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GYNECOLOGY

Temporal trends in obstetric trauma and inpatient surgeryfor pelvic organ prolapse: an age-period-cohort analysis
Sarka Lisonkova, MD, PhD; Jessica A. Lavery, MS; Cande V. Ananth, PhD, MPH; Innie Chen, MD, MPH;Giulia Muraca, MPH; Geoffrey W. Cundiff, MD; K. S. Joseph, MD, PhD
BACKGROUND: The rates of cesarean delivery have increased over rates declined from 6.3-3.9 per 1000 women. Obstetric trauma decreased

time in industrialized countries, while the rates of instrumental vaginal

delivery have declined. Instrumental vaginal delivery and obstetric trauma

are risk factors for pelvic floor disorders.

OBJECTIVE: We carried out a population-based study to quantify theassociation between temporal changes in obstetric trauma during child-

birth and temporal changes in surgery for pelvic organ prolapse.

STUDY DESIGN: We designed a retrospective analysis to examine

age-specific trends in vaginal and cesarean delivery, obstetric trauma, and

surgery for pelvic organ prolapse among all women (pregnant and

nonpregnant) in Washington State, from 1987 through 2009. Cases of

obstetric trauma (including severe perineal tears and high vaginal lacer-

ations) and inpatient surgery for pelvic organ prolapse were identified

among all hospitalizations. Temporal trends and age-period-cohort

regression analyses were used to quantify the time period, age, and

birth cohort effects among women born from 1920 through 1980.

RESULTS: From 1987 through 2009, cesarean delivery rates among

women aged 15-44 years increased from 12.7-18.1 per 1000 women,

vaginal delivery rates remained stable, and instrumental vaginal delivery

Cite this article as: Lisonkova S, Lavery JA, Ananth CV,et al. Temporal trends in obstetric trauma and inpatient

surgery for pelvic organ prolapse: an age-period-cohort

analysis. Am J Obstet Gynecol 2016;215:208.e1-12.

0002-9378ª 2016 The Authors. Published by Elsevier Inc. This is an

open access article under the CC BY-NC-ND license (http://

creativecommons.org/licenses/by-nc-nd/4.0/).http://dx.doi.org/10.1016/j.ajog.2016.02.027

208.e1 American Journal of Obstetrics & Gynecology AUGUST 2016

from 6.7 in 1987 to 2.5 per 1000 women aged 15-44 years in 2009.

Surgery for pelvic organ prolapse decreased from 2.1 in 1987 to 1.4 per

1000 women aged 20-84 years in 2009. Obstetric trauma rates in 1987

through 1999 among women 15-44 years old were strongly correlated

with the rates of surgery for pelvic organ prolapse among women 25-54

years of age 10 years later in 1997 through 2009 (correlation coefficient

0.87, P < .001). Similarly, rates of midpelvic forceps delivery in 1987

through 1999 were correlated with the rates of surgery for pelvic organ

prolapse 10 years later (correlation coefficient 0.72, P< .01). Regression

analyses showed a strong effect of age on surgery for prolapse, temporal

decline in surgery, and an effect of birth cohort, as younger cohorts

(women born in �1965 vs 1940) had lower rates of surgery for pelvic

organ prolapse.

CONCLUSION: Temporal decline in instrumental vaginal delivery andobstetric trauma may have contributed to the reduction in surgery for

pelvic organ prolapse.

Key words: obstetric trauma, pelvic organ prolapse, temporal trend

IntroductionPelvic floor disorders, including pelvicorgan prolapse, urinary incontinence,and fecal incontinence, greatly impactthe quality of life of a large number ofwomen and represent a significant pub-lic health burden.1-3 It is estimated that25% of adult women in the United Stateshave�1 pelvic floor disorders, and that 1in 4 women will undergo surgery forstress urinary incontinence or pelvicorgan prolapse during their lifetime.1

Routine gynecologic examinationsreveal evidence of pelvic organ prolapsein up to 50% of adult women.4,5

