Cesarean Section and Operative Vaginal

Delivery in Low-Risk Pdmiparous

Women, Western Australia

A B S T R A C I
Objectives. A major component
of the increasing trend in cesarean
sections in Western Australia is the
rise in emergency cesarean sections
in primiparous women. The aim of
this study was to identify independent risk factors (particularly those
known early in pregnancy) associated with operative delivery in lowrisk primiparous women.
Methods. Retrospective multivariate lo^stic regression analyses of
antenatal and perinatal data were
conducted for all low-risk primiparous women entering labor spontaneously and giving birth in Western
Australia in 1987 (n = 3641).
Reisults. Of the subjects, 58%
had a spontaneous vaginal delivery,
8% had an emergency cesarean section, and 34% had an operative vaginal delivery. The significant indejjendent risk factors for emergency
cesarean section were older maternal
age, shorter maternal height, heavier
infant birthweight, and long labor.
The risk factors for operative vaginal
delivery were older maternal age,
shorter maternal height, heavier infant birthweight, epidural anesthesia,
labor/delivery complications, male
infant, private patient status, and being married.
Conclusions. This multivariate
analysis confirms known risk factors
for operative delivery in low-risk
primiparous women and suggests
that it may be possible to predict the
likelihood of operative delivery for an
individual woman by using knowledge of maternal age and height and
assessment of infant birthweight.
(AmJ Public Health. 1994;84:37-42)

Januaiy 1994, Vol. 84, No. 1

Anne W. Read, PhD, Walter J. Prendiville, FRACOG, Vivienne P. Dawes,

MBChB, and Fiona J. Stanley, MD
Introduction

Methods

Many countries have recently experienced a progressive rise in the incidence

of cesarean section.^-^ Western Australia,
which witnessed an increase from 5% to
19% in the proportion of women delivered
by cesarean section from 1975 to 1990, is
included in this trend.^ Cesarean sections,
while usually undertaken in the interests
of the offspring, may result in complications for the mother."* Accordingly, the
wisdom of the increasing trend is in question, and efforts have been made to stabilize or reverse this situation.^
In a previous paper,^ we identified
the two major components of the increasing trend in Western Australia as the rise
in emergency cesarean sections in primiparous women and the rise in repeated elective cesarean sections in multiparous
women. Clearly, these two circumstances
are related in that if afirstbirth is delivered
by cesarean section, then subsequent
births are more likely to be delivered by
the same method. Therefore, it is important to investigate emergency cesarean
sections in primiparas with the aim of ascertaining why they are being performed
morefrequently.During the 1980s, as cesarean sections increased in frequency,
operative vaginal deliveries decreased.^
TTius, we considered it important to investigate all types of operative delivery in
the population.
This study was based on the total
population of apparently low-risk primiparas who began labor spontaneously at
term with a cephalic presentation of a singleton infant. We sought to identify, using
logistic regression analysis, the significant
risk factors associated with an increased
chance of either ojjerative vaginal (forceps
or vacuum extraction) or cesarean section
delivery in this population.

This study was carried out on existing computer files of the Western Australian Midwives' Notification of Case Attended Form 2, which are linked to the
Western Australian Hospital Morbidify
Data System, for the year 1987. The Midwives' Form is a statutory document completed by the midwife in attendance at
each live birth and stillbirth in Western
Australia, provided the infant is at least of
20 weeks gestation or 400 g birthweight.^
There are about 25 000 births annually in
Western Australia.
All primiparous women with low-risk
pregnancies who gave birth in Western
Australia in 1987 were selected. We defined low-risk pregnancies as follows: (1)
singleton infant, (2) no recorded medical
conditions or pregnancy complications,
(3) vertex presentation of the infant, and
(4) sfKjntaneous commencement of labor
at term (at least 37 weeks).
Women whose pregnancies fulfilled
these criteria were divided into three
groups according to whether they had a
spontaneous vaginal, operative vaginal

