Variation In Caesarean Section Rates Research Articles

1.O. Workshop: Caesarean section in Europe: Are women and babies receiving evidence-based obstetric care?

Abstract Every year in Europe, over 1.5 million women have a caesarean section (CS). The use of this surgical procedure is increasing globally, leading to concerns about a caesarean “epidemic”. While CS is a lifesaving procedure for mothers and babies with complications during pregnancy or labour, national variations in CS rates suggest the absence of standardised indications: in Europe rates vary from lows of 16% (Nordic countries, the Netherlands) to over 40% (Poland, Romania, Greece, Cyprus). Worldwide, the gap between low and high CS countries is even greater. To assess the magnitude of the variations in CS in terms of numbers of women experiencing the procedure in Europe, the Euro-Peristat network calculated that there would be 500,000 fewer CS if all countries had the rates in the lowest CS country. There is uncertainty about what the “optimal” CS rate should be and how this might differ in relation to the health of the childbearing population. CS risk is associated with characteristics of the childbearing population, such as older maternal age, nulliparity, higher body mass index and maternal chronic conditions. The optimal CS rate may also differ depending on the organisation and capacity of the health system. European countries provide a unique context for exploring these questions they have similar standards of living and access to advanced medicine, but differ greatly in the organisation of their health systems and CS practices. In this session, we will present three studies reporting recent data on CS variations and trends in Europe from the Euro-Peristat network to shed light on these questions. The presentations will be followed by a round table discussion about the next steps for evaluating the reasons as well as the health impact of varying practices in order to ensure that European women receive evidence-based obstetric care. Key messages • The persisting variation in the use of caesarean section between European countries raises questions about whether pregnant women and babies are receiving evidence-based care. • Europe provides a unique context for exploring these variations because despite high standards of living and access to medical care, marked differences persist between countries.

Caesarean section in Sudan: findings from nationwide household surveys on rates, trends, and geographic and sociodemographic variability

BackgroundMedically unjustifiable caesarean section (CS) deliveries have been rising rapidly in many developed countries over the last three decades. While many developing countries show rates beyond optimal levels, few poorer countries appear to have sub-optimal obstetric care in relation to essential surgeries. The objective of this study is to document the rates of CS delivery, its time trend, and geographic and sociodemographic variability in Sudan.MethodsWe utilized a number of Multiple Indicator Cluster Surveys (MICS) conducted in 2014, 2010, and 2006 to quantify CS rates per 1000 live births. We also documented absolute changes in rates over three-time points and variation in CS rates across geographic regions and areas of residence.ResultsOver a decade, CS rates in Sudan increased steadily from 4.3% in 2006 to 6.7% in 2010 and 9.1% in 2014. During this period, CS rates varied considerably across regions showing higher rates in the Northern region (7–25%) and lower rates in Darfur (2–3%). Urban areas experienced rapidly increasing rates (6–14%), while rural areas showed negligible changes to absolute CS rates over time (5–7%). We also found geographic regions, maternal age, maternal education, receiving antenatal care, and birth order of the child were important determinants of CS in Sudan.ConclusionSudan may be facing a double burden of problems associated with surgical interventions for childbirth. While the wealthier parts of Sudan are experiencing a rapid surge in CS, some poor parts of rural Sudan may not be getting the essential surgical intervention for birth when mandated. Urgent improvement to obstetric care and the development of appropriate public health interventions that focus on regional disparities are warranted.

Caesarean birth in women with infertility: population-based cohort study.

ObjectiveCaesarean section (CS) is more common following infertility treatment (IT) but the reasons why remain unclear and confounded. The Robson 10‐Group Classification System (TGCS) may further explain variation in CS rates. We assessed the association between mode of conception and CS across Robson groups.DesignPopulation‐based cohort study.SettingOntario, Canada, in a public healthcare system.Population921 023 births, 2006–2014.MethodsModified Poisson regression produced relative risks (RR) and 95% confidence intervals, comparing the risk of CS among women with (1) subfertility without IT, (2) non‐invasive IT (OI, IUI) or (3) invasive IT (IVF)—each relative to (4) spontaneous conception (SC).Main outcome measuresCS rate according to one of four modes of conception, overall and stratified by each of the TGCS groups.ResultsRelative to SC (26.9%), the risk of CS increased in those with subfertility without IT (RR 1.17, 95% CI 1.16–1.18), non‐invasive IT (RR 1.21, 95% CI 1.18–1.24) and invasive IT (RR 1.39, 95% CI 1.36–1.42). Within each Robson group, similar patterns of RRs were seen, but with markedly differing rates. For example, in Group 1 (nulliparous, singleton, cephalic at ≥37 weeks, with spontaneous labour), the respective rates were 15.0, 19.4, 18.7 and 21.9%; in Group 2 (nulliparous, singleton, cephalic at ≥37 weeks, without spontaneous labour), the rates were 35.9, 44.4, 43.2 and 54.1%; and in Group 8 (multiple pregnancy), they were 55.9, 67.5, 65.0 and 69.3%, respectively.ConclusionsCS is relatively more common in women with subfertility and those receiving IT, an effect that persists across Robson groups.Tweetable abstractCaesarean delivery is more common in women with infertility independent of demographics and prenatal conditions.

