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To the Editor: A recent study¹ in Washington State found that cesarean and instrumental delivery increased the risks of maternal postpartum rehospitalization among primiparous women. The generalizability of the findings to women of greater parity and in other geographic areas is unknown. Furthermore, the relative risks associated with vacuum delivery remain unknown.¹ Vacuum delivery is considered by some to be relatively safe compared with forceps²; thus, the reported increased risk of rehospitalization among women with instrumental vaginal deliveries may have been primarily due to the use of the latter. We sought to estimate and compare the risks of rehospitalization following cesarean, forceps-assisted, vacuum-assisted, and spontaneous vaginal deliveries among residents of a major urban area in the northeastern United States.

Methods
The data source for the study was the Philadelphia Perinatal Database. The database, which has been described elsewhere,³ contains merged elements from hospital discharge and birth certificate records for 85% of all live births (n = 82 264) in 1994-1997 among Philadelphia residents. This study was limited to singleton births and infants weighing 1500 to 4500 g. As in the study of Lydon-Rochelle et al,¹ women with morbidities most likely to increase the risk for rehospitalization and influence delivery mode were excluded. Logistic regression (adjusted odds ratios) was used to estimate the relative risks for rehospitalization within 60 days of discharge for the final study sample (n = 74 888).

Results
The overall rehospitalization rate was 21.6 per 1000 births. The RRs for rehospitalization were higher for cesarean and instrumental as opposed to spontaneous vaginal deliveries, in magnitudes similar to those reported by Lydon-Rochelle et al (Table 1). Moreover, both vacuum-assisted and forceps-assisted deliveries had higher relative risks than did spontaneous vaginal deliveries. Subanalyses of the data further excluding women with other complicating diagnoses (including all those assigned to a Diagnostic Related Group of 370 or 372, indicating any major complicating condition) yielded very similar results, suggesting that the observed relationships were unrelated to antenatal morbidity factors.

View this table: [in this window] [in a new window] Table. Rehospitalization Following Discharge After Delivery, by Delivery Mode: Philadelphia Resident Live Births, 1994-1997*

Comment
These findings confirm and complement those of Lydon-Rochelle et al, indicating differential morbidity associated with method of delivery, serious enough to warrant rehospitalization following childbirth. Hence, they underscore the need to avoid unnecessary cesarean delivery and, in cases where it is necessary, to adhere to those practices shown to prevent postoperative infection and other cesarean-related morbidity. Moreover, the results suggest that, while vacuum extraction may be the preferred option when instrumental delivery is indicated,² neither procedure should be considered risk free.^4-5

David A. Webb, PhD; Jessica M. Robbins, PhD
Philadelphia Department of Public Health
Philadelphia, Pa

1. Lydon-Rochelle M, Holt VL, Martin DP, Easterling TR. Association between method of delivery and maternal rehospitalization. JAMA. 2000;283:2411-2416. FREE FULL TEXT 2. Johanson RB, Menon BK. Vacuum extraction versus forceps for assisted vaginal delivery. Cochrane Database Syst Rev. 2000;(2):CD000224. 3. Webb D, Culhane JF, Snyder S, Greenspan J. Pennsylvania's early discharge legislation: effect on maternity and infant lengths of stay and hospital charges in Philadelphia. Health Serv Res. 2001;36:1073-1083. WEB OF SCIENCE | PUBMED 4. Drife JO. Choice and instrumental delivery. Br J Obstet Gynaecol. 1996;103:608-611. PUBMED 5. Lucas MJ. The role of vacuum extraction in modern obstetrics. Clin Obstet Gynecol. 1994;37:794-805. PUBMED

Letters Section Editor: Stephen J. Lurie, MD, PhD, Senior Editor.

JAMA. 2003;289:46-47.

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