Anne W. Read is with the Western Australian

Research Institute for Child Health, Perth.
Walter J. Prendiville is with the University Department of Obstetrics and Gynaecology, King
Edward Memorial Hospital for Women, Subiaco, Australia. Vivienne P. Dawes is with the
Epidemiology Branch of the Health Department of Western Australia, Perth. Fiona J.
Stanley is with the Department of Paediatrics,
University of Western Australia, and the Western Australian Research Institute for Child
Health.
Correspondence should be sent to Anne
W. Read, PhD, Western Australian Research
Institute for Child Health, GPO Box D184,
Perth 6001, Western Australia.
This paper was accepted with revisions
May 3,1993.

American Joumal of Public Health 37

Read et al.

(vacuum or forceps), or emergency cesarean section delivery. There were no elective cesarean sections because these
women, by definition, all had spontaneous
onset of labor.
Frequencies of selected demographic
and perinatal characteristics for women in
the three groups were coded, as shown in
Table 1, in preparation for multivariate
analyses. The "other" category of maternal race comprised mostly (78%) Asian
women. With regard to patient classification, the universal health care system in
Australia provides public hospital care by
hospital doctors. In addition, people may
obtain insurance that provides for treatment in private or public hospitals by doctors of their own choice. We chose a priori
to investigate the variables in Table 1, together with maternal age and height, either
because they have known associations
with pregnancy outcome or because they
are apparent early in the pregnancy and
can therefore be useful predictor variables
if shown to be significant. Maternal age
and height can always be determined at
the first antenatal visit, and we were particularly interested in these variables as
potential independent risk factors for operative delivery.
Egret software (Statistics and Epidemiology Research Corporation, Seattle,
Wash) was used to perform two separate
multiple logistic regression analyses.^
First, we identified the significant independent risk factors for emergency cesarean section relative to spontaneous vaginal delivery, and, second, we carried out
a similar analysis for operative vaginal relative to spontaneous vaginal delivery.
A two-stage logistic regression procedure weis used tofitthe initial models. In
the first stage, the demographic variables
(maternal race, maternal area of residence, marital status, patient classification, maternal height, and maternal age)
were added, followed by the perinatal
variables (infant gender, infant birthweight, hours of labor, labor/delivery
complications, and anesthesia/analgesia)
in the second stage. At each stage, the
nonsignificant variables were left in the
model. The anesthesia/analgesia and
labor/delivery complications variables
were not used in the emergency cesarean
section analysis because these items were
recorded as positive for almost all women
who had emergency cesarean sections
(the labor/delivery complications were the
indications for cesarean section). Eight
women whose maternal height was not
known and 44 whose patient classification

38 American Journal of Public Health

was not known were excluded from these

analyses (a total of 51 women).
In the models described here, the coefficient for each variable was adjusted for
the effects of all other variables, however,
the nonsignificant variables {P > .05) are
not shown in the tables (with the exception of "patient classification" in Table 3).
Maternal height, maternal age, and infant
birthweight were factored to allow comparison with the strata at lowest risk for
operative delivery according to previous
literature (i.e., maternal height of 165 cm
or more, maternal age of less than 20
years, and infant birthweight of less than
3000 g).7-io
In addition to the initial models being
fitted, separate models were fitted to obtain estimated odds ratios (unadjusted for
other risk factors) for emergency cesarean section and operative vaginal delivery for each maternal age/maternal height
category. Further models were fitted to
obtain unadjusted estimated odds ratios
for each maternal age/maternal height/
infant birthweight category; these values
provided an estimate of the risk involved
for a woman of a particular age and height
according to the birthweight grouping of
her infant.

