Abstract
BackgroundInternationally, repeat caesarean sections make the largest contribution to overall caesarean section rates and inter-hospital variation has been reported. The aim of this study was to determine if casemix and hospital factors explain variation in hospital rates of repeat caesarean sections and whether these rates are associated with maternal and neonatal morbidity.MethodsThis population-based record linkage study utilised data from New South Wales, Australia between 2007 and 2011. The study population included maternities with any previous caesarean section(s) and were singleton, cephalic and ≥37 weeks’ gestation (Robson Group 5). Multilevel regression models were used to examine variation in hospital rates of ‘planned repeat caesarean section’ and, among women who planned a vaginal birth, ‘intrapartum caesarean section’. We assessed associations between risk-adjusted hospital rates of planned and intrapartum caesarean sections and rates of casemix adjusted maternal and neonatal morbidity, postpartum haemorrhage and Apgar score <7 at five minutes.ResultsOf 61894 maternities with a previous caesarean section in 81 hospitals, 82.1 % resulted in a caesarean section (72.7 % planned and 9.4 % unplanned intrapartum caesareans) and 17.9 % in vaginal birth. Observed hospital rates of planned caesarean sections ranged from 50.7 % to 98.4 %. Overall 49.0 % of between-hospital variation in planned repeat caesarean section rates was explained by patient (17.3 %) and hospital factors (31.7 %). Increased odds of planned caesarean section were associated with private hospital status and lower hospital propensity for vaginal birth after caesarean. There were no associations between hospital rates of planned repeat caesarean section and adjusted morbidity rates. Among women who intended a vaginal birth, the observed rates of intrapartum caesarean section ranged from 12.9 % to 71.9 %. In total, 27.5 % of between-hospital variation in rates of intrapartum caesarean section was explained by patient (19.5 %) and hospital factors (8.0 %). The adjusted morbidity rates differed among hospital intrapartum caesarean section rates, but were influenced by a few hospitals with outlying morbidity rates.ConclusionsAmong women with at least one previous caesarean section, less than half of the variation in hospital caesarean section rates was explained by differences in hospital’s patient characteristics and practices. Strategies aimed at modifying caesarean section rates for these women should not affect morbidity rates.
Highlights
Repeat caesarean sections make the largest contribution to overall caesarean section rates and inter-hospital variation has been reported
The aims of this study were, among women with at least one previous caesarean section (Robson Group 5), a) to explore variation in hospital rates of planned and intrapartum repeat caesarean section by intended mode of birth; b) to determine whether casemix and hospital factors explain the variation between hospital rates and c) to examine the association between hospital rates of planned and intrapartum caesarean sections with maternal and neonatal morbidity outcomes
The analyses of intrapartum caesarean section rates following a trial of labour were restricted to hospitals with at least 20 women undergoing a trial of labour during the study period to ensure that only hospitals that offered vaginal birth after caesarean section were included, and to provide sufficient data for modeling of the hospital rate of intrapartum caesarean section
Summary
Repeat caesarean sections make the largest contribution to overall caesarean section rates and inter-hospital variation has been reported. The previous study lacked information about differences in maternal and infant outcomes or evaluation of hospital characteristics that may contribute to the variation Clinical factors such as offering trial of labour may contribute to the variation in elective repeat caesarean section rates and subanalysis of this group by onset of labour has been suggested [17]. The aims of this study were, among women with at least one previous caesarean section (Robson Group 5), a) to explore variation in hospital rates of planned and intrapartum repeat caesarean section by intended mode of birth; b) to determine whether casemix and hospital factors explain the variation between hospital rates and c) to examine the association between hospital rates of planned and intrapartum caesarean sections with maternal and neonatal morbidity outcomes
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