The Rate of Caesarean Sections in Burkina Faso’s Regional and University Hospitals According to the Classification System of Robson’s Ten Groups

Background: Quality assurance in labor and delivery is needed. The method must be simple and consistent, and be of universal value. The 10-Group Classification System is a simple method providing a common starting point for further detailed analysis within which all perinatal events and outcomes can be measured and compared. Objective: The purpose of this study was to analyze cesarean section (CS) rates using the classification system of Robson’s ten groups and to identify the main contributors to the overall CS rate in Burkina Faso’s regional and university hospitals. Materials and Method: A cross-sectional study with retrospective collection was carried out. All women who gave birth between July 1, 2017 and June 30, 2018, in the Regional Hospital Centres (RHC) and University Hospital Centres (UHC) of Burkina Faso were classified according to the Robson ten-group method. The overall CS rates and in each Robson group were calculated, as well as the contribution of each group to the overall CS rate. Results: The CS rate was 26.5% (8543 out of 32,240 deliveries) during the study period. nulliparous women with single term pregnancy in cephalic presentation during spontaneous labour (group 1), multiparous women with single pregnancy in cephalic presentation, gestational age ≥37SA, spontaneous labour (group 3) and multiparous women with previous CS (group 5) were the main contributors (67.7%) to the overall CS rate. In addition, we observed a variation in CS rates between different hospitals, especially among women with full-term pregnancies in cephalic presentation without previous CS (groups 1 to 4), showing large differences in emergency obstetric and neonatal care across the country. Conclusions: Women in groups 1, 3 and 5 were the most important contributors to the overall CS rate in Burkina Faso. It appears that efforts to reduce the overall rate of CS should focus on vaginal delivery on the scarred uterus, reduction of CS rates in nulliparous women with full-term pregnancy in cephalic presentation (groups 1) and proper monitoring of multiparous women with full-term pregnancy in spontaneous labour (group 3).

Design characteristics of studies on medical practice variation of caesarean section rates: a scoping review

BackgroundMedical practice variation in caesarean section rates is the most studied type of practice variation in the field of obstetrics and gynaecology. This has not resulted in increased homogeneity of treatment between geographic areas or healthcare providers. Our study aim was to evaluate whether current study designs on medical practice variation of caesarean section rates were optimized to identify the unwarranted share of practice variation and could contribute to the reduction of unwarranted practice variation by meeting criteria for audit and feedback.MethodsWe searched PubMed, Embase, EBSCO/CINAHL and Wiley/Cochrane Library from inception to March 24th, 2020. Studies that compared the rate of caesarean sections between individuals, institutions or geographic areas were included. Study design was assessed on: selection procedure of study population, data source, case-mix correction, patient preference, aggregation level of analysis, maternal and neonatal outcome, and determinants (professional and organizational characteristics).ResultsA total of 284 studies were included. Most studies (64%) measured the caesarean section rate in the entire study population instead of using a sample (30%). (National) databases were most often used as information source (57%). Case-mix correction was performed in 87 studies (31%). The Robson classification was used in 20% of the studies following its endorsement by the WHO in 2015. The most common levels of aggregation were hospital level (35%) and grouped hospitals (35%) e.g. private versus public. The percentage of studies that assessed the relationship between variation in caesarean section rates and maternal outcome was 9%, neonatal outcome 19%, determinants (professional and organizational characteristics) 21% and patient preference 2%.ConclusionsStudy designs of practice variation in caesarean sections varied considerably, raising questions about their appropriateness. Studies focused on measuring practice variation, rather than contributing to the reduction of unwarranted practice variation. Future studies should correct for differences in patient characteristics (case-mix) and patient preference to identify unwarranted practice variation. Practice variation studies could be used for audit and feedback if results are presented at lower levels of aggregation, and appeal to intrinsic motivation of physicians, for example by including the health effects on mother and child.

Variations in use of childbirth interventions in 13 high-income countries: A multinational cross-sectional study.

