Cesarean delivery rates in the United States have been rising steadily since 1996 despite public policy pressure to reduce these rates due to both economic concerns, and concerns for the health of the mother and child. What is known about neonatal and early childhood outcomes of cesarean delivery is based on a body of research that is almost exclusively observational in design. Observational research, regardless of the quality of the study design or the data, is potentially subject to omitted variable bias. The sole adequately powered randomized controlled trial for mode of delivery did show a beneficial effect of cesarean delivery for the neonate; however this study was limited to a high risk subpopulation. Since there has never been a RCT for the population of low risk deliveries, it remains uncertain whether the results of this RCT on high risk deliveries are generalizable to the low risk population. The objective of this dissertation was to conduct three studies using instrumental variable analysis, a quasi-experimental design capable of controlling for omitted variable bias, to examine the effects of 1) elective primary cesarean delivery (EPCD) on neonatal health, 2) elective repeat cesarean delivery (ERCD) on neonatal health and, 3) elective cesarean delivery (ECD) on health in early childhood. Data for these studies came from statewide administrative databases linking maternal and infant healthcare data to vital records data. The studies were restricted to term, singleton, vertex, defect free deliveries. Study 1 indicated a significant decrease in both neonatal mortality (Adjusted Risk Ratio (ARR) 0.16, 95% CI 0.05-0.50) and respiratory morbidity (ARR 0.70, 95% CI 0.60-0.81) for EPCD. Study 2 indicated no statistically significant difference in either neonatal mortality (ARR 0.67, 95% CI 0.09-5.18) or respiratory morbidity (ARR 0.92, 95% CI 0.74-1.15) for ERCD. Study 3 indicated a significant decrease in risk for allergic rhinitis (ARR 0.89, 95% CI 0.82-0.98) for ECD, but not for either asthma (ARR 1.04, 95% CI 0.94-1.15) or diabetes (ARR 0.73, 95% CI 0.33-1.63). These studies indicate that cesarean delivery for low risk pregnancies is not detrimental to either neonatal or early childhood health, and could be beneficial.
|Advisor:||Mays, Glen P., Tilford, John M.|
|Commitee:||Hall, Richard W., Magann, Everett F., Robbins, James M.|
|School:||University of Arkansas for Medical Sciences|
|Department:||Health Systems Research|
|School Location:||United States -- Arkansas|
|Source:||DAI-B 73/05, Dissertation Abstracts International|
|Keywords:||Cesarean delivery, Early childhood outcomes, Instrumental variable analysis, Neonatal mortality, Neonatal outcomes, Respiratory morbidity|
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