Skip to main content

Table 3 Impact of emergency obstetric care on stillbirths and perinatal mortality

From: Reducing stillbirths: interventions during labour

Source Location and Type of Study Intervention Stillbirths/Perinatal Outcomes
Quality and availability of obstetric care
Abdel-Latif et al; NICUS Group 2006 [57] Australia (New South Wales and Australian Capital Territory). 10 neonatal intensive care units; stillbirth analysis done from other regional data.
Retrospective analysis. Infants (N = 8654) < 32 wks' gestation born 1992–2002 (N = 1879 rural areas, N = 6775 urban). Regional SB analysis: N = 14,707 births.
Compared the impact of rural vs. urban residence and associated differentials in access to higher-level emergency obstetric care on perinatal mortality measures. NMR (in NICU): adj. OR = 1.26 (95% CI: 1.07–1.48, P = 0.005) in rural vs. urban group.
SBR: OR = 1.20 (95% CI: 1.09–1.32; P < 0.001).
[727/3530 (20.6%) vs. 1991/11177 (17.8%) in rural and urban infants, respectively].
Cameron 1998 [25] Australia (Far North Queensland). Atherton Hospital.
Descriptive study. N = 2883 deliveries from 1981–1990 (N = 1974 public confinements, N = 909 private confinements).
Assessed annual obstetric audit data from 1981–1990 to compare publicly versus privately funded facilities. PMR: 5.1/1000 vs. 5.5/1000 in public and private confinements, respectively.
PMR (corrected): 9.6/1000 vs. 13.5/1000 vs. 16.9/1000 in public patients, Queensland (1987) and the Far North Statistical Division (1987), respectively.
Gaffney et al. 1994 [48] UK (Oxford). National Perinatal Epidemiology Unit.
Case control study. N = 573 participants, of whom N = 141 cerebral palsy group (N = 257 controls) and N = 62 perinatal deaths (N = 119 controls).
Compared the frequency of events during labour and delivery, and the suboptimal care among cases (with perinatal deaths) vs. controls. Intrapartum haemorrhage: OR = 5.3 (95% CI: 1.4–20.1) in cases of deaths vs. controls.
Meconium stained amniotic fluid: OR = 12.3 (95% CI: 3.6–41.4) in cases of deaths vs. controls.
Failure to respond to signs of severe fetal distress: OR = 26.1 (95% CI: 6.2 – 109.7) in cases of deaths vs. controls.
Goldenberg et al. 2007 [3] Review. Data from 51 countries (WHO and other sources). Logistic regression analysis of measures of antenatal and obstetric care with perinatal outcomes. Intrapartum SB: for each 1% increase in the percentage of women with at least 4 antenatal visits, the intrapartum SBR decreased by 0.16/1000 births (P < 0.0001).
Intrapartum SB: as Caesarean section rates increased from 0 to 8%, for each 1% increase, the intrapartum SBR decreased by 1.61/1000 births. No relationship between Caesarean section and SBR in high-income countries.
Stronger relationship between various measures of care with intrapartum versus antepartum SBR.
Grzybowski et al. 1991 [59] British Columbia (Queen Charlotte Islands). 21-bed hospital and medical clinic.
Descriptive study. All women (N = 286) >20 wks' gestation delivering from 1984–88. 33% were primiparous, 20% native. N = 192 (67%) delivered locally, N = 33 (12%) transferred after admission for complications, N = 61 (21%) delivered elsewhere.
Assessed the PMR among women delivering at a small hospital without Caesarean section capability delivering <50 infants per year. PMR: 20.8 (95% CI: 4.4–37.2); N = 6.
Adverse perinatal outcome: 6.2% (12/193 newborns) (95% CI: 2.8–9.6%).
Kiely et al. 1985 [56] USA (New York City).
Prospective study. All births of infants weighing > 1000 g from 1976–78.
Computed fetal mortality rates (adjusted for confounding by birth weight, gestational age, and other variables) at different levels of care. Intrapartum SBR: 61% excess risk in Level 1 (community hospital) vs. Level 3 (perinatal intensive care) maternity units)(P > 0.01).
Intrapartum SBR: 35% excess risk in Level 2 units (intermediate level of care) vs. Level 3 units (P = 0.06).
Korhonen and Kariniemi 1994 [54] Finland.
Prospective study. Cases of emergency Caesarean section (N = 101). N = 60 cases study group, N = 41 controls.
