National Cesarean Section Rate Research Articles

Induction of labour: are we doing the right thing at the right time?

Twenty percent of labours in the UK are induced.1 However; induction of labour (IOL) involves increased obstetric risk, and should be used judicially.ObjectivesWe audited IOL at a London Teaching Hospital,...

A pilot randomised controlled trial (RCT) to assess the effect of antenatal counselling sessions on vbac rates

BackgroundThe national Caesarean Section (CS) rate in the UK is almost 25%, having increased by 5.7% in the last 10 years; primary CS is a significant contributory. There are two...

Clinical performance management through inclusive critical analysis – impact on the highest caesarean section rate in England and Wales

IntroductionRising Caesarean section rates are a global concern. In the last 15 years the rate of Caesarean section birth in England has doubled to approximately 150 000 operations per year...

Screening for inter-hospital differences in cesarean section rates in low-risk deliveries using administrative data: An initiative to improve the quality of care

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.

Cesarean Section Rates and Maternal and Neonatal Mortality in Low‐, Medium‐, and High‐Income Countries: An Ecological Study

Cesarean section rates show a wide variation among countries in the world, ranging from 0.4 to 40 percent, and a continuous rise in the trend has been observed in the past 30 years. Our aim was to explore the association of cesarean section rates of different countries with their maternal and neonatal mortality and to test the hypothesis that in low-income countries, increasing cesarean section rates were associated with reductions in both outcomes, whereas in high-income countries, such association did not exist. We performed a cross-sectional multigroup ecological study using data from 119 countries from 1991 to 2003. These countries were classified into 3 categories: low-income (59 countries), medium-income (31 countries), and high-income (29 countries) countries according to an international classification. We assessed the ecological association between national cesarean section rates and maternal and neonatal mortality by fitting multiple linear regression models. Median cesarean section rates were lower in low-income than in medium- and high-income countries. Seventy-six percent of the low-income countries, 16 percent of the medium-income countries, and 3 percent of high-income countries showed cesarean section rates between 0 and 10 percent. Three percent of low-income countries, 36 percent of medium-income countries, and 31 percent of high-income countries showed cesarean section rates above 20 percent. In low-income countries, a negative and statistically significant linear correlation was observed between cesarean section rates and neonatal mortality and between cesarean section rates and maternal mortality. No association was observed in medium- and high-income countries for either neonatal mortality or maternal mortality. No association between cesarean section rates and maternal or neonatal mortality was shown in medium- and high-income countries. Thus, it becomes relevant for future good-quality research to assess the effect of the high figures of cesarean section rates on maternal and neonatal morbidity. For low-income countries, and on confirmation by further research, making cesarean section available for high-risk pregnancies could contribute to improve maternal and neonatal outcomes, whereas a system of care with cesarean section rates below 10 percent would be unlikely to cover their needs.

Private-sector caesarean sections in perspective

Extracted from text ... SAJOG 66 September 2005, Vol. 11, No. 3 In a recent issue of the Journal, 1 views were expressed that our national private sector caesarean section (CS) rate is too high at over 60%, and government and/or funders are likely to intervene unless doctors begin to self-regulate by developing appropriate protocols and guidelines. This is not a new issue for South Africa or for medically insured populations around the world, and the sheer volume of literature on the subject of high CS rates indicates that it is unlikely one will reach consensus on a national target CS rate simply by ..

