Abstract
BackgroundWhile international variations in overall cesarean delivery rates are well documented, less information is available for clinical sub-groups. Cesarean data presented by subgroups can be used to evaluate uptake of cesarean reduction policies or to monitor delivery practices for high and low risk pregnancies based on new scientific evidence. We studied differences and patterns in cesarean delivery rates by multiplicity and gestational age in Europe and the United States.MethodsThis study used routine aggregate data from 17 European countries and the United States on the number of singleton and multiple live births with cesarean versus vaginal delivery by week of gestation in 2008. Overall and gestation-specific cesarean delivery rates were analyzed. We computed rate differences to compare mode of delivery (cesarean vs vaginal birth) between selected gestational age groups and studied associations between rates in these subgroups namely: very preterm (26–31 weeks GA), moderate preterm (32–36 weeks GA), near term (37–38 weeks GA), term (39–41 weeks GA) and post-term (42+ weeks GA) births, using Spearman’s rank tests.ResultsHigh variations in cesarean rates for singletons and multiples were observed everywhere. Rates for singletons varied from 15% in The Netherlands and Slovenia, to over 30% in the US and Germany. In singletons, rates were highest for very preterm births and declined to a nadir at 40 weeks of gestation, ranging from 8.0% in Sweden and Norway, to 22.5% in the US. These patterns differed across countries; the average rate difference between very preterm and term births was 43 percentage points, but ranged from 14% to 61%. High variations in rate differences were also observed for near term versus term births. For multiples, rates declined by gestational age in some countries, whereas in others rates were similar across all weeks of gestation. Countries’ overall cesarean rates were highly correlated with gestation-specific subgroup rates, except for very preterm births.ConclusionsGestational age patterns in cesarean delivery were heterogeneous across countries; these differences highlight areas where consensus on best practices is lacking and could be used in developing strategies to reduce cesareans.
Highlights
While international variations in overall cesarean delivery rates are well documented, less information is available for clinical sub-groups
International comparisons of cesarean rates highlight differences in delivery practices and provide useful benchmarks for the evaluation of national practices. Such comparisons have been made using data in international databases run by Eurostat, OECD and WHO but these organizations collect overall cesarean rate data whereas comparisons stratified by risk groups may better inform cesarean reduction policies [5,13,14]
We examined the associations between cesarean rates in singletons and multiples and the overall cesarean rate using Spearman’s rank tests; we carried out this analysis in each of our gestational age subgroups
Summary
While international variations in overall cesarean delivery rates are well documented, less information is available for clinical sub-groups. Studies have linked cesarean delivery with complications in subsequent pregnancies for women (placentation disorders, uterine rupture and stillbirth) [7,8] as well as adverse long term child health outcomes such as asthma and type-1 diabetes [10,11]. Given these risks and concerns about the optimal use of health resources, professional societies in many high income countries recommend strategies to reduce unnecessary cesareans [4,12]. The Robson Ten-Group classification is a robust system which allows comparisons of cesarean rates based on characteristics of pregnancies, [15] but the data needed to identify cesareans based on this system are not available in any of the international databases and may be difficult to obtain in some countries on the national level
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