Abstract
BackgroundAlthough the evaluation of caesarean delivery rates has been suggested as one of the most important indicators of quality in obstetrics, it has been criticized because of its controversial ability to capture maternal and neonatal outcomes. In an “ideal” process of labor and delivery auditing, both caesarean (CD) and assisted vaginal delivery (AVD) rates should be considered because both of them may be associated with an increased risk of complications.The aim of our study was to evaluate maternal and neonatal outcomes according to the outlier status for case-mix adjusted CD and AVD rates in the same obstetric population.MethodsStandardized data on 15,189 deliveries from 11 centers were prospectively collected. Multiple logistic regression was used to estimate the risk-adjusted probability of a woman in each center having an AVD or a CD. Centers were classified as “above”, “below”, or “within” the expected rates by considering the observed-to-expected rates and the 95% confidence interval around the ratio. Adjusted maternal and neonatal outcomes were compared among the three groupings.ResultsCenters classified as “above” or “below” the expected CD rates had, in both cases, higher adjusted incidence of composite maternal (2.97%, 4.69%, 3.90% for “within”, “above” and “below”, respectively; p = 0.000) and neonatal complications (3.85%, 9.66%, 6.29% for “within”, “above” and “below”, respectively; p = 0.000) than centers “within” CD expected rates. Centers with AVD rates above and below the expected showed poorer and better composite maternal (3.96%, 4.61%, 2.97% for “within”, “above” and “below”, respectively; p = 0.000) and neonatal (6.52%, 9.77%, 3.52% for “within”, “above” and “below”, respectively; p = 0.000) outcomes respectively than centers with “within” AVD rates.ConclusionsBoth risk-adjusted CD and AVD delivery rates should be considered to assess the level of obstetric care. In this context, both higher and lower-than-expected rates of CD and “above” AVD rates are significantly associated with increased risk of complications, whereas the “below” status for AVD showed a “protective” effect on maternal and neonatal outcomes.
Highlights
The evaluation of caesarean delivery rates has been suggested as one of the most important indicators of quality in obstetrics, it has been criticized because of its controversial ability to capture maternal and neonatal outcomes
Quality of care is an important topic in modern obstetrics of which risk-adjusted caesarean delivery (CD) rate is often used as an indicator, with the implicit assumption that low rates may reflect evidence-based intervention [1,2,3,4,5,6,7,8]
Distributions of non-missing independent variables and CD/assisted vaginal delivery (AVD) rates were similar across the analyzed and the excluded records
Summary
The evaluation of caesarean delivery rates has been suggested as one of the most important indicators of quality in obstetrics, it has been criticized because of its controversial ability to capture maternal and neonatal outcomes. The evaluation of risk-adjusted CD rates is an important factor in quality assessment, it is just one of the elements to be considered in the process of labor and delivery auditing. In this regard, a comprehensive assessment should encompass both maternal and neonatal outcomes according to mode of delivery [4]. Several studies focused on the association between institutional adjusted CD rates and outcomes reporting controversial results In their retrospective cohort study on 748,604 low risk singleton pregnancies, Gould et al observed that neonatal morbidity (birth asphyxia and intensive caretherapeutic interventions) was increased both in low- and high-CD rate hospitals [5]. Their conclusion was that lower-than-expected risk-adjusted CD rates were associated with an increased risk of maternal or neonatal complications and that above than expected risk-adjusted CD rates did not result in improved outcomes [8]
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