The National Sentinel caesarean Section Audit in the UK

Concern over the rapidly rising rate of caesarean section led the World Health Organisation, in 1985, to release a statement suggesting that a caesarean section rate greater than 10–15% was excessive. This recommendation was based on the figures from countries with caesarean section rates of under 10% that also had some of the lowest perinatal mortality rates. It had little impact on the global trend. The UK Department of Health commissioned an audit into caesarean sections from the Royal College of Obstetricians and Gynaecologists (RCOG). This was undertaken in collaboration with the Royal College of Anaesthetists (RCA), the Royal College of Midwives and the National Childbirth Trust. Clinical audit standards were drawn up from stringently scrutinised reviews, published guidelines and other evidence-based sources. A questionnaire was produced that recorded clinical information, sought clinicians’ views and maternal opinions. The audit booklet was circulated to over 250 National Health Service consultant-led maternity units, 20 midwife-led units and three private maternity hospitals in the UK. Scotland was not included. The audit captured 99% of all births in a 3-month period between 2000 and 2001. Supplementary organisational surveys examined midwifery, obstetric and anaesthetic data. Nearly 92% of the organisations and 77% of the consultants surveyed responded. Over 30% of the mothers contacted returned survey material. The National Caesarean Section Audit Report,1 presented at the RCOG in October 2001, showed that the national caesarean section rate in the UK had risen to 22%, in line with the developed world and similar to the rate in the United States of America (USA) and Italy. France and Scandinavian countries have lower rates (see Table 1). This report gives a detailed insight into current practice related to caesarean section in one country.

Cesarean section delivery in the 1980's: International comparison by indication

OBJECTIVE: We compared trends and current levels of cesarean section delivery by indication in four countries to help us understand factors underlying national differences in obstetric delivery practice and identify pathways to lower cesarean rates. STUDY DESIGN: We carried out a measurement of change in the use of cesarean delivery by indication in Norway, Scotland, Sweden, and the United States during intervals centered on 1980, 1985, and 1990. Indication for cesarean delivery was determined by a standard set of selection rules. RESULTS: The rate of growth of national cesarean section rates dropped significantly between the time periods 1980 to 1985 and 1985 to 1990 in all four countries; in Sweden this led to an actual decline in the cesarean section rate. Fetal distress and previous cesarean section were important contributors to cesarean section growth in three of the countries in 1980 to 1985, but their contribution to growth dropped off sharply in 1985 to 1990. By the 1990 interval, the overall rate ranged from 24% (United States) to 11% (Sweden), and all four countries had similar cesarean section rates for breech presentation, fetal distress, and “other” indications. Cesarean section deliveries for previous cesarean section and dystocia accounted for the substantially higher U.S. cesarean section rate. CONCLUSIONS: Cesarean section rates are approaching stability in the four countries and have declined in Sweden. Previous cesarean delivery and dystocia may be the major sources of future reductions in the U.S. cesarean rate. The Swedish example shows that it is possible to reduce a relatively low national cesarean section rate. (AM J OBSTET GYNECOL 1994;170:495-504.)

Trends in obstetric operative procedures, 1980 to 1987.

Increasing rates of cesarean deliveries have received widespread attention in recent years, as concern in the United States about unnecessary surgical procedures has increased. However, little information has been published on the national trends of other operative obstetric procedures occurring during deliveries. We analyzed data from the National Hospital Discharge Survey to examine trends in the use of forceps, vacuum extraction, and cesarean section from 1980 through 1987. The rate of cesarean sections increased by 48%, while the rate of forceps procedures declined by 43%. Although the risk of cesarean section was significantly increased for older women, the risk of forceps and vacuum extraction procedures did not vary by age. Women with private insurance were significantly more likely to receive a cesarean section (rate ratio [RR] = 1.2), forceps procedure (RR = 1.7), and vacuum extraction procedure (RR = 1.8) than were women without private insurance. As pressure mounts to decrease the national cesarean section rate from 24% to 15% by the year 2000, attention should also be given to surveillance of other operative delivery procedures.

The Israel perinatal census.

A nation-wide perinatal census which included 22,815 deliveries was carried out. The cesarean section rate was 9.6% and the perinatal mortality rate was 13.5/1000. Using a logistic regression analysis the risk factors for cesarean section and for perinatal mortality were ranked. Breech presentation and one uterine scar were found to be the most important risk factors for cesarean section and breech presentation, maternal disease and multiple pregnancy for perinatal mortality. Low birth weight rate was 6.9% with nonsignificant differences between the various ethnic groups. The national cesarean section rate in breech presentation was 57.8%. It was performed mainly at the extremes of birth weight. From those with one previous cesarean section 55.1% delivered vaginally and 44.9% abdominally. The chance for vaginal delivery is higher (67.2%) providing the woman had delivered vaginally in the past. Comparison between primiparae and multiparae showed that preeclampsia, hypertension and diabetes mellitus were all significantly more frequent among older parturients and among primiparae.

