Mode of delivery and pregnancy outcomes in preterm birth

  • Bao Yen Luong Thanh Student, Master of Public Health in Biostatistics, Department of Epidemiology and Biostatistics, Faculty of Public Health, Khon Kaen University, Khon Kaen, Thailand
  • Porjai Pattanittum Department of Epidemiology and Biostatistics, Faculty of Public Health, Khon Kaen University, Khon Kaen, Thailand
  • Malinee Laopaiboon Department of Epidemiology and Biostatistics, Faculty of Public Health, Khon Kaen University, Khon Kaen, Thailand
  • Pisake Lumbiganon Department of Obstetrics and Gynaecology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
Keywords: Mode of delivery, Preterm birth, Pregnancy outcomes


To assess the association of mode of delivery and pregnancy outcomes in preterm birth. This is a secondary analysis of Thai database of the World Health Organization Multi-country Survey. We included 880 women with singleton neonates who delivered between 22 and <37 weeks of gestation from 12 hospitals in Thailand. We used multilevel logistic regression to assess the association between mode of delivery and pregnancy outcomes in singleton preterm births, including maternal intensive care unit (MICU) admission, maternal near miss, maternal death; Apgar score <7 at 5 minutes, neonatal intensive care unit (NICU) admission, fresh stillbirth, early neonatal, and perinatal death. All analysis were performed by R program. The prevalence of women delivered by Caesarean Section (CS) was 34.7%. There was only one maternal death and this case was observed in vaginal birth group; only two women delivered by CS were admitted to MICU. CS was associated with significantly increased odds of maternal near miss (adjusted odds ratio (aOR): 12.0; 95% confidence interval (CI): 1.6-87.4), NICU admission (aOR: 1.8; 95%CI: 1.2-2.9). The odds of Apgar score <7 at 5 minutes (aOR: 1.9; 95%CI: 0.8-4.3), fresh stillbirth (aOR: 0.8; 95%CI: 0.2-2.8), early neonatal death (aOR: 0.6; 95%CI: 0.1-6.3), and perinatal death (aOR: 0.7; 95%CI: 0.1-3.2) were not significantly different between CS and vaginal birth. In preterm birth, CS was associated with increased the odds of  maternal near miss, and NICU admissions but not significant different for the odds of Apgar score <7, fresh stillbirth, early neonatal death, and perinatal death.


1. Betran AP, Ye J, Moller AB, Zhang J, Gulmezoglu AM, Torloni MR. The Increasing Trend in Caesarean Section Rates: Global, Regional and National Estimates: 1990-2014. PloS One. 2016 Feb;11(2):e0148343.

2. Tangcharoensathien V. Pattern of hospital delivery in Thailand 1990-1996. 1998.

3. Lumbiganon P, Laopaiboon M, Gülmezoglu AM, Souza JP, Taneepanichskul S, Ruyan P, et al. Method of delivery and pregnancy outcomes in Asia: the WHO global survey on maternal and perinatal health 2007–08. The Lancet. 2010;375(9713):490-499.

4. Kovavisarach E, Ruttanapan K. Self-Preferred Route of Delivery of Thai Obstetricians and Gynecologists. J Med Assoc Thai. 2016;99 Suppl 2:S84-90.

5. Kovavisarach E, Sukontaman W. Preferred Route of Delivery of Thai Pregnant Women. J Med Assoc Thai. 2017;100(2):131.

6. Appropriate technology for birth. Lancet. 1985 Aug; 2(8452): 436-437.

7. Demol S, Bashiri A Fau - Furman B, Furman B Fau - Maymon E, Maymon E Fau - Shoham-Vardi I, Shoham-Vardi I Fau - Mazor M, Mazor M. Breech presentation is a risk factor for intrapartum and neonatal death in preterm delivery. Eur J Obstet Gynecol Reprod Biol. 2000 Nov; 93(1): 47-51.

8. Hogberg U, Hakansson S, Serenius F, Holmgren PA. Extremely preterm cesarean delivery: a clinical study. Acta Obstet Gynecol Scand. 2006; 85(12): 1442-1447.

9. Hogberg U, Holmgren PA. Infant mortality of very preterm infants by mode of delivery, institutional policies and maternal diagnosis. Acta Obstet Gynecol Scand. 2007; 86(6): 693-700.

10. Malloy MH. Impact of cesarean section on intermediate and late preterm births: United States, 2000-2003. Birth. 2009 Mar; 36(1): 26-33.

11. Sangkomkamhang U, Pattanittum P, Laopaiboon M, Lumbiganon P. Mode of delivery and outcomes in preterm births. J Med Assoc Thai. 2011 Apr; 94(4): 415-420.

12. Haque KN, Hayes AM, Ahmed Z, Wilde R, Fong CY. Caesarean or vaginal delivery for preterm very-low-birth weight (< or =1,250 g) infant: experience from a district general hospital in UK. Arch Gynecol Obstet. 2008 Mar; 277(3): 207-212.

13. Alfirevic Z, Milan SJ, Livio S. Caesarean section versus vaginal delivery for preterm birth in singletons. Cochrane Database Syst Rev. 2013 Sep 12(9): CD000078.

