct 17;142(42):2300-3
pubmed: 9864525
Obstet Gynecol. 2013 Mar;121(3):561-9
pubmed: 23635619