BackgroundVariations in intervention rates, without subsequent reductions in adverse outcomes, can indicate overuse. We studied variations in and associations between commonly used childbirth interventions and adverse outcomes, adjusted for population characteristics.Methods and findingsIn this multinational cross-sectional study, existing data on 4,729,307 singleton births at ≥37 weeks in 2013 from Finland, Sweden, Norway, Denmark, Iceland, Ireland, England, the Netherlands, Belgium, Germany (Hesse), Malta, the United States, and Chile were used to describe variations in childbirth interventions and outcomes. Numbers of births ranged from 3,987 for Iceland to 3,500,397 for the USA. Crude data were analysed in the Netherlands, or analysed data were shared with the principal investigator. Strict variable definitions were used and information on data quality was collected. Intervention rates were described for each country and stratified by parity. Uni- and multivariable analyses were performed, adjusted for population characteristics, and associations between rates of interventions, population characteristics, and outcomes were assessed using Spearman’s rank correlation coefficients. Considerable intercountry variations were found for all interventions, despite adjustments for population characteristics. Adjustments for ethnicity and body mass index changed odds ratios for augmentation of labour and episiotomy. Largest variations were found for augmentation of labour, pain relief, episiotomy, instrumental birth, and cesarean section (CS). Percentages of births at ≥42 weeks varied from 0.1% to 6.7%. Rates among nulliparous versus multiparous women varied from 56% to 80% versus 51% to 82% for spontaneous onset of labour; 14% to 36% versus 8% to 28% for induction of labour; 3% to 13% versus 7% to 26% for prelabour CS; 16% to 48% versus 12% to 50% for overall CS; 22% to 71% versus 7% to 38% for augmentation of labour; 50% to 93% versus 25% to 86% for any intrapartum pain relief, 19% to 83% versus 10% to 64% for epidural anaesthesia; 6% to 68% versus 2% to 30% for episiotomy in vaginal births; 3% to 30% versus 1% to 7% for instrumental vaginal births; and 42% to 70% versus 50% to 84% for spontaneous vaginal births. Countries with higher rates of births at ≥42 weeks had higher rates of births with a spontaneous onset (rho = 0.82 for nulliparous/rho = 0.83 for multiparous women) and instrumental (rho = 0.67) and spontaneous (rho = 0.66) vaginal births among multiparous women and lower rates of induction of labour (rho = −0.71/−0.66), prelabour CS (rho = −0.61/−0.65), overall CS (rho = −0.61/−0.67), and episiotomy (multiparous: rho = −0.67). Variation in CS rates was mainly due to prelabour CS (rho = 0.96). Countries with higher rates of births with a spontaneous onset had lower rates of emergency CS (nulliparous: rho = −0.62) and higher rates of spontaneous vaginal births (multiparous: rho = 0.70). Prelabour and emergency CS were positively correlated (nulliparous: rho = 0.74). Higher rates of obstetric anal sphincter injury following vaginal birth were found in countries with higher rates of spontaneous birth (nulliparous: rho = 0.65). In countries with higher rates of epidural anaesthesia (nulliparous) and spontaneous births (multiparous), higher rates of Apgar score < 7 were found (rhos = 0.64). No statistically significant variation was found for perinatal mortality. Main limitations were varying quality of data and missing information.ConclusionsConsiderable intercountry variations were found for all interventions, even after adjusting for population characteristics, indicating overuse of interventions in some countries. Multivariable analyses are essential when comparing intercountry rates. Implementation of evidence-based guidelines is crucial in optimising intervention use and improving quality of maternity care worldwide.

Variations in the use of caesarean section: a Comparison between France and Australia

Abstract Background There has been a rise in obstetric intervention during labour and birth including rates of caesarean section around the world. The rates of caesarean section are lower in France (20%) than Australia (34%). Both countries have universal health care systems. Australia has a well-established program of obstetric benchmarking and national data collection for comparing maternal and perinatal outcomes taking into account maternity units and maternal characteristics. Although the optimal caesarean section rate is not known, variation in caesarean section rates raise questions about what is driving variation in practice and whether the right care is being delivered. The World Health Organisation has recently released non-clinical recommendations aiming to reduce unnecessary caesarean sections, including that births are classified by Robson classification for easier comparison. Methods We aim to compare rates of mode of birth in 2 tertiary hospitals- one in France and one in Australia using Robson classification. This project will investigate differences in patient casemix, and obstetric management that may lead to differences in outcome. In addition, we will try to explore differences in the health systems including clinical activity, induction rates, staffing (number, type (medical, nursing, midwifery)), and models of care. Outcomes Caesarean section is one of the most common operations performed in hospitals. Important variations of surgical rates raise question regarding whether access to this procedure is optimized. Determining current practice and outcomes of women in two different settings will provide important data to inform hospital practice and further research. In addition, this research may inform national guidelines about indications for caesarean section.

An ecological study of geographic variation and factors associated with cesarean section rates in South Korea

BackgroundKorea is in a condition where the impact of patient and supplier factors on cesarean section rates can be clearly described. The cesarean section rates in Korea are among the highest in the world while the number of obstetricians is decreasing sharply. This study aimed to investigate the geographic variation in cesarean section rates in Korea and its factors.MethodsThe data were obtained from the National Health Insurance database in Korea in 2013. We calculated the age-standardized and crude cesarean section rates of 251 districts in Korea and variation statistics. A linear regression analysis was performed to determine factors for cesarean section rates.ResultsThe overall cesarean section rate in Korea was 364.6 cases per 1000 live births. The deprivation index score was strongly associated with the increase in the cesarean section rate while the density of hospital obstetricians and hospital beds showed a negative association. Average maternal age and total fertility rate showed a negative relationship with the cesarean section rate.ConclusionsKorea is suffering from a continuing decrease in obstetricians. Our study shows that this decline has more of an effect on mothers in the disadvantaged areas. Securing equal access to obstetric care among areas is necessary, and measures to encourage obstetricians and mothers not to opt for cesarean section are required.

Variation in caesarean section rates in Cyprus, Italy and Iceland: an analysis of the role of the media.