While the mechanical causes ofpelvic floor disorders remain poorly

understood, age, obesity, and obstetrictrauma increase the risk of these dis-orders.6,7 Studies have shown that par-ous women are 3 times more likely tohave urinary and fecal incontinence8,9

and are twice as likely to experiencepelvic organ prolapse compared withnulliparous women.10 Vaginal birth inparticular has been implicated in the riskof pelvic organ prolapse and urinaryincontinence later in life. One vaginaldelivery is associated with a 2-foldincreased risk of urinary incontinenceand a 4-fold increased risk of pelvicorgan prolapse, while 2 vaginal deliveriesincrease the risk 2.4-fold for urinaryincontinence, and 8-fold for prolapse(as compared with women who have nothad a vaginal delivery).11-13 Long-termfollow-up studies show a 40%increased risk of fecal incontinenceamong women with at least 1 vaginaldelivery (as compared with 1 cesareandelivery), while a significant perinealtear (second-degree tear or higher)doubles the risk.14 Conversely, cesareandelivery is associated with less need for

incontinence or prolapse surgery15 andis protective against prolapse symp-toms.16 There is substantial epidemio-logical evidence showing a lower risk ofpelvic floor disorders following cesareandelivery without labor as compared withvaginal delivery.11,17-19

The last 2 decades have witnessed anunprecedented increase in the rate ofcesarean delivery in high-income coun-tries.20-22 In the United States, the per-centage of cesarean deliveries increasedby 62.6% from 20.1% in 1996 to 32.7%in 2013. Cesarean delivery is the mostcommon surgical procedure among USwomen, with close to 1.3 million cesar-ean deliveries performed annually.23,24

While rates of cesarean delivery haveincreased, the rates of instrumentalvaginal delivery have declined in theUnited States (from 9.0% of live births in1990 to 3.3% of live births in 2013).24,25

We hypothesized that the decrease ininstrumental vaginal delivery, especiallymidpelvic forceps delivery, would haveled to a decrease in pelvic floor injuryrequiring subsequent surgery for pelvic

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organ prolapse. We therefore carried outa population-based study to examinethe temporal changes in instrumentalvaginal delivery rates and obstetrictrauma rates and their association withtemporal trends in surgery for pelvicorgan prolapse.

Materials and MethodsWe carried out a population-based studyto assess the association between ob-stetric events, including midpelvic for-ceps and obstetric trauma, and surgeryfor pelvic organ prolapse. We examinedtemporal trends in cesarean and vaginaldelivery; instrumental vaginal delivery,including midpelvic forceps; and ob-stetric trauma among women whoresided in Washington State duringthe period from 1987 through 2009. Wealso examined temporal trends insurgery for pelvic organ prolapse. Allwomen (both pregnant and nonpreg-nant) in the appropriate age group wereincluded in the analysis to assess theeffect of childbirth and related eventson population rates of pelvic organprolapse.

Information on the mode of deliverywas obtained from the ComprehensiveDischarge Abstract Database, whichincluded all hospitalizations in Wash-ington State from 1987 through 2009.International Classification of Diseases,Ninth Revision, Clinical Modification(ICD-9-CM) diagnostic and procedurecodes were used to identify childbirth(Appendix Table 1); procedure codes74.^^ were used to identify cesarean de-livery and all other deliveries wereconsidered vaginal. ICD-9-CM codeswere used for identifying women whohad an instrumental vaginal delivery andthe subset with a midpelvic forceps de-livery (Appendix Table 1).Womenwith adiagnosis of pelvic floor trauma duringthe delivery hospitalization, includingthird- and fourth-degree perineal lacer-ation, anal sphincter tear, obstetriclaceration of cervix, and high vaginallaceration were also identified usingICD-9-CM diagnostic codes 664.2,664.3, 664.6, 665.3, and 665.4, respec-tively. In addition, we examined tem-poral changes in the rates of prolongedlabor, identified on hospital discharge

abstracts by ICD-9-CM diagnostic codes662.20, 662.21, 662.22, and 662.23.ICD-9-CM procedure and diagnostic

codes were also used to identify inpatientsurgery related to pelvic organ prolapseamong all women in the ComprehensiveDischarge Abstract Database (AppendixTable 2). This included prolapse sur-gery among all women 20-84 years ofage. Among women with multiple sur-geries for the same indication, only thefirst surgery was used to calculate rates(identified though an internal linkage ofhospital records). US census data forWashington State for the years 1990through 2000 and yearly intercensal age-specific population estimates for womenwere used to calculate population ratesof cesarean and vaginal delivery, instru-mental vaginal delivery, pelvic floorinjury during childbirth, and surgery forpelvic organ prolapse. For calculation ofthe overall rates of childbirth-relatedevents, the number of women aged15-44 years residing in Washington Statewas used as the denominator, while forcalculation of surgery for pelvic organprolapse, the number of women aged20-84 years was used.We used age-period-cohort ana-