Results
Of the 3641 primiparas with low-risk
pregnancies who gave birth in Western
Australia in 1987, 2116 (58%) had a spontaneous vaginal delivery, 1242 (34%) had
an operative vaginal delivery (642 forceps,
600 vacuum), and 283 (8%) had an emergency cesarean section.
Table 1 shows the numbers and percentage distribution of women in each delivery category for selected demographic
and perinatal variables. Labor or delivery
complications were recorded for all but
three of the women who had emergency
cesarean sections. The indication for cesarean section for two of these women
was long labor; the third gave birth to an
infant who required intubation. Women
could have had more than one complication (indication) recorded, and those recorded most frequently were ccphalopelvic disproportion (56%), fetal distress
(40%), and failure to progress (27%). In
addition, 16% had other complications recorded, such as antepartum hemorrhage
and prolapsed cord. By contrast, labor
and delivery complications were recorded
for only 48% of the women who had operative vaginal deliveries (3% had cephalopehdc disproportion, 20% had fetal distress, 10% failed to progress, and 21%

experienced other complications). However, for some of the women in this group,
the processes that led to an operative delivery would have been recorded elsewhere (e.g., a long labor would have been
recorded under "hours of labor").
Women who were younger and taller
were less likely to have had operative deliveries than women who were older and
shorter (Table 2). Generally, within each
maternal height category, the percentages
of women with operative deliveries increased with increasing maternal age.
Within each maternal age category, the
percentages of women with emergency
cesarean sections increased with decreasing height; however, this trend was not
seen for operative vaginal deliveries, except in those women 35 years of age or
more (Table 2).
Table 3 shows the results of the multiple logistic regression analysis in which
significant independent risk factors for
emergency cesarean section were compared with those for spontaneous vaginal
delivery. Among the potential demographic risk factors analyzed, the most
important were maternal height and maternal age, the odds ratio increasing with
decreasing maternal height and increasing
maternal age. All of the selected variables,
with the exception of anesthesia/analgesia
and labor/deliveiy complications, were included in this model; however, the area
of residence, marital status, maternal
race, and infant gender variables were
not significant when all of the other variables were entered (data not shown). Although the patient classification variable
was not significant in the model, it has
been included in Table 3 because it represents an area of special interest with
regard to the debate concerning the progressive rise in cesarean births. Private
patient status was significantly associated
with the outcome of emergency cesarean
section until maternal age was added to
the model. There were few private patients in the younger age groups; thus,
any association between being a private
patient and having an emergency cesarean section was due to private patients
being older (data not shown). With regard
to the perinatal variables, heavier infant
birthweight and long labor were significant independent risk factors for emergency cesarean section.
Short maternal height was a significant risk factor for operative vaginal delivery, although there was little difference
in the odds ratios for women less than 160
cm in height and those 160 to 164 cm in
height. Maternal age was also a significant

January 1994, Vol. 84, No. 1

Cesareans and Operative Deliveries

predictor, the odds ratio for operative vaginal delivery increasing with each older
group (Table 4). In contrast to the risks for
emergency cesarean section, private patient classification and being married remained significant risk factors for operative vaginal delivery, even when the other
variables were added to the model. As
with the emergency cesarean section analysis, infant birthweight was a significant
independent risk factor for operative vaginal delivery. Both labor/deliveiy complications and anesthesia/analgesia were significant independent risk factors for
operative vaginal delivery when all other
variables were included in the model, and
epidural anesthesia was the most significant risk factor of all those included in the
model (Table 4).
Table 5 shows that the estimated
odds ratios increased as maternal age increased and maternal height decreased;
thus, women 35 years of age or more and
less than 160 cm tall were at the highest
risk. In Table 6, the estimated odds ratios
increased with maternal age within each
height category but did not vary greatly
between the height groups.
Estimated odds ratios for each maternal age/matemal height/infant birthweight category (unadjusted for other
factors) were also obtained for both emergency cesarean section and operative vaginal delivery. The complete results from
this analysis are not shown because there
were small numbers in some of the cells.
For example, in Table 5, there were fewer
than five women in three of the categories,
and these women would have been subdivided further into the three birthweight
categories. However, with larger numbers
of deliveries available for analysis, it
would be useful to examine the combined
risk for operative delivery according to
birthweight of the infant as well as age
and height of the mother. As an example,
in one of our categories with a satisfactory number of women for analysis (those
25 to 29 years of age and 160 to 164 cm
tall), the estimated odds ratios for emergency cesarean section relative to spontaneous vaginal delivery were 7.2 if the
infant's birthweight was less than 3000 g,
14.9 if birthweight was 3000 through 3499
g, and 34.0 if birthweight was 3500 g or
more. The estimated odds ratios for operative vaginal relative to spontaneous
vaginal delivery for women in the same
age/height category were 3.3 if the infant's birthweight was less than 3000 g,
5.4 if birthweight was 3000 through 3499
g, and 9.4 if birthweight was 3500 g or
more.

