Objective To describe the annual incidence over time of postpartum haemorrhage (PPH) in the Netherlands as documented in routine birth statistics, stratified by induction of labour, augmentation of labour and mode of birth for nulliparous women. Design Population-based cohort study. Setting Nationwide. Population All nulliparous women who gave birth after 22 weeks’ gestation in the Netherlands between January 1, 2000, and December 31, 2020 (n=1,568,279). Methods This study used the Dutch Perinatal Registry (Perined) from 2000 to 2020. PPH trends were analyzed for nulliparous women based on mode of birth, induction and/or augmentation of labour. Main outcome measures PPH, defined as blood loss of >1000 ml. Results Documented PPH increased from 4.4% to 7.0 % of all births between 2000 and 2009, after which the rate stabilized until 2020. In the entire period, PPH rates were higher after vaginal birth compared to caesarean section. Induction of labour was consistently correlated with higher PPH rates, which increased further in the presence of augmentation. The sharp increase in all groups in the first decade occurred after guide line adjustments and introduction of the mandatory training for health professionals active in obstetric acute care: the Managing Obstetric Emergencies and Trauma (MOET) course, particularly after caesarean section, and indicates that better objectifiable measurements of blood loss might have played a role. Conclusion After an initial increase, the documented rate of PPH stabilized in the Netherlands. Induction and augmentation of labour are associated with a higher risk of PPH.

Objective: Assess to what extent caesarean section (CS) indications followed evidence-based, locally co-created guidelines and identify reasons contributing to non-medically indicated CSs. Design: Retrospective cross-sectional study. Setting: Five urban, high-volume maternity units in Dar es Salaam, Tanzania. Population: Women underwent CS during a three-month period at each maternity unit, between 1. October 2021 and 31. August 2022. Exclusion criteria: unavailable records or unknown indication. Methods: Case files of CS were audited against pre-defined, localised criteria. Main Outcome Measures: CS rate, indications and proportion of non-medically indicated CSs. Results: The CS rate was 31% (2949/9364); 2674/2949 (91%) CSs were included for analysis. Main indications were previous CS (1133/2674; 42%), prolonged labour (746/2674; 28%), and fetal distress (554/2674; 21%). Overall, 1061/2674 (40%) did not comply with audit criteria, main reasons being one previous CS with no trial of labour (526/1061; 50%); reported prolonged labour without actual slow labour progress (243/1061; 23%); and fetal distress with normal FHR (120-160 BPM) at time of decision (225/1061; 21%). Conclusion: Two in five CSs were categorised as non-medically indicated at time of decision. Particularly, fear of poor outcomes and delay in accessing emergency surgery may cause resource-consuming ‘defensive decision-making’ for CS. Investments in conducive urban maternity units are crucial to ensure safe vaginal births and to reach a population-based approach to ensure best possible timely care for all with the limited resources available. Funding: Danida Fellowship Centre, Denmark (18-08-KU), Aarhus University Research Foundation and Laerdal Global Health (2021-0095; 40662).

Objective: To estimate the proportion of caesarean sections (CS) not meeting audit criteria for prolonged labour. Design: Cross-sectional. Setting: Five urban maternity units in Dar es Salaam, Tanzania. Population: Women giving birth by CS with an indication of prolonged labour, from October 1 st, 2021 to August 31 st, 2022. Exclusion criteria: referral to the study sites because of prolonged labour or cervical dilatation >6 cm upon admission; non-cephalic presentation; multiple pregnancy; intrauterine fetal death; failed induction; previous CS; or other reasons for CS. Methods: Criterion-based audit of CS case files with an indication of prolonged labour. Main Outcome Measure : CSs in women with uncomplicated labour progress. Results: Overall CS rate was 32% (2949/9364) and 746/1517 (47.9%) of first-time CSs were performed because of prolonged labour. Out of these, 456 met inclusion criteria and 243/456 (53.3%) CSs were in uncomplicated labour: 1) women not being given a trial of labour (78/243, 32.1%); 2) women in first stage of active labour not crossing the partograph action line (145/243, 59.7%); and 3) women in second stage less than 1 hour (20/243 8.2%). Conclusion: Almost half of CS in the unscarred uterus were because of prolonged labour and many did not meet audit criteria for prolonged labour. Crowded hospitals and inadequate monitoring may have prompted defensive decision-making. Unconducive labour wards may, therefore, indirectly drive the CS epidemic while clinical guidelines for CS decision-making remain scarce.

