National Variation in Caesarean Section Rates: A Cross Sectional Study in Ireland.

Richard Layte,Nathan Cunningham,Sarah-Jo Sinnott,Aoife Brick,Michael J. Turner

doi:10.1371/journal.pone.0156172

Abstract

ObjectiveInternationally, caesarean section (CS) rates are rising. However, mean rates of CS across providers obscure extremes of CS provision. We aimed to quantify variation between all maternity units in Ireland.MethodsTwo national databases, the National Perinatal Reporting System and the Hospital Inpatient Enquiry Scheme, were used to analyse data for all women delivering singleton births weighing ≥500g. We used multilevel models to examine variation between hospitals in Ireland for elective and emergency CS, adjusted for individual level sociodemographic, clinical and organisational variables. Analyses were subsequently stratified for nullipara and multipara with and without prior CS.ResultsThe national CS rate was 25.6% (range 18.2% ─ 35.1%). This was highest in multipara with prior CS at 86.1% (range 6.9% ─ 100%). The proportion of variation in CS that was attributable to the hospital of birth was 11.1% (95% CI, 6.0 ─ 19.4) for elective CS and 2.9% (95% CI, 1.4 ─ 5.6) for emergency CS, after adjustment. Stratifying across parity group, variation between hospitals was greatest for multipara with prior CS. Both types of CS were predicted by increasing age, prior history of miscarriage or stillbirth, prior CS, antenatal complications and private model of care.ConclusionThe proportion of variation attributable to the hospital was higher for elective CS than emergency CS suggesting that variation is more likely influenced by antenatal decision making than intrapartum decision making. Multipara with prior CS were particularly subject to variability, highlighting a need for consensus on appropriate care in this group.

Highlights

The rate of caesarean section (CS) has risen steadily and substantially in recent decades
The proportion of variation in CS that was attributable to the hospital of birth was 11.1% for elective CS and 2.9% for emergency CS, after adjustment
The proportion of variation attributable to the hospital was higher for elective CS than emergency CS suggesting that variation is more likely influenced by antenatal decision making than intrapartum decision making

Summary

Introduction

The rate of caesarean section (CS) has risen steadily and substantially in recent decades. Across Organisation for Economic Co-operation and Development (OECD) countries, the average rate of CS is at one in four births, an increase from one in five in 2010.[1]. The World Health Organisation has estimated the global cost of “excess” CS to be $2.3 billion dollars.[7]. Adding to this concern is recent evidence that highlights the wide variation in CS rates both between and within countries. The extremes of CS provision are a more useful indicator of obstetric performance and quality, as we have previously highlighted.[10] Second, variation within countries points to a lack of consensus on what CS rates should be. The issue of quality of care is implied given the absence of a standardised approach

Results

Discussion

Conclusion