1. 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 12 th 2007 Neetu.Jain@doh.state.nj.us

2. 2 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. 2

3. 3 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 Mother’s medical risk factor 3

4. 4 Method and Subject Selection Created a linked perinatal dataset by matching New Jersey’s 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. 4

5. 5 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

6. 6 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 6

7. 7 Trends in Mode of Delivery in NJ, 1997-2005

8. 8 Trends in Select Neonatal Complications in NJ, 1997-2005

9. 9 Respiratory Distress Syndrome by Mode of Delivery

10. 10 Intra-Ventricular Hemorrhage by Mode of Delivery

11. 11 Transient Tachypnea of Newborn by Mode of Delivery

12. 12 Injuries in Newborn by Mode of Delivery

13. 13 Relative Risk: Cesarean After Trial of Labor v. Vaginal Delivery

14. 14 Relative Risks: Cesarean/No Trial of Labor V. Vaginal Delivery

15. 15 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. 15

16. 16 Respiratory Distress Syndrome by Mode of Delivery & Gestational Age

17. 17 Intra-Ventricular Hemorrhage by Mode of Delivery & Gestational Age

18. 18 Transient Tachypnea of Newborn by Mode of Delivery & Gestational Age

19. 19 Injuries in Newborn by Mode of Delivery & Gestational Age

20. 20 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). 20

21. 21 Trends in Mother’s Medical Risk Factors

22. 22 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. 22

23. 23 Conclusion Overall trend for neonatal complications are either decreasing or leveling off. Relative risks hasn’t change much over 3 time periods. Gestational age is important for all the complications we looked at. 23

24. 24 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? 24

25. 25 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