Januaiy 1994, Vol. 84, No. 1

TABLE f-^-MatenruM and Infant Chameterlstics of Prlnyparous Wonwn with

Low-Risk PragnanclM, by Method of DaHvery: WMtwn Austnidla, 1987
Method Of Delivwy
Operative
\larAncA

(Vacuum
Spontaneous
Vaginal
(n2116)
Characteristic
(Regresstoi Analysis Code)

No.

Forceps

Emergency
Cesarean
Section
(n 283)

No.

No.

Malemal
Marital status
Unmanied (1)
Man1ed,(2)

. .

V Race '.::.>,
=:,' Caucasian(1)
: ;,: Aborigine-(2)
Other ( 3 ) '

/ : ;-:
',:" '
';

: , Area of residice
K:
Ruta((1).
5 > : Metropditan ( 2 ) ,

. , i .,
':;:

Patient ciassification -....

Public (1)
\.
Private (2)
V Untoiowh (9)
'\
length of iabw.h
: ':
:
<13(1)::
,;
13+(2)'
?,.

Anesthesia/aialgesia
:
None/btlieH(1) . 'A'--

j//epidurai.(2li

;:'

: , General (3)
1. Labw/delivery compilations

468
1648

22.1
77.9

152
1090

12.2
87.8

44
239

15.6
84.5

1917; :
93 .'
106

90.6
4.4
5.0

1128
28
86

90.8
2.3
6.9

247
10
26

87.3
3.5
9.2

737,
1379

34.8

326
: 916

26.3

73.8

82
201

29.0
71.0

1163
910
43

55.0
43.0
2.0

463
778
1

37.3
62.6
0.1

151
0

46.6
53.4
0

1871
245

88.4
11.6

990
252

79.7
20.3

192
91

67.8
32.2

92.5
7.0
0.5

706
527
9

56.8
42.4
0.7

0
176
107

0
62.2
37.8

72.4
27.6

648
594

52.2
47.8

3
280

1.1
98.9

147
519
576

11.8
41.8
46.4

29
115
139

10.3
40.6
49.1

547
695

44.0
56.0

119
164

42.1
58.0

:.
148 :
11 :
1531
585

Infant
; BIrthweight'g
;/
<3000 (1)
?-

3000-3499(2)

'

3500+(3)'

''

Female; (1)

g-- Male^,,-,

'
, 7
'-:.>:.,

;;;;;:
;-

,,y:'..

463
21.9
980 ; 46.3
673 : . 31.8
1095
1021;

51.8
48.3

-:-Includes stable defectorelaitbh^lps.

' . / "Includes Inhalants (e.g., nitrdtm bxlda], nanottcs (e.^., peth dne), and caudal/pudendal neive blocks.

Discussion
Most studies of obstetric databases
have been descriptive. More recently,
multivariate techniques have been described in order to control for confounding
factors so that significant independent risk
factors for obstetric outcomes may be ascertained and quantified." However,
there have been few population-based
studies, such as ours (which included all
low-risk primiparas giving birth in Westem Australia in 1987), that use multivariate analyses and include factors such as

maternal age and height and infant birthweight.