lyses26,27 to analyze temporal changes inthe rates of childbirth-related events andpelvic organ prolapse surgery amongvarious birth cohorts of women. Suchanalyses are important for describing theeffects of age, period, and birth cohortsimultaneously, as age effects can beconfounded if period and/or cohorteffects occur. Thus in our analyses,women aged 20 years in 1990 belongedto the cohort of women born in 1970.This cohort of women may have expe-rienced the events of interest as 25-year-old women during the period 1995,and as 30-year-old women during theyear 2000.Age-period-cohort effects on pelvic

organ prolapse surgery weremodeled foreach year from 1990 through 2009. Asage, period, and cohort are linearlydependent (cohort ¼ period-age), weused a regression model that first esti-mated an overall linear trend in surgeryrates that reflected the sum of period andcohort effects (a drift parameter).28,29

Deviation from linearity uniquely

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attributable to period and cohort effectswas then modeled to estimate indepen-dent period and cohort effects. Theseestimates of curvature, or deviationsfrom linearity, were interpreted as ameasure of change in the linear trend forperiod and cohort.

Temporal trends were assessed usingthe Cochran-Armitage test for a lineartrend in proportions. Pearson correla-tion coefficients were used to assess thecorrelation between the rates of obstetricevents among women 15-44 years old inthe years from 1987 through 1999 andthe rates of prolapse surgery 10 yearslater (from 1997 through 2009) amongwomen aged 25-54 years. In addition,temporal trends in the number ofbirths to primiparous women wereexamined to assess the potential effect ofchanges in parity. Data on the number ofbirths by birth order and maternal agewere obtained for years 1990 through2009 from the Washington StateDepartment of Health. Information onthe total number of first births per yearfrom 1987 through 2009 was also avail-able from public vital statistics files(through the Washington State Depart-ment of Health).

Sensitivity analyses were carried out toexamine the potential impact of changesin insurance status among women withsurgery for pelvic organ prolapse. Thedistribution and types of primary payerswere evaluated to assess if changesin medical insurance contributed totemporal changes in the number ofprocedures performed.

Since all analyses were performed onpublicly accessible deidentified data, anexemption from ethics approval wasgranted by the Department of Social andHealth Services, State of Washington.Analyses were carried out using software(SAS, Version 9.3; SAS Institute Inc,Cary, NC). Age-period-cohort modelswere fitted using the apc.fit function inthe Epi package of the R program(Version 2.14.2).

ResultsThe number of women aged 15-84 yearsin Washington State increased from1,769,357 in 1987 to 2,634,461 in 2009.The number of women aged 15-44 years

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Original Research GYNECOLOGY ajog.org

also increased from 1,093,389 in 1987 to1,352,302 in 2009.

Obstetric eventsWhile population rates of vaginal de-livery remained relatively stable duringthis period (approximately 45 per 1000women aged 15-44 years), the rate ofcesarean delivery increased from 12.7per 1000 women aged 15-44 years in1987 to 18.1 per 1000 women in 2009.During this period, the rate of instru-mental vaginal delivery decreased from6.3 in 1987 to 3.9 per 1000 women aged15-44 years in 2009, midpelvic forcepsuse declined sharply from 4.1-0.1 per10000 women aged 15-44 years, whilethe rate of obstetric trauma declinedfrom 6.7-2.5 per 1000 women aged15-44 years (P value for linear trend<.001 for all trends). These proportionswere calculated using all women (preg-nant and nonpregnant) in the denomi-nator to allow comparisons with rates ofprolapse surgery and differ from ratescalculated using a denominator of preg-nant women only (which would producemore commonly reported rates). In factrates calculated using pregnant womenin the denominator yielded cesareandelivery rates that increased from 22.1%in 1987 to 29.8% in 2009, instrumentalvaginal delivery rates that decreasedfrom 10.9-6.4%, and midpelvic forcepsdelivery rates that declined sharply from0.7-0.1%. The rate of perineal traumadeclined from 27.5% in 1987 to 15.0% in2009 among women with instrumentalvaginal delivery, and from 12.9 to 4.9%among women with noninstrumentalvaginal delivery. The rate remainedrelatively stable among those with mid-pelvic forceps delivery (average 35.5%).There was a strong correlation betweentemporal declines in rates of instru-mental vaginal delivery and temporaldeclines in obstetric trauma (correlationcoefficient 0.93, P < .001).

