A Systematic Evaluation of Hospital Performance of Childbirth Delivery Modes and Associated Factors in the Friuli Venezia Giulia Region (North-Eastern Italy), 2005–2015

Abstract

Cesarean sections (CS) have become increasingly common in both developed and developing countries, raising legitimate concerns regarding their appropriateness. Since improvement of obstetric care at the hospital level needs quantitative evidence, using routinely collected health data we contrasted the performance of the 11 maternity centres (coded with an alphabetic letter A to L) of an Italian region, Friuli Venezia Giulia (FVG), during 2005–15, after removing the effect of several factors associated with different delivery modes (DM): spontaneous vaginal delivery (SVD), instrumental vaginal delivery (IVD), overall CS (OCS) and urgent/emergency CS (UCS). A multivariable logistic regression model was fitted for each individual DM, using a dichotomous outcome (1 = each DM; 0 = rest of hospital births) and comparing the stratum specific estimates of every term with their respective reference categories. Results were expressed as odds ratios (OR) with 95% confidence intervals (95%CI). The Benjamini-Hochberg (BH) false discovery rates (FDR) approach was applied to control alpha error due to the large number of statistical tests performed. In the entire FVG region during 2005–2015, SVD were 75,497 (69.1% out of all births), IVD were 7,281 (6.7%), OCS were 26,467 (24.2%) and UCS were 14,106 (12.9% of all births and 53.3% out of all CS). SVD were more likely (in descending order of statistical significance) with: higher number of previous livebirths; clerk/employed occupational status of the mother; gestational age <29 weeks; placentas weighing <500 g; stillbirth; premature rupture of membranes (PROM). IVD were predominantly more likely (in descending order of statistical significance) with: obstructed labour, non-reassuring fetal status, history of CS, labour analgesia, maternal age ≥35 and gestation >40 weeks. The principal factors associated with OCS were (in descending order of statistical significance): CS history, breech presentation, non-reassuring fetal status, obstructed labour, multiple birth, placental weight ≥ 600 g, eclampsia/pre-eclampsia, maternal age ≥ 35 and oligohydramnios. The most important risk factors for UCS were (in descending order of statistical significance): placenta previa/abruptio placenta/ antepartum hemorrage; non-reassuring fetal status, obstructed labour; breech presentation; PROM, eclampsia/pre-eclampsia; gestation 33–36 weeks; gestation 41+ weeks; oligohydramnios; birthweight <2,500 g, maternal age ≥ 35 and cord prolapse. After removing the effects of all other factors, we found great variability of DM rates across hospitals. Adjusting for all risk factors, all hospitals had a OCS risk higher than the referent (hospital G). Out of these 10 hospitals with increased adjusted risk of OCS, 9 (A, B, C, D, E, F, I, J, K) performed less SVD and 5 (A, C, D, I, J) less IVD. In the above 5 centres CS was therefore probably overused. The present study shows that routinely collected administrative data provide useful information for health planning and monitoring. Although the overall CS rate in F...

Understanding Factors Leading to Primary Cesarean Section and Vaginal Birth After Cesarean Delivery in the Friuli-Venezia Giulia Region (North-Eastern Italy), 2005–2015

“…The calculation of the PPCS rate may have been slightly inflated, since the respective numerator obtained from CEDAP comprised both planned CS and CS performed after failed induction, distinguished categories which were impossible to disentangle though. However, the crude rate of labour induction was 15.6% out of all births in FVG during 2005-2015 14 , hence the impact of CS for induction failure on the calculation of the PPCS rate was likely marginal in our study.…”

“…Strengths of this study have been reported elsewhere 13,14,44 . There are, however also some limitations.…”

“…CS should therefore be performed only if clinically indicated, especially considering also the associated enhanced health care costs as compared to a vaginal delivery (VD) 1,[13][14][15][16] . In Ireland it was estimated that a planned CS costs 739 € more than a VD, and an urgent/emergency CS (UCS) is 1,180€ more expensive than a VD 16 .…”

“…The database we analyzed included information from two sources: hospital discharge forms (ICD-9 codes) and the Certificate of Delivery Care (CEDAP, Italian acronym), a formatted questionnaire collecting clinical and personal information on women and newborns (supplementary file) 13,14,44 .…”

“…• Since shoulder presentation is incompatible with SVD, and its management by IVD is an exceptional procedure, 39 shoulder presentations delivering by SVD and 1 shoulder presentation delivering by IVD were reclassified as cephalic; • Differently from a previous study using the same database 14 , placenta previa/abruptio placenta/ante-partum hemorrage delivering by SVD (N = 133) and by IVD (N = 22) were retained in the analysis.…”