BACKGROUND: Despite decades of research aimed at prevention, preterm birth remains an enormous leading cause of infant mortality in the United States and worldwide. Of concern, racial disparities in preterm birth remain an intractable public health issue. In an effort to reduce preterm birth, organizations such as the American Congress of Obstetricians and Gynecologists (ACOG) released policy statements in 2009 aimed at reducing early elective deliveries. Subsequently, the incidence of preterm birth in the United States has decreased, but whether this decrease is due to a reduction in iatrogenic or "medically-indicated" preterm birth is unknown. Further, the effect of the reduction in early elective deliveries on racial disparities is unknown. Our hypotheses were that 1) after 2009, preterm births would be less likely to be medically-indicated than due to spontaneous causes and 2) black-white differences in preterm births would be unchanged. OBJECTIVES: 1) Determine the proportion of preterm deliveries at Beth Israel Deaconess Medical Center (BIDMC) from 2004-2013 that were medically-indicated versus spontaneous. 2) Due to persistent disparities, determine if shifts in type of preterm delivery varied by race/ethnicity. METHODS: We reviewed the first 87 deliveries in 2013 and randomly selected 15% of the records for each year from 2004-2013. Additionally, we reviewed 69 charts to oversample black women's deliveries. We manually abstracted data from BIDMC's online medical record and designated each delivery as either medically-indicated (preeclampsia, poor fetal growth, hypertension, or other fetal/maternal condition) or spontaneous (preterm labor, preterm premature rupture of membranes or cervical incompetence). Two reviewers independently reviewed 18 records for concordance of medically-indicated versus spontaneous preterm birth typing. If the first reviewer could not phenotype the delivery, then a neonatologist and obstetrician were consulted. We reviewed 971 out of the 5,566 preterm deliveries and included 930 that were confirmed preterm and had a clear medically-indicated or spontaneous phenotype. We dichotomized the time period into early (2004-2009) and late (2010-2013). Statistical methods included comparisons of early versus late using Chi-Square tests, logistic regression models to adjust for potential confounding variables, and stratified analyses (singletons and black versus white). RESULTS: There were 46,981 deliveries at our institution during the study period, 5,566 of which were preterm. Among the 930 preterm deliveries sampled from the 10-year period, 45.6% were medically-indicated with a non-significant, subtle difference between the early (48.3%) and late (41.9%) (P=0.05) time periods. The odds ratios of medically-indicated versus spontaneous preterm birth in late versus early were 0.77 (P=0.05) and 0.73 (P=0.03) for all participants, unadjusted and adjusted, respectively. While not statistically significant, a higher proportion of preterm deliveries among black women were medically-indicated in the early (50.4%) versus late (40.6%) periods (P=0.19). There was a similar trend among white women between the early (50.0%) and late (46.9%) periods (P=0.48). The odds ratios of medically-indicated versus spontaneous preterm birth from late versus early were 0.67 (P=0.19) and 0.63 (P=0.14) for black participants, unadjusted and adjusted, respectively. For white participants, the odds ratios were 0.88 (P=0.48) for unadjusted and 0.80 for adjusted (P=0.20). Overall at BIDMC, the preterm delivery rate was significantly higher in the early period (12.3%) compared to the later period (11.2%) (P=0.0003). While we observed a reduction of preterm birth among all women, black women experienced a 20.8% decrease (from 16.2% in the early period to 12.8% in the late) in preterm birth, while white women experienced just a 4.9% decrease (from 12.4% to 11.7%), resulting in a narrowing of the racial disparity of preterm birth in our institution. CONCLUSION: At a Massachusetts birth hospital we found a reduction in the incidence of preterm deliveries over a 10-year period that coincided with policy efforts to reduce early elective deliveries. There was a reduction in the proportion of preterm births that were medically-indicated from 48.3% to 41.9%. The reduction in medically-indicated preterm birth was most evident among black women at BIDMC with concurrent decrease in the overall preterm birth rate among black women resulting in a near elimination of the racial disparity in preterm birth at BIDMC. Future work includes statistical analysis to account for the oversampling of deliveries in 2013 as well as oversampling of black women's deliveries using inverse probability weighting. We also plan to analyze which underlying conditions (preeclampsia, intrauterine growth restriction, fetal distress, etc.) were responsible for the reduction of the medically-indicated deliveries.

Au Burkina Faso, le taux populationnel de césariennes reste encore faible (2% en 2012). Cependant, depuis l’exemption partielle (80%) pour les familles du paiement à l’acte en 2006, et la mise à disposition de médecins généralistes, sages-femmes et infirmiers formés à la pratique des césariennes dans les hôpitaux les plus reculés, on observe une augmentation constante des taux de césariennes dans les établissements de santé et il est difficile de savoir si toutes ces interventions sont réellement utiles. L’objectif principal de cette thèse est d’identifier les déterminants d’une césarienne de qualité en Afrique de l’Ouest pour orienter les politiques de santé reproductive dans les pays concernés. Les résultats des travaux menés dans le cadre de cette thèse montrent que le niveau de qualification du personnel de santé travaillant dans les hôpitaux du Burkina Faso et son expérience professionnelle déterminent globalement son niveau de connaissance en matière de gestion du travail et de l’accouchement compliqué. De plus, une supervision régulière de son travail semble améliorer sa performance. Le niveau de qualification du personnel de santé au Burkina Faso influence également la pratique de césariennes non médicalement justifiées. Mais l’environnement social joue aussi un rôle dans cette pratique abusive. Les résultats de cette recherche montrent enfin que la pratique systématique d’une césarienne après une césarienne antérieure n’est pas justifiée dans ce contexte. Les résultats de cette thèse ont permis de développer et de mettre en œuvre un essai d’intervention visant à réduire des césariennes sans raison médicale en Afrique de l’ouest. / In Burkina Faso, the national caesarean section rate is still low (2% in 2012). However, since the introduction of caesarean user fee exemption in 2006 and the availability of trained staff to perform a caesarean section in the most remote hospitals, the institutional caesareans rates have risen steadily and it is unclear whether all of these interventions are necessary. The main objective of this thesis is to identify the determinants of an optimal practice of caesarean section in three western African countries that favour access to caesarean section. The results of the work carried out in the framework of this thesis show that the level of qualification of the health personnel working in Burkina Faso hospitals and his professional experience determine globally his level of knowledge in the management of labor and complicated childbirth. . In addition, regular supervision of his work by daily review of clinical records (partograms) seems to improve his performance. The level of qualification of health personnel in Burkina Faso also influences the practice of non-medically justified caesareans. But the social environment also plays a role in this abusive practice. The results of this research show that the systematic practice of cesarean section after an anterior caesarean section is not justified in this context. The results of this thesis led to the development and implementation of a multi-faceted intervention trial aimed at reducing caesareans without medical reason in West Africa.