Variation in hospital caesarean section rates for women with at least one previous caesarean section: a population based cohort study

Abstract

Background: Internationally, 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.

Methods: This 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.

Results: Of 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.

Conclusions: Among 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.

Fig. 1

Hospital planned repeat caesarean section rates in NSW, 2007–2011. ^* The data points represent the rates of planned repeat caesarean section among multiparous women with a singleton, cephalic-presenting infant of ≥37 weeks gestation in 81 hospitals, ordered from lowest to highest unadjusted hospital CS rate. The vertical error bars indicate the 95 % confidence intervals for each estimate. Dashed horizontal lines indicate the mean risk-adjusted planned caesarean section rate

Fig. 2

Hospital intrapartum repeat caesarean section rates in NSW, 2007–2011. ^* The data points represent the rates of intrapartum repeat caesarean section among multiparous women with a singleton, cephalic-presenting infant of ≥37 weeks gestation undergoing a trial of labour in 73 hospitals, ordered from lowest to highest unadjusted hospital CS rate. The vertical error bars indicate the 95 % confidence intervals for each estimate. Dashed horizontal lines indicate the mean risk-adjusted planned caesarean section rates

Fig. 3

Severe maternal morbidity and risk-adjusted hospital (a) planned and (b) intrapartum caesarean section rates. Dashed lines indicate the respective mean risk-adjusted caesarean and case-mix adjusted morbidity rates. The study population consisted of multiparous women with a previous caesarean section and a singleton, cephalic-presenting infant of ≥37 weeks gestation in NSW, 2007–2011

Fig. 4

Severe neonatal morbidity and risk-adjusted hospital (a) planned and (b) intrapartum caesarean section rates. Dashed lines indicate the respective mean risk-adjusted caesarean and case-mix adjusted morbidity rates. The study population consisted of multiparous women with a previous caesarean section and a singleton, cephalic-presenting infant of ≥37 weeks gestation in NSW, 2007–2011

Fig. 5

Postpartum haemorrhage and risk-adjusted hospital (a) planned and (b) intrapartum caesarean section rates. Dashed lines indicate the respective mean risk-adjusted caesarean and case-mix adjusted morbidity rates. The study population consisted of multiparous women with a previous caesarean section and a singleton, cephalic-presenting infant of ≥37 weeks gestation in NSW, 2007–2011

Fig. 6

Apgar score below 7 at five minutes and risk-adjusted hospital (a) planned and (b) intrapartum caesarean section rates. Dashed lines indicate the respective mean risk-adjusted caesarean and case-mix adjusted morbidity rate. The study population consisted of multiparous women with a previous caesarean section and a singleton, cephalic-presenting infant of ≥37 weeks gestation in NSW, 2007–2011