INTRODUCTION: Efforts to lower cesarean delivery rates have largely been unsuccessful. At our community hospital, a multifaceted strategy was initiated to lower cesarean delivery rates, and we analyzed the results over a 4-year period. METHODS: Beginning in 2011, we reviewed cesarean delivery indications daily, initiated a physician and nursing education program, encouraged resident involvement, and implemented a laborist program. Cesarean delivery rates between January 2010 and June 2013 were calculated overall and per individual physician based on inpatient records. STATA 12.1 was used to calculate risk ratios of cesarean delivery by calendar year, which was compared using the χ2 test. To explore the effect of individual physicians, a sensitivity analysis was performed to remove the highest individual physician rates from the 2010 data and compare the results with 2013. RESULTS: Cesarean delivery rates decreased from 44.6% to 35.6% from 2010 to 2013 with a 20% lower risk of having a cesarean delivery overall (relative risk [RR] 0.80, 95% confidence interval [CI] 0.69–0.92; P=.001) and a 28% lower risk of having a primary cesarean delivery (RR 0.72, 95% CI 0.57–0.90; P=.003) (Table 1). In 2010, the highest three individual rates were 72.0%, 63.8%, and 47.9%, accounting for 314 (22%) deliveries. After removing these physicians from the 2010 data set, there is no significant difference between 2010 and 2013 rates for primary CD (RR 0.87, 95% CI 0.69–1.11; P=.3) or cesarean delivery overall (RR 0.90, 95% CI 0.78–1.04; P=.1).CONCLUSION: Implementing a comprehensive strategy can dramatically lower cesarean delivery rates. Although many factors were involved, the effect of the individual physician should not be underestimated.
Objective This study aimed to examine the association between transportation assistance and study visits, and explore differences by transportation modality. Study Design This was a secondary analysis of prospective cohort study. We identified patients requesting transportation support for research ultrasound visits and identified controls (1:2 ratio) who did not request support matched for age, race, and insurance type. Conditional logistic regression examined the association between transportation support and mode of transportation with study visit attendance. Results Transportation support was requested by 57/1,184 (4.8%) participants. Participants that requested transportation support were three times more likely to attend visits than their matched controls (adjusted odds ratio [aOR] = 3.16, 95% confidence interval [CI]: 1.76–5.68). Among visits with transportation support, those supported by a ridesharing service had five-fold higher odds of attendance than visits supported with taxi service (aOR = 5.06, 95% CI: 1.50–16.98). Conclusion Transportation support, especially a ridesharing service, is associated with improved attendance at research study visits in a sample of predominantly low-income, Black, pregnant participants. Implementing transportation support may be a promising strategy to improve engagement in research studies. Key Points
Headache and neck pain are common postpartum symptoms. However, these symptoms can rarely be associated with internal carotid artery and vertebral artery dissections. We aimed to review five cases of postpartum cervical artery dissection and to review the clinical course of previously reported cases.Patients with postpartum dissections diagnosed at our institution since 2005 were identified through a database maintained by the senior author, and their clinical data were reviewed. Additionally, a literature search for previously reported cases was performed, and the clinical data in those reports were reviewed.Five patients presented with cervical artery dissections within 6 weeks postpartum. Four patients had delivered vaginally and one delivered by emergent cesarean. Headache and neck pain were the primary presenting symptoms of all five patients. Four patients demonstrated neurologic symptoms, and one had development of stroke. Two patients had single internal carotid artery dissections, one patient had bilateral dissections of the vertebral artery, and two patients had dissections in the internal carotid artery and vertebral artery. All patients were treated with either anticoagulation therapy or antiplatelet therapy. Two patients required endovascular stenting. Four of five patients returned to neurologic baseline after treatment. A literature search yielded 27 previously reported cases, with similar clinical characteristics of older reproductive age, presentation days to weeks from delivery, and recovery to neurologic baseline in the majority of patients.Postpartum cervical dissections are rare occurrences that require prompt diagnosis to prevent long-term neurologic deficits. Individualized management strategies include medical treatment (anticoagulation therapy, antiplatelet therapy, or anticoagulation and antiplatelet therapy) and endovascular recanalization.