Compared the impact on survival of cases with the operating team in the hospital (study group) vs. cases with the team on call (outside the hospital) (controls). Live birth/neonatal survival rate: significantly higher when the operating team was in the hospital vs. on call outside the hospital), P = 0.05. SBR: 0/60 vs. 3/41 in intervention vs. controls, respectively
Hypoxic ischemic encephalopathy: 1/41 in the controls.
Lansky et al. 2007 [50] Brazil (Belo Horizonte). Population-based in 24 hospitals.
Cohort study. N = 36,469 births, N = 419 perinatal deaths in 1999.
Compared PMR in hospitals contracted to the National Public Health System (SUS) with non-SUS hospitals. PMR: OR = 2.92 (95% CI: 1.87–4.54) in the private-SUS vs. private non-SUS hospitals.
PMR: OR = 1.81 (1.12–2.92) in the philanthropic-SUS vs. private non-SUS hospitals.
PMR: OR = 1.30 (95% CI: 0.82–2.05) [NS] in the public SUS vs. private non-SUS hospitals.
Lansky et al. 2007 [49] Brazil (Belo Horizonte).
Cohort study. N = 40,953 births and N = 826 perinatal deaths in 1999.
Compared PMR in hospitals linked to the national Universal Public Health System (SUS) vs. non-SUS hospitals. PMR: highest in private and philanthropic SUS-contracted hospitals relative to private, non-SUS-contracted hospitals.
Quality of care also associated with PMR.
Leeman et al. 2002 [30] USA (New Mexico). Native American hospital.
Retrospective cohort study. All pregnant women (N = 1132) > 20 weeks gestation 1992–1996. N = 735 (64.7%) gave birth at the hospital without operative facilities; N = 290 (25.6%) were transferred before labour; and N = 107 (9.5%) were transferred during labour.
Compared the PMR at hospital lacking on-site Caesarean capability but with a high-risk obstetric population) with the nationwide PMR (historical controls). PMR: 11.4/1000 (95% CI: 5.1–17.8) vs. 12.8/1000 at the hospital vs. nationwide, respectively [NS].
Caesarean section rate: 7.3% vs. 20.7% at the hospital and nationwide, respectively (statistically significant).
Low Apgar score: 0.54% vs. 1.4% at the hospital and the nationwide, respectively (statistically significant).
Resuscitation required: 3.4% vs. 2.9% at the hospital and nationwide, respectively [NS].
Longombe et al. 1990 [41] Zaire. Rural setting.
Retrospective study. Total deliveries (N = 9947) during a five-year period. N = 8476 (85.2%) normal deliveries; N = 1014 (10.2%) Caesarean; N = 484 (4.9%) complicated vaginal deliveries.
Compared the impact on perinatal mortality in the Caesarean group (study group #1) vs. complicated vaginal deliveries (study group #2) vs. normal deliveries (comparison group). PMR: 3.67% vs. 2.29% vs. 0.75% in study group #1, study group #2, and comparison group, respectively.
McClure et al; NICHD FIRST BREATH Study Group 2007 [137] Democratic Republic of Congo, Guatemala, India, Zambia, Pakistan, Argentina. Population-based study, community-based.
Prospective cohort study. N = 60,324 deliveries over an 18-month period.
Assessed care-based risk factors for SBR in different low-/middle-income countries. SBR: 34/1000 vs. 9/1000 in Pakistan and Argentina, respectively.
Maceration: 17.2% of stillbirths.
Higher SBR significantly associated with less-skilled providers, out-of-hospital births, and low Caesarean section rates.
Rautava et al. 2007 [51] Finland. 14 level II (central) and 5 level III (university) hospitals.
Retrospective national medical birth-register study. N = 2291 very pre-term infants (gestational age <32 weeks at birth or birth weight of ≤ 1500 g) born from 2000–2003.
Compared PMR between level II (central) and level III (university) hospitals. IMR + SBR: 494/2291 infants (21.6%).
IMR: 224/2021 (11.1%) among live-born infants.
Both the total 1-year mortality and the 1-year mortality of live-born infants were higher in level II hospitals compared with level III hospitals.
Steyn et al. 1998 [58] South Africa. Hospital records.
Retrospective analysis. N = 174,713 deliveries during 1975–1994), of which N = 22,773 were by Caesarean.
To describe trends in Caesarean section and PMR over the study period. PMR: 34.7/1000 vs. 18.4/1000 in 1975 vs. 1994, respectively.
