Abstract
BackgroundRising national cesarean section rates (CSRs) and unexplained inter-hospital differences in CSRs, led national and international bodies to select CSR as a quality indicator. Using hospital discharge abstracts, we aimed to document in Belgium (1) inter-hospital differences in CSRs among low risk deliveries, (2) a national upward CSR trend, (3) lack of better neonatal outcomes in hospitals with high CSRs, and (4) possible under-use of CS.MethodsWe defined a population of low risk deliveries (singleton, vertex, full-term, live born, <4500 g, >2499 g). Using multivariable logistic regression techniques, we provided degrees of evidence regarding the observed departure ([relative risk-1]*100) of each hospital (N = 107) from the national CSR and its trend. To determine a benchmark, we defined three CSR groups (high, average and low) and compared them regarding 1 minute Apgar scores and other neonatal endpoints. An anonymous feedback is provided to the hospitals, the College of Physicians (with voluntary disclosure of the outlying hospitals for quality improvement purposes) and to the policy makers.ResultsCompared with available information, the completeness and accuracy of the data, regarding the variables selected to determine our study population, showed adequate. Important inter-hospital differences were found. Departures ranged from -65% up to +75%, and 9 "high CSR" and 13 "low CSR" outlying hospitals were identified. We observed a national increasing trend of 1.019 (95%CI [1.015; 1.022]) per semester, adjusted for age groups. In the "high CSR" group 1 minute Apgar scores < 4 were over-represented in the subgroup of vaginal deliveries, suggesting CSs not carried out for medical reasons. Under-use of CS was also observed. Given their questionable completeness, except Apgar scores, our neonatal results, showing a significant association of CS with adverse neonatal endpoints, are to be cautiously interpreted. Taking the available evidence into account, the "Average CSR" group seemed to be the best benchmark candidate.ConclusionRather than firm statements about quality of care, our results are to be considered a useful screening. The inter-hospital differences in CSR, the national CS upward trend, the indications of over-use and under-use, the geographically different obstetric patterns and the admission day-related concentration of deliveries, whether or not by CS, may trigger initiatives aiming at improving quality of care.
Highlights
Rising national cesarean section rates (CSRs) and unexplained inter-hospital differences in CSRs, led national and international bodies to select CSR as a quality indicator
Completeness and accuracy of the data According to residence of the mother, the Minimal Clinical Data (MCD) data showed very similar to those of the National Institute of Statistics (NIS), indicating their high degree of completeness regarding the number of live births (Table 1, section 1)
As to the neonatal characteristics we observed an acceptable agreement between MCD and Study of Perinatal Epidemiology (SPE) regarding multiple gestation, gestational age, cesarean delivery, presentation, weight at birth, gender and Apgar scores (Table 1, section 2)
Summary
Rising national cesarean section rates (CSRs) and unexplained inter-hospital differences in CSRs, led national and international bodies to select CSR as a quality indicator. Over the past few decades, there has been a tremendous rise in the number of deliveries performed through cesarean section in most industrialized countries While both longitudinal as well as cross-sectional variations in cesarean section rates would be expected to reflect primarily differences in obstetric complications, it is observed that wide differences occur between countries, regions or even hospitals within the same region with similar socio-economic profiles and patient characteristics [1,2]. The latter seems to suggest that CS is probably often performed for non-medical reasons leading to an overall overuse of this surgical obstetric intervention. Vaginal birth after cesarean delivery (VBAC) rates decreased by 27% between 1996 and 2000, because of the rare but potentially catastrophic risks and medical litigation [4,5]
Sign-in/Register to view highlights & summary Sign-in/Register to access full text options 
Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a callDisclaimer: All third-party content on this website/platform is and will remain the property of their respective owners and is provided on "as is" basis without any warranties, express or implied. Use of third-party content does not indicate any affiliation, sponsorship with or endorsement by them. Any references to third-party content is to identify the corresponding services and shall be considered fair use under The CopyrightLaw.