The operative delivery rates in this
low-risk group of women were foimd to be
high. While similar proportions may be
found in other units and populations of the
Western world, lower operative delivery
rates in low-risk primiparas have been reported by individual hospitals in Ireland
(cesarean section rate = 6%, operative
vaginal rate = 19%) and the United States
(cesarean section rate = 12%, operative
vaginal rate = 27%).i2 However, a study
of a comparable Australian population

American Joumal of Public Health 39

Read et al.

TABLE 2-{Hsirlbutk)n of Method of Delivery In Each Maternal Age/Matemal Height

Category for Primiparous Women wWi Low-Risk Pregnandes: Western
Australia, 1987
Method Of Delivery
Spontaneous
Vaginal
Height, cm<160
:.

Age,y
<20
20-24
25-29
30-34-

35+
Total
160-164

<20
20-54, ,
25-^--*;
30-34

35+
Total
165+

^
-: '

No.

' %"

No.

>

%"

116
190
168
47
5
526

73.9
57.4
47.6
41.6
19.2

17.2
31.4
132 , 37.4
4 7 .= = 41.6
13
50.0
323

101
229
220
77
13
640

69.7
60.6
50.8
53.8
39.4

27.6
31.7
175-C ' 40.4
55 " 38.5
16
48.5
406

<20 . i'i 120 , ;78:4

20-24'.''. ' 329
654
25-29
367
61.0
30-34
105
50.2
24
44.4
35+
Total;
945 . : : . . .

27
104

40

120 ;

19.6
ie6-ft-!." 31^8
207
34.3
92
44.0
22 ; 40.7
5ir-jsf.- , . . .

*Eight women whoee heights were not known'were exduded..

I^ercentage of all primlpaRXts women with kw-rlsk pre^andes.

giving birth in Sydney teaching hospitals

found a cesarean section rate of 5% and a
forceps delivery rate of 43%." A degree of
caution is needed when comparing different publications referring to low-risk
populations, even when relatively strict
inclusion criteria, such as those we have
described here, are used. For example,
including only primiparas in spontaneous
labor excludes those whose labors are induced; indications for induction of labor
vaiy considerably from one hospital to another and will affect the population "allowed" to proceed to spontaneous labor.
In our multivariate model, private
patients were not significantly more
likely to have an emergency cesarean
section than were public patients, but
they were more likely to have an operative vaginal delivery. Caryi'' studied 24to 25-year-old low-risk primiparas in
Queensland, Australia, and found more
cesarean section (15% vs 10%) and operative vaginal deliveries (32% vs 21%) in
private than public patients. However,
Cary did not control for maternal height,
infant birthweight, or other potential confounding factors. Hewson et al." studied
a similar group of low-risk primiparas in
Sydney teaching hospitals and found no
significant differences between private

40 American Joumal of Public Health

Emergency
Cesarean
Section

Operative
Vagfrilal

%"

14
37

8.9
11.2
15.0
16.8
30.8

157
S31
353
113
26
980

2.8
7.7
8.8
7.7
12.1

145
378
' 433
143
33
1132

2.0
2.8
4.7
5.7
14.8

. =153
503
602
209
54
1521

-19
8
131
4
.29..
': "SB- '
11
4

86
. '^4.
28
12
.8

'

Risk Factor

No.

53

TABLE 3Logistic Regression Analysis

of RMcs for Emergency
Cesarean Section:
Primiparous Women wHh
L o w ^ k PregnancfaM,
Western Australia, 1987

Total

.'T

and public patients with regard to mode

of delivery. In a study of low-risk women
in the United States, Haynes de Regt et
al.15 found significantly higher proportions of cesarean sections in private than
public patients after allowing for age and
parity in one analysis and infant birthweight category in another. In a low-risk
population in the United Kingdom, Klein
et al.i6 found a significantly higher proportion of forceps deliveries in private
than public patients, but there was no significant difference in these two groups
with respect to cesarean sections. This
was a result similar to that of our study,
but Klein et al. did not control for potential confounding factors.
The strong independent effect of maternal age was an important confoimding
factor when investigating the public/
private patient dichotomy with regard to
emergency cesarean section, and maternal age may have more influence in primiparas than mtiltiparas.2.9 Although primiparas of advanced maternal age (e.g., over
35 years) have long been thought to be
more likely to have an operative delivery,''
it is apparent from these analyses that
primiparotis women 20 to 30 years of age
are also more likely to have such an outcome than are primiparas less than 20