A successful program to lower cesarean-section rates.

Despite the consensus that national cesarean-section rates are excessive, they continue to rise. Currently, approximately one of every four deliveries is by cesarean section. We developed an initiative to reduce the number of cesarean deliveries to a rate of 11 percent of all deliveries at our inner-city hospital. Participation by attending physicians was voluntary and not linked to any sanction. The program included a stringent requirement for a second opinion, objective criteria for the four most common indications for cesarean section, and a detailed review of all cesarean sections and of individual physicians' rates of performing them. During the first two years of the program, the cesarean-section rate fell from 17.5 percent of 1697 deliveries in 1985 to 11.5 percent of 2301 deliveries in 1987 (P less than 0.05). The proportion of infants with five-minute Apgar scores lower than 7 increased from 3 percent in 1985 to 4.9 percent in 1987 (P less than 0.05), but neither the fetal mortality rate (11.9 per 1000) nor the neonatal mortality rate (11.2 per 1000) in 1987 differed significantly from the rates in 1985. A single maternal death, unrelated to cesarean delivery, occurred during the study. Rates of both primary and repeat cesarean sections decreased, although only the decline in the rate of primary cesarean sections, from 12 to 6.8 percent, was statistically significant (P less than 0.05). During the same period, operative vaginal deliveries (i.e., forceps deliveries and midpelvic procedures) declined from 10.4 to 4.3 percent (P less than 0.05) of total deliveries. We conclude that an initiative within an obstetrics department can reduce cesarean-section rates substantially without adverse effects on the outcome for mother or infant.

Comparison of National Cesarean-Section Rates

Comparison of National Cesarean-Section Rates

Comparisons of National Cesarean Section Rates

Our study of cesarean rates in 19 industrialized countries of Europe, North America, and the Pacific revealed sharp differences in rates, ranging from a low of 5 (Czechoslovakia) to a high of 18 (United States) per 100 hospital deliveries in 1981. Differences in cesarean rates according to maternal age, parity, and complications of pregnancy and childbirth reflected national differences in obstetrical practice. For example, the percentage of mothers who had a vaginal birth after a previous cesarean section was only 5 in the United States as compared with 43 in Norway, where the cesarean rate was half that in the United States. Despite the wide range of cesarean rates, almost all the countries studied have had consistent increases over the past decade, and the annual rate of increase for all countries appears to be converging. The steady pace of increase in developed countries, combined with comparable or even higher rates of cesarean delivery now being reported in less developed countries, underscores the need for the medical community to consider the appropriateness of this continued rise in the number of cesarean deliveries.

Cesarean Section Rates in the United States

The magnitude of cesarean section rates in the United States has been of increasing public concern. A consensus development conference in 1980 formulated recommendations that were expected to lead to a decrease in national cesarean section rates. A review of cesarean section patterns for the last five years in many representative states revealed, contrary to expectations, a continuing increase in cesarean section delivery rates even after the conference. A review of underlying causes for these developments suggests that only a more efficient peer review process, involving individual physicians as well as institutions, will lead to a decline of unacceptably high cesarean section rates in this country.

Cesarean section rates in the United States. The short-term failure of the National Consensus Development Conference in 1980

The magnitude of cesarean section rates in the United States has been of increasing public concern. A consensus development conference in 1980 formulated recommendations that were expected to lead to a decrease in national cesarean section rates. A review of cesarean section patterns for the last five years in many representative states revealed, contrary to expectations, a continuing increase in cesarean section delivery rates even after the conference. A review of underlying causes for these developments suggests that only a more efficient peer review process, involving individual physicians as well as institutions, will lead to a decline of unacceptably high cesarean section rates in this country. (<i>JAMA</i>1984;252:3273-3276)