Analysis by birth cohort (Figure 1)showed that each cohort experiencedsimilar rates of vaginal delivery, while theyounger cohorts (born from 1970through 1985) were more likely toexperience a cesarean delivery at ages�25 years. Successive cohorts of womenhad lower rates of instrumental delivery,

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especially midpelvic forceps delivery,and lower rates of obstetric traumacompared with older cohorts. The rate ofmidpelvic forceps delivery and obstetrictrauma declined for each successivecohort, particularly those born in�1970, and a similar decline wasobserved for prolonged labor amongwomen born in �1975.

Surgery for pelvic organ prolapseThe rate of surgery for pelvic organprolapse remained relatively stable from1987 through 1998 and then decreasedfrom 2.1 in 1998 to 1.4 per 1000 womenaged 20-84 years in 2009 (Figure 2, A).Age-specific incidence rates of surgeryfor pelvic organ prolapse showed abimodal distribution, with a smallerpeak at age 45-54 years, especially from1990 through 1994, and a larger peak atage 70-74 years; this peak shifted to65-69 years in later years (2005 through2009). A temporal decline in surgery forpelvic organ prolapse was observed forall age groups (Figure 2, B).Women in each subsequent birth

cohort were less likely to experiencesurgery for pelvic organ prolapsecompared with earlier cohorts (Figure 2,C). This was apparent mainly amongwomen born from 1920 through 1934,to a lesser extent in the cohort born in1935 through 1939, and from 1940through 1969. In general, each successivecohort had a lower rate of surgerycompared with earlier cohorts, with theexception of women aged 70-75 yearsborn in 1920 through 1924, women aged60-64 years born in 1930 through 1934,and women aged 50-54 years old born in1935 through 1939, who did not expe-rience lower rates of surgery comparedto the previous cohort of women of thesame age.

Age-period-cohort analysisRegression models revealed a large ageeffect, with a steep increase in the rate ofprolapse surgery between 20-45 years ofage from <0.05% to approximately0.4%. This was followed by a plateau insurgery rates, another increase from age60-71 years, and then a decline in rates ofprolapse surgery (Figure 3). The birthcohort effect was less pronounced,

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although a progressively lower rate ofprolapse surgery was evident amongyounger cohorts (born in �1965) ascompared with those born in 1945. Theperiod effect (ie, rate ratio of prolapsesurgery by calendar year) showed thatthere was a gradual decline in prolapsesurgery rates from 1990 through 2009(Figure 3).

Correlation between obstetrictrauma and surgery for pelvicorgan prolapseThe rates of obstetric trauma and therates of midpelvic forceps delivery ineach year from 1987 through 1999 werehighly correlated with the rates of pro-lapse surgery 10 years later (from 1997through 2009) among women aged25-54 years: correlation coefficients (r)were 0.87 and 0.72, respectively, bothP values <.01 (Figure 4).

Potential effects of temporalchanges in insurance and paritySensitivity analysis showed that the dis-tribution and types of primary payers forsurgery hospitalization did not changeappreciably during the study period.The largest proportion of hospitaliza-tions for pelvic organ prolapse wascovered through commercial insurance(21-32%), health care service contrac-tors (22-30%), and Medicare (24-30%).The first-birth rates per 100 women aged15-44 years were essentially stable from1987 through 2009, changing onlyslightly from 2.6 per 100 women in 1987to 2.8 per 100 women in 2009. Thisrepresents an increase in the proportionof first births from 44.4% of all births in1987 to 45.5% of all births in 2009. Thefirst-birth rate declined among womenaged 15-24 years and increased inwomen 25-44 years old (AppendixFigure 1 and Appendix Table 3). Therates of birth to grand-multiparas(fourth or subsequent birth) were alsostable, within the range from 0.69 per100 women in 1990 to 0.74 per 100women in 2009.

