title: A Population-based study on trends in the mode of delivery subsequent to stillbirth, infant mortality and severe infant malformations in the state of Hesse, Germany between 1990 and 2012.
abstract: BACKGROUND
  Women giving birth to a child with severe infant malformations or suffering a stillbirth certainly experience a mental trauma. Therefore the objective of the present study is to examine the incidence of deliveries subsequent to such a traumatic experience as well as the mode of delivery. Secondly, the results are compared to the changes of a non-affected group of deliveries over the last 23 years in the state of Hesse, Germany.
  
  
  METHODS
  The total obstetric dataset of the Hessian Perinatal Registry (HEPE) was assessed for women with regard to one item of the pregnancy risk factors. This particular HEPE item comprises information on the rates of stillbirth, early and late infant mortality (≤7 days,<1 year) as well as severe infantile malformations in women giving birth subsequent to such an extensive traumatic experience. The identified women were categorized with respect to the mode of delivery (spontaneous, vaginal operative or Cesarean section), pre- and full-term birth and according to 4 time-frames between 1990 and 2012. The results of women with a positive HEPE item were compared to those of women without such a traumatic experience (non-affected group) of the HEPE analyzed in the same categories and time-frames.
  
  
  RESULTS
  The obstetric dataset from 1990 until 2012 of the HEPE comprised altogether 1 224 760 deliveries including a group of 19 726 (1.61%) deliveries subsequent to a positive result for the analyzed HEPE item. Over the duration of follow-up the rate of subsequent pregnancies following such a traumatic experience showed a significantly decrease of 43% in comparison to the previous time-frame, respectively (1990-1996: 30.3%; 2008-2013: 17%; P≤0.0001). With respect to the mode of delivery (spontaneous, vaginal operative, Cesarean section) the results in the group subsequent to the positive HEPE item (1 862, 55.5%; 70, 2.1%; 1 416, 42.2%) were significantly different (P<0.001) in comparison to the non-affected group (142 846, 59.9%; 13 875, 5.8%; 81 089, 34.0%), respectively.
  
  
  CONCLUSIONS
  Rising rates of CSs and conversely decreased numbers of vaginal deliveries in most cases of full-term pregnancies contrast with the reduction of the positive HEPE item over the last 23 years. There seems to be an urgent need for action since this observed critical trend remains highly significant in comparison with the rising trend of CS in general. Pre-pregnancy counseling and continuous monitoring during pregnancy and delivery in consciousness of evident risk factors may be an opportunity to cope with these serious findings.
authors.affiliation: Department of Obstetrics and Gynecology, Philipps University of Marburg, Germany.
authors.forename: M
authors.initials: M
authors.lastname: Kalder
authors.affiliation: Department of Obstetrics and Gynecology, Philipps University of Marburg, Germany.
authors.forename: J
authors.initials: J
authors.lastname: Reichelt
authors.affiliation: Department of Obstetrics and Gynecology, Philipps University of Marburg, Germany.
authors.forename: I
authors.initials: I
authors.lastname: Kyvernitakis
authors.affiliation: Institute of Quality Assurances, Eschborn, Germany.
authors.forename: B
authors.initials: B
authors.lastname: Misselwitz
authors.affiliation: Department of Obstetrics and Gynecology, Philipps University of Marburg, Germany.
authors.forename: P
authors.initials: P
authors.lastname: Hadji
authors.affiliation: Department of Obstetrics and Gynecology, Philipps University of Marburg, Germany.
authors.forename: S
authors.initials: S
authors.lastname: Schmidt
mesh_terms: D002585:Cesarean Section / Q000401:mortality*; D000013:Congenital Abnormalities / Q000401:mortality*; D005260:Female; D005858:Germany / Q000453:epidemiology; D006801:Humans; D015994:Incidence; D007223:Infant; D007226:Infant Mortality; D007231:Infant, Newborn; D008297:Male; D009321:Natural Childbirth / Q000401:mortality*; D011159:Population Surveillance; D011247:Pregnancy; D012042:Registries; D012307:Risk Factors; D050497:Stillbirth / Q000453:epidemiology*; D016064:Vaginal Birth after Cesarean / Q000401:mortality*