The Caesarean section rate stayed constant at about 13% during this period.
Practice of Caesarean section and impact on perinatal mortality
Bottoms et al. 1997 [37] USA. Academic referral centers with neonatal intensive care units.
Prospective observational study. Singleton extremely low birth weight (LBW) infants (N = 713) over a one-year study period (N = 482 study group, N = 231 controls).
Compared the impact on PMR of provider willingness to perform Caesarean delivery at 24 weeks for indications of fetal distress (intervention) vs. provider unwillingness to provide early Caesarean for these indications (controls). Neonatal survival: adj. OR = 3.7 (95% CI: 2.3–6.0); P = 0.0001 in the study vs. control group, respectively.
Survival without serious neonatal morbidity: OR = 1.8 (94% CI: 1.0 = 3.3) [NS] in the study vs. control group, respectively.
SB: 19.5% vs. 0% for 21 weeks vs. > 28 weeks, respectively.
NMR: 78% vs. 3.3% in 21 weeks and 30+ weeks, respectively.
De Muylder and Amy 1993 [40] Zimbabwe (the Midlands Province). 12 hospitals.
Prospective study. Deliveries from 1985–1986 in 12 hospitals (N = 19,363 deliveries/year), with Caesarean section rates ranging from 2.2–16.8%.
To assess the impact of high versus low Caesarean section rates on perinatal outcome. PMR: 51.9/1000 vs. 39.7/1000 births in 6 hospitals with high rate of Caesarean section vs. 6 hospitals with high rate of instrumental delivery, respectively. Statistically significantly higher in hospitals with instrumental:Caesarean section ratio < 0.2.
Caesarean section and PMR positively correlated: R2 = 0.429 (P = 0.021).
Hankins et al. 2006 [36] USA.
To assess the impact on neonatal morbidity and mortality in a high-income country setting of allowing women to opt for delivery by elective Caesarean section at 39 weeks of gestation. Extracted findings from reviewed studies:
SBR: steady from 23–40 wks gestation, 5% of all stillbirths occurring at each week of gestation (Copper).
SBR: 0.6/1000 vs. 1.9/1000 live births at 33–39 wks vs. >39 wks' gestation (Yudkin).
SBR: 1.3–4.6/1000 live births from 37–41 wks' gestation (Fretts).
Estimated prevention of SB associated with elective Caesarean for all births at 39 wks: 2/1000 living fetuses (6000 SBs prevented in the US each year).
Iffy et al. 1994 [38] Ireland (Dublin) and USA (Newark, New Jersey). 2 large hospitals.
Observational study. N = 68479 births (excluding malformations). Caesarean section rates: 6% in Ireland hospital, 17.5% at USA hospital.
Compared the PMR associated with different Caesarean section rates at 2 different hospitals. PMR: 611/50768 (12.0/1000) vs. 343/17711 (19.8/1000) in Newark vs. Dublin, respectively; P < 0.01.
NMR: No impact.
Ilesanmi et al. 1996 [47] Nigeria (Ibadan). Oluyoro Catholic Hospital.
Descriptive study. Breech singleton deliveries (N = 441 of 21,243 deliveries).
Compared the intrapartum stillbirth rate associated with breech (study group) vs. cephalic deliveries (controls). Fresh SBR: 7.8% vs. 1.2% for breech and cephalic, respectively over the same time period.
Caesarean section performed for 15.7% of breech singleton deliveries (indicatioN = fetal distress).
McClure et al. 2007 [21] 188 developed and developing countries. WHO data.
Regression analysis.
To analyze correlation between SBR and multiple measures of antenatal and obstetric care (Caesarean section rates, skilled delivery attendance, and complete ANC). SBR and MMR: strongly correlated, ~5 SBs for each maternal death. Ratio: 2:1 in least developed countries vs. 50:1 in the most developed countries.
SBR: Decreased sharply as Caesarean section rates increased from 0 to about 10%, (same for MMR).
SBR: No significant reductions associated with skilled attendance until coverage rates ~40%.
SBR: No reductions associated with complete ANC until 60% coverage was achieved (modest reduction).
Mekbib and Teferi 1994 [138] Ethiopia (Addis Ababa). Hospital-based study.
Retrospective review of hospital records. N = 11,657 consecutive deliveries 1987–1992). N = 645 Caesarean sections (5.5%).