CommentThis study showed a temporal increase inthe population rates of cesarean deliveryand a concurrent decline in the

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FIGURE 1Birth cohort effects associated with obstetric events

Rates of vaginal delivery, cesarean delivery, instrumental vaginal delivery, midpelvic forceps delivery, obstetric trauma, and prolonged labor by birthcohort, Washington State, 1990 through 2009. Birth cohorts include women born at specific time periods from 1960-64 to 1980-84.

Lisonkova et al. Obstetric trauma and pelvic organ prolapse. Am J Obstet Gynecol 2016.


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FIGURE 2Trends in surgery for pelvic organ prolapse

Washington State rates of surgery for pelvic organ prolapse by A, calendar year; B, age; and C, birthcohort. A, 1987 through 2009. B and C, 1990 through 2009.Lisonkova et al. Obstetric trauma and pelvic organ prolapse. Am J Obstet Gynecol 2016.


population rate of instrumental vaginaldelivery and obstetric trauma in Wash-ington State from 1987 through 2009.Rates of cesarean delivery increased, andrates of instrumental vaginal delivery,including midpelvic forceps delivery,


prolonged labor and obstetric traumadeclined for each subsequent birthcohort, particularly for women bornin 1970 or later. Age-period-cohortregression analysis showed that youngercohorts of women born >1965 had

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lower rates of surgery for pelvic organprolapse and rates of prolapse surgerydeclined from 1990 through 2009. Pop-ulation rates of obstetric trauma in 1987through 1999 were strongly correlatedwith population rates of surgery forpelvic organ prolapse in 1997 through2009 (correlation coefficient 0.87,P < .01).

The rates of surgery for pelvic organprolapse in our study are consistentwith findings based on the US NationalHospital Discharge Survey, whichshowed that age-adjusted rates of inpa-tient prolapse procedures (including allhysterectomies irrespective of indica-tion) declined significantly from 2.9 in1997 to 1.5 per 1000 women in 2006.30

The temporal trends in the rates ofvaginal delivery, cesarean delivery, andinstrumental vaginal delivery observedin our study were comparable with thoseobserved in other studies.31

There is substantial epidemiologicalevidence for the association betweenvaginal delivery and pelvic floor disor-ders, including evidence from case-control and cohort studies.6-19,32,33 Arecent population-based study showed a70% reduced lifetime risk of pelvic floorsurgery among women who deliveredexclusively by cesarean in 1970 or latercompared with women who had vaginaldeliveries. Similarly, women who had atleast 1 perineal laceration or forcepsdelivery had an increased risk of pelvicfloor surgery.33 A cohort study including>1000 women followed for 5-10 yearsafter their first delivery found a 5-foldincreased risk of prolapse amongwomen who delivered vaginally ascompared with those who delivered bycesarean without labor.18 In this study,instrumental vaginal delivery increasedthe risk of prolapse 7-fold.18 In ourstudy, the age-period-cohort modelshowed that age had the largest effect onpelvic organ prolapse surgery; ratespeaked at 45 years of age with a second,higher peak around 70 years of age. Theanalysis also revealed that more recentbirth cohorts of women were at lowerrisk of surgery as compared with thoseborn in 1945, suggesting that lower ratesof midpelvic forceps delivery and ob-stetric trauma in these cohorts may have

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FIGURE 3Age-period-cohort analysis of pelvic organ prolapse surgery

Age-period-cohort analysis of pelvic organ prolapse surgery among women 20-84 years old, Washington State, 1990 through 2009. The first panel (left)shows the effect of age expressed as increasing rate of prolapse surgery; the second panel (middle) shows the birth cohort effect expressed as rate ratiocompared with the reference cohort of women born in 1945; and the third panel (right) shows the period effect (time trend) expressed as rate ratiocompared with the reference year 1990.



contributed to lower rates of pelvic or-gan prolapse surgery. The earlier cohorts(born in 1905 through 1925) showedlower rates of surgery as compared tothose born in 1945; this may have beendue to a lesser tendency to seek surgicaltreatment among the oldest generationof women. Our findings, however, donot indicate that the population preva-lence of pelvic floor disorders willnecessarily decline in the future. With ademographic shift toward a higher pro-portion of older women in the popula-tion, the demand for such surgery mayactually increase, as older women havethe highest prevalence of this disorder.34

