Multicenter Study

. 2016 Feb;123(3):427-36.

doi: 10.1111/1471-0528.13509. Epub 2015 Aug 10.

A global reference for caesarean section rates (C-Model): a multicountry cross-sectional study

J P Souza¹, A P Betran², A Dumont³, B de Mucio⁴, C M Gibbs Pickens⁵, C Deneux-Tharaux⁶, E Ortiz-Panozo⁷, E Sullivan⁸, E Ota⁹, G Togoobaatar⁹, G Carroli¹⁰, H Knight^{11

12}, J Zhang¹³, J G Cecatti¹⁴, J P Vogel², K Jayaratne¹⁵, M C Leal¹⁶, M Gissler¹⁷, N Morisaki^{9

18}, N Lack¹⁹, O T Oladapo², Ö Tunçalp², P Lumbiganon²⁰, R Mori⁹, S Quintana²¹, A D Costa Passos¹, A C Marcolin²¹, A Zongo^{3

22}, B Blondel⁶, B Hernández²³, C J Hogue⁵, C Prunet⁶, C Landman¹⁶, C Ochir²⁴, C Cuesta¹⁰, C Pileggi-Castro^{25

26}, D Walker²⁷, D Alves¹, E Abalos¹⁰, Ecd Moises²¹, E M Vieira¹, G Duarte²¹, G Perdona¹, I Gurol-Urganci^{11

12}, K Takahiko⁹, L Moscovici^{1

25}, L Campodonico¹⁰, L Oliveira-Ciabati^{1

25}, M Laopaiboon²⁸, M Danansuriya¹⁵, M Nakamura-Pereira¹⁶, M L Costa¹⁴, M R Torloni²⁹, M R Kramer⁵, P Borges¹⁶, P B Olkhanud²⁴, R Pérez-Cuevas³⁰, S B Agampodi¹⁵, S Mittal³¹, S Serruya⁴, V Bataglia³², Z Li⁸, M Temmerman², A M Gülmezoglu²

Affiliations

¹ Department of Social Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil.
² Department of Reproductive Health and Research, UNDP-UNFPA-UNICEF-WHO World Bank Special Programme of Research, Development and Research Training in Human Reproduction, WHO, Geneva, Switzerland.
³ Research Institute for Development, Université Paris Descartes, Sorbonne Paris Cité, UMR 216, Paris, France.
⁴ Latin American Center for Perinatology, Women and Reproductive Health, (CLAP/WR), WHO Regional Office for the Americas, Montevideo, Uruguay.
⁵ Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA.
⁶ Inserm U1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Center for Epidemiology and Biostatistics, Paris Descartes University, Paris, France.
⁷ Center for Population Health Research, National Institute of Public Health, Cuernavaca, Mexico.
⁸ Faculty of Health, University of Technology, Sydney, NSW, Australia.
⁹ Department of Health Policy, National Center for Child Health and Development, Tokyo, Japan.
¹⁰ Centro Rosarino de Estudios Perinatales, Rosario, Argentina.
¹¹ Royal College of Obstetricians and Gynaecologists, Office for Research and Clinical Audit, Lindsay Stewart R&D Centre, London, UK.
¹² Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK.
¹³ Ministry of Education-Shanghai Key Laboratory of Children's Environmental Health, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
¹⁴ Department of Obstetrics and Gynaecology, School of Medical Sciences, University of Campinas (UNICAMP), Campinas, SP, Brazil.
¹⁵ Family Health Bureau, Ministry of Health, Colombo, Sri Lanka.
¹⁶ Escola Nacional de Saúde Pública (ENSP), Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro, Brazil.
¹⁷ National Institute for Health and Welfare, Helsinki, Finland.
¹⁸ Department of Paediatrics, Graduate School of Medicine, University of Tokyo, Tokyo, Japan.
¹⁹ Bayerische Arbeitsgemeinschaft für Qualitätssicherung in der Stationären Versorgung (BAQ), Bayerische Krankenhausgesellschaft, Munich, Germany.
²⁰ Department of Obstetrics and Gynecology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand.
²¹ Department of Gynaecology and Obstetrics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil.
²² Direction de la santé de la famille, Ministère de la Santé, Ouagadougou, Burkina Faso.
²³ Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.
²⁴ School of Public Health, Health Sciences University of Mongolia, Ulaanbaatar, Mongolia.
²⁵ GLIDE Technical Cooperation and Research, Ribeirão Preto, SP, Brazil.
²⁶ Department of Paediatrics, Ribeirão Preto Medical School, University of Sao Paulo, Ribeirão Preto, SP, Brazil.
²⁷ Departments of Obstetrics & Gynaecology and Global Health Sciences, University of California, San Francisco, CA, USA.
²⁸ Department of Biostatistics and Demography, Faculty of Public Health, Khon Kaen University, Khon Kaen, Thailand.
²⁹ Department of Obstetrics, School of Medicine of São Paulo, São Paulo Federal University, São Paulo, Brazil.
³⁰ Social Protection and Health Division, Inter-American Development Bank, Mexico City, Mexico.
³¹ Fortis Memorial Research Institute, Gurgaon, Haryana, India.
³² Hospital Nacional de Itauguá, Itauguá, Paraguay.

PMID: 26259689
PMCID: PMC4873961
DOI: 10.1111/1471-0528.13509

Multicenter Study

A global reference for caesarean section rates (C-Model): a multicountry cross-sectional study

J P Souza et al. BJOG. 2016 Feb.

. 2016 Feb;123(3):427-36.

doi: 10.1111/1471-0528.13509. Epub 2015 Aug 10.