Compared the impact PMR of deliveries by Caesarean section vs. all deliveries (controls). PMR: 153.5/1000 (N = 99) vs. 67.5/1000 live births in Caesarean section group vs. rate for all deliveries respectively (P < 0.01).
O'Driscoll et al. 1988 [39] USA (Dallas, TX) and Ireland (Dublin).
Retrospective analysis of hospital records from 1982–84. Pregnant women admitted to hospital (N = 24441 at Dublin; N = 22580 women in Dallas).
Compared the impact on PMR between a low Caesarean section rate hospital (Dublin) vs. a high Caesarean section rate hospital (Dallas). CS rates: 482/8068 (6.0%) vs. 2001/10988 (18.0%) in Dublin vs. Dallas, respectively in 1983.
[330/7782 (4.2%) vs. 2022/11592 (17.3%) in Dublin vs. Dallas, respectively in 1984.]
PMR: 148/8199 (17.9/1000) vs. 161/11098 (14.5/1000) in Dublin vs. Dallas, respectively in 1983.
[119/7879 (15.1/1000) vs. 207/11716 (17.8/1000) at Dublin and Dallas, respectively in 1984.]
Intrapartum SB: 7-fold lower in Dallas compared to Dublin in 1983. Including 1982 & 1984, no significant difference in overall PMR despite 4 times as many Caesareans in Dallas as Dublin.
Wright et al. 1991 [139] Nigeria. Jos University Teaching Hospital (high-risk population).
Descriptive study. N = 757 patients undergoing Caesarean section.
Assessed PMR among a case series of Caesarean section. PMR: 235/1000 (N = 69 stillbirths and N = 107 early neonatal deaths).
Caesarean section rate: 4.4%.
Management of risk factors for stillbirth
Abate et al. 2006 [140] Ethiopia (Addis Ababa). Two teaching hospitals.
Retrospective study. Eclamptic cases (N = 216) diagnosed, admitted and managed from October 1994 to September 1999.
To assess the stillbirth rate (SBR) and perinatal mortality rate (PMR) among women admitted to hospital who presented with or who developed eclampsia. SBR: 44/216.
Early neonatal deaths: 25/216.
PMR: 312.2/1000 deliveries.
Alessandri et al. [35] Australia (Western Australia).
Matched case-control study. Intrapartum stillbirths ≥1000 g (cases) and live born infants (controls) matched for year of birth (1980–1983), plurality, sex, birth weight, and race of mother.
To determine antenatal and intrapartum risk factors for intrapartum stillbirths at the population level. Placental abruption: OR = 9.55 (95% CI: 2.09–43.69) in cases versus controls, respectively.
Fetal distress: OR = 4.64 (95% CI: 1.92–11.19) in cases versus controls, respectively.
Cord prolapse: OR = 10.00 (95% CI: 1.17–85.60)
Placental problems (OR = 2.26, 95% CI: 1.13–4.52)
Vaginal breech delivery: OR = 3.51 (95% CI: 1.40–8.80) and
Emergency Caesarean section: OR = 2.15 (95% CI: 1.13–4.10).
No antenatal risk factors predicted deaths.
Basso et al. 2006 [141] Norway. Population-based using data from the Medical Birth Registry.
Longitudinal study. Singleton firstborn fetuses (N = 804,448) with Norwegian-born mothers born 1967–2003.
Compared the impact on perinatal outcomes of being born to preeclamptic (exposed) vs. non-preeclamptic (unexposed) mothers in the period from 1991–2003 vs. 1967–1978. SBR: OR = 1.3 (95% CI: 1.1–1.7) in exposed vs. unexposed group, respectively from 1991–2003 vs. adj. OR = 4.2 (95% CI: 3.8–4.7) in exposed vs. unexposed group from 1967–78.
Induction before 37 weeks for preeclampsia: 20% vs. 8% in 1991–2003 vs. 1967–78, respectively.
Bhattacharyya et al. 1979 [142] India.
Prospective study. Patients (N = 60) with previous stillbirths. A majority (75%) had a history of repeated stillbirths, and responsible pathology was detected in 55% of the cases.
To assess the impact of active antepartum, intrapartum, and early postnatal care in women with previous stillbirths. Live birth: 75%.
Cruikshank and Linyear 1987 [53] USA (Virginia).
Perinatal audit. N = 108 term fetal deaths in 1983.