14. Ghi T, Maroni E, Arcangeli T, Alessandroni R, Stella M, Youssef A, et al. Mode of delivery in the preterm gestation and maternal and neonatal outcome. J Matern Fetal Neonatal Med. 2010 Dec; 23(12): 1424-1428.

15. Malloy MH, Onstad L, Wright E. The effect of cesarean delivery on birth outcome in very low birth weight infants. National Institute of Child Health and Human Development Neonatal Research Network. Obstet Gynecol. 1991 Apr; 77(4): 498-503.

16. Sonkusare S, Rai L, Naik P. Preterm birth: mode of delivery and neonatal outcome. Med J Malaysia. 2009 Dec; 64(4):303-306.

17. Souza JP, Gulmezoglu A, Lumbiganon P, Laopaiboon M, Carroli G, Fawole B, et al. Caesarean section without medical indications is associated with an increased risk of adverse short-term maternal outcomes: the 2004-2008 WHO Global Survey on Maternal and Perinatal Health. BMC Med. 2010 Nov 10; 8: 71.

18. Lumley J, Lester A, Renou P, Wood C. A failed RCT to determine the best method of delivery for very low birth weight infants. Control Clin Trials. 1985 Jun; 6(2): 120-127.

19. Penn ZJ, Steer PJ, Grant A. A multicentre randomised controlled trial comparing elective and selective caesarean section for the delivery of the preterm breech infant. Br J Obstet Gynaecol. 1996 Jul; 103(7): 684-689.

20. Viegas OA, Ingemarsson I, Sim LP, Singh K, Cheng M, Ratnam SS, et al. Collaborative study on preterm breeches: vaginal delivery versus caesarean section. Asia Oceania J Obstet Gynaecol. 1985 Sep;11(3): 349-355.

21. Wallace Rl, Schifrin BS, Paul RH. The delivery route for very-low-birth-weight infants. A preliminary report of a randomized, prospective study. J Reprod Med. 1984 Oct; 29(10): 736-740.

22. Zlatnik FJ. The Iowa premature breech trial. Am J Perinatol. 1993 Jan; 10(1): 60-63.

23. Souza JP, Gulmezoglu AM, Carroli G, Lumbiganon P, Qureshi Z, WHOMCS Research Group. The world health organization multicountry survey on maternal and newborn health: study protocol. BMC Health Serv Res. 2011 Oct 26; 11: 286.

24. Vogel JP, Souza JP, Mori R, Morisaki N, Lumbiganon P, Laopaiboon M, et al. Maternal complications and perinatal mortality: findings of the World Health Organization Multicountry Survey on Maternal and Newborn Health. BJOG. 2014 Mar; 121: 76-88.

25. Akaike H. A new look at the statistical model identification. IEEE Transactions on Automatic Control. 1974 Dec; 19(6):716-723.

26. R Development Core Team. R: A language and enviroment for statistical computing. Vienna, Austria: R Foundation for Statistical Computing; 2014.

27. Bates D, Maechler M, Bolker B, Walker S. Fitting Linear Mixed-Effects Models Using lme4. Journal of Statistical Software. 2015; 67(1): 1-48.

28. Villar J, Carroli G, Zavaleta N, Donner A, Wojdyla D, Faundes A, et al. Maternal and neonatal individual risks and benefits associated with caesarean delivery: multicentre prospective study. BMJ. 2007 Nov; 335(7628): 1025.

29. Durnwald CP, Rouse DJ, Leveno KJ, Spong CY, MacPherson C, Varner MW, et al. The Maternal-Fetal Medicine Units Cesarean Registry: safety and efficacy of a trial of labor in preterm pregnancy after a prior cesarean delivery. Am J Obstet Gynecol. 2006 Oct; 195(4): 1119-1126.

30. Phaloprakarn C, Manusirivithaya S, Boonyarittipong P. Risk score comprising maternal and obstetric factors to identify late preterm infants at risk for neonatal intensive care unit admission. J Obstet Gynaecol Res. 2015 May; 41(5): 680-688.

31. Wylie BJ, Davidson LL, Batra M, Reed SD. Method of delivery and neonatal outcome in very low-birthweight vertex-presenting fetuses. Am J Obstet Gynecol. 2008 Jun; 198(6): e1-7; discussion e1-4.

32. Durie DE, Sciscione AC, Hoffman MK, Mackley AB, Paul DA. Mode of delivery and outcomes in very low-birth-weight infants in the vertex presentation. Am J Perinatol. 2011 Mar; 28(3): 195-200.

33. Werner EF, Savitz DA, Janevic TM, Ehsanipoor RM, Thung SF, Funai EF, et al. Mode of delivery and neonatal outcomes in preterm, small-for-gestational-age newborns. Obstet Gynecol. 2012 Sep; 120(3): 560-564.

34. Riskin A, Riskin-Mashiah S, Lusky A, Reichman B, Israel Neonatal Network. The relationship between delivery mode and mortality in very low birthweight singleton vertex-presenting infants. BJOG. 2004 Dec; 111(12): 1365-1371.

35. Werner EF, Han CS, Savitz DA, Goldshore M, Lipkind HS. Health outcomes for vaginal compared with cesarean delivery of appropriately grown preterm neonates. Obstet Gynecol. 2013 Jun; 121(6): 1195-1200.