Cyprus has Europe's highest rate of births by caesarean section (CS). In 2015 56% of all babies were born by CS. This compares with 36% in Italy, and 16% in Iceland, which is among the lowest rates in Europe. There is some evidence that CS rates are partly driven by maternal request and media representation. The aim of this review is to explore the depiction of childbirth by CS in the media, and more specifically in newspapers, television, web and informational leaflets in Cyprus, Italy and Iceland. A thematic review of the depiction of CS in the media of Cyprus, Italy and Iceland was carried out through an examination of newspapers, television, web, and informational material published or presented in the included countries in 2017. Materials were identified by searches in PubMed and Google Scholar, using pre-determined key words, inclusion and exclusion criteria, and inclusion was agreed by at least two of the authors. Key themes in each data source were triangulated with each other and between the three countries. The review comprised 81 articles, 10 videos, six birth shows, two informational leaflets and one scientific paper. The central themes were: 1) CS as risky and unnecessary intervention, failure of maternity system; 2) CS as a necessary, life-saving intervention; 3) the ethical dimensions of CS; 4) the changing landscape of childbirth and medicalization; and 5) informed choices. In both Cyprus and Italy, the media focus was on a need to reduce high levels of CS. The focus in Iceland was on normal birth and midwife led care. The differing media messages in the three countries could partly explain the differing CS rates, suggesting that high CS rates are a social phenomenon, rather than a result of clinical need. The media may have a significant influence on the beliefs and choices of maternity service users, their families, and society in general, as well as health professionals and policy makers. Those working in the media have an ethical responsibility to critically examine the impact of high national CS rates, and to report on solutions that could optimize both the safety and the wellbeing of mothers and babies.

Caesarean section among immigrants with different obstetrical risks.

To determine the variation in caesarean section rates among immigrant populations. Australia is one of the most multicultural in the world and is also among those with the highest caesarean section rates. Secondary data analysis. Routinely collected data from a Local Heath District between 2011 and 2015 were analysed. Women were categorized into regional groups based on country of birth. Obstetrical risk was classified using the Robson classification. In total 48711 women gave birth, of whom 64.0% were born overseas; 13966 had a caesarean section (28.7%). South and Central Asia women had a high number of caesarean sections (n=4139; 29.6% of all caesarean sections), a high overall adjusted caesarean section rate (31.4%; 95% CI, 30.5%-32.3%), and consistently high caesarean section rates among women with single cephalic term pregnancy without a previous caesarean section. High adjusted caesarean section rates were seen among South East Asia women with nulliparous, single cephalic, term pregnancy, and spontaneous labour. Demographic and clinical characteristics explained 83.5% of the variation in overall caesarean section rates between country of birth and 21.8% to 100% depending on Robson group. Caesarean section rates varied by country of birth and within some Robson groups. The studied factors had various effects on the variation in caesarean section rates between country of birth and Robson groups.

National Variation in Caesarean Section Rates: A Cross Sectional Study in Ireland.

ObjectiveInternationally, caesarean section (CS) rates are rising. However, mean rates of CS across providers obscure extremes of CS provision. We aimed to quantify variation between all maternity units in Ireland.MethodsTwo national databases, the National Perinatal Reporting System and the Hospital Inpatient Enquiry Scheme, were used to analyse data for all women delivering singleton births weighing ≥500g. We used multilevel models to examine variation between hospitals in Ireland for elective and emergency CS, adjusted for individual level sociodemographic, clinical and organisational variables. Analyses were subsequently stratified for nullipara and multipara with and without prior CS.ResultsThe national CS rate was 25.6% (range 18.2% ─ 35.1%). This was highest in multipara with prior CS at 86.1% (range 6.9% ─ 100%). The proportion of variation in CS that was attributable to the hospital of birth was 11.1% (95% CI, 6.0 ─ 19.4) for elective CS and 2.9% (95% CI, 1.4 ─ 5.6) for emergency CS, after adjustment. Stratifying across parity group, variation between hospitals was greatest for multipara with prior CS. Both types of CS were predicted by increasing age, prior history of miscarriage or stillbirth, prior CS, antenatal complications and private model of care.ConclusionThe proportion of variation attributable to the hospital was higher for elective CS than emergency CS suggesting that variation is more likely influenced by antenatal decision making than intrapartum decision making. Multipara with prior CS were particularly subject to variability, highlighting a need for consensus on appropriate care in this group.

International caesarean section rates: the rising tide.