Assessed circumstances and management of term fetal deaths occurring in Virginia to determine potential preventability. Preventable fetal death: 52/108 (48%)
Risk factors for antepartum fetal death: maternal hypertension, diabetes, inadequate fetal surveillance, post-term pregnancy
Major cause of intrapartum fetal death: delay between obvious fetal compromise onset and delivery.
Incidence of preventable term stillbirth lower in larger hospitals.
Onyiriuka 2006 [143] Nigeria (Benin City).
Retrospective, observational study. All babies born weighing > 4000 g.
Compared the fetal outcome in high birth weight babies (study group) vs. normal weight babies (controls). Risk of fetal death higher in high birth weight babies (full text not available).
Risk of Caesarean section higher in high birth weight babies (full text not available).
Management and mortality of twin delivery, including impact of Caesarean section
Ananth et al. 2004 [144] USA.
Retrospective cohort study. Twin live births and stillbirths between 1989–91 and 1997 = 99 (N = 1,102,212).
Compared the changes in the SBR (≥22 weeks), labour induction, and Caesarean rates among twin births from 1989–91 and 1997–99. SBR: RR = 0.52 (95% CI: 0.49–0.55) [13.9/1000 vs. 24.4/1000 in 1999 vs. 1989, respectively (48% decrease).]
SBR excluding births weighing < 500 g and adjusting for changes in labour induction and Caesarean delivery: RR = 0.75 (95% CI: 0.72–0.79)(25% decrease).
Labour induction: 13.8% vs. 5.8% in 1997–99 vs. 1989–91, respectively (138% increase).
Caesarean delivery: 55.6% vs. 48.3% in 1997–99 vs. 1989–91, respectively (15% increase).
Fakeye 1988 [145] Nigeria (Ilorin). University of Ilorin Teaching Hospital.
Descriptive study. Consecutive twin pairs (N = 622). N = 146 twin-1 and N = 192 twin-2 breech births.
Compared PMR between first and second twin breech infants. SB and asphyxia (Apgar 1,2, or 3) high in both first and second twin breech infants.
PMR: 13.7% vs. 18.8% for twin-1 and twin-2 breech, respectively.
Corrected PMR: 9.3% vs. 12.4% for twin-1 and twin-2 respectively among infants weighing 2.0 kg or more. Twin-specific breech PMR lowest in 2.5–2.9 kg group (higher for smaller and larger twins).
Breech-breech or primary breech managed by Caesarean section: lower PMR than vaginally delivered breech twin pairs.
Rydhstrom and Ingemarsson 1991 [146] Sweden (Stockholm). The National Medical Birth Registry.
Matched case-control twin study. N = 273 twin pregnancies delivered 1973–1983 weighing 1500–2499 g. N = 91 pregnancies (cases), N = 182 controls.
To compare the Caesarean section rates between the cases where one or both twins died vs. controls with similar birth weight (+/- 100 g) and year of delivery (+/- 1 year). Caesarean section rate: 20% vs. 50–65% in 1973–76 vs. 1981–83 respectively, with an increase for both cases and controls. No significant difference between groups [NS]
Smith et al. 2005 [147] UK (Scotland).
Retrospective cohort study. All twin births (N = 8073) ≥36 weeks of gestation, excluding antepartum stillbirths and perinatal deaths due to congenital abnormality, 1985–2001; of which N = 1472 deliveries by planned Caesarean section.
To determine PMR among twins born at term in relation to mode of delivery. PMR (2nd twin vs. 1st): OR = 5.00 (95% CI: 2.00–14.70)
[6 vs. 30 deaths in first vs. second twins, respectively].
PMR (either twin): OR = 0.26 (95% CI: 0.03–1.03) [NS].
[2/1472 (0.14%) vs. 34/6601 (0.52%) deliveries in either twin by planned Caesarean section vs. other means, respectively; P = 0.05]. No association of birth order and PMR among those delivered by planned Caesarean section.
Smith et al. 2007 [148] UK (England, Northern Ireland and Wales).
Retrospective cohort study. N = 1377 twin pregnancies with one twin dying perinatally (excluding malformations) and one surviving, 1994–2003.
To assess PMR based on birth order in twin pregnancies. Birth order and the risk of death overall: OR = 1.0 (95% CI: 0.9–1.1) for the second twin [NS].
However, there was a highly significant interaction with gestational age (P < 0.001).