OR ^ % 01)

Private patient

1.32(0.97,1.7^

Matemal height,
cm*
180-164
<160

2.43(1.70,3.48) <.OO1
5.30 0.72,7.560 <.OO1

Maternal age, y^
20-24

25-29
30-34
35+

.074

1.96(1.12,3.42)
.019
^85 (1.60,5.06) <.OO1
3.31(1.73,6.35) <.OO1
11.87 .24,26.88) <.OO1

infant birthweight, g

3000-3499
3500+
Long labor
( 3 )

.004
1.92(1.24,2.99)
4.16(2.66,6.51) <.OO1
3.74(2.74,5.09) <.OO1

Note. The ncnsignlflcant variables of area of re6idenoe, nrarital stEtus, matemai race, and Infant
sender are not shown, although they were In.
duded Inthe model, OR - odds talio; a oonfldenoeMetval.
"Odds rstiosratsUveto fnatBrna) height of 165 cm or
more.
Xidcls ratios relafive to moemal e of lees than 20
years.
Odds rati08 relative to bitthweight of less than
3000 g.

years old. The precise explanation for this

age-related trend remains uncertain.
Yudkin and Redman''' found dystocia to occur more frequently in older
primiparas than in teenagers. It may be
that teenagers are physically more fit for
the processes of labor and delivery than
are older women. A recent Israeli study
using multivariate analysis found a decrease in the risk of cesarean section for
teenagers and an increase for women 37
years of age or more, the authors noting
that the management of labor may be different in teenagers than in older women."
Also, Gordon et al.'^ found that matemal
age per se may influence an accoucheur's
decision regarding method of delivery,
and this may have been the case in our
population.
Short maternal height predisposes
women to operative delivery.''-^ Our study
has documented an increased chance of
operative delivery for low-risk primiparas
of both short (less than 160 cm) and medium stature (160 to 164 cm) relative to
taller women. Moreover, these increases
were independent of other potential and
real risk factors such as matemal age,
race, and marital status and infant birth-

January 1994, Vol. 84, No. 1

Cesareans and Operative Deliveries

TABLE 4-ijogiatlc FtograMrion Analysis

of RMcs tor Operative V i ^
DeOvery: Prfmlparous Women
witti Low^Usk Pragnandes.
Wetsm Australia, 1907
Risk Factor
Private patient
Married
cm*
ieO-164
<160

TABLE 5Emergency Cesarean Section Odds Ratios for Eaeit Matsmai

Age/Matemai Height Category: Primiparous Women wtth Low-Risk
Pragnanciss, Westem Australia. 1987
Matemai Height, cm
<160

OR(95%a)
1.74(1.45,210)
1.46(1.12,1.91)

<.OO1
.006

1.38(1.14,1.68)
1.32(1.07,1.64)

<.OO1
,011

1.44(1.05,1.99)
1.59(1.14,221)
2.03(1.39,297)
2.94(1.68,5.16^
1.33(1.13,1.57)

.025
.006
<.0O1

160.-164

165+

Matemal Age, y

No.*

Ockls Ratio

No.*

OtkJs Ratio

No.*

Otkis Ratio

<20
2(^4
25-29
30-34
35+

14
37
53
19
8

4.1
8.1
12.6
14.7
44.1

4
29
38
11
4

2.1
4.0
6.3
7.3
22.1

3
14
28
12
8

1.0
1.9
3.0
3.5
10.7

Maternal age,/>

25-29
30-.34
35-f
Irrlant isirthweight, g
3000-3489
3500+
t^edxxcomplica-

1.52(1.19,1.95)
2.52(1.96,3.24)

Note. One woman whose height was not known was exdudad.
'Number of women with emergency.cesarean seolJona.