Historically, the introduction of caesarean section surgery was associated with an improvement in maternal and perinatal health outcomes. WHO has stated that no empirical evidence exists for an ideal caesarean rate, but “what matters most is that all women who need caesarean sections actually receive them”.1WHOMonitoring obstetric care: a handbook. WHO Press, World Health Organization, Geneva2009Google Scholar In areas with very high mortality rates, such as Africa, inadequate availability of caesarean section contributes to substantial maternal and perinatal morbidity and mortality.2Chu K Cortier H Maldonado F Mashant T Ford N Trelles M Cesarean section rates and indications in sub-Saharan Africa: a multi-country study from Medecins sans Frontieres.PLoS One. 2012; 7: e44484Crossref PubMed Scopus (82) Google Scholar Conversely, in many developed countries, concerns exist about high rates of caesarean section, since increasing rates of this procedure show little evidence of leading to further improvement in perinatal outcomes.3Ye J Betrán AP Guerrero Vela M Souza JP Zhang J Searching for the optimal rate of medically necessary cesarean delivery.Birth. 2014; 41: 237-244Crossref PubMed Scopus (174) Google Scholar Caesarean section carries its own risks for maternal and infant morbidity and for subsequent pregnancies.1WHOMonitoring obstetric care: a handbook. WHO Press, World Health Organization, Geneva2009Google Scholar At some point, these risks will outweigh the potential benefits associated with lowering the threshold at which the procedure becomes indicated. The skill needed to make a balanced clinical decision for an individual woman might well be greater than the skill required to actually undertake the procedure.4Smith GCS Variation in caesarean section rates in the US: outliers, damned outliers, and statistics.PLoS Med. 2014; 11: e1001746Crossref PubMed Scopus (2) Google Scholar Joshua Vogel and colleagues' study in The Lancet Global Health5Vogel JP Betrán AP Vindevoghel N et al.Use of the Robson classification to assess caesarean section trends in 21 countries: a secondary analysis of two WHO multicountry surveys.Lancet Glob Health. 2015; (published online April 10.)http://dx.doi.org/10.1016/S2214-109X(15)70094-XGoogle Scholar provides much-needed data to inform the debate about the global rise in caesarean section rates. Vogel and colleagues analysed data from 287 facilities in 21 countries that were included in both the WHO Global Survey of Maternal and Perinatal Health (2004–08) and the WHO Multi-Country Survey of Maternal and Newborn Health (2010–11). The results show not only the large increase in the caesarean section rate as countries move from lower to higher Human Development Index (HDI) categories, but also that rates are consistently rising even within these categories. As acknowledged by Vogel and colleagues, the data are not necessarily representative of the caesarean section rates in the overall populations of the included countries. The sample populations are drawn from large hospitals (>1000 deliveries per year), almost 70% of which were located urban areas. However, 54% of the world's population lived in urban areas in 2014, and this percentage is expected to rise to 66% by 2050.6United NationsWorld urbanization prospects: 2014 revision. Highlights. United Nations, New York2014Google Scholar The study's results are a signpost for the future of maternity care as country incomes and urbanisation increase, unless changes to birth management can be achieved that will safely reduce the propensity to resort to caesarean delivery. Vogel and colleagues' study5Vogel JP Betrán AP Vindevoghel N et al.Use of the Robson classification to assess caesarean section trends in 21 countries: a secondary analysis of two WHO multicountry surveys.Lancet Glob Health. 2015; (published online April 10.)http://dx.doi.org/10.1016/S2214-109X(15)70094-XGoogle Scholar adds depth to the comparison of international caesarean section rates through the use of the Robson classification.7Robson MS Classification of caesarean sections.Fetal and Maternal Medicine Review. 2001; 12: 23-39Crossref Scopus (287) Google Scholar The Robson classification is a widely accepted, risk-based, ten-group classification system developed specifically to assess caesarean section rates. It allows comparison of clinically meaningful maternity population subgroups and the associated caesarean section rates across institutions, countries, development groups, and time. This system helps to account for some of the population variations that can occur (eg, populations with lower fertility rates will have comparatively more nulliparous births than will more fertile populations). In most countries and HDI categories, the rates of obstetric interventions (both caesarean sections and labour inductions) increased.5Vogel JP Betrán AP Vindevoghel N et al.Use of the Robson classification to assess caesarean section trends in 21 countries: a secondary analysis of two WHO multicountry surveys.Lancet Glob Health. 2015; (published online April 10.)http://dx.doi.org/10.1016/S2214-109X(15)70094-XGoogle Scholar Overall, the caesarean section rate increased over time in all countries except Japan, from 26·4% in the WHO Global Survey to 31·2% in the WHO Multi-Country Survey (p=0·003). Japan's small decrease in caesarean section rates, including a decline in caesarean section rates for nulliparous women at term in spontaneous or induced labour, was a notable exception and warrants further exploration for lessons to be learnt. The substantial variation in caesarean section rates within HDI categories is also notable, and probably indicates some underuse of appropriate caesarean sections as well as likely overuse of the procedure. This study raises as many questions as it answers. To what extent the caesarean section rate increases are caused by changes in pregnancy management, the availability of maternity services, and patient or provider expectations is not clear. Efforts to explain variation in Australian caesarean section rates within Robson groups showed that patient factors explain most of the variation in prelabour caesarean section rates but not after labour inductions, and that adjustment for private obstetric care, labour, and delivery practices actually increased the amount of unexplained variation in intrapartum caesarean section rates.8Nippita T Lee Y Patterson J et al.Variation in hospital caesarean section rates and obstetric outcomes among nulliparae at term: a population-based cohort study.BJOG. 2015; (published online Jan 21.)https://doi.org/10.1111/1471-0528.13281Crossref PubMed Scopus (46) Google Scholar Concerns about high rates of caesarean section in private obstetric care settings also exist in low HDI nations, with countries such as Bangladesh reporting caesarean section rates as high as 73% in private facilities.9Neuman M Alcock G Azad K et al.Prevalence and determinants of caesarean section in private and public health facilities in underserved South Asian communities: cross-sectional analysis of data from Bangladesh, India and Nepal.BMJ Open. 2014; 4: e005982Crossref Scopus (89) Google Scholar Another important question is whether or not the different rates of caesarean section are associated with variation in maternal and infant morbidity. In particular, it would be useful to know whether or not improvements in perinatal mortality have occurred that correspond to each country's change in caesarean section rate. Ideally, assessment of obstetric interventions and outcomes should be based on high-quality, recent data from the entire population or a representative sample. A key feature of the Robson classification is that it uses information that is available at the onset of labour or delivery, is routinely collected (although this is not necessarily so, even in high-income countries),4Smith GCS Variation in caesarean section rates in the US: outliers, damned outliers, and statistics.PLoS Med. 2014; 11: e1001746Crossref PubMed Scopus (2) Google Scholar and is reliably reported.7Robson MS Classification of caesarean sections.Fetal and Maternal Medicine Review. 2001; 12: 23-39Crossref Scopus (287) Google Scholar Data validity is unknown for this study, and the increase over time in maternal records that could not be classified (an indicator of data quality) and the higher than expected relative size of Group 9 (which has been suggested as a self-validation group within the Robson classification)10Betrán AP Vindevoghel N Souza JP Gülmezoglu AM Torloni MR A systematic review of the Robson classification for caesarean section: what works, doesn't work and how to improve it.PLoS One. 2014; 9: e97769Crossref PubMed Scopus (134) Google Scholar is of concern. Vogel and colleagues' study5Vogel JP Betrán AP Vindevoghel N et al.Use of the Robson classification to assess caesarean section trends in 21 countries: a secondary analysis of two WHO multicountry surveys.Lancet Glob Health. 2015; (published online April 10.)http://dx.doi.org/10.1016/S2214-109X(15)70094-XGoogle Scholar represents an important step in exploring and understanding how obstetric intervention rates are both increasing and also vary widely between countries and levels of development. In the absence of country-specific information about maternal and child health outcomes, caution is needed before recommending strategies aimed at modifying practices. However, this is not to suggest that any efforts to improve the availability of a skilled workforce and health services should be stalled. CLR is supported by an Australian National Health and Medical Research Council Senior Research Fellowship (#APP1021025). The funder had no role in the preparation, review, or approval of the Comment. We thank Charles Algert for his assistance in preparing and critically reviewing the Comment. We declare no competing interests. Use of the Robson classification to assess caesarean section trends in 21 countries: a secondary analysis of two WHO multicountry surveysUse of the Robson criteria allows standardised comparisons of data across countries and timepoints and identifies the subpopulations driving changes in caesarean section rates. Women who have previously had a caesarean section are an increasingly important determinant of overall caesarean section rates in countries with a moderate or low HDI. Strategies to reduce the frequency of the procedure should include avoidance of medically unnecessary primary caesarean section. Improved case selection for induction and prelabour caesarean section could also reduce caesarean section rates. Full-Text PDF Open Access