PMR among 2nd twins born at term: OR = 2.3 (95% CI: 1.7–3.2, P < 0.001). Higher risk for vaginal birth (OR = 4.1, 95% CI: 1.8 to 9.5) compared with Caesarean section (OR = 1.8, 95% CI: 0.9 to 3.6); P = 0.10.
PMR among 2nd twins at term associated with intrapartum anoxia or trauma (OR = 3.4, 95% CI: 2.2 – 5.3).
VBAC vs. repeat Caesarean section
Bahtiyar et al. 2006 [149] USA. Perinatal mortality data (1995 to 1997).
Cross-sectional study. Deliveries of singleton term pregnancies (N = 11,061,599) in women 15–44 years collected 1995–97. Caesarean delivery rate was 19.6%.
Compared the impact on SBR among pregnant women with a prior Caesarean delivery (intervention) vs. women with no prior Caesarean delivery (control). Crude fetal death (miscarriage+SB): 1.3/1000 vs. 1.5/1000 births in intervention vs. control groups, respectively.
Adjusted fetal death (miscarriage+SB): 0.4/1000 vs. 0.6/1000 births in intervention vs. control groups, respectively.
Subset of women with only 1 prior delivery:
Fetal death (miscarriage+SB): RR = 0.90 (95% CI: 0.76–1.06) [NS].
[0.7/1000 vs. 0.8/1000 births in intervention vs. control groups, respectively].
Kumar et al. 1996 [42] Western Australia.
Retrospective study. Women (N = 79) with prior Caesarean section. N = 33 (41.8%) women agreed to a trial of vaginal birth. N = 29 women had labour induced and 26 (89.7%) of them had a successful vaginal delivery.
To assess the PMR in women attempting vaginal birth after Caesarean section (VBAC). PMR: 0/79.
Vaginal delivery rate: 87.9% in women undergoing a trial of vaginal birth.
Caesarean section for fetal distress: 4/33 (12.1%).
Caesarean section rate: fell from 32.2% to 11% in hospital during the study period.
Meehan et al. 1989 [43] Ireland (Galway). Regional Hospital.
Retrospective analysis. N = 27,072 babies born 1972–1982. N = 1498 patients with prior Caesarean section, including N = 654 (44%) with repeat elective Caesarean section and N = 844 (56%) with VBAC.
Compared the impact on PMR among women with prior Caesarean section according to the mode of delivery: elective Caesarean section, VBAC, and emergency Caesarean section). PMR: 30.3/1000 (N = 46) vs. 22.5/1000 in all women with prior Caesarean section vs. overall hospital population, respectively.
PMR: 10.6/1000 vs. 90.3/1000 in those delivered by elective Caesarean section vs. those by emergency Caesarean section (statistically significant)
Successful vaginal delivery occurred in 702 (83%) patients and 142 (17%) had emergency repeat operations. Corrected PMR was twice as high in the trial of scar group.
Mock et al. 1991 [45] West Africa. Rural hospital based.
Descriptive study. Women (N = 220) with prior Caesarean section delivering 1987–1990. N = 169 patients given a trial of labour, of whom vaginal delivery was achieved in 111 (66%).
Compared the impact on maternal and fetal outcome between women given a trial of labour and those given elective repeat Caesarean section. PMR: [NS]
Nyirjesy et al. 1992 [44] Northeastern Zaire. Rural referral hospital.
Descriptive study. Women (N = 33) with previous Caesarean given trial of labour in 1989–1990, of which 22 (67%) had successful vaginal deliveries.
Assessed the PMR in women given a trial of labour (study group) vs. the overall rate for the institution (controls). PMR: 60.1/1000 (study group) [NS] compared to controls.
van Roosmalen 1991 [46] Tanzania. 2 rural hospitals.
Observational study. N = 134 women with a history of previous Caesarean section, of which N = 87 had a vaginal delivery after a trial of labour.
Compared PMR in women with a previous Caesarean birth in relation to the indication of the previous operation, a history of previous vaginal delivery and the number of previous operations. PMR: 9/64 (14%) vs. 4/45 (9%) vs. 0/25 (0%) where the indication for previous Caesarean was CPD vs. nonrecurrent vs. unknown, respectively [NS].
PMR: 3/43 (7%) vs. 10/91 (11%) in women without previous vaginal birth vs. with previous vaginal respectively [NS].
PMR: 10/114 (9%) vs. 3/20 (14%) in women with one previous Caesarean vs. more than one Caesarean, respectively [NS].