Objective Describe changes over time regarding mode of birth and perinatal outcomes in women with one previous caesarean section in the Netherlands over the past 20 years. Design Population-based study. Setting Nationwide. Population All women with one previous caesarean section and no previous vaginal birth, who gave birth to a term singleton in cephalic presentation between 2000 and 2019 (n=143,308). Methods Analysis of Dutch perinatal registry data. Main outcome measures Primary: mode of birth per year, intended vaginal birth versus planned caesarean section. Secondary: failed versus successful vaginal birth in case of intended vaginal birth after caesarean (VBAC), and adverse perinatal outcome (perinatal mortality up to 28 days, low Apgar score at 5 minutes, asphyxia, and NICU admission >24 hours). Results A decrease of 21.5% was seen in women with one previous caesarean section intending VBAC in a subsequent pregnancy, from 77.2% in 2000 to 55.7% in 2019, with a marked acceleration from 2009 onwards. The VBAC success rate dropped gradually, from 71.0% to 65.3%. Overall caesarean section rate (planned and unplanned) increased from 45.1% to 63.6%. Adverse perinatal outcomes were higher in women intending VBAC compared to planned caesarean section. However, after an initial decrease, perinatal mortality remained stable from 2009 onwards with only a minimal difference between both modes of birth. Conclusions In the Netherlands, the proportion of women intending VBAC after a previous caesarean section has decreased markedly, particularly from 2009 onwards. This decrease was not accompanied by a synchronous decrease in perinatal mortality after that year.

Commentary

Objective: To calculate maternal mortality ratio (MMR) for 2006-2018 in the Netherlands and compare with 1993-2005. Describe women’s and obstetric characteristics, causes of death and improvable factors. Design: Prospective cohort study. Setting: Nationwide. Population: 2,304,271 livebirths. Methods: Analysis of all maternal deaths between January 1st, 2006, and December, 31st, 2018 as reported to and audited by the national Audit Committee Maternal Mortality and Morbidity. Main outcome measures: MMR, causes of death, improvable factors. Results: Overall MMR was 6.2 per 100,000 livebirths, a decrease from 12.1 in 1993-2005 (Odds Ratio (OR) 0.5, 95%CI 0.4-0.6). Women with non-Western ethnic background had a slightly increased MMR compared to Dutch women (MMR 6.5 vs 5.0, OR 1.3, 95%CI 0.9-1.9), and was particularly increased among women with a background from Surinam/Dutch Antilles (MMR 14.7 OR 2.9, 95%CI 1.6 – 5.3). Half of all women had an uncomplicated medical history (79/161, 49.1%). Of 172 pregnancy-related deaths within one year postpartum, 103 (60%) had a direct and 69 (40%) an indirect cause. Leading causes within 42 days postpartum were cardiac disease (n=21, 14.8%), hypertensive disorders (n=20, 14.1%) and thrombosis (n=19, 13.4%). For deaths up to one year postpartum, suicide was the third commonest cause (n=20, 11.6%). Improvable factors in care were identified in 76 (47.5%) of all deaths. Conclusions: Maternal mortality halved in 2006-2018 compared to 1993-2005. Unlike before, cardiac disease outnumbered hypertensive disorders as main cause of death. Women with a background from Surinam/Dutch Antilles had a threefold higher risk of death compared to Dutch women.

Objective: Description of characteristics, risk factors, management strategies and maternal, obstetric and neonatal outcomes of SARS-CoV-2 infected pregnant women in the Netherlands. Design: Multi-centre prospective nationwide population-based cohort study. Setting: Nationwide. Population: All pregnant women in the Netherlands with confirmed SARS-CoV-2 infection in home-isolation or admitted to hospital between March 1st, 2020 and August 31st, 2020. Methods: Pregnant women with positive PCR or antibody tests were registered using the Netherlands Obstetrics Surveillance System. Testing occurred according to national guidelines (selective testing). Data from the national birth registry (Perined) and Dutch National Institute for Public Health and the Environment (RIVM) were used as reference. Main Outcome Measures: Incidence of pregnant women with SARS-CoV-2 infection. Maternal, obstetric and neonatal outcomes including hospital and critical care admission, clinical management and mode of birth. Results: Of 312 registered women, 65 (20%) were admitted to hospital, of whom 5 (2%) to intensive care and 9 (14%) to obstetric high care units. Risk factors for admission were non-Caucasian background (n=28; OR 6.67, 95%CI 4.08-10.90) and being overweight or obese (n=38; OR 2.64, 95%CI1.51 to 4.61). Hospital and intensive care admission were higher compared to age-matched infected women (respectively, OR 14.57, 95%CI 10.99-19.03 and OR 5.02, 95%CI 2.04-12.34). One maternal death occurred. Caesarean section after labour onset was increased (OR 2.50; 95%CI 1.57-3.97). Conclusions: Pregnant women with SARS-CoV-2 infection are at increased risk of hospital admission, ICU admission and caesarean section. Funding: No funding was received. Keywords: Pregnancy, COVID-19, SARS-CoV-2, Pregnancy complications, Pregnancy outcome, Obstetric surveillance system.