Variation in hospital caesarean section rates and obstetric outcomes among nulliparae at term: a population-based cohort study.

To explore the variation in hospital caesarean section (CS) rates for nulliparous women, to determine whether different case-mix, labour and delivery, and hospital factors can explain this variation and to examine the association between hospital CS rates and outcomes. Population-based cohort study. New South Wales, 2009-2010. Nulliparous women with singleton cephalic live births at term. Random effect multilevel logistic regression models using linked hospital discharge and birth data. Prelabour and intrapartum CS rates following spontaneous labour or labour induction; maternal and neonatal severe morbidity rates. Of 67 239 nulliparous women, 4902 (7.3%) had a prelabour CS, 39 049 (58.1%) laboured spontaneously, and 23 288 (34.6%) had labour induced. Overall, there were 18 875 (28.1%) CSs, with labour inductions twice as likely to result in an intrapartum CS compared with women with a spontaneous onset of labour (34.0% versus 15.5%). After adjusting for differences in case-mix, labour and delivery, and hospital factors, the overall variation in CS rates decreased by 78% for prelabour CSs, 52% for intrapartum CSs following spontaneous labour and 9% following labour induction. Adjusting for labour and delivery practices increased the unexplained variation in intrapartum CSs. The adjusted rates of severe maternal and neonatal morbidity were not significantly different across CS rate quintile groups, except for women in spontaneous labour, where the hospitals in the lowest CS quintile had the lowest neonatal morbidity rate. Differences in clinical practice were substantial contributors to variation in intrapartum CS rates. Our findings suggest that CS rates in some hospitals could be lowered without adversely affect pregnancy outcomes.

Variation in caesarean section rates in the US: outliers, damned outliers, and statistics.

Gordon C. Smith discusses the study by Katy Kozhimannil and colleagues that examines variations in cesarean section rates in the US and argues for the need for high-quality routine data collection to better understand the reasons for these variations. Please see later in the article for the Editors' Summary.

Does a Caesarean section increase the time to a second live birth? A register-based cohort study.

Does a primary Caesarean section influence the rate of, and time to, subsequent live birth compared with vaginal delivery? Caesarean section was associated with a reduction in the rate of subsequent live birth, particularly among elective and maternal-requested Caesareans indicating maternal choice plays a role. Several studies have examined the relationship between Caesarean section and subsequent birth rate with conflicting results primarily due to poor epidemiological methods. This Danish population register-based cohort study covered the period from 1982 to 2010 (N = 832 996). All women with index live births were followed until their subsequent live birth or censored (maternal death, emigration or study end) using Cox regression models. In all 577 830 (69%) women had a subsequent live birth. Women with any type of Caesarean had a reduced rate of subsequent live birth (hazard ratio [HR] 0.86, 95% confidence intervals [CI] 0.85, 0.87) compared with spontaneous vaginal delivery. This effect was consistent when analyses were stratified by type of Caesarean: emergency (HR 0.87, 95% CI 0.86, 0.88), elective (HR 0.83, 95% CI 0.82, 0.84) and maternal-requested (HR 0.61, 95% CI 0.57, 0.66) and in the extensive sub-analyses performed. Lack of biological data to measure a woman's fertility is a major limitation of the current study. Unmeasured confounding and limited availability of data (maternal BMI, smoking, access to fertility services and maternal-requested Caesarean section) as well as changes in maternity care over time may also influence the findings. This is the largest study to date and shows that Caesarean section is most likely not causally related to a reduction in fertility. Maternal choice to delay or avoid childbirth is the most plausible explanation. Our findings are generalizable to other middle- to high-income countries; however, cross country variations in Caesarean section rates and social or cultural differences are acknowledged. Funding was provided by the National Perinatal Epidemiology Centre, Cork, Ireland and conducted as part of the Health Research Board PhD Scholars programme in Health Services Research (Grant No. PHD/2007/16). L.C.K. is a Science Foundation Ireland Principal Investigator (08/IN.1/B2083) and the Director of the SFI funded Centre, INFANT (12/RC/2272). The authors have no competing interests to declare.