<.OO1
<.OO1

<.OO1

TABLE 6Operative Vaginal iSelivery Odds Ratios for Each Matemal Age/Htatemal
Height Categoiy: Primiparous Wrnnen wtth Low-Risk Pregnancies,
Western Austraila, 1987
Matemal Height, cm

2.44(2.06,290) <.OO1
8.37(6.73,10.41) <.OO1
Nota T!ie nan8igiicar variables c area of rs^
denoe; matemai race, and long ietor am not
. 6hawn,diaughttwywerelndudadln<hemocM.
! C^oodcis ratio; Cl<oanfid6nc8inteivad.
Odds ratios relativetD maismal height of 165 cm or

yams.
"HMds ralios relative to blrthwel^ of less than
: 30(g.

weight. For primiparas, the increasing

trend in emergency cesarean section rates
with decreasing matemal height has also
been shown by Yudkin and Redman, i^
As illustrated in Tables 5 and 6, matemal age and height can be used together
to provide an indication of the increased
risk for operative delivery in this population as matemal age increases and matemal height decreases. At every age,
women of medium height were twice as
likely as taller women to have a cesarean
section, and women of short stature were
four times more likely to undergo the procedure. At every height, the likelihood of
a cesarean section was 10 times greater for
women 35 years of age or more than for
teenagers. In contrast, height was not as
imjxjrtant for operative vaginal delivery,
but age was strongly related.
Tumer et al.,'" when investigating
nulliparas, found that heavier infant birthw e i ^ t was a significant risk factor for
both cesarean section and forceps delivery for dystocia. In our study, the relationship between birthweight and operative delivery persisted when adjusting for

January 1994, Vol. 84, No. 1

<16O

165+

160-164

MatnalAge,y

No.*

Odds Ratio

No*

Odds Ratio

No.*

Odds Ratio

<20
20-24
25-29
30-34
35+

27
104
132
47

1.2
2.2
3.0
3.7
5.3

40'
120

1.2
2.2
2.9
3.7
5.3

30
160
207

1.0
1.8
2,4
3.0
4.4

13

175
55
16

92
22

Note. Two wonien whose heights were not known were exduded.
*Numb6 r of women with operative vaginal delivery.

confounding factors such as matemal age

and height and infant gender.
Because the timing of epidural anesthesia during the course of labor was not
available in our database, we did not investigate this procedure with regard to cesarean section delivery. However, because of the likelihood that most epidurals
would have been instituted in early labor
and the importance of epidural anesthesia
in the progress of labor and type of
delivery, i*-2i we included it in our regression models for operative vaginal delivery. Here we found it to be the most important independent risk factor, the
relative odds being approximately three
times greater than those for labor and
delivery complications. Several studies,i3.i9.2o including randomized controlled trials,2i have shown that epidural
anesthesia is likely to lead to longer labor
and operative delivery.
Our analysis has shown the value of
using multivariate models to identify risk
factors for operative delivery, particularly
when comparing outcomes for different
hospitals. Investigations of modifiable risk

factors and evaluations of different forms

of management of labor should use similar
techniques. D

AcknoMdedgments
The TVW Telethon Foundation (Westem Australia) and the Wellcome Trust (United Kingdom) provided financial support.
Portions of this paper were presented at
the International Conference on Primary Care
Obstetrics and Perinatal Health, 's Hertogenbosch, the Netherlands, March 1991.
We wish to acknowledge the staff at the
Health Department of Westem Australia, particularly Vivien Gee, for the provision of midwives' data. We thank Maxine Croft, John Gibbins, and Carol Garfield, who maintained the
Matemal and Child Health Research Data Base
at the Westem Australian Research Institute
for Child Health, and Dr Nicholas de Klerk for
statistical advice.

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January 1994, Vol. 84, No. 1