Authors

Affiliations

¹ Department of Social Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil.
² Department of Reproductive Health and Research, UNDP-UNFPA-UNICEF-WHO World Bank Special Programme of Research, Development and Research Training in Human Reproduction, WHO, Geneva, Switzerland.
³ Research Institute for Development, Université Paris Descartes, Sorbonne Paris Cité, UMR 216, Paris, France.
⁴ Latin American Center for Perinatology, Women and Reproductive Health, (CLAP/WR), WHO Regional Office for the Americas, Montevideo, Uruguay.
⁵ Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA.
⁶ Inserm U1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Center for Epidemiology and Biostatistics, Paris Descartes University, Paris, France.
⁷ Center for Population Health Research, National Institute of Public Health, Cuernavaca, Mexico.
⁸ Faculty of Health, University of Technology, Sydney, NSW, Australia.
⁹ Department of Health Policy, National Center for Child Health and Development, Tokyo, Japan.
¹⁰ Centro Rosarino de Estudios Perinatales, Rosario, Argentina.
¹¹ Royal College of Obstetricians and Gynaecologists, Office for Research and Clinical Audit, Lindsay Stewart R&D Centre, London, UK.
¹² Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK.
¹³ Ministry of Education-Shanghai Key Laboratory of Children's Environmental Health, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
¹⁴ Department of Obstetrics and Gynaecology, School of Medical Sciences, University of Campinas (UNICAMP), Campinas, SP, Brazil.
¹⁵ Family Health Bureau, Ministry of Health, Colombo, Sri Lanka.
¹⁶ Escola Nacional de Saúde Pública (ENSP), Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro, Brazil.
¹⁷ National Institute for Health and Welfare, Helsinki, Finland.
¹⁸ Department of Paediatrics, Graduate School of Medicine, University of Tokyo, Tokyo, Japan.
¹⁹ Bayerische Arbeitsgemeinschaft für Qualitätssicherung in der Stationären Versorgung (BAQ), Bayerische Krankenhausgesellschaft, Munich, Germany.
²⁰ Department of Obstetrics and Gynecology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand.
²¹ Department of Gynaecology and Obstetrics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil.
²² Direction de la santé de la famille, Ministère de la Santé, Ouagadougou, Burkina Faso.
²³ Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.
²⁴ School of Public Health, Health Sciences University of Mongolia, Ulaanbaatar, Mongolia.
²⁵ GLIDE Technical Cooperation and Research, Ribeirão Preto, SP, Brazil.
²⁶ Department of Paediatrics, Ribeirão Preto Medical School, University of Sao Paulo, Ribeirão Preto, SP, Brazil.
²⁷ Departments of Obstetrics & Gynaecology and Global Health Sciences, University of California, San Francisco, CA, USA.
²⁸ Department of Biostatistics and Demography, Faculty of Public Health, Khon Kaen University, Khon Kaen, Thailand.
²⁹ Department of Obstetrics, School of Medicine of São Paulo, São Paulo Federal University, São Paulo, Brazil.
³⁰ Social Protection and Health Division, Inter-American Development Bank, Mexico City, Mexico.
³¹ Fortis Memorial Research Institute, Gurgaon, Haryana, India.
³² Hospital Nacional de Itauguá, Itauguá, Paraguay.

PMID: 26259689
PMCID: PMC4873961
DOI: 10.1111/1471-0528.13509

Abstract

Objective: To generate a global reference for caesarean section (CS) rates at health facilities.

Design: Cross-sectional study.

Setting: Health facilities from 43 countries.

Population/sample: Thirty eight thousand three hundred and twenty-four women giving birth from 22 countries for model building and 10,045,875 women giving birth from 43 countries for model testing.

Methods: We hypothesised that mathematical models could determine the relationship between clinical-obstetric characteristics and CS. These models generated probabilities of CS that could be compared with the observed CS rates. We devised a three-step approach to generate the global benchmark of CS rates at health facilities: creation of a multi-country reference population, building mathematical models, and testing these models.

Main outcome measures: Area under the ROC curves, diagnostic odds ratio, expected CS rate, observed CS rate.

Results: According to the different versions of the model, areas under the ROC curves suggested a good discriminatory capacity of C-Model, with summary estimates ranging from 0.832 to 0.844. The C-Model was able to generate expected CS rates adjusted for the case-mix of the obstetric population. We have also prepared an e-calculator to facilitate use of C-Model (www.who.int/reproductivehealth/publications/maternal_perinatal_health/c-model/en/).

Conclusions: This article describes the development of a global reference for CS rates. Based on maternal characteristics, this tool was able to generate an individualised expected CS rate for health facilities or groups of health facilities. With C-Model, obstetric teams, health system managers, health facilities, health insurance companies, and governments can produce a customised reference CS rate for assessing use (and overuse) of CS.

Tweetable abstract: The C-Model provides a customized benchmark for caesarean section rates in health facilities and systems.

Keywords: Benchmarking; caesarean delivery rates; caesarean section rates; logistic regression.

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Figures

**Figure 1**
Analysis flowchart for model building and validation.

See this image and copyright information in PMC

Comment in

A global reference for CS at health facilities? Yes, but there is work to do.
Robson M. Robson M. BJOG. 2016 Feb;123(3):437. doi: 10.1111/1471-0528.13619. Epub 2015 Sep 28. BJOG. 2016. PMID: 26412795 No abstract available.

References

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A global reference for caesarean section rates (C-Model): a multicountry cross-sectional study

Affiliations

A global reference for caesarean section rates (C-Model): a multicountry cross-sectional study

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