BJOG Editor's Choice

In a 2008 World Health Organization (WHO) study of caesarean section (CS) rates worldwide in which data were obtained for 137 countries, representing 95% of global births in the year, it was calculated that approximately 18.5 million CS are performed yearly worldwide. The study clearly showed that there is considerable variation in CS rates between countries and more recent data demonstrate that these differences persist (Figure 1). For example in the USA the proportion was 33% in 2010, with a nearly 60% rise from 1996 to 2009, (Births: Final Data for 2010, National Vital Statistics Reports, 61:1) and in the UK and Australia the corresponding figures for 2010 are 25% (Hospital Episode Statistics: NHS Maternity Statistics 2010–11) and 32% (Australia’s mothers and babies 2010. Perinatal statistics series no. 27) respectively. In contrast, the latest data for India, for example, demonstrate that only 8.5% of deliveries are by CS (Maternal Health, India DHS, 2005–06). The WHO concluded from their analysis that, ‘Worldwide, CS that are possibly medically unnecessary appear to command a disproportionate share of global economic resources. CS arguably function as a barrier to universal coverage with necessary health services. “Excess” CS can therefore have important negative implications for health equity both within and across countries’. Strategies to reduce the financial effects of high CS rates include reducing the rate of CS, reducing the cost of each CS and reducing the long-term sequelae of this procedure. In this edition we publish four studies that address these issues. In 2010–11, of the 67 000 planned CS in England, approximately 7% of women were discharged on the day following surgery and 53% on the day after that. (Hospital Episode Statistics, NHS Maternity Statistics 2010–11). Encouraging more women to go home the day after elective surgery is likely to decrease expense, and is in keeping with the UK National Institute for Health and Care Excellence guidance which states that, ‘women who are recovering well, are apyrexial and do not have complications following CS should be offered early discharge (after 24 hours) from hospital and follow-up at home (NICE, CG132 Caesarean section). In this issue we publish two meta-analyses that examine the effect of chewing gum on postoperative bowel recovery following CS. On page 787 Yi-Ping Zhu and colleagues from China report that in six randomised controlled trials including 939 women, chewing gum was associated with a reduction of 6.4 hours for time to first flatus, 3.6 hours for time to first bowel sound, 6.6 hours for time to first stool and a reduction of nearly 6 hours for length of hospital stay. Craciunas and co-workers from the UK on page 793 in an analysis of seven randomised controlled trials involving 1462 women (728 in the 42 chewing gum group, 734 controls) arrived at similar conclusions and report that chewing gum significantly reduced the risk of postoperative ileus (odds ratio 0.36; 95% confidence interval 0.19–0.69) although they did not find an effect on duration of hospitalisation. Both studies suggest that chewing gum for 30–60 minutes at least three times a day appears to be effective in improving bowel function after CS. The clinical significance of these two studies is discussed in an accompanying commentary on page 793. It remains to be seen whether this sham-feeding intervention will be helpful for women who are already being encouraged not to interrupt normal perioperative food intake as part of the ‘Enhanced recovery from obstetric surgery’ programme that is being introduced in the developed world. A recent survey of UK obstetric units indicates that over two-thirds of units are already using this strategy (Aluri and Wrench, Int J Obstet Anesth 2013 Nov 26. pii: S0959-289X(13)00162-3.). On page 784 we also publish a commentary that includes eloquent explanation of the PROSPERO international prospective registration of systematic review protocols which aims to avoid duplication of effort and publication in meta-analysis. A previous CS is an important risk factor for further CS and in the developed world there has been a clear move to encourage women to have discussions concerning trial of labour after CS (TOLAC), with the aim of reducing CS rates. Attempts have been made over decades to develop models to allow accurate counselling about the likely success of TOLAC, but these calculator models have very seldom been applied to other populations. The study by Schoorel and colleagues (page 840) sought to externally validate two US model calculators for prediction of success of vaginal birth after CS within 17 hospitals in the Netherlands. Their results suggest that both calculators are valid in this European population. The paper and its significance are discussed in a commentary on page 847. It remains to be seen whether such information will influence women's choices in the clinical setting. It is possible that only women who have very high or very low predicted rates of TOLAC success will be influenced in their decision making by such models. Placenta accreta occurs in one per 2500 total deliveries and is associated with costly interventions to ensure the wellbeing of the mother and baby. Previous CS is the most important risk factor and the risk increases with the number of previous CS. To date no variation in operative technique (e.g. single versus double uterine closure) has been shown to influence this association. On page 866 Sumigama and colleagues from Japan in a case–control study of 98 cases of placenta praevia report that placenta accreta occurred among 29.9% of women when the inner layer of the previous hysterotomy was closed with interrupted sutures, compared with 58.1% when continuous sutures were used. The significance of this novel and interesting finding is discussed in an accompanying commentary on page 875.

