Cesarean section and rate of subsequent stillbirth, miscarriage and ectopic pregnancy: a Danish register-based cohort study

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dc.contributor.author O'Neill, Sinéad M.
dc.contributor.author Agerbo, Esben
dc.contributor.author Kenny, Louise C.
dc.contributor.author Henriksen, Tine B.
dc.contributor.author Kearney, Patricia M.
dc.contributor.author Greene, Richard A.
dc.contributor.author Mortensen, Preben Bo
dc.contributor.author Khashan, Ali S.
dc.contributor.editor Fisk, Nicholas M.
dc.date.accessioned 2014-09-30T16:33:22Z
dc.date.available 2014-09-30T16:33:22Z
dc.date.issued 2014-07-01
dc.identifier.citation O'NEILL, S. M., AGERBO, E., KENNY, L. C., HENRIKSEN, T. B., KEARNEY, P. M., GREENE, R. A., MORTENSEN, P. B. & KHASHAN, A. S. 2014. Cesarean Section and Rate of Subsequent Stillbirth, Miscarriage, and Ectopic Pregnancy: A Danish Register-Based Cohort Study. PLoS Med, 11, e1001670. http://dx.doi.org/10.1371%2Fjournal.pmed.1001670 en
dc.identifier.volume 11 en
dc.identifier.issued 7 en
dc.identifier.startpage e1001670 en
dc.identifier.uri http://hdl.handle.net/10468/1676
dc.identifier.doi 10.1371/journal.pmed.1001670
dc.description.abstract Background: With cesarean section rates increasing worldwide, clarity regarding negative effects is essential. This study aimed to investigate the rate of subsequent stillbirth, miscarriage, and ectopic pregnancy following primary cesarean section, controlling for confounding by indication. Methods and Findings: We performed a population-based cohort study using Danish national registry data linking various registers. The cohort included primiparous women with a live birth between January 1, 1982, and December 31, 2010 (n = 832,996), with follow-up until the next event (stillbirth, miscarriage, or ectopic pregnancy) or censoring by live birth, death, emigration, or study end. Cox regression models for all types of cesarean sections, sub-group analyses by type of cesarean, and competing risks analyses for the causes of stillbirth were performed. An increased rate of stillbirth (hazard ratio [HR] 1.14, 95% CI 1.01, 1.28) was found in women with primary cesarean section compared to spontaneous vaginal delivery, giving a theoretical absolute risk increase (ARI) of 0.03% for stillbirth, and a number needed to harm (NNH) of 3,333 women. Analyses by type of cesarean section showed similarly increased rates for emergency (HR 1.15, 95% CI 1.01, 1.31) and elective cesarean (HR 1.11, 95% CI 0.91, 1.35), although not statistically significant in the latter case. An increased rate of ectopic pregnancy was found among women with primary cesarean overall (HR 1.09, 95% CI 1.04, 1.15) and by type (emergency cesarean, HR 1.09, 95% CI 1.03, 1.15, and elective cesarean, HR 1.12, 95% CI 1.03, 1.21), yielding an ARI of 0.1% and a NNH of 1,000 women for ectopic pregnancy. No increased rate of miscarriage was found among women with primary cesarean, with maternally requested cesarean section associated with a decreased rate of miscarriage (HR 0.72, 95% CI 0.60, 0.85). Limitations include incomplete data on maternal body mass index, maternal smoking, fertility treatment, causes of stillbirth, and maternally requested cesarean section, as well as lack of data on antepartum/intrapartum stillbirth and gestational age for stillbirth and miscarriage. Conclusions: This study found that cesarean section is associated with a small increased rate of subsequent stillbirth and ectopic pregnancy. Underlying medical conditions, however, and confounding by indication for the primary cesarean delivery account for at least part of this increased rate. These findings will assist women and health-care providers to reach more informed decisions regarding mode of delivery. en
dc.description.sponsorship Health Research Board (PhD Scholars programme in Health Services Research, Grant No. PHD/2007/16) ; Science Foundation Ireland (08/IN.1/B2083, 12/RC/2272) en
dc.format.mimetype application/pdf en
dc.language.iso en en
dc.publisher Public Library of Science en
dc.rights © 2014 O'Neill et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. en
dc.rights.uri http://creativecommons.org/licenses/by/4.0/ en
dc.subject Caesarean section en
dc.subject Pregnancy en
dc.subject Population based cohort-study en
dc.subject Cesarean section
dc.title Cesarean section and rate of subsequent stillbirth, miscarriage and ectopic pregnancy: a Danish register-based cohort study en
dc.type Article (peer-reviewed) en
dc.internal.authorcontactother Richard Greene, Obstetrics & Gynaecology, University College Cork, Cork, Ireland. +353-21-490-3000 Email: r.greene@ucc.ie en
dc.internal.availability Full text available en
dc.date.updated 2014-08-28T13:55:00Z
dc.description.version Published Version en
dc.internal.rssid 255442108
dc.internal.rssid 279268720
dc.internal.rssid 279268720
dc.contributor.funder Health Research Board en
dc.contributor.funder Science Foundation Ireland en
dc.contributor.funder National Perinatal Epidemiology Centre, College of Medicine and Health, University College Cork
dc.description.status Peer reviewed en
dc.identifier.journaltitle Plos Medicine en
dc.internal.copyrightchecked Yes. CORA - PV permitted. en
dc.internal.licenseacceptance Yes en
dc.internal.IRISemailaddress r.greene@ucc.ie en


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© 2014 O'Neill et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Except where otherwise noted, this item's license is described as © 2014 O'Neill et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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