Interinstitutional Variation of Caesarean Delivery Rates According to Indications in Selected Obstetric Populations: A Prospective Multicenter Study

Abstract

The aim of the study was to identify which groups of women contribute to interinstitutional variation of caesarean delivery (CD) rates and which are the reasons for this variation. In this regard, 15,726 deliveries from 11 regional centers were evaluated using the 10-group classification system. Standardized indications for CD in each group were used. Spearman's correlation coefficient was used to calculate (1) relationship between institutional CD rates and relative sizes/CD rates in each of the ten groups/centers; (2) correlation between institutional CD rates and indications for CD in each of the ten groups/centers. Overall CD rates correlated with both CD rates in spontaneous and induced labouring nulliparous women with a single cephalic pregnancy at term (P = 0.005). Variation of CD rates was also dependent on relative size and CD rates in multiparous women with previous CD, single cephalic pregnancy at term (P < 0.001). As for the indications, “cardiotocographic anomalies” and “failure to progress” in the group of nulliparous women in spontaneous labour and “one previous CD” in multiparous women previous CD correlated significantly with institutional CD rates (P = 0.021, P = 0.005, and P < 0.001, resp.). These results supported the conclusion that only selected indications in specific obstetric groups accounted for interinstitutional variation of CD rates.

Understanding inappropriateness in health spending: The role of regional policies and institutions in caesarean deliveries

“…As observed by Maso et al (2013b), this means that there are variations in clinical evaluation and management of risk factors in deliveries. These variations might be related either to differences across care givers (for instance, different physicians might evaluate dystocia in different ways), or to differences in hospital practices and organization.…”

“…First, by taking an aggregate approach, it adds to patient level studies on the determinants of caesarean deliveries (see, e.g., recent examples of different approaches in Maso et al, 2013a;Maso et al, 2013b;Bragg et al 2010;Dranove and Watanabe, 2010;Ecker and Frigoletto, 2007;Fantini et al, 2006;Baicker et al, 2006;Johanson et al, 2006). Second, proposing an analysis at the regional level, the present work is also related to papers on regional variations in health care and in medical practice (e.g., Skinner, 2012, andChandra et al, 2012 for recent surveys).…”

“…For instance, obesity, chronic hypertension, gestational diabetes are all clinical conditions used in the medical literature to adjust observed caesarean sections for risk, and to define the quality of obstetric care (see, e.g., recent works by Maso et al, 2013a;Maso et al, 2013b;Fantini et al, 2006;Bragg et al 2010 ). All these factors have deteriorated in recent decades.…”

“…The variables that have been identified as risk factors in the choice of a caesarean delivery by the medical literature based on Italian microdata (e.g., Maso et al, 2013a;Maso et al, 2013b;Fantini et al, 2006) include both foetus characteristics (like malposition/malpresentation and weight), and mother characteristics (like ante-partum haemorrhage, APH, umbilical cord prolapse, UCP, but also age, past experience of a caesarean section, and lifestyle habits). However, the literature makes clear that, even controlling for these risk factors, differences across hospitals still persist.…”

Interinstitutional variations in mode of birth after a previous caesarean section: a cross-sectional study in six German hospitals

“…Not only national variations in caesarean section rates have been noted [8,34,40], regional variations within countries and interinstitutional variations have been observed as well [2,15,25,28,30,31,36]. As a consequence, when interinstitutional variations in caesarean sections rates [2,30] are analysed, variations in regional patterns [15,28,31] need to be taken into account. For example, the caesarean section rate in the states of eastern Germany has always been much lower than in western Germany (22% vs. 30% [31]).…”