Unexplained variation in hospital caesarean section rates

To assess recent hospital caesarean section (CS) rates in New South Wales, adjusted for case mix; to quantify the amount of variation that can be explained by case mix differences; and to examine the potential impact on the overall CS rate of reducing variation in practice. Population-based record linkage study of births in 81 hospitals in New South Wales, 2009-2010, using the Robson classification to categorise births, and multilevel logistic regression to examine variation in hospital CS rates within Robson groups. Hospital CS rates. The overall CS rate was 30.9%, ranging from 11.8% to 47.4% (interquartile range, 23.9%-33.1%) among hospitals. The three groups contributing most to the overall CS rate all comprised women with a single cephalic pregnancy who gave birth at term, including: those who had had a previous CS (36.4% of all CSs); nulliparous women with an elective delivery (prelabour CS or labour induction, 23.4%); and nulliparous women with spontaneous labour (11.1%). After adjustment for case mix, marked unexplained variation in hospital CS rates persisted for: nulliparous women at term; women who had had a previous CS; multifetal pregnancies; and preterm births. If variation in practice was reduced for these risk-based groups by achieving the "best practice" rate, this would lower the overall rate by an absolute reduction of 3.6%, from 30.9% to 27.3%. Understanding hospital heterogeneity in performing CS and implementing evidence-based practices may result in improved maternity care. We have identified five risk-based groups as priority targets for reducing practice variation in CS rates.

Variation in cesarean section rates is not related to maternal and neonatal outcomes

The aim of this study was to compare the rate of cesarean sections in 12 delivery units in Finland, and to assess possible associations between cesarean section rates and maternal and neonatal complications. Prospective multicenter cohort study. The 12 largest delivery units in Finland. Total obstetric population between 1 January 2005 and 30 June 2005 (n=19764). Prospectively collected data on 2496 cesarean sections and data derived from the Finnish Birth Register on all deliveries in these units were compared. Cesarean section rates and maternal complication rates were adjusted for known risk factors. Cesarean section rate, maternal complications related to cesarean section, and neonatal asphyxia. The cesarean section rates varied significantly between the hospitals (12.9-25.1%, p<0.0001), as did the maternal complication rates related to cesarean section (13.0-36.5%, p<0.0001). There was no relation between maternal complications and the cesarean section rate. The differences remained after adjusting for risk factors. Neonatal asphyxia rates varied between 0.14 and 2.8% (p<0.0001) and were not related to the cesarean section rates. The rates of cesarean section, maternal complications and neonatal asphyxia vary markedly between different delivery units. Good maternal and neonatal outcomes can be achieved with cesarean section rates <15%.

International variation in caesarean section rates and maternal obesity

This study examined variations in caesarean section (CS) rates associated with a woman's birthplace and differences in maternal adiposity. Women were enrolled in the 1st trimester. Maternal adiposity was assessed by body mass index (BMI) and bioelectrical impedance analysis (BIA). Irish women were compared with women born in the 14 countries who joined the European Union (EU) before 2004 (EU 14), and with those born in 12 countries who joined following enlargement (EU 12). Of the 2,811 women enrolled, 2,235 women were born in Ireland, 100 in EU 14 countries and 476 in EU 12 countries. Based on a BMI > 29.9 kg/m2, maternal obesity was higher in Irish (19.8%; n = 443) and EU 14 women (19.0%; n = 19) compared with EU 12 women (9.5%; n = 45), p < 0.001. BIA of maternal body composition confirmed increased adiposity in both the Irish and EU 14 women. Variations in emergency CS rates in primigravidas based on the woman's birthplace were associated with maternal adiposity and induction of labour, both modifiable risk factors for CS. We recommend, therefore, that induction of labour in obese primigravidas should be undertaken only in carefully considered clinical circumstances. Our findings also suggest economic development in Europe may drive an increase in the CS rates mediated through increased levels of maternal obesity and, therefore, public health interventions should focus on optimising a woman's prepregnancy weight.

Adoption of diagnostic technology and variation in caesarean section rates: a test of the practice style hypothesis in Norway.

To examine whether the introduction of advanced diagnostic technology in maternity care has led to less variation in type of delivery between hospitals in Norway. The Medical Birth Registry of Norway provided detailed medical information for 1.7 million deliveries from 1967 to 2005. Information about diagnostic technology was collected directly from the maternity units. The data were analyzed using a two-level binary logistic model with Caesarean section as the outcome measure. Level one contained variables that characterized the health status of the mother and child. Hospitals are level two. A heterogeneous variance structure was specified for the hospital level, where the error variance was allowed to vary according to the following types of diagnostic technology: two-dimensional ultrasound, cardiotocography, ST waveform analysis, and fetal blood analyses. There was a marked variation in Caesarean section rates between hospitals up to 1973. After this the variation diminished markedly. This was due to the introduction of ultrasound and cardiotocography. Diagnostic technology reduced clinical uncertainty about the diagnosis of risk factors of the mother and child during delivery, and variation in type of delivery between hospitals was reduced accordingly. The results support the practice style hypothesis.