Objective Describe changes over time regarding mode of birth and perinatal outcomes in women with one previous caesarean section in the Netherlands over the past 20 years. Design Population-based study. Setting Nationwide. Population All women with one previous caesarean section and no previous vaginal birth, who gave birth to a term singleton in cephalic presentation between 2000 and 2019 (n=143,308). Methods Analysis of Dutch perinatal registry data. Main outcome measures Primary: mode of birth per year, intended vaginal birth versus planned caesarean section. Secondary: failed versus successful vaginal birth in case of intended vaginal birth after caesarean (VBAC), and adverse perinatal outcome (perinatal mortality up to 28 days, low Apgar score at 5 minutes, asphyxia, and NICU admission >24 hours). Results A decrease of 21.5% was seen in women with one previous caesarean section intending VBAC in a subsequent pregnancy, from 77.2% in 2000 to 55.7% in 2019, with a marked acceleration from 2009 onwards. The VBAC success rate dropped gradually, from 71.0% to 65.3%. Overall caesarean section rate (planned and unplanned) increased from 45.1% to 63.6%. Adverse perinatal outcomes were higher in women intending VBAC compared to planned caesarean section. However, after an initial decrease, perinatal mortality remained stable from 2009 onwards with only a minimal difference between both modes of birth. Conclusions In the Netherlands, the proportion of women intending VBAC after a previous caesarean section has decreased markedly, particularly from 2009 onwards. This decrease was not accompanied by a synchronous decrease in perinatal mortality after that year.

Commentary

Objective: To calculate maternal mortality ratio (MMR) for 2006-2018 in the Netherlands and compare with 1993-2005. Describe women’s and obstetric characteristics, causes of death and improvable factors. Design: Prospective cohort study. Setting: Nationwide. Population: 2,304,271 livebirths. Methods: Analysis of all maternal deaths between January 1st, 2006, and December, 31st, 2018 as reported to and audited by the national Audit Committee Maternal Mortality and Morbidity. Main outcome measures: MMR, causes of death, improvable factors. Results: Overall MMR was 6.2 per 100,000 livebirths, a decrease from 12.1 in 1993-2005 (Odds Ratio (OR) 0.5, 95%CI 0.4-0.6). Women with non-Western ethnic background had a slightly increased MMR compared to Dutch women (MMR 6.5 vs 5.0, OR 1.3, 95%CI 0.9-1.9), and was particularly increased among women with a background from Surinam/Dutch Antilles (MMR 14.7 OR 2.9, 95%CI 1.6 – 5.3). Half of all women had an uncomplicated medical history (79/161, 49.1%). Of 172 pregnancy-related deaths within one year postpartum, 103 (60%) had a direct and 69 (40%) an indirect cause. Leading causes within 42 days postpartum were cardiac disease (n=21, 14.8%), hypertensive disorders (n=20, 14.1%) and thrombosis (n=19, 13.4%). For deaths up to one year postpartum, suicide was the third commonest cause (n=20, 11.6%). Improvable factors in care were identified in 76 (47.5%) of all deaths. Conclusions: Maternal mortality halved in 2006-2018 compared to 1993-2005. Unlike before, cardiac disease outnumbered hypertensive disorders as main cause of death. Women with a background from Surinam/Dutch Antilles had a threefold higher risk of death compared to Dutch women.

Objective: Description of characteristics, risk factors, management strategies and maternal, obstetric and neonatal outcomes of SARS-CoV-2 infected pregnant women in the Netherlands. Design: Multi-centre prospective nationwide population-based cohort study. Setting: Nationwide. Population: All pregnant women in the Netherlands with confirmed SARS-CoV-2 infection in home-isolation or admitted to hospital between March 1st, 2020 and August 31st, 2020. Methods: Pregnant women with positive PCR or antibody tests were registered using the Netherlands Obstetrics Surveillance System. Testing occurred according to national guidelines (selective testing). Data from the national birth registry (Perined) and Dutch National Institute for Public Health and the Environment (RIVM) were used as reference. Main Outcome Measures: Incidence of pregnant women with SARS-CoV-2 infection. Maternal, obstetric and neonatal outcomes including hospital and critical care admission, clinical management and mode of birth. Results: Of 312 registered women, 65 (20%) were admitted to hospital, of whom 5 (2%) to intensive care and 9 (14%) to obstetric high care units. Risk factors for admission were non-Caucasian background (n=28; OR 6.67, 95%CI 4.08-10.90) and being overweight or obese (n=38; OR 2.64, 95%CI1.51 to 4.61). Hospital and intensive care admission were higher compared to age-matched infected women (respectively, OR 14.57, 95%CI 10.99-19.03 and OR 5.02, 95%CI 2.04-12.34). One maternal death occurred. Caesarean section after labour onset was increased (OR 2.50; 95%CI 1.57-3.97). Conclusions: Pregnant women with SARS-CoV-2 infection are at increased risk of hospital admission, ICU admission and caesarean section. Funding: No funding was received. Keywords: Pregnancy, COVID-19, SARS-CoV-2, Pregnancy complications, Pregnancy outcome, Obstetric surveillance system.