Trends in Mode of Delivery and Neonatal Complications in New Jersey, 1997-2005

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Trends in Mode of Delivery and Neonatal
Complications in New Jersey, 1997-2005

• Neetu J. Jain BHMS MPH
• Lakota K. Kruse MD MPH
• Kitaw Demissie MD PhD
• Meena Khandelwal MD
• New Jersey Department of Health and Senior
  Services
• Maternal and Child Health Epidemiology
• MICHEP Conference - December 12th 2007
• Neetu.Jain_at_doh.state.nj.us

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Background

• Nationally as well as in New Jersey overall
  deliveries by cesarean section are on the rise,
  while instrumental and unassisted vaginal
  deliveries are declining.
• In 2006, New Jersey cesarean delivery rate were
  37, higher than national average rate.
• This change in trends may have also had an impact
  on the short and long term maternal and neonatal
  outcomes.
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Study Question?

• What are the trends in the risk of selected
  neonatal complications associated with mode of
  delivery?
• Do the changing trends in mode of delivery have
  an impact on neonatal complication rates?
• Compare relative risk of specific neonatal
  complications by cesarean trial of labor and
  cesarean no trial of labor vs. Vaginal delivery
• Are there any covariates that are confounding
  these trends?
• Gestational Age
• Mothers medical risk factor
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Method and Subject Selection

• Created a linked perinatal dataset by matching
  New Jerseys 1997 to 2005 electronic birth
  certificate (EBC) records to hospital discharge
  (UB) records for mothers and newborns, resulting
  in a total of 1,004,116 records (births).
• This linked perinatal dataset including EBC and
  UB data will provide us an opportunity to examine
  trends in outcomes and comparisons by method of
  delivery for all New Jersey births.
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Data Source

• The International Classification of Disease
  (ICD-9-CM) codes from UB records and check boxes
  from EBC records were used to identify the mode
  of delivery and selected neonatal complications.
• Mode of Delivery Categorized into Instrumental
  Delivery, Unassisted Vaginal Delivery,
  Cesarean/Trial of Labor and Cesarean/No Trial of
  Labor.
• Neonatal Complications Respiratory Distress
  Syndrome, Transient Tachypnea of Newborn,
  Intraventricular Hemorrhage and Injuries to the
  Newborn. 5

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Diagnostic Codes

• ICD-9 codes Neonatal Complication
• Respiratory Distress Syndrome 769
• Transient Tachypnea of Newborn 770.6
• Intra-Ventricular Hemorrhage 772.1
• Injuries 767.1 (brachial), 767.2 (clavicle),
  767.3 (skeleton) and 767.6 (scalp).
• Check boxes from EBC were used for Respiratory
  Distress Syndrome and Transient Tachypnea of
  Newborn
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Trends in Mode of Delivery in NJ, 1997-2005
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Trends in Select Neonatal Complications in NJ,
1997-2005
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Respiratory Distress Syndrome by Mode of Delivery
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Intra-Ventricular Hemorrhage by Mode of Delivery
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Transient Tachypnea of Newborn by Mode of Delivery
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Injuries in Newborn by Mode of Delivery
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Relative Risk Cesarean After Trial of Labor v.
Vaginal Delivery
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Relative Risks Cesarean/No Trial of Labor V.
Vaginal Delivery
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Explanation for these declining trends?

• Cesarean and complication are not rising in
  parallel
• Are there some underlying factors/covariates that
  are confounding the risk of the mode of delivery
  on these complications.
• So the first step we took was to explore the
  relation of the gestational age to individual
  complication and compare by mode of delivery
  irrespective of the time period.
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Respiratory Distress Syndrome by Mode of Delivery
Gestational Age
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Intra-Ventricular Hemorrhage by Mode of Delivery
Gestational Age
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Transient Tachypnea of Newborn by Mode of
Delivery Gestational Age
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Injuries in Newborn by Mode of Delivery
Gestational Age
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Results for Gestational Age Stratification

• Stratification based on gestational age shows
  that gestational age is very important for all of
  these neonatal complications.
• IVH have higher incidence in early preterm
  newborns (24-30 weeks), while RDS has higher
  incidence in late preterm newborns (32-34), while
  TTN Injuries is more prevalent in near term
  newborns (34-37weeks).
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Trends in Mothers Medical Risk Factors
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Limitations

• Reliance on coding of ICD-9 neonatal
  complications.
• Limited to 9 discharge diagnoses.
• Coding changes over time.
• Under-reporting of mothers medical risk factor
  during pregnancy in both these datasets.
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Conclusion

• Overall trend for neonatal complications are
  either decreasing or leveling off.
• Relative risks hasnt change much over 3 time
  periods.
• Gestational age is important for all the
  complications we looked at.
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Further Research Agenda

• The next steps would be to control for
• Analyze the interventions
• Prenatal steroids for the mothers.
• Surfactant therapy for the newborn.
• Re- analyze the trend for these complications by
  mode of delivery after adjusting for gestational
  age to see if cesarean and complications are
  rising in parallel?
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Collaborators

• We are jointly working with clinicians
  (Obstetricians Neonatologists) and researchers
  who are expert and knowledgeable in this field
• Dr. Kitaw Demissie, MD, PHD Division of
  Epidemiology Associate Professor at UMDNJ-SPH.
• Dr. Meena Khandelwal MD Division of Maternal
  Fetal Medicine Associate Professor at Cooper
  Hospital.
• THANK YOU 25