Limitations of the studyBefore the findings can be interpretedwithin the context of other studies, a fewlimitations of the data merit somediscussion. Importantly, we includedwomen with pelvic organ prolapse whorequired inpatient surgery only. Studiesshow that the burden of this disorder is

larger, as an estimated 3% of womenexperience symptoms of pelvic organprolapse.6,35 A recent study showed thatapproximately 16% of procedures forpelvic organ prolapse were performed inambulatory settings in California in2008.36 Extreme assumptions regardingoutpatient surgery (ie, no surgery vs 16%of prolapse surgery performed outsidehospital in 1987 and in 2009, respec-tively) show that a shift to outpatientprocedures could potentially account forapproximately 32% of the observeddecline in surgery for pelvic organ pro-lapse in our study. As mentioned, this isan extreme estimate as the number ofwomen undergoing ambulatory pro-cedures in the United States has beenrelatively stable from 1996 through2006.37 Second, we did not have infor-mation on the number of repeat vaginaland cesarean deliveries and only limitedinformation on parity. The populationchanges in parity (first-time births,births to grand-multiparas) provide little

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evidence to suggest that temporalchanges in this factor were critical ininfluencing rates of pelvic organ pro-lapse. Data on temporal trends in thefirst-birth rate showed a decline amongyoung women and an increase amongolder women. This corresponds with thetrend toward delayed childbearing,38-40

increased cesarean delivery rates,25,41

and decline in total fertility rates.25

These temporal changes may (or maynot) have contributed to the decline insurgery for pelvic organ prolapse. Wewere unable to include data on womenwho delivered at home or out of state.This proportion, however, is likely to besmall and unlikely to substantially in-fluence our findings. In addition, thechildbearing experience of women whoimmigrated to Washington State withchildren was not accounted for in thisstudy. Finally, the accuracy of the datawas dependent on the quality of thecoding, although coding errors for majorprocedures have been reportedly small.42


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FIGURE 4Correlation between the rates of obstetric trauma, mid-pelvic forceps, andthe rates of pelvic organ prolapse surgery

Correlation between A, rates of obstetric trauma among women age 15-44 years in 1987 through1999 and rates of surgical procedure for pelvic organ prolapse among women age 25-54 years in1997 through 2009, and between B, rates of midpelvic forceps delivery in 1987 through 1999 andrates of surgical procedure for pelvic organ prolapse in 1997 through 2009. Dots represent years.Washington State, 1987-2009.



Since we utilized aggregate-level datain our analyses, our findings are poten-tially subject to the ecological fallacy, abias that can occur when inferencesbased on group-level associations areapplied to individuals. However, a sub-stantial body of previous research dem-onstrates individual-level associationsbetween obstetric trauma and pelvicfloor disorders, and our results merely


quantify these findings on a populationlevel.

Strengths of the studyThe strengths of our study include itspopulation-based nature, with outcomesobtained from hospital admissionscollected in a consistent manner over anextended period of time using ICD-9-CM. In contrast to similar population-

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based studies, we were able to excludeall rehospitalizations for the same sur-gery or indication (pelvic organ pro-lapse); the reoperation rate for pelvicorgan prolapse is estimated to be be-tween 17-30%,6,43 and this can artifi-cially inflate the population rate of suchsurgery if repeat surgeries are counted.We were also able to show that thetemporal trends in pelvic organ prolapsesurgery were likely not influenced bytemporal changes in medical insurance.

ConclusionsThe temporal decline in operativevaginal delivery and obstetric trauma inprevious decades was associated withsubsequent reductions in surgical inpa-tient procedures for pelvic organ pro-lapse. This adds to the epidemiologicalevidence of an association betweeninstrumental vaginal delivery and ob-stetric trauma and subsequent pelvicorgan prolapse. n

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Author and article informationFrom the Department of Obstetrics and Gynecology

(Drs Lisonkova, Cundiff, and Joseph) and School of

Population and Public Health (Ms Muraca and Dr Joseph),

University of British Columbia, and the Children’s and

Women’s Hospital and Health Center of British Columbia

(Drs Lisonkova, Cundiff, and Joseph), Vancouver, British

Columbia, Canada; Department of Obstetrics and Gyne-

cology, College of Physicians and Surgeons (Dr Ananth)

and Department of Epidemiology, Mailman School of

Public Health (Ms Lavery and Dr Ananth), Columbia

University, New York, NY; and Department of Obstetrics

and Gynecology, University of Ottawa, Ottawa, Ontario,

Canada (Dr Chen).

Received Sept. 23, 2015; revised Jan. 29, 2016;

accepted Feb. 9, 2016.

This study was supported by a Canadian Institutes of

Health Research (CIHR) Team grant in severe maternal

morbidity (MAH-115445). G.M. is supported by a Vanier

Canada Graduate Scholarship from CIHR. K.S.J. holds a

CIHR Chair in maternal, fetal, and infant health services

research and his work is also supported by the Child and

Family Research Institute.

The authors report no conflict of interest.

Corresponding author: Sarka Lisonkova, MD, PhD.

[email protected]














































































































































mailto:[email protected]

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APPENDIX FIGURE 1Birth cohort effect on first-birth rates

First-birth rates per 1000 women aged 15-44 years by birth cohort, Washington State, 1990through 2009. Birth cohorts include women born at specific time periods from 1960-64 to 1980-84.




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APPENDIX TABLE 1Diagnostic and procedure codes to identify childbirth hospitalization

Diagnosis ICD-9-CM code

Outcome of delivery V27

Normal delivery 65

Complication mainly related to pregnancya 64

Normal delivery and other indications for care in pregnancy,labor, and deliverya

65

Complications occurring mainly in course of labor and deliverya 66

Procedure ICD-9-CM code

Forceps, vacuum, and breech delivery 72

Other procedures assisting or inducing delivery 73

Cesarean delivery and removal of fetus 74

Repair of current obstetrics laceration of uterus 75.5

Repair of current obstetric laceration 75.6

Obstetric tamponade of uterus or vagina 75.8

Other obstetric operations 75.9

ICD-9-CM, International Classification of Diseases, Ninth Revision, Clinical Modification.

a Only with fifth digit 1 or 2 (delivered with or without mention of antepartum or postpartum condition).




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APPENDIX TABLE 2Surgical procedures for pelvic organ prolapse

Surgical procedure for pelvic organ prolapse ICD-9-CM code

Anterior and posterior colporrhaphy 70.5

Anterior colporrhaphy 70.51

Posterior colporrhaphy 70.52

Repair of cystocele and rectocele with graft or prosthesis 70.53

Repair of cystocele with graft or prosthesis 70.54

Repair of rectocele with graft or prosthesis 70.55

Other operations on vaginaa 70.91

Other repair of vaginaa 70.79

Other uterine suspension 69.22

Other repair of uterus/supporting structuresa 69.29

Vaginal suspension/fixation of vagina 70.77

Vaginal suspension and fixation with graft or prosthesis 70.78

Other operations on cul-de-sac (includes enterocelerepair and cul-de-sac obliteration)

70.92

Vaginal hysterectomya 68.5

Subtotal hysterectomya 68.3

Total abdominal hysterectomya 68.4

Laparoscopically assisted vaginal hysterectomya 68.51

LeFort operation 70.8

Obliteration and total excision of vaginaa 70.4

Other and unspecified hysterectomya 68.9

Other vaginal hysterectomya 68.59

Watkins procedure 69.21

Vaginal repair of chronic inversion of uterus 69.23

ICD-9-CM, International Classification of Diseases, Ninth Revision, Clinical Modification.

a Included only with concomitant International Classification of Diseases, Ninth Revision diagnosis for pelvic organ prolapse(618.0e618.6, 618.8, 618.9).




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APPENDIX TABLE 3Temporal trends in age-specific rates of first birth to women 15e44 years old, Washington State, 1990 through 2009

Age, y

Year

Rate ratio (95% CI)1990 through 1994 1995 through 1999 2000 through 2004 2005 through 2009

15e19 42.6 28.8 28.0 26.4 0.62 (0.61e0.63)

20e24 58.1 52.4 50.7 49.0 0.84 (0.83e0.85)

25e29 41.6 41.6 39.8 47.7 1.15 (1.13e1.16)

30e34 23.2 22.3 28.6 31.4 1.35 (1.33e1.38)

35e39 8.2 8.3 10.3 13.2 1.62 (1.58e1.66)

40e44 1.4 1.7 2.0 2.4 1.65 (1.54e1.76)




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original research ajog - connecting repositoriesvaginal